Guidelines for Music Therapy Practice in Mental Health [1 ed.] 9781937440473, 9781937440466

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Guidelines for Music Therapy Practice in Mental Health Edited by Lillian Eyre Copyright © 2013 by Barcelona Publishers All rights reserved. No part of this e-book may be reproduced and/or distributed in any form whatsoever. Print ISBN: 978-1-937440-46-6 E-ISBN: 978-1-937440-47-3 To obtain chapters separately in epub or Mobi formats, please visit: www.barcelonapublishers.com Distributed throughout the world by:

Barcelona Publishers 4 White Brook Road Gilsum NH 03448 Tel: 603-357-0236 Fax: 603-357-2073 Website: www.barcelonapublishers.com SAN 298-6299 Cover illustration and design: © 2013 Frank McShane Copy-editor: Jack Burnett

Dedication

To my mother, Huguette Jacqueline Lahaie Eyre, a woman of faith who has taught me to follow the heart’s intuition, especially when the path disappears And To my husband, David McKnight, who has never faltered in his support and who understands and values the healing power of music

Acknowledgments

I am deeply grateful to Kenneth E. Bruscia whose vision, commitment, guidance, and patience throughout this process have greatly contributed to my development as an editor as well as to the continued advancement of the field of music therapy. To the authors who so generously gave of their time, expertise, and themselves, to share what they have learned throughout their careers, I extend my gratefulness for their engagement and willingness to work through all the difficulties until they were satisfied with their contributions. I am humbled and grateful for all that they have taught me. To my colleague and friend, Anthony Meadows, I am indebted for his professional support and personal encouragement when it was most needed. I would also like to thank Darlene Brooks and Bryan Muller for their friendship and their unique abilities to listen intently and discuss enthusiastically. I am especially grateful to Sister Ann Heath, Dr. Janet Kane, Dr. Thomas O’Brien, my colleagues in the Music Department, and Immaculata University for academic and personal support that they have provided that allowed me to take on this challenge. I would also like to thank my family—my sisters Cynthia, Cheryl, Patricia, Susan, and my sister-in-law Miriam, my brothers Derrick and Robert, as well as Wayne, Laura Lee, and Lucy for their love and acceptance.

Table of Contents Dedication Acknowledgments Table of Contents Contributors Preface An Evolving Perspective Kenneth E. Bruscia

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Chapter 1

3

INTRODUCTION Lillian Eyre Chapter 2

21

ADULTS WITH SCHIZOPHRENIA AND PSYCHOTIC DISORDERS Andrea McGraw Hunt Chapter 3

71

ADULT GROUPS IN THE INPATIENT SETTING Lillian Eyre

115 Chapter 4

ADULTS IN A RECOVERY MODEL SETTING Lillian Eyre Chapter 5

168

CHILDREN AND ADOLESCENTS WITH EMOTIONAL AND BEHAVIORAL DISORDERS IN AN INPATIENT PSYCHIATRIC SETTING Bridget Doak Chapter 6 FOSTER CARE YOUTH Michael L. Zanders

205

Chapter 7

237

SURVIVORS OF CATASTROPHIC EVENT TRAUMA Ronald M. Borczon

Chapter 8 WOMEN SURVIVORS OF ABUSE AND DEVELOPMENTAL TRAUMA Sandra Lynn Curtis

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viii Chapter 9

289

ADULT MALE SURVIVORS OF ABUSE AND DEVELOPMENTAL TRAUMA Jeffrey H. Hatcher Chapter 10

313

CHILDREN AND ADOLESCENTS WITH PTSD AND SURVIVORS OF ABUSE AND NEGLECT Penny Rogers Chapter 11

339

ADULTS WITH DEPRESSION AND/OR ANXIETY Nancy A. Jackson Chapter 12

378

ADULTS AND ADOLESCENTS WITH BORDERLINE PERSONALITY DISORDER Janice M. Dvorkin Chapter 13

402

ADULTS AND ADOLESCENTS WITH EATING DISORDERS Peggy Tileston Chapter 14

449

ADULTS WITH SUBSTANCE USE DISORDERS Kathleen M. Murphy Chapter 15

502

ADOLESCENTS WITH SUBSTANCE USE DISORDERS Katrina Skewes McFerran Chapter 16

526

ADULT MALES IN FORENSIC SETTINGS Vaughn Kaser Chapter 17

559

ADULT FEMALES IN CORRECTIONAL FACILITIES Karen Anne Litecky Melendez Chapter 18

ADJUDICATED ADOLESCENTS Susan C. Gardstrom

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ix Chapter 19

658

JUVENILE MALE SEX OFFENDERS Lori L. De Rea-Kolb Chapter 20

685

ELDERLY RESIDENTS IN NURSING FACILITIES Elaine A. Abbott Chapter 21

718

PERSONS WITH ALZHEIMER’S AND OTHER DEMENTIAS Laurel Young Chapter 22

767

PROFESSIONAL BURNOUT Darlene M. Brooks Chapter 23

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STRESS REDUCTION AND WELLNESS Seung-A Kim Chapter 24

840

MUSICIANS Gro Trondalen Chapter 25

873

SPIRITUAL PRACTICES Annie Heiderscheit INDEX

911

Contributors

Elaine Abbott, Ph.D., MT-BC is an assistant professor and chair of music therapy at Duquesne University. She received her music therapy degrees from Michigan State University and Temple University. She has over 20 years of clinical experience in continuing care retirement communities, skilled nursing facilities, behavioral health hospitals and private practice. As a Fellow of the Association of Music and Imagery, she works with trainees at the Anna Maria College Institute for Music and Consciousness. Currently, she chairs the American Music Therapy Association (AMTA) Scholarship Committee and represents the Mid-Atlantic Region on the AMTA Assembly. Dr. Abbott’s research interests include client, therapist and paraprofessional experiences in music therapy processes. Ronald M. Borczon, MT-BC, founded the Music Therapy program at California State Northridge in 1984 and is the Director of the CSUN Music Therapy Wellness Clinic. He has received numerous awards from the American Music Therapy Association including a Presidential Award, the Award of Merit and the Professional Practice award. He has published three books: "Music Therapy, Group Vignettes", "Music Therapy: A Fieldwork Primer" and “Life’s Lessons from Your Guitar.” 
He has extensive experience in working with trauma victims and carefigers, including the 1994 Northridge earthquake, the Oklahoma City bombing, Columbine High School, Santee High School shootings, and Hurricane Katrina. He continues to mentor music therapists who are involved with working in areas who have suffered mass trauma. Darlene Brooks, PhD, MT-BC, LPC, FAMI, LCAT is Director of Music Therapy at Temple University. She worked many years in psychiatry, served on the Executive Board, the Assembly of Delegates and on the Education and Training Advisory Board (ETAB) for NAMT & AMTA. She has been on the Editorial Board of the JMT and currently serves on the Editorial Board for the Arts in Psychotherapy. Her research interests include supervision, historical and burnout research. She served as principal investigator on Creative approaches to reducing burnout in medical personnel. Sandi Curtis, PhD, MT-BC, MTA, Vice-President, American Music Therapy Association, is Professor, Graduate Music Therapy Program Director, and founder of the music therapy programs at Concordia University. She is an internationally-trained music therapist with more than 25 years’ experience in clinical practice, education, and research. Dr. Curtis specializes in work with survivors of violence, people with differing abilities, and in palliative care, with current research interests in Feminist Music Therapy and Community Music Therapy. She is recipient of a Social Justice Person Award (University of Windsor).

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Contributors

Lori DeRea-Kolb is a full-time Music Therapist in Pennsylvania. She received her Masters of the Arts in Music Therapy from Immaculata in 2009, and has professional experience with populations such as children and young adults with developmental disabilities , as well as adult mental health. She worked with juvenile male sex offenders are the residential level of care, and continues to work with adolescents with various behavioral issues and trauma histories. Bridget Doak, Ph.D, MT-BC has worked as a music therapist on the child and adolescent mental health units in Fairview Behavioral Services (at the University of Minnesota Medical Center, Fairview) for more than 22 years. She currently oversees staff training and education as the Clinical Development Manager for Fairview Behavioral Services and as the Music Therapy Internship Director. She has also taught as an adjunct instructor of music therapy, with primary responsibilities for clinical supervision, at Augsburg College for over 20 years. Bridget is a past president of the Music Therapy Associate of Minnesota. She has presented at state, regional, and national music therapy conferences and is currently a member of the Education Training Advisory Board for the American Music Therapy Association. Dr Janice Dvorkin, Psy.D, ACMT, is the Coordinator of the Music Therapy program at the University of the Incarnate Word, in San Antonio, Texas. She has been a Music Therapist for 34 years and a Psychologist for 21 years. She is licensed as a Psychologist in New York and Texas. Dr. Dvorkin has a part-time music psychotherapy and psychological practice with clinical supervision for music therapists and a Music Therapy Services Center. She was a president of the American Association for Music Therapy and has published and presented nationally and internationally on the “Emotional Development of Individuals with Autism” and “Music Therapy and the person with Borderline Personality Disorders. Lillian Eyre is Assistant Professor of Music Therapy at Immaculata University in Pennsylvania. She graduated from the University of Quebec in Montreal (UQAM) and has a PhD in music therapy from Temple University. She has worked extensively in psychiatry and in community mental health, and with adults in private practice. Her research interests include applications of narrative therapy practices in music therapy, recovery in mental health, clinical improvisation, and music therapy supervision. She serves on the editorial review board of The Arts in Psychotherapy and Music Therapy Perspectives and is a member of the Professional Supervision Training and Continuing Education Committee for the Canadian Music Therapy Association. Susan C. Gardstrom, PhD, MT-BC, is Professor of Music Therapy at University of Dayton, where she has coordinated the undergraduate training program for 15 years. Gardstrom holds a Master’s degree in Counseling from Western Michigan University and a Doctoral degree in Music Education with a Music Therapy cognate from Michigan State University. Before teaching, she worked with adjudicated adolescents at The Starr Commonwealth Schools and The Adrian Training School, both in Michigan. Gardstrom has published in multiple journals, has edited Qualitative Inquiries in Music Therapy, and is the author of a textbook titled Music Therapy Improvisation for Groups: Essential Leadership Competencies.

Contributors

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Jeffrey M. Hatcher, MA, MTA studied at Capilano and Simon Fraser Universities. He works in the fields of fetal alcohol disorders, brain injury, HIV/AIDS, trauma, and addictions. Jeffrey is a staff therapist and also works in private practice. He has written on his work and presented at national and international conferences. Annie Heiderscheit, Ph.D., MT-BC, LMFT, Fellow in the Association of Music and Imagery. She is an assistant professor and director of the master’s in music therapy at Augsburg College, assistant professor at the University of Minnesota Center for Spirituality and Healing, and clinical music therapist at University of Minnesota Amplatz Children’s Hospital. She is also a member of an interdisciplinary research team at the University of Minnesota. Dr. Heiderscheit is president of the World Federation of Music Therapy and frequently speaks and lectures nationally and internationally. She has authored several book chapters and articles based on her research and clinical work with mechanically ventilated patients, eating disorder and chemically dependent clients. Andrea McGraw Hunt, PhD, MT-BC, Fellow of the Association for Music and Imagery, is the Assistant Director of the Arts and Quality of Life Research Center (AQLRC) at Temple University. Her clinical experience includes work with clients in skilled nursing, inpatient psychiatric, and residential drug and alcohol rehabilitation settings, in addition to private practice in the Bonny Method of Guided Imagery and Music. In her role at the AQLRC, she oversees all aspects of the Center’s operations, including project and research designs; community partnerships; obtaining funding; data collection, management, and analysis; and reports of project outcomes. Her personal research interests include multicultural competence in music therapy practice, music-based assessment in music therapy, and neurophenomenology. Nancy A. Jackson, PhD, MT-BC, is a board certified music therapist with 20 years of clinical experience working with people in mental health and medical settings, including 15 years of work in in-patient mental health treatment. She received her undergraduate degree in music therapy from the University of WisconsinMilwaukee, and both her Master’s in Music Therapy, and Doctor of Philosophy in Music Therapy degrees from Temple University. She frequently presents at conferences and teaches workshops at regional, national, and international levels, and has a number of publications in professional journals and books to her credit. She is Associate Professor of Music, and Director of Music Therapy at Indiana University - Purdue University Fort Wayne. Vaughn Kaser, MCAT, MT-BC; Received Bachelor of Music-Music Therapy from Arizona State University in 1979. Completed MCAT at Hahnemann University (now Drexel University) in 1984. Has worked in Forensic Mental Health at both the Hahnemann Mental Health Services at the Philadelphia County Prisons (1987-1988); and Atascadero State Hospital in Atascadero, CA for the last 26 years. Clinical music therapy emphasis has been on small group improvisation, performance groups, and aggression reduction. Former Internship Director of AMTA at Atascadero State Hospital. Recipient of the WRAMTA Professional Practice Award in 2005.

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Contributors

Seung-A Kim, PhD, AMT, LCAT, MT-BC, is Assistant Professor of Music Therapy at Molloy College. A graduate of Temple University, Dr. Kim’s research specialties include stress reduction and wellness, Analytical Music Therapy (AMT), multicultural training utilizing music, and cross-cultural supervision. She has worked with clients and interns from a variety of ethnic and racial groups over the years. She also developed a music therapy program for Korean-American immigrant families in NY and organized Korean Alliance of Licensed Creative Arts Therapy meetings. She is a co-editor of the interview section on Voices: A World Forum for Music Therapy and serves on the AMTA Diversity Committee and MAR Assembly. Dr. Kim is the author of several chapters and has been invited to present nationally and internationally. Dr. Katrina Skewes McFerran is a registered music therapist with the Australian Music Therapy Association, as well as Associate Professor and Head of Music Therapy at the University of Melbourne in Australia. Katrina has been focused on generating knowledge about working with adolescents for the past decade, beginning with a doctoral investigation of the experience of group music therapy with bereaved adolescents, and more recently expanding into a preventative orientation inschools. Katrina has published widely in international journals, as well as two books, ‘Adolescents, Music and Music Therapy’ and ‘Lifelong Engagement with Music: Benefits for Mental Health and Well-Being’, which she co-edited with Nikki Rickard. She is also co-director of MusicMatters in Schools, with Kate Teggelove and Lucy Bolger. Karen Anne Litecky Melendez, LPC, NCC, MT-BC received her Masters from Drexel MCP Hahnemann University in 1998. She has worked in mental health for 14 years; including 11 years at the University of Medicine and Dentistry of New Jersey, where in 2005 she founded the Music Therapy program at Edna Mahan Correctional Facility for Women; and works in private practice. She is an Advanced Trainee in the Bonny Method of Guided Imagery and Music, a regular presenter, and a clinical supervisor. As her first published writing, Karen Anne is honored to be among such esteemed authors. She is grateful to contribute this cornerstone, from which indepth music therapy with incarcerated women may develop. Kathleen M. Murphy, PhD, LCAT, LPC, MT-BC is an Assistant Professor of Music Therapy at the University of Evansville. She received her PhD in Music Therapy from Temple University. Kathleen has over 30 years of clinical experience working with adults and children in healthcare and educational settings. Since 2005 her clinical work has been primarily with adults who are in early recovery. Currently, she is working with adults in hospice care who have a history of substance abuse. Penny Rogers, LGSM(MT) has three master’s degrees (cognitive neuropsychology, child protection, and systemic psychotherapy). With 30 years of clinical experience in mental health and music therapy, she is now Head of Safeguarding of North Essex Partnership NHS Foundation Trust. She has written extensively on her clinical work with both abused and abusing young people and their families, and has lectured extensively nationally and internationally.

Contributors

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Peggy Tileston, MA, MT-BC, received her BA in Music Therapy from Loyola University in 1980, her MA from Lesley University in 1987, and certifications in psychodrama, NLP, meditation, yoga, and Laughter Yoga along the way. She has spent the last 30+ years serving as a therapist and educator in a variety of settings, from inpatient psychiatric hospitals and community mental health centers to residential treatment programs and private practice. Her greatest joy is found when helping people navigate away from beliefs and behaviors that cause suffering towards ways of thinking and daily practices that create resiliency, compassion,connection, and well being in all aspects of their lives. Gro Trondalen, PhD, Music Therapist, Fellow of AMI, is Professor in Music Therapy and Head of Centre for Music and Health at the Norwegian Academy of Music. She is a former Head of the MA program in music therapy and Head of the PhD program in music. Trondalen is an experienced music therapy clinician and supervisor in the field of child welfare and adult mental health (26 years), and maintains a private practice in GIM. Her research focus has been on clinical work linked to philosophical and theoretical perspectives. She has published four anthologies/books, and a number of articles in Norwegian, Swedish and English, of which some have been translated into German and Japanese. Dr. Laurel Young is an accredited music therapist (MTA) and a certified practitioner in the Bonny Method of Guided Imagery & Music (FAMI). She is an Assistant Professor of Music Therapy in the Creative Arts Therapies Department at Concordia University in Montreal, Canada. She has over 19 years of clinical experience in various areas including geriatrics/dementia, cancer, HIV, palliative care, community mental health, and developmental disabilities. Dr. Young has published in several peerreviewed journals, served as Editor-in-Chief for Barcelona’s Qualitative Inquiries in Music Therapy Series, and actively participates in a wide range of research activities. She is on the Board of Directors of the Canadian Music Therapy Trust Fund and has served as Vice President of the Canadian Association for Music Therapy. Michael Zanders received his B.M., M.M.T, and Ph.D from Temple University. He is a BoardCertified Music Therapist (MT-BC), and a Licensed Professional Counselor (LPC). Currently, he is assistant professor of music therapy at Texas Woman’s University. Dr. Zanders has over 16 years of clinical experience in music therapy. Areas of clinical specialty include trauma psychotherapy, music therapy with children and adolescents, developmental disabilities, cardiac care, psychiatry, and foster care youth. He has presented both nationally and internationally, and has served on the Editorial Board for Qualitative Inquiries in Music Therapy. He is currently on the CBMT 2013 practice analysis committee. His current research interests include: music therapy for foster care youth, and reflexive methodologies.

Preface

An Evolving Perspective Kenneth E. Bruscia

Music therapy has grown dramatically in the last 20 years—in theory, practice, and research. New training programs have been founded in many countries, and global networks have been formed through federations, conferences, journals, and online media. The technological revolution has made it possible for professionals and students around the world to communicate their thoughts and discoveries about music therapy in the flash of one simple click. New generations of music therapists have begun to explore the endless horizons of music therapy in different cultures, while the more experienced generations have had the time and resources to reflect upon what has been evolving in the field. Theory, practice, and research can no longer be defined or delimited in terms of a single culture, treatment philosophy, method, training program, or individual. The traditional modus operandi of music therapists has always been to find or develop the most appropriate methodological approach to meet the unique health needs and resources of each individual client, population, and treatment milieu. This aim has not changed. What has changed, however, is the growing awareness that understanding what these needs and resources are is not as simple as we had previously imagined. Once the strait jackets of a particular theoretical orientation or a single method are removed, and once cultural and individual differences are fully acknowledged, most of the older guideposts disappear, and therapists today are faced with the daunting task of apprehending each client’s resources and needs within the full richness and complexity of his or her own unique world. The primary mission of this series is to provide new, diverse, and more up-to-date guideposts for clinical practice. This mission is based on the belief that music therapy students and professionals have an ethical responsibility to be knowledgeable of all approaches to clinical practice that have been found effective for clients within different contexts. The implications are threefold. First, this series advances the notion that no potentially effective practice should be excluded from the study of music therapy for reasons of personal, organizational, or institutional bias. Gone are the days that music therapists can assert that only their own approaches belong within the definitional boundaries of music therapy. Gone are the days when music therapists can assert that music therapy is only improvisational, or that music therapy is only behavioral, or that improvisational or behavioral approaches can be used with every clientele in all contexts. This narrowmindedness is no longer acceptable. Music therapy is not just what you do, or just what I do—it is what we all do within the boundaries of ethical practice—and within the context of a discipline that also includes theory and research. Moreover, ethical practice can no longer exclude what others do with significant clinical effect. Second, this series underlines the premise that music therapy is first and foremost a discipline of practice. As such, the practice of music therapy cannot be based solely on theory and research, it must also be informed by what practitioners have learned over the years about what works and what does not work in actual clinical settings. Very often these clinical details and anecdotes cannot be subjected to the rigors of research, yet they have significant practical value. Thus, notwithstanding the contributions of

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theory and research, clinical practice must be based on the accumulated insights of practitioners who have the experience, expertise, and ethical values needed to serve as our models. In short, music therapy is not merely evidence based or theoretically informed, it is even more essentially clinically based. Third, this series reinforces the notion that like in other scholarly health care disciplines, music therapists must begin to write about their own clinical work within the context of what others have done in the same area of practice. In the early days, music therapists developed their own ways of working with a particular clientele or method independently of one another, and without the benefit of a world-wide communication network—there were no journals, books, or websites that could provide the wealth of practical information available today. This had a rather bizarre outcome that to some extent still continues today. Not being aware of what had already been done in the field, music therapists often considered and presented themselves as pioneers—touting that their own particular method of working as if it were entirely new—when in fact other music therapists had already been doing the same thing for quite some time. This sometimes made attending a conference a deja-vu experience, where it seemed as if we were proudly re-inventing the wheel and then giving the wheel our own new brand. Mary from Podunk would give a presentation announcing that she had discovered how to use the cello in therapy, when unknown to her, Juliette Alvin had already been doing it for years. Then to further complicate the matter, therapists in Podunk would call it Mary’s method, and people in England would call it Alvin’s method, even if the methods were practically identical. Of course, this was not the case for the many true pioneers of music therapy who actually invented or created a specific approach or model. But the problem remains: how can one distinguish between ignorant vanity and a truly new contribution to the field? Today there is no excuse for not knowing what others have done, and even less justification for not being interested. All we have to do is a computer search of the rapidly developing literature, and we can find others who are working in the same area of practice. And then our responsibility is quite simple: we have to contextualize what we have discovered about clinical practice in terms of the current state of knowledge in the field. Just like researchers who are expected to review the literature on their research question, modern practitioners are expected to know what they are doing within the context of their discipline. The specific objectives of the series is to provide practical guidelines for implementing receptive, improvisational, re-creative, and compositional methods of music therapy with major client populations, supported by a comprehensive and critical review of existing literature. These methods are thoroughly defined and discussed in every chapter of the series. The major client populations were identified and categorized by diagnosis and age. As a result, four main areas of practice were identified: developmental health, mental health, pediatric care, and adult medical care. Primary diagnosis was used to distinguish between populations with mental health versus medical needs, and age was used to distinguish between the needs of children, adolescents, and adults. Authors were carefully selected according to two criteria. First, they had to have extensive clinical experience in the area of practice about which they were writing; and second, they had to acknowledge and recognize significant clinical work done by others in the same area. Their charge then was not to merely write about what they did and believed, but to present a comprehensive picture of a particular area of practice to which they themselves had contributed significantly. Obviously, some areas of practice are more developed than others and in some instances the authors could only rely upon their own experiences. Music therapy is practiced in so many areas that this unevenness in development is to be expected for some time, and also is bound to be evident in the present series. Given the aims and issues addressed so far in this Preface, it should come as no surprise that unlike many edited books in music therapy that support the “pioneer” syndrome, every chapter in every volume of this series follows the same outline. Authors were not free to determine what would and would not be covered in their respective chapters. A uniform outline was fashioned to ensure not only that the same basic topics would be addressed for each area of practice, but also to ensure that all relevant literature on each area was included. The basic outline is as follows:

Preface

Diagnostic Information Needs and Resources Assessment and Referral Multi-cultural Issues Overview of Music Therapy Methods Guidelines for Receptive Music Therapy a. Method A: i. Overview: Definition, indications, goals, contraindications ii. Preparation of Session and Environment iii. What to Observe iv. Procedures for Conducting Session v. Possible Adaptations b. Method B: c. Etc.. 7) Guidelines for Improvisational Music Therapy 8) Guidelines for Re-creative Music Therapy 9) Guidelines for Compositional Music Therapy 10) Working with Caregivers 11) Research Evidence a. Receptive Music Therapy b. Improvisational Music Therapy c. Compositional Music Therapy d. Re-creative Music Therapy 12) Summary and Conclusions 13) References 14) Resources (Optional)

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1) 2) 3) 4) 5) 6)

One of the consequences of following the same outline is that there are bound to be repetitions in the information presented. The editors and authors have done their best to reduce unnecessary redundancies, while recognizing that some redundancies are important to keep. For example, many redundancies between chapters were left because each chapter will be made available separately in electronic formats, apart from the other chapters. Thus, each chapter had to be a complete presentation in itself, without requiring the reader to consult another chapter that the reader may not have. Redundancies within chapters are another matter. These kinds of repetitions can be quite revealing. Several clinical questions are pertinent. For example, why is it that with a particular population, contraindications or “what to observe” are the same across certain methods but not others, or why are they the same for one population but not others? In some cases, a redundancy can reveal something about the population—that regardless of method, there are certain fundamental considerations that must be made when working with them. In other cases, a redundancy can reveal something about methods and how, though very different, may make the same demands on the client. And lastly, some redundancies can reveal blind-spots in the practitioner, that is when the music therapist can only see certain aspects of the client or clinical situation, regardless of the many complexities or variations present. For this reason, readers are urged to interrogate each redundancy. What does it reveal about the client, method, or therapist? Another consequence of following the same outline is the opposite problem—disagreements. The authors in these four volumes were sometimes definite about using specific terminology and definitions

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for music therapy phenomena, even if doing so created disagreements and inconsistencies with other authors or the editors. Sometimes there was good reason, other times there was not. Sometimes it was the “Mary-Podunk” problem of wanting to name and thereby own a particular method or procedure that the author believed that she or he developed; other times it reflected deep theoretical divisions in the field itself; and other times it merely revealed aspects of music therapy that still need further conceptual clarity. It is important to be aware of these disagreements and inconsistencies, not only to better comprehend what the authors have written, but also to understand the theoretical and practical issues confronting present-day music therapy. Three important differences of opinion became obvious in the planning, writing, and editing of these four volumes—differences that could not always be resolved within the context of the editorial process. First, there are inconsistencies in how basic terms such as model, approach, method, protocol, procedure, and technique are used and defined. What one calls a model, others call an approach, and what one calls method, others call a technique. In this series, the basic premise was that there are four main “methods” of music therapy: listening (or receptive) experiences, improvisational experiences, recreative experiences, and compositional experiences, each with their own set of procedural variations. This premise was not shared by all authors. Second, there are disagreements in how to differentiate these methods. When does improvising become listening, and when does composing a song become improvising? Isn’t listening a part of all musical activity, and doesn’t listening require activity? So then why and how do we differentiate between receptive and active? An even more important dilemma for music therapy is: Should a method be defined by what the client “experiences” or by what the therapist “does?” If the therapist improvises for the client, is the method improvisational or receptive? Again this dilemma remains unresolved in these volumes. Finally, there are considerable controversies over what practices a particular “model” (or method, or approach) does and does not include. For example, there is substantive confusion over what practices are legitimately considered part of the “Bonny Method of Guided Imagery and Music (BMGIM),” and which are not, and whether this “method” should be called BMGIM or simply “Guided Imagery and Music” (GIM). Then there is the onslaught of terms for the various “whatevers” that also involve music and imagery. Can anyone explain the procedural differences between the terms “Guided Imagery”, “Directed Music Imagery,” “Music and Imagery,” “Music-imaging,” and “Music-assisted imagery?” And do these names actually reflect those procedural differences? This is an example of an area of practice that begs for greater conceptual clarity. These are not idle or “so what?” questions. How can we communicate about practice if we ignore differences between a model and a method, and if we invent idiosyncratic names for every method and technique? How can we train music therapists in the “discipline” of music therapy if there is no shared vocabulary or common language? How can we develop sensible “protocols” of practice to test through research if we do not understand the basic properties of the music experience that we hope to study, and if we are unclear in specifying what the client experiences and what the therapist does? And, how can we ever imagine an organized body of theory if practitioners and researchers do not use language intentionally and consistently? It is hoped that this first attempt to present procedural, populational guidelines for practice will highlight the myriad implications of how we talk and write about music therapy. We need to be more aware of our discourses, not only from a philosophical or theoretical perspective (as in feminist and sociocultural streams of thought), but also from a practical point of view. Hopefully, the language problems encountered in this series will lead to a discourse analysis that will spawn more serious efforts to clarify and unify our diverse vocabularies about practice. One final issue needs to be addressed. This series was envisioned as a teaching tool. Its purpose is to inform students as well as professionals about areas of practice that may not have been studied or

Preface

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experienced previously. The hidden yet obvious assumption is that the way to learn how to practice music therapy is by studying it in reference to each client population rather than by method. This relates directly to the redundancy problem. If the reader scans across “receptive” methods used across different client populations, many redundancies will be found, and the same kinds of repetitions will be found in recreative, improvisational, and compositional methods. This poses an important pedagogical question: Would it be more economical and effective to first learn how to design music experiences (or use different methods of music therapy), and then learn how to implement or adapt them for different clients? Or is it more economical and effective to first learn about the characteristics and needs of each population, and then learn to design methods within that specific context? Put another way, is it easier and more effective to generalize or extrapolate from method to clients or from clients to method? Should we be training specialists in working with each population, or generalists who master the methods of music therapy? The vote is still out on this because unfortunately these pedagogical issues have not been recognized or discussed widely in the field. Notwithstanding the decided emphasis given to clinical practice in this series, theory and research are still very much needed in music therapy—and in music therapy education as well. It is hoped that these volumes will stimulate the field to address the myriad research questions and theoretical issues raised by an organized and comprehensive presentation of what we know in practice. Further, it is hoped that this presentation will soon become outdated, and that revised, new, and increasingly more effective methods of practice will be conceived and tested.

Chapter 1

Introduction Lillian Eyre

AIMS Music therapy literature has increased prolifically in the last 20 years, growing from a few texts and articles to many clinical and theoretical texts, books, and functional skills guides, all supported by research literature. As a whole, this literature provides much needed information on the majority of populations with whom music therapists work. As an educator, however, it has been a personal concern that this literature does not completely meet the needs of the average undergraduate student, intern, or clinician who is searching for clear guidance on how music can meet the various needs of a particular group of clients so that they can design, implement, and evaluate appropriate music therapy experiences for them. This volume aims to provide this information. Based on current research, books, articles, and clinical practice, each population-focused chapter provides guidelines for receptive, improvisational, recreative, and compositional music therapy practices with a wide range of clients who have mental health issues.

MENTAL HEALTH PRACTICES REPRESENTED IN THIS VOLUME Mental health encompasses a wide spectrum of therapeutic practice and includes children, adolescents, and adults of all ages. In this volume, mental health is viewed as salutogenic—meaning that health “exists in the presence of (and in spite of) ongoing health threats or life stressors” (Bruscia, 1998a, p. 81). In the salutogenic orientation, mental health is relative and can be imagined as existing on a continuum. Every individual experiences various degrees of mental health at various times in life, and thus wellness and spirituality coexist on the spectrum of mental health with serious mental illness (SMI). In fact, the broad goal of therapeutic practice in mental health is to help persons access their sources of wellness and their internal resources to bring strength and balance to their lives in spite of mental health problems. This book aims to be as comprehensive as possible with regard to recognizing music therapy practices that are currently being utilized to address a wide variety of mental health issues. Attempting to delineate chapters that would address all the mental health needs of persons of all ages has been a challenge that is, by nature, destined to be incomplete and in constant evolution. There were a number of considerations in choosing the topics and client groups that were assigned in these individual chapters. First, some client populations have not been included simply because there has been nothing substantial written on music therapy procedures or research with them. Some of these regrettable omissions include veterans with Post-traumatic Stress Disorder (PTSD); persons with PTSD due to accident or violence; personality disorders such as Obsessive Compulsive Disorder, Antisocial Personality Disorder, and Narcissistic Personality Disorder; children, adolescents, and adults with bipolar disorder; persons who are homeless; couples and families; and persons belonging to groups struggling with stigma and identity

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issues associated with sexual orientation, economic hardship, or a criminal record. It is gratifying, however, to discover that there are many groups of persons that are being treated by music therapy. Another consideration in the assignment of chapters occurred with regard to medical issues. While music therapists often deal with mental health issues when working with persons with chronic or life-threatening disease, this aspect of mental health is addressed in the medical volume, the rationale being that the etiology or exacerbation of the mental health issues are based on the client’s physical condition. In the same manner, mental health issues occurring in hospice care and bereavement are considered to be an aspect of the Adult or Pediatric Medical Care volume. Work with children posed another challenge. Because children are in a process of development, neuroplasticity is in constant evolvement in childhood; therefore, any mental health problem might be perceived as a developmental issue. Here, the delineation for developmental vs. mental health issues was based on the Diagnostic and Statistical Manual (DSM) [American Psychiatric Association (APA), 2000], which provided a guide to psychiatric issues in mental health as opposed to developmental issues related to processing and learning. Thus, issues of psychological functioning or problematic behavior resulting from affective and/or environmental difficulties with children and adolescents is the subject of the Mental Health volume, while issues related to organic problems, sensory integration, and learning aspects of cognition are covered in the Developmental Health volume. Chapters included in this volume were chosen based on the following criteria: (1) categories of psychiatric issues of children, adolescents, and adults defined by the DSM (APA, 2000); (2) availability of music therapy research literature and clinicians working with these client groups; (3) particular settings in which music therapists work; and (4) identification of clinicians/researchers working on a continuum of mental health issues with client groups not listed in the DSM (APA, 2000). Chapters that are based on DSM diagnostic categories include clients with schizophrenia, PTSD, depression and anxiety, dementias, eating disorders, borderline personality disorder, substance use disorders, and juvenile sex offenders. Chapters that focus on particular settings include inpatient psychiatry, psychiatry in the recovery model, foster care children and adolescents, survivors of catastrophic event trauma, correctional and forensic facilities, and adjudicated adolescents. Individual clients in these groups may or may not have diagnoses identified in the DSM (APA, 2000). The fourth criterion for inclusion for this volume includes clients with mental health issues not included in the DSM (APA, 2000). While the DSM provides diagnoses of major mental health disorders based on “patterns of symptoms that tend to cluster together” (APA, 2012, para. 3), some mental health problems or diagnoses are not included in the DSM because there is “not sufficient data to justify [their] inclusion” (APA, 2012, para. 5). The lack of inclusion of a disorder, however, “does not necessarily mean that it is not worthy of being a focus of research or treatment” (APA, 2012, para. 5). One of the categories not included in the DSM is developmental trauma, which has been distinguished from PTSD. Although a group of researchers and clinicians led by van der Kolk et al. (2009) attempted to have developmental trauma included as a diagnosis in the DSM-5, the editorial board decided not to include it, although “PTSD will also be more developmentally sensitive for children and adolescents” (Grohol, 2012, Posttraumatic stress disorder, para. 1). Chapters in this volume, however, address developmental trauma as experienced by adult men and women and by children who are survivors of abuse and neglect. Another mental health issue that does not appear in the DSM but has a chapter in this volume is professional burnout. This problem is one that affects many persons in the caring professions, music therapists not excluded. Musicians, as well, have unique problems related to their profession, and music can be a therapeutic resource even while aspects of being a professional musician can be a source of physical or emotional pain; thus, a chapter on musicians is included. In the spectrum of wellness, the everyday occurrence of stress and concerns about dealing with the effects of negative stress overload is an issue that affects everyone and in particular caregivers; thus, this chapter is included. Finally, while it is difficult to define spirituality, it is nevertheless a common experience that music can open the person to

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the aesthetic or spiritual realm through expanded or altered states of consciousness. Thus, music and spirituality is also included as a chapter, as it is an important aspect along the continuum of mental health.

DEFINITION OF MUSIC THERAPY IN MENTAL HEALTH PRACTICE The wide range of populations treated in this volume calls for an explanation of how music therapy is defined in mental health. Bruscia’s (1998a) definition of music therapy is certainly applicable to all the chapters included in this volume: “Music therapy is a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change” (p. 20). More specifically, though, mental health is primarily concerned with how one perceives oneself, the world, and one’s relationships with oneself and others. For the purpose of this volume, mental health is signified by the health of one’s intrapersonal and interpersonal relationships (Bruscia, 1987, p. 19) as subjectively experienced by the individual. These relationships provide the basis for one’s experience of wholeness and connection to others, which, in turn, rely upon one’s ability to grow continually toward one’s potential, however the individual may define this potential. The various ways that music can be used in a therapeutic relationship to achieve these goals is applied to all aspects of personal growth. Thus, music therapy in mental health is the systematic use of music in a therapeutic relationship that encompasses a wide range of intrapersonal and interpersonal needs related to personal growth in order to facilitate the development of individual and group potential and to improve one’s quality of life.

A BRIEF HISTORY OF MENTAL HEALTH PRACTICE It is common knowledge among music therapists that treatment for mental health issues has played a pivotal role in the history of the development of modern music therapy practice as a whole. Music was used in the early 20th century to soothe, to positively alter one’s mood, and to normalize the hospital environment for patients whose medical needs “could be addressed only marginally by typical hospital care” (Davis, Gfeller, & Thaut, 2008, p. 27). Anecdotal observations of the power of music increased with the return of World War (WW) I and II veterans (Taylor, 1981, as cited in Davis et al., 2008, p. 27). Based on the significant success of music with WWI veterans suffering from psychological conditions, most probably related to PTSD, a number of musician-healers attempted to establish music therapy as a profession throughout the early 20th century in hospitals and, later, in prisons (Davis et al., 2008). Despite the persistent efforts of these pioneers in both clinical treatment and education, music therapy nevertheless was not accepted as a profession during the early 20th century (Davis et al., 2008). By the fourth decade of the 20th century, however, music therapy was beginning to become more accepted by the medical community. For example, based on surgical procedures, Esther Gatewood and, later, Ira Altshuler developed a method of using music to match the patient’s mood that would later become known as the Iso principle (Taylor, 1981, as cited in Davis et al., 2008). Then, in 1938, Altshuler instituted a program that combined psychotherapy and music therapy methods for groups of persons with mental illness in a large urban hospital (Davis, 2003). In 1944, Van de Wall was appointed to oversee the progress of music therapy programs in psychiatric hospitals and, in this capacity, was a key figure in the development of music therapy in mental health institutions (Davis et al., 2008), thus preparing the ground for music therapy as a profession. Also in the 1940s, E. Thayer Gaston began to champion music therapy as a profession. As the chair of music education at the University of Kansas, he was keenly aware of the unique opportunities afforded by music in the area of education and child development. His vision also included mental health. With the influential Menninger Clinic, one of the nation’s leading psychiatric

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inpatient hospitals, he established the first internship training site in the United States and, later, at the University of Kansas, the first graduate music therapy program (Davis et al., 2008). All this suggests that the use of music to treat issues related to mental health was at the vanguard of the development of music therapy as a modern profession. After the return of veterans from WWII, music became notable for its ability to motivate depressed patients and to support their physical and psychological rehabilitation (Wilson, 1990). Modern music therapy was still in the infancy of its development during this period, and the concept of music as a therapeutic medium was naturally based on the social or recreational experience of music—one either listened to music or learned to play an instrument (or voice), with the ultimate goal of being able to perform. As a result, music therapy procedures at this time most commonly consisted of individual instrumental or vocal instruction and individual or group performance (Crowe, 2007). The therapeutic value of group singing was also exploited to foster a sense of belonging for the most isolated patients (Tyson, 1981). By the mid-1950s, new tranquilizing medications provided relief to many psychiatric patients, allowing them to return to their homes (Tyson, 1981). With ever-growing numbers of persons with mental health issues living in the community and expressing a need for an improved quality of life, long-term therapy aimed at addressing the psychological needs of these patients began to be practiced outside of the hospital. These changes in mental health treatment in the era of the 1960s and 1970s heralded the beginning of the development of a music therapy depth-psychology approach to psychiatry and mental health. Beginning in 1962, Tyson instituted her community music therapy clinic, where she developed a practice that was informed by concepts from psychoanalysis and gestalt therapy in addition to cognitive behavioral techniques (Bandini, 2004). Sadly, this clinic closed in 1995 after more than three decades of service to persons with mental health needs when it could no longer raise sufficient funds to remain open (Saxon, 2001), although the Florence Tyson Fund to support music therapy for mental health needs in the community exists to this day. The 1970s saw the culmination of the previous two decades of developments in music therapy practice and education in the emergence of two music therapy models that have continued to flourish to the present. In England in the 1970s, Mary Priestley, along with Marjorie Wardle and Peter Wright, developed Analytical Music Therapy (AMT) (Priestley, 1994). Based on Freudian analytical concepts of conflicts, drives, and transference and countertransference, as well as the therapeutic significance of symbols and images, Priestley advanced the method of improvisation as a means of exploring the unconscious (Priestley, 1994). Priestley’s model was an outgrowth of her work in a psychiatric hospital, and in her private practice she treated clients with a range of mental health issues from schizophrenia and depression to couple therapy and personal growth. Coincidentally in the USA at the same time, Helen Bonny developed the Bonny Method for Guided Imagery and Music (BMGIM), a receptive music-listening method with a focus on the exploration of the psyche in an altered or expanded state of consciousness (Pickett, 2002). The origin of BMGIM is in stark contrast to that of AMT, as the BMGIM procedure initially grew out of research experiments with mystical experiences while under the influence of Lysergic Acid Diethylamide (LSD) and was carried out with persons who were healthy, functioning adults (Clark, 2004). Bonny built upon the therapeutic potential of this method and her followers adapted the method to treat persons with good ego structure for a variety of mental health, growth, and spiritual needs. Thus, the first few decades of modern music therapy theory and practice contained the burgeoning seeds of the various psychological and methodological approaches on which contemporary music therapy theory, practice, and research are based. Currently, music therapists continue to provide services for persons who have a wide range of mental health and wellness needs, as evidenced by the populations represented in the chapters in this volume. Approximately 18% of music therapists in the USA work in the field of mental health in a variety

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of settings, including hospitals, diagnosis-specific treatment centers, community services, and private practice (American Music Therapy Association [AMTA], 2012}. As mental health needs and services continue to grow, so too does the profession of music therapy, and clinicians and researchers continue to be motivated to discover new and creative ways of using music to bring healing and solace to persons in need.

ROLE AND SIGNIFICANCE OF MUSIC THERAPY IN MENTAL HEALTH Music has an ability to evoke images, associations, and feelings; it is engaging and motivates people to connect to others; it offers a medium of nonverbal communication that transcends words, transporting people to a common, shared field of experience. These unique qualities render it an efficient and distinctive therapeutic approach that can be successful even with clients who are resistant or unresponsive to other therapies. For example, it is common for a music therapist working with an inpatient psychiatric group to notice that at the beginning of the session, a number of clients are isolated from each other, withdrawn, depressed, paranoid, or manic and intrusive, but that by the end of the session, the same clients are in a better mood and more connected, collaborative, and engaged. Similar experiences occur with other populations as well. Elderly persons who are withdrawn or lost to dementia come alive and remember language and connect to their emotions and to each other when singing; even adolescents or children with behavioral problems may find themselves cooperating with each other when given the opportunity to make sounds on a drum. Music, in the hands of a skilled, trained, and intuitive music therapist, has this strength. One of the most illuminating aspects of music therapy is music’s ability to put people in touch with their internal positive resources. Music helps clients who are stuck in a negative space to shift it and to find the source of healing that exists within. The communal nature of music allows clients to share the personal benefits of accessing the positive, resourceful aspects of themselves as they collaborate together, whether this is in a dyadic relationship with the therapist or with peers in a group. Such collaboration addresses the intrapersonal and interpersonal needs that are necessary to achieve therapeutic gains in mental health. The nonverbal nature of music, its rhythmic movement in time, and the fact that it opens people up to the language of feeling and emotions renders it an organizing force that breaks through the barriers of confusion and circular, stuck, or obsessive thoughts, bringing us to a place where new ideas and feelings can challenge destructive thoughts and feelings. Yet this is all accomplished with little resistance or conscious thought, thus empowering individuals to experience the natural healing capacities that each of us possesses, but with which we can all so easily lose contact. Because mental health issues are often accompanied by stigma and guilt, this experience of empowerment can provide a strong internal representation of one’s potential that lasts far beyond the confines of the music therapy session. When working at a deeper or unconscious level, the capacity of music to evoke images, memories, and associations can be of inestimable value in making meaning of one’s life, bringing past trauma into the present where it can be given voice and worked through, and providing solace and healing. Music can also be combined with other mediums such as drawing, sculpting, drama, movement, and writing to appeal to clients’ various talents and abilities and bypass conscious and unconscious resistance. In a similar manner, music can be structured to the extent that clients need it. Clients who function at a concrete level and those who are psychotic can engage in music therapy just as easily as someone who is high-functioning and doing depth psychology with unconscious processes. A cursory glance at the chapters in this volume reveal innumerable goals connected to specific populations, particular needs, and the various methods of music therapy used to meet these goals and needs. These include, to name a few, behavioral goals, e.g., to improve social skills by greeting someone or

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responding musically appropriately; cognitive goals with a self-perception perspective, e.g., improving one’s sense of self by recognizing and stating one’s contribution to the group or accessing one’s resources; cognitive goals with a functional perspective, e.g., helping to recall words or memories and identify objects; affective goals, e.g., improving one’s mood through receptive listening, movement, expression, and/or musical interaction with others; psychodynamic goals, e.g., gaining insight about one’s feelings or behaviors; and spiritual goals, e.g., expanding one’s awareness or getting in touch with one’s sense of wholeness or connectedness to others. The applications of music therapy in mental health are wide and meet an infinite number of clients’ needs. Ultimately, music therapy is of inestimable value in mental health treatment. It addresses the creative process within oneself, allows us to transform difficult feelings into positive expression, and helps us to connect to others, shifting us from places in which there seems to be no egress toward the light of which we have lost sight.

APPROACHES TO MUSIC THERAPY Music therapists in mental health use a number of approaches, the most common being behavioral, cognitive, humanistic, and psychodynamic. These theoretical constructs were developed in verbal therapy and became integrated into verbal and nonverbal music therapy processes. The methods outlined in the various chapters in this volume attest to the fact that individual therapists use different theoretical approaches at different levels of intervention based on the client’s manifested needs. Other determinants of the approach that therapists use include the setting, whether the therapy is individual or group work, the homogeneity or heterogeneity of groups, the amount of time that that clients will spend in therapy, and, where applicable, the client’s expressed goals. For example, procedures used in these chapters for clients who come for therapy to deal with professional burnout or stress relief are based on cognitive, behavioral, or humanistic approaches; a psychodynamic approach would be contraindicated because the client is seeking a solution to the immediate problem. Therefore, the therapeutic approach must be centered on the here-and-now conscious awareness of the client. On the other hand, a psychodynamic approach is found in some procedures in these chapters that address work with clients with trauma or therapy with a goal of uncovering disruptive relational patterns based on transference issues. The psychodynamic approach is also used with some methods for individuals with eating disorders, substance use problems, or personality disorders. In other instances, a psychodynamic approach with the same client group might be contraindicated based on the therapist’s training limitations, the behavioral health mission of the institutional setting, the length of stay, the fact that all work is done in groups with a problem-oriented or symptom-specific focus, or because of the vulnerability of the client. The authors in this volume used approaches that were appropriate to the particular intervention, the goals, and the client group. The concept of the “eclectic” approach—the use of multiple approaches—that is presented in this volume bears further exploration. Consider, for example, the fact that clients who have functional cognitive difficulties can often benefit from cognitive remediation. The cognitive approach in this volume will be found, for example, in descriptions of music therapy procedures used with persons with dementia or with those persons whose mental illness makes it difficult for them to be oriented to reality. There are also examples in this volume of therapists who use a cognitive approach when working with persons who exhibit thought distortions or poor self-esteem. Yet, examples can also be found where the cognitive approach is integrated with a behavioral approach. For example, adolescents and children often need a cognitive-behavioral orientation. Good boundaries are necessary to establish a feeling of safety, so behavioral rules are often established in working with these groups, but the therapeutic focus may be on

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understanding or learning about oneself or practicing good social interactions, s0 a cognitive approach is also used. Therapists also often adopt a humanistic stance along with a cognitive and/or behavioral orientation. Humanism implies authenticity, respect, and belief that given the proper environment, clients will evolve toward their potential. In working with the same group of adolescents or children, for example, a therapist might focus on helping them to express themselves appropriately on instruments, while at the same time behaviorally reminding them of group rules and responding to them in an authentic, humanistic relationship. Psychodynamic approaches are indicated in this volume only in longterm settings and most often with individual clients, such as when working with musicians. In all cases of psychodynamic work, clients must have a good ego structure. Psychodynamic approaches are also most often practiced in a Guided Imagery and Music (GIM), Analytical Music Therapy (AMT), or vocal psychotherapy model.

METHODS OF MUSIC THERAPY Given the wide variety of clients engaged in music therapy, it is not surprising that all the major methods of music therapy have been developed in clinical practice for the populations addressed in each of the chapters in this volume. Each music method has unique characteristics, has a different process of engagement, and makes particular demands on or requires different skills of the client (Bruscia, 1998a, p. 113). Thus, the therapist’s choice and use of a particular method is connected to the client’s abilities and preferences as well as to specific therapeutic goals. With regard to the abilities needed by the client to work productively in the method, receptive experiences, for example, require that the client be able to hear and take in the music, process it, and respond to it in a therapeutic way (Bruscia, 1998a, p. 121). Receptive experiences were used in this volume for a wide range of client needs, such as to evoke imagery, to stimulate sharing and discussion, to facilitate engagement, to foster movement, to support artistic creation, or to encourage a relaxation response. Receptive methods are used when listening to and discussing songs or while listening to instrumental music in conjunction with other media such as art, writing, and movement. Definitions of each method are provided for the authors to ensure clarity and consistency. The guidelines for receptive music therapy are as follows: The therapist engages the client in any kind of listening experience. The experience may focus on physical, emotional, intellectual, aesthetic, or spiritual aspects of the music, and the client may respond through activities such as relaxation or meditation, action sequences, structured or free movement, perceptual tasks, free association, storytelling, drawing or painting, dramatizing, reminiscing, imaging, etc. The music used for such experiences may be live or recorded improvisations, performances or compositions by the client or therapist, or commercial recordings of music literature in various styles (e.g., classical, popular, rock, jazz, country, spiritual, New Age, etc.) (Bruscia, 2011, pp. 5–6). Improvisation experiences make different demands of clients, thus meeting different needs. In order to improvise, the client must be connected to his impulses and able to express them while having some measure of control and organizational skills. In improvising with others, the client also needs to be aware to some extent of the other player’s contribution, and this, in itself, is often the therapeutic goal. Improvisation experiences are used in groups to facilitate cohesion, social skills, self-expression, and communication with short-term clients and for those with weaker ego structure, but it is also used with

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individuals with a stronger ego structure and in groups in long-term settings to uncover thoughts and feelings and to facilitate insight. Guidelines for the improvisational method are defined as follows: In improvisational therapy, the client “makes up” music while playing or singing, extemporaneously creating a melody, rhythm, song, or instrumental piece. The client may improvise a “solo” or participate in a duet, trio, or ensemble that also includes the therapist, relatives, or other clients. The client may use his/her voice or any musical instrument of choice within his/her capability (e.g., drums, cymbal, xylophone, autoharp, melodica, piano). The therapist helps the client to improvise by creating an ongoing musical accompaniment that stimulates or guides the client’s sound productions; presenting the client with a musical theme or structure upon which to base the improvisation (e.g., a rhythm, melody, scale, form); or presenting a nonmusical idea to express through the improvisation (e.g., an image, feeling, story, movement, dramatic situation) (Bruscia, 2011, p. 6). It is notable that re-creative experiences, usually in the form of sing-alongs, are the most widely used with both individuals and groups in all the chapters in this volume. Everyone has experience in listening to songs, and most people have meaningful associations to songs. Re-creative experiences such as singing songs demand that the client be oriented to reality and that he possess a modicum of selforganization. Singing together provides a way that clients of diverse functioning levels can have a unified experience, thus facilitating group cohesion. Song-singing is often used as a way to stimulate lyric discussions or to lead into other methods such as song composition, song improvisation, and chanting. Playing music together or re-creating rhythms also provides cognitive stimulation and is particularly helpful in working in groups that are both homogeneous and heterogeneous. Re-creative experiences are depicted as follows: The therapist engages the client in vocal or instrumental tasks that involve reproducing music in some way. This may include learning how to use the voice or produce sounds on an instrument, imitating melodies or rhythms, learning to sing by rote, learning to use musical notation, participating in a sing-along, rehearsing, taking music lessons, performing a song or instrumental piece from memory, working out the musical interpretation of a composition, performing in a musical show or drama, etc. (Bruscia, 2011, p. 6). Finally, compositional experiences are well represented, predominantly in the form of a variety of structured methods for writing songs. Song composition demands different levels of cognitive functioning based on the difficulty of the intervention, the least demanding being the highly structured fill-in-theblank format and the most demanding being writing a newly composed song with little predetermined structure. Compositional experiences require that the client have good cognitive functioning and be able to access his creative abilities in order to organize, plan, integrate, and synthesize parts into a whole (Bruscia, 1998a, p. 120). Words and/or music can be used to create song and/or instrumental compositions, and a wide variety of music genres can be employed to appeal to clients of different cultures, ages, and demographics, rendering it a versatile method. In addition, choosing a group of songs to reflect a theme or using technology to create music or a video is also considered a compositional method. Compositional methods are defined as follows:

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The therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually, the therapist simplifies the process by engaging the client in the easier aspects of composing (e.g., generating a melody or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation) (Bruscia, 2011, p. 7).

PSYCHOTHERAPEUTIC LEVELS OF PRACTICE The variety of clients, settings, and goals requires that music therapists implement different kinds of therapeutic processes, some of which are short-term (e.g., a single session) and some of which are longterm (e.g., a year). As such, they engage clients in different levels of experience to meet the clients’ therapeutic needs. Throughout this volume, authors have indicated which level or levels of practice they use with each method. A level of practice “describes the breadth, depth, and significance of therapeutic intervention and change accomplished through music and music therapy” (Bruscia, 1998a, pp. 162–163). Very often, authors indicate that a method can be practiced at two or even three levels. This means that the method itself is flexible and the depth of therapy—or level—is dependent upon the situation in which the method is practiced. Factors that play a role in the choice of the level of practice are first and foremost the setting, the mission of the institution where the client is being treated, whether the therapy is in individual or group format, the client diagnosis, and the length of stay. Other factors might include whether or not the therapist has specialized training in a certain method and the client’s expectations for therapeutic outcome. The chapters in this volume address three levels of therapy that have a particular profile in psychotherapeutic or mental health practice. These are: augmentative, intensive, and primary. At the augmentative level of practice, the client–therapist relationship is important in facilitating music experiences and “enhancing their therapeutic value” (Bruscia, 2012, August, p. 1). However, the client– therapist relationship often “does not develop the depth needed for it to serve as the primary vehicle or context for psychological change” (Bruscia, 2012, August, p. 1). Thus, the music experience is of primordial importance at the augmentative level. The therapeutic focus at the augmentative level is to help the client to discover and use available resources to recover or adapt to his situation or condition (Bruscia, 2012, August, p. 1). Goals at the augmentative level are to help the client to re-establish his “psychological equilibrium, build ego strength, reduce the impact of negative psychological events, and strengthen psychological defenses and coping mechanisms” (Bruscia, 2012, August, p. 1). The augmentative level of therapy is the one that is most often used in the methods described by music therapists in these chapters. It is particularly suitable for acute psychiatry or long-term recovery for psychiatric or forensic clients, or as a preparation for intensive therapy (Bruscia, 2012, August, p. 1). An example of this level would be a method in which clients imitate the therapist’s or each other’s rhythms to improve reality orientation and communication. At the intensive level of therapy, both the music experience and the client–therapist relationship are of “equal significance in accessing, working through, and resolving problems” (Bruscia, 2012, August, p. 1). Because the relationship and the music share therapeutic value, verbal processes take on greater importance at the intensive level. Awareness and insight that the client gains through verbal communication are important elements, as well as the examination and resolution of client resistance to therapy (Bruscia, 2012, August, p. 1). The therapeutic focus at the intensive level is to help the client to expand his internal resources and to find new ways to solve problems. These new skills help the client to find greater meaning in life (Bruscia, 2012, August, p. 1). Another important element in the intensive level of therapy is that it often uncovers and works through “unconscious conflicts underlying chronic or

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debilitating life problems” (Bruscia, 2012, August, p. 1). While this level of therapy is most often used with nonpsychotic individuals, in situations where a psychotic client is seen individually for a length of time that allows a trusting therapist–client relationship to be established, the intensive level of therapy may also be appropriate. Therapeutic goals at this level of therapy include gaining insights into the effects of one’s unconscious processes, self-expression, adaptation to change, and the healthy use of defenses. An example is improvising with the client to evoke imagery or to uncover patterns of relationships with others. At the primary level of therapy, the client–therapist and music experiences are again equally significant, but the therapeutic intent is to “help the client work through all defenses, resistances, and transferences” (Bruscia, 2012, August, p. 2). This level requires that therapist and client work to “uncover and work through unconscious material at the depth and breadth necessary to make pervasive changes in the personality” (Bruscia, 2012, August, p. 2). In this depth work, the client and therapist would not only work through the client’s unconscious conflicts originating in “every previous stage of development,” but also simultaneously work to “integrate unconscious material into conscious life,” thereby “building new approaches to psychological adaptation” (Bruscia, 2012, August, p. 2). It is clear from this description that only persons with strong ego strength, internal motivation, and time to invest in long-term therapy would be appropriate to work at this level of therapy. While there may be some exceptions, such therapy would also most often occur in individual sessions. An example would be a client–therapist improvisation in which there are assigned roles of self and mother while the client re-experiences feelings related to a particular conflictual situation or memory. In this volume, authors who work with clients who have a strong ego structure and who have the option of long-term therapy use the primary level of therapy in some methods. Examples of this are developmental trauma experienced by women and men, clients with depression, and musicians. The chapter on persons with schizophrenia also presents some methods that can be used with this population at the primary level, but this assumes that the client would be stable, nonpsychotic, and in individual long-term treatment. The primary level of therapy is also most often practiced in the context of a music therapy model or adaptation of a model such as GIM, AMT, or vocal psychotherapy.

THEORY AND RESEARCH It is edifying to note that with each passing year, more and more research and clinical studies appear in the literature. There are three print journals in the USA alone that publish regularly in addition to one each in Australia, Britain, Canada, and Norway. Recently, online AMTA journals and Barcelona Publisher’s monograph series entitled, Qualitative Inquiries in Music Therapy (QIMT) http://www.barcelonapublishers.com/online-periodicals/) have been added to the long-standing online Voices publication (www.voices.no/), providing another forum for published, peer-reviewed research. There are three PhD programs offered with a focus on music therapy, one of which is in the USA. Added to this is a large number of master’s degrees in music therapy. All of these programs and publications attest to the health and growth of the profession as we continue to conduct and publish research to improve clinical treatment, to advance knowledge in the field of music therapy, and to claim our place among the healing professions. This health is evident by the number of references and resources used by authors in writing the chapters in this volume. Theories related to clinical work in the field of music therapy in mental health are also well developed and are based on reflective clinical practice. This is evident in the many books and articles found in the references in each chapter. The models of GIM (Bruscia & Grocke, 2002) and AMT (Priestley, 1994) are clearly explained by their founders and developed by their proponents in various articles and books in the literature. Theories related to the psychodynamic approach to music psychotherapy have

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been presented from a number of different perspectives (Bruscia, 1998b) and applied and developed in case studies (Hadley, 2003). Hadley (2006) also edited a book on music therapy from a feminist perspective. A music psychodrama approach using improvisation has also been developed and is described in the literature (Moreno, 2005); more recently, Austin (2008) has developed a model and training for vocal psychotherapy. Approaches to work with mental health clients have been presented in a number of in-depth qualitative dissertations and studies, providing theoretical frames which help to orient the clinician and provide insight into the client’s needs and responses and how music therapy methods can best be used. For example, Rolvsjord (2010) expounded upon a mental health approach that focuses on accessing and utilizing clients’ resources, and Meadows (2011) edited a book of case studies in which each author linked theory to practice and described the theoretical framework that informed the clinical case study. This is a cursory sampling of the many erudite books, chapters, and articles that continue to be published, providing an in-depth analysis and understanding of music therapist–client interactions in the field of music therapy and attesting to the depth and breadth of theory and research in the field in general. A review of the research presented in this volume reveals some interesting trends, however. The reader might observe an inconsistency in the quantity and quality of research for various client groups treated in mental health. This, in itself, is not surprising. Some client groups, such as those treated in inpatient psychiatry and elderly persons with dementia, have seen decades of development in clinical practice, and the research literature naturally reflects this. However, the equation of prevalence of clinical practice and research does not always hold true. There is a dearth of research on music therapy with inpatient groups and little more available for outpatient groups, while there is much more research and clinical literature devoted to persons with schizophrenia. Yet, most of the work done by music therapists in inpatient psychiatry is conducted in heterogeneous groups that are not diagnosis-specific. In addition, much of the clinical literature presents individual case studies, while music therapists spend most of their direct clinical hours in group work (Silverman, 2007). There is also scant research or clinical literature available for persons with comorbid diagnoses such as SMI and intellectual challenges or substance use, although clinicians regularly treat clients with comorbid diagnoses of this type. One population that is well represented in the literature is elderly persons with dementias; here, there is ample research and clinical literature available for both groups and individuals. Yet, elderly residents in nursing facilities, or the “frail elderly” population, had significantly less research literature than that for dementias. There is also some research available for the forensic population, but much more so with men than with women. As a whole, though, the research is scant when one considers that music therapists have been working with these client groups for decades. Many of the populations written about in this volume reflect the work of individual clinicians/researchers who have little research on which to rely to support or guide their clinical work. In some cases, such as in the chapters on adults and adolescents with borderline personality disorder, children with PTSD, sexual trauma, and abuse and neglect, the literature consists of one or a few case studies. Other populations, such as adjudicated adolescents, children and adolescents in foster care, and juvenile sex offenders, are the subjects of almost no music therapy research literature, and clinicians must draw from literature that deals with similar symptoms found in other populations. The eating disorders literature is relatively well represented in clinical studies but has only one research study. Adolescents with substance use problems have very little research available to guide the clinician, yet adults with the same diagnosis have robust research literature in both qualitative and quantitative paradigms at the clinician’s disposal. Thus, it would seem from the literature that music therapists are represented in substance use or “addiction” clinics for adults as well as, to a lesser degree, in diagnosis-focused eating disorders treatment centers, but this remains speculation, as there are no data to support these conjectures. Another question that the lack of research brings up is whether clinicians

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who may be working with groups such as eating disorders clients have jobs in which they have ample time to carry out research as opposed to contractual work. With populations without a DSM diagnosis, there is little, if any, research available. Vocal psychotherapy treatment for adults with developmental trauma disorders is an exception to this; treatment for this population is well established in the work of Austin (2008), but has not been addressed in other methods. Children and adolescents with developmental trauma disorder are not represented in the music therapy research or clinical literature. A similar dearth of literature exists for other populations on the wellness spectrum, including music therapy for musicians’ problems, professional burnout, and stress reduction. The one exception to this is the use of music therapy to heighten one’s spirituality or sense of wholeness—though this literature is entirely to be found in the Guided Imagery and Music (GIM) domain. Finally, some chapters include a section entitled Caring for the Caregiver. While caregivers are certainly an important population in the field of mental health—many of them care for family members with chronic disabilities—this section was omitted in many chapters simply because there was nothing written in the literature and the author of the chapter had not carried out significant work, if any, with this population. This lack of literature points to a significant population that may benefit from music therapy treatment but currently is not, it would seem, being treated. The chapters on stress reduction and spirituality may address some of these issues, but it appears that music therapy treatment for caregivers of persons with SMI and the elderly is another underdeveloped area in music therapy. At this juncture in our profession, it may be time to reflect on what the future holds and where we are going in terms of our research foci in mental health. Mental health is a competitive field. There are many other treatments and professions that are helpful to persons with mental health issues, but music therapists have very good reasons to believe that our practice contributes something unique and even indispensable to standard medical treatment (as suggested in the Role and Significance section above). Our qualitative research provides us with the depth that allows us to continue to deepen our understanding of the therapeutic use of music and the therapeutic relationship. Continued research in this paradigm is essential to the growth and development of the field. In contrast, the current climate of evidence-based practice that relies upon randomized trials as the gold standard in research renders it difficult for music therapists to make claims to the effectiveness of music therapy based on our research in the evidence-based quantitative paradigm. To illustrate, consider the Cochrane Database, which defines the highest criteria for evidencebased research and conducts meta-analyses on all studies with a particular population focus that meet their criteria. Because of the low number of music therapy studies that meet the Cochrane Review’s criteria for evidence-based practice, authors have been able to complete reviews on only three populations treated in mental health with music therapy—persons with depression, schizophrenia, and the dementias. Furthermore, the authors found that the methodological problems in the music therapy studies were so serious that they were unable to complete the quantitative meta-analyses on two of the three populations. Only five studies met the inclusion criteria for the review on depression (Maratos, Gold, Wang, & Crawford, 2008). The data of these studies could not be synthesized because there was too much variation in the interventions offered, the populations studied, and the outcome measures used. A similar problem occurred in the study with persons with dementia (Vink, Birks, Bruinsma, & Scholten, 2003). Although 10 studies met the criteria for inclusion, the authors found that the methodological quality of these small, short-term studies was generally poor and the reporting of the results was incomplete, preventing them from being able to draw any useful conclusions. The study on schizophrenia (Mössler, Chen, Heldal, & Gold, 2011) was somewhat better. Eight studies met the inclusion criteria and had a similar outcome focus and provided appropriate reporting of results. Based on these results, authors were able to provide indications of the conditions under which music therapy is most useful for these clients and to offer

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suggestions for future research that, if carried out, would contribute significantly to the development of our field. It seems, then, from an analysis of the Cochrane Review reports, that research in the mental health field reflects a deficiency of collaborative research. This is evident in the lack of consistency in the outcome focus and in the interventions used, as well as a lack of appropriate methodology that requires large numbers of participants, repeated studies, multisite inquiries, control groups, and randomization, if the studies are to measure up to criteria for evidence-based research. One successful model for this type of research collaboration already exists as the Grieg Academy Music Therapy Research Center in Norway (GAMUT), where a number of senior researchers are headed by Brynjulf Stige. They design and conduct randomized controlled studies using collaborative research in multiple sites and conduct meta-analyses. Qualitative research projects are also incorporated into larger research studies. Information on GAMUT can be found at http://helse.uni.no/ContentItem.aspx?site=4&ci=1715&lg=2. Thus, while the existing research literature has helped to establish and develop music therapy as a profession in the field of mental health and has provided us with theoretical foundations and clinical applications from which our work has developed, in the current climate, it may be necessary for us, as a profession, to consider how research can best be developed. One area that might hold great promise is that of neuroscience. Neuroscience research is beginning to map how music can alter the brain. Preliminary research has supported some observations of music therapists regarding music’s ability to organize, synthesize, evoke memory, create new neural networks for language, alter mood, change one’s thoughts, and help connect people to each other. It is more difficult, however, to provide empirical evidence of these outcomes as the result of music therapy treatment. As new advances are made and the feasibility of conducting research with neuroimaging technology continues to improve, music therapists may find that neuroscience research will open avenues of inquiry that provide insight into the therapeutic use of music in music therapy practices, thereby providing the empirical evidence that is so urgently needed.

ORGANIZATION OF THE BOOK Each chapter is organized using the following section headings, which will be described in detail subsequently in this section: Diagnostic Information; Needs and Resources; Referral and Assessment; Multicultural Issues; Overview of the Methods and Procedures; Guidelines for Music Therapy Practice (each of the methods presented in turn); Closing Remarks on Methodology; Caring for the Caregiver; Research Evidence; Summary and Conclusions; and References. In addition to describing the content of each section, specific challenges encountered by authors will be identified and discussed. These reflect the challenges in the evolution of practices in mental health and speak to areas pertinent to the development of clinical practice with each population. The first section consists of diagnostic information related to the population presented in the particular chapter and includes “official definitions of the disorder or condition, and all of its subcategories” (Bruscia, 2011, p. 5). In writing a mental health volume, the DSM is crucial to identify client groups and diagnoses from which the chapters are determined. The first problem that the editor and authors encountered was the fact that the DSM-IV-TR (APA, 2000) was in the process of being rewritten and scheduled to be published in May, 2013, just as this volume was going to press. The APA created a temporary website (APA, 2013) in which it regularly posted articles, concepts, questions, and information related to changes that were being considered for the proposed DSM-5, but this was by no means finalized and use of the website came with a caveat that all information was subject to revision. Authors were free to use either the DSM-IV-TR or the DSM-5 website. In all chapters, authors consulted the DSM-5 website to determine if there were any possible changes that would be crucial to the diagnostic

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category about which they were writing; if there were, these were indicated in the chapter. In most chapters, DSM-IV-TR criteria were also used to describe diagnostic features. Following the diagnostic information, clients’ needs and resources are examined. These include “personal and musical characteristics of the population, including both strength and problem areas” (Bruscia, 2011). Needs and resources can be difficult to determine if one considers the entire population group, as it is difficult to make general statements about an entire population, but the task becomes somewhat easier when thinking about individuals who have a particular diagnosis. Needs are described as the everyday obstacles faced by these individuals, often as a result of symptoms that cause existential difficulties and may even be impediments to their treatment (Bruscia, 2012, November). Resources include a description of the qualities of these individuals, their potentials for growth, and the capacities that enable them to benefit from music therapy (Bruscia, 2012, November). The referral and assessment section outlines how clients would typically be referred to music therapy and how the music therapist assesses clients. Particular assessments for client groups are included when they are available. The major problem encountered in this section is the lack of populationspecific music therapy assessments. This problem seems to exist, at least in part, because assessments are generally done with individuals, and most music therapists in the USA are doing group work (Silverman, 2007). This discrepancy reveals a deeper problem, that of professional identity—for if there is no music therapy assessment documentation for clients, how can music therapy be implemented as a treatment, and how can treatment be evaluated? Taken one step further, how does the lack of music therapy specific assessments, treatment plans, and evaluations in many settings where music therapy is practiced impact the profession of music therapy? The multicultural issues section provides information on cultural issues that would be helpful in treating this population. The concept of culture is broad, including gender, race, economic and social status, sexual orientation, musical preferences, heritage, environmental factors, and previous life experiences. For each population, authors attempted to provide insight into how these cultural issues might impact treatment, attitudes to music, and the clients’ ability to benefit from therapy. As an introduction to all the procedures that are presented in each method, an overview of the methods and procedures was provided. Under a heading for each of the four methods, the authors presented the name and brief definition of each procedure that would later be described in detail. This provides the reader with a quick guide to locating the procedures located in each method in the chapter. The next section of the outline—guidelines for music therapy practice—constitutes the major portion of the chapter. Each method of music therapy—receptive, improvisational, re-creative, and compositional, in that order—is presented according to specific criteria. Each author defined and named each procedure used in each method and provided information on the following: • • • • •

Overview: name of the procedure, definition, indications, contraindications, goals, and level of therapy Preparation of the session and environment What to observe Procedures for conducting the session Adaptations

The overview section at the start of each new procedure provides its name, defines the procedure, and describes the rationale for its use as well as conditions under which the procedure would be contraindicated. Various goals for each procedure are identified, some from the literature and some based on the author’s clinical experience. The level of therapy appropriate for this procedure and any special training or skill needed by the therapist to implement it are also stated.

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Not to be overlooked is the preparation of the session and the environment. For some procedures, this is straightforward, requiring at most a description of the room and supplies. However, other procedures, such as directed imagery or concert performance, require a significant amount of preparation on the part of the therapist, and this section includes all the details that need to be attended to before beginning the session. An integral part of every procedure is observing individual clients’ engagement, perceptions, and group dynamics so that the therapist can interact therapeutically in the moment. Thus, the section on what to observe provides guidelines on client responses that are therapeutically significant. Where appropriate, suggestions are also given to deal with possible abreactions to the procedure. The section on procedures for conducting the session was initially problematic for many authors, both conceptually and in its organization. To research the information for this section, each author conducted a complete search to identify all the music therapy literature that dealt with the population addressed in the chapter. Obviously, for some populations, such as elderly persons with dementia, the literature was overwhelming. For other chapters, such as men with developmental trauma, the literature was almost nonexistent. Both extremes posed problems. When there was little literature available, authors provided procedures for their methods based on their expertise and clinical experience, drawing at times on methods used for other populations in mental health. However, even where there was a relative plethora of literature, descriptions of the procedures and techniques that were used in each method were often scant and incomplete. In this case, authors had the problem of integrating fragmentary descriptions while filling in the gaps, or trying to pull together myriad aspects of a method with slight differences from various sources into one cohesive and methodological procedure. Thus, where possible, authors integrated pertinent sources in the literature, providing references to these sources, while using their clinical expertise to fill in the steps used in each procedure to provide a clear description of each practice. To address the fact that one basic procedure might be enhanced, developed, or altered in some way, a section on adaptations is included at the end of the procedure section. In this section, authors describe how the main procedure might be varied, and for what therapeutic reasons, as well as include possible variations on the procedure found in the literature. To conclude the methodological sections, a final procedural section provides closing remarks on methodology. Here, authors provide session guidelines describing when to offer individual or group sessions, the frequency and length of sessions, and the group size for the population, as well as how to sequence and combine different procedures from all of the methods within a session or series of sessions. Thus, while the procedures are organized into step-by-step sequences under each method to provide clarity, in the methodology, authors present how they construct and integrate the various procedures to create a cohesive session. Where applicable, a section on caring for the caregiver is presented following the methodology section. For many chapters in this volume, there was no information available in the literature on caregivers for the particular client group. For example, while many caregivers are intimately involved in caring for family members with a serious mental illness, which is often a chronic illness, as is the case with persons with schizophrenia, there is nothing in the literature that addresses such needs. This volume has tried to address this lack of information by including four chapters that specifically meet the needs of caregivers—Professional Burnout (Chapter 22), Stress Reduction and Wellness (Chapter 23), Musicians (Chapter 24), and Spiritual Practices (Chapter 25). The research evidence section includes research that has been conducted on the population featured in each particular chapter. Organized to complement the procedural method section, the research, where warranted, is categorized according to the four methods. Qualitative and quantitative paradigms were included wherever possible. Some authors added comments on research in their area of focus and in some cases made suggestions for further research. Taken as a whole, it becomes very clear that there are populations in mental health on whom little, if any, research has been done. Even where the

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research is more significant, the research focus of the population as a whole is disparate and may even be perceived as disconnected. The final section in each chapter is entitled summary and conclusions. In this section, each author summarizes thoughts about music therapy practice and research as a whole.

HOW TO USE THIS BOOK When viewed as a whole, this book provides protocols, guidelines, and research related to clinical practice with specific populations who are treated in mental health practices. It will be useful to students, interns, educators, and experienced clinicians alike. There is a wealth of information here, and as this editor eagerly delved into each new chapter, I often felt I was having a profound conversation with an erudite group of experienced colleagues about detailed aspects of their clinical work. It is my hope that readers will have a similar experience. Readers can choose to read chapters based on their current interest in a particular population, focusing on the diagnoses, needs, and resources, and/or readers can focus on clinical procedures, choosing from a variety of methodological procedures in one specific chapter or across related chapters to acquire information on specific methods that they can implement and adjust to suit their clinical work. In addition, the research section provides substantial information on the current research in the field. Each chapter, therefore, provides pertinent information on a specific population of clients, music therapy protocols from every method that are helpful with this population, and current research literature that pertains to the population. Readers might also read about a particular method throughout the chapters to discover a range of approaches from a number of clinicians using that method. Other sections, for example, Research Evidence, might be read throughout all or many of the chapters in this volume to provide an overview of the particular topic. The reference section of each chapter provides an excellent bibliographical source of the major clinical and research literature dealing with each population. In some chapters, resources and websites are also listed. Readers might also wish to compare various sections in other volumes in this series for a more in-depth look at any topic, for example, research or any particular method. Finally, a note on the use of gender in this volume. The English language is noted for its illusive simplicity. Yet, where pronouns are concerned, a text can easily become mired in “his or her” and “she or he” at the turn of every pronoun. In an effort to alleviate the cumbersomeness of this turn of phrase, the editors have asked each author to refer to clients in the opposite gender to themselves. So, for example, a male author would refer to the therapist as “him or he” and to his clients as “her or she.” Similarly, a female author would refer to the therapist as “her or she” and to her clients as “him or he.” Common sense dictates an exception to this rule in chapters in which a therapist worked exclusively or predominantly with clients of the same gender.

CONCLUDING REMARKS The efforts of all of the clinicians/authors who have contributed to this volume have resulted in a creative and inspiring collection of ideas related to clinical practice for a variety of problems and conditions that are treated in the field of mental health. This collaborative work gives credence to the expression that the whole is greater than the sum of its parts. However, while it is hoped that this attempt to map the field of mental health protocols is relatively comprehensive and useful, it is also destined to be incomplete. It is hoped that this work will be understood as a starting point and that clinicians will add to the literature where methods and client populations have inevitably been overlooked and where mental health practices expand to provide services for new client groups.

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One observation that surfaced repeatedly as this editor began to read through all the chapters was related to the multitude of descriptors used to identify similar procedures. For example, a group of similar receptive procedures for relaxation was variously called music-assisted relaxation, music-centered relaxation, music relaxation, music-assisted breathing, relaxation, relaxation and guided imagery, relaxation experiences, relaxation skills, and imagery-based relaxation. The lack of specific names for protocols in each method had not appeared to me to be a problem previously in my work as a clinician or educator. However, reading the volume as a whole, I encountered a repetition of the same phenomenon for the majority or protocols, and thus I wondered if the field might benefit from a more unified way of using terms. One advantage of greater consistency in terminology might be that we would find it easier to communicate clearly and succinctly to each other as well as to professionals outside our field for purposes of clinical exchange, education, or research presentations. This thought also led me to wonder if the use of standardized names and definitions of protocols might better represent the cohesive, organized, and mature profession that has developed in the field of music therapy. In closing, I would like to observe that the experience of working with so many fine clinicians and researchers has been edifying. The level of commitment, creativity, clinical expertise, and depth of work evident throughout these pages is a testament to the strength and health of our profession. These authors have made a great contribution to education and clinical advancement by sharing their work in these chapters. It is my fervent hope that readers will be inspired and find like-minded companionship in these pages.

REFERENCES American Music Therapy Association (AMTA). (2012). Descriptive statistical profiles. Retrieved May 11, 2013, from http://www.musictherapy.org/members/jobcenter/resources/ American Psychiatric Association. (2013). DSM-5 Development. Retrieved May 11, 2013, from http://www.dsm5.org/Pages/Default.aspx American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). (DSM-IV-TR). Arlington, VA: Author. American Psychiatric Association (APA). (2012). DSM: Frequently asked questions. Retrieved May 12, 2013, from http://www.psychiatry.org/practice/dsm/dsm-frequently-asked-questions Austin, D. (2008). The theory and practice of vocal psychotherapy: Songs of the self. Philadelphia, PA: Jessica Kingsley. Bandini, C. (2004). Preface. In M. McGuire (Ed.), Psychiatric music therapy in the community: The legacy of Florence Tyson (pp. xvii–xviii). Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas, Publishers. Bruscia, K. E. (1998a). Defining music therapy (2nd ed.). Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (Ed.). (1998b). The dynamics of music psychotherapy. Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (2011, October). Conceptualization of practice series. Unpublished guidelines. Bruscia, K. E. (2012, August). Psychotherapeutic levels of practice. Unpublished document. Bruscia, K. E. (2012, November 10). Needs and resources. Unpublished email communication. Bruscia, K. E., & Grocke, D. (2002). (Eds.). Guided Imagery and Music: The Bonny Method and beyond (pp. 5–27). Gilsum, NH: Barcelona Publishers. Clark, M. (2002). Evolution of the Bonny Method of Guided Imagery and Music (BMGIM). In K. Bruscia & D. Grocke (Eds.), Guided Imagery and Music: The Bonny Method and beyond (pp. 5–27). Gilsum, NH: Barcelona Publishers.

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Crowe, B. (2007). History of mental disorders and music therapy. In B. Crowe & C. Colwell (Eds.), Music therapy for children, adolescents, and adults with mental disorders (pp. 3–13). Silver Spring, MD: American Music Therapy Association. Davis, W. (2003). Ira Maximillian Altshuler: Psychiatrist and pioneer music therapist. Journal of Music Therapy, 40(3), 247–263. Davis, W., Gfeller, K., & Thaut, M. (2008). An introduction to music therapy theory and practice (2nd ed.). Silver Spring, MD: American Music Therapy Association. Grohol, J. (2012). Final DSM-5 approved by American Psychiatric Association. Psych Central. Retrieved May 11, 2013, from http://psychcentral.com/blog/archives/2012/12/02/final-dsm-5-approvedby-american-psychiatric-association/ Hadley, S. (Ed.). (2006). Feminist perspectives in music therapy. Gilsum, NH: Barcelona Publishers. Hadley, S. (Ed.). (2003). Psychodyamic music therapy: Case studies. Gilsum, NH: Barcelona Publishers. Maratos, A. S., Gold, C., Wang, X., & Crawford, M. J. (2008). Music therapy for depression. Cochrane Database Systematic Reviews, 1. DOI: 10.1002/14651858.CD004517.pub2. Meadows, A. (Ed.). (2011). Developments in music therapy practice: Case study perspectives. Gilsum, NH: Barcelona Publishers. Moreno, J. (2005). Acting your inner music: Music therapy and psychodrama. Gilsum, NH: Barcelona Publishers. Mössler, K., Chen, X., Heldal, T. O., & Gold, C. (2011). Music therapy for people with schizophrenia and schizophrenia-like disorders. Cochrane Database of Systematic Reviews, 12. Art. no.: CD004025. DOI: 10.1002/14651858.CD004025.pub3. Pickett, E. (2002). A history of the literature on Guided Imagery and Music (GIM). In K. Bruscia & D. Grocke (Eds.), Guided Imagery and Music: The Bonny Method and beyond (pp. xxv–xxxv). Gilsum, NH: Barcelona Publishers. Priestley, M. (1994). Essays on Analytical Music Therapy. Gilsum, NH: Barcelona Publishers. Rolvsjord, R. (2010). Resource-Oriented music therapy in mental health care. Gilsum, NH: Barcelona Publishers. Saxon, W. (2001, January 31). Obituaries. Florence Tyson, 82, early advocate of creative art therapy. New York: New York Times. Retrieved May 15, 2013, from http://www.nytimes.com/2001/01/31/nyregion/florence-tyson-82-early-advocate-of-creativearts-therapy.html Silverman, M. (2007). Evaluating current trends in psychiatric music therapy: A descriptive analysis. Journal of Music Therapy, 44(4), 388–414. Tyson, F. (1981/2004). Music therapy in hospitals. In M. McGuire (Ed.), Psychiatric music therapy in the community: The legacy of Florence Tyson (pp. 303–311). Gilsum, NH: Barcelona Publishers. van der Kolk, B., Pynoos, R., Cicchetti, D., Cloitre, M., D’Andrea, W., Ford, J., Lieberman, A. F., Putnam, F. W., Saxe, G., Spinazzola, J., Stolbach, B. C., & Teicher, M. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Retrieved May 11, 2013, from http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf Vink, A. C., Birks, J. S., Bruinsma, M. S., & Scholten, R. J. (2003). Music therapy for people with dementia. Cochrane Database of Systematic Reviews, 4. Art. no.: CD003477. DOI: 10.1002/14651858.CD003477.pub2. Wilson, B. (1990). Music therapy in hospital and community programs. In R. Unkefer (Ed.), Music therapy in the treatment of adults with mental disorders (pp. 126–144). New York: Schirmer Books.

Chapter 2

Adults with Schizophrenia and Psychotic Disorders Andrea McGraw Hunt _____________________________________________ DIAGNOSTIC INFORMATION Symptoms, Diagnoses, and Diagnostic Criteria Schizophrenia and psychotic disorders have historically been grouped together in a constellation of diagnoses relating to psychosis, disorganized thoughts, and catatonic behavior; however, these disorders do not necessarily have a common etiology, and psychosis is not a core symptom across disorders (American Psychiatric Association [APA], 2000). The symptoms associated with these disorders are grouped into three broad categories: positive symptoms, negative symptoms, and cognitive symptoms (National Institute of Mental Health [NIMH], 2009). Positive symptoms are symptoms that “add” to the client’s behavior, which include psychotic symptoms such as hallucinations, delusions, thought disorder, movement disorder, and catatonia. Hallucinations are perceptual experiences that are not real, such as voices of a person that no one else but the client can see or hear. Delusions are fixed beliefs that are false, such as when a client believes he is a famous rock star and will not change his mind despite any evidence to the contrary. Delusions can also be paranoid in nature, e.g., when a client fears that a particular person wants to cause him harm. Thought disorders include disorganized thoughts as well as “thought blocking,” which occurs when a client suddenly stops speaking in the middle of a thought and cannot complete what he was saying. Neologisms are another feature of thought disorder, where the client makes up meaningless words. Movement disorder can take the form of agitated or repetitive movements. Catatonic symptoms include immobility and stupor, or waxy flexibility (e.g., when one’s posture can be altered by another person, but then remains fixed in the new position), mutism (not speaking), echolalia (involuntarily repeating another person’s speaking), echopraxia (involuntarily mirroring another person’s movements), resistance to all prompts to move or maintenance of a rigid posture, inappropriate or bizarre movements or gestures, stereotypical movements, mannerisms, or grimacing (APA, 2012). Negative symptoms occur when the client’s behaviors are diminished in some capacity, such as a flat emotional expression, avolition (lack of initiative or motivation), difficulty in starting and sustaining planned activities, talking very little, and/or apathy toward pleasurable activities. Clients experiencing negative symptoms often neglect personal hygiene due to the severity of the disorder (NIMH, 2009). Cognitive symptoms may be difficult to detect and may require testing to determine their presence or absence. In general, they include difficulty with executive functions, such as problem-solving and making decisions; difficulty achieving and sustaining focus on a task; and decreased ability to use new information immediately after acquiring it (working memory) (NIMH, 2009).

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The presence of any of these symptoms, together with knowledge about the context in which they occur, for how long, and to what degree, helps to form a diagnostic picture of the client. The preliminary DSM-5 (APA, 2012) diagnostic criteria for schizophrenia and psychotic disorders seek to describe these diagnoses across a spectrum of severity and duration of symptoms. Some diagnoses are less severe in terms of the type of symptoms attributed to them. Schizotypal personality disorder’s most prominent symptoms involve disorganized thoughts, odd or unusual beliefs or perception of reality, detachment, and suspicion of others. None of these symptoms crosses into full psychosis, although if they do for at least one month, and the individual’s functioning is not severely impaired, then delusional disorder may be an appropriate diagnosis. If the psychotic symptoms do not persist for at least one month, then the DSM would classify the symptoms as a brief psychotic disorder. There are three diagnoses which identify a known causal agent for the symptoms. Substanceinduced psychotic disorder requires that the symptoms (delusions, hallucinations, and/or disorganized speech) be directly related to the use of a substance (legal or illegal) and that the symptoms cause clinically significant distress in one’s functioning. Likewise, psychotic disorder attributable to another medical condition requires that the psychotic symptoms are directly related to a medical condition, and is not better accounted for by some other cause (such as a drug or an unrelated psychotic disorder). Finally, catatonic disorder attributable to another medical condition relates to catatonic symptoms that are clearly related to a medical condition. A diagnosis of schizophrenia requires two or more of the following symptoms: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly abnormal psychomotor behavior, including catatonia, and (5) negative symptoms, e.g., diminished emotional expression or avolition. The symptoms must have caused a significant impairment in one or more areas of the client’s life (school, work, interpersonal relations, and self-care); in addition, there cannot be a concurrent mood disorder, and the symptoms are not caused by substance use or a medical condition. The symptoms have to have been present for at least six months. If they have been present for at least one month but not yet six months, then schizophreniform disorder applies. Schizoaffective disorder is differentiated from schizophrenia because of the presence of a mood disorder (for more than 50% of the time, including when controlled by medication) along with at least two of the primary symptoms required for a diagnosis of schizophrenia. Mood disorders can be bipolar or depressive in nature; bipolar disorders involve shifts from manic, severely agitated behavior and mood to severely depressed mood.

Cultural Considerations In some cultures, brief episodes of hallucinations or seemingly psychotic behavior may be considered appropriate for particular situations. For instance, the onset of hallucinatory experiences could be viewed by some cultures as an initiation into the vocation of shamanism (Halifax, 1979), while in Latino cultures, an overwhelming grief reaction could trigger a temporary and socially acceptable condition called ataque de nervios (Applewhite, Briggs, & Herrera, 2009). Furthermore, studies have found that the nature and frequency of schizophrenic symptoms are often determined by one’s culture. For example, it has been shown that West African patients have a significantly higher rate of visual hallucinations compared to Pakistani patients, who in contrast, infrequently experience religious delusions (Stompe et al., 2006). Thus, the client’s cultural background is an essential component of making an accurate and helpful diagnosis. A client’s cultural background must also be an important consideration in designing a treatment approach for clients. Most Western approaches to treating schizophrenia and psychosis are based upon research with primarily Caucasian and Western populations in a Western treatment model. The cultural

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assumptions of this treatment model may not mesh well with collectivist cultures that assume a great deal of family involvement in the recovery process (Drapalski & Dixon, 2012). In Latino, African-American, and Asian-American cultures, individuals with schizophrenia are more likely to live with and receive practical support from their families than Caucasian individuals with schizophrenia (Snowden, 2007). Depending on the treatment context, this may have implications for music therapy treatment, such as family participation in treatment planning and even caregiver support through music therapy. However, at this time, most treatment settings for acutely ill clients in North America offer limited opportunities for family involvement. Hopefully, over time, clinical settings will become more flexible in utilizing not only the clients’ personal resources, but also their cultural and social resources in promoting mental health.

NEEDS AND RESOURCES Over the years, music therapy and related literature has gradually documented quantitative evidence to verify previously observed and described musical behaviors and characteristics of persons with schizophrenia and psychosis. Interestingly, when compared to mentally healthy people, persons with schizophrenia have demonstrated better music memory than nonmusical sound or verbal memory, based on pitch span tests compared to digit span tests (Rogers & Smeyatsky, 1995). Thus, it would seem that schizophrenic clients may be more attentive to musical sounds and better able to process musical sounds than nonpsychotic persons. However, this population typically engages in music in ways that reflect disorganized thinking and cognition, as well as problems with interpersonal interaction. Cognitive difficulties seem to be related to De Backer and Wigram’s (2007) broad description of severely ill schizophrenic clients’ music-making: repetitive and yet random playing which lacks phrasing, dynamics, or accents; it also tends to be atonal, without harmony or melody—that is, notes do not relate to other notes. De Backer and Wigram call this “sensorial play.” Boone (1991) made similar anecdotal observations based on her work at a state psychiatric hospital, saying that groups of persons with psychosis or schizophrenia often engage in musical improvisation in a perseverative manner, with fixed or rigid volume, meter, volume, and rhythm patterns, as well as lack of melodic continuity or creativity. There also may be short intervallic sequences repeated within a perseverative rhythmic structure. Booth went on to say that, in her experience, when clients attempt to vary any of these musical tendencies, they may find that they are unable to or have great difficulty in doing so. Researchers have also observed limitations in the way psychotic or schizophrenic clients tend to interact with the therapist in music-making. During sensorial play, De Backer and Wigram (2007) noted that clients exhibit little or no interaction with or response to the therapist. Through validation of their assessment tool, Pavlicevic and Trevarthen (1994) found that schizophrenic clients interacted significantly less with the therapist in individual improvisation when compared to depressed clients and healthy controls. Pavlicevic, Trevarthen and Duncan (1994) also established that the degree of musical isolation in improvisational sessions correlated with the severity of the psychotic or schizophrenic symptoms. Much of the literature relating to music therapy with schizophrenia or psychosis discusses work with clients over many months or years in inpatient settings. Over the past decade, mental health care has changed a great deal in the U.S., such that the likelihood of being able to work with clients over long periods of time has become rare. Therapists who work in settings that serve very chronically ill persons may be fortunate enough to be able to establish a longer therapeutic relationship with their clients who require long-term treatment; however, often it is difficult to know when clients will be discharged to other settings. Therefore, it can be difficult to make long-term plans for music therapy. For inpatient settings, the priorities of short-term treatment usually focus on stabilizing the client so that he is able to function in his usual living situation, e.g., the client may remain psychotic, but less so, and he would be less likely to

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hurt himself or others. Therefore, throughout this chapter, therapists should keep in mind the length of stay their clients will likely have in their settings and select interventions and treatment goals that are reasonable and achievable for their client’s situation.

REFERRAL AND ASSESSMENT PROCEDURES Music therapy assessment tools for clients with schizophrenia or psychotic disorders need to be appropriate for the clinical setting and for the clinical purpose of the assessment. Because inpatient settings usually hospitalize patients for no more than several days, assessment procedures must efficiently identify the most relevant and important clinical information. When developing an assessment procedure, determine: (1) For whom is the assessment? The music therapist alone? Or a team of therapists of varying disciplines? (2) What is the purpose of the assessment? To prescribe particular music therapy or other interventions? To determine appropriate group assignment? To evaluate progress in treatment? (3) What is a realistic time frame for completing the assessment? (4) When and how would it be done and by whom? Once the audience, purpose, timeline, and procedure for the particular clinical situation have been determined, then the therapist can either develop her own assessment tool or adapt existing ones. The following tools reflect the current state of the literature in assessment with this population, but have their limitations according to their clinical contexts.

Inpatient CAT Assessment One example of an assessment tool to be used in a group format comes from the Rehabilitative Creative Arts Therapy Service (RCATS) at Girard Medical Center, Philadelphia, PA (Howard-Jones & Melsom, n.d.). This assessment was used by a group of creative arts therapists, primarily to determine each patient’s group assignment. The assessment forms and procedures have been developed and used over 20 years of practice, and the examples cited here are used in the Acute and Extended Acute inpatient units. At this facility, all patients are expected to attend the RCATS groups; therefore, there is no referral system. Within 72 hours of a patient’s admission, the therapist must write an initial note in the chart and start an assessment form (a revised, music-based version appears in Appendix A) and Treatment Objectives Flow Sheet (Appendix B). The initial note highlights relevant chart information, such as needs/problems that can be addressed in RCATS groups, the patient’s ability to maintain safety and participate in group therapy, patient’s degree of reality orientation and thought organization, etc. Based upon this information and any observation the therapist has been able to make of the patient’s demeanor in the unit up to that point, the therapist will make a tentative assignment to a more structured group (Project Group) or a more open-ended, insight-based group (Problem-Solving Group). Also based on chart information and milieu observations, the therapist identifies two or three treatment objectives and initiates the Treatment Objectives Flow Sheet, where RCATS therapists will document the patient’s behavior in groups. All new clients are observed within the same treatment groups as the other clients on the unit, permitting their ability to maintain safety. In these initial groups, patients are encouraged to engage in whatever music experiences are provided for the other clients at that time. Observations are made not only of how the client engages in the music experience, but also in regard to how reality-based and insightful the client is in his speech and dialogue (see assessment form for more details). After the assessment period, therapists review the data documented by the different RCATS therapists and determine the client’s group assignment based on the quality and nature of his participation. The therapist writes an assessment note in the chart and updates the Flow Sheet with new treatment objectives. These objectives should mesh with the larger treatment objectives in the patient’s interdisciplinary treatment plan, which will have identified the patient’s main reasons for being

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hospitalized as well as overall goals to be met in order for the patient to be discharged. The therapist documents the client’s progress on a weekly basis and updates treatment objectives accordingly, while also updating the treatment team on the client’s progress. Overall, the tool provides a means for assessing clients in situ, and gains information unique to the creative arts therapy groups that is relevant to treatment goals.

Music Interaction Rating Scale (Schizophrenia) (MIR[S]) In an assessment approach designed for individual therapy, Pavlicevic (1989, 1994, 1995, 2007) developed and tested an assessment scale for clients with schizophrenia which sought to assess the degree of musical interaction with the therapist. Pavlicevic drew from theories that described the synchrony of social behavior, particularly among those with emotional and cognitive disturbances, as a rationale for her assessment method. Using improvisational techniques from the Nordoff-Robbins approach, the therapist first interviews the client to assess his previous musical experience, then improvises with the client in two different situations: first, with client on bongos and therapist on piano, and then with client and therapist taking turns dialoguing on a marimba. The therapist uses different interventions, varying her rhythm, tempo, and phrase length in techniques such as mirroring, reflecting, and holding, to elicit interactive responses from the client. The improvisation is recorded, and the therapist later listens to the recording and rates the improvisations according to the degree of interaction with the therapist, from 1–9 (from “no contact” through to “musical partnership”) and marks the duration of time the client sustains that level of interaction. The total MIR(S) score is calculated by averaging the ratings and weighting each rating according to the length of time the client sustained that level of interaction. For example, a client’s playing could vary from very musically interactive (level 8) to not musically responding to the therapist (level 3), but he spends most of his time tenuously musically responding to the therapist (level 5) (Pavlicevic, 2007). The detailed assessment procedure can provide a more objective perspective on the client’s ability to engage in improvisation, one which may not be obvious to the therapist otherwise. This assessment can have both prescriptive and evaluative purposes. Clients who score low on the scale have difficulty sustaining musical interaction with the therapist, a primary focus for NordoffRobbins music therapy. The therapist would approach such a client with musical techniques that would develop increased musical interaction. The assessment could also be used at the end of a treatment period to determine clinical progress. Research on this assessment tool showed that a client’s improvement in MIR(S) scores coincided with improvement in Brief Psychiatric Rating Scale scores (Pavlicevic, 1994). These results suggested that the music therapy group had an increased level of musical interaction with the therapist concurrent with improvement in clinical status. Pavlicevic (1989) also demonstrated that the assessment could have a diagnostic application, as she discovered that schizophrenic patients scored lowest compared to clients with depression and healthy controls, meaning that the schizophrenic group had the lowest degree of musical contact with the therapist. While this assessment approach is likely not feasible for settings where most music therapy clients would be treated for a short length of time in a group context, it could be useful for work with individual clients where the therapist feels that interpersonal interaction would be a primary clinical concern. Given that the assessment arose from the author’s orientation as a Nordoff-Robbins music therapist, clinicians should develop the listening skills that this assessment tool demands before implementing the MIR(S). Such skills are developed through extensive use and analysis of clinical improvisation, as well as supervision by a clinician experienced in clinical improvisation.

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OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy •

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Music Games: In Music Bingo, bingo cards naming different musical sounds, songs, or genres are listed on each square and clients mark the appropriate square as they hear examples; in Name That Tune, the therapist or client chooses a song or piece of music and plays it for the group to guess the name of the song. Music Appreciation: Clients listen to a wide range of music styles and genres as an educational and/or recreational experience with therapeutic goals. Structured Song Discussion: Clients listen to a particular song together and then discuss the lyric content and musical expression of the song. Music Relaxation: Clients learn relaxation techniques such as breathing awareness, progressive muscle relaxation, and autogenic relaxation with recorded music, with or without directed imagery. Group Music and Imagery: Based on Guided Imagery and Music (GIM) experiences, clients listen to recorded music in a relaxed state while the therapist directs them to imagine themselves in a scene; this is followed by verbal discussion. Live Music Listening: This is an individual experience in which the therapist plays music at the client’s request in order to develop a trusting relationship. Music Listening with Art: Clients draw, paint, or sculpt while listening to music as a way to create a visual response to the music. Sound Training for Attention and Memory (STAM): Clients are instructed to listen to a specific CD from recordings created by Ceccato, Caneva, and Lamonaca (2006) and respond to particular sounds by moving body parts or making body percussion sounds. Movement to Music: Clients move to music at different levels of structure. Psychodynamic Music and Movement: Clients move freely to recorded or therapistimprovised music using a referential theme; this is followed by discussion and relaxation.

Improvisational Music Therapy •

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Rhythm and Sound Improvisation: Clients engage in a number of body percussion and/or found object experiences to create a mood or illustrate a referential theme; this is followed by a free improvisation using musical instruments with or without a referential theme. Improvisation and Storytelling: incorporates improvisation with simultaneous storytelling, using instrumental sounds and music to enliven the story. Structured Instrumental Group Improvisation: Clients play instruments in a group to express musical elements or nonmusical themes (emotions, role-playing, imagery, poems). Group Drumming: Clients play drums and nontuned percussion instruments together in a unified rhythm. Group Vocal Improvisation: Clients improvise together using only their voices. Free Group Improvisation: Clients improvise individually as a warm-up and then the group improvises freely together on a wide range of tuned and nontuned percussion instruments to depict a referential theme or explore sounds nonreferentially.

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Free Individual Improvisation: An individual client freely creates music with or without reference to a theme, usually with the therapist. Individual Nordoff-Robbins Music Therapy (NRMT): An individual client improvises with the therapist or therapists with a focus on the development of musical interaction between them. Analytical Music Therapy (AMT): Clients improvise on nonreferential and referential themes, most often with the therapist, and discuss the experience as it relates to conscious and unconscious processes.

Re-creative Music Therapy • • • •

Structured Group Sing-Along: The therapist leads a group of clients in singing along to familiar songs. Recreational Music Performance Groups: Clients learn and practice songs or musical selections for recreation. Vocal or Instrumental Performance Ensemble: Clients learn and practice songs or musical selections with a goal of performing them for others. Individual Vocal or Instrumental Instruction: The client receives individual instruction from the therapist as a means to acquire musical skills and achieve therapeutic goals.

Compositional Music Therapy • • •

Lyric Substitution: The therapist chooses a song for the client/group and removes particular words from the lyrics, asking the client(s) to fill in their own words. Song Parodies: The client or group rewrites an entire song’s lyrics with the clients’ own words. Collaborative Songwriting: An individual client and therapist collaborate to compose a song.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Because receptive methods involve the client’s internal experience with the music, this can be problematic for clients whose internal worlds may be disorganized and who may not be able to accurately perceive reality, as can be the case with this population. In these situations, it may be helpful to use an accompanying activity to help connect the client’s internal experience with external reality, such as drawing or moving to music, reading a lyric sheet while the music is playing, or listening to live music. In this way, the music experience is more directly connected with the environment and therefore can ground the client in the here-and-now. These receptive approaches are described with music-only activities first, then music and art, and then music and movement. Within each subgroup, the activities are described in order of most structured to least structured.

Receptive Music Games Overview. Examples of receptive music games include Music Bingo, where bingo cards naming different musical sounds, songs, or genres are listed on each square and clients mark the appropriate

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square; or Name That Tune, where the therapist or client chooses a song or piece of music and plays it for the group to guess the name of the song (Houghton et al., 2002). Clients who exhibit impaired cognitive functioning, often characterized by impaired auditory discrimination and poor memory, would benefit from these activities. Goals include retraining auditory and perceptual skills, improving memory, improving social skills, and promoting leisure skills. This intervention is augmentative in nature, with no specific contraindications other than that clients who cannot maintain safe behavior in a group setting should not attend. Preparation. Depending on the game, the therapist will need props, for example, Music Bingo cards, as well as assorted recordings of music along with a sound system and clear rules by which to play the game. What to observe. Note how well clients are able to follow the rules, how well they can track the progress of the game (and thus, how their memory and cognition are doing), and how they cope with winning or losing. Procedures. Procedures can vary depending on the game, but in general, the therapist will need to explain the rules of the game step-by-step and may need to facilitate the game (though a client could do so if he is able). The therapist can also add a group cohesiveness goal by creating subgroups from the group to form teams. The games can be employed as a re-creative method if clients play/sing the music clues themselves.

Music Appreciation Overview. This activity can be used with a group or individual client, and involves listening to a wide range of music styles and genres as an educational and/or recreational experience with therapeutic goals (Houghton et al., 2002). This intervention is helpful for clients who have difficulty engaging in goaldirected behavior, have lack of interest in pleasurable activities, and demonstrate compulsive or ritualistic behaviors. Goals may include increased concentration and attention, increased confidence in ability to express oneself in a group, and increased interest in new music or renewed interest in preferred music. This is an augmentative-level intervention, with no specific contraindications other than those assumed for safe participation in a group activity. Preparation. The therapist selects one to a few pieces of music, either focusing on a particular genre or style for that group, or to contrast different styles and genres. The therapist may choose to provide background information about the music group or composers who made the music and/or about the music selections. Live music could be used, but recordings are usually preferable in order to expose clients to new performance styles. What to observe. Observe whether and how clients attend to the music, how they respond to both familiar and unfamiliar music, and whether and how they express their opinions about the music. Also consider the group dynamics of how individuals respond to and share about the music. Do particular clients dominate the conversation? Can withdrawn clients find a way to ask questions or contribute to the discussion? Do group members interact in any way? Procedures. The therapist introduces each musical selection according to the clients’ ability to take in or require background information; pieces can be simply played without any preface, or with some description beforehand. The group can discuss each piece after it is played, or wait until all the selections are played. Discussion can focus solely on the musical content or on the relationship of the music to the composer/performer’s background. The therapist may choose pieces or artists whose contexts or music can relate in some way to the clients’ situations; the therapist may present her observations of these relationships if the group seems ready to examine them. But on the whole, the purpose of the session is to

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explore new kinds of music, and particularly pieces that the clients would not otherwise choose to listen to. In a group, clients could take turns presenting their own music selections to the group as a way of introducing group members’ music preferences (and identities) to each other. This would be particularly useful for very diverse groups where members have difficulty relating to each other due to cultural differences.

Structured Song Discussion Overview. This activity, usually employed with groups, involves members listening to a particular song together and then discussing the lyric content and musical expression of the song. The therapist moderates the discussion and may have particular questions or ideas to present to the group centered on particular treatment issues. Houghton et al. (2002) describe these activities as Supportive Group and/or Individual Music Therapy, and Interactive Music Group and/or Individual Therapy; the main difference between these is the degree to which clients can engage in problem-solving or gain insight from the discussion about the songs. This approach is particularly useful for clients who are resistant to therapy, but who are attracted to particular artists/groups. Using music that is familiar and meaningful to clients can help clients open up to affective experiences, practice identification of feelings and coping skills for strong affect, develop trust and share with peers, engage in supportive reality testing, improve attention span, and connect content from the songs to their personal lives. The activity works at the augmentative level. Because much of the activity involves group discussion, this kind of experience may not be suitable for clients who have very disorganized thinking. Clients who intellectualize (avoiding one’s feelings or reactions through excessive rationalization) as a defense could benefit from this kind of activity, but nonverbal experiences would be a more efficient way to work around these defenses. Preparation. Songs may be played live (by the therapist, for the group to listen to) or be prerecorded. For live music, prepare the song with appropriate accompaniment on piano or guitar, and for recorded music, bring the recording and a sound system on which to play it. Recordings may be preferred for clients who have strong attachments to the particular artists singing the songs (be sure to use the most well-known recording). Depending on how the songs are chosen, the therapist can bring songs she has selected for the group, or the therapist can bring songs chosen by one or more group members prior to the group. In either case, it is helpful to have copies of the song lyrics printed out for the group members’ reference. If songs are chosen by group members during the group, then the therapist should bring a selection of recordings from which the group can choose. Songs can also be stored on an iPod or tablet or be accessed through YouTube. What to observe. First, take note of the dynamics of the group during the selection of songs (if not selected prior to the group), during the playing of the song, and during the discussion. Do one or more clients dominate the group? Are there any particularly withdrawn members? Then be aware of the content of the discussion. When clients talk about the song, how do they relate to it? Are they focused on the lyrics? If so, how? Are they aware of or connected to the music? If so, how? Do the members’ verbalizations make sense, or are they disorganized in any way? Are the group members’ thoughts based on reality? If not, how are they delusional? Do any clients avoid talking about themselves or their emotions, and instead focus on other facts or ideas about the music? Can any of the clients relate the song to their personal lives, and gain any insight about their illness or life from the song? Procedures. If the group is choosing songs during the session, the therapist can distribute either the lyric sheets or a list of the recordings from which clients can choose. The therapist should set ground rules for how to select the song (e.g., “We will discuss two songs during today’s group … let’s choose songs

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that relate to how you are feeling today.” “Because Ben chose the song last time, let’s let someone else choose this time.”). If the therapist has prepared songs to share with the group, the therapist should distribute the lyric sheets to each member. Whoever selected the song (therapist or client) can choose to introduce the song if necessary. The therapist will then play the song, while group members follow the words on the lyric sheets. After the song is completed, the therapist facilitates the discussion. If the song was chosen with a particular concern or issue in mind, the therapist can guide the discussion around this theme. The therapist should encourage each member to reflect on the song, but with awareness of each member’s abilities and needs. Adaptations. Some clinicians use specific pop songs to focus on particular concerns (Cassity & Cassity, 2006). Should the therapist choose this approach, the songs will more likely receive a positive response if the clients can relate to the artists and genre. Clients can also choose to play and discuss particular songs as dedications to peers in order to give a message of support or to say good-bye when a client is leaving the group. In this case, the discussion can focus on the relationship between the song and to whom it is dedicated. In sessions with individual clients (Naess & Ruud, 2007), the client can choose the songs and listen to them (either live or recorded) with the therapist, and then discuss the song with the therapist. Perilli (1991) also used a similar intervention with an individual client, with the added dimension of asking the client to, after listening to several pieces, rank each according to personal preference or other characteristic. Some goals of this approach included helping the client to increase his ability to cope with and adapt to changes in the world and identify his own perceptions and preferences and how these influence his view of reality.

Music Relaxation Overview. In this intervention, clients learn relaxation techniques such as breathing awareness, progressive muscle relaxation, and autogenic relaxation with recorded music, with or without directed imagery. The aim is to teach clients about ways to use music for relaxation and stress management. Houghton et al. (2002) call this approach Music with Progressive Muscle Relaxation Training and Music for Surface Relaxation. It is appropriate for both groups and individual clients. This intervention is designed for clients who need increased awareness of their own body tension related to stress. The main goal of the activity is to acquire ways to cope with stress or tension. This is an augmentative intervention. Client(s) should not be actively psychotic and/or unable to tolerate increased awareness of internal experience. Preparation. The therapist or clients (with therapist’s guidance) will select music that is quiet and structured; music could be live or recorded, New Age or classical, but should not be too ethereal, nor particularly familiar to clients. In other words, the music should have a regular, steady pace or rhythm as well as a clear tonality, and should not have strong associations with it that could distract clients from the relaxation goal. Music that lacks tonality or musical structure would be less advisable. Generally, because clients with schizophrenia could experience hallucinations or have difficulty tolerating focusing on their internal sensations, provide chairs rather than mats so that they can sit upright instead of lying down. The group/client can decide whether or not the lights should be dimmed for the experience, but it may be helpful to do so. If the therapist is inexperienced in leading guided imagery for relaxation, published scripts are available for this purpose. What to observe. Notice the clients’ posture and any tension/relaxation, fidgeting, or restlessness. Note if anyone needs to keep his eyes open during the experience—this is okay, but may indicate feelings of paranoia or vulnerability. Also note if clients become agitated, as the relaxation experience could lead to feelings of vulnerability and/or awareness of suppressed emotions that are

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surfacing. In the latter situation, if necessary, calmly bring the relaxation exercise to a close and assist the client in safe expression by grounding him in the here-and-now, perhaps through an active music-making activity. After the relaxation exercise, note whether clients appear to be more relaxed, and how long any benefits of the experience seem to last. Also note whether clients are aware of any changes in their body tension or stress levels. Procedures. Explain the purpose of the experience (music and relaxation exercise), and offer suggestions regarding physical posture and how to follow the therapist’s direction during the music. Clients will be most comfortable sitting tall, but relaxed, in their chairs, with their feet flat on the floor and hands resting comfortably in laps; if clients are resistant to taking this particular position, make this a suggestion and move on. Tell clients that while the music is playing, the therapist will describe ways to relax each part of their bodies, and that the music will help them to do so. If this group is not actively psychotic and can tolerate directed imagery, tell the group that after the body relaxation directions are over, the therapist will describe relaxing scenes that will be accompanied by the music; clients may have suggestions for scenes they would prefer (e.g., the beach, a forest, etc.), so the group can determine the scene they would like to imagine. When the group is ready, start playing the music (either live or recorded), and begin the relaxation exercise, first by directing them to bring awareness to their breathing and then starting at the feet and working section by section to the head, describing ways that each part of the body can relax. Encourage clients to allow the chair to support their body weight, and/or describe the breath as a way of gathering up the body’s tension (breathing in) and then releasing the tension (breathing out). Time the guiding with the pace of the music, and model breathing with audible inhalations and exhalations. A good concrete means of encouraging relaxation is to direct clients to first tense up their muscles in each section (e.g., make a fist when focusing on the hands), hold the tension for a few seconds, and then quickly release the tension (e.g., release the fist); guide the clients to notice the difference in sensation between the tense and relaxed experiences. Again, pace the timing of the tension/release with the pace of the music; if using live music, use changes in dynamics and tempo to mirror the tension/release action and the rate of breathing. If using directed imagery, locate where the clients are in the image by describing them standing in the scene and observing what is immediately around them. Then go on to describe the rest of the scene in more detail, using different sensory modalities (visual, auditory, kinesthetic, etc.). Allow a few moments for clients to be with the imagery, but not too long (15 seconds is plenty), in order to avoid the development of hallucinatory imagery. The therapist can direct clients to interact with the images (e.g., pick up a shell on the beach; smell a flower) if they wish. Keep the imagery section short, however (around 5 minutes), and bring the clients back to the same place where they started in the image. To close the relaxation/imagery exercise, fade out the music, bring the group’s awareness to sounds in the room and how their bodies feel in their chairs, remind them of where they are, and then, when ready, they can open their eyes. If the group wishes, they may share what their experiences were like, and which cues/directions helped them to relax, and which ones did not. Group members may identify ways they could independently use what they learned from this experience and under what circumstances. The therapist can offer further suggestions, such as what kind of music to use, ways to practice relaxation in and out of the hospital, and so on. Adaptations. Houghton et al. (2002) differentiate between a long-term process where the therapist trains the client in progressive muscle relaxation with music and a short-term intervention designed to meet the client’s acute needs for stress management. In a longer-term process, the therapist can teach the client about music selection and ways to use the musical elements to maintain attention and to relax the body. Imagery is an option if the group/individual is able to handle the task, but the intervention does not need to involve imagery at all.

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Group Music and Imagery Overview. Clients listen to recorded music in a relaxed state while the therapist directs them to imagine themselves in a scene; this is followed by verbal discussion. This approach, detailed by Moe (2002), is an adaptation of Summer’s Group Music and Imagery (2002), based on the Bonny Method of Guided Imagery and Music (BMGIM). Schapira (2003) has also described a similar adaptation called EISS (stimulation of images and sensations through sound). Both methods require training in BMGIM and are briefly described here. In general, clients who are indicated for this intervention should be psychiatrically stable, with psychotic symptoms under control. They also should be able to engage in a long-term therapy process with the therapist (several months, if not a year or more). Goals include development of the sense of self, moving from concrete to abstract thinking; improving the ability to relate to others; and increasing the structure of the inner sensory and experiential world. This intervention works at the intensive and primary levels of therapy. Because engaging with music to explore one’s internal imagination can be regressive, music and imagery experiences can induce or worsen existing psychotic symptoms. As Summer (1988) stated, for a person who has psychotic delusions, “not only can an imagined octopus be representative of a mother … it is, quite literally, an octopus …. If clients are too disorganized or symptomatic to verbally describe their inner state, they are not appropriate for this approach” (p. 32). Preparation. This is a ninety-minute session; therefore, the space must be private and quiet enough to host a session without disturbances for that length of time. Provide chairs and mats (if that option is appropriate) for the clients. Group discussion portions for the session should be done in a circular arrangement, but clients may choose to scatter themselves around the room in a comfortable spot for the music and imagery portion of the session. Appropriate musical selections include classical music pieces that are structured (baroque or classical pieces are good, such as Pachelbel’s Canon in D or Mozart’s Clarinet Concerto in F major); a reliable sound system is also needed. The therapist should know the length and structure of the pieces well enough to be able to manage changes in volume and intensity during the session. What to observe. Group discussion should be focused on here-and-now feelings, experiences, and concerns; the therapist should help focus and guide this sharing. Look for abreactions during the music and imagery session, that is, negative and destructive regressive reactions to the music and imagery. Guide the client out of the imagery and return to awareness of the environment and of his safety. Clients should use the closing conversation to help gain grounding after the imagery experience and to relate their imagery experiences to their concerns in the preliminary conversation. Procedures. As in individual GIM sessions, there is a preliminary conversation where individuals in the group can share their preoccupations and needs in the here-and-now. The therapist selects the music based on the group needs and atmosphere after the preliminary conversation. Meanwhile, the clients can choose to sit in a chair or lie down on a mat on the floor and get comfortable. The therapist then leads the group in a short (two-minute) relaxation exercise, with a focus on breathing. The therapist transitions into the music-listening phase of the session by starting the music recording and verbally guiding the group to begin imagining a scene to the music. Such scenes could be a exploring a house or going on a boat trip. The guiding is fairly directive and structured, but allows patients to experience their own images and associations. The music and guiding lasts only 10 minutes. Following this, the patients return to the group discussion format, sitting up and in chairs, and each person can share his imagery experience, including images, thoughts, and feelings. This part of the session can last about 45 minutes.

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Live Music Listening Overview. As described by Metzner (2010) in her work with an individual, the therapist plays music at the client’s request in order to develop a trusting relationship. This intervention may arise inthe-moment in individual work, when a client presents with resistance or inability to make music with the therapist due to lack of trust with the therapist, disorganized thoughts, or fears/delusions about the therapist. Thus, the primary goal is to develop trust with the therapist. This intervention functions at either the intensive or primary levels of therapy. Metzner (2010) advises using this intervention with care, as the therapist’s playing for the client could become a compulsive musical need for him such that the client would not develop the ability to initiate a musical interaction with the therapist. Preparation. This may occur spontaneously, but in the event that the therapist is aware in advance that she will be playing for the client, the therapist should determine what music would be most relevant for the client’s needs (simply by asking the client), and then be prepared to play for the client. Over time, this music could become incorporated into improvisations or songwriting experiences; therefore, the therapist should become comfortable with the music. What to observe. Pay attention to the client’s affect, eye contact, and physical posture. In general, note the client’s physical presence and whether he appears to be affected by the music, and if so, how. Also note whether the client appears to be experiencing internal stimuli (such as auditory hallucinations), and if so, whether the client can attend to the music despite these stimuli. After the music is over, see if the client wishes to respond in some way, either verbally or nonverbally, to this experience. Procedures. The client could initiate the intervention by requesting it, and the therapist would assent if it seems clinically appropriate. Otherwise, if the client is mute and not responsive to encouragement or prompts to engage in music with the therapist, the therapist could then choose to play a song or piece for the client to try to elicit a response. The therapist should find a comfortable place for the client to sit and observe/listen to the playing, if the client is amenable to the suggestion, and then the therapist can begin to play. The therapist should be attentive to the client’s responses (both verbal and nonverbal) while playing, and be prepared to repeat the entire song/piece or sections of the music where it feels appropriate. The therapist should bring the music to an end when the client seems ready to respond to the experience, or if the client has not presented with a clear response for some time. The therapist’s act of playing for the client could become a prelude to mutual music-making in subsequent sessions, depending on the client’s response to the music. Adaptations. In a study conducted by Hyashi et al. (2002), music therapists played live for groups of clients as an initial phase of their therapy. Live music for groups could also serve as a trustbuilding experience for both therapist and clients, particularly for groups who are new to the therapist. The therapist could play her major instrument for clients, particularly if this is not an instrument clients would otherwise usually see in music therapy groups. The therapist’s sharing of her musical identity with the group models personal musical sharing for the clients, and can help the group members feel more comfortable taking a risk by making music in the presence of the therapist. However, the therapist should be careful to not play music that is technically overwhelming or particularly elaborate, as this could intimidate clients and lead to more rather than less resistance to engage in music with the therapist.

Music Listening with Art Overview. Clients draw, paint, or sculpt while listening to music as a way to create a visual response to the music. The resulting artwork can serve as a jumping-off point for verbal processing or other kinds of expressive experiences. This adaptation of BMGIM is appropriate for either groups or

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individual clients who have poor ego strength, fragile emotional stability, and a history of psychosis (Summer, 1998). Thus, the intervention’s goals are to develop ego strength and emotional stability, and to maintain reality-based perception. This intervention works at either the intensive or primary level of therapy. There are no specific contraindications beyond those assumed for safe engagement in sessions involving props or art materials. The level of therapy is augmentative or intensive. Preparation. Therapists need to decide what kind of art medium to use in the session and then prepare the materials needed. For instance, if drawing mandalas, the therapist should gather white and/or black paper, draw large circles in pencil on the paper, and then make sure there are enough chalk and/or oil pastels, pencils, and/or markers for the clients to use. Paper towels are handy to have on hand for materials that could get messy. The session room should be arranged so that clients can comfortably create their artwork while listening to the music; if this will be a group session, make sure that clients have sufficient working space at the table. The therapist’s music selection should address the clients’ needs and preferences, and could be selected in advance of the session or at the beginning of the session with the clients’ input. The music selection should take into account clients’ ability to use music and art to respond to and channel emotion, and the clients’ need to be structured by the music. If clients need help containing their expression, then more structured and predictable music would be best, e.g., moderately paced baroque classical music. If clients need to express stronger feelings, then find music that will permit them to do so in a safe way; these pieces should have a strong rhythmic structure that will provide a safe container for strong emotions. Use care when selecting New Age music, as some pieces may leave clients feeling ungrounded. New Age pieces that are rhythmically and harmonically grounded may be appropriate. Songs with lyrics may be appropriate for individual sessions with clients who have particular attachments to specific artists or songs, and who need to find appropriate ways to express feelings related to these attachments. What to observe. Clients may tend to draw or sculpt even before the music starts; see if clients can take a few moments to listen first to the music before using the art materials. As the clients work, note if their artwork seems to be at all congruent with the music, while being aware that the client has his own perspective of the music. If the client’s art does not seem to be related to the music, see if it’s possible to determine why the client is expressing himself in that way—is it due to internal stimulation, events prior to the session, or something else? When talking about the artwork, note whether the client can connect musical events or ideas with the artwork, and if so, how abstract or concrete these connections are. Also note whether the client depicts any affect in the artwork, or if the client tends to avoid affective expression. Procedures. The therapist describes the nature of the activity, and introduces the art materials to the clients, perhaps demonstrating the properties of the different materials (e.g., the look of an oil pastel compared to that of a chalk pastel). The therapist can check in with clients and ask them to share how they are feeling in the moment, and perhaps what kind of art they would like to make, or what kind of music they need. The therapist directs the clients to take a few moments to listen to the music before using the materials. When the clients are ready, the therapist plays the music recording. The therapist can choose to use the materials as well, as long as she is able to observe the clients and be available for them at the same time. Allow the music to play for 5 to 10 minutes, depending on the clients’ attention span and involvement in the activity. If the piece is not complete but the clients are finished with their artwork, then fade out the music. Give the clients the opportunity to share about their art if they wish. If the group is able, relate the artwork to the clients’ needs and concerns in the here-and-now. Adaptations. Eyre (2003) used drawing to recordings of music as a starting point for her individual client’s improvisations. When the client completed his drawing, the therapist asked him to give a title to the drawing, and this title would become the theme for the free improvisation. Alternatively, the client used the title of the artwork as a theme for spontaneous movement to music that the client selected.

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Sound Training for Attention and Memory (STAM) Overview. Clients are instructed to listen to a specific CD from recordings created by Ceccato et al. (2006) and respond to particular sounds by moving body parts or making body percussion sounds. This protocol was designed for schizophrenic clients who have cognitive impairment such as problems with memory, attention, language, visual-motor skills, and executive functions. Clients who are unable to sustain attention and focus on a structured activity for at least 10 minutes and who cannot maintain safe behavior in a group setting would be contraindicated for this protocol. The goals of the protocol are to improve ability to discriminate auditory stimuli, increase attention span, and be able to shift attention from one task to another. This approach works at the augmentative level of therapy. Preparation. The session space should be clear of chairs so that clients have room to walk freely around the space. The therapist will need the CD created by Ceccato et al. (2006) and a reliable sound system. The therapist should be familiar with different phases of the STAM protocol in order to introduce and facilitate each phase. What to observe. Note whether and how clients respond to the sound cues for each task, and whether clients are able to perform the tasks involving short-term memory and sequences of sounds. As the clients move through the phases of the protocol, note any increase in attention span, improvement in memory, and improvement in auditory discrimination skills. Procedures. The therapist introduces the task to the group by describing the required steps to accomplish the first task in the protocol, e.g., clients freely walk around the room to recorded music, and whenever the recording presents a particular sound stimulus (such as a cymbal crash), the clients are instructed to move a body part in response. The therapist introduces more complex associations of sound stimuli and body movements or body percussion according to the protocol. In general terms, phase 1 involves movement associated with particular sounds; phase 2 involves discriminating particular sounds from background noise and tracking their incidence; phase 3 involves two- and three-step auditory cues for body movement; and phase 4 involves clients’ repeating back progressively more difficult sequences of sounds. Adaptations. If the therapist is unable to acquire the Ceccato et al. (2006) STAM CD, then the principles of this protocol could be adapted into a type of music game involving associations between music or sound stimuli and body movements or body percussion. Clients could develop their own movements for such a game, and take turns introducing their own movements or selecting a sound stimulus, perhaps using live music rather than a recording. Movement to Music Overview. In this experience, clients move to music with instructions provided at different levels of structure according to the clients’ needs. Wolfgram (1978) described a very structured form involving action songs as an intervention designed for a group of clients with intellectual disability and psychotic overlay. However, this activity could be useful for any patient with schizophrenia and/or psychosis who has movement disorder and/or cognitive impairments, as it is designed to address needs such as short attention span, low frustration tolerance, and anxiety. The activity’s goals include stimulating group cohesiveness, reducing tension, and developing gross motor skills. This is an augmentative-level intervention. While there are no specific contraindications, Wolfgram (1978) suggests limiting stimuli to prevent overwhelming clients with multistep instructions and elaborate music. Clients can also explore movement to music through the therapist’s modeling and then the client’s own creative movements (Houghton et al., 2002). These movements are guided more by musical qualities

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than by the lyrical content of action songs. In the most freely structured format, the therapist facilitates clients’ free movement to music, which may involve spontaneous interactive movement with peers. The movements and music may be based upon particular themes or imagery. Therapist-led movement groups are appropriate for clients who present with poor body awareness, lack of self-direction and insight, avolition, and/or impaired cognitive functioning. Clients’ free movement to music is most appropriate for individuals or groups with disturbed affect, particularly with blunting and flattening, and/or monotonous voice, or for clients who are nonverbal. The treatment goals for both of these more freely structured formats include improving body awareness and body image; developing identity through creative expression; improving problem-solving skills; improving auditory and perceptual skills; improving memory; increasing range of self-expression (and spontaneous self-expression); and developing coping skills for dysphoric mood and anxiety. Clients who are catatonic or too withdrawn to initiate spontaneous expressive movement may not yet be ready for these freely structured activities, and would need preparation through a more structured approach. Preparation. The space should be open and free of obstacles. Cotherapists can help facilitate the group, with one therapist playing live music for the movement while the other therapist leads the movement. Using the action song format, the therapist should choose an action song or create actions to another song. Select music and actions that are appropriate to the age and culture of the clients. Set up the space according to the type of movement that will be used, e.g., if clients are standing and moving around the room, clear the space of chairs and tables. If clients are seated, arrange chairs in a circle but with room around each chair for free movement. Wolfgram (1978) prefers live music, as this can be adapted in-themoment in order to capture clients’ attention and interest more easily than recorded music, while also encouraging group interaction. Depending on the kind of movement the therapist wants to lead, a guitar or piano could be an appropriate accompanying instrument, but other instruments (woodwinds, strings, percussion, voice) may be just as adaptable to leading movement while playing. For the more freely structured formats, the music can be either live or recorded, chosen and played by the therapist. Select music according to qualities that will encourage movement, such as its rhythm, texture, tempo, etc. The therapist should also choose movements to demonstrate to clients as a warm-up to more spontaneous movement. The therapist can also select themes for the movement and music, and these should be short, concrete, age-appropriate, and enjoyable. The movements should encourage client interaction and self-expression. If the therapist is working without the assistance of a cotherapist or student to play music or lead in movement, then recorded music is preferable, as this permits the therapist to engage more directly with the clients in the movement. What to observe. Observe whether clients follow movement directions, and if not, to what extent they are attending to the therapist, their peers, and the environment. If a client appears to be responding to internal stimuli (e.g., whispering/talking to self, perseverative movements), the therapist should gently redirect the clients back to the music and movement. Note any increasing agitation and assist these clients in feeling more comfortable in the session. With the more freely structured formats, take note of the ability of clients to vary and expand their movement repertoire, using the music to help time and structure movements; look at fast/slow motion, sharp/smooth motion, different parts of body alone and with other body parts, use of space, crossing the body’s midline, and how clients move alone versus with partners or the entire group, and how their movements align with the music elements. Pay attention to the degree to which clients, first, respond to cues to move (whether musical, gestural, or verbal) and, second, initiate their own unique movements. Note any change in affect and the range of expression (including use of only particular body parts, or moving only to particular cues or music).

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Procedures. When using the action song format or any highly structured approach, keep activities to 15 minutes or less, according to the abilities of group members to sustain attention on the task and not become frustrated. Model the movement(s) to the group, and allow group members time to attempt the movement and master it. Add the movement(s) to the accompanying music, step by step, until the group expresses confidence. If movements appear too complex for the group, adapt the movements to match the members’ abilities. For groups where the therapist leads free movement to music, the therapist should lead the group in a warm-up activity where she demonstrates different types of movement with different musical features or element. Connect the qualities of movement with the qualities of the music. Encourage controlled movements that match the qualities of the music, and encourage creative expression within the structure of the qualities being explored. If clients appear ready to initiate their own movements to the music, facilitate their taking turns leading the group. For groups where the therapist facilitates more client-led movement, the therapist introduces the activity by explaining that the group will be moving to music, starting with a warm-up or stretch led by the therapist. The therapist starts the music and demonstrates warm-up movements, which should be simple and gentle and be a first step in connecting movement to music, e.g., raising arms with an inhale, lowering arms on an exhale, in rhythm to the music. Lead this warm-up for five minutes, gradually involving the entire body and gradually encouraging clients to create their own movement to music and leading the group in a warm-up movement. When clients are warmed up, encourage them to move independently to the music, creating their own movements to follow the rhythm, tempo, melody, texture, etc. If using a theme or image to also guide the movements, the therapist should verbally introduce this theme after the warm-up and allow clients the opportunity to initiate their own movements along this theme before contributing to the group’s movement. Themes could be drawn from stories, poems, dramatic scenes, role-playing around a situation, feelings, etc. Adaptations. For clients with severely impaired movement and cognition, or for severely withdrawn clients, start with small movements, and perhaps incorporate props such as balls or streamers to help clients connect their movements with the environment and with others. Encourage group members to interact with peers through their movements, by using greeting gestures or via the props (e.g., tossing the ball to another person). An option for clients invested in movement to music, but who also need structure, could be to encourage clients to choreograph their own movements or a simple group dance routine to a song or favorite piece of music. The therapist should assist in structuring the choreography process for the group, rehearsing the movements/dance, and then perhaps performing the piece. In this case, the activity could become more performance-oriented. For groups where the clients have more leadership, the therapist can encourage individuals to lead the group in movements, and after doing so for several minutes, they can pass the leadership role to another member or take a cue from the therapist to do so. The clients could accompany their movements with musical instruments, and/or use poems, stories, or a song’s lyrics to provide an interactive theme for the group’s movements.

Psychodynamic Music and Movement Overview. Clients move freely to recorded or therapist-improvised music using a referential theme; this is followed by discussion and relaxation. This group intervention is based upon techniques developed for Analytical Music Therapy, and therefore requires additional training. A brief summary is provided here for reference. This group technique is not only used for groups of clients, but also for trainees in the Analytical Music Therapy approach (Pedersen, 2002). It is indicated for clients who are

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psychotic and who need to develop stronger awareness of their bodies and feelings and the connection between them. Goals include increased attention to body sensation and expanded experience of tension and relaxation; connecting body sensations evoked by music to associations and feelings; exploration of one’s own personality via the body and music; and concretizing and clarifying movement experiences through verbal processing. While actively psychotic patients would not necessarily be excluded from this approach, Pedersen (2002) advises to consider clients’ abilities to manage their internal stimuli in a lying down position during the relaxation experiences, and that sitting upright may be a preferable option for these clients. This approach works at the primary level of therapy. Preparation. This approach requires two music therapists to lead the session; one is the lead therapist who gives direction to the group, facilitates the discussion, and joins with the group in movement, while the other therapist observes and provides improvised music when required. The therapists should select two different recordings of contrasting music for the first movement experience and have a reliable sound system. Typically, the cotherapist uses piano for the improvised music. The room should have plenty of space for group members’ free movement, and perhaps chairs or cushions for the periods of group processing. Mats should be available for individuals to use for the final relaxation exercise. What to observe. Note the clients’ movement repertoire and how this changes over time. Also note how aware the clients’ are of their emotions and body sensations, and of any relationships between their emotions and body. As the clients engage in movement with the music, see whether the clients gain any more awareness of their emotions, their ability to express their emotions, and their bodies, and the relationship among these. Also listen for the clients’ ability to verbally express their experiences of movement to the music. Procedures. The therapists invite the clients into the space and to stand comfortably. After a period of quiet focus, a therapist plays two different pieces of recorded music and instructs the group members to move freely, allowing their bodies to respond to the music. A therapist then leads the group in verbal reflection of the experience, which leads to the group determining a “playing rule” for the group’s movement to live music. At this point, the cotherapist accompanies the group’s movements on the piano. The group may use imagery (e.g., walking in forest) or act out different sides of personality traits (e.g., introvert/extrovert) or particular feelings, alone or with others, based upon the playing rule. The group determines when the improvisation/movement is finished, and then comes together to verbally reflect on this experience. Next, the group members sit or lie down and the therapist guides the group through a check-in with the different parts of their body; the cotherapist plays a short improvisation on piano to accompany the relaxation exercise. Elements of this approach can be used in isolation, particularly movement to recorded music if a cotherapist is not available to provide improvised music. This approach could also be used with individual clients.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Improvisation is perhaps the most widely used and adapted method for this population, and it has been used by music therapists who operate in very diverse orientations, from cognitive-behavioral to humanistic to psychodynamic. While much of the literature regarding music therapy interventions for persons with psychosis and/or schizophrenia describes the use of free improvisation in one-to-one sessions, often in a very long-term therapeutic relationship, this is not common practice with this population in the U.S. However, it is important to be aware of this approach as it is inherently flexible and able to meet the client’s needs in-the-moment in a way that other methods cannot, which is very useful for

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psychotic clients whose needs can change from moment to moment. Furthermore, improvising with a music therapist helps the client develop structure and relationship out of a disintegrated and timeless psychotic world (De Backer, 2008). Given the range of this method’s applicability, there is also a wide range of skill levels required on the part of the therapist; whereas highly structured improvisational groups could be led by an entry-level music therapist with good leadership skills, other applications require advanced training, such as Analytical Music Therapy, Nordoff-Robbins Music Therapy, and psychodynamic approaches. While these approaches are described here, please note that further training should be acquired before using them. The following protocols are listed in order from those requiring only entry-level skills to those that require advanced skills and training.

Rhythm and Sound Improvisation Overview. Clients engage in a number of body percussion and/or found object experiences to create a mood or illustrate a referential theme; this is followed by a free improvisation using musical instruments with or without a referential theme. Lehrer-Carle (1971) states that this approach works well with clients who are not interested in learning an instrument or taking part in a performance group, as well as clients who are “regressed, poorly coordinated, poorly motivated … who cannot concentrate … and are minimally involved in an ongoing activity” (p. 112). In addition, this protocol would be particularly useful for groups who are resistant to group therapy and/or may need a fresh start in music therapy, because it breaks from the use of instruments in order to develop group cohesion and awareness of the environment and peers. Therefore, some of the appropriate goals include: to establish group cohesion and identity, to develop sense of belonging, to reduce preoccupation via active engagement in structured, concrete tasks, and to increase group interaction through group dynamics and music. This augmentative-level intervention is not suitable for patients who cannot attend to tasks for at least 15 minutes. It is also not suitable for patients who cannot maintain safety in a group setting. Preparation. This approach has several phases, which require different kinds of preparation. For the first four phases, no instruments are required. The therapist provides a piece of paper for the passing activity described below. The chairs should be arranged in a circle with the therapist sitting among the group members. For the fifth phase, the therapist should bring a variety of musical instruments suitable for instrumental improvisation. They can be arranged in an accessible location either inside the circle of chairs or in another location in the session space. What to observe. The therapist should notice the clients’ affect and awareness of environmental sounds during the first phase. Notice if the clients appear to be responding to internal stimuli, and whether this decreases while they are attending to external sounds. Notice clients’ reactions/attention to peers, and in later phases, how their musical expression relates to peers’ expression, e.g., does the group form a coherent rhythmic pulse? Do members take turns or acknowledge melodic or soloistic contributions? In later phases, do members take on leadership roles? Do quieter members contribute more to the group’s sound, and do “compulsive sharers” leave space for others to share? Procedures. The first phase of this approach involves listening activities. In these activities, the group members and therapist sit silently for several minutes and listen for any sounds within the range of the room. The therapist cues the start and end of the period of silence. Then, the therapist asks each member to share what was heard during that period of silence. The group members can comment on sounds that they also heard or sounds that they missed. Another activity involves silently passing a sheet of paper from person to person, attempting to make as little sound as possible. After the paper makes its round through the entire group, the therapist then asks the group members to share what they heard. In the second phase, the group members begin creating sound pictures of different images using only body parts, e.g., using only their mouths to depict a rainstorm. The sound pictures can expand to

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include other body parts and sounds (e.g., snapping, slapping knees, stomping) to describe other scenes, moods, or images. The therapist can select these scenes, or the group can determine the scenes if they are willing and able. After each improvisation, the therapist leads the group in a discussion regarding the sound qualities, moods, and feelings of each sound painting. For the third phase, the therapist asks two group members to use only body percussion to engage in a conversation. The rest of the group observes and listens to this conversation, and the therapist then asks the observers to offer their feedback to the ones who engaged in the conversation. Different group members can then take turns in the conversation roles, while the rest of the group again observes and offers feedback. After engaging in the preparatory sessions, the group is now ready to try free improvisation using only body percussion or other materials in the room (e.g., walls, trash can, tables, chairs, etc.). The therapist or group could suggest a theme or not, but the group otherwise freely improvises together. When the improvisation ends, the group members can reflect on their experience. The final phase introduces musical instruments into free group improvisation. The therapist should demonstrate the instruments in order to show how to properly play and handle each one. As with the body percussion improvisation, there could be a theme or image guiding the improvisation. When the improvisation ends, the therapist can again facilitate group reflection on the experience. The discussion could address the members’ roles, the structure of the music, and/or musical relationships that occurred in the improvisation. This entire protocol does not necessarily need to be adopted in its entirety, as each phase could be a separate intervention incorporated into a group’s use of improvisation depending on its needs at the time.

Improvisation and Storytelling Overview. This activity incorporates improvisation with simultaneous storytelling, using the instrumental sounds and music to enliven the story. Clients who present with inappropriate or blunted/flat affect, as well as those who have short attention span and thought disorder, would benefit from this intervention. Clients who are particularly disorganized would benefit from a more structured approach using a prewritten story, while clients who are more organized could create original stories. Perilli (1991) identified some appropriate treatment goals as integrating cognition and affect, integrating own needs and goals, increasing attention span, and developing problem-solving skills. This intervention could work at all levels of therapy (augmentative, intensive, or primary), depending on the treatment context. There are no particular contraindications other than those assumed for safe participation in an individual therapy session. Preparation. If the client and therapist wish to use a prewritten story, the therapist should select one to three short, age-appropriate stories from which the client can choose. Stories should be interesting to the client, and the client may have indicated his preference for a particular story theme. Choose stories that can easily incorporate sound or music effects. If the client is easily overwhelmed with choices, limit the number of stories to a manageable number. Write out the story on a handout so that the client can keep it after the session. If the client needs a lot of structure, go through the story and identify where sounds or music could depict different characters or actions. Underline the key words or phrases that would cue the client’s playing. Perilli (1991) asked her client to create her own story, and to accompany the story with music or sounds. If the client and therapist wish to take this approach, the therapist may consider a few story themes to suggest to the client. The therapist and client could either write down the story or record it as

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the client creates it; therefore, bring the appropriate materials or equipment, depending on how the story will be documented. Finally, select a range of instruments for the client to choose from to portray the story’s characters or actions. Do not bring too many instruments, as this can be overwhelming for disorganized clients. What to observe. If using a prewritten story, observe how the client goes about choosing the story to use for the session, and whether the client has difficulty making a selection. Note the client’s attention span, and whether the client needs prompting to focus on reading or playing along with the story. If the client is creating his own story, see how coherent the story line is, and how the client responds to any questions the therapist asks about the characters, the sequence of events, and any cause-effect relationships. Also, does the client portray his own needs or concerns in the story in some way? Can the client create a resolution to the problems in the story that is satisfying to him? When working with the music and the story, how easily can the client assign sounds or music to the story elements? Is there a logical relationship between the sounds and the story? Can the client use the music and story together to express emotions, and if so, does this influence his affect in any way? Procedures. For sessions using prewritten stories, the therapist would introduce one to three stories to the client, allowing the client to read them to herself, or the therapist could describe them to the client. If the client needs support in making a selection, the therapist helps the client choose a story that seems to meet the client’s interests and needs at that moment. Once the client has chosen the story, the therapist and client read through the story together once, and then discuss possible sounds and music to assign to different characters or events. The therapist supports this process by asking the client to consider each story element and demonstrating the sounds of different instruments if necessary. Once the sounds have been assigned to each character or story, the therapist and client again tell the story, this time with the accompanying sounds played by the client (or therapist, if the client assigns roles to the therapist). At the end, the client and therapist may choose to reflect on the experience of telling the story with the instrumental sounds. If the client has already written her own story, he would bring it or tell it to the therapist, and then go through the above process of assigning sounds to the story elements. If the client is writing his own story during the session, the therapist can suggest possible story themes if the client needs ideas to get started. If desired, the client may request to record the story or write it down as it is being told. Then the client and therapist can play/read back the story so that the client can assign sounds to the story elements. As above, the client and therapist may reflect on the experience of telling the client’s story in this way. Adaptations. In Perilli’s case study (1991), sometimes these storytelling experiences evolved into improvisations based upon a theme that emerged from the client’s story. In this way, the client has a means of expressing his unique self through the form of the story, while also practicing linking music/sounds with his expression. This kind of experience develops trust with the therapist; therefore, this intervention can lead into many other interventions as the client feels more comfortable with selfdisclosure and musical expression. Prerecorded music can also be used with story writing in a receptive twist to this idea: Summer (1988) suggested the use of classical music to guide the spontaneous writing of short stories in a group setting. Group members work individually on their stories while listening to the same piece of classical music, and then come together to share their stories. The group discussion can address treatment concerns related to the themes in the stories.

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Structured Instrumental Group Improvisation Overview. In this intervention, clients play instruments in a group to express musical elements or nonmusical themes (emotions, role-playing, imagery, poems). Clients with blunted/flattened or inappropriate affect, delusional thinking, avolition, distorted self-image, or lack of self-identity; who are socially withdrawn; and who present with preoccupation with internal stimuli would benefit from structured group improvisation. Clients who present with unsafe impulsive behavior (particularly violent or aggressive acting out) which precludes group attendance and safe use of musical instruments would be contraindicated for this activity. There are many possible goals that could be used with this intervention, including increasing nonverbal creative expression, appropriate identification and expression of affect, channeling negative affect, modulating mood, increasing reality orientation, engaging in problem-solving and decisionmaking, developing a sense of identity, increasing peer interaction, decreasing preoccupation, and increasing attention on music tasks. This is an augmentative-level intervention. Preparation. For all sessions using instrumental improvisation, the following general preparation advice applies. The therapist should select instruments that meet the clients’ functioning and skill level, and assemble a diverse, and yet not overwhelming, array of instruments. Make sure that all instruments are in good repair and do not present any hazards such as sharp edges or loose strings. Depending on the clients’ impulse control and group rituals/habits, instruments could be displayed in the center of a group of chairs on the floor, or laid out on a table or cart outside of the circle. In either case, each instrument should be visible and accessible. It is advisable to take an inventory of instruments and tools brought to the session and to check this inventory immediately at the end of the session, to be sure that clients have returned all instruments and accessories. If the therapist chooses to use particular modes or scales as a basis for improvisation, she can prepare instruments by arranging the appropriate keys in place (e.g., Orff instruments), marking the instruments with color-coded tape (e.g., keyboard, omnichord, or autoharp), or changing an instrument’s tuning (e.g., guitar to an open chord). If the therapist wishes to use particular themes to guide referential improvisations, she may choose to create a deck of cards with words of different emotions, situations, or scenes on them from which clients may choose. Clients could shuffle through cards to choose a theme they prefer, or choose blindly. What to observe. Do clients initiate choosing instruments? If not, do they respond to support and prompting from peers or the therapist to try instruments? How spontaneously do clients engage in the music, and can they do so within the given structure? If clients tend to disregard the structure, do they respond to redirection? Do clients relate to each other or to the therapist in the music? Are clients playing in a repetitive or rigid manner? Are they playing randomly without regard to musical or other cues? Procedures. The therapist introduces the experience by explaining that the group will be making its own music together using the instruments provided. The therapist may need to demonstrate instruments to the clients, to show safe and proper playing technique, as well as to stimulate interest in the activity. Clients should be encouraged to try different instruments to find the ones they prefer to play. The therapist then explains the specific rules or directions to guide the group’s playing. The directions limit or focus the ways clients can play, which can enable clients to feel more comfortable engaging in improvisation. Direction can be based around musical elements, such as exploration of tempo and/or volume (alternating between fast and slow/loud and soft, or gradually moving from one extreme to another), timbre (alternating or turn-taking between or among different kinds of sounds), tonality (using different modes or scales), harmony (using a blues chord progression), etc. Direction can also involve themes such as portraying emotions, images, or dramatic scenes. The therapist can choose the type of

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direction the group will use to guide the improvisation, and then ask clients to suggest the specific elements or themes (spontaneously, or via the card deck described above). The therapist can model the direction during the improvisation, and then ask clients to take on this leadership in turns. Direction during the improvisation can happen in many different ways, such as gestures, like those made by a musical conductor, or sound cues, such as a cymbal crash to signal a change of direction/theme, or even paper signs with symbols or words indicating the direction. The therapist can use particular playing techniques to musically guide the improvisation within the structure. Such techniques may include rhythmic grounding (maintaining a basic beat or rhythmic foundation for the group’s playing), reflecting (musically matching the clients’ expression), modeling (demonstrating something for group members to try or emulate), or intensifying (increasing dynamics or tempo, or increasing rhythmic or harmonic tension) (Bruscia, 1987). After improvising, if the group is able and willing, the therapist may ask the clients to give verbal feedback on the music. For clients who have difficulty concentrating on external stimuli, this discussion should focus on the instrumental sounds and musical events (e.g., “I noticed that drum was suddenly very loud after you told us to play quietly”), and then perhaps can address personal reactions to these events (e.g., how clients felt when the music became very loud and fast versus how they felt during the slow and soft music). For clients who have very disorganized or delusional thinking, it is best to stick to more concrete themes (such as musical elements of tempo and dynamics) rather than symbolic themes (such as emotions or imagery), and verbal processing does not need to venture into insight-based territory.

Group Drumming Overview. In this improvisation experience, clients play drums and nontuned percussion instruments together in a unified rhythm. Unlike other instrumental improvisation approaches, this one utilizes mainly drums and other percussion, and excludes melodic percussion such as Orff instruments. Group drumming is most appropriate for clients who have difficulty integrating into groups or who need to develop social skills. Therefore, this group can also be considered an intervention for an entire group of clients who need to develop cohesiveness or a group identity. Drumming can also provide an effective outlet for strong emotions while also connecting the body with expression of affect. Thus, appropriate treatment goals could include increasing interaction with peers, development of social skills, integration into group activities, channeling strong affect via music, and awareness of connection between emotion and body. Depending on the treatment setting, this intervention could work at both augmentative and intensive levels of therapy. Clients who may become overstimulated and/or overwhelmed by loud sounds would not be appropriate for this group. Furthermore, clients who have difficulty containing their expression to safe and appropriate use of props and musical instruments should not attend a drumming group. . This is an augmentative level of therapy. Preparation. The therapist should provide many different kinds of drums, from different drum families, in order to permit clients to have choices in timbres. Congas and djembes and similar drums provide deep bass sounds as well as contrasting higher-pitched sounds when struck near the edge of the head. Native American frame drums or Irish bodhrains produce deep bass sounds, while rattles, tambourines, and agogo bells lend contrasting textures and timbres. Arrange the instruments in an accessible location either inside a circle of chairs or elsewhere in the room. Clients may decide to change instruments in the middle of an improvisation, so place the instruments somewhere so that clients can easily do this. Make sure all the instruments are in good repair prior to the session. Especially with large groups, take an inventory immediately before and after each session to ensure that all instruments and accessories (e.g., mallets, tuning keys) are returned.

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What to observe. The therapist will likely first notice the group’s ability to come together rhythmically. Note where the rhythmic grounding comes from, and how long it takes to become established. Consider the rhythmic texture, whether there is much variation in patterns and timbres, or if the group seems to perseverate on a particular rhythmic phrase. Also note whether group members respond to new thematic material introduced by other members or the therapist, and how. See if the group’s playing shifts in tempo or volume, and whether the group is cohesive enough to conclude the improvisation on its own or if it needs a leader to facilitate this. Procedures. The therapist welcomes the clients to the session and introduces the group members to the drums and the concept of group drumming. The therapist may need to demonstrate how to play the different drums and other instruments. Then the therapist explains that this group’s intention is to work together to find a common rhythm and see what that experience feels like. As Ross et al. (2008) described, the therapist starts the improvisation by modeling a rhythmic foundation upon which the group can base their own playing. As the group’s playing becomes established, the therapist can pull back and let the clients lead the drumming. The therapist may interject different rhythmic patterns or accents to assess the group members’ ability to respond to these ideas and either incorporate them into the group rhythm or add their own ideas. If the group’s playing lacks variety or energy, the therapist could take on more leadership by standing and demonstrating different rhythmic ideas in a call-and-response fashion, or by pushing changes in tempo or volume. If the group does not seem able to bring the improvisation to a close, the therapist can lead the group in closing by conducting an ending; this could take the form of a verbal or gestural countdown or cue that can be clearly understood by the group. Adaptations. A drumming group can be more structured if desired, incorporating more direction from the therapist or clients to explore contrasting musical ideas or timbres, for example. The leader uses gestural cues to indicate shifts from one way of playing to another, and the leader can also pass leadership to another group member.

Group Vocal Improvisation Overview. Another approach to free improvisation in a group setting involves using only voice, rather than instruments. Voice work is a much more personal and expressive medium, as by definition it uses a person’s unique sound that can only be produced by his body. Some of this method is described in Houghton et al. (2002) as a part of Group Singing Therapy. This method would be most appropriate for clients who have difficulty with communication and expressing affect appropriately, particularly in doing so in their speech/voice. Practicing this expression in a group setting provides opportunities for peer feedback and response to a client’s individual vocalizations. In addition, because the voice is unique to each individual, gaining experience in using it as an expressive instrument provides opportunities to explore one’s unique identity in a musical context. These benefits are in addition to those ascribed to instrumental improvisation, such as increased reality orientation. Therefore, treatment goals include developing appropriate ways to express affect, developing self-esteem and self-identity, and developing group cohesion. Clients who are mute despite encouragement to sing/vocalize and/or those who are unable to maintain safe behavior in group settings would not be appropriate for this intervention. In the former case, such clients may benefit from individual vocal work rather than groups focused on singing. Depending on the treatment context, this approach could work at the augmentative or intensive level of therapy. Preparation. The room should be arranged as usual for group improvisation sessions (chairs in a circle, with therapist sitting among the clients), but without instruments. The therapist may choose a theme prior to the group according to the group’s functioning and process leading to that session.

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However, the group could determine their own theme based upon their needs at the time of the group. Themes may include nonmusical ideas such as depicting different emotions, scenes or stories, or images, or themes could explore musical ideas, such as contrasting dynamics, tempi, vocal timbres (high/low, male/female, etc.), and song forms/styles (such as blues or beatboxing; solo with background ensemble, etc.). The therapist should be vocally competent in the musical forms and styles that are most familiar to the clients, which may require some preparation prior to leading this kind of group. Some vocal training would be helpful in order to increase awareness of the physiology of vocal production, so that the therapist can provide accurate and helpful guidance to clients in use of the voice. As the purpose of the group is expressive vocalization rather than a musical product, there is no need to prepare repertoire or instructional materials. What to observe. Starting with the warm-up, see how the clients use their voices, including their use of their breath, where the voice resonates in their bodies, and the range of their affective and musical expression. Pitch accuracy may not be most important at first; instead, note how well-supported clients’ voices are and how much they can vary volume, pitch, and inflection, as well as whether they can match others’ singing. Also pay attention to group dynamics, noting how clients respond to each other’s contributions to the improvisation. Do they echo each other, sing in unison, elaborate on each other’s expressions, or negatively respond? For clients who are reluctant to sing, under what circumstances will they sing, and can the client describe why this is the case? As the clients become more comfortable with vocal expression, note how each of these domains changes, and whether they are able to appropriately expand and develop their vocal and affective expression with others. Procedures. The therapist should lead the group in a vocal warm-up; the purpose is not only to acclimate the group to vocal expression, but also to increase awareness of how the voice produces sound and to lay a foundation for exploring vocalizations. The warm-up should include breathing exercises to practice diaphragmatic breathing and sustained exhalations, gradual expansion of pitch ranges (e.g., pitched sighing or siren sounds, scales), and mouth exercises (e.g., humming, lip trills, consonant sounds). If clients wish, they can suggest their own sounds for the warm-up, and the therapist can facilitate these suggestions. After warm-up, the therapist should present the improvisation theme to the group, or facilitate the group’s own determination of the theme. The theme can be tied to seasonal or personal events, situations occurring in the treatment setting, or previous themes the group has explored. The therapist should move into the improvisation theme as soon as it has been determined, to promote vocal exploration rather than further discussion and intellectualization about the theme. The therapist may model her own creative expression to start the group, or elicit a group member’s interpretation of the theme. The therapist uses improvisational techniques such as reflecting, modeling, or intensifying (Bruscia, 1987) to facilitate the group’s improvisation. When the group ends each improvisation, the therapist can moderate a brief verbal discussion about the experience, seeking members’ reflections on how it felt to vocalize with their peers around the theme, and their feedback to peers about their vocalizations. The therapist may need to guide group members on how to give constructive feedback to each other. After the final improvisation and reflection, the therapist should ask members to identify experiences or insights they wish to remember and think about after the session. Adaptations. Houghton et al. (2002) described several adaptations to this intervention. First, groups could collaborate on songwriting as a way to concretize ideas or themes that emerge out of improvisations. Instruments such as the kazoo or props such as microphones can help clients to transition from speaking to singing. In addition to these ideas, therapists could audio record the improvisations and play them back as part of the reflective process; this would help clients get a different perspective of the sounds of their voices in the group.

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Free Group Improvisation Overview. Clients improvise individually as a warm-up, and then the group improvises freely together on a wide range of tuned and nontuned percussion instruments to depict a referential theme or explore sounds nonreferentially. In this experience, the group freely uses musical improvisation and group discussion to address needs and concerns in the here-and-now. Free group improvisation is indicated for clients who have the attention span and cognitive skills to engage in spontaneous, creative group expression, and who do not need the kinds of structures provided in Structured Group Improvisation. Odell-Miller (1991) found that this intervention was particularly helpful for clients who experience difficulty in utilizing verbal therapy to develop appropriate coping skills for stressors. Ross et al. (2008) used this approach for clients who were dually diagnosed with schizophrenia and substance addictions. Appropriate treatment goals for this intervention include increasing self-awareness, developing nonverbal creative self-expression, increasing self-esteem, improving interpersonal communication and socialization skills, and decreasing isolative behaviors. This intervention would be appropriate for either augmentative or intensive therapy contexts. The free-flowing format of this group would be contraindicated for clients who have cognitive difficulties and short attention span. Clients who are unable to maintain safe behavior in a group setting would also be contraindicated. Preparation. As with structured group improvisation, the therapist should assemble a wide range of instruments, including tuned and nontuned percussion, melodic percussion, and perhaps piano and/or guitar. Clients could also use voice or nonpercussion instruments as the therapist deems appropriate. The instruments should be arranged in an accessible location in the room, either inside or outside a circle of chairs for the group. The therapist should sit among the clients. As mentioned previously, the instruments should be in good repair, and the therapist should take an inventory before and after each group to ensure that all instruments, parts, and accessories have been returned. What to observe. Take note of whether and how clients initiate playing in the session, and how clients relate to one another in their playing. Do they merge with each other, do they work in opposition to each other, do they avoid musical contact, or can they contribute their unique sound in a way that also fits with the group’s playing? How do the clients respond to new musical ideas? Do they ignore them, incorporate them, assimilate them, or react negatively to them? Are clients expressing affect that is congruent with what they presented during the warm-up? Does their affect change in any way, and if so, does it seem appropriate? During group discussion, are the clients able to make connections between their internal states (feelings, body responses, thoughts) and the music? If so, can the clients gain any insight from these relationships? Procedures. After welcoming the group, the therapist can lead the group in an improvisational warm-up, where clients have the opportunity to try the instruments during a brief structured activity while also focusing their awareness on the here-and-now. The warm-up should involve some way that clients can express their current mood or feeling state, usually by taking turns playing a brief solo. After the warm-up, the therapist can ask the group to determine a theme or idea around which to improvise, or clients could freely improvise together to see what happens. The clients should begin the improvisation, but at times the therapist may need to model how to start the improvisation for the group. The therapist employs playing techniques such as those as mentioned previously in structured group improvisation (mirroring, modeling, rhythmic grounding, etc.) (Bruscia, 1987), in order to empathize with the clients’ expression, elicit responses, structure the group’s playing, create intimacy, or redirect the group’s playing. The group can choose to engage in verbal processing if they wish. The discussion, facilitated by the therapist, can explore relationships between the clients’ music and personal needs and feelings. The discussion could also relate the clients’ playing to their illnesses and problems, and could

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lead to generation of insights related to their treatment needs. The group could explore particular themes that emerged from the first improvisation and discussion through additional improvisations. The therapist can close the group through some kind of closing ritual, such as assigning a title to the session, or asking clients to identify a positive event in the session they wish to take with them as they leave.

Free Individual Improvisation Overview. As with free group improvisation, this approach focuses on freely created music, usually with both client and therapist. This approach is perhaps the most widely discussed in the music therapy literature regarding schizophrenic or psychotic clients (De Backer, 2008; Free, 2006; Jensen, 1999; John, 1995; Metzner, 2010; Pedersen, 1999; Tyson, 1979). Jensen (1999) felt that psychotic or schizophrenic clients who experience problems with interpersonal contact and communication, difficulty with self-awareness and expressing emotion, difficulty with self-identity, and who have distorted reality perception would benefit from individual improvisation with a music therapist. Pedersen (1999) felt that clients with such difficulties needed some way to break through their isolation from others and the environment, and that improvisation was an effective means to reach such clients. Some of the goals appropriate for this approach include containing psychotic symptoms, developing a therapeutic alliance, developing the ability to express oneself freely, decreasing isolation, and developing a sense of identity. Pedersen (1999) required the client’s commitment to engaging in individual improvisation as a primary therapy; however, it may be possible that this approach could also function at the intensive level. Other than the usual contraindications assumed for safe participation in individual therapy, there are no specific contraindications. Preparation. The therapist should provide a selection of instruments that provide some options for the client while not being overwhelming in range. These may include tuned and nontuned percussion, and could include guitar, autoharp, and piano and/or electric keyboard. The therapist and client may share instruments (such as the piano or an Orff xylophone), depending on the client’s interests and needs during the session. The room should be arranged with enough space for the client to move around and explore the instruments according to his desires. What to observe. Observe under what circumstances the client engages in the music, whether he is drawn to a particular instrument or plays only after the therapist begins to play in a particular way. Once the client is playing, note whether the client’s music is organized in any way, and what its musical features are. Notice whether the music is indicative of “sensorial play” (De Backer, 2008)—that is, without any kind of rhythmic, melodic, or harmonic organization—and whether that playing can shift with musical guidance from the therapist. Over time, notice whether the client’s musical relationship with the therapist changes, and whether the client is able to interact with the therapist as his own musical person. If the client is able to verbalize about his experiences, see how reality-based these observations are, and whether the client has gained any new awareness of his feelings or relationship with others through his playing. Procedures. The therapist welcomes the client to the session and follows the client’s lead regarding what and how to play. If the client seems hesitant, the therapist can model playing different instruments to elicit a response. Once the client starts to play, the therapist does not need to immediately join the client; Pedersen (1999) describes this as a moment where the therapist needs to “resonate” with the client. On the other hand, Pedersen states, the therapist may need to play for the client in order to develop a trusting relationship with the client. Over time (years, perhaps), the client can work toward playing with the therapist in a reciprocal manner. The improvisations do not refer to any themes, images, or ideas at first, but as the client becomes more able to verbally reflect upon the improvisations, the therapist and client can begin improvising with a theme in mind.

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De Backer (2008) outlined several specific ways the therapist could musically interact with the client during his improvisation: (1) playing a bass line or descant with the client’s melody; (2) anticipating the client’s internal sound by waiting for the client to play, creating a preparatory silence; (3) leaving silence at the end of the improvisation to allow the sounds to die away; (4) engaging in empathic listening during sensorial play; (5) trying to relate any musicality in the client’s music; and (6) doing the opposite of the client to provoke a response. Some therapists blended this approach to improvisation with music lessons (Metzner, 2010; Tyson, 1974). The flexibility of this combination allows clients to engage in the music in a way that is comfortable for them while providing opportunities for growth.

Individual Nordoff-Robbins Music Therapy (NRMT) Overview. In NRMT, an individual client improvises with the therapist or therapists with a focus on the development of musical interaction between them. This primarily improvisation-based approach was initially developed for use with children with developmental disorders by Paul Nordoff and Clive Robbins (Nordoff & Robbins, 1977). Since that time, NRMT therapists have explored and expanded its application to other populations, including adults with schizophrenia and psychosis. NRMT is a specialized model of music therapy; therefore training in the method is required to utilize it. NRMT is best suited for clients who have difficulty with interpersonal interaction and communication, and especially those clients who find engaging in verbal therapies particularly difficult. Some goals that therapists have cited with this method include to improve general mental health; to improve global functioning; to improve emotional state/reduce emotional disturbances; to improve communication and social interaction; to reduce paranoid agitation, delusional thought processes, and perceptual disorders; to strengthen client’s resources; to develop the client’s sense of self; and to increase musical interaction with therapist. There are no specific contraindications other than those usually assumed for safe participation in individual therapy sessions. Depending on the treatment context, this can be either an intensive- or primary-level intervention. Preparation. The therapist should have a wide range of musical instruments available: both tuned and nontuned percussion, as well as a piano and possibly a guitar. The selection should be varied, but not overwhelming for the client. The instruments should be arranged in a way that they are accessible to the client, and the client should have sufficient space to move around the room if he needs to. NRMT sessions are often videotaped for the therapist’s supervision, so if the therapist plans to do this, she will need to have permission from the client or his legal guardian to make the recording, and set up the necessary equipment prior to the session. What to observe. For a complete picture, Pavlicevic’s (2007) MIR(S) assessment tool identifies the particular aspects of musical relatedness that this improvisation approach seeks to address. Does the client respond to the therapist’s playing? If so, how? Is the playing perseverative, reactionary, or interactive? How long can the client sustain musical interaction with the therapist? Can the client and therapist together establish a musical “groove” that utilizes the client’s musical resources (Naess & Ruud, 2007)? Over time, does the client’s playing change, and specifically, does it become more related to the therapist’s playing? Procedures. The therapist carefully observes and listens to the client in order to find any possible opportunities for cocreating music. The therapist may initiate exploratory musical sounds on an instrument and watch to see whether the client responds. If the client declines to play an instrument, the therapist can take cues from his body movements and any related sounds or gestures that could be interpreted musically. The therapist uses techniques such as rhythmic grounding, reflecting, modeling, and others (Bruscia, 1987) to cocreate music with the client, accompanying in a way that meets the client’s

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emotional expression (Talwar et al., 2006). Another way of describing the therapist’s role is that she seeks to help establish a “groove” and rhythmic structure for the client, especially if this is culturally indicated for the client. This is an example of using the client’s background culture as a musical strength and resource upon which he can establish his identity (Solli, 2008). If the client is willing and able, he and the therapist may choose to talk about the music they created in order to identify features or patterns in the playing (Talwar et al., 2006) or to guide future music-making. While the NRMT approach is “music as therapy,” focusing on the music-making process as all that is necessary to achieve health, occasionally therapists may engage in brief discussions about the music to guide, interpret, or enhance the experience.

Analytical Music Therapy (AMT) Overview. Clients improvise on nonreferential and referential themes most often with the therapist and discuss the experience as it relates to conscious and unconscious processes. This is a particular approach to improvisation developed by Priestley (1994) and used with a wide range of clients, including those with psychosis and/or schizophrenia. This method requires additional training and therefore, is only briefly summarized here. In order to fully participate in AMT, clients need to be able to verbally reflect upon their experiences of music-making with the therapist. However, if clients tend to intellectualize, AMT can offer a more direct connection between thoughts and feelings by bypassing the intellectualization process. Clients who are very withdrawn, who have severe anxiety, who have poor boundaries, who have poor self-esteem or lack a sense of identity, who have obsessive or compulsive behaviors, and who have problems regulating their mood would also benefit from the AMT approach. Thus, possible goals can address affect (freer expression, ability to cope and recover from difficult affective experiences), improvement and development of self-esteem and self-identity, increased risktaking, greater ease with interpersonal interaction and relationship with others, and increased vitality. Priestley (1994) stated that clients with profound hearing impairment, with an IQ below 80, who have overtly psychotic symptoms, or who are “psychopathic” (have antisocial personality disorder) would be contraindicated for AMT. This intervention functions at the primary level of therapy. Preparation. The therapist should provide a wide range of instruments from which the client and therapist can choose during the session. The themes of the improvisations are determined during the session, so the only other preparation required is the therapist’s readiness to listen to the client and work with his presenting needs. What to observe. The therapist must closely observe, listen to, and intuit the client’s experience throughout the session by attending to what the client is expressing and how the client is expressing it. This means not only hearing the client’s words and music, but also noting the client’s affect, eye contact, body posture, energy level, and so on, and relating these observations together to get a whole picture of the client in the moment. The therapist must also attend to her countertransference responses, not only because these need to be brought to awareness for the sake of managing the therapist’s reactions to the client, but also because they may contain useful observations about the client that the therapist notices on a subconscious level. Altogether, these observations contribute to the therapist’s assessment of the client’s current needs as well as progress toward his therapy goals. Procedures. These procedural descriptions are based upon Pedersen’s (2002) summary of her work with adults in psychiatric settings. The session begins with an opening ritual, which helps orient the client to the “here-and-now.” This can take different forms, such as a relaxation exercise, or a musical warm-up of the voice, or listening to a short piece of music to focus the client’s attention on the momentby-moment nature of music.

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Next, the therapist and client talk about what is happening “here-and-now” for the client. This opening verbal discussion may relate to issues or feelings that have come up in previous sessions, but which are still immediately important to the client. Out of this discussion, the client and therapist agree upon a “playing rule,” which is the theme of the improvisation to follow. These rules may relate to particular emotions, imagery, feelings in the body, role-playing, and so on. Once the playing rule is established, the client and therapist engage in an improvisation. The therapist may choose to play piano in order to have a wide range of expressive possibilities to offer the client’s playing. But the therapist may also choose to double or complement the client’s playing by choosing a different instrument or singing. The therapist and client usually will come to an agreement about the therapist’s role in the improvisation before playing. The therapist intuitively responds to the client’s music, acting out her responses to the client in the “here-and-now.” The therapist may rely on different psychoanalytic or communication theories to help guide her responses to the client during improvisations. After the improvisation ends, the client has an opportunity to reflect upon the experience of playing with the therapist. The therapist should openly listen to the client’s responses (both verbal and nonverbal) and seek to resonate with the client’s experience. The therapist can restate what the client is saying and relate it to the client’s here-and-now context. The therapist could also make observations about what the client expressed in the music in contrast to what the client has expressed in words. The session ends with a closing ritual which helps to summarize what occurred in the session. This may take the form of the use of imagery (closing eyes and letting go of parts of the session that were not important, but recalling the most important parts and holding on to them) or of giving the session a name or title. Adaptations. Pedersen (1999) has developed an approach specifically for psychotic clients called “Holding and Reorganizing Music Therapy Modality.” The approach is suitable for clients who are overtly psychotic and who may not be ready for an intimate therapeutic relationship or able to engage in verbal reflection of their improvisation experiences. Thus, the therapist focuses on listening to the client’s playing and, at most, attempts to “resonate” with the client. If the client is reluctant to play, the therapist may play for the client in order to increase trust. Very gradually (over years, if needed), the therapist guides the client into more reciprocal improvisations with the therapist.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Re-creative approaches offer a great deal to clients who have difficulty with relating to others and the environment, as they are structured, manageable, and predictable musical experiences that are often familiar and thus feel safe. Music therapists can use these qualities of re-creating existing songs or musical pieces to help clients musically relate to the therapist in a one-to-one situation, or to help clients make music together in groups. Thus, they can become a starting point for building a therapeutic relationship and establishing trust with peers. The following activities are described in order from most structured to least structured.

Structured Group Sing-Along Overview. As the name implies, here the therapist leads a group of clients in singing along to familiar songs. This activity works especially well for clients with disorganized thinking, psychotic symptoms, and social withdrawal, with the related goals of increasing organized thinking and realitybased responses, and encouraging appropriate peer interactions through a group music experience. This

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is an augmentative-level intervention. There are no particular contraindications except for those typically assumed for any group activity. Preparation. The clients will need a way to choose from a wide range of songs, so prepare enough copies of a songbook that includes songs from genres and styles that will appeal to them. Ring binders work well for these, as it is easy to add new songs as clients request them over time. The songbook should only contain lyrics for each song, as music notation could be distracting for the clients. The therapist’s copy should contain chord notation or scores for each song. Be prepared to lead each song included in the book. The room should be set up with chairs in a circle formation, with the therapist sitting alongside the clients. Set the songbooks in an accessible location, and if using rhythm instruments, select the most appropriate ones and arrange them near the songbooks. The therapist’s accompanying instrument (guitar, keyboard) should be tuned/plugged in and ready to play. Finally, leading songs requires a strong voice from the therapist. If at all possible, take a moment or two before the session to gently warm up the voice so that it is comfortable and strong. Therapists may try to “sing through” a cold or sore throat, and unfortunately may strain the voice—this is an occupational injury! Therefore, therapists should maintain awareness of their vocal strengths and abilities and sing with care. During the session, it may not be necessary to sing at full volume at all times; pull back when the clients are able to carry the song on their own, and then sing with more intensity when the clients feel unsure of the melody or lyrics. This will also allow the clients to take on more musical leadership and ownership of the song. What to observe. Pay attention to whether and how the clients go about choosing songs from the songbooks—if there is a theme to the song choice, do their selections fit the theme? If not, what is guiding their selection(s)? Do they sing along? If so, do they sing for the entire song, or for parts of the song? If they are not sustaining their singing, what appears to be the reason for stopping? What is the quality of their singing? Does it match the group’s volume and intensity? Are they singing the correct words? If they are playing instruments, how does the instrumental playing fit with the group singing (particularly in terms of rhythm and dynamics)? Do the clients interact with their peers while engaging in the activity? What is the quality of their interaction? Do they initiate spontaneous, appropriate interactions with peers? Are the clients able to wait their turn in singing their songs? Can they resolve conflicts on their own, or with the support of the therapist? Procedures. The therapist asks group members to suggest songs either according to a theme (e.g., “How I feel today”) or according to personal preference, and then clients choose songs from songbooks containing lyrics of songs from a wide range of genres and styles. The therapist moderates the clients’ suggestions and helps organize the sequence of selected songs. Clients may choose to take more or less leadership in singing their chosen songs, and the therapist provides accompaniment via guitar or keyboard and her voice, varying vocal support according to the clients’ needs. The therapist encourages clients to provide brief feedback to peers after each selection and at the end of the group. Adaptations. This activity can be done with or without musical instruments—the therapist should assess whether adding instruments to singing would be beneficial to the group. Instruments and singing together could overwhelm some clients, while on the other hand, instruments could provide another avenue for musical expression for clients who are reluctant to sing or who need more kinesthetic activity to channel energy. Developing or revising the songbooks for sing-along groups could be an activity in itself. The therapist could bring additional song collections for clients to look through to suggest new songs for the songbooks, and the therapist could sight-read them to try them out with the group. This approach also models for the clients ways to take risks and try new experiences, while allowing for mistakes (e.g., sightreading mistakes).

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A theme for song selections could be song dedications, where clients choose songs to dedicate to specific peers, or to send messages to peers through the song. The clients can share their dedication before or after singing the song with the group, and the group can briefly give feedback on this dedication if it wishes.

Recreational Music Performance Groups Overview. Clients learn and practice songs or musical selections for recreation. Houghton et al. (2002) described these instrumental or vocal music groups as opportunities for clients to come together to make music, and possibly group performances (though this is not the emphasis of the group). It is primarily a social and recreational group to address social goals while also providing reality orientation and motivating activity. Clients who would benefit most from this activity are those who experience delusions or ideas of reference (where irrelevant or innocuous events, objects, and people are perceived by the client as having special significance to him personally); preoccupation with internal stimuli; anhedonia (lack of pleasure in activities that are usually pleasurable, or lack of motivation to engage in such activities); lack of self-identity; confusion about self-determination; and/or social isolation. The treatment goals would be to improve reality orientation; increase attention and focus in order to complete tasks or follow-through pursuit of activities; increase sense of autonomy; and increase peer interaction and social engagement. This is an augmentative-level activity. There are no specific contraindications other than those typically assumed for group attendance. Preparation. For instrumental groups, Houghton et al. (2002) suggested omnichord, autoharp, recorder, ukulele, guitar, keyboard, and various percussion. Choose instruments that are suitable for the functioning level of the clients and which would be of interest. The therapist may or may not use notation, and can create adapted notation (e.g., color coding over song lyrics on a large chart) or simply conduct the group with hand signs and other gestures. If using karaoke, have a wide range of musical selections available, and preferably a sound system with a microphone for clients to use when singing (a full-fledged karaoke system is not necessary, as clients often prefer to sing along with the original recordings). What to observe. How well do clients work together in making music, in taking on roles, and in making decisions? Do clients who are normally reserved or preoccupied initiate action in the music or in their roles? Note if a delusional client focuses on a particular song or piece of music, believing it has special meaning or reference for him; this may be an opportunity to learn more about the delusion, but if the preoccupation causes distress, the therapist may need to redirect the client’s attention to something else. Procedures. The therapist or clients may choose songs/pieces to perform, and the therapist teaches the songs/pieces as appropriate for the types of music and instruments being used. The therapist may assign musical parts and roles with a therapeutic aim, such as to encourage a client to take more leadership, or to synchronize or harmonize with peers. If the group wishes, it may decide to focus on particular pieces for a performance, and rehearse them over several sessions. In a karaoke group, clients freely choose the songs they wish to sing and then perform them for the group. Adaptations. If the group becomes more focused on presenting a polished performance of a piece of music, then it may become more of a performance ensemble (see next entry) rather than a recreational group.

Vocal or Instrumental Performance Ensemble Overview. This client group meets regularly to rehearse music for the purpose of performing for others. Thus, the group is not so much process-oriented as product-oriented, focusing on creating a

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pleasing performance (Eyre, 2011; Houghton et al., 2002). Clients who present with the following symptoms would likely benefit from this kind of group activity: impaired cognitive functions, such as problems with auditory discrimination and memory; avolition; anhedonia; lack of self-direction and lack of insight; social isolation; and difficulty responding to internal stimuli. Correspondingly, the treatment goals would include improvement in auditory and perceptual skills; improvement in short-term memory; increased motivation and interest in activities; increased attention and focus in order to complete tasks or follow-through pursuit of activities; increased sense of autonomy; development of positive self-image; increased peer and social interaction; and improved reality orientation. This is an augmentative intervention. There are no specific contraindications, aside from those typically assumed for group participation. Preparation. Once the type of group has been determined (choral/vocal, rock band, other kind of instrumental ensemble), the therapist can work with group members to select repertoire. The therapist will likely need to create arrangements of pieces in order to meet the functioning and skill levels of the various group members. This may also include using lyric sheets and notation or creating adapted notation schemes as necessary. The therapist should consider individual members’ abilities and assign roles according to their clinical needs as well as strengths. The therapist will have to bring the instruments and other materials the group needs to the session. It is recommended to arrange chairs in a semicircle around the therapist, who acts in the role of conductor/director. What to observe. Pay attention to how well the group can work cooperatively toward the performance goal, and how well individuals can suppress their individual needs for the sake of the group’s success. Note any difficulties with perception or attention, and help clients focus on the task at hand. Also note changes in individuals’ self-perception as well as development of group identity. Procedures. For new pieces, the therapist will present the music to the group by playing a recording or playing the music live. The therapist will then assign roles/parts to the clients and begin teaching the music step by step. For subsequent sessions, the therapist can set a goal for practicing a particular section of music or working out an aspect of the performance (e.g., dance steps or motions to the music). Depending on the motivation and functioning level of the group, the therapist can solicit client input at different stages of the process, including repertoire selection, music arranging, role assignments, and staging the performance. Clients who present with higher levels of cognitive functioning and who display strong leadership skills can, at the therapist’s discretion, take on some of the leadership in the group by perhaps directing some of the rehearsal, arranging the music, or choreographing dance moves.

Individual Vocal or Instrumental Instruction Overview. The client receives individual instruction from the therapist as a means to acquire musical skills and achieve therapeutic goals. Some therapists have used this approach as a starting point for individual work, particularly with clients who come to therapy with previous musical experience and who need to establish a safe, trusting relationship with the therapist before engaging in work that explicitly addresses treatment issues (Aigen, 1990; Metzner, 2010). Houghton et al. (2002) cited the same indications for this approach as those cited for Vocal or Instrumental Performance Ensemble—impaired cognition and auditory discrimination, avolition, anhedonia, social isolation, and preoccupation with internal stimuli. The treatment goals include developing trust with therapist and improving quality of interpersonal interaction with therapist; improving auditory and perceptual skills; improving short-term memory; increasing motivation and interest in activities; increasing attention and focus in order to complete tasks or follow-through pursuit of activities; increasing sense of autonomy; developing positive self-image; increasing peer and social interaction; and improving reality orientation. If this intervention is

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provided alone, it functions at the augmentative level. But if it is used in combination with other methods as part of a larger music therapy treatment plan, then it could function at either the intensive or primary levels of therapy. This activity is not recommended for clients who have poor impulse control and are unable to be safe in a one-on-one interaction with the therapist. Clients referred to this intervention in an inpatient setting may need to be accompanied by an additional staff person to ensure safety; if this is the case, consider whether the client can maintain safe behavior even under these circumstances. Clients who are particularly paranoid or aggressive will need careful attention to not trigger adverse reactions—be aware of how the client responds to others’ direct eye contact, body posture, and use of personal space. If the client perceives the therapist as being a threat, then he will not be able to engage in therapy and could act out. Preparation. Formal instructional materials may or may not be needed, depending on the client’s functioning level and previous experience. Clients who are very disorganized will likely benefit from brief sessions focusing on playing preferred music or basic instruction on how to hold, play, and care for an instrument. Books and papers with notation can be easily lost and may become a distraction to clients who have cognitive problems and/or delusional thought processes. If a client is ready and motivated, the therapist can introduce basic music notation or create adapted notation that suits the client’s abilities. The session room should be free of extraneous materials and instruments, to reduce distraction, while also allowing some space for the client to move around if he needs to do so. What to observe. Depending on the client’s needs, observe how well the client relates to the therapist’s instruction and feedback, including whether the client can incorporate feedback into his playing. Note changes in musical aspects of the client’s playing—rhythmic organization, tempo, fluidity and ease in playing, and expressiveness. Procedures. While the format is generally like that of a private music lesson, the therapist needs to adapt the session according to the client’s cognitive abilities, attention span, musical abilities, and capacity for relating to the therapist. For very disorganized clients, the therapist will have to follow the client’s lead most of the time; the client may have a particular piece he wants to work on, and the therapist can assist with technique and other concerns related to executing the piece. Be prepared for incremental progress, with sessions lasting as briefly as only a few minutes for clients who are very acutely ill. As clients become more organized and able to focus for longer periods of time, they can collaborate with the therapist on setting goals for working together, including selection of repertoire and whether to work toward a performance goal. Adaptations. Tyson (1974), Aigen (1990), and Metzner (2010) incorporated music instruction into their improvisational work with individual clients, in these cases for clients who were experienced musicians. Others (Free, Tuerk, & Tinkleman, 1986) used instruction as a starting point for building a relationship with particularly paranoid or withdrawn clients, later moving on to other methods such as songwriting or improvisation, either in individual work or in groups.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Composing songs or music provides opportunities for clients to musically tell their stories or create an original product showcasing their creativity. Therapeutic songwriting can involve varying degrees of support and structure from the therapist, who may provide most of the musical ideas to a client’s own lyrics, or who may simply support the client’s independent songwriting process. Recording and playing back the compositions provide opportunities for clients to receive feedback on their work, while also developing positive and reality-based self-esteem. The literature on the use of this method is limited, but in general, songwriting (rather than composing music) is effective in helping clients with disorganized

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thoughts and difficulties with affect/emotion to find ways to express themselves. These activities are again described in order from most structured to least structured.

Lyric Substitution Overview. This is a highly structured activity where the therapist chooses a song for the client/group and removes particular words from the lyrics, asking the client(s) to fill in their own words. e.g., using the Paul Simon song “El Condor Pasa,” leaving out a few words so that the song would read: “I’d rather be a […] than a [….]. Yes, I would, if I could, I surely would.” The clients then fill in their own words for the missing lyrics. The structure provides opportunities for clients to express their own feelings in familiar songs with immediate success. Cassity and Cassity (2006) stated that this activity is helpful for clients who have such a short attention span that they have difficulty expressing themselves. In general, any client who needs support in identifying and expressing his needs and emotions, whether due to thought disorder or difficulties with affect, could benefit from this intervention. The structure of the song provides a starting point for expressing thoughts and feelings, while the song form helps hold clients’ attention on the task. This task is also helpful for building group cohesion through the collaborative effort of determining the new lyrics to the song. Thus, the goals for this intervention could involve increasing attention span, identification and expression of thoughts and feelings, organization of thought processes, and building group cohesion. This is an augmentative-level intervention, with no specific contraindications other than those usually assumed for group attendance. Preparation. Prior to the group, the therapist will need to select a song that works well with this technique. When dropping words from the lyrics, consider the possible options clients could use in those spots, and be aware that clients will often use concrete ideas to accomplish this task. Lyrics that are very abstract or metaphoric may not make sense to clients with thought disorder, and therefore may not provide the kind of structure they need to contribute their own lyrics. For instance, even though the original lyrics of “El Condor Pasa” describe metaphoric situations, the lyric substitutions still make sense when clients contrast very concrete situations, such as “I’d rather have food than be hungry.” Once the song is chosen, write out two versions of the lyrics onto large sheets of paper or provide them in handouts. The first version is the original song, with all the lyrics; the second version has spaces in place of the missing words. If using large sheets of paper for the entire group to view and use together, bring markers to fill in the new lyrics. If using handouts, bring pencils or pens so that clients can write in the new lyrics themselves. Arrange the room so that clients and therapist can view the lyrics or write on the lyric sheets as appropriate. This may mean putting chairs around a table in the latter situation. The therapist will be playing the song live as the group works on the new lyrics, so bring an accompanying instrument and the music score. If the group would want to record the song, then bring the equipment needed to record and play back the song as well. What to observe. Notice whether clients need modeling or much prompting to think of lyrics to suggest for the song. Whether clients are shy or confused about the task, they may need modeling or suggestions to get started. Once the group starts coming up with ideas, pay attention to the group dynamics: Do particular members dominate the songwriting process? Can they step back and allow others to contribute if prompted to do so? Will the more withdrawn clients contribute when given the opportunity? Also consider the content of the new lyrics, including whether they are reality-based, whether they are coherent, and whether they express emotions, needs, or concrete concepts. Finally, note how the clients respond to the finished song, including whether or not they gained any new awareness or insights from the process of writing the song.

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Procedures. At the start of the session, the therapist should explain that the group will be working with a particular song. The therapist should introduce and play the song for the group, and encourage the group to sing along. Then the therapist should explain the concept of substituting particular words in the lyrics, providing an example if necessary. The therapist should present the second version of the lyric sheets with the blanked-out words, and ask the group for suggestions for the new lyrics. Depending on the size of the group, the therapist can assign a verse to each client, or ask each client to come up with one word for the song. The therapist facilitates the turn-taking and suggestions of new lyrics, and seeks feedback from the entire group as the new lyrics are added to the song. The therapist can ask clients to explain or describe their intended meaning behind their lyric suggestion if it is not clear to the therapist or group. When the group agrees upon new lyrics, a client can volunteer to write them into the blank spots on the large sheets for the entire group to see, or clients can write them into their own lyric sheets if using handouts. The therapist should periodically sing and play the newly composed lines to test out the new lyrics and get feedback from the group. Continue the songwriting process until each group member has the opportunity to contribute to the lyrics, and until the song is complete. At that time, the group should sing and play through the entire song, and has the option to record the song and hear it back. Adaptations. As clients become more comfortable with the task, they could take a few minutes to work independently on their own lyrics, and then bring them back to the group to share with everyone. Each member could be responsible for one verse of the song, and then the whole group could collaborate on the chorus.

Song Parodies Overview. In this activity, the client or group rewrites an entire song’s lyrics with the clients’ own words. The therapist assists as necessary to help the clients complete the song. The song may retain its original meaning, but with details that have personal relevance for the client. On the other hand, the new lyrics could change the song’s meaning completely, but express what the client wants to say. Because song parodies can involve a group’s expression about a person or idea, this activity is indicated when the group is in need of establishing a group identity or building cohesion (Cassity & Cassity, 2006). Thus, there are many associated goals related to client’s ability to contribute to the group process and present with appropriate social skills. Accordingly, individual clients can use song parodies to express something about themselves or their feelings about another person or idea. Goals would focus on development of reality-based, positive self-concept, and appropriate expression of feelings and thoughts. This activity could be contraindicated for a client who is delusional about a particular music group, or who has especially strong attachments to a specific song. Using songs by that music group, for instance, or songs that clients are particularly attached to could cause clients to become more fixated on these songs or upset by any changes to music upon which their identity hangs. In these cases, it is better to avoid using music that has such strong attachments or associations for the client. This activity could be used in both augmentative and intensive levels of therapy, depending on the treatment context. Preparation. The therapist might choose the song for the group, but it is more likely that the group will select the song they most want to work with. The selection process may occur over time, with some discussion among the group members and therapist. Prior to the session, the therapist should prepare lyric sheets or posters with the original lyrics printed out. The therapist should also have the score to the song and be able to lead it. The clients will also need blank paper and pencils, and/or large sheets of paper or an easel upon which they can write the new lyrics. What to observe. Take note of the clients’ choice of the song for the parody—why do they want to rewrite this particular song? What message are they trying to convey? If working in a group situation, is

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the group in agreement about the purpose of the song? How does the group come to consensus (if at all)? How well can the group work out their conflicts and disagreements? Does the finished song have a coherent message? If the song is directed to a specific person, can the group find ways to express their feelings about this person in an appropriate yet meaningful way? If the song is about the group’s identity, does the group come together through the songwriting experience? Procedures. The therapist may suggest the idea of a song parody to the group, and then, over one or more sessions (for just a couple minutes of time), the group members and therapist could determine which song to use. When the group is ready to start working on the song, they sing the original song together with the therapist’s support, and then they discuss what the theme of the new lyrics will be. As with lyric substitution, the group could work with large sheets of paper posted to the wall/easel, or on their own pieces of paper at a large table. The group could work one section at a time all together, or as individuals working independently on a verse or section of the song; the therapist can facilitate whichever method would work best for each particular group. As the group works out each line or section of the song, they can play that portion with the therapist’s assistance to check it with the music. If using an easel to compile the finalized lyrics, a group member can volunteer to write out the new lyrics on the easel pad/board. Once the song is complete, the group will sing the completed version, and could record or perform it for its intended audience. The procedure is similar for individual sessions. Adaptations. Song parodies can be written for specific people who are important to the group, perhaps as a way of saying good-bye to a leaving peer or staff member, or to express a particular sentiment to someone. In these situations, the group uses the song to convey memories or shared experiences with each other and with the recipient of the song. The group could then present the recipient with a printout of the new lyrics or a recording of the song.

Collaborative Songwriting Overview. This approach involves a mutual contribution from both client and therapist, and as such works best on an individual basis. The client might write lyrics to fit the therapist’s precomposed original music (Silverman, 2003a), or the therapist could compose music around lyrics or poems written by the client (Boone, 1991; Morgan, Bartrop, Telfer, & Tennant, 2011). This songwriting approach is suitable for individual clients who do not need as much structure or support as the lyric substitution or song parodies approaches, but who are not ready to compose a song independently. Clients who already write their own lyrics or poetry will likely find this intervention appealing. As with other songwriting approaches, this intervention helps clients express themselves effectively and appropriately with others, while also helping increase reality orientation and reduce delusional thought processes and perceptual disorders. This intervention should be used with care for clients whose delusions could be reinforced by this kind of collaboration. Clients may believe that they and the therapist will become “rock stars” because of the songs they write together. While this in itself is not sufficient reason to abandon collaborative songwriting with such clients, therapists should gently and positively redirect clients to the reality of the situation. This means that the client may be praised for the songs he writes among friends and family, but be dissuaded from expectations that this song will be heard on the radio or presented in music magazines. The intervention would be appropriate for both augmentative and intensive levels of therapy. Preparation. What the therapist should prepare for the session depends on how she and the client plan to collaborate. If the therapist is writing music to the client’s precomposed lyrics, then the client could provide the lyrics to the therapist prior to the session so that the therapist could work on some musical ideas. However, the therapist could spontaneously work on these ideas while the client is present in their session. If the client is writing lyrics to the therapist’s original music, then the therapist

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should prepare a selection of short pieces that the client can choose from, perhaps with varied moods and styles. The session space should have a table available for writing notes about the song, paper, and pencils, as well as the therapist’s accompanying instrument. If the client wishes to record the final song, the therapist should have a recording device in order to make the recording. What to observe. If clients are bringing in their own poetry, notice what the overarching themes of the poems are, and how the client presents them. What kind of affect does the client express, and how does the client deal with affect? When setting these lyrics to music, how does the client respond? Does the client have ideas of what the music should be like, and if so, does the music seem to match the tone of the lyrics? Is the lyrical content concrete or abstract, reality-based or delusional? If clients are writing their own lyrics to precomposed music, assess how much support clients need to compose the lyrics. Do they have difficulty coming up with words to express what they want to say? Do the lyrics fit the phrasing of the music? In both cases, how does the client respond to the finished song? Does the client want to share it with others? If so, how? Does the client have reality-based expectations of the song? Procedures. Clients may initiate this collaboration by bringing in their own poetry to sessions and asking to work with the therapist on turning it into a song; otherwise, the therapist can suggest to a client that he write a poem as a basis of future songwriting. Either way, the therapist may have the poem prior to the session and may have prepared a few musical ideas to share with the client at the session. The client can also bring the poem to the session, and the therapist can suggest musical ideas from which client can choose. Once the music and lyrics are complete, the client and therapist sing the song together. If the client wishes to write lyrics to precomposed music, the therapist can play the pieces for the client so that he can choose the piece he prefers. From there, the client can work with the therapist to compose lyrics that fit the music. If the client needs more time beyond the session to finish the song, the therapist could record the music onto a device that the client can listen to on his own. In both cases, when the song is complete, the client and therapist can practice singing and playing it together, and can record it if the client wishes. Adaptations. The client can take on more leadership and responsibility in the songwriting process, directing the therapist’s playing in order to collaboratively create music that meets the client’s vision for the piece. Jensen (1999) stated that clients would benefit from this kind of songwriting structure if they are experiencing problems with interpersonal interactions and communication, have difficulty with self-awareness and self-identity, need support in expressing emotion, and/or have a distorted perception of reality. Compared to the other songwriting options, this intervention would require a greater attention span and capability for abstract thinking compared to lyric substitution or song parodies, for example. Generally, this approach would work best in an individual therapy setting. The therapist gives the client a length limit to the songs or pieces to be composed, and then works with the client to determine a theme for the song. The therapist asks the client to sketch/outline ideas for the compositions, and then the therapist incorporates these ideas into some playing on the accompanying instrument. The client guides and corrects the therapist’s playing until the music matches the client’s ideas. The process continues until the entire song or piece is composed.

CLOSING REMARKS ON METHODOLOGY Guidelines on Group Format Group versus individual sessions. Depending on the treatment setting, therapists may be required to provide primarily group or individual sessions. But even in settings where clients usually

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attend group sessions, a client may be contraindicated for group work. In general, clients who are unable to maintain safe behavior in groups, whether due to impulsivity, paranoia, or acute psychosis, should not attend group therapy sessions. If the therapist can establish a safe setting in which to work (often with additional staff nearby or in the room for assistance), and if the client seems willing to meet with the therapist and either listen to or play music with the therapist, then individual sessions may be indicated. These clients may be unable to meet for more than a few minutes at a time at first, so initial sessions are geared toward helping the client feel safe with the therapist and the music. Over time, as the client and therapist establish rapport and the client increases his tolerance for musical interaction, the therapist could work toward transitioning the client to group work, if she chooses. Individual work does not need to be limited to clients who are unable to tolerate groups, however. Clients who show potential to use music in a more intensive way to positively affect their mood and other symptoms could also benefit from individual music therapy sessions. Some therapists have also used individual work with clients as a contingency reward for safe behavior or progress toward meeting treatment goals (Silverman, 2003a), in order to motivate clients who have a strong affinity for music. Therapists use many different methods for individual sessions, as described above. Clients who are extremely withdrawn may be unable to do more than engage in receptive experiences until they feel more comfortable with the therapist. Clients who have problems with impulsivity will require highly structured sessions with limited musical options. Other clients prefer a lesson format and the familiarity and safety of being in the student role with the therapist as teacher. Thus, the therapist will need to assess each client and plan carefully for each session. The length and frequency of individual sessions are primarily dependent on the client’s needs and abilities, and may also be determined by the therapist’s availability at the treatment setting. Clients with limited ability to interact with the therapist or with the music could meet for five minutes at a time, a few times a week. Clients who are able to sustain attention and focus on a longer session may meet weekly for 30 minutes per session. In the U.S., music therapy is primarily offered in group sessions, which focus on developing not only interpersonal skills and peer support, but also reality orientation. Therapists should design groups to meet common needs and interests of the clients, and make group assignments accordingly. This could mean a group for clients with limited functioning that meets several times a week and which may employ a variety of structured music therapy approaches, or it could mean a weekly songwriting group for higherfunctioning clients. An ideal group size is around 8 to 10 members, but groups with a recreational focus (karaoke, sing-alongs, drumming) are often larger. Clients with limited attention span and tolerance for interaction will need shorter sessions, around a half-hour in length; individual clients coping with acute symptoms may only be able to attend a portion of this time, as they are able. Clients who are able to focus and engage for longer periods could have sessions as long as 50 to 60 minutes. For an inpatient setting, groups may be offered anywhere between one and five times per week, depending on the availability and support of music therapy and other services. For outpatient settings, music therapy groups may be offered one to three times per week.

Guidelines on Sequencing Activities/Experiences within a Session Opening/warm-up experiences. In general, the initial activity of each session should serve as a means of orienting clients to the session environment, the purpose of the session, and the expectations of the session, all to prepare clients for the primary experience that the therapist has planned. For group sessions, opening experiences are often framed in terms of a “warm-up” to both the music and interacting with others. They should be fairly structured, simple, active activities that introduce an element of the main purpose of the session in an accessible, approachable way. For example, if the therapist intends to

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explore affective expression, then the warm-up may consist of a very structured song completion activity to a prewritten Hello Song, where individual members can take turns stating how they feel at the moment; or the therapist may ask the clients to each choose an instrument and then take turns playing it solo (a musical “check-in”), either to nonverbally express how they are currently feeling or simply to engage in using the instruments. Receptive experiences do not generally work well as warm-up activities in groups, as they require clients to focus on their personal experiences of the music, and do not help clients increase awareness of, or interaction with, their peers. If the therapist intends to use a receptive experience as the main focus of the group time, then the warm-up should address the need for a receptive experience in an active way. If the need is stress reduction, then the group may talk about their awareness of stress, or depict their experience of stress musically, as a starting point for the receptive focus of stress reduction. For sessions with individuals, a separate opening experience would only be indicated if the client is able to tolerate a series of music experiences; otherwise, clients who can tolerate only a few minutes’ interaction with the therapist will likely try only one kind of experience during that time. For the latter situation, a couple of receptive approaches to use have been described above (e.g., Music Appreciation, Live Music Listening); these can be helpful for clients who are too paranoid or disorganized to attempt more active experiences, such as singing or playing instruments. Improvisational experiences (such as Nordoff-Robbins Music Therapy) would approach the client according to his abilities and needs at the moment, not using an “opening” experience as much as a careful musical meeting with the client with the intention of developing that meeting into increased musical interaction throughout the session. For those clients who can tolerate a series of musical experiences, the opening experience serves the same purpose as it does for group work—to actively warm up the client to the intention of the session time, and to prepare the client for the work of the main music experience. Transitions between experiences. Particularly in group work, therapists may use a few different methods and experiences from the opening through to the closing of a session. The shifts from warm-up to the main activity to closing activity should not be jarring or abrupt. First, the therapist needs to have a theme or concept in mind in order to make smooth transitions. A highly structured instrumental, improvisational check-in around “How are you feeling today?” can very easily segue into a songwriting experience using a blues progression or fill-in-the-blank song lyrics to a precomposed song around feelings. Second, the therapist should consider the energy level required for each activity, and design the session around the energy level that the group presents at the beginning, the energy level required for the main activity, and then the energy level desired for when the clients leave the session. Experiences should not demand large shifts in energy from one activity to the next—thus, if a group of clients tend to enter the group with a lot of energy, and the therapeutic goal is to help them modulate the energy, select activities that will allow them to musically expend some of that energy gradually over the course of the session so that they leave the group in a more controlled, modulated demeanor. When the sequence is planned carefully in terms of a session theme and group energy levels, transitioning to the next activity is simply a matter of taking the main theme of the previous activity and using it to introduce the next activity, demonstrating how to do so with the required energy level. As mentioned earlier, when using receptive methods as the primary experience of a group session, it is necessary to first develop a group process before entering the receptive experience, perhaps through a group discussion or musical check-in. When moving from this kind of active opening activity to a receptive activity, the therapist should summarize the group’s experiences of the former in order to highlight ideas or concepts that individual clients can keep in mind while going into the latter. This way, group members can draw on the group experience as they enter a more reflective engagement with the music, and notice physical or emotional responses they have in common with their peers. As appropriate, after the receptive activity, the therapist will continue to help individual clients relate their experiences with their peers, often through discussion and reflection of personal responses to the music.

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Closing experiences. At the end of the session, the therapist helps the clients close the session in a way that contains any difficult or strong emotions, or excess energy, so that they can manage their feelings or behaviors until the next session. In general, this means a more structured experience, using either talking or music, that helps to organize and concretize the events that occurred during the session. This may mean a “cooldown” in a particularly active group (perhaps a very energetic improvisational experience) or asking clients to state what they learned from the group that day as part of a discussion summarizing the group’s events. The closing should help clients prepare for reentering the world outside of the session, so that that they can draw from any positive experiences they had during the session. Regardless of the type of closure, the therapist again needs to somehow use or revisit the theme which was the focus of the session’s opening experience, to tie all the session’s events together into a cohesive experience. While the therapist can guide the group to revisit the theme in the closing, whenever possible, the clients should take the lead in identifying how they perceived or experienced the theme from their perspectives. Verbal or discussion-based closing experiences can range from a brief recap of the group’s events to a more insight-based summary of positive ideas that group members will take away from the session. When using very task-based activities such as Music Bingo or very structured songwriting, a verbal recap can provide assessment information about clients’ reality orientation, memory, or cognitive processes. In these cases, the concluding discussion would be brief and focus upon positive behaviors or new skills that clients presented while engaging in the activity (e.g., “Jerry, thank you for writing down the lyrics for us today—that was the first time you did that for the group.”). When using verbal reflection or discussion as part of the main group experience (e.g., song discussions, free improvisation, or group music and imagery), a longer closing discussion would be more appropriate These discussions could go beyond merely summarizing the events of the session and involve insights or new awareness that clients experienced by engaging in the music. Music-based closing experiences should be more structured than the main activity, and again somehow revisit or highlight the session’s theme. Perhaps, during an improvisation, a particular musical motive stood out for the group; therefore, the group can turn this motive into a song or chant to summarize an important insight or awareness. A drumming group could close with the therapist taking on more leadership and leading the group in a call-and-response format for a minute or two, and providing a countdown to a closing rhythmic figure. After a sing-along song discussion group, the group may identify a particular song that resonated with most of the group members, and the group could sing this song again as a final anthem. On ongoing group could choose a closing song to use for every session they meet, which perhaps could be modified from session to session to fit the group’s needs each day. If the therapist chooses to use a music-based closing, clients may wish to verbalize briefly about the session. Therefore, the therapist should be prepared to facilitate the discussion according to the group’s abilities and needs.

RESEARCH EVIDENCE Research of the effectiveness of music therapy for persons living with schizophrenia and/or psychosis has grown in the past 15 years, but remains somewhat limited compared to research for other clinical populations. Much research reflects the researchers’ own clinical practice; therefore, many studies include a variety of methods and approaches rather than an investigation into the effectiveness of a specific music therapy technique or approach. However, there are a few studies which do look at the effectiveness of particular approaches, and these are described below. More recently, some researchers have conducted meta-analyses to discover the broad effects of music therapy treatment for persons living with schizophrenia and psychosis. These analyses are discussed in the following section.

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Meta-Analyses Meta-analyses are usually quantitative analyses of a group of research studies examining similar outcomes. By grouping together research studies in this way, researchers hope to discover patterns in research data that may not be detectible in individual studies. The first meta-analysis conducted on research related to music therapy and schizophrenia (Silverman, 2003b) found that music was effective at reducing symptoms of psychosis, although the author found no differences between the use of live vs. recorded music in music therapy interventions. Since that first meta-analysis, two Cochrane Systematic Reviews have been conducted on studies examining the effects of music therapy on schizophrenia and psychosis. Cochrane Reviews are considered the gold standard in medical evidence, as the criteria for including research studies for statistical analysis are stringent in order to limit analysis to only the highest-quality studies. In the most recent Cochrane Review, Mössler, Chen, Heldal, and Gold (2011) could only examine the results of eight randomized controlled trials which met the inclusion criteria. These eight trials, several of which are discussed in later sections, utilized a wide range of methods, including improvisation (Ceccato et al., 2006; Talwar et al., 2006; Ulrich, Houtmans, & Gold, 2007, Yang, Weng, Zhang, & Ma, 1998), re-creative approaches (Tang, Yao, & Zhang, 1994; Ulrich et al., 2007), and receptive approaches (Ceccato et al., 2006; Tang et al., 1994; Yang, et al., 1998). The results indicated that, on the whole, music therapy improves clients’ global state, negative symptoms, and social functioning, but only if a sufficient number of music therapy sessions are provided by qualified music therapists. As the included studies’ treatment dosages ranged from 7 to 78 sessions, the authors recommended that further research should address the long-term effects of music therapy and dose-response relationships. Furthermore, research also needs to investigate the relevance of outcome measures for music therapy research.

Receptive Music Therapy Research on the effects of receptive methods found positive outcomes related to a wide range of treatment needs and concerns, despite the quite varied interventions employed. In Hyashi et al. (2002), where therapists performed live music for group listening experiences as an initial phase of therapy, clients demonstrated a reduction in symptoms and improved quality of life. Tang et al. (1994) also showed a reduction in negative symptoms, as well as an increase in clients’ communication with others, reduced social isolation, and increased interest in community events. For this study, clients listened to recordings of Chinese folk songs in addition to group singing and instrumental playing. Social measures also improved in Ceccato et al. (2006), along with memory. The method employed in this study was the STAM protocol, where clients responded to recorded sound stimuli with prescribed movements and body percussion. Finally, Moe, Roesen, and Raben (2000) conducted a study examining first the outcomes of engaging in group music and imagery, and then the client responses to the intervention. Though this was a small study (N = 9) the quantitative data showed an improvement in Global Assessment of Functioning (GAF) scores, and surveys collected from the clients showed that subjects felt the therapy was beneficial and provided them support. Moe (2002) went on to qualitatively investigate clients’ responses to the intervention and found that the music’s structure, dynamic, and nonverbal characteristics helped the clients form healthier inner psychological structures while also alleviating stress through relaxation. Thus, research evidence shows that receptive methods directly address negative symptoms of schizophrenia while also addressing cognitive, social, and physical domains.

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Improvisational Music Therapy Five different quantitative studies examining the effects of improvisation found several positive outcomes across different domains for clients with schizophrenia and/or psychosis. Three of these studies were randomized controlled trials (Ceccato et al., 2006; Talwar et al., 2006; Ulrich et al., 2007), while the fourth study utilized a quasi-randomization procedure (Morgan et al., 2011) and the fifth study was a pilot investigation without a comparison or control group (Ross et al., 2008). Each of these studies except for Ross et al. utilized client-led improvisational approaches with limited structure. Ross et al.’s method incorporated more structured and therapist-led improvisational methods. These studies found significant improvement in subjects’ social measures (Ceccato et al., 2006; Ulrich et al., 2007), reduction in negative symptoms (Ulrich et al., 2007), and reduction in acute psychiatric symptoms (Morgan et al., 2011). In Talwar et al.’s (2006) study, which used NRMT, the sample size was too small to lead to significant results. However, the data indicated a short-term reduction in general and negative symptoms of schizophrenia, and increased participation in inpatient activities. Two studies found significant results related to treatment contexts: Ross et al. (2008) showed that subjects who attended more music therapy sessions demonstrated increased adherence to their discharge treatment plans. Morgan et al.’s (2011) music therapy group data showed a trend toward shorter length of stay in the psychiatric facility when compared to the control group. Pavlicevic (1994) demonstrated that schizophrenic patients who received 10 weekly individual sessions had higher MIR(S) scores along with decreased brief psychiatric rating scale (BPRS) scores when compared to controls who received only assessment sessions.

Compositional Music Therapy Only two studies specifically examined outcomes of compositional approaches in music therapy. Grocke, Bloch, and Castle (2008) studied the effects of songwriting and recording in a community music therapy group. Subjects reported improved quality-of-life scores, and thematic analysis of the songs written by the clients indicated that clients felt connected with the world and their environment, struggle with living with mental illness but feel supported by others and by religion/spirituality, experience pleasure by living in the present moment, and experience joy from being part of a cohesive group. Morgan et al. (2011) studied the effects of both improvisation and songwriting in their quasi-randomized controlled trial. As mentioned above, the subjects in the music therapy group experienced a reduction in acute psychiatric symptoms, and the data showed a trend toward a shorter length of stay in the facility.

Re-creative Music Therapy All of the studies that utilized re-creative methods did so in combination with other methods; therefore, it is difficult to make direct links between re-creative approaches and the outcomes found in this research. Again, the studies found that music therapy had a positive impact on a wide range of outcomes. Subjects experienced improved social interaction (Ulrich et al., 2007), increased ability to converse with others and reduced social isolation (Tang et al., 1994), and decreased social withdrawal (Yang et al., 1998). Also in regard to the social domain, Hyahsi et al. (2002) found that patients reported an increase in their own participation in group singing over time in music therapy groups, and Tang et al. (1994) found that clients expressed increased interest in external events. In terms of mental state, Yang et al. (1998), Tang et al. (1994), and Ulrich et al. (2007) all found that subjects experienced a reduction in negative symptoms due to music therapy. Furthermore, Yang et

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al. also found that the music therapy group experienced some relief from hallucinations and disorganized thoughts.

SUMMARY AND CONCLUSIONS As this chapter illustrates, music therapy in the treatment of schizophrenia and psychosis is a very broad and eclectic area of practice, but one which operates on basic principles of the use of music to promote mental health. Music therapy has been utilized with this population for decades, yet there is a great deal of work to be done to fully utilize music therapy as well as build the research evidence for specific music therapy interventions and protocols. While improvisation is the method most frequently used with this population, very few studies have examined the effectiveness of any one method in particular, as most quantitative research has investigated the effects of a combination of methods with the study sample. This may reflect the reality of music therapy treatment for this population, but as a result it is difficult to isolate the aspects of each method that are most helpful in promoting health for these clients. At the very least, systematic investigation of the effects of the improvisation, receptive, re-creative, and composition/songwriting methods is needed, while investigation into particular approaches within each method (e.g., Nordoff-Robbins, music games, song discussion, etc.) would be more helpful for clinicians. Such investigation would help elucidate the specific and efficient ways in which music works at metaphoric, paraverbal, and preverbal levels to promote mental health. In the U.S., music therapy for persons living with schizophrenia and other chronic mental illness is usually limited to group work at inpatient settings, and very little is offered either for individual clients or for clients in outpatient or community settings. While there is evidence that clients appear to benefit from group work, little is known about ways in which individual music therapy could complement group work, or ways in which music therapy could provide support for clients attending outpatient treatment or in community settings. After discharge, many clients do not receive enough support to sustain their recovery in the community; music therapy could provide a much needed support to these clients who face a difficult transition from a highly structured and supported daily routine in a hospital to a far less structured and supported life outside of the hospital. Therefore, future research must investigate the effect of music therapy on treatment utilization and rehospitalization rates, as well as empowerment and quality of life for persons living with chronic mental illness, all factors important in the recovery model for mental health treatment (Jacobson & Greenley, 2001). In the meantime, clinicians can press for increased music therapy services at all levels of care— whether for more frequent and intensive work with inpatient clients, or for increased opportunities for clients attending outpatient care to utilize music therapy. Clinicians should stay abreast of research in this population, and share the evidence of music therapy’s effectiveness; such advocacy can improve reimbursement and funding of music therapy, leading to expansion of services. Clinicians should also investigate all available licensure options in their respective states, which could also improve reimbursement rates. Music therapy is greatly underutilized in outpatient and community settings. Therapists providing services to clients in the community need to measure and publish the outcomes of their work, and new community programs need to be established, carrying on the pioneering work of therapists such as Florence Tyson (McGuire, 2004). Today, such work would be included under the expanding umbrella of Community Music Therapy (Stige & Aarø, 2012), which holds great promise for people living with schizophrenia and/or psychosis. Music therapy applications that help to create a bridge between treatment settings and independent living in the community provide much needed support for clients to integrate into their communities and helps to reduce the stigma of mental illness in the community.

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In conclusion, music therapy is powerful, unique, and multidimensional tool with enormous potential to help persons living with schizophrenia and/or psychosis reconstruct their identities and recover from the trauma of these disorders. Further research and clinical development will help to establish music therapy as a vital and essential treatment modality for this population.

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Pavlicevic, M. (2007). The music interaction rating scale (schizophrenia) (MIR(S)): Microanalysis of coimprovisation in music therapy with adults suffering from chronic schizophrenia. In T. Wosch & T. Wigram (Eds.), Microanalysis in music therapy: Methods, techniques and applications for clinicians, researchers, educators and students (pp. 174–185). Philadelphia, PA: Jessica Kingsley. Pavlicevic, M., & Trevarthen, C. (1989). A musical assessment of psychiatric states in adults. Psychopathology, 22, 325–334. Pavlicevic, M., Trevarthen, C., & Duncan, J. (1994). Improvisational music therapy and the rehabilitation of persons suffering from chronic schizophrenia. Journal of Music Therapy, 31(2), 86–104. Pedersen, I. N. (1999). Music therapy as holding and re-organizing work with schizophrenic and psychotic patients. In T. Wigram & J. De Backer (Eds.), Clinical applications of music therapy in psychiatry (pp. 24–43). Philadelphia, PA: Jessica Kingsley. Pedersen, I. N. (2002). Analytical Music Therapy with adults in mental health and counseling work. In J. T. Eschen (Ed.), Analytical Music Therapy (pp. 64–84). Philadelphia PA: Jessica Kingsley. Perilli, G. G. (1991). Integrated music therapy with a schizophrenic woman. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 403–416). Gilsum, NH: Barcelona Publishers. Priestley, M. (1994). Analytical Music Therapy. Gilsum, NH: Barcelona Publishers. Rogers, P., & Smeyatsky, N. (1995). Short-term verbal and musical memory in schizophrenia: Implications for theories of working memory and cerebral dominance. In T. Wigram, B. Saperston, & R. West (Eds.), The art and science of music therapy: A handbook (pp. 139–156). Chur, Switzerland: Harwood Academic Publishers. Ross, S., Cidambi, I., Dermatis, H., Weinstein, J., Ziedonis, D., Roth, S., & Galanter, M.(2008). Music therapy: a novel motivational approach for dually diagnosed patients. Journal of Addictive Diseases, 27(1), 41–53. Schapira, D. (2003). Last sounds of the shipwreck: Aspects of the plurimodal method in the treatment of psychosis. Nordic Journal of Music Therapy, 12(2), 163–172. Silverman, M. J. (2003a). Contingency songwriting to reduce combativeness and non-cooperation in a client with schizophrenia: A case study. The Arts in Psychotherapy, 30(1), 25–34. Silverman, M. J. (2003b). The influence of music on the symptoms of psychosis: A meta-analysis. Journal of Music Therapy, 40(1), 27–40. Simon, P. (1970). El Condor Pasa. On Bridge over Troubled Water [record]. New York: Columbia Records. Snowden, L. R. (2007). Explaining mental health treatment disparities: Ethnic and cultural differences in family involvement. Culture, Medicine, and Psychiatry, 31, 389–402. Solli, H. P. (2008). “Shut up and play!”: Improvisational use of popular music for a man with schizophrenia. Nordic Journal of Music Therapy, 17(1), 67–77. Stige, B., & Aarø, L. (2012). Invitation to community music therapy. New York: Routledge. Stompe, T., Karakula, H., Rudalevičiene, P., Okribelashvili, N., Chaudhry, H. R., Idemudia, E. E., & Gscheider S. (2006). The pathoplastic effect of culture on psychotic symptoms in schizophrenia. World Cultural Psychiatry Research Review, October, 157–163. Summer, L. (1988). Guided imagery and music in the institutional setting. St. Louis, MO: MMB Music. Summer, L. (2002). Group music and imagery therapy: Emergent receptive techniques in music therapy practice. In K.E. Bruscia & D.E. Grocke (Eds.), Guided Imagery and Music: The Bonny Method and beyond (pp. 297-306). Gilsum, NH: Barcelona Publishers. Talwar, N., Crawford, M. J., Maratos, A., Nur, U., McDermott, O., & Procter, S. (2006). Music therapy for inpatients with schizophrenia: Exploratory randomised controlled trial. The British Journal of Psychiatry, 189, 405–409.

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Tang, W., Yao, X., & Zheng, Z. (1994). Rehabilitative effect of music therapy for residual schizophrenia. A one-month randomised controlled trial in Shanghai. The British Journal of Psychiatry, Supplement, 24, 38–44. Tyson, F. (1979). Child at the gate: Individual music therapy with a schizophrenic woman. Art Psychotherapy, 6(2), 77–83. Ulrich, G., Houtmans, T., & Gold, C. (2007). The additional therapeutic effect of group music therapy for schizophrenic patients: A randomized study. Acta Psychiatrica Scandinavica, 116(5), 362–370. Wolfgram, B. (1978). Music therapy for retarded adults with psychotic overlay: a day treatment approach. Journal of Music Therapy, 15(4), 199–207. Yang, W., Li, Z., Weng, Y., Zhang, H., & Ma, B. (1998). Psychosocial rehabilitation effects of music therapy in chronic schizophrenia. Hong Kong Journal of Psychiatry, 8(1), 38–40. Zhang, X., & Ke, C. (1997). Effect of music therapy on chronic schizophrenia. Chinese Journal of Clinical Psychology, 5(1), 48–49.

ACKNOWLEDGMENT The author would like to thank Anne Margrethe Melsom, Chief of the Rehabilitative Creative Arts Therapy Service at Girard Medical Center, Philadelphia, PA for permission to use the Rehabilitation Creative Arts Therapy Service (RCATS) Assessment Tool and Treatment Objectives Flowsheet, shown in Appendix A and Appendix B.

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APPENDIX A Girard Medical Center Rehabilitative Creative Arts Therapy Service 9 Day Group Assessment (Music) NAME:___________________________________ Date:______________ Unit:______ Key: 1—never 2—seldom 3—sometimes 4—often 5—consistently Patient focused on music at least 15 minutes Patient organized thoughts and behavior via music Patient responded to music in reality-based manner Patient maintained control of impulses during group

Patient demonstrated initiative in structured music tasks/group process Patient used music to modulate affect and behavior Patient engaged in interactive problemsolving task Patient identified treatment issues via music task

Patient’s priorities for hospitalization: ______________________________________________________________________ Patient’s strengths:______________________________________________________

Clinical impressions related to use of music: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________ Group Assignment:

Project:_______

Problem-Solving:______

Needs support:_________________________________________________________ Unable to tolerate group activity:____________________________________________

Signature:_________________________________Date:________________________

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APPENDIX B Girard Medical Center Rehabilitative Creative Arts Therapy Service Treatment Objectives Flow Sheet Client Name____________________________________________Unit__________ Week of_______ Objective Met (Y) – No (N) – Refused (R) – Excused (E) – Not Available (NA) Creative Arts Therapy Group Objectives  [Date]

*RCATS staff initial Comments:

Week of_______ Objective Met (Y) – No (N) – Refused (R) – Excused (E) – Not Available (NA) Creative Arts Therapy Group Objectives  [Date]

*RCATS staff initial Comments:

*Initial Key:

Chapter 3

Adult Groups in the Inpatient Setting Lillian Eyre _____________________________________________ DIAGNOSTIC INFORMATION Since the revolution in mental health care services in the 1980s, there has been a shift from long-term to short-term acute care for persons with Serious Mental Illness (SMI) (Fakhoury & Priebe, 2002). SMI is defined as having a diagnosable mental, behavioral, or emotional disorder that meets criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association [APA], 2000) and resulted in functional impairment that substantially interfered with or limited one or more major life activities (Oklahoma Department of Mental Health and Substance Abuse Services, 2007, p. 65). The average inpatient stay for a person with a major mental disorder in an American hospital in 2009 was 7.5 days (Centers for Disease Control and Prevention, 2009). The diagnoses prevalent in an adult inpatient unit are composed of a number of serious mental illnesses, including persons with schizophrenia, psychotic disorders, bipolar disorders, major depression and/or anxiety, substance misuse, eating disorders, and some personality disorders such as borderline personality disorder and obsessive compulsive disorders. Specific diagnostic information about adults with schizophrenia and psychotic disorders can be found in Chapter 1; depression and anxiety, Chapter 11; borderline personality disorder Chapter 12; eating disorders, Chapter 13; and substance misuse, Chapters 14 and 15. The purpose of this chapter is to present music therapy guidelines for working with an inpatient group, which is composed of persons with SMI with a variety of diagnoses and levels of functioning. The short length of stay and the constantly changing composition of the inpatient group pose particular challenges for the music therapist in the inpatient setting. This is complicated further by the demographic diversity found in many urban hospitals, engendering an array of multicultural needs and occasional language barriers with which the music therapist must contend. In today’s inpatient unit, the clients are acutely ill. The basis on which a person is brought to the hospital is usually that he is a danger to himself or to others. Persons who are psychotic and unable to negotiate the basic tacit agreements of shared reality become unable to care for themselves; they may suffer from bizarre delusions that necessitate hospitalization in order to become stabilized on medication. Persons who are depressed or have a major personality disorder may be in danger of self-harm, and persons who misuse drugs or food may also need to be hospitalized for their self-protection. There are significant differences in these clients’ functional abilities and in their motivation to participate in the music therapy group that stems from the scope and varied stages of these disorders. Thus, it is helpful to consider the symptoms that the music therapist may encounter in such a group. Persons with schizophrenia experience three major groups of symptoms: (1) positive symptoms, such as psychosis, hallucinations, delusions, thought disorders, movement disorders, and catatonia; (2) negative symptoms such as flat affect, little access to emotion, poverty of speech, and poor hygiene; and (3) cognitive symptoms such as poor executive functions, poor planning, attention and focus deficits, and poor working memory (National Institute of Mental Health [NIMH], 2009). Persons with depression

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exhibit anhedonia, which means that they are unable to experience pleasure, have little motivation or energy, and may have poor self-image with feelings of worthlessness and hopelessness, suicidal thoughts, and difficulties with concentration (NIMH, Schizophrenia, 2009). Clients with a bipolar disorder in the manic phase may have psychotic symptoms, which means they are out of touch with reality and may have delusions and/or hallucinations, have racing thoughts, and may be irritable or overtly outgoing and impulsive, while in the depressed phase they would have symptoms similar to those with depression (NIMH, Bipolar Disorder, 2009). Persons with anxiety experience constant worry and have difficulty concentrating or interacting with others (NIMH, Generalized Anxiety Disorder, 2009), and persons with a borderline personality disorder have difficulties tolerating emotions and experience extreme, inappropriate anger, feelings of emptiness, suicidal thoughts, and an unstable self-image (NIMH, Borderline Personality Disorder, 2009). Each inpatient group is therefore a unique constellation of the dynamic interactions of the random composition of individuals who have an array of diagnoses, histories, personalities, and functioning levels, as well as unique strengths.

Client Experiences in the Inpatient Setting In recent years there has been a greater tendency to seek out service user—or patient—evaluations and recommendations for mental health services (Breeze & Repper, 1998; Happell, 2008; Hopkins, Loeb, & Fick, 2009; Noble & Douglas, 2004; Odell, Murphy, Woods, & Williams, 2012; Shattell, Andes, & Thomas, 2008; Silverman, 2010). In a phenomenological study, Shattell, Andes, and Thomas investigated the experience of nurses and service users in an acute care unit of a large urban hospital in the southeastern United States and found that persons in the inpatient psychiatric setting experienced their environment as a prisonlike and boring existence that was lacking in satisfying opportunities to connect with staff. Recurrent themes were feelings of “powerlessness, intimidation, harassment, suffocation, and control” (p. 245). The patients in Noble and Douglas’s study described hospitalization as ineffective and possibly even harmful, while patients who were described by nurses as being difficult experienced being controlled and coerced (Breeze & Repper, 1998). Service users also had clear notions of what constituted a therapeutic experience, citing positive relationships with staff and peers and respectful interactions as highly desirable healing factors (Happell, 2008; Hopkins et al., 2009; Noble & Douglas, 2004; Shattell et al., 2008). One study found that building staff and patient relationships, integrating arts for healing, introducing recreational activities, and promoting community integration skills improved patient satisfaction ratings by 29% (Odell et al., 2012). One obstacle to therapeutic care described by users is that much of the therapeutic work done in the inpatient setting is in generic groups; patients described being assigned to inappropriate diagnostic groups and identified a need for group therapy that addressed their issues (Shattell et al., 2008). Although there has been little research into patients’ perceptions of music therapy groups in the inpatient unit, patients on one urban psychiatric unit supported music therapy groups (Silverman, 2010) and a metaanalysis of music therapy treatment for persons with schizophrenia showed significantly improved global and social functioning (Gold, Heldal, Dahle, & Wigram, 2005). When this information is considered from the perspective of music therapy services, opportunities and challenges in meeting the needs of clients in this setting are revealed. The greatest opportunity lies in the power of music which, when used therapeutically by a trained music therapist, has the capacity to build trust and help to form meaningful relationships with the therapist, with peers in the group, and with oneself. The challenge is that while some institutions have a structure that permits music therapists to run diagnosis- or symptom-focused groups, most institutions provide generic groups in the inpatient setting. The inclusion criteria for generic groups are based on the conveniences of client availability; this results in a group composed of persons with a wide range of functional abilities and

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divergent orientations to reality, musical preferences, ages, ethnicities, cultures, spiritual beliefs, energy levels, and even different languages. While this diversity may be an obstacle to the delivery of therapeutic services in groups based on verbal sharing, experiencing and making music together can circumvent some of these differences, allowing the therapist to use the group dynamics to promote the discovery of commonalities and sharing among the participants.

NEEDS AND RESOURCES Clients in the inpatient group are diverse in terms of demographics, including culture, race, age, diagnosis, music preferences, and functional abilities. What clients have in common is that they are experiencing an acute psychiatric emergency. Within the inpatient group, one may expect to have clients who are confused or psychotic and who are experiencing intense emotions or, conversely, feeling emotionally flat. They may have a poor self-image and/or be struggling with recurring desires to selfharm, and feel alienated or isolated from themselves and their environment. Some individuals may have low energy and few musical or verbal responses, while others may be physically agitated, intrusive, or overwhelming and lack appropriate boundaries. Thus, the most important aspect in assessing the needs of the inpatient group is the therapist’s awareness of the dynamic composition of a particular group. This includes noting not only the symptoms of the disorders and their effect on one’s personality, but also each person’s openness to creativity and how each one relates to others. Many clients in the inpatient unit will have had many previous stays in the hospital, and a pervasive characteristic of learned helplessness is often present—and reinforced by the regressive atmosphere and attitude present on many inpatient units. Stigma is something with which many longterm psychiatric clients have had to contend, and this has left them feeling worthless and marginalized from society. The exception to this may be the manic or psychotic patient whose grandiose defense mechanism serves to shield him from these difficult feelings. In addition to this is the fact that persons with schizophrenia in particular tend to isolate themselves socially and have great difficulty making and maintaining connections with others. Thus, persons in the inpatient unit have a need to reconnect with themselves and others, to be listened to, to listen and respond to others, to feel valued, to access their personal resources, and to identify and strengthen the positive aspects of themselves. Clients demonstrate different characteristics in their musical interactions based on the nature of their disorder, their personality, their medications, and their current functional ability. For example, in a singing experience, some clients are able to follow the music and sing along earnestly with the lyrics, while others with flat affect may have no preference for musical choice; some may fall asleep or be unable to follow the song because the medications make them sleepy, and still others may sing along with the lyric sheet with great gusto while being unaware that they are inventing completely new lyrics. In receptive experiences using movement and imagery, some clients will enthusiastically embrace the experience, while others may have little energy or have difficulty moving because of the medication’s side effects. Clients in this group often have difficulty listening to one another, and while some are able to be very creative in the sounds explored in improvisation, others will have difficulty spontaneously connecting to their inner world. This range of responses is typical for all music experiences in the inpatient group. While it is not a simple feat to bring the diverse participants together in a positive dynamic in the inpatient group, the wide variety of music genres and experiences available to the music therapist render this a challenge rather than an obstacle to therapeutic care. For the majority of these individuals, music has been a solace throughout their lives and music often provokes responses or eases their sense of isolation even when they may not appear to be optimally engaged. When listening to music, many psychotic clients experience some relief from aural hallucinations (Silverman, 2003), but just as importantly, music provides them with a way of connecting with their identity and sense of self through

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associations to the music (Eyre, 2008), and helps individuals to connect to each other when they share their responses to the music. Regardless of the music experiences the therapist chooses to use in a session, the most important factor in ensuring success is to work toward group cohesion. This is achieved by determining which music methods will best promote the ability of individuals in the group to relate to each other from among the various possibilities—for example, singing together, singing and discussion, drumming, using imagery with movement or improvisation, creating new words to a song, or focusing on more didactic communicative experiences with instruments. The methods presented in this chapter focus on group music experiences with this goal in mind. Integrating the music experiences and providing a structure for the session will be presented in Closing Remarks on Methodology.

MULTICULTURAL ISSUES The United States Census Bureau (2011) reports that the largest minority groups are composed of Latinos (16.7%), African-Americans (13.1%), and Asians (5%). As noted above, this diverse population is represented in the urban inpatient unit; thus it is not uncommon to have persons of different races, cultures, and spiritual beliefs in the same group. Different cultures have different attitudes toward mental health counseling practices and different expectations of the therapist/patient relationship (Pedersen, 2004). It is therefore imperative that the music therapist is aware of the demographic makeup in her particular area and has a basic knowledge of the norms and attitudes toward therapeutic interactions for the cultures and races served. Furthermore, within each of these groups there are individual value systems, religions, and levels of acculturation. Thus, it is equally important for the therapist to be aware of the particular value system of each individual and avoid making assumptions about the client based on race. Diversity also has an impact on music choices. The music therapist can play an essential role in fostering group cohesion by sharing music preferred by different cultures. Having a few songs to sing or play that are likely to be known by persons of different demographics is essential, for example, including a few popular Latino songs, as well as music that is favored by African-Americans of different age groups. Most importantly, one must keep in mind that cultural competence is an ideal; it is impossible to possess a deep understanding of all the cultures that one may encounter in the inpatient unit, and therefore, a stance of cultural humility might be more realistic. Cultural humility accepts a position of not knowing, and in doing so, encourages openness to learning from others; it incorporates values of self-reflection and minimization of the power imbalances between patient and therapist (Tervalon & Murray-Garcia, 1998).

REFERRAL AND ASSESSMENT There is a rapid rate of admission and discharge in the current inpatient psychiatric unit (Centers for Disease Control and Prevention, 2009). Different settings have particular guidelines regarding patient attendance in groups. Normally, patients are not referred specifically to the music group, but they will be required to attend the music group as part of their rehabilitation plan. Depending on the structure of the hospital’s psychiatric services and one’s job description, the music therapist may provide services for multiple units or multiple teams and have little formal individual contact with clients. In these situations, she may see clients for the first time in the music therapy group and have few opportunities for individual assessment beforehand. (See Chapter 2 for individual assessments.) This poses a challenge to providing a group that will meet the divergent needs of all the participants. It is therefore advisable to begin each group with a couple of music experiences that will allow the therapist to assess client behaviors and attitudes that will indicate the kinds of therapeutic group processes and methods that are most appropriate.

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The client behaviors that the therapist assesses include the client’s ability to attend to a task, to listen to instructions, understand, and follow them, and to be attentive and empathetic to others; the therapist will also assess one’s orientation to reality, the range and intensity of mood and energy levels in the group, the presence of psychosis, and each client’s responsiveness to music. Attitudes that are assessed are music preferences, motivation to participate in the group, level of engagement, self-image, suicidal thoughts, and the need for self-expression. In addition, the music therapist will note the various ages, genders, and cultures present in the group demographic. Experiences that will reveal this information are described in the methods sections below; these might include an opening song in which clients are asked to participate verbally or musically or both, relatively short movement experiences in which the client is invited to use imagery, and instrumental experiences using short, repetitive call-andresponse rhythms.

OVERVIEW OF METHODS AND PROCEDURES The following methods and procedures are used most commonly with inpatient psychiatric groups.

Receptive Music Therapy • • • • •

Song Lyric Discussion: Clients listen to songs and discuss the song lyrics. Movement to Music: The therapist provides various levels of structure and instruction to facilitate clients’ ability to move to music. Music, Imagery, and Relaxation: Clients listen and image to relaxing music while the therapist directs the imagery with a script. Evening Relaxation Group: The therapist presents relaxation procedures in the evening to prepare the clients for sleep. Musical Games: Clients play musical games that have a variety of forms, the most common being quizzes based on musical knowledge and/or discrimination (Name That Tune, Hangman, Musical Bingo, and Musical Jeopardy), while others require active participation such as drawing or movement (Music Charades, Simon Says, and Music Pictionary).

Improvisational Music Therapy •

• •

• • •

Nonreferential Percussion Warm-ups: Clients engage in rhythmic exercises based on calland-response and imitation to help them to establish basic rhythmic and percussion skills. Nonreferential Group Percussion Groove: The client group plays together maintaining the same pulse while each client in turn spontaneously explores rhythm and dynamics. Nonreferential and Referential Instrumental Exploration: Clients explore a range of instruments to become aware of the associative and evocative possibilities of tuned percussion and atmospheric instruments (e.g., rain stick, ocean drum). Referential Conversation: clients communicate on instruments with others to express specific emotions or themes. Programmatic Referential Improvisation: Clients use instruments to connect to and express their inner world and to share this with others in referential improvisations. Vocal Toning Improvisation: Clients use their voices extemporaneously to sound a vowel in a structured or unstructured improvisation with or without instruments.

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Re-Creative Music Therapy •

Song Singing: Clients sing pre-composed songs with or without instrumental accompaniment.

Compositional Music Therapy •

Song Writing: Clients and therapist change some or all of the lyrics and/or music of an existing song to personalize it, or write entirely new music and lyrics to create a new song.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY METHODS Song Lyric Discussion Overview. Clients listen to songs and discuss the lyrics. This is a commonly used receptive method in the inpatient setting (Thomas, 2007). This highly adaptable music experience can meet the needs of a range of clients with different diagnoses and functional abilities, allowing each person to relate and respond to the music in an individual way while at the same time providing a positive group experience. It is not necessary for each client to function at a homogeneous level in order to participate in the group; rather, clients listen to the songs in a parallel process. A variety of responses to the music can be easily managed in the group, allowing clients who are psychotic or less responsive or high-functioning to participate equally. In fact, the different associations that clients have to a song may evoke both parallel and contrasting meanings, providing rich opportunities for therapeutic discussion (Sullivan, 2003). The only contraindication for participation in this group would be the inclusion of a client who is unable to maintain a nonintrusive presence for the duration of the experience, or one whose psychosis is so florid or whose mania is so intense that the lyrics and music might be overstimulating. There are myriad goals for this listening experience: (1) increase reality orientation, (2) improve self-expression, (3) identify personal difficulties, (4) identify coping skills, (5) improve socialization skills, (6) reduce isolation, (7) increase awareness of others, (8) improve self-image, and (9) develop insight. Goldberg (1989) cites additional goals for activity therapy in the inpatient unit that are pertinent for this experience: (1) increase internal and external organization, (2) increase peer relatedness, (3) decrease internal preoccupation, and (4) decrease withdrawal. The level of therapy is augmentative or intensive depending on how the goals are addressed. Where possible, the therapist would address the interdisciplinary team’s goals for each client. Advanced training is not needed for this experience, but skill with verbal techniques is a requisite, as well as a solid knowledge of symptoms of psychosis and group management skills. Preparation. Chairs are arranged in a circle with a few inches of space between each chair so that everyone can see each other, yet everyone has a secure sense of their own space. The therapist positions herself in the circle. If the therapist plays the songs, appropriate instruments such as guitar and piano will be placed in proximity to the therapist’s chair. If recorded music is used, then the therapist will set up a CD player or iPod or iPad with a good-quality speaker attached. Some therapists use books with printed lyrics of often-requested songs, while others prefer to bring in file folders with single lyric sheets to be passed out; still other therapists prefer not to use lyric books at all. There are good reasons for either choice. The lyric sheets might intimidate clients who are unable to read or who have language barriers; clients who are floridly psychotic may see entirely different lyrics from what is written; the lyrics may distract some clients from listening to the song. Alternatively, many clients enthusiastically embrace the

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song’s words on the page and discover something new they had never before heard even after having listened to a song many times. Gardstrom and Hiller (2010) provide guidelines for formatting lyric sheets so that they are clear and easy to read. Clients have often asked this author to keep the lyric sheets, treating the written words as a highly valued gift that they can keep and refer to when they need. It should not be overlooked that what may appear to be commonplace—a lyric sheet—may be an object of great importance to the client in an inpatient unit. When lyrics and music are significant to a client, being able to refer to the lyric sheet may provide a tangible means of invoking the meaningful therapeutic moment that occurred with the song in the session, thereby enhancing the client’s coping skills throughout the hospital stay and beyond. What to observe. The most important thing to observe is the clients’ emotional responses, particularly if anyone is becoming agitated or more withdrawn. This might indicate that the client’s mood is being altered by the songs in general or a song in particular in a way that is not therapeutic. In both situations, a verbal check-in with the client will provide the therapist with the information needed. If a client becomes too agitated—evidenced by raised voice, pressure of speech, or increased motor activity— the therapist may suggest the group is not the best place for him at this time and invite the client to leave for a few minutes. If this is said in a calm and empathetic manner, clients will usually identify with the statement and leave the group without difficulty. If, however, the client refuses to leave, the therapist should seek help immediately. If a client seems to become more withdrawn, it is important to check in immediately with the client and help the client express what he is experiencing with open-ended or more direct questions. Occasionally, in discussing songs, clients may reveal disturbing thoughts such as suicidal ideation. The therapist should follow up with the client individually after the group and follow the institution’s protocol for responding to suicidal ideation. The therapist also observes how each client’s response to the music and to the discussion relates to his individual goals. Finally, the therapist observes how the group is functioning as a whole in this experience, notably, if members are connecting to each other socially, responding to each other’s comments, and supporting each other’s feelings with some degree of empathy regardless of the differences in levels of functioning. Procedures. There are two primary methods used when conducting a lyric discussion session. In the first, the clients are given a list or a songbook from which to choose the songs they would like to hear, while in the second, the therapist chooses the song list for discussion. Often, these two methods are also combined. In the first method, the therapist either instructs the clients to choose any song that they would like to hear, or she can provide a thematic focus for the song choice. For example, the therapist might suggest that the client choose a song that “makes you feel comforted, safe, or happy; describes a feeling you have; says something about what is important to you in life; makes you feel better when you’re down.” There are a few caveats for choosing themes in the inpatient psychiatric unit. They should be focused on the here-and-now events and relationships to encourage reality orientation and to discourage psychotic confusion, and the themes should be supportive, i.e., focused on helping the clients to gain access to and recognize their internal resources, strengths, and unique identity. If the group is of a size that permits each client to choose a song and hear it within the session, then this is the preferred approach because it responds to each person’s need for gratification in a hospital environment where clients may feel frustrated in getting their perceived needs met. After each song, the therapist checks in with the person who chose the song, encouraging a discussion about why he chose it, its personal meaning, his relationship to it, and what the music and words evoke for him. Crowe (2007) suggests providing clients with questions about the song beforehand to focus the client’s listening. For example, the therapist might ask the client to notice what lines jump out at them or to try to understand what the songwriter is feeling (p. 42). If a client is not able to say very much, the therapist might ask him

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to choose the line or words that he remembers best or likes most, and why. It is important to try to engage other group members in a response as well so that the song becomes a shared experience. In this way, it provides an opportunity for clients to find commonalities and experience both receiving empathy and providing it. As different songs are chosen and discussed, the therapist should attempt to find unifying themes that emerge to involve everyone in the group discussion. This can be achieved by pointing out similar ideas, feelings, or responses that emerged in song discussions. If the group is too large to permit each client to choose a song, the therapist can have a two-session procedure wherein half the requests are processed in each group. Alternately, not all clients will want to choose a song, or two or more clients might choose the same song. When the group is too large to have a song chosen by each client and the two-session format is not possible, the therapist must make certain that she checks in with each client verbally and that each one is involved in the discussion. It is sometimes easier to structure the discussion around themes when the therapist chooses the song list for the group, but there is no guarantee of this in the inpatient unit. The advantage of choosing the theme and accompanying song material for the group is that the therapist can focus the session therapeutically and provide more structure for the clients. Gardstrom and Hiller (2010) provide excellent guidelines for this type of song experience. They suggest that considerations for song selection include these factors: the client’s cognitive abilities, sex, preferences, familiarity with the music, stage of treatment, lyrical theme, mood, use of literary elements and techniques, and attributes of the song’s musical accompaniment. Discussion of the song and lyrics follows the same guidelines as when using the client’s individual song choice method. One challenge that may occur is that clients in an inpatient unit may have difficulties staying on topic verbally because psychosis affects cognition and language. To allow a psychotic client to get lost in his thoughts is not therapeutic, and the therapist must bring the client back to the topic and the group. This can be achieved with a summary statement of the client’s verbal communication or with a gentle statement that sets limits to the conversation for the time being such as, “I know what you are telling me is very important, but can you hold on to that thought until after the group? I want to make sure that everyone gets a chance to hear their song before the group ends.” It is essential to establish a good balance between words and music so that everyone has a chance to choose a song and to ensure that the music is the main experience in this group, for it is in the music that these clients achieve their highest level of functioning (Nolan, 1994) and are most readily able to access positive images and resources. Some topics that clients bring up in a song discussion may pose a challenge for the therapist, e.g., the clients’ dismay or anger at being in the hospital and not understanding why, concern that the medications they are taking are having a negative effect on them physically or cognitively, anger with roommates or other clients, belief that people are stealing from them, or negatively charged reactions to the terrible state of the world, the economy, and current wars. It is not usually helpful to discuss these concerns directly in this group. Rather, the therapist should recognize that these feelings and ideas are often projections of the internal experiences of the clients and that she can better address these issues by changing the focus to the here-and-now experience in the group. This therapeutic shift can occur by responding to the clients’ feelings that are behind each of these issues. For example, many of the clients’ concerns with the state of the world are related to internal feelings about lack of empowerment and perceptions about not being cared for; concern with medications is often an expression of lack of internal control. When such concerns are voiced, the therapist can help clients to identify that while they don’t have the power to stop a war or world hunger, they do have power over the decisions they make in their lives, such as the choices they have in managing their moods and in establishing caring relationships with each other. Each client’s personal decisions can create a better world, thus empowering him to choose a positive role in changing the world. By identifying common concerns, experiences, and emotions, and then facilitating mutual support and sharing in the lyric

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discussion group, clients can experience decreased isolation and reduced negative feelings; clients may even begin to feel that there is some personal meaning that might come from being in the hospital. Adaptations. Song and lyric discussion is sometimes presented as a re-creative experience where the clients sing the songs that will be discussed. The re-creative song experience will be discussed in the re-creative method section. Receptive or re-creative song experiences with lyric discussion are also often used in conjunction with lyric substitution in a compositional method. After listening to or singing a song and discussing it, the therapist will suggest that words or lines of the song be rewritten to express some aspect of the clients’ experience. This will be discussed in the composition method section.

Movement to Music Overview. The therapist provides various levels of structure and instruction to facilitate clients’ ability to move to music. Movement has an impact on breathing, energy level, cognitive functioning, emotional states, and connection with self and others (Hartley, 1989). Yet, movement is one of the primary aspects of human functioning that is limited in an inpatient unit. Music and movement is indicated particularly when clients are in a psychotic or manic state where the movement helps them to dissipate their energy in a constructive manner. It can also help disorganized clients to become more organized in their thoughts (Goldberg, 1989) and help improve the mood of those who are depressed and have little energy at their disposal (Penedo & Dahn, 2005). The creativity that is evoked through movement also helps clients to achieve a better understanding of feelings, thoughts, and emotions (Houghton et al., 2002). Movement experiences help clients to develop awareness, control, competence, and confidence in their bodies, which improves their body image, self-esteem, and ability to use their bodies expressively and functionally (Houghton et al., 2002). All clients in the group can participate to some extent in this parallel experience. If a client is dizzy or fatigued, which are both common side effects of many neuroleptic medications, the therapist may suggest that the client perform the movements while seated in a chair. Other than excluding clients who are so ill that they are disruptive to the group, there are no contraindications. The goals of movement to music are to provide the opportunity for physical release, to connect with one’s body and with others, to practice making decisions, and to improve self-esteem. In addition, Houghton et al. (2002) emphasize that a comfortable movement experience helps participants to “eliminate self-conscious behaviors that inhibit movement and the expression of feelings” (p. 195). Throughout the movement experiences, the therapist helps the client to become aware of his ability to move in a less restricted fashion (Houghton et al.). The level of therapy is augmentative, and there is no special training involved beyond professional competencies. Preparation. This experience is often used at the beginning of an active music therapy group; it should last from five to 10 minutes. Chairs should be moved away and clients are invited to stand in a circle spread out in the room with enough space between them to raise their arms to the side, but in a position that allows them to maintain eye contact with others. Position the chairs of seated clients so that they remain a part of the circle. A device to play recorded music is required. What to observe. Notice the extent to which each client is able and willing to carry out the movements. Watch for signs of weakness, fatigue, or dizziness and provide the client with a chair immediately. Pay attention to any other behaviors that may be of importance in the individual client’s functioning and treatment goals. Observe the client’s verbal responses, particularly the feelings that are evoked during the experience. In movement and imagery experiences, it is important to check in with each client to determine his response to the imagery, for example the color or particular image that he chose, the ease or

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difficulty with which he was able to find an image, and how the image developed. In movement involving taking in and letting go, notice each client’s choices related to what is taken in and what is let go. Procedures. Begin by choosing music based on the energy level of the group. If the energy level of clients differs widely, choose music that is moderately paced, or a group of selections that begin slowly, become livelier, and then finish moderately or slowly. Much New Age music with nature sounds can be used for this experience, as well as more lively instrumentals from the popular genres. To be successful, it is first necessary to provide the clients with a vocabulary of movements that they can imitate, integrate, and, finally, recombine (Houghton et al., 2002). Houghton et al. suggest including concepts such as fast vs. slow, sharp vs. smooth, and moving through space on different levels, in different directions, and with different degrees of strength and muscle tone. For client groups with less energy, stretching movements serve to introduce them to movement in a gentle manner and to provide them with other options in their vocabulary of movements. Crowe and Wigle Justice (2007) suggest three levels of complexity. At the first or basic level is using the large muscle groups, for example, bending the head, reaching arms, touching knees or toes, and twisting the upper back. The second or average level involves smaller muscle groups, with more precise directions such as tilting the head at various angles, squeezing elbows front and back, and pointing toes and flexing feet. The third, or intricate, level addresses even smaller muscle groups and includes face, eyes, hands, shoulder stretches, and circling ankles (p. 37). All of these stretches should be held for 10 seconds statically and should only be done to the point that they are comfortable. Jacobson techniques involving tensing and relaxing various muscle groups may also be used as a warm-up (p. 38). The therapist models a few simple movements that can be done standing or sitting, beginning with stretching various parts of the body. Breathing should also be attended to by reminding the clients to breathe slowly, deeply, and mindfully while doing the stretches. If clients complete this portion of the movement and still have energy, segue into more lively music with a beat and model a repetitive movement or easy dance-style movement, such as lifting one arm up, then the other, twisting at the hip, or an easy step movement, paying attention to include at least one movement that uses each major body part. When clients are able to execute these movements, ask if anyone has a movement they would like to show everyone, then have everyone in the group repeat it. Since these movements are related to common dance motions, many clients are inspired by the music to create a movement that others can imitate. If the movement is too complicated, help the client to simplify it so that it can be replicated; in doing so, the therapist is helping the client with his internal organization. Make sure that everyone has an opportunity to contribute a movement if he wants to, and take time to encourage any client who seems to need support to do so. Return to a slower pace for the last minute of music as the clients are directed to stretch, breathe, and return to their chairs. Follow up the experience by checking in with each client verbally and giving everyone a chance to express what the experience was like. Adaptations. Houghton et al. (2002) suggest that clients can move alone, within the group, or in pairs. Another option particularly suited to large groups is to have one group of clients provide improvised music while the other group moves to it. These authors also have a number of suggestions regarding the therapist’s use of live music as a stimulus to integrate the auditory and kinesthetic experience. Live music can be used as a “timing cue” (p. 194), where an acoustic signal determines the kind of movement that is required. For example, staccato chords signify a fast motion that becomes slow when a sustained legato chord is sounded, or a harmonic progression indicates to the clients to gradually move from one position to the next. In a similar manner, in the “designative accompaniment” method (p. 195), each movement is synchronized to a particular musical texture; for example, interval leaps relate to jumps, and ascending or descending melodies indicate upward or downward movement.

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Movement to music can also be combined with directed imagery. Based on the clients’ needs, the therapist can elaborate on the introductory slow movements described above by incorporating imagery into the movement and leaving out the modeling and imitation sequence. The imagery might be as simple as suggesting that each client choose a color that he needs in his life and imagine it surrounding him, or imagine breathing it in as he begins his stretching. For clients who are feeling vulnerable, the suggestion that the color forms a protective bubble around the client can be helpful. This may also be elaborated to include imagining something in nature that goes with that color, or a feeling that the color brings. The therapist can suggest to the client that he keep the feeling, or bubble, or image with him throughout the day and imagine it whenever he has the need. Imagery is often based on nature and has a psychological valence. For example, sun images are associated with warmth, empathy, and love, while water imagery is associated with cleansing and washing away that which is not wanted; it is also associated with movement, flowing, and change; earth imagery evokes feelings of being grounded, solid, and strong, while wind imagery connotes change and transition from one thing to another. One caveat is that fire imagery may suggest a psychic danger for a person who is psychotic, so it should not be used in an inpatient unit. If a client brings up fire imagery, the therapist should obtain exact information regarding the image to ascertain if this needs to be discussed with the team. In choosing the imagery to use in the directed imagery and movement experience, the therapist considers the symbolic value of the image and how it corresponds to the needs of the clients in the particular group. Thus, the therapist might choose water imagery to help clients access their spontaneity and life force, to facilitate openness to change, to help a client let go of the past, or to feel a sense of renewal. After gently stretching, for example, the therapist says, “Imagine now that you are standing firmly on a flat rock in a shallow pool under a beautiful waterfall. You can see through the beads of falling water and you reach out to play with it. Allow yourself to make any movements that the falling water inspires. You hear the gentle sound of cascading water and see the sun glinting through it. Allow yourself to play with the water, safe on your flat, secure rock, and as you do so, let your body make any movement it needs to.” Imagery and movement can also be implemented as a projective experience. In this adaptation, the images are introduced by the therapist and then developed internally by the client as each one continues to move to the music. For example, begin with stretching and gentle music and then ask everyone to imagine that they are a plant in nature that is growing—a flower, a tree, or even a blade of grass. Suggest that each person imagine how he is growing, noticing the rate at which the growth is taking place, what it feels like to reach toward the light, what it feels like to receive water from the sky and nourishment from the earth, how it feels to grow. Guide the clients intermittently and model continuously as you encourage the clients to let their movements be inspired by the music and the image of growing. After the movement is finished, ask clients to share their experiences. This kind of experience can serve as an individual and group assessment, providing the therapist with information about what other kinds of experiences would be appropriate and most therapeutic for this group. Another example of a projective movement and imagery experience is to ask clients to imagine that each one is a bird and is able to fly wherever he wishes. Suggest that each person imagine what it feels like to fly, whether he is alone or with other birds, what he sees from the sky, and to note anything else that comes to mind. Afterward, verbally check in with the clients to determine what this experience was like, including where the client went, what he saw, what it felt like. Much pertinent information about the client’s internal life can be derived from these experiences, and this can also serve as an assessment of the individuals and the group. Movement and music can also be used in a way that facilitates change, for example, in the psychological task of letting go and/or taking in. The music should be slow to moderately paced and repetitive with regular, moderately long phrases. Model a repetitive and flowing movement that requires

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balancing and shifting from one side to the other, or incorporates a forward and backward shift in one position. Many simplified tai chi movements are well suited to this experience. After teaching the clients the movement, model how to pace it with the music and practice it with them. Once they are able to do the movement, direct clients to think about some feeling or thought in their lives that they want to let go. Emphasize that this is not a determined or willful process, but a simple letting go with ease of something for which we have no use and is getting in the way of realizing one’s needs and desires. Do the movement, repeating, “I release this,” accompanied by an outward movement with one or both arms. After a few repetitions, allow the clients to continue the movement, repeating the phrase internally. Next, ask the clients to imagine something they need more of in their lives, for example, calm, peace, love, or anything that addresses the client’s needs and desires. Focusing on an arm movement that moves from outside toward the body, repeat, “I take this in” a few times, leaving the clients to continue the movement to the music. Close the experience by minimizing the movement, making it smaller and smaller until it comes to a natural stop. Allow clients to share whatever they wish to share about the experience.

Music, Imagery, and Relaxation Overview. Clients listen and image to relaxing music while the therapist directs the imagery with a script. These experiences provide clients with an opportunity to relax and to access supportive imagery while listening to music, thereby meeting a common therapeutic need in the inpatient unit. While many clients can benefit greatly from this, relaxation and imagery with music is contraindicated for others because the negative feelings and thoughts they may be experiencing in psychosis can be exacerbated by the capacity of music to evoke feelings and imagery. This experience should only be carried out in a group where every client can safely engage in and feel supported by the imagery and music. Assessment for a client’s ability to benefit from relaxation using music and imagery can be done in team meetings, by reading patient charts, or during music experiences such as movement, song singing and discussion, or improvisation. The therapist would assess if the client is able to be attentive and quiet for five minutes or more, if he is organized in his thinking, and if he is able to access positive feelings, associations, and imagery when the opportunity is presented. Clients who have akathisia or cannot focus or sit quietly for the duration of any group and clients who are not oriented to reality would be contraindicated for this experience. The goals are to promote relaxation, evoke positive imagery, and empower clients to connect with their internal resources as a coping mechanism. When the therapist works with the clients to construct the imagery rather than using a precomposed script, the additional goals are to improve one’s ability to solve problems, increase the ability to structure one’s thoughts, and increase meaningful interpersonal communication. The level of therapy is augmentative or intensive, and the therapist would support client goals indicated by the team. Some training in advanced music and imagery techniques such as Guided Imagery and Music (GIM) or other music and imagery methodologies is needed for the music and imagery or music and art experiences. No special training beyond professional competencies is needed to implement the music and body relaxation or music and writing experiences. Preparation. This experience is presented as a segment in the inpatient group where the therapist may include other experiences such as singing songs and playing instruments. No additional setup is required. Clients sit in chairs for the experience, which stimulates “a more rational form of listening” (De Backer, 1996, p. 28). The therapist uses a CD player or iPod or iPad to play recorded music. The music chosen should be highly structured (Crowe & Wigle Justice, 2007). Such music would be harmonically simple and tonally stable; be repetitive; have regular, predictable phrases with a soft to moderate range of volume; have an arpeggiated or sustained chord texture; be melodic; and have a consistent tempo of approximately 50 to 70 beats per minute. The music selection should last from three

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to five minutes. The music is not usually classical music, as the musical elements may evoke imagery that is unsettling for clients in the inpatient setting. Examples of music to use might be some New Age music such as that composed by Daniel Kobialka, Liquid Mind, and Secret Garden, or some examples from the Paul Winter Consort. One adaptation requires drawing paper and oil pastels, while another requires a pencil and writing paper. What to observe. It is important to notice which images the clients are identifying with as well as which images any client might reject or avoid commenting on. It is imperative to make certain that each client is in agreement with the images that will be verbalized by the therapist. While narrating the imagery, observe clients for the level of physical calm or restlessness and whether eyes are closed or open. Afterward, observe the client’s responses to the experience during the verbal check-in. Of particular note are the feelings that are evoked during the experience, the particular unique events that occurred, and each client’s subjective evaluation of the experience. When assessment and proper guidelines for imagery and music choices are carried out, this is a safe experience for clients. However, there are always unpredictable exceptions. Thus, the therapist should be alert not only for clients who seem to be agitated, but also for any client who seems to be frozen. The client will have no movement, which may suggest that he is calm, but the breathing will be very restricted and the frozenness will be evident by subtle signs of tension such as a clenched jaw or hands or holding tightly onto the chair. If you suspect that a client is frozen in the experience, approach the person without touching him and ask quietly if he is feeling all right; if there is no response, speak louder, calling the person by name and asking him to open his eyes. Gently bring the imagery to a close and soften the music, then return to the client and bring his attention to his breathing, and then have him rub his hands together and feel his feet grounded to help him return to a normal state. Procedures. There are many variations for this kind of experience, but the guidelines for each are similar. The therapist must first determine that imagery is suitable for everyone in the group; otherwise, it is contraindicated. The first step is to decide on the script of the imagery experience. There are two ways to do this. In the first method, the imagery is chosen and scripted prior to the session. This imagery would be based on positive, supportive themes such as nature images or a pleasurable excursion. This is usually most effective when the therapist has prior knowledge of the clients, their needs, and their imagery preferences. The therapist may create the script or use or adapt a precomposed script. The second method involves constructing the imagery together with the clients in the group. In this method, a discussion about when and where people feel most relaxed will provide ideas for the kinds of images that can be used. The therapist listens for commonalities among the clients’ ideas and finds a composite imagery that will have something that appeals to everyone. For example, if three people want to go to the beach, and four prefer a country walk, and another wants to visit New York City (NYC), it is important to find out what it is about NYC that is attractive. It may not be possible to include NYC with the nature imagery, but if, for example, the attraction in NYC is the buildings, then the imagery could include a beautiful building that is found in the nature walk or on the beach; if the attraction is the excitement of all the people, during the country walk, a scene of celebration with a group of people in a town might play a role. In this method, the imagery is discussed with the clients beforehand and the therapist makes certain that everyone is in agreement with the scenario that will be presented. It is important to exclude any imagery that is rejected by clients—for some, this might even be the beach or a country walk. In both methods, the clients can be offered the opportunity to choose between two selections of music, or the therapist may decide on the best musical choice for the imagery. Once the imagery and music has been chosen, begin by elaborating on these basic instructions to the clients: “Find a comfortable position in your chair, noting how the chair supports your body; feel your feet on the ground; bring your attention to your breath and notice its natural rhythm, in and out; you may close your eyes, or if you prefer, simply look downward; listen to the music and to my voice. If, at any

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time, you feel uneasy with the experience, open your eyes and look up. You may also gently stretch your legs, arms, and neck to bring you gently out of this state if you feel the need.” Next, begin the music at a moderate volume. The therapist can guide the clients through a brief body scan, beginning with the feet to establish grounding, and moving through the legs, abdomen and hips, internal organs, chest, lungs, and back, shoulders arms and hands, neck, throat, and head. Periodically, remind the clients to bring the breath to any part of the body where they might feel tension. This process should take approximately two minutes. Following the brief relaxation and body scan, the therapist narrates the imagery, occasionally giving clients time to form images in intervals of 7 to 15 seconds. Clients should not be left alone in the music for more than 15 seconds. The imagery should be timed to end 30 seconds before the end of the music. When the music ends, bring the clients back to reality with instructions such as: “The music has ended; allow the images to fade, knowing that you can keep inside of you any of the positive feelings that you enjoyed in this imagery. Begin to become aware of your breathing again, and begin to stretch your arms and legs, noticing how your body feels. Open your eyes when you are ready.” The imagery is followed by a discussion about what the experience was like for each client. The therapist brings to each client’s attention the positive effect of any image and discusses with the clients ways that they can use these images as their personal resource in their daily lives. Commonalities and differences among client responses may also be discussed for the purpose of helping clients to recognize how each individual can use music, imagery, and relaxation in his or her life to cope with stress. Individual and common group responses to the imagery may suggest intrapersonal and interpersonal issues that need to be worked through using other methods such as song choice, song singing, songwriting, or improvisation themes. Adaptations. Some therapists prefer a more focused physical relaxation followed by a nondirected imagery experience. De Backer (1996) uses a short Jacobsen relaxation with a body scan followed by six to seven minutes of music without a narrated script. Afterward, clients share personal imagery, associations, and emotions that were evoked during the music listening to facilitate interpersonal communication. To stimulate “emotional listening” De Backer suggests listening while lying down (p. 28). Lying down, however, is contraindicated for any client with active psychosis. Another adaptation focuses on body relaxation throughout the music; in this variation, the relaxation instructions are extended to last the duration of the music. Either autogenic or Jacobsen (1970) relaxation can be used (Crowe & Wigle Justice, 2007). In Jacobsen relaxation, specific muscle groups are tensed for 8 to 10 seconds and then relaxed for the same amount of time according to the therapist’s guidance. It can be very effective when the therapist can provide simple, live music with two different chords or sounds to differentiate the tension and relaxation effect. In autogenic relaxation, the client is directed to focus on each body part with a relaxation focus, e.g., a feeling, color, temperature, or energy that is repeated by the therapist. There is no tension involved. Because this is the least active relaxation exercise, it is not recommended for persons with active psychosis (p. 38). The same grouping levels of basic, average, and intricate presented in the Movement to Music section can be applied to Jacobsen and autogenic relaxation (p. 38). De Backer (1997) uses drawing while listening to music for clients who are confused. The music choices follow the guidelines above, but the clients convert associations and imagery that are evoked by the music into drawings. In this author’s experience, this adaptation can be effective in helping clients who are disorganized when the therapist provides a mandala or a large circle outlined in pencil on a sheet of paper for the clients. Clients can have a choice of oil pastels or markers to create colors and shapes to draw within the circle or to go beyond it if they wish. The music selection may need to be played a second time to allow clients time to finish. This is followed by a discussion related to the meaning of the drawing for each person and what they experienced in the process.

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Goldberg (1989) employs receptive music experiences with writing in a similar way to the art experience above. While listening to music, clients write down feelings, associations, or images that occur to them. Group discussion afterward focuses on how their writing relates to personal issues. The art and writing experiences are contraindicated for any group in which any client may not feel comfortable using art media, writing, or listening.

Evening Relaxation Group Overview. This relaxation follows similar guidelines to the relaxations outlined above. The main difference is that this relaxation procedure occurs in the evening after dinner to prepare the clients for sleep, and the entire group time is spent in relaxation rather than having a short relaxation as a part of a session with other music experiences. The best assessment for a client’s readiness for this group is the client’s reaction to any of the above short relaxation procedures. Clients who are able to focus during a group for 30 to 40 minutes and who are not actively psychotic may benefit from this group. Clients who have difficulty sleeping and who need to decrease internal stimulation are indicated for the group. Clients who have difficulty remaining attentive, who are floridly psychotic, or who have poor reality orientation are contraindicated. A maximum of 10 clients can attend this group if the room has ample space; more than 10 clients is contraindicated because one therapist cannot observe more than 10 clients effectively. Goals for this experience are to decrease internal preoccupation (Goldberg, 1989), enhance relaxation, encourage natural sleep, and facilitate psychoeducational coping mechanisms to deal with stress-related sleep disorders. The level of therapy is augmentative, and there is no special training needed beyond the professional-level competencies. Preparation. A quiet space away from environmental noise is prerequisite for this group. Lighting should be dim. There must be ample room to allow each client to have a space around him without being concerned about being touched by others to ensure each person’s psychological and physical safety. Clients can choose to lie on mats on the floor or sit in comfortable chairs. If chairs are used, a second chair or footrest should be provided so clients can raise their legs and recline comfortably in the chair. Clients can be encouraged to bring their preferred blanket and pillow. The therapist may use recorded music or she may improvise music for the clients. The former requires a device on which to play recorded music, while the latter requires a keyboard, guitar, or other instrument of choice. What to observe. Note any client who becomes physically restless or fidgety. Check in verbally with clients before the relaxation to determine if anyone is having psychotic thoughts or is too anxious or fragile to benefit from this group. During the relaxation, note whether any client opens his or her eyes. If this occurs, make eye contact with the client so that he knows to follow instructions given at the opening of the group. Observe signs of agitation or frozenness as for the imagery experience above. Procedures. The therapist begins by giving the clients information about how the group will proceed, informing them that the purpose of the group is to prepare them for sleep, and as such, it will require no activity, but that they will need to feel comfortable reclining or lying down and listening to music for about 30 to 40 minutes. It is recommended that clients close their eyes, but if they don’t wish to do so, they may soften their gaze and look downward. Inform clients to open their eyes and make eye contact with the therapist if they become uncomfortable at any time and to sit up if not already doing so. If a client communicates distress in this way, the therapist follows the guidelines above for helping the client to become grounded and alert. Once each client has found a comfortable position and has understood the purpose and demands of the group, the therapist conducts a brief check-in and asks clients how they are managing sleep to better understand the kinds of challenges these clients are facing when attempting to sleep. Some psychoeducational information is helpful, for example, talking about how practicing skills to relax the

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body and paying attention to the breath can help with sleep and also help to clear the mind. Dietary cautions such as caffeine and sugar as impediments to sleep should also be discussed. An assessment to determine further procedures is conducted after the introductory verbal instructions. In a brief exercise, the therapist asks everyone to close his or her eyes and imagine relaxing in a favorite place. Allow about 30 seconds then ask the clients to open their eyes. Verbally check in to see what the experience was like for each person and to determine if there is anyone in the group for whom this experience is contraindicated. This will be evident if the client had a negative or disturbing reaction to the 30-second imagery. In this situation, provide suggestions to the client to sit up and to listen to the music with eyes open throughout if the client wishes to remain in the group. During the check-in, the therapist will also listen for the particular needs of individuals in the group to choose a relaxation method. The Jacobsen method is indicated when clients feel some anxiety or experience difficulties achieving a relaxed state with mental imagery alone. If all the clients are able to tolerate this check-in experience without discomfort, then autogenic relaxation is indicated. Recorded music should be selected according to the guidelines in the Music, Imagery, and Relaxation section above with the only difference being that the recorded music should last about 20 minutes; shorter selections can be repeated. Begin by giving everyone time to settle in their position again; focus attention on the breath and its natural rhythm. Invite the clients to inhale deeply, hold it, gathering up the tension in their body, and let it go with an exhalation. Do this three or four times. At this time, the therapist will begin the autogenic or Jacobsen relaxation. If Jacobsen relaxation is used, the therapist will give instructions to tense each group of muscles, hold for about five seconds, then let the muscles relax. Begin with the client’s feet, and move through the body as indicated in the Music, Imagery, and Relaxation section above. Each area of the body may need to be done more than once. The length of the relaxation can be altered as needed by doing smaller or larger muscle areas, or one side of body and then the other. When using autogenic relaxation, the therapist chooses imagery that facilitates relaxation for each body part. Clients are instructed to imagine each body part feeling one way in a consistent manner with consistently formulated language. For example, “My feet feel warm [or heavy, or supported] and more and more relaxed.” Avoid using terms that connote feeling “light” or “floating” in the inpatient unit because of the tendency of some clients to dissociate. Wait three to five seconds, timing the directions with the musical phrasing, and then repeat the direction. The therapist can also find images that suit the particular group based on the clients’ needs as expressed in the check-in. For example, after relaxing each muscle group, another phrase can be added, such as “I feel more and more peaceful [or calm, or supported, or confident, or hopeful]. More developed images can be used in autogenic relaxation as well, for example, breathing in a particular color that each client wants to imagine and sending it to each part of the body, or imagining that the breath is moving to each part of the body and leaving it feeling a particular way. An example of this is: “See in your mind’s eye a color that brings you a feeling of relaxation. Imagine that this color is all around you. Allow yourself to gently breathe it in and send it to your feet. As the color moves all around and through your feet, it leaves them feeling more and more relaxed.” These examples are only indications; the therapist develops images inspired by the individuals in each group using her creativity to respond to particular clients’ needs. Following the relaxation, a vocal improvisation by the therapist for the clients can be very therapeutic when clients are in this state. Clients should be told at the beginning of the group that this will occur. Gently lower the music volume if it has not come to an end, and using two chords with an open sound on the guitar or keyboard (for example, F major 7th to d minor 7th) in arpeggiated style, begin to hum or softly improvise a repetitive, predictably phrased melody in lullaby style in 4/4 or slow 6/8 time. Leave predictable and recurring spaces in the music to allow ample time to breathe. Continue for three to six minutes. Be silent for about one minute afterward and then begin to bring the clients to a more alert state. Say in a moderately loud voice, waiting for two seconds between each sentence: “The music has

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ended. Bring your attention back to your breath. Notice how your body feels when it is relaxed, and know that you can keep this relaxed state as you begin to wake up. Notice the sounds in this room and the sounds outside of it. Stretch your feet, legs, arms, neck, and any part of your body that needs to be stretched. When you are ready, open your eyes and sit up.” This group ends with a brief check-in to determine that each client is psychologically safe and that the experience was a positive one. If a client has an abreaction to any part of the relaxation experience, help the client to express this. If the relaxation evoked negative imagery or thoughts or hallucinations, it is important to follow up with the client individually after group and report it to the charge nurse. Adaptations. The music can be adapted in this experience. Although it requires a great deal of skill to narrate relaxation and play an instrument at the same time, if the therapist is able to do so, this can be a very effective alternative to using recorded music. The therapist chooses two open chords and plays these so that they coincide with the relaxation narrative. This can be especially effective in the Jacobsen technique where the instruction to tense the muscles is accompanied by a solid chord or a suspended harmony that increases the dynamic tension, followed by an arpeggiated softer resolving chord when the client relaxes the muscle group. Other instruments can also be used in conjunction with tension and release, e.g., a drum can accompany the tension, while a gentle downward scale on the chimes or a few tones on the hang drum can accompany the release. Instruments such as the ocean drum, hang drum, chimes, rain stick, guitar, or keyboard can also be used to accompany autogenic and Jacobsen relaxation. When using this adaptation, the therapist should practice integrating the instrumental accompaniment and relaxation narrative before using it with clients. Another adaptation involves the addition of a toning experience of about three to five minutes with the active participation of the clients prior to the relaxation. Procedures for toning are described in the Improvisation Method in this chapter.

Musical Games Overview. Musical games are experienced in a variety of forms, the most common being quizzes based on musical knowledge and/or discrimination, while others require active participation such as drawing or movement. They are enjoyable activities that may be perceived as less threatening than other therapeutic techniques, yet they are able to meet the functional needs of clients both in terms of the amount of structure used and the nature of interactions required (e.g., cooperative, competitive, expressive, strategizing) (Silverman, 2005). They also permit the therapist to experience different aspects of the clients and provide new insights into their cognitive and relational abilities. Games should be motivating, enjoyable, relatively simple, age-appropriate and growth-oriented (Silverman). Goals include improved socialization and interpersonal behavior; they promote leisure skills and improve reality orientation (Houghton et al., 2002), decision- making, problem-solving, role identification, and leadership (Silverman) and they improve cognitive skills. Clients who have cognitive difficulties from medication adjustments or because of psychosis may not benefit from such groups. The level of therapy is augmentative. Preparation. The room is set up with chairs in a circle. Team games may be more successful if the seating arrangement is organized to accommodate the teams rather than have clients choose who will be on their respective teams (Silverman, 2005). Therapists can use their creativity to adapt games that are familiar (e.g., Musical Jeopardy, Musical Trivial Pursuit, charades, board games, Music Pictionary, Name That Tune) and familiar games are more successful than entirely new games (Silverman). Depending on the requirements of the game, the therapist prepares the materials beforehand, e.g., music trivia questions, bingo cards with the names of songs substituted for numbers, a recording of familiar melodies and/or songs and technology to play it, a dry-erase board, or paper and pencils.

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What to observe. Observe clients’ interactions and social skills, their ability to take turns, and their sense of belonging to a team, where applicable. Note which clients may not be participating and encourage them to do so, giving assistance where necessary. Be aware of each client’s ability to understand and follow the rules and be oriented to reality. During verbal processing after the games, note how each client is able to connect the experiences in the game to life skills. Procedures. Some games are useful as warm-up activities. For example, in Hot Potato (Silverman, 2005), clients toss a ball to music, and when the music stops, the player with the ball answers social questions about music and activity preferences. This works best when the therapist provides examples of the kinds of questions that are appropriate to ask or prepares questions that clients can choose to ask. Another opening game is a Rhythmic Ball Game (Silverman) in which the participants toss or bounce a ball to another peer on the musical beat. There are a number of games that rely on song recognition. In Name That Tune (Houghton et al. 2002), the group is divided into two teams and the dry-erase board is used as a scoreboard. The therapist plays and sings melodies from well-known songs, leaving out the lyrics. Each team has an opportunity to respond to the mystery song, and if they correctly identify the title or the lyrics, they score a point; if not, the other team has a chance to do so. Whichever team identifies the most songs by the end of the game is the winner. A variant of this game is Hangman. Here, each wrong answer or unidentified song results in one element of the hangman being drawn. The group wins if the song is identified before the hangman is completed. In Musical Bingo (Houghton et al., 2002; Silverman, 2011b, 2011c) clients are given bingo cards with song titles on them and markers. The therapist plays about 20 seconds of a recorded song and if the client’s card includes the title of that song, he marks it. After each song, the therapist asks questions about the song such as personal memories associated with it, artists performing in it, or other facts about the song. The winner is the first client to have his card filled in. An adaptation is the TV Theme Song Game in which the participant identifies the TV show based on its musical theme (Silverman, 2005). In Lyric Completion the therapist sings a part of the song and the player identifies the lyrics that follow (Silverman, 2005). Musical Jeopardy focuses on information about songs. Usually, the therapist chooses a particular genre, epoch, or theme. She prepares questions about the songs and organizes the questions into categories, placing them in a box. The group is again divided into two teams and each team chooses a question, meriting a point if they can answer it correctly. To add a musical component, the therapist can sing the songs used in the game as well. Some games require clients to be more actively involved. In Music Charades, one participant acts out the song title while the team guesses it; in a similar vein, in Music Pictionary, one person draws a picture representing a song, artist, or instrument, while the teams attempt to guess it before the picture has been completed (Silverman, 2005). In another active game, Simon Says, participants follow a peer’s musical directions to remain in the game. Finally, a game that promotes socialization is My Song; in this game, each player writes a song title on a piece of paper and the teams decide which player they think chose the song (Silverman). At the end of each game, the therapist processes the clients’ experiences, focusing on interactions, feelings, skills, and events that occurred during the game and draws pertinent comparisons between these experiences and life situations (Silverman, 2005).

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY There are a significant number of articles, chapters, and books on the use of improvisation as a therapeutic technique in music therapy (Bruscia, 1987a; Gardstrom, 2007; Lee & Houde, 2011; Nordoff &

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Robbins, 2007; Wigram 2004). In particular, Bruscia’s (1987b) seminal work on improvisation identifies and defines 64 techniques used in clinical improvisation under the following categories: empathy, structuring, elicitation, redirection, intimacy, procedural, referential, and emotional exploration (pp. 533–557). While these improvisation books provide indispensable information regarding the development and application of improvisational skills for the music therapist, relatively little literature exists that describes how these techniques are specifically employed with groups in the inpatient setting. There are several important factors to consider when presenting improvisation experiences specifically for inpatient psychiatric populations, and these apply to all the experiences described in this chapter. The first consideration is the need for a highly developed structure. This constitutes using predictable harmonic sequences, a strong and constant rhythmic pulse and regular phrases, and clear instructions and cues for the participants (Bruscia, 1987b). De Backer (1996) indicated the necessity of establishing a strong rhythmic pulse when working with psychotic persons because of their need to fuse into the common rhythm of the whole group. At the same time, she stresses that a principal therapeutic factor in improvisation involves the ability to separate from the group and to express one’s uniqueness in the improvisation. Thus, the therapist must both provide musical structure and security while also providing opportunities for individual expression. Other elements that need to be considered in preparing an improvisation are the various ways in which clients and therapist interact in the music and the choice of instruments. Crowe, Nolan, and Ierardi (2007) describe the client and therapist roles in improvisation as leading, imitating, following, entering into the group’s music one client at the time, supporting, and soloing. Thus, the therapist must consider these roles based on the functional abilities and needs of her clients. The choice of instruments also contributes to various degrees of complexity in improvisation. The therapeutic goal for the improvisation will inform the therapist’s decision regarding the use of drums only vs. the use of drums with other nontuned percussion instruments such as shakers, wood blocks, and cymbals, or the use of melodic instruments such as metallophones and xylophones and imagery-evoking instruments such as rain sticks and ocean drums. Vocal improvisation may be substituted for the use of instruments or it may be integrated with instrumental playing. The final primary element that must be decided in preparing an improvisation is whether it will be referential or nonreferential. A nonreferential improvisation has no reference to ideas external to the music, while a referential improvisation portrays a nonmusical idea in sound (Bruscia, 1998a). Houghton et al. (2002) specified that the focus of a nonreferential improvisation is the musical elements of volume, tempo, register, texture, rhythm, and melody, which include Bruscia’s (1987c) musical elements used in the Individual Assessment Profiles. Referential improvisations may portray emotions, dramatic scenes, images, poems, pictures (Houghton et al.), impressions, situations, or roles (De Backer, 1996). Because of the wide variety of structural and musical choices available, improvisation can address myriad therapeutic goals and benefits for inpatients. These goals address socialization, communication, expression of one’s feelings, self-esteem, sensory- and reality-ordered behavior (Houghton et al., 2002), internal and external organization, internal preoccupation, withdrawal (Goldberg, 1989), interaction with and relatedness to peers (Stephens, 1983), spontaneity, cognition, sensual stimulation, and identity formation (Bruscia, 1998a). Given the wide range of choices and therapeutic possibilities, as well as the various levels of skills needed by the therapist and clients to implement different improvisational forms, the therapist must carefully consider each of these elements in choosing an improvisation experience. As the various structures are presented below, the reader might keep in mind that these examples serve as a guide and that there are countless other creative and unique possibilities available.

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Nonreferential Percussion Warm-ups Overview. These activities focus on helping clients to establish the basic skills needed to engage in playing percussion instruments together. The structures used to achieve this are based on call-andresponse and short imitative exercises using tuned and nontuned percussion. Most first-time clients in the inpatient unit will not have experienced therapeutic improvisation previously, and those who have may need some assistance, depending on their mental status. The first undertaking in presenting improvisation is to help the clients become aware of their internal urges and feelings and translate them into sound. Once that has been accomplished, clients are invited to become aware of how to listen to others and how to listen to and alter the musical elements they are using. Thus, before any of the more complicated referential improvisations are attempted, clients need to be introduced to rhythmic improvisation exercises that pose minimal challenges related to expression, organization, listening, repetition, and matching. All clients who are in the active inpatient group can benefit from these percussion warm-ups. Patients who are overstimulated by volume, however, might find the percussion to be overwhelming depending on the size of the group. Specific client goals for this type of improvisation activity are to improve sensory- and realityordered behavior, self-organization, relatedness with peers, and cognitive skills. The therapeutic aim is to introduce the clients to listening and playing with others while expressing something from within, to develop a vocabulary of rhythmic figures that can be combined and recombined, and to develop familiarity with rhythm, various sounds, and the expressive possibilities of percussion instruments. The level of therapy is augmentative. Preparation. Set up the room with chairs in a circle a few inches apart so that everyone can see everyone else. If the therapist will use a piano, position the piano so that it is at an angle and forms part of the circle. Provide a range of percussion instruments, giving consideration to a variety of sizes and materials. Include freestanding drums such as djembes, tubanos, or congas; hand drums; bongos; wood percussion such as blocks, claves, tone bars or tone drums; and metal instruments such as finger cymbals, triangles, or a bell tree. What to observe. Observe the organization of each client’s rhythm, his physical connection to the instrument, his ability to create, recall, and imitate a short, repetitive rhythmic figure, and his engagement with the music experience and with others. In the verbal check-in afterward, note each client’s subjective evaluation of the experience and the level of interaction in the group. Procedures. The simplest introductory rhythmic experience consists of playing a short rhythmic pattern of one or two measures in 4/4 time using half, quarter, and eighth notes for the group and asking the group to play it back. If necessary, repeat it twice consecutively, taking care to make the last note of the rhythmic motif a value of two beats or more. Show the clients how to respond beginning on the next bar, cuing the clients in verbally saying “Your turn” in the last beat if necessary. At first, do this with the whole group responding together, and once the clients have become more adept at hearing the various rhythms, ask each individual client to respond to a pattern in a group go-round. When the clients are able to imitate these rhythms with relative precision, ask each client to invent and play his own rhythm so that the group can respond to each soloist. Another variation is to ask each client to play a short rhythm of his own invention that the client next to him will repeat. After repeating the rhythm, the second client plays his own rhythm that will be repeated by the client next to him, continuing until everyone has had one or two opportunities to play. When clients have difficulty organizing the rhythm, help them to feel the pulse of one measure by playing the pulse with them; likewise, if a client has difficulty repeating a rhythm, don’t stop to try to correct it, but instead, keep the flow going without drawing attention to the client.

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Adaptations. Crowe, Nolan, and Ierardi (2007) reverse this procedure by asking the client to play a short rhythm pattern while the therapist responds with a chord progression in a familiar style that supports the client’s rhythm. As the group joins in with the client’s rhythm, the therapist uses other techniques of elaboration and elicitation (Bruscia, 1987b). In another adaptation by the same authors (Crowe, Nolan, & Ierardi, 2007), the therapist plays a rhythm and asks the group to join in when they are ready, each playing a pattern that fits. This rhythm activity can be elaborated by playing four-measure phrases and leaving the last three beats of the fourth measure silent; the group practices stopping at this point while each individual client in turn fills in the last three beats with a solo. Another variant is to have the whole group play during the therapist’s rests. The length of solo and group can be altered so that the group and soloist play an equal number of measures. There are an infinite number of possibilities for this kind of rhythm activity that help to create group cohesion and internal organization in addition to preparing the clients for more elaborate improvisations by honing their cognitive and perceptual skills of memory and listening. Reuer, Crowe, and Bernstein (2007) describe some of these in detail. One example is the “Egg Shakin’ Blues” (pp. 46– 47), in which egg shakers are used with a song composed to provide choices in the way that the shakers are used, and clients learn to both sing and play in rhythm, using rests as cues. In another (p. 50), names and other words are used to identify, recall, and imitate rhythms. Examples of appropriate call-andresponse rhythms are also provided (p. 62), along with a technique (p. 53) that works very well to improve attention and group cohesion, especially in large groups. Using this technique, assign each person in the group a number and then call out the numbers at random during the improvisation. The client plays only when his number is called. This numbering technique can be applied to large groups by giving everyone a number up to four. Once the group has been divided according to number, the therapist can invent ways of having numbered subgroups play together, rapidly changing randomly from group to group, or assigning a particular rhythm or role (e.g., keep the pulse) to each subgroup as they play simultaneously.

Nonreferential Group Percussion Groove Overview. In these percussion experiences, the group plays together, maintaining the same pulse while each client explores his individual potential for rhythmic and dynamic inventiveness. Once the group is able to keep a pulse together and participate in a rhythmic call-and-response activity, clients are ready to explore other musical elements available to them to further develop their unique musical responses. Clients who are unable to keep a pulse or imitate rhythms may still be able to function well in this group because of the tendency to become entrained to the group rhythm. The contraindication for this group would be someone who is overly stimulated by loud sounds. This may include persons who are manic or floridly psychotic or who have experienced trauma. In addition to the goals stated for the warm-up exercises above, the goals for this experience are to improve group cohesion; develop self-expression using musical elements of rhythm, volume and tempo; and increase impulse control. The level of therapy is augmentative, and no training is needed beyond professional competency. The environment and session preparation follows the guidelines for the warm-up exercises above. Observations are identical to those for nonreferential percussion warm-ups, with the added observation of the clients’ abilities to create appropriate changes in volume, phrasing, and tempo. Procedures. Begin by demonstrating the musical elements that will be used in these experiences. First, establish a steady pulse and demonstrate how long eight beats last, asking the group to join in playing eight beats and then stopping for four before starting again. Next, introduce the group to volume:

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Playing 16 continuous beats, demonstrate how to get louder for the first eight beats, then softer for the next eight beats, and invite the group to do the same. Finally, demonstrate how the group can get faster or slower together, using the same eight- and eight-beat formula. To practice using these elements together, the therapist can lead with cues or with drumming. Individual clients can take a leadership role by using specific gestural cues for volume and tempo or by drumming. The first method promotes eye contact, while the second promotes listening. Adaptations. Once the group is able to execute changes in volume and tempo and feel the pulse together, other combinations of group and solo playing can be employed. For example, the group can play the pulse, while each client in turn takes the soloist role for eight beats. If there is a lack of large drums, one large drum can be placed in the center of the circle, and each client goes to the center to execute his solo. Everyone should be encouraged to take on a solo role, but any individual who wishes to abstain should be allowed to do so, as this solo role can be intimidating, especially for someone who has recently arrived on the unit. If the group is small and the drumming is not too loud, a different solo instrument such as a xylophone can be used for the soloist. In this case, the soloist would play for longer than eight beats. A variant for a large group involves dividing the group into two and using a responsorial structure with each group playing for eight or 16 beats. Groups can be instructed to alter volume and tempo as well. Song forms can also be used to accompany a group percussion groove. For example, Gardstrom (2007) used the harmonic structure for the song “Hit the Road, Jack” on the piano, while Solli (2008), working with an individual, played harmonic structures from rock songs on the guitar. Crowe, Nolan, and Ierardi (2007) used other familiar styles to accompany group percussion, including blues, pop styles, and rock ballad. They also suggested using individual entrance cues so that each person learned to listen and to fit in with the music. Another formal structure that these authors used was the classical rondo form, where the A section was the main theme, composed of a predictable short harmonic phrase and melody, and the B section exhibited melodic variation where clients interacted freely in the improvisation; this was followed by a return to A and then another variation for the C section. The drum circle, which was popularized in North America by Arthur Hull (1998, 2007) is a common experience used in psychiatric facilities. Gardstrom (2007) elucidates the difference between clinical improvisation and drum circles, identifying the goal of drum circles as promoting “social unity and personal enjoyment through rhythm-based playing” (p. 21). It is precisely for this reason—providing social unity and enjoyment—that drum circles can be very therapeutic in the inpatient unit. Hull (1998, 2007) and Stevens (2003) have described drum circle facilitation techniques, and, more recently, Matney (2008) produced an excellent guide to the therapeutic use of a wide array of percussion instruments and leadership skills needed to facilitate percussion groups. While these guides are indispensable to any music therapist who leads percussion groups, there are a few aspects of drum circles that are of special note when facilitating such groups in the inpatient unit. The first of these is to provide the clients with a constant reference to keep the pulse. The therapist can keep the pulse using large visual gestures and instruct anyone who is having trouble hearing the pulse to look at her to get back in sync with the group, or she can give that role to someone in the group who is able to keep the pulse without wavering. Volume may be an issue in the inpatient unit. Clients tend to get louder and louder, trying to hear themselves, and in the process, they may get faster as well, making it difficult for the individual client to hear himself. An excellent way to address this is to employ the African technique of using claves to signal a measure or two of silence. The therapist can practice this with the group beforehand. After the group has begun playing, instruct them that when the claves are held in the air and played four times (twice for each measure), this is a signal that everyone will stop on the next beat, or when they hear the claves for the fifth time (measure three). Participants stop playing while they count up to four or eight, then resume playing, beginning with a soft volume. The therapist can use strong visual cues, such as jumping up and landing on

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the beat that begins the silence, and using a large arm gesture to cue the return to playing. The stopping and silence serve to reset the dynamic level and prevent the clients from experiencing sensory overload. Facilitating a drum circle that is cohesive in the inpatient unit takes some preparation. The therapist can begin by asking each person one by one to play the rhythm of their heartbeat. From this departure, the therapist can ask everyone to entrain to find the same heartbeat pulse if a common pulse has not emerged in the process. Next, take the clients through a few exercises, getting louder and softer, and staying together. Once they feel the pulse together, designate half the clients to keep the pulse, and demonstrate how each person can play different rhythms and stay with the group as long as everyone keeps the same heartbeat pulse. Allow the clients to change roles so that everyone has a chance to experience playing patterns while keeping the beat. Remind clients that one person will keep the pulse with a strong visual cue if anyone loses it. A final consideration in the therapeutic use of the drum circle in the inpatient unit is the sense of community inherent in the experience. The therapist can discuss the meaning of community drumming, emphasizing that people traditionally came together to drum in times of celebration or in times of need. In drumming together, we share our energy and we support one another. She might suggest that each client use the drum circle to draw from it whatever he needs. Multicultural awareness is also important. For example, when working with Latinas and Latinos, demonstrate some Latin beats or ask the clients to teach them to the group. Indigenous peoples who are present in some demographics may also have particular knowledge about drumming that they are willing to share. In working with African-Americans, it is important to pay homage to the African culture from which so much of our drumming techniques have derived. Informing the group about some of the techniques and rhythms used in African drumming can be an enriching and empowering experience for African-Americans in the inpatient unit. Chants may be added to the drumming once the group is in a groove. The therapist can use African, Latin, or indigenous people’s chants or even a few meaningful lines from popular songs to bring a melodic component into play. This can be done in a call-and-response manner, and may become improvisational in nature as the therapist improvises using only a few words of the original chant and encourages clients to do the same. Some clients can be encouraged to spontaneously improvise when the therapist models this. If the drum circle is used as a closing experience in the session, the therapist might use the chorus of a song that was particularly meaningful in the group and repeat a couple of lines from the chorus, leaving space for clients to do the same. Some song lyrics may easily be adapted to spontaneous lyric substitution to reflect individual needs during the drum circle as well. For example, the chorus from Bob Marley’s “Three Little Birds” can be sung while substituting each client’s name with a personal message or coping technique that the client will use to help him through the day.

Nonreferential and Referential Instrumental Exploration Overview. Clients explore a range of instruments to become aware of the associative and evocative possibilities of tuned percussion and atmospheric instruments (e.g., rain stick, ocean drum). Unless clients have been previously introduced to music therapy or have used these instruments in school, it is unlikely that they will be familiar with them. Instruments should be of a high quality so that clients do not associate them with childlike musical activities. Nonreferential instrumental exploration activities are an important introductory step to referential improvisations and should precede referential ones. Clients in the inpatient unit often find that these instruments can help them to identify and express their internal life in a nonverbal and appropriate manner, and therefore there are few contraindications for these activities. Clients who are easily overstimulated and who cannot tolerate groups are contraindicated. De Backer (1996) described how, through the exploration of instruments in the inpatient unit, clients came into contact with themselves and their needs and learned to listen to others. In addition to

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these goals, instrumental exploration helps clients to identify and express feelings; “establish a nonverbal channel of communication, and a bridge to verbal communication” (Bruscia, 1998a, p. 116); organize one’s internal urges; improve the ability to make decisions; increase self-esteem; try out a new behavior; and increase peer relatedness. The level of therapy is augmentative, and no training is needed beyond professional competency in improvisation methods. Preparation. The room should be prepared as it was for the nontuned percussion activities. The instrumentarium should also include a variety of high-quality instruments, for example, xylophone, metallophone, glockenspiel, tone drum, tuned split log drum, hang drum, kalimba, shakers of many varieties, authentic world beat instruments, chime bells, gong, cymbals, temple blocks, ocean drum, and rain stick. For a more exhaustive list of types of instruments, consult Gardstrom (2007, pp. 38–42). The instruments should be placed within easy reach in the center of the circle, but if space does not allow, spread them out in a location in the room where clients can easily explore each one. What to observe. In addition to observing all the music parameters discussed in nonreferential improvisation, the therapist observes the client’s ability to exploit the expressive capacity of the instruments. Take note of the type of instrument chosen by the client, including the material it is made from, its size, the way it is played, the client’s associations to it, the energy invested in playing it, how it is held in relation to the body, and any images or feelings that are evoked by the client’s chosen instrument and those played by others. Another important component is the interpersonal interactions formed in playing the instrument with others. Notice how the client relates to others and how the client perceives he is relating to others. Procedures. To begin, the therapist demonstrates the sounds of various types of instruments (Gardstom, pp. 48–49) and asks clients to respond with a word or image describing what the sound evokes. Next, invite the clients choose an instrument, taking some time to explore how it feels, looks, and sounds, pointing out that there is no right or wrong way to play. Once each client has chosen an instrument, ask each to play it for the group and follow up by asking what he liked about the instrument, why he chose it, and what it reminds him of. Other clients may wish to comment as well, and sharing responses to the instruments with the group should be encouraged. It should be noted that while the exercise related to choosing and playing the instrument was nonreferential, once the client is asked to associate the sound to a feeling or idea, the experience becomes referential. Adaptations. The first adaptation is group alteration of musical elements. After each person has had a chance to present his instrument, the clients can play together as a group, blending their sounds by getting gradually louder or softer, slower or faster. The therapist can model how to use cues to alter these music elements, and then individuals may be asked to volunteer to use the same cues to “conduct” the group. This leadership role can be very empowering for individual clients as well as for the group as a whole. Another variation to this experience is the division of instruments into categories. Dividing the instruments up by material—atmospheric, wood, skin, or metal—and playing each group in turn can facilitate sound exploration. This can be followed by a discussion of what was evoked by the different sounds in each group and personal preferences for one particular group of instruments. Subgroups can be formed with various combinations of instruments to explore blending different sounds. Playing a familiar and unfamiliar instrument is another way to encourage exploration. As clients become familiar with sounds, each person can choose two instruments, one that he has already played and another that is different or unfamiliar, playing them both in succession during the improvisation. The therapist can play guitar or piano or use voice to accompany the group. Discussion can focus on how it was to play something familiar and something new. In some groups, this discussion can be related to trying new and different behaviors in life.

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A group instrument exchange can be facilitated in the same manner to structure the exploration a variety of instruments. In this experience, the therapist asks everyone in the group play one instrument of choice while the therapist accompanies on piano or guitar or on a percussion instrument. On a musical, visual, or verbal cue, everyone stands and moves to the chair to the right, leaving the instrument he has just played and playing the instrument placed on the next chair. This is helpful for clients who are reticent to explore new instruments on their own, and it also creates peer relatedness because everyone can share their experience of playing the same instrument. The therapist can also draw attention to how the unique identity of each client was manifested in the way he played each (or a particular) instrument; this discussion might include pointing out the subtle and obvious changes that occurred in the group improvisation when all the parameters remained constant with the exception of who played which instrument. Conducting an improvisation can be combined with the instrumental exploration improvisation. After experiencing instrumental exploration, the therapist can decide with the group how particular cues will be used to conduct the group in a way that will help them to explore changes in musical elements of tempo, dynamics, and timbre. Conducting cues for louder, softer, faster, slower, and starting and stopping are established, and the therapist conducts the group in creating a variety of sounds. Individuals can be cued to drop out for a few moments or to increase or decrease their sound to hear different combinations of timbre along with the changing musical elements overall. Once the therapist has demonstrated this, clients can be asked to volunteer to be the conductor. This improvisation may have only musical referents, or the client may choose to express a referential theme such as a color or emotion, or even choose from a list of titles or a group of suggestive pictures prepared in advance by the therapist. Some clients may even accept the opportunity create the sounds they desire by asking their peers to play certain instruments for their composition. Care should be taken to help clients connect the image or feeling to the sound that is produced; this is explained in the section below titled Programmatic Referential Improvisation. A variant of conducting is leading with an instrument. The therapist designates one instrument as the leader’s instrument and the client leader takes a central position with his instrument. In this case, he will conduct by cuing his peers with his instrumental sounds using gradients of musical elements of fast, slow, loud, or soft. The client can also choose specific instruments for the members of the group. Conducting experiences are very helpful in the development of leadership and self-esteem. Related to the experience of leading the group with an instrument is the concerto form in which the soloist plays an instrument that stands out. A good solo instrument is, for example, a metallophone or xylophone, hang drum, piano, or guitar. To accompany the soloist, the other group members play their instruments in a way that allows them to hear the soloist at all times. The soloist can choose to play a nonreferential improvisation or use any of the themes or methods used for referential improvisations.

Referential Conversation Overview. The referential conversation involves communicating on instruments with others to express specific emotions or themes. It is used to help clients to develop relatedness and learn nonverbal communication skills. This experience is similar to the nonreferential rhythmic warm-up exercises described above in that it prepares the clients for a more elaborate referential improvisation. All clients in the inpatient unit can participate in this experience, and there are no contraindications. In addition to general improvisation goals stated at the outset of this method, the particular goals for this experience are to improve the ability to listen to others; improve engagement with others; practice appropriate nonverbal conversation skills; and improve self-organization and reality orientation. The level

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of therapy is augmentative or intensive, and no training is needed beyond professional competency. The preparation is the same as the nonreferential instrumental exploration. What to observe. In this experience, the client’s ability to manage an interpersonal communicative exchange through the nonverbal means of instruments is of paramount importance. The therapist should be aware of appropriate matching skills related to duration, volume, rhythm, phrasing, timbre, and mood. Equally important is the client’s flexibility with autonomy, i.e., the ability to be both leader and follower, to suggest new musical ideas as well as being able to support others’ musical ideas, and to move between these two roles with ease and spontaneity. Also noteworthy is the client’s subjective reaction to the experience. Procedures. This activity is best when done in pairs with other group members observing. The two clients decide on two similar tuned or nontuned percussion instruments and sit facing each other to participate in the musical conversation. The therapist prepares the instrumental play by discussing how we carry on a conversation with others, including discussions and demonstrations of concepts such as waiting for the other person to finish, and matching or altering length, volume, pacing, and intensity. After two clients play conversationally, the group can discuss what feelings they heard in the conversation and anything else related to communication that was noteworthy in their exchange. Variants include having one client play tuned and the other play nontuned percussion, for example, a xylophone and a djembe, or two instruments of different strength such as bongos and a conga set, followed by a discussion on how this changed the conversation and how similar conversations might occur in life. Another variant involves using the group to keep a steady beat on nontuned percussion instruments while the two soloists converse musically. Smaller groups can be divided in half to carry on similar conversations. In this version, the therapist cues one group to initiate change while the other follows, then the groups switch roles. When this has been successfully achieved, the group can decide on cues for getting louder and faster or slower and softer, stopping and starting. The therapist can conduct both groups in concerto style, and after modeling this, clients can volunteer to conduct the groups. The composition of the two groups can also be altered so that each subgroup has a variety of instrumental sounds, or each subgroup has instruments that are in contrast to the other subgroup. A variant of this experience is to have a client take the role of conducting the two small groups after the therapist has modeled how to lead the group and practiced the conducting gestures with the client. Adaptations. Crowe, Nolan, and Ierardi (2007) use xylophones in pairs for reciprocal communication and suggest preparing the xylophones in specific tonalities or limiting the number of tones to create a different sound. The authors provide a number of scale patterns that can be used with prepared instruments (p. 58). Crowe and Colwell (2007) refer to Bitman, Stevens, and Bruhn’s (2004) use of drums in nonverbal communication in a drumming group. The therapist or a client asks a question to another client, who answers on the drum. This can be followed by a group discussion of the meaning of the responses. An adaptation to this technique is to ask a client to choose an instrument to send a nonverbal message to the group or to play how he is feeling. The next person in the group responds to the message in an empathetic manner, e.g., matching the musical elements, or the entire group can respond empathetically with their respective instruments. This helps clients to access and express different feelings and understand how musical elements can be altered to represent different feelings. Murphy (1983) developed a freer form of communication using percussion instruments. The warm-up consisted of each client sharing an improvisation pattern based on what he was feeling in the moment. This improvisation was then developed into a group improvisation, with the client taking the role of leader and orchestrator of the pattern. The client selected other clients to play certain instruments

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to communicate his improvisation pattern while other members of the group listened. Verbal feedback included acknowledgement of each client’s contribution.

Programmatic Referential Improvisation Overview. In the following group of experiences, clients use instruments to connect to and express their inner world and to share this with others. This is often followed by a verbal discussion. Referential themes are used to facilitate this expression; this includes emotions and images emanating from the individual or from external sources such as pictures or metaphors suggested by the therapist. Referential experiences help clients to improve intrapersonal and interpersonal communication (Bruscia, 1998a) by evoking feelings, images, and memories that can be shared with others, and by providing a nonverbal means of communicating these internal experiences to others in an appropriate manner. Optimally, this experience demands some ability for abstraction in order to derive personal insight from it; however, clients who are extremely concrete may still benefit by playing sounds that match their internal experiences and by relating to others in the group through the sound. There are no contraindications for this experience other than the client’s ability to attend active groups without disrupting others. In addition to the goals for nonreferential instrumental improvisation, the particular goals for these experiences include improving one’s ability to “externalize impulses, release energy, express ideas and feelings, give form to one’s images and fantasies, and recognize and further develop one’s identity” (Bruscia, 1987b, p. 560). In a group experience, referential improvisation has interpersonal goals; it helps clients to identify and share common issues and feelings, thereby increasing their awareness of others (Langdon, Pearson, Stastny, & Thorning, 1989). The level of therapy is augmentative or intensive, and there is no special training needed beyond professional competency. It should be noted, however, that experience or training in applications of music and imagery or in analytically oriented music therapy (AOM) improvisation (Wigram, Pedersen, & Bonde, 2002) is highly recommended. Preparation. The environment is organized in the same manner as it is for the referential instrumental improvisation. Be sure to include a number of small and a few large instruments with a variety of sounds and in a variety of shapes. This improvisation requires the use of some props for imagery. The therapist should collect a number of relatively large photographs such as the kind that would be found in calendars and have on hand a variety of these from which to choose. Choose images that are concrete, yet provide ample opportunity for projection, such as a scene in nature or animals in their natural habitat with their young. Take into account the feelings that might be evoked in the scene by the season represented, the presence or absence of signs of animal or human relationships, the colors, and the atmosphere. For some of the adapted experiences where external images are not used, the therapist prepares words or phrases written on colored paper from which the clients will choose. What to observe. The therapist will observe all the elements discussed in the Referential Conversation section and in the Referential and Nonreferential Instrumental Exploration section. In addition, the therapist will note any individual responses to the music experience and relate it to the client’s presenting problems, being aware that significant and new information may be evoked by the music experience. Procedures. This kind of improvisation takes place at the heart of the session, after the clients have settled into the group and are at ease using the instruments to express themselves and to connect to others. In essence, everything that has occurred in the group previous to this experience is a preparation for it; the thoughts, images, and feelings that clients have expressed contribute to the therapist’s rationale in deciding both the form and content of the programmatic improvisation. The most important aspect of this experience in the inpatient unit is to present it in a way that makes it therapeutically beneficial to all

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the clients in the group regardless of their level of functioning. This requires taking a few minutes at the outset to prepare the clients for the experience by teaching them how to relate their internal experiences to the sound of the instruments and dynamic changes in the musical elements. The first step is to help the clients to access some aspect of their internal life, or inner music (Priestley, 1994). This process will have already begun in previous experiences, and the therapist can now focus on sharpening each client’s apprehension of how his internal experience relates to the programmatic theme. Based on the kinds of feelings and images that clients have verbally expressed in the group thus far (Crowe, Nolan, & Ierardi, 2007), the therapist chooses an image or photograph and presents it to the group as a theme for the improvisation. Sometimes the clients can be asked to choose between two possible photographs, or two photos can be used for the same improvisation as long as they are not antipathetic. The next step is primordial to the therapeutic success of this improvisation. It involves helping the client to connect a significant feeling, image, thought, or memory in his life to an image or feeling in the photograph. It helps to discuss the photograph and its various meanings and feelings evoked by it with the whole group, and then to bring the photo to each client in turn, allowing him to look at it more closely in detail and to specify what it is that he is choosing to represent in the improvisation. The client may require help to identify the connection and translate the idea into a feeling and then into a sound. For example, if a client chooses the smoke coming out of a chimney of a house in a winter scene, ask him what it is about the smoke that is attractive; if the client chooses a particular bird in a picture of birds in flight, ask what is special about that bird. Similarly, work on achieving a level of detail to the extent possible for each client. If a client remarks that he likes the flying birds, ask what the birds might be feeling, or ask him to choose which bird he might be in the picture. This can be done in a relatively short amount of time if it is prepared with a group discussion. As each client begins to specify which image or feeling he chooses, ask him to think about which instrument or instruments would best make sounds that go with his chosen feeling or image. Once the clients have all identified their internal focus and the instrument they will use to depict this in the improvisation, briefly discuss what kind of sounds each person will make and how the sounds will be blended, relating them to musical elements of dynamics, rhythm and tempo. Sometimes, the discussion of various images and feelings leads to a natural development of a programmatic narrative that can unite and integrate the clients’ individual musical ideas. If there are any structural elements such as a change in any musical element from one section to another representing a development in the programmatic narrative, these will be discussed with the group at this time and a decision will be made about how to indicate the change. The therapist also has an indispensable musical role to facilitate the integration of the sounds and to provide the creative atmosphere that will establish the mood of the chosen theme or program. To do this, she must use an instrument or combination of instruments that can express all the musical elements: rhythm, dynamics, texture, timbre, harmony, and melody, listening throughout for rhythms, textures, and timbres played by the clients that she can imitate, integrate, support, or develop (Bruscia, 1987b). When the improvisation has ended, allow a few moments of silence and then ask the group for comments. Discussions can focus on individual responses to the process, for example, how well the music matched each client’s feelings, what kinds of images and feelings were evoked, or how clients related to the group sound and to the sounds of other individual clients. Gardstrom (2001) provides a list of categories of questions that can be addressed in discussions about the improvisations. If the improvisation was not given a title beforehand, the therapist can ask each client to suggest a title that reflects his experience of it. Listening back to a recording sometimes provides insights that go beyond what one can apprehend in the moment (Eyre, 2007; Priestley, 1994). Some institutions require a signed consent form for any recording, even if is not disseminated. In this case, the improvisation can only be recorded if every client signs the consent. If, however, the institution permits recordings to be used only during sessions

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and there is no objection by clients, the improvisation can be recorded and the clients can listen to it, focusing on their own instrument, how they blended with the group sound, how they responded to others and how others responded to them, how the theme was expressed in the sound, how the sound related to their feelings, and how they perceived their role in this improvisation. Adaptations. When individuals in a group have very different energies and expressive needs, the therapist can work with them to find a thematic way of integrating the divergent musical needs into a whole; this can be called integration of polarities. For example, sometimes an inpatient group can consist of hypomanic, manic, or psychotic clients who have much energy and an accompanying need to play loudly to release this energy and have it reflected back to them. The same group might also include clients who are depressed or heavily medicated, or who have flat affect with little energy and an accompanying need to play and hear peaceful, calm, undemanding sounds. One way to negotiate this difference is to work with the group to find a programmatic narrative that reflects the differences and how they will be expressed in the improvisation. Providing musical or conducted cues for structural changes or for transitions is very important. For example, the group might decide that nature holds both elements of calm and storm and choose to do a theme that begins with calm, develops into a storm, and then goes back to calm. It is important to limit both the calm and the storm, to verify that everyone can tolerate both parts, and to provide indications of how the group will know to transition from one part to the other and back again. Another adaptation is to use a referential title chosen by the therapist. During the group process, the therapist might become aware that a particular kind of improvisation would fit the therapeutic needs of the group members. There are various ways to guide the individuals toward this goal, the most common being that the therapist chooses the title of the improvisation for the clients (Priestley, 1994). She would then proceed to help clients to identify with the therapeutic aspects of the theme and the instruments and sounds related to the image or feeling based on each client’s individual goal. The procedure is the same as above. Gardstrom (2007) provides a comprehensive list of titles that can be used to achieve therapeutic goals. Similar to the process of starting with a title chosen by the therapist, one can also use metaphors as improvisation themes to help the client access and express his internal life (Gardstrom, 2007; Goldberg, 1989). For example, the therapist can collect a number of metaphors to have on reserve and write them on a piece of colored heavy paper. She then chooses the most appropriate ones for a particular therapeutic goal and asks the clients to decide which one they would like to do. Alternately, she can divide the group into subgroups of two to four clients and ask them to choose a metaphor that appeals to them. Some examples are The Raging River of Life, Dancing in Chains, Wild Horses, The Spirit of Man and Woman, Phoenix Rising from the Ashes, or The Life of a Sparrow. The procedure unfolds as above, and the therapist takes care to visit each group and help them to decide together how they will portray their theme. Clients can also be encouraged to verbally expand on the metaphor to create a story. The therapist may offer to play with each group and have the group indicate how she should play and which instrument she should use, or the group can improvise on their own. Each subgroup plays while the others listen and then give them feedback about what they heard. After all the groups have played, the therapist discusses what the process was like, encouraging clients to share common experiences and differences. This can be useful for large groups, especially when there may be a student or intern present to help with the process. This structure can be particularly helpful to achieve goals related to social communication and group cohesion. Dualistic themes can be structured in subgroups by facilitating a small group improvisation of dualities. The goal here is not to integrate two disparate feeling states, but rather to help clients to symbolically explore the psychological valence of different ways of being and interacting with the world. Some examples are Open–Closed; Heavy–Light; High–Low; Bright–Dark; Night–Day; Ocean–Sky;

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Earth–Sky; Sun–Moon; Confrontation–Withdrawal; Love–Fear; or Engagement–Retreat. This works well in dyads where decisions can be made about how both ideas will be represented in sound, for example, consecutively, or with each partner taking a specific role. Again, the therapist helps the subgroups relate the feelings and ideas they have about the concept to their life experiences and then to create this in sound on their chosen instruments. An interesting version of the metaphor improvisation is the random metaphorical theme. The therapist writes a number of different active verbs, each on a strip of colored construction paper, and a number of imaginative subjects on other strips of colored paper. Ask clients to randomly choose from each color, then to look at the text and put the two colors together to create a subject and verb, such as a candle (subject) … singing or praying or jumping (three possible verbs). The combinations are infinite and variable in the moods that are associated with them. The therapist helps the clients to create a narrative around their metaphor, urging them to be as imaginative as they wish in their explanation of how this situation, e.g., a candle jumping came about. Thus, in the same improvisation process, subgroups or dyads may have metaphors that evoke serious life experiences (the moon wishing or a fish screaming) to joyous (a leaf flitting) to the absurd (a worm jumping). This projective experience has the potential to bring clients to deeper levels of awareness of their internal life and helps them to share their imagination with others. Referential themes can also be drawn from a line chosen from a song, or a title may be inspired from a previous group experience. The final adaptation is the use of emotions as a theme. In this experience, the therapist writes out emotions on pieces of colored heavy paper and then puts them face down and asks clients to choose them at random. Emotions are matched by color, and subgroups are formed by the color choices. The therapist asks each client if he is satisfied with the chosen emotion, and if anyone is uncomfortable with it, she asks for a volunteer to change with him. This can also lead to discussions about each person’s reactions to specific emotions. Clients can discuss together how to represent the emotion in sound. The therapist helps each subgroup to connect the emotion to life experiences and to its representation in sound, and then each subgroup plays for the others. This can bring up very interesting discussions and provide opportunities to help clients understand their emotions better. Often, two clients playing fear will discover that they have very different representations in sound. By helping them relate their real-life experiences of fear to sound, they become aware that each person has different experiences of fear and different reactions dependent on the situation, and also different individual tendencies to react in a certain way. Love, too, has many different manifestations, both in life and in sound. Clients may hear that emotions considered to be negative, such as anger, have sounds similar to those of excitement or strength; this can lead to a discussion about the positive aspects of anger and ways to manage it so that it doesn’t become a negative force in one’s life. A variant of the emotion improvisation experience involves keeping the subgroup’s emotion a secret and allowing the others in the group to guess what energy they hear in the music and which emotions might carry this energy. This variant is particularly helpful when encouraging discussions about experiencing and coping with emotions.

Vocal Toning Improvisation Overview. Vocal improvisation involves using the voice extemporaneously in a structured or unstructured improvisation alone or in combination with instruments. This might occur within any improvisation, in a drum circle, or in a song elaboration. The first two have been discussed above, and the latter will be discussed in the re-creative section. In addition, the therapist can focus on vocal improvisation as the primary mode of improvisation in the inpatient unit. This would be indicated when clients need to either metaphorically or physically find their voice. Vocal improvisation can be

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intimidating for clients, so structure, simplicity, and clear instructions of what to do are essential. Any clients who can participate in an active music group are indicated for this experience, and there are no contraindications. However, many clients with trauma or who are psychotic or depressed may find the tense, constant tone of the tuning bowl to be eerie and frightening. Use these bowls only as a gong. In addition, dissonant vocal toning may be difficult to endure for some clients. It has been this author’s experience that some persons who are floridly psychotic are unable to match pitch during this phase of the illness. There is nothing in the literature that supports this observation, and thus no protocol for working with this symptom. Perhaps a vocal improvisation where one perceives external stimuli (sound) and attempts to match it to one’s internal experience and reproduce it may help such a client to orient himself to reality in a way that bypasses higher cognitive functions and favors the sensory-perceptual functions. In this author’s experience, such clients seem to respond to having the opportunity to work out their matching difficulties on their own in vocal improvisation and in singing, rather than through working on the problem directly with the therapist. Thus, vocal improvisation may provide an opportunity for psychotic clients to orient themselves to the external world in a nonthreatening manner. Goals for vocal improvisation are to express oneself using the voice, to improve the ability to express one’s needs, to access one’s internal life, to express difficult emotions in an appropriate manner, and to improve self-esteem. The level of therapy is augmentative or intensive. There is no training required beyond professional competency, but some training in vocal psychotherapy is of benefit. The room would be prepared as it was for the improvisation with chairs in a circle, but instruments may not be needed. What to observe. Observe the extent to which the client is involved in the improvisation. Some clients need more encouragement and vocal support to feel safe enough to make a sound. If a client withdraws completely, allow him to do so without prompting him to reengage. Notice the range, volume, strength, timbre, and flexibility of the client’s voice. Be aware of the client’s reaction and feelings about his voice. Procedures. Helping the client to become aware of his breath is the first step in preparation for toning. Begin by teaching clients about abdominal breathing, demonstrating that they can feel the breath extend into the abdomen by placing their hands on their rib cage and feeling it expand. First, place particular emphasis on a slow exhalation because this provides release from physical and psychological tension. Also, if the release is not complete, clients will have a difficult time taking in breath and tension will increase. When breathing, count up to four to inhale, four to hold, and four to exhale. Next, practice exhaling while making a soft ah sound as though sighing, and then allow this sound to carry some tone with it so that it creates a sound. For a first experience, start with a given sound in a moderately low register or use a gong or bowl to provide a resonating sound; the therapist creates a sound that is loud enough to hold the group while taking care not to overpower them. Invite the clients to make a sound to go with the primary tone while breathing naturally and making each sound as long or short as they wish. Give them the option of choosing a different tone or vowel and altering the volume if they wish. Make sure they understand that not everyone has to sing the same note and that all sounds are acceptable. After clients have been introduced to the naturalness of making sounds in this way, encourage them to explore making sounds on various tones during the course of the next experience. Introduce them to the concept of finding the feeling of high, middle, and low ranges, explaining that they are free to find different tones in different registers and on different vowels (ah, a, e, o, u) and notice how it feels to make them. Ensure clients there is no wrong sound and that humorous sounds are also permitted—in fact, any sound that they have an urge to make is permitted. If some clients begin to add body percussion, encourage them to do so. Encourage any improvised musical play that comes from this and use

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improvisation techniques of empathy (Bruscia, 1987b) to encourage clients to express themselves to the fullest. Afterward, discuss with the clients how it felt to make these sounds, what other sounds they were aware of, and any feelings that the sounds brought up. The last inquiry is important because the external sounds and the internal experience of making sounds may bring up difficult feelings and physical memories of pain, sadness, and emptiness; they may also evoke feelings of well-being or evoke feelings related to earlier developmental periods. Adaptations. Using vocally improvised words based on a particular theme can be helpful to clients who don’t enjoy toning on vowels or who are more concrete. For example, if the theme is food, ask every client to think of a food that he likes. Find a rhythm and a repetitive melodic motif to accompany the word and ask everyone to practice singing this word together. Each client’s word can be practiced in turn, and then, in a free improvisation, the clients can each sing their own word or change to someone else’s at any time as they improvise on these words together. The improvisation can be free or a repeated ostinato, or a combination of both. If clients wish to use a percussion instrument or body percussion to accompany their word motif, this can be added to the vocal improvisation. Different themes can be used, such as friendship, things I like to do, or places I’d like to visit. Another adaptation of vocal improvisation that may help clients who are having difficulty using their voices is song as improvisational chant. In this experience, the therapist chooses a couple of meaningful lines from the chorus or refrain of a song that the group has sung and introduces these lines as a chant that everyone sings a capella. When everyone in the group is comfortable with the chant, each person chooses a drum or percussive instrument. Beginning with a steady percussion beat, invite clients to fill in the beat with their own rhythmic motives, and then begin singing the chant with the group. The therapist can lead the group in singing it louder and softer, and then end the chant while the percussion beat continues softly. In a related experience, the therapist can encourage clients to improvise vocally on any syllable in a way that expresses how this chant makes them feel. The therapist gives these suggestions verbally and models the improvisation for the clients while everyone continues to beat the pulse. The therapist then continues to provide a grounding rhythm while encouraging clients to spontaneously use a word or syllable from the song as the basis of a vocal improvisation. To end, the therapist can initiate a return to singing the chant segment of the song. Structured song forms such as the blues have been used to encourage improvised blues that facilitate spontaneous verbal contributions. Silverman (2009) played a blues progression on guitar or piano and asked the clients to state how they were feeling to the instrumental accompaniment. Clients can also be encouraged to sing their responses to this (Silverman, 2011a) or any other question. Different genres, such as reggae, gospel, or pop played with a structured, repetitive, and predictable chord sequence, can be used as well.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Song Singing Overview. Singing songs involves re-creating precomposed songs with or without accompaniment, while engaging clients emotionally, physically, and neurologically (Sullivan, 2003). Singing is one of the most utilized traditional and current techniques in music therapy. Bruscia (1998b) identified some of the reasons why songs play such an important role in music therapy treatment. First and foremost, human beings can explore emotions through songs. Everyone has personal associations to songs; songs are imbued with personal and shared meaning; they help us to connect to significant times or situations in our lives; they evoke emotions and psychological material; they help us to examine our

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past, our present, and our relationships. In the inpatient unit, song singing is a common technique (Bonhert, 1999; Cassity & Cassity, 2006; Goldberg, 1989; Houghton et al., 2002; Murphy, 1992; Silverman, 2009, 2011a). Singing songs provides a way of being with others while allowing clients of various levels of functioning to participate at the same time. This contributes to group cohesion. Thus, singing songs is especially therapeutic when the group consists of clients with divergent needs and abilities. There are no contraindications. Goals for group singing are to improve social skills, increase attention (Crowe, 2007; Johnson, 2007), increase reality orientation (Houghton et al., 2002), improve self-expression and self-esteem (Johnson, 2007; Houghton et al., 2002), and increase emotional awareness (Murphy, 1983). The level of therapy is augmentative or intensive. Preparation. The room is set up with chairs in a circle. It is recommended that the therapist prepare a book with song lyrics or prepare lyric sheets to distribute to the clients. The therapist will also need a piano or guitar to accompany the songs. What to observe. Observe the level of participation of each client, e.g., whether or not the client is singing, the volume of his voice, if he is willing to choose a song, and the client’s posture and affect. Note which song each client chooses and what this choice may reveal about his psychological and emotional state, or how it may relate to other comments the client has made in the group. Note how the clients interact with each other and if they share feelings and experiences related to the songs. Procedures. Assemble a book of song lyrics with a variety of popular genres and eras that will appeal to the clients; take into account the demographics of the population in the institution. There are two basic ways to organize the song choices: the clients can each choose a song from the selections presented, or the therapist can present a theme and ask the clients to choose a song related to it. Themes might include a song that describes something about yourself, makes you happy (or another uplifting emotion), makes you hopeful for your future, reminds you of a specific time in your life, helps you cope with difficulty, or has a special meaning for you. Once the song has been chosen, the therapist leads the singing and accompanies the group on guitar or piano. The therapist will determine the volume of her singing based on the clients’ needs; it is necessary to sing at a volume that will provide security and hold the group without overpowering them. Another way of conducting the song singing group is to encourage a client to lead the song for the group, supporting him musically to the extent necessary (Murphy, 1992). Some clients who have difficulty letting their voice be heard may benefit from having a microphone to hear their voice more clearly (Houghton et al., 2002), especially if they are leading a song. Kazoos can also be used to encourage the use of the singing voice (Houghton et al., 2002). Regardless of the method chosen to lead the singing group, care should be taken when choosing the final song. The final song should reflect a theme or process that has emerged in the song choices, and it should have a positive focus that matches the emotional energy of the group. Adaptations. Singing and lyric discussion is the most common adaptation to the singing group. After singing a song chosen by the clients or the therapist, the therapist engages clients in a discussion using the guidelines for Song Lyric Discussion above. The therapist can also use singing and discussion in a psychoeducational manner. In this variant, she chooses a particular song for the clients to sing and then asks specific questions focused on a predetermined theme (Silverman, 2009). Another adaptation is the combination of role-play and rock opera. Silverman (2011b) integrated verbal role-play with song in rock opera style in an assertiveness training group. Clients identified a situation in their lives where they wanted to be more assertive and acted it out verbally with other clients. The group stood up and sang “Get Up, Stand Up” by Bob Marley after each scenario. Instrumental accompaniment with song singing is an adaptation in which the clients choose a rhythm instrument and accompany themselves as they sing along together. If a song has particular

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meaning or brings the group enjoyment, the therapist can ask the clients if they would like to work on it together to improve it. The song can be rehearsed with specific instruments and be recorded for playback if this is allowed in the institution (Bonhert, 1999). Hearing their performance can be very empowering for clients. It is important to note, however, that some clients may be disappointed that they don’t sound like the original singer. The therapist must make the decision regarding whether listening to the recording of their performance will have a positive or negative effect on the self-esteem of any particular group of clients. Instrumental interludes can be developed from the song as well. This can take the form of a very structured improvisation in which the clients play their chosen instruments at a particular place, e.g., between two verses or after the chorus. The therapist plays the chord progressions and rhythm of the song without singing the words. Clients can also improvise on the melody line during this interlude. Karaoke is another adaptation of the song group (Crowe, 2007; Peng, Koo, & Kuo, 2010). This requires no particular music skills on the part of the therapist; nevertheless, it is therapeutic because it allows the client to step into the role of a singer; his amplified voice can increase self-esteem, and karaoke can provide a relaxing and enjoyable way for clients to interact. Therapists can also encourage small group of duets or soloists with backup singers.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting Overview. Songwriting occurs when changes are made to some or all of the lyrics and/or music of an existing song, or when a new song is written in its entirety. This is usually done with client participation and is facilitated by the therapist. Songwriting is an invaluable tool for treatment goals in the inpatient unit. It can help clients to focus on coping skills (Silverman, 2011a), gain insight about their problems (Murphy, 1983), amplify their strengths (Rolvsjord, 2005), decrease internal preoccupations (Goldberg, 1989) and develop organizational and planning abilities (Bruscia, 1998a). Crowe (2007) also noted that songwriting helps clients to appropriately express emotions, improves self-esteem, enhances feelings of accomplishment, and improves decision-making skills. A variety of songwriting methods have been used in mental health practice (Camilleri, 2001; Crowe & Colwell, 2007; Ficken, 1976; Freed, 1987; Goldberg, 1989; Houghton et al., 2002; Murphy, 1983, 1992; Rolvsjord, 2005; Silverman, 2011a). The procedures used in songwriting can be easily adapted to provide the amount of structure needed by a particular client group; songwriting can be spontaneous or preplanned, and it responds to a wide range of human needs and emotions. The only contraindication for using this technique is the group size. When the group is too large (over 10 persons), it becomes difficult to include everyone in the procedure unless they are all functioning at a higher level and capable of independent, guided work. The level of therapy is augmentative or intensive. Preparation. The room should be set up with chairs in a circle. Clients may use instruments to accompany the song, and the therapist will provide accompaniment on piano or guitar. If an original song is being used as the basis for the songwriting, the therapist will be prepared to sing and play it; a recording might also be used. For some experiences, pencils and paper or a dry-erase board may be used. What to observe. Observe the level of participation of each client, i.e., the content and quantity of responses each client offers. Notice any cognitive distortions that may appear or other cognitive issues in the area of thinking and logic. Be aware of verbal and nonverbal reactions to the contributions of other clients, how the clients interact with each other, and if they share feelings and experiences related to the songwriting. In particular, note which ideas and emotions appear to resonate with each client and how

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these may relate to other comments the client has made. If clients are not participating, encourage them to do so, giving assistance where necessary. Procedures. There are a number of techniques used in composing a song. Given that in the current inpatient unit, one cannot expect to have the same group from one session to the next, and given the brevity of the length of stay for most clients, the techniques discussed here will be those that can be accomplished within one session. The most accessible and structured technique is the cloze technique (Ficken, 1976; Freed, 1987; Schmidt, 1983), in which words or lines from the song are removed and replaced with new words to personalize the sense of the song. The message and essence of the song remain the same and the music is unchanged, but the clients can fill in words that are personally meaningful. For example, the song “I Can See Clearly Now” lends itself to substituting words and lines that express why the client sees things more clearly and what obstacles have been removed. The process in this technique involves choosing a song that reflects something meaningful about what the clients are experiencing and singing it together. After a brief discussion of how the song relates to the clients’ lives, present the idea of changing some of the words to reflect the personal ideas and feelings that have been expressed. The therapist then writes all the ideas on a board and works with the clients to see where in the song they would best fit, ensuring that each client has ownership of at least one line. The therapist can also prepare for herself a lyric sheet with chords and blanks for the words that will be substituted so that she can easily sing it for the clients when they have finished the composition. This is followed by a short discussion of how the experience of songwriting affected them and their attitudes toward themselves. A variant on this technique is to prepare a lyric sheet with some of the words left out for lyric substitution and provide each client or pairs of clients with the sheet. The therapist helps each client or dyad choose which lines they want to complete and then combines the clients’ compositions, singing the song through as many times as necessary to create a version in which everyone can hear the lines in his song. Adaptations. Songwriting is most often a prepared experience, but it also happens that clients’ reactions to a singing or hearing a song demonstrate that they find meaning and resonance with it. If the clients are invested in this way in the song, it may suggest that this is an opportune therapeutic moment to engage in spontaneous song composition. For example, Camilleri (2001) found that her clients responded to both parts of “I Believe I Can Fly,” where the chorus describes the writer’s optimistic feelings about the present and the verse recounts how life felt much more difficult in the past. She spontaneously modeled changing the verse to reflect her own past struggles and facilitated a process by which her clients did the same. Each time, the optimistic chorus was repeated as it was in the original. Another commonly used technique is song parody (Houghton et al., 2002; Murphy, 1983). It is similar to the cloze technique, but in song parody, all the words are recomposed and the music remains unchanged. This technique is less structured and therefore the therapist must assess if the clients have the functional ability to complete it. It is important to choose an original song that reflects feelings similar to those of the new one being written because the music retains the associations to the original song. The major challenge here is to generate ideas and organize them. There are many different ways to generate ideas for songs. A list of words can be compiled from a discussion with clients about the chosen topic, or the therapist can choose words that reflect a theme and invite the clients choose which of these they want to include to begin the writing process (Rolvsjord, 2005). Once words have been chosen, the therapist works with the group to expand them into phrases and then creates sentences to fit the rhythm of the original song. Another method is to begin with a verbal discussion on a particular topic with the intention of composing a song. In this procedure, the therapist facilitates a simple question-and-answer format with

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open-ended questions based on a theme and poses these to the group, using the clients’ responses as the starting point for song lyrics (Freed, 1987; Schmidt, 1983). Another approach is to have a discussion with the clients about a theme that the therapist selects beforehand or one that is evoked in another music experience. During the discussion, the therapist writes down the ideas and then begins to reframe them with the group (Schmidt, 1983). The therapist and clients discuss which precomposed song might be appropriate to express these thoughts and feelings, taking into account the feeling in the music as well as the lyrics. The group sings the original song, and if they are satisfied that it is a good match, they create new lyrics based on ideas from the discussion to fit the rhythm and melody of the original song. The therapist and group sing the new song together and follow up with a discussion about the experience of songwriting. The most challenging and least structured technique in songwriting is composing new lyrics and new music without relying on a previously composed song. This is a technique that is well suited to individual work and high-functioning groups that are able to meet for more than one session because of the time it may take to complete. In the inpatient unit, a variant of the newly composed song can be facilitated by using a specific genre of music as the basis for a new composition. A standard blues pattern can be used to provide the basis for a new melody and lyrics, or the lyrics can be spoken to the blues pattern. For example, Silverman (2011a) facilitated a discussion about common problems that psychiatric clients faced and then helped the group to write lyrics about appropriate coping skills they might use to deal with their problems and wrote these on a white board. While playing a standard blues progression, clients sang a melody or spoke the lyrics they had written to create the song. A similar process as used in the blues can be used with other genres such as reggae, rap, and hiphop, as long as the musical elements are predictable enough to evoke and support ease of melodic invention. An example of this would be using a reggae beat with a basic I IV V or II V I sequence and minor harmonic variation. Rap and hip-hop are also popular among young urban clients. When clients are able to provide body percussion or use instruments to create rap beats, this can be the foundation for an improvised song with individuals spontaneously adding a line or verse. Alternately, the therapist can facilitate the creation of group lyrics to a prerecorded beat. Beats and background music that serve as the basis of rap lyrics can be downloaded as well and played for the clients, and lyrics can be composed individually or facilitated in the group and performed. To help clients spontaneously rap, the therapist can prepare a written sheet with four to eight lines of a current song or poem, or simple questions based on personal likes and dislikes, and invite the client to rap these lines over the beats created by the group. Clients can also spontaneously add their own words to what is written on the sheet, but having a written text helps to provide the safety and support that encourages improvisation (M. K. McNulty, Personal Conversation, August 3, 2012). In a similar manner, the therapist can create a list of incomplete phrases that the client will answer in rap style while the group continues with the beat. This can be very concrete and simple, such as: Well, I’m a man (woman) with a lot of soul, I’m (color of hair, eyes, any other physical characteristics). I like people who are …. And I like (continue about kinds of people the client likes), but I don’t like it when (something the client doesn’t like). Other themes can be created and discussed before the rap begins, giving clients an opportunity to think about what they might add to the rap. Themes based on desires, hopes, and vision for one’s future can also be approached in this way. A melodic chorus from a precomposed or newly composed song can be added between the rapping in a hip-hop style as well. Another variation on the newly composed song is the song collage (Ficken, 1976; Tamplin, 2006). In this technique, words and phrases from existing songs that are meaningful to clients are identified and recorded on a white board. The therapist discusses how these different phrases might be recombined to make a new song, adding original phrases if needed to connect the original phrases. Although new music is usually created for these lyrics, the music from a precomposed song might also be used if the music and emotional associations are appropriate.

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CLOSING REMARKS ON METHODOLOGY Each of the methods presented here follows a sequence of the most easily accomplished to the most intricate or difficult. In some instances, such as songwriting, the therapist would likely choose one particular procedure over another (e.g., cloze technique vs. newly composed song) based on the functional ability of the group members and/or the number of sessions available to work with the same clients, while in other situations, experiences would be presented in a hierarchical manner. In particular, given the nature of the inpatient group—lack of homogeneity of group composition from one session to the next— preliminary activities with the voice or instruments are necessary to facilitate successful improvisation experiences where group cohesion can be achieved within the improvisation. The structured presentation of improvisation examples described herein can be combined differently to achieve that end, depending again on the particular group and the clients’ experience with improvising on instruments or using the voice. The typical inpatient group should begin with a few short experiences that will provide the therapist with a way of assessing the individuals in the group and their functioning level, energy, and needs, as well as how these individuals might work together. In addition, the therapist might discern if some individuals have had altercations outside of the group and take steps to de-escalate potentially aggressive behavior. Typically, an opening song in which each person is greeted or asked to play their instrument provides a gauge of both individuals’ participatory abilities and the group dynamic. A chant or introductory drumming jam might also serve this purpose. This might be followed by a short opening warm-up experience from among those described in the receptive section involving imagery and movement or one of the preliminary improvisation experiences; both are helpful as assessments. Alternatively, sometimes a song that has impacted some members of the group in a previous session can be used as an opening experience. These experiences, in general, demand parallel play from the clients, i.e., they are involved in doing the same thing together or in turn, but they are not required to interact to a great degree—or they might involve highly structured interactions such as imitative or call-and-response experiences. Once the preliminary experiences have provided the therapist with a sense of the group dynamic and individual needs, she can choose another experience that requires greater self-reflection and interaction among the participants. It is important to keep two strategies in mind: (1) provide a variety of experiences within the same group to hold the clients’ attention and to appeal to preferences of different clients, and (2) maintain thematic coherence as the underlying focus. Working with songs, for example, might be the entire focus for the group, although there would be some discussion, singing, listening to recorded music, and perhaps even a song composition in the same session. Nevertheless, such a group would provide variety in the number of songs, the method of delivery, the moments of discussion and reflection, the interaction of clients singing and playing, and finally, by personalizing a song to reflect the work done by the group in the session. The theme would be developed by listening carefully to client choices of songs and their responses to them. Themes in the inpatient unit should be focused on self-expression and positive internal and group resources. Creating thematic coherence is important because the theme can bring clients more deeply into connections with the self, one’s imagery, feelings, identity, and resources. Thus, an idea or some lyrics from a song that holds particular meaning for a majority of group members might be used as the basis of a referential improvisation. Similarly, feelings and images that were expressed in a movement experience with imagery might be used as the basis of a song singing and songwriting activity, or an improvisation experience. Another example might be taking the theme of feeling lonely or isolated and using call-andresponse improvisation experiences or those that require group members to empathetically listen and

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respond to each other. Such a group might find closure with a song that reinforces the theme of both supporting and being supported by each other. Finally, it is important to end with something that is hopeful and helps clients to strengthen contact with their identity, resources, and power to make choices. Chants that repeat something that will be helpful to keep in mind can be personalized for the group, and each individual can also add what is important to him. Alternately, the therapist might choose a song that evokes the theme that has developed in the session and have everyone sing it together, or she might close by singing an improvised song in which each person in the group is thanked for his unique contribution to the group. Each session should be conceived as a complete therapeutic process in the inpatient unit, for this may be the last—or only session that the client may have. Thus, the overriding goal of the session is to facilitate greater strength in relationships with one’s resources, positive emotions, and internal images for each client in the group, as well as strengthening the positive connections among group members.

RESEARCH EVIDENCE This section reviews the research literature that addresses music therapy for inpatient groups. While the majority of studies used mixed music therapy methods, at least one research study has been carried out using each of the music therapy methods, with the exception of improvisation. All of the studies were quantitative or mixed methods. A few studies have been conducted to evaluate patient preferences for music experiences. Silverman (2010) used a mixed methods study with 15 inpatients to obtain perceptions of clients regarding their preference for active (games, sing-along, lyric analysis, and songwriting) and receptive (listening to chosen songs on an iPod) music therapy experiences. Clients found that individual games were the most helpful and the group music game was the most enjoyable, but there were no overt differences between music therapy interventions. In a related study, Silverman (2012) conducted two experiments nine months apart with different groups of clients to determine if there were differences between active music therapy (experiment one) and receptive music listening (experiment two) with regard to attendance rates and treatment perceptions. A higher percentage of clients attended active music therapy sessions and spent more time in the active sessions; participants also found the active music therapy to be more helpful in managing their mental illness than those in the receptive groups did. Silverman (2009) also compared receptive psychoeducational music therapy to psychoeducation. Both conditions used scripted questions focused on relapse prevention. In the music condition, participants listened to “Don’t Stop” by Fleetwood Mac and used the lyrics as the basis of the thematic discussion. There were no significant differences found between groups in measures of helpfulness, enjoyment, satisfaction with life, or psychoeducational knowledge; however, music therapy was as effective as psychoeducation. In addition, in the music group, there were more self and cognitive insight statements and participants had more verbalizations. In a similar psychoeducational study, Silverman (2011a) researched the effect of songwriting on coping skills and working alliance. Again, although the results between the psychoeducational music and psychoeducation groups were not statistically significant, music proved to be equally valuable in teaching life management skills. In addition, the participants perceived music as being more enjoyable, and the music group had higher attendance rates. These two studies support Silverman’s (2006) survey study in which inpatients rated psychoeducational programs and found music therapy to be significantly more helpful in addressing deficit areas. Another musical psychoeducational approach (Silverman, 2011b) incorporated song re-creation with verbal role-play to improve assertiveness. Participants in both the musical psychoeducation and the psychoeducation groups improved their internal locus of control and overall quality of life scores

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compared to the control group, but there was no statistical difference. Didactic group guitar lessons were used as a re-creative method in an experiment with female inpatients. Cassity (1976) compared interpersonal relationships pre- and posttest in the guitar group with the control group. He found that the music group made significant gains in peer acceptance and group cohesiveness after two weeks. Nine studies using mixed music therapy methods with inpatient groups were identified. Outcomes related to social functioning and interpersonal relationships and/or a reduction of negative symptoms were the focus of a number of these studies. Tang, Yao, and Zheng (1994) provided participants with musical instruments to practice, offered receptive experiences, and sang songs chosen by participants over five weeks. The subjects increased interpersonal communication, were less isolated, and had an increased interest in external events. In a similar manner, Ulrich, Houtmans, and Gold (2007) used improvisation and singing popular songs for seven sessions and found that negative symptoms were diminished and interpersonal contact was improved. Yang, Zhen, Weng, Zhang, and Bio (1998) found similar positive psychosocial outcomes after three months of sessions. Improvements in personal relations and the participants’ subjective sense of participation were found in a study using all the methods of music therapy in fifteen sessions over four months (Hayashi et al., 2002). Choi, Lee, and Lim (2008) examined depression, anxiety, and relationships using relaxation, song singing, instrument playing, and receptive methods over fifteen sessions. The music group showed significant improvements in these outcomes compared to the control group. A reduction in positive symptoms as an outcome was researched in three studies. Peng, Koo, and Kuo (2010) employed karaoke singing and receptive music therapy in groups for 10 sessions. The music experimental group had significantly lower positive and negative symptoms and lower resistance to therapy than the control group. Silverman (2003) examined the effects of reading, interactive live musicmaking, and recorded music on auditory hallucinations. While no statistical significance was found, music was found to suppress auditory hallucinations more than reading; live music-making was more effective than recorded music. A study using improvisation and songwriting with actively psychotic individuals found a significant difference for a reduction in positive and negative symptoms for the music group as compared to the control group that listened to a CD of nature sounds (Morgan, Bartrop, Telfer, & Tennant, 2011). One study evaluated the immediate changes of common psychiatric deficit areas with inpatients using a variety of music therapy methods. Silverman (2004) examined the self-rated effects of group drumming, songwriting, lyric analysis, rock-and-roll bingo, and a combination of listening and singing along with popular songs. Participants completed 189 pre- and postsession Likert scale surveys during eight inpatient groups over three weeks. The surveys assessed changes in self-ratings for emotional expression, self-esteem, coping, anger, mood, symptoms, situation in the hospital, and attitude to music therapy groups. Means and standard deviations pre- and postgroup showed that all music therapy interventions were rated as having a positive influence on participants. Three meta-analyses have been undertaken examining all music therapy methods, and of these, two were Cochrane reviews (Gold, Heldal, Dahle, & Wigram, 2005; Mössler, Chen, Heldal, & Gold, 2011). In 2005, only four studies met the stringent requirements for inclusion in the review, while seven studies were included in 2011. All methods of music therapy were found to have a significant positive effect on symptom reduction and improved functioning in the global state and mental state for persons living with schizophrenia—in particular, with regard to a reduction of negative symptoms, depression, anxiety, and improved social functioning. The authors suggested that further qualitative research is needed to identify outcomes that are connected directly to music therapy, such as quality of life, that might be more relevant to both the client and to the music therapy treatment approach. Benefits of music therapy were noted when clients participated in sessions regularly over some time (Mössler, Chen, Heldal & Gold, 2011); positive effects on mental state were unclear with participation in fewer than 20 sessions (Gold, Heldal, Dahle, & Wigram, 2006).

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The third meta-analysis was undertaken by Silverman (2003) and determined that music was significantly effective in reducing symptoms of psychosis. Interestingly, the author found that there was no difference between live and recorded music, between structured music therapy groups and receptive listening, or between preferred or therapist-selected music. Classical music was not found to be as effective as nonclassical. These meta-analyses were consistent in their results and provide evidence that music therapy is an effective treatment for positive and negative symptoms of schizophrenia.

SUMMARY AND CONCLUSIONS Music therapy has a long history of use in the psychiatric setting—in fact, the origins of modern music therapy can be traced to its use with WWI veterans, and the establishment of professional music therapy educational programs was a direct outgrowth of the therapeutic use of music with WWII veterans (Davis, Gfeller, & Thaut, 2008). The literature for music therapy with persons with mental health problems extends back to modern music therapy’s historical roots. Music therapy is common clinically in psychiatric settings as well; an AMTA survey from 2007 found that institutions serving persons with behavioral and emotional disorders employed 19% of all music therapists (Davis, Gfeller, & Thaut, 2008). It is somewhat surprising, then, that there is relatively little research in this area, and still more surprising that the clinical literature does not present a varied profile of the use of the music therapy methods. This author’s anecdotal experience also seems to suggest that there is a discrepancy between the manner in which music therapy in the mental health setting is presented in the literature—mostly individual case studies based on long-term therapy—and the manner in which it is practiced in the USA, which is for the most part in groups—sometimes very large ones—and often with rapid changes in group composition. In reviewing the literature for this chapter, it was evident that there are few indications of protocols and procedures for group therapy in the inpatient unit in spite of the number of therapists working in this area. The focus of this chapter is to provide examples of how the music therapy methods can be used therapeutically with this population, and, where possible, to support these approaches with evidence from the literature. It is hoped that as this field continues to grow, music therapists will benefit not only from sharing clinical information and approaches, but also from designing and participating in large research protocols that will further support our field and bring music therapy to the many clients who, in the midst of great personal obstacles, courageously seek to improve their quality of life through the therapeutic use of music.

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Chapter 4

Adults in a Recovery Model Setting Lillian Eyre

INTRODUCTION The process of deinstitutionalization (the release of psychiatric patients from institutions and into their communities), which began in the 1970s, was hastened by the advent of a new generation of psychotropic medications in the 1990s. These two factors resulted in a substantial reduction in the need for hospitalizations for persons with Serious Mental Illness (SMI). To illustrate the scope of this change, it is notable that between 1955 and 1994, public mental hospital beds in the USA were reduced by 91% (Thesen, 2001, as cited in Douglass, 2011). Unfortunately, the social and community supports necessary to accommodate the process of deinstitutionalization were not sufficient to meet the multiple and varied needs of thousands of persons (defined as “consumers” of mental health services) as they tried to cope with living in an unwelcoming world with little social, mental, and medical support, lack of housing options, and, often, very little money (Cook & Wright, 1995, as cited in Douglass; Douglass, 2011). There have been significant improvements in the intervening years, and consumers now have a range of services to meet various levels of need for support. These include Programs of Assertive Community Treatment (PACT) that provide individualized services and support directly to individuals with SMI in the community, case management services that have a mandate to provide mental health services and connect consumers with housing and rehabilitation services (National Alliance of Mental Illness [NAMI], 2013), and Clubhouses, which are community-based services that offer members “opportunities for friendship, employment, housing, education, and access to psychiatric and medical services” (Clubhouse International, 2013, para. 2). As mental health care workers of all professions first attempted to meet the needs of the influx of persons with SMI in the community, the concept of psychosocial rehabilitation emerged as the foremost model of treatment. Psychosocial rehabilitation (PSR) provides training and services that are needed to help persons with SMI learn to adapt to the routine demands of living in the world (Deegan, 1988). Specifically, PSR helps consumers to identify their goals and the steps they will take to achieve them, and develop the skills and supports they need to do so (Anthony, Rogers, & Farkas, 2003, as cited in Chhina, 2004). Consumers soon began to distinguish between the medical treatment model embodied in rehabilitative service delivery and the concept of recovery. While PSR services were welcomed, consumers began to object to being thought of as passive recipients of a service. Deegan (2000), who had personally experienced the delivery of human services as dehumanizing and depersonalizing, was a leader in the consumer-driven recovery movement. While PSR services are still perceived as positive, the recovery movement advocates an attitude in which persons with disabilities are perceived as being in the process of “recovering a new sense of self and of purpose within and beyond the limits of the disability” (Deegan, 2000, p. 11). This distinction is important because the recovery process implies that these persons are

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“active and responsible participants in their own rehabilitation project” (Deegan, 2000, p. 11) as they engage in accepting and overcoming the challenge of disability. Deegan notes that an important aspect of recovery is learning what one can and cannot do or be, and discovering what one is and can be (Deegan, 2000, p. 15). In opposition to the overwhelming inertia, despair, and anguish that is the lived experience of catastrophic illness or disability (Deegan, 2000, p. 13), one must experience a “tiny fragile spark of hope” that holds the promise of “something more than all of this darkness” (Deegan, 2000, p. 15). Hope is the turning point on the path of recovery. The idea of light, hope, and love that is embodied in this phase of recovery has implications for music therapy. The ultimate goal of music therapy in the recovery model setting is to contribute to the creation of an environment in which this tiny spark of hope—the experience of something unexpected, new, and positive—can be kindled. This chapter will explore how music therapy methods can nurture this hope through the discovery of the self as one connects to music and to others in music.

DIAGNOSTIC INFORMATION Clients who receive music therapy services in the recovery or community setting likely have a chronic disability related to SMI. These persons belong to two primary groups: The first is composed of persons who need assistance in adjusting to living in the world after a hospitalization for an acute episode of SMI. The second group is composed of persons whose needs, due to their chronic disability, are best supported by ongoing services in the community. Some of these persons may use the psychosocial services as a stepping-stone to part-time employment, whether that be in a sheltered workshop environment, volunteer work, or paid employment, or they may use these support services concurrently with a parttime work schedule. Others are unable or not yet ready to tolerate the stress such a venture involves. Despite the stage in recovery, the struggle with SMI should be seen as a continuum, with consumers requiring different levels of support at various times in their lives. The diagnoses that are found in clients in a recovery model setting are identical to those found in the inpatient group setting and include, among the most common disorders, all forms of schizophrenia (Hunt, Chapter 2 of this volume), depression and/or anxiety (Jackson, Chapter 11), borderline personality (Dvorkin, Chapter 12) and bipolar disorder. It is common for many of these clients to have also experienced developmental trauma or post-traumatic stress disorder (Curtis, Chapter 8, and Hatcher, Chapter 9). Thus, for information on these specific disorders, the reader is directed to the appropriate chapters. A description of the salient characteristics of persons with these disorders is provided in Chapter 3 of this volume (Eyre).

NEEDS AND RESOURCES Persons with SMI are challenged each day with problems of existence brought about by economic marginalization; finding and keeping adequate, affordable housing; their inability to sustain full-time employment; and the stigma of having a mental illness (Kuntz, 1995, IV, Conclusion, para. 8). In addition, many of these persons have difficulty in performing instrumental tasks of daily living and socializing (Kuntz, para. 2). A study by Sheridan, Zuskar, Walsh, and O’Brien (1989, as cited in Wilson, 2002), found that having difficulty in finding meaningful ways to use leisure time was one of the five major predictors of failure for clients who transitioned from hospital to community. In a review of the literature, Wilson (2002) also found that there was substantial evidence that persons who had access to and participated in intensive community support programs had a better outcome in transitioning from institution to community. The opportunity to engage in meaningful and structured leisure activities was a vital aspect of these programs. These findings are congruent with core beliefs of the recovery model that stresses the

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cooperative nature of the rehabilitative environment as members of a group working together to achieve their individual and communal goals (Deegan, 1988). Thus, making interpersonal connections, working with the concepts of hope and empowerment, and finding and strengthening one’s identity are central concepts in recovery from SMI (American Psychological Association, 2009; Davidson & Strauss, 1992; Deegan, 1988; Lysaker et al., 2005; Rolvsjord, 2010; Vander Kooij, 2009). These notions are essential if the service user is to lead “a fulfilling, meaningful life beyond the limitations of illness or symptomatology” (McCaffrey, Edwards, & Fannon, 2011, p. 185). Music therapists have also identified core issues that reflect the philosophy of the recovery model (McCaffrey et al., 2011). For example, Odell-Miller (1995) and Stephens (1983) emphasized the importance of meaningful interpersonal contact with others as an essential aspect of well-being. A focus on developing personal strengths and resources has been identified as primordial in recovery by Grocke, Bloch, and Castle (2008) and Rolvsjord (2010). This approach is similar to the narrative therapy approach advocated by White (1995) in his work with persons with SMI in which he advocated helping the person to identify new narratives of personal strength as opposed to focusing on the problem-laden story of failure, illness, and disability. These tasks cannot be completed in isolation. Like all human beings, persons with SMI need to have a group to which they can connect, where they can feel accepted and offer acceptance to others. They need to replace unrealistic expectations based on pre-illness aspirations with engagement in the present and the discovery or rediscovery of interests and talents. Thus, in working with persons with SMI, the music therapist helps clients to identify and cultivate positive elements in their lives based on their values, interests, and strengths. This promotes the process of reclaiming one’s identity as a unique person, as opposed to living under the oppressive narrative of disability and hopelessness. Relationships based on reciprocal humanness between the client and therapist, as well as among clients themselves, lead clients to reignite their hope and envision their potential. O’Donovan (2011), a mental health patient representative, chronicled the power of creativity and forming relationships with others in his journey of healing and transformation. Mössler, Assums, Heldeal, Fuchs, and Gold (2012) describe how these values and goals can be translated into clinical practice: Their needs and wishes may initially be connected to: (a) a joint activity such as playing something together; (b) experiencing joy; (c) experiencing mastery; or (d) experiencing a safe place through playing or singing familiar songs. Interpreting these wishes, therapeutic goals may be formulated as follows: (a) nurturing social and relational abilities, (b) improving quality of life; (c) supporting self-esteem and self-efficacy; and (d) gaining self-confidence (p. 335). Because music has often served as a companion to assuage the loneliness and isolation in the lives of many persons with SMI, the music therapist has an advantage in using music to establish and develop relationships with individual clients as and among the clients themselves. This is achieved as clients discover musical commonalities, as they share emotions evoked by the music and its associations, and as they discover musical and expressive skills. A love of music and a prior relationship with it may be the most powerful resource that clients with SMI have. Through music experiences, the therapist can facilitate the discovery or rekindling of individual creative strengths, interests, and imagination while fostering mastery and connection to others.

MULTICULTURAL ISSUES Multicultural issues are the same as those discussed in Chapter 2 (Hunt) and Chapter 3 (Eyre).

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REFERRAL AND ASSESSMENT The reader is directed to specific chapters for assessment of clients with the following diagnoses: schizophrenia, Hunt, Chapter 2; depression and/or anxiety, Jackson, Chapter 11; borderline personality disorder, Dvorkin, Chapter 12; developmental trauma or post-traumatic stress disorder, Curtis, Chapter 8, and Hatcher, Chapter 9.

OVERVIEW OF METHODS AND PROCEDURES The methods and procedures described in Chapter 2, Adults with Schizophrenia and Psychotic Disorders, and Chapter 3, Adult Groups in the Inpatient Setting, are also applicable to the clients described in this chapter. Adults in the recovery model setting are essentially from the same population as those presented in Chapters 2 and 3, with the primary focus being that clients who are in recovery are mentally stable and living in the community while coping with SMI. To reduce redundancy, this chapter will not repeat the information contained in other chapters, but will instead focus on methods that are particularly applicable to clients who are stable and in recovery. The reader is therefore referred to Chapters 2 and 3 for other essential methods and techniques. In addition, pertinent information on methodologies can be found for persons with specific mental health problems in other chapters in this volume.

Receptive Music Therapy •

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Thematic Song Lyric Discussion: Clients listen to and discuss the lyrics of songs chosen by themselves or by the therapist with themes that are related to challenges and resources in their lives. Playlist Creation: Clients and therapist create a song list designed to create a common bond, to alter one’s mood, or to reinforce a desired mood state. Progressive Relaxation with Music: Clients improve their relaxation response by tensing and relaxing various muscle groups while listening to music. Autogenic Relaxation with Music: Clients improve their relaxation response by using an image to release tension from various muscle groups while listening to music. Dance and Exercise with Music: Clients move to music according to structured cues by the therapist. Mirrored Movements with Music: Clients move together to music in dyads, creating spontaneous mirrored movements in leader and follower roles. Human Sculptures with Music: Clients place each other in positions to create composite human sculptures based on a feeling or theme. Art with Music: Clients create drawings, collages, or sculptures individually or in a group mural based on feelings evoked while listening to music. Storytelling with Music: Clients write or orally present a story individually or collectively as a group while listening to music. Peer Support Writing: Clients write something they appreciate about each person in a group while listening to music. Writing Identity Documents with Music: Clients create identity documents while listening to music that include details about their internal resources, how they have overcome difficulties in the past, and how they have empowered themselves to act on their own behalf in spite of these difficulties.

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Projective Letter-Writing: Clients write a letter projecting their feelings about a core issue in their lives. Supportive Music and Imagery: Clients listen to recorded music in a relaxed state while imaging or creating poetry or art based on a positive theme set by the therapist; this is followed by verbal processing, improvisation, or songwriting. Song Communication: The client selects a song or piece of music that expresses or discloses something about the client that is therapeutically relevant and plays it for the group; this is followed by a group discussion.

Improvisational Music Therapy • •

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Group Improvisation: Clients improvise on percussion instruments together and with the therapist in referential and nonreferential improvisations. Music Psychodrama: Clients act out issues from their lives verbally and concurrently with vocal and instrumental improvisational support; group members enact various roles related to the individual’s drama, using a number of techniques. Improvisation to Strengthen the Ego: Clients improvise with the therapist on themes designed to support creativity and conscious control to deal with matters in external reality. Improvisation in Individual Sessions: Clients improvise with the therapist or alone in individual sessions on referential and nonreferential themes.

Re-creative Music Therapy •

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Group Sing-Along: Clients choose familiar and personally significant songs and sing them together; they are accompanied by the therapist and may also accompany themselves instrumentally. Didactic Instrumental or Vocal Lessons: Clients learn to play or sing in structured, regular lessons to meet therapeutic goals. The Choir Performance Group: Clients sing together and practice regularly to prepare a performance of a set program of selections for an audience.

Compositional Music Therapy •

Songwriting: Clients and therapist compose lyrics to personalize existing songs or compose lyrics and music to create new songs.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY METHODS Thematic Song Lyric Discussion Overview. Clients listen to and discuss the lyrics of songs chosen by themselves or by the therapist with themes that are related to challenges and resources in their lives. Procedures for conducting song lyric discussions are presented in Chapters 2 and 3; it is recommended that these procedures be used to introduce the recovery group to lyric discussion. The following approaches are designed for groups that have developed some cohesion and familiarity with the process of lyric

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discussion. Once clients in the recovery group have become familiar with sharing ideas regarding the thoughts and feelings evoked by the songs to which they listen, the therapist can become more active in focusing the themes of the songs on therapeutic and existential issues as they arise in the group’s discussions. In this way, concerns that are raised in one session can be explored more deeply in the following session. Because clients in recovery are faced with a multitude of challenges related to stigma and living in the world with a mental illness that affects their cognition, emotions, and perceptions, the song discussion is an excellent way to open the door to such discussions; the process of listening and discussion uncovers emotions and allows clients to work through their pain, while listening to healing lyrics can help clients to develop an outlook that may lead to greater happiness (Gladding, Newsome, Binkley, & Henderson, 2008). At the same time, listening to songs can normalize the difficulties the clients are experiencing. The fact that the songwriter and singer are expressing similar emotional problems helps clients to feel less isolated in their challenges. This method would be indicated for clients in recovery who are experiencing difficulties in relating to others; who feel sad, lonely, or marginalized; who are experiencing conflict or ambivalence; and/or who are working on building internal resources. This method also improves group cohesion. Each client participates at the level that is comfortable for him, and thus there are no contraindications. Goals are to establish a group identity and to promote individual sharing around a common interest (Bednarz, 1992); to promote supportive verbal interaction, social participation, and practice healthy behavior patterns (Houghton et al., 2002); and to foster discussion focused on treatment goals (de l’Etoile, 2002), life challenges, and resources for healthy coping skills. The level of therapy is intensive, and therapist experience using advanced verbal skills is recommended. Preparation. There are two ways to structure this method. In the first, the therapist chooses songs that are appropriate to evoke a discussion on the predetermined theme; in the second, the clients bring in a preferred song or song title related to the theme. Normally, the chosen theme would emerge from a group process and be discussed with the clients, at which time the clients would be invited to bring in songs for the following session, or the therapist would offer to bring in songs for the discussion. If clients have ideas about songs but do not have access to the songs, a computer, iPhone or iPad with Internet connection can be used to bring up the songs on YouTube or Grooveshark; it is best to play the song without the video because the video can be distracting. Lyrics should be made available to clients, preferably with individual printed copies, but if this is not possible, then a computer screen that is large enough for everyone to see can be used. A good-quality sound system should also be used so that the emotional impact of the music is not compromised; thus, a good set of speakers should be attached to electronic devices. Once the therapist has identified a theme, she must find songs that explore the theme from different perspectives and with varied emotional and cognitive content. Depending on the group and individual preferences, she may also have to find similar themes in different genres. If clients are choosing the songs, the therapist should also have a few songs ready to use, keeping in mind that she may want to shift the focus from challenges and problems to solutions and resources. Thus, preparation of song choices and familiarity with the messages and emotional scope of the songs is of paramount importance. What to observe. The most important thing to observe is the clients’ emotional responses to the lyrics and music of the songs. Confronting problems may be difficult for clients, but doing so in a place that provides support from peers and a therapist is therapeutic and provides clients with the best opportunity to reach their potential. Notice which clients are able to authentically express their difficulties, and which clients avoid this or are conflicted about the issues and feelings being presented. Notice as well how the discussion relates to each client’s goals, or how the discussion may reveal new goals for a client that may be worked on therapeutically. Finally, the therapist observes how the group is

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functioning as a whole in this experience, notably, if members are connecting to each other socially and emotionally, responding to each other’s comments, and supporting each other’s feelings with some degree of empathy. Procedures. Typically, this would not be the first experience in the session, and the therapist would begin with movement and music, a short relaxation experience, a short structured improvisation, or a greeting song (see Chapters 2 and 3). The therapist then presents the theme for song discussion, including the context in which the group decided on this theme, and relates it to issues group members are currently experiencing. The therapist may begin with a song that she has chosen to open the discussion, and then ask members to comment verbally. An example of a song that might open a group discussion is “Within These Walls” by Richard Barone. While the song expresses a certain malaise or disappointment in things that have happened in life, the music is open and most phrases end with an upward motion; most importantly, Barone sings of the urgency he has to tell his story, thereby setting the tone for clients to tell their stories through the song choice as well. The therapist may also choose to begin with the clients’ songs immediately. Clients then volunteer to present their songs, with each one explaining his choice either before or after playing the song. Other clients may comment on the song immediately after hearing it, or wait until other songs have been heard. Between songs, the therapist draws out client discussions on commonalities or differences among the songs by asking leading questions related to the themes and to individual client goals for therapy. One challenge that might occur in a session is that clients may focus on the negative aspects of experience presented in songs, thereby becoming lost in their difficulties. When this happens, the therapist will be aware that the group is becoming listless and perhaps withdrawn. It is important to guide the conversation so that problems and difficult emotions are not ignored and left to fester internally, but neither are clients left to experience them as hopeless. Thus, the therapist should always have a couple of songs ready that have a hopeful outlook on the chosen theme. Another way to circumvent this problem would be to get a list from the clients at the beginning of the session, and decide on the order for the songs in the group. If the therapist is unfamiliar with some of the songs, she might ask the clients for verbal introduction for each song choice. This process allows the therapist to organize the songs so that those with a more hopeful message are placed at the end. For example, for a theme of Feelings About My Life, a client might bring “Creep” by Radiohead. There is little that is hopeful in this song about someone who loves someone else but feels hopelessly inferior to that person. Another might bring in “Beautiful World” by Carolina Liar or Dar Williams’s “After All.” Both of these songs express positive ways of coping with feeling sad and hopeless, and these songs could be placed after “Creep” as examples of healthy ways of coping with the feelings evoked in “Creep.” There is another advantage in using these two songs as well—both of them were written as a response to mental illness. Dar Williams wrote hers as she was coming out of a long depression, and Carolina Liar based his song on his friend’s struggles with bipolar disorder. Thus, the closing discussion could incorporate these singers’ personal experiences as inspiration for the group. After the last song, the therapist facilitates a group discussion on the feelings evoked by the songs and how the songwriter and clients deal with these feelings. She then sums up by noting the array of feelings and challenges experienced by the clients, noting each one’s unique experience as well as commonalities among the group members. To close, the therapist can replay a song that the group found to be positive and hopeful, or the therapist may have a song prepared to play that provides the clients with a positive therapeutic direction in dealing with their difficulties. The closing may also be re-creative, such as a chant from a line or two of lyrics in one of the songs; creative, in which clients create words and melody for a repetitive chant using words that are inspiring; or improvisational, in which clients improvise vocal and/or instrumental sounds to create a feeling they want to hold on to.

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Adaptations. Houghton et al. (2002) describe a song discussion in which the therapist is responsible for selecting a group of songs to lead a discussion based on music elements, lyric content, the mood of the music, and clients’ personal interpretations. They also suggest that the therapist may wish to guide the discussion to clients’ conscious conflicts and the use of unhealthy defenses. In this case, she would focus on each client’s experiences with and personal associations to the music, especially those that have relevance to the client’s conscious conflicts. In this procedure, the therapist has the primary responsibility in the selection of music based on the clients’ needs as they emerge in the therapeutic process. This might be more easily achieved in an individual session than in a group, where there may be divergent defense mechanisms at work and different needs. De l’Etoile (2002) had a similar procedure in which she played music from the clients’ young adult years and facilitated a discussion in which clients were asked to identify how music may have influenced their lives. She also discussed how lyrics related to their treatment goals and encouraged clients to reflect on how they might “formulate concrete plans of therapeutic change and make a commitment to those plans” (p. 70). Gladding et al. (2008) describe a cognitive counseling approach in which lyrics are used in various ways in song discussion. One way is to have clients not only discuss, but also write about how the words and thoughts of a song they have chosen relate to their situations. In contrast, clients can explore their unique resources by discussing or writing about how the emotions and situations in the song differ from as well as compare to their experiences. The therapist might group together and present a few songs and have the clients compare how lyrics from these songs compare to the song they selected on the same theme. In this way, the therapist can help clients to identify positive and negative lyrics, and facilitate a discussion on different perspectives and solutions to problems presented in these songs. Another suggestion is to follow the song discussion with a compositional experience in which clients write new lyrics on the theme of a message they need to hear. Bednarz (1992) describes using lyric discussion in individual crisis intervention and in groups to assess the individual’s crisis conditions as well as to open a discussion on coping skills. Song discussions are also used to increase the interpersonal connection between therapist and client, or to increase group identity.

Playlist Creation Overview. Clients and therapist create a song list designed to establish a common bond, alter one’s mood, or reinforce a desired mood state. Sharing song preferences in a group can reveal a common interest and help to establish group identity (Bednarz, 1992). This can be very helpful at the beginning of a group or when there have been a few new members added to an existing group. It helps clients get to know each other and provides them with ways of relating to each other through the music in a nonthreatening manner. It also provides the therapist with insight into group dynamics and gives information about the genre and song preferences of individuals and the group as a whole. Songs not only express a wide variety of feeling states and moods, but also listening to songs can also evoke these feelings and moods; thus, a song list can also be helpful for individual mood management (Gladding et al., 2008). Goals for creating a song list are to alter feelings of anger or depression or to evoke and maintain a state of relaxation or positive emotion. There are no contraindications. The level of therapy is augmentative. Preparation. The therapist should have easy access to a wide variety of songs on an iPod, iPhone, computer, or iPad. If songs are going to be downloaded or burned on a CD, the therapist must have an account to enable her to buy songs for the client without violating copyright law. Clients need to have a method of playing the song using the above devices with good speakers.

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What to observe. In group processes, notice whether clients are able to communicate their likes and dislikes, and if they are able to tolerate the preferences of other clients. Notice that if clients have commonalities, which genres are preferred. In working with individual mood alteration, notice if the client can identify which moods he experiences that are unpleasant or challenging, and which mood states he desires. Notice whether he can identify music that mirrors these mood states. Note the client’s emotional response to the songs that he chooses, and note whether or not the music has an effect on his emotions. Procedures. The process of creating a song list for a group may take several sessions. Begin by introducing the idea of creating a song list of the top 10 songs for the group, and then discuss songs that are clients’ favorites, playing a minute or so of each song, including the chorus to familiarize everyone with the song. Take a few minutes to discuss each song and what each client likes (or doesn’t like) about it. Compile all the songs on a list. This might be something that is done for 15 minutes in every session for a month until everyone has had a chance to choose one or two songs. After the list is compiled, listen to a few moments of each song again and ask the clients to vote, coming together in a decision about the top 10 songs. In the discussion of the final list, note similarities and differences in the music and lyric content, and note commonalities and unique preferences among the clients. The group can decide to use a song as an opening or closing song for the next few sessions. If appropriate, the therapist can also use some of these songs in subsequent sessions for music and movement, or clients can create art while listening to one or more songs. For the goal of mood alteration with individual clients, this process may also take more than one session and may take place as a significant part of multiple sessions. Once started, it is best to continue the process in each session until it is completed in order to maintain coherence and relevance. Begin by helping the client to identify a mood that is problematic (e.g., anger). Some clients may be very ambivalent and have flat affect, rendering them unable to identify any problematic feeling state. In this situation, have the client identify what feelings he would like to experience more of in his life (e.g., calm, happy, peaceful). Once the emotions are identified, help the client to find a song or two that exemplify the energy level and feelings in the most intense experience of this state (e.g., extreme anger). Continue by finding songs that express a reduction of intensity (e.g., rising anger, agitation), and continue finding songs that express a movement toward the desired feeling state (e.g., moderate energy that would correspond to an irritated state) until the desired state is achieved (e.g., bright, energetic music or calm and peaceful music). In the case of feeling states of ambivalence or depression, begin with a song that reflects this and proceed with songs that become more animated—or whatever mood is desired. Clients may have difficulty identifying not only songs, but also feelings and emotions, so suggesting songs and listening to them together, checking in with the client for how the song matches his mood, can be very therapeutic in helping the client to recognize internal states before they become overwhelming. When this process is done individually in this manner, it is an intensive level of therapy. Adaptations. A playlist of instrumental music collated by the therapist can be used to help clients identify moods and feeling states. The therapist plays an instrumental selection and then asks the group to decide on a feeling in one word that describes each musical selection. The therapist focuses a discussion on individual differences and commonalities and is attentive to group dynamics that emerge (Plach, 1996, p. 31). Clients who have difficulty naming or being aware of their feelings can also benefit from this playlist mood identification experience. In individual sessions, the therapist can create a playlist composed of music with widely contrasting dynamics, tempi, orchestration, and moods, asking the client to identify each mood and to narrate stories or events from his life that would match the music and the feelings in each piece of music. This helps the client to become more aware of the variety of his feeling states, how these states are reflected in music, and how listening to music may affect one’s internal state.

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Progressive Relaxation with Music Overview. Clients improve their relaxation response by tensing and relaxing various muscle groups while listening to music. Clients with SMI living in the community have many sources of tension and anxiety, ranging from completing instrumental activities of daily living (IADLs) to dealing with stigma and poverty. Using music to promote relaxation can be helpful in establishing a relaxation response. All clients would benefit from this experience, particularly those who have anxiety problems. Goals would be to learn to relax physically and mentally, to increase body awareness, to increase a sense of control and empowerment, and to experience a feeling of calm. Clients also learn to discriminate between relaxation and tension responses and to substitute relaxation responses for stress or anxiety responses (Houghton et al., 2002). This method is contraindicated for clients who are actively psychotic, though clients in recovery should not be in this state. The level of therapy is augmentative. Preparation. The most important aspect of preparation is the music choice. The therapist finds relaxing ambient music that maintains a steady pulse and tempo; has a quiet, predictable mood; and has few dynamic changes (Grocke & Wigram, 2007). Most important, however, is the choice of music that is appealing to the individual client or to the group (Grocke & Wigram). The ultimate aim of the music is to elicit a positive mood and feeling responses that will facilitate relaxation (Houghton et al., 2002). A combination of musical instruments with various timbres such as drums, ocean drum and bells, or piano may be used to facilitate relaxation. A quiet room with dimmed lighting and adequate space for clients to spread out in a reclining or sitting position is required. Mats, blankets, and pillows are also required, as is a good sound system. Some therapists may feel more comfortable using a script or phrases in outline form. The therapist should also practice the relaxation to provide a well-modulated, calm, but wellprojected voice with few inflections, and appropriately paced breathing (Grocke & Wigram). What to observe. Notice if the clients are becoming more relaxed by observing their breathing, which should become more regular and deeper, and their bodies, which should become still. Notice whether some clients are feeling agitated, moving around as if unable to find a comfortable position, or unable to close their eyes. Notice as well clients who may become frozen in a rigid position and whose breathing is shallow or restricted, as this could indicate that the client is having a difficult experience. Procedures. If this is a new experience for the clients, the therapist can begin with a discussion about how everyone has stress, anxiety, and relaxation, being sure to normalize the experience of stress and anxiety rather than to pathologize it. Clients can discuss what stresses they have in their lives and what it feels like when they are relaxed. After determining that the client or group would like to do a relaxation to practice the relaxation response, the therapist can play a few excerpts of music and have the clients choose which one they would prefer. Once the therapist knows what style and genre of music the clients prefer, she can choose appropriate music in the future based on this experience. Clients are then instructed to raise their hand, sit up, or indicate to the therapist that they are having difficulty if they experience agitation at any time during the experience. Each client is given a choice of sitting or lying down on a mat, and given a blanket and pillow. The preferred position is on one’s back with the feet apart and legs straight. Closed eyes are preferred, but some clients may not feel comfortable with eyes closed, so this option should be presented to them. Each relaxation begins with an induction in which the clients are drawn more and more deeply into the relaxation. Begin by focusing the clients’ attention on the feeling of support, followed by the rhythm of their breathing. For example, say, “As you move around a little to find a comfortable position, notice how the mat or chair supports your body. Notice where your head and shoulders, back, and legs are supported, and where you feel your body in contact with the mat or chair … allow your eyes to close if you wish, and bring your attention to the rhythm of your breath. Follow the breath as you inhale, as it moves through your body, and as you exhale … notice that with each breath, you let go more and more

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of the tension in your body … notice the breath, gently rising and falling, notice your own rhythm … allowing it to become deeper and slower in its own time … gently breathing as you feel more and more relaxed … letting go more and more of the tension.” Once the clients have settled into a relaxed state, begin the Jacobsen Progressive Muscle Relaxation procedure (Jacobsen, 1970). In this relaxation, clients are directed to focus on muscle groups by tensing, increasing the tension, and holding the tension, then relaxing. A typical script might be: “And now focus on the muscles in your right foot … tense the muscles of the foot (by drawing the foot back toward the body) … Tense the muscles tighter … tighter … and tighter … tighter … and relax” (Grocke & Wigram, 2007, p. 104). This would be followed by the left foot, right and left leg and hips, pelvis and lower back, stomach, and then drawing the shoulders back to tense the muscles of the back and drawing them forward to tense the muscles of the chest, clenching the hands, stretching the arms to create tension, pulling the shoulders up to the ears, and raising the head off the pillow to stretch toward the chest. Finally, the jaw is tensed by clenching the teeth, the eye muscles are tightened, and the forehead is tensed with a frown. As each of these muscle groups is tensed, the tension is increased, held, and then relaxed. At the end, direct the clients to feel the body fully relaxed, allowing any remaining tension to be released from the body (Grocke & Wigram, pp. 104–105). At this point, the clients can rest in this state for a few minutes before coming back to an alert state, or another piece of music can be played for five minutes while the clients rest. When bringing clients out of the relaxed state, the therapist changes her voice from a flat, hypnotic dynamic to one that has more dynamic inflections. First, turn down the music gradually if it has not ended, and inform the clients that the music has now ended. Direct them to listen to the sounds inside and outside the room, and to become aware of their breathing and its rhythm and depth, noticing how it moves into their lungs. Direct them to become aware of how their bodies feel in contact with the mat or the chair, and tell them to place their feet flat on the ground. Tell them to stretch their arms, and to rub their hands together until their palms feel warm, then to place their palms over their eyes and to open their eyes. Ask them to sit up when they feel ready. Once everyone has come to a sitting position, ask them to share what the experience was like, encouraging them to talk about discomforts and difficulties as well as pleasant experiences. Ask if there were some body parts that were more relaxed than others, and if they were able to follow the therapist’s suggestions. Help the clients to connect this experience to their lives, noting in which circumstances they might use this experience and how it might be useful in assisting them with coping skills as well as healthy sleep patterns. Adaptations. There are infinite variations to relaxation experiences. In the experience described above, for example, the progressive relaxation may be done without music, and the music may be played only after completing the tension/release exercise. One music selection may be played throughout and for the rest period afterward, or a different music selection may be played for the tension/release and for the rest period. Live music may also be used. This takes some skill on the therapist’s part, but it can be very effective. For example, the therapist can play a drum, increasing the dynamic level for the tension, and play another instrument such as the chimes or a rain stick or ocean drum for the relaxation. The rhythm and dynamics of the instruments provides a predictable and sensory stimulus to both the tension and relaxation. The same thing can be done on a piano or guitar. In using these instruments, it is important to maintain a repetitive sequence with no variation so that the tension and relaxation cue is always clearly indicated and the clients are not distracted by unpredictable sounds. This can be followed by recorded or live music in the rest period.

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Autogenic Relaxation with Music Overview. Clients improve their relaxation response by using an image to release tension from various muscle groups while listening to music. The indications and goals are the same as for the Jacobsen relaxation. Clients who are able to concentrate and who have some experience with relaxation may be more appropriate for autogenic relaxation, as it requires some familiarity with feeling states associated with relaxation as well as the ability to concentrate, follow instructions, and focus on different parts of the body (Grocke & Wigram, 2007). Jacobsen would be more appropriate for clients who have difficulty feeling their bodies or who have a tendency to lose concentration easily or become disorganized internally. Contraindications are the same as for Jacobsen relaxation, and the level of therapy is also augmentative. The preparation and what the therapist would observe is the same as for Jacobsen relaxation. As in the Jacobsen procedure, clients may be involved in the choice of music or the therapist may choose music based on her knowledge of clients’ preferences. Preliminary instructions include asking the clients to indicate to the therapist if they find themselves feeling uncomfortable. Instruct clients to find a comfortable position on a mat or chair as above, and lead the clients into the breathing and support induction as above. Direct the client to feel the support for each body area on the mat or chair—legs and hips, arms and hands, the back, down the length of the spine from the shoulders to the hips, and the head and shoulders. Then, reaffirm that the clients feel completely supported so that they feel physically safe (Grocke & Wigram, 2007). Bring the clients’ awareness back to the breathing, asking them to notice the movement in the chest as they take in and release air, noticing if their bodies feel lighter or heavier (either is fine), and gradually allowing themselves to take deeper breaths, gently taking it in and gently releasing, while allowing the breath to rise and fall in its own natural pattern (Grocke & Wigram, 2007). Proceed through each of the body parts repeating a script such as: “As you continue to breathe deeply, become aware of the muscles in your right foot … relax those muscles, so that your right foot feels gently relaxed … become aware of the muscles in your right leg …” (Grocke & Wigram, p. 99). Continue through each of the body parts as for the Jacobsen relaxation. When the relaxation is finished, the clients can remain in a relaxed state for 5 to 10 minutes or they can be brought out of the relaxed state. Follow the guidelines in Jacobsen relaxation above for bringing the clients back to an alert state and following up with a discussion. Adaptations. Adding a color to the autogenic relaxation can increase the client’s awareness of his body. After the breathing induction, invite the client to think of a color that he would like to take into his body, suggesting that the color be one that can resonate with how he is feeling. Give the client time to become aware of the color, inviting him to be aware of its texture, shade, and vibration. Inform the client that he will be taking this color through his body, and that if the color begins to change, to simply allow it to do that. Then begin the autogenic relaxation, with the color being drawn in through the bottom of the feet so that it fills both feet to the ankles. Continue the relaxation, suggesting that the client take in as much color as he needs as he is directed to move it up through the body. At various moments, repeat that the color is bringing into the body whatever it needs. Bring the client back to an alert state as above. In the discussion, ask the clients about the color, what it brought, and how it felt (Grocke & Wigram, 2007). Grocke and Wigram (2007) propose two additional variations to the autogenic relaxation that involve taking in light. In the first, a ball of light is sensed and the client is directed to allow the image of the ball of light to form in his mind. As the client breathes, the therapist suggests that the ball of light hovers over his head and in doing so, the light fills this part of his body, again, taking in as much as the client needs. Proceed with the rest of the body until the light reaches the feet. In this induction, the

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therapist can also suggest that the light leaves the client feeling glowing and radiant, or energetic, or calm and peaceful. In the second light adaptation, the induction can be given in a way that the light enters the body in the core and radiates throughout. Because the light is taken directly in through the core, persons who have experienced psychosis may find this to be overwhelming. However, those who are stable and have enjoyed the ball of light and color inductions may find this to be pleasing. After the breathing induction, instruct the client to take a few moments to sense where the core or center of his being is located, saying: And now beginning to be aware of the centre part of your being … take a few moments to feel where the centre of your being might be … allow yourself to feel that core part of yourself, the very centre of who you are … take a few moments to sense where this centre is in your body … and when you have found that core place, breathe into that core place, allowing it to become alive … and now imagine a ray of light entering this core part of yourself … allow the light to radiate from the core place, gently filling the area around the core of your being … filling it with as much light as you need … gradually allow the light to radiate from this centre … gradually moving through the areas of the body … moving slowly and gradually through the cells … filling the body with the light of your core being (Grocke & Wigram, 2007, p. 103). At this point, the therapist continues with the induction, allowing the light to radiate through the head, arms, hand, fingers, spine, legs, and feet, feeling the body filled with light. The client is then directed to bring the music into the core of his being as well and to allow the music to bring to him whatever he needs. This is followed with a few minutes of music and then a return to an alert state and the discussion. A final adaptation is the music-centered relaxation suggested by Houghton et al. (2002), which involves music as the primary relaxation stimulus. The therapist provides music selections based on the clients’ preferences and instructs them to follow the music by listening to different elements (instruments, dynamics, rhythm) and events (changes in these elements) as their attention is drawn to them. Clients are encouraged to let their attention wander freely back and forth among the music, their bodies, their thoughts, and their feelings. This may work well as an introduction to relaxation for clients who have difficulty concentrating. The music should be kept to five minutes or less to prevent the clients from getting lost in their thoughts.

Dance and Exercise with Music Overview. Clients move to music according to structured cues by the therapist. Movement using musical cues is discussed in Chapters 2 and 3. Clients in recovery will benefit from movement and exercise. Often, medication side effects result in lack of body awareness, lack of energy, and lethargy. As clients are recovering, they need more active movement experiences; the music is an energizing factor in stimulating movement. Goals are to increase muscle tone and energy; increase or maintain a range of movement; connect with one’s body in a pleasant way; help with balance; promote relaxation; gain pleasure; promote group cohesion; and develop creativity. For gentle movements there are no contraindications, but for any exercise routine, the therapist should verify with the doctor if there are any physical contraindications for each client. The level of therapy is augmentative. Preparation. The therapist prepares music or a series of excerpts of music that matches the energy and goal of the physical exercise. For example, stretching music should be slower and have long, legato phrases, while music for exercise should have regular strong rhythms; music for dance should have

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a strong beat in a particular genre to inspire dance movements. The therapist should plan the movement sequence and practice it before using it with the clients. A room with enough space for clients to move without bumping into each other is needed, along with a good sound system. What to observe. Notice to what extent clients are able to learn movements that are modeled, invent their own movements, and coordinate their bodies; if they have more difficulty with one side of the body or the other; if they have a good range of motion; if the movements have the appropriate energy and range; and if the clients are able to derive pleasure from movement and interactions with others. Notice when the clients are becoming tired or enjoying a certain movement so that it can be extended or curtailed. Procedures. Begin by using structured movements so that clients feel less inhibited. This also helps them to internalize movements so that they can access their creativity in less structured movement experiences. The therapist puts on the music selection playlist and begins the exercises with stretching routines. Typically, this involves raising the arms high and lowering them while coordinating one’s breathing, and then bending over while clasping the hands behind the back and raising the arms. This can be followed by raising the arms above the head and bringing them down while forming a circle, doing some neck rolls, stretching the neck muscles from side to side and the chin down to the chest, then pulling each shoulder to the opposite side with the opposite arm. For the trunk, do a twist and swing from side to side. Stretch each leg out and point and flex the foot, then roll the spine down, bringing the hands as close to the floor as possible, and gently roll back up, feeling each vertebra, as the client comes to a standing position. Close the stretching segment by breathing in and out while raising the arms up and down again and coordinating it with a long breath. After the preliminary stretch, a number of options exist. The music is changed to something livelier, and the therapist models simple movements involving the large muscle groups in a repetitive manner, such as arm swinging, raising and lowering, and bending at the elbows; for legs, lift the knees one side at the time, move at a quick pace out to the side and back in, or slide forward and backward. Avoid jumping, as this may be too strenuous for some clients. What is important is that the clients feel competent while they are moving arms and legs rapidly and repeating the motion a number of times. Five minutes of this vigorous movement is sufficient. End the segment with a stretch similar to the one at the beginning. Another option after the stretch is to put on exercise music and ask the clients each to model a movement that goes with the movement; all the clients imitate the movement and the group continues the movement for 8 to 16 times before proceeding to the next client. Dance music can also be used after the preliminary stretch. The therapist can demonstrate a dance routine such as a line dance or the “Macarena” or the “Chicken Dance.” The therapist teaches the dance step based on the ability of the clients to master the steps, and in so doing, she may alter the original steps or construct new ones (Houghton et al., 2002). Many of these dances are demonstrated on YouTube. Alternatively, dance music can be played and clients can be directed to take this time to allow their bodies to make whatever movements they are inspired to do with the music—no movement is too silly. Adaptation. If clients feel embarrassed about moving their bodies in public, use scarves to put the focus on something outside the body. Silk scarves move easily in the air and are found in bright colors. Clients can also share a scarf and create movements together.

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Interpretive Movement with Music The reader is directed to Psychodynamic Movement in Chapter 2 (Hunt) and Movement to Music in Chapter 3 (Eyre), particularly Directed Imagery and Movement, Projective Imagery and Movement, and Letting Go and Taking In.

Mirrored Movements with Music Overview. Clients move together to music in dyads, creating spontaneous mirrored movements in leader and follower roles. Mirroring another person in movement is an intimate experience that requires close and constant attention to one’s partner as well as spontaneity and creativity. This exercise also brings up issues related to taking on the role of leader (initiator) or follower. For clients in recovery, this experience can be germane to the challenges they are facing in life, as they are required to take on roles both as leader, i.e., take initiatives in their own lives, and as follower, i.e., understand and adhere to societal norms. Some clients will naturally feel more comfortable in one role than another, and this exercise often brings this insight to clients. Goals are to increase interpersonal skills and connection with others (Plach, 1996), to increase spontaneity, and to gain insight into personal characteristics related to leader and follower roles. There are no contraindications for this experience in the recovery setting. The level of therapy is augmentative or intensive. Preparation. A selection of instrumental musical excerpts of different moods, tempi, orchestrations, genres, and styles is needed for this experience. Classical, New Age, ambient, folk, jazz, and popular instrumentals can all be included. Occasionally, based on group preferences, a particular song might also be used. A room with enough space for clients to move and a good sound system are needed. What to observe. Notice how at ease clients are with moving in both the leader and follower roles, as well as how creative, spontaneous, and varied their movements are as leaders. Notice how well clients in the dyads are able to mirror or create movements, and how these movements express the mood of the music. Observe the clients’ level of insight into creativity and roles in the verbal discussion. Procedures. Present the experience to the clients. The therapist or the clients and therapist can choose the music together. Once the music has been selected, explain that they will be matching up in pairs to do spontaneous and free movements together to the music. One person will take on the role of the leader, and the other person will follow the movement so closely that it will look like the other in the mirror. Suggest that the leader execute the movement so that the other client can follow, either by making the movement slow enough, or repetitive enough to be predictable. Stress that the goal is to have such a close connection in the movement that an observer would have difficulty determining which person is the leader or follower. The clients will swap roles either when the music changes or when the therapist indicates. When the experience is over, have a discussion about how clients felt in their bodies when doing movements, how they experienced each role differently, observations of each other (Plach, 1996), and how the feelings that were evoked relate to leading and following roles in their lives. Adaptation. Plach (1996) suggests including facial expressions as well as body movements in the music to encourage self-expression. The music should stimulate a variety of different moods and feelings to be mirrored (p. 47).

Human Sculptures with Music Overview. Clients place each other in positions to create composite human sculptures based on a feeling or theme (Plach, 1996, p. 49). This is a projective experience that requires some insight into

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personal issues and a level of group cohesion to be successful. This is indicated for groups that have experienced other less intimate movement experiences and for those whose members have developed a level of familiarity. It is contraindicated for newly formed groups or groups that have many new members. Goals are to encourage self-reflection, to identify and externalize feelings, to facilitate interpersonal contact, and to increase group cohesion. The level of therapy is augmentative or intensive. Preparation. The therapist should have a good knowledge of individuals in the group and individual issues. If recorded music is used, musical excerpts expressing a variety of feelings and moods should be prepared beforehand. A large enough space for clients to move about is needed as well as a sound system. If improvisation is used, instruments should be provided. What to observe. Notice how well clients are able to identify feelings and moods in the music, and how well they are able to visualize and translate these feelings into form. Observe which clients are able to volunteer for the experience. Observe how clients respond to being asked to take a position in the sculpture, and if they are able to contribute ideas to the creation of it. In the verbal discussion, note how clients responded to the close proximity in physical space and how they are able to relate to each other’s experiences of the feeling or theme. Procedures. The therapist chooses music selections that express a particular feeling state or mood and tells the clients that they will listen to the selection of music and to be observant about what feelings or moods the music evokes. She then does a short induction, bringing the clients into a relaxed state by bringing their attention to their breath and to how their bodies are supported on the chair, and plays the music selection. When the selection is finished, she asks the clients to contribute a word or two that will identify how the music made them feel. In the next step, she asks the clients to close their eyes and envision how this feeling would look if it were a sculpture or a statue. The sculpture could also have the ability to move in space and metamorphose into a different form. After a minute, she asks for a volunteer to describe his sculpture. He then begins to create that sculpture using all the clients as his artistic “material.” Anyone who does not want to participate in the physical sculpture should be excused. The volunteer can seek help from the therapist and group in working out how the sculpture will be created and how or if it will change shape, or he can do it entirely on his own. The therapist plays the musical selection again while the client creates his sculpture. The position is held for a few moments. Each client is then given the opportunity to discuss how it felt to be a part of the sculpture, and the volunteer contributes how it felt to create the sculpture. Discussion can also include how it felt to be integrated in close physical space with others, as well as how the sculpture related to the feeling. Adaptations. The therapist listens to everyone’s input on the feelings evoked by the music, finds commonalities and discusses them with the group, and works together with the group to decide how to create the sculpture. The therapist can play two excerpts of music with contrasting feelings. In this situation, the client or clients create two sculptures and work together to design a way in which all the clients will move from one shape into the next for a moving sculpture. A psychodrama adaptation of this experience is to do a family photograph. In this experience, a client creates a sculpture in which he positions himself within his family. The therapist helps the client to place “family members” in positions based on emotional closeness to each other (including himself), and she helps the client to create postures that express an essential characteristic about each family member represented. Each person in the photograph can also be given a word or sound to repeat vocally, verbally, or with an instrument to create a family improvisation. This is followed by discussion of the client’s feelings, and clients are encouraged to share their feelings and responses.

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Art with Music Overview. Clients create drawings, collages, or sculptures individually or in a group mural based on feelings evoked while listening to music (Houghton et al., 2002). These experiences provide clients with an alternative way to express feelings. Clients who have schizophrenia often experience difficulty with language skills; the disorder can cause a regression in which the client is immersed in a world of pictures similar to those experienced in thinking states of early ego development (Searles, 1965, p. 574). Thus, although clients who enjoy visual expression are well suited to this experience, clients who do not identify with having artistic talent will also benefit from exploring art as a medium of self-expression. It is helpful if the therapist places the emphasis on the process rather than on the product. There are infinite ways to use art with music. Art therapists will often use music with art, but for the music therapist, the focus is on how the music is expressed in the artwork and how the clients derive meaning from this process rather than the artwork itself. Goals are to increase the ability to identify feelings, to increase one’s sense of self and one’s identity, to expand media for self-expression (Houghton et al., 2002), and, when doing a group project, to work on problem-solving and to increase group cohesion. A therapist goal for this experience is to gain insight about how clients are managing early developmental stages. There are no contraindications for this experience, but if there are any clients who have self-harming tendencies, any activities with scissors or sharp writing objects should be avoided. The level of therapy is augmentative or intensive. Preparation. The therapist should have a large supply of art materials on hand. These might include black and white sheets of paper of various sizes (8.5 x 11 and larger), a roll of white paper, chalk and oil pastels, colored felt pens, an assortment of magazines with a variety of pictures, glue sticks, dulledged scissors, and other accessories such as glitter, sequins, or feathers. For sculpting, Play-Doh, Plasticine, or clay is required, along with materials for cleanup. Tables are required for most activities, as well as a selection of music appropriate to the focus of the experience. What to observe. Notice how the clients are able to relax and engage with the music to deepen their self-reflection and how well they are able to connect the music to images, colors, shapes, and forms in artistic expression. Notice group dynamics in experiences that require group communication. Observe what insights clients derive from the experience and how they respond to one other. Note the commonalities and differences in the responses, and note what the artwork reveals about the client’s internal world and his self-awareness, as well as his organizational and problem-solving abilities. Procedures. The first experience presented here is Trio (Summer, 1988, p. 32), in which clients draw while listening to three classical pieces. Depending on the length of the group, the frequency of meetings, and the number of participants, one drawing can be done per session, or all three can be done in one session. The three pieces are: (1) the second (“Adagio”) movement of Beethoven’s Fifth Piano Concerto, (2) Holst’s “Mars, God of War,” and (3) Berlioz’s “Ball Scene” in Symphonie Fantastique. It is notable that the piano and orchestra in the first piece evoke a mother/infant symbiotic closeness; the second piece evokes the oppositional stage of developing identity and autonomy; and the third evokes feelings of intimacy and connection with another in a meaningful relationship. The therapist begins by telling the group that they are going to draw the feelings that they experience in the music, and that it is not important to draw actual pictures of things, but that colors, shapes, and forms are just as valid. The purpose is to connect to the music and let the music dictate the image. The therapist then passes out a white or black sheet of paper according the client’s preference and provides oil and chalk pastels and colored felt pens. Before beginning the music, she takes the clients through a short induction as for Human Sculptures above. Once the music begins, she instructs the clients to wait until the music guides them to choose a color or create a line on the paper before beginning their drawing. When the music is finished, give the clients a few more minutes to finish the drawing and wait in

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silence until everyone is done. If one drawing will be done in that session, a discussion follows. If all three drawings will be done in one session, then once everyone has completed the first drawing, it is put aside and new paper is handed out. The therapist proceeds with a short induction and plays the second piece. The same procedure is carried out for the third. The verbal discussion proceeds, with everyone being given a chance to describe how they reacted to the music; what feelings, thoughts, and images it evoked; and what the process of drawing to it was like for them. The therapist asks questions to help the clients connect the different forms and colors they used to the music and to issues and feelings in their lives. Once all the clients have shared their feelings, the therapist continues a discussion by drawing clients’ attention to commonalities and unique differences in the group. Adaptations. There are a number of ways to use art materials with music. Specific themes can be used for the artwork or sculpture, for example, drawing or sculpting someone who was important to the client in childhood (Houghton et al., 2002). MacRae and Smith (1973) suggest an ethnic theme for individual artwork. They provided examples of colors and patterns of artwork of a particular country, and then used ethnic music while clients created simplified versions of typical artwork of that country. Mandalas: One important adaptation is to draw a circle about the size of a dinner plate on a piece of paper and ask the client to use that to draw his picture. This is known as a mandala, and the circle drawing represents the self (Fincher, 1991). The therapist chooses the same music as above, or she may choose nurturing, containing music such as Kobialka’s version of Pachelbel’s “Canon in D.” The procedure is the same as above. Although drawing in a circle can be a containing, comforting experience for clients, this adaptation will be more fruitful if the therapist has some training in mandala interpretation. Music may be chosen specifically by the therapist, according to the mood it conveys, with the instruction to clients to draw their feelings as they emerge in the music (Houghton et al., 2002). Individual collages: Clients may develop ego strength by working on individual collages. In this experience, the therapist sets a theme based on previous issues and needs that have arisen in group discussions. For example, themes might be: Who I Am; What’s Important to Me; Friendship and Family; Things I Like to Do; A Vacation in My Mind; or Things That Help Me Feel Good. Based on the theme, the therapist chooses a music selection and begins with a short induction to the theme after the clients have been put in a relaxed state with a breath support experience as above. For example, in relation to the first theme, the therapist might say, “Think of all the things that make you who you are … all the things you like, what is important to you in life, how you deal with difficulties, what makes you happy, even the colors and kinds of music that you like. Then when the music starts, take some time to list these things either mentally, or you can write them down.” After the clients have taken a few moments to reflect, invite them to begin looking through the magazines and find pictures, colors, shapes, words, and letters to make up words that will describe who they are. Invite them to play around with these images, placing them on the paper until they find a composition that is pleasing to them before they begin to glue the images on the paper. Glitter, sequins, and other materials can be added as decoration. Follow this up with a discussion in which each person presents his collage. The therapist can use this opportunity to illuminate comparisons, commonalities, and unique characteristics among the clients. MacRae and Smith (1973) suggest choosing music of varied textural qualities and providing varied textured materials such as soft, scratchy, or furry cloth with which to create a collage inspired by the musical texture. This can help clients develop their sensory awareness with a focus on touch and sound. Clay and Plasticine sculptures: Any of the above experiences can be carried out using clay and Plasticine to express themes or images. If clay sculptures are used, they can be left to dry and painted in a later session.

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Group collage: This experience is similar to the collage experience above, with the exception that all the clients create a collage together on a long piece paper from a roll. The same themes can be used and the procedure is the same. However, clients are instructed to discuss how they will put all the different images together once they have chosen and cut out their individual images. The therapist can help the group to problem-solve how they will combine the images—by shape, categories, size, and color—to create a unified composition rather than having each client place his items in one section. Macrae and Smith (1973) suggest using popular rhythmic music for group murals. Instructions to the clients are to allow the music to flow through them and to represent the feeling of the music in shapes and colors. MacRae and Smith (1973) describe using varied music with instrumental solos as an inspiration for individual drawings. The clients translate the sounds into shapes and colors, and then they decide which parts of various drawings they will cut out and paste together to create a group collage. Collage of the self: This experience is used to help clients identify who they are, and it is another way of approaching the Who I Am theme. Clients work in dyads initially in this collage. The therapist explains that they will be lying down on a sheet of roll paper on the floor and that their partner will draw an outline of the partner’s body with a thick felt pen. In this body outline, the client will then place all the things that make up who he is in the body shape, taking care to feel where, exactly, in the body shape each word or image belongs. The therapist then begins the short breathing and support induction and plays music of a holding and containing nature. The clients take a minute or two to reflect on what they will put in their body shape, and then they pair off in dyads and take turns drawing the shape of each other’s bodies on the paper. They can fill in the body shape with colors, words, or pictures from magazines, or a combination of all three. This is followed by a discussion in dyads and then a return to the group for discussion.

Storytelling with Music Overview. Clients write or orally present a story individually or collectively as a group while listening to music. These experiences are helpful when clients have already had experiences listening to music and expressing the feelings it brought up through movement, art media, and discussion. Expressing feelings, sensations, and images in writing requires self-organization, intrapersonal awareness, and secondary process skills such as logic, matching, and verbal skills that are controlled by the ego. Goals are to increase spontaneity, imagination, creativity, self-organization, self-awareness, self-expression, and communication. In groups, the goals are to improve problem-solving skills and to foster group cohesion, enjoyment, and pleasure. Groups and individuals who have not reached a level of self-understanding and self-expression that can be articulated verbally would benefit from movement and art activities before attempting writing experiences. The level of therapy is augmentative or intensive. Preparation. The therapist needs to plan for these activities and prepare the necessary materials. These include appropriate songs and music instrumental selections, as well as paper and pencils. What to observe. Notice if clients are able to access internal imagery and observe clients’ creativity and spontaneity. Notice whether they are able to express their internal world in words. Be aware of how clients make connections to what others have said or written, and how they are able to open, develop, and end a story appropriately. Procedures. The first experience presented here is a group storytelling composition (Plach, 1996, p. 14). The group is invited to create a story based on a musical selection played for them. The clients are told that they will listen to the music and bring their awareness to the images and ideas that it evokes. They will then each contribute a couple of lines to create a collaborative story. The therapist then begins with an induction similar to those described for the art experiences above. Clients listen to the music in a

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relaxed state. When the music has finished, the therapist may begin the story by writing a couple of sentences, and then the person to the left adds two more sentences, and so on, until everyone has contributed something. The therapist may also collate three musical excerpts to depict an opening scene, a development with more conflict, and a closing, or resolution. If a second and third selection of music is used, the procedure follows the same steps as above. Adaptations. Clients may begin the story instead of the therapist. The therapist would begin the story only if the clients are unable to do so. The therapist may also pass each person a piece of paper so that there will be as many collective stories as there are people in the group. This story line is more difficult to develop and should only be used with high-functioning groups who have had some experience orally presenting stories. Another variation is to play all three music selections continuously while each client writes his story. When the music has finished, clients in the group read their stories to each other. This can also be used in individual sessions.

Peer Support Writing Overview. Clients write something they appreciate about each person in a group while listening to music. Many clients in recovery suffer from poor self-esteem. This is often related to stigma they experience because of their mental illness. Clients are often unable to recognize their qualities, and this makes it difficult to improve their self-esteem and affects their motivation. Goals are to increase selfesteem and awareness of one’s qualities, and to develop empathy and awareness of others. Preparation. The therapist finds an appropriate song and brings supplies of paper and pencils. A sound system is needed. What to observe. Notice if clients are able to find authentic qualities in others that they appreciate, and how they respond to what others say about them. Procedures. The therapist begins by telling the group that everyone has a tendency to see the problems and things that one lacks in life, but that it is often more difficult to see the gifts and talents we possess. She gives each client a piece of paper and a pencil and asks them to put their name at the top and pass it to the person at their right. She then tells them that she will be playing a song and she would like each person to take as much time as they need to think about the person whose paper they have, and when they are ready, to write a word or sentence about something that they appreciate about that person. It could be something general, like a quality (e.g., kindness, fairness, a sense of humor), or something specific (e.g., you walked me to the bus stop, we had a nice conversation while waiting for group, your smile). The therapist then plays a song, such as Christine Aguilera’s “Beautiful,” Billy Joel’s “Just the Way You Are,” Cindi Lauper’s “True Colors,” Mary J. Blige’s “Take Me As I Am,” or Ingrid Michaelson’s “The Way I Am,” while the clients pass around the paper. When the clients receive the paper with their own name, the music is turned down and the therapist asks everyone to read their papers and/or comment on them. The group discussion focuses on how it feels to hear about what others think of them. She may also suggest that clients keep this in their possession to use it to remind themselves of their qualities. Writing Identity Documents with Music Overview. Clients create documents while listening to music that include details about their internal resources, how they have overcome difficulties in the past, and how they have empowered themselves to act on their own behalf in spite of these difficulties. White (1995) uses this narrative therapy approach with clients with psychosis to help them to identify and reaffirm their unique abilities and strengths in the face of difficulties. White states:

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In times of stress—when we find ourselves under significant duress when facing situations of adversity—we are all vulnerable to being separated from our knowledgeableness. At these times, we often experience a dearth of creative responses to the situations we find ourselves in; our usual problem-solving skills don’t seem available to us, and our options for action seem to evaporate. … Now, those people who have experienced psychotic episodes are ever so much more vulnerable to being dispossessed of their knowledgeableness and their preferred sense of identity at such times. And it is this dispossession that sets the scene for the experience of great personal insecurity and distress, and for further acute episodes. So it makes a great deal of sense for these people to carry with them, at all times, documents of their identity. These are documents that they can consult under those circumstances when they are losing sight of their knowledgeableness, when their sense of identity is at risk (p. 142). Goals are to identify and affirm internal resources and unique strengths and to increase self-esteem and resilience in the face of difficulties. There are no contraindications for this experience for clients who are in recovery. The level of therapy is intensive or primary. Preparation. The therapist prepares supportive, containing, instrumental music (e.g., Kobialka or Liquid Minds), or moderately paced baroque music (e.g., Bach’s “Air on a G String),” or dramatic, inspiring music like instrumental sound tracks to movies (e.g., the “Circle of Life” from The Lion King). Paper and pencils are needed, as well as a sound system. What to observe. Notice how well the client is able to identify how he has coped with and triumphed over difficulties. Note if he is able to recognize when he has acted in his own behalf, and taken action to move his life in the direction he desires. Note how the client reacts on a feeling level when discussing this issue. Procedures. The therapist opens a discussion on the theme of how clients have dealt with difficulties and what strengths they have developed to do so. It may help to ask clients to think of one event or time when they have experienced a particular difficulty or obstacle and have had to deal with sad, depressed, negative feelings and thoughts about themselves. Ask the clients to think about how they overcame these difficulties, and then ask for a volunteer to narrate his story of this event to the group. The therapist may have to facilitate the narrative construction with questions that lead the client to identify strengths and resources he accessed. Most often, the therapist may also need to ask leading questions designed to point out evidence of how the client’s actions demonstrated determination, resilience, hope, creativity, innovation, and other strengths. It is not uncommon to find that the client is not aware of these. When everyone has shared their stories, the therapist passes out pencils and paper and asks clients to write the story down, giving instructions to use the third person to narrate how he has faced difficulties and how he is continuing to face them. The voice should be that of a proud parent/friend describing with admiration how the client has succeeded in surmounting obstacles. The therapist then begins to play background music to support the mood of the document as the clients write. Clients may share their feelings about creating the documents or read the documents to each other with the music played in the background. Adaptations. Clients can, in subsequent sessions, create artwork to support their identity documents with appropriate background music to set the mood. The therapist can also facilitate composition experiences, such as a group or individual song that documents resilience in the face of difficulty. Chants of one phrase that summarize the essence of one quality that each client needs to hold on to in times of difficulty can also be created for each client in the group or as a composite group chant. The creation of identity documents is particularly adaptable to individual sessions.

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Projective Letter-Writing Overview. Clients write a letter projecting their feelings about a core issue in their lives. Clients in later stages of recovery may need to work on issues related to the life challenges presented by the disorder and/or by their environment. Writing a letter is a way to express one’s thoughts that can be less confrontational than verbalization. Clients may feel more at ease complaining or venting difficult emotions like rage or resentment in a letter format than by talking. Goals are to express difficult thoughts and feelings, to work through challenging issues, and to identify internal and external resources. This experience is contraindicated for clients who are fragile, recently discharged from the hospital, and/or have not developed internal resources sufficiently, or lack external support. The level of therapy is intensive or primary. This experience is also used in individual work. Preparation. The therapist prepares supportive, containing instrumental music for a group experience (e.g., Kobialka or Liquid Minds; also, short contained classical music such as Bach’s “Air on a G String”). If the letter-writing theme is specified, e.g., anger, the music should reflect that (e.g., Holst’s “God of War”). Paper and pencils are needed, as well as a sound system. What to observe. Listen for the content of the letter to gain insight into the client’s issues and how he is handling them. Notice what emotions the client expresses, and whether the difficult emotions are mitigated by positive emotions and resources. Note how the client relates to his disorder and what level of awareness and acceptance the client has achieved. Notice what the core issue is, if applicable to the theme. Notice how the client is able to construct his thoughts about the issue and how he is able to share his feelings about it. Procedures. The therapist introduces the subject of letter-writing according to the theme. A typical theme is to write a letter to my disorder. The therapist then invites the clients to think about everything that the disorder has created in their lives, the good as well as the bad, giving the clients permission to use this time to say everything they need to say with all the emotions that they feel about it. She also suggests that they think about not only how the disorder has made their lives difficult, but also what they have learned from it and how they have grown by facing these unique challenges. Such a letter might also include all the resources they have had to develop to cope with it. Paper and pencils are distributed, and the therapist begins a short breathing and support induction. When the clients are in a relaxed state, she plays the music and tells the clients to begin writing whatever they want to say to the disorder. When everyone has finished writing, the therapist turns down the music and gives clients a few moments to read what they have written silently. In the verbal discussion, clients discuss their reactions to the experience, the content of the letter, and the feelings that were evoked. The therapist makes certain that everyone is able to express their feelings and that everyone is connected to their strengths and resources before ending the experience.

Music and Imagery The reader is directed to Music Relaxation, Group Music and Imagery, Live Music Listening, and Music Listening with Art in Chapter 2 (Hunt), as well as Music, Imagery and Relaxation in Chapter 3 (Eyre), for additional approaches and adaptations when using music and imagery methods. The following additional methods are appropriate for nonhospitalized clients who are stable and in recovery, but methods in Chapters 2 and 3 should be used before proceeding to these methods.

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Supportive Music and Imagery Overview. Clients listen to recorded music in a relaxed state while imaging or creating poetry or art based on a positive theme set by the therapist; this is followed by verbal processing, improvisation, or songwriting. This group method is presented by Summer (2002) as a task-oriented process in which clients build group cohesion by putting aside their individual concerns so that they can “discover a positive common denominator upon which it is possible to construct the prerequisites for true group process” (p. 301). In this structured technique, fragile clients are assisted in the process of stimulated conscious, supportive imagery rather than unconscious imagery, and in so doing, trust and unity among group members is fostered. Goals are to foster group cohesion, to establish trust among the therapist and group members, to access and reinforce positive resources, to discover commonalities with others, and to become fully engaged in the therapeutic process (Summer, 2002). There are no contraindications for this method. The level of therapy is augmentative or intensive. It is highly recommended that the therapist have completed at least Level I training for Guided Imagery and Music (GIM). Preparation. The theme and the music chosen to support the theme must be selected with great care because the imagery for this level of therapy should “provide the clients with a catalyst for immediate and positive interpersonal interaction” (Summer, 2002, p. 300). The music selected should reflect the clients’ inner states through the use of ambiguous music. By matching the musical elements of rhythm, tempo, timbres, dynamics, harmonies, and melodies to the clients’ energy and mood, clients are more easily able to feel recognized, identify with the music, and immerse themselves in it (Summer, 1994). Clearly, this is a greater challenge in a group than with an individual client, and therefore this process should be used only when group members are experiencing similar inner states that can be represented in the music. Music should be either classical or nonclassical selections lasting between 5 and 10 minutes, with “minimal musical development and considerable repetition” (Summer, 1994 p. 301) to keep the clients focused on one image. Examples of classical music are Reger’s “Lyric Andante,” Warlock’s “Pieds en L’Air” (Summer, p. 302), or Haydn’s “Adagio” from the Cello Concerto in C Major. Examples of nonclassical music include David Lanz’s “Cristofori’s Dream” or “The Enchantment,” or Secret Garden’s “Nocturne.” Drawing paper and pastels are provided if art materials are used. This requires a room with a good sound system and comfortable chairs. What to observe. Notice how well clients are able to relax and how they experience the process. Are they able to engage with the music, generate images and/or sensations, develop the images, and access positive resources during the music experience? Notice how the clients make meaning of the content of their experience, and how they relate to others’ experiences. Note if this is a positive experience for the clients, or if it leaves anyone feeling chaotic and unsettled. If so, this method is contraindicated. Procedures. The focus of this experience is to facilitate a positive internal experience for the clients regardless of the conscious and unconscious conflicts they may be feeling. The therapist begins with a discussion of where clients experience support and sustenance in their lives, helping each client to focus on a particular theme such as connection, support, or strength. This might be achieved through imagining a supportive family member, friend, or group member. The therapist might also suggest a theme of feeling safe, relaxed, or energized (Summer, 2002, p. 301). It is paramount to ensure that the therapist check in with each client to ascertain that he has a concrete image related to the theme before beginning the music. The therapist then leads the group through a short breath and support relaxation induction and turns on the music. During the music segment, clients can develop their internal imagery, or they can complete a task-oriented activity such as drawing a visual image of the theme (relaxation, support, strength, feeling safe, etc.) or write a poem or piece of prose about the theme. This common theme holds the clients in a common positive feeling and establishes a sense of group unity. After the

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imagery is finished, the therapist brings the clients back to the room if they have been imaging with closed eyes, saying, “The music has ended now. Allow the images to fade, but keep the positive feelings as you return to the room.” Bring the clients’ awareness to feeling their breath, feeling their feet grounded on the floor, and listening to the sounds inside and outside the room before opening their eyes. The imagery is followed by a verbal discussion or sharing of the artistic product they have created. The focus of the conversation is on similarities and commonalities among group members as well as experiences of mutual support and empathy in order to strengthen trust. Summer (2002) also suggests reinforcing the positive feelings that have emerged through spontaneous songwriting, structured improvisation, or singing (p. 302). Korlin, Nyback, and Goldberg (2000) used a similar approach and had clients draw pictures reflecting their experience immediately after the music ended. Clients then processed the entire experience in a verbal discussion. Clients without sufficient ego strength (i.e., clients with psychosis) were not included in this group. Another way of reinforcing these feelings is to create a chant that relates to the group’s common experience, compose a melody for it, and sing it together with or without accompaniment. Adaptations. Plach (1996) suggests using the theme Perfect Day Fantasy. The therapist opens with a discussion of how clients imagine a perfect day, and what activities and feelings that day would include. She then takes them through a short relaxation induction and begins to play a music selection, saying, “Imagine for the next few minutes that you are able to live out what for you would be a perfect day. Fantasize about who you would be with, where you might go, and what you might be doing …” (p. 28). The music choice could be a particular song that has pleasant associations and is favored by everyone in the group, or a pleasant, moderately paced nonclassical piece of music. Plach also suggests that an alternative way to conduct this experience is to have the clients draw a picture of the most important aspect of their fantasies while listening to the music (p. 49). Another adaptation suggested by Plach (1996) for the supportive imagery experience is to use a song or a group of songs as the basis of a themed supportive group therapy experience (pp. 33–34). The therapist chooses a song (or songs) that has a story, characters, and setting, and, after the induction, invites the clients to close their eyes and visualize the story as it is being sung. After the song, clients discuss the feelings and thoughts that it evoked. An example of a current song to use that is a supportive, hopeful experience is Bruno Mars’s “Today My Life Begins.”

Explorative Music and Imagery Overview. Clients listen to recorded music in a relaxed state while imaging on an evocative theme based on the clients’ issues; this experience is followed by verbal processing. Summer (2002) refers to this imagery experience as re-educative group music and imagery therapy (p. 302). Moe (2002) practices a similar imagery experience that will be described in the adaptations section below. The primary difference between these procedures and supportive music and imagery is that clients explore their current feelings and life issues, and this may evoke tension in conscious or unconscious conflicts. Goals are to provide a way for clients to access internal resources and imagery, to experience themselves in a new way (Moe), to facilitate clients to tell stories about themselves and to understand themselves better (Moe), and to decrease anxiety by having their feelings contained in the music (Moe). Summer (2002) focuses on goals related to group development: to help each client to experience himself in relation to other group members; and to help each other become aware of maladaptive patterns of interpersonal relating that are hindering daily life. Groups that have not reached a level of trust and understanding are contraindicated for this experience, as are individuals in the group who are experiencing chaotic feelings or a depressed mood, or who are feeling fragile and have labile moods. The level of therapy is intensive or primary. The therapist should be in Level III GIM training or beyond.

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Preparation. Clients may lie down or sit in a comfortable chair for this method. Blankets, pillows, and mats should be provided. The room must be adequate to allow everyone to have their own space, and a good sound system is required. Art materials may also be used. The music should last from 7 to 10 minutes and be repetitious and with little musical development, but have more structural and textural complexity (Summer, 2002, p. 303). Examples of classical music include slow movements from classical and early romantic music, or neo-classic or neo-romantic music such as Greg Stephen’s “Adagio.” What to observe. Observations are the same as for the Supportive Music and Imagery experience above. In addition, note how the clients manage conflicting feelings and content that emerges, how they integrate ambivalent feelings, and the role they play in the group dynamics in the discussion. Procedures. Summer (2002) uses an induction that stimulates individual psychological issues. This may result in significant differences among group members’ imagery experiences, which promotes interaction among clients regarding their unique images and experiences as well as shared feelings. After introducing the music listening experience (the clients will have experienced other listening and imagery experiences, so this will not be new to them), the therapist begins a relaxation procedure that includes deep breathing, muscle relaxation, or a centering exercise. The relaxation experiences described in this chapter might also serve as an induction for this experience. The therapist then begins the music and provides a starting image for the clients, perhaps a field in a meadow, a country lane, a voyage on a boat, or a house, making certain beforehand to be aware if any particular image should be avoided because of a client’s negative personal associations. When the music ends, she brings the clients back gently to the room as described in the autogenic relaxation. Afterward, the therapist focuses the verbal discussion not on solutions to problems evoked in the imagery, but instead on the imagery that each client experienced and the group process by facilitating interactions regarding clients’ perceptions of each other’s imagery. The client explores how his internal conflicts are represented through the imagery and the music listening process itself, and how these conflicts “impact his interpersonal relationships with specific members of the group” (Summer, 2002, p. 304). Adaptations. Moe (2002), while working at the same re-educative or exploratory level of therapy, uses an adaptation of GIM and structures his session a bit differently. Short excerpts of classical music similar to those described above are used; these should include soft tones and harmonies, a predictable tempo, and a pleasant mood to create a feeling of safety in the client and to decrease anxiety (p. 168). The process begins with a preliminary conversation in which clients share what preoccupies them in the here-and-now. Clients then lie down on a mat or sit in a comfortable chair. The induction is kept to two minutes, with a focus on breathing. There is no dialoguing while listening to the music, but the therapist may be more directive in guiding—she may direct the clients to imagine specific images before the music begins, at the beginning of the music, or periodically throughout the music, depending on the theme and the clients’ need for structure. Clients freely associate to the music between guiding directives. Clients are gently brought back to the room after the music has ended and discuss their experiences, sharing images, thoughts, and feelings. In verbal discussion, the therapist helps clients relate their experiences to their current situation as revealed at the beginning of the experience. Bonny and Savary (1973) describe some exercises based on GIM for individuals that can also be used with groups. These experiences are appropriate for persons in recovery who have had some experience in directed imagery and listening to music in a relaxed or altered state. As indicated above, therapists should be in Level II or III GIM Training at a minimum to practice these experiences. Clients may lie down or sit in comfortable chairs, though sitting in chairs is advisable when any of these exercises are introduced for the first time, as sitting keeps clients more grounded. After a short breathing and grounding induction, the therapist begins the music and says,

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As the music begins, transport yourself to a beautiful meadow. It is your favorite time of year. Let the music, like a gentle breeze, take you all around the meadow and help you to notice important details—the color of the flowers, the moisture of the earth, the rough texture of the bark of a tree, the pattern of its branches. … Let the music evoke your feelings as you enjoy this scene. Perhaps it will bring back images and feelings that are important and satisfying to you. Dwell on these images which the music shows you and discover the meaning which they have for you. … Let the music suggest what to do and what to think or feel (Bonny & Savary, 1973, p. 55). The clients are left to image while the music is played. Bonny and Savary (1973) suggest directing the clients to count from three to one when they feel their experience is complete and open their eyes. Another method would be to wait until the music is finished and bring the clients back to a more alert awareness by focusing on the breath, sounds inside and outside the room, and feeling grounded. This is followed by a discussion. The authors suggest any of the following musical selections: Beethoven’s Second Movement, Sixth Symphony, “By the Brook”; Delius’s “Song of the Cuckoo”; or a song such as Cat Stevens’s “Morning Has Broken.” Other themes, scripts, and musical selections are more exploratory in nature, for example, The Mountain (Bonny & Savary, 1973, pp. 55–56), in which clients follow a path through a meadow up to the top of the mountain. At the top, the music helps to reveal something important to the clients. Clients are then directed to return to the bottom of the mountain along the same path. Possible music choices are Grofe’s “Sunrise” from the Grand Canyon Suite or Rodgers and Hammerstein’s “Climb Every Mountain” from The Sound of Music. Other themes developed by Bonny and Savary (1973) include: following a brook to the ocean (pp. 56–57), exploring a house (pp. 57–58), finding a friend (pp. 58–59), taking a trip on a raft, or exploring a sense of peace near the ocean (p. 60). Plach (1996) presents another adaptation in which a problem or conflict area is evoked by connecting songs that describe a development of a theme. For example, using songs that explore various stages of relationships as the basis for imagery can be an indirect way of helping the client to begin to confront difficult issues. Some clients in recovery may be more ready than others to deal with their problems, and using a song or a group of songs that tell a story allows clients to engage with their feelings in a nonthreatening manner. Goals are to increase self-awareness, to confront problems, and to reinforce positive feelings. The therapist discusses the themes of the issue to be explored with the group, and then gives a short induction, inviting the clients to visualize the setting and suggesting that they may wish to explore their identification with one or more characters in the song. For example, a group of songs on the theme of relationships might include meeting, or affirmation of friendship, following by a song with the theme of parting, and closing with a song with the theme of return, or reconciliation (pp. 35–36). After listening to the songs in a relaxed state, the clients are brought gently back to a more alert state. The therapist then facilitates a discussion on their personal associations to the song and their thoughts and feelings about the experience; she also makes connections about common feelings and responses as well as unique experiences.

Song Communication Overview. Clients select a song or piece of music that expresses or discloses something about the client that is therapeutically relevant and plays it for the group; this is followed by a group discussion (Bruscia, 2012, p. 30). Clients may be more easily able to communicate feelings and thoughts stemming

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from historical, existential, and/or psychological issues through a song than through direct verbal discussion. Often, clients may communicate more than they realize through song choice, and this provides the therapist with insight that can help to guide the client’s treatment. This experience also brings group members closer, helps to establish intimacy and interpersonal connection, and improves group cohesion. Thus, the goals are to improve interpersonal relationships, to increase the depth of self-expression, to begin to work through personal issues, and to increase empathy and group cohesion. Clients can participate in this experience at any level of depth; therefore there are no contraindications. Preparation. The therapist asks the clients to identify a song and bring it in to the following group. In many instances, clients do not have the means to access songs at will, so the therapist should also have the option of downloading or playing the song for the group in the moment. This is possible with YouTube or Grooveshark and an iPhone, iPad, or computer. An appropriate sound system should be available for CDs, iPod, and computer or iPad. In some cases, the therapist may want to review the songs beforehand and/or print out a copy of the lyrics for each person in the group. What to observe. Notice the content, feelings, and mood of the song. Also note the gender of the singer and how it relates to the gender of the client, to whom the client imagines that the singer is singing, and with whom the client identifies in the song (Bruscia, Class Lectures, October, 2003). Note how clients react to others’ song choices and whether or not they can be attentive to others. Notice the similarities between their respective song choices, the level of empathy among clients, and group dynamics. Procedures. The therapist asks clients to choose a song that is meaningful to them and to bring it in or identify it for the therapist in the following session. This experience can be based on a theme (e.g., a song that gives me hope, a song that describes what my days are like), or the therapist can provide clients with ideas such as choosing a song that represents their beliefs or feelings, or a song that relates to a particular period of life, a person, or a relationship (Bruscia, 2012, p. 30). The clients are urged to spend some time listening to songs and reflecting during the week, and in the following session each client plays his song and explains what is important about the song and why he chose it either immediately before or after. The therapist then follows up with a group response to the song, and may ask the client pertinent questions to obtain more detailed description about the client’s relationship to the song if these are lacking. After everyone is given a chance to respond to the client, the next song is listened to. The therapist sums up by referring to each client’s unique contribution and draws connections among common and unique experiences among clients. In large groups, it may be necessary to divide the group and continue the process in the following group. Another option is to have two or three clients present their song in each group until everyone has finished. The process is not as intense when it is a segment of a session, so the therapist must consider the group’s needs when deciding on the format. Adaptation. Song Dedication may be used. In this experience, the therapist asks the client to select a song that describes a significant person in the client’s life (Bruscia, 2012, p. 31). For groups that have developed a good sense of cohesion, clients can be asked to bring in a song to dedicate to a particular person in the group. If the therapist chooses this option, she should assign group members to each other based on her knowledge of group dynamics according to who might be best able to choose a song for whom, or the process of choice should be random, for example, by drawing names. This is to prevent any client from feeling anxious about not being chosen or chosen last. The therapist may also suggest a particular theme, such as choosing a song that talks about a quality that is admirable in another person, or one in which something is mentioned that a client would like to give as a gift to the other person (e.g., confidence, friendship).

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GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Hunt (Chapter 2) and Eyre (Chapter 3) provide descriptions of numerous processes involved in body percussion, drumming, vocal, and instrumental improvisation. The reader is first directed to these improvisation experiences. Although clients in recovery are relatively stable, improvisation is a skill that takes some practice in order to be used to its full potential. The experiences in Chapters 2 and 3 are designed to introduce the clients to nonreferential and referential improvisation techniques, and they should be used with clients to prepare them for the following experiences. The procedures presented in this chapter include processes that develop relatedness among group members over time in a stable group as well as techniques to work through conscious and unconscious psychological problems and challenges of living in the community. These experiences should be used with groups and individuals that are seen on a regular basis, as the issues they explore may need ongoing treatment.

Group Improvisation Overview. Clients improvise on percussion instruments together and with the therapist in referential and nonreferential improvisations. Clients who are transitioning from inpatient care and/or living in the community need support to meet the challenges posed by daily living, including interpersonal relatedness, intimacy, communication, problem-solving, and mood stabilization. Improvising together in a group provides clients with a means of learning about, practicing, and improving their abilities to meet these interpersonal needs. Goals are to reduce resistant behavior (Nolan, 1991), increase reality orientation (Nolan, 1991), identify one’s common issues and feelings with others (Langdon, Pearson, Stastny, & Thorning, 1989), foster communication, improve the ability to relate to others (Nolan, 1991; Odell Miller, 1981; Stephens, 1983), focus on the present (Stephens), improve emotional self-expression (Lehrer, 1982), and improve cognitive functioning (Longhofer & Floersch, 1993). There are no contraindications for stable clients in recovery. The level of therapy is intensive or primary. Preparation. A wide range of tuned and nontuned percussion instruments, including xylophones, metallophones, ambient sound instruments, handheld percussion, thunder shakers, drums, and bells to create a variety of sounds, is needed. Piano, omnichord, and guitar can also be used, along with any instruments that clients may know how to play. What to observe. Observe the client’s ability to express himself on the instrument, the variety of sounds and rhythms he makes, his preference and variety of instrumental choices, the client’s ability to structure his playing as well as his ability to explore, the client’s ability to cognitively understand playing rules and carry them out, and the client’s ability to play with the group pulse, to be aware of others, and to both offer ideas and imitate or support ideas of others in the improvisation. Procedures. Drumming: In addition to the procedures in Chapters 2 and 3, the following drumming techniques are used to focus on cognitive, expressive, and interpersonal goals of leading and following (Clare, 2008). Drumming groups are especially useful in opening and closing groups because they provide a common experience and increase feelings of unity, acceptance, communication, and inclusiveness (Clare, 2008). Improvised and composed chants and vocal songs can be used in conjunction with drumming. In addition to drumming procedures presented in Chapters 2 and 3, Longhofer and Floersch (1993) suggest teaching more demanding and complex African polyrhythms to clients over a series of sessions to improve clients’ self-esteem, cognition, and relatedness. After clients have been introduced to basic drumming together in the same pulse, introduce a particular rhythm and repeat it consecutively, altering the dynamics until all the clients feel secure with it. Then introduce a second rhythm the same way. The group can then be divided, with half the group playing one rhythm while the

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other half plays the second rhythm together. Subsequent rhythms can be introduced over time and combined and recombined in structured and free drumming. Additional Group Improvisation Techniques: Clients, particularly in a newly formed group, may have difficulty relating to others or finding common ground. Langdon et al. (1989) worked with clients who were transitioning into the community to help them to experience common feelings and issues through group improvisation. In this technique, the therapist played a harmonic sequence on the guitar and modeled singing single words or simple phrases, encouraging the clients to add words and phrases as they associated to the therapist’s words or to their own thoughts and feelings. This helped to uncover personal preoccupations and allowed the group to experience common feelings and issues. From this improvisation, individual words were used as a title for another improvisation based on a common group theme. Stephens (1983) and Odell-Miller (2002) focused on developing relatedness and helping clients to focus on the present moment in group improvisation. Stephens began by creating group improvisations based on musical elements of volume, rhythm, and tempo, and then progressed to improvisations based on verbal imagery transformed into sound. The role of the therapist was to initiate musical events through role-play and by modeling different ways of playing to stimulate group members; to support what members played by mirroring or imitating their contributions; and to provide musical structure and support by favoring particular sounds and rhythms. Odell-Miller noted that clients played out interpersonal dynamic interactions in the improvisation, and she helped clients to understand these interactions and intrapersonal changes that occurred in verbal discussions after the improvisations. Similarly, Nolan (1991) increased group relatedness in nonreferential and referential improvisations by asking one person in the group to be responsible for the creation of a musical statement or mood; the therapist and other group members joined in when they felt they had a sufficient understanding of the musical expression. Discussion served to elucidate individual therapeutic issues as well as group awareness and interactions. Lehrer (1982) also focused on communication in improvisation by engaging clients in dyadic conversations in the group. To facilitate expression, the therapist began with body percussion, voice, and percussion instruments in a structured way to create sound collages in the groups, and then proceeded to use emotions as the themes for improvisations. Incorporating art, clients each made a wire sculpture and then improvised on their impression of it. In an adaptation to this experience, other clients in the group might be given a particular musical role to play to support the individual’s interpretation of his sculpture.

Music Psychodrama Overview. Clients act out issues from their lives verbally and concurrently with vocal and instrumental improvisational support; group members enact various roles related to the individual’s drama using a number of techniques. Music Psychodrama was developed by J. Moreno (2005) and is based on drama therapy techniques developed by J. L. Moreno (1964). This is a powerful method in which improvised dramatization and role-playing is used to uncover unconscious feelings and thoughts and gain insight into conscious issues and conflicts. Such issues include self-relationships and relationships with others, limiting beliefs, and emotions such as anger, fear, grief, and loss. Fantasies, dreams, unfinished situations in the client’s past, and rehearsals for future undertakings can also serve as subjects for the drama. These situations are used as the basis of re-enactments, and various techniques are used to process the drama. Goals are to foster insight, work through unconscious issues and limiting beliefs, develop a stronger sense of self, and increase insight into oneself. Clients involved as supporters of the individual—or protagonist who presents the issue to be explored—develop empathy and insight into their own problems as well. Because this process is very powerful, clients who are not stable should participate

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as supporters, and not as the protagonist. Clients can derive therapeutic value from participating even if not in a leadership role. The level of therapy is intensive or primary. The therapist should have advanced training that includes skill in improvisation, preferably some training in drama therapy, and advanced verbal skills. Before presenting the procedures, it is necessary to define the roles that clients will play and the techniques that are used in the process. Definitions, unless otherwise referenced, are from Gibbs (2010). In this method, one client takes on the role of Protagonist, and it is his situation that is acted out with the help of the Director, who is usually the therapist. The Auxiliary is a group member who plays a role in the enactment; this is usually someone in the protagonist’s life, a fantasized figure, an inanimate object, or an abstract concept. The protagonist or the director chooses the auxiliary (or auxiliaries). The Double is an auxiliary who takes on the part of the inner self of the protagonist and provides support in presenting the protagonist’s position or feelings. The double might also offer suggestions or interpretations to the protagonist (Gibbs, 2010, p. 3). “The function of the double is to provide the protagonist with the experience of being fully supported and understood, to assist the protagonist in deepening the feeling and insight” (Nelina, 2012, para. 15). This role also helps the auxiliary experience empathy and increase relatedness to the protagonist. A Chorus is often used to improvise music. The group is instructed to repeat certain phrases or sounds during the action, like a Greek chorus. “This technique can deepen the protagonist’s experience or help move him toward a healthier integration” (Gibbs, 2010, p. 3). This summarizes the main roles in psychodrama. Preparation. A room that is large enough for people to move around and create a space for a scene is needed. A wide range of tuned and nontuned percussion instruments, including xylophones, metallophones, ambient sound instruments, handheld percussion, thunder shakers, drums, and bells to create a variety of sounds is needed. Piano, omnichord, and guitar can also be used. Props may also be assembled. What to observe. Consider the themes and ideas brought forth by the group to find a subject that has pertinence in some way for all members of the group. Ascertain that the person who brings forth the issue is stable and able to work on his issue at a deep emotional level. Notice whether the protagonist is able to access issues and conflicts and express them verbally and musically. Note the level of authentic emotion and the client’s ability to work through the emotions by developing the action. Observe the client’s openness to new directions or solutions. Notice how the auxiliaries are able to relate to the protagonist with insight and empathy, and note how each person is able to relate to some aspect of the current psychodrama in play. Procedures. Warm-up exercise are used to help the group access their creativity and to identify a protagonist and a topic for the psychodrama enactment. Any of the vocal and instrumental warm-ups or nonreferential improvisations presented in Chapters 2 and 3 can be used, as well as many breathing and grounding inductions, relaxations, or short directed imagery experiences found there as well. Another example of a possible warm-up is to begin with body percussion, voice, percussion instruments, and environmental sounds such as crunching up paper or using any objects in the room to make sounds. Creating sound collages of this type helps clients to access their creativity and spontaneity (Lehrer, 1982). Moreno (2005) is the main proponent of Musical Psychodrama. Unless otherwise referenced, all page references in these procedures refer to Moreno’s (2005) publication. He includes a number of chapters on psychodrama warm-ups similar to those discussed elsewhere. For example, clients are asked to choose instruments and to improvise individually on a chosen emotion, how they are feeling in the moment, or how they are feeling about their overall life situation. The improvisations can be recorded and played back for discussion to reveal potential issues for psychodrama treatment (p. 19). The same process may be used with a nonreferential group improvisation (p. 27). In this improvisation, clients may

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recognize issues related to their role and place in the group manifested in sound, for example, being heard or not being heard, following or leading, and expressing oneself fully or being unable to do so. Music and imagery experiences provide fertile ground for issues appropriate for psychodrama exploration as well (p. 32). Moreno suggests using a relaxation induction coupled with an undirected listening experience. The discussion of this experience will yield many issues for further development. The music and imagery experiences described in this chapter and in Chapter 2, and the imagery and movement experiences described in Chapter 3, are all suitable as introductory exercises used to reveal appropriate issues for psychodrama. Moreno (2005) describes how to facilitate a smooth transition from imagery to drama. In the verbal discussion following the imagery experience, the therapist determines whose imagery in the group holds the most potential for dramatic treatment and if the topic would be meaningful to the whole group, while taking into consideration whether the client is ready and able to take on the role of protagonist (p. 43). He then replays the music that was used in the imagery experience and asks the protagonist to close his eyes and return to a critical moment in his imagery, while describing in detail the images of this pivotal moment. As he develops the imagery, the director (therapist) silently directs different group members to take on auxiliary roles of persons or concepts (e.g., two choices faced by the protagonist) identified in the imagery, physically placing them with musical instruments around the protagonist in the proximity described by him. When all the auxiliaries are in place, the director brings the recorded music to a close and asks the protagonist to open his eyes, telling him that he is now in the scene he has described. Auxiliaries improvise appropriate spoken lines and sounds in character and the psychodrama begins, taking on a life in the present. The protagonist now has the opportunity to extend this imagery into the future by trying out new developments and resolutions (pp. 43–44). Once the psychodrama begins, the director facilitates improvised music with the protagonist and auxiliaries for the purpose of setting the emotional tone, as catalyst to action, or as a substitute for words (p. 44). Adaptations. Role-Play: The participants replay a situation in order to gain insight into it or to discover better alternatives to the action that has been dramatized. Replay is a related technique in which scenes are reenacted with changes in order to focus on different feelings or to experience a different approach or ending (Gibbs, 2010, p. 3). In Musical Role Reversal (Moreno, 2005, p. 46), the protagonist takes on the role of a significant other and the auxiliary takes on the protagonist’s role, helping the protagonist to understand the issue from other perspectives. This helps the protagonist to gain new insights and develop new styles of communication. This is often a difficult process for the protagonist, and the director employs techniques to facilitate this reversal. One is to bring in the verbal double—someone who will support, provide insight, and speak for the protagonist. Another technique is to move to musical expression without words. The auxiliary and protagonist choose instruments and continue the dialogue expressing all the feelings they have, but without using verbal language. Roles may be reversed multiple times during the communication, and instruments would be exchanged at the same time as well. A shared drum may also be used in role reversal; each time the roles change, the participants also exchange their positions on the drum (p. 48). Musical Dialogue can be used throughout the dramatic enactment in place of verbal communication. When the interaction between players seems to be flat, lacking in emotion, or stuck, the director can ask the protagonist to choose an instrument to express himself musically, or with alternating music and verbal communication. The auxiliary may respond in words, with an instrument, or with a combination of the two (Moreno, 2005, p. 48). The music helps the participants to respond from a deeper level and evokes conflicted and ambiguous feelings that get lost in verbal translation. The Divided Self is a technique used to explore issues related to choice, ambivalence, and conflicted thoughts and feelings (Moreno, 2005, p. 50). Ambivalence and internal conflict is a challenge faced by many clients in recovery, and externalizing or projecting these inner divisions symbolically can

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help the client to confront the issue directly in order to gain clarity and promote action. After the protagonist clearly identifies the issue, the director helps the protagonist to reflect upon the feelings involved and to choose two or more auxiliaries to represent the conflicting sides of his ambivalence. The protagonist describes sounds and helps to choose instruments for the auxiliaries as well as his own, and then dialogues musically and verbally with them, engaging in techniques of role-play and role reversal. Because situations of ambivalence often contain many different feelings, the protagonist can act as a composer/orchestrator in assigning sounds to various auxiliaries and directing the creative musicmaking. Staging is an important part of this technique; the protagonist should be placed in the middle of the scene so that he can both see and hear his polarities from both sides (pp. 50–51). Mirroring is a technique in which the protagonist watches while the auxiliary replays the role the protagonist portrayed; this helps him to see himself as he appears to others (Gibbs, 2010, p. 3). Auxiliaries can also mirror the protagonist’s general behavior and interactive style throughout the session (Moreno, 2005, p. 53). In Musical Mirroring, auxiliaries mirror the protagonist’s musical styles and patterns of interaction. This is a technique that must be used with caution in the recovery setting, as it can feel like mimicry. It should therefore be reserved to mirror positive qualities. Practiced in this way, mirroring is similar to the technique of Ego Building. Here, the group discusses the protagonist and his situation, emphasizing positive qualities only, while the protagonist faces the group and listens (Gibbs, p. 3). Musically, the auxiliaries can mirror the musical and personal qualities that they respect and admire in the protagonist. Musical Modeling is a natural extension of mirroring. Here, auxiliaries suggest ways for the protagonist to interact through active demonstration in role modeling (Moreno, 2005, p. 54). For example, the auxiliaries might demonstrate a strong way of playing to suggest confidence and empowerment. This technique as well should be used with care in the recovery setting, and prioritizing music over words is an ideal way to proceed because it is less threatening and more ambiguous, and allows the protagonist to interpret the sounds and draw meaningful conclusions on his own or with some help from the director and group members. The protagonist is more likely to accept musical modeling to help him to identify new ways of being and interacting than verbal modeling, because the interpretation comes from the protagonist himself rather than from others. Musical Doubling provides support to protagonists while they are verbalizing. The double (or double group) follows the protagonist around the stage playing music that sets the emotional mood; this can help to liberate the protagonist’s expression. The double can provide both musical and verbal support at the same time, or two auxiliaries could play the respective verbal and musical supportive roles. A larger group could support the double’s musical role as well by providing musical support with a combination of instrumental and vocal sounds. The role of the musical double is extensive. In addition to playing a supportive role, the double can musically reflect conflicting or unconscious feelings and/or thoughts related to what the protagonist is presenting, he can exaggerate a feeling, or he can favor feelings and thoughts that are minimized in the protagonist’s presentation (Moreno, 2005, pp. 53–54). The Empty Chair is a Gestalt therapy technique in which the protagonist sings, plays music to, or interacts with a significant other or a concept or part of the self who is imagined to be in an empty chair (Moreno, 2005, p. 57). The protagonist can also play the part of the person in the empty chair, which then produces a Monodrama, or drama for one. This is used when no one in the group feels prepared to play the auxiliary, when the person in the chair is deceased or not physically present in the protagonist’s life, or when the chair represents a concept (e.g., strength, hopelessness, addiction). The protagonist chooses an instrument or a group of instruments to “speak” to the empty chair, and symbolically express very intimate and private feelings of this relationship in front of the group without having to reveal specific content. This experience may help the protagonist to subsequently communicate verbally with the empty chair. Although the action begins with a sole protagonist and the group acts as witnesses, the

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director can bring in the group as a chorus or assign auxiliary roles to move the drama into a role-play as the action develops. Musical Closures are helpful to bring closure to various kinds of relationships (Moreno, 2005, p. 49). This can be accomplished in psychodrama by saying good-bye to someone, something, or a part of oneself that is represented by an auxiliary. Symbolically acting this out can provide the protagonist with the courage and conscious conviction needed to let someone or something go while reinforcing the mental image, emotions, and resolve required to do so. Providing the protagonist and/or his double with instruments to reinforce the accompanying emotions can be very powerful. The auxiliary who plays the part can be escorted off the stage to the last notes of the protagonist’s musical good-bye. Musical Sharing is an essential part of every psychodrama group (Moreno, 2005, p. 58). It occurs at the end of a psychodramatic enactment and serves to bring closure for all members in the group. While the focus is on the protagonist during the psychodrama, it is expected that the enactment of one client’s challenges will evoke feelings in other clients at some stage in the action. In musical sharing, all the clients share in the ways that they have been able to identify with the protagonist’s experience. Clients do not offer advice or criticism, but instead share how they have dealt with their own similar issues in their lives. This also helps the protagonist to realize that he is not alone in his struggles. Musical sharing is also encouraged. Individuals can improvise a final musical statement that nonverbally expresses feelings of empathy or support for the protagonist. The director (therapist) can also summarize some essential feeling or concept germane to the drama that everyone can relate to and use this as the theme for a final group improvisation.

Improvisation to Strengthen the Ego Overview. Clients improvise with the therapist on themes designed to support creativity and conscious control to deal with matters in external reality (Priestley, 1994, p. 57). In addition to dealing with symptoms and side effects from medications, clients living in the community with SMI are confronted with myriad difficulties, including poverty and adjusting to difficult living situations to dealing with stigma. Often, it is a major challenge to simply survive, so working on personal growth may be a difficult task for clients to undertake. Improvisation can help clients to develop confidence and motivation by developing a more positive relationship with the self and others. The techniques described here focus on strengthening the client’s ego so that he can take steps to develop his potential in the external world. While these techniques are usually practiced in individual sessions, they can also be applied to groups with a cohesive membership because many clients face similar issues. Thus, as in psychodrama, while one person may be the focus of the improvisation, other group members may play supportive roles and gain insight into their own problems as well. The goals are to increase confidence and one’s positive sense of self, increase motivation, experience support, try out new behaviors and ways of being, and celebrate accomplishments. There are no contraindications for persons in recovery who are stable. The level of therapy is intensive or primary. The therapist should have advanced training in improvisation and verbal skills or be trained in Analytical Music Therapy (AMT). Preparation. A wide range of tuned and nontuned percussion instruments including xylophones and metallophones is necessary to provide a variety of sounds, as well as a piano or other harmonic instrument for the therapist and recording equipment. What to observe. Notice if the client can identify issues in his everyday life that can be worked on therapeutically. Determine if the client is able to recognize successes and strengths in his life as well as areas that hold potential for growth. Note how the client is able to articulate and musically express the feelings associated with his issues and achievements. Notice how clients are able to be empathetic to

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others, provide musical and verbal support, and recognize feelings and thoughts that they have in common. Procedures. These techniques are based on Priestley’s (1994) AMT procedures. Unless otherwise stated, all references are from Priestley’s (1994) publication. Reality Rehearsal is used when a client is in the process of making a decision or has made a decision about a direction he wishes to take in life, and needs support to carry it through or prepare for it (p. 57). By facing the new situation in the imagination while improvising, the client is able to confront anxieties and doubts and be better prepared to face the situation in reality. The therapist and client discuss the new direction or goal together, and include all of the negative urges and inner fears the client has in this discussion, as well as the strength of his desire and purpose. Any of these may become the title of an improvisation in and of itself. Once the client has thoroughly examined his feelings about this situation verbally and, if desired, musically, the reality rehearsal improvisation is titled and the therapist and client play together. For example, a client might wish to ask someone in the group home to go for a coffee with him, but fears being rejected. Preliminary improvisations to explore the client’s feelings might be Fear of Being Rejected and Embarrassment or Sadness as well as Feelings About Friendship with J and Feeling Strong. The title of the reality improvisation might be Asking J to Coffee. The client chooses instruments that can express all the feelings he has and the therapist plays piano or another major instrument using improvisational techniques of empathy, elicitation, structuring, intimacy, and emotional exploration (Bruscia, 1987). After the improvisation, they discuss what it felt like to imagine asking J to coffee, the feelings that were brought up, and the strengths that were accessed. The improvisation may also be recorded with the client’s permission so that they can listen to it together. In a group situation with this example, each of the preliminary improvisations could be done with the whole group. The therapist would ask each client for his personal associations to and experiences with the emotions of fear, embarrassment, sadness, strength, and friendship before playing the improvisation. In the final reality rehearsal improvisation, the clients might be silent witnesses to the dyadic improvisation, or they might play in a supportive manner. Other clients in the group might have their own particular situations connected to these themes that they may wish to rehearse as well, and each of these could be played in a dyad with the therapist. Such a process might also continue over a series of sessions. Exploring Relationships (Priestley, 1994, p. 59) can also be used as an ego-strengthening theme. For many clients in recovery, relationships are a source of difficulty, sadness, and insecurity. As in all AMT techniques, the client verbally discusses the relationship he has in mind and its difficulties, as well as the hopefulness that it encompasses. The therapist then titles the improvisation—it may simply be the name of the person who is the object of concern, or it may indicate the source of difficulty being examined, such as E’s Angry Outburst. Client and therapist play the improvisation together as above and discuss it afterward. A recording may be made to listen to afterward for verbal discussion. In a group, group members may be assigned musical roles, and other clients may subsequently investigate their significant relationships. Patterns of Significance (Priestley, 1994, p. 61) are improvisations used to explore the inner patterns and feelings surrounding significant events in life. For many clients, their lives are problemfocused, while their accomplishments go unnoticed or are minimized. This technique allows clients to fully honor and claim their accomplishments and to be supported in these. The procedure is to identify an accomplishment, small or large, and then to do an improvisation with the therapist to celebrate it. Group members can be powerful musical supporters and witnesses to the event. Affirmations (Priestley, 1994, p. 60) can be used in a similar manner. Clients can look back on moments of peace, joy, and well-being and celebrate these musically with the group and/or therapist.

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Wholeness (Priestley, 1994, p. 58) is another ego-strengthening technique similar to affirmations and patterns. Here, the client who may be struggling to feel whole or connected to himself simply plays as if he were whole. He summons up in his imagination all the ideas, feelings, and fantasies he associates with feeling whole, as well as any past experiences in which he felt whole, and improvises on an instrument or group of instruments to express the entirety of this feeling. This solo improvisation can also be played in a soloist and orchestra format with the support of the therapist and group.

Improvisation in Individual Sessions Overview. Clients improvise with the therapist or alone in individual sessions on referential and nonreferential themes. Clients may have the opportunity to do long-term work with a therapist on an individual basis. Individual sessions allow time for the client to explore issues, develop intimacy through musical and verbal sharing in an interpersonal relationship, and work on mood stabilization. Clients who are too fragile for groups or those who have major unresolved issues related to trauma, grief, or loss are particularly appropriate for individual sessions. Often, individual work prepares clients for group work with a focus on peer-relatedness. Goals include to achieve positive affect modulation (Ansdell, Davidson, Magee, Meehan, & Procter, 2010); aid self-expression and release (Boone, 1991; De Backer, 1996; Houghton et al., 2002); improve communication, relatedness, and social skills (Metzner, 2010; Naess & Rudd, 2007; Tyson, 1979); increase cognitive abilities (Perilli, 1991); and work through unconscious issues and traumatic experiences (Metzner, 2010; Priestley, 1994). Therapists can adjust the depth of work and use procedures that meet the individual client’s needs and level of functioning; therefore, there are no contraindications. The level of therapy includes augmentative procedures, but the therapist will most often work at an intensive or primary level. Preparation. As stated above, a variety of instruments of all kinds are needed. What to observe. Note the client’s level of functioning; the level of spontaneity; his ability to process material, to express his internal world, and to manage feelings that are evoked; his orientation to reality; his ability to gain insight and to articulate his experiences verbally; the function and use of his defenses, including resistance; his ability to use imagery and imagination in improvisation; and his ability to use the process to achieve progress in his therapeutic goals. Procedures. Each therapist and client dynamic creates a unique set of circumstances. Each therapist has particular strengths and adheres to a particular set of theories in her practice, just as each client has his unique strengths, needs, and level of functioning. Therefore, techniques are altered and adjusted according to the needs of the client and the individual therapist’s theoretical frame and skills. That being said, some of these procedures will be described here. Ansdell et al. (2010) used improvisation with a client who had chaotic and undifferentiated emotional states to help the client to modulate severe affective dysregulation. Much of the improvisation was done with the client and the therapist playing duets at the piano as they traded melodic phrases back and forth and then shared singing. The authors attributed the therapeutic gains made by the client to the significant moments experienced by the client in the interpersonal relationship that was established. Naess and Ruud (2007) used improvisation on a synthesizer to help a client adjust to living in a community setting, and Perilli (1991) used short rhythms on drums with her client in call-and-response, leader-and-follower patterns to help her to improve her internal organization and her ability to express herself. As the client progressed, Perilli used storytelling with improvisation as a projective technique. The client began to tell a story verbally, and the therapist helped her to complete it; they then chose instruments to illustrate the various characters in the story. As the client played the instruments, Perilli

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asked her questions to deepen the client’s expression and understanding of the symbolic meaning of the story (pp. 409–410). De Backer (1996) noted that when improvising with psychotic clients in particular, the therapist must be aware of the rhythm in improvisational dialogues. Whereas the psychotic client may try to fuse with the therapist’s pulse to regain a pleasant sense of symbiotic union and acceptance, synchronicity may be overused and, as a result, the client may lose his sense of identity. Although De Backer used musical dialogues in improvisation, he also used referential improvisations to musically depict feelings, impressions, and various situations the client experienced to help the client to rediscover and affirm his identity. In working with a psychotic client, Metzner (2010) improvised with a focus on establishing relatedness in the musical contact. In this situation, the musical intimacy helped the client to deal with her feelings of emptiness, persecution, fusion, dissociation, and unreachableness. Priestley (1994) and Tyson (1979) worked with clients in recovery to help them work through unconscious issues and traumatic experiences. Tyson noted that because the client felt understood and accepted by the therapist through symbolic communication in music, her client released repressed feelings of rage. This release allowed her to communicate a wider range of positive feelings and to improve her contact with reality. Priestley (1994) developed a number of techniques based on referential symbols to work with the unconscious using individual improvisation with stable clients. These were developed from Assagioli’s book, Psychosynthesis (1965, cited in Priestley, 1994, p. 48). The therapist may prepare the client by playing preliminary improvisations together to help the client feel held and secure and to relieve anxiety. The therapist then provides the title of the improvisation based on what unconscious conflicts and urges the client needs to explore, and the client chooses an instrument or group of instruments to play the titled scene. The client is given the following instruction: “Just see the scene and start playing; let anything happen, but keep contact with me through your sound expression” (Priestley, 1994, p. 49). The therapist plays the piano to accompany, support, and hold the client in his musical expression. Afterward, client and therapist verbally discuss the feelings and meanings of the improvisation. The improvisation may be recorded for playback and further discussion. Priestley uses the following themes. In The Cave Mouth, “the client imagines that she is standing hidden behind a tree in a forest clearing watching the mouth of a cave. As she watches, something emerges” (Priestley, 1994, p. 49). Priestley states that the forms that emerge represent projections of suppressed or undeveloped areas of the client’s responsibility. Ascending a Mountain is a symbolic task that reveals the client’s degree of aspiration in life and how he deals with inner or outer obstacles. The client imagines that he “is climbing a mountain and is asked afterward to report on such details as the climate, the terrain, the size of the mountain, the view from the top if the mountain is reached, [his] apparel, and any obstacles in the way of the ascent” (p. 50). In the Door in the High Wall, the therapist sets the scene by inviting the client to imagine a long, high wall in which there is a door. On that door are words that state the matter that is under investigation, for example, fear, love, or why. The client “imagines that she goes through the door and notices what is on the other side” (p. 50). Myths (Priestley, 1994, p. 53) is a more elaborate technique in which a fairy tale or story is used as a projection of the client’s unconscious. Priestley uses this when the client is threatened by a more direct exploration of personal imagery. The therapist reads a simplified version of the myth or story, and then she accompanies the client using the holding technique (pp. 38–39) as the client improvises while imagining each scene. In the verbal discussion that follows, the client is encouraged to elaborate on each scene. These details, in addition to the musical expression and the relationship with the therapist while improvising, will reveal pertinent information about the client’s hidden or repressed feelings. Intracommunication (Priestley, 1994, pp. 53–54) is a method for working on dreams. The therapist considers that all content in the dream is an expression of the client’s internal life; all objects are split-off parts of the self that are put outside the client’s awareness to be examined. The therapist asks the

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client to recount his dream while providing a number for each noun that appears, and then asks him to first give associations to each noun, then to speak in the first person as if he were that object. Parts of the dream can be improvised on, and objects that did not interact or communicate in the actual dream can do so using the splitting technique (p. 42) to represent the different parts. In a verbal discussion, the therapist and client can find meaning by relating the dream to life circumstances. In a related technique, Dream Resolution (p. 55), the client returns to an unsatisfactory or frightening dream in an improvisation to find another ending that is more reassuring.

GUIDELINES FOR RE-CREATIVE METHODS Guidelines for re-creative methods outlined in Chapters 2 (Hunt) and 3 (Eyre) should be consulted in addition to the following procedures. Of particular note is Hunt’s description of the Developed Sound Training for Attention and Memory (STAM) Protocol. Developed by Cecato, Caneva, and Lamonaca, (2006), this intervention is aimed at increasing cognitive skills for persons with schizophrenia in the rehabilitative setting and involves receptive and re-creative skills in a sensory integration protocol. The following procedures are specific to stable clients in recovery settings who are able to meet regularly in continuous groups or clients who are able to regularly attend individual sessions.

Group Sing-Along Overview. Clients choose familiar and personally significant songs and sing them together; they are accompanied by the therapist and may also accompany themselves instrumentally. This is a popular method in recovery music therapy groups (Baines, 2000; de l’Etoile, 2002; Goldberg, 1989; Grocke, Bloch, & Castle, 2008; Houghton et al., 2002) that allows all members to participate at various levels of activity and skill. When used in community group homes, the group sing-along can foster enjoyable interpersonal connections between clients and staff, thereby creating a positive atmosphere (Baines). Clients who have difficulty with verbal communication may be able to express themselves through singing and song choice (Baines). Goals include to discharge energy; to experience sensory gratification, comfort, and validation; self-expression; to work through grief; to experience familiarity and togetherness within the group; and to foster positive relationships between clients and staff (Baines). There are no contraindications for this method. Therapy is practiced at the augmentative and intensive levels. Preparation. The preparation of lyrics and songbooks for the group is highly recommended. The therapist may put together lyric books based on popular choices and add new requests from group members and appropriate new songs as needed. The therapist will also need lead sheets and lyrics and to have prepared the appropriate accompaniments to the songs. Instruments such as handheld percussion and drums may be made available to clients to accompany the songs. If there are clients who are skilled in playing a particular instrument, they may be given lead sheets and accompany the songs as well if they are able to do this appropriately. What to observe. Observe the level of participation of each client, e.g., whether or not the client is singing, the volume of his voice, if he is willing to choose a song, and the client’s posture and affect. Note which song each client chooses and what this choice may reveal about his psychological and emotional state, or how it may relate to other comments the client has made in the group. Note how the clients interact with each other and if they share feelings and experiences related to the songs. Procedures. The reader is referred to Structured Group Sing-Along in Chapter 2 (Hunt) and Song Singing in Chapter 3 (Eyre) for procedures. In recovery groups, there is more focus placed on song choices. The therapist can suggest themes based on what stage the group is in in terms of their recovery and issues that have arisen in the course of other music experiences. She may also ask clients to bring in

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songs or listen for songs throughout the week that reflect aspects of these themes and discuss them the following week. Taking note of the songs that clients suggest, the therapist may prepare these songs for a subsequent group. Song choice is most often followed by song discussion in the recovery setting (see Thematic Song Lyric Discussion in this chapter). Adaptations. In individual sessions, songs can be used to help clients to communicate meaningful messages to the therapist that they would otherwise have difficulty expressing. Song choice can also provide the therapist with insight into the client’s unconscious and repressed issues (Eyre, 2003). Meaningful words and lyrics in the chosen songs can then be used as the basis of referential improvisation to help the client to uncover and work through these issues in a nonthreatening and ego-strengthening way (Eyre). Rolvsjord (2010) used song singing to help a client to regulate moods, improve self-esteem, and create a positive view of herself (pp. 105–106).

Didactic Instrumental or Vocal Lessons Overview. Clients learn to play or sing in structured, regular lessons to meet therapeutic goals. An approach has been described in Chapter 2 (Hunt) in Individual Vocal or Instrumental Instruction. The recovery setting is particularly suitable to didactic lessons for a number of reasons. Clients are more stable and have better cognitive skills when they are stabilized on medication, they are able to focus better, they have more motivation to learn, they may be able to attend individual sessions for an increased amount of time, adaptation to living in the community requires the ability to learn new skills and to improve the skills one has, and individual lessons can achieve a variety of therapeutic goals. A wide range of goals may be addressed in individual music instruction. Bednarz (1992) and Houghton et al. (2002) describe the use of didactic lessons in individual therapy to help clients to gain insight and to improve self-discipline and cognitive skills, and to increase tolerance for frustration, while Hadsell (1974) and Houghton et al. find that didactic lessons help clients acquire a skill that is accepted and valued in a community social environment. Tysmans (1986) taught flute to a client to increase her interest in a personally meaningful activity, improve decision-making skills, and increase spontaneous verbal communication. Tyson (1979, 1982) took a more psychodynamic approach to individual lessons with clients in recovery. With a client who had classical training, Tyson (1979) helped her to access traumatic experiences, improve her ability to express herself, and increase her mental clarity and contact with reality through playing classical compositions. With a client who wanted vocal lessons, Tyson (1982) focused on warm-up exercises such as humming and breathing with diaphragmatic support and appropriate placement of the vocal apparatus. Postural and vocal problems were identified and interpreted in a psychodynamic frame so that they could be worked on both in an embodied way as well as psychotherapeutically. Clients must be stable, cognitively focused, and oriented to reality enough to be able to hold their attention on a demanding task for 15 minutes to an hour at the time on a regular basis to be able to benefit from didactic lessons. Clients who are unable to do so, who are too disorganized to keep regular appointments, or who are not oriented to reality and have poor tolerance for frustration are not suitable for didactic lessons. The level of therapy is augmentative, intensive, or, if practiced psychodynamically, primary. Therapists should have enough knowledge and skill on the particular instrument to provide the client with appropriate instruction. Preparation. The therapist should gather appropriate materials for the individual client’s needs and level of ability on the instrument. This will include some kind of notation, regular or adapted (colorcoded keyboard) music books, chord charts, and/or tablatures. If an open tuning is to be used with the guitar, this should be prepared ahead of time along with adapted notation for the songs that will be practiced. Some clients have vision difficulties because of the medication side effects, so if this occurs,

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songs, notation, or scores may have to be enlarged. A quiet room where there will be no disturbances is needed. What to observe. Notice the client’s ability to focus on the task, his tolerance for difficulty, and his determination to overcome difficulties. Notice how every aspect of the learning process relates to the client’s therapeutic goals and to the challenges he faces in living in the community. Where appropriate, be prepared to speak with the client about these connections between patterns in learning and life, and discuss how the lessons can be used to support therapeutic, life goals. Observe how the client relates to the therapist as a teacher and guide, and use this knowledge to determine how the therapeutic lessons will proceed. For example, if the client fears judgment and is rigid and worried about mistakes, introduce improvisation into the lesson and work on referential themes related to the roots of this fear. Procedures. The therapist begins by setting up an introductory assessment of the client to determine his readiness for learning an instrument or voice production. Included in the assessment is an interview to determine the client’s music preferences, including genres, artists or composers, his past experiences with music and with the instrument, and the logistics of regular attendance and conditions for practice (e.g., does the client have access to an instrument and a place to practice?). The therapist assesses the client’s skills, if any, on the instrument and his ability to focus, as well as his patience and ability to work at something that may be frustrating and difficult at times. This knowledge will enable her to plan the amount of time the client can tolerate in a session and the materials that will be used for the first session. For example, Cassity (1976) used open tuning in E Major on a guitar so that the client could easily play I, IV, and V chords by barring the 5th and 7th frets. Song sheets were made up indicating the fret position to facilitate a successful experience for the client. In the interview, the therapist also assesses the client’s goals at this juncture in his life and his personal motivation so that therapeutic goals can be taken into account when determining how to structure the lessons. The time spent in a lesson should depend on the client’s ability to focus productively. Setting a time of 15 to 20 minutes to begin may be more than adequate for clients who are beginning an instrument. The time can be increased when the client is able to focus his attention for longer periods. Sometimes clients may not know what instrument they would like to play, so a few lessons can be spent trying out various instruments. For some clients, simply having time alone with the therapist to experiment and improvise with the various percussion instruments used in the group may be helpful. Individual lessons may also be used with introverted or withdrawn clients as a first step to preparing them for group interactions (Eyre, 2003). Some clients want to play an instrument for themselves only, and have no desire to perform even for a small group. Others, however, may welcome an invitation to perform for a small group or may wish to be integrated into a small performance group and perform in a concert or in a talent show. In this case, attention should be given to the location, the size, and the type of audience. For example, clients who are members of another therapeutic group can play for this trusted membership, or they may play for a couple of friends who are invited. A few clients who are taking lessons may play for each other. If clients are willing and not overcome by performance anxiety, they should be encouraged to play for others, as it is of enormous benefit to the individual’s self-esteem (Douglass, 2011; Tysmans, 1986).

The Choir Performance Group Overview. Clients sing together and practice regularly to prepare a performance of a set program of selections for an audience. Clients who are in recovery and living in the community strive to be accepted and valued members of that community. Singing in a performance group has a wide variety of goals and offers many intrinsic and extrinsic rewards. Choir members who participate in performance experience an improved sense of self-esteem, feel valued by others, value themselves for what they have to

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offer, and take pride in their achievements and in what they have to offer to the community (Bailey & Davidson, 2003; Eyre, 2011). Bailey and Davidson interviewed a group of homeless men who formed a performance choir and noted that they experienced positive emotional change originating from their connection with the music as well as with each other; it provided them with a voice and respect in a society in which they felt marginalized and ridiculed; and it helped them to relate to each other and accept each other’s differences, resulting in respite from feelings of isolation. The authors also found that singing connected the men to their creativity, increased their cognitive abilities, and instilled meaning and hope in their lives. Eyre (2011) found similar outcomes in her study with clients with SMI in recovery who sang in a choir performance group. In addition to the cognitive and social gains, these clients found that they had increased ability to cope with emotions and express themselves emotionally, and experienced an improved overall mood as well as increased creativity. Many of the clients found engagement in performance to be anxiety-producing, but also that performing helped them to cope better with daily life stressors. Interestingly, many clients initially pathologized their performance and learning-related anxieties, but when they learned that this was a normal response to stress, and that they could use techniques to deal with stress, they began to challenge other limiting self-beliefs in their lives. This realization was instrumental in helping members to seek other opportunities to work as volunteers or in sheltered work environments and to participate in other activities outside of the group. Thus, the performance group can serve as a prevocational step and is instrumental in community integration. Members should only be integrated into a community performance group when they are oriented to reality well enough to follow directions, accept group procedures, and learn social skills (Houghton et al., 2002). Cognitively, members need to be able to learn music with assistance, focus attentively for the required practice time, and be responsible in attending practices and performances regularly and on time. The level of therapy is augmentative because the therapist is not taking into account individual goals. Through adherence to the group, clients benefit from the group goals. The therapist should have some music arrangement and transposition skills using notation software and be adept at conducting and playing instruments. It is strongly recommended that two therapists or a therapist and musical assistant work together for optimum functioning of a choral group, as in any choir in the community that is not a capella. Preparation. This group takes an enormous amount of preparation on the part of the therapist so that the most can be made of the group time. Clients in recovery may need various levels of assistance in learning and remembering music. Often, they may find it too difficult to learn many new selections, or songs that they wish to sing are originally written in an inappropriate key. One solution is to prepare medleys of songs based on a theme common theme. For example, a medley on songs about The Sea, Spring, an Irish Medley, or songs from a particular genre (Motown, folk, Broadway) or decade (1920s or 1960s) or artist or group (Alicia Keys, the Beatles) can be exciting for the clients, introduce them to something new, and bridge different preferences and age groups. The advantage of a medley is that the most “singable” parts of the songs can be integrated into a whole, omitting the more difficult, less familiar melodic sections. Care must be taken to arrange the songs in the same or in compatible, harmonically related keys and in an order that is conducive to following the themes and melody line from one song to another. In addition, short instrumental interludes should be placed appropriately to give the singers a rest, allowing them just enough time to organize themselves. If there is a transposition to a neighboring tonality, the tonic must be clearly established in the instrumental interlude, and the new starting note must be clearly evident to help the clients enter on pitch. In any song that is used for the choir, care must be taken to provide the clients with audible musical cues for the starting note and beat in order to create a successful experience and reduce the anxiety involved in performance. As the group becomes more capable of singing in unison, the therapist can arrange

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harmonic parts. Begin with having one choir section holding a note while another section echoes the original line or fills in the space with a simple melody. Again, make certain that the starting pitch is the same as the previous ending pitch or that it is clearly sounded in the accompaniment. If the group is able to manage this, other more adventurous part-writing can be added, always making certain to ensure that the choir is able to succeed, rather than presenting them with something that will provoke too much anxiety or something at which they may fail. Some members, particularly new members who join a group already in progress, may need additional support to learn the songs. The therapist can provide these clients with a copy of a recorded performance of these songs by the choir, but in many cases, it is very helpful to make a recording of these songs at a slower tempo with basic accompaniment. The therapist can record this outside of group practice time, or the group can sing the songs in this manner and record them as a part of their rehearsal. The therapist can then meet with the new member to go over the songs, and then provide the member with the recording and a practice assignment. Copies of the music should also be provided so that the client can practice following the music while listening to the recording. Once the music is arranged, choir members should be given matching binders with the music placed in order. Pages should be numbered for each selection, and colored dividers can be used between songs. This helps to alleviate anxieties related to finding one’s place and staying with the group. When the selections are changed, it is best for the therapist to prepare the books ahead of time. While some members may be able to follow instructions to add and remove selections, others may become overwhelmed, causing them to feel they cannot continue in the choir. Other preparations might include developing a logo for the group and securing a minimum amount of funding to purchase some kind of common apparel to unite the members as a group. A common shirt with a group logo instills in the choir members a belief that they are respected, and this helps them to develop the motivation and pride that encourages them to invest the time and effort in the group despite the anxiety and fear they may sometimes feel (M. F. Boudreault, personal communication, October, 1998). In addition, if the choir directors (therapist included) wear the same apparel, choir members do not feel discriminated against and the stigma that some might feel when performing in the community is reduced. Funds can be used to have pins made with the logo so that each member can be given a pin for his first performance. These rituals and external signs of belonging do much to increase the members’ pride and motivation (M. F. Boudreault, personal communication, October, 1998). For concerts, programs need to be prepared. Clients may need to sign a consent form to have their names included on the program. Often, it is at this point that difficulties with stigma may emerge, and a frank discussion about these feelings can be very therapeutic. In the group with whom the author was involved, the clients were able to embrace the idea of presenting themselves in public only when the codirector suggested to them that they were Ambassadors of Mental Health and that they were making a difference in the world. Programs can include artwork created by clients. What to observe. Notice whether the client is able to follow the music and how the client is singing—vocal production, dynamics, ability to match tones. Observe the client’s attention span and orientation to reality. Notice how the members interact with each other, and which songs they relate to and enjoy. Note individual skills and abilities for singing and composing songs. Be prepared for difficulties at the time of performance, when clients often lose their voices in fear, and plan beforehand to work through that. Procedures. Beginning a choir may take much patience. At the beginning of such a venture, determine if there is a large enough pool of interested clients from which to draw. Five to eight members is enough to start with, especially if they are committed members. Assess the clients’ musical preferences and begin singing songs from a sing-along songbook used in other music therapy groups. Propose

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learning a few songs to the clients, and observe the range and expressivity of the group to inform future song choices. Decide on a program with the clients and create the song arrangements. Each practice should begin with at least 10 to 15 minutes of breathing instruction and vocal exercises. Make sure that clients are aware of how to use diaphragmatic support for their voices and work on staccato and legato warm-ups while extending their range in either direction. When beginning a new song, play the original artist’s recording of the song, and then introduce each phrase in a model and singback format. Spend enough time repeating each phrase so that clients are familiar with it. Chain two, three, and four phrases together, repeating as necessary. At the same time, be aware of when the group is beginning to lose focus or attention. This may occur after only a few minutes for some members. Take a break from the singing and use the time to direct their attention to the notation, pointing out how the contour of the melody is mirrored by the notation, and teach or review rhythmic notation, dynamics, and other indications in the particular phrases on which they are working. After some progress has been made on the new song, sing a song that is already familiar to them. Following this, review what has been previously learned in another new song and continue learning new phrases in this song. Alternate learning new songs, which makes significant cognitive demands, with singing a familiar song already in their repertoire. When working on a new program, always try to incorporate songs that have already been learned to minimize the difficulty. New clients who come into the group may need, in addition to recordings of the songs already learned by the group, some individual lessons to help them learn the songs, and also to help them feel valued and welcomed. Clients may have questions and insecurities that they are too embarrassed to bring up in the group. Often, clients may not join the group even though they very much want to be a part of it because they have low self-esteem and can’t imagine being able to succeed. Individual attention and assistance can be very helpful in assuaging the client’s concerns and providing the support needed. Some new clients may not want to perform at first, and they may find that sitting out one performance will help them to prepare mentally to perform for the next performance. However, if a client establishes a persistent pattern of missing the performances for whatever reason, the therapist needs to have a conversation with him about the roots of the problem. It can be debilitating for other choir members to have absences when it comes time to perform, and each member needs to fulfill his responsibility to the extent possible. When preparing for a concert, consider who the audience will be. Find friendly venues and opportunities where the audience has empathy for and an understanding of the challenges the members of this group face. Each group will have its own strengths, and the frequency of performances should be based on the particular group’s ability. Three weeks before the concert, begin to address the issue of performance anxiety and encourage the members to talk about how they feel about performing, helping them to fully express their feelings. Normalize the situation by talking about performance anxiety in that context, and do breathing and focusing exercises with affirmations to provide members with coping skills. Immediately before the performance, gather the group together and establish a ritual to deal with anxiety. For example, have the group stand in a circle and take them through some breathing and stretching exercises, then have each person symbolically throw their fear into the center of the circle; review for the group how much they have accomplished, and focus on the excitement of the imminent opportunity to sing for others and brighten their lives. Then join hands and repeat an affirmation or sing a chant together; spend a moment in silence before closing with having everyone smile and wish each other well before going onstage. Make sure everyone knows the program and their order in line so that they look professional as they take their places to sing. Where possible, the concert should be video recorded and certainly audio recorded (signed consent is necessary). The director(s) should review it first, noting the successes and what needs improvement. The following rehearsal can be devoted to debriefing, in which clients talk about their feelings before, during, and after the concert, and the video or audio can be played for the clients. Make

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certain to highlight the positive musical elements and audience response, noting the contribution of the choir members to the community; discuss what can be improved in an optimistic light. Adaptations. Small vocal ensembles such as a sacred or gospel choir or jazz or folk ensemble can also be formed (Houghton et al., 2002). Drumming ensembles can provide the means for individuals to be productive and have a meaningful group role while making a positive contribution to society (Longhofer & Floersch, 1993). Such ensembles can be combined with a larger choir in a talent show. Small Performance Group: It often happens that clients have a particular skill in playing an instrument such as percussion or guitar. It can do much to raise the client’s self-esteem if these skills are used to form a small performance group. For example, one client might have some guitar skills and another might play piano at a basic level and is able to read music. The therapist can arrange music based on the group’s interests—from an arrangement of a simple Bach minuet to a folk song to an arrangement of a current popular song. In addition to piano and guitar, simple parts may be arranged for Orff and percussion instruments, often incorporating ostinatos. Some kind of notational score can be used to cue clients who don’t read music, and the group can rehearse the pieces together to improve their performance. Clients who have a good attention span and wish to improve their cognitive skills can benefit very much from such a group. The Talent Show: Choir members or other individuals in recovery groups may have different talents that can be shared in the choir performance. For example, some clients may help with art for the program, or they may take photographs or create art to go with the songs that are being sung. Digital photos of the art may be projected onto a screen as a backdrop for the choir during the performance. Others may write poems, and the therapist can work with the group to create improvisation soundscapes as a background to each poem while it is recited. Still others might compose songs that can be sung by the choir. The small performance group described above might perform in a talent show or with the choir. Bednarz (1992) describes a guitar ensemble in which each person led the group and played a solo in one song or instrumental while the others accompanied by singing or playing percussion. Baines (2000) suggested another model in which trained musicians and music therapists in the community were invited to perform with the consumers (clients), who invited family, friends, and service providers so that they could develop their performance skills in front of a supportive audience and increase community ties. Douglass (2011) wrote a book detailing how to put together a talent show that includes costumes, theatrical, and song and dance numbers. In it, she includes information on the journeys of individual group members as they struggled with issues of stigma and low self-esteem. She offers many guidelines to working with clients in recovery, including exercises and strategies to reduce stress and increase resilience and recovery through performance. She also discusses pertinent research and literature on the subject of performance and recovery and provides examples of useful forms such as confidentiality statements and pre- and postperformance evaluations.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Techniques for composing lyrics and music in songwriting have been addressed in Chapter 2 (Hunt) and Chapter 3 (Eyre); the techniques presented in these chapters are applicable to songwriting in the recovery setting. The following section will elaborate on composition techniques appropriate for the recovery setting.

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Songwriting Overview. Clients and therapist compose lyrics to personalize existing songs or compose lyrics and music to create new songs. Songwriting is particularly indicated in the recovery setting because more time may be spent in multiple sessions to facilitate discussions on how songs are composed so that both new music and lyrics can be composed. Groups in recovery tend to have a more stable membership and writing a song together builds group identity and cohesion. Songs created from client-generated material may allow for greater creativity and provide the clients with a means to reflect on and communicate their group and individual identities (Baker & Wigram, 2005). The creation of a group song can instill a sense of pride in one’s contribution and creative abilities (Grocke, Bloch, & Castle, 2008). Thompson (2009) worked on song composition with groups in a psychiatric rehabilitative program and found that resistant personal constructs could be accessed through song composition. Clients were able to represent and project their experiences symbolically with metaphors and music, providing them with a means to connect with each other and feel valued. While the songs often began with metaphors of hardship and unhappiness, telling their stories and hearing them in the song narratives gave clients the opportunity to collectively alter their story themes. In the process of songwriting, they discovered that they were not alone in their feelings. The use of metaphors helped the clients to objectify their problems, find hope, be inspired by others in the group who were more optimistic, and, together, recognize how they could reframe their thinking to be more positive. Vander Kooij (2009) analyzed themes of clients in recovery and discovered that the composed song was an extension of a narrative account of the client’s life. While she set out to discover what songs would reveal about illness narratives and the participants’ experience of SMI, she found that the more important focus for the clients was their experiences of recovery. These included relationships, recreation, creative expression, and hope. Thus, songwriting may be an essential tool in developing creativity, in helping clients to identify what helps them to cope with the illness, and in promoting health. Goals for songwriting include to express feelings, increase self-esteem and feelings of accomplishment, promote group cohesion (Ficken, 1976; Grocke et al., 2008), access creativity (Vander Kooij, 2009), instill hope (Thompson, 2009; Vander Kooij), facilitate meaning-making and provide interpersonal connections (Thompson), promote identity and group identity (Baker & Wigram, 2005; Vander Kooij), and improve cognitive functioning as well as identification and expression of emotion. There are no contraindications for this in the recovery setting. The level of therapy is dependent on the depth involved and the techniques used; thus, it may be augmentative in a recreational method, intensive in a group process, or primary in individual work. Preparation. Depending on the technique used, the therapist may have different preparations. For example, she may provide original printed lyrics for each client as well as another copy of the song with original lyrics removed and blank spaces left to fill in the blanks; a wall board or poster paper to write the new lyrics in a group, or pencils and paper for each member. A songbook with chords and lyrics, the recorded original song and a sound system, and accompaniment instruments will also be needed to sing the new song together. The therapist may choose the song for lyric completion in advance, or the group may decide on the song together. The therapist must be able to play and sing the song. Recording equipment may be needed (and signed consent forms) if the group has agreed to have it recorded for playback. What to observe. Observe the content of the client’s contributions and how this connects to what he is experiencing in his life. Notice if there are expressions of feeling and the quality of these, openness to new ideas, and degrees of creativity, spontaneity, or frozenness and rigidity. Be aware of the client’s ability to follow group process, his attention, and his cognitive organization. Pay attention to group dynamics, e.g., clients who are withdrawn or dominating.

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Procedures. It is important to improve clients’ cognitive abilities and to facilitate learning new skills in the recovery setting. Songwriting can be an excellent way to do this. Thus, an important part of skill-building is to learn how to listen to the lyrics and music of a song to discover what elements create pleasurable, successful songs. Ficken (1976) and Schmidt (1983) both suggest beginning this process by teaching clients. The therapist can discuss with clients which songs they prefer, categorizing song choices into genres or styles and eras. Discussions that analyze how songs are put together, including song forms and rhythm patterns (Ficken) and types of poetry and rhyme schemes (Schmidt), can help clients develop their creative writing style. Clients can then practice using these different approaches in the cloze method, where they substitute a few specific words in place of the original song, and then develop this technique by matching the rhyming schemes of the original song in a parody. Ficken (1976) suggests singing some precomposed parodies of songs to provide clients with a model of how parodies can be constructed. Clients can also develop their individual creativity and skills by writing out their own parody of a particular song and then sharing it with the group. Schmidt (1983) believes that when using the cloze method, it may be helpful to have the client fill in the blanks to the song before hearing the original lyrics so that the client can have more freedom in his creativity. Brainstorming is a very helpful approach to facilitate group process in songwriting (Grocke et al., 2008; Schmidt, 1983; Thompson, 2009). Brainstorming “encourages clients to speak openly and generates discussion [and] … rapport” (Thompson, p. 27). The therapist begins the group by brainstorming themes, for example, their experiences of living with mental illness (Grocke et al.) or situations they have experienced (Schmidt), and the group decides on one theme that applies to everyone (Thompson). The therapist helps the clients to generate ideas by asking them about personal associations (hopes and frustrations) and meanings of the theme, and records key words and phrases—welcoming conflicting ideas—on a wallboard. These ideas are then grouped together to create lyrics to a song (Thompson). Specific rhyme schemes can be used, and the clients can apply their previous learning to compose the lyrics. Another approach is to ask each of the group members to write down a couple of thoughts or feelings about the chosen theme in poetic style, and then share them. Again, the group works together to create a song from the combined lyrics. Another technique that is particularly useful in the recovery group is the collage format. Here, clients go through songbooks of familiar songs and identify lines from lyrics that have particular meaning for them (Ficken, 1976; Rolvsjord, 2005; Schmidt, 1983), writing them down on strips of paper that can be combined to create a group song (Schmidt). Group discussions can focus on personal meanings, while the therapist helps clients to share commonalities and different perspectives that can be united in one coherent song. The therapist can also suggest a particular theme to achieve a therapeutic goal. For example, asking each client to write down a line or phrase that expresses the meaning of being in the group as the basis of a group song could be helpful for cohesion. Other techniques for songwriting can be improvisatory in nature. For example, the therapist and clients can play a repeated harmonic and rhythmic structure during which the therapist sings questions to individual clients and has them sing back the answers. The questions can be constructed in a way to achieve therapeutic goals such as to encourage expression of feelings or to find answers to problems (Schmidt, 1983). A 12-bar blues is a common example of a rhythmic and harmonic structure that might be used. This form is helpful when clients have not had experience improvising melodies, for the words can easily be spoken as well. Clients may find it easier to respond if the therapist sings the first few words of the song and leaves space for the client to fill in while continuing to play the musical sequence (Schmidt). The tempo of the song can be changed to reflect the theme—feeling sad, frustrated, mellow, or happy. To involve clients in writing the music for lyrics they have composed, the therapist can begin by deciding with the group on a genre and style such as blues, country, folk, pop, rock, gospel, rap, or hip-

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hop. The therapist can play sample songs from these genres, discussing the song’s theme and which genres might best communicate the lyrics. Songs might also be written in more than one style for variety. After the genre has been chosen, the therapist can provide the clients with examples of options for harmonic sequences, melodic contour, rhythmic elements, tempo, and form, such as the combinations of the verse, chorus, and bridge; clients make decisions together to create the song (Grocke et al., 2008; Schmidt, 1983; Thompson, 2009). Other methods may be used to facilitate writing melodies. Clients can repeat the lyrics to explore natural speech inflections, rhythm, and pitch as an indication of melodic contour, phrasing, accentuation, and rhythm. Melodic instruments like xylophones and metallophones or bell sets can be used to explore melodies based on the speech rhythms and inflections (Ficken, 1976; Schmidt, 1983). To help clients find melodies, simple rhythmic ostinatos can be used as a background to structure the melody. The therapist helps the clients to create a composite melody by combining together fragments of melodies to create a cohesive melodic phrase or phrases over the ostinato (Ficken). Adaptations. Individual Composition to Group Song: Sometimes an individual will bring to the group a song fragment or lyrics that he wishes to turn into a song. In working with her performing choir (Eyre, 2011), these individual compositions were welcomed with the intention that the choir could perform them. However, the songs were often not entirely suitable because of problems with form, style, or thematic content. While giving primary authorship to the group member who initiated the lyrics, and secondary authorship to the group, the therapist worked with the songwriting group to modify the lyrics and create a new song using the techniques above. In this way, the therapist was able to help the group to compose a song that would be meaningful to the whole group and have aesthetic appeal for them, as well as for the public that would hear it in performance (M. F. Boudreault, personal conversation, May 5, 2012). Recording: Songs may be recorded for clients to hear if they have given written consent. Meaningful songs can be burned on a CD, and copies can be distributed to clients to share with families and friends (Grocke et al., 2008). Apps and Software: Technology is providing many new and innovative ways to approach songwriting and composition in music therapy. Apps can be useful in providing clients with an instantaneous and satisfying product with minimum effort. This is very useful when clients lack selfesteem, and it is difficult to break through resistance to writing a song. For example, using Songify, each person in the group can speak one phrase into an iPhone or iPad. Together, the group can choose from a number of different genres, and their voices are immediately played back in a melody with accompaniment in that style. This can be helpful, especially in newly formed groups where there is little cohesion or with members who are resistant to working together to create a song. In a similar manner, Auto Rap matches the syllables of speech to a rap song and provides the background beat, creating a rap song. Magic Piano records piano music in various styles from Mozart to rock, allowing one to control the notes, rhythm, and tempo of each piece by touching the light beams. These apps function well as ice-breakers by creating opportunities for the clients to have fun and increase their spontaneity, as well as helping them to feel more comfortable with technology. It is important though, that clients do not become seduced by the immediate gratification these compositional aids offer. After using these apps successfully with clients for a period, the therapist can naturally draw their attention to the limitations of these apps and direct them to more appropriate technology for composition such as GarageBand. This more complicated software (or app) provides the clients with a vast number of options and greater control to create a meaningful group (or individual) composition. This is particularly useful when clients want to create something in hip-hop or rap style. The beats and loops generated by GarageBand can be used as the basis of the song over which the therapist and clients can record sung and spoken lyrics, rhythmic ostinatos on percussion instruments, and/or melodies or melodic

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ostinatos on keyboard and other melodic instruments. At the same time, the therapist is able to use group process regarding decision-making during the song writing to achieve therapeutic goals. Individual Sessions: In working with clients in individual sessions, all of the above techniques for songwriting can be used. The therapist can also work with the client as a partner by creating one line of lyrics and asking the client to fill in the second line, and continuing this way until the song is complete (Eyre, 2003). Ficken (1976) explored ambivalent feelings with clients by writing a song with the client about a particular feeling, and then asking the client to write another that had a contrasting feeling. Rolvsjord (2005) used the collage technique with one client to explore the client’s internal resources and to amplify his strengths. Instrumental Compositions: Compositions can be created with clients using Orff and percussion instruments to create various moods or to compose a piece in a particular style. This can be done most easily in individual sessions, but the therapist might also adapt the group techniques presented above to create group compositions. Some kind of notation system is helpful as a mnemonic aid, in addition to the use of a recording device.

RESEARCH EVIDENCE All the music therapy methods are reflected in quantitative research studies with persons with SMI in the day hospital or community setting. These studies examined outcomes of cognition, coping, symptomatology, motivation, and musical engagement. A study by Mössler, Assmus, Heldal, Fuchs, and Gold (2012) primarily employed re-creative methods of singing songs and learning musical skills along with some improvisation experiences in three individual sessions for 31 participants with SMI who had minimal verbal interactions, had difficulty articulating feelings or reactions, and had low motivation to attend therapy. Standardized scales were used to test self-esteem, self-efficacy, interpersonal problems, quality-of-life enjoyment and satisfaction, and interest in music. The focus of this study was how different music methods might be indicators of change in mental health care. The re-creative methods were most effective when interacting with clients who had low motivation. These techniques also tended to decrease interpersonal problems and increase social relationships. Silverman (2011) used a cognitive-behavioral approach with songwriting, lyric analysis, and musical games with psychiatric patients one month after discharge to compare the effects of music therapy and psychoeducation on positive coping skills. There were no statistically significant betweengroup differences, though participants in the music therapy condition had higher proactive coping skills than those in the psychoeducational control condition. Ceccato, Caneva, and Lamonaca (2006) designed a music therapy protocol using receptive and re-creative methods to affect attention and memory, called the Sound Training for Attention and Memory (STAM) protocol. In a pre-/postexperimental design with 16 subjects, the experimental group significantly improved their performance on the Wechsler Memory Scale (WMS) and the Life Skills Profile, suggesting that this protocol can improve memory for persons with schizophrenia. A pilot study by de l’Etoile (2002) with adults with SMI in a short-term day treatment program employed all methods of music therapy to examine its effectiveness on symptomatology, curative factors, and patients’ attitudes toward seeking professional help. Six out of nine symptoms decreased; hostility and paranoid ideation decreased significantly. Eight out of 10 curative factors increased, most notably, cohesion, though these did not reach significance. Improvisation was used with 41 patients in a rehabilitation day hospital to measure musical interaction using the Music Interaction Rating for Schizophrenia (MIRS) scale developed by Pavlicevic, Trevarthen, and Duncan (1994). After 10 weeks of individual improvisation sessions, the experimental group showed a statistically significant improvement

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in their clinical state in the Brief Psychiatric Rating Scale and an increased length of musical interaction. Analysis suggested that those persons who were more severely ill benefited most from music therapy. Mixed methods or qualitative studies were used to explore choir experiences (Bailey & Davidson, 2003; Eyre, 2011; Rio, 2005), music and imagery (Moe, 2002; Moe, Roesen, & Raben, 2000), songwriting (Grocke, Bloch, & Castle, 2009; Vander Kooij, 2009), and improvisation (Ansdell et al., 2010; De Backer, 2008). The improvisation studies focused on theory-building. Thus, all the methods were represented in research using qualitative or mixed methods studies as well as in quantitative studies. Using interpretive phenomenological analysis, Bailey and Davidson (2003) studied qualitative interviews of seven homeless men who participated in singing in a choir. They found that this experience resulted in positive life transformations and emotional change of increased self-esteem and greater emotional awareness. These changes appeared to originate from their connection with the music, as the participants felt that singing afforded them an opportunity to explore buried emotions and find a release from their problems, resulting in feelings of rejuvenation. Rio (2005) used both singing and group improvisation in a church gospel choir with persons who were homeless or had recently been homeless. Participants experienced increased emotional expression, experiences of beauty and spirituality, improved relationships, and experiences of mutual support and intimacy. The music was found to provide a unifying force, physical and emotional connection, and meaning. These findings were supported in a separate study (Eyre, 2011), who used mixed methods and included a self-rated questionnaire and openended questions with 16 choir participants with SMI living in the community. Participants reported improvements in mood, emotional expression and coping with difficult emotions, self-concept, happiness with achievement in life, cognitive improvements, and health benefits. Participants also demonstrated a correlation between emotional expression, emotional coping, and happiness with their achievements in life. Grocke, Bloch, and Castle (2008) used song singing, song composition, and instrumental improvisation to examine the effect of group music therapy on the quality of life and social anxiety for people with SMI living in the community. Using 17 data sets, the authors found that five items in the quality-of-life scores changed significantly, indicating a better general quality of life, health, and support from friends. Improvement also occurred in reduction of physical pain and opportunities for leisure, though there were no significant results for anxiety. Qualitative results revealed that participants experienced pleasure, joy, and relaxation; felt a sense of belonging in the group and achievement in producing a song; and were surprised to recognize their creativity. Song compositions were analyzed to reveal the following themes: a concern for the world, difficulty of living with mental illness, coping with mental illness requires strength, religion and spirituality are sources of support, living in the present is healing, and working as a team is enjoyable. In a related study, Vander Kooij (2009) used hermeneutic phenomenology to examine illness narratives through songs she wrote with adults with SMI. She also interviewed them after a series of songwriting sessions to discover their lived experience of mental illness. The author discovered that the recovery themes that emerged in the songs of her clients are also well established in the recovery literature. These included hope, identity, social connection, and empowerment. Writing songs with clients promoted expression and communication, and helped clients to build connections to internal resources as well as to form a relationship with the therapist. Moe (2002) adapted the receptive music and imagery method of GIM for a group of nine persons with schizophrenic disorder and used this method in weekly sessions over six months. A quantitative study showed a median improvement of 7.2 in the Global Assessment Functioning (GAF) score (Moe, Roesen, & Raben, 2000). In the qualitative section of the study, Moe found that music served as a catalyst to bring the clients into contact with their prehistory and their feelings through images, thus creating engagement with their internal life and with others. He concluded that persons with schizophrenia have a sense of their inner core self and that contact with this inner “damaged core self” (p. 178) is created

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through the music and imagery, which begins the process of internal repair and unification of “stranded objects” (p. 178). The final two qualitative studies involved improvisation and focused on theory development. De Backer (2008) conducted a study examining the development of an improvisational process as a treatment for psychosis. Aspects of synchronicity between therapist and client and the development of musical form were found to be essential in the treatment and denoted that the client was creating a psychic space in which symbolic thought and experiences leading to psychic integration were possible. Another improvisation study, by Ansdell, Davidson, Magee, Meehan, and Procter (2010), analyzed micro details of the musical clinical process in segments of a session with an individual client. The focus was to gain understanding and describe the phenomenon of how the music therapy process related the client’s experience of affect dysregulation and regulation as a result of being in a psychotic state. The analysis suggested that the musical and therapeutic relationship is crucial in helping the client to modulate volatile affective episodes as the client finds resolution in the “moment of meeting” with the therapist (p. 7). While there is admittedly little research literature with persons with SMI in recovery, these studies, in both qualitative and quantitative paradigms, are very positive in a wide range of outcomes using all the music therapy methods. Particularly significant for this group of clients in recovery are the indications of emotional improvements, connection with others, and hope that music seems to evoke. These are core values of the recovery movement. Much research is needed to determine which methods and protocols might be best suited for specific disorders as well as for acute stages and chronic levels of functioning in various disorders.

SUMMARY AND CONCLUSIONS Persons with SMI in recovery face daunting challenges every day of their lives that surpass the understanding of those of us fortunate enough to be blessed with good mental health. It is remarkable that despite the overwhelming difficulties and stigma that they face, music offers the light of companionship and decreases the heavy isolation of silence for many of these persons. As music therapists, we see the power of music in every session, and there is a good deal of literature that addresses the use of music therapy with persons with SMI. This literature reveals positive outcomes and seeks to examine the intricacies of the relational triad of music, therapist, and client or clients. Much of the literature does not describe how the methods are practiced, however, leaving each clinician to develop his or her unique approach. While this is a very positive aspect—and bespeaks the enormous creativity prevalent in our field—it is also a double-edged sword. Creativity is built through connections, both within and without; the more that we as music therapists share the details and particular protocols of our work with each other, the more we can build and learn together. It is the hope that the information presented in this chapter will offer a positive contribution to this goal.

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Eyre, L. (2003). Into the labyrinth: Music therapy in the treatment of an individual with chronic schizophrenia. Canadian Journal of Music Therapy, 10(1), 8–32. Eyre, L. (2011). Therapeutic chorale for persons with chronic mental illness: A descriptive survey of participant experiences. Journal of Music Therapy, 48(2), 149–168. Ficken, T. (1976). The use of songwriting in a psychiatric setting. Journal of Music Therapy, 13(4), 163– 172. Fincher, S. (1991). Creating mandalas for insight, healing, and self-expression. Boston, MA: Shambhala Publications, Inc. Gibbs, S. (2010). Experiential therapy: Psychodrama and the concepts of sociometry. Retrieved February 25, 2013, from http://serendip.brynmawr.edu/bb/ Gladding, S., Newsome, D., Binkley, E., & Henderson, D. (2008). The lyrics of hurting and healing: Finding words that are revealing. Journal of Creativity in Mental Health, 3(3), 212–219. Goldberg, F. (1989). Music psychotherapy in acute psychiatric inpatient and private practice settings. Music Therapy Perspectives, 6, 40–43. Grocke, D., Bloch, S., & Castle, D. (2008). Is there a role for music therapy in the care of the severely mentally ill? Australasian Psychiatry, 16(6), 442–445. Grocke, D., & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators and students. Philadelphia, PA: Jessica Kingsley. Hadsell, N. (1974). A sociological theory and approach to music therapy with adult psychiatric patients. Journal of Music Therapy, 11(3), 113–124. Taxonomy of clinical music therapy programs and techniques. In R. Unkefer & M. Thaut (Eds.), Music therapy in the treatment of mental disorders: Theoretical bases and clinical interventions (pp. 181–206). Gilsum, NH: Barcelona Publishers. Houghton, B., Scovel, M., Smeltekop, R., Thaut, M., Unkefer, R., & Wilson, B. (2002). Taxonomy of clinical music therapy programs and techniques. In R. Unkefer & M. Thaut (Eds.), Music therapy in the treatment of mental disorders: Theoretical bases and clinical interventions (pp. 181-206). Gilsum, NH: Barcelona Publishers. Jacobsen, E. (1970). Modern treatment of tense patients. Springfield, IL: Charles Thomas Publishers. Korlin, D., Nyback, H., & Goldberg, F. (2000). Creative arts groups in psychiatric care: Development and evaluation of a therapeutic alternative. Nordic Journal of Psychiatry, 54(5), 333–340. Kuntz, C. (1995). Persons with severe mental illness: How do they fit into long-term care? U.S. Department of Health and Human Services. http://aspe.hhs.gov/daltcp/reports/mentalil.htm#sectionI Langdon, G., Pearson, J., Stastny, P., & Thorning, H. (1989). The integration of music therapy into a treatment approach in the transition of adult psychiatric patients from institution to community. Music Therapy, 8(1), 92–107. Lehrer, C. I. (1982). Music therapy in a different key. Music Therapy, 2(1), 63–71. Longhofer, J., & Floersch, J. (1993). African drumming and psychiatric rehabilitation. Psychosocial Rehabilitation Journal, 16(4), 3–10. Lysaker, P. H., Davis, L., Eckert, G., Strasburger, A., Hunter, L., & Buck, K. (2005). Changes in narrative structure and content in schizophrenia in long-term individual psychotherapy: A single case study. Clinical Psychology and Psychotherapy, 12, 406–416. MacRae, M., & Smith, G. (1973). Combining music with art therapy. Art Psychotherapy, 1, 229–241. McCaffrey, T., Edwards, J., & Fannon, D. (2011). Is there a role for music therapy in the recovery approach in mental health? The Arts in Psychotherapy, 38, 185–189. Metzner, S. (2010). About being meant: Music therapy with an in-patient suffering from psychosis. Nordic Journal of Music Therapy, 19(2), 133–150.

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Schmidt, J. (1983). Songwriting as a therapeutic procedure. Music Therapy Perspectives, 1(2), 4–7. Searles, H. (1965). Collected papers on schizophrenia and related subjects. New York: International Universities Press. Sheridan, P., Zuskar, D., Walsh, S., & O’Brien, S. (1989). Identifying variables predictive of success: The next step in alternatives to psychiatric hospitalization research. Journal of Community Psychology, 17(4), 356–368. Silverman, J. (2011). Effects of music therapy on psychiatric patients’ proactive coping skills: Two pilot studies. The Arts in Psychotherapy, 38, 125–129. Stephens, G. (1983). The use of improvisation for developing relatedness in the adult client. Music Therapy, 3(1), 29–42. Summer, L. (1988). Guided imagery and music in the institutional setting. St. Louis, MO: MMB Music. Summer, L. (1994). Considering classical music for use in psychiatric music therapy. Music Therapy Perspectives, 12, 130–133. Summer (2002). Group music and imagery therapy: Emergent receptive techniques in music therapy practice. In K. Bruscia & D. Grocke (Eds.), Guided Imagery and Music (GIM): The Bonny method and beyond (pp. 298–306). Gilsum, NH: Barcelona Publishers. Thesen, J. (2001). Being a psychiatric patient in the community: Reclassified as the stigmatized “other.” Scandinavian Journal of Public Health, 29(4), 248–255. Thompson, S. (2009). Themes and metaphors in songwriting with clients participating in a psychiatric rehabilitation program. Music Therapy Perspectives, 27, 4–10. Tysmans, D. (1986). The use of instrumental music instruction in a music therapy programme with a young schizophrenic patient. The Australian Music Therapy Association Bulletin, 9(4), 2–10. Tyson, F. (1979). Child at the gate: Individual music therapy with a schizophrenic woman. Art Psychotherapy, 6, 77–83. Tyson, F. (1982). Individual singing instruction: An evolutionary framework for psychiatric music therapists. Music Therapy Perspectives, 1(1), 5–15. Vander Kooij, C. (2009). Recovery themes in songs written by adults living with serious mental illnesses. Canadian Journal of Music Therapy, 15(1), 37–58. White, M. (1995). Re-authoring lives: Interviews & essays. Adelaide, Australia: Dulwich Center Publications. Wilson, B. (2002). Transitioning from institution to community. In R. Unkefer & M. Thaut (Eds.), Music therapy in the treatment of mental disorders: Theoretical bases and clinical interventions (pp. 104–116). Gilsum, NH: Barcelona Publishers.

Chapter 5

Children and Adolescents with Emotional and Behavioral Disorders in an Inpatient Psychiatric Setting Bridget Doak _____________________________________________ INTRODUCTION Music therapy is commonly used to treat a wide range of psychiatric illnesses in children and adolescents in the United States and in Europe (Gold, Voracek, & Wigram, 2004; Gold, Wigram, & Voracek, 2007a; Gold, Wigram, & Voracek, 2007b; Wigram & De Backer, 1999). The treatment approaches that music therapists use are based on different theoretical orientations that include (but are not limited to) psychodynamic, behavioral, educational, and humanistic philosophies (Bruscia, 1998; Priestley, 1994; Soshensky, 2007; Wigram, Pederson, & Bonde, 2002). Music therapists have also begun to develop theories of music therapy that integrate research and evidence from neurology, biology, developmental psychology, neuropsychology, psychotherapy, and transpersonal psychology (Crowe, 2004; Taylor, 2010). It is beyond the scope of this paper to address every possible philosophy of care and music therapy technique or intervention for this population. It is, however, important for music therapists to have a general knowledge of music therapy theory and practice from a variety of perspectives, theories, and techniques to best meet the needs of each patient. Neuroscientists have validated the need for individualized interventions because different people have different emotional styles, reactions, and coping responses to emotional challenges that differ in kind, intensity, and duration (Davidson & Begley, 2012). Music therapists in practice report using various treatment approaches in which ideas and techniques from several different theoretical backgrounds are used. Based on the data from their metaanalysis, Gold, Voracek, and Wigram (2004) concluded that no single treatment approach was effective for all types of psychiatric illnesses: Our results suggest that eclectic approaches to music therapy, where techniques from different models or theories are mixed, are particularly effective. As an interpretation of this finding, it may be important that therapists have a flexible attitude and openness to what a child brings into the music therapy situation (p. 1059).

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PATIENT- AND FAMILY-CENTERED HOSPITAL CARE PHILOSOPHY Regardless of her personal treatment philosophy and approach, it is important for the music therapist to understand and adhere to the primary treatment philosophy of the hospital or institution in which they are delivering services. This is true whether the music therapist has regular therapy sessions with family members or whether the music therapist conducts sessions primarily with the patients. In Patient- and Family-Centered Care, the patients and families are considered to be important members of the treatment team. According to the Institute for Patient- and Family-Centered Care, Patient- and Family-Centered Care is defined as “an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. It redefines the relationships in health care” (Institute for Patient- and Family-Centered Care, 2012). This humanistic-based philosophy requires that the music therapist not only acknowledge the individual needs of the patients and their families, but also actively embrace them as an integral part of every decision related to their care. As a result, the music therapist may need to use a variety of different methods with different patients based on the specific needs, motivation, preferences, and desired outcomes of the patients and their families. Furthermore, in Patient- and Family-Centered Care, the music therapist must first establish a connection and therapeutic relationship in which the patient is willing to engage and participate in his care. To this end, the music therapist must be prepared to establish therapeutic relationships with a diverse clientele.

DIAGNOSTIC INFORMATION Children and adolescents are admitted to the hospital because their anger, defenses, and/or trauma have resulted in behaviors that keep them from connecting to others in a positive way. These children and adolescents can be placed into one of three different categories: They are suicidal, aggressive, or psychotic. They often pose safety risks to themselves and/or to others and are in need of acute psychiatric treatment. This may be the first admission and the first manifestation of the behavior and symptoms. It may also be a chronic problem for which many treatment options have already been tried. There is no common diagnosis. Children and adolescents may not yet have a psychiatric diagnosis or they may have any diagnosis (or multiple diagnoses) that can be found in the current Diagnostic and Statistical Manual (American Psychiatric Association [APA], 2000). Some of these diagnoses and behaviors that lead to a psychiatric admission have been described by Brooks (1989) and Crowe (2007). Many children and adolescents who are ill enough to be admitted to an inpatient mental health unit may also have suffered developmental trauma, although this is not currently recognized as a separate diagnosis (van der Kolk, 2011). It is common for patients to have multiple diagnoses and complicated medical and social histories. Frequently there is a need for a more accurate diagnosis with recommendations because previous treatment has either failed or is no longer sufficient. According to the proposed 5th edition of the Diagnostic and Statistical Manual, psychiatric diagnostic categories include neurodevelopmental disorders such as attention deficit hyperactivity, learning disorders, and autism spectrum disorders; anxiety disorders, depression, and bipolar disorders, trauma- and stress-related disorders, beginning traits of personality disorders; and schizophrenia and psychotic disorders. The diagnostic information in this chapter is based on the proposed revisions for the forthcoming 5th edition of the Diagnostic and Statistical Manual (American Psychiatric Association [APA], 2012, DSM-5 Development).

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Neurodevelopmental Disorders Children and adolescents who have neurodevelopmental disorders have specific problems with learning that can be addressed through music therapy. These may include problems with cognitive processes, delays in speech and language, impaired social skills, and difficulty with emotional and behavioral regulation. Attention Deficit Hyperactivity Disorder (ADHD) interferes with the ability to stay focused and on task. Children with ADHD may be able to focus on tasks that they enjoy but often get distracted. They generally prefer shorter, frequent interventions and hands-on tasks. Other learning disabilities include difficulty with expressive and receptive language, challenges with reading and writing, and problems with hearing and listening Children on the Autism Spectrum may have a variety of learning problems, along with difficulties understanding and interpreting social cues. They are also often sensitive to sensory input. Structure, consistency, and predictability are important for learning. These children and adolescents may need to have step-by-step practice to interact positively with others. The development of positive social skills may be further complicated if they have learned antisocial, sarcastic, or disrespectful behaviors by observing interactions of others and repeating them.

Anxiety Disorders Children and adolescents who suffer from anxiety disorders experience both physical and emotional pain and discomfort. This diagnostic category includes panic disorders, obsessive-compulsive disorder, posttraumatic stress disorder, social and generalized anxiety disorders, and specific phobias. Symptoms may include sweating and irregular heart rate as well as feelings of terror, self-consciousness, and overwhelming worry and fear. Patients may attempt to alleviate their pain through rituals (e.g., hand washing in obsessive compulsive disorders) or through attempts to avoid situations (e.g., school refusal in social anxiety disorders). These children and adolescents may want reassurance that the music therapy equipment is being disinfected between uses. Children and adolescents who have a posttraumatic stress disorder are easily startled and may appear as if they are currently re-experiencing the traumatic event. Overstimulation (e.g., sounds, lights, smells) can be a trigger, although it is not always possible to know this in advance. In general, it is best to avoid music and sounds with sudden changes and bursts of emotional intensity when working with these children.

Depression and Bipolar Disorders Depression may include a single episode, it may be recurrent (occurring at least twice) or it may be chronic. Any of these can lead to a suicide attempt. As with any diagnosis, there are many factors that can be related to depression, including genetics and social issues. Some children and adolescents may have situational depression in which there was a loss, such as the death or loss of a parent or loved one. Adolescents frequently report recent break-ups of a romantic relationship. Others struggle with sexual orientation, gender issues, and bullying. Some have histories of abuse and neglect. Serious medical conditions can lead to depression. Being aware of specific factors related to depression will help the music therapist develop a more effective treatment plan. Some children and adolescents have no additional trigger and may simply have a chemical imbalance. This may also manifest as a mood disorder. Bipolar disorder is a mood disorder for children and adolescents in which the patient experiences extreme shifts in mood from depressed and/or suicidal to mania.

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Personality Disorders Extreme shifts in mood may also be an indicator of an emerging personality disorder. Personality disorders are not usually diagnosed until adulthood, but adolescents can exhibit traits of antisocial, narcissistic, and borderline personality disorders. Personality disorders are characterized by significant impairments in identity and interpersonal functioning. Borderline personality traits, for example, may manifest as mood lability, self-harm (e.g., cutting), and intense unstable relationships. These behaviors reflect a lack of self-identity and are significantly more intense than would be expected by the typical hormonal and mood shifts in adolescents.

Schizophrenia Spectrum and Psychotic Disorders The onset of schizophrenia and psychotic disorders rarely occurs in childhood, although it is possible. Children will more commonly exhibit symptoms of bipolar disorder with psychotic features. Physicians will also rule out a history of an autism spectrum disorder or pervasive developmental delay before considering a diagnosis of psychosis or schizophrenia if these children are reporting visual or auditory hallucination (APA, 2012, DSM-5 Development). Although schizophrenia is usually considered to be an adult-onset diagnosis, adolescents can begin to manifest symptoms near the age of 16 years. In addition, some adolescents may have a substance-induced psychosis due to an adverse reaction to alcohol, amphetamine, cannabis, cocaine, hallucinogens, or sedatives. Substance abuse can be an ongoing problem in treating adolescents, whether the psychosis was induced by the drug use or whether the psychosis existed first (APA, 2012, DSM-5 Development). Symptoms of schizophrenia and psychosis include hallucinations, disorganized speech, restricted affect, and abnormal psychomotor behavior such as catatonia. Speech may be rapid and pressured, and the content may not appear logical. Paranoid thoughts can lead to aggression, and this behavior can occur suddenly with no obvious trigger. Mood lability is also present in schizophrenia. These adolescents typically need reduced stimuli, smaller groups with higher staff ratios, and a focus on calming experiences. Avoid lengthy relaxation sessions or imagery in which the adolescent could become disoriented. This is especially important for adolescents who have witnessed significant trauma, violence, and death (e.g., spent time in refugee camps) and who have schizophrenia.

NEEDS AND RESOURCES Emotional Regulation These children and adolescents are, by definition of meeting admission criteria, emotionally dysregulated. The primary treatment objective for all patients is to promote emotional and behavioral regulation by providing safety, empathy, support, and calming experiences. Additional treatment objectives, including the development of coping skills, insight and self-awareness, and problem-solving skills, can be addressed only after the patient is emotionally regulated. Adolescents and children in a psychiatric unit need calm adults who can model a nonanxious presence and provide opportunities for new experiences with others. Under the guise of music therapy, the music therapist can go through a side door using music, movement, and humor to reconnect with them. Neuroscientists are discovering why engaging in music activities helps to regulate emotions. The brain is sculpted by experience. Furthermore, the brain develops in a hierarchical pattern. Basic needs of

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survival need to be met, and the environment must be safe before the child can engage in brain functions that require cognition and executive functioning. If the child is constantly scanning the environment for safety, the brain’s ability to engage in complex thinking and problem-solving is not engaged (Perry, 2009). The developmental stage of the child at the time of either positive or negative experiences has a significant impact on brain development and functioning levels. For example, an infant who is rocked and held responds more quickly and efficiently to nurturing in order to shape attachment neurobiology than an adolescent. In addition, the lower innervating neural networks (such as the locus coeruleus and norepinephrine systems) need to be intact and well regulated to develop higher functions such as speech, language, and socioemotional communication (Cozolino, 2006, 2010; Siegal, 2012). Researchers studying how to treat patients who are emotionally and behaviorally dysregulated have borrowed concepts from restorative neurology for stroke patients. These findings suggest that patterned, repetitive, neural input through somatosensory interventions, such as music and movement, can organize and regulate the neural networks and systems. Researchers are recommending that therapists prompt nonverbal interventions that integrate the left and right hemispheres. These can include drumming, humming, singing or chanting, and any rhythmic physical activity such as yoga, dancing, tossing a ball, or crossing the midline. As a result, this rhythmic and regulating input diminishes anxiety, impulsivity, and other symptoms of dysregulation (Siegal, 2012; van der Kolk, 2006).

Music and Adolescents Music is very important to many adolescents and can increase their motivation and willingness to participate in music therapy. Music is often a significant part of their identity, along with their social connections to peers. Music also offers a place to express feelings of anger and alienation and/or to have those feelings expressed by others and validated. Each generation of adolescents seems to create a new genre or type of music that offends their elders. Rebellion against adult authority can be heard in music with angry and aggressive or sexualized lyrics. Recent research on adolescent brain development and neurology provides some explanation for this behavior and adolescent music preference/resonance (Cadesky, Mota, & Schachar, 2000; Dodge, Price, Bachorowski, & Newman, 1990). Spear (2010) explains that adolescents may be processing emotions in the fear and anger center of the brain at a time when the frontal cortex that manages impulses and logic is not fully developed. Some adolescents report that listening to loud, fast music helps them to become calm. This seems to be opposite the conventional thinking that slow, soft music induces the relaxation response. However, Doak (2006) found that rapid (shamanic) drumming induced a relaxation response in some individuals. It is possible that rapid rhythms may have a paradoxical effect in overstimulating subcortical processes that promote relaxation when adolescents listen to rapid, repetitive music. In addition, Cripe (1986) hypothesized that rock music might be beneficial for adolescents with attention deficit hyperactivity. This can be correlated to the use of stimulants for this population, which also seems to be paradoxical. This is not to suggest that adolescents cannot learn to calm themselves with more traditional relaxation music. However, they may need to start with music that has strong, rapid rhythmic patterns. Some adolescents have taught themselves to play a particular instrument and are very motivated for music therapy, while other adolescents have little interest in playing any instruments. Others have little interest in treatment but like listening to music. Some adolescents are already able to identify how they relate to music and may already play an instrument, sing, dance, or listen to music to feel better. Others may lack insight, motivation, and interest.

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One of the most common questions asked of a music therapist who works with adolescents is: “What kind of music do you use?” The answer is: “It depends.” The best way to find out the adolescent’s preferred music is to ask. This is best done during a brief assessment before the adolescent attends the first music therapy group. This also provides an opportunity for the music therapist to initiate contact with the adolescent and to begin to develop a therapeutic relationship. Having a conversation about the adolescent’s preferred music is a great way to demonstrate that the music therapist cares about the adolescent and is interested in him or her. Adolescents’ music preferences vary widely and include a variety of popular music, rap, rock, hiphop, alternative, underground, classic rock, grunge, metal, Latino, screamo, dubstep, country, and new forms of music that have yet to be classified. Adolescents who have formal music training may report liking other forms of music (e.g., classical, jazz), but this is less common. It is also important to note that some adolescents’ music preferences may be connected to their treatment issues (Doak, 2003; Martin, Clarke, & Pearce, 1993; Took & Weiss, 1994). There are many resources from which the music therapist can acquire music preferred by adolescents. Many stores that sell music have listening stations to preview music. It is even easier to search the Internet to listen to music samples and to purchase individual songs or entire albums. The lyrics to most popular songs are available for free. It is also possible to find guitar chords and fingering/picking patterns through an Internet search. When in doubt, collections with various artists (e.g., Now That’s What I Call Music, Now Esto Es Musica Latino, Now That’s What I Call Country, and Grammy Nominees) are good options for obtaining the most popular songs by a variety of artists. In outpatient programs, the adolescents may even be able to bring in their own music. Technology is making it increasingly easy to access a wide variety of music, from the most popular to the most obscure.

Music and Children Children are in different developmental stages and are less likely than adolescents to strongly identify with their music. Children may prefer traditional folk or popular children’s songs they have learned at home, in music classes, or through media (e.g., children’s television shows, radio shows, and movies). Children often report liking music that is preferred by their parents, although they may also express a strong dislike for this music. Young children also seem to prefer music with words and express little tolerance for instrumental music by asking, “When is the music going to start?” In addition, young children often listen repeatedly to the same song. Music for children has become readily available, and there are radio stations entirely devoted to children’s music (e.g., Radio Disney). There are also recordings of popular music that are sung by children (e.g., Kidz Bop) and popular recording artists who started their career as children (e.g., Britney Spears, Lil Bow Wow). Music therapists who work with children have a wide range of choices for music. Children are also more likely than adolescents to be motivated to play instruments and to engage in active music therapy interventions. It is important to understand the developmental stage of each child when selecting music and therapeutic interventions. Schwartz (2008) provides an excellent summary of these developmental stages. It is important to be familiar with this information and to be able to recognize typical development as well as developmental delays in these children and adolescents.

Cultural Diversity Children admitted to the hospital range in age from 5 to 12 years, and adolescents range from 13 to 18 years of age. Although most patients and their families speak English, some clients may not speak

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English, while a few others may have limited language and communication skills (e.g., clients with autism or developmental issues). Cultural backgrounds may include Caucasians from various European backgrounds, Native Americans, Asian-Americans (especially Hmong), African-Americans, Africans (especially from Somalia), and a growing population of Latinos. In addition to cultural and religious diversity, there is also diversity regarding socioeconomic background; gender and sexual orientation; developmental, intellectual, physical, and emotional skills; severity of illness; and motivation for treatment. It is important to be aware of cultural diversity in developing music therapy interventions. Mental illness is not well accepted in Western medicine and patients and families may refuse treatment for a variety of reasons. Some patients and families may not trust hospital staff due to fear of overmedication. This is especially true for African-Americans. Others may lack trust in institutions. Native American families who have had their children systematically removed from their homes and placed in boarding schools are just one example of this. Parents of young children may be afraid to leave their children in the hospital for an overnight stay. Some families may believe that their child has become possessed by an evil spirit and may want to bring in a priest or shaman to perform an exorcism. Others may deny symptoms or may be unaware of the severity of their child’s mental illness. Adolescents who have immigrated to the United States from another country learn English and quickly adapt to Western culture. They may, however, be rebelling against their parents’ cultural values, causing tension for all. The music therapist has to use clinical judgment in selecting music and treatment interventions when there is cultural tension. For example, traditional Somalis (Sunni Muslims) may not believe that the use of music is appropriate in a hospital setting, unless the music consists of sung scriptural texts. An adolescent who states that s/he doesn’t listen to music during the initial music therapy assessment may later admit to preferring popular Western music as s/he becomes more comfortable in the unit. When in doubt, improvisation (especially using the drum) can be a successful intervention to establish rapport and a connection with the adolescent.

Safety Issues It is important to remember that the reason for admission is unsafe behaviors toward self and/or others. Therefore, the first priority for a music therapist in this setting is safety. The music therapist can take steps to ensure safety by first being aware of the environment at all times. For example, search the room (including the trash) to make sure no plastic bags, glass, or aluminum cans have been left. Do not assume that items that are not allowed in the unit will not be there. Know the location of the exits and have an exit strategy. Wear an emergency beeper and have a plan to call for help if necessary. Second, watch for verbal and nonverbal signs of escalation and intervene early. Pay attention to interactions between the children. Be aware of overt and subtle interactions that indicate aggression. Use de-escalation techniques such as: calm tone of voice, open body posture, distraction, and collaborative problem-solving (Greene & Ablon, 2006). Maintain a calm, nonanxious presence that conveys care and empathy. Third, keep equipment safe and monitor use of anything that could be used to hurt anyone. Count small items that may be used for cutting. This includes compact discs, instruments with sharp edges or metal, wire strings, and cords. Plan treatment interventions to minimize potential misuse of equipment. The music therapist who can maintain safety by following the above guidelines, develop therapeutic relationships, and maintain a calm presence will be successful with almost any music therapy intervention. The ability and skill of the music therapist to develop a therapeutic relationship with each child or adolescent is very important (De Backer & Van Camp, 1999). To this end, who the therapist is and

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how the therapist relates to these children and adolescents is ultimately more important than what is done in a session.

GENERAL GUIDELINES FOR MUSIC THERAPY Role of the Music Therapist In the psychiatric inpatient setting described in this chapter, the music therapist is an integral part of the daily treatment team. The music therapist works collaboratively with other members of the treatment team to develop and implement a treatment plan based on the needs of each child or adolescent. It is widely recognized that psychiatric treatment is most effective when pharmacological interventions are combined with other approaches. Medications alone cannot teach new coping strategies, insight, or other skills necessary to return to society. As a result, the team meets daily to discuss the interventions, progress toward goals, adjustments that need to be made, and readiness for discharge. Certain patients may respond more to music therapy than to other treatment modalities, making the role of the music therapist more prominent in some cases. For example, let’s imagine that the police have brought an adolescent to the hospital. The patient’s language is unintelligible. No one can communicate or make a connection, although an interpreter has tried. The music therapist may be able to assess the patient musically by having the patient repeat sound patterns vocally and/or on a drum and then increase the complexity of responses. In one such case, the music therapist discovered that the adolescent could repeat simple rhythms and patterns and even seemed to know simple children’s songs in English. It became evident that the patient had significant developmental delays. This patient also responded to the rhythm and structure of drumming and vocalizing to become calmer. Music therapy was an important part of the diagnostic process and continued to be a significant part of this patient’s treatment.

Unit Characteristics All children and adolescents who are admitted to an inpatient psychiatric unit meet the same admission criteria. However, the children and adolescents who are admitted to the Intensive Treatment Center need a higher level of care. Children and adolescents who may need this higher level of care include those with significant developmental delays/autism, limited language and communication skills, and extreme anxiety with difficulty being around people; those who are actively psychotic; and those with extreme aggression or ongoing suicide attempts who need more close observation. In this area, there are only single rooms, more staff to care for these patients, and some additional restrictions (e.g., all patients on the ITC wear hospital scrubs). Music therapy groups in this area are limited to no more than six patients in a group. Many of these children and adolescents are too ill to attend groups and may be seen individually. They are also sometimes (but not necessarily) in the hospital for longer than average due their level of acuity. Inpatient psychiatric treatment has changed in this hospital (and across the country) from an average of three weeks (and sometimes up to three months) to less than seven days. It is common for patients to be in the unit for only three to five days. This shorter length of stay requires the music therapist to work differently. In 1991, this author was able to complete an hour assessment on every child who was admitted to the children’s mental health inpatient unit, which was separate from the adolescent inpatient unit at that time. That is no longer possible. In the year 2000, separate outpatient psychiatric units for children and adolescents were started to meet the need for treatment after stabilization of the crisis.

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Outpatient programs have an average length of stay of three weeks and are completely separate from the inpatient units. These programs require separate staff and additional music therapists. Some of the differences between music therapy on the inpatient and outpatient units will be described throughout this chapter. Some children and adolescents may be admitted to the outpatient program after being stabilized on the inpatient psychiatric unit. In such cases, the music therapist may be able to continue the music therapy treatment plan that was begun on the inpatient unit.

Group Size and Structure The music therapist generally works with every patient who is admitted to the inpatient unit, and most children and adolescents are encouraged to participate in group music therapy. Groups are typically limited to eight patients at a time and may be held for one hour most days of the week. Music therapy sessions (along with occupational therapy, therapeutic recreation, art therapy, and dance/movement therapy groups) are organized by chronological age, developmental and diagnostics factors, and acuity of illness. Each group should begin with a check-in process during which each patient briefly identifies his feeling(s) and goals for the group. This process is also followed at the end of the group during which each patient identifies his progress toward his goal(s). Patients who are unable to attend groups due to the severity of their illness, or who need additional therapy sessions, may be seen in individual sessions. Individual music therapy sessions often include practice and training in relaxation/stress management techniques and self-regulation. Davis, Eshelman, and McKay (2008) wrote a step-by-step workbook detailing relaxation and stress reduction techniques that may be useful for the therapist who lacks this training. These sessions in the unit may involve receptive music therapy with listening to music while practicing breathing, progressive muscle relaxation, drawing to music, or imagery. Alternately, individual sessions may also include more active forms of music therapy such as breath work and singing, or playing an instrument (guitar, piano, drum, etc.). The latter may involve improvisational or re-creative music therapy.

Family Interactions In the United States, families are not typically in psychiatric units throughout the entire day. As a result, they do not participate with the children or adolescents in music therapy groups (or other scheduled therapy groups) in either the inpatient psychiatric unit or day treatment (outpatient) programs. In fact, it is considered a violation of confidentiality and patient rights to have family members participate in therapy programs with a group of children who are not members of their immediate family. In these programs, another therapist on the treatment team meets with individual family members or caregivers to address the family’s needs and resources and treatment concerns, and to coordinate the discharge plan. This type of meeting is likely to occur only once in an inpatient unit, although complicated discharge plans may require additional meetings. The music therapist may be invited to this meeting if the child or adolescent has responded especially well to music therapy (and the meeting time does not conflict with another scheduled music therapy session). This is usually an informative session in which the music therapist recommends specific music and/or music therapy interventions that helped the child. In addition, some children and adolescents may want to show their newly developed musical skills on a particular instrument to their family or primary caregiver. This is often a brief demonstration and can be especially helpful to reconnect a child to a family that has experienced significant stress and tension. Sometimes the family decides to enroll the child or adolescent in music classes (or purchase a

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musical instrument) after discharge to support this interest. Referrals may also be made for outpatient music therapy.

MUSIC THERAPY ASSESSMENT AND DOCUMENTATION The music therapy assessment forms the foundation for planning the music therapy intervention(s). The music therapist gathers information from the medical records and from an interview with each child or adolescent. Other information is gathered through observations of social interactions with peers and staff, fine and gross motor skills, communication and speech patterns, the content and quality of verbal and nonverbal statements, observations of behaviors during both groups and nonstructured times (e.g., meal times), and discussions with treatment team members about the patient’s behaviors in other groups. A lot of information can (and needs to be) gathered in a brief period of time due to the short length of stays and the potential for multiple daily admissions and discharges. Documentation of the music therapy assessment, treatment goals, and daily progress toward meeting goals is often done in an electronic medical record. The music therapist typically completes the initial assessment after the first music therapy session and then completes daily charting thereafter. Templates for charting (including the music therapy assessment) were developed by this author and are built into the electronic health record. A paper example of the music therapy assessment is included in Appendix A.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • • •

Music Listening for Individuals and Groups: Client or clients choose songs to relax or elevate one’s mood and listen to them together. Song Choice and Discussion for Adolescents: Clients choose and listen to a song or songs to illustrate a biographical narrative theme for discussion. Music Games for Teaching Social Skills: Clients interact following rules for games based on musical content or process.

Improvisational Music Therapy •

Drum Improvisations: Clients learn a series of structured rhythmic exercises leading to clients’ extemporaneous self-expression on drums.

Re-creative Music Therapy • •

Re-creative Instrument Playing: The therapist teaches the client to play an instrument while focusing on therapeutic goals. Singing and Vocal Re-creation: Clients sing a chosen song using a karaoke machine or with accompaniment provided by the therapist.

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Compositional Music Therapy •

Individual and Group Songwriting: The client or clients write new lyrics with personal meanings to songs or compose an entirely new song.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Music Listening for Individuals and Groups Overview. This method involves client or clients choosing songs to relax or elevate one’s mood and listening to them together. Many adolescents do not want treatment and may be angry that they have been admitted to an inpatient mental health unit. Even if the adolescent was admitted voluntarily, he was subjected to a safety search and asked (required) to give up cell phones and/or iPods along with other personal belongings to be sent home or to locked storage. This does not encourage the adolescent to trust or want to connect with adults. The first goal may be to initiate a therapeutic connection by discussing music preferences and inviting the adolescent to choose a song for listening. Keep in mind that adolescents who do not want to connect with people may want to connect to music. One such case involved an adolescent who had a significant hearing impairment and refused to communicate with anyone. He literally ran down the hall to avoid his sign language interpreter. One might think he would be able to connect with staff and peers through the drums, but he refused. Instead, he grabbed a compact disc from the case and indicated through gestures that he wanted to listen on headphones. Despite his significant loss of hearing, he smiled and nodded his head to the beat of the music. It is unlikely that he heard much besides the beat and rhythmic patterns. However, he made a connection to the music, which was important because he frequently avoided connecting with people. For him, this was an important treatment goal and choosing music for listening was the place to start. Offering choices for music listening can also be an appropriate strategy to help calm adolescents and children who are very agitated and are not ready to be or motivated or interested in connecting with others. This approach is more commonly used with adolescents, but some children may have such a low tolerance for peer interactions that they may need opportunities to listen to music to decrease stimuli, block out other sounds, and just be immersed in the music. For children, this approach of offering music for listening is usually done after engaging in a more active music therapy intervention. As such, it may not be an actual session. It may only be utilized for 10 to 15 minutes, or however long the child can tolerate sitting still. This is typically done as individual listening using headphones. Thus, goals for music listening include to initiate and/or strengthen a connection to the therapist and to help calm adolescents and children who are agitated. Depending on the skills of the therapist and the situation, music listening for calming agitation may be concerned augmentative or intensive. If done at the end of the music therapy group, it may be augmentative or supportive in that it provides reinforcement for successfully participating in the session. For a child or adolescent who cannot yet tolerate groups, it may be more at the intensive level. In this situation, the music therapist uses the music as a primary modality for calming the child while also attempting to begin a relationship with the child as tolerated. This may be especially true for children and adolescents who may refuse other treatment modalities but are calmed by music listening. Music listening for calming agitation is contraindicated for some children and adolescents. Those who have severe sound sensitivities may tolerate certain sounds and not others. Music and/or sounds that are irritating will obviously not be calming. This can be determined through the initial music therapy assessment and an ongoing observation of behaviors and responses. Actively psychotic adolescents may also not be able to tolerate music listening unless the music includes words to help them stay focused.

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Instrumental music longer than 10 to 15 minutes is generally best avoided with this population. This includes conventional relaxation music that is designed to induce an altered state of consciousness. For some children and adolescents, listening to their preferred music may reinforce behaviors of opposition and isolation rather than encourage engagement with people. This is not a significant issue during a short-term stay in an inpatient mental health unit. However, it may be an important consideration for outpatient music therapy sessions. In such cases, music listening may not be an appropriate therapeutic intervention, unless the therapist is leading a structured relaxation or song discussion session. Preparation. The group music listening session described in this section is designed for adolescents who are able to tolerate listening to music in a group, can wait/take turns, and are able to keep their personal space (in their chair or on a beanbag chair). It may be the place to start for adolescents who are not ready to engage in an active intervention and who would benefit from an introduction to the idea that music affects mood. All music therapy sessions begin with six to eight chairs (as needed for the number of group members) arranged in a circle or semicircle. Beanbag chairs may also be used, but it is more effective to start with regular chairs and then shift to beanbag chairs after the group check-in. The music therapist will need a good-quality stereo or compact disc player and a large collection of music. This author uses a case that holds 100 compact discs with a variety of musical styles and artists. The music therapist will have met with every adolescent prior to group to ask about their music preferences and will have at least some representative styles of their preferred music. No music with explicit lyrics or parental advisory is included in the collection. This is consistent with the unit policy of restricting all media and movies to G or PG-13 ratings. What to observe. Listening to music and paying attention to thoughts, feelings, and/or mood requires some ability of self-awareness. Not all adolescents in this setting have developed these skills or are motivated to use them. Expectations can be lowered if necessary, but all adolescents need to be respectful, even if that just means listening quietly. Pay attention to all verbal and nonverbal expressions of each adolescent. It is especially important to watch for interactions between the adolescents when they perceive that they are not being watched. This can include whispering, attempts to pass notes, finger/hand gestures, and facial expressions. Procedures. During the check-in process, explain basic expectations for group behavior. This includes respecting all group members’ music choices and listening without interrupting. The music therapist may also make a few statements about the use of music to change mood. Examples can be given of music that is used to set the mood in movies, to motivate athletes and spectators at sporting events, or to elevate mood in other situations. After the introduction, invite two adolescents at a time to come forward to select a song that puts them in a good mood. Limiting the number of adolescents searching for music at the same time makes the process easier. Adolescents who have difficulty making a choice can be encouraged just to select a song they like or want to hear. After each adolescent has made their selection and has returned to their seat, the music therapist operates the sound system and plays each song for the group. This author writes down the song selections and the name of the adolescent on a piece of paper to help keep track of this information during the session and for documentation afterward. After each song has finished, the music therapist asks each adolescent to rate his/her mood on a scale of 1 to 10, with 10 being the best mood. Some adolescents may choose to pass and not share their mood, which is acceptable as long as they are listening respectfully. Be aware that the adolescents may choose whatever music resonates with them regardless of a suggested theme. Furthermore, it may be important to consider the song in the context of each adolescent’s music preferences and suspend one’s own judgment about the use of the music to elevate

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mood. The focus needs to be on helping the adolescents begin to identify music that changes their mood so they can ultimately make choices about their own use of music in the future. Adaptations. This type of group music listening can be easily adapted to almost any subject as a focus for song selections. One easy adaptation of this method is to suggest relaxation as a focus for song selections. The music therapist would then give each adolescent a biodot (small round sticker that changes color according to body temperature). The only difference to the above process is to invite the adolescents to look at the color of their biodot before and after listening to each song. Another adaption may be to offer the option of doing artwork during the group music listening. This may be appropriate for adolescents in the group who use drawing or coloring to help them stay calm and focused. These adolescents can be given blank paper and washable markers for drawing while listening. A clipboard or book can be used for a hard surface if a table is not available. Adolescents who want to write the lyrics can be given paper and a pencil. The rest of the session proceeds as described above. Some adolescents may be doing art, while others may not. Adolescents in the inpatient unit who use art for calming may or may not be willing to share their work with staff or peers. For any session that involves group music listening, the music source can be easily adapted to whatever system is available. If the music is loaded into an iPod or other digital device, the music therapist will want to have a written list of available songs. Pictures of the albums may be helpful for anyone who has difficulty with reading. Adaptations for individual music listening. If the adolescents are too agitated to participate in a group listening exercise, they may be offered individual compact disc players or iPods/MP3 players with headphones. If this is done in a small group, the music therapist would then monitor each adolescent’s use of the music and equipment. The headphones have cords, which are not allowed in the unit without staff supervision. Therefore, it is possible that the music therapist could supervise this type of music listening for one or more patients simultaneously. The technology exists that allows music to be provided in patient rooms through cordless/wireless radios that are permanently attached to the wall. This permits children and adolescents to choose from a variety of preselected radio channels for music listening at bedtime or whenever they are in their room. Another option for individual music listening is to have wireless headphones connected to a stereo or iPod that is located in an area accessible only to staff. The music therapist would coordinate the music available for each patient and the unit staff would distribute the wireless headphones and play the music for the patient as needed to reduce agitation and promote relaxation. This type of music listening would be more individual and not conducted in a group setting.

Song Choice and Discussion for Adolescents Overview. This involves the clients choosing and listening to a song or songs to illustrate a biographical narrative and/or theme for discussion. Song discussion is one of the most common receptive music therapy interventions that is used with adolescents (Cassity & Cassity, 2006; Frohne-Hageman, 2007; Grocke & Wigram, 2007). In addition to establishing a therapeutic connection through the music, inviting adolescents to select their own music helps move through resistance. They frequently express surprise that the music therapist is familiar with their preferred music. A primary goal for this intervention is for each adolescent to make a connection with a song that has meaning and to be able to share why that music is significant or important to them. Even if the adolescent is unable to describe why he picked a certain song, the song choice indicates something about the adolescent. This process also gives the music therapist insight about the adolescent (including motivation for treatment), which is very helpful. Therefore, a secondary goal may be to assess/understand more about the adolescent and provide an opportunity to share insights and/or to develop new insights.

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The adolescent may or may not be ready to identify or acknowledge any insights, but connecting insights to the song is often easier than just talking without a song to reference. In this setting, this intervention is usually done at the intensive level, with a focus on addressing important treatment goals and developing insight for change. However, this intervention may also be done at the augmentative level if the therapist chooses songs with topics that are more general, educational, and/or theme-based without knowing much about each individual’s current situation. Adolescents who are actively psychotic are not likely to be able to concentrate or focus well enough to participate. This is also not a good intervention for young children who are unable to focus or sit still long enough to participate in verbal discussions of the music. As a result, this author does not do song discussions with children in the inpatient unit. This is also obviously not appropriate for anyone who is nonverbal, unable to participate in group discussions, or cannot tolerate listening to music that is selected by others. Preparation. The preparation of the session and environment is the same for song discussion as was previously described for music listening. This author prefers to use compact discs in their original packaging because it is easy to find a song listed on the case of the compact disc. If the music therapist has loaded a significant portion of the music therapy collection onto a digital device that does not have a picture display, it will be important to provide a written list of available songs to each adolescent. In this case, someone may need to read aloud the songs on the list for adolescents who cannot read well. If the music therapist has a more sophisticated iPod or iPad that has a good visual display of each song, it would be possible to view a picture of the album cover art during the song selection. Again, advances in technology will continue to change the way the music therapist provides the music. Also, in an outpatient setting, it may be possible for the music therapist to invite the adolescents to bring in their own music on their iPods or digital devices and just connect each one to a docking station or to a speaker system. Again, this is not possible in an inpatient setting due to safety issues and unit restrictions. What to observe. This session is most effective with adolescents who are able to verbalize thoughts, feelings, and/or insights. Each adolescent differs in what he projects onto the music and what he is willing to share or not share with the group. Be aware that the adolescent may be guarded and not willing to share much. It is rare for music therapy groups in an inpatient unit to have the same participants on any consecutive day. The adolescents do not know each other and may not be comfortable sharing anything about themselves in the group. They will usually choose their songs according to their comfort level. Some may choose music that accurately reflects significant issues in their life, whereas others may just select a song they find humorous or want to hear. Pay attention to the song selection and what the adolescent chooses to share about it. For example, one adolescent may choose a song by Evanescence such as “My Immortal,” which has a haunting melody and lyrics reflecting feelings of depression and being alone. Another adolescent may ask to hear “Baby Got Back” (also known as “I Like Big Butts”) by Sir Mix-A-Lot because he listened to it when he was younger and it made him laugh. The music therapist may notice that this same adolescent uses humor and sarcasm to avoid more meaningful conversations. This type of session, in which the adolescents choose songs that are meaningful to them, can produce a session with diverse music and issues. Regardless of the genre, most music expresses issues of relationships and feelings such as love, hate, anger, disappointment, vulnerability, pain, and sometimes hope and healing. Sometimes emotions are mixed in the same song, as in Linkin Park’s “Numb,” with lyrics of “I hate everything about you, why do I love you?” These kinds of mixed-up feelings are common for adolescents, and especially for those who have histories of trauma and abuse. Procedures. The procedure for conducting the session begins in the same manner as described previously for group music listening. However, instead of asking the adolescents to select a song to elevate their mood or to relax, ask them to pick a song that “tells their story” or “that has meaning for them.” If

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this is too difficult or they resist, they can be invited to select any song they like. Whatever music they select will provide an opportunity for discussion about why they chose that music. It is extremely rare that an adolescent is unable to find a song if the therapist has met with each adolescent to discuss music preferences prior to group and has a wide choice of music available. To keep up to date with current trends, the music therapist can add or remove music as needed from the music collection based on ongoing requests from patients. Occasionally, an adolescent will be unable to make a choice of any kind. Other adolescents may offer to choose a song for someone who is having difficulty making a choice. Sometimes this is enough to encourage the adolescent to choose a song. If not, the inability or unwillingness to choose a song has clinical relevance (e.g., depression, opposition, lack of motivation, etc.). No one is forced to participate or to choose a song if he is unable or unwilling. After the songs have been selected, the group listens to each adolescent’s choice of music together as described previously. After each song is finished, the adolescents are invited to share whatever aspect of the song (including instrumentation, melody, harmony, rhythm, lyrics, associations, etc.) they prefer, starting with the adolescent who chose that song. The easiest way to begin is to ask open-ended questions such as: “Tell us why you picked that song” or “Tell us about that song” or even “What do you like about that song?” Each adolescent is offered a turn (going around the circle) to share his own thoughts or insights about each song. If someone prefers not to speak, he may pass. After each person speaks, thank him for sharing. If an adolescent has a strong difference of opinion about the meaning of a certain song (or a strong dislike), the music therapist may need to remind the group about the importance of being respectful. It may also be helpful to remind the group before the song discussion starts that it’s okay to not like everyone else’s preferred music but that everyone still needs to be respectful. When there is disagreement, the music therapist may need to intervene by explaining, modeling, or demonstrating how to talk about one’s own personal feelings and reactions without saying negative things about someone else or his music preferences. The music therapist must also establish guidelines regarding how to handle adolescents who refuse to listen to other styles of music. If not, some adolescents may decide to leave the room if rap music is played and they prefer country (or vice versa). This could be very disruptive to any group process (i.e., if adolescents left and returned according to their music preferences). In general, a brief statement about the importance of being respectful and listening to everyone’s music at the beginning of group is sufficient. Adaptations. Sometimes the music therapist may want to encourage an adolescent (or group) to shift his thinking to a new idea. This requires some clinical judgment and is best done in a nonconfrontational way. An easy way to do this is for the music therapist to simply take a turn and choose a song that reflects an idea the therapist wants to share with the group after all of the group members have had their turn. Occasionally, this author has selected a song that suggests the possibility of finding one’s voice and making a difference for change (e.g., “One Mic” by Nas) or that expresses hope that things will get better (e.g., “Three Little Birds” by Bob Marley). The latter song is upbeat and can be a good way to end the group on a positive note. However, the adolescents may self-select music that already spans the range of possibilities from anger to hope, and it may not be necessary for the music therapist to interject a song choice. Remember that adolescents often respect input from their peers over feedback from adults. As described previously, this author prefers to have the adolescents select music for song discussion without suggesting a theme because this allows for the ideas and issues to emerge during the session. However, another approach is to ask the adolescents to select a song that relates to a theme chosen by the therapist. Usually, these themes are related to treatment issues.

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Keen (2004) suggested that a lack of self-concept and low self-esteem underlies a variety of behaviors, including suicide attempts, anger, withdrawal from the family, isolation from peers, running away, and alcohol and drug abuse. Therefore, it is not surprising that some common themes for adolescents include music for elevating mood and improving self-esteem (Clendenon-Wallen, 1991; Henderson, 1983; Hendricks, Robinson, Bradley, & Davis, 1999; Johnson, 1981; Michel & Farrell, 1973). In a theme-based song discussion, the music therapist asks the adolescent to select a song according to the theme. For example, the instructions for a theme to explore relationship issues can be: “Choose a song about a friendship or relationship that helps you to feel better.” For a theme of exploring feelings, the instructions can be: “Choose a song that expresses how you feel.” The session would then follow the same procedure already described to prompt adolescents to share their thoughts, feelings, and reactions to each song. Another option is for the music therapist to select both the theme and the song. This gives the music therapist more control. It is also easier for the music therapist to provide the music, either by bringing a recording or by singing and playing it personally. This approach does require some knowledge of the adolescent’s treatment issues and music preferences. Otherwise, it is possible for the music therapist to do an educational session that focuses on whatever topic the therapist thinks is relevant.

Music Games for Teaching Social Skills Overview. In music games, clients interact following rules for games based on musical content or process. It is important to be aware that many of these children are in the hospital because they are not able to interact in socially acceptable ways (e.g., hitting others, yelling, breaking or throwing objects, and/or being unable to focus, sit still, or follow directions). When admitted to the hospital, they may be angry, frustrated, reactive, impulsive, and disorganized. They may also be very needy and anxious. Some may seek out adult attention and nurturance or peer interactions, whereas others may want to isolate and/or hide under blankets, in corners, or under furniture. In addition to establishing a therapeutic connection, music therapists can successfully use recorded music to teach a variety of skills, including boundaries, impulse control, language, and social skills. Live music can also be used, although it may be easier to use recorded music to be free to monitor and intervene with the children as needed. According to Gold, Voracek, and Wigram (2004), the most effective music therapy interventions with children engage them actively with the music. This can include playing musical games that provide an opportunity for practicing the skills they need to learn. The inherent structure in music helps children to organize and to practice social skills. Musical characteristics such as loud and soft and fast and slow can cue communication and behavioral responses in children who lack these skills. Either recorded or live music can also be used with children to provide structure and cues for movement and for playing musical games that address goals such as improving impulse control, boundaries, taking turns, and social skills. Music therapists often adapt listening and movement games from a wide variety of sources, including books and recordings that are used in educational and recreational settings. The music therapist who lacks experience and knowledge with engaging children in music activities may want to search online for these resources. Due to the wide availability of music and resources for children, this chapter will not address these in detail. However, a couple of examples will be described. Regardless of the specific music therapy intervention, each session should be structured so that every child can feel some success and accomplishment toward their goals. These types of musical games are often done at the augmentative level to support the overall treatment plan. However, in the inpatient setting, developing social skills is often a priority goal, and discharge is dependent on significant improvement. In these cases, music therapy may be practiced at the intensive level. Furthermore, the music therapist may provide suggestions

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and/or instructions for other staff members to continue using songs and musical games throughout the day as needed. Some children who are agitated may not be ready to engage in interactive music therapy interventions, whether the therapist uses recorded or live music. The first priority may be to calm their agitation in individual music therapy sessions before they are ready to engage with their peers. This is especially true for children with developmental delays or who are on the autism spectrum, as well as anyone who has issues with sensory input (e.g., easily overwhelmed by sights, sounds, touch, smells). These children may not be able to tolerate even small group sessions. Adolescents may sometimes want to play musical games like those that will be described in this section. However, most will not be interested and will resist participating in something they believe is beneath their age level. Therefore, this author does not generally engage adolescents in these interventions. What to observe. It is important to focus on the observable behaviors that are desired rather than focusing on the negative behaviors or failures. It is sometimes possible to ignore negative behavior and encourage children who are demonstrating positive behavior. However, if the children do not know what behavior is expected, they will not know what to do. Be aware of each child’s need for reminders, prompts, and support while practicing skills. For example, some children may need to be told to keep an arm’s-length distance from peers. Others may need verbal praise and encouragement to participate. Those with difficulty managing their anger and impulses may need the music therapist to stop before anything escalates. Constantly watch the children’s verbal and nonverbal communications, facial expressions, and level of participation. Children’s behavior can change very quickly, but there are usually cues before they act out their aggression. Procedures. One example of using recorded music to practice boundaries, impulse control, and social skills is to play the well-known game of musical chairs in which children walk around chairs that are placed back to back. In this setting it is best to start with an equal number of chairs and children. When the music stops, the children are supposed to sit in a chair (and not on another child). Not getting a chair can be very frustrating for some children and can lead to pushing, hitting, swearing, or other aggressive behavior. Repetitive practice may lead to each child successfully finding a chair when the music stops. As each child’s skill improves, it may be possible to play musical chairs as it is typically done and remove one chair during each round. The child who is “out” of the game can choose the music for the next round. Again, this requires the ability to manage frustration, wait, and take turns. Children who struggle with these issues can have a plan in advance to play on an instrument independently (e.g., lighted keyboard with headphones) while the rest of the group finishes the game. As with all interventions, the music therapist must use clinical judgment and have a good therapeutic relationship with the child to ensure success. Adaptations. As mentioned previously, there are almost endless possibilities for using live or recorded children’s music to teach social skills. Another simple example of using recorded music to teach social skills is to do the limbo. This author prefers to use the song “Limbo Rock” by Chubby Checker. This and other similar songs can be found on the compact disc Radio Disney’s Move It! (2005, Walt Disney Records). For the limbo, the music therapist just needs some kind of stick that is approximately four feet in length. This can be an old pool stick (wrapped in plastic tape) or even two plastic boom whackers taped together. To do the limbo, invite the children to line up on one side of the limbo stick. Hold the stick at a height that is taller than all of the children. Start the music and direct the children to go under the limbo stick. Make sure they are all going in the same direction. Most will need instructions to wait until the person in front of them has already gone under the stick. It may help to remind the children to keep their distance so that no one will accidentally fall on anyone. The game continues, with the stick being lowered after everyone has successfully gone under the stick in any way they choose. This may include crawling on

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their belly or back. Children who touch the stick are out of the game, which can be handled in the same manner described for musical chairs.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Drum Improvisations Overview. In drum improvisations, clients learn a series of structured rhythmic exercises leading to clients’ extemporaneous self-expression on drums. This can be an effective way to establish basic social and communication skills with many of these children and adolescents. Remember that children and adolescents in an inpatient mental health unit are often emotionally dysregulated. Many of them are angry. Uhlig (2011) describes how aggression can be transformed through musical expression. However, it is not a good idea to suggest or to encourage these patients to “express their anger” by playing loud, fast, and hard on a drum. Expressing anger in this way is likely to lead to an increase in anger and aggression (as well as a broken instrument). Improvisations that encourage self-expression with some control and structure are more likely to be successful (Flower, 1993; Wigram, 2004). It is also helpful to be familiar with developmental approaches for any improvisational process (Friedlander, 1994). Children often learn by exploring their environment and like to try new instruments and sounds. Younger children are often more open to playing instruments than adolescents because the adolescents may have performance anxiety and concerns about being embarrassed in front of their peers. In general, improvisation can be used with both children and adolescents, but children are more open to musical explorations in this setting. Adolescents are, however, often willing to engage in drum improvisations. An important primary goal of drum improvisation at the intensive level is to promote emotional regulation. This occurs through both the rhythmic patterns and drum beat as well as through the process of playing and interacting creatively with others. The therapist who works in this way at the intensive level must be skilled at leading the client through intense emotional responses. Secondary goals of drum improvisation are to encourage and practice social interactions, self-expression, and creative problemsolving skills. These goals may also be achieved at the augmentative level of therapy. Drum improvisation may be contraindicated for children and adolescents who have sound sensitivities, and for some who are on the autism spectrum. Improvisation requires some basic prerequisite skills and tolerance. Even when played softly, drums are loud. Some children and adolescents may not be able to tolerate loud sounds. Conversely, some speak very loudly and do not modulate their voices well. They may need more practice with listening skills and repeating sounds prior to participation in improvisation. Psychotic adolescents who are acutely ill may also not be able to tolerate a drum improvisation group because they need reduced stimuli and a calming environment. An adolescent who has both an autism spectrum disorder and psychosis may simply walk out of the music therapy room before the improvisation begins when he sees the drums arranged in a circle and ready for group. Preparation. All sessions begin in a circle or semicircle. The music therapist will need to have a variety of good-quality drums. This author places a drum in front of each chair, which allows the adolescents and children to choose their drum when they come into the room and sit. Before anyone enters the room, it is important to give some instructions about sitting in a chair and waiting to play the drums. This can be done after the music therapist has escorted the group down the hallway and just before unlocking the door to the music therapy room. What to observe. Because improvisation is a projection of one’s internal experience, it is important to pay attention to both verbal and nonverbal behaviors. For example, notice the type of drum that is chosen by each group member. Observe how willing each person is to play the drum and how he

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approaches the drum and plays it. Some children and adolescents will barely tap the drum. Others will play it hard, fast, and loud. Some will want to change drums frequently, whereas others will prefer to keep the same drum for the duration of the session. Some may fight/argue over the drum they prefer. Others may be passive and need prompts and encouragement to participate. In addition, those with some experience playing the drum may demonstrate some skills and may be interested in leading the group. Procedures. All music therapy sessions begin the same way with brief introductions and identification of a goal for the day (or for the group). Some adolescents and children may also be willing to share how they are feeling using just one word. Both children and adolescents who are in the hospital usually need some form of structure to be successful with improvisation. There are many ways to provide this. A good way to start is to have each participant take turns making a sound on his instrument while the rest of the group members listen to each “introduction.” This can be done during the regular introductions. The names of the drums can also be introduced. This mimics the social skill of introducing oneself in a new situation. It also provides an opportunity to work on a basic prerequisite for improvising in a group, which is to be able to listen to others. After the drum introductions, the group can practice basic communication skills. The music therapist can model this by playing a short rhythm pattern and inviting the group to repeat it back. Each person then gets a turn to play a short rhythmic pattern and have the group repeat it. This allows each adolescent to practice listening skills, following, and leading. After everyone has had a chance to lead a short rhythm pattern and follow, the group can move toward more freestyle improvisation (Wigram, 2004). Before beginning an improvisation, it is important to decide how to end it. One option is for the adolescents to decide how to start and end the improvisation when it is their turn to lead. Sometimes the adolescents give a hand or drum signal, and sometimes they just want to end when the leader stops. Each adolescent can then be invited to have a turn at being the leader and starting the improvisation. If the group is not ready to improvise spontaneously, it is possible to structure the beginning as well. For example, the leader can start the improvisation and the adolescent sitting to the right of the leader can listen and then join, followed by the others in succession. In a short period of time, the adolescents will be able to take turns leading and following and will be projecting their typical patterns of individual and group behaviors through their improvisations. The music therapist may need to provide a grounding beat to musically support the improvisation. The music therapist can also encourage verbal processing about the improvisation and discuss insights related to the drumming. After the improvisation, she may ask the adolescents (and children if they are capable of verbal processing), “What did you notice?” This can be directed to each individual as well as to the group. Some adolescents may be able to identify patterns of behavior they observed during the drumming. For example, an adolescent who is hesitant to interact with peers may notice that he watches first and hesitates to join the drumming until he is more comfortable. Another adolescent may notice a pattern of wanting to start playing immediately and continuing to play loudly without listening to anyone else in the group. The music therapist may also provide feedback by adding additional observations. Adaptations. Any combination of instruments may be used, but this author prefers to start with a variety of drums. This allows for some choice and variability and also provides the greatest chance of success because everyone has a nonpitched instrument. Xylophones or other pitched instruments can also be used if they are tuned to a pentatonic scale. Dissonance can be important in improvisation, but clients who are struggling to interact respectfully may benefit from having instruments that support producing coherent sounds and music. It is easy to add dissonance as desired. Another adaptation of drum improvisation is to invite two adolescents (or children) to communicate on the drums while the rest of the group watches and waits a turn. The easiest way to begin

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is to invite one person to choose someone with whom he wishes to have a nonverbal conversation. If the group has already had some experience with drum improvisation, very few instructions are needed. The two people play back and forth (one at a time) until they finish (which usually isn’t very long). Then two more people are invited to play. After each dyad finishes playing, the music therapist can initiate verbal processing as was described previously. In this case, it is best to start by asking each person what he noticed about his own playing. This intervention may be brought to closure by inviting everyone to play together and start and stop when they feel like it. The group may also be able to discuss the group dynamics and interactions but that is more likely to occur in the outpatient programs due to the short length of stay and transient nature of the inpatient groups. It is also possible to do drum improvisation as described previously, using various sizes of paddle drums. Paddle drums are easiest to play with a padded drumstick rather than with the hand. However, it may not be a good idea to give sticks to some children and adolescents if they are impulsive and aggressive. Sometimes the sticks break and/or the rubber mallet can literally “fly off the handle” if too much force is used. Therefore, this author prefers to use the paddle drums with Nerf balls. To play with the paddle drums, give each person in the group a choice of drum size. Instruct the group members to hit the ball to each other (suggesting an underhand approach to make it easier to return the ball). It helps to give the group an incentive to work together by counting how many times the ball hits the drum. If the group can play well, a nice drum pattern will be created. If not, the music therapist will need to do a lot of prompting and encouraging. After the group has reached a certain goal (e.g., hitting the ball back and forth to the count of 25), individuals may want to play independently. Playing paddle drums in this manner can be very therapeutic toward practicing social and communication skills, as well as managing frustration, keeping boundaries, taking turns, and developing motor skills. It is also a good example of movement to music that helps to integrate the left and the right brain.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Re-creative Instrument Playing Overview. This method involves teaching a client to play an instrument with a focus on therapeutic goals. It is usually done at the augmentative level. Some children and adolescents may be motivated to learn to play an instrument, and this experience can be an effective way to build a therapeutic relationship with a child or adolescent who feels discouraged and disconnected from any caring adult. Learning to play a simple song or melody may also encourage a sense of pride and accomplishment. This is usually done on an individual basis during choice time at the end of a group or during individual sessions. Adolescents who already play the guitar or piano may find it comforting and relaxing to play (and/or) sing. Some of them may already play the guitar or piano and may enjoy the freedom to play and express their feelings and emotions through songs with which they resonate. If they have the courage to play in front of the group, the group members may express admiration and give positive feedback. Be aware that children and adolescents may also be blunt and can be unkind as well. The goals of building a therapeutic relationship, emotional self-expression, and opportunities for positive feedback from peers may be sabotaged if the therapist is not careful in monitoring the group’s behaviors. Re-creative instrument playing is contraindicated for children and adolescents who have no interest in learning to play an instrument. This type of music therapy may seem too similar to school or other music classes in which these children have had very frustrating experiences. It is also contraindicated for children or adolescents who are too emotionally distraught to play an instrument.

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Preparation. Instrument playing may be done at the end of a group experience in which the children or adolescents are invited to make a choice to play an instrument or listen to music. The music therapist needs to structure this transition so that every child or adolescent has the opportunity to make a choice. This may also require taking turns or sharing. A simple way to do this is to ask each person one at a time what instrument they would like to play. If two children or adolescents want to play guitar, it may be possible to work with two at a time if they are interested in learning the same song (and the therapist has multiple guitars). Another option is to have both electric and acoustic guitars. The music therapist can have one person playing electric guitar on headphones while another plays an acoustic guitar. This same process can be used for playing the keyboard, with one child on headphones while another person plays the piano. However, some children and adolescents may not be able to tolerate any acoustic instrument, which then requires everyone either to use an instrument with headphones or to not use this intervention. What to observe. It is important to pay close attention to levels of frustration. Many of these children and adolescents are hospitalized because they are not emotionally regulated. Some children (or adolescents) may want to play an instrument but may lack the ability to stay focused and concentrate. Others may struggle with motor skills. Some may want to “help” a peer but may be bossy and demanding. There may also be children or adolescents who purposefully try to interrupt a peer by making noise or playing on the instrument when it is not their turn. Adolescents who are skilled on the piano or guitar may be able to read music and/or guitar tablature. They may also play by ear or play by memory. These skills become more evident as the psychiatric illness improves. The music therapist may take note of musical skills and the ability to keep a rhythmic beat or melodic pattern during the initial and ongoing assessment. Procedures. The music therapist needs to manage the environment to maximize opportunities for making music while minimizing potential tension. Decide which instrument (if any) will be played aloud and make sure the rest are on headphones. Constantly scan the group for any signs of escalation or frustration. Set up the children with the lowest frustration tolerance first and put them on self-teaching instruments. For example, keyboards that have keys that light up to indicate the next note to play can be helpful for some children and adolescents. Most keyboards have songs like “Twinkle, Twinkle, Little Star” preloaded. If the child cannot follow the lighted keys, set up a rhythmic pattern to play a beat and set the sound so that the keys play different types of drums or another sound the child prefers. Others can play by matching numbers or letters. Each child is unique and has an individualized preference and style for learning that needs to be accommodated. Due to the short length of stays in an inpatient unit, there isn’t time to work on complicated music. Simple melodies that can be learned easily work well. Many children and adolescents want to learn to play “Fur Elise” on the piano. This song is often preloaded into keyboards and is also available in easy/beginning piano books. In addition, many children learn best by rote, with the music therapist (or another child) demonstrating short phrases until the melody is memorized. Some children and adolescents already know parts of a piano duet (such as “Heart and Soul”) and will play with the music therapist or with another group member. This usually requires some supervision. Few children and adolescents in the inpatient setting are able to play their part of a duet for any length of time while another person is playing a different part. The music therapist may need to play the melody or accompaniment, which can be varied or improvised within the chord structure as long as the rhythmic pattern is repeated. (“Heart and Soul” is a very popular piano duet. A demonstration video is available on the Internet for music therapists who are unfamiliar with this song.) Guitar players may request guitar chords and tablature for their favorite music. These resources can also be easily found through an Internet search and are usually available at little to no cost. However,

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the majority of children and adolescents will respond best to learning to play by rote. An easy song to teach on guitar is “Smoke on the Water” by Deep Purple. This song can be taught on the low E string by using modeling and verbal cues. For example, the word open indicates that the E string is plucked without pushing on the guitar string. The number three indicates that one finger pushes down on the E string on the third fret. Similarly, the number five indicates that the E string is pushed down on the fifth fret. The entire melody can be taught using these words: open three five, open three six five, open three five three open. It helps if the music therapist sings these words to the tune and rhythm of the song. After the child or adolescent learns this pattern, it can be transferred to any string. Other simple melodies can be taught in the same manner. The most important factor in ensuring success is to have a melody that is short and simple. Adaptations. Re-creative instrument playing can lead to the creation of songs, as described with the two adolescents who created a rap song with Pachelbel’s “Canon.” In an outpatient or longer-term setting, it may be possible to engage the entire group in playing together. One example of this might be a follow-up to a song discussion group in which the children or adolescents choose songs according to a particular theme. The group may then decide to sing these songs as way to make these songs become more personally meaningful. The songs will become even more personal if instruments are added and the children or adolescents are able to re-create the songs themselves.

Singing and Vocal Re-creation Overview. This method involves clients singing a chosen song using a karaoke machine or with accompaniment provided by the therapist. Singing is best used on the inpatient unit when the children and adolescents are motivated and want to sing. Children are usually less inhibited about singing and may ask to sing along with songs and act or dramatize the songs through gestures and dance movements. Some adolescents like to sing and aspire to be performers like their favorite artists. However, adolescents are also very sensitive to peer pressure. If others in the group are interested in singing, it is more likely to inspire participation. Singing is a good technique for reality orientation for patients with psychosis and cognitive impairments if they are well enough to focus and concentrate. Goals that the music therapist might address using singing are to improve children’s cognitive and emotional development (Uhlig, 2011). Singing also provides an opportunity for expressing emotions and building self-confidence. When done in a group setting, it can also foster the development of social skills and staying focused on task. This can be done at the intensive level, especially if done in individual music therapy sessions. However, it is more frequently done at the augmentative level. Singing is more personal than playing an instrument. It can be a very powerful tool for therapy. It can also expose a person’s vulnerabilities. Children and adolescents are often more willing to play an instrument (even if they are resistant) than to sing, especially in a group. So, singing is contraindicated in the inpatient setting unless the children and adolescents indicate an interest and are willing to sing. Sometimes this interest arises spontaneously. Usually, one person expresses an interest in singing. Others indicate they might sing if they know the words to the song. This may be a prompt to the music therapist to bring out the karaoke machine. Preparation. Karaoke is rarely used for an entire session, although this is possible. Most often karaoke is used after the group has finished another type of music therapy intervention such as song discussion or improvisation and there is time for choice. Any kind of karaoke system may be used. This author uses a portable karaoke machine that has a small screen for the words to the songs. The children or adolescents are invited to gather around the karaoke machine so that all can see the words on the screen.

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Options for singing songs that are not available on karaoke are described below as an adaptation of this intervention. What to observe. Notice the level of participation. Some children and adolescents will observe and not actively participate. Others will sing along quietly on some songs. A few will want to take control and may not want to share. Also pay attention to the sound of the voice and vocal qualities. As with any music therapy interventions, both verbal and nonverbal behaviors provide important information regarding progress toward meeting treatment goals. Procedures. Make sure that everyone who wants to participate can see the karaoke screen with the words to the songs. To begin, the music therapist invites each person to choose a song from a collection of approximately 20 compact discs (CDs) that are designed for karaoke (i.e., have been loaded with graphics so the words to the songs display on the screen). The person who selected the song decides if he will sing a solo or a duet, or if everyone can sing along. Each compact disc is loaded into the karaoke machine according to the order in which the songs were chosen. The basic rules for participation in any group apply. This includes the expectation that all group members be respectful to one another. Some children and adolescents will need support and encouragement, even though they have indicated a desire to sing a certain song. It is a good idea to have other choices available for children and adolescents who are not interested in participating with the singing. Adaptations. Not everyone needs the words to sing their favorite songs. Some children and adolescents may want to sing a song that is not on the karaoke compact discs but that are on another disc in the music therapy collection. This expands the repertoire of recorded music available. It is also possible for another group member or the music therapist to provide the accompanying music. Any instrument may be used to provide the accompaniment. A drum, guitar, or piano/keyboard are the most common accompanying instruments. Because this singing is usually spontaneous, song sheets are not typically used. However, it is easy to get song sheets of lyrics and chords from the Internet if the children and adolescents want to continue singing in music therapy on the following day.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Individual and Group Songwriting Overview. In this method, the client or clients write new lyrics with personal meanings to songs or compose an entirely new song. Creating songs and composing on the inpatient unit is typically done in individual sessions and is often an expression of the patient’s personal experiences with his mental health issues and/or with his experiences in the unit. Songwriting has also been described as a successful strategy to address treatment goals with adolescents who have experienced abuse. Some of these treatment goals include the use of songwriting to identify and express feelings, increase self-esteem, engage in social interactions, and reduce anxiety and tension (Lindberg, 1995; Robarts, 2003). Songwriting may be used at different stages of the treatment process. Some music therapists use this technique during a diagnostic assessment (Oldfield, 2006; Oldfield & Franke, 2005). Behavioral observations, interactions, and nonverbal communications during songwriting can provide valuable diagnostic information to the treatment team. Music therapists also use songwriting to direct a change in treatment, as a transitional phase to prepare for verbal therapy, and as part of closure and termination of treatment (Davies, 2005). This method may be practiced at the augmentative or intensive levels, depending on the extent to which the songwriting supports the overall treatment plan or takes a more central role in inducing clinical outcomes (Bruscia, 1998).

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Songwriting is contraindicated for children and adolescents who are not motivated to participate in treatment, are actively psychotic, or are too agitated to engage in an interactive process with another person. Song creating may also be contraindicated because it requires the ability to stay focused on an idea, work collaboratively with others, and be motivated to express ideas, thoughts, and/or feelings through music. This may be a more effective intervention in an outpatient mental health program in which the children and adolescents have more time to develop relationships with their peers and are more emotionally regulated. Preparation. There is no exact formula of when and how to introduce songwriting. The most important consideration in preparing for the session is to create an environment that allows for the development of a trusting, therapeutic relationship. The children and adolescents need to feel safe with the therapist before they can feel free to express themselves and create songs. The therapist will need a quiet room with access to instruments, including a drum, keyboard and/or guitar, writing utensils, paper, and perhaps a white board if working with a group. In addition, songbooks and a recorded song collection with a device for playing the songs may be helpful. What to observe. Song creating provides an opportunity to observe children and adolescents in both verbal and nonverbal interactions. Some may be hesitant to try anything, whereas others might be interested in trying a variety of instruments and musical styles. Some children may need structure and directions. Others may prefer the freedom to explore a variety of options. Progress toward treatment goals may be evident in the content of the songs (including the lyrics) or in instrumental music that becomes more organized and coherent. If permission is granted, it may be helpful to record the songs. Children and adolescents often enjoy listening to the songs they created. They may or may not be interested in verbal processing about their song creations. Procedures. Each individual session differs according to the needs and interests of the children/adolescents and the purpose of the session. It is not possible to give a detailed description of all of the procedures for conducting songwriting in this chapter. However, a couple of representative examples will be briefly described. Readers who are interested in more detail are referred to the sources listed. Songwriting may begin as an improvisation or as a more structured process. If the song creating flows from an improvisation, the therapist often starts with material presented by the child. This may include beginning with a musical phrase from a previous improvisation, or from lyrics, melodies, or beats from an existing song. It may also begin from explorations of style and mood with instruments to evoke a certain mood or feeling (Davies, 2005). Another option is to invite the child to “tell a story” through improvising and/or with words (Oldfield & Franke, 2005). The role of the music therapist may also vary. Some children and adolescents may direct the music therapist to play a certain instrument or accompaniment. Others may want the music therapist to play along. Some may simply want an audience. The best way to prepare for these individual sessions is to be open to the needs of each child and adolescent, with an awareness of the treatment setting and goals. Often these types of song creating experiences arise from the interest of the child and/or adolescent, and the music therapist’s role is to support the process. Music therapists who do songwriting in a group (which is more likely to occur in an outpatient setting) will need to provide some structure. This includes deciding whether the group will write ideas on individual papers or generate ideas together on a white board. Very few young children will want or need to write anything on paper or on a white board. Older children and adolescents are more likely to bring parts of a song or verses they have already written to a music therapy session. Baker and Wigram (2005) provide detailed examples of how to structure group song creating experiences for the music therapist who wants more detail in this area.

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Oldfield and Franke (2005) provide detailed descriptions and several case studies of how improvised songs and stories can be used with children in a psychiatric inpatient unit for diagnostic assessment. These authors describe an assessment process that includes two individual assessment sessions over the course of two weeks. Each session has a clear beginning and ending, which usually includes a “hello” and “good-bye” song. The rest of the session evolves according to the choices, strengths, and weaknesses of the child. The music therapist pays attention to the ways in which the child makes choices and communicates, both verbally and nonverbally. Information gathered during the songwriting process is then shared with the treatment team as part of the overall diagnostic assessment. Rolvsjord (2005) also uses an improvisatory approach to creating songs. Rolvsjord explained: “I do not have a rigid procedure in my method of songwriting, but adjust the method to the client’s skills and resources” (p. 100). As a result, the starting point can begin with a musical theme such as a melody or harmony. It can also begin with lyrics (especially if a client has written a poem). Rolvsjord also suggests/prompts the creation of lyrics by inviting the client to select words from a list or having the client spontaneously write down a few words to include in a song. The music therapist can then add music between sessions or during the session. Alternately, the music therapist and the client can improvise a melody and/or create the music together during the session. Adaptations. One adaptation is Dyad Song Creation. Although songwriting is often done in individual sessions in an inpatient psychiatric unit, sometimes two adolescents may work together to compose a song. This is most likely to occur when the two adolescents are close to discharge and have already built a good therapeutic relationship with the music therapist and have some respect for each other. This is not usually planned or structured by the therapist but may happen spontaneously at the end of a group. Alternately, two adolescents may ask to come together to the music therapy room to create a song. The latter only happens if the two adolescents have already made a connection through their music during the music therapy group. One example of this occurred after a group drumming improvisation. The adolescents were given time at the end of the group to explore other instruments or to relax to music, according to their choice. One adolescent sat down at the piano and began to play Pachelbel’s “Canon,” which he had learned during a previous admission to the hospital. Another adolescent (who had started creating rap songs outside the hospital) asked if he could create a rap (i.e., freestyle). The adolescent on the piano began to create vocal beats while he was playing Pachelbel’s “Canon.” The vocalizations were breathy and created a beat that varied with different vocal sounds: 1 boom

2 chuh

+ (3) boom

+ 4 boom chuh (repeat)

1

+ hah

2

+ hah

Rest

Rest

The piano player continued to play Pachelbel’s “Canon,” while the other adolescent began to rap using some of these words: I know the sky seems high and churches seem deep, but I’ll pick you up when you’re feeling down and weak. Just give me a call, let me know what’s up, and if you ever need a hand I’ll pick you up. Yo—and when you look left, just look right, you got to keep walking straight and use your might. I know you can do it, just look to the sky. I know sometimes you feel a little curious and ask why. But, things will be good in the end, and if you ever need a hand, I’m your friend. And just let me know what’s going on in life. I know sometimes you’re dealing with the pain and all the strife. But just relax and take things easy, no one ever told you that life would be easy. I know sometimes it gets a little hard but you just

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got to play with the cards that life has given you—in your hand. You got to grow up strong and be a good man. Both adolescents were discharged the day they created this song. Another adaptation is the Group Song Creation, in which clients work together in a group to write a song. It is a good idea to establish group guidelines in advance when working with a group of children and adolescents to create songs (Baker & Wigram, 2005). Some music therapists begin by selecting a song the group already knows. The group is then directed to write new words to the existing melody spontaneously or based on a theme. An easy way to do this is to keep most of an existing song and just change some of the words or phrases. Even young children can be successful in changing song lyrics because they already do this naturally (e.g., jingle bells = batman smells). Very simple examples of this type of songwriting are “piggyback songs,” in which the group changes the lyrics to well-known songs (including nursery rhymes). Examples of songs that are easily adapted can be found through an Internet search for “piggyback songs”. Some settings may require an even more structured approach to songwriting and composing. Derrington (2005), for example, explains that adolescents in a school setting that is organized by “rules and timetables” may not respond well to improvisation. These students may respond better to songwriting as a “project” with a focus on writing lyrics to express themselves (p. 70). According to Derrington, there are seven stages of songwriting with adolescents in a school setting. These include: (1) making the decision to write a song, (2) discussing ideas for themes, (3) creating or using existing lyrics, (4) writing the lyrics, (5) discussing ideas for composing the music, (6) writing the music or score, and (7) making a recording (p. 72). This particular style of composing ends with a product, which is consistent with a school- and project-based system.

CLOSING REMARKS ON METHODOLOGY Group or Individual Sessions As mentioned previously, children and adolescents are typically seen in daily music therapy groups that are limited to a group size of eight or fewer members for a maximum of 60 minutes. Some children and adolescents may be too ill for group sessions and may need to be seen individually. These factors have been described in the section on diagnostic information and in the indications and contraindications listed in each method. The composition of the group is determined in collaboration with the treatment team members according to age, developmental factors, diagnostic factors, social skills, level of aggression, and intensity of illness.

Sequence of Methods There is no set sequence of methods that works with every group all of the time. There are many variables that influence the selection of a method for any specific group or individual. Some of these variables have been described in the description of the methods. In general, the therapist must assess the needs, skills, and motivation of each individual and group member and match these to the method that fits best. This may include mixing different methods in the same session. For example, it is not uncommon to begin with an improvisational drum group and end the session with receptive music listening or re-creative instrument playing. A karaoke session may evolve into re-creative dance and/or freestyle dance and back to karaoke. In general, it is best to start with a more structured method or process with clear expectations and guidelines.

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Order of Methods Presented The methods in this chapter are presented in the order that they are most commonly used. Receptive methods and improvisation are the most common methods and are typically used with new patients. In both methods, the therapist can use the music to make a therapeutic connection and to promote selfregulation. This does not mean that re-creative methods and songwriting are never used for single sessions or at the beginning of hospitalization. An adolescent who is an accomplished guitar player and who plays in a band may find it very calming and comforting to play his guitar and sing recorded or original music. A structured group songwriting session done at the augmentative level may provide a sense of connection to group members around a common theme. However, these latter methods are often better done at an intensive level in an outpatient setting where the participants are better able to focus their creative energies.

CARING FOR THE CAREGIVER Working with Caregivers and/or Family Members Occasionally, a parent (usually the mother) will ask to learn specific therapeutic interventions and will spend time in the unit watching individual music therapy sessions with her child and then practicing some of those skills to deescalate the child and to connect with him or her. This may be as simple as modeling and then encouraging/coaching the parent to sing simple children’s songs and lullabies for calming and to provide nurturing. This is not nearly as intense as Alvin’s approach, in which the music therapist establishes a relationship with the child and then brings the mother into the therapy session with the intention to transfer the client-therapist relationship to the parent (Bruscia, 1987, pp. 97–102). That type of work requires a longer time frame for therapy than an average three- to five-day length of stay that focuses on crisis stabilization. Music therapists who work with children and adolescents who are not actively suicidal, aggressive, or psychotic (e.g., who are in a 30-day diagnostic center, a step-down inpatient unit that focuses primarily on family issues, or a longer-term outpatient program) may be able to use interactive/improvisational techniques with families that are described by Oldfield (2006). This work is unique in describing psychiatric music therapy both with children (ages 4 to 12 years) and with families, as there is little literature on either of these topics. Oldfield provides case examples and descriptions of improvisational music therapy with families in the United Kingdom. She also explains that improvisational music therapy has been used to help families to interact nonverbally, develop insight into relationship dynamics and control issues, experience pleasure and positive moments with each other, express feelings, and develop new insights about relationship dynamics and control issues (pp. 97–98).

Caring for the Caregiver: Understanding Compassion Fatigue Compassion fatigue is a serious issue for music therapists who work in an inpatient mental health setting. Compassion fatigue, also called secondary trauma, is very common due the nature of working with traumatized individuals, listening to stories of trauma and violence, and experiencing it personally by being threatened, hit, bit, or injured on the job. Compassion fatigue is defined as emotional, physical, and spiritual exhaustion in which the caregiver is no longer able to feel compassion, empathy, or joy (Gentry & Baranowsky, 2005). In the humanistic framework, the ability to develop a therapeutic relationship based

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on empathy and compassion is central to the therapy process. This is so important that unmanaged compassion fatigue has been called “malpractice.” It is important to understand that compassion fatigue will happen unless the therapist learns to manage it. Strategies to manage compassion fatigue include developing a resiliency plan that contains the following: identifying one’s purpose for doing this work (mission statement), identifying people for support, learning and practicing self-regulation skills, and exercising or doing physical activity for 15 to 20 minutes at least three times a week (Figley, 1995). Family members and other caregivers also experience compassion fatigue. Sometimes the family member just needs some time away from the patient to rest and rejuvenate. Therapy sessions that are offered to this group are not likely to succeed if they won’t attend. Relaxation, stress management, and an awareness of compassion fatigue may be helpful to family members who may be experiencing it. In the inpatient setting, it is important to validate the parents’/caregivers’ frustration and anxiety and offer reassurance and hope.

RESEARCH EVIDENCE There is very little research on the effectiveness of music therapy with children and adolescents in an inpatient psychiatric unit. This is partly due to the fact that Child and Adolescent Psychiatry is a relatively new specialty. Dr. Leo Kanner founded the first Division of Child and Adolescent Psychiatry in the world at the Johns Hopkins Hospital in Baltimore, Maryland, in 1930. He wrote the first textbook on this topic in 1935 and is credited with creating the term Child Psychiatry (Johns Hopkins Hospital, 2012). However, child and adolescent psychiatry was not recognized as a legitimate board-certifiable specialty until 1959 (American Academy of Child and Adolescent Psychiatry, 2012). As a result, there were fewer psychiatrists, fewer inpatient treatment programs, and fewer opportunities for music therapists to work with these children and adolescents. There are also some barriers that make it more difficult to conduct research with children and adolescents in an inpatient psychiatric unit. First, research with minors requires both the assent of the child and consent by the parent or legal guardian. It may be challenging to get both parties to agree to participate (and cooperate) in research when they are experiencing a crisis situation. Second, it may be difficult to identify patients who meet research criteria if they do not have a diagnosis or have an inaccurate diagnosis. This is further complicated by the fact that many children and adolescents have multiple diagnoses. Finally, the short lengths of stay make it very difficult to recruit subjects, get consent, and gather data. Researchers investigating the effectiveness of music therapy for children with any health care need have faced challenges also, even though many people believe in the innate healing potential of music therapy. The following research can provide some guidance for future studies.

Review of Randomized Control Studies with Children Mrazova and Celec (2010) reviewed published randomized clinical trials of music therapy in children (not necessarily in mental health) with the intention of identifying issues for research. These authors concluded that “studies on the effects of music therapy on children have one common feature—variability” (p. 1093). This variability included everything from the use of receptive and active music therapy interventions to the type of music, variability between control groups, lack of clearly identified music therapy interventions, lack of information or inconsistency of the length of the intervention, and the low number of participants in the study.

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They concluded that “without a thorough description of the methods, including patients, interventions, and statistics, it is difficult to replicate the results of the research or to apply such results in the clinical setting” (p. 1093). Their final recommendations for further research suggested larger “multicenter randomized control trials” that clearly identified the music therapy intervention.

Meta-Analysis: Music Therapy for Children and Adolescents with Psychopathology Gold, Voracek, and Wigram (2004) conducted the first meta-analysis on the effects of music therapy for children and adolescents with psychopathology. The authors conducted a systematic literature review of all quantitative studies that focused on music therapy with this population. Eight of the 11 studies that were included in the meta-analysis were done in the United States. All of the studies were done between 1970 and 1998. Subjects included a wide range of mental health diagnoses and were seen in individual and/or group sessions. The outcomes included behavioral observations, developmental tests, and selfreports. The results of the meta-analysis “showed that music therapy has a highly significant, medium to large effect on clinically relevant outcomes” (p. 1059). Music therapy was most effective for children and adolescents who had multiple diagnoses. In addition, an especially large effect was found with subjects who were diagnosed with either developmental or behavioral disorders. Both children and adolescents responded equally well to music therapy. Furthermore, measures of overt behavior, which are easier to assess, had larger effects than subjective reports (e.g., measures of self-esteem). The authors hypothesized that active music making, in particular, helped children to sustain and focus their attention. The authors also suggested that making music motivates the children and helps them to feel successful because the music therapist creates an opportunity for them to succeed. This is also supported by anecdotal reports (Wigram & De Backer, 1999). Active music therapy groups in which the therapist gave specific feedback improved self-concept better than active music therapy groups in which feedback was not given (Johnson, 1981). This suggests that some verbal feedback and processing may be helpful in music therapy sessions. There is also some evidence that group music therapy may be superior to verbal group therapy in enhancing self-esteem, although the results were not significant (Haines, 1989). Music therapy interventions that use an exclusively behavioral approach are the least effective for children and adolescents who are mentally ill (Gold, Voracek, & Wigram, 2004). These authors found that behavioral approaches in music therapy had the smallest effects, whereas eclectic approaches to music therapy had the largest effects. As a result, they suggest that music therapists in clinical practice use a variety of approaches and interventions that are designed to meet the individual treatment needs of each child or adolescent. These authors also recommend larger-scale studies to address the clinically relevant questions of the effectiveness of specific music therapy interventions for specific children for specific outcomes (Gold, Wigram, & Voracek, 2007b).

Qualitative and Observational Research Given the complexity and challenges of doing research with this population, it would seem logical to look at the evidence of music therapy in qualitative research, case studies, and observational research. While it is hard to establish evidence for a music therapy intervention based on a single case, case studies are useful for informing music therapy practice. They also give direction for further research. One group of researchers decided to do an observational study of multiple music therapists in multiple outpatient treatment settings. Gold, Wigram, and Voracek (2007a) investigated the effects of music therapy interventions in actual cases of common music therapy practice. In their “quasi-

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experimental study,” 136 children and adolescents were treated in weekly individual music therapy sessions by 15 music therapists. All music therapists were trained at the same university. They all used clinical improvisation (both free and structured improvisation) with some use of verbal discourse. The children and adolescents ranged in age from 3.5 to 19 years of age. They had a variety of diagnoses but were classified into three main categories: adjustment and emotional disorders, behavioral disorders, and developmental disorders. Outcomes were measured through standardized ratings scales (e.g., behavior checklist, quality of life, changes in symptoms) and observational reporting by trained observers, therapists, and primary caregivers. The analysis of the data indicated a significant improvement in overt behaviors (as measured by the Child Behavioral Checklist) and on quality of life as measured by the parents. Younger children and those with an adjustment disorder also showed greater improvement. However, the effect sizes were small. The authors stated that “the results suggest that there may be a discrepancy between good efficacy, suggesting that music therapy is a powerful treatment, and poor effectiveness, suggesting that in routine work, it does not work as well as it could” (Gold, Wigram, & Voracek, 2007a, p. 293).

Considerations for Developing Future Research Design After reviewing a large number of studies on music therapy with mentally ill children and adolescents, one group of researchers concluded that “certain forms of music therapy are effective for some groups of children” (Gold, Wigram, & Berger, 2001, p. 20). Although this statement appears to be vague, the authors explained that it is difficult to be more precise given the lack of evidence and the need for replication in larger studies. Gold, Wigram, and Berger (2001) suggest that future research start by addressing the following general questions: (1) Is there a difference between asking if music therapy clients are better off after therapy or if they are better off if they had not received music therapy? and (2) How does one measure/determine if these patients are “better off”? (p. 18). These questions were developed into more specific research questions to address whether individual music therapy sessions with children and adolescents resulted in measurable and clinically relevant improvements in psychiatric symptoms as compared with others who had the same problems but did not receive music therapy (p. 20). In their pilot study, Gold, Wigram, and Berger (2001) suggested that (1) evaluation tools that are used to assess clinical outcome must fit the population and measure clinically relevant constructs that are sensitive to changes that are induced by treatment (p. 21); and (2) results need to include a pretest comparison of treatment and control groups, a summary of the treatment intervention with clear descriptions, and a pretest and posttest comparison of the treatment group (pp. 22–23). The authors concluded that a posttest may be taken after a fixed period of time if the therapy continues. They recommended that both the treatment group and control group receive a “dosage” of 25 sessions. In summary, research with children and adolescents suggests that music therapy is a unique method of treatment and may be more effective than other types of psychiatric interventions for some patients. In order to further develop the field of music therapy, future research needs to (1) define/describe the specific music therapy intervention, (2) identify which interventions are most effective for specific client needs, (3) identify outcome measures that are clinically relevant, (4) determine the “dosage” of sessions, and (5) compare music therapy treatment with other forms of treatment or no treatment on clinically relevant improvements.

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SUMMARY AND CONCLUSIONS Music therapy with children and adolescents in an inpatient, hospital-based, psychiatric unit is, by definition, short-term treatment. These children and adolescents have anger, defenses, trauma, and walls that keep them from connecting with other humans in a positive way. Music therapists can model a nonanxious presence, prompt emotional regulation, and provide opportunities for new experiences with humans by using music to reconnect. Although more research is needed, evidence from neuropsychology suggests that music therapy (especially interventions that engage the left and right brain) may be more effective than verbal psychotherapy for emotional regulation. Music therapists who can develop therapeutic relationships with children and adolescents who are hospitalized due to aggressive, suicidal, or psychotic behavior may be in a unique position to help these patients calm and learn the skills needed to return to society.

REFERENCES American Academy of Child & Adolescent Psychiatry. (2010). Retrieved from http://www.aacap.org American Psychiatric Association. (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). Arlington, VA: Author. American Psychiatric Association (APA). (2012). DSM-5 Development. Proposed Revisions. Retrieved from http://www.dsm5.org/ProposedRevisions/. Materials in revision and subject to change. Baker, F., & Wigram, T. (2005). Songwriting methods, techniques, and clinical applications for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica Kingsley. Brooks, D. (1989). Music therapy enhances treatment with adolescents. Music Therapy Perspectives, 6, 37–39. Bruscia, K. (1998). Defining music therapy (2nd ed.). Gilsum, NH: Barcelona Publishers. Bruscia, K. (1987). Free improvisation therapy: The Alvin model. Treatment procedures. In Improvisational models of music therapy (pp. 96–102). Springfield, IL: Charles C. Thomas. Cadesky, E., Mota, V., & Schachar, R. (2000). Beyond words: How do children with ADHD and/or conduct problems process nonverbal information about affect? Journal of American Academy of Child Psychiatry, 39, 1160–1167. Cassity, M., & Cassity, J. (2006). Multimodal psychiatric music therapy for adults, adolescents, and children: A clinical manual (3rd ed.). Philadelphia, PA: Jessica Kingsley. Clendenon-Wallen, J. (1991). The use of music therapy to influence the self-confidence and self-esteem of adolescents who are sexually abused. Music Therapy Perspectives, 9, 73–81. Cozolino, L. (2006). The neuroscience of human relationships: Attachment and the developing social brain. New York: Norton. Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain (2nd ed.). New York: Norton. Cripe, F. (1986). Rock music as therapy for children with attention deficit disorder: An exploratory study. Journal of Music Therapy, 23, 30–37. Crowe, B. (2007). Diagnostic categories for children and adolescents with mental disorders classified as emotionally/behaviorally disturbed. In B. Crowe & C. Colwell (Eds.), Music therapy for children, adolescents, and adults with mental disorders: Using music to maximize mental health (pp. 201–205). Silver Spring, MD: American Music Therapy Association. Crowe, B. (2004). Music and soulmaking: Toward a new theory of music therapy. Lanham, MD: Scarecrow Press.

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Davidson, R., & Begley, S. (2012). The emotional life of your brain: How its unique patterns affect the way you think, feel, and live—and how you can change them. New York: Hudson Street Press. Davies, E. (2005). You ask me why I’m singing: Song-creating with children at a child and family psychiatric unit. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques, and clinical applications for music therapy clinicians, educators, and students (pp. 45–67). Philadelphia, PS: Jessica Kingsley. Davis, M., Eshelman, E., & McKay, M. (2008). The relaxation and stress workbook (6th Edition). Oakland, CA: New Harbinger Publications. De Backer, J., & Van Camp, J. (1999). Specific aspects of the music therapy relationship to psychiatry. In T. Wigram & J. De Backer (Eds.), Clinical applications of music therapy in psychiatry (pp. 11– 23). Philadelphia, PA: Jessica Kingsley. Derrington, P. (2005). Teenagers and songwriting: Supporting students in a mainstream secondary school. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques and clinical applications for music therapy clinicians, educators, and students (pp. 68–81). Philadelphia, PA: Jessica Kingsley. Doak, B. (2003). Relationships between adolescent psychiatric diagnoses, music preferences, and drug preferences. Music Therapy Perspectives, 21(2), 69–73. Doak, B. (2006). Effects of shamanic drumming on anxiety, mood, states of consciousness, imagery, and brain patterns in adult subjects. Unpublished doctoral dissertation, Temple University, Philadelphia, PA. Dodge, K., Price, J., Bachorowski, J., & Newman, J. (1990). Hostile attributional biases in severely aggressive adolescents. Journal of Abnormal Psychology, 99, 385–392. Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel. Flower, C. (1993). Control and creativity: Music therapy with adolescents in secure care. In M. Heal & T. Wigram (Eds.), Music therapy in health and education (pp. 40– 45). Philadelphia, PA: Jessica Kingsley. Friedlander, L. (1994). Group music psychotherapy in an inpatient psychiatric setting for children: A developmental approach. Music Therapy Perspectives, 12(2), Special Issue: Psychiatric music therapy, 92–97. Frohne-Hageman, I. (Ed.). (2007). Receptive music therapy: Theory and practice. Germany: Zeitpunkt music, Reichert Velag Wiesbaden. Gentry, E., & Baranowsky, A. (2005). Compassion fatigue prevention and resiliency: Fitness for the frontline-training manual. Sarasota, FL: Compassion Unlimited. Gold, C., Voracek, M., & Wigram, T. (2004). Effects of music therapy for children and adolescents with psychopathology: A meta-analysis. Journal of Child Psychology and Psychiatry, 45(6), 1054– 1063. Gold, C., Wigram, T., & Berger, E. (2001). The development of a research design to assess the effects of individual music therapy with mentally ill children and adolescents. Nordic Journal of Music Therapy, 10, 17–31. Gold, C., Wigram, T., & Voracek, M. (2007a). Effectiveness of music therapy for children and adolescents with psychopathology: A quasi-experimental study. Psychotherapy Research, 17(3), 293–300. Gold, C., Wigram, T., & Voracek, M. (2007b). Predictors of change in music therapy with children and adolescents: the role of therapeutic techniques. Psychology and Psychotherapy: Theory, Research, and Practice, 80(4), 577–589. Green, R., & Ablon, J. (2006). Treating explosive kids: The collaborative problem solving approach. New York: Guilford Press.

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Grocke, E., & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica Kingsley. Haines, J. (1989). The effects of music therapy on the self-esteem of emotionally disturbed adolescents. Music Therapy, 8, 78–91. Henderson, S. (1983). Effects of a music therapy program upon awareness of mood in music, group cohesion, and self-esteem among hospitalized adolescent patients. Journal of Music Therapy, 20(1), 14–20. Hendricks, C. B., Robinson, B., Bradley, L., & Davis, K. (1999). Using music techniques to treat adolescent depression. Journal of Humanistic Counseling, Education & Development, 38(1), 39–45. Institute for Patient- and Family-Centered Care. (December 2010). Retrieved from http://www.ipfcc.org/faq.html Johns Hopkins Hospital. (September, 2012). Retrieved from http://www.hopkinsmedicine.org Johnson, E. (1981). The role of objective and concrete feedback in self-concept treatment of juvenile delinquents in music therapy. Journal of Music Therapy, 18, 137–147. Keen, A. (2004). Using music as a therapy tool to motivate troubled adolescents. Social Work in Health Care, 39(3–4), 361–373. Lindberg, K. (1995). Songs of healing: Song writing with an abused adolescent. Music Therapy, 13(1), 93– 108. Martin, G., Clark, M., & Pearce, C. (1993). Adolescent suicide: Music preference as an indicator of vulnerability. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 530– 535. Michel, D. E., & Farrell, D. M. (1973). Music and self-esteem research with disadvantaged boys in an elementary school. Journal of Research in Music Education, 7, 124–127. Mrazova, M., & Celec, P. (2010). A systematic review of randomized controlled trials during music therapy for children. The Journal of Alternative and Complementary Medicine, 16(10), 1089–1095. Oldfield, A. (2006). Interactive music therapy in child and family psychiatry: Clinical practice, research and teaching. Philadelphia, PA: Jessica Kingsley. Oldfield, A., & Franke, C. (2005). Improvised songs and stories in music therapy diagnostic assessments at a unit for child and family psychiatry: A music therapist’s and psychotherapist’s perspective. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques, & clinical applications for music therapy clinicians, educators, and students (pp. 24–44). Philadelphia, PA: Jessica Kingsley. Perry, B. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14, 240–255. Priestley, M. (1994). Essays in analytical music therapy. Gilsum, NH: Barcelona Publishers. Robarts, J. (2003). The healing function of improvised songs in music therapy with a child survivor of early trauma and sexual abuse. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 141–182). Gilsum, NH: Barcelona Publishers. Rolvsjord, R. (2005). Collaborations on song writing with clients with mental health problems. In F. Baker & T. Wigram (Eds.), Song writing: Methods, techniques, and clinical applications for music therapy clinicians, educators, and students (pp. 97–115). Philadelphia, PA: Jessica Kingsley. Schwartz, E. (2008). Music Therapy and early childhood: A developmental approach. Gilsum, NH: Barcelona Publishers. Siegal, D. (2012). Pocket guide to interpersonal neurobiology: An integrative handbook of the mind. New York: W. W. Norton & Company.

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Soshensky, R. (2007). Music therapy with children with emotional disturbances. In B. Crowe & C. Colwell (Eds.), Music therapy for children, adolescents, and adults with mental disorders: Using music to maximize mental health (pp. 206–223). Silver Spring, MD: American Music Therapy Association. Spear, L. (2010). The behavioral neuroscience of adolescence. New York: W. W. Norton. Taylor, D. (2010). Biomedical foundations of music as therapy (2nd ed). Eau Claire, WI: Barton Publications. Took, K. J., & Weiss, D. S. (1994). The relationship between heavy metal and rap music and adolescent turmoil: Real or abstract? Adolescence, 29, 613–623. Uhlig, S. (2011). Rap and singing for the emotional and cognitive development of at-risk children: Development of a method. In F. Baker & S. Uhlig (Eds.), Voicework in music therapy: Research and practice (pp. 63–82). Philadelphia, PA: Jessica Kingsley. van der Kolk, B. A. (2006). Clinical implications of neuroscience research in PTSD. Annals of New York Academy of Sciences, 40, 1–17. New York: Academy of Sciences. van der Kolk , B. A. (2011). New frontiers in trauma treatment. Santa Rosa, CA: Institute for the Advancement of Human Behavior. Wigram, T. (2004). Improvisation: Methods and techniques for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica Kingsley. Wigram, T., & De Backer, J. (Eds.). (1999). Clinical applications of music therapy in developmental disability, paediatrics, and neurology. Philadelphia, PA: Jessica Kingsley. Wigram, T., Pedersen, I., & Bonde, L. O. (2002). A comprehensive guide to music therapy: Theory, clinical practice, research, and training. Philadelphia, PA: Jessica Kingsley.

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APPENDIX A MUSIC THERAPY ASSESSMENT This template was developed/designed by Dr. Bridget Doak and can be formatted into an electronic health record for institutional use. Permission to use this document is granted by the author. Primary Reason for Referral/Target Problem:  Mental Health Inpatient Comments: _____________________(Free text box).  Mental Health Outpatient  Comments: ____________________(Free text box).  Substance Abuse/Dependence  Comments: ________________(Free text box).  Relaxation/Stress Management  Comments: _______________(Free text box).  Pain Management  Comments: __________________________ (Free text box).  Physical Rehabilitation  Comments: _____________________(Free text box).  Sensory Motor Integration  Comments: ___________________(Free text box).  Procedural Anxiety  Comments: _________________________(Free text box).  Hospice/Transitional Services  Comments: _________________(Free text box).  Other ________________________________________________(Free text box). Music Background and Preferences: 1.

Instruments you have played:  Piano/keyboard  Acoustic Guitar  Electric Guitar  Drums  Voice/Singing  Other___________________.

2. Played in Band or Orchestra?  Yes  No  Comments: ________________. 3. Current music involvement:  Band  Choir  Dance  Concert  Other _______. 4. Favorite music _______________________________________(Free text box). 5.

Music disliked _______________________________________(Free text box).

6. Preference for music therapy interventions:  Music Listening  Playing Instruments  Improvisation  Drumming  Songwriting  Relaxation to Music  Music and Art  Dance/Movement  Singing  Song Discussion  Music for Pain Management  Other ________________(Free text box). 7.

Cultural Concerns/Additional Comments ___________________. (Free text box).

Emotions/Affect: 1.

Current Feelings:  Sad  Depressed  Overwhelmed  Angry  Anxious  Suicidal  Guilty  Calm  Hopeful  Other ___________________________ (Free text box).

2. Additional Comments/Observations ______________________ (Free text box).

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Cognition: 1.

Current Thoughts:  Confused  Trouble Concentrating  Difficulty Making Decisions  Hearing Voices  Thoughts of Suicide  Thoughts of Hurting Self  Thoughts of Hurting Others  Typical/Normal Thoughts  Oriented to reality (x3)  Other __________________________________________(Free text box).

2. Additional Comments/Observations _______________________(Free text box). Communication: 1.

Communication:  Verbalizes feelings  Asks for needs to be met  Initiates Conversation  Speaks clearly  Speech is difficult to understand  Other __________(Free text box).  Language other than English __________ (Free text box).  Needs simple 1-step sentences  Other ____________________________________________ (Free text box).

Motor Functioning (Fine/Gross; Perceptual Motor): 1.

Fine Motor Functioning:  Finger dexterity adequate for tasks  Able to grasp object  Comments: ________(Free text box).

2. Gross Motor Functioning:  Walks/stands without assistance  Maintains balance/posture  Comments___________ (Free text box). 3. Perceptual Motor—Able to complete tasks requiring :  Eye-hand coordination  Rhythmic/Movement/Dance  Auditory-Visual Skills  Other/Comments ________(Free text box). Developmental Level/Adaptive Needs: 1.

Developmental Level:  No adaptations required  Adaptations required: _____(Free text box).

Sensory Processing/Planning/Task Execution: 1.

Sensory Processing:  Processes Sensory input/information with no concern sensitivity  Tactile/Touch Sensitivity  Light/Vision Sensitivity

 Sound

 Difficulty with

hearing/listening  Comments: ________ (Free text box). 2. Planning/Task Execution:  Able to complete tasks without problems

 Difficulty

completing sequential tasks  Comments: ____(Free text box). Substance Use/Abuse: 1.

Substance Abuse:  No substance abuse issues reported  Music and substance use is separate  Music is linked with substance abuse  Other/Comments _____________________________________________________(Free text box).

Social: 1.

Social Skills:  Interacts respectfully  Argues/Fights  Isolates/Withdrawn Other ____________________________________________ (Free text box).

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Stress Management and Coping Skills: 1.

Stress Management Rating: Manages stress on a scale of 1–5  1  2  3  4  5. 1 = Very Poor; 2 = Poorly; 3 = Okay; 4 = Well; 5 = Really Well

2. Causes of stress: _____________________ (Free text box). 3. Stress Management Skills:  Listen to music  Breathe Deeply  Exercise  Visualize/Do Imagery  Meditate  Do muscle relaxation  Talk to someone  Reduce sound stimuli  Take time alone  Use sensory intervention _______ (Free text box).  Other: _____________ (Free text box). Music Therapy Assessment Summary and Treatment Recommendations: (Free text box)

Chapter 6

Foster Care Youth Michael L. Zanders

INTRODUCTION This chapter focuses on children and adolescents who are involved with the child welfare system. The goal of child welfare services is to provide an array of prevention and intervention services to youth and families, particularly for youth who have been or are at risk of abuse or neglect (National Association of Social Workers [NASW], 2005). The child welfare system is not a single entity. Various organizations in the community work together to preserve and strengthen families to keep children safe. Public agencies, such as departments of social services or child and family services, often contract and collaborate with private child welfare agencies and community-based organizations to provide services (Child Welfare Information Gateway, 2011). Child welfare systems are also complex, and their specific procedures vary widely by state. When a family becomes involved with a public agency, it is not a singular event. Families, with assistance from child welfare workers, will be involved in different levels of care. Although there are specific programs for families, each family will navigate through the system differently. Typically, families first engage with the principal child welfare agency based on where the family resides. Different communities and cities define this main agency differently. For example, in Philadelphia, the leading agency is called the Department of Human Services (DHS) and is run by the city. In other cities or counties, this agency may be called the Department of Youth and Family Services (DYFS) or Children and Youth Services (CYS). Regardless of how it is characterized, the child welfare system is designed to support families and to protect children from harm. For the remainder of this chapter, for congruence, DHS will be used as the term for the main public agency.

HOW THE CHILD WELFARE SYSTEM WORKS Typically, when youth are involved with the child welfare system, state and local agencies will provide programs to prevent out-of-home placements, reunify families, and provide long-term care to families in need (NASW, 2005). DHS will first receive and then investigate reports of possible child abuse and neglect. This report may come from a mandated reporter or even a member of the community. When the family comes to the attention of DHS, initial services will be provided by DHS or DHS will collaborate with a public or private agency that focuses on the specific needs of the family. Normally, the first service is in the home of the family and the goal is to prevent the youth from being removed from the home. Therefore, services are designed to provide immediate support and stability for the family, such as substance abuse treatment for the parent(s), parenting skill classes, domestic violence services, employment assistance, and financial or housing assistance. However, when youth are identified (a report is founded or proven) as being maltreated, child welfare agencies are obligated to remove the youth from her home and place her in safe out-of-home care environments. This is commonly referred to as foster care. As there are different levels of prevention services there are also different levels of foster care. For

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example, if a safe out-of-home environment cannot be found and/or a youth’s behaviors are detrimental to herself or the community, the youth may enter a residential treatment facility or be hospitalized due to psychiatric needs. However, the majority of youth involved with child welfare agencies are entered into foster care. Foster care is intended as a temporary, not permanent, living arrangement. Once removal occurs, it is the responsibility of the state (usually the child welfare agency working in conjunction with the family and the courts) to return the child or adolescent to his or her home after foster care or find another permanent home for the child (Zanders, 2012). Foster care youth are at times viewed as an at-risk population. The term at risk, however, has no consistent definition and can be viewed as stigmatizing certain groups (Moore, 2006). Nevertheless, it is widely used. The positive side of this confusion is that program providers have some leeway in how they define “at risk” for their programs. For example, in this book the five chapters dealing with children and adolescents with mental health issues all could be defined as an at-risk population. Despite this flexibility, it still is important to have a standard or a reference point. The term at-risk youth typically implies a future with less than optimal outcomes. Youth are considered at risk for a number of reasons. Examples include youth who may be homeless or transient; involved in drugs or alcohol; abused sexually, physically, or emotionally; mentally ill; neglected at home or live in stressful family environments; lacking social or emotional supports; and involved with delinquent peers (NASW, 2005). Therefore, this brief discussion is not about defining, but describing youth who are considered at risk.

DIAGNOSTIC INFORMATION Foster care youth exhibit an array of behavioral and adaptive functioning problems that far exceed those of youth with no foster care experience. This is clearly evident even when foster care children are compared with non-foster care children with similar socioeconomic and demographic profiles (Kerker & Morrison-Dore, 2006). One research study notes that children entering foster care are up to 80% more likely to have significant mental health problems (Kerker & Morrison-Dore, 2006). Other estimates indicate that children in foster care are as much as eight times more likely to have a mental health diagnosis than the population overall (Sieracki, Leon, Miller, & Lyons, 2008). Research suggests that the possibility of multiple foster placements, disrupted medical and educational services, and the potential for abuse while in foster care all place children and adolescents at risk for increased adversity and concomitant psychiatric symptoms (Sieracki et al., 2008). Armour and Schwab (2007) found that at least “56% of children had disorders that fit into as many as three of four categories inclusive of (1) diagnoses with psychotic features, (2) diagnoses with elevated mood, (3) diagnoses with acting-out behavior, and (4) diagnoses of mild mental retardation and borderline intellectual functioning as well as learning disorders” (p. 86). Foster care youth who enter into mental treatment receive a psychiatric diagnosis or diagnoses from the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association [APA], 2000). The evaluating psychiatrist typically gives the diagnosis or diagnoses; however, trained or licensed clinicians also diagnose. The diagnoses provide a framework for understanding symptoms, and the majority of youth will fall under more than one diagnostic category. All behavioral health insurance companies require at least an Axis I diagnosis (clinical disorders, developmental or learning disorders) in order to reimburse for treatment. The following is a list of common diagnoses used with foster care youth, including subcategories and symptoms, and brief information about those diagnoses. All of this information draws heavily on the DSM IV-TR. Mood Disorders are mental disorders characterized by periods of depression, sometimes alternating with periods of elevated mood. While many youth go through sad or elated moods from time

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to time, those with mood disorders suffer from severe or prolonged mood states that disrupt their daily functioning. There are several mood disorders commonly found with this population. Major Depressive Disorder refers to a single severe period of depression, marked by negative or hopeless thoughts and physical symptoms like fatigue. Bipolar Disorder includes a history of at least one or more episodes of major depression and presence or history of at least one episode of mania. Also, there is rapid cycling between depressed mood and elation or agitation. Dysthymia is a recurrent or lengthy depression that may last a lifetime. It is similar to major depressive disorder, but dysthymia is chronic, long-lasting, persistent, and mild. Anxiety Disorders are a group of mental disturbances characterized by anxiety as a central or core symptom. Generalized Anxiety Disorder (GAD) is typified by having recurring fears and worries that are difficult to control. Panic Disorder is characterized by having unexpected and repeated periods of intense fear or discomfort, along with other symptoms such as a racing heartbeat or shortness of breath. Separation Anxiety Disorder is developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the child is attached. Social Phobia usually emerges in the midteens and typically does not affect young children. Young people with this disorder have a constant fear of social situations such as speaking in class or eating in public. Obsessive Compulsive Disorder (OCD) occurs when one has frequent and uncontrollable thoughts called obsessions. Youth with this disorder may perform routines or rituals called compulsions in an attempt to eliminate the thoughts. In the case of OCD, these obsessions and compulsions take up so much time that they interfere with daily living and cause anxiety. Behavior Disorders. A variety of behavior disorders occur among children and adolescents in this population. Oppositional Defiant Disorder is a repeated pattern of negative, hostile, and defiant behavior. Conduct Disorders emerge in childhood and are typified by inappropriate acts, infringements on the rights of others, and violations of the behavioral expectations of others. Youths who have this diagnosis may engage in a variety of antisocial and destructive acts, including violence toward people and animals, destruction of property, lying, stealing, truancy, and running away from home. Disruptive Behavior Disorder is used as a diagnosis when there are elements of either Oppositional Defiant Disorder or Conduct Disorder but all of the requirements for either diagnosis are not met. Attention Deficit/Hyperactivity Disorder (ADHD) includes some combination of problems, such as difficulty sustaining attention, hyperactivity, and impulsive behavior. Learning Disorders include Reading Disorders, Mathematics Disorders, and Disorders of Written Expression. Post-Traumatic Stress Disorder (PTSD) emerges when an individual has been exposed to trauma; however, not everyone exposed to trauma will develop PTSD. Attachment Disorders are caused by the lack of an emotionally secure attachment to a caregiver in the early stages of life and are typically characterized by an inability to form healthy relationships. Reactive Attachment Disorder is characterized by a marked disturbance and developmentally inappropriate social relatedness in most contexts and begins before age five. It is indicated by a persistent failure to initiate or respond in an appropriate fashion to most social interactions, and is manifested by excessively inhibited, hypervigilant or highly ambivalent and contradictory responses (e.g., child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting or may exhibit frozen watchfulness). Diffuse attachments are manifested by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures). Elimination Disorders describe conditions characterized by a lack of control over bladder (enuresis) or bowel (encopresis), unrelated to a physical disorder. Encopresis is a repeated passage of feces into inappropriate places (e.g., clothing or floor), whether involuntary or intentional. Enuresis is a

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repeated urinating into bed or clothes, whether involuntary or intentional. These behaviors are clinically significant if they occur twice a week for at least three consecutive months or if they involve clinically significant distress or impairment in social, academic, or other important areas of functioning. Psychotic Disorders are less often present than the other disorders listed above. Symptoms of psychosis may include: (1) delusions—beliefs that are disconnected from reality; (2) hallucinations— seeing, hearing, or feeling things that are not present; (3) disorganized speech—sentences don’t make sense; (4) grossly disorganized or catatonic behavior—behavior that is abnormal, out of control, without logical intent, or the youth does not move and is frozen in one position. Thus, there is a continuum of the variety and degree of symptoms that can challenge youth in foster care that therapists must be prepared to address.

NEEDS AND RESOURCES There are numerous studies which document the specific types of psychological problems that foster care children exhibit (Armour & Schwab, 2007); however, there are two main themes inherent in their diagnoses: attachment and trauma. In working with foster care youth, it is important to focus on dealing with the symptoms as a way to promote health, rather than focusing on the diagnoses. Currier, Holland, and Neimeyer (2007) found that studies that focused on diagnostic status tended to produce poorer outcomes than studies focusing on specific symptoms. Youth in the foster care system tend to be insecurely attached because they have often been denied the essential reciprocal relationship with a fully committed caregiver (Goncik & Gold, 1991). Goncik and Gold note that, “without such a relationship, the child’s capacity for positive self-esteem and trust in others can never fully develop” (p. 434). Whereas some children develop a secure maternal attachment and can rely on the mother’s presence to explore the environment and develop healthy autonomy, foster care children are less fortunate (Goncik & Gold, 1991). Broken attachments in childhood create serious psychological problems for later development. These problems include impaired conscience development, trouble with basic cause-and-effect awareness, impaired sense of time, and difficulty with auditory processing (Goncik & Gold, 1991). Also common are difficulties in verbal expression and delays in both gross and fine motor skills (Goncik & Gold, 1991). The social experiences that predicate entry into care represent critical developmental risks for their well-being and mental health. Foremost of these is exposure to psychological trauma, emotional deprivation, and other conditions that negate opportunity for secure attachments (Tarren-Sweeney, 2008). Research has shown that a high percentage of foster care youth suffer from Post-Traumatic Stress Disorder (PTSD) (Armour & Schwab, 2007), which stems from the various types of abuse they have encountered, including verbal, emotional, physical, and sexual abuse. Children whose abuses are compounded by additional types of maltreatment have even higher rates of PTSD (Armour & Schwab, 2007). Likewise, Pelcovitz, DeRosa, Mandel, and Salzinger (2000) found that children who both witnessed domestic violence and were physically abused were three times more likely to suffer from PTSD, five times more likely to have major depression, and four times more likely to have oppositional defiant disorder than children who reported only physical abuse. Because of the abuse and subsequent post-traumatic stress, many foster care children become self-abusive. In one study (Armour & Schwab, 2007), 80.8% of 26 children engaged in a variety of selfabusive behaviors, including suicidal threats and suicide attempts. In the same study, self-cutting was done by 26.9%. Also, refusal to follow the medical regime prescribed for physical disorders was a problem for 15.4% (Armour & Schwab). Other self-harming behaviors included head banging, scratching or stabbing oneself, and swallowing both plastic and pieces of metal. In the study, suicide attempts were made by 68% of the youth. The methods used included “cutting their wrists, tying hair scrunches around

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their necks, swallowing metal from objects they took apart, and swallowing coins” (Armour & Schwab, 2007, p. 87). Mental health interventions for foster care populations can be understood within four categories: “first, interventions that are not specific to these populations; second, interventions and treatment services designed for these populations; third, interventions directed to caregivers, with a view to maximizing the therapeutic potential of the child’s care; and fourth, therapy-focused models of alternate care” (Tarren-Sweeney, 2008, p. 347–348). There are, however, limited and inconclusive findings on the effectiveness of common psychological and pharmacological treatments for foster care populations (Tarren-Sweeney), and findings for other populations may not generalize to children in foster care. Another problem is that treatment programs are not meeting the individualized needs of the client. Dore (2008) notes that “pressures from federal and state agency funders and third-party payers on mental health providers to adopt treatment models that appear to have an evidentiary base are intense, leading, at times, to the application of evidence-based models to populations and problems for which they are untested and potentially inappropriate if not harmful” (p. 527). In one study that used a national sampling frame, it was discovered that although over 94% of sampled child welfare agencies assessed all children entering foster care for physical health problems, only 47.8% were routinely assessed for mental health problems (Kerker & Morrison-Dore, 2006). Despite a high prevalence of mental health difficulties, foster youth are at an increased risk of not receiving services necessary to address their needs. Foster youth may be particularly vulnerable to not receiving care for their mental health needs because they often lack a person in their life who feels responsible for their well-being. Untreated mental disorders among children in the child welfare system impact not only children’s functioning and well-being but also society (Dore, 1999; Landsverk, Davis, Ganger, Newton, & Johnson, 1996), as children in foster care with untreated mental health disorders often find themselves homeless or in prisons, jails, institutions, or mental hospitals as adolescents (Kerker & Morrison-Dore, 2006). The negative mental health characteristics of foster care youth are a significant concern; however, music therapy has appeared to be a benefit to this population (Austin, 2007; Dvorkin, 1991; Salkeld, 2008). One therapist found that during her 10 sessions of the Bonny Method of Guided Imagery and Music (BMGIM) in working with an adopted, now adult client, “she was able to break through and finally convert her intellectual knowledge into genuine physical, emotional, and intuitive knowing and healing” (Rehrer, p. 58). Austin (2007) found that the music therapy proved effective in facilitating self-expression and nonviolent communication, and in creating a “safe and playful environment” in which the adolescents could grow (p. 94). Salkeld (2008) discussed how music therapy and interactive music-making “become foundational to the development of their [the adoptive parent] relationship with their adopted son” (p. 156) while working with trauma, bereavement, and attachment issues typically associated with foster care youth. Hasler (2008) developed a model for music therapy that includes the foster parents as part of the treatment. She noted that three key issues for foster care youth are bereavement, trauma, and attachment, and that secondary trauma is an issue for the people involved in their lives. Finally, Dvorkin (1991) discusses a case study where she worked with an adolescent diagnosed with borderline personality disorder in an inpatient psychiatric unit. Although the client was hospitalized at the time of the study, she had been in foster care previously. The music therapy process included connecting her impulses to feelings and regaining control of appropriate expression of her feelings. Although there are patterns or similarities found across foster care youth regardless of age, there are differences in treatment protocols provided with adolescents in foster care versus children in foster care. For example, masked depression typically occurs with children and includes symptoms of anger and irritability. The attention needs are exaggerated and discussion of emotions is avoided. The adolescent may encounter bouts of major depression, excessive self-recrimination and expressions of low selfesteem, persistent sadness, inhibition, isolation from peers and family, sleep problems, and eating

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disorders. Children in foster care typically are anxious and are reluctant to talk directly about their thoughts and feelings. In fact, children often cannot understand what emotions they are feeling. Interventions that are creative and music-based not only engage children emotionally, but also allow for safe expression of feelings. Adolescents, however, experience unique changes in cognitive, emotional, social, and physical functioning. This is because they are engaged in establishing their independence and identity and creating new roles and boundaries regarding responsibility and autonomy (Abad, 2003, p. 21). Although both children and adolescents struggle with regulating affect, adolescents in foster care are easily set off or triggered, have difficulty calming down, may exhibit self-destructive behavior, excessive risk-taking, problems with sexual involvement, and suicidal preoccupation. Children are unprepared for and have a limited capacity to understand and deal with traumatic situations. They are forever changed by these experiences. Often the only way that they can express the effects of such intense stress and anxiety in their lives is in their outward behavior. This emotional turbulence with negative behavior often then accompanies the child as she moves toward adolescence. “It is at this point that the emotional scarring as a result of being the victim or witness to a traumatic event surfaces” (Keen, 2004, p. 363). Youth with foster care experience have different personal biographies than youth without foster care experience (Zanders, 2012). This leads the therapist to consider that foster care youth are a population with different needs and resources than youth with similar symptomatology or diagnoses. Foster care youth have a need for safety and security both physically and emotionally. Unfortunately, not every foster home is able to provide this. Therefore, the therapist ensures that she feels safe and secure within the session. Similarly, foster youth also need to trust and establish relationships. Typically, her experience is one of constant placement disruption and multiple moves. It is an obvious difficulty to trust, but there is also limited time or opportunity for her to establish a relationship, which, again, is why understanding attachment patterns, is important for the music therapy process. Finally, the majority of foster care youth, particularly those who have spent a significant amount of time in foster care, have difficulty expressing emotions. This is made even more difficult when she is unable to even describe her emotions. Thus, there is a need to describe and then be able to regulate emotions. Currently in the field of child welfare, particularly where this author has worked, there is a push for programs and clinicians to work within recovery and resiliency models. It is this author’s belief that these models are just brief reiterations of the broad focus of humanistic therapy. Music therapy is invaluable to this population due to its unthreatening and creative nature. According to humanistic principles of therapy, there is an innate goodness and potential for growth for foster care youth, and there is also an innate connection to music. For children, this includes their ability to adapt, and enter into creative play with music. For adolescents, there is a clear connection to music (Zanders, 2012), and music’s ability to express is clearly a resource. Also, music experiences create trust and establish a relationship, as well as provide safety and security. Particularly with adolescents, this author (Zanders, 2012) has found that adolescents with foster care experience use music as a psychological resource.

REFERRAL AND ASSESSMENT Clients are referred to treatment in various ways. For example, referrals have been received from biological parents, foster parents, school personnel, and other individuals with a stake in the client’s health. However, and most common, clients are referred via the Managed Care Organization (MCO) that provides behavioral insurance, the local department of human services, and/or social welfare agencies who also work with this population—what are anecdotally known as the “system.” The majority of clients have health insurance, but more specifically have behavioral health insurance. Very few clients who have private insurance have been referred, due to the costs. For those who are referred with only private health

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insurance, the clients have also had a physical or developmental disability which private insurance then covered. Although it may occur, this author has never worked with a client whose treatment was paid for solely by the caregiver, whether the biological or foster care family. After the referral process, where the agency gathers demographic, historical, medical, and other information, an assessment is then provided. A thorough assessment underlies treatment with any population. There are no music therapy assessments that specifically assess foster care youth and their unique needs. However, in order to limit decompensation and promote placement stability, the therapist immediately addresses the severity and level of risk of specific problems that may lead to potential placement disruptions. For example, potential problems that can cause decompensation include aggression, sexual acting out, defiance, fire-setting, drug use, theft, school problems, ineffective medication regimen, and inadequate therapeutic support. Also, it is imperative that the therapist assess for suicide. A typical suicide risk assessment includes prior suicide attempt; co-occurring mental and alcohol or substance abuse disorders; family history of suicide; parental psychopathology; hopelessness; impulsive and/or aggressive tendencies; easy access to lethal methods (especially guns); exposure to the suicide of a family member, friend, or other significant person; history of physical or sexual abuse; impaired parent-child relationships; life stressors, especially interpersonal losses and legal or disciplinary problems; and lack of involvement in school and/or work (drifting). Fortunately, there are numerous programs and websites to aid the therapist in assessing the risk for suicide, e.g., The American Association of Suicidology and The American Foundation for Suicide Prevention. The music therapy assessment should provide a multiperspective or holistic view of the client. The general purpose is to collect information to define problems, understand how they are related to each other, and make decisions on how to proceed. This can be achieved through both standardized (evidenced-based) and nonstandardized assessments, within and outside the field of music therapy. However, clinical information should be documented in a way that can be used for accreditation, regulatory review, and quality improvement efforts. Without an assessment, both formally (i.e., with standardized tools) and informally (within the therapeutic context), client treatment will lack direction. Significant for the foster care population is exploring the psychosocial elements in the client’s life. Foster care youth are often greatly impacted by their caregivers. Any exploration of the social elements, resources, and/or supports should incorporate a thorough examination of the youth’s family, including any custody issues. Also, finding and working with individuals and/or organizations that provide positive support to the client in their treatment will identify additional supports. These may include, but are not limited to, spiritual supports, support groups, or community-based organizations. The issues guiding treatment are unique to each client, although Managed Care Organizations (MCOs) typically encourage behaviorally defined interventions. However, based on the clinician’s experience within a type of model or specific intervention, the clinician is able to define the presenting problems within their own area of expertise—in this case, music therapy. Before working with this population, it is highly recommended that the therapist become well acquainted with assessing for trauma. A thorough screen, whether formally or informally, will assess physical abuse, sexual abuse, traumatic loss, domestic violence, community violence, motor vehicle accidents, fires, industrial accidents, crime victimization, and weather-related traumas (tornadoes, hurricanes, floods, etc.). Breslau, Lucia, and Davis (2004) found that 82.5% of youth residing in a large U.S. city had experienced a trauma by the age of 23. In summary, the therapist should assess for psychosocial supports, trauma, and attachment patterns as the main issues for foster care youth. The assessment can use both standardized (formal) and nonstandardized (informal) assessments. The use of music therapy assessments modified for this population is recommended; however, assessments outside of the field are useful when no music therapy assessment is available or indicated. Within the assessment process, the therapist should take a musical

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inventory or musical biography of the client that includes assessing for involvement in music (formally or informally), history with music (formally or informally), and current relationship to music.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • •

Group Song Discussion: Clients and therapist listen to a song together and then discuss the meaning and relevance of the song to each client’s life. Music, Relaxation, and Mindfulness: focuses on the use of music to promote relaxation and mindfulness skills.

Improvisational Music Therapy •

Affective Regulation—How Does a Feeling Sound? Clients and therapist create music extemporaneously on tuned and nontuned percussion instruments to portray a feeling or emotion.

Re-creative Music Therapy •

Singing Songs: involves choosing and singing popular songs together that are meaningful to clients.

Compositional Music Therapy • •

Music Collage Narrative: focuses on the use of songs or sequences of music to express one’s life narrative. Songwriting: Clients and therapist create new lyrics for an existing song or create entirely new music and lyrics.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Group Song Discussion Overview. In song discussion, the client(s) and therapist listen to a song together and then discuss the meaning and relevance of the song to the client’s life (Bruscia, 1998a). This is a valuable intervention for adolescents in foster care; the method is not intended for children. This method fosters engagement, self-exploration and meaning-making through familiar and pleasurable music. Involvement in song discussion serves in the development of the self and one’s identity (Ruud, 2010, p.50). Gardstrom and Hiller (2010) describe the therapeutic value of song discussion: “Music itself serves as a catalyst for the surfacing of cognitions and emotions of the client; these are then explored primarily through verbal processing as a means of developing meaningful insights” (p. 148). Goals include meaning-making, identity development and formation, and processing and expressing feelings related to grief and trauma. McFerran, Roberts, and O’Grady (2010) report that adolescents find “expressing their grief-related emotions valuable but struggle to find a forum where this is viable” (p. 546). Adolescents enjoy the relationships and musical connections they make while listening to music with peers. Thus, song

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discussion in a group context not only helps adolescents feel comfortable with peers with similar backgrounds but also allows for engagement and open communication through the use of the group’s shared musical preferences. Group members are given the freedom to choose the song for discussion. Typically, a topic or theme is discussed in a previous group and the therapist instructs group members to choose a song that relates to that theme for the next group. When there is a group that has no specific topic or theme, members are able to share a song that is readily available, which may lead to the discussion that day. At times, this author will choose a song as a point of discussion for the group. This can occur because the group has difficulty with discussing a topic or theme and/or lacks the ability to decide on a theme. Of course, the song chosen by the therapist is pertinent and meets the treatment needs of the clients. The therapist should have some level of experience/training not only with adolescents who have psychiatric symptomatology, but also in working with groups. This method is considered a primary level of music therapy. Contraindications include the readiness of the client for the group and for this level of therapy. Many adolescents come into treatment at a late age and therefore suffer from unhealthy coping skills. Each client in the group must have a level of emotional maturity and insight that does not disrupt the natural flow of the group. At times, a client might disrupt the flow of the group in order to meet her basic psychological needs. For example, such a client might choose a song for the discussion that does not relate to the current theme of the group and/or use a song that is offensive to the group, e.g., a song that glorifies rape, while the group is expressing thoughts and feelings about sexual abuse. At times, a group member may become disruptive. If this occurs, the therapist should provide a warning, and if further disruption occurs, the group member will be asked to leave the group for that session. Since the therapist will most likely work with that member individually, further attendance in the group can be discussed, and more importantly, the therapist can explore the issue that may have triggered the disruption so that she can attend the group again. Preparation. The therapist prepares the environment or therapeutic space before the clients arrive. This includes having the technology to play songs through an MP3 player, such as an iPod, with speakers for an appropriate level of sound. If a song has been chosen at the previous group, it is recommended that the therapist have it prepared. However, if a group member brings in the song, then the therapist should have the capacity to play it. The room should be set up with enough chairs arranged in a circle for each member of the group, without any empty chairs in the circle. This allows the members to see each other. The therapist should situate himself so that he can see a clock, or have a watch or timepiece to be aware of the time. If the therapist is aware of the songs that will be discussed in the next group, and/or the therapist chooses the song, then the song lyrics are printed out for each group member’s reference. What to observe. During the group session, the therapist must simultaneously assess and observe each individual in the group, as well as the changing group dynamics as they emerge. This includes observing the timing and pacing between discussions, the intensity of emotion of each group member, and possible conflicts with group members. A group member’s affect is an important indicator of the intensity of an emotion she may be feeling. This can be subtly expressed in body language, for example, a client whose face seems to be tightening may be feeling angry. Conflict indicators include, but are not limited to, arguments, verbal threats, and physical threats (e.g., a group member getting of her seat to confront another member). Other noteworthy observations include how engaged each member is, how the group members relate to each other, and each individual’s ability to discuss the theme of the session. Procedures. The procedures for this session imply that the group is ongoing and not a first or beginning session; thus group members are aware of several guidelines for the group. These guidelines

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will be discussed more fully in the Adaptations section. The therapist may remind clients of or reinforce the guidelines during any session and at any appropriate time during the session. The therapist begins the group by welcoming and checking in with each group member. Since the group members may not be consistent, each member should introduce herself. Each group should last between one hour and 1.5 hours. Basically, the group then involves three components: the song selection, the listening experience, and processing the song through discussion (Bruscia, 1998a). A group member, as discussed above, presents the chosen song. She has the option to first discuss what the song means to her, or just have the song played. The group members then listen to the song without any interruption. No conversation should occur during the listening, and the therapist may need to redirect a group member to ensure that this doesn’t happen. Each member of the group has the option of listening to the song again, particularly if the second listening is used for clarification or to understand the meaning of the song. After the song is played and sufficiently listened to, the therapist verbally processes the song with the group. Questions structured in a colloquial language that might be suitable include: “What are you thinking now? What are you feeling? Is there any part of the song that sticks out for you?” The verbal processing not only includes the lyrics but also may include the basic elements of the music, such as rhythm, harmony, melody, etc. The discussion is not about the quality of the song or how good it is, since each individual will find meaning in her own way. The listening habits of foster care adolescents do not seem to be different from those of adolescents who have not had foster care experience (Zanders, 2012). The favorite types of music for foster care youth are hip-hop, rap, and R&B, while favorite artists are Meek Millz, Young Money, Trey Songz, Rihanna, Beyoncé, Lil Wayne, Jay-Z, and Lady Gaga. However, there are themes and songs that arise more frequently within the group, which may help the therapist with choosing songs if need be. For example, DMX has a song titled “Lord Give Me a Sign,” which is a plea for guidance. Other songs describe emotional states or perhaps even existential crises, such as “Runnin’” by Tupac Shakur or “Drop the World” by Lil Wayne. Of course, common themes are songs that talk about biological family in some way, such as “Dance with My Father” by Luther Vandross, “Mockingbird” by Eminem, and “21 Guns” by Green Day. Finally, songs about multiple placements or overall foster care experience, such as “Yesterday” by Mary Mary and “Why Me?” by Kiki Sheard, are also popular. Adaptations. Group discussions are necessary and beneficial for adolescents; however, the group needs to be structured and prepared in order to create a positive atmosphere. The first adaptation, then, is to prepare a potential group member through individual sessions first. For this method, a new client should never start music therapy with the group. The therapist will need to assess and then treat the client individually, which will subsequently lead to the evaluation of whether a client is ready, or not, for the group. As the therapist begins with treatment, and the client is a potential group member, the structure of the group (song selection, listening, and verbal processing) is used individually. Also, the following guidelines are discussed with her intermittently during sessions. Limits of confidentiality are emphasized, particularly on the sharing of information outside of the group. The group members should feel safe discussing the songs and subsequent feelings and thoughts that arise in the session. She is reminded that she should not be under the influence of any drugs or alcohol during both individual sessions and the group. She is to be respectful of other group members. If any member is in the process of discussing, then the other members should be attentive, with no side conversation, remembering that this group is for them. She may be asked to leave the group if she is disruptive. The therapist encourages group members to share in the group and provides instruction to her on how this may occur, such as not giving advice or telling others what to do or why it is their fault.

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The second adaptation that may need to be made is if there is more than one therapist to colead the group. In these cases, the coleaders should not sit next to each other, in order to have a clear view of each group member. Before the group begins, the therapists decide which one of them will discuss the initial guidelines with the group and begin the song discussion. If the coleaders are a therapist and practicum or intern student, then the therapist should direct the student regarding his or her responsibilities. If the coleaders are both therapists, then agenda, guidelines, and responsibilities can all be arranged before the session. Finally, a third adaptation includes using relaxation and mindfulness exercises to help to prepare the group for discussion. There are instances where group members have heightened anxiety, for example, a group member who may be psychiatrically hospitalized during the week. In such a circumstance, the therapist will have to assess the group’s readiness and decide if song discussion is appropriate for the group or if a discussion on the situation at the moment is first necessary. At other times, the group may just not be ready to discuss a specific topic, so doing a relaxation or mindfulness exercise will be calming and allow for possible discussion. Relaxation and mindfulness experiences are discussed more fully below as a receptive method in this chapter.

Music, Relaxation, and Mindfulness Overview. This method focuses on the use of music to promote relaxation and mindfulness skills. The music is improvised by the therapist, however there are times when the improvisation will be re-created, thus implicating a re-creative approach. This will be explained more in the procedural section below. The method is useful for both children and adolescents, as well as in individual and group sessions. However, it is preferred that this method first be used in individual sessions, due to the difficulty of even one foster care youth learning relaxation and mindfulness, as opposed to a group. Grocke & Wigram (2007) provide excellent examples of various types of relaxation exercises that are useful for therapists using a receptive music therapy method. When one is truly mindful, she is totally focused on a specific object, a bodily sensation, or a mantra. However, being mindful also means embracing all that occurs in the moment, including interruptions such as physical discomfort, negative thoughts or memories, and unpleasant feelings. Perhaps a simple definition would be a focused awareness of the mind and body through relaxation. Important for this chapter is that the relaxation and mindfulness exercises learned may be transferred to other sessions, for example, group song discussion with adolescents (as noted above) or individual sessions that may be anxiety-provoking for the client. These techniques can also be applied as life skills to use in situations of stress outside the music therapy session. Relaxation and mindfulness experiences are indicated for foster youth because they have an extreme amount of anxiety and stress, which is closely related to depression. Relaxation reduces the manifestations of trauma symptoms such as increased heart rate, increased startle response, hypervigilance, agitation, difficulty in sleeping, restlessness, irritability, and anger/rage reactions (Cohen, Mannarino, & Deblinger, 2006, p. 75). Used as an element in a medical treatment, this is an augmentative level of therapy. However, the intention of the method is to reduce psychological symptoms of stress and promote awareness, and when used in this way, it is a primary level of music therapy. Of course, as a client uses relaxation and mindfulness in their daily life, an additional benefit will be a physiological reduction in stress symptoms. Goals for this method include reducing stress and tension, reducing anxiety, regulating breathing, reducing agitation, and focusing the client’s attention on himself (awareness of body and breathing). Also, as the treatment progresses, and perhaps becomes at times overwhelming, youth can rely on the relaxation/mindfulness strategies they have learned. The verbal processing after the session allows for the

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opportunity for the therapist to understand the client’s current level of functioning and simultaneously the client’s ability to relax. The client’s mind turns inward; therefore thoughts, feelings, and memories arise. Another benefit is that verbal processing prepares both therapist and client for future relaxation/mindfulness exercises. The therapist should have experience and awareness of their own skills with relaxation and mindfulness. Accordingly, he is then able to observe the client’s ability to relax or become mindful. Also, he is observant of the client’s reactions to the relaxation exercise. Similarly, the therapist should be skilled in improvisation enough so that the music matches and reflects her experience. Therapeutic skills needed by the therapist include voice quality, pacing, model breathing, and creativity. Particularly for voice quality, the skills needed are a midrange, consistent, voice tone and an ability to produce vocal projection and vocal dynamics. The therapist must also be skilled in having the client gradually return to a normal state so that the voice tone and volume match the client’s experience. It is recommended that the therapist record himself presenting a relaxation exercise, as if working with a client. When finished recording, the therapist should place himself in a comfortable position and listen to his own voice in the music induction, noticing the quality and the pacing of the relaxation. It is this author’s experience that clients with complex trauma may become more agitated or anxious when learning relaxation and mindfulness skills. For some clients, this is the first time that they have had to focus on their body. There is a large body of research and literature connecting trauma to physical sensations in the body and/or sensorimotor psychotherapy. So, during a relaxation/mindfulness exercise, a client may become more agitated as she feels physical sensations in a specific part of her body that is subconsciously related to a traumatic experience, e.g., repressed trauma. For more information on somatic trauma see Rothschild (2000) and her discussion on the neurobiological consequences of repeated dissociative or hyperarousal responses on developing brain organization. Each client has the ability or potential to use relaxation, even if it is just short breathing exercises. Preparation. The preparation of the session and environment is just a little different from what would normally occur in a session. For example, the therapist should be aware of factors such as light versus darkness in the room, and have full assurance of no interruptions. The client should be able to participate in a comfortable position. Clients are able to do relaxation and mindfulness exercises sitting in a chair, lying down on the floor, or wherever they feel comfortable. It is important to note that clients who exhibit severe trauma symptoms will initially find lying down to relax very uncomfortable and anxietyprovoking. What to observe. Generally, the therapist should be observant of the client’s reactions to the music and how effectively she is relaxing. When clients direct their attention to the act of breathing, simultaneously, there is a loss of tension and a gain in focused awareness. Clients need to first be able to recognize that they have stress in order to become aware of the feelings that come from that stress. The therapist is observant of cues that will inform him of the effectiveness of the relaxation such as tension (physically in the body), affect, breathing, and focused attention. Essentially, the therapist is aware of any body changes (positive or negative) that are occurring. The therapist ensures that the language used resonates with the client’s developmental and maturity level. Also, during the verbal processing, the client is able to discuss how the music was useful for relaxation, or not. Procedures. If this is a first session, before beginning, the therapist describes to the client safe and effective breathing exercises that may help them and demonstrate proper body positions and breathing technique. The client will demonstrate back to the therapist to ensure proper technique. During subsequent sessions, the therapist may need to continue to reinforce appropriate relaxation skills. The typical session proceeds in the steps described below. The therapist prepares the client for the relaxation and mindfulness exercise. The therapist describes what is going to occur in the session, ensuring that the client is comfortable. The therapist then

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models breathing. At times, this author will use a mantra or use a calming word or phrase to assist the client in breathing—for example, having the client repeat the phrase “breathe in the good feeling, breathe out the bad.” There are some clients who need much more basic assistance in breathing. In such instances, using an instrument such as the piano or the sound of glissando with a xylophone is helpful for simple controlled breathing. Interestingly, the guiro has proved useful in assisting clients to slowly breathe in and out. Even though the guiro may seem to have a grinding sound, some clients find it useful for its strong tactile sense and sound vibration, which gives them a feeling of control. After basic breathing techniques are achieved, the therapist presents subsequent exercises and more advanced relaxation techniques. These exercises can also lead to progressive relaxation exercises (Jacobson, 1938) with music. Since progressive muscle relaxation is alternately tensing and relaxing the body and specific body parts, it assists with helping the client know what tensed and relaxed feels like from a cognitive or conscious perspective. This provides the framework for mindfulness. Following the introduction to breathing, the therapist improvises music for relaxation. Typically, this includes improvising with 2-1 suspensions on I, IV, and V chords over a figured bass on a piano. The 2-1 suspensions act as reinforcement for tension and release as key components of relaxation. As the client breathes in and holds her breath, the music is suspended; the resolution of the suspension leads to the breathing out and provides the musical cue for the client. Although there is a structured framework for the music, the therapist is keenly aware of the music matching and enhancing her experience. Therefore, the bass might be more flowing or moving in one session for one client, and more holding or sustained for another session for another client. Similarly, the chords might be more sustained while the bass moves or the chords might be based on a popular pattern such as the sequence heard in John Lennon’s “Imagine.” At other times, this author will use a guitar similarly using suspensions and resolutions or finger picking popular chordal patterns, e.g., I-V-vi-iii-IV-I-IV-V, and repeat. Therapists will find this chord pattern in Pachelbel’s “Canon in D,” which is appropriate for relaxation in itself. The therapist verbally processes the relaxation experience with the client to promote mindfulness. At the beginning of mindfulness, the therapist can assist the client by having her understand her thoughts in relation to her body. When her mind races or she has intrusive thoughts, the therapist can ask her to focus on a part of her body that is connected in a feeling sense to these cognitive experiences. For example, the therapist may ask the question, “In what part of your body do you feel these thoughts?” This leads her to consciously scan her body and then to be aware of her thoughts. As she learns this technique, the client begins to work with the therapist to connect her thoughts to the sensations in her body. When using mantras as a mindfulness intervention, the mantra may be a word or a line that is meaningful to the client. The word or line can be taken from one of her favorite tunes or books, or her own unique words. The goal for the client is to become so well acquainted with her mantra that it becomes a part of her. The therapist may have her write the mantra on a piece of paper for her to keep with her and memorize. When clients are ready, homework exercises can be incorporated. These exercises are simply a repetition of the session exercises and help her track her own progress. This allows her to transfer skills outside of the therapeutic environment. Typically, initial homework exercises are to practice controlled breathing for two times a day for 10 minutes, every day until the next session. A form can be provided for older youth to record these home practices. Discuss with her when and where the homework will be done, and try to identify likely barriers to homework completion. Initially, the practice sessions should be done when she is calm and can concentrate, not at times of stress and anxiety. For mantra/mindfulness exercises, homework typically consists of 10 to 12 minutes, twice daily, of silently saying to themselves the mantra. With the homework exercises, this author will record the improvisation for her to use at home. The mantra and music help by calming her when faced with life stressors. Another homework assignment related to mindfulness is sound meditation. For sound meditation, the client is to find a quiet place and to sit comfortably in a chair or lie down on the floor. With her eyes closed, she attempts to tune in to all the various sounds she hears around her. While

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listening to each sound, she is not to get too attached to what she hears, but just simply label it in her mind. This meditation should be done for up to 10 to 12 minutes. At the next session, she may talk about this experience or, more preferably, try to improvise the sounds. This exercise is explained to her during sessions but is not useful during sessions since there is a limited amount of various sounds in a therapy room. However, in working with foster care youth, the therapist will potentially work in the foster home. In this case, the sound meditation is a useful intervention and homework assignment. I make certain to include foster parents in these homework assignments. Sometimes in sessions or after individual sessions this author will have a foster parent join and participate in the relaxation/mindfulness exercises. Interestingly, encouraging foster parents to practice exercises with their foster child is a way of helping, and it also provides the foster parent some level of control in dealing with acting-out behaviors. Specifically, by knowing and practicing the exercises with the foster child, the foster parent is provided with a practical application for both understanding and connecting with their foster child. Adaptations. One adaptation is to use prerecorded music. The advice is mixed about the appropriate music choice for music and relaxation. Research indicates that choice of music does not affect the degree of relaxation that listeners self-report (Thaut & Davis, 1993), although others argue that personal preference is vital (Stratton & Zalanowski, 1984). The research generally supports the use of classical over New Age music (Abad, 2003). Abad (2003) also suggests that physical and mental relaxation may be facilitated by music, which is composed of “slow tempi and constant rhythmic patterns, and that the addition of rich harmonies may also enable a sense of security, being nurtured, and safety” (Abad, 2003, p. 27). However, classical music also has implications for eliciting increased tension or anxiety. If classical music is used, then it is recommended that the music be highly structured and have repetitive rhythms and consonant chordal themes, such as Pachelbel’s “Canon in D”; the same indications are true for New Age music. Important for this chapter is that the relaxation and mindfulness exercises learned may be used in other sessions, for example, in a group song discussion with adolescents or in individual sessions that may be anxiety-provoking for the client. Another adaptation is to use music with elicited or directed imagery. Music-elicited imagery involves listening to music in a relaxed state to elicit a client’s spontaneous imagery to address therapeutic goals, including relaxation (Maranto, 1993). Directed imagery is where the therapist guides the client through a series of images that are predefined by the therapist. As the client listens to a clinically appropriate piece of music, the therapist provides the imagery sequence. Music-elicited imagery in music therapy is most closely related to the Bonny Method of Guided Imagery and Music (BMGIM). In BMGIM, the “client images to specifically designed programs of classical music and verbally dialogues with the therapist while imaging” (Zanders, 2008, p. 45). However, musicelicited imagery can also occur with specifically designed music where there is no interaction between the client and therapist while the music is playing (Maranto, 1993). In either case, typically before the music begins, the therapist provides a relaxation induction. It is not recommended to provide either type of imagery experience without proper training and education. Notably, a therapist is certified as a “Fellow” after completing training in BMGIM.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Affective Regulation: How Does a Feeling Sound? Overview. This method is a referential improvisation for individual sessions for both children and adolescents with foster care experience. Bruscia (1998a) defines referential improvisation as: “The client extemporizes on a musical instrument to portray in sound something nonmusical” (p. 117). For this

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method, the reference is to an emotion or feeling. Also, Skewes and Thompson (1998) note that improvisation motivates clients to interact with objects, i.e., instruments, which is a primary step in helping them to develop the basic skills that are required for successful interactions with others to occur (p. 39). Affective regulation is a common approach in cognitive-behavioral methods where the goal of interventions is to establish the appropriate emotion in the appropriate circumstance. For example, an unhealthy affect would be someone who laughs at a funeral. Thus, healthy self-regulation is a capacity to tolerate the unhealthy thoughts and feelings that accompany symptoms of neglect and abuse. Improvisation stimulates the client to respond to their environment, “promoting their ability to respond by encouraging them to initiate and sustain interactions and communication” (Skews & Thompson, 1998, p. 39). This method is indicated with foster care youth who do not have the vocabulary to verbally express a variety or intensity of feelings and rely heavily on avoidance as a way to cope. The increased use of effective expression and management of feelings equals a decreased need to use avoidance strategies. Goals include improvement of psychosocial skills, appropriate expression of feelings, and coping skills. As internal stability increases, so will greater self-awareness, self-expression, interpersonal and intrapersonal skills, and insight into personal problems or issues. This method is a primary level of music therapy. This method is not useful for clients who have a severe lack of coping skills and/or who are verbally and physically abusive. It is this author’s experience that when a client is unable to connect a feeling with sound, she becomes frustrated and will act out. This includes, but is not limited to, throwing instruments, destroying instruments, and physical threats using an instrument, such as a drum stick, as an accessory. Typically, this occurs most often with aggressive males. Percussion instruments at times symbolize an inner experience, acting as a bridge between the physicality of the experience of anger and the ability to speak and think about this experience (Currie, 2004). “This symbolization acts as a metaphor for internal experience, assisting boys to understand the difference between their internal response to a situation and the situation itself and addresses characteristic habits of angry boys to blame others for their feelings and actions and to confuse emotion and action” (Currie, 2004, p. 277). Preparation. The preparation of the session and the environment is a rather simple task. The therapist needs space and privacy, and a sufficient number of instruments for improvisation, such as Orff instruments, and various percussive (drums) and handheld instruments. The therapist must also have the technology to record and play back the improvisation. What to observe. The therapist needs to be aware of both lengthy and very short improvisations as an avoidant defense mechanism. There is no specific amount of time recommended, but as the therapist observes the client’s physical relation to the instrument and affective relation to the sound, he will notice defenses or a lack of congruence between the sound and the feeling. At times, and typically with a client who has inadequate coping skills, she will become severely emotionally dysregulated or she may dissociate. The hearing of her emotions may lead to a mental withdrawal, which occurs more readily with foster care youth. She may even feel “detached from the body or self, as if what is happening is not happening” (Amir, 2004, p. 96). If this occurs, it is imperative that the therapist use his skills to navigate the situation and, if possible, cease the intervention. The therapist should observe body language and affect related to withdrawal, which includes having unexpected and repeated periods of intense fear or discomfort, along with other symptoms such as a racing heartbeat or shortness of breath. Also, the therapist should be aware of any symptoms of psychotic disorders that are mentioned above, which include delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. Procedures. The procedures for this method are similar for both individual and group. The therapist should begin by explaining to the client the rationale for working on identification of feelings.

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The next step is to ask the client to choose an emotion that she is feeling. At times, foster care youth have trouble naming their feelings. If she cannot name an emotion, the therapist can provide a list of emotions from which she can choose. Finding an instrument to match the feeling is an important aspect of this experience. The therapist asks the client to explore the various sounds of the instruments, the size, the shape, and how it feels to hold a particular instrument, keeping in mind how the instruments match her feeling. Once she has had ample time to work on matching the instrument to her feeling, she chooses an instrument that would best describe that feeling in sound. The therapist may be less or more active in helping the client, depending on the client’s ability to match and choose. The client then plays her feeling on her chosen instrument while the therapist records it. She is able to improvise as long as she needs to appropriately play the feeling. After the improvisation, the therapist checks in with the client briefly to understand how she experienced the improvisation, and then he plays the recording for her. After she hears the recording of her feeling, he asks, “Does the sound match the feeling?” The discussion is elaborated on the basis of the client’s reactions to this experience. This procedure continues until the improvisation seems to appropriately match what that feeling should sound like. This may seem subjective, but the importance is having her realize what her specific feelings sound like. The therapist should be aware that she may not be matching the sound to the emotion initially. This is an appropriate reflection of the process, which at times relates to her internal fear of not doing well or finally hearing herself. Therefore, it may take several attempts for the client to finally match the feeling with the sound. As this method is a coping and restructuring intervention, the therapist assists the client in transferring the skills learned in therapy to outside the therapy environment. This is achieved by discussing the improvisation(s) to help the client develop her conscious awareness of how her feelings are related to thoughts and behaviors. For the client’s reference, a good context to providing how feelings, thoughts, and behaviors relate is the use of the cognitive triangle. When working with a group, each member should be given the chance to improvise her emotion individually as a soloist. After each solo improvisation, the therapist discusses with the individual, then with the group, how the improvisation related to the sound of the emotion. This continues as each member has been given an opportunity to improvise and discuss her improvisation. Adaptations. This method focuses on the client’s conscious awareness of feelings. An adaptation is to expand on how that feeling relates to others. This then adapts the method from intrapersonal to interpersonal. In adapting musically, improvisations then can be completed in dyads. For example, one client improvises her feeling to another client, who then responds about the appropriateness of the improvisation related to the feeling. The clients then switch roles. Another adaptation is the group improvising together on a feeling. Typically, not everyone has the same feelings on any given day; however, there are times when a particular emotion is thematic of the group. As the group plays, the therapist observes the improvisation and then discusses with the group the thoughts and feelings they experienced during the improvisation. This is similar to what one might experience in a drum circle. For example, Bittman, Dickson, and Coddington (2009) found that drumming as a creative expression increased quality-of-life characteristics for adolescents.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Song Singing Overview. This method involves choosing and singing popular songs together that are meaningful to clients. Singing songs within a music therapy session for this population is an important component to the overall treatment and would seem an obvious intervention. Singing is innate to us as

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human beings and is easily accessible (Iliya, 2011). In the act of singing songs, the voice is the primary means of self- expression (Katsh & Merle-Fishman, 1985), while the lyrics express thoughts and feelings that are sometimes difficult to communicate through speaking (Baines, 2000). Bruscia (1998a) defines singing songs as the vocal reproduction of precomposed songs. Austin (1998) describes singing songs as being “intimately connected to our breath, our bodies, and our emotional lives” (p. 316). She also notes that singing allows the client to “reconnect with her essential nature by providing her with access to, and an outlet for, intense feelings” (Austin, 2001, p. 28). However, for this population, there are processes and possibilities that must be considered in designing re-creative experiences that may be different from those for other populations. These include: • • • • • •

Emotional and developmental readiness versus lack of readiness Children versus adolescents Individual versus group Processing versus non processing Organic versus intended Songs chosen by therapist versus songs chosen by client

These considerations will be discussed more fully within the remaining description of this method. This method is indicated for both children and adolescents and for both group and individual work. Typically, goals will focus on interpersonal interactions with the therapist, and if in a group, with each other. Also, “maladaptive behavior may be challenged and new, adaptive patterns of thought, reaction, and behavior learned and practiced” (Crowe & Colwell, 2007, p. 29). However, the emotional stability and developmental ability will dictate the treatment goals and objectives, as well as the level of therapy. For example, with both children and adolescents who have developmental disabilities, singing songs will focus on sensorimotor skills, psychosocial skills, and “foster adaptive, time-ordered behavior” (Bruscia, 1998a, p. 118). With youth who have more emotional stability and developmental ability, goals include developing skills in “interpreting and communicating ideas and feelings” (Bruscia, p. 118), “promot[ing] identification and empathy with others” (Bruscia, p. 118), and promoting the expression of feelings. Promoting the expression of one’s feelings in this context does not necessarily denote that the client is expressing her immediate feelings, but singing a chosen song may represent or lead to a more meaningful expression of her feelings. Particularly for adolescents, another goal is understanding and adapting to the “ideas and feelings of others while still retaining their own identity” (Bruscia, p. 118). The level of therapy may overlap; however, there are differences between children and adolescents, the emotional and developmental ability, and group and individual work. In the interest of time and space, the following table is used as a basic description of the differences and level of therapy, and is not meant as a comprehensive explanation. Table 1. Guide to levels of therapy Lack of Emotional and Developmental Stability Children: Augmentative Level Adolescents: Augmentative Level Relative Emotional and Developmental Stability Children: Intensive Level Adolescents: Primary Level

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Individual Children: Primary Level Adolescents: Primary Level Group Children: Intensive Level Adolescents: Primary Level The procedural differences between children and adolescents, and between individual and groups are discussed further below. Austin (1998) notes that in singing, one can “celebrate and express joy” and can connect with others (p. 316). While it would seem that every foster care youth would be able to sing songs, there are obvious contraindications, such as vocal reproduction, especially if the client is unable to vocalize. This does not occur often, but some clients have selective mutism. Otherwise, if the client is able to sing, regardless of vocal skills, then contraindications are limited. However, Austin (1998) states that singing is a “powerful experience but can also be threatening” (p. 316). She further notes: Fear of judgment about the way one sounds can inhibit any attempt to sing even when there is a strong desire to do so. For the untrained singer, the singing voice often carries the projection of the vulnerable, undeveloped young part of the self. Singing might then be experienced as exposing and anxiety-producing. For the abused client, the very act of opening his mouth can be extremely stressful. When he has learned to survive by living in silence and denying his emotional truth, finding his voice requires courage. The client is often fearful of what might emerge if he produces vocal sounds. (p. 316) Although this quote is specifically referring to vocal improvisation, there is a similarity in the implicit contraindication. This does not mean that singing songs should not be used, particularly as this population is vulnerable. It does mean that the therapist should be aware of these concerns and adjust the use of singing songs accordingly. As mentioned previously, trauma symptoms are closely connected with the body, so this method should not occur if clients exhibit severe physical tenseness or are extremely anxious. Also, it is not recommended for children and adolescents who do not have the emotional or developmental readiness to participate in groups, such as for example, clients who have severe acting-out behaviors. Preparation. Typically, the therapist will have an accompaniment instrument, e.g., guitar and/or piano, as well as song lists, fake books, etc., that relate to the client’s style of music. With this population, having a computer program such as GarageBand is useful due to the nature of the music that foster youth enjoy (hip-hop, rap), or a keyboard that can produce beats/rhythms. Also, karaoke-style accompaniment is useful and can be found through a search of various websites, such as YouTube. Otherwise, the environment is similar to that for other methods mentioned in this chapter with both individual and group. What to observe. The therapist should be aware of the client’s ability to sing songs. This observation focuses on both the body (such as struggling with breath) and the voice (vocal reproduction). Overall, it is important that the therapist observe body tenseness due to the connection of trauma and the body. At times, clients will struggle with singing; however, the struggle is part of the treatment process. It is the specific nature of the struggle (e.g., physical manifestations, high anxiety) that the therapist should observe.

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Procedures. The procedures for singing songs are similar to song discussion. First, the song is chosen, either by the therapist or client. Second, the song is sung, by client or by therapist and client together. Third, the song is processed. The song may be processed in one of three ways: verbally, in an improvisation, or in a composition. With verbal processing, the song’s lyrics and music are discussed verbally. In improvisation, the client, either alone or with the therapist, processes the song’s theme(s) through improvisation and verbal processing. For example, if a client identifies feelings of loss in a song, the therapist can facilitate her in an improvisation to bring her closer to and help her to express her feelings and emotions related to the song. In processing these feelings through a composition, the client may engage in a song parody or lyric substitution to allow for a more personal connection with the song and her emotions or feelings. Again, there is still some verbal processing as it relates to either writing a song or substituting lyrics for a song. As mentioned previously, there typically are different procedures between singing songs with adolescents and singing songs with children, as well as differences in emotional and developmental readiness. In working with foster care youth, the action of singing songs in sessions has both an organic and intended element. As an organic element, the singing of songs emerges within the process of treatment, in that the method is not specifically planned but spontaneously occurs, particularly while working within another method. For example, while improvising with one client (therapist on the piano, client on a glockenspiel), the client’s improvisation seemed to be leading to a song. The melody was not completely distinct, but recognizable as John Lennon’s “Imagine.” In response to this, the therapist began to re-create the piano accompaniment of the song, and both client and therapist sang the song together. In verbally processing the song after singing, the client noted that the song reminded her of her mother, which was significant to the treatment goals. Although the client was an adolescent who usually preferred the songs of her generation, i.e., hip-hop, rap, etc., the improvisation led to singing a song from a different generation, and this experience induced her experiences and feelings about her mother. We had not planned to sing this song, nor was there any previous indication that this song was important to the therapeutic process. However, singing the song emerged organically from the session and, as a result, the therapist and client were able to process a significant treatment need. In the second procedure, singing with intention, singing is planned by the therapist and there is a procedural agenda to singing songs. For example, the therapist asks the client to choose a song that she would like to sing within the session, or a song she would like to sing in the next session related to the treatment goals or particular feeling, emotion, or topic. In this case, singing is planned as part of the process, and although there may be a natural inclination to sing a particular song, the song experience is planned and prepared by both the therapist and client. There are several other differences or characteristics that may be important to mention in the use of this method. In working with children and adolescents who do not have the emotional or developmental readiness, whether individually or in a group, songs are chosen by the therapist to meet specific treatment needs. Typically, songs that are used are hello and good-bye songs, and songs that promote appropriate interaction or engagement. Based on the client’s level of engagement with a particular song, the therapist may use it in subsequent sessions. Verbal processing of the song does not usually occur. Songs are usually sung by the therapist for or with the client, and are not typically sung by the client alone, unless there is a specific treatment need that solo singing might meet. Examples of this might include when the client fills in the last phrase or word to a known song, or sings alone in a call-and-response as with a hello song. Goals are similar for both individual and group; however, in individual sessions, the interpersonal and psychosocial skills are worked on with the therapist, while in the group setting these skills are worked on with other group members. In working with children who have the emotional and developmental readiness in both individual and group sessions, songs may be chosen by either therapist or client, although typically the therapist will

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have planned to use specific songs that meet targeted treatment needs. At this level of treatment, songs are used to identify feelings while still promoting appropriate interactions. The song is processed in a way that promotes connection to the self rather than insight; typically, this is not done through verbal processing, but through musical means. For example, after singing a song such as “My Favorite Things,” the client can substitute her own favorite things in place of the song’s lyrics. For adolescents who have the emotional and developmental readiness, in both individual or group sessions, singing songs occurs naturally and organically within the session. Organic denotes a relationship between the client and her treatment in which singing is part of the whole treatment and arises naturally within the process of therapy. In this situation, both the client and therapist choose songs for the session. Typically, when the client is having difficulty expressing herself, the therapist chooses a song that relates to a current feeling or emotion the client may have. Typically though, clients choose songs because they have sufficient self-awareness and are able to process in one of the ways mentioned above. For group settings, singing songs together promotes connection and identification with others. There are also instances when a client will sing a solo as a way of expressing herself to the group. Adaptations. The concept of song choice as an organic process describes the nature of these song choices as arising spontaneously out of the process in the session. As an adaptation, particularly with adolescents, it is important to discuss the idea of induced song recall or songs that are evoked from the subconscious within and outside of sessions. To access subconscious song recall, the therapist can stop at various stages in the session and ask the client what song she is reminded of in this moment; another method is to begin the session by asking the client if she currently has or has had any song running through her head in the past few days. Diaz de Chumaceiro (1998) notes that whether a song is unintentional, spontaneous, or unplanned, the timing of the song’s emergence is spontaneous but “not its dynamic contents” (p. 336). This means that when the song suddenly arises in a session, this is a spontaneous event; however, within the client’s subconscious, the song has already manifested, and thus the psychodynamics of her experience with this song are not spontaneous. This evoked remembrance of songs occurs within the overall process of working with clients, and for some clients, this process may occur frequently. It is this author’s experience that adolescent clients will frequently bring in titles of songs or music to sing. This is related to the client’s identity in that the music, and oftentimes the singer, are representations or introjects from her subconscious. Because there is an implicit orientation to psychodynamic principles in this particular adaptation, this technique is best situated within an insight-oriented music therapy approach with re-educative or reconstructive goals (Wheeler, 1983). In this context, the therapist works with the client to bring insight to make meaning of the client’s unconsciously induced or evoked songs. The theory and clinical practice of unconsciously induced song recall is presented in Chumaceiro’s Chapter 15 in Bruscia’s (1998b) The Dynamics of Music Psychotherapy.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Music Collage Narrative Overview. This method focuses on the use of songs or sequences of music to express one’s life narrative with foster care youth. Bruscia (1998a) defines a music collage in the following manner: “The client selects and sequences sounds, songs, music, and fragments thereof in order to produce a recording which explores autobiographical or therapeutic issues” (p. 120). At times, it is encouraged that the therapist incorporates the use of songwriting (discussed more fully below) in creating the music collage as a constructive means in creating a personal narrative.

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Songs, and parts thereof, are useful interventions for therapists. Hadley (1996) stated that “the use of songs is one of the most common approaches in music therapy, whether it be singing, song recall, song communication, or songwriting” (p. 22). Bruscia (1998a) describes the therapeutic elements in song: Songs are ways that human beings explore emotions. They express who we are and how we feel, they bring us closer to others, they keep us company when we are alone. They articulate our beliefs and values. As the years pass, songs bear witness to our lives. They allow us to relive the past, to examine the present and to voice our dreams for the future. Songs weave tales of our joys and sorrows, they reveal our innermost secrets, and they express our hopes and disappointments, our fears and triumphs. They are our musical diaries, our life stories. They are the sounds of our personal development. (p. 9) This method is indicated when the client is ready to engage in a creative process and to explore meaning or find insights in her personal life. Specifically, goals then include meaning-making, expressing feelings, and exploring issues related to grief and trauma. It is in the process of organizing songs that the client’s personal biography or narrative emerges. The therapist can work with the client on as many parts of the collage as needed to create the narrative, including both self-composed and borrowed songs. The sharing of a personal story that may be trauma-based can be referred to as a trauma narrative, and this sharing is critical for the client for three main reasons. The client: (a) gains mastery over the trauma reminders, (b) resolves avoidant symptoms, and (c) enhances healthy coping skills. Since this method is a process that leads to a client’s own product, the level of therapy is primary. This method is not recommended for groups. Contraindications include the client’s level of readiness and/or developmental stage. If she is unable to appropriately choose music that relates to her personal biography, even with assistance, then this is viewed as a lack of readiness. If she does not have the cognitive ability or maturity to discuss her life, then this method is viewed as not being developmentally appropriate. Another contraindication, noteworthy with this population, is that the therapist should not proceed with this method if a client is in the middle of or about to move to another placement. The client should be in a stable home environment, since she will need more support during the narrative formation. Of upmost importance, the client should not be in a situation where she feels unsafe, such as an abusive environment. Preparation. For the environment, the therapist should have various percussive instruments, devices for playing music such as an iPod or MP3 player, and either a piano or a guitar for accompaniment. It is beneficial if the therapist has more technological access to computer programs such as GarageBand. The therapist should also have staff paper, music notation paper, blank tabs, and other notepaper to help with organizing the songs. If during the process the client is working on lyrics, then paper should also be available for the client to write and edit lyrics as needed. A recording device is used for any completed sections of the narrative for posterity or what might be better defined as artifacts of the process. What to observe. The therapist must be keenly aware of how each sound sequence connects with the overall experience of the client, i.e., the client’s musical life story. During the session, the therapist should continually assess and observe the client’s readiness. The emotional readiness of the client is similarly as important due to the nature of this approach. The therapist observes the client’s engagement in the process, including both the natural narrative connection between the sequences of songs and the overall narrative of the musical story (beginning, middle, and end of story).

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Procedures. This method is fully conceived over several sessions. Within the first couple of sessions, the therapist assists with choosing songs that relate to different periods of her personal biography or different topics such as feelings, thoughts, and ideas. For example, this might include songs about her childhood, parents, foster care, etc. These initial songs are then used within the overall narrative. At times, a song may not fit naturally within the narrative; the appropriateness of the song in this context is then discussed with the client. She is then able to inform the therapist about how the song matches the theme for her. Similarly, foster care youth listen to the music of their peers (Zanders, 2012), such as rap and hip-hop, which are foundational for lyrics. Within the next sessions, the therapist and client begin to formulate the narrative. This includes organizing the songs and sound sequences with her input. It is during this part of the process that the “story” is emerging. The therapist is able to notice patterns or themes that lead to an overall narrative. If continued assistance is needed to complete the narrative, the therapist may orient the client to specific times in her life and prompt with open-ended questions such as, “What were you thinking at that time?” “What would you say about that time?” “What were you feeling?” A question this author usually uses within every session is “What happened next?” This question is narrative-based, as most stories have something that happens chronologically. A narrative has a beginning, middle, and end, and provides a story—in this case, “her” story. In this approach, the narrative does not have to be linear, but the songs should relate in some way to tell a story, or tell a story about a particular period of her life. The narrative may take several sessions to complete; this process should not be rushed, as each individual tells her own story in her own way in her own time. Narratives are constructed in different ways, as a narrative is a unique expression that is central to one’s identity and to the creation of one’s personal meaning. The therapist and client focus is on how the songs and music sequences connect to each other and to her internal life and external life events. She may have more than one story that needs to be told, so the process should continue until the therapist deems the narrative sufficient, meaning that the story is vivid and meaningful, and that it makes sense. Throughout sessions, during each stage of the narrative, the therapist will verbally process the experience. This is an opportunity to explore how the music resonates with her. This may involve some deconstruction and subsequent meaning-making as emotions and meaningful insights emerge through the narrative. Songs are powerful agents in helping clients to understand themselves, and the verbal processing provides the client with further insight into her experience. Significantly, the verbal processing allows for connecting the songs as a full narrative. Homework is an important component in this method. The therapist will provide instructions on searching and choosing music to be included in the narrative. For example, the client can be encouraged to write a poem on a particular theme such as when she entered into foster care; this can then provide a recall of songs that relate to her experience. This is useful for the client because she becomes engaged in the construction of her narrative—reviewing and making meaning of her life—as a part of her daily living. An added advantage is that the session time is not overwhelmed with foundational elements. Adaptations. If the client wants to accompany herself for her own composed songs to be recorded, then learning an instrument is an important factor. Learning an instrument provides a motivating and age-appropriate way to engage the client. Foster care youth perceive music as an activity that they have under their control (Becker, cited in McFerran-Skewes, 2003). The client controls the choice of songs, and learning an instrument to play her song provides an additional level of control. Of course, this may take numerous sessions, so lyric substitution, or choosing songs, may be used while she is learning. Another adaptation is the playing of the music narrative, whether with the recordings or the client performing the music. Also, with narratives, since it is a story, the client will want and need to express her story to others outside of the therapy session. This is particularly true for narratives that revolve around

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trauma. The therapist and client should discuss with whom she intends to share her story, i.e., it should be only with people she trusts. In the case of foster care youth, sharing the narrative with the foster family, particularly a family that is planning to adopt her, may be healing for both her and the family.

Songwriting Overview. This method focuses on songwriting, which is the creation of new lyrics for an existing song or writing entirely new music and lyrics. Songwriting may be incorporated as part of a narrative. However, the description of the process more fully lends itself to a different method. Songwriting by the client alone or with help “allows ideas to be expressed with an emotional colour that is often lacking in spoken words” (Bright, 2006, p. 68). Abad (2003) observes that songwriting “provides a flexible yet structured musical medium for the expression and communication of thoughts and feelings” (p. 24). McFerran, Roberts, and O’Grady (2010) mention that “songwriting was the most powerful strategy” in working with a group of clients (p. 5). Eventually, a song provides a documented end product of the client’s process in therapy. This method is indicated for clients who are progressing in therapy sufficiently in order to gain further insight into their problems or issues. Specifically, songwriting is used as a psychological resource, and the goal is to reveal emotions while gaining insight to thoughts and feelings. The therapist must be able to deal with the emotions the client is feeling while being both supportive and nondirective. The client should be prepared not only to write her own song, but also to deal with the emotional issues that may arise. This requires a trusting and safe relationship. This method is closely related to the above music collage method. Thus, songwriting is useful as a singular method, or within another method. This method is viewed as a primary level of therapy. Contraindications include the client’s level of readiness and/or developmental stage. If a client is unable to write a song or choose music appropriately that relates to her personal biography, even with assistance, then this is viewed as a lack of readiness. If a client does not have the cognitive ability or maturity to discuss and write about her life, then this method is viewed as not being developmentally appropriate. Another contraindication, as in the above method, is that she was not relatively stable both in her physical environment and emotionally. However, the experienced therapist will find that clients who are struggling with placement disruption may find this method useful as a resource for discussing her emotions. Preparation. The therapist should have staff paper or other music notation paper, such as blank tabs, to notate the songs. If during the process the client is working on lyrics, then paper should also be available for the client to write and edit lyrics on as needed. The therapist should have various music instruments available for her to use, including a piano and guitar. Also, technological resources such as an electric piano or GarageBand are useful. A recording device is needed after completion of the song. Foster care youth listen to the music of their peers (Zanders, 2012), such as rap and hip-hop. The therapist will benefit by being prepared with the basic elements of these styles in order to guide her in the songwriting process. In later sessions, the therapist may want a recording device to play back the already composed music so that she can sing with the recording, as in karaoke, but with her own song. What to observe. The therapist is aware of the relationship between the lyrics and the music and observes whether the client is connecting to the lyrics personally or not. For example, some clients may seem to be ready to write songs; however, during the initial stages of the process, the therapist quickly realizes that the lyrics are derogatory. For other clients, the lyrics may seem to bear no relationship to the client’s feelings. Male clients who are not ready for this experience may compose misogynistic lyrics. The therapist should observe the client’s process in developing her own music and lyrics. As a preparation leading to songwriting, if the client seems engaged in making minimal changes to the lyrics to songs, then

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she is developmentally more suited to song parody than song composition, which requires more independent thinking and more pervasive changes to the song. The emotional readiness of the client is similarly as important due to the nature of this approach. In summary, the therapist observes the client’s engagement in the songwriting process, the natural connection between the music and lyrics, and the overall theme of the song, e.g., an emotion, an experience, etc. Procedures. In the beginning stages of this method, the therapist provides much more hands-on assistance with the music (rhythm, melody, etc.) and the lyrics. For example, the common blues progression is a good foundation for modeling the elements of music. The therapist plays the music as the client sings self-composed lyrics. Lyrics may arise from any number of sources, from poems she may have written to topics presented in other songs, and even free association. Also, the therapist will have some idea of potential topics for lyrics for a particular client from previous sessions. Subsequent sessions may employ other music methods, e.g., improvisation, re-creative, receptive, to contribute to the song composition, but the focus is the song composition itself. The process and use of other music methods is based on the therapist’s assessment of the client’s needs in completing her song composition. For example, the therapist might use improvisation to stimulate the creation of song lyrics. In this technique, the therapist may improvise on an instrument while the client improvises lyrics with her voice or improvises with her voice alone to find inspiration. This allows for a spontaneous expression of thoughts and feelings. To assist the client, the therapist can present varying styles of beats or rhythms on an electric piano with which she can rap. Also, when she is ready, she can improvise on an instrument of choice while using her voice or spontaneously composing lyrics. When using a re-creative method to foster song composition, the therapist and client may sing songs together, which provides ideas about how to structure the composition of a song, e.g., three chords and the “truth.” The receptive method may be used when the client and therapist listen to songs that the client likes and discuss the structure and how the song may have been written. Compositionally, they work together in substituting lyrics to songs and changing the music or lyrics as needed. The music in these instances seems to provide a safe foundation for expression of feelings, even if the emotions seem initially stunted or undeveloped. Ultimately, since this is a composition method, the end product is a song written by the client with guidance by the therapist. As the client progresses, the therapist will provide assistance where needed. The therapist will most likely need to play the music while she sings her song. If continued assistance is needed to complete songs, particularly the lyrics, the therapist may orient the client to specific times in her life and prompt with open-ended questions such as, “What were you thinking at that time?” “What would you say about that time?” “What were you feeling?” Like the other methods discussed in this chapter, homework is useful for this method. The therapist may provide assignments such as having her choose a song that matches the style of her intended song. In her choosing a song she may then become aware of the structure and how to be involved in composing a song. Also, as with music collages, having the client develop lyrics and/or topics outside of the session allows for more music development in the session. Adaptations. In instances where a client is unable to write a song, the therapist might find it useful to use song parody or lyric substitution. The procedures would be similar in that the songs used would follow a songwriting process; however, the songs chosen would all be precomposed and the client would just change the lyrics. Also, and if necessary, when doing song parody or lyric substitution, if the client chooses a song that is too difficult to render appropriately with acoustic instruments, the therapist can use a website to download music without the artist singing (karaoke-style) from YouTube or other websites. Also, learning an instrument may be useful for the client; in this case, see the method on didactic lessons.

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Performing the song may be an adaptation or end product of the songwriting experience. Song performance allows youth to bring ownership to their creations and to showcase their ownership of the material to others. Song performance also brings a new dimension to the song creation process (Aasgaard, 2000). Baker and Wigram (2005) note, “The process and the product of writing a song within therapy sessions is the therapeutic intervention. The therapeutic effect is brought about through the client’s creation, performance, and/or recording of his/her song” (p. 14). If an upcoming event such as a school or community concert occurs in the client’s life, the therapist might use the opportunity to have her perform her song. However, this should be done only if she is ready and has sufficiently processed her experience. Simply, this is about her and not the therapist, so there should be no coercion or pressure about performing. The therapist will need to be aware of both his and her feelings as to whether this adaptation is warranted. Finally, if the client is a part of group therapy, sharing the song might be fruitful as part of a song discussion, as a method described previously in this chapter.

CLOSING REMARKS ON METHODOLOGY The methodologies discussed above are viewed as being fluid or seamless, and not fixed or rigid in regards to the client’s treatment. For example, there is a process involved in providing appropriate treatment, but there is no standardized model. The therapist will need to account for each client’s individual needs and relationship with the music method. That said, there are guidelines that may be useful for the therapist who works with foster care youth. These guidelines are viewed from the perspective of a continuum, in that the therapist needs to assess and then evaluate the relevant criteria for how and when the method is used. The first guideline is the group versus individual perspective. Each client is initially seen individually to assess her emotional stability, which will determine how best to proceed with treatment. For children, individual treatment is the most common. However, group treatment is used when the client has siblings (biological or foster care) in the same home and the sibling(s) can join in the treatment. For adolescents, it is important to provide individual sessions, but as mentioned previously, group work is more attuned to a wide array of their interpersonal treatment needs. During times of severe emotional stress or crises, individual work can then be reincorporated into the overall treatment. For both individuals and groups, therapy is provided for about 50 minutes. For children, the main portion of treatment is about 30 minutes, and additional time is then taken to work with caregivers. For groups composed of children, the time frame is similar. Based on the need, some adolescent groups may extend past an hour. However, there is still a boundary with start and end time. For example, the session is planned for an hour, but time is allotted near the end for the therapist to assess emotional stability and also to plan the next session with the clients. This is the reason that 50 minutes is denoted above; 10 minutes are used for unplanned issues or problems. Clients are typically seen once weekly, although if individual treatment is needed, the client is then seen once weekly for individual and once for group. As treatment progresses, clients may be seen biweekly. Group composition and size also vary based on need. Typically group sizes are between four and six clients. Fewer than four clients is also acceptable; however, more than six clients in a group leads to logistical and management problems. Adolescent groups with more than six clients may also be successful, but only when each individual has the emotional stability and readiness to work within the group. The dynamics and theories associated with adolescent group work are similar to those with other populations. In working with groups of adolescents, the therapist needs to have a basic understanding of group dynamics and be skilled at managing boundaries. The second guideline is the specific versus whole session perspective, and addresses how each method is integrated within the treatment process. Group song discussion in receptive methods is

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presented as a whole session. The session includes giving each member time to discuss her song, as well as have an opportunity to discuss thoughts, feelings, etc., related to other clients’ song choices. At the end of the session, the therapist brings closure to the discussion. Music, relaxation, and mindfulness, is more fluid and flexible as a process. For example, this method is typically not a whole session but is incorporated into other experiences. When a client is “relaxed,” she is able to connect with her feelings and open herself to discussion and other experiences with more ease. Therefore, this method can be used in the beginning, end, or middle of sessions, based on the need or anxiety level of the client. Also, this method is used with both groups and individuals. Improvisation is typically used at the beginning of the treatment process and also to open a session. At times, the referential improvisation will lead to other improvisations that are open or nonreferential. At other times, the improvisation may even lead to a composition (songwriting) or recreative method (singing songs). Thus, this method is used within specific sessions and throughout treatment as clients fluctuate between understanding their emotions and being unable to express what they are feeling. The re-creative method can be used as a part of a session or as an entire session. In this case, several songs are sung and the therapist facilitates discussion about each song related to all the members in the group. If a client is having difficulty expressing herself verbally, the therapist may reintegrate the improvisation method to help her express herself nonverbally, and then process it in a discussion. Finally, singing a song at the end of a session is valuable in that both the client and therapist can conceptualize the overall theme of the session while having a musical reminder of the session. Similarly, songwriting is used with improvisation, receptive, and re-creative methods, in that it is used at any time within a session and throughout treatment. Songwriting is usually incorporated with the other methods as part of a process and not exclusively as its own process. However, there are times when a whole session, or several sessions, are used to write one song. At these times, the other methods are used to assist the client in completing a song. For example, relaxation experiences may be presented if the client is tense, or clients may sing a song to help them understand form and style, or for inspiration. In the same manner, in a songwriting experience, improvisation may be incorporated as a way of helping the client to find a “sound” that matches her feelings. The music collage is most often used as the main method throughout the treatment process. While the completion of the music collage may be the ultimate therapeutic goal, the therapist may also incorporate any of the above methods in order for the client to fully explore her narrative. The third perspective is homogeneous vs. heterogeneous. Homogeneous methods are used throughout the treatment process as the primary method to meet the goals and needs of the client. An example of this is the music collage narrative or the group song discussion. Heterogeneous methods are used collaboratively within sessions to meet the goals and needs of the client. For example, relaxation, affective regulation, songwriting, and singing songs are commonly used in combination with each other within sessions and throughout treatment. These guidelines should not be rigid, however. The ultimate deciding factor in the choice of a method or technique is the immediate need of the client. For example, if a client needs to write her own song to complete a collage, then the collage narrative method becomes more heterogeneous, while if a client finds songwriting to be the most effective way of exploring and expressing her emotions and feelings, then songwriting becomes a homogeneous method in regard to treatment. Ultimately, the methods are not hierarchical or exclusive of each other, and it falls upon the therapist to use his skill, experience, and insight to make appropriate decisions regarding when and how to use a method.

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WORKING WITH CAREGIVERS AND FAMILIES Therapists who work with foster care youth and the foster care system will most likely find two key components to working this population: (1) working in the foster home and not necessarily in an outpatient setting, and (2) incorporating the foster parents/caregivers into the therapeutic process. Years ago, Bronfenbrenner (1986) asserted that child maltreatment is a manifestation of community conditions as much as it is a reflection of parents, and urged individuals involved with youth to view maltreatment ecologically. An ecological framework involves “considering families within multiple, interactive contextual layers ranging from individual factors to community issues and broader social contexts” (McWey, Humphreys, & Padera, 2011, p. 138). A key advantage to in-home music therapy is that by providing therapy in the home, services are directly accessible to clients who arguably need it most. Additionally, therapists will observe family dynamics and can intervene accordingly (McWey et al., 2011). Outside the field of music therapy, in-home treatment has been shown to significantly increase attendance and engagement of youth and their families in comparison with office-based therapy (McWey et al., 2011). Home-based therapy has also been compared with residential treatment for youth, where families participating in home-based therapy were more likely to be living together one year after treatment (McWey et al., 2011). Families report satisfaction with in-home family therapy, and therefore satisfaction is a predictor of home-based therapy success (Johnson, Wright, & Ketring, 2002). Today, there are a number of agencies offering home-based family therapy in response to the increasing need to reach out to multifaceted-problem families and to ensure the continuity and effectiveness of treatments. Nonetheless, there is little research and literature supporting this approach, and “no clear guidelines for home-based therapy practice have been developed to date” (Cortes, 2004, p. 184). Cortes notes, “Many academic institutes fail to train therapists in this area, despite the fact that it is a growing market trend” (p. 184). There are characteristics that define working with families and foster care youth in their homes that create dualities (McWey et al., 2011). Treatment versus need: Families are overwhelmed with the amount of child welfare workers who are in and out of the home. Each family is required to have an overall treatment plan but finds it stressful having social workers, therapists, child advocates, etc., in their homes on a weekly basis. Conversely, in times of great stress and need (crises), families are more willing to have more people in their home to help meet the demands. Therefore, the therapist balances the crises versus meeting the treatment needs. Natural environment versus security: Providing therapy in families’ homes is a useful and perhaps necessary treatment; however, it also tends to make families vulnerable (McWey et al., 2011). For example, when child welfare workers are involved with the families, the workers are mandated reporters and must therefore report any signs of neglect or abuse. This creates an environment where the families cannot fully discuss situations or problems for fear of being reported and losing contact with their children. For the therapist, this is a difficult task in ensuring that youth are safe while focusing on treatment. Therefore, the “skill of the therapist in initiating therapy and gaining the family’s cooperation may assist the family in staying together and meeting treatment goals” (McWey et al., p. 144). Pacing versus time: Because most foster care youth have some type of behavioral health insurance, treatment may be time-limited. This is particularly notable for in-home therapy. In-home therapy is more intensive (seeing families more than once weekly), but as clients’ progress, the insurance company (Managed Care Organization—MCO) may change the treatment to only traditional outpatient therapy. This creates a problem due to families still wanting the same in-home therapist. Unfortunately, since outpatient therapy is deemed a different service, the in-home therapist cannot continue. Perhaps a key determinant of how clients interpret the intentions of the therapist is the therapeutic alliance.

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Families have “highlighted the value of the therapeutic relationship and how disruptive termination of that relationship can be” (McWey et al., p. 148). In the relaxation and mindfulness method, it was stated that homework might be assigned to clients. It is highly recommended that the caregiver become involved not only in the homework but also in participating in the sessions. Research has shown that when foster parents become involved with their foster youth’s music experiences, placements tended to stabilize (Zanders, 2012). It would then seem that involving the foster parent in the music therapy treatment would provide not only placement stability but also healthy attachment and bonding with the foster parent. Abad (2007) notes that “it is important to ensure that a child's early life experiences include provision for a loving, safe, and supportive environment, as well as an environment in which the capacity for attachment and close bonding between parent and child is available and realized” (p. 52). Music has long been associated with parent-child interactions and bonding. “The act of singing is one of the earliest and most common forms of musical interaction shared between a parent and child” (Abad, 2007, p. 53). Thus, music used with foster families aids in developing skills that enhance parent-child relationships.

RESEARCH EVIDENCE The literature on music therapy and foster care youth is limited and typically focuses on therapists’ work with at-risk or similar populations. Above, this author mentions briefly the clinical work done with foster youth by therapists (see “Needs and Resources”). Only one research study in music therapy has been completed that focuses on foster care youth (Zanders, 2012). This author has worked extensively with both children and adolescents in foster care. However, as a foundational study, a dissertation was completed that examined the musical and personal biographies of only adolescents with foster care experience. A structured interview was developed and used with a sample of 10 participants (six males, four females) enrolled in outpatient therapy. Participants were chosen based on three criteria: (1) were between the ages of 13 and 18 years, (2) had present or past experience in foster care placements, and (3) were willing and able to discuss their lives and musical backgrounds. A qualitative biographical inquiry was the specific method used to gather data on the musical lives of adolescents in foster care in order to discern how the musical and personal biographies may have been related to one another. In the study, a musical biography was defined as the sum total of music experiences a person has had and the various meanings given to them, both in the past and present. It was assumed that one’s musical life is part of one’s personal biography, which also includes nonmusical events, experiences, and meanings. The study was organized according to two basic questions: (1) What music experiences had these adolescents in foster care had throughout their life span, and what meanings had they attached to those experiences?, and (2) What relationships could be found between the musical and personal biographies? Results of the study showed that these adolescents with foster care experience used music consciously and actively in their everyday lives, similar to the ways in which adolescents with no foster care experience do. For example, adolescents with and without foster care experience share the same listening habits, music preferences, and ways they use music. The results also showed that the music experiences of these adolescents did affect their life in foster care, and their life in foster care did affect their overall relationship to music. In regard to foster care’s influence on an adolescent’s relationship to music, the results showed that when an adolescent had a relationship to music that was shared with a biological family member before foster care, this music relationship ceased when the participant entered foster care. Also, adolescents generally had a positive relationship with their foster family when involvement with music was encouraged. Conversely, music influenced the foster care experience of these

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adolescents. First, listening to music by oneself tended to increase in frequency and importance when the adolescent did not have a positive relationship or healthy attachment with the foster parent. Second, formal and active involvement in music (e.g., participating in school or group music, or taking lessons) seemed to be associated with a positive or healthy relationship with the foster family. Third, adolescents tended to listen to music for personal, psychological reasons, often to cope with the trauma, grief, and loss they continued to encounter throughout their lives. Implications for music therapy research, theory, and practice were drawn based on the conclusions, hence the formulation of this chapter.

SUMMARY AND CONCLUSIONS It is hoped that this chapter will provide some foundational information and interventions that are suitable for foster care youth. Music is a valuable resource for foster care youth, and the role that music plays in their lives is integral to making meaning of one’s life, particularly in the process of therapeutic change or growth. Foster care youth use music consciously and actively in their everyday lives. As this chapter shows, the difference is that youth with foster care experience have vastly different personal biographies, which is pertinent in understanding their mental health needs.

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Breslau, N., Lucia, V. C., & Davis, G. C. (2004). Partial PTSD versus full PTSD: An empirical examination of associated impairment. Psychological Medicine, 34, 1205–1214. Bright, R. (2006). Coping with change: The supportive role of the therapist. Australian Journal of Music Therapy, 17, 64–72. Bronfenbrenner, U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22, 723-742. Bruscia, K. (1998a). Defining music therapy (2nd ed.). Gilsum, NH: Barcelona Publishers. Bruscia, K. (Ed.). (1998b). The dynamics of music psychotherapy. Gilsum, NH: Barcelona Publishers. Child Welfare Information Gateway. (2012). Supporting families across the service continuum. Retrieved from http://www.childwelfare.gov/supporting/continuum.cfm Cohen, J., Mannarino, A., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: The Guilford Press. Cortes, L. (2004). Home-based family therapy: A misunderstanding of the role and a new challenge for therapists. The Family Journal, 12, 184–188. Crowe, B. J., & Colwell, C. (2007). Music therapy for children, adolescents, and adults with mental disorders: Using music to maximize health. Silver Spring, MD: American Music Therapy Association. Currie, M. (2004). Doing anger differently: A group percussion therapy for angry adolescent boys. International Journal of Group Psychotherapy, 54(3), 275–294. Currier, J. M., Holland, J. M, & Neimeyer, R. A. (2007). The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research. Journal of Clinical Child and Adolescent Psychology, 36, 253-259. Diaz de Chumaceiro, C. L. (1998). Unconsciously induced song recall: A historical perspective. In K. Bruscia (Ed.), The dynamics of music psychotherapy, pp. 335–364. Gilsum, NH: Barcelona Publishers. Dore, M. M. (1999). Emotionally and behaviorally disturbed children in the child welfare system: Points of preventive intervention. Children & Youth Services Review, 21(1), 7–29. Dore, M. M. (2008). Book Review: Burns, B. J., & Hoagwood, K. (2002). Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders. Research on Social Work Practice, 18, 526–527. Dvorkin, J. M. (1991). Individual music therapy for an adolescent with borderline personality disorder: An object relations approach. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 251-270). Gilsum, NH: Barcelona Publishers. Gardstrom, S., & Hiller, J. (2010). Song discussion as music psychotherapy. Music Therapy Perspectives, 28(2), 147–156. Goncik, R. S., & Gold, M. (1991). Fragile attachments: Expressive arts therapy with children in foster care. The Arts in Psychotherapy, 18(5), 433–440. Grocke, D., & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica Kingsley. Hadley, S. (1996). A rationale for the use of songs with children undergoing bone marrow transplantation. Australian Journal of Music Therapy, 7, 16–27. Hasler, J. (2008). A piece of the puzzle: Music therapy with looked after teenagers and their carers. In A. Oldfield & C. Flower (Eds.), Music therapy with children and their families (pp. 159–176). Philadelphia, PA: Jessica Kingsley. Iliya, Y. A. (2011). Singing for healing and hope: Music therapy methods that use the voice with ndividuals who are homeless and mentally. Music Therapy Perspectives, 29(1), 14–22. Jacobsen, E. (1938). Progressive relaxation. Chicago, ILL: University of Chicago Press.

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Johnson, L. N., Wright, D. W., & Kettering, S. A. (2002). The therapeutic alliance in home-based family therapy: Is it predictive of outcome? Journal of Marital and Family Therapy, 28, 93–102. Katsh, S., & Merle-Fishman, C. (1985). The music within you. New York: Simon & Schuster. Keen, A. (2004). Using music as a therapy tool to motivate trouble adolescents. Social Work in Health Care, 39(3–4), 361–373. Kerker, B. D., & Morrison-Dore, M. (2006). Mental health needs and treatment of foster Youth: Barriers and opportunities. American Journal of Orthopsychiatry, 76(1), 138–147. Landsverk, J., Davis, I., Ganger, W., Newton, R., & Johnson, I. (1996). Impact of child psychosocial functioning on reunification from out-of home placement. Children & Youth Services Review, 18, 447–462. Maranto, C. (1993). Applications of music in medicine. In M. S. Heal & T. Wigram (Eds.), Music therapy in health and education (pp. 153–174). Philadelphia, PA: Jessica Kingsley. McFerran, K., Roberts, M., & O’Grady, L. (2010). Music therapy with bereaved teenagers: A mixed methods perspective. Death Studies, 34(6), 541–565. McFerran-Skewes, K. (2003). Contemplating the nature of adolescent group improvisation. Voices: A World Forum for Music Therapy, 3, 3. McWey, L. M., Humphreys, J., & Pazdera, A. L. (2011). Action-oriented evaluation of an in-home family therapy program for families at risk for foster care placement. Journal of Marital and Family Therapy, 37(2), 137–152. Moore, K. A. (2006). Defining the term “at risk.” Reasearch to results: Child trends. Retrieved from http://www.childtrends.org/Files/DefiningAtRisk%5B1%5D.pdf NASW standards for social work practice in child welfare (2005). National Association of Social workers. Retrieved from http://www.socialworkers.org/practice/ standardsNASWChildWelfareStandards0905.pdf Pelcovitz, D., Kaplan, S. J., DeRosa, R. R., Mandel, F. S., & Salzinger, S. (2000). Psychiatric disorders in adolescents exposed to domestic violence and physical violence. American Journal of Orthopsychiatry, 70, 360–369. Reher, M. (2003). The dance of belonging: An exploration of identity through the Bonny Method of Guided Imagery and Music. In D. Betts (Ed.), Creative arts therapies approaches in adoption and foster care: Contemporary strategies for working with individuals and families (pp. 41–61). Springfield, IL: Charles C. Thomas Publishers. Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York, NY: W. W. Norton & Company. Ruud, E. (2010). Music therapy: A perspective from the humanities. Gilsum, NH: Barcelona Publishers. Salkeld, C. (2008). Music therapy after adoption: The role of family music therapy in developing secure attachment in adopted children. In A. Oldfield & C. Flower (Eds.), Music therapy with children and their families (pp. 19–36). Philadelphia, PA: Jessica Kingsley. Sieracki, J. H., Leon, S. C., Miller, S. A., & Lyons, J. S. (2008). Individual and provider effects on mental health outcomes in child welfare: A three-level growth curve approach. Children and Youth Services Review, 30, 800–808. Skewes, K., & Thompson, G. (1998). The use of musical interactions to develop social skills in early intervention. Australian Journal of Music Therapy, 9, 35–44. Stratton, V. N., & Zalanowski, A. H. (1984). The relationship between music, degree of liking, and selfreported relaxation. Journal of Music Therapy, 21, 184–192. Tarren-Sweeney, M. (2008). The mental health of children in out-of-home care. Child and Adolescent Psychiatry, 21(4), 345–349. Thaut, M. H., & Davis, W. B. (1993). The influence of subject-selected versus experimenter chosen music on affect, anxiety, and relaxation. Journal of Music Therapy, 30(4), 210–233.

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Wheeler, B. L. (1983). A psychotherapeutic classification of music therapy practices: A continuum of procedure. Music Therapy Perspectives, 1, 8–16. Zanders, M. L. (2008). Metaphors clients use to describe their experiences in BMGIM. Qualitative Inquiries in Music Therapy: A Monograph Series, IV, 45–68). Zanders, M. L. (2012). The musical and personal biographies of adolescents with foster care experience. In L. Young (Ed.), Qualitative Inquiries in Music Therapy: A Monograph Series, VII, 71–109.

Chapter 7

Survivors of Catastrophic Event Trauma Ronald M. Borczon _____________________________________________ DIAGNOSTIC INFORMATION Trauma in communities may be categorized into two types, those caused by man and those caused by nature. Examples of traumatic events caused by man include: the Sandy Hook elementary school shootings in December 2012; the July 20, 2012, movie theater shooting in Aurora, Colorado; the April 16, 2007, Virginia Tech shootings; the attack on the United States on September 11, 2001, by terrorists; the April 20, 1999, Columbine High School massacre; the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City; and all acts of war. Examples of nature-induced trauma are: October 29, 2012’s Hurricane Sandy along the east coast of the United States; the March 11, 2011, earthquake and tsunami in Japan; tornados of 2011 and 2012 in the United States; the earthquake in Port-au-Prince, Haiti, on January 12, 2010; August 28, 2005’s Hurricane Katrina; and the October 2003 Cedar Fire in San Diego County, California. Whether it is manmade or nature-induced, the traumatic effect of these events on the populace can be devastating and long-lasting. While there are many survivors in the communities, the communities are nonetheless made up of individuals who are all coping with the trauma in their own way. These traumatic events can completely overwhelm an individual in her ability to cope with emotional fallout from the experience, and this can lead to the development of Posttraumatic Stress Disorder (PTSD). The DSM-5 (American Psychiatric Association [APA], 2012) cites that some of the symptoms include having intrusive distressing memories of the event; recurring distressing dreams related to the event; flashbacks as if the traumatic event were reoccurring; and physiological reactions because of being reminded of the event. Because of the significance of the event, there can be lingering feelings of fear, sadness, helplessness, guilt, and hopelessness. Additionally, there can be a feeling of detachment and a difficulty in relating to others. Often overlooked regarding the diagnosis of PTSD is the consideration of the diagnosis of Acute Stress Disorder (ASD). Many of the experiences that lead to the diagnosis of PTSD are found within the description of Acute Stressed Disorder, the primary difference between these disorders being that in Acute Stress Disorder, the symptoms occur within one month after the exposure to traumatic event and must last at least two days (DSM-5 Development, APA, 2012). The other prominent difference is that ASD is more associated with dissociative symptoms, which may include extreme emotional disconnection, difficulty experiencing pleasure, temporary amnesia, depersonalization, and derealization. If the experiences associated with Acute Stress Disorder last more than one month, the case moves into the diagnostic area of PTSD (APA, 2012).

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NEEDS AND RESOURCES Concept of Trauma Both natural and man-made disasters carry with them destruction, devastation, stress, loss, and trauma. It is necessary to understand the impact that trauma may have on an individual following a disaster and how it may affect one’s ability to survive physically and emotionally. A survivor of mass trauma moves from the immediate focus on survival to that of eventually rebuilding her life. The experienced trauma, without treatment, can linger for months or even years. While the diagnostic criteria for PTSD is comprehensive, the psychological effect of the traumatic experience on a community can vary to some extent by the cause of the event. When the cause of the trauma is based in human actions, the two main psychological responses that come to the forefront are anger and hopelessness (Loewy, 2002b, p. 26). With trauma initiated by human behavior, the victim can feel anger toward a specific person(s) that, through therapy, can be explored and processed. In nature-induced trauma, there is no human entity to point to as the cause. Loewy (2002b, in citing Lifton & Olsen, 1976) states, “when nature afflicts humans, they tend to ultimately accept the event as fate or as the will of God” (p. 27). McFarlane and Potts (1999) also support the concept that manmade disasters are more likely to be difficult for individuals to tolerate than natural disasters.

Effects of Trauma The effects of a large-scale traumatic event can be extensive. The aftermath of a traumatic event can be thought of as a long echo into the future: a direct and immediate link to a past event which extends along after rescue services have left the scene. This is often experienced as a form of compressed time, in which our earliest experiences instantaneously meet an event in the present that changes the future forever (Schimpf et al., 2010, p. 103). Sutton (2002) also uses the metaphor of an “echo” illustrating the wide range influence of a single traumatic event, stating that not only are those who survived the trauma affected, but also those involved in rescue services as well as an extended community that views the event and its aftermath through the media (p. 27). The memories associated with a traumatic experience can be vividly remembered or may be blocked out by dissociation. Many survivors of trauma state that the particular emotions, images, sensations, and muscular reactions related to the trauma are deeply imprinted on in their minds (van der Kolk & Fisler, 1995) and these experiences become “frozen” within them. In essence, the survivor who lives in a state of dissociation still has these experiences “frozen” within, although the brain, in its present state, is not accessing the memory. The idea of being “stuck” and/or “frozen” in the trauma can manifest itself in such a manner that the individual’s normal level of functioning is disrupted. Sutton and De Backer (2009) state: “External trauma can come into someone’s inner world in a shocking and alarming way, where it remains unknown until the point at which psychic pain is experienced, even when there may be no conscious experience of this pain (as with dissociation). As a result of the inner impact of an external trauma, a normal way of living is disrupted” (p. 76). The need for expression, release, and/or reframing of these memories is at the core of trauma work.

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Trauma leads to stress. In the physical sense, stress is needed in life to survive as our bodies utilize stress to function; cognitively, our minds use stress to move forward toward goals. But in terms of traumatic stress, Mitchell (2007) states: “Stress, however, is expensive. It consumes a great deal of emotional and physical energy” (p. 234). Some of the effects of stress are: 1) 2) 3) 4) 5) 6) 7)

Blood pressure rises Breathing becomes more rapid Digestive system slows down Heart rate (pulse) rises Immune system is compromised Muscles become tense Sleeplessness (heightened state of alertness)

Whether the trauma is caused by human involvement or by nature, there is a shock factor that is immediately experienced by the community. If the event is a natural disaster, there may be a need for food and shelter as well as medical assistance. This chapter is not intended to go into the methodology of immediate Psychological First Aid. “Psychological First Aid is a supportive intervention for use in the immediate aftermath of disasters and terrorism. Psychological First Aid is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping” (Brymer et al., 2006, p. 4). Rather, this chapter is designed for one involved in the treatment of trauma weeks or months after the event has occurred. Within this time frame, the effects of the traumatic event may become more internalized. It is interesting to note, however, that after a catastrophic event there is a resolution of symptoms for many, and these persons do not develop PTSD. “Only a minority of the victims go on to develop PTSD, and with the passage of time, the symptoms will resolve in approximately twothirds of these” (Macfarlane & Yehuda, 1996, p. 156). While a clinical diagnosis of PTSD may not be applied to many of those affected by the trauma, there may be many of the features of the diagnosis that are experienced to a lesser extent. This can include anxiety, stress, emotional disturbance, pressured social interaction, concentration, sadness, and a sense of loss. In working with groups, the following goal areas can be addressed: 1) 2) 3) 4)

Relieve tension through the musical experience and expression of anxiety Explore feelings Look for and/or foster signs of hope Explore the use of musical tools as stress relief strategies—i.e., when the therapist leaves thinking “What can I leave them with?” and “What can they take and remember from this?” (Schimpf et al., 2010, p. 108).

Music Therapy and Trauma Levine (2002) states: “Trauma, a disorder of helplessness and disconnection, has at its core a profound dysregulation of internal physiological rhythms” (p. 151). Volkman (1993) states that a relationship to the traumatic material is repressed and “health suffers as a consequence. Energy is bound, disturbing the natural cycle of tension and release” (p. 234). In both of these descriptions, there are attributes of music mentioned. Levine speaks of rhythm, and Volkman speaks of tension/release that is akin to harmony. The complexities of emotional disruption and physical manifestation of the stress or trauma bring individuals and communities into a need for avenues of treatment that are both conventional and unconventional. The use of music as a treatment modality is becoming more widely accepted as a complementary means of

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treatment. Schimpf et al. (2010) look at the many aspects of using music in the treatment of traumatized individuals. Music has a unique ability to assist individuals to reorient themselves following a traumatic event. Music can also provide opportunities for reentry into communities that have experienced mass trauma, as music’s timbres and tones affect the body and may assist in organizing the mind. Additionally, one can develop integrative mechanisms to support reframing of the traumatic event. By this, we can understand the power of music to recontextualize, and thus shift, the experience of past threatening and overwhelming trauma experienced by individuals and groups in the aftermath of traumatic experiences (p. 117). Borczon, Jampel, and Langdon (2010) speak of the importance of music in creating a safe environment and opening up the psyche through the music experience. The importance of music is paramount as it is the vehicle that allows the psyche to be opened to new ways of working through trauma. The therapist aims to create a safe environment through it with the music while helping the trauma survivors discover tools that he or she can use in their journey in recovery. Through this process, music therapy attempts to strengthen the client’s feelings of positive self-regard by facilitating deep engagement in the aesthetic and emotional dimensions of the music experience (p. 39) . Levine (2002) addresses the biosocial level of the individual and how important the music experience is in helping a traumatized person move through the feelings that they become “stuck” in. Traumatized people tend to get stuck—stuck in their trauma, stuck in the sensation of emotions and the feelings. The beauty of music and rhythm is that they allow people to move through the trauma at a fundamental biosocial level free of second-guessing and critical self-judgment (p. 39). The community is also brought together through music experiences. The idea of Community Music Therapy such as community music circles and drum circles can facilitate a sense of belonging and shared purpose, expressing elements that may have been lost, damaged, or threatened by a traumatic event. Community Music Therapy has no identified “patient,” but instead focuses on the community and the group process. Through the music experience, those who have felt isolated or without a “voice” can find connection with others and expression of their deepest feelings (Stige, 2002). According to Herman (1992), recovery from trauma has three stages: the establishment of safety; remembrance and mourning; and reconnection with self and others and finding meaning and purpose. The music therapy experience after a traumatic event can be utilized in these three stages. Volkman (1993) uses this model in using music therapy for the treatment of trauma-induced dissociative disorders. These stages can occur within either a group or individual therapy session and can exist in either a onetime experience or over a span of time. Many of the interventions that are offered in the remainder of this chapter will be addressing these stages.

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The Affected Community Often after a large-scale traumatic experience the surviving community experiences a coming together that may not have been present before the event. The shared experience creates a new sense of community in that they all have gone through and survived something extraordinary. There is a shared sense of loss that binds them together. Many of them might be in a “survival mode,” where the main concern might be staying alive as well as assessing the damage inflicted. There can be an activation of the “fight or flight” response that is continual through the days/weeks/months following the event. If enough individuals become stuck in this stage, they will not be able to move forward to psychologically to rebuild the sense of self, hence the community. Thus, the coping skills of the community will be tested through the weeks and months to follow, and how the individuals of the community process and work through the event can help in the redefinition of the community. Tramotin and Halpern (2007) mention how close relationships become more important as well as thoughts about the purpose of life. These existential feelings can be a way in which the community can find affirmative avenues to connect that can supersede the feelings of loss. The music experience can help the community express the feelings of loss as well as help to connect the community members to a sense of purpose. These shared experiences and the strength of the community can be actualized through music.

The Therapist’s Experience Last, the therapist who is providing services in this setting must be prepared for the responses that may come during the sessions. “One must be prepared to deal with the demons one invites. This requires confidence in one’s own abilities, knowledge of the direction to pursue, and faith in this particular process of healing. By offering such a space, the door is open for traumatic material to emerge, and it will” (Volkman, 1993, p. 246). “In working with traumatized individuals, the greatest challenge is to remain present in the face of the unbearable. To do this while also remaining musically present requires sensitivity, tenderness, passion, and thoughtful diligence” (Schimpf et al., 2010, p. 105). These two previous quotations point out the dangers of this work and imply the personal tools that are required of the therapist. Mass trauma carries with it a palatable energy that exists within and between the survivors. This energy is fluid, with an ebb and flow as if it is, in itself, a personality that becomes ingrained in the soul of those who survived the event. It can be seen in their eyes, felt in their touch, and heard in their words. The music therapist must be able to empathize and yet keep that healthy distance for his own well-being. The music therapist must take care of himself through supervision and his own therapy. Figley (1995) speaks of “secondary traumatic stress” as that “stress resulting from wanting to help a traumatized or suffering person” (p. 53). If the music therapist is also part of the environment where the trauma occurs, it might be necessary to seek supervision and therapy from someone outside the region, as this can provide for an objective viewpoint and an avenue of support. Through all of this, the music therapist must have faith that the music will do its work in the therapeutic process. It is through the music that the individual can understand her own emotional reaction to what has happened and begin to realize that there will be a “new normal” that will now be integrated into her personality.

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OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy •

•

Relaxation Experiences: The therapist creates live music or uses recorded music with breathing and progressive muscle relaxation techniques to promote the client’s relaxation. Storytelling with Music: The therapist creates live music and narrates a mythical story to facilitate discussion and meaning-making related to the event the clients have experienced.

Improvisational Music Therapy • •

Group Drumming: involves clients repeating a rhythm in a group drumming experience followed by a discussion. Group Expressive Improvisational Experience: The client plays an instrument(s) individually to express how she feels, then plays how she would like to feel while being supported by group members improvising with her.

Re-creative Music Therapy •

Song Sensitation: A client chooses a song and listens to it in a relaxed state, then in a more alert state; the song is processed with journaling, art, and/or discussion, and then the song is re-created in the group.

Compositional Music Therapy • •

Group Songwriting: Clients create their own lyrics based on a melodic and/or harmonic sequence provided by the therapist and then sing it together. Narratives/Poetry to Music: Clients create a written poem or narrative and guide the group in choosing instruments and playing them to accompany the recitation of the written work.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Relaxation Experiences Overview. The therapist creates live music or uses recorded music with breathing and progressive muscle relaxation techniques to promote the client’s relaxation. Anxiety is a common feeling in those who have PTSD and “by raising the threshold for anxiety, [one can] reduce the likelihood of resurgence of traumatic memories” (Swallow, 2002, p. 50). Anxiety can also lead to physical and emotional issues that can create more stress in the survivor. Experiences such as feeling lethargic, having shortness of breath, a general feeling of uneasiness, difficulty in falling asleep, feelings of being overwhelmed, fear that the event will reoccur, and feeling like the heart is beating too fast or pounding in the chest are just a few of the many symptoms of anxiety. Child soldiers of Uganda in a rehabilitation center thrived in music therapy specifically noting that they liked relaxation exercises (Harris et al., 2010).

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Surviving a traumatic event can be overwhelming, inducing much stress and anxiety. Therefore, learning to induce the relaxation response by learning relaxation skills can be a valuable tool. In many cases, the survivor(s) may need to learn these skills for the purpose of desensitizing the anxiety-producing thoughts. In addition to finding a sense of peace, relaxation can induce the experience of positive images as well as increase positive self-regard through affirmations. This is an intensive level of therapy; the music therapist should have advanced training and an understanding of posttraumatic stress disorder as the client(s) may also open up verbally after the experience. The knowledge of properly inducing the relaxation response is also needed. Sometimes the trauma survivor feels quite vulnerable when asked to close her eyes. This is something the therapist needs to be aware of and discuss with the client prior to beginning the relaxation session. Preparation. The room should have warm, low lighting and a comfortable reclining chair or a couch that is long enough to lie down upon. Having a quiet place is conducive to working with relaxation. If using prerecorded background music, there should be good sound system where the volume can be controlled by remote. If using live music, the instruments should be of good quality. What to observe. As the client begins to relax, watch for signs that the client is following instructions. For example, if the therapist is asking the client to take a long, deep breath to a count of four, he must watch and see if she is doing that and being present in that moment. Watch for any sign of discomfort or affective responses where the client appears to be having a negative reaction to the experience. The therapist can also ask the client to raise a finger if she is feeling uncomfortable at any time during the session. After the session, look for affect and visual signs of a relaxed client. Notice a more relaxed body language and less muscle constriction in the face. Relay these observations to the client as an affirmation of what was just achieved. Procedures. Either live or recorded music can be used for this session. If live music is used, it is important that the therapist is completely comfortable with the instrument that is being used so that the focus can be entirely on the client. Using an instrument is a way to regulate the beat and the overall sound while being involved in the session. Some live music ideas are: using a hand drum with its many different sounds to keep a beat and to provide different timbres within that beat; using a keyboard synthesizer to provide a background sound pad and, if wanted, a controlled beat that can also be increased or decreased; using a guitar, often tuned to an “open” tuning that can act as a drone and also have simple melodic contours; and creative use of any instrument that can provide for a drone and controlled rhythm. When using recorded music, it is important that the music have a slow rate of rhythm. While client preference is always a consideration, the therapist might have three or four styles of music ready and provide the client with an opportunity to briefly listen to each in order to choose the style to which she most relates. Deep breathing is part of most relaxation exercises. Conscious control of the breath through a rhythmic structure allows for the body to relax. The rhythmic structure that is often used is four beats inhale, four beats hold, four beats exhale, four beats rest, and then start again with the inhalation. The introduction of the “progressive relaxation model” would be next in a basic relaxation exercise. In this, the client will tighten up muscle groups and then relax them. In tightening up the muscle groups, they should be held for a short period of time and then let to fully relax. The progression through the muscle groups is as follows: 1) 2) 3) 4)

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If the purpose of the exercise is to understand what relaxation is, then this experience in and of itself will accomplish this goal. Once the experience is over, it is good to ground the client in this feeling by having her think of a word or phrase associated with the relaxation response that she can say or think of when she starts feeling anxiety. Positive affirmations, positive images, and desensitization can then be then introduced at the end of the progressive relaxation exercise. Processing the event with the experience includes discussing what the exercise was like and how this can help the client outside the therapy session. In helping to control anxiety, it is necessary for the client to practice the relaxation skills. Giving the client prerecorded music that has a script over it can help in this area. Additionally, having the client anchor the experience by focusing on a word or phrase when they are deeply relaxed, or even holding something physical such as a small stone or something else with which they are comfortable can aid them in calling upon the relaxation response when they are feeling anxiety. Personalized recordings can be made for the client that can address the client’s needs. Also, short recordings can be given as a means for small “tune-ups” during the day. Adaptations. This experience can also be integrated with a compositional method. Having the client take an active role in recording her own relaxation piece can be quite empowering. The therapist can utilize recording programs that include various instruments and sounds from which the client can choose; the combination of synthesized sounds with live-recorded sounds is also effective. Instruments that are easy for the client to play for this experience are gongs, drums, chimes, singing bowls, xylophones, metallophones, kalimba, strum sticks, tank drums, shruti box, and tamboura.

Storytelling with Music Overview. This involves the therapist creating music and telling a mythical story to facilitate discussion and meaning of the story and relating it to the event the clients have experienced. “Myths have vital meaning. Not merely do they represent, they are the psychic life of the primitive tribe, which immediately falls to pieces and decays when it loses its mythological heritage, like a man who has lost his soul” (Jung, 1964, p. 248). When a story or a myth is told over a musical landscape, the words of the story seem to be given a different life for the client as opposed to telling a story without music. When rhythmic entrainment or a background drone is used, the clients are drawn in and experience the story in an almost meditative or trancelike state. For rhythmic entrainment, the utilization of a hand drum is preferred; a type of musical or sonic entrainments can be accomplished with drone instruments, which can include an open-tuned guitar, a zither, or harplike instruments tuned to d-e-g#-a-b (which creates an ethereal background); tamboura; shruti box; or any other instrument that creates a background soundscape. Stories and myths combined with music can be a powerful means for self-discovery and can stimulate discussion of feelings regarding traumatic events. Rubin-Bosco (2002) utilizes a technique called “story song” wherein the client participates in creating a story with music. “Story song is a technique that offers a safe container for resolving a traumatic event. The story song structure offers a creative working through one’s issue. Story song offers us a safe container to reenact issues that we may be through with” (p. 120). The use of storytelling can help clients identify with aspects of the story and then internalize the morals of the story as well as the meaning behind why they identify with certain characters and situations that occurred during the story. This can lead to new insights into the feelings that the survivor is experiencing but may not be able to identify without an external frame of reference. These feelings and insights can be further examined through improvisation and the writing of their own story presented as an ancient myth. Unresolved trauma may become evident and addressed during this process. The music therapist should be able to understand the concept of archetypes and symbols and how they are activated via the story.

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The use of story with music can be a powerful means of energizing the feelings frozen by the traumatic event, and because of this, sometimes the client can become overwhelmed. In becoming overwhelmed, the client may fall apart and become very fragile or the client may shut down and emotionally dissociate from experiencing the story. This is an intensive level of therapy wherein the music therapist should have advanced verbal processing skills. Preparation. “Whenever a fairy tale is told, it becomes night. No matter where the dwelling, no matter the time, no matter the season, the telling of tales causes a starry sky and a white moon to creep from the eaves and hover over the heads of listeners” (Pinkola-Estes, 1995, p. 504). This description of what can occur during the telling of a story also can be a model of what the environment should be. There should be a comfortable environment where the clients can lie down if they wish and if possible have a dimming of the lights. There should be a sense of calm so that the clients can allow the words and music to come into their presence and be accepted by them. What to observe. While telling the story, it is important to be able to observe the clients in their resting state, watching for any overt signs of discomfort, anxiety, or pleasure. These should be mentally noted so that they may be processed when the story is over. Procedures. Finding the story to tell and what music to use is a process. Stories such as that of Khdir and Moses (Borczon, 1998) and Too-too-moo and the Giant have morals that can be applicable to working with survivors of trauma (http://www.aaronshep.com/stories/022.html). Both of these utilize a constant drumbeat that entrains the listener as well as a short song that recurs at select points during the story. As a synopsis of the first story, Khdir and Moses are walking together, and Khdir asks Moses not to question what will happen that day as Khdir seemingly instigates three acts that appear destructive to communities and a person. Moses questions each one, breaking his promise to Khdir. After Moses questions him, Khdir sings to Moses a song stating, “The things that I do you may not understand, you promised not to question me.” After the third question, Khdir says to Moses that they can no longer walk together but he does explain to Moses why each situation happened. In this explanation, Moses learns that something greater comes out of each one of the events. The therapist helps the clients to process the story with the theme of trying to understand why things happen in the world. Many times in the aftermath of traumatic events, clients verbalize that they must make sense of what the future might hold, even though they cannot see it now. Understanding the story on two levels is imperative. The first level is the moral(s) of the story. Here the clients can discuss what they believe the story is teaching them and whether or not they can relate it to their lives. The second level of the story is how the characters or the events of the story resonate with the listener. On this deeper level, the symbolic nature of the story comes to life. Jung (1935) postulates that myths and fairy tales are likened to dreams in that the psyche tells its own story, and the interplay of the archetypes is exposed. Moving to this level of processing requires the therapist to understand how the client’s relationship to symbols from the story can be explored in a therapeutic manner. Knowing how to ask the right questions of the client based on how the client attaches herself to the symbol requires an adept form of verbal processing.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY “What I have rediscovered is that music, and in particular improvisation, can evoke positive, lifeenhancing attitudes despite the external conditions that create instability and fear. Taking action by creating music can move one past the sense of helplessness that one often feels when experiencing trauma” (Turry, 2002, p. 50). Limb and Braun (2008) did a study in which they discovered that during improvisation with jazz musicians, the prefrontal cortex essentially “shuts down,” allowing for improvisational material to come from “a combination of psychological processes required for

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spontaneous improvisation, in which internally motivated, stimulus-independent behaviors unfold in the absence of central processes that typically mediate self-monitoring and conscious volitional control of ongoing performance” (p. 5). In essence, this points to the fact that improvised music comes from a deeper place that is not consciously monitored, and it opens up the person’s emotions allowing them to flow freely. According to Volkman (1993), “Musical improvisation gives the individual the power to respond. Improvisation goes beyond the telling of the details, combining the story, the emotions in an active response” (p. 250). Improvisation is a powerful tool to help the community express, resolve, empathize, and unite through music.

Group Drumming Overview. This involves clients in a group drumming experience followed by a discussion. Drumming has been used with various groups of trauma survivors. Burt (1995) and Bensimon, Amir, and Wolf (2008) used drumming with veterans; MacIntosh (2003), with survivors of sexual abuse; Bosco (2010), with groups after 9/11; Slotoroff (1994), in a psychiatric setting with adults and adolescents; and Borczon, after the 1994 Northridge earthquake, the 1995 Oklahoma City bombing, and Hurricane Katrina in 2005. Through these drumming experiences, the participants were able to express feelings often through cathartic release on the drum as well as finding a new way of communicating. This experience can address many individual goals as well as goals of the community. The expression of individual feelings can create group cohesion and sense of community through shared feelings. Along with sharing, empathy can be expressed and experienced. The physical action of playing percussion instruments can help reduce tension and anxiety. Introducing positive affirmations into the drumming experience can instill hope. Individuals can explore being creative and also find a sense of emotional and physical grounding. Drumming can be overpowering for some individuals, especially if the traumatic event is associated with loud sounds. However, drumming can also be empowering because a survivor can find a sense of control with the loudness of the experience. The sound of drums in rhythm can also activate overwhelming emotions as entrainment occurs and reaches into repressed energy. The sound of the crystal toning bowl can also have a negative effect on some of the participants. The music therapist must be skillful in moving from an augmentative level of music therapy into an intensive one when needed. Being able to be creative in the moment is necessary to adeptly maneuver what begins as a drum circle into a therapeutic experience. Preparation. It is important to have high-quality drums and percussion equipment. The participants should not feel like they are doing a childlike activity based on the appearance and the sound of the equipment. The resonance of good instruments is imperative so that the body can experience vibration. The room is generally set up in a circle with a large gathering drum in the center of the circle. Have a quartz crystal toning bowl of at least 18 inches in diameter sitting on the gathering drum. The instruments should be placed on a table outside of the circle. What to observe. As the participants become involved with the session it is important to watch for anyone having an abreaction to the experience. This can be seen in the change of one’s affect, the slow or immediate disengagement from playing an instrument, or an individual leaving the room. The manner in which one plays the instrument can give the therapist information on her level of presence in the activity. For example, if the instruction is to become quiet and an individual continues to play strongly, this could point to dissociation experienced by the participant. Procedures. The beginning of the session starts with an overview of what will happen, stating that it will be a time of creating rhythmic music together. This overview is very general, as it is unknown what will come out of the session at this point. A brief explanation as to what the sound of the crystal

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toning bowl will be like follows, with the caveat that if anyone is bothered by the sound, they should plug their ears and/or step out of the circle until the playing of the bowl is finished. It is explained that the vibration that they will feel from the bowl is similar to the vibration that occurs between each one of them, that they cannot see the vibration, but they certainly can feel it. The bowl is then sounded, and individuals are invited up in small groups to put their hands near the toning bowl to feel the vibration emanating from it. They are also given the option not to come up and feel the vibration if they do not wish to. After all of those who wish to experience the bowl have returned to their seats, the bowl is not put away until the sound completely fades away. A brief introduction is given on how to play the various types of drums. The individuals in the group are instructed to find a drum they want to play. They are then invited to explore the various sounds they can get from their instrument. The first experience is to help the group play in rhythm by teaching them the following constructs. Rhythms are taught via accents/meter and are associated with nonmusical concepts. The feeling of two (strong–weak) is given to them, saying that this is the feeling of rhythm that “opens the door.” The feeling of three (strong–weak–weak) relates to “moving the body.” The feeling of four (strong–weak–weak–weak) “opens the mind.” The feeling of five (strong–weak–weak–weak–weak) “touches the soul.” With this basis of rhythm, the group immediately begins to bond. They are then taught how to play within the beats. With the therapist providing a strong unmetered beat, the group is asked to play along initially with that beat and then to find a rhythm on which they can then focus and play over and over again. Within this experience, various facilitation techniques can be used, such as getting louder and softer, having certain parts of the group play while others remain quiet, and also inviting small groups to come up to the center drum and play together. When this first experience comes to a close, everyone is instructed to take a good deep breath, and then an open-ended question is asked about how that experience was for each person. After a brief processing time occurs, the question is asked about how they have been doing since the event. During this process, connections among group members are made. When this comes to a close, the question is asked, how would each person like to feel? Through this experience, various words are gathered based on the discussion, and these words will become a “home base” for the next rhythm activity. This sense of “home” will be made up of the rhythm of the syllables of words chosen, with attention given to making the last word one syllable for a sense of finality. A “home base” might be made up of words such as: calm, peaceful, hopeful, secure, happy, free. The participants are taught the rhythm and are asked to say the words as they play their rhythm. The next experience begins with the home base played three times, and then the group is free to play their own rhythms with an underlying beat. Periodically, the leader will call out the home base and the entire group will unite in the same rhythm. As the section concludes, the drums fade away and there is only a quiet chant of the words. The group is instructed to take a deep breath, and then the group processes that experience. The session ends with the leader playing a quiet drumbeat in the group and chanting the words from the home base. If the group is not extremely large, there can be a sense of closing by having each participant pass a harmony ball from one to another and mention what they will remember from this session. Adaptations. Bosco (2010) gives another protocol that he calls “drum dialogue” that can be added to the above experiences. He explains it as: 1) Say it, then play it: The client first voices her feelings, then plays them on the drum. 2) Play it, then say it: When it is more difficult to articulate an emotion verbally, the client is asked to attune to it and express it through drum play. This drum play can then be translated into words and/or discussed. It can function as a step toward enhancing the

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client’s ability to express their feelings verbally in therapy and can improve selfexpression in a life situation that triggers the same or similar emotions. 3) Say and play it together: The therapist demonstrates the act of accompanying the articulation of each word or syllable with a tap on the drum. The client is then asked to replicate this activity as they continue their verbal process with the support of the therapist. This is a more challenging experiment that may require other supportive techniques, such as supplying a steady rhythmic accompaniment. 4) Say it with a steady rhythmic accompaniment: The client and/or therapist provides a background rhythmic structure to support and enhance verbal expression. The client is asked to verbalize issues pertaining to the therapy process, while using the constant drum rhythm to emphasize expression and to spur the process forward. Elements of the third technique can be incorporated into the steady rhythm. This is an improvisational form, similar to a musical solo with accompaniment. 5) Therapist adds emphasis to client’s words: Using a steady rhythm, as in the fourth technique, the therapist emphasizes the words of the client by using rhythmic accents and articulations. Repetition of the client’s words, as well as appropriate verbal interventions, can be infused into this process as a variation that yields a more complete client-therapist exchange (p. 66). Another adaptation occurs when the drumming is progressing and it sounds like the community does not need the leader to still keep a beat. In this situation, the leader can turn to a melodic or harmonic instrument to play such as an Indian flute, tin whistle, strumstick, guitar, banjo, or accordion. A chant using the words of positive affirmation can be put into a song that is sung as part of the process. Finally, adding other percussion instruments to the mix can add variety and allow for more personal expression.

Group Expressive Improvisational Experience Overview. In this group experience, the client plays an instrument(s) individually to express how she feels, then plays how she would like to feel while being supported by group members improvising with her. The participants should have prior experience of a more structured form of improvisation or at least an extended warm-up on the instruments that are to be used. This prior experience will help the person feel more comfortable with the medium of music, instruments, rhythm, and expression. “By playing music together as a group and processing what was in the music, the feeling of being silenced and isolated changed into a feeling of being listened to and connected to others” (Scheiby, 2002, p. 93). Herman’s (1992) threefold process for recovery from trauma can take a great amount of time; however, each stage can be part of the process of an improvisational experience. Volkman (1993) utilizes this approach in the treatment of trauma-induced dissociative disorders. The improvisational experience can address many goals for the survivors of a traumatic event. The physical aspect of playing instruments can help to release anxiety and tension that are experienced with PTSD. The improvisational experience can be structured to help in the expression of feelings as well as providing emotional grounding. Participants can support others musically, and feelings of empathy can be fostered. The music that comes from the creative outlet of improvisation can be utilized as a metaphor to what is going on in the survivors’ lives. They can find hope and learn to develop coping skills from the improvisation experience. The music therapist should be adept at understanding how to relate the music that the group creates to aspects of living.

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In this experience, there is also a possibility of being overwhelmed by emotions that may be evoked through the music. Memories that have been repressed may become energized and conscious and thus surprise the survivor. When this happens, the sense of ego can disintegrate because the feelings are too much to handle. Thus, the therapist’s musical and verbal processing skills need to be at a high level. This experience is at the intensive level of music therapy. Preparation. Quality percussion pitched and nonpitched instruments should be utilized so that the participants can truly experience their vibrations. The instruments can be in the center of the circle or outside the circle of the table. If the group feels comfortable, they can sit on the floor in a circle. Have a quartz crystal toning bowl of at least 18 inches in diameter sitting in the middle of the circle. What to observe. In sessions such as these, there can be a participant who begins to monopolize the discussion, leaving little time for others to process their experience. Being able to adeptly maneuver this situation is critical so that no one in the group is alienated. It is sometimes necessary to ask someone who obviously needs more time if they would like to meet after the group. Watch for any signs of someone who might be beginning to emotionally fall apart. This might be indicated when someone begins to sob, becomes shaky, or disengages/dissociates from the experience. Procedures. In utilizing the Herman model (1992), the first part of the session is devoted to creating a safe place. Sounding the quartz toning bowl and having the participants gather around it to experience its vibration and to breathe slowly helps bring the group into a sense of calm through sound, vibration, and the regulation of their breathing. Following this, there is a check-in to see where people are in the moment (if the group has played the instruments before, then they can utilize the instruments to describe their current state). If the instruments are new to the group, the therapist can demonstrate how to play each of the instruments and explain that the instruments can also be played symbolically and as transitional and communicational objects (Scheiby, 2002). The group members are then invited to try out different instruments. The therapist leads the group in a short rhythmic warm-up so that the members can find a comfortable way to play. After the warm-up, the participants can also be given a choice to change instruments if so desired. The second stage of the experience incorporates exploration, expression, and integration (Herman, 1992). The members are invited to express how they feel on their instruments while the group listens. The therapist should observe how the instrument is being played and listen for sounds that might be congruent or incongruent with what the player states about her feelings. It is important during the processing of the experience that the therapist keep connecting the client to the music and her relationship to the music. Once everyone has had an opportunity to do this, invite the members to think about how they would like to feel. In this part of the experience, each client becomes a leader by suggesting how she wants other members to play in support of how she would like to feel. “The client leader sets the tone, content, volume level, and so forth of the music, while fellow group members try to empathically ‘be with’ the soloist. Musical improvisation seems able to tap into reserves of strength and empathy not always encountered in other types of relationship” (Volkman, 1993, p. 246). After each musical experience, the therapist verbally processes how the client wants to feel and relates this to the music that the client just improvised and led. The group ends with the passing of a harmony ball between the participants and having each person share what they can take from the experience. The therapist ends the group by summarizing and validating the experiences for each person in the group. Adaptations. An experience that can be added to the middle section in the above improvisational session utilizes a simple chant: “There are two sides of me, one on the inside, and one on the outside. Here is my ______” (Bitcon, 1989, p. 22). The participants take turns at various times during the improvisation repeating this chant and then playing their “inside” or their “outside” for the group. After everyone has had her turn, verbal processing then takes place.

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Another chant by Bitcon (1989) that can be used is: “Step by step, step by step, little by little, this I want to try” (p. 20). In this experience, the participants will play something that they want to try on the instruments in order to find that something that they need in their lives. This experience is processed verbally to help enable individuals to try out real-life behaviors that have been portrayed through the music. There are many different ways to move through an improvisation because by its very nature the session is improvisational. Guidelines for improvisation can help structure the session when structure is needed. Usually, the more comfortable the group is with the instruments, the easier it is to move away from structure.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Song Sensitation Overview. Song Sensitation is a technique in which a client chooses a song and listens to it in a relaxed state and then in a more alert state; the song is processed with journaling, art, and/or discussion, and then the song is re-created. This technique was developed by Dr. JoAnne Loewy and presented in Caring for the Caregiver (2002), a text that was developed after 9/11 and that documents various interventions that were utilized with caregivers. Through this experience of “song sensitation,” a person may come to know parts of herself that she has never before explored. It is by processing the lyrics with the group members as well as re-creating the song that the individual can gain a better understanding of who she is, what she is going through, and how she might connect to others through the experience. After a traumatic event, survivors can be overwhelmed with a feeling of hopelessness. Through this experience, there can be installation of hope, which in times of great loss can be a powerful feeling that can help some people find the means to make a positive change. Being able to support others as well as accepting support is an important cornerstone in healing the community. This experience can facilitate creativity and self-reflection. Sometimes the population/culture may not be literate; if lyric sheets are utilized, this experience would be difficult and they possibly might feel embarrassed or negatively react to the situation. It is necessary to be aware of cultural songs that may not be understood by others in the group and preface those songs by helping people to understand that there is a respect that must be honored when responding to those songs. If the song seems quite inappropriate for use in the group, the music therapist must tactfully work with the group member who is suggesting the song prior to the group time. The music therapist must possess good musical and verbal processing skills in this intensive level experience. Preparation. This session can be done lying down or sitting. If it is done lying down, then comfortable mats should be utilized. Paper and pencils will be needed, as well as a way to play back music that is brought in. If it is possible, dim the lights for a portion of the listening experience. What to observe. As people are processing and reflecting about the music and lyrics, be aware of any projections that they may be having. How the participants talk about the music/lyrics is directly coming from an internal frame of reference and gives a great amount of information about them. Some people may have an abreaction to certain songs, and when this happens, they may need additional support. Watch for those who might monopolize any conversation regarding a song or if someone is critical of someone’s choice of song. Procedures. Loewy (2002a) describes the experience in four steps: 1) Song selection: Member brings a favorite song to group. If the therapist can receive the song prior to the group, she can be familiar with how to support the selection musically

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and clinically. Additionally, if the song is inappropriate for the session, that can be addressed. 2) Relaxation and listening twice: (a) lights off, eyes closed, in a relaxed state; (b) lights on, lyrics and pencils to write or draw thoughts or feelings related to the lead member, the song, or self. 3) Feedback-Reflection: processing and sharing feedback about music, lyrics, how/why members feel that this song is important to remember, and self. 4) Actualizing the song: Group members play this song in their own way; lead member (who selected the song) provides preference of instruments, tempo, dynamics, and harmonies (p. 36).

Adaptations. Loewy’s protocol for this experience can be expanded in that instead of asking the participants to bring in a favorite song, an instruction can be given to bring a song that reminds them of something in the past; helps them to feel good; energizes them; is hopeful or has a hopeful theme; they find relaxing; or is aligned with any topic or feeling that is prevalent in the area that is afflicted with the trauma. Another adaptation is for the music therapist to bring a song that may be pertinent to members of the group. When coming to number four in the process, this might be substituted by taking out key words or sentences from the song and having the group rewrite the song from their perspective. Some songs to consider are: “Win” by Brian McKnight “The Climb” by Miley Cyrus “The Storm Is Over” by R. Kelly “The Story of Your Life” by Matthew West “Keep Holding On” by Avril Lavigne “Little Wonders” by Rob Thomas “Lean on Me” by Bill Withers “Secret of Life” by James Taylor “Fire and Rain” by James Taylor “On the Roof” by Carole King “We Will Rock You” by Queen In “We Will Rock You,” it is more about rewriting the lyrics than examining them. The driving beat and then finding a theme to replace the words “we will rock you” can be a powerful experience.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Group Songwriting Overview. In this experience, clients create their own lyrics based on a melody and harmonic sequences provided by the therapist and then sing it together. Working with a small group to compose a song can be both cathartic and also inherently a vehicle to instill hope. Orth (2005) discusses how recording one’s own story (or song) can help in the telling of one’s story and also how to manage it. While the group may silently share many of the same feelings, they might not understand from a personal perspective that others may feel the same way. A group identity can be established through writing songs. “Self and group identity may also be explored interrelationally by singing songs that are important to each individual or by supporting the group’s composition of an original song using group words and themes”

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(Borczon, Jampel, & Langdon, 2010, p. 46). The way the group negotiates the songwriting process should be considered when processing how the song came about. In a group songwriting experience, the process reflects the dynamics of the group. Group members take on various roles as decisions about themes and lyrics are made (Baker & Wigram, 2005). Writing a song in a group can accomplish many different goals. First and foremost, this experience can help the group bond together around themes or issues with which the group has been struggling and/or enable them to start looking forward to a new sense of normal. Individuals can support others through the shared expression of the emotions that are being experienced. This creative endeavor is a powerful means by which the group can take pride in their accomplishment as well as have a cathartic experience. The music therapist must be creative in different musical styles in order to adapt to the type of song the group wishes to compose. Writing about events can stir up many emotions. While processing emotions is important, one still must be careful that participants do not get overwhelmed while writing the song. Sometimes the group members may disagree on how things might be worded. It is necessary to make sure that through the process, group members respect each other’s ideas. This is an intensive music therapy experience because exploring the lyrics that are being written can lead to discussions about what the survivors have gone through as well as what the future might hold. Preparation. Having a white board that everyone can see is conducive to writing lyrics. Instruments for accompaniment, such as guitar, piano, ukulele, or auto harp, should be available, along with any percussion instruments that might be utilized for further accompaniment or participation by the group members. Some members might want to have paper and a pencil in order to jot down some of their ideas. What to observe. There may be some group members who will take a more active role. Notice those that are not as active and try to get them involved by having them suggest ideas for verses or contributing a word or two within the verse. Watch for anyone who might be having an adverse reaction to the experience. Procedures. Songwriting can take on many different styles of music. Sometimes the culture will dictate what is the most comfortable style from which to start. Some approaches to songwriting in music therapy start with a precomposed song, and the group members then fill in blanks in the song where the therapist has taken out key words in order to foster self-expression. The songwriting experience described here differs from “filling in the blank” and is based on the needs of the group and fostering their creativity. When songs come from client-generated material, it often allows for greater creativity (Wigram & Baker, 2005). For this particular songwriting experience, a very simple chord progression and melody is used, based on the song “Wounded Bird” by Graham Nash (http://www.youtube.com/watch?v=QXeIdIcNk2U) The simplicity of the song lies in that there is no chorus and no bridge, but just simple verses. The first part of the songwriting experience is to have the group agree on a topic for the song. This can be done through brainstorming and can be often the hardest thing for the group as most of them have never written a song and have no real idea of how to write one. If they are having trouble coming up with a theme, a good place to begin is with what they are feeling on that day, in that present moment. It can begin with writing down feeling words that they are experiencing and then focusing on one or two related words to start the first verse. Sometimes the song can progress with how they are currently feeling to how they would like to feel. From here, the verses can be structured with a rhyming pattern and the therapist helps them find the rhymes as needed. Once the song has been written, the group learns to sing the song. If there are members of the group who do not wish to sing, they can utilize percussion instruments to add rhythm and create a different sense of timbre for the song. The song can then be recorded and distributed to the group via email, the Internet, or CDs.

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Adaptations. Setting the lyrics that have been written to different musical styles can be creatively rewarding for the group. By taking the lyrics and putting them into a rap framework and then a folk song paradigm, they can see if a particular style adds something unique to the feeling of the lyrics. Having subgroups writing different sections of the song can be a way for smaller groups to bond; the therapist then discusses how the verses should be laid out with the group. Songwriting can also be used as a way to distract the group from the event by writing about something unrelated to it. This can be therapeutic in that they take time to be separate from the event and focus instead on their creativity.

Narratives/Poetry to Music Overview. Clients create a written poem or narrative and guide the group in choosing instruments and playing them to accompany the recitation of the written work. Narrative is telling a story or relating an account of events; poetry has definitions that relate it to verse and lofty ideas. For the purpose of this experience, writing will be viewed as using a combination of words with the intent of conveying feelings. Writing can be effective in processing traumatic events and feelings: “Many survivors … felt compelled to search for or cite preexisting poems and songs that expressed what they were not able to find the words to express, and they found solace when they located a poem or song that was salient” (Stepakoff, 2009, p. 206). Stepakoff adds: The writer who engages in an instinctive process of poem-making does not necessarily recognize that she or he is striving to heal from trauma. She or he may feel that the identity of artist supersedes that of trauma survivor, and that the primary aim is aesthetic value rather than psychological repair. Nevertheless, in the aftermath of a significant loss, it can be argued that the effort to write poems arises from a psychological need to come to terms with the enormity of what has occurred (p. 108). Adding music to a narrative and/or poetry can create a more powerful and emotional impact. This might be due to the affective quality of the music itself as well as the fact that music involves more emotional aspects of the brain than language alone. For whatever reason, it appears that when music is used to structure the lyrics in a song or as a background to the spoken word, there is a greater overall effect on the listener. In this personal experience, the feelings of the participants will have an outlet through both the written word and the musical background. The focus of the writing can be on the past, present, or the future. In each of these instances, the writer can express herself, and if there is more than one session like this, each composition can be taken separately and perhaps made into a narrative story. The narrator will experience support from the group as they play instruments to reflect the story. Writing about the event can stir up many different emotions. It is important to be observant of those who are not prepared to deal with these aroused emotions. If the word “poetry” is used, some participants might have a negative reaction to the concept of writing poetry, and in this case, they may not be willing to engage in the experience. The music therapist must have good verbal processing skills because the lyrics will be discussed. This is an intensive level of therapy as many emotions might be aroused. Preparation. For this experience, there should be a large number of pitched and unpitched percussion instruments, an acoustic piano, an electric keyboard with samples of many different instruments, guitar, and any other instruments with which the music therapist is comfortable. Recording

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equipment of some type is needed. The session should be done with smaller groups of 10 to 12. The room should be large enough to comfortably accommodate the members and instruments. What to observe. As the session combines words with music, it is important to notice which sounds are used to accompany which words and feelings. The congruity or incongruity of the sounds and their relationship to the words is something of which the therapist should be cognizant. These events are something that can be processed verbally if they are significant. Procedures. Whether the session is focused on narrative or poetry, the first thing that should be conveyed to the participants is that they will be doing an exercise in writing and music. In this way, the concept of writing poetry would not be mentioned. The therapist introduces the participants to the instruments, unless they have played the instruments before. If they have played the instruments before, then focus only on any new instruments to which they have not yet been exposed. Once everyone is comfortable with the instruments, the therapist can demonstrate the difference between a song in which the lyrics are only read and singing the lyrics with the music. Discuss with them the differences. Explain to them that they are now going to be writing and then orchestrating their writing. The therapist can give them an option of writing styles as well as topics, such as writing in a narrative style is similar to writing a brief story. Another example of a form that can be used is haiku, which uses five syllables, then seven syllables, and then five syllables. The last form of writing can be explained as free verse, in that the sentences are loosely connected and on separate lines. With each of the three forms, it is good to have an example for demonstration. Suggested topics might be organized around the different time frames related to the event. Topics closer in time to the event might include the feeling of the event; what happened during the event; what happened immediately after the event; and what is happening right now. As time moves away from the event, topics might include remembering the event; what life has been like since the event; what they want life to look like; and what is happening right now. If they are having trouble coming up with the opening sentence or verse, suggestions can be offered such as: I remember …; When it happened, I felt …; What I miss most (is) (about) …; Someday, I (hope) (will) …; There are times when I …; Sometimes the pain …; When I think about …; People think that I am …; The last time I was (put in a feeling word) …; My life is just …; The future will be …; I am grateful for …; Today, I am going to try …; I am different now because …; In the future, I will …. It is helpful to put a time limit on the writing experience and to give them fair warning (e.g., five minutes) before time is up. Each person in the group will then read what she wrote without music. She will then select instruments that she would like to have to play during her next reading. She can instruct other group members on how loud or quiet, and how fast or slow the music will be. The person will then read what she has written, with the music accompaniment. If she wishes to have help with conducting what will happen when, the music therapist can be enlisted to assist in this fashion. Each person’s reading/composition will be recorded for her to have. Processing the writings can happen in two ways: After everyone has done the recording, a discussion about the process and what they wrote can occur, or, each person can listen to the recording and the therapist can process what they feel when they hear the recording. During this time, the music therapist can get a good feel for what the group members are experiencing. In closing, the therapist should summarize the session by bringing out any significant areas/themes that came up for the group. Those persons who seem to be stuck in an emotional state can be offered encouragement, and those who are growing in the aftermath can be affirmed. Adaptations. A group writing experience can occur by having an opening line on a piece of paper and then having each group member write the next line on the paper—in this way, every person has the opportunity to contribute something to the writing. The group as a whole then decides how the music is going to be performed. Another adaptation is that dyads can be created in order for people to share and

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create more intimately with one another in the group; then, as one reads the written composition, the other improvises the music.

CLOSING REMARKS ON METHODOLOGY In looking at all the previous concepts that have been presented in the methodology of working with trauma victims and music therapy, there is overlap with some methodologies that are cited. For example, in working with compositional music therapy methods, the idea of improvising music to accompany poems and other writings is stated. It is also mentioned that having prior experience with the instruments is helpful when playing the background music; hence, having some exposure to improvisational music therapy would aid in this experience. Also noted in the receptive music therapy section is the idea of improvising a piece of music that could be used as a background for relaxation. In working with these methodologies, you can also integrate ideas between two different experiences. For example, the positive themes that come up within group drumming can be used as a structure in songwriting or poetry-writing in compositional music therapy. Improvised music for receptive music therapy experiences could also be used as a background for writing experiences. Storytelling is often best presented after a group drumming or improvisational experience, as the clients might need a bit of downtime after playing. The discussion of feelings that come up in improvisational music therapy can be used as thematic material for poetry and songwriting. Much of the creative spirit in music therapy is finding the crossover between different methods so that one can enhance the other and in that a client can be offered a threading together of experiences in which to find her expression. The presentation of the material in the methodology of improvisational music therapy is the only one that has an implied suggestion of a hierarchy of moving from one experience into another. The idea of moving from a drumming experience that can focus on tension release from the body and feeling rhythm to a more intimate improvisational experience of describing what one feels like on the inside and the outside helps the participants to move through comfort level stages regarding the use of the instruments for different purposes. All the experiences that have been presented can be done in a group format. The general size of the group should be less than 20. However, some experiences such as relaxation exercises, storytelling, and group drumming, can be used with groups larger than 20. In working with individual sessions, all the methodologies can be used except for group drumming, which can nevertheless be adapted for an individual.

CARING FOR THE CAREGIVER When dealing with areas of mass trauma, the caregivers are often as affected as those whom they are treating. It can be difficult for the therapist to remain truly present in taking care of others when the therapist is triggered by what his clients are saying and experiencing. “Traumatic experiences can sweep therapists. They are intense and immediate and often breach our own defenses—we wonder whether we are therapists or participants” (Shalev, 2006, p. 116). So how does the caregiver take care of him- or herself in the midst of the tragedy? Finding a therapist outside of the geographical location is a good first step. There are music therapists in various parts of the country who are skilled in understanding what a large traumatic event entails. By using Skype, the author of this chapter was able to connect with a music therapist from Japan after the 2011 earthquake and tsunami. The music therapist from Japan has communicated how much the support meant to him. The book Caring for the Caregiver (2002), edited by Joanne Loewy and Andrea Frisch-Hara, came out of the experiences of music therapists who participated in the New York City Music Therapy

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Relief Project after the attacks on the World Trade Center in 2001. In this book, various music interventions are presented, as well as the effects of these interventions on the music therapists and participants. It is very important for the music therapist who is in the midst of a mass trauma situation to be mindful of what is happening to him. Being aware of how the event is affecting him on both physiological and psychological levels is imperative in order for him to remain available for others. If being able to process the event with an outside therapist is not a possibility, then there are other means to help alleviate the stress and trauma. The physical act of playing an instrument can help to channel pent-up emotions. This can be done alone or by being a part of an improvisation group or drum circle. Being part of a regular support group for caregivers can be effective; in this model, the leader of the group rotates from meeting to meeting. Taking time to meditate or relax on a regular basis can help in grounding the therapist in order to be more present and open. In Carolyn Braddock’s book Body Voices (1993), she writes about the “State of the Therapist” for those therapists who are doing work in trauma. She suggests the following guidelines in working with trauma: 1) 2) 3) 4)

Paying attention and intentionality is critical for healing. Excellence and integrity. Being authentic—telling the truth. I feel what goes on inside of me—my feelings, my body sensations, triggers, intentions, breath, thoughts, etc. 5) I must be able to concentrate and focus on my client and then come back to myself. I call this coming back “home” to my breath. 6) I must be able to set limits. 7) I must be aware and follow all internal and external experiences, my own internal process and the process of the client. I must know how to connect and disconnect emotionally, especially during intense times. I must know how not to interrupt my clients’ process (p. 95). Braddock’s remarks point to a type of mindfulness that one must have in order to keep the ability to be present for the client while still maintaining a sense of separateness in order to not become enmeshed with the client. Being able to come back to “myself” helps the therapist keep his issues separate from the client’s. If a music therapist is coming from the outside into an area of mass trauma, the therapist must also be aware of how the event and the survivors of the event are impacting him. As one who comes in from the outside, he must be prepared to be the container for many. Like the therapist who survived an event and is working with similarly affected survivors, an outside caregiver needs to have someplace to process what he is hearing, seeing, and experiencing. For any therapist, self-care is paramount. For those therapists working in the area of mass trauma, the trauma can be so overwhelming and emotionally laden that the therapist must simply have a source that he can go to in order to process his feelings.

RESEARCH EVIDENCE Music therapists working with individuals who have been involved in large-scale traumatic events are becoming more prevalent. This needs to be differentiated from those who have worked with trauma survivors from other sources of trauma, as that area has been more established. While much has been

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written on PTSD and music therapy, less has been written about music therapy and working with survivors of mass trauma.

Receptive Music Therapy Blake and Bishop (1994) used the Bonny Method of Guided Imagery and Music (GIM) with a Vietnam veteran over a 16-week psychiatric stay and found that the veteran “expressed feeling physical and emotional relief as result of the GIM experience” (p. 128). Additionally, Blake (1994) found that Vietnam veterans reported that they could reconnect with their emotions and have greater self-understanding in addition to increasing their ability to concentrate and experience relaxation.

Improvisational Music Therapy John Burt (1995) focused on drumming and trauma survivors from the Vietnam War in 1995. In his article in the section entitled “Information Sharing” in Music Therapy Perspectives, he wrote of the process of drumming and its positive effects on the veterans. Amir, Bensimon, and Wolf (2008) found that drumming with soldiers diagnosed with PTSD was effective in the following ways: 1) Group drumming increased a sense of openness, togetherness, belonging, sharing, closeness, connectedness, and intimacy. 2) Drumming evoked associations that were connected to trauma. This activity took place in a creative and safe atmosphere. Thus, it may have established a platform for accessing traumatic memories in a non-intimidating way. 3) Group drumming facilitated an outlet through “drumming out the rage” as an acceptable way of expression. This activity ultimately enabled the sublimation of latent rage while promoting a sense of relief, satisfaction, and empowerment. 4) It may be assumed that the participants were able to regain a sense of control and increase self-confidence by obtaining rhythmical synchronization while playing basic and complex rhythmic patterns in a circle group drumming (p. 46). Lang and McInerney (2002) describe in depth the situation in postwar Bosnia-Herzegovina and how music therapy was used with children. Primarily using improvisation, they discuss how music was used with children suffering from depression, regression, avoidance behaviors, and aggression. In small vignettes, they describe interventions and what progress the children made.

Multiple Music Therapy Methods A Community Music Therapy approach was used effectively with teenagers in Australia after the “Black Saturday Fires” (McFerran & Teggelove, 2011). The teens “could elect to play instruments, share songs, compose, listen, or supplement their musical experience with talking, drawing, or dancing, depending on their individual interests” (McFerran & Teggelove, 2011, Considering Theoretical Frameworks, paragraph 4). The feelings of group cohesion, the feeling that something positive was happening, and the ability to still be an individual within the group experience were major points that came from the experience. Harris, Katz, Kenny, Nolan, Price, and Schimpf (2010) found that child soldiers of Uganda who reported liking relaxation exercises with music responded well to songwriting and learning chords on the ukulele. The children also reported that they loved to sing, to learn new songs, and to use music in ways

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they had not previously experienced, such as guided relaxation and songwriting. They also report positive results with a child who was a second-generation trauma survivor in postwar Bosnia. The child was able to generalize areas of growth from his music therapy sessions with family and community. There is a paucity of research when it comes to studying PTSD and music therapy in working with a large-scale disastrous event. There are logistical difficulties that can include coordination with disaster agencies (Else, 2010), physical access to areas of the disaster, and establishing a presence in the disaster zone in order to offer services. The need for research in this area is imperative to have more recognition by the agencies that help organize interventions; in achieving that recognition, music therapy can be integrated into the organized response as a means to achieve a multitude of goals, including providing relief and comfort to the survivors.

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Baker, F. (2005). Working with impairments in pragmatics through songwriting following traumatic brain injury. In F. Baker & T. Wigram (Eds.), Songwriting methods, techniques and clinical applications for music therapy clinicians, educators and students (pp. 134–153). Philadelphia, PA: Jessica Kingsley. Baker, F., Kennelly, J., & Tamplin, J. (2005). Songwriting to explore identity change and sense of self concept following traumatic brain injury. In F. Baker & T. Wigram (Eds.), Songwriting methods, techniques and clinical applications for music therapy clinicians, educators and students (pp. 116–133). Philadelphia, PA: Jessica Kingsley. Brodsky, T. (1991). A personal perspective of the power of music and mass communication, prior to and during the Gulf War crisis in Israel: Implications for music therapy. Music Therapy, 10(1), 99– 113. Carey, L. (Ed.) (2006). Expressive and creative arts methods for trauma survivors. Philadelphia, PA: Jessica Kingsley. Everly, G. S., Jr., & Lating, J. M. (2004). Personality-guided therapy for posttraumatic stress disorder. Washington, DC: American Psychological Association. Feiner, S. (2002). Imagery through music. In J. Loewy & A. Frisch-Hara (Eds.), Caring for the caregiver: The use of music therapy in grief and trauma (pp. 128–137). Silver Spring, MD: American Music Therapy Association. Frisch-Hara, A. (2003). The NYC (New York City) music therapy relief project: A personal and professional odyssey. Voices: A World Forum for Music Therapy, 3(1). Retrieved February 5, 2012, from https://normt.uib.no/index.php/voices/article/viewArticle/113/89 Geller, K. (2002). Nurturing ourselves and others through singing. In J. Loewy & A. Frisch-Hara (Eds.), Caring for the caregiver: The use of music therapy in grief and trauma (pp. 155–164). Silver Spring, MD: American Music Therapy Association. Golden, K. M. (1994). The wffect of collaborative writing on cohesion in poetry therapy groups. Doctoral dissertation, American University. Dissertation Abstracts International, 56, 867–868. Green, A. (2011). Art and music therapy for trauma survivors. Canadian Art Therapy Association Journal, 24(2), 9–14. Gregorian, C. (2011). Six-string heroes. St. Louis Post-Dispatch, July 14. St. Louis, MO. Johnson, D. (2009). Commentary: Examining underlying paradigms in the creative arts therapies of trauma. The Arts in Psychotherapy, 36, 114–120. Krout, R. (2011). Our path to peace: Songwriting-based brief music therapy with bereaved adolescents. In A. Meadows, Developments in music therapy practice: Case study perspectives, pp. 230-247, Gilsum, NH: Barcelona Publishers. Montello, L. (1989). Relational issues in psychoanalytic music therapy with traumatized individuals. In K. Bruscia, The dynamics of music psychotherapy (pp. 299–313). Gilsum, NH: Barcelona Publishers. Ng, W. F. (2005). Music therapy, war trauma, and peace: A Singaporean perspective. Voices: A World Forum for Music Therapy, 5(3). Retrieved April 29, 2012, from https://normt.uib.no/index.php/voices/article/viewArticle/231/175 Ng, W. F. (2011). Can music therapy be an answer to the terrorist question? A Singaporean music therapist’s perspective. Voices: A World Forum for Music Therapy, 11(1). Retrieved April 29, 2012 from https://normt.uib.no/index.php/voices/article/viewArticle/564/444 Orth, J., & Verburgt, J. (1998). One step beyond: Music therapy with traumatised refugees in a psychiatric clinic. In D. Dokter (Ed.), Art therapists, refugees and migrants (pp. 80–93). Philadelphia, PA: Jessica Kingsley.

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Orth, J., & Verburgt, J. (2004). Sounds of trauma: An introduction to methodology in music therapy with traumatized refugees in a clinical setting. In J. P. Wilson & B. Drozdek (Eds.), Broken spirits: The treatment of asylum seekers and refugees with PTSD (pp. 443–481). New York: BrunnerRoutledge Press. Otera, M. (2012). What do music therapists need to know before a disaster strikes? Voices: A World Forum for Music Therapy, 12(1). Retrieved May 2, 2012, from https://normt.uib.no/index.php/voices/article/view/625 Polak, P. R., Egan, D., Vandebergh, R., & Williams, W. V. (1975). Prevention in mental health: A controlled study. American Journal of Psychiatry, 132, 146–149. Raphael, B., Wilson, J., Meldrum, L., & McFarlane, A. (1996). Acute Preventive Interventions. In van der Kolk, McFarlane, & Weisæth (Eds.), Traumatic stress: The overwhelming experience on mind, body, and society, pp. 132-76. New York: The Guilford Press. Robb, S. (1996). Techniques in songwriting: Restoring emotional and physical well-being in adolescents who have been traumatically injured. Music Therapy Perspectives, 14, 30–37. Rothbaum, B. O., Meadows, E. A., Resick, P., & Foy, D. W. (2000). Cognitive behavioral therapy. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: practice guidelines from the international society for traumatic stress studies (pp. 60–83). New York: The Guilford Press. Schulberg, C. (1997). An unwanted inheritance: Healing transgenerational trauma of the Nazi holocaust through the Bonny Method of Guided Imagery and Music. The Arts in Psychotherapy, 24(4), 323–346. Short, A. E. (1991). The role of Guided Imagery and Music in diagnosing physical illness or trauma. Music Therapy, 10(1), 22–45. Sillup, A. (2011). Music therapy for symptoms of PTSD. http://amy-sillup.suite101.com/music-therapy-for-symptoms-of-ptsd-a362903 Toner, E. (2011). Guitar heroism: Veterans fight PTSD with music. http://www.npr.org/2011/07/03/137588367/guitar-heroism-veterans-fight-ptsd-with-music Tramontin, M., & Halpern, J. (2007). The psychological aftermath of terrorism: The 2001 World Trade Center attack. In E. Carll (Ed.), Trauma psychology: Issues in violence, disaster, health, and illness (pp. 1–31). Westport, CT: Praeger Pub. van der Kolk, B., Turner, S., & McFarlane, A. (1996). The therapeutic environment and new explorations in the treatment of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisæth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body and society (pp. 544–555). New York: The Guilford Press. van der Kolk, B., & Fisler, R. (1995). Dissociation & the fragmentary nature of traumatic memories: Overview and exploratory study. Journal of Traumatic Stress, 8(4), 505–525. West, H. (2006). Addressing the traumatic impact of disasters on individuals, families, and communities. This paper represents an overview of four resource papers that were presented at the After the Crisis: Healing from Trauma after Disasters Expert Panel Meeting (April 24–25, 2006, Bethesda, MD). Yawney, R. (1993). Music therapy in Gaza: An occupational hazard? Canadian Journal of Music Therapy, 3(1), 1–17.

Chapter 8

Women Survivors of Abuse and Developmental Trauma Sandra Lynn Curtis _____________________________________________ DIAGNOSTIC INFORMATION There is a small but growing practice of music therapy with women survivors of violence, first identified and described in 1990 by Cassity and Theobod and gradually growing since then (Austin, 2006; Curtis, 2000, 2006, 2007, 2008; Curtis & Harrison, 2006; Day, Baker, & Darlington, 2009; Fesler, 2007; Gonsalves, 2007; Hahna & Borling, 2004; Hammel-Gormley, 1995; Hernández-Ruiz, 2005; Lasswell, 2001; MacIntosh, 2003; Montello, 1999; Rinkler, 1991; Rogers, 1993, 1994; Slotoroof, 1994; Teague, Hahna, & McKinney, 2006; Ventre, 1994; Whipple & Lindsey, 1999; York, 2006). This has accompanied an increasing awareness overall of the serious extent and nature of violence against women. In the United States, during their lifetime, one in four women will experience domestic violence and one in five women will be raped, with 1.3 million women raped every year and an average of three women per day killed by their intimate partners (Black et al., 2011; Kanani, 2012). Furthermore, an estimated 12% to 38% of American women have experienced childhood abuse (Schacter, Stalker, Teram, Lasiuk, & Donilkewich, 2009). Yet it is difficult to accurately document the full prevalence of violence against women because of underreporting and undercounting (Curtis, 2006; Hahna & Borling, 2004; Kanani, 2012). These are hidden crimes, with many reluctant to report because of the personal nature of the violence and for reasons of fear and shame. With gender frequently neglected in reporting processes, the challenge to fully capture the incidence rate is further exacerbated. While violence against women has been ignored or overlooked until recently, there is now a growing recognition that it is pervasive, persistent, and incredibly detrimental. This recognition includes an understanding of the broader scope of the costs of such violence—the personal costs (both short-term and long-term) and the societal costs in terms of public health, criminal justice, and the economy (Curtis, 2008; Kanani, 2012; Statistics Canada, 2006). At the societal level, economic costs alone for women, children, and communities run in the billions of dollars annually. These include medical and mental health care costs, law and legal services costs, shelter and foster care costs, property loss, and workplace costs such as productivity loss (Teague, Hahna, & McKinney, 2006). At the personal level, the cost is immeasurable (Curtis, 2007; Kanani, 2012). Ultimately, it damages the very fabric of social justice. In the estimation of Susan Carbon, Director of the U.S. Department of Justice Office of Violence against Women: I view violence against women, in all its forms, as a fundamental human rights issue. And whether it is used as a weapon of war against an entire people, or to break one individual’s spirit, we all know its impact is profound: it usurps victims of their right to sovereignty over their own person (Kanani, 2012).

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Regardless of the incidence rate, even one woman harmed by such violence is one woman too many (Curtis, 2000). Given the large numbers of women experiencing violence, both in their adulthood and in their childhood, and given their understandable reluctance to reveal these experiences, one thing is certain. Music therapists can expect to see among their clients a number who have been touched by violence against women (Curtis, 2007). And these clients are “deserving of the best we can offer them, an approach informed by the latest understanding of violence against women and children … and of effective intervention strategies” (Curtis, 2007, p. 199). While the topic of this chapter is clearly identified as and limited to women survivors of abuse and developmental trauma, a question may arise for some readers concerning the exclusion of male survivors. This exclusion was purposeful and based on compelling reasons. Male violence against women has unique parameters and dynamics in our sociocultural context. It is rooted in a patriarchal culture that has historically accepted and condoned such violence. Typically, women’s experiences of violence are very different than those of men. Women are more likely to experience violence in their own homes at the hands of a significant other, with greater risk of sexual abuse (Curtis, 2008; Kanani, 2012; Statistics Canada, 2006); men’s experiences of violence are more often outside their homes at the hands of strangers. Male violence against women cannot be completely understood without an examination of the dimensions of gender and power, or without an understanding of the historical and current sociopolitical underpinnings within our sociocultural context. It is rooted in a culture of inequality. As such, it requires not only a sociopolitical understanding, but also a sociopolitical solution (Curtis, 2000, 2007, 2008; Worell & Remer 2003; Yllö & Bograd, 1988). Gender-based violence is perhaps the most widespread and socially tolerated of human rights violations. It both reflects and reinforces inequities between men and women and compromises the health, dignity, security, and autonomy of its victims (Statistics Canada, 2006, p. 8). Men do experience violence within adult relationships; however, their experiences are unique, as are the impact and the sociocultural response. In the case of child abuse, boys are affected as well as girls, and this is rooted in patriarchal culture. As such, men’s and boys’ experiences should not be underestimated. It plays out, however, quite differently because of their particular gender role socialization in a patriarchal culture. It can also play out differently in the case of same-sex child abuse within the context of a homophobic culture. It is important therefore that separate time and attention be given to the unique experiences of abused men and boys in order to provide unique guidelines for appropriate and sensitive practice in this area. For similar reasons, violence against women within same-sex relationships is not examined in this chapter. The dimensions of gender and power are very different in a culture that is both patriarchal and homophobic. As such, separate time and attention to this unique experience are also needed in order to provide unique guidelines for appropriate and sensitive practice here as well. Having identified and examined the scope of this chapter, only one thing remains prior to proceeding—to identify what Brown (2008) refers to as multiple social locations. These personal identities and experiences form the lenses of each person’s particular worldview. Disclosure of these social locations is critical, particularly given the identified sociocultural dimensions of work with women survivors of violence. My own social locations include my experiences as a white, middle-class, educated, able-bodied, heterosexual woman born in the mid-1950s. Furthermore, over the past years, my work has included social activism, anti-oppression work, and feminist music therapy practice. It is the combination of these social locations that provides the framework for my practice, research, and writing.

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In this chapter, I will look at the full scope of practice of music therapy with women survivors of abuse and developmental trauma, grounded in work with those from a broad array of social locations. Attention will focus first on pertinent diagnostic information as well as on identifying the needs and resources of women who have experienced violence. The diversity of women and of their experiences of violence will then be examined in the area of multicultural issues. The importance of social locations will be further highlighted here, with attention to their complex interaction with both clients and therapists. A detailed and comprehensive overview of music therapy practices will follow, providing guidelines for receptive music therapy, improvisational music therapy, compositional music therapy, and re-creative music therapy for use with women survivors of violence. The chapter will conclude with a look at efficacy research supporting and informing this emergent area of music therapy practice.

DIAGNOSTIC INFORMATION Diagnostic information in this emergent area is still at a preliminary stage, with existing controversies concerning not only diagnosis and diagnostic criteria, but also whether or not a diagnosis should be made at all (Brown, 2008; Burstow, 2005; Curtis, 2000, 2007, 2008). This is perhaps not surprising given the newness of the field and given the long-standing contention surrounding the naming of the very phenomenon of violence against women. The power of naming (and diagnosing) should not be underestimated. It can reflect and perpetuate understandings or misunderstandings; it can acknowledge a phenomenon or deny existence of that which is not named. Until fairly recently, there was no name for the phenomenon of violence against women within their intimate relationships. Initially viewed as a husband’s right, then challenged and identified as a problem during the second wave of the women’s movement, it was subsequently given an assortment of names—from wife abuse, spousal abuse, and marital conflict to domestic violence. Many of these masked the dimensions of gender and power, and moved the dialogue from political to personal. Lenore Walker’s concept of Battered Woman Syndrome (BWS) gained widespread acceptance for a time and appeared to address some of these issues. Ultimately, however, it posed its own set of problems in pathologizing women, not accurately capturing women’s experiences of violence, and not serving adequately as the hoped-for legal defense (Curtis, 2000). Current attempts to address these problems have seen rise of the use of the concepts of PostTraumatic Stress Disorder (PTSD) or “trauma with adult women experiencing male violence” (APA, 2000; Brown, 2008). PTSD—a diagnostic category of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM)—is one of the few categories by and large established and accepted by nonpsychiatrists; its impetus was to validate the experience of trauma, to acknowledge its effects, and to provide access to services (APA, 2000; Burstow, 2003). Applied to adults, adolescents, and children older than 6 years (with a separate Pre-School subtype for younger children), PTSD is identified in the DSM-5 Development under Criterion A as “exposure to actual or threatened (a) death, (b) serious injury, or (c) sexual violation” (APA, 2012, DSM-5 Development, “Post-Traumatic Stress Disorder,” para. 1); Criteria B, C, D, and E identify associated clusters of symptoms or disturbances, including intrusive, distressing memories and dreams; dissociative reactions; psychological distress; physiological reactions to trauma reminders; negative alterations in cognitions and mood; and marked alterations in arousal and reactivity associated with the traumatic event (APA, 2012). The use of the PTSD diagnosis with women who have experienced male violence has been criticized, with considerable efforts put into its revision for the 2013 edition of the DSM-5 (APA, 2012; Brown, 2008; Burstow, 2005). Burstow (2005), however, contends that no revisions would be adequate, that the PTSD diagnostic category is fundamentally neither valid nor redeemable. She challenges it as being reductionistic, contradictory, inaccurate, and incomplete, serving to pathologize purposeful coping

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strategies. In medicalizing trauma, it ignores the context of the individual, the trauma, and the response; it further neglects the particular context for those who belong to oppressed groups. “PTSD is a grab bag of contextless symptoms, divorced from the complexities of people’s lives and the social structures that give rise to them. As such, the diagnosis individualizes social problems and pathologizes traumatized people” (Burstow, 2003, p. 1296). Furthermore, the diagnosis (with its use of the term “post”) does not accurately capture the ongoing nature of this type of violence. Burstow (2003) contends that while the concept of PTSD is flawed, there are some compelling reasons to continue with the use of the term “Trauma” (viewed not as a diagnosis, but as a reaction): It is a term used by traumatized people themselves, and not part of professionalized psychiatric language; it captures the overpowering nature of the experience; and, as “contested terrain” (Burstow, p. 1294), it contains potential for its meaning to be transformed to include the sociopolitical context. It also, however, continues to mask the dimensions of gender and power, as well as the connection between the various types of male violence against women (Curtis, 2000, 2008). Similar difficulties have been identified with diagnoses surrounding childhood abuse. Additionally, they neglected the unique nature of this violence and its impact at a child’s critical developmental age (van der Kolk & Pynoos, 2009). Attempts to address this can be seen in proposals for a new Developmental Trauma Disorder diagnosis and for inclusion in the DSM-5 within the PTSD category of a Pre-School subtype for children 6 and younger (APA, 2012; van der Kolk & Pynoos, 2009). Across the board, however, with all of these changes, what remains is that the dimensions of gender and power continue to be masked, as does the connection between all types of violence against women and children (Curtis, 2000, 2006, 2007, 2008). “Woman abuse” is an alternative supported by many to address these issues (Curtis, 2000, 2006, 2007, 2008; Worell & Remer, 2003). It is “the preferred term to identify all forms of male violence against women” (Curtis, 2007, p. 204), with the purpose of each type being to assert and maintain control. “It is a pattern of coercive control over women that uses diverse methods and leaves women questioning their self-worth and perception of reality” (Yllö & Bograd, 1988, p. 14). The various types of violence can occur at any time throughout a woman’s life span and may include physical, verbal, sexual, psychological, and systemic violence, the latter resulting from the failure of legal, social, and mental health care services agencies to respond or to respond appropriately (Curtis, 2000; Statistics Canada, 2006; United States Department of Justice, 2012). Music therapists need to be familiar with these issues surrounding women survivors of violence, the information provided on one hand and the challenges faced on the other with diagnosing or naming. They will also be better prepared in having an understanding that many of their clients may arrive without diagnosis or any previous indication of experiences of violence.

NEEDS AND RESOURCES In light of this understanding of the complexities surrounding violence against women, the section that follows will examine women’s experiences in terms of their responses exemplifying both strengths and challenges, both resources and needs. Women, women’s experiences, women’s experiences of violence, and the meanings women make of these experiences are incredibly diverse. This diversity will be explored not as symptoms of a disorder, nor as causes of the violence, but as characteristics resulting from women’s experiences of extraordinary trauma. It is important that women be neither pathologized nor blamed for the violence; nor should they be defined by it (Curtis, 2008). While there is no doubt they have been victimized, they are survivors, rather than simply victims, of violence. Their diverse responses reflect resourceful coping strategies, great strength, and remarkable resilience. As such, they may differ in what time and help they may need to heal, and this will depend on the nature of the violence, the available resources (personal, social, and societal), the coping skills, the presence of children, and the intersection

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of any other sources of oppression (Curtis, 2008). These and other issues of diversity will be examined more fully later in this chapter in the Multicultural Issues section. What follows immediately is an identification of the full scope of possible responses and characteristics—short-term and long-term; physical, emotional, psychological, and behavioral—as described in trauma work literature and in the DMS-5 Development (APA, 2012; Amir, 2004; Austin, 2006; Burstow, 2003; Carey, 2006; Curtis, 2006, 2007, 2008; MacIntosh, 2003; Montello, 1991). Women survivors of violence can experience profound and persistent long-term as well as shortterm effects. With betrayal and coercive control underpinning all types of this violence, the impact may often be hidden, unidentified, or unacknowledged. For some survivors of childhood abuse, it may only be as adults that the experience is revealed. For many, the impact can be reflected in their adult health, with increased risk of depression, suicidal tendencies, substance abuse, smoking, obesity, and sexual problems (van der Kolk, 2005). For all, the damage to the core self is identified as one of the most significant and long-lasting harms, the most difficult to overcome (Curtis & Harrison, 2006). The DSM-5 Development (APA, 2012) identifies and organizes the possible scope of responses in the areas of intrusion, avoidance, negative cognitive or mood alterations, and arousal or reactivity alterations. These responses may include intrusive distressing memories or dreams; dissociative reactions such as flashbacks; intense psychological distress; physiological reactions to reminders of the trauma; avoidance of external reminders of the trauma; avoidance of internal reminders in terms of thoughts or feelings; negative beliefs or expectations about themselves, others, or the world; distorted self-blame; negative emotional states such as fear, horror, anger, guilt, or shame; diminished involvement in activities; numbing; detachment; irritable or aggressive behavior; reckless or self-destructive behavior; hypervigilance; and sleep disturbances. The responses can present in oppositional fashion: intrusion vs. numbing, hypervigilance vs. denial, flooding vs. constriction (Burstow, 2003; Montello, 1999). Burstow (2003) encourages an understanding of women’s responses as including effective coping strategies under the circumstances. Furthermore, she urges caution in assessing survivors’ fears as exaggerated, noting that their view of the world as unsafe might be closer to reality than not. Ultimately, the critical role of context cannot be ignored. The violence takes place within what was a loving, trusted relationship (Austin, 2006; van der Kolk, 2005). The violence also takes place within a larger sociopolitical context. Burstow (2003) describes women’s responses with an understanding of the many layers of trauma: individual response, response of other individuals, response of the community, and response of institutions. In examining the responses of women survivors of violence, their strengths should not be overlooked. Rather than helpless, they actively seek help—although institutional response may not itself be helpful. Abused women develop many effective survival skills, making use of coping strategies, some of which serve them well at the time. They also demonstrate an understanding of others who have been traumatized, along with a strong commitment to social justice and much-needed activism (Burstow, 2003; Curtis, 2008; Curtis & Harrison, 2006). Just as abused women’s responses and strengths are reflective of great diversity, so too are their music interests and abilities. Abused women come from all walks of life; they are represented in all ethnic identities, in all socioeconomic classes, and among people of all abilities. As a result, little specific concerning music can be said about abused women as a whole. Music therapists working in this area can be guided by an understanding of the importance of individual preference. Furthermore, there is an enriching opportunity which comes from supporting clients in sharing the wealth of their expertise— expertise in their music, as well as their culture, their experiences, and the meaning they make of these. Additionally, as will be explored later in this chapter in the Guidelines section, some music therapy methods in this area of practice include the use of women’s music. Equally as diverse as the practice itself, women’s music can be defined as “music written by, for, and about women which began as a recognizable

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genre during the women’s movement of the 1970s and continues today as a source of empowerment and social change” (Sallie Bingham Center for Women’s History and Culture, 2012, para. 1).

MULTICULTURAL ISSUES Given the diversity of abused women and their experiences of violence, attention to multicultural issues is critical. While important in any area of music therapy practice, the need is underscored in work with abused women not only by their diversity, but also by the clearly identified, powerful sociopolitical underpinnings of violence against women. In this section of the chapter, multicultural issues will be carefully examined. The scope of this examination will move beyond a look at music and the meaning of music in a particular culture, the look primarily taken until recently in music therapy. This examination will encompass multicultural issues as they play out in the lives of abused women, in their interactions in the client-therapist relationship, and in the lives of therapists as well. Until recently, it was easier for healthcare professionals (including music therapists) to see themselves as neutral, caring individuals (Brown, 2008). There is now, however, an increasing understanding of the myth of this neutrality, an understanding of the complex influence of multiple identities in the lives of everyone—client and therapist alike. Brown conceptualizes this diversity in terms of social locations—“a variety of different experiences that can affect identity. Some can have a biological portion; all are socially constructed to a degree” (Brown, 2008, p. 21). These multiple and intersecting social locations include: age, disability, religion, ethnicity, social class, sexual orientation, indigenous heritage, national origin, and gender/sex, as well as vocation, body size, health, experiences of colonization, and choices concerning partnering and parenting. These can be sources of privilege or oppression, with most people experiencing some combination of both. Privilege arises from the unearned advantages that come with dominant group membership, while oppression is “a pervasive pattern of prejudice and discrimination at the individual and systemic levels, resulting in personal and societal barriers and power differentials” (Curtis, 2007, p. 204). Additionally, oppression can be internalized, with the oppressed coming to believe they are deserving recipients of discrimination. Therapists, in addition to any personal experiences of privilege or oppression, are privileged by virtue of their professional training and the power differential in the client-therapist relationship. For clients, there is the additional complex interaction of the trauma itself: “Trauma and its psychic aftereffects have a texture. The experience conveys meanings that derive from personal histories; cultural heritages; and the social, political, and spiritual contexts in which the painful event happens” (Brown, 2008, p. 3). Even with such a seemingly neutral trauma as a hurricane, the complex interaction of diversity, privilege, and oppression became quickly and powerfully evident in New Orleans with Hurricane Katrina. With violence against women, deeply rooted as it is in the sociopolitical context, the interaction is undeniable. In light of this, how are music therapists to prepare themselves to provide the best possible practice with women survivors of violence? It requires a thoughtful and self-reflective process. While some efforts have been focused on acquiring cultural competence, others recommend cultural humility (Brown, 2008; Juarez et al., 2005; Schacter et al., 2009; Tervalon & Murray-García, 1998). With a focus on both attitude and skill development, cultural humility is defined as “a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners” (Juarez et al., 2005, p. 118). With the best of both in a culturally sensitive practice, therapists examine their own multiple social locations and related attitudes and beliefs. Within their practice and as part of an ongoing process, they take three stances: an alliance stance, an ignorance stance, and a respectful stance (Brown, 2008; Tervalon & Murray-García, 1998). Within an alliance stance, the therapist acts as ally and advocate, recognizing the client’s own skills and efforts in problem-

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solving. The ignorance stance is an acknowledgement of the therapist’s limitations but openness to learn. A therapist takes a respectful stance in honoring the client’s perspective and in recognizing the diversity of human experience. These three stances can be taken in relation to the client in general terms as well as to the clients’ music, their understanding of the role of music in their culture, and their understanding of the role of music in healing. Having looked at the preparation needed by music therapists in terms of diagnostic information, client characteristics, and multicultural issues, specific guidelines for clinical practice with abused women will be presented in the section which follows. While the methods may vary, one constant is the need for therapist attention to the possibility of vicarious trauma, which is the trauma that may be experienced by therapists while their clients relive and retell their stories of trauma (Burstow, 2008). Music therapists can continue to provide an effective music therapy practice in this area with careful attention to self-care, supervision, and any necessary support.

OVERVIEW OF METHODS AND PROCEDURES What follows are guidelines for a variety of receptive music therapy methods. The application of these methods, as with those for improvisational, re-creative, and compositional methods, has been seen within individual settings, group settings, or some combination. Some working in this area highlight the importance of group therapy, which can be particularly effective in the critical work of breaking the social isolation in which women are placed by their abusers (Curtis, 2000, 2006, 2008; Teague, Hahna, & McKinney, 2006; Whipple & Lindsey, 1999). It should also be noted that the particular application of these methods can be varied, with a combination of several methods used in a single session, while conversely, a single method may be spread across several sessions. Each session is generally 90 minutes to 2 hours in duration and held once or twice weekly. The following methods and procedures are used most commonly with women survivors of abuse and developmental trauma.

Receptive Music Therapy • • •

Music-Centered Relaxation: includes a variety of exercises, including breathing, progressive muscle relaxation (PMR), and guided imagery. Lyric Analysis: The client chooses songs, listens to a recording and/or sings them with the therapist, and discusses the themes which arise. Bonny Method Guided Imagery and Music (BMGIM): involves the client (traveler) listening to classical music programs in an altered state while dialoguing with the therapist (guide) about the images and sensations that are evoked.

Improvisational Music Therapy • •

Group Music Improvisation: involves creating music extemporaneously in a group with the voice or instruments, with or without a theme. Individual Music Improvisation: involves creating music alone or with the therapist extemporaneously using voice or instruments with or without a theme.

Re-creative Music Therapy •

Reflective Singing: Clients are engaged in singing with the therapist along with the original recording of a song.

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Performance: Clients select pieces, practice them, and perform them for an audience.

Compositional Music Therapy •

Songwriting and Recording: clients work individually or in a group to write a song on a therapeutic theme, then perform, record, and listen to it.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Music-Centered Relaxation Overview. Music-Centered Relaxation can include a variety of exercises, including breathing, progressive muscle relaxation (PMR), and guided imagery. Typically, abused women, whether their experience of abuse is recent or long-standing, can benefit from support in increasing their relaxation. Caution is advised to first ensure that a safe place has been successfully established for the client in therapy, prior to undertaking this method. The goals of this method are to increase relaxation and effective use of relaxation skills, including independent stress management skills by the client outside of therapy. Additionally, within a framework of Feminist Music Therapy, Music-Centered Relaxation is used as part of feminist analysis of gender-role socialization with a goal of increasing understanding of women’s need for self-nurturance (Curtis, 2000). The level of therapy involved is augmentative or intensive. While no specialized training is needed to use this method, previous experience in stress management would be beneficial. Preparation. The location used for this method should be a quiet, private space which is conducive to relaxation—comfortable seating, appropriate lighting which can be dimmed as needed, and a door which can be closed to minimize outside distractions. The therapist can use live or recorded music. In the case of recorded music, a good selection of diverse music choices appropriate for relaxation should be on hand; instrumental music is recommended so as not to distract from the verbal relaxation guidance provided. Music selections and playlists prepared in advance on an iPod or iPad can be very useful, with CDs as an alternate option. The therapist may also wish to have relaxation CDs with recorded relaxation scripts on hand for clients to borrow for independent use between sessions. The relaxation script used by the therapist in session or on CD can be individualized; samples of such scripts and exercises are available commercially and online (Davis, Eschelman, & MacKay, 2000). What to observe. The therapist can attend to client response—verbal and nonverbal, including breathing rate, body position, and muscle tension. Pre- and postsession discussions can provide additional information. The therapist may also opt to have clients complete pencil and paper pre- and postsession relaxation self-ratings on simple Visual Analog Scales (VAS) or 5-point Likert Scales; clients may also use these to track their own progress in relaxation work between therapy sessions. Procedures. The Music-Centered Relaxation method starts with a brief discussion; this allows the therapist to share some information about stress management and the method being used, and it allows the client to check in. In Feminist Music Therapy, this discussion includes feminist analysis of gender-role socialization, which may be completed with additional, preliminary use of Lyric Analysis based on the theme of self-nurturance (see the section which follows for more details on this). Following any preliminary discussion, the therapist moves into the music-centered relaxation experience. Clients are directed to get into a comfortable position (they may be seated if comfortable chairs/sofas are available, or they may lie stretched out if yoga mats are available). Clients may close their eyes or, for those more anxious, look at a blank spot in the room that offers no distractions. In guiding clients through this experience, it is helpful for the therapist to think of giving permission, rather than

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giving directions. For example, use phrases such as “allow yourself to focus on your breathing” or “you might imagine a warm relaxing sensation moving through your muscles.” The therapist can enhance the experience by reflecting a sense of relaxation in the tone, pitch, and pacing of her voice. With the clients seated comfortably and the music started, the therapist can guide them through a short induction where they focus on the music and their breathing, gradually slowing their breathing as they match it to the music’s tempo. If live music is being used, the therapist can move from a faster, more dynamic style, to a slower, more static one. The therapist can then guide the clients through a musiccentered PMR experience. Music-centered PMR involves alternately tensing and relaxing muscle groups throughout the body in a systematic process. Grounded in a very physical response, it can be helpful for those at the beginning stages of the therapeutic relationship, where guided imagery might be too threatening. The therapist can guide clients through this process, starting with the feet and gradually moving upward through the body to the head. Time can be allowed for the client to feel the opposing sensations of tension and relaxation; time can also be allowed to redirect focus to the breathing and to the music. Allowing opportunity for the music to play alone without any verbal guidance can also be beneficial. The therapist may end the experience here or may follow it with an extended music-centered guided imagery. If choosing to end the experience with PMR, the therapist then guides the client’s attention back the feel of the body, its place and position in the room, and its feeling of relaxation, and then back to the sounds of the room, as each client becomes more aware of their surroundings. The session can wrap up in verbally processing the experience and its meaning for the moment and for the future. Adaptations. Music-Centered Guided Imagery is another receptive method; it may be used alone or in some combination with Music-Centered PMR (before or after). In this method, the therapist guides the client through a relaxing scenario. While the term “imagery” is used, this involves a focus on all of the senses, not just the visual. In working with an individual client, the client can provide input for the scenario to be described; in working with a group, this may have to be negotiated. Alternately, the therapist can guide the group, using broad descriptions which allow each client to fill in the blanks. For example, they may be guided to imagine themselves in a familiar, relaxing place. As with Music-Centered PMR, this method closes with an opportunity for verbally processing the experience.

Lyric Analysis Overview. In lyric analysis, the client chooses songs, listens to a recording and/or sings them with the therapist, and discusses the themes which arise. Lyric Analysis has been shown to be an effective music therapy method used across diverse approaches with abused women (Cassity & Theobold, 1990; Curtis, 2000, 2006, 2008; Curtis & Harrison, 2006; Teague, Hahna, & McKinney, 2006; Whipple & Lindsey, 1999; York, 2006). It can be particularly effective in a group therapy setting where each woman can contribute at the level she is able to. There are generally no contraindications for clients if the experience is handled by the therapist in a skilled and sensitive manner. The goals of this method are varied and can include allowing opportunities: to explore issues related to violence against women, first at the impersonal level of the songwriter, and later at the personal level of the client; to break the social isolation in hearing other women’s stories of abuse (the songwriter’s and other clients’); to give voice to woman clients long silenced; to validate women’s experience of abuse; and to empower women. Lyric analysis can also serve as a first step in the music therapy method of songwriting (see the Guidelines for Compositional Music Therapy section later in this chapter for further details). The level of therapy involved is intensive or primary. While no specialized training is needed to use this method, experience with in-depth verbal processing and concomitant skills in dealing with intense emotions which may arise

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would be beneficial. A deep understanding of the issues involved in violence against women and the diverse experiences faced by abused women is critical, as is cultural humility. Preparation. As with most music therapy methods used with abused women, the location should be a quiet, private space with comfortable seating typically arranged in a circle, and with a door which can be closed to provide a sense of safety and minimize outside distractions. A wide selection of music representing diverse music genres/styles is essential; the particular clients may determine the genres and styles needed. This collection typically starts with the music therapist’s own choices and then grows rather organically, as clients make requests and, in my case, colleagues make many suggestions after hearing about my area of practice. Encouraging clients to bring in their own music provides a wonderful opportunity which should not be overlooked, particularly when working in a cross-cultural context. In bringing their own music, clients are accorded the role of experts in their own music, their own experiences, and their own experiences of violence. The music provides an invaluable vehicle for bridging cross-cultural barriers. For the therapist, having the music organized on an iPod or iPad (with accompanying high-quality docking station stereo) can be very helpful; having the original CDs, with cover artwork and inserts, also enhances the experience. For the client, having a copy of printed song lyrics for all songs is a must. With the lyrics organized alphabetically in a binder (one for each client) with a Title Table of Contents and a Thematic Index, clients (and therapists) can easily find the ideal song for the moment, and new songs can be readily added as clients make suggestions. Depending on the setting and the budget, clients may keep these Song Lyric Binders with them throughout the week between therapy sessions. A separate Song Lyric Binder for the music therapist is helpful, as it can include chords for piano or guitar accompaniment as well. Clients may also have access to recordings of the music, again depending on the setting and the budget, with possible purchases through iTunes. The selection of the songs and their themes is individualized by the therapist to meet the purpose of the particular music therapy group. Specific examples of music selections by theme are provided below in the Possible Adaptations section. What to observe. The focus of the music therapist’s observations within this music therapy method is quite varied and can include client engagement in the process (in selection, discussion, or recommendations of songs); response to the music and to other group members; verbal responses; themes, memories, and experiences that arise and are shared; and nonverbal responses such as facial expressions, demonstrations of emotions, and moving or singing to the music. Procedures. The session can start with a preliminary client check-in, followed by distribution of the Song Lyric Binders. The choice of songs and their themes may develop out of any check-in themes, or they may be selected by the therapist or the clients. In some settings, the format is a drop-in one, with different clients each week and a different stand-alone theme predetermined by the therapist; in other settings, attendance may be ongoing over a period of time and themes develop organically to meet the needs of the group as it progresses. However the themes are determined, clients should have the opportunity for their own choice of song within that theme. Within the session, each song can be first listened to on the recording, then sung along by all with the recording, and finally sung along with the therapist as she accompanies the group. This moves the music therapy method from a receptive method to a re-creative one (see the later Guidelines for Re-creative Music Therapy section for more details). Each of the three ways of experiencing the song offers important unique contributions to the therapeutic process. In listening to the recorded music, clients hear the voices of other women and their experiences of violence; this breaks their social isolation and allows them an understanding that they are not alone in experiencing violence. In singing along with the recorded music, clients can begin to internalize the message and the emotions of the song. Additionally, the recorded song provides support, especially important in the initial stages of involvement in music therapy, as well as for those whose self-esteem is

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not yet strong; group singing enhances a sense of group cohesion. In singing along with the music therapist, the clients can move to making the song and the story their own, embodying the experience. The use by the clients of their own voice, and the experience of truly being heard, can be very beneficial for abused women, women who have not been heard in the past—by their abusers or by others who have failed them (Curtis, 2000, 2006, 2008; York, 2006). Throughout all of the three phases of experiencing the song, the music therapist will facilitate and support discussion of the song and the themes which arise. While the therapist may make use of some open-ended questions, it is further helpful if the therapist sees this as a dialogue rather than a series of questions. This can work to establish a relationship of give-and-take, with a more egalitarian relationship in terms of power. This can be critical in the healing process for women whose experiences of violence have been characterized by abuse of power and control. An example of phrasing used by the therapist which fosters a dialogue, rather than questions, would be, “what struck me while listening to this song was …” or “I was wondering if this part of the song evoked a strong emotion for anyone else ….” In this approach, a certain amount of appropriate self-disclosure can enhance the therapeutic process (Worell & Remer, 2003). Adaptations. One adaptation of this method involves feminist analysis of gender-role socialization and power through lyric analysis (Curtis, 2000, 2006, 2008; York, 2006). This feminist analysis is a signature technique of Feminist Music Therapy, making use of a number of music therapy methods including lyric analysis, music-centered relaxation, songwriting, recording, and performance. The goal of each is to increase women’s understanding of the sociopolitical underpinnings of violence against women—in general terms and in specific terms as they apply to the clients’ experiences; the goal is also to examine the role of women’s and men’s gender-role socialization and power within the context. To accomplish this in lyric analysis, the music used is typically music written and/or performed by women. This makes it easier for the clients to see and hear themselves in the music. The themes selected for this work are broad-ranging and can include women’s voices on violence, anger, change, control, freedom, gender-role socialization, healing and recovery, love and romance, needs, self, strength, support, and truth-telling. There is a wealth of popular songs in diverse styles available for this method. Online resources can be helpful, such as Lady Slipper Music at http://www.ladyslipper.org/; so too can the annual editions of the Grammy Nominees. A partial listing of women’s songs by theme follows. Theme of Being Alone: “All by Myself,” Jamie O’Neal “Sand and Water,” Beth Nielson Chapman Theme of Anger: “Bitch with a Bad Attitude,” Saffire: The Uppity Blues Women “Good-bye, Earl,” Dixie Chicks Theme of Change “Do Something,” Macy Gray “Pissin’ on a Skunk,” Saffire: The Uppity Blues Women “Why?,” Tracy Chapman Theme of Control “Don’t You Tell Me,” Saffire: The Uppity Blues Women Theme of Freedom “Dear Someone,” Gillian Wench “Dreaming on a World,” Tracy Chapman “Going Out Tonight,” Mary Chapin Carpenter

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Theme of Gender-Role Socialization “Equal/Equally,” Parachute Club “Good Thing He Can’t Read My Mind,” Four Bitchin’ Babes “He Thinks He’ll Keep Her,” Mary Chapin Carpenter “If I Were a Boy,” Beyoncé Knowles “Women’s Work,” Tracy Chapman Theme of Healing and Recovery “Blackbird,” Sarah McLachlan, Dionne Farris “Broken Wing,” Martina McBride “Get Up Blues,” Joyce and Jacque “Hope,” Sweet Honey in the Rock “Love’s Recovery,” Indigo Girls Theme of Leaving/Staying: “Dump that Chump,” Saffire: The Uppity Blues Women “Let Him Fly,” Dixie Chicks “Sun Comes Up, It’s Tuesday Morning,” Cowboy Junkies “When the Heartache’s Over,” Tina Turner Theme of Love: “Any Man of Mine,” Shania Twain “Exhale,” Whitney Houston “Not the Doctor,” Alanis Morissette “Passionate Kisses,” Mary Chapin Carpenter “You Say You Will,” Trisha Yearwood Theme of Self: “Not a Pretty Girl,” Ani Difranco “Video,” India.Arie “Woman’s Worth,” Alisha Keyes Theme of Strength: “Bitch,” Meredith Brooks “You Learn,” Alanis Morisette Theme of Truth-Telling: “Telling Stories,” Tracy Chapman Theme of Violence: “Behind the Wall,” Tracy Chapman “Bonnie and Clyde ’97,” Tori Amos “Don’t Ever Touch Me [Again],” Dionne Farris “She Won’t Be Walking,” Four Bitchin’ Babes Another adaptation of the Lyric Analysis method is its use as a first step in songwriting. With this adaptation, the focus in listening to and performing songs changes. In addition to looking at the themes, attention is directed to how the song is written in terms of both the lyrics and the music. The purpose is to assist clients later as they move into writing their own original compositions (see the Guidelines for Compositional Music Therapy section which follows later). This can be an important opportunity to set clients’ minds at ease if they are uncertain about the songwriting process. Clients will come from diverse backgrounds, many of whom may be insecure about their English language skills, possibly making writing intimidating. Fears can be allayed in listening to song examples, such as Tracy Chapman’s “Behind the Wall,” which are written in simple language; clients can be encouraged to use their own speaking style and find their own authentic voices in this process.

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Bonny Method of Guided Imagery and Music (BMGIM) Overview. BMGIM involves the client (traveler) listening to classical music programs in an altered state while dialoguing with the therapist (guide) about the images and sensations that are evoked. Recent research has shown BMGIM to be effective with women survivors of intimate partner violence under certain circumstances (Hahna & Borling, 2004). However, a careful assessment of the severity of the violence and an indication of the last incidence are needed, with contraindications for those with any disassociation. Training in the BMGIM method is required, and, additionally, those trained must have awareness of issues surrounding intimate partner violence. Further information about BMGIM training can be found at http://www.ami-bonnymethod.org/. Because extensive BMGIM training and credentialing is required, this section will be limited to an overview with a focus on the particularities of the practice of BMGIM as it is used with abused women (Hahna, 2004; Hahna & Borling, 2004; Ventre, 1999). The overall goal of BMGIM is for individuals to “integrate mental, emotional, physical, and spiritual aspects of themselves” (Association for Music and Imagery (AMI), 2012a, para. 1). It is “the conscious use of imagery which has been evoked by relaxation and music to effect self-understanding and personal growth processes in the individual” (Hahna & Borling, 2004, p. 44). The level of therapy is primary. Preparation. The location used for this method should be a quiet, private space which is conducive to BMGIM—comfortable seating, a place to stretch out while listening to recorded music, a place for the making of artwork (mandala drawing), appropriate lighting which can be dimmed as needed, and a door which can be closed to minimize outside distractions. A high-quality sound system and art supplies are required. In preparation for BMGIM work, the therapist must have successfully completed all requirements of the Association for Music and Imagery. What to observe. Detailed notes are taken during and after each BMGIM session, documenting the client’s words, imagery, and responses (verbal and nonverbal). Procedures. In broad terms, BMGIM is “the use of specially sequenced western classical music designed to stimulate and sustain a dynamic unfolding of imagery experiences” (AMI, 2012b, para. 2). BMGIM sessions are conducted in individual therapy, in two-hour sessions with a format comprised of four parts (Hahna, 2004; Ventre, 1999): (1) prelude or preliminary conversation; (2) induction; (3) music program; and (4) postlude or integration/processing, which can involve artwork in the form of mandalas. Adaptations. In reviewing the practice of BMGIM, Hahna and Borling (2004) note that certain adaptations are needed in work with women survivors of intimate partner violence: (1) shortened music programs; (2) less intense music programs at the initial stages; (3) longer session duration; (4) client support with relaxation; and (5) greater client control. Of the BMGIM music programs, Mostly Bach is seen as one of the most helpful, but it is contraindicated at the beginning, trust-building stage of therapy. Additionally, current knowledge of intimate partner violence, including assessment and safety issues, is critical; feminist approaches to the BMGIM work are recommended (Hahna, 2004; Hahna & Borling, 2004). GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Group Music Improvisation Overview. This involves creating music extemporaneously in a group with the voice or instruments with or without a theme. Most women survivors of violence can benefit from group improvisational music therapy, instrumental and/or vocal (Amir, 2004; Austin, 2001; Slotoroff, 1994).

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The intensity of the experience and the degree of client engagement can be modified by the therapist to meet the ability and needs levels of the client. Challenges can arise, depending on the client, around issues of self-esteem, and physical and emotional responses evoked, as well as around participation in this type of music-making for those inexperienced with it. These can be handled by a skilled music therapist with forethought and attention. Caution is advised to first ensure that a safe place has been successfully established for each client in therapy, prior to undertaking this method. Goals used with this method are diverse and can include opportunities for body work (many of the effects of this type of interpersonal trauma can reside in the survivor’s body), for expression of emotions, for being heard and validated, for building self-esteem, for building group cohesion and breaking social isolation, and for empowerment. Depending on the particular application of this method, the level of therapy can be intensive or primary. While no specialized training is needed to use this method, experience with in-depth verbal processing and skills in dealing with intense emotions which may arise can be beneficial. Furthermore, experience and skills in facilitating group music improvisations can be helpful—this includes music and verbal skills. Preparation. For group instrumental improvisation, a good collection of high-quality instruments intended for adults is essential. This ensures that each client feels respected and honored in the therapeutic process. The instrument collection should include instruments of a variety of sizes as well as types—pitched and nonpitched, handheld and freestanding (on the floor or in adaptive stands), of definite and indefinite rhythmic sounds (e.g., drums hit with the hand or mallet, shakers, ocean drums, etc.), small, intimate instruments and large, powerful ones such as large djembes or Japanese traditional taiko drums. The instruments can be arranged in the center with client chairs placed in a circle around them. In selecting the particular instruments for use, the therapist needs to be sensitive to multicultural issues and may need to consult with individual clients. Some are not comfortable with traditional Native American drums in the hands of white people. This can, however, be a teachable moment where the clients can be the experts once again in their own music and culture. The room itself needs to be soundproofed or in a location such that sound transfer does not pose a problem for others, thus permitting freedom of musical expression within the group. What to observe. During the course of the session, the music therapist makes observations on musical and nonmusical levels. On the musical level, observations can include verbal and nonverbal responses such as choice of instrument, approach in playing (e.g., hesitant, forceful, quiet, loud, etc.), interaction with other group members, participation in the structured portions, and participation in the nonstructured portions. On the nonmusical level, observations can include emotional responses (verbal and nonverbal), connections made within the improvisation to any established therapy topics, and themes that arise in the postimprovisation discussions. Procedures. If this is the first experience of the day’s session, it starts with an opportunity for clients to check in. Issues that might arise are noted for possible inclusion in the group music improvisation. The session start-up might also include warm-up singing of a song or a simple chant to set the mood, establish a sense of group cohesion, and help clients to focus. An introduction to the group improvisation experience is then provided for first-timers, along with brief guidelines in performance and/or sounds of the instruments as needed if the group is new, or if members of the group are new. In the case of a new group, the group music improvisation can be moved by the therapist from a more structured experience to a freer type of improvisation; while the choice is theirs, the clients may equally be guided as needed to move from smaller instruments to more powerful ones. For some who are new to improvisation, the experience can initially be intimidating, so this guidance from the therapist can provide the needed support. In a more structured improvisation, the music therapist may provide a basic beat or rhythmic ostinato and then invite the group to join in playing it. Once the group is comfortable and the rhythm well established, an opportunity is provided that is built

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into the structure of regular musical phrases for free improvisation, followed by a return to the structured ostinato. The group then alternates regularly between structured playing and free improvisation. Initially, the free improvisation can be done by all members of the group, then in smaller groups, trios, then duos, then solos, while the remaining group members play the ostinato or keep the beat. This allows the clients a sense of safety and support, moving to greater independence as their confidence builds. The improvisation may be referential—i.e., focused on a theme—one chosen ahead for the day or one that emerges out of the preliminary check-in discussion. Alternately, the improvisation may be nonreferential, i.e., may commence musically, without a predetermined theme, allowing clients’ emotions and responses to emerge organically. The improvisation is allowed to unfold naturally, drawing to a close at the clients’ discretion. The improvisation is concluded with an opportunity for verbal processing of the experience. As with the previous Lyric Analysis method, this should be more within a dialogue framework than an educational or question-and-answer framework. In work with abused women, effort must be taken to facilitate a client-therapist relationship which is as egalitarian as possible. Ultimately, the women are experts of their own experiences and can accomplish their own healing and recovering with the support provided by the music therapist and with interactions with other survivors and the music therapist. Adaptations. While the above music therapy method is described with instrumental improvisation, it can play out equally well with vocal improvisation. In this case, the music therapist may or may not provide support with an accompaniment instrument like guitar or piano or handheld drum. The voice is a particularly intimate and revealing instrument, and its use in improvisation may therefore be more intimidating for some clients; when used appropriately, it can be an incredibly effective medium for women’s empowerment, providing a real and authentic voice, as well as the metaphoric voice gained in the healing process. As with instrumental improvisation, the therapist can guide clients in vocal improvisation, moving from more structured to freer improvisation. Starting with a familiar song or a simple chant (either existent or composed by the therapist for the improvisation) can also provide clients with needed support. The chant might have words in keeping with an established theme, or it might be sung without any words.

Individual Music Improvisation Overview. Individual music improvisation involves creating music alone or with the therapist extemporaneously using voice or instruments with or without a theme. Some women survivors of violence can benefit from individual improvisational music therapy (Amir, 2004; Austin, 2001). This method is not recommended for those in need of work on breaking their social isolation, which can best be accomplished in hearing the voices of other abused women in group therapy. It is also not recommended at the beginning stages of therapy, where trust-building is still under way. Austin (2001) provided case study examples with this method which, because of the method’s intense nature, first involved lengthy periods of preliminary work prior to the start of individual improvisation. As with group music improvisation, goals used with this method are diverse and can include opportunities for expression of emotions; for being heard and validated; for building self-esteem; for exploration of issues surrounding the experience of violence; for bringing to the conscious thoughts, feelings, and memories of the trauma and for the subsequent processing of these in a safe environment; and for empowerment. Depending on the particular application of this method, the level of therapy can be intensive or primary. While no specialized training is needed to use this method, experience with in-depth verbal processing and skills in dealing with intense emotions which may arise can be beneficial. Furthermore, experience and skills in facilitating individual music improvisation can be helpful—this includes music and verbal skills.

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Preparation. As with other described music therapy methods used with abused women, the location should be a quiet, private space. The individual music improvisation can be vocal, instrumental, or some combination used by therapist and client together. The room can be arranged with a small collection of instruments representing a variety of sizes as well as types, as described in the previous section on group music improvisation. The instruments can be arranged in the room adjacent to a piano or guitar, for possible use in accompanying the improvisation. What to observe. Similarly to group music improvisation work, the music therapist makes observations on musical and nonmusical levels. On the musical level, observations can include choice of instrument, approach in playing (e.g., hesitant, forceful, quiet, loud, etc.), participation in the structured portions, and participation in the nonstructured portions. On the nonmusical level, observations can include emotional responses (verbal and nonverbal), connections made within the improvisation to any established therapy topics, and themes that arise in the postimprovisation discussions. Procedures. Again the procedures for conducting individual music improvisation are similar to those used in the group improvisation. The session may start with a client check-in, possibly identifying themes for the individual improvisation to come. The music therapist guides the client through the session, moving from more structured experiences to freer improvisation. If vocal improvisation is used, great care must be taken to gradually ease the client into it, because the voice is such an intimate and revealing instrument. The therapist may choose to start with the singing of a familiar song. She may then introduce the client to a simple chant; possible options include a traditional chant such as a Native American women’s chant (Smithsonian Folkways, 1995), depending on the client’s cultural background, or a chant with simple melody and words composed by the therapist specifically for the client. Drum, guitar, or piano may be used optionally to provide grounding and support. Once the client is comfortable engaging in the music at this level, the music therapist can gradually guide her to further experimentation, adding her own words or musical lines, or singing without words. As with the group music improvisation methods described previously, the improvisation may be focused on a theme (client or therapist choice) or it may start without a predetermined theme, allowing the client’s emotions and response to emerge freely. Themes selected by the therapist will focus on issues appropriate to the individual client’s progress within therapy; these may include reflections on the experience of trauma/violence; healing and recovery; coping strategies; and dealing with the responses of others. Themes selected by the client may be identified in discussion immediately prior to the improvisation or in previous work in earlier music therapy sessions. The music therapist provides musical support in improvising with the client, at times mirroring the client’s musical and emotional content, while at other times extending it. The improvisation is allowed to unfold naturally, drawing to a close at the client’s discretion. The improvisation is concluded with an opportunity for verbal processing of the experience. Adaptations. In a psychoanalytic approach to improvisation with survivors of abuse, Amir (2004) outlines three possible adaptations used with individual rather than group improvisation: (1) an improvisation paired with reading, (2) a projective improvisation; and (3) a musical life story improvisation. The purpose of each of these adaptations is to bring issues to the conscious, to process the trauma, and to facilitate the healing process. With the first adaptation, the client reads a book while improvising; this is designed so that the client is not focusing on the improvisation itself; in this manner, the client can reflect on and access unconscious material. The second adaptation involves short projective improvisations played by the client in response to words provided by the therapist. The words presented by the therapist move from less evocative to more evocative (e.g., sky, ground, sun, then power, anger, etc.). In the final adaptation, the client plays an improvisation which reflects her life story. Verbal processing is an integral part of all three of these adaptations.

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As part of her approach with women trauma survivors, Austin (2001) outlines several individual vocal improvisation music therapy methods: Vocal Holding techniques and Free Associative Singing. Austin developed and codified these as part of her Vocal Psychotherapy practice. The level of therapy involved is primary and preparation for this practice requires advanced training; more information about the method and training is available at http://dianeaustin.com/music/. As a result, what follows here is a brief description only. Austin’s Vocal Holding technique makes repetitive use of two chords along with the music therapist’s voice to create a safe musical container to support the improvised singing of the client in interaction with the therapist. The purpose of this method is to allow access to and processing of unconscious material arising from the trauma. In describing this method, Austin indicates that the client and therapist start with unison singing for support and then move to harmonizing reflective of the client’s readiness to be separate but in relationship. Free Associative Singing arises when words are introduced to the vocal improvisation. In this approach, the client sings whatever words come to mind and the therapist contributes musically and verbally to the stream of consciousness. In this manner, the therapist serves as both a container to hold and a force to further the therapeutic process.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Reflective Singing Overview. In reflective signing, clients are engaged in singing with the therapist along with the original recording of a song. This method is indicated for clients as a preliminary step in songwriting and in individual vocal improvisation, and as a follow-up step in the lyric analysis method. There are generally no contraindications if handled skillfully by the music therapist. The goals include allowing clients to internalize the emotions and experiences reflected in the song; to gain a deeper understanding of the song’s theme and musical structure; to gain an understanding of the songs’ themes as they relate to the clients’ own experiences; and to achieve a sense of safety in the therapeutic relationship prior to individual vocal improvisation work. The level of therapy can be augmentative or intensive. No specialized training is needed on the part of the music therapist; however, strong music and verbal processing skills are needed. Preparation. As with other described music therapy methods used with abused women, the location should be a quiet, private space. Appropriate room and acoustics for vocalizing are needed, along with a high-quality stereo system and such accompanying instruments as guitar and piano. What to observe. The focus of observation will depend on the purpose of the method, but will include musical and nonmusical observations, as well as verbal and nonverbal ones. The music therapist will be looking to see that the client is ready to move to the advanced level in songwriting and in vocal improvisation. Comfort and participation levels will be observed. Verbalizations concerning ideas, themes, memories, and insight will be observed as they are evoked by the music. Procedures. With use of reflective singing in preparation for songwriting and in culmination of the lyric analysis methods, clients will be engaged in singing with the therapist along with the original recording of a song. Songs will be selected according to themes identified by the music therapist and/or the clients. Focus may be directed to the musical structure, as well as to the emotions evoked and experiences described through the song. Verbal processing may completed after each song. With reflective singing used in preparation for later individual vocal improvisation, the music therapist may sing songs to the clients, or the clients themselves can sing—alone or with the therapist. Austin (2001, p. 137) describes songs as “a container that has a beginning, a middle, and an end. … The song can be a catalyst for buried emotions while also providing a container for them.” In singing songs with and for the client, the music therapist works to build a trusting therapeutic relationship. Once this is

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accomplished, she may move on into vocal improvisation with the client. This method can be used in an individual or group setting.

Performance Overview. In performance, clients select pieces, practice them, and perform them for an audience. This method can be appropriate for clients who have already progressed considerably in therapy. Clients need both adequate personal and musical/performance skills in order for successful engagement in this method (York, 2006). Goals for this music therapy method include increasing selfexpression, self-esteem, self-advocacy, and social justice activism. The level of therapy is augmentative or intensive. No specialized training is needed on the part of the music therapist; however, strong music and performance skills are needed, as well as an understanding of social activism work. Preparation. This performance method is typically the final product of the music therapy process involving clients creating their own original music, artwork, poetry, and play scripts. As a result, the music therapist works with the clients to gather and select the pieces they will perform. What to observe. In terms of the nonmusical, the music therapist will observe clients’ verbal and nonverbal indications of comfort and preparedness for a performance. Music and performance abilities will be evaluated as they progress over the rehearsal period. Indications of group interactions and group cohesion can also be observed. While the final performance is one of the goals of this method, the importance of client progress within the rehearsal process cannot be underestimated. Procedures. This method should start with consensus-building among the group as to the purpose, the process, the performance materials, and the final venue of the intended performance. Once these have been established, along with rehearsal dates and schedule, each session may include: (1) a group member check-in; (2) physical and vocal warm-ups; (3) rehearsal of the performance materials; and (4) wrap-up session, with an opportunity for feedback from group members. At various points within the rehearsals, there may need to be full and sectional rehearsals. Closer to the performance, session time may also include staging, choreography, and dress rehearsals. The duration, frequency, and nature of these sessions may vary considerably depending on the initial decisions concerning the originally agreedupon purpose and venue of the final performance. In some instances, the performance can be used in increasing public awareness and social activism. The performance may then be followed by a discussion period for performers and audience members (York, 2006). Adaptations. This method can involve pure music performances or interdisciplinary arts performances, which can include music, theatre, and artwork. Performances may be done in a variety of contexts, from private settings to performances for family members, at a selected agency, or as open to the public. GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting and Recording Overview. In songwriting and recording, clients work individually or in a group to write a song on a therapeutic theme, then perform and record it to listen to themselves sing it. One of the most powerful methods for enabling abused women to be heard, to reclaim their voices and their lives, is through songwriting. It is a method used widely by most working with survivors of violence (Curtis, 2000, 2006, 2008; Cassity & Theobold, 1990; Day, Baker, & Darlington, 2009; Whipple & Lindsey, 1999). Songwriting in this area has been approached within both individual and group therapy settings. Talking and writing about women’s experiences of violence in the process of songwriting can evoke very powerful

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emotions and memories; it can also evoke, on the other hand, great resistance. Once again, great caution must be taken to first ensure that a relationship of trust has been successfully established with each client in therapy, prior to undertaking this method. The preliminary use of lyric analysis and re-creative methods in trust building can be helpful to ensure that the client is ready to proceed to work using this method. The goals achieved through this method can be varied depending on the approach and may include expression of emotions; exploration of issues related to the experience of violence and its impact; giving voice to experiences of violence and truth-telling, validation and empowerment; exploration of effective coping strategies and stress management skills; increasing self-esteem; breaking social isolation; and increasing understanding of gender-role socialization and power, along with the role these play in the clients’ lives. The level of therapy involved can be either intensive or primary. While no specialized training is needed to use this method, experience with in-depth verbal processing and skills in dealing with intense emotions which may arise can be beneficial. As with lyric analysis, a deep understanding of the issues involved in violence against women and the diverse experiences faced by abused women is critical, as is cultural humility. Preparation. In addition to the traditional quiet, private space needed for most work with abused women, for this method the therapist may choose to have on hand a white board and/or individual writing journals for each client. The music therapist should also have on hand a good sound system, with an appropriate selection of recorded songs; accompaniment instruments such as keyboard or guitar; and other small percussion instruments as needed. The songwriting session is best prepared for by engaging the clients previously in lyric analysis and vocal improvisation experiences focused on the experiences of both the songwriter and the client, and allowing the client to feel more comfortable and supported for the songwriting experience. What to observe. The music therapist can observe a full array of musical and nonmusical responses, verbal and nonverbal responses. These can include engagement in the process; level of comfort with various segments of the experience (making suggestions, writing, volunteering ideas); ideas, theme, memories, and experiences that arise; interactions with other group members; and any insights gained in connections to the songs used in lyric analysis, the clients’ own experiences, and any themes established for therapy. Procedures. Songwriting is typically an extended music therapy method which extends over several sessions. It can, however, be modified on occasion to be completed within a single session depending on client skills and needs. This method can involve writing as a group, individual writing within the group, or some combination. Having completed previous work (in this session or proceeding ones) on lyric analysis, singing, and some simple vocal improvisation, the music therapist and clients are ready to start the songwriting experience. Without adequate preparation, songwriting may seem daunting at first, particularly for abused women whose voices have been silenced and whose self-esteem has been the target of much violence. A helpful approach to address this involves moving gradually from simple, structured writing to more complex, freer writing. This transition—in terms of both lyrics and music— enhances the development of skills, confidence, and self-esteem. In an example of writing at its simplest, clients can be directed to individually write five sentences in their journals as follows: (1) one word that is the song’s theme; (2) two words that are synonyms of the first; (3) three words that are adjectives for the first; (4) four words that are descriptive gerunds (ending in “ing”); and (5) the first word repeated (the song’s theme). Depending on the clients, the therapist could select the song’s theme and first word to be the client’s name. These five lines are suitable as lyrics for use with a 12-bar blues pattern. Clients are asked if they are willing to share their writing, and those who agree have their first writing sung to them by the music therapist. If in agreement, the lyrics can be written on the white board and the entire music therapy group can sing them. Alternately, clients could

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work together using this method to write a single song, making use of the white board. Whichever approach is used, an opportunity for verbal processing follows, addressing both the songwriting process and any emotions or themes that are evoked. Work with this method has shown clients to be consistently open to this process, delightfully surprised at the ease of their writing, and genuinely pleased with their first song (Curtis, 2000). The music therapist can then move to the next phase in songwriting, making use of a longer “cloze,” or fill-in-the-blank, technique. Clients are involved in adding single words or complete sentences to precomposed songs. Certain songs lend themselves readily to this because of the structure of their lyrics and melody, although care must be taken to choose songs such that the experience is mature, not childish. Examples of these include Alanis Morissette’s “Hand in My Pocket” and Edie Brickell’s “Oak Cliff Bra.” Ultimately, clients can gain more satisfaction in working with original music so the songs they create are their own. To facilitate this, music therapists can write their own songs to be used by the clients at this stage. Once clients have successfully and confidently completed this work, they are ready for the next phase, which involves writing their own completely original lyrics and/or music. Typically clients are more comfortable starting with the lyrics and then building the music around these. In doing this, they are working individually within the group, bringing back their ideas and writings to the group for feedback and support. At this stage, themes for individual songs are selected by each client, with ongoing support of the music therapist. Throughout this process, part of each session can be spent in listening to and performing recorded songs, which can provide ideas and inspiration. Depending on the skills and interests, clients may choose to write their own music (assisted in singing improvisation work with the therapist) or have their lyrics set to music by the music therapist, with feedback and choices made by the client. Throughout each of these phases in the songwriting process, ample time and opportunity is allowed for verbal processing. Clients can benefit greatly when the songwriting experience ends with recording of their songs. The music therapist should secure an informed consent form from each client prior to completing any recording. The recording may be done by the client or by the therapist, at the client’s discretion. Fairly modestly-priced home recording studio equipment is now available commercially to ensure a high-quality final CD. Clients can be also involved in the process of creating the artwork—either hand-drawn or computer-generated images—for their CDs. As a whole, the songwriting/recording method provides an ideal therapeutic medium for abused women in having their voices heard and in reclaiming their unique authentic voices. Adaptations. Some adaptations of the songwriting/recording have already been described in the previous section, including individual work vs. group work, more structured vs. structured work, and work within and outside the therapy group. This method is widely used in work with abused women, and its use has been adapted with great diversity in terms of the selected therapeutic goals: to enhance communication, expression of emotions, psychoanalytic insight, and feminist analysis of gender-role socialization.

CLOSING REMARKS ON METHODOLOGY The procedures described above in each of the methods have been conceived as complete sessions. Nevertheless, different parts of sessions may be combined, depending on the needs of clients. In this section, the procedures are summarized and options for combinations of different procedures are presented. The music-centered relaxation group includes a variety of experiences, including breathing, progressive muscle relaxation (PMR), and guided imagery. After a check-in discussion, the therapist

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begins the music-centered relaxation experiences, gradually moving from the least demanding— breathing—to progressive muscle relaxation (PMR), and finally, to the experience that involves the psyche most deeply—music-centered guided imagery. This sequence is designed to assist the clients to gradually let go of their anxieties and to access their inner resources. However, the therapist may also use the initial breathing exercise as an opening for other groups and may use the breathing and PMR without the musiccentered imagery experience, depending on the particular needs of the clients. These techniques can be used both in the individual and group setting. For therapists with specialized training working in individual sessions, the Bonny Method Guided Imagery and Music (BMGIM) might also be used; this process by definition proceeds through discussion, relaxation, music imagery, and back to discussion phases, incorporating an array of receptive techniques. While improvisation may be the main focus of a particular session, other methods are also used to establish group cohesion and establish a focus for the improvisation, for example, beginning with a discussion and then proceeding with singing or listening to a song or a simple chant. This format can be used with both groups and individuals. Similarly, with sessions involving the use of songs, various methods are often combined. For example, lyric discussion may involve listening to songs, but also singing them. In some situations, writing new lyrics to the song might also be therapeutically indicated, thus moving from receptive through to re-creative and compositional methods. Clients may also perform songs that are meaningful to them or songs that they have written after working on them in sessions. Each session has a life of its own, depending on the group composition or the individual, the issues that are revealed, and the energy of the participant(s). The sequences of therapeutic procedures presented herein represent some possible groupings, but there are infinite combinations available.

RESEARCH EVIDENCE Research evidence in the area of music therapy with women survivors of abuse is limited, in keeping with this area’s emergent nature. Of the existent literature, the majority is composed of anecdotal and casestudy reports. Whether more formal research or anecdotal, most examines the effectiveness of some combination of music therapy methods, with only a smaller portion dedicated to examining single methods.

Receptive Music Therapy Laswell (2001) and Hernández-Ruiz (2005) identified the effectiveness of music-assisted relaxation in increasing relaxation, decreasing anxiety, and improving sleep for abused women at shelters. Within a randomized control trial, 28 women participated in a music-assisted relaxation protocol involving a 20minute recording of participant-selected music combined with a progressive muscle relaxation script over a period of five consecutive days (Hernández-Ruiz, 2005). Pretest/posttest measures showed: an increase in sleep quality as measured on the Pittsburgh Sleep Quality Index (PSQI); a decrease in anxiety levels as measured on the State-Trait Anxiety Inventory (STAI); and an improved overall quality of experience for all of the women. In a narrative case study report, Rinker (1991) described the effectiveness of Bonny Method Guided Imagery and Music (BMGIM) for a woman survivor of intimate partner violence. Over a fourmonth period, the woman showed improvement in her confidence, strength, and empowerment. Similarly, Ventre (1994) provided a narrative report on positive outcomes for an abused woman participating in BMGIM for two years. In later research, Hahna (2004) found a feminist approach to BMGIM with women survivors of intimate partner violence to be effective in improving their empowerment as measured on the Personal Progress Scale Revised.

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Improvisational Music Therapy In description of her clinical work with a 32-year-old women survivor of childhood sexual abuse, Amir (2004) identified the positive outcomes of improvisational music therapy, highlighting its ability to give “trauma a voice and bring harmony to the soul” (p. 103). Austin’s case study work (2001) described the particular effectiveness of vocal improvisation techniques with adults who have been traumatized as children.

Compositional Music Therapy The music therapy method of songwriting was examined by Day, Baker, and Darlington (2009) for its use with mothers who had experienced child abuse. This qualitative research involved in-depth interviews of five women three years after their participation in a songwriting experience embedded within a parental support program. All reported positively on their songwriting experience; for most, songwriting and listening to those songs afterwards served to facilitate communication with others, enhance self-esteem, and allow reflection on their resolution of past harm.

Multiple Methods of Music Therapy Montello (1999) provided a narrative account of the effectiveness of a combination of music therapy methods she used in clinical case study work with adults traumatized as children. Similarly, Austin (2006) described her use of several music therapy methods, including breathing exercises, song singing, vocal improvisation, and psychotherapy. She outlined this Vocal Psychotherapy approach and its positive outcomes through clinical vignettes from her work with adults traumatized as children. In a research protocol which evaluated the effectiveness of an eight-week music therapy program for women at battered women’s shelters, Whipple and Lindsey (1990) found that all 15 women participants responded positively. Relaxation, feelings about self, and feelings about the situation were measured on a 5-point Likert scale. The most effective music therapy methods included group singing, which improved mood and social interaction; songwriting for improved communication; and experiencesharing and drawing for improved self-esteem. The effectiveness of group music therapy using multiple methods was further evaluated within a research design with women at a shelter for domestic violence (Fesler, 2007). Of the three women completing the study, all benefitted from increased self-confidence and positive changes on the post-traumatic Symptom Checklist 90 Revised (SCL-90R). Multiple music therapy methods which also included the use of creative arts were examined for their effectiveness with seven women who had experienced intimate partner violence (Teague, Hahna, & McKinney, 2006). Results, using Visual Analogue Scales (VAS), showed a significant decrease in depression and a moderate decrease in anxiety. Most participants identified all of the music therapy methods as helpful, including use of singing bowls, journaling, clay work, lyric analysis, singing, and songwriting. Several recent studies examined the effectiveness of Feminist Music Therapy with multiple music therapy methods for women survivors of violence (Curtis, 2000, 2006, 2008; Curtis & Harrison, 2006; York, 2006). Curtis (2000) described her development of this new approach and reported on a research study evaluating its effectiveness as applied specifically in group therapy with women who had experienced intimate male partner violence. Of the six women completing the study, five showed significant improvements in their Tennessee Self-Concept Scale scores (TSCS), and all showed improvements as measured in post-therapy interviews and analysis of their composed lyrics. Music

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therapy methods adapted for use in Feminist Music Therapy included music-centered relaxation, lyric analysis, singing, songwriting, performance, and recording. Curtis (2006, 2008) provided further descriptions and narrative reports of the use of these methods with diverse women in feminist music therapy. A follow-up research study examined the effectiveness of a collaborative approach using Feminist Music Therapy and feminist social work with adult women survivors of childhood sexual abuse (Curtis & Harrison, 2006). The therapy methods used were expanded to include those previously identified as well as journaling, CD artwork, genograms, and discussions led jointly by music therapist and social worker. All five women participants showed significant increases in their self-esteem as measured on the TSCS and in exit interviews. York (2006) examined her own feminist approach to music therapy, expanded in collaboration to incorporate psychoeducational and psychodrama elements. In this clinical qualitative research, eight women survivors of domestic violence participated in group music therapy weekly for eight months, and showed decreased anxiety and increased self-esteem, positive interactions, and risk-taking.

SUMMARY AND CONCLUSIONS This chapter has explored the information, knowledge, preparation, and skills needed for effective and culturally sensitive practice with women survivors of violence. A preliminary look at the incidence rate and the effects of violence against women has shown its impact to be significant at both personal and societal levels. Information has been provided concerning diagnosis, along with surrounding controversies. While not yet resolved, these highlight the importance of sociocultural and political underpinnings. Whether or not women who have experienced such violence should be or will be diagnosed, music therapists can expect to see a number of them in their practice during their careers— whether or not those careers are specifically in trauma work. The diversity of women’s experiences of violence has been identified, looking at the full range of their characteristics (seen not as pathological symptoms, but as responses to extraordinary violence). Women’s strengths and resilience in light of this violence are noteworthy, and can include effective and active use of coping strategies, empathy for others traumatized, and a passion for social justice and activism. Women’s responses to the violence have been shown to be as diverse as they are, and can include intrusion, avoidance, negative cognitive or mood alterations, and arousal or reactivity alterations. Shown to be equally diverse is the amount of time and support needed to recover from the harm of this violence. An understanding of these complex issues, an awareness of the role of cultural diversity in the lives of clients and therapists, and a commitment to cultural humility will best prepare music therapists to provide women the support they need, when and as they need it, for their recovery and ultimate empowerment. The current scope of the practice of music therapy with women survivors of violence has been explored, identifying a diverse array of methods used involving receptive, improvisational, re-creative, and compositional music therapy. A newly-developed practice of Feminist Music Therapy has been outlined, with its particular use of music therapy methods infused with an understanding of the importance of the sociopolitical. There is a relatively small but gradually increasing amount of available research which documents the effectiveness of music therapy methods used in this area of music therapy practice—documenting their effectiveness as they have been traditionally used and as they have been adapted more recently within Feminist Music Therapy. An examination of these music therapy methods, supported by the research, has also identified the importance of group work, particularly effective in breaking the isolation so often experienced by women survivors of violence. While there is a need for further research and literature, a strong and vibrant scope of clinical practice currently exists in this emergent area. Underlying this is an understanding of the power of music

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to transform lives, which in the hands of a well-informed, well-prepared, well-trained, and culturally sensitive music therapist can be used to effectively empower women survivors of violence.

REFERENCES American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). (DSM-IV-TR). Arlington, VA: Author. American Psychiatric Association (APA). (June 15, 2012). DSM-5 Development. Post-traumatic Stress Disorder. Retrieved from http://www.dsm5.org/Pages/Default.aspx. Material in revision and subject to change. Amir, D. (2004). Giving trauma a voice: The role of improvisational music therapy in exposing, dealing with, and healing a traumatic experience of sexual abuse. Music Therapy Perspectives, 22(2), 96– 103. Association for Music and Imagery (AMI). (2012a). Association for Music and Imagery. Home page. Retrieved from http://www.ami-bonnymethod.org/index.asp Association for Music and Imagery (AMI). (2012b). Association for Music and Imagery. The Bonny method. Retrieved from http://www.ami-bonnymethod.org/index.asp Austin, D. (2001). In search of self: The use of vocal holding techniques with adults traumatized as children. Music Therapy Perspectives, 19(1), 22–30. Austin, D. (2006). Songs of the self: Vocal psychotherapy for adults traumatized as children. In L. Carey (Ed.), Expressive and creative arts methods for trauma survivors. (pp. 133–151). Philadelphia, PA: Jessica Kingsley. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., Brown, L. S. (2008). Cultural competence in trauma therapy: Beyond the flashback. Washington, DC: American Psychological Association. Burstow, B. (2003). Toward a radical understanding of trauma and trauma work. Violence Against Women, 9, 1293–1317. DOI: 10.1177/1077801203255555. Burstow. B. (2005). Critique of post-traumatic stress disorder and the DSM. Journal of Humanistic Psychology, 45(429). doi10.1177/0022167805280265. Carey, L. (2006). Expressive and creative arts methods for trauma survivors. Philadelphia, PA: Jessica Kingsley. Cassity, M., & Theobold, K. (1990). Domestic violence: Assessments and treatments employed by music therapists. Journal of Music Therapy, 27, 179–194. Curtis, S. L. (2000). Singing subversion, singing soul: Women’s voices in feminist music therapy. Doctoral dissertation, Concordia University, 1997. Dissertation Abstracts International, 60(12A), 4240. Curtis, S. L. (2006). Feminist music therapy: Transforming theory, transforming lives. In S. Hadley (Ed.) Feminist perspectives in music therapy (pp. 227–244). Gilsum, NH: Barcelona Publishers. Curtis, S. L. (2007). Claiming voice: Music therapy for childhood sexual abuse survivors. In S. L. Brooke (Ed.), Use of creative arts therapies with sexual abuse survivors (pp. 196–206). Springfield, IL: C. C. Thomas. Curtis, S. L. (2008). Gathering voices: Music therapy for abused women. In S. L. Brooke (Ed.), Creative arts therapies and domestic violence (pp. 121–135). Springfield, IL: C. C. Thomas. Curtis, S. L., & Harrison, G. (2006). Empowering women survivors of violence: A collaborative music therapy-social work approach. In S. L. Brooke (Ed.), Creative modalities for therapy with children and adults (pp. 195–204). Springfield, IL: Charles C. Thomas.

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Davis, M., Eschelman, E.R., & McKay, M. (2000). The relaxation and stress reduction workbook (5th ed.). Oakland, CA: New Harbinger Publications. Day, T., Baker, F., & Darlington, Y. (2009). Experiences of songwriting in a group programme for mothers who had experienced childhood abuse. Nordic Journal of Music Therapy, 18(2), 133–149. Fesler, M. M. (2007). The effect of music therapy on depression and post-traumatic disorder in a shelter for victims of domestic violence. Unpublished manuscript. Radford University. Gonsalves, M. C. (2007). Music therapy and sexual violence: Restoring connection and finding personal capacities for healing. In S. L. Brooke (Ed.), Use of creative arts therapies with sexual abuse survivors (pp. 218–234). Springfield, IL: C. C. Thomas. Hahna, N. D. (2004). Empowering women: A feminist perspective of the Bonny Method of Guided Imagery and Music and intimate partner violence. Unpublished master’s thesis. Radford University, Radford, VA. Hahna, N. D., & Borling, J. E. (2004). The Bonny Method of Guided Imagery and Music (BMGIM) with intimate partner violence (IPV). Journal of the Association for Music & Imagery, 9, 41–57. Hammel-Gormley, A. (1995). Singing the songs: A qualitative study of music therapy with individuals having psychiatric illnesses as well as histories of childhood sexual abuse. Doctoral dissertation. New York University, 1995. Dissertation Abstracts International, 56(10B), 5768. Hernández-Ruiz, E. (2005). Effect of music therapy on the anxiety levels and sleep patterns of abused women in shelters. Journal of Music Therapy, 42(2), 140–158. Juarez, J. A., Marvel, K., Brezinski, K. L., Glaznen, C., Towbin, M. M., & Lawton, S. (2005). Bridging the gap: A curriculum to teach residents cultural humility. Family Medicine, 38(2), 9–102. Kanani, R. (2012). DOJ director on violence against women in the United States. Retrieved from http://www.forbes.com/sites/rahimkanani/2012/03/08/doj-director-on-violence-againstwomen-in-the-united-states/ Laswell, A. (2001). The effects of music-assisted relaxation on the relaxation, sleep quality, and daytime sleepiness of sheltered, abused women. Unpublished master’s thesis. Florida State University, Tallahassee, FL. Rinker, R. L. (1991). Guided imagery and music (GIM): Healing the wounded healer. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 309–319). Gilsum, NH: Barcelona Publishers. Rogers, P. J. (1993). Research in music therapy with sexually abused clients. In H. Payne (Ed.), Handbook of inquiry in the arts therapies: One river, many currents (pp. 197–217). Philadelphia, PA: Jessica Kingsley. Rogers, P. J. (1994). Sexual abuse and eating disorders: A possible connection indicated through music therapy? In D. Dokter (Ed.), Arts therapies and clients with eating disorders: Fragile board (pp. 262–278). Philadelphia, PA: Jessica Kingsley. Sallie Bingham Center for Women’s History and Culture. (June 15, 2012). Sallie Bingham Center for Women’s History and Culture. Women’s Music. Duke University Libraries. Retrieved from http://library.duke.edu/rubenstein/bingham/guides/music/muwomen.html Schacter, C., Stalker, C., Teram, E., Lasiuk, G. C., & Danilkewich, A. (2009). Handbook on sensitive practice for health professionals: Lessons learned from women survivors of childhood sexual abuse. Retrieved from http://www.phac-aspc.gc.ca/ncfv-cnivf/pdfs/nfntsx-handbook_e.pdf Slotoroff, C. (1994). Drumming technique for assertiveness and anger management in the short-term psychiatric setting for adult and adolescent survivors of trauma. Music Therapy Perspectives. Special Issue. Psychiatric Music Therapy, 12(2), 111–116. Smithsonian Folkways. (1995). Voices of the First Nations women [CD]. Rockville, MD: Author. Solomon, M. F., & Siegel, D. J. (Eds.) (2003). Healing trauma: Attachment, mind, body, and brain. New York: W. W. Norton.

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Statistics Canada. (2006). Measuring violence against women: Statistical trends 2006. Commissioned by the federal/provincial/territorial ministries responsible for the status of women. Ottawa, Canada: Statistics Canada. Teague, A. K., Hahna, N. D., & McKinney, C. H. (2006). Group music therapy with women who have experienced intimate partner violence. Music Therapy Perspectives, 24(2), 80–86. Tervalon, M, & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. DOI: 10.1353/hpu.2010.0233. United States Department of Justice. (2012). Office of violence against women: Areas of focus. United States Department of Justice, Office of Violence against Women. Retrieved from http://www.ovw.usdoj.gov/index.html van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401–408. van der Kolk, B. A., & Pynoos, R. S. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-5. Retrieved from http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf Ventre, M. (1994). Healing the wounds of childhood abuse: A Guided Imagery and Music case study. Music Therapy Perspectives. Special Issue. Psychiatric Music Therapy, 12(2), 48–53. Whipple, J., & Lindsey, R. S. (1999). Music for the soul: A music therapy program for battered women. Music Therapy Perspectives, 17(2), 61–68. Worell, J., & Remer, P. (2003). Feminist perspectives in therapy: Empowering diverse women. New York: Wiley. Yllö, K., & Bograd, M. (Eds.). (1988). Feminist perspectives on wife abuse. Newbury Park, CA: Sage. York, E. (2006). Finding voice. In S. Hadley (Ed.), Feminist perspectives in music therapy: Empowering women’s voices (pp. 245–265). Gilsum, NH: Barcelona Publishers.

RESOURCES APA Resources on Cultural Competence/Humility Guidelines for Psychological Practice with Girls and Women: http://www.apa.org/about/division/girlsandwomen.pdf Guidelines for Psychotherapy with Lesbian, Gay, & Bisexual Clients: http://www.apa.org/pi/lgbc/guidelines.html Guidelines for Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists: http://www.apa.org/pi/multiculturalguidelines/formats.html Guidelines for psychotherapy with PTSD: Information for ordering at http://www.istss.org Intimate Partner Abuse and Relationship Violence: http://www.apa.org/pi/iparv.pdf Women’s Music Resources Lady Slipper Music: http://www.ladyslipper.org/

Chapter 9

Adult Male Survivors of Abuse and Developmental Trauma Jeffrey H. Hatcher

INTRODUCTION Existing music therapy literature reveals little with regard to initiating specific and successful interventions with the participant population of adult male survivors of chronic, long-term abuse. Clinical accounts from outside the music therapy field suggest that treatment of trauma, whether post-traumatic stress disorder (PTSD) or developmental trauma (van der Kolk, Roth, Pelcovitz, Mandel, & Spinazzola, 2005), which was first identified as complex trauma (Herman, 1997), tends to fall within traditional methods of verbal psychotherapy in the Western world. It is also acknowledged that inroads have been made by other creative arts therapies and by methods which have been, until recently, alternative to classic verbal dyadic or group discourse (e.g. narrative, movement, and drama therapies). This chapter describes clinical music therapy techniques used in the treatment of adult males with a history of survival of childhood abuse, which is now commonly referred to as Developmental Trauma Disorder (van der Kolk et al., 2005). The trauma described here is the result of one or more manifestations of abuse: physical, sexual, psychological, and/or emotional. In their adult lives, these clients may subsequently become perpetuators of abuse toward others or toward themselves. This chapter does not address abuse of adult men that began in adulthood. The author offers a cursory theory based on his clinical experience that research might reveal significant differences between persons whose abuse began in adulthood and those whose abuse began in childhood. Because of the relative dearth of available material in music therapy literature regarding treatment of adult male survivors of developmental trauma, this chapter seeks to address that gap by using examples from the author’s own clinical work (Hatcher, 2004, 2007). That clinical work, which began in 2000, was first informed by the definition of “Post-Traumatic Stress Disorder” (PTSD) and then deepened by an understanding of “Complex Trauma” (Herman, 1997) and “Developmental Trauma” (van der Kolk et al., 2005). PTSD first appeared as an operational diagnosis in the American Psychiatric Association (APA) 1980 publication of the Diagnostic and Statistical Manual (DSM) (APA, 1980). It was revised in the DSM-III-R (APA, 1987) and again in the DSM-IV (APA, 1994). It then appeared in the International Classification of Diseases in 1992 (World Health Organization). Also, in 1997, Judith Herman’s Trauma and Recovery described what she saw as a distinction or set of distinctions between the survivors of onetime traumatic events, and those who had survived long-term, chronic abuses of the types described above: emotional, physical, sexual, and psychological. Herman (1997) believed she was witness to a phenomenon that required further refinement of the diagnosis of PTSD. She named this Complex

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Trauma, but it is now more commonly referred to as Developmental Trauma (DT). By the time of this writing (spring, 2013) developmental trauma had not been included in the DSM. This chapter begins with a brief look at how current theorists define developmental trauma and provides a description of DT’s most salient effects: alterations both to one’s sense of identity and to one’s neurological system. It then reviews clinical philosophies offered by those who work with male survivors of DT, cites extant music therapy literature with regard to that particular population, and continues with the text’s major section: examples of clinical interventions, separated into particular approaches, each supported by specific activities. Contraindications and adaptations to the interventions are discussed. Numerous investigations trace the link between early life abuse and negative performance in later life. Bessel van der Kolk et al. (2005) cites the Adverse Childhood Experiences (ACE) study (Felitti et al., 1998), which found evidence of increased rates of “… depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases …” in survivors of DT. This research additionally found that when the experiences were more severe (“adverse”) there was a positive correlation with incidences of heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease. The ACE study also noted: Isolated traumatic incidents tend to produce discrete conditioned behavioral and biological responses to reminders of the trauma, such as are captured in the PTSD diagnosis. In contrast, chronic maltreatment or inevitable repeated traumatization, such as occurs in children who are exposed to repeated medical or surgical procedures, has pervasive effects on the development of mind and brain. Chronic trauma interferes with neurobiological development … and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole (Felitti et al., pp. 245–258).. The above-mentioned “interference with neurobiological development” is referred to again and again within the trauma literature. Current schools of thought are unanimous in striving, through various approaches, to address this arrested and sometimes brutalized development so that the client may improve his ability to understand and manage his difficult emotions, reactions, and other symptoms of DT, and adopt positive behaviors and establish healthy interpersonal relationships.

DIAGNOSTIC CRITERIA Post-Traumatic Stress Disorder The Diagnostic and Statistical Manual (DSM-IV-TR) (APA, 2000) cites the following criteria for a diagnosis of PTSD: exposure to a traumatic event where the experience involves the threat of harm or death and where the person’s response involves helplessness and intense fear; re-experiencing the traumatic event through intrusive and distressing thoughts, perceptions, imagery, dreams; experiencing the feeling as though the event is reoccurring, or acting as though it were; a feeling of emotional numbing that the person describes as new; a level of responsiveness that has been dulled and was not present before the trauma; making efforts to avoid stimuli that remind one of the trauma; and evidence of increased arousal not seen before the traumatic event, such as outbursts of anger, sleeplessness or difficulty sleeping, hypervigilance, and a heightened startle response. The disturbance to the person must last longer than one month and must cause “clinically significant distress” in crucial areas of functioning.

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Developmental Trauma The effects of PTSD tend to follow the path of an isolated incident leading to conditioned biological and behavioral responses which “… act as reminders of the original trauma …” (van der Kolk et al., 2005). However, in chronic traumatization, the person is subjected to “totalitarian control over a prolonged period” (Herman, 1997, p. 121), which has long-term, pervasive effects on the development of mind and brain. Van der Kolk (2005) elaborates further in maintaining that the experience of chronic trauma generates interference to the survivor’s neurobiological development and to their capacity to incorporate discrete perceptual and cognitive segments of information into a cohesive whole. Herman (1997) describes the core characteristics of the impact of Complex Trauma (Developmental Trauma) as follows: • • • • • •

Alterations in affect regulation; Alterations in consciousness, including reliving experiences; Alterations in self-perception, including sense of helplessness or paralysis of initiative; shame, guilt, and self-blame; and sense of stigma; Alterations in perception of the perpetrator; Alterations in relations with others, including isolation and withdrawal, disruption in intimate relationships, and repeated failures of self-protection; Alterations in systems of meaning, including loss of sustaining faith, sense of hopelessness and despair (p. 121).

Herman acknowledges core similarities between the effects of DT and those of PTSD: “… hyperarousal, or the persistent expectation of danger; intrusion, or the imprint of the traumatic event(s); and constriction, or the numbing response of surrender” (p. 35). A client who is additionally a survivor of long-standing, chronic trauma will often, though not always, display a significant low level of selfconfidence. Self-inhibiting behavior, shaped and molded by early-life traumatic experiences, may figuratively or even literally silence some survivors’ voices, lead to restricted physical movements, or limit their mobility, actions, and interactions within their living environment. Conversely, others with a similar background may present the opposite: “acting out” with high energy, inappropriateness, aggression or violence, and a chaotic lifestyle. The clients who fall within the parameters of abuse and DT addressed in this chapter include survivors of childhood neglect and emotional, verbal, sexual, and other physical abuses. Behaviors that are manifested as a result may be early exit from school, alcohol and illicit drug abuse, experience with the justice and prison systems, illness and disease associated with a marginalized life such as hepatitis C and HIV/AIDS contracted from shared needle use, and premature failing health. These clients may share many of the co-occurring experiences of “street life” such as homelessness, broken or absent family contact, lack of true friendship, heightened risk of assault, discrimination by the general public, limited community resources, and a social system that recognizes the health care nature of their addictions but a legal system that sees addiction to street drugs as a personal choice and thus a criminal matter. Higherfunctioning male clients—active, employed, in long-term relationships, etc.—struggle with the effects of developmental trauma despite being more fully integrated into the social fabric. The work described in this chapter is necessarily particular to a dynamic created between a male music therapist and a male survivor of DT. It cannot, certainly, be representative of all male–male therapeutic alliances. Every gender combination of therapist/client is unique, and generalizations related to any particular combination cannot be accurately predicted. The factors of transference, countertransference, projection, and therapeutic alliance, to name a few, are powerful forces, particularly

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in working with survivors of DT. Therefore, the particular client’s gender, the gender or gender(s) of his abuser(s), his current relationships with women if his abuser was female, and the gender of his therapist can be regarded as significant players within the therapeutic dynamic. Though these factors must always be considered, they cannot predict accurate assumptions about the relationship.

NEEDS AND RESOURCES In the treatment of abuse survival, both PTSD and DT, the client population of adult men has not yet been served by the creative arts therapies with the same level of attention given to children and adult women. There is little in the creative arts literature that addresses abuse of men and boys. This silence may not be surprising, as only recently has society begun to provide an opportunity for male survivors of abuse to speak out and be heard. With regard to male clients in music therapy, factors to be considered may include their preconceptions of “the type” of man who requires therapy; what they need from therapy, and music therapy in particular; their sometimes previously unacknowledged strengths and skills, which can form the foundation of sessions; biological issues (how abuse has impacted their physical well-being and/or sexual function); relationships in their past and present; their perceptions of self versus what they see as public impressions of them; and acknowledging that they may have grown up to become abusers themselves, combined with an emerging desire to take responsibility for these actions. Internal resources clients may possess that will be brought to bear in the sessions include intelligence, imagination, knowledge of music (perhaps even being a musician), creativity, the ability to generate imagery, and verbal skills. This chapter speaks to the abuse survivor’s own voice, literally and metaphorically, and to therapeutic interventions that address the client’s self-expression, particularly as manifested in his speaking and/or singing voice. Austin (2008) reaffirms the need to circumvent most clients’ (and most people’s) negative view of their own singing voice, often reinforced by negative or even harsh comments during formative years. She observes that when one’s own voice “… is insulted, it can feel like a rejection of one’s self because of the ability of the voice to reflect the personality and the intimate connection between our voices and ourselves” (p. 116). Speaking in public, the most common of phobias, may be all the more intimidating for participants when speaking expands into musical vocalizing, the learning and playing of instruments, improvising musically, or playing/performing where others can hear and observe. This intense emotional connection between “voice” and trauma should be thought of as being applicable to all forms of voice. Because the music experience has, at its heart, inherent connections to emotions and memories (Levitin, 2006), and using one’s voice in music is so intensely personal (Austin, 2008), the therapist should anticipate that the experience of making music in the recovery of trauma will touch upon the areas of mourning, establishment of safety, and reconnection (Herman, 1997). A sizeable subgroup among the abuse survival population may demonstrate inhibition to the point of being unwilling to consider holding or even touching a musical instrument. For this group, new activities of any kind may be intimidating by the mere nature of their being new. Though such inhibition can be daunting for the therapist, he must not lose sight of the strength inherent in these persons who have survived so long and have reached out to seek therapeutic assistance. Despite their inhibition, they are often desperate to “see change” in their lives, and they trust the therapist to know the territory where the exploration will take place better than they trust themselves. Therapists need to inform participants in the music therapy process of the difficult elements that can sometimes surface during therapy. The effects of DT—intrusion, hyperarousal, and constriction—are challenged by music therapy experiences that access memories that might be painful and emotions that are often confusing. Abuse survivors require a new, healthier, and better-integrated relationship with themselves and others, and those who have entered therapy are aware of this need. They need to be

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advised of the therapist’s intentions to assist them in finding the means to accurately identify and safely and appropriately live and express their emotional lives. This may involve other component needs, such as learning to separate reactionary feelings from deeper, more considered ones; to know it is “a right” to acknowledge and express anger appropriately; and to develop the abilities to trust, to imagine, and to dream. Further, they need to feel the support of other people in these endeavors and to know that progress is possible and that wellness is attainable. Even high-functioning individuals will often experience a particular feeling of “nakedness” surrounding use of the voice; these feelings of discomfort may be greatly augmented for persons who have survived abuse. The adult with DT, regardless of age or gender, often speaks quietly and in a monotone, which is another example of the feeling of “restriction” that is a feature of the condition. In contrast, another subset of the survivor population may behave in much the opposite manner, “acting out” with extravagant gestures and behaviors or with colorful, attention-getting, vocal mannerisms. Yet, even with clients who have what may seem to be an insurmountable level of inhibition, the therapist should never abandon the hope of utilizing the intervention of vocalizing for the male survivor of abuse. The therapist should take care to avoid a tendency to promote “regression,” or the deliberate inculcation of the reliving of past trauma. Such a route may be greatly beneficial for some clients, but it cannot be pursued without great consideration; many clients have erected well-established defensive walls around their past which clearly serve a purpose. Only when the client seems amenable to such investigation can it safely be introduced and, even then, the therapist must feel confident that they are both able to “leave” any territory they have entered if it proves emotionally damaging. Thus, as a general guide, the therapist should instead focus on identifying and building upon strengths the client has developed, helping the client to reveal past traumatic experiences only when and if he demonstrates readiness. The resources of survivors of DT are many and are unique to each person. The therapist must keep in mind that at the point where the client has entered therapy, he may be feeling that his resources are beginning to break down or are now inadequate. Still, the resources themselves speak to the client’s resilience and ability to adapt, though the client himself may feel a sense of stasis. A good many clients have experienced marginalizing social strictures. These clients demonstrate resourcefulness in their knowledge of how systems work, an awareness—sometimes distorted—of the inequities of society, and an ability to survive frequent upheaval (evictions, loss of friends, changing fortunes). Others have had little or no experience with these life factors and instead progressed successfully through school, postsecondary education, even employment, and may seem to be high-functioning. These clients’ resources may rest upon their ability to control their surroundings, minimizing the appearance of a chaotic life, and to control their emotional responses, and their efforts to be, or appear to be, independent. Overall, the therapist will take note of the client’s resources—both what he observes and what the client reports and demonstrates—and then, throughout the therapy process, assist the client in realizing what the best aspects of those resources are, how they can be maximized, and how new ones can be explored and employed.

REFERRAL AND ASSESSMENT PROCEDURES Clients who are, or are thought to be, living with DT may be referred to music therapy for various reasons, including that other therapeutic efforts have found limitations to “talk” therapy; the client has expressed an interest in music and/or music therapy; and/or the referring person or body believes the area of creative arts therapies, as “something new,” may provide the “shake-up” the client is thought to require. In assessing a survivor of DT the therapist will keep in mind that, although the universal effects of surviving those experiences—namely, Herman’s (1997) symptoms of hyperarousal, intrusion, and

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constriction—will likely be found in varying degrees from one client to the next, the variety in the effects themselves can be as immense as the imagination allows. Often, an informal process of assessment and information-gathering may take several sessions of informal conversation that focuses on areas of how the client reports he feels; how long or often he feels this way; how in touch or out of touch he feels he is with his body, his feelings, and/or emotions; how he assesses his interpersonal relationships; what personal, family and community supports, if any, he believes he can count on; how he hopes music therapy can benefit him; and his feeling about the likelihood of success from therapy. The therapist will observe both what the client reports and how he reports it. Much may be ascertained from this tactic. Realization, early in therapy, of a client’s incongruities and inconsistencies between his reported feelings and his outward presentation and behaviors can reveal the client’s self-awareness, his current coping strategies, his nature and the quality of the pain he feels, and the level of hope with which he lives.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • • •

Directed Listening and Discussion: The client and therapist select music or songs, listen together, and discuss the music and lyrics. Music Listening to Identify Visceral Responses: The therapist helps the client to focus on his body responses while listening to music. Music and Imagery: The client listens to either instrumental music or songs and attends to verbal suggestions from the therapist while describing mental images that occur to him during the experience.

Improvisational Music Therapy • •

Safe Group Jamming: A group of music-makers, each with a chosen instrument, plays together based on an agreed-upon, simple, music/song structure. Voice and Body Exploration: The client practices mindful breathing and vocalizing while being guided by the therapist to focus on somatic experience.

Re-creative Music Therapy • Didactic Therapeutic Lessons: The therapist provides the client with voice or instrumental lessons to help the client to acquire an introductory facility with a musical instrument or instruments. • Pitch-Finding: The client locates and vocalizes particular pitches based on hand directions and vocalizations from the therapist. • Song-Singing and Rapping: The client uses his voice to create melodies and/or rhythmic speech through humming, singing, or rapping, both with the therapist and in solo expression.

Compositional Music Therapy •

Therapeutic Song Composition—Lyric Writing: The client composes song lyrics with the therapist to create a new song.

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Therapeutic Song Composition—Original Music: The client and therapist compose a melody and harmonic structure for newly composed original lyrics.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Directed Listening and Discussion Overview. The client and therapist select music or songs, listen together, and discuss the music and lyrics. The client explores his emotional responses to the music he selects and discusses with the therapist the meaning(s) that the selections have for him. Client goals are to become familiar and comfortable with his emotional responses; to acknowledge music “touchstones” in his life’s journey; to verbally reflect upon his social and emotional development as reflected in the music of his life; and to imagine his future using music. It is indicated when a client demonstrates a willingness to begin to define, or redefine, his emotional life. It is an exercise that may additionally help form a strong therapeutic alliance between therapist and client. There are no contraindications. The level of practice is augmentative or intensive. Preparation. This activity requires a quiet room where the chance of disturbance is minimized. A music playback medium and a variety of music for selections are essential; more than one playback option is recommended, including the cassette tape, CD, DVD, laptop computer, iPad, iPod, and/or sound files recorded on a mobile phone. In time, some of these media will surely be replaced; it is the therapist’s task to remain knowledgeable of current playback methods. Internet access is now also an invaluable resource, advisably via free streaming that does not violate copyright. It is rarely sufficient to rely only upon one’s memory to generate titles for discussion, so the therapist and client must discuss how to access song lists and the music media that contain the recordings they will require. The therapist should request that the client bring some personal favorites, as these will remain a “safe zone” to which they can return should emotions become difficult to contain. The therapist should ultimately make attempts to have a variety of music genres available. He may prepare by researching radio playlists from particular years or eras and chart placement lists from industry magazines or blogs and online radio websites. He should suggest that the client also attempt to do search out song titles and that they will compare what they have found at the next session. The therapist should consider all of the following as potentially therapeutically useful: music the client loves, that he once loved but about which he now declares ambivalence, musical qualities he wishes he could create for himself, and music he is embarrassed to admit he enjoys. The purpose of this is to stimulate discussion of the emotional impact that various music has for the client as a means of gaining insight into the deeper aspects of his current emotional life. What to observe. The therapist will pay attention to the client’s visible and vocalized responses to the music. Note in what ways he responds. Is he verbal? Does he seem uncertain? Does he seem not to respond at all? He must also watch for signs of unease on the part of the client, as music’s ability to stimulate memory and trigger emotion can be a potent negative combination if it leads the client to relive painful memories. This response of regression can be a high risk for the acquiescent client who may see this song choice experience as a deliberate therapeutic strategy with which he must go along. Once thought to be essential in the therapeutic process of treating past emotional or physical abuse, regression is now considered to be useful only in specific circumstances but remains potentially harmful and retraumatizing in others. Many abuse survivors have erected substantial “walls” between their past and the present. Whether those walls are erected through denial or as a response to perceived threat, for survivors of traumatic, chronic abuses, they have served a purpose. While these rigid defenses may be an

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impediment to healing, they serve to shield them from reliving memories and experiences they believe to be too difficult to face in the present day. Procedures. The therapist should first present a rationale to the client for the choice of listening as a therapeutic intervention, explaining that we often take our artistic preferences and dislikes for granted, responding viscerally, but that we can learn much about ourselves by examining them. By reviewing, with another person, musical works that are important to us, we can often gain insight into our emotional life. During listening, the therapist can ask the client, for example, where he “sees himself” in the music; how he chose the songs he did; and what some of the easiest decisions to make were, and why. What does he believe his choices say about him? Who in his life would be surprised at his choices, and who would not? The therapist’s contribution to the discussion will flow from client responses. Knowledge that a particular genre, for instance, holds special negative or positive emotional significance for the client could prompt the therapist to inquire as to its meaning for him. The therapist can ask the client how he would “change” a particular song, style, or genre, if he could. Who would benefit, and how? Each directed listening session should end with a plan for the next, if there is to be one—that is, what to listen to, expectations that might exist, reasons for the choice. Adaptations. The therapist and client can choose songs randomly from one or many lists that they have designed or selected together. Songs, song titles, or specific recording artists can be selected and discussed. The songs themselves may also be played, live or via recordings, and their content can be discussed based on limitless criteria, e.g., those that represent the past, the present, or the future; those that represent happy occasions; those which the client feels should never be heard again, and why; those that represent strength, or make one angry upon hearing, or that one finds relaxing, and why; or those to which one can go to sleep. Sessions can also focus on instrumental music of different genres. The above adaptations should be utilized when the therapist has some certainty that the client is capable of engaging in discussion with some rigor; it may be less useful in early stages. .

Music Listening to Identify Visceral Responses Overview. The therapist helps the client to focus on his body responses while listening to music. This procedure is indicated when a client suffers physical inhibition due to traumatic experience; this likely indicates emotional and psychological inhibition as well. It may be contraindicated if, once initiated, the therapist sees that the client does not (yet) respond, in which case it may be reintroduced later in the recovery cycle. Goals for the client are to become familiar with noting visceral responses to musical stimuli; to feel safe to acknowledge them; to note the relationship between his physical responses and his emotional state; to understand that unpleasant visceral responses can be overcome; and, ultimately, to set the stage for creating music of his own—improvising, composing—to move further along in the process of recovery. The level of practice is augmentative or intensive. Preparation. The preparation is the same as for Directed Listening and Discussion. What to observe. The therapist will note both what he himself observes as well as what the client reports the client is feeling. It is important to note congruencies and discrepancies between the two participants’ observations, as these are both points for discussion. For example, the client may report that he feels “nothing” or that he is totally relaxed, and yet the therapist might observe the client’s hands clenched tightly into fists or that his closed eyelids are fluttering. Conversely, the client may report that the music makes him upset or angry, yet he may be presenting as still, peaceful, even uninvolved. The therapist will point out discrepancies between the client’s reporting and the therapist’s observations so that he fosters awareness in the client of those differences.

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Procedures. The therapist chooses music based on knowledge of the client’s tastes. Typically, the music chosen at first will be agreeable to the client, though there may be, in the future, therapeutic value in using music the client dislikes. Once the music is chosen, the therapist invites the client to position himself comfortably near the speakers, and he begins the playback. As a first option, he may turn the playback’s bass controls up higher than usual. While the music is playing, the therapist asks the client to describe the experience of feeling and hearing the low frequencies on or in his body. He will ask the client to expand upon those reported sensations: If “pleasant,” in what way? Is it a whole-body experience or is it localized? If it is unpleasant, try to say why this is so; what does it remind him of, or is he not able to identify it? In the discussion at the music’s conclusion, the therapist will explain that this experience may require only a slight perceptual shift to move from feeling in the body to emotional feeling. He shares with the client how identifying sensations in his body can relate to emotions he feels and suggests that to heighten these sensations in an emotionally safe manner can be a therapeutic goal. As noted above, the therapist may point out to the client anomalies between his reported feelings and the therapist’s observed responses. The therapist may ask the client: “Are you aware that you report [as an example] feeling ‘fine’ but are clenching your fists?” “Can you describe how you would expect someone to physically appear who is feeling as you say you are?” “Describe a type of music that, for you, would be likely to cause such a reaction.” “Let’s choose music to listen to that reflects how you say you feel.” Such questions and prompts will serve to generate, define, and strengthen any relationship(s) the client now has between his emotional life and his corporeal experience. He will, from session to session, become increasingly aware of the physical sensations generated by his therapeutic listening experiences and should experience both an increased range of sensations and a higher comfort level with that awareness.

Music and Imagery Overview. The client listens to either instrumental music or songs and attends to verbal suggestions from the therapist, describing mental images that occur to him during the experience. This method is indicated when a client shows the ability to access imagery and a desire to emotionally explore his inner world. It is contraindicated in cases where the client still shows high levels of anxiety or trepidation about “examining” his abuse. However, if the client has a sense of control and is aware that he—and not the music or the past—controls his imagery, it may still be indicated. This is most appropriate for Herman’s (1997) recovery stage of reconnection; goals for the client are to broaden his emotional experience, to identify images he finds significant, to examine their importance to him through discussion and other therapeutic experiences, and to visualize connections between the generated imagery and significant people, places, and events in his present-day life. The therapist should have training in advanced skills in music and imagery, such as those completed in a Guided Imagery and Music (GIM) level I Training or the equivalent. The level of therapy is intensive. Preparation. The space must be soundproof and comfortable, with the possibility of having dimmed lighting. Material required may be minimal: a chair or couch for the client to lay or sit upon, a chair for the therapist, a blanket and pillow for the client, and one polyphonic instrument. The author recommends that the therapist use a guitar or keyboard rather than recorded music, as this will allow for in-the-moment adjustments to tempo, timbre, and volume. What to observe. The therapist observes the client’s level of comfort with each stage of the experience. This is necessary because maintaining a feeling of relaxation and safety is therapeutically necessary for persons with trauma. This relaxed state in itself helps the client to experience the music more deeply and connect to his internal imagery at a deeper level.

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Procedures. The therapist begins by helping the client to find a relaxing position either sitting up or lying down with eyes closed. The client is then led through a progressive relaxation experience. To do this, the therapist plays a repeating motif on an instrument while directing the client, to alternately tighten and relax his body’s muscles with each intake and exhalation of breath. Begin at the toes and proceed to the neck and head. With each intake of breath, add another muscle group, until the last few inhalations/exhalations involve the entire body. When the client is relaxed, the therapist continues to play a repeating motif on his instrument and invites the client to visualize a peaceful place or situation from his life or his imagination. Then encourage the client to mentally take a journey from that starting point to wherever the music “takes” him. The therapist will encourage the client to describe the imagery he encounters and prompt his journey with questions such as: From where is he starting? Where is he going? Does he know? Does he feel he needs to know? Describe the scene. What and whom does he see? What does he smell and feel? How does he hope or believe it will end? Instrumental music may be most useful, certainly in the beginning of a series of sessions. It is sometimes the case that lyric content and singing voices prove to be distractions for the client, leading him away from the therapist’s verbalized directions. It may transpire, however, that at some point the therapist finds specific songs or other vocalizing with instrumental accompaniment that suits the therapeutic goals. At those times when songs are used, the therapist will exploit the lyric content to integrate it into his directions and encouragement: “Can you imagine yourself singing this?” “Have you ever done that?” “Tell me what that was like.” “Maybe we can sing it together now?” “Maybe you would like to sing it alone?” “If someone you knew, or know, was singing this, who would it be?” “What values do these words represent for you?” “What lyrics or thoughts could we add to this song?” “How do you feel now compared to when we began?” The “journey” taken may end at the same visualized place where it began; it may stop at a previously chosen destination, or merely conclude when the client says he feels it is coming to a natural close. To wrap up, the therapist will encourage the client to “come back,” “reach the end,” or “tell me when you feel you are done,” at his own rate of comfort. He will then have the client describe what he sees, experiences, and feels as he concludes. As the client nears the visualization’s end, the therapist will gradually lower the music’s volume while guiding the client “home” or to the end spot. Processing of the experience will follow. The therapist will have the client describe the overall experience and prompt elucidation of responses. If it was “good,” “In what way? Say a bit more about that.” “How surprised are you that you feel this way?” “What do you think this trip you created might say about you?” “Who do you know who might say they are not surprised to hear you say this? Who would be surprised?” “Was this an experience you might choose to have again? If not, then why not? If so, would you take the same journey or would you prefer a different one? How different?” “Are these feelings the kind you can find outside of an experience like this? If so, where and when?”

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Safe Group Jamming Overview. A jam session involves a group of music-makers, each with a chosen instrument, playing together based on an agreed-upon, simple, music/song structure. The “group” may have several members or consist only of client and therapist. The philosophy behind a jam session is to start from a small musical idea and to take it “where it goes” and enjoy the experience. The jam should change over its course, partly through the efforts of one or more members, and partly in an organic way that reflects the group’s changing mood. The therapist will initiate and guide the process and be conscious of when it

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might reasonably be brought to a close and do so. With some rudimentary instruction, a client can almost immediately take part in an exhilarating and emotionally generative group activity. Reflecting back to Herman’s (1997) stages, the jam session can be a very effective therapeutic intervention to utilize in the recovery stage of reconnection. It may additionally provide an opportunity for the emotionally self-restricting participant to safely “stray” outside his area of safety. Client goals include achieving connection with others, mastering or gaining facility on an unfamiliar instrument or on one which the client has always wanted to play, increasing one’s awareness of one’s environment, and having an expressive, creative experience in a safe setting. The level of therapy for this intervention is augmentative. The therapist should have a high level of experience with improvisation and be able to shift his role to lead, accompany, or follow the client(s) as needed. Regardless of their declared enthusiasm, some clients may nonetheless have their self-restricting behavior triggered by a new, unstructured, and possibly noisy therapeutic activity. Should he feel a particular client to be at risk of this occurring, the therapist may minimize this likelihood by engaging in a one-on-one jam with the client to acquire a sense of his readiness before including him in a group experience. This intervention may be contraindicated for clients sensitive to cacophony or the threat of it because jam sessions, though ostensibly under the therapist’s control, can still become spirited and loud, to the delight of some and the discomfort of others. The level of therapy is augmentative. Preparation. For group jamming, the ideal space is a large, private, soundproofed room that can accommodate up to 10 people. A variety of instruments should be available, and at least three should be polyphonic, that is, capable of playing several notes simultaneously. A keyboard can prove useful, while guitars, banjos, mandolins, etc., are recommended for their portability and cultural familiarity. There must also be a wide selection of percussion instruments, as less skilled or less confident participants will often have less inhibition about taking them up. Stringed, bowed instruments such as the violin, viola, or cello can be excellent tools as well, for their different texture, cultural familiarity (though rarely seen and heard), and ability to sustain long notes. There should be more instruments available than there are participants, in order to provide numerous choices. Chairs should be arranged in a circle so that participants have visual contact with each other. Participants who wish to watch and listen but not participate must be encouraged to do so, as this may prove to be their way of easing into a future jam. What to observe. The therapist will observe each participant’s level and quality of engagement, most particularly to notice signs from participants that they might wish to leave the group. Restlessness, fidgeting, diverted visual attention, or signs of irritation may indicate discomfort. If this occurs, participants should be allowed to leave and return when they wish. He will also watch for overall intragroup participation, with a goal to encourage (approximately) equal individual participation. Because the thought of improvising music or making music with few rules and no “map” can be daunting even for experienced musicians—and may be more so for those in recovery from DT—when a jam session or other improvisation is initiated, the client may be doubtful that he will be able to accomplish such a feat and therefore will be resistant to the experience. If a client is truly too inhibited to take part, then, of course, other methods can be pursued. But, for occasions when persistence on the part of the therapist seems appropriate, some methods for “safely” introducing the intervention are discussed within the following section. Procedures. Once seating is established, the therapist will begin by offering instruments to the participants. He should first supply instruments to anyone who declares a preference (keeping in mind that in the future he will encourage them to move beyond their comfort area) and offer choices to others. With initially reluctant clientele, this is most easily accomplished by offering a choice of simple percussion instruments: tambourine, maracas, other shakers, etc. Presenting a choice will result in willing participation more often than when only one instrument is offered. The choice may be between two

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similar drums of different sizes or loudness, or it may be, depending on the therapist’s knowledge of the clients’ history and preferences, between quite different ones such as a rain stick versus a cowbell. If clients continue to be reluctant, the therapist can easily demonstrate the ease with which instruments can be played in concert with others in a musical manner. For example, fretted instruments can be tuned to an open chord—“open” meaning that, without fretting, strumming, or playing arpeggios, the strings with the (usually right) hand will produce a full-sounding chord. Inexperienced players can remain on this single chord throughout a jam regardless of other chords that may arise, and the result will still be pleasing and the client will be able to fully participate. If a violin is available, a quick introduction to bowing technique may be needed. Slightly tighten the hairs of the bow and draw the bow perpendicular to the instrument, remaining between the bridge and the start of the neck. When a client remains on the violin’s G and D strings, anything he plays will be consonant to a jam in G Major or minor (and bowing the two middle strings, D and A, will support the keys of D Major or minor, while using the two highest strings, A and E, will support the keys of A Major and minor). Encourage the client to keep the bow moving, and he will avoid the squeaky sound that discourages further exploration for many a student. Mandolins have the same tuning as violins (G-D-A-E); rather than detuning the A and E strings, encourage players to form the G Major chord by placing the middle finger on the third fret of the E string, and the second finger on the second fret of the A string, or the first fret of the A to form G minor. If available, the viola and cello have the same tuning (C-G-D-A) one octave apart; if the client remains on the middle two strings (G and D), he will match the violin. A client at a keyboard can be asked to remain on the white keys. Since these are the notes that constitute the scales of both C Major and A minor, either of those modes may be employed. If the jam is in G Major, the F keys, with a simple direction, can be avoided if a major-key, consonant sound is desired or employed should the client prefer to explore the (partial) blues scale. To change key to C Major, the fretted instruments can then be capoed at the fifth fret or at the seventh for D Major, the third for Bb, etc. Clients playing percussion instruments can be directed to simply match the therapist’s tapping foot or strumming hand. The therapist should have a guitar or piano, though he, as well as other participants, may switch instruments during the activity. He will select either a minor or major key, ensure that each participant has been instructed in how to play in that key, suggest a tempo or have the group agree to one, select a strumming or chording style for himself, and begin playing. He may have to briefly demonstrate to the percussion players how best to play their particular instrument to keep time with the others. It may take a few or many moments for the group to achieve a sense and sound of cohesion. At that point, the therapist can introduce variations to the group. For example, the therapist can encourage the group to, by turns, be responsible for increasing or decreasing the music’s volume or tempo; ask all but one participant to play quieter while a featured player is heard (usually the therapist will take the first turn), then return the group’s volume to the previous level; sing a phrase either from an existing song or one that is improvised in the moment and that matches the jam in some way (do not resist the temptation to use humor!); or shift the rhythm from straight 4/4 time to 12/8 in the same tempo, demonstrating to the group that subtle differences can produce notable change. As with other interventions, verbal processing of the experience, though it need not always be extensive, will conclude the session. Guiding questions may include: “Can you tell me what that was like for you?” “How do you think we could adjust the exercise for next time?” “Where did it feel like we were ‘going’?” “Did you feel you wanted to stop at any time? Why? [or Why not?]” “Tell me/us how you feel now compared with how you felt at the start.” “How did it feel when you switched instruments?” “How do you feel your playing contributed to the whole sound?” Adaptations. One-on-one jamming: This typically group intervention can be adapted to a one-on-one client session. Preparation and observations remain the same as with the group jam, and there are no contraindications. It is indicated for the very inhibited client for whom the ultimate goal is to

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facilitate participation in a group jam. The one-on-one jam can be an excellent way to address the classic response of constriction to chronic trauma exposure and what Herman (1977) describes as “… the numbing response of surrender” (p. 35). Because the one-on-one jam is essentially an improvisation that musically can start from and go to anywhere the therapist and client agree upon, the therapist is free to tailor the activity to the client’s level of comfort.

Voice and Body Exploration Overview. The client practices mindful breathing and vocalizing while focusing on somatic experiences. The focus here is the connection between trauma experience and identifying where and how in the body the experience is stored. Through the physical acts of breathing and deliberate vocalizing, the client will learn “where” in the body stresses are stored and discover the importance of connecting oneself to the physical memories of one’s abuse to gain mastery over those emotions. At this level of vocalizing, the client will use his speaking/singing voice in ways mostly unfamiliar to him. It is indicated when a client demonstrates emotional inhibition or discomfort with his feelings. The sessions will serve to augment the self-imposed restricted, monotone voice or to moderate an overly expressive, inappropriate one. As with singing and rapping (below), because the intervention can be minimized to include even silence, there are no contraindications for it except the client’s refusal to try this experience. Therapist goals include to help the client to become familiar and comfortable with his voice; to assist the client in “knowing” his voice’s capabilities, strengths, and challenges, and the factors he feels limit its use; to extend the voice to express new physical and emotional “territory”; to observe, feel, and describe the changes experienced during the exploration; and to integrate those experiences and sensations into a new awareness of the client’s accepted self. Client goals include to achieve comfort with his voice and with new ways of using it to gain control over its qualities of timbre, volume, and pitch; and to use it to more appropriately in social interactions and for personal expressiveness. The level of practice is primary. Preparation. One requires a room or space that is as near to soundproof as possible, to minimize client inhibition about being overheard by others (at a future point, others may be, at the client’s discretion, considered as invitees to a performance or to a group music-making experience). A keyboard or guitar can be helpful in order to establish pitch when necessary, though a pitch pipe or harmonica will do. What to observe. Particularly regarding vocalizing interventions such as this, it is relatively easy for a client to lose confidence in his ability to achieve what seems to a musician to be modest goals. Thus, it is important that the therapist pay close attention to the client’s nonmusical responses as well as the musical ones, as they will give the therapist instant indications as to the client’s feeling about his ability to follow the therapist’s lead. Procedures. Begin with the simplest of vocalizing, that is, with the therapist asking the client to join him in humming, or singing the vowel sounds “ah,” “ooh,” or “oh” in a pitch that is relaxed and natural. The therapist will match the client’s pitch. As the technique is elaborated, emphasize that pitch is unimportant; simply breathe in, and exhale using one’s vocal cords to produce the pitch. Repeat several times, encouraging the client to lengthen notes. Progress to, as examples: agreed-upon words, song lyrics, phrases of a familiar song, or lines from a song. In a situation where the client is reluctant to try this exercise, the therapist may point out that the client is already verbal and may suggest, “Let’s use the words and voice you normally use.” Because concentration on a particular body area—in this case, the vocal cords, throat, tongue, lips—can easily lead to neglect of the rest, the therapist will, to maintain focus on the whole-body experience, periodically ask the client throughout the exercise how he feels doing it and where he feels it.

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He will explain that experienced, trained singers typically feel that their whole body is engaged when they are singing well and properly. The therapist can ask the client if he feels the effects of vocalizing anywhere else. If so, where? He may also, at various points in the session, direct the client to relax, move his limbs, shake his arms and hands, move around the room, etc., in order to maintain awareness of his whole self. Some clients may report feeling tightness in one or more places while vocalizing. Ask how severe it is, and can he continue? If so, encourage him to breathe deeply, vocalize a comfortably low pitch, and attempt to “direct” it to the body area that feels strain, in an effort to “warm” and relax it (as sometimes used in meditation practice). Persistence is recommended; cease only if the client reports continued discomfort. The value, among others, of this area of verbal processing is to bring awareness to the client of his whole person, to be able to identify where discomfort is felt, and to know that one can often control and conquer it. Additionally, the client may be drawn to an awareness of inner conflicts that are as yet unresolved. He may then draw encouragement from being informed that such awareness is the essential first step in healing. Adaptations. The same activity can be employed with a group of up to four or five. Adjustments might include simply spending a longer time on each aspect of breathing and sounding vowels to accommodate the greater number of participants.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Didactic Therapeutic Lessons Overview. In this intervention, the therapist provides the client with voice or instrumental lessons to help the client to acquire an introductory facility with a musical instrument or instruments. It is indicated particularly at the beginning of the therapeutic alliance as a method of introduction between therapist and client, but may be useful at any point in a series of sessions. The lessons may create or strengthen social connection and lead to other interventions of greater depth. Recalling Herman’s (1997) stages of recovery, this activity is most appropriately aligned with that of reconnection, where the aim is for the client to feel safe to consider rejoining the greater society from which he feels estranged. In this intervention, the therapist’s facility on any instrument need only be at a higher level than that of his client. This method may be contraindicated due to the client’s inhibition. Goals are to step outside of the restriction that accompanies survival with a feeling of safety, to learn something new in a safe environment, to challenge one’s self-restrictive tendencies, to recognize both one’s latent abilities and new strengths, to partner with another in a shared task, and to discover that one is capable of doing something different and that it is safe to do so. The level of practice is intensive. Preparation. Have the chosen instrument easily available or, if a particular instrument has not yet been selected, it is important to have at least a guitar and a keyboard at hand. Other instruments, such as a variety of percussion instruments commonly used in therapy sessions, may be used as well. Client and therapist should be in close proximity to each other, possibly facing one another but with the option to angle each other’s chairs slightly, to reduce the intensity of face-to-face contact. If client or therapist is at the keyboard, the other should face into them at an angle that allows eye contact and lines of sight so that both participants’ hands on their instruments are visible. If the client is learning by ear, he may require no more materials than his memory, although the client may find it helpful for his future reference to at least have a notebook in which to record the steps taken in the lessons. Lyric sheets with chords written above the lyrics or chord charts and/or tablature may also be prepared in advance for songs the client wishes eventually to learn or for songs which the therapist feels will be helpful. What to observe. The goal is to provide a safe environment where the client can learn a new skill and eventually develop future goals that will augment that achievement. Objectives that will mark the

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steps to that goal must be designed so that the client will always experience success. As any new interventions have the potential to be intimidating, the therapist will watch for signs of reluctance, hesitation, or discouragement from the client at all times. If the client’s hesitation turns to strong reluctance, the therapist must find ways to encourage the client so that he doesn’t experience this as failure. At these times, rather than discontinue the lessons, the therapist must instead scale back the demands to an achievable level. That level must not only be attainable but also provide a measure of challenge; this balancing on the therapist’s part will continue throughout the lessons. The therapist may, in some circumstances, use discretion in sharing with the client some of the music lessons that the therapist himself experienced. He can explain his own challenges at that time, his feelings of intimidation, and his own doubts that what he wished to do—learn to play a musical instrument—seemed impossible. The therapist will also watch for behaviors and verbalizations that suggest the client’s confidence is growing and that he is increasingly comfortable with the concept of attempting to master a new discipline. Be aware of indications that suggest the client is enjoying expressing himself—“finding his voice,” literally and figuratively—in a positive way and feeling comfortable in doing so. Procedures. Procedures vary with each client’s abilities, motivation, and therapeutic development. One example of a procedure that is useful at the beginning stages of learning the guitar is the following: Work with the client on strumming an open-tuned guitar with the guitar lying on a table, desk, or on the floor; this is a one-handed activity. An easy and versatile tuning is the “open G tuning.” This involves tuning both E strings down to D and the A string down to G. Because fretting the guitar’s neck is now unnecessary to produce one chord (G), the client can strum with their thumb, finger or fingers, or a guitar pick. The client will strum along with the therapist, keeping a simple 4/4 or 3/4 time signature. At the therapist’s direction, they will increase and decrease the tempo or the volume, simply as exercises in dynamics and exploring a mutual activity. As suggested, the therapist will also be playing a guitar to start. With increased comfort on the client’s part, the therapist will eventually “answer” in response to what the client plays and he, too, can initiate motifs that the client will replicate. The therapist eventually will—musically and metaphorically—“move away” from the client, or “give him space,” by changing instruments. Further use of the open-tuned guitar: When the client’s comfort level has increased, he can be given instruction to fret the guitar. A forefinger on the first fret of the B string will add the note middle C to the open tuning, forming a partial C Major chord, and an additional finger on the second fret of the G string will produce a credible D7 chord (strum all six strings for all chords). Adaptations. On any keyboard, a similar easy introduction to didactic music instruction may be achieved. The therapist will direct the client to play a major third with his right hand (e.g., C and E above middle C) and, with his left hand, form an octave with thumb and little finger. The therapist will point out the octaves of C, A below the C, F above the C, and back to C. With the client playing four beats on each chord, he can play a simple but dramatic figure while the therapist accompanies the structure on the guitar. Establish a tempo and begin. The therapist is free to accompany simply or to elaborate, or to depart from chords and create a solo, or to sing. The therapist and client can explore musical elements of tempo, volume, timbre, and mood, and discuss their effects; together, they can make imaginative plans together to develop the exercise.

Pitch-Matching Overview. At this level of vocalizing, the client learns to locate particular pitches based on hand directions and vocalizations from the therapist. Through this exercise, the client will develop a heightened ability to “hear” himself and to use his voice deliberately and accurately, fostering an even greater appreciation of his new capabilities. This experience is indicated when a client has achieved a level of familiarity with his voice and is ready for further exploration of his emotional range. There is no

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contraindication for this experience. The main goals are to achieve greater facility with one’s voice, to become comfortable with singing, to further integrate one’s mind–body connection, and to prepare the client to sing both solo and with others. This level of vocalizing is augmentative and may sometimes be primary. Preparation. Preparation is the same as with the Voice and Body Exploration above. What to observe. As stated above, it is important that the client feel relatively comfortable with using his voice before this vocal technique is introduced. For the survivor of DT, striving to “improve” or even access his voice may evoke particular feelings of failure that the therapist must strive to avoid. During the exercise, the therapist carefully observes the client’s physical responses (e.g., breathing, ability to match pitches, stiffness of posture, fidgeting) and his emotional responses as well (e.g., irritation, disappointment in himself, anger, surprise, delight, happiness, excitement) as the client moves through the various steps of the exercise. The therapist notices if the client’s breathing is steady and encourages regularity if it is not; to allow unsteady breathing is destabilizing and can be uncomfortable to the point of bringing up negative memories of body states for the client. The therapist observes and interprets as best he can what the client’s vocalizations communicate about the client’s emotional state. The act of vocalizing and singing can sometimes be very emotional for both the client and therapist; it is a window on an intimate aspect of the client’s emotional life. Thus, the therapist uses this opportunity to help the client to explore and understand his emotional life more deeply. Procedures. The client must already be familiar with using his voice with the therapist. The therapist will ask the client to vocalize on a comfortable pitch; he can be singing any vowel sound or humming. While the client’s voice is engaged, the therapist will ask him to raise or lower the pitch of his voice, guided by the therapist’s hand motions. The therapist will experiment with faster or slower hand movements or vary the length of time on pitches based on the client’s perceived comfort. Next, the therapist will vocalize a comfortable pitch easily within the client’s vocal range and ask the client to sing a tone. The therapist will then use his hand movement to “move” the client’s pitch up or down to become in line with his own pitch. He will ask the client to notice the feeling of being in or out of pitch with another voice, to observe the synchronous vibrations created by being in pitch with one another, and the “frictional” feeling when two different pitches are sounded simultaneously. The exercise should be repeated with a variety of pitches, one goal being to increase the client’s vocal range, but also another being to make him aware of how limited his range (sometimes metaphorically) has been and to help him become aware of the possibilities available to him. Alternatively, the roles can be reversed, with the client directing the therapist’s vocalizing. This can contribute to an egalitarian mood in the session, give the client a sense of control, and allow him to explore the idea of creating options. Adaptations. The client may even, as a result of this exercise, become interested in receiving sight singing/ear training instruction to further develop his abilities and resources. The therapist can also use vocal pitch-finding to expand vocal expression in addition to the matching of tones. This activity may also be employed with a group of clients who have demonstrated some comfort with, and willingness to use, their voices. A community choir may even be formed. When conducted with a group, the alternative action of role reversal can again be useful, with various members leading the others.

Song-Singing and Rapping Overview. The client uses his voice to create melodies and/or rhythmic speech through humming, singing, or rapping, both with the therapist and in solo expression. To review Herman’s (1997) stages of recovery from developmental trauma: a healing relationship is established, safety is achieved, remembrance and mourning are observed, and, finally, reconnection with society is established. This intervention may be used to address client needs in any or all of these stages. The abuse survivor’s voice

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has been metaphorically “silenced” in ways particular to each individual. Through use of his musical voice, he may achieve a heightened degree of comfort with himself and others; reach out to connect with others; acknowledge and express past and present pain; affirm his place within his world (social, family, community); assert his presence, individuality, and sense of self; declare his intentions; and learn a new skill. This experience is indicated with survivors of DT who demonstrate a debilitating degree of inhibition, detachment from self, self-restricting physical movements, self-restricting societal involvement, depression, self-harm, or substance dependence. Because it is possible to use the voice at minimal levels, including silence, there are no contraindications for this experience. Main goals for the client are to find “one’s voice”; understand its capabilities, strengths, and challenges; identify factors that limit its use; practice breath and diaphragm control; acknowledge the past; appreciate one’s present-day voice; “support” the voice of the past; establish connection with the therapist and, eventually, others; challenge the restriction associated with abuse; explore new physical and emotional “territory”; experience safety during an inherently self-conscious activity; and/or experience the emotional and physical bonds that develop when people vocalize together (Levitin, 2006). The therapist should have a high degree of comfort with his own voice and be confident with providing basic vocal instruction. The level of practice may begin at an augmentative level before progressing to the intensive level. Preparation. The room should be soundproof, if possible, and have a locking door (Austin, 2008). The music space should have some melodic and polyphonic instruments, such as guitar, piano, xylophone, glockenspiel, electronic keyboard with sampled sounds, and a range of diverse percussion instruments. Accompanying instruments can include guitar, xylophone, and/or glockenspiel. If the use of polyphonic sound is overstimulating for the client, then solely percussion may be employed. The therapist may prepare a song list in advance based on the client’s preferences and therapeutic needs. Lyric sheets for the client and chord sheets for each song will also be prepared if needed. If rap and hip-hop are to be employed, there must be an electronic drum machine on hand, and a keyboard/computer arrangement that can generate instrumental sounds and also allow multitrack recording in order to build up a “beat” (explained below) over which the client will vocalize. What to observe. The therapist will watch for verbal and nonverbal signs of reluctance and restriction. Male survivors of DT may live with the feeling that their voice is inadequate or that it is not safe to use it as one feels. They may also, as do most of us, possess culturally inculcated notions that singing is “unmanly” or “for children.” On the other hand, the therapist can easily mistake acquiescence on the part of the client as true agreement. A client may be uneasy in expressing “negative” responses or be accustomed to pleasing others, having experienced negative consequences as a child if they were perceived as insufficiently deferential. The therapist might also consider “postponing” rather than “abandoning” the intervention because other interventions and techniques can make the future introduction of “vocal play” more viable at a later time. Procedures. The client will, for warm-up purposes, have been introduced to the earlier level of vocalizing, Pitch-Matching. If a client is experiencing some inhibition or difficulty singing, a gradual approach to song-singing is recommended. For example, he may be encouraged to recite lyrics to a favorite song as though it were a poem. Another technique is merely to read song titles aloud with expression or to hum the melody of a chosen song. To encourage a client to vocally participate, the therapist can model these tasks or improvise a melody and hum it for the client. If the client is willing to sing or rap from the start, the therapist may sing or rap along with the client to a song of the client’s choice. Once the client has warmed up his voice and is ready to sing, he can choose a song from a list the therapist provides based on therapeutic need and the client’s preferences. At times, the therapist may choose a song and suggest it to the client. The therapist will help the client to choose instrumentation with which to accompany the song and will provide the accompaniment with guitar or keyboard as they sing the song together. If the client chooses to play a melodic instrument, the therapist can prepare the

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instrument so it matches the key of the song, for example, by open-tuning a guitar and then adding a capo to find an appropriate key. If the client is willing and able, and it is deemed therapeutically beneficial, he can be urged to sing the song alone with the therapist’s musical accompaniment. For rap and hip-hop motifs, the client may already possess recorded “beats” that he uses (in hiphop culture, “beats” do not represent percussion only; rather, this is the preferred term for a prerecorded backing over which one raps). If a client does not have beats already prepared for use, the therapist will need to utilize a drum machine. Together, he and the client can experiment in order to select a beat they wish to use. If, as mentioned above, additional equipment is available to generate instrumental sounds that are recorded through multitracking, the client should then have a solid instrumental beat over which to then add lyrics. The final rap itself may be performed in the session only or for others, and may or not be recorded. Multiple versions of the recording, i.e., different mixes of the recorded tracks, should also be a future available option. Discussion afterward may focus on any of the following topics: client’s surprise, or not, at his new abilities; what that might say about his ability to learn other new skills or ways of behaving; and who he feels would be surprised to know he could accomplish this, and who would not. Prompting questions can include: What might he believe this says about his inner thoughts/feelings, his resilience, his ability to adapt and change, etc.? What meaning does the final song or rap have for him? What associations can he find between what he has produced and what others whom he admires have done (taking care to stress the emotional qualities versus the quality of professional product)? And, at any selected stage of this process where the client gradually extends and expands the use of his voice, the therapist will reflect back to the client what he observes and ask the client how he is experiencing the music in the moment. The therapist will then solicit client input as to the possibilities he sees for future vocal exploration by saying, for example, “Tell me where you feel this could go next.” Adaptations. This intervention can be conducted in the group setting. It will necessarily require more time for several individuals to achieve the same level of comfort and ability in working together than it does with one client. The therapist will tailor his discussion of emotional issues related to the singing/rapping to reflect the level of receptivity he sees in the group.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Therapeutic Song Composition—Lyric Writing Overview. The client and therapist write original song lyrics to replace the lyrics of a precomposed song. The intervention is indicated when a client shows an interest in musical creativity, when he shows a need for self-reflection and personal insight, or when he is ready to integrate therapeutic gains, reflections on the past, or hopes for the future, into a song. Clients must have a level of selfawareness that permits them to draw on their experiences, and they must possess the mental capacity and organizational abilities to verbally communicate their internal experiences. It may be contraindicated if the client is grossly inhibited; however, the therapist must keep in mind that because the therapist can structure songwriting so that with maximum guidance it requires a minimal input from the client, most clients in this population could benefit from taking part in therapeutic songwriting. Client goals are to explore his emotional life; to generate creativity; to consider and assume positive “roles” in his life that counter negative images of himself, such as victim, underachiever, and/or one with a “wasted life”; to connect strong emotional memories with relevant current aspirations; and to imagine positive aspects and hopes for his future. The therapist’s role is to assist the client to generate ideas upon which to write songs, to facilitate the transformation of prose words into lyrics, to compose and co-compose music to suit those lyrics, and to encourage reflection upon the lyrics and musical choices

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the client makes, as well as the meaning, for the client, of the song. The activity can be applicable to any of Herman’s (1997) stages of recovery. The therapist must be experienced and comfortable with songwriting and comfortable in various music styles, or certainly be willing to engage in any genre. The level of practice is augmentative and occasionally will be intensive. Preparation. A comfortable, private space is needed. Pen and paper, songbooks, and lyric sheets, along with piano or guitar and some accompanying percussion instruments must be on hand. What to observe. The activity of songwriting can be intimidating for clients; most have not written music before or had much experience in doing so. The therapist must be watchful for signs of the client’s comfort and satisfaction at each stage of the process. In particular, the therapist must be able to note how much assistance the client requires at every stage and offer support to the extent it is needed. In the course of creating personal lyrics, there is also a risk of regression because of the anxiety it may evoke or because of the nature of the client’s reflection. The client may spontaneously regress to feelings or images related to past abuse that might cause him to negatively judge and censor himself or discontinue the activity. Should this occur, the therapist must take care to reassure the client that reliving the past is not the goal or a necessary step in the process but that the goal, instead, is to gain and maintain control of oneself and one’s experiences. Should the client express reluctance or seem to suffer a crisis of self-confidence at any point during a session, the therapist must reassure him that the activity may be canceled or postponed until he feels more comfortable. Procedures. The therapist can begin by discussing instrumentation possibilities, style preferences, and even artists whom the client wishes to imitate or pay homage to. Next, review with the client the various steps involved in songwriting: writing the lyrics, composing the music, editing, and arranging. Recording and performing the completed song might also be options. Discuss with the client different procedures for working on the song, as well as how much help he feels he might require at each stage. Encourage the client if he seems daunted by the task. Hint that the process will likely prove to be easier than he believes. Next, proceed to selection of lyric topics. Review the subject matter of songs the client already knows and likes, note categories they represent (e.g., songs about love relationships in the first, second, or third person; political observations; giving advice; desires for the future; relationship observations; etc.), and then decide on a topic to use in writing the first song. The therapist then asks the client to reflect on a chosen topic, for example, “What You Should Know About Me,” and, as the client reflects verbally on this topic, the therapist records key phrases (e.g., “You think you know me,” “Don’t be a judge,” “I am just like you,” “Who do you think you are?”). The therapist will make suggestions and/or ask the client to elaborate, and generally maintain the activity’s momentum. Each thought or comment can be given its own line, as in a poem. This will better enable the later transformation of words into song lyrics. The therapist helps the client to decide at which point enough material has been gathered in order to move on to the next stage (he may reflect on many famous songs that have only a few, repeated, lines: The Beatles’ “Here Comes the Sun,” Pete Seeger’s “If I Had A Hammer,” and countless others). Often, rough lyrics of eight lines or more can be sufficient. If the song lyrics are a rewrite of an original song in parody style, the therapist and client will adapt the new lyrics into the song and sing it together with the therapist providing supportive accompaniment vocally and with guitar or piano. They will then decide to work on an arrangement of the song with the client playing percussion or melodic instruments while both sing it together. If the lyrics are an original composition not based on an existing song, the therapist and client can then create original music for the lyrics as described below in Therapeutic Song Composition—Original Music. Adaptations. The therapist should consider all possible permutations of the song format. If a client has achieved a certain level of sophistication with the process, other forms beyond the standard structure of verse/chorus/verse/chorus/bridge/chorus (or ABABCB) can be introduced if therapeutic

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benefit is likely to result. These can include the 12-bar blues format (verse structure: AAB, repeat) or the 12-bar blues AAB lyric form supported by other rhythms (rock-and-roll, folk, country, and any “World Music” styles, as examples), free-form stream-of-consciousness lyrics with no repeated musical motif, and songs based on collage in which lines of lyrics from different songs are chosen and reorganized to create a new song. This can be especially useful when examining with the client a feeling, thought, or memory that is experienced in separate parts.

Therapeutic Song Composition—Original Music Overview. In this process, the client and therapist will compose a melody and harmonic structure for the newly composed lyrics. The songwriting procedure might also begin with writing the music before the lyrics. This experience is indicated for clients who are able to make choices about preferred music and who have a need to express themselves and their lyrics in an original manner. Goals are to assist the client in expressing and feeling strong emotions, to locate his lyrical narrative within the landscape of the music, to practice being in control of his emotions and feelings in the music, and to envision a new, future story where he is more empowered and in control. Clients who have no interest in creating new music are contraindicated for this experience and may prefer to create new lyrics to an existing song. The level of therapy is augmentative or intensive. The skill level required of the therapist in this endeavor is reasonably high, and his experience with composition should be at a point where he feels totally comfortable with the activity. Preparation. The client and therapist should first both be satisfied with the lyrics and feel that they are ready to “make the lyrics sing.” A comfortable music space that is reasonably soundproof and private is needed, along with a piano or guitar; perhaps literature on hand that contains descriptions or examples of song structures and harmonic sequences; possibly other percussion instruments for musical arrangements; and possibly a recording device for playback. What to observe. Because the idea of writing a song seems to many clients to be so daunting a task, the therapist must keep a close eye (and ear) on the client’s responses so that he is ready at the right moments to encourage the client to continue in the process. Note his level of involvement and signs of fatigue such as inattention, lack of creative ideas, or disinterest. If any of these signs occur, the therapist should check with the client to understand what he is feeling and determine whether the session should continue, discontinue, or resume another day. Also note if the client seems to have reached a limit to his level of ability or, more important, believes he has done so. The therapist’s task is to assess exactly where he feels he must intervene: to assist, clarify, encourage, extend, elaborate, make suggestions, or support in order to move the process forward. In practical terms, he must decide when and if it is time to change/extend/augment a lyric, to make a verse longer or shorter, or to show how and where repetition can be effective. The author finds that the act of producing a song or piece of music, particularly by a survivor of trauma, can result in a significant elevation in a client’s level of pride and confidence in his abilities. This may result in a consequent wish to “go further,” sometimes to the point of creating unrealistic expectations for oneself. The author has observed many clients who, having cowritten a song and produced a recording, now believe that they have “entered” the world of the recording artist and that they will now experience an inevitable rise to the “top” of the profession. It does little good to inform the client of one’s reservations about the likelihood, or not, of the client “making it.” Instead, at such times, the author has found it most beneficial to follow these steps: Acknowledge the client’s dream to be noticed for their musical talents; share with them the knowledge that, of course, “anything can happen” and how wonderful it would be to have that opportunity; and then conclude by noting that, since so much of the

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process of “being discovered” is out of one’s hands, one should determine exactly over what one does have control (e.g., what one writes, if and what one records, when to do so, if one performs for others, when and for whom) and over what one does not have control (e.g., whether influential people hear their work, whether they like it, whether they decide to support the client in his career). Procedures. Many techniques can be used to transform words into lyrics and lyrics into music; each therapist who attempts the task will certainly find his own method. What follows is a common series of steps. Begin by reading the edited lyrics aloud. Explain that at this stage, one is looking to find the “music” in the words, that is, where a singer might naturally place emphases or pauses and how each line itself “cascades,” or rises and falls, as words become lyrics. The therapist will recite the words with or for the client in order to initiate the activity. After a run-through, with the therapist mentally noting where the client has placed emphasis in the text, he will encourage another reading, and perhaps even a third or fourth, until both therapist and client are comfortable knowing where to place the emphasis by exaggerating the cascades, pauses, and strongly voiced passages or words. The preceding is accomplished without definite pitches being selected. Next, the therapist will offer to play a rhythm to accompany the voiced passage. He may still recite the words along with or for the client if it is necessary, with the goal of eventually having the client singing the passage himself. He will choose percussion instrumentation that either feels appropriate in the moment or upon which they have decided in advance: a full drum kit, electronic drums, or any percussion, including tapping feet and slapping hands on knees. Both should notice that the accompanying rhythm helps to move the recited lyrics into “song territory” with signs of a melody forming in the now rhythmically accompanied lyric-speaking/-singing. During the accompanied recitation, the therapist and client will listen for a short phrase to be selected to form the core of the song, its catch phrase, and perhaps its title, if one has not yet been decided upon. When a “form” has developed for the recited lyrics-with-rhythm, the therapist and client will together decide upon a tempo for the emerging song. This should follow easily if it has not already naturally emerged. The therapist and client then begin to create the harmonic structure for the song. Once a rhythm and tempo are established and therapist and client are rhythmically reciting the chosen words together, the therapist will note changes in the client’s vocal expression that suggest pitches. As the process intensifies over several workings of the emerging song, signs of a developing melody will become more pronounced, and any variation from a monotone can be seized upon by the therapist and emphasized. He is likely to find that any suggestion of melodic development is met with client agreement, as the client quite quickly begins to “leave the words behind” while he works to transform them into song lyrics. The therapist can take advantage of the positive mood that has been created to further develop the melody. As an example, the phrase “What you don’t know about me” can be seized upon and vocalized over and over until emphasis emerges, for example, on the words “What,” “know,” and “me.” Add a pause after “don’t” and again after “about” to hear a natural rhythm develop over the words that have now become lyrics. Using guitar or keyboard, the therapist can then add chords to define the emerging pitches that the lyrics now support. The therapist may offer many options, but keep in mind that the client is likely to agree to one of the first few. The therapist should keep the first song simple to maximize a successful experience. Complexity can be introduced after the client has had some practice and has developed sophistication in songwriting. In writing the first song, it can be helpful to make the chosen phrase the title and the starting point for the verses. Be open to simplicity and repetition. The therapist can create the harmonic accompaniment by observing and exploiting the natural rise and fall of pitches that appear during the vocalizing of lyrics stage. A few simple rules regarding chord selection may be helpful. First, help the client decide whether a major or minor key makes the song sounds “right.” If major, have the first chord change be either the major IV or V (dominant 7th) chord or one of the commonest minor chords: ii, iii, or vi. If in a minor key, suggest a minor IV or major IV

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(dominant 7th). Again, keep in mind that the client may appear to appreciate any consonant chord movement, as he will likely be pleased at the very prospect of his original ideas quickly becoming a song. Adaptations. The process described above is designed to produce songs in classic Western formats, that is, folk music, pop songs, country, rock, rock-and-roll, rhythm-and-blues, heavy metal, etc. These are music genres familiar to almost everyone who has lived in the Western world, and they cover most clients’ music-making preferences. However, the therapist must leave open the option for the client to create songs in unfamiliar genres or to step outside the accepted boundaries for purposes he and the therapist will discuss. This may include, for example, songs that are incredibly brief or especially long or songs with no discernible form or sung in a made-up language, with no words but only phonetic sounds. Because the daily experience engendered by living with DT can and does lead to constrictions of so many kinds—physical, emotional, psychological, behavioral, perceptual, and more—the music therapist who works with such clients must keep in mind the importance of maintaining awareness of established forms while acknowledging that boundaries can sometimes become strictures that invite challenge and reinvention.

CLOSING REMARKS ON METHODOLOGY Most of the interventions described will be most effective, and most viable, in one-on-one, individual sessions. The clinical treatment of DT tends to demand this, and it is certainly so in the beginning of treatment. A major goal for the survivor is reintegration with the larger society, which requires positive contact and interaction with others. To these ends, jamming, group singing and other vocalizing, and listening and discussion are the most suitable in the group setting. There is a general order to the abovelisted interventions. The sequence is only suggested and must be subject to the therapist’s ongoing assessment of the client’s emotional readiness to advance clinically. Some interventions may be easily partnered within the same session or series of sessions. Directed Listening and Discussion is a very suitable beginning to therapy, as it is among the interventions most likely to be similar to activities in which the client already engages. Dependent on client readiness, it may be combined with or followed by Music and Imagery and/or Music Listening to Identify Visceral Response. Should that not yet be the case, Didactic Therapeutic Lessons might be next instead. It may be found that once begun, Lessons tend to become the primary therapeutic method because their instructional focus is somewhat different from the rest and they require constancy over time to achieve success. Voice and Body Exploration may appropriately follow, though the therapist should keep in mind that it is an intervention capable of eliciting troubling emotional and visceral memories. Therapists may thus find that Safe Group Jamming is a more logical next step. Jamming can be among the safest of activities to use in a session, although group experiences rest upon a wide continuum of emotional safety in the clinical field of DT. If it seems to be a threatening activity for the moment, the therapist may wish to first bring it to the client in the one-on-one setting. Jamming can easily be combined with vocalizing, especially in groups, as the instrumental variety and volume can form a safe setting in which clients can sing. For some clients, use of the voice is not an inhibiting issue; for them, Pitch-Matching and SongSinging and Rapping may be introduced early. For others, these experiences may be better placed as later-stage interventions because they can quickly move into the emotionally fragile area of the human voice. To engage in Therapeutic Song Composition may seem to require some musical sophistication; it is thus left to a later time in the therapeutic relationship, but, again, if client inhibition seems low, it may be considered at any time. This intervention can also have graduated levels of input, from writing song titles only to rewriting lyrics to existing songs, to writing a complete, original composition.

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RESEARCH EVIDENCE There is almost no music therapy literature on the treatment of men who have experienced DT. Hatcher (2004) has contributed a master thesis and an article (Hatcher, 2007) on this topic. The thesis, entitled I Am Your Son: Therapeutic Songwriting with a Man Living with Complex Trauma, features a case study drawn from a research project funded by the Canadian Music Therapy Trust Fund. Vocal psychotherapy practices with clients with DT have also been researched by Diane Austin (2008) and presented in her book The Theory and Practice of Vocal Psychotherapy. Case studies involving male survivors of abuse are also presented (pp. 64–78). Beyond the music therapy field, Judith Herman (1997) and Bessel van der Kolk (2005) are two of the foremost researchers and clinicians in the field. Van der Kolk and his coauthors have written numerous valuable papers on the etiology of DT and its recovery. Antonio Damasio, in The Feeling of What Happens (1999), contributes invaluable insight into the connection between emotion and the body. Aaron Kipnis, in Angry Young Men (1999), describes his personal story, a trajectory of abuse survival, antisocial and self-damaging behaviors, and ultimate recovery. Gabor Mate’s book In the Realm of Hungry Ghosts (2008) describes the link between abuse survival and both addictions and compulsive behaviors. Developmental trauma is just beginning to be understood in terms of its etiology, symptoms and long-lasting effects, and treatment. There is much that is to be researched, but the early indications are that mind/body experiences and expressive modalities that allow the person to project one’s inner life, understand it, experience one’s emotions, and connect to others are the preferred treatments for DT. There is clearly much need for music therapy research in this area.

REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders. (3rd ed.). Arlington, VA: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders. (3rd ed., text rev.). Arlington, VA: Author American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (4th ed.). Arlington, VA: Author American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). (DSM-IV-TR). Arlington, VA: Author. Austin, D. (2008). The theory and practice of vocal psychotherapy: Songs of the self. Philadelphia, PA: Jessica Kingsley. Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. Orlando, FL: Harcourt. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258. Hatcher, J. H. (2004). I am your son: Therapeutic songwriting with a man living with complex trauma. Unpublished master’s thesis. Simon Fraser University, British Columbia, Canada. Hatcher, J. H. (2007). Therapeutic songwriting and complex trauma. Canadian Journal of Music Therapy, 13(2), 115–131. Herman, J. (1997). Trauma and recovery: The aftermath of violence, from domestic abuse to political terror. New York: Perseus.

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Kipnis, A. (1999). Angry young men: How parents, teachers, and counsellors can help “bad boys” become good men. San Francisco: Jossey-Bass. Levitin, D. (2006). This is your brain on music: The science of a human obsession. New York: Dutton. Mate, G. (2008). In the realm of hungry ghosts: Close encounters with addiction. Toronto, ON: Knopf. van der Kolk, B. A., Roth, S., Pelcovitz, D., Mandel, F. S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Trauma and Stress, 18(5), 389–399. World Health Organization. (1992). ICD-10 classifications of mental and behavioural disorder: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: World Health Organization.

RESOURCES Carlsen, M. B. (1995). Meaning-making and creative aging. In R. Neimeyer & M. Mahoney (Eds.), Constructivism in psychotherapy (pp. 127–153). Washington, DC: American Psychological Association. Edgerton, C. (1990). Creative group song writing. Music Therapy Perspectives, 8. Epston, D., & White, M. (1990). Narrative means to therapeutic ends. New York: Norton & Norton. Ficken, T. (1976). The use of song writing in a psychiatric setting. Journal of Music Therapy, 13(4), 163– 171. Freed, B. (1987). Song writing with the chemically dependent. Music Therapy Perspectives, 4, 13–18. Lee, C. (1996). Music at the edge: The music therapy experience of a musician with AIDS. London: Routledge. Long, V. A. (1997). Playing the piano by ear: A critical analysis of pathways and processes from life stories. Unpublished doctoral dissertation. University of Wisconsin, Madison, WI. McAdams, D. P. (1993). The stories we live by: Personal myths and the making of the self. New York: Guilford. Pollock, W. S. (2000). Real boys’ voices. Toronto, ON: Penguin. Robb, S. L. (1996). Techniques in song writing: Restoring emotional and physical well-being in adolescents who have been traumatically injured. Music Therapy Perspectives, 14, 12–37.

Chapter 10

Children and Adolescents with PTSD and Survivors of Abuse and Neglect Penny Rogers _____________________________________________ This chapter is written to support music therapists working with children and adolescents who have survived abuse or severe neglect but may be living with the symptoms of post-traumatic stress disorder (PTSD). Therapeutic work with such service users typically occurs in individual sessions lasting 50 minutes held on a weekly or biweekly basis. Sessions are held at the same time each week and in the same therapy room.

DIAGNOSTIC INFORMATION Post-Traumatic Stress Disorder and the dissociative disorders were first codified in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorder, Third Edition (DSM-III) in 1980. Traumatisation is part of the human experience. Any catastrophic event (whether caused by an act of nature or a human) can overwhelm our ability to cope, resulting in a range of posttraumatic responses. Response to trauma varies across the population, but the probability of developing PTSD is generally higher for life-threatening events. Kessler, Sonnega, and Bromet (1995) note that although men are more likely than women to be exposed to traumatic conditions, women are twice as likely as men to develop PTSD. They hypothesise that this result may point to women’s increased vulnerability to PTSD or more likely to the more severe sequelae of certain types of traumatisation, as women are more likely than men to be victims of rape or sexual molestation. Children and young people presenting with PTSD may have experienced a variety of different types of trauma—from involvement in a car crash to abuse (of all types). For PTSD to be diagnosed, the child or young person will have directly experienced or witnessed another experience trauma, which could result in death or significant harm or sexual violation. They will experience distressing memories or dreams of the event and may experience flashbacks. The violation of a child’s body, especially by a person in a position of trust, affection, or authority, creates deeply held difficulties with trust, intimacy, and dependency. The traumatisation causes profound vulnerability and vigilance, which typically continues into adulthood. Victims of childhood abuse develop a number of “coping strategies” with which to manage their everyday lives, including disconnecting from the existence, impact, and/or meaning of their histories, or numbing their bodies. They may experience intense flashbacks or (particularly in younger children) may show repetitive play of the event of the trauma. The hypervigilance that these children and young people develop can impact on their capacity to learn. Sinason (1992) proposes that children with histories of abuse can develop a secondary handicap. The child or young person who is eventually diagnosed with PTSD may initially be diagnosed with depression, especially where their abuse has not been previously disclosed. A detailed description of PTSD can be found in the DSM-5, due for publication in May 2013. The revised edition will, for the first time, include criteria for PTSD in children under 6 years

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old, emphasizing the repetitive trauma-related play that younger children experiencing PTSD may exhibit (Zeanah, 2010). In recent years, researchers have noted that the PTSD model is not a perfect fit for the aftereffects of abuse, and they have proposed another conceptualisation referred to as Complex, or Developmental, PTSD. This model stresses the developmental implications of abuse especially in terms of the alteration of fundamental aspects of personal and interpersonal development (Gold, 2000). Since the publication of the DSM-III in 1980 and the specific identification of PTSD, there has been an increased awareness among mental health professionals of the interrelationships between a history of child abuse and subsequent development of mental illness. The prevalence of sexual abuse has been explored in a number of studies. Finkelhor (1994), in his overview of child sexual abuse surveys in 21 countries, concluded that the different ways in which child sexual abuse was defined in each country made cross-country comparisons largely impossible. This point has been vividly illustrated by Kelly, Regan, and Burton’s (1991) survey of the prevalence of sexual abuse among college students, where a number of different definitions of sexual abuse were used. The most rigorous “cases involving some form of penetration or coerced/forced masturbation where the abuser was at least 5 years older” (p. 4) yielded a prevalence figure for child sexual abuse of 4% for women and 2% for men. The broadest definition, “any event/interaction that the young person reported as unwanted/abusive before they were 18,” (p. 12) gave prevalence figures of 59% for women and 27% for men. Seventy percent to 90% of perpetrators of sexual abuse are family members or others known to child victims (excluding noncontact abuse). Prevalence in the learning disability population is five times higher than the national average and of course many more incidents go unreported. The consequences of abuse and neglect and the interrelationship between childhood abuse and mental health problems in adulthood have been well documented. They include depression, anxiety disorders, post-traumatic stress disorder, eating disorders, dissociative disorders, personality disorders, sexual dysfunction, and substance abuse (Beitchman et al., 1992; Boney-McCoy & Finkelhor, 1995; Briere, Berliner, Bulkley, Jenny, & Reid, 1996). A growing number of studies also demonstrate a relationship between child abuse and schizophrenia (Briere, Woo, McRae, Foltz, & Sitzman, 1997; Read, 1997; Read & Argyle, 1999; Ross, Anderson, & Clark, 1994). Furthermore, it has been demonstrated that child abuse is positively related to measures of disturbance severity, including suicidality (Beitchman et al., 1992; Briere et al., 1996; Read, 1998; Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Research suggests that over 60% of psychiatric inpatients have suffered physical or sexual child abuse (Itzin, 2006; Read, 1997). Both male and female psychiatric inpatients have also been shown to have significantly higher rates of child abuse than the general population (Jacobson & Herald, 1990; Palmer, Bramble, Metcalfe, Oppenheimer, & Smith, 1994; Rose, Peaboy, & Stratigeas, 1991). Sexual and physical assault in adulthood has also been found to be related to severe psychiatric disorders (Goodman, Rosenburg, Mueser, & Drake, 1997; Ritscher, Coursey, & Farrell 1997). Regardless of the issue of causality, many researchers have for some years recommended, on the basis of the sheer volume of abused individuals in contact with mental health services, that routine inquiry about abuse history be conducted in all mental health settings (e.g., Briere, 1989; Jacobson & Richardson, 1987; Read & Fraser, 1998; Swett, Surrey, & Cohen, 1990). Chu (2011) notes that from a treatment perspective it is essential to correctly diagnose a patient’s difficulties and to understand the etiology of their problems. Chu notes that while many traumatised patients will meet the DSM-IV criteria for a major depressive disorder, it is more helpful to recognise the symptoms as trauma-related. Where symptomatology is trauma-related, such patients will not respond optimally to treatments for major depression such as depression medication. Chu, Dill, and Murphy (2000) compared patients with childhood trauma with nontraumatised patients with major depression, finding that the only symptoms that differentiated these two groups were the characteristics of sleep disturbance. The depressed group had difficulties falling asleep despite feeling tired and experienced midsleep awakening with an inability to fall back to sleep, while the traumatised group had difficulties

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falling asleep because they were too anxious or fearful to sleep, and they subsequently woke multiple times during the night with anxiety that was sometimes caused by traumatic nightmares. In the UK, The Care Programme Approach (CPA) provides the overarching framework for the provision of mental health services through the National Health Service (NHS) and by many private providers of mental health services. Implicit is the involvement of the person using the service and, where appropriate, their carer. The strong association between a past history of abuse and a presenting mental illness has resulted in a national requirement that all CPA assessments include exploration and questioning of the service user’s history and experience of abuse—commonly referred to as the “abuse question”—“Have you experienced physical, sexual, or emotional abuse at any time in your life?” This has been part of the UK Department of Health’s policy agenda since 2003 and was included in the National Mental Health Minimum Data Set (MHMDS) in April 2011. The statutory context in which professionals work is further re-enforced by the lessons learned from Serious Case Reviews (SCR), which are held where a child is seriously abused or harmed or dies as a consequence of abuse or neglect. Every 10 days in England and Wales, a child is killed at the hands of their parent. In almost two-thirds (65% on average) of all cases of children killed at the hands of another person, the parent is the principal suspect (Brandon et al., 2009-2011). Lessons learned from such SCRs have led to requirements that all CPA assessments additionally include the completion of a genogram (family tree) which, as a minimum, records information about all members of the service user’s household. It is in this context that working with children and adolescents with PTSD and with survivors of abuse and neglect is a core business for all music therapists. Consequently, music therapists (like all colleagues in health and social care) require detailed knowledge and understanding of the impact of abuse and neglect on individuals and of the challenges of working therapeutically in a context where the legal domain may, of necessity, be privileged.

WHY USE MUSIC THERAPY WITH THIS POPULATION? Music therapy offers a safe, nonthreatening space for children and young people to address personal and wider societal issues through a musical and verbal dialogue and to use their relationship with the music and with the therapist to help address their transition from childhood to adulthood. Sessions can be 1:1 or in groups, depending on the level of psychological support needed and the need for emphasis on peer relationships. Austin (2007) cogently argues that music therapy is a logical form of treatment for adolescents, as it plays such a central component in their lives, providing them with object consistency and a means of self-expression and self-identity. Austin (2007) and Rogers (1995) observe that verbal therapy used in isolation is often met with resistance by victims of sexual abuse because their abuser or other trusted adults used words to lie to, threaten, or mislead them. MacIntosh (2003), Robarts (2009), and Rogers (2003) and all argue that music therapy is specifically effective with those who have experienced abuse, as it offers a nonverbal communication that they can safely use to express traumatic material and because its symbolic aspects make it a nonthreatening form of communication (Austin, 2007). The argument that music therapy offers a safe space in which trauma can be explored is acknowledged by a number of therapists (Amir, 2004; Purdon, 2006; Robarts, 2009; Rogers, 1992, 2003), with Amir noting the role of improvisational music therapy to help expose, deal with, and heal the traumatic experiences of sexual abuse. Amir defines musical improvisations as “musical acts that can bring out hidden, unconscious material and make it conscious and available to the client” (p. 96). Music therapy provides a safe environment, unlike the original traumatic environment, where clients are able to re-experience their trauma.

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MacIntosh (2003) and Rogers (2003) both emphasize that memories of abuse and trauma may have been experienced at a preverbal developmental level and the child may experience these memories as sensations or emotions rather than in words. Rogers notes that regardless of the age when trauma occurred, memories can be too traumatic to approach on a verbal level; music can provide a release of traumatic experiences that might not otherwise have surfaced. Amir (2004) asserts that music can directly access emotions and that although memories of trauma could be painful and upsetting, music has the potential to “convert feelings of shame, anger, and helplessness into a creative force that eventually brings power and healing” (p. 97). MacIntosh (2003) argues that music therapy can bridge an individual’s defense mechanisms and reconnect bodies and minds that were separated during trauma. Recent research comparing psychoneuroimmunology and music revealed that physical health and immune function were improved by musical interventions in therapy. Robarts (2009) describes how music therapy can assist “the creation and restoration of meaning, when meaning and a cohesive sense of sense are lost or impaired” (p. 377). In exploring why music therapy may be more effective than other “traditional” forms of therapy with children and young people who have experienced abuse, Robarts (2009) suggests that children enact and express their feelings, responses, and all kinds of motivations primarily in bodily movement, gesture, and vocalization and observes that these primary forms of self-experience and expression are essentially musical—rhythmic and tonal. Robarts (2009) advocates that this explains why a child’s emotional experience can be so readily reached and affected by music, and why music continues to be an intrinsic motivating part of human experience throughout the life span (p. 377). Rogers (2003) argues that music therapy enables the individual to explore past experiences of abuse and, in languaging these experiences, to create new meanings. The use of music therapy as opposed to verbal therapy provides a safe context within which the service user can maintain control (p. 137) Osborne (2009) studied the effects of music therapy on a group of children in postwar Bosnia. He wanted to offer children a distraction from the brutal conditions of their everyday life and allow them a creative outlet. He did this through “a small number of creative workshops … organized in collaboration with local artists in the besieged city of Sarajevo” (p. 333). Osborne suggests that music therapy can help children with Post-Traumatic Stress Disorder (PTSD) because of its ability to help “modulate and regulate the autonomic nervous system” (p. 335). Osborne advocates the practicality of this approach since it is noninvasive and simultaneously supports community-building. Osborne suggests that music therapy is effective from a physiological view, stating that the effects of music on basal metabolism, emotion, feeling, mood, and related symptoms of PTSD are linked closely to the following issues of hearing sensing, respiration, and basal metabolism: 1) Hearing may modulate movement, the heart, respiration, and basal metabolism. 2) The heart may modulate the basal metabolism and may condition respiration and movement. 3) Respiration may modulate the heart and basal metabolism, condition movement, and generate sound. 4) Movement may modulate heart rate, respiration, and metabolism and generate sound. 5) The basal metabolism may modulate heart rate and respiration and may condition movement. (p. 349)

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NEEDS AND RESOURCES Needs and Resources of the Music Therapist The challenges of working with service users who have experienced PTSD and have histories of abuse and/or neglect can be experienced by therapists as overwhelming. To work effectively with these individuals, the therapist needs to be able to experience the unbearable, think the unthinkable, and be prepared to experience the re-creation of scenarios of victimisation, abandonment, control, betrayal, manipulation, and exploitation that have characterised the childhood experiences of the service user. Any professional in the UK who is working with children or young people who may have a history of abuse (clinicians, teachers, police officers, social workers) is required to complete mandatory level 3 training in Safeguarding Children (2 to 3 full days); such training needs to be repeated every three years and is typically provided by an employer. Similar requirements exist in the USA and Canada. Music therapists working with children or adolescents with symptoms of PTSD may choose to further develop their safeguarding skills by accessing additional safeguarding training. The safety of the therapist must also be considered. Sadly, some service users with complex histories may make false allegations of abuse against a therapist. Such allegations may devastate a professional and lead to their immediate suspension, the involvement of the police in an investigation, and occasionally a breakdown in the therapist’s own emotional well-being. It is therefore essential that the potential risks of false allegations are evaluated and mechanisms put in place to protect both the therapist and the service user—this can include working transparently with a clinical team behind a one-way screen or involving another clinician in the therapeutic work, either as a cotherapist or observer. Clinical Supervision. As therapists, many of us entered this field of work with a degree of innocence or naivete; we wanted to help and perhaps believed that if only we could be good enough, we would be rewarded with our service user’s respect and appreciation and we would support our patient’s positive growth and change. The reality can be much more challenging. It is essential that therapists working in this domain actively engage in good-quality clinical supervision in which space the therapist can explore her own feelings of powerlessness, panic, and even anger and hatred. Austin (2007, p. 96) describes in honest detail the sense of powerlessness she experienced as she established group music therapy using improvisation with abused teenage girls. In addition to clinical supervision, music therapists need to maintain and develop their musical skills. Therapists need to acquire the ability to differentiate between feelings that they recognize as their own and those that seem peculiar to the clienttherapist relationship. This can be nurtured through personal therapy, clinical experience, clinical supervision, and further study and training (Forinash, 2001; Odell-Miller & Richards, 2008; Robarts, 2009; Rogers, 1992, 2003). Austin comments on the specific challenge of working with adolescents, noting that music therapists need to be “conscious of and comfortable with their own sexual and aggressive energy” (p. 102). Good-quality clinical supervision is thus essential to ensure that the music therapist can maintain her own curiosity while simultaneously acknowledging her personal beliefs and prejudices (Rogers, 2003). The music therapist must take care of herself through supervision and her own therapy. Figley (1995) speaks of “secondary traumatic stress” as that “stress resulting from wanting to help a traumatized or suffering person” (p. 53).

Needs and Resources of the Service Users The primary need of such clients or service users is for a safe therapeutic space, a therapist able to listen and offer careful empathetic listening, even when listening is unbearable, to challenge and reflect, to

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think, to offer a nonjudgmental attitude. Therapy sessions must have clear boundaries, with sessions occurring at the same time and in the same space every week (Rogers, 1992). Service users presenting with PTSD may well be cognitively intact, may function well in their community and have no physical difficulties, or they may present with significant mental health difficulties, require inpatient admission, or have associated learning difficulties (Rogers, 2003). They may bring their own considerable musical skills into the therapy room or may bring negative past experiences of music-making and an intense fear of musical expression. Service users always have a choice (right) to engage or disengage from therapeutic work and may choose to exercise this right to disengage should the therapeutic work become too challenging or difficult. Consideration needs to be given to the gender and cultural origin of the therapist and the relation of these to both the individual service user and their abuser. Rogers (2003) explores the personal challenge of being a female therapist working with a young woman with a known history of paternal sexual abuse who subsequently disclosed that her mother had both failed to protect her from abuse from her father and also sexually abused her herself. I was a white, middle-age female (as her mother had been) and was taking this child into a room alone and closing the door … the parallels with the traumatic abusive experiences that Jenny had previously experienced were considerable, resulting in increased anxiety and flashbacks, in addition to her need to provoke—even musically abuse—to check out how safe I really was. One of the specific needs of adolescents or young people includes the need to be recognised. Adolescence is a time of turbulent development, of puberty, of identity formation and autonomy—the search for an answer to the question “Who am I?” The young person living with a history of abuse or trauma can have a particular struggle with the question “Who am I?” Music plays a natural role in this development, as young people use music to assert their own identity and express themselves. Laiho’s (2004) review of music and adolescents identifies the emotional field as an important psychological function during this developmental stage. Music is one of the ways that adolescents express their feelings, hopes, and dreams, as well as exert a considerable consumer influence (McFerran, 2004). McFerran (2010) has explored the challenges of working with adolescents, observing that for an adolescent, the function of music is metaphorically both a mirror and a window, drawing on the work of Ruud (1997), who described this relationship as the “performance of identity,” distinguishing from the mirrorlike constructions of music as “reflecting” the soul. Ruud emphasized that young people use music to assert their public personality; they share music that supports their consciously chosen stereotypical persona— be that the “chav” listening to R&B, pop, and hip-hop and wearing the associated uniform of tracksuit, half-mast jeans, hoodie, cap, and caked-on makeup or the studiously appearing classical music follower. The therapist working with children and adolescents who have experienced abuse or neglect and are living with the symptoms of PTSD must be prepared to adopt a stance of “active engagement” (Olio, 1989). The transference expectations such children and young people may bring into the therapy room include failure to protect, abandonment, indifference, and even assault. These fears and expectations can be intensified by the therapist’s silence and passivity (Rose, 1991). A neutral stance, appropriate for some types of clients, is not effective and can even be harmful. Spiegel (1986) notes that “traditional analytic reserve is often perceived by the patient as a lack of concern or even a sadistic pleasure in the patient’s suffering” (p. 72). The music therapist must therefore adopt a more proactive approach, offering explicit and repeated opportunities for musical contact with the therapist, followed by observation and inquiry regarding the meaning to and impact on the child/young person. The therapist must always be aware of the potential to overwhelm emotionally or musically and also be sensitive to the potentially persecutory effect of silence (Rogers, 2003). Consideration attention must be paid to the dynamic of power with a shift from the “therapist as expert” to the “client as expert.”

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In addition, the music therapist must be aware that children and young people whose own body boundaries may have been violated by abuse may seek to provoke and test out their therapist in many ways, and clear structures and boundaries to the session will be essential.

REFERRAL AND ASSESSMENT PROCEDURES The referral to music therapy may be a self-referral or be made by another professional—such as a psychiatrist. The origin of the referral may determine how much accompanying information is provided to the therapist. Where the referral for therapy is from a fellow professional, it may be accompanied by a detailed clinical and social history; where this is absent, it will be essential for the therapist to take this history from the service user herself or her representative (parent/carer). Such histories will need to include a detailed risk assessment. Where the parent of the child or young person living in the community makes the referral, the therapist must be curious about the motivation of the parent. Occasionally, parents may bring their child to therapy as part of conflict over a marriage breakdown or divorce and may make allegations that their child has been abused, which subsequently emerge as a pointer to their own personal history or anger and distress at the breakdown of their relationship. Regardless of the origin of the referral, the therapist needs to ascertain who else is working with the service user (both agencies and individuals) and ensure that others within the professional system are aware of the referral to music therapy. Service users with complex histories of abuse and symptomatology of PTSD can provoke anxiety within the professional system, resulting in a splatter-gun approach to referring for therapy, with the service user being referred to many types of therapeutic interventions (e.g., music, art, and psychotherapy) simultaneously, in the vague hope that one approach will fit or work. While the splattergun approach may alleviate some of the referrer’s anxieties, it unfortunately does little to contain those of the service user and can be antitherapeutic. Liaison with the referrer and others in the professional system will be essential in this situation. The origin of the referral can influence the service user’s engagement in the therapeutic process, particularly where this is mandated as part of a child protection plan. In such circumstances, the service user’s motivation to attend therapy may be solely to comply with the mandate, but they may be intensely reluctant to engage in any therapeutic work. Aside from compiling a detailed clinical and social history, there are a number of issues that must be explored in detail with all service users presenting for therapeutic work. The most significant with children and young people presenting with known histories of abuse or neglect is to determine: 1) whether they are currently safe; 2) if there is a protective adult (parent/carer) who is aware of their history (e.g., mother); 3) what therapeutic work has been offered to the protective adult (parent/carer)—and if so, who is working with the parent/carer and how frequently the therapist will liaise with them; 4) that the abuse they experienced has ceased; 5) knowledge of the whereabouts of their alleged abuser—e.g., left the family home, in custody, only having supervised contact; 6) the service user’s legal status—is the child or young person subject to a child protection plan? If so, the therapist must liaise with the allocated social worker and should be actively involved in any statutory work occurring with the child and her family—such as by working with the child protection core group and contributing to child protection plans.

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In this author’s clinical experience, it is more common that children and young people who are referred for music therapy do not have known histories of abuse or neglect. While they may present with the symptomatology of PTSD, they may have been misdiagnosed with depression and/or self-harm and never have made a previous disclosure. They may still be living in the household of their abuser (another family member) or have ongoing contact with their abuser and may still be experiencing abuse. In such circumstances, the safety of the child or young person will always be paramount, and limits of confidentiality and work across the professional system with colleagues in police and social care will be essential. Where the child/young person is living in the community and is referred for therapy, consideration needs to be given as to where parents/carers wait for their child. Parents/carers should not be seated so close to the therapy room that they can overhear the musical content or verbal content of sessions. Parents/carers need to feel cared for themselves while waiting for the young person—a comfortable space, the opportunity to make a cup of tea/coffee, magazines, toys and games for younger children, and bathroom facilities preferably including a diaper-changing station—are all important tools in valuing the parent/carer. In addition to the above issues, exploration of the following domains is essential with all service users. Each is explored briefly below. These include: 1) 2) 3) 4) 5) 6) 7) 8) 9)

Limits of Confidentiality Mental Capacity Boundaries Genograms The “Abuse Question” The Legal/Therapeutic Context Transparency of Documentation The Therapeutic Context for Music Therapy Caring for the Nonabusive Parent/Carer?

Limits of Confidentiality All therapeutic work with service users should commence with discussion of the boundaries of work and the limits of confidentiality. The limits and boundaries of work need to be explicitly explained in language that a child or young person can understand. This may include a statement such as: “These sessions are confidential; however, if you tell me that you are being hurt or that someone else is being hurt, then I have a legal duty to share that information with other professionals. This may include my colleagues in the Police and Social Care. We would need to share this information to protect you or others.” It is essential that in exploring the limits of confidentiality with a child or young person, the therapist explore their understanding of confidentiality. A child or young person may assert that they understand the notion of confidentiality when in fact they have no concept of its meaning. I frequently use examples of good and bad secrets—for example, a birthday present might be a good secret, but not telling that I have a cut or have been hurt is a bad secret, as others might need to know to be able to help. In addition, I clarify that while I will respect their confidentiality within the explained limits, it is the service user’s right to talk about their therapeutic work freely should they wish to do so—e.g., to a supportive parent or trusted teacher—but that no one should expect them to do so. The legal limits of confidentiality require exploration and discussion with parents and carers as well as with the young person. In practice, it may be easier and more transparent to hold such conversations with the family as a whole. Such conversations can include exploration about what

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information will be shared with the parent/carer and what information will not be shared. They enable the therapist to evaluate how the parent/carer responds to an explanation of the limits of confidentiality and to explore whether the parent is comfortable allowing a child/young person to be seen without their presence. Exploration of the limits of confidentiality includes not only what information might be shared with the family and with other professionals within one’s own agency, but also externally with other agencies (e.g., Police, Social Care). Parents may seek information about how the therapist will record and store clinical information. Where legal proceedings (whether through the family courts or criminal courts) are already in play, the therapist needs to be transparent about what information may be reported and how such information will be shared. The therapist may need to share information with Police or Social Care or indeed with the courts; such information may include formal reports, clinical notes, or recordings of improvisations. In sharing information with professionals from other domains, the therapist needs to be sensitive to the different positions and languages used by others—a detailed explanation of the work of the therapist will be essential. In addition, the service user deserves the clarity of knowing what information the therapist is sharing with others—both in the multidisciplinary and multiagency context when attending Safeguarding Children/Child Protection or Safeguarding Adults/Adult Protection meetings. In this author’s practice, it is routine to share therapeutic reports prepared for such meetings transparently with service users prior to such meetings and to seek to ensure that the service user is invited to and present at the meeting. The service user with a history of abuse may struggle to trust their therapist; clarity about what information is being shared, with whom, and why can help to facilitate the development of trust.

Mental Capacity In the UK and the USA, one legally remains a child until the age of 18 (Children Act, 1989, UK), and parents retain parental responsibility until a child reaches the age of 18. While one remains a child in law until the age of 18, the Mental Capacity Act (2005) has legislated that every young person from the age of 16 has capacity, regardless of disability or illness. Thus a young person age 16 can self-refer and engage in therapeutic work without parental knowledge or consent. Where a young person with capacity refuses to engage in therapeutic work or medical treatment, then even where their parent might wish them to engage, the parent’s wishes do not override the right of the competent child/young person to refuse. Evidence that a young person over 16 years of age lacks capacity requires a specific assessment of capacity that enables an individual decision to be made. In the UK, young people under 16 are not presumed to have capacity, but the law acknowledges that some young people under 16 may have capacity—aka be Gillick Competent. A professional needs to evidence that a young person has capacity, through completion of a capacity assessment (often referred to as an assessment of Gillick Competence). While a 14-year-old who is competent (has capacity) and is refusing to attend music therapy could theoretically be overruled by her parent who holds Parental Responsibility, in reality it would be very difficult to work with such a young person and legal advice would need to be sought before overrruling a competent young person’s refusal. Where a young person has capacity but is detainable under the MHA (Mental Health Act, 1983/2007), then this would enable their wish to refuse treatment to be overruled. Capacity is important in all therapeutic work, but particularly so in work with survivors of abuse and neglect; the competent 15-year-old may disclose information about abuse to their therapist, who has a legal duty (under the Children Act, 1989) to share such information with the police, but the competent 15year-old may then refuse to talk with the police. This can create significant ethical dilemmas for the music

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therapist who may find herself working with a young person who refuses to disclose information to the police or social care and is effectively choosing to remain in an abusive context while simultaneously accessing music therapy.

Boundaries Clarity of boundaries is vital in all therapeutic work (Rogers, 1992), but particularly so with those with known or suspected histories of abuse whose own body boundaries may have been violated. Boundaries of time and space are helpful in therapeutic work. Boundaries about how language is used and how objects and people are treated also need to be spelled out and adhered to. Boundaries include body space and professional boundaries. In the UK, it is a criminal offense under the Sex Offenders Act (2003) to knowingly commence a sexual relationship with an individual with a mental disorder for whom you hold a position of trust, while all professional bodies have codes of practice emphasizing that dual relationships between therapist and client must be avoided. Such legislation acknowledges the confusion that breaching such boundaries can create. Boundaries for the child or young person who has experienced PTSD can be confusing—as a therapist, you must be clear about how you will respond to the child who is distressed and seeks to climb onto your lap or the child who seeks to masturbate within the clinical room. Robarts (2009) notes that “in work with children who tend to act out their feelings, boundaries of behaviour need to be set, in the interests of the child’s (and sometimes the therapist’s) actual physical safety, and the child’s internalizing a sense of containment in ways that are consistent and trustworthy” (p. 253).

Genograms Lessons learned from Serious Case Reviews have resulted in requirements that all initial therapeutic assessments include the completion of a genogram with a service user, which, as a minimum, records who lives in the same household. The genogram is an important therapeutic tool, which reminds both service user and therapist of the system within which the service user is living. Patterns of abuse in families can be explored through a genogram, with the genogram serving as a safe external object through which difficult themes and issues can be explored. Completion of the genogram can be therapeutic in and of itself, requiring reflection on these patterns of belief and behaviour. The acronym “graces” is commonly used as a therapeutic reminder of the range of patterns that might be explored through a genogram, including (but not limited to) gender, race, religion, age, ability, culture, class, education, employment, and sexuality. The musical history of a family can clearly be mapped onto a genogram; families can have strong stories about music (musical patterns). For example, in this author’s maternal family for at least four generations, the eldest child has played the cello, with the same cello being passed down the generations. Genograms can also be used to explore the quality of relationships between different family members. Therapy is always about relationships, and the use of different questioning styles can elicit different views of a family or system. The therapist with an interest in social construction theory will acknowledge that while exploring the world out there, she is at the same time one of the weavers and one of the threads and her hope is to set up the conditions that evoke “the situation’s potential for transformation” (Schoen, 1984). The music therapist can use instruments to explore the quality of relationships, using instruments to symbolise family members or clinical improvisation to explore the quality of a particular relationship (Rogers, 1992). These tools can add additional insight and information to a genogram. The music therapist can explore with the service user how they would like relationships to improve or change through the use of instruments as symbols or through clinical improvisation. In addition, symbolisation

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can be used to explore family relationships pre- and post-trauma. Finally, the music therapist can use sculpting (placing instruments around a room in relation to each other) to explore the quality of relationships.

The Abuse Question As stated above, in the UK, it is mandatory for NHS professionals (DH, 2003) working in mental health to ask the “abuse question” in all initial assessments—“Have you experienced physical, sexual, or emotional abuse at any time in your life?” This policy pertains to all women and men service users and is promoted by the National Violence and Abuse Mental Health Policy through the National Mental Health Development Unit (http://www.nmhdu.org.uk). In asking this question of service users, the therapist is implicitly giving permission that it is okay to talk about violence, abuse, and neglect and that she perceives such issues as being relevant to a service user’s mental health or PTSD. All the evidence points to survivors wanting to be asked about their experience of abuse, as long as it’s done sensitively. Asking at assessment gives service users the positive message that: 1) The therapist knows that the service user may have been abused and, by asking, hopefully it might make it easier for them to disclose. 2) The therapist thinks it’s important to know “what’s happened to you” as well as “what’s wrong with you.” 3) The therapist is equipped to support the service user if she has been abused and chooses to tell us about it. In contrast, not asking gives service users a negative message and reinforces the message that many survivors will have heard from their abusers—that it’s something not to be spoken about; a history of abuse or neglect is so shameful that even mental health services avoid it. By not asking, a clinician can paradoxically increase a service user’s anxieties that she may be blamed, not believed, not listened to or supported. Therapists who feel that asking about abuse should wait until rapport has been established should consider that, for many survivors, asking may well facilitate rapport rather than be a barrier to it. It increases survivors’ confidence in disclosing. Research indicates that routine inquiry in assessments significantly increases the rate of disclosure (Read & Fraser, 1998), and the question should be repeated in therapeutic reviews. Therapists should never ask this question in isolation; asking the question within routine inquiries helps avoid accusations of asking a leading question, planting the idea in the service user’s head, or encouraging the client to construct a false memory. False memory allegations resulting from routine inquiries are less likely to be challenged as therapist-induced false memories, should a case go to court. Where a therapeutic relationship has already been established, there’s a risk of a false disclosure occurring if the matter is asked as a sole question—because some clients may need and want to please a practitioner as well as find an explanation for their own distress.

The Legal/Therapeutic Conflict The legal domain works in a context of certainty and has a discourse that places significant value on facts and evidence; the level of evidence required for a criminal conviction is high. In contrast, the therapeutic domain places value on not knowing (Anderson & Goolishian, 1992), creating contexts of safe uncertainty (Mason, 1992, 2005), and in valuing positions of curiosity. These two domains can clearly come into

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conflict where the therapist may be required to give evidence in a criminal case against an alleged abuser or to provide evidence to Social Care when they are considering removing a child from a family or in making a child the subject of a child protection plan. It is therefore essential that the music therapist maintain detailed records of music therapy intervention with a young person; that they never ask leading questions; and that their clinical practice is embedded in a detailed knowledge of the legal framework within which we all work. The adage that all clinicians and therapists remain agents of the state is a useful one, as it reminds both service user and clinician of the legal duty to share certain information and of the limits of confidentiality.

Documentation Therapeutic work must be documented. This must be legible, detailed, and signed and dated, with the detailed notes maintained in chronological order. In the event of a disclosure of abuse, such documentation (including video or DVD recordings) can be subpoenaed by a court and a therapist may be called to give evidence. In essence, from a legal perspective, if it is not documented, it simply did not happen—thus while the therapist may assert she has discussed the limits of confidentiality or considered capacity, if these issues are not documented, then they did not happen. With some service users (young people or adults), this therapist has used narrative letters to the service user (written after each therapeutic session) to summarise the contents of the therapeutic work. This process is informed by the work of White and Epston (1990). A copy of the therapeutic letter is held in the service user’s clinical file and usually constitutes the only written record of the session. In this way, the clinical file is virtually shared with the service user and provides a more egalitarian relationship between therapist and service user. Service users with histories of abuse typically have a complex relationship with issues of power and therapeutically the therapist has the power—she has the knowledge, clinical and musical skills, and control. Therapists hold power through holding the written file and history of the service user. The use of narrative letters can begin to acknowledge and address this power imbalance; they can provide the service user with a history of their therapeutic work and progress. The language used in such narrative letters is important. With younger children, the narrative letter may be written to both the child and their parent(s). Documentation of therapeutic work is not simply written; records can include drawings and recordings of improvisation. The recording of therapeutic work must distinguish between what are facts and what is clinical opinion—for example: “Bob hit the instruments so hard that the skin on the drum was broken, and he kicked the cymbal across the therapy room floor. It appeared to me that Bob was full of rage and anger and that this was linked with his previous spontaneous comment that he hated his mother.”

The Therapeutic Context for Music Therapy When children and young people have been abused, the perpetrator is in most cases an adult or another young person with whom they have had a relationship of trust; they will have been groomed. They may well have been told that “this is our little secret; you must not tell”; they may have been taken into a room and the door may have been shut, the abusive aspects of the relationship between abuser and victim typically occurring behind a closed door in secret. The child may be taken into a therapy room and the door may be shut—in the child or young person’s world, immediate parallels can be found with their experience of abuse; she may become more

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anxious or resistant to being in a room alone with an adult. Such behaviours by the therapist can evoke flashbacks. Work occurring in the therapy room needs to achieve a balance between privacy (so that therapeutic work cannot be overheard) with transparency. The door to the therapy room should ideally be equipped with a small window so that others external to the room may glance in to observe. Recording equipment should be available to enable choice to occur about whether improvisations might be recorded and played back within the session. A box of tissues should be discretely available. The gender and cultural origin of both therapist and service users need to be acknowledged.

Caring for the Nonabusive Carer Children need protection from their abusive parents. In the realm of litigation that involves abuse, the abusive parent tends to be the father while the protective parent is usually the mother, because most perpetrators of domestic violence and of child sexual abuse are male. The impact on a mother who learns her child has been abused is considerable. The mothers of children who disclose abuse often find themselves in a confusing double-bind situation—in order to protect their children, they leave the children’s abuser (typically their partner and/or the child’s father), only to find that the threshold for justice in court is not “on the balance of probability” (as it is for child protection) but “beyond reasonable doubt” (as it is for criminal proceedings). As a result, the nonabusive parent is then expected to permit or even facilitate contact by their child with their alleged abuser—only now the protective parent is sending their child to be alone with the alleged abuser and is unable to protect them. This double-bind situation can result in the nonabusive parent experiencing feelings of complete impotency, powerlessness, and anger toward the child protection system. The music therapist working with a child or young person who has disclosed abuse needs to be sensitive to the overwhelming distress the nonabusive parent may be experiencing, alongside all the practical dilemmas—such as ending a relationship, working with Social Care and Police, finding a new home, and informing family and friends of the breakdown of the relationship without breaking their child’s confidentiality. Nonabusive parents need to be listened to, encouraged to notice what they do well for their children, and supported to continue to advocate for their children.

OVERVIEW OF MUSIC THERAPY METHODS AND PROCEDURES Improvisational Music Therapy •

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Group Improvisation: Clients choose instruments and play them alone and together in the group in a variety of warm-up and expressive improvisations. These improvisations have different levels of structure and may be either referential or nonreferential. Individual Improvisation: The client and therapist improvise together using instruments symbolically to convey meaning about the client’s family relationships and to express her concerns. Systemically Informed Family/Music Therapy: Family members improvise alone and together; each member of the family uses the instruments in referential improvisations to symbolically explore relationships and difficulties.

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Re-creative Music Therapy •

Reflective Group Singing: Clients choose songs and sing them together, accompanied by the therapist, and then discuss the meaning of the songs.

Compositional Music Therapy •

Individual Songwriting: The client writes lyrics on a theme suggested by the therapist, who also provides a melody and harmonic structure for the song.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY This author has not been able to identify any literature describing the use of receptive music therapy with this specific population, nor does this author use receptive music therapy as a singular method.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Group Improvisation Overview. Clients choose instruments and play them alone and together in the group in a variety of warm-up and expressive improvisations. These improvisations have different levels of structure and are either referential or nonreferential. Group therapy provides an environment where children who are traumatized can connect and have their symptoms normalized by learning that others experience the similar issues; this effectively helps address their feelings of social stigmatisation and isolation. Service users who may be admitted to the same unit or attend the same day hospital or clinic where all share a known history of abuse may be suitable for group therapy. Group Improvisation Groups can also be established with children and their families living in the community. Group members should be of similar age and cognitive abilities. Group improvisational therapy in this setting may support interaction and help reduce feelings of isolation. It may be contraindicated where there is an unwillingness to participate or where the clinical team has concerns about a competitive culture emerging within the group—for example, involving who can self-harm the most. Group sessions allow young people to find positive and creative ways of relating with others through the music, which they may not have previously experienced. The therapeutic goal is to build a group culture, to aid self-expression and awareness of others, to interact with others, and to make choices (Darnley-Smith & Patey, 2003). Group improvisation can provide a sense of belonging and shared purpose; this can be particularly important for the abuse survivor whose experiences may have left her feeling alienated or isolated from others. Stige (2002) notes the role music therapy can play in enabling individuals to find a voice. The expression of feelings can create group cohesion and a sense of community through shared feelings. Along with sharing, empathy can be expressed and experienced. The level of therapy is intensive. The therapist should have advanced training in improvisation techniques. Preparation. Good-quality percussion instruments should be available including xylophone, glockenspiel, gong, bongo and conga drums, small hand instruments such as small maraca, triangle, jingle bells, small shekere, and a tree chime on a stand. This author always includes a broken instrument—this could be a sound-bar which is unable to sound or a drum with a broken skin. The service user who deliberately chooses a broken instrument is conveying a powerful message of their sense of self. If a piano is in the therapy room, the therapist must be aware of the potential dynamics of power and potential for abuse of power regarding who plays the piano.

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The therapeutic room should be enclosed, with chairs provided set out in a semicircle. The group will be closed, and attendance at the group should be expected for several weeks. A consistent cotherapist is advisable—this might be a member of the multidisciplinary team, for example, a nurse. A cotherapist will be able to support the therapist should any group member need to leave a session or become distressed and will additionally facilitate feedback to the permanent staff team in a unit or ward. What to observe. The therapist needs to be particularly sensitive to group dynamics and the safety of the group. There may be power struggles regarding who plays which percussion instrument. In addition, group members may have doubts about their musical skill and worry that they are not making “real music” (Darnley-Smith, 2002). Choice of instrument, manner of playing, timbre, volume, and personal interactions will all need to be observed. Procedures. To open the session, group members should be encouraged to discuss the rules for the group and to write these down. These might include: 1) 2) 3) 4) 5) 6) 7) 8)

Being respectful to others Confidentiality Not bringing food or drink into the session Ensuring that when you attend the group, you are sober or not under the influence of any substances Listening No swearing or threatening behaviour, no spitting Taking turns/not monopolising an instrument Discussion about whether it is okay to arrive late or leave early

Facilitating the group to develop their own rules is an important part of the process of enabling the group to own the therapeutic work. Rules can develop with the group and change over time. This can also promote discussion of group members’ fears of the therapeutic process. Many groups may wish to keep the rules displayed throughout their work together and may amend or add to them over time. Austin (2007) comments that the rules developed by groups of adolescent girls with histories of abuse can be harsh and attributes this to the “harsh super-ego that is often part of the make-up of the abused or neglected child” (p. 98). It is important in work with young people to give them some direction before commencing an improvisation—for example, reminding young people that improvising is about listening to each other, that there is no right or wrong way to play, that you can move around the room and change instruments, that you do not need to play all the time, and above all that it might sound strange. To begin the working phase of the session, encourage each member of the group to choose an instrument which tells the other group members something about herself—for example, the quiet individual might choose a quiet instrument or conversely might choose a louder instrument and state that she wishes she were able to be louder. Such an activity can be used on a regular basis as an introduction. Use the instruments to facilitate discussion between group members. Instruments can be used symbolically or as transitional or communication objects. Group members may be anxious about playing their instruments. A useful way of commencing is to ask the group to “make a sound and pass it on through looking at another group member”—this simple activity can promote eye contact and listening skills; it enables those with little confidence to make a single sound and pass it on, while others may wish to play for longer. Discussion of how this exercise felt should be encouraged. Austin (1995) hypothesises that the young people with histories of abuse and neglect struggle with simple listening activities (such as following a rhythm), as they have not experienced being listened to themselves.

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A wide variety of improvisational activities can be used within such a group setting, from the highly structured—drumming activities—following rhythm, dynamics, the use of pentatonic improvisation (using glockenspiels, xylophones, and metallophones), and conducting activities that implicitly acknowledge power imbalance within therapy groups (therapist–client) to more free improvisation. The pacing of activities is essential. The issue of power and abuse of power is extensively explored in the literature regarding music therapy with this population (Austin, 1995; Rogers, 1992, 2003). Structured group activities such as conducting, which enables the young person to experience being a leader or in control (having power), can enable young people to gain an important sense of their own autonomy. Both Austin (1995) and Rogers (1992) note that structure can be essential in work with young people with histories of abuse and that without structure, music improvisation can quickly reflect the chaos of their own internal worlds. The music therapist needs to be present, responding, listening, and noticing every action and interaction of the group. Adaptations. The intention is to ensure that all group members are engaged in a cooperative, group experience. The approach can be adapted, such that the group-work includes psychoeducational work held over a fixed number of sessions—each session having a theme, for example, names of body parts, good and bad touching, the right to say no, sex education, managing future relationships with partners. Parallel group work (same time, same building, and separate therapists) can be offered to the nonabusive parents.

Individual Improvisation Overview. The client and therapist improvise together, using instruments symbolically to convey meaning about the client’s family relationships and to express her concerns. Robarts (2006) observes that: Improvisation is a form of shared play, a musical interplay that is developed through the therapist musically listening to, exploring, and working with the qualities and characteristics presented in the client’s “being” and “being with,” as well as in the client’s “not being,” and “not being with.” (p. 251) Individual psychoanalytically informed improvisational music therapy seeks to create second-order change in the beliefs of the individual service user, to facilitate both self-expression and insight. The only contraindication for individual improvisational music therapy would be the refusal of the service user to attend or engage in the process. The child or young person referred for individual music therapy should not be engaged in any other psychological or psychotherapeutic individual therapy, although she may be engaged in family work and group work simultaneously. This is primary-level therapy; it requires advanced improvisational skills and an understanding of the psychodynamic approach. Preparation. Consideration of the timing of sessions and consistency of the location of sessions is vital. The therapeutic space needs to be contained and welcoming, equipped with a couple of equally comfortable chairs (one for therapist and another for the service user) and a range of good-quality tuned and nontuned percussion instruments. A couple of broken instruments should be included. Most therapists will require a piano. Paper and pens should be available to facilitate work using a genogram, and there should be the possibility of sticking work on the walls. Consideration needs to be given as to what activity the service user will engage in after the session, particularly if they are acutely unwell. Feedback to the multidisciplinary team caring for the individual should occur immediately after the session, preferably in the presence of the service user. This might be very brief, e.g., “Anna could do with

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a little support this afternoon, she has been working very hard,” or lengthier: “Anna has made a new disclosure. Anna is aware that I need to liaise with Social Care and inform them of this; please, could you ensure that Anna’s mother does not try to remove her from the unit later today and protect Anna from any unexpected phone calls this afternoon. I am sure Anna would love a cup of tea right now.” What to observe. The therapist must be sensitive to the potential for improvisation to evoke painful memories or to overwhelm the service user. Wigram (2004) eloquently describes musical techniques to assist the therapist—how to convey empathy by mirroring and matching the music made by the client, how to develop frameworks to help clients express themselves, and how to challenge clients to move beyond ritualised styles or patterns of playing. Procedures. Rogers (2003) includes a detailed account of the process of improvisational music therapy with a young person with a history of abuse. All therapeutic work should include exploration of the concerns the individual is bringing with her into the therapeutic room that day. Flexibility is essential. Rogers (1992, 2003) describes the use of genograms and musical sculpting to enable children and young people to begin to explore their family history in a safe, structured form while using the instruments symbolically to convey meaning about their family relationships. The child/young person can be invited to choose an instrument to show something about themselves—they should then be invited to choose instruments to represent other members of their family. The child/young person can physically place the instruments in the therapy room to show whether relationships are perceived as close, enmeshed, or conflictual. It is important to be observant about all aspects of symbolic use of an instrument—its size, appearance, sound quality, timbre, the manner and rhythm in which it is played, and dissonance between any of these factors. The presence of the broken instrument in the therapy room is useful in this activity, for example, the broken sound-bar which superficially appears intact—even beautiful—but is unable to sound or have a voice. This approach can also be used with families and in conjunction with drawing a genogram. Circular and reflexive questions can be particularly used in conjunction with this activity, for example, “What instrument do you think your mum would choose to tell us something about you, and why?”; “How would your dad describe your relationship with your brother … how would that sound?”; “If you could change your relationships, what would they look like?” Circular questions invite new information into the system in a way that encourages new ways of viewing a problem or relationship (Tomm, 1988). Storytelling in improvisational music therapy with individuals who have experienced sexual abuse is also described in the work of Stephanie Thompson (2007), who describes how she uses music to contain and hold the child and in turn develops a relationship of trust in which the child feels safe to vent his feelings and express his fears, and in Rogers (2003), in which the service user improvised a narrative/metaphorical tale over many sessions. Adaptations. Ostertag (2002) describes how, “based on psychodynamic and cognitive principles reflected in musical improvisations,” he has developed “other expressive activities (art, movement, storytelling) and verbal processes in the music therapy session” (p. 12). Robarts (2006) and Rogers (1992, 1994, 2003) each emphasize that improvisation by child and therapist is a dynamic process that enables the immediate expression and communication of emotions through feelings, thoughts, and memories. The child’s past and present situation, family issues, experiences of abuse and trauma, and coping skills can be cognitively explored. The use of narrative, storytelling, and verbal exploration is seen as an important component of such work, with such structures providing containing forms (providing a secure base) within which such work can occur.

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Systemically Informed Family/Music Therapy Overview. Family members improvise alone and together; each member of the family uses the instruments in referential improvisations to symbolically explore relationships and difficulties. Systemically informed family/music therapy pays considerable attention to dynamics of power and language. It’s highly appropriate to use with children and adolescents who are living with PTSD and histories of abuse, as it supports families in exploring the emotional impact of trauma through music where languaging emotions may initially be difficult or where words are inadequate. Systemically informed music therapy is particularly useful where families struggle to find the language to convey their often intense emotions or to discuss the trauma or abuse which will have affected the whole family in different ways. A mother may, for example, struggle to come to terms with the abuse her daughter has suffered, her own feelings of guilt or inadequacy, her anger with her partner, and her sense of loss—of the relationships she thought she had or would have in the future. The mother may experience guilt at her difficulties in accepting that the focus of therapeutic work will largely be on the victim of abuse—the daughter—or may struggle to work with her daughter in a supportive way. Verbalising such emotions may be too difficult, but systemically informed music therapy offers a means of exploring these emotions. Systemically informed family/music therapy can be offered to children or young people and their nonabusive carer. The involvement of the abusive parent is rare and should only occur when this is mandated and approved by Social Care and sufficient previous therapeutic work with the alleged abuser has occurred to confirm the safety of the child. Therapists offering this approach should be qualified in both music therapy and systemic psychotherapy. Otherwise, their work should be supervised by a systemic psychotherapist who observes from behind the one-way screen. Therapists using this approach may seek further training in systemic approaches to therapy. This is intensive-level therapy, the focus of which is to ensure that the child is not perceived as the problem, and instead that the family is living with “the problem”; thus the abuse is externalised (White & Epston, 199o). Systemically informed family therapy enables all members of the family to explore and language the impact of the trauma on them, through musical improvisation and subsequently in words, and to find new ways of relating and acknowledging the hurt and anger which results. Preparation. A large therapy room will be required for this approach, able to accommodate the family and a wide selection of tuned and nonntuned percussion instruments; a good-quality keyboard or preferably a piano is needed. The room should have a one-way screen and recording equipment—the remainder of the family therapy team will observe the session through the one-way screen and provide a reflecting team. The clinical team will need to be explicit and transparent about who is involved in this work, who is observing, and how information will be shared with any other professionals working with the family. The therapist and clinical team come to this work with a collaborative, respectful, nonjudgmental approach. Not knowing is key, with the therapist deferring to the family’s expertise, allowing the presumption of knowledge to be distributed through a conversation (Anderson & Goolishian, 1992). Use of the reflecting team (Andersen, 1987, 1991) ensures that conversations are held transparently in the presence of the family, and in this way, the clinical team seeks to share its thoughts and concerns with the family rather than impose them. Through the team’s discussion, the family is invited to consider alternative stories, explanations, or meanings regarding their lives together. Sometimes the reflecting team may disagree or debate differing views, allowing family members holding differing perspectives to feel understood.

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What to observe. Systemically informed family/music therapy has the advantage of a clinical team to observe through the one-way screen as well as the family/music therapist in the room. Key skills for the therapist include curiosity about what is not said or sounded, the silences as well as what is said (musically and both verbally and nonverbally). The reflecting team can come into the therapy room and discuss in the family’s presence what they have heard and observed. The clinical team will need to be attentive to dissonance between verbal and musical expression and body language. In addition, differences of perception between the observing team and the therapist in the room or between the members of the observing team provide valuable information. The observing team might notice the mother discretely checking her mobile phone throughout the session, whenever the therapist’s attention was focused elsewhere, and occasions where the mother did not respond to the nonverbal communication of her daughter, whereas the therapist in the room might notice that the same mother was affectionate to her children, asked advice, and returned to the next session commenting on things she had tried to do differently. Such differences can be verbalised and explored openly with the family. It is important to be sensitive to the needs of others in the family who may have their own personal histories of abuse and trauma, mental health needs, drug or alcohol misuse problems, or cognitive difficulties. The ability to contain and refer to other professionals where necessary is an important component of the structure of this work. Procedures. The therapist will introduce the family to the clinical team and show them how the session is observed. The therapist will seek a history from the whole family of the presenting difficulties and may construct a genogram with the whole family. Each member of the family will be asked why they are here now (in therapy) and what he or she hopes to gain from therapy. Each member of the family should be included. Family members can be invited to use the instruments symbolically: Choose an instrument and play it to show how you feel about being here today, or in sculpts. Family members can be invited through musical improvisation to reflect on current difficulties or past difficulties or to think about a specific relationship. Younger children may find it easier to explore themes when actively engaged in activities such as improvisation and sculpting. Improvisation ensures that all members of a family can engage in the therapeutic work. In working with the family in this way, the therapist needs to be an active participant in the therapeutic process, to improvise, and in doing so, to invite the family members to similarly improvise and attempt new patterns of relating, with new alternatives and possibilities. This approach requires a certain irreverence (Cechhin, Lane, & Ray, 1992) on the part of the therapist. Languaging and reflecting on improvisations enable new narratives and meanings to emerge. All therapy is an improvisation, an attempt to notice and be aware of the language, nonverbal language, and breathing of each family member, to be sensitive to what is not spoken as well as what is. To be with a family in family therapy means that the therapist must have a willingness to learn how this specific family relates to each other and then to seek to create a safe-enough context, the context of safe uncertainty (Mason, 1993), in which improvisation can occur. As the family’s therapist, this author seeks to emotionally connect with each and to attend to their emotional well-being through improvising with the family musically. There is no predetermined map for this process; rather, the therapist needs to trust the therapeutic tools in her repertoire and improvise. Adaptations. Oldfield and Flower (2008) describe in detail their work with children and families with developmental delay, where the parent is used to support the therapeutic work as a working partner to the music therapist.

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GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Reflective Group Singing Overview. Clients choose songs and sing them together, accompanied by the therapist, and then discuss the meaning of the songs. This approach may be used for a group of service users who are all inpatients in the same unit. It may provide a nonthreatening and supportive means of social support and opportunities to reflect on personal issues and their experiences of them. The method is contraindicated for residents unwilling to attend and who are consistently disruptive during group conversations. This approach in the UK may be delivered jointly by an occupational therapist (with musical skills) and second professional and is not always delivered by the music therapist. Consistent attendance at the group by a permanent member of staff from the unit is essential. Some young people may be resistive to using their own voices due to anxiety and may need support to engage. Some popular songs include swear words and sexually inappropriate language, and clinicians managing this activity need to be particularly sensitive to the potential to distress or alienate young people or their parents/carers if some songs are included in this activity. Group rules should therefore be agreed upon by the group. Goals for young people are to recognize and accept feelings, to find ways of expressing these in nondysfunctional ways, and to promote awareness of others. The level of therapy is augmentative. The therapist should be aware of community choirs and seek to encourage young people to engage in musical activities within the community on discharge from the inpatient unit. Engagement in external musical activities can be promoted and facilitated by staff while a young person is an inpatient, and this should be encouraged. The level of therapy is augmentative or intensive. Preparation. Referrals to such a group will require that all group members have similar levels of cognitive functioning. The group can be an open group, i.e., open to all inpatients on an adolescent unit who may need social support and an opportunity to reflect on personal issues, with the membership fluctuating as some patients are admitted and others discharged. Other staff on the unit should be encouraged to attend. The therapist should be able to accompany herself while singing a broad repertoire of songs, and she should have knowledge of popular songs which will be familiar to young people. It is important that this group work occurs in a room where the young people will not be disturbed by other activity in the unit. A piano should be available for the therapist to use. The therapist should acknowledge that young people may have their own musical skills and may wish to lead the singing themselves from the piano, and this should be facilitated. What to observe. Each young person’s verbal communication, body language, and facial expressions should be observed, with particular attention paid to evidence of emotional pain. Watch for denial of feelings through song choices that do not match verbal and/or nonverbal expressions of emotion. Young people can respond to the emotional content of a song and become overwhelmed by their response. McFerran (2010) notes that it is crucial that the music therapist be “aware of how common these reactions can be” (p. 79). Procedures. Open the session by asking group members to comment on how they are. Use questions to promote group awareness and awareness of others by asking each group member to comment on how another group member might be feeling today, for example, “Anna—how do you think Rupesh is feeling today? Can you say why you think he is feeling [‘x’]?” Allow plenty of time for each group member to be engaged in this activity and note if anyone is struggling with waiting for her turn. This activity can promote discussion about recent incidents in a unit, particularly where one young person might recently have self-harmed. Encourage the group to identify a song they wish to sing, and encourage the group to participate in singing together. If a young person is too inhibited to sing, encourage her to hum or tap out the rhythm

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of the music in an accompanying manner. Some service users may wish to conduct the others, and this can provide an opportunity for them to experience power and control where they have no experience in their day-to-day lives. After singing, allow time for verbal and nonverbal responses to the song, and to comment on the lyrics and their meaning. Such discussions can become important, for example, in enabling a detailed discussion about the media’s objectification of women or idealisation of love and relationships. Musical activities—such a singing a rhythm or a familiar song as a round—can be enjoyable and lead to a sense of achievement for the group, many of whom may bring experiences of music-making from school choirs into the group or may be accomplished musicians in their own right. Following singing, encourage reflection on the song and musical choices made, encouraging service users to acknowledge different musical tastes and experiences and to tolerate difference, to recognise their shared similarities. The therapist should facilitate discussion by asking open questions such as “How was it to sing that song?” and promote awareness of other’s reactions by asking, “Did you think X enjoyed that song or would have preferred a different tune?” Listen for an emerging theme in the group’s verbal and nonverbal responses. Group members may wish to work on a song over several weeks, and the therapist can therefore provide song sheets to the group for specific songs. A group may develop a signature tune for themselves—the Monty Python lyric “Always look on the bright side of life” is often chosen by staff as an upbeat tune to focus discussion on the future and the positives rather than the past. The black humour of “Always look on the bright side …” appears to resonate with young people, who are often amused as some of the lyrics include swear words. Observing staff struggle with whether to sing the lyrics or not can cause some hilarity and facilitate discussion about boundaries. Such a signature tune can be used at the end of every group, and group members may wish to develop their own words for the verses. Adaptation. This approach can also be used in individual work with a young person.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Individual Songwriting Overview. The client writes lyrics on a theme suggested by the therapist, who also provides a melody and harmonic structure for the song. Lindberg (1995) discusses the use of songwriting with an abused adolescent female to increase expression of feelings and build self-esteem. The article includes a description of the author's procedure for songwriting sessions. Finally, client progress is shared through a number of original song lyrics. Mayers (1995) describes a song production technique that can be used with traumatized children. The technique involves children and therapists working together to produce a song. The children use the song to calm and reassure themselves by singing the song in a repetitive fashion as a therapeutic ritual, with the goal of decreasing anxiety and distress. Four cases are described of children (age 4 to 7 years) traumatized by sexual abuse or by a hostile custody battle. The children were able to deal with many of their anxious feelings by creating and singing their own songs. The technique can also be used in group therapy. Both Lindberg (1995) and Mayers (1995) note that songwriting may be considered as poems set to music, with songs providing a vehicle for the expression of concerns and anxieties. Goals of songwriting are to provide young children with techniques to “heal themselves, to develop songs as they need them and to use the therapeutic song when the need arises” (Mayers, 1995, p. 497). The songwriting technique can be effective in decreasing anxiety and distress and in empowering children to manage difficult situations. The level of therapy is intensive. It provides children with a technique that they can implement, teaching them that they are “creative and capable of nurturing and

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healing themselves” (Mayers, p. 498). Preparation. As in all therapeutic work with children and young people, a safe therapeutic space free from interruption needs to be provided, with material to record the song, such that a child may take home a recording of their work. What to observe. Therapists utilising this approach should praise the child’s creative abilities and notice the response of parents and carers to this activity. The verbal language used by the child in creating a song can provide the therapist with valuable insight into the child’s concerns. Procedures. Mayers (1995) reports that children are told they are going to write a song to help “assuage the bad feelings”; the therapist suggests a very simple tune together with a theme and approach. For example, the song may use animal characters that had a problem similar to that of the child but found an effective solution. The child is supported to write her own song and to perform it. Parents are encouraged to support the ritualistic use of the therapy song and empowered to implement the technique independently. Mayers describes a number of successful uses of this approach with young children who used the learned written song to self-soothe.

RESEARCH EVIDENCE While there is a wealth of case study material reporting the value of improvisational music therapy with children and adolescents who have experienced traumatic abuse, there is limited quantitative or qualitative research. Without further research, agencies may fail to fund music therapy intervention for children and young people who have experienced trauma and abuse. All authors writing about the use of music therapy with this client group agree on the importance of providing a safe environment, because the traumatization of a relationship destroys the capacity to trust (Amir, 2004, p. 97; Purdon, 2006, p. 214; Rogers, 2003, p. 128; Strehlow, 2009, p. 172). Ostertag (2002) presents the findings of a one-year qualitative research project that examined the specific dynamics and outcomes of music therapy interventions with abused children. Eight children (age 6 to 12 years), referred by the Children's Aid Society (Canada), participated in weekly music therapy sessions where their music and behavioural changes were documented. The outcomes from this study demonstrated that music therapy can play a very important role in the change process of abused children, particularly in addressing emotional and relationship issues which are difficult to address with cognitive or behavioural treatment models. The article focuses on the unique experiences and benefits of music therapy for abused children and emphasizes the need for a well-coordinated community response to violence against children that includes work with caregivers. Rogers (1992, 1993, 1994, 1995, 2003) emphasizes that therapy with children and young people living with PTSD and the consequences of abuse may use music therapy to provide a safe context within which to explore emotionally laden memories and to generate new means of relating with and to others. Robarts (2006) notes that among her main teachers “were the very disturbed children who had histories of familial sexual abuse, leading to post-traumatic stress disorder,” noting that “[u]sing improvisation in music therapy, the therapist can work directly with a child’s emotions and behaviour in order to develop experiences of self-regulation, healthy attachment, and a capacity for play” (p. 255). Robarts (2006) concludes that “because music can both reach and regulate the core of our beings, for the traumatized child it can work to support and transform the distorted and disrupted foundations of the bodily emotional self” (p. 265). Thus music therapy helps: … to build new patterns of being and being with, as well as working through the trail of devastation left by early trauma. In so doing, a coherent sense of self begins to form. From this self-coherence or “connectedness,” children can then

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begin to find a safe space within as well as between themselves and others that can be felt as stable, yet flexible in its vitality. (p. 265) Strehlow (1999) notes that “being stuck in silence is one of the results of being sexually abused, and music therapy offers a good way of dealing with it” (p. 168). McFerran’s (2011) research into the music listening preferences of adolescents raises some interesting questions about the impact of heavy metal music on mood. McFerran found that young people at risk of depression were more likely to choose to listen habitually and repetitively to heavy metal music, using music to isolate themselves or escape from reality. Because depression can be linked with trauma and PTSD can be misdiagnosed as depression, awareness of the music choices made by adolescents is essential.

SUMMARY AND CONCLUSIONS Working with children and young people who have experienced abuse is a core business for many music therapists, and this is reflected in the number of case studies in the literature. Central to the varying approaches described in working with traumatised and abused children and young people (and adults) is a recognition of the flexibility of music therapy and the importance of careful listening, a skill music that therapists develop early in their musical careers. The second quality implicit within the literature is an emphasis on authenticity. It is the author’s view that it is precisely this attentive listening—to the rhythm of an individual’s breathing, to what is said and not said (both musically and verbally), and the acknowledgment of the potential for the cocreation of new meanings through music (and verbal and nonverbal interaction)—that makes music therapy invaluable in meeting the needs of abused children and their families.

REFERENCES American Psychiatric Association. (APA). (1980). Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: APA Amir, D. (2004). Giving trauma a voice: The role of improvisation music therapy in exposing, dealing with and healing a traumatic experience of sexual abuse. Music Therapy Perspectives, 22(2), 96–103. Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26(4), 415–428. Andersen, T. (1991) The reflecting team: Dialogues and dialogues about the dialogues. New York: Norton & Company. Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee & K. Gergen (Eds.), Social construction and the therapeutic process (pp. 25–39). Newbury Park, CA: Sage Publications. Austin, D. (2007). Life-songs: Music therapy with adolescents in foster-care. In V. Camilerri (Ed.), Healing the inner city child: Creative arts therapies with at-risk youth (pp. 92–104). London: Jessica Kingsley Publishers. Beitchman, J. H., Zucker, K. J., Hood, J. E., daCosta, G. A., Akman, D., & Cassavia, E. (1992). A review of the long-term effects of child sexual abuse. Child Abuse and Neglect, 16, 101–118. Boney-McCoy, S., & Finkelhor, D. (1995). Psychosocial sequelae of violent victimization in a national youth sample. Journal of Consulting and Clinical Psychology, 63, 726–736.

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Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., & Megson, M. (2009-2011). New learning from serious case reviews: A two-year report for 2009-2011. Research Report DFERR226. Department for Education. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFERR226_Report.pdf Briere, J., Berliner, L., Bulkley, J., Jenny, C., & Reid, T. (Eds.). (1996). The ASPAC handbook on child maltreatment. Newbury Park, CA: Sage Publications. Briere, J., Woo, R., McRae, B., Foltz, J. & Sitzman, R. (1997). Lifetime victimization history, demographics, and clinical status in female psychiatric emergency room patients. Journal of Nervous and Mental Disease, 185, 95–101. Briere, J., & Zaidi, L. Y. (1989). Sexual abuse histories and sequelae in female psychiatric emergency room patients. American Journal of Psychiatry, 146, 1602–1606. Cecchin, G., Lane, G., & Ray, W. (1992). Irreverence: A strategy for therapists’ survival in systematic thinking and practice series. London: Karnac Books. Chu, J. A. (2011). Rebuilding shattered lives: Treating complex PTSD and dissociative disorders. New York: Wiley Publishing. Chu, J. A., Dill, D. L., & Murphy, D. E. (2000). Depressive symptoms and sleep disturbance in adults with histories of childhood abuse. Journal of Trauma and Dissociation, 1(3), 87–99. Darnley-Smith, R., & Patey, H. (2003). Music therapy, creative therapies in practice. Thousand Oaks, CA: Sage Publications. Department of Health. (2003). Gender and women’s mental health implementation guidance, Section 8, Violence and abuse. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publi cations/PublicationsPolicyAndGuidance/DH_4072067 Figley, C. R., (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder and those who treat the traumatized. New York: Brunner/Mazel. Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse and Neglect, 18(5), 409–417. Forinash, M. (2001). Overview. In M. Forinash (Ed.), Music therapy supervision (pp. 1–8). Gilsum, NH: Barcelona Publishers. Gold, S. (2000). Not trauma alone: Therapy for child abuse survivors in family and social contexts. Hove, UK: Brunner-Routledge. Goodman, L., Rosenburg, S., Mueser, T., & Drake, R. (1997). Physical and sexual assault history in women with serious mental illness: Prevalence, correlates, treatment and future research directions. Schizophrenia Bulletin, 23, 685–696. Itzin C. (2006). Tackling the health and mental health effects of domestic and sexual violence and abuse. Department of Health. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publi cations/PublicationsPolicyAndGuidance/DH_4136610 Jacobson, A., & Herald, C. (1990). The relevance of childhood sexual abuse to adult psychiatric inpatient care. Hospital and Community Psychiatry, 41, 154–158. Jacobson, A., & Richardson, B. (1987). Assault experiences of 100 psychiatric in- patients: Evidence of the need for routine inquiry. American Journal of Psychiatry, 144, 508–513. Kessler, R. C., Sonnega, A., & Bromet, E. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048–1060. Laiho, S. (2004). The psychological functions of music in adolescence. Nordic Journal of Music Therapy, 13, 47–63.

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Lindberg, K. A. (1995). Songs of healing: Song-writing with an abused adolescent. Music Therapy, 13, 93– 108. Kelly, L., Regan, L., & Burton, S. (1991). An exploratory study of the prevalence of sexual abuse in a sample of 16-21-year-olds. Child Abuse Studies Unit. University of North London, London, UK. http://www.cwasu.org/publication_display.asp?pageid=PAPERS&type=1&pagekey=44&year=19 91 McFerran, K. (2004). Using songs with groups of teenagers: How does it work? Social Work with Groups, 27, 143–157. McFerran, K. (2010). Adolescents, music and music therapy: Methods and techniques for clinicians, educators and students. Philadelphia, PA: Jessica Kingsley. MacIntosh, H. B. (2003). Sounds of healing: Music in group work with survivors of sexual abuse. The Arts in Psychotherapy, 30, 17–23. Mason, B. (1993). Towards positions of safe uncertainty. Human Systems, 4, 189–200. Mason, B. (2005). Relational risk taking and the training of supervisors. The Journal of Family Therapy, 27, 298–301. Mayers, K-S. (1995). Songwriting as a way to decrease anxiety and distress in traumatized children. The Arts in Psychotherapy, 22(5), 495–498. National Mental Health Minimum Data Set (MHMDS). (April, 2011). Retrieved from http://www.mhmdsonline.ic.nhs.uk/ Odell-Miller, H., & Richards, E. (2008). Supervision of music therapy: A theoretical and practical handbook. Oxford: Routledge. Oldfield, A., & Flower, C. (2008). Music therapy with children and their families Philadelphia, PA: Jessica Kingsley. Olio, K. (1989). Memory retrieval in the treatment of adult survivors of sexual abuse. Transactional Analysis Journal, 19(2), 93–100. Osborne, N. (2009). Music for children in zones of conflict and post-conflict: A psychobiological approach. In S. Malloch & C. Trevarthen (Eds.), Communicative musicality: Exploring the basis of human companionship (pp. 331–356). New York: Oxford University Press. Ostertag, J. (2002). Unspoken stories: Music therapy with abused children, Canadian Journal of Music Therapy, 9, 10–30. Palmer, R., Bramble, D., Metcalfe, M., Oppenheimer, R., & Smith, J. (1994). Childhood sexual experiences with adults: Adult male psychiatric patients and general practice attenders. British Journal of Psychiatry, 165, 675–679. Purdon, C. (2006). Feminist Music Therapy with abused teen girls. In S. Hadley (Ed.), Feminist perspectives in music therapy (pp. 205–226). Gilsum, NH: Barcelona Publishers. Read, J. (1997). Child abuse and psychosis: A literature review and implications for professional practice. Professional Psychology: Research and Practice, 28, 448–456. Read, J. (1998). Child abuse and severity of disturbance among adult psychiatric in-patients. Child Abuse & Neglect, 22, 359–368. Read, J., Agar, K., Barker-Collo, S., Davies, E., & Moskowitz, A. (2001). Assessing suicidality in adults: Integrating childhood trauma as a major risk factor. Professional Psychology: Research and Practice, 32, 367–372. Read, J., & Argyle, N. (1999). Hallucinations, delusions and thought disorder among adult psychiatric inpatients with a history of abuse. Psychiatric Services, 50, 1467–1472. Read, J., & Fraser, A. (1998). Abuse histories of psychiatric in-patients: To ask or not to ask? Psychiatric Services, 49, 355–359. Ritscher, J. E., Coursey, R. B., & Farrell, E. W. (1997). A survey on issues in the lives of women with severe mental illness. Psychiatric Services, 48, 1273–1282.

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Robarts, J. (2003). The healing function of improvised songs in music therapy with a child survivor of early trauma and abuse. In S. Hadley (Ed.), Psychodynamic music therapy case studies (pp. 141– 182). Gilsum, NH: Barcelona Publishers. Robarts, J. (2006). Music therapy with sexually abused children. Clinical Child Psychology and Psychiatry, 11(2), 249–269. Robarts, J. (2009). Supporting the development of mindfulness and meaning: Clinical pathways in music therapy with a sexually abused child. In S. Malloch & C. Trevarthen (Eds.), Communicative musicality: Exploring the basis of human companionship (pp. 377–400). New York: Oxford University Press. Rogers, P. (1992). Issues in child sexual abuse. Journal of British Music Therapy, 7(2), 5–15. Rogers, P. (1993). Research in music therapy with sexually abused clients. In H. Payne (Ed.), Handbook of inquiry in the arts therapies: One river, many currents (pp. 197–217). Philadelphia, PA: Jessica Kingsley. Rogers, P. (1994). Sexual abuse and eating disorders. In D. Doktor (Ed.), Arts therapies and clients with eating disorders: Fragile board (pp. 262–279). Philadelphia, PA: Jessica Kingsley. Rogers, P. (1995). Child sexual abuse: Dilemmas in therapeutic practice. Music Therapy Perspectives, 13(1), 24–30. Rogers, P. (2003). Working with Jenny: Stories of gender, power and abuse. In S. Hadley (Ed.), Psychodynamic music therapy case studies (pp. 123–140). Gilsum, NH: Barcelona Publishers. Rose, D. (1991). A mode for psychodynamic psychotherapy with the rape victim. Psychotherapy, 28(1), 85–96. Rose, S., Peabody, C., & Stratigeas, B. (1991). Undetected abuse among intensive case management clients. Hospital and Community Psychiatry, 42, 499–503. Ross, C., Anderson, G., & Clark, P. (1994). Childhood abuse and the positive symptoms of schizophrenia. Hospital and Community Psychiatry, 45, 489–491. Ruud, E. (1997). Music and identity. Nordic Journal of Music Therapy, 6, 3–13. Sinason, V. (1992). Mental handicap and the human condition. London: Free Association Books. Spiegel, D. (1986). Dissociation, double binds and post-traumatic stress in multiple personality disorder. In B. Braun (Ed.), Treatment of multiple personality disorder (pp. 61–78). Washington, DC: American Psychiatric Press. Strehlow, G. (2009). The use of music therapy in treating sexually abused children. Nordic Journal of Music Therapy, 18(2), 167–183. Swett, C., Jr., Surrey, J., & Cohen, C. (1990). Sexual and physical abuse histories among male psychiatric out-patients. American Journal of Psychiatry, 147, 632–636. Thompson, S. (2007). Improvised stories in music therapy with a child experiencing abuse. British Journal of Music Therapy, 21(2), 43–52. Tomm, K. (1988). Interventive interviewing, part III: Intending to ask linear, circular, strategic or reflexive questions. Family Process, 27(1), 1–15 White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton & Co. Wigram, T. (2004). Improvisation methods and techniques for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica Kingsley. Zeanah, C. (2010). Proposal to include child and adolescent age related manifestations and age-related sub-types for PTSD in DSM-V. Washington, DC: American Psychiatric Association (APA). Retrieved on April 19, 2013 from: http://www.dsm5.org/Proposed%20Revision%20Attachments/DSM5%20Child%20PTSD%20Re view%2012-22-08.pdf

Chapter 11

Adults with Depression and/or Anxiety Nancy A. Jackson _____________________________________________ DIAGNOSTIC INFORMATION Depression is a state that is commonly experienced by most people at some point in their lives. It is a normal and natural reaction to the experience of loss or trauma. When a state of depression falls outside the range of normal response to a loss or trauma, however, it is considered a mental illness. In conjunction with normal responses to loss and trauma, which include intense sadness, sleep and eating disturbances, and worry or rumination, the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association [APA], 2012a) identifies suicidal ideation, feelings of worthlessness, psychomotor disturbance, and significant impairment in daily functioning as symptomatic of the mental illness of depression. Individuals may experience a depressive disorder as repetitive episodes of severe symptoms each lasting two weeks or more (major depressive disorder), or as a chronic state of less severe but notably dysfunctional symptoms over multiple years’ time (dysthymic disorder). While the general symptoms noted above are criteria for a diagnosis of a depressive disorder, the exact symptomatology of depression may be different from individual to individual. For example, eating and appetite disturbances may involve loss of appetite, decreased nutrient intake, and weight loss, or it may involve an increase in appetite, overeating or binge eating, and weight gain. Sleep disturbance can include frequent waking, restless sleep, or general insomnia. Many individuals experience poor selfesteem, feelings of guilt, or a sense of helplessness, as well as feelings of hopelessness. A loss of interest and pleasure in previously preferred activities is quite common. Psychomotor disturbances may manifest in a notable slowing of physical movements and lethargy, or in physical agitation. In addition to intense sadness and grief, irritability and anger outbursts with aggression may be experienced, which sometimes meets the criteria for the diagnosis of disruptive mood dysregulation disorder (APA, 2012a). If, prior to the depressed state, the individual has also experienced at least one episode of hypomania (a period of elated, expansive, or irritable mood with symptoms such as high energy, lack of sleep, pressured speech, racing thoughts, increased involvement in pleasurable activity, etc.) (APA, 2012a), this may be an indication of bipolar illness, which requires different treatment than depressive disorders. It is common for a depressed individual to also experience symptoms of anxiety. Anxiety is characterized by restlessness or agitation, excessive worry and rumination, procrastination, avoidance of perceived anxiety-producing experiences and events, and physical tension (APA, 2000). Anxietyproducing experiences might include social situations and events or situations related to employment, and may lead an individual to take excessive time to prepare for such events. Those who are anxious may be fearful that terrible things may happen. They are likely to withdraw and to experience a good deal of distress that interferes significantly with their daily functioning. Because of the common features and comorbidity (occurring together) of depression and anxiety, a potential new diagnosis called mixed anxiety/depression is under consideration, pending further research (APA, 2012b).

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NEEDS AND RESOURCES Clients with depression and anxiety are likely to present with sad and static affect and low energy. Those with anxiety may demonstrate high levels of agitation, but this energy typically is not useful in a functional sense. Often, they will have difficulty connecting with their bodies and with their inner emotional experiences, as well as difficulty in connecting with others in social interactions. Suicidality or suicidal ideations may be present, along with feelings of helplessness and hopelessness. For clients in an acute crisis stage (e.g., suicidal, with psychotic symptoms, etc.), pharmaceutical intervention may be necessary to effect enough mood regulation to allow them to work on the psychological aspects of their illness. Luckily, unlike some other similar mental illnesses (e.g., bipolar disorder), depression and anxiety are illnesses that can be resolved with good results when the client follows through with recommended treatment. While the symptomatology may create obstacles that must be overcome in therapy, these clients tend to be cooperative, and usually do not demonstrate overt behavioral problems that must be managed within sessions. Musically, depressed and anxious clients demonstrate the same type of constriction in their musical interactions as they do in their affect and social interactions. Creativity in musical expression may be notably lacking, including little or no use of tonal range, lack of dynamics, lethargic tempi, and lack of energy in musical movement. It is not unusual for the depressed client to have notably limited range of motion when playing instruments and nondominant sides of the body may even seem to be frozen. So, for example, if a depressed client is playing a xylophone while using a mallet in each hand, it would not be uncommon to see no use of the nondominant hand and apathetic, timid striking of the bars with the dominant hand, using a range of only two or three pitches. Breathing tends to be shallow and ineffective for singing, sometimes creating the impression that the vocal sound is actually going inward as opposed to being projected out of the body. The client may exhibit difficulty in musically interacting with others, and may only mimic others’ playing, or even play in a manner that is completely disconnected and unresponsive to others. Additionally, those with depression and anxiety tend to be unable to recognize and respond to affective states (Hills & Lewis, 2011), and so are likely to demonstrate inability to hear and identify the emotional expressiveness in music that they play or hear (Naranjo et al., 2011; Punkanen, Eerola, & Erkkilä, 2011). These clients need to reconnect and work through the internal issues that are interfering with their ability to respond to experiences in the present moment with congruent emotional responses. This includes resolving past emotional experiences and traumas that keep the client focused in the past, as well as learning functional self-expressive skills and effective stress management skills to facilitate the maintenance of healthy, dynamic, emotional responses in daily life. The lack of emotional connectedness and responsiveness and the anhedonia (lack of interest or pleasure in usually enjoyable experiences) typically are the blocks which are holding back deep emotions; so, unlike the blunting and anhedonia that might be a permanent state for those with illnesses like schizophrenia, the depressed client tends to feel very deeply and has the capacity to be quite expressive and creative when the blocks are removed. The inability to express these deep feelings and emotions and share them with others keeps the client in a static internal state, but an expressive music process can be effective in mobilizing the client to find means of allowing them to be expressed and in propelling the client forward toward resolution of the blocks that stand in the way of functional self-expression. Depressed and anxious clients usually have a strong desire to no longer feel the way that they do, and tend to become increasingly invested in their therapeutic process as symptoms begin to recede and blocks begin to be resolved. Additionally, it is not uncommon for these clients to have a history and perhaps some current level of successful functioning in education, employment, and intimate and social relationships, which predisposes them to successful engagement in

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a therapeutic process, as well as providing familial and social support networks that can assist in the client’s stabilization and recovery.

REFERRAL AND ASSESSMENT PROCEDURES Clients with depression and anxiety come to treatment through several different referral sources. If the client is an inpatient in a health care facility, the music therapist will receive a referral from the attending physician. More often than not, the referral will be initiated through a multidisciplinary treatment team that has determined that music therapy may be beneficial to the client. Music therapists also may receive referrals from therapists or social workers in the community who have a client they feel will benefit from the services. On occasion, a client may self-refer or be referred by a friend or family member. Music therapists in private practice may receive referrals from individuals in the community. In each of these cases, the assessment process may require different approaches and may have different purposes. When the client is referred through the recommendation of a treatment team, there is usually is good bit of information about the client that is available through his or her medical chart. In this case, the referral will specify a particular area of concern that prompted the request (e.g., social withdrawal, inappropriate expression of emotion, etc.). Also, the client will likely have a specific diagnosis. The music therapist’s assessment in this situation will usually be descriptive (to understand the client’s strengths and needs) or prescriptive (to determine how to best treat the client) (Meadows, Wheeler, Shultis, & Polen, 2005) in order to formulate a plan for music therapy that can be included in the client’s overall treatment plan. If the referral comes from a community therapist or social worker, again, the client is likely to have a specific diagnosis, and may have a treatment plan that is maintained by a case worker. Consent for release of health care information in order to obtain this information from other professionals should be requested of the client (or the client’s guardian). Descriptive or prescriptive assessment of the client may be the most appropriate focus in order to formulate an effective treatment plan in these situations. Those who are referred by other means may not necessarily have a clinical diagnosis and typically do not have a treatment plan developed from some other health care source. In this case, the music therapist may want a diagnostic focus (to determine the type of condition the client has) (Meadows, Wheeler, Shultis, & Polen, 2005) to the assessment as well as a prescriptive one in order to determine if the client is, indeed, appropriate for music therapy services. A second, follow-up assessment that is descriptive in nature may be desirable when there is little information available from the referral source. In all cases, assessment should utilize musical information to reveal information about the client’s current state, as well as behavioral observations and biographical information that will allow a full understanding of the client’s strengths and needs as they pertain to daily functioning. This includes information on family, social support, education, and employment; physical functioning; presenting emotional state; other current treatment; communication and expressive skills; self-awareness and selfesteem; thought and behavioral patterns; and the client’s own perception of his or her current state and the problem or issue at hand. The client’s experience with music and musical preferences are also necessary areas of assessment. The assessment should result in identified needs as well as the client’s personal strengths and resources that can be utilized as a source of empowerment in creating change. In addition, it is important to assess depressed and anxious patients for indications of suicidality and selfharm. Considerations in assessing suicide risk include factors such as history of suicidal ideations or attempts; current suicidal ideations; alcohol or substance abuse; history of abuse; presence of severe psychosocial stressor; level of social support, etc. (APA, 2003). The initial assessment with a specific treatment plan should be submitted to the referral source in the facility or agency, as should session documentation and subsequent evaluative assessments. When there is no formal referral source, these documents should be maintained in a file not just for the

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therapist’s own records, but also in case they are called for by other professionals working with the client or by a legal source. It is always advisable, particularly when the therapist is in private practice or working as a private contractor, to work as closely as possible with the client’s other care providers (e.g., individual psychotherapist or counselor; social worker; psychiatrist, etc.) in assessing, formulating treatment plans, and documenting the client’s progress. Collaborative work on behalf of the client results in the most effective outcomes, and helps to protect both the client and the therapist in situations in which the client experiences suicidal thoughts, bouts of self-harm, or other difficult events during the course of treatment. As mentioned earlier, it is good practice to obtain consent for release of information among all professionals invested in the client’s treatment at the time of referral. This is usually not an issue within the multidisciplinary treatment team.

OVERVIEW OF METHODS AND PROCEDURES The following methods and procedures are most commonly used with persons with depression and anxiety.

Receptive Music Therapy • • •

•

Music Relaxation and Stress Reduction: involve the client in listening to music for the purpose of effecting a relaxation response. Song Discussion: involves the use of recorded or therapist-performed songs for the purpose of stimulating discussion around a therapy-related topic or issue. Self-Expression and Exploration with Expressive Arts: utilize recorded or therapistperformed music in conjunction with other creative arts (drawing, poetry, creative writing, movement or dance, etc.) to provide the client with an expressive outlet that allows a new perspective on problems. Bonny Method of Guided Imagery and Music (BMGIM): involves the use of specifically programmed prerecorded music to evoke imagery in the client.

Improvisational Music Therapy • • • •

Music Improvisation to Mobilize Affect: involves the use of spontaneously created music to stimulate emotional expression. Musical Feelings Exploration: involves the use of spontaneously created music for the purpose of identifying and exploring feelings and emotions. Improvisational Problem-Solving: involves the use of spontaneously created music to explore thought and behavioral patterns. Musical Catharsis Improvisation: involves the use of spontaneously created music to bring about a release of repressed or pent-up feelings and emotions.

Re-creative Music Therapy • •

Vocal and Instrumental Ensembles: use precomposed music to involve clients in recreating or performing compositions. Therapeutic Lessons: involve engagement of the client in vocal or instrumental lessons that focus on working on a therapeutic issue through the learning and performing of musical repertoire.

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Compositional Music Therapy • •

Songwriting: involves the creation of original music and lyrics, resulting in a composition that can be performed repeatedly by the composer or others. Musical audiobiography: is a compositional approach that involves an individual client selecting and compiling music and sounds into a music product that reflects important events and experiences in the client’s life related to treatment issues.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Music Relaxation and Stress Reduction Overview. Music relaxation and stress reduction involve the client in listening to music for the purpose of effecting a relaxation response. Music relaxation can be an effective experience for helping those with depression to decrease anxiety and tension and to reconnect with their bodies. The ultimate goal of music relaxation is to release physical tension and increase the sense of well-being, while more specific goals might include, for example, decreasing worry and mental rumination, releasing emotions that are being carried in the musculature, and increasing knowledge and application of relaxation strategies to broaden the client’s personal repertoire of stress management skills. Either live or recorded music can be used, and the client can be engaged in the relaxation process through physical relaxation exercises, movement, diaphragmatic breathing, imagery, or a combination of these. Having multiple options for facilitating music relaxation allows the music therapist to tailor the relaxation experience to the exact needs of the individual client or client group, thereby increasing the effectiveness of the experience. The choice of the type of client engagement in the music relaxation must be made based not only on the immediate need of the client, but also in consideration of the client’s physical and emotional state. Avoid the use of imagery with clients who may be cognitively impacted by their depression (slow mental processing, confusion, psychosis, etc.), and with those who are excessively worrying or ruminating. These clients are best engaged in physical relaxation exercises and movement that will encourage grounding in the here-and-now and mental focus on a physical task that will stimulate a relaxation response. A client who is experiencing psychomotor retardation (decreased energy and slowing of physical movement) may not have the energy required to engage in active relaxation exercises and movement, and may respond better to relaxation imagery or diaphragmatic breathing. Care should be taken to avoid reclining positions that could possibly stimulate traumatic memories in those clients with a history of abuse. Additionally, be prepared for instances in which a relaxation response leads to an outpouring of pent-up emotion, and be ready to positively direct that expression and facilitate processing of the client’s experience afterward. The level of therapy is augmentative or intensive. Preparation. In preparation for music relaxation, make the physical environment as safe and comfortable as possible. Allow space for clients to lie on the floor if appropriate, and if movement might be utilized, clear furniture and objects as far away from the space as possible to ensure against injury. Even when the floor is carpeted, thin, transportable mats (e.g., yoga mats) can help clients to be more comfortable lying or sitting on a hard surface. Comfortable chairs should be available for those who are unable to use the floor, or for whom reclining positions are contraindicated. Soft or adjustable lighting is preferable; if the space has only ceiling fluorescents, bring in a lamp or two to use in place of the room lighting. If using recorded music, a good quality sound system with easily controlled volume (push-button volume can be problematic when subtle or quick volume changes are necessary) and a variety of music chosen in relation to the needs and preferences of the client or client group are necessities.

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It is imperative to have music of varying tempi, levels of musical complexity, styles/genres, and instrumentation in order to make music choices that are comfortable for the client (preferred genres) but also match the client’s energy level and utilize the structural elements of music that will best lend themselves to a relaxation response in the client. There is no particular type of music that is best for relaxation in general; it is often best to select music that is of the patient’s preferred genre but that is unfamiliar and does not have words/lyrics so as to avoid personal associations and memories that could inadvertently work against a relaxation response. Additionally, unfamiliar music in a preferred style offers the opportunity for the client to use the music as a cue for future relaxation practice outside of therapy. It is advisable in most cases to avoid music with words, even when the words are in a language that is not understood by the client, to avoid evoking “thinking” and associations that might interfere with relaxation. If creating live music, a selection of instruments should be available to provide options for tailoring the music to the client’s relaxation response in the moment. What to observe. During engagement in the music relaxation experience, closely observe the client’s responses as indicators of the degree to which a relaxation response is being achieved. Breathing is a good indicator of relaxation, with slowing of breathing rate and increased movement into the abdomen upon inhalation being common indicators of increased relaxation. Release of tension in the musculature is also a good indication of relaxation, and this can often be seen in the lowering of shoulders, release of clenched lips and furrowed brow, unclenching of hands, and, if the individual is sitting or reclining, the appearance that bodily weight has been released into the chair or floor/surface. Relaxation can also be observed in increased range of motion and fluidity of large muscle movements. When vocalizing, relaxation often increases the resonance of an individual’s voice, as well as the tonal range. Procedures. To begin a music relaxation session, identify two things: (1) how the client is experiencing stress and tension in the moment (physical signs, mental/emotional signs, energy level, etc.) and (2) the client’s music style and genre preferences. A decision should be made about whether passive or active relaxation will be most effective for the client. Passive relaxation uses mental processes (e.g., imagery) to effect a response, making it more suitable for clients with low energy or other physical symptoms. Active relaxation engages the client physically through movement or isometric tension and release to effect a response, making it most suitable for clients who are agitated, holding excess tension in their bodies, worrying or ruminating, or experiencing cognitive symptoms such as confusion or psychosis. Select music according to the guidelines stipulated above. In selecting the music, the client’s current level of energy should be initially matched (Iso-principle), with subsequent selections chosen to move the energy level in a specific direction. For example, if a client is highly agitated and anxious, the energy level of the selected music should be higher in order to meet the client’s state, but then should be gradually changed to music with less energy and more flow. A client with psychomotor retardation may need to be energized by the relaxation session, and the music should be selected to begin at a slow, undemanding pace, but end in a more upbeat and energized manner, and so forth. Avoid music that does not have a clear sense of pulse or a tonal center. A sense of safety and security is a necessity for relaxation. Help the client to choose a comfortable position on the floor or in a chair. Using the structure of the music, give the client verbal directives to tighten or tense the muscles of a particular part of the body while inhaling, hold the tension for several seconds, and then release on an exhalation. Focus on specific muscle groups such as hands, feet, shoulders, stomach, hips, legs, arms, face, etc. (as in progressive muscle relaxation). After each release, direct the client to attend to the physical sensation of having released the tension in that area of the body and to deeply breathe the sound of the music into that area of the body in order to solidify that feeling. It is useful to repeat the clench/hold/release pattern twice in each area in order to reinforce the client’s awareness of what the release feels like. Decide whether to start from the top of the body and move down, or vice versa, as well as the speed with which to move up or down the body. The less energy a client has, the less specific the therapist should be about moving through

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every muscle group of the body, and the more quickly the therapist should move up or down the body in order to effect relaxation throughout the body before the client’s energy is depleted. Throughout the experience, continually redirect the client to the sound of the music to assist in the tension and release process. Adaptations. All of these types of music and relaxation experiences can be implemented, and in fact might be most effective, using therapist-improvised, live music instead of preselected, recorded music. The therapist must feel comfortable with improvising in a variety of styles on an appropriate instrument. While all instruments might potentially be useful in relaxation improvisation, it is likely that some instruments will be perceived as more relaxing than others (for instance, a guitar more so than a trumpet). The level of skill with an instrument, however, will determine the extent to which the client will perceive the improvised music as relaxing. The great potential in improvised, live music for relaxation lies in the ability of the therapist to musically respond to the client’s state from moment to moment— something not possible with even the most carefully selected recorded music. Using the principle of musical entrainment, carefully watch changes in breathing, affect, and musculature, to adjust the music to support and move the client toward full relaxation. This may include changing from an instrument of one timbre or range to another as the client’s state changes, adding a layer of sound by vocalizing, or simply making alterations in tempo or dynamics. In all cases, the music should create a sense of safety and stability through phrasing and repetition, with all changes—elemental or instrumental—made slowly and in a fashion congruent with the client’s state. Music with diaphragmatic breathing is especially useful for clients who may be anxious but also have low energy or psychomotor retardation. Stress and tension greatly decrease the depth of one’s breathing, and returning to diaphragmatic breathing can effect a relaxation response quickly. For this type of experience, select music that has a good flow as well as a predictable, periodic phrase structure. A moderate tempo in the vicinity of 60 beats per minute is preferable. After getting the client comfortable in a chair or on the floor, give the client directives to breathe in, allowing the stomach to relax and extend, to hold the inspiration momentarily, and then to slowly release the air, using the structure of the music to support this breathing process. Some clients may respond to the image of breathing in or with the music; others may respond to suggestions that they be aware of the pathway of air as it moves in and out of the body, or of how the internal space changes with the breathing. As the client’s breathing becomes deep and steady, decrease directives, eventually giving only occasional cues to keep focused on breathing, and being mindful of the fit of the music to the client’s breathing. Use of music with imagery for relaxation is effective for clients who have little energy, or who can benefit from a multisensory experience. For this type of experience, ask the client to give suggestions that will become the relaxation images, focusing on sensory elaborative cues. For example, ask the client to suggest a color that is warm and comforting, a favorite thing in nature, or a favorite experience that they find comforting. Then use that suggestion to give the client directive images in conjunction with the music. The focus is on the sensory nature of the suggestions, and the music serves as the vehicle to move the sensation through the body. So, if a client indicated that a favorite thing from nature is the feeling of a breeze on a hot, sunny day, then begin by suggesting that the breeze is moving on the music, and ask the client to notice the feeling of the warm breeze moving either up or down the body. The more sensorially elaborative the suggestions are and the more use that is made of the movement of the music, the more effective the relaxation response for the client. Move the imagery through different parts of the body from top to bottom, as in progressive muscle relaxation. Combinations of physical exercises, diaphragmatic breathing, and imagery can also increase the effectiveness of the music experience, and there are many ways to do this. Common combinations are to begin with a physical exercise like progressive muscle relaxation and bring diaphragmatic breathing into the experience: “Inhale by pulling the sound of the music deeply into your abdomen, and hold it as you

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make your hands into fists. Hold the air and the tension in your arms … and then release all the tension along with the air as you exhale,” etc.; to incorporate imagery into diaphragmatic breathing: “As you inhale, imagine that the music moves through your torso into your legs … and as you exhale, imagine that the music and the air travels out through the bottoms of your feet,” etc.; and to begin with imagery that supports diaphragmatic breathing: “Imagine that the air is like a warm, radiating light that fills your torso as you inhale …that fills your arms … that fills your legs,” etc. Movement can be incorporated into both diaphragmatic breathing and imagery experiences. This can be effective for individuals who may be experiencing agitated anxiety, who may have difficulty with full diaphragmatic breathing because of muscle tension, and who experience physical pain as a symptom of their depression. Movement can be added whether the individual is seated or on the floor. Movements that are incorporated should be natural, flowing movements that are not strenuous and that are comfortable and pleasing to the client. Examples of this include raising arms in a relaxed manner to a comfortable height with an inhale and lowering them on the exhale; extending legs from the knees or stretching gently through pointed toes; moving arms and legs in gentle movements along with the music, etc. Music relaxation can be an excellent resource for the client to practice outside of the music therapy session. Work with the client to learn and practice a series of relaxation experiences that are effective for that individual, and then to create a compilation of recorded music that the client uses only to practice the learned relaxation. It is important that the music be a preferred style but unfamiliar when beginning the training, and that the client only uses the music when practicing relaxation, so that the music can become an automatic cue that results in a relaxation response each time it is used. The client’s music selections may need to be revisited and changed if being used long-term, since improvements in the client’s physical and psychological state will warrant changes in relaxation experiences.

Song Discussion Overview. Song discussion involves the use of recorded or therapist-performed songs for the purpose of stimulating discussion around a therapy-related topic or issue in a group or individual session. The content of the song lyrics and the emotional expression of the music provide the material for exploration, and the therapist provides the structure for the discussion that will encourage group members to relate the song to their own experiences and to share those experiences with others. Songs are expressions of peoples’ thoughts, feelings, relationships, and experiences. They serve as objects themselves with which we develop relationships, and they serve as links to important people, events, and experiences in our lives (Bruscia, 1998). For these reasons, songs are powerful tools for music therapy. In song discussion, clients can interact with songs in order to examine their own thoughts and feelings, to reminisce, to communicate, and to problem-solve. Goals related to these interactions might include increasing self-awareness around a particular topic, behavioral pattern, or emotion state; exploring ways of expressing specific emotions; identifying and practicing communication of thoughts and feelings; and working through the thoughts and emotions resulting from difficult experiences in one’s life. Song discussion can be implemented at either the augmentative or the intensive level of practice, based on the needs of the clients and on the level of skill and training of the music therapist. On an augmentative level, the intended outcome of the discussion might be increased insight into one’s own feelings and behaviors, the development of supportive relationships within the group, and problemsolving around the identified topic of the song discussion. On an intensive level, the intended outcome might involve increased awareness of self in relation to the projections onto and identifications with the musical material (lyrics and/or other musical elements). Because lyrics are one of the primary features of

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songs, those clients who are cognitively challenged and lack the abstraction ability to gain insight through verbal communications are unlikely to benefit from song discussion. Preparation. In preparation for the session, carefully select the song to be used, taking into consideration the specific strengths and needs of the client, the lyric content of the song and its clinical relevance, and the musical qualities of the performance, whether live or recorded. The cognitive level of the client should be considered, recognizing that the more poetic or metaphorical the lyrics of the song are, the more abstraction ability is necessary to gain insight into the meaning of the song. The content of the lyrics need to clearly reflect the topic at hand for the discussion, such as dealing with anger, feeling hopeless, being trapped in an unhealthy relationship, etc. While familiar songs may sometimes be useful, it is often preferable to use a song that may not be well known so that preconceived notions or emotional associations do not interfere with the intent of the song. The message of the lyrics and the qualities of the performance should guide the song selection, not the preference of the therapist. (For more detailed information about song selection for discussion, see Gardstrom & Hiller, 2010.) The choice of using a recording or performing the song live should be based on the musical qualities that will best communicate the meaning of the song. For songs with simple accompaniments, perform the song live in order to bring emphasis and clarity to particular parts or to utilize the therapeutic relationship to facilitate the communication of meaning. Other songs may be available in recordings that provide musical qualities (e.g., orchestration, rhythmic complexity, etc.) that would be difficult to accomplish in a solo performance. Additionally, performing a song live in the session requires thorough preparation to perform the song well, which may require practice time that is not available to learn the song; recordings are better choices at these times. If using recorded music, a quality sound reproduction is necessary so that the clients can properly hear and understand the content of the song, as well as experience the expressive nature of the recording. Prepare lyric sheets to be given to clients so that they are clear about what is being sung. Give the name of the song and the composer/artist at the top, and clearly label each part of the song (chorus, verse 1, bridge, etc.) so that in the discussion, mention can be made of specific parts of the song, and the clients can easily find those particular parts of the lyrics. Use the largest, clearest font possible that will allow you to print the song in its entirety on one sheet of paper. Arrange the space in the room in a circle so that clients can easily see each other even while looking at the lyric sheets. Additionally, prepare the way that the song will be discussed with the group. Consider if it is beneficial to “set up” the group’s listening by giving a directive beforehand (e.g., “Listen for a theme” or “Listen for what the song has to say about …”). For client groups that lack abstraction ability, or that are experiencing cognitive effects of depression, a sheet of specific questions that is distributed before listening may be helpful for facilitating attention and focus on the content of the song. Discussion can focus on any aspect of the experience, for example, on the lyrics, on the effect perceived from the specific performance, or on the clients’ emotional reactions to the song. Regardless of the focus of the discussion, be clear ahead of time how to best facilitate the discussion for the group. What to observe. While the group is listening, be aware and take note of client reactions by watching affect and body language. Reactions while listening can provide additional information for focusing the discussion. Continue watching for these signs as well as listening to verbal content of the clients’ discussion afterward. Draw attention to and reflect statements made by clients that indicate a moment of insight into something relevant in the lyrics, and encourage development of thoughts and ideas to which the group members are relating together. Also, take note of clients’ interactions with each other, as these can be indicative of return from withdrawal, or be revelatory about specific issues that are related to underlying issues for the clients. Remember to make note of any personal reactions to the song, and consciously put aside any troublesome reactions to be addressed at a later time in supervision or personal therapy.

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Procedures. Distribute lyric sheets and question sheets (if applicable) to the group members. If setting up the listening experience, pose the question or directive to the group. If the setup is intended to stimulate a cognitively elaborated experience, allow brief discussion prior to the listening. If the setup is intended to stimulate emotional awareness and response, take a moment to help the clients to quiet and center themselves. A few moments of relaxation breathing prior to starting the music can be effective for this. Encourage the clients to listen with their eyes closed if they know the words to the song, or to use the lyric sheet to help focus on the song content. After playing the recording or performing the song live, allow the clients to sit for a moment with the experience. If you have distributed questions, allow the clients a few minutes to write down some responses. Then, begin the discussion. Verbally direct the discussion only as much as necessary to engage the clients and to stimulate thoughtful verbalization from the clients. For some groups, this may require only a leading question and some occasional refocusing, whereas other groups may require numerous questions and assistance with making sense of what they have heard and how it relates to their own experiences. Be aware of tendencies to give the clients the “answers”; insight that comes from the client’s own personal experience is far more healing and transformational than anything that another person says, regardless of how insightful a comment might be to someone else. Instead, highlight, reflect, and question in order to move the clients to their own insights. It is sometimes helpful to replay the song a second time during or after the discussion, either to clarify or reexperience for further insight, or as a way for the group members to solidify and integrate the insights they may have gained from the discussion. Adaptations. At times, it may be advantageous for a client to make the song selection. This is typically effective in an individual format when the client’s choice of song itself can be explored in terms of identification or projection, or in a group format when the group has begun working together cohesively and individual members are able to take responsibility for selecting songs that can be explored in relation to the needs of the group. In these situations, as well as when it seems appropriate to spontaneously move to a song discussion in response to some other experience in a session, there may be no opportunity for preparation of questions ahead of time. Reliance on well-developed verbal skills is necessary in order to successfully focus and direct the discussion in a positive and useful direction. Another adaptation is song selection for song communication (Bruscia, 1998), in which a song, selected by either the therapist or the client, is presented in order to communicate something important about the self or about what is happening in the therapeutic process. Again, this may or may not provide opportunity for preplanning, and may require some quick “thinking on one’s feet” in order to focus and direct the resulting discussion.

Self-Expression and Exploration with Expressive Arts Overview. Self-expression and exploration with expressive arts utilize recorded or therapistperformed music in conjunction with other creative arts (drawing, poetry, creative writing, movement or dance, etc.) to provide the client with an expressive outlet that allows a new perspective on problems. While the client is not actively engaged in creating the music, he is utilizing the music to assist with the active expression of thoughts, feelings, and emotions through an additional creative art format. Incorporation of other expressive arts into music experiences provides types of opportunities to move away from everyday thought and behavior patterns and to “walk around” one’s internal experiences, similar to walking around a statue. When viewing a statue from the front, it appears one way, but slowly walking around it increases the awareness of it in a three-dimensional sense that cannot be experienced by viewing it only from one place. Often when clients begin to identify and explore their feelings, emotions, and behavioral patterns, facilitating discovery of new perspectives on those feelings and emotions can be especially helpful for their progress. Incorporation of other creative arts also provides

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concrete evidence that can help clients with exploration of experiences that are not concrete. These types of experiences focus on elaboration of exploration intended to increase self-understanding, problemsolving, and skill-building. Goals might include increasing awareness of emotion states and resultant behavioral patterns; increasing awareness of antecedents to difficult feelings and emotions; increasing ability to actively name and express feelings and emotions; and increasing ability to consciously respond to feelings and emotions. Self-expression and exploration with expressive arts tends to be an augmentative-level intervention that is particularly good for clients who are just beginning to move beyond a superficial examination of the issues related to their depression and anxiety, or who need assistance with connecting to their internal experiences of feelings and emotions. These experiences can also be quite useful as a processing and bridging experience at the intensive level of practice. Individual needs of clients can be addressed through the choice of creative, expressive media that are incorporated into the music experience. For example, a client who is experiencing a high degree of anxiety will probably do better working with clay than with an empty piece of paper on which to draw. The use of certain types of materials (scissors, cutting and shaping instruments, etc.) may be contraindicated for those individuals who are in crisis and are suicidal or selfharming. Preparation. A variety of materials will be needed in order to incorporate other expressive arts into music. A selection of crayons and oil pastels, drawing paper, writing paper, pencils, markers, old magazines, scissors, tape and glue, modeling clay, and decoupage materials are all useful. The ends of newsprint rolls are useful if they are available from a local printer. Access to tables and a sink are necessary to use some of these materials, and an area to display expressive works is desirable. When using large paper, it is good to have appropriate-size tables or access to a large wall space on which to mount the paper. If offering the same medium to all members of a group, have enough materials so that clients do not need to share, unless sharing is specifically related to the clients’ treatment objectives. Plan the use of materials based on the realistic constraints of the available space and budget. Be aware of how materials are stored, taking care to keep materials that can potentially be used for self-harm in a place to which individuals who are suicidal or have self-harm tendencies have no access. Selection of music for use with other expressive arts should focus on the intent of the exploration. Often, this type of experience will be planned after the client has made some progress in naming emotions and identifying those that he or she experiences as difficult. For a group, it will be based on a particular issue or need that is shared by all group members. The music choice should reflect the issue at hand, with the various musical aspects of the piece chosen to support the movement that is desired. For example, if a client is trying to explore feelings of frustration that occur in relationship to others, then the musical choice should have clearly discernible voices or melody lines that interact with each other, and periods of both consonance and dissonance between them. In most cases, it is preferable to use recorded music so that, when necessary, assistance can be given to the client in using the other expressive art in conjunction with the music. Decide beforehand whether it will be more helpful to the client if a choice of medium is given, or if only one medium will be offered. Consider the client’s ability to make choices and whether making choices is related to the treatment objectives. What to observe. As the client engages in creating expressive media or movement, focus on how the media or movement expresses something about the music. Remember that the additional expressive art added to the music is not going to be processed in the way that the music will be (i.e., there is no interpretation of the art), but instead will simply elaborate the music experience to allow it to be understood in a new way. Look and listen for descriptive words used by the client or other group members and use those words to assist the clients to connect to the music experience and to their internal experience. Highlight insights that can assist clients in identifying functional new behavioral choices (e.g., “So, the next time you get that heavy feeling in your stomach, what will it tell you?”).

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Procedures. Before starting the music experience, discuss with the client the intent of incorporating another expressive art into the music. If giving the client a choice of other expressive art media or movement, demonstrate the choices by pointing out the different ways that the materials can be used and options for being expressive through that medium. Give the client a clear directive so that it is clear what type of response is being sought (e.g., “Use the pastels to make a representation of what the music feels like” or “As you listen, pick the medium that you can best use to express the way you feel the music”). Urge the client to use the music as the source of creativity for expressing through the art medium. Repeat the music as many times as the client needs to complete some representation that feels right. Ask the client to share how the resulting expressive artwork reflects the experience of the music, and how it relates to the thoughts, feelings, and emotions related to the issue at hand. Ask other group members to comment on what they notice about the artwork in relation to the music, and encourage discussion about differences in perception that might arise among group members. Use the clients’ own descriptions as much as possible to highlight opportunities for increased self-awareness and problemsolving. Adaptations. Music with other expressive arts experiences is an excellent bridging experience, providing opportunities to move from one method of exploration to another when working with an individual client. When the other expressive art is serving as a bridge, it becomes a concrete product on which to base another form of musical exploration. For example, a client begins experiencing emotional distress during a music and relaxation experience, but can’t identify what it is he is experiencing. He is urged to use drawing materials to make a visual representation of his internal experience. Then, the drawing can be used as a visual basis for a music improvisation to help to explore and identify the feeling state that is being experienced (see the improvisation experiences described below). If the client is able to specifically identify feeling or emotion states through his music improvisation, he might then be encouraged to write creatively in a simple poem form about that feeling or emotion. Using his own words from the creative writing, the client can be given related directives in another music relaxation experience to work through those emotional blocks to relaxation. Again, the related expressive arts media are not intended to be the focus of analysis, but merely a different perspective that will move the client in new creative spaces that will afford him more opportunity for self-understanding and problem-solving.

Guided Imagery and Music Overview. The Bonny Method of Guided Imagery and Music (BMGIM) involves the use of specifically programmed prerecorded music to evoke imagery in the client. It allows the client to access and work with unconscious information through examination and interaction with the imagery evoked by the music, leading to resolution of internal conflict, greater self-awareness, and improved coping skills. Clients who are past the initial, acute stage of depression and who have regained some of their self-awareness and ability to connect with and express feelings and emotions may need to deal with deeply buried issues that are the source of the inability to let go of troublesome emotions from the past and respond more functionally in the present. This requires longer-term, depth-therapy intervention. BMGIM addresses treatment goals such as resolution of emotion from past trauma, increased selfawareness and self-understanding, and increased perception of physical and psychological wholeness. The client must be free from psychosis and have intact ego identity, be invested in the therapeutic process, and have the cognitive capacity to explore and interpret the metaphorical content of imagery in order to benefit from this intervention. This approach is usually practiced at the primary level of practice, and sometimes at the intensive level of practice. In either case, the music therapist must have advanced formal training in a BMGIM training program culminating in the Fellow of the Association for Music and

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Imagery (FAMI) credential to safely and effectively engage the client in this type of work. For this reason, only the approach will be described herein. Preparation. The BMGIM therapist will prepare the space so that it is private and free from excessive outside noise or other distractions. Low lighting is preferred to help shift the client’s focus inward. A comfortable place for the client to partially or fully recline is necessary, as is a good-quality sound system with easily manipulated controls on which to play the prerecorded music programs. Each therapist will have a personally preferred format for the programs, including electronic formats such as a loaded iPod or MP3 player, and will select a sound system which provides the easiest and most versatile playback of their chosen music format. The therapist should be seated in direct proximity to the client, but with easy access to the sound system controls and with room to write. Paper and pens for writing the transcript as well as drawing paper, pastels, and other arts supplies should be on hand for possible use in processing the imagery session after the music program is complete. Because some clients might experience increased sensory awareness during their imagery, eye shades and a blanket should be easily available. What to observe. During the preimagery discussion (described below), the therapist will take careful note of how the client presents in affect, body language, and energy level in order to determine what type of relaxation induction might be most effective in shifting the client’s conscious awareness. As the music program plays and the client is experiencing imagery, the therapist will listen carefully for images, feelings, and internal experiences that the client describes which might indicate that an internal conflict or an emotionally charged topic is being addressed. Vigilant attention to the client’s visible affect and body language will continue throughout the imagery session, since the combination of observable reactions and the client’s subjective descriptions is integral to the therapist’s ability to witness and understand the client’s experience. The therapist will also listen closely to the music program throughout the session in order to ascertain the extent to which the music is being effective in moving the client through the imagery process. Depending to the direction that the client’s imagery takes, it may sometimes be necessary for the therapist to switch the music program in the middle of the imagery to best support the client’s process. Procedures. To begin the session, the therapist will have a discussion with the client about how he or she is feeling, what issues seem to be most pressing at the moment, and any other information that the client has to share. The therapist will get the client into a relaxed position (usually reclining) and will lead an induction that will help the client to relax both physically and mentally. The intent is to effect a shift in the client’s focus away from the everyday waking state into a nonordinary state of awareness, similar to a waking dream state. Often, an intention or a restating of the issue identified in the presession discussion will be included with the relaxation induction, or as an entry into the music portion of the session as a means of stimulating the unconscious mind to produce imagery that is directly relevant to the client’s therapeutic process. Based on the discussion and the observations, the therapist will choose a prerecorded music program of masterworks that has been specially designed to evoke imagery and to initiate an internal experience. In BMGIM, the therapist and client are often referred to as “the guide” and “the traveler,” respectively. This describes the type of relationship and the roles that are assumed during the imagery part of the session. As the music program begins, the traveler verbally relates to the guide the internal experiences that are evoked by the music. These might include pictures or scenes that come to mind, physical sensations, memories that are experienced in the present moment, or simply an intuitive sense of emotion states, places, or experiences. The guide assists the traveler in allowing the music to bring forth the internal experiences, focusing on images and experiences that seem particularly important, and encouraging and supporting the traveler in working through the emotions and experiences that take place within the imagery. The guide also keeps a written transcript of everything that the traveler says during

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the imagery for examination and discussion after the imagery part of the session is complete. The guide does not typically give the traveler any specific directives after the relaxation induction, in order to allow the traveler’s internal process to take its natural course, but instead asks questions and makes observations that focus the traveler’s attention and encourages active exploration within the imagery. At the conclusion of the client’s imagery, the therapist will assist the client in becoming reacclimated to an everyday, waking state of awareness. They will then discuss the content of the client’s imagery, the feelings and emotions that the imagery evoked, and any themes that might become apparent. The therapist will help the client to consider this information in light of the issue that was identified in the opening discussion, and to draw conclusions or integrate any insights that come. The therapist might give the client “homework” between BMGIM sessions, such as keeping a journal or writing down any dreams that occur, in order to keep the client’s internal process moving forward. Adaptations. When adaptations are made to the original Bonny Method, the term GIM is used to distinguish between the original format and those that are adapted in various ways (Bruscia, 2002). BMGIM is in an individual therapy format, but in some situations, BMGIM has been used for group situations. This is likely to occur in facilities where the therapist might be seeing a small group with similar treatment issues. For clients who are depressed and anxious, it may be that a full BMGIM session, which might run from 1½ to 2 hours, is simply too overwhelming, or requires more energy than the client has. In these cases, a modified GIM session might be preferable, in which a shortened version of a program of one or two pieces might be used. Some GIM practitioners will also use music that is not from the masterwork genres because of the specific qualities of the music that speak to the individual client’s specific needs.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Music Improvisation to Mobilize Affect Overview. Musical mobilization of affect involves the use of spontaneously created music to stimulate emotional expression. Those with acute clinical depression often find themselves “stuck” in a mood state seemingly with no way to be released. This “stuckness” is, in and of itself, an indicator of the illness, since a healthy state is one of homeodynamism (Rider, 2005), or one in which the individual is continually changing in response to the demands and experiences of life from moment to moment. Mobilization of affect is necessary to return to a more dynamic affective state that allows movement away from the depressed stuckness, and improvisation can be an effective way of achieving this. Improvisation for mobilization of affect is a non–in depth, augmentative-level music experience that focuses on increasing dynamic change in client affect through engagement in increasingly dynamic, expressive music-making. Specific goals can include increasing the range of pitches used, increasing the dynamic range of playing, increasing the rhythmic complexity of playing, increasing creation of melody lines, and so on. Immediate objectives should be based upon the needs apparent in the client’s initial improvised music. Because the purpose of this type of experience is to increase the dynamic nature of music-making, thereby increasing changes in affect, and not to explore deeper issues, it tends to be a safer and more comfortable experience for those clients who are experiencing cognitive difficulties or psychomotor retardation, or for those just beginning treatment in music therapy who may be recovering from an immediate crisis or be uncomfortable with more demanding music-making. Preparation. A good selection of both pitched and nonpitched instruments should be made available to the client. Refer to Gardstrom’s (2007) Music Therapy Improvisation for Groups if assistance is needed in building a good instrumentarium for improvisation. The voice is always a musical option when improvising. Display the instruments in such a way that the client can see them all and can

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freely pick each instrument up to try; spread the instruments out on shelves or a table, or in a central place on the floor. Have appropriate level surfaces or instrument holders available for larger instruments (e.g., adjustable xylophone/metallophone stands, tables of varying heights, drum stands, etc.) so that clients can feel physically comfortable in managing them. Armless chairs should be available. Clear a space for playing that is near the instrument selection so that the client has room to move while playing and can easily change instruments when desired. Make the space big enough that the therapist also has sufficient room to move about and change instruments in order to encourage and support the client’s improvisation. This experience is most effective with an individual client, although it can be done with a very small group of no more than three clients. In a small group situation, adjust the size of the open playing space accordingly and ensure that you have a large enough selection of instruments to accommodate the preferences of everyone involved. What to observe. Constantly assess the client’s improvisation in order to make decisions about how to support and encourage an increase in the expressive quality of the music. All aspects of the client’s music will provide opportunity for change: choice of instrument, tempo, rhythm, articulation, timbre, tonal range, melody, etc. Any change noted in the expressive quality of the client’s playing should be immediately musically encouraged. The client’s facial and physical affect should also be observed, and changes there supported by eye contact and the therapist’s own affect. A clear sign that a client’s affect is mobilizing is when he or she initiates an expressive musical change without simply mimicking a change made by the therapist. This is usually accompanied by a facial or physical change in affect that is notable to an observer. Procedures. In order to begin, introduce the instrument choices to the client. If the client has no experience with music improvisation, demonstrate each instrument, including different ways to use and sound them. If the client does have some experience, do a less involved, “refresher” demonstration. Explain that improvisation is the spontaneous creation of musical sound, and that the client is free to create, shape, and change the music however he may like, emphasizing that it is possible neither to play the “wrong” thing nor to musically express in the “wrong” way. Also explain that the therapist’s playing will be there to support the client’s musical expression. Allow the client to pick whatever instrument is preferred or is most interesting. For less experienced clients, it is best to take a more directive role and give the client a steady pulse at a very moderate tempo. As the client plays, assess the client’s playing and pick an aspect through which to encourage change. For clients whose improvising is severely limited (little to no contrast in any aspect, and perhaps simply mimicking the therapist’s pulse), it is often most effective for the therapist to start gently challenging the client by altering the tempo of the pulse, and then by adding small rhythmic changes. Think of taking “baby steps” in encouraging change, so that only one change is made at a time. For example, speed up and slow down the pulse repeatedly; then, as the client begins to respond to the changes in tempo, add a simple rhythmic variation to the pulse. As the client increases in ability to make changes in one aspect, either increase the size of change in that aspect or add another aspect, such as changing dynamic levels, and so on. To further support and encourage dynamic change in the client’s improvisation, it is helpful to incorporate specific improvisational techniques. Some of the most useful techniques for this type of experience are imitation, synchronizing, reflecting, exaggerating, modeling, interjecting, making spaces, and extending (Bruscia, 1987). Imitating the client’s playing is to echo what the client has played, while synchronizing is playing simultaneously what the client is playing, and reflecting is playing in a manner (feeling or mood, for example) that matches the client’s playing. To exaggerate means to notably amplify some quality or musical aspect of the client’s playing. These “Techniques of Empathy” (Bruscia, 1987, p. 535) are useful in providing a feeling of acceptance and safety in the improvisation. They also musically communicate that the client is being heard. To model is to musically demonstrate something that the

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client can imitate. Interjecting is musically filling a gap in the client’s playing, while making spaces provides opportunity for the client to interject. The therapist can also extend by musically adding something supportive or encouraging to a client’s improvisation. These are “Elicitation Techniques” (p. 535), which are helpful in encouraging the expansion of expressiveness in the client’s playing. Adaptations. As the client demonstrates greater mobilization of affect over time, increase the demands that will facilitate change in the client’s improvisation. For example, ask the client to use a pitched instrument, which will add the musical aspects of range of pitch and melody. Or, the client can be encouraged to experiment with different ways of using an instrument. Engage the client in improvisations in which the therapist and the client take turns “conducting” the other’s improvisation by physically and affectively directing changes in tempo, dynamics, articulation, etc. When the client is comfortable with these types of improvisational experiences, it is easy to move on to more therapeutically demanding experiences, such as musical feelings exploration, feelings exploration with expressive arts, or selfexpression through music and movement.

Musical Feelings Exploration Overview. Musical feelings exploration involves the use of spontaneously created music for the purpose of identifying and exploring feelings and emotions. The client’s emotions are expressed and become manifest in the sounds and the relationships in the spontaneous music, providing opportunities for recognizing and naming them, exploring their meaning, and exploring the manner in which those feelings and emotions are communicated to others. Emotional “shutdown” and withdrawal that frequently occurs with depression can cause a sort of chasm between the individual and his or her feelings and emotions, which makes it difficult to deal with the real issues that underlie the depressed state. Often the individual will need help in naming and owning the feelings that have been ignored and unexpressed. Recognizing what is being experienced internally is an imperative step toward working through and resolving difficult emotions. Improvisational feelings exploration provides clients with the opportunity to explore and name the emotional content of musical expressions. Musical improvisations reflect the player’s internal emotional state, but because the emotional content can be experienced as “out there,” this type of emotional exploration may feel less threatening than other means of emotional self-exploration. Goals for this experience may include naming emotions heard in improvisations, recognizing and naming feelings that occur during improvisation, and practicing musical expression of emotions and feeling states. Like affect mobilization, this is an augmentative-level experience that prepares the client and develops emotional skills needed for more indepth work that may follow. The client must have some mobilization of affect in order for this type of experience to be useful, as well as the cognitive capability and enough energy to focus on the expressive content of what is being played and heard during the improvisations. Preparation. The setup for this type of experience is like that for affect mobilization. Because this experience tends to work quite well in a small to moderate-size group, adjust the number and variety of available instruments to provide adequate choice for the number of people in the group. Likewise, ensure that there is adequate space for all group members to be able to move, play, and exchange their instruments if they so wish. Arrange group members so that each can see and hear the others, typically in a circle. Decisions about room setup and the instrumentarium used must be based on the realities of any particular setting, keeping in mind the spirit and intent of this type of experience. What to observe. In this experience, listen to both the group members’ musical expressions and what they say about the improvisation. The focus is on developing the ability to identify one’s internal experience of emotion. One must be able to identify external representations of emotions by name, however, before being able to recognize and name those emotions within oneself. The amount of structure

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that is built into the improvisational experience and discussion will be relative to the amount of skill (or lack thereof) that the group members possess, and this ability needs to be constantly assessed and the demands of the experience adjusted accordingly. Procedures. Begin this experience by introducing and demonstrating the instruments, as in the affect mobilization experience. It is helpful if there is at least a brief discussion about the ways emotions can be expressed through music, perhaps with the therapist or a volunteer group member creating a sound with an instrument that could be an example of a specific feeling. Then provide a focus for the improvisation and direct them to listen to something specific during the playing. The role of the therapist in the improvisation is typically to provide the basic musical structure that will provide safety and support for the clients in expressing themselves and experimenting musically. Providing a steady pulse or rhythmic grounding with a drum or a simple chordal ostinato, assist the group in beginning the improvisation. At the conclusion of the improvisation, facilitate a discussion that focuses on naming emotions that were played and heard within the improvisation. The manner in which the experience is facilitated will depend on several things. First, the level of experience of the group members must be considered. For inexperienced groups, the therapist initially takes the lead and continues to provide some structure as the experience unfolds. This may include providing a simple rhythmic ground that sets and maintains a pulse for the group, “directing” the improvisation by cuing group members to begin playing and indicating when it the improvisation will stop, and building in opportunities for, or cuing, turn-taking so that all players can be heard. More experienced group members may only need a steady pulse and subtle cuing. Secondly, consider the usefulness of referential vs. nonreferential improvisation. Referential improvisations are based on a nonmusical idea, such as a specific emotion, an event, an interaction, a scene, etc., which is musically represented in the improvisation, while a nonreferential improvisation is not based on a predetermined referent, allowing for a free flow of musical expression in the moment. When clients are having difficulty identifying the emotional expression heard in any music, it may be a good choice to give an emotion as a referent (the nonmusical idea upon which the improvisation will be based). For example: “Let’s improvise sounds and music that are like the feeling of sadness.” As clients gain in their ability to identify emotions, nonreferential improvisations (those not based on a nonmusical subject) can be useful in developing skill in identifying the emotional content of their own improvisations: “Listen while you play, and see if you can identify the emotions that you hear in the music that the group improvises.” Depending on the abilities of the group members, it might be useful to discuss how different emotions might sound either before the experience (“What might the feeling of sadness sound like in music?”) or after (“What about the way you were playing made it sound like sadness to you?”). Additionally, the ability of the group members to work together and help each other with skill development should be considered. While clients who have a poor ability to hear and identify feelings may need a lot of support and structure provided by the therapist, they will ultimately increase their awareness and skill most when they are making these observations within their own personal experiences and in those of other group members. Continually assess the extent to which external facilitation is needed, and adjust the level of musical and verbal support so that the clients are challenged to provide their own structure and support to the extent they are able. For example, for clients with little awareness and ability, providing examples or naming emotions may be needed. For those with some skill, reflecting the clients’ own words to assist them in naming experiences for themselves might be of most help. For more advanced clients, little or nothing may be offered in the way of examples or descriptive words, but instead, the group can be encouraged to continue discussing a particular topic in order to figure things out on their own. The group’s natural process should be allowed to direct the course of the group improvisation and discussion to the fullest extent possible.

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Adaptations. Many of the adaptations that can be made to this type of experience have already been mentioned, since the nature of the experience is such that adaptations should be constantly made in response to the client’s ability to recognize and name the emotions that are expressed within the musical improvisation, as well as those that the client experiences internally during the experience. It may be helpful to have emotion pictures available to provide a visual cue. For clients who are making progress in identifying emotion that is depersonalized (e.g., emotions that they hear in others’ playing) but are not ready to focus on an immediate internal experience of feelings or emotions, recognition and expression can be practiced in a game format. In order to do this, prepare small cards or folded papers, each of which will identify a common emotion. Group members will take turns drawing an emotion from a box or basket, and then will improvise music that they think expresses the emotion on the card without telling the rest of the group what that emotion is. The other group members will guess the emotion played by the client. If the client’s playing has not expressed the emotion in a manner so that other group members can identify it, this provides opportunity for discussion about that emotion and how it might sound when someone expresses it. Other group members may be given the chance to musically express that emotion in a way they think it would sound. In this way, clients are practicing recognition of feelings and emotions, as well as developing some skill in recognizing different ways in which that emotion might be expressed. The opportunity may also arise to discuss appropriate vs. inappropriate means of expressing emotions. This experience can also be used with the individual client. In this situation, the therapist will need to take a more active role in the improvisation than simply creating a safe and contained musical space. The therapist’s improvisation with the client should make use of techniques that will fulfill the roles that are usually filled by other group members: musically and verbally imitating or reflecting the emotional content of the client’s playing or singing; modeling different expressive choices; exaggerating the emotional content; etc. Because of the safety and confidential nature of individual sessions, discussion of the improvisational experiences can be more focused on the specific needs and limitations of the client than they might normally be in a group setting.

Improvisational Problem-Solving Overview. Improvisational problem-solving involves the use of spontaneously created music to explore thought and behavioral patterns, creatively considering other means of thinking and behaving, and playing out or practicing alternative patterns. When clients have developed sufficient self-awareness to recognize and name their own feelings and emotions, they will benefit from more in-depth exploration of their internal experiences. Improvised problem-solving creates an avenue for focusing on a specific emotion or group of related feelings, providing opportunity to actively express, work through, and problem-solve. This type of music experience can be implemented on both the augmentative and the intensive levels of practice, as determined by the client’s needs, and the preparation and experience of the music therapist. On the augmentative level, the goals of improvisational problem-solving might include exploration and practice of alternate ways of expressing emotion, situational response rehearsal, and exploration of antecedents which trigger specific emotional states. There is generally some psychoeducational problem-solving involved in this type of work. In this case, the client must have the cognitive clarity to think about emotions, feelings, and behavior patterns, and to draw conclusions about functional behavior and how to institute change. Those clients who are cognitively impacted by their depression, who are experiencing psychomotor retardation, or who may be stabilizing from other crisis symptoms are generally not prepared to benefit from this type of experience. At this level of practice, improvisational problem-solving is effective in a group. On the intensive level, the goals of improvisational problem-solving might be to explore relationships or behavioral patterns around particular emotion states, or to more deeply explore the

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internal experience of an emotion state with the opportunity to increase awareness of related preconscious (subconscious) thought and behavior patterns or reveal related unconscious material. These types of exploration require that a client have sufficient ability for abstract thought as well as enough ego strength to effectively utilize internal experiences that may be more psychodynamic in nature. They should also demonstrate willingness and desire to change (readiness). Care should be taken with clients who experience high anxiety, as internal exploration can make the perception of anxiety increase. Likewise, care should be taken with clients with a history of suicidality, as risk is typically highest when a client remains depressed but experiences an increase in available energy and resources. In these cases, intensive work should not be undertaken without sufficient, appropriate support and environmental controls in place for the client (e.g., psychotherapy, supervision, or residential support, etc.). The music therapist, as well, must be properly prepared to effect a useful, safe, and productive exploration of the client’s internal experience, which requires both musical and counseling skills that protect both the client and therapist from moving into areas that are inappropriate, or that neither is prepared to handle. The therapist must have a well-developed and trusting therapeutic relationship with the client, and should have enough background information about the client to be as prepared as possible for issues that might arise in the musical exploration and subsequent processing. This work is typically conducted in individual sessions, though it is possible to do it in a small group (3 to 4 clients, at most) that is cohesive and has formed trusting relationships. Preparation. As in the previously described improvisation experiences, an instrumentarium with a sufficient variety of pitched and nonpitched instruments is necessary to provide the client with expressive choices. The voice, as always, serves as a musical option. Instruments must be at easy reach and have stands or surfaces from which they can comfortably be accessed and played. Room for movement is essential, as is enough empty space to allow for “big” expressiveness without risk of injury from running into or tripping over instruments and furniture. Quiet and privacy are necessities. Carrying out this type of experience in an open space, such as a day room or a common room, does not provide an environmental container that is safe, supportive, and confidential, and this will hinder the degree of useful self-exploration in which the client will engage. It is helpful, whenever possible, to record improvisations in order that they may be replayed during discussion. A small, digital voice recorder will be sufficient for this purpose and is easy to erase immediately after use in order to protect the confidentiality of the client’s therapeutic process. What to observe. If engaging a client group on an augmentative level, listen closely to the feelings expressed and the emotion states of the clients, as well as listening and watching for behavioral patterns that are played out through the musical improvisation. Increased musical creativity and expressiveness, perseverance through musical tensions, and increased communicativeness are all signs that the clients are engaged in a process of working out emotional and behavioral issues. Attention should also be paid to dysfunctional behavioral patterns and areas of the improvisation during which expressiveness and creativity seem to diminish or are lacking. These instances provide further information on which to focus in discussion and follow-up musical experiences, and can serve as opportunities for increased self-awareness and skill-building. If engaging the individual client on an intensive level, closely listen to the feelings, emotion states, and behavioral patterns that the client plays out in the improvisation, as well as musical expressions and behaviors that may be indicative of transference (a playing out in the improvisation of roles or behavior patterns that were developed in past relationships). Again, the quality of affect and physical movement can be revealing of internal processes. Ideally, the client will musically try out different means of interacting within the improvisation, will persevere through emotion states until a change is effected, and/or will expand the creativity and expressiveness of the music. As mentioned earlier, stuckness or lack of change in any of these areas provides opportunity for increasing client self-awareness and engaging in

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further musical exploration, as will new insights that come to the client during the improvisation experience. Procedures. Begin this experience by discussing the focus and intent of the improvisation. Part of this discussion should cover the therapist’s musical role in the improvisation (e.g., supporter, challenger, reflector, etc.). Give the client(s) a referent or a specific expressive intention to begin the improvisation and encourage the selection of an instrument with which the intention of the improvisation might best be expressed. As the client improvises, play out the agreed-upon role(s), which may include any number of techniques (see those identified for Mobilization of Affect). At the conclusion of the improvisation, discuss the content of the improvisation, including feelings and emotions that were expressed, behavioral patterns that were demonstrated, and any thoughts or insights that came to the client during the experience. On the augmentative level, musically respond to the group’s playing so as to support and encourage active exploration. This may include instances of musically frustrating the client’s expressions (e.g., rhythmically interfering with the client’s playing) or musically “poking at” the client (playing in a manner that stimulates an emotional response from the client) to instigate musical change when it is appropriate, as well as reflecting, supporting, and musically emphasizing the client’s expressions and behaviors. It is important to carefully watch and listen to musical responses of the client in order to provide enough frustration to encourage change without creating an experience that feels uncaring, disrespectful, or hopeless to the client. At the conclusion of the improvisation, focus discussion of the group’s improvisation experience in relation to the referent or intention that was initially identified. Often, clients will need the therapist to translate their musical behaviors into correlating everyday behaviors so that the musical experience will have functional meaning for them. For instance, call to the client’s attention that: “When I tried to play with you, your playing became very timid and quiet. Why do you think that happened?” Then, parallels can be drawn between timid and quiet playing and styles of interacting with others in everyday life. Listening together to the recording of the improvisation can be useful in helping the group to recognize these expressions and behaviors. If the group is able to identify ways of interacting or self-expressing that may be more effective, help them to immediately practice those types of interactions musically in a new improvisation and then discuss how it felt, again drawing parallels to functional, everyday behaviors. On the intensive level, musically interact in ways that meet the moment-to-moment needs of the client. In this way, the client’s improvisation, supported by the therapist’s playing, creates a process that takes on a life of its own. The therapist may use any number of techniques to encourage and support the client’s process. In addition to those described previously, elicitation, redirection, and emotional exploration techniques are useful in keeping the client productively engaged in the improvisation. The therapist practicing at this level will have knowledge of and skill in using the many different techniques available to assist the client in moving through a musical therapeutic process (refer to Bruscia’s Improvisational Models of Music Therapy [1987] for complete information on clinical improvisation). Choose the responses made within the improvisation based on the intent of the improvisation and the role or roles that are being played out, realizing that as the improvisation progresses, expressions may be made that change the course of the improvisation. For example, the intention of an improvisation may be to explore feelings of worthlessness; as the improvisation progresses, it may become clear that the client is playing out a transference based on a relationship with a significant other from the past. Based on the circumstances in the moment, it may be advantageous to musically play out the role that the client is projecting, or it may be determined that it is beneficial to the client for that projected role to be rejected. Regardless of whether the intention in the moment is to support or challenge what is occurring in the improvisation, always remain present to the client and create an emotional and musical container within which the client can safely work through the content of the improvisation.

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At the conclusion of the improvisation, allow the client time to reflect upon the experience, and help to highlight important occurrences. Listening together to the recording of the improvisation can be helpful to the client in thinking through the emotional content of the experience as well as examining the thought processes and behavioral patterns associated with those feelings and emotions. While it is important for the client to identify underlying meanings and issues, the therapist can focus the discussion by asking leading questions and calling attention to specific instances within the improvisation that might be helpful to the client in making meaning of the experience. Adaptations. This type of improvisational problem-solving can be modified in a number of ways. On the augmentative level, the referent or intention of the improvisation is typically one that is a related to an issue that all members of the group have in common (e.g., feelings of hopelessness, lack of assertiveness, etc.). Group members can be assigned specific roles to play within the improvisation, and all can add their experiences and observations to the discussion afterward, creating their own support system and providing opportunity to learn from each other. This is an effective way for group members to explore different means of expressing themselves and behaving in a supportive environment, without fear of the consequences that might occur in everyday situations outside of the therapy room. Assigning very specific roles within the improvisation can result in an experience that is reminiscent of psychodrama. This type of improvisational problem-solving allows clients to explore what situations feel like from the position of “someone else’s shoes,” and can assist them in identifying ways to express themselves and behave that are more functional and realistic in achieving what they wish to gain within different kinds of relationships. Facilitate the preplanning of these improvisations by leading the group discussion about which instruments will be used and how they will be played to represent different roles, as well as starting and stopping the improvisation in order for clients to switch roles. A similar adaptation for the individual client is an exploratory improvisation in which the client and the therapist change roles within the improvisation. This is reminiscent of the empty chair exercise in gestalt therapy. Start and stop the improvisation for the switching of roles, and after a switch, continue playing the client’s role in the same manner that the client had been playing before the switch. This provides a mirroring for the client that can expand the client’s insight into the issue at hand, and open new ways of thinking about it.

Musical Catharsis Improvisation Overview. Musical catharsis involves the use of spontaneously created music to bring about a release of repressed or pent-up feelings and emotions. One common feature of depression and anxiety is that, in these states, the individual’s focus tends to be in the past. This contributes to the emotional stuckness that resists change over time. When one’s focus is in the present, it is difficult to stay emotionally the same since everything in the present moment is in continual flux. An effective way of breaking through this stuck state is to demand that the emotion be experienced in the present. The primary goal of musical catharsis is to actively work through a stuck emotional state in the present moment in order for it to be brought to resolution. This type of individual experience will typically evolve out of some other exploratory music experience in which the client has recognized and identified an issue or emotional state that underlies the more superficial issues and symptomatology of depression and anxiety. Many times, the client’s emotion will be visibly on the surface (affect), and emotionally and physically palpable to the therapist (see Priestley’s 1994 description of e-countertransference), indicating readiness to actively address it. Musical catharsis can occur spontaneously or can be provoked by the intervention of the therapist. Containing and positively directing the catharsis does require some skill on the part of the therapist, as will processing the experience to a safe point of resolution. This type of music experience, therefore, will only be encouraged within the trusting therapeutic relationship that is

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developed at an intensive or primary level of practice. The client who is in a particularly vulnerable state, such as one who is suicidal or has recently experienced suicidality or ideations, is not a good candidate for this type of experience unless he or she is in a safe, supervised environment and demonstrates readiness to address internal issues head-on. On occasion, a client may spontaneously move into musical catharsis in the midst of some other experience. At these times, the therapist must be cautious about finding a resolution point before releasing the client from the session, and about communicating the client’s state to the appropriate others if there is any concern about safety. Luckily, a client will usually not move into musical catharsis until psychologically ready to do so and in a safe and trusting environment. Preparation. To prepare for a musical catharsis experience, arrange the space as it might be for any other type of improvisatory experience, but pay extra attention to creating as much safe and open space as possible. Releasing powerful emotion can often require and/or result in large physical movement. Because the type of emotion that needs to be experienced and released will have been identified and previously explored, specific instruments might be selected and made available. For example, if the client is going to need to experience and express anger, larger percussive instruments may be most suitable. For the client who may need to actively grieve, more melodically expressive instruments may be the better choice. The best selection of instruments possible should be provided even when intentionally limiting the choices. The space needs to be quiet and private, and as free from potential external interruptions as possible. When musical catharsis spontaneously occurs in a session and the therapist determines that it is appropriate to support and encourage that catharsis, the space will need to be quickly made safe even as the client is musically emoting. If this occurs in a group session, other group members should move back to create a safe space. What to observe. In this type of experience, the therapist acts as the initial catalyst, but will also serve as the boundary-holder for the client. Listen and watch closely to ensure that the client is in a present moment experience of the emotion that is being played. The client should be responsive to the musical and verbal interactions of the therapist, and there should be a discernible movement in the music that the client is making. Keeping the client engaged in the present moment is paramount to this experience; lack of active involvement may lead to wallowing in the emotional state or, worse, reexperiencing emotional trauma related to past experiences. The improvisation should come to a natural conclusion after catharsis has occurred, and the client should express a feeling of relief in some form. Be aware that relief is not necessarily synonymous with happiness or “feeling good.” Relief may mean a release of internal pressure, the ability to cry, etc. The client’s safety should always be assessed at the conclusion of a session involving musical catharsis, and appropriate protective steps taken when needed. Procedures. Identify a clear intention before beginning the improvisation. Usually this intention will be working through a specific emotion, like anger, frustration, grief, hopelessness, etc. Instruct the client to pick the instrument or instruments that can best express the intention of the improvisation. The therapist provides the initial musical catalyst that propels the client through the cathartic process; so, select an instrument that provides enough options for change in musical elements to both stimulate movement and provide needed containment and safety. For instance, a set of claves may be percussive and cutting in a way that initiates the client’s musical catharsis, but may not be useful for providing a safe and holding feeling as the client moves through the difficult emotion and into other emotional spaces, whereas a very resonant and responsive djembe may be able to do both. Also consider the usefulness of having more than one instrument at the ready, to which a switch can be made when needed during the improvisation. Listen closely and musically support and encourage the client. As the client fully engages in emotive music-making, musically encourage the active experience of the emotion being expressed by reflecting, intensifying, and amplifying the client’s musical expression, and hold the client in that experience until the client has fully emoted. It is a necessity to remain constantly present to the client’s musical expression and accepting of the emotional content, no matter how big, loud, or disturbing it may

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become. The container for the experience that will allow the client to feel safe in musically abandoning to the emotion is created by this presence and acceptance, and by groundedness. This includes the musical interaction within the improvisation, as well as any verbal directives and encouragement given to the client. At times, a client might become so emotive that there is risk of injury in some way. The therapist’s task is to encourage continuation of the expression while maintaining safety. This usually calls for both action and verbal instructions. For example, if a client began the improvisation with a small drum and bamboo handle mallets, but has begun to release very strong anger in large and violent strikes against the drum that might shatter the mallets, some metal-shaft mallets and a larger drum on a secure stand close to the client may be offered, saying, “Keep going! I’m handing you new mallets for this larger drum so you can hit as hard as you need to.” When the client is fully engaged in the emotive process, giving verbal instructions will usually not interrupt it as long as the therapist has been very present to the client throughout the experience. A complete cathartic improvisation will sound and feel like a very strong crescendo to a climax, with a notable decrescendo to a culminating cadence. Give the client plenty of time and space at the conclusion of the improvisation to take in the experience. It is best to wait for the client to begin speaking. Allow the client to express subsequent thoughts and feelings, as well as to identify the parts of the experience that were most meaningful. Allow the client to lead the discussion, and refrain from putting any words into the client’s mouth. It is important to be aware that this type of improvisatory experience will necessarily have an effect upon the therapist as well as upon the client; therefore, intentionally separate personal feelings and thoughts from the client’s experience, and do not share them except in the case that they may appropriately inform the client’s process (e.g., “When you played those low clusters on the piano, I sensed a painful feeling of loss,” etc.). Additionally, make use of some sort of supervision (peer or formal, as best fits the situation) to process residual personal feelings or countertransference issues that might arise. Adaptations. Each experience of musical catharsis is an individual adaptation in and of itself since the process will take on a life of its own. It can be helpful, however, to add another expressive art (see the music and expressive arts experiences described above) either to stimulate the musical catharsis, or immediately after the catharsis to help concretize and ground the client. For example, in order to get the client connected with an active experience of a strong emotion like rage, cover a bare wall with large paper sheets and direct the client to make as large a representation of the feeling as possible with crayons or nonpermanent markers, encouraging use of the whole body to make the marks on the paper. As the client physically connects with the feeling of rage, move to the instruments to musically explore and work through the emotion. Or, after a musical catharsis working through an emotion that has been repressed or trapped until that time, allow the client to write creatively about the experience of expressing the emotion, or to use art materials to create a visual representation of it. This can concretize the experience for the client and sometimes might be perceived by the client as a prize or a trophy for having moved past a block interfering with their health.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Vocal or Instrumental Ensembles Overview. Vocal and instrumental ensembles use precomposed music to involve clients in recreating or performing compositions. Individuals with depression and anxiety often experience withdrawal and isolation from others, which encourages other symptoms of the illness. Because they may have lost the ability to enjoy activities that may have previously been enjoyable and held importance (anhedonia), they may find themselves in a vicious cycle that keeps them mired in a sense of

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worthlessness and hopelessness. Music ensembles provide opportunities for the depressed and anxious individual to begin to reemerge from withdrawal without making demands for self-disclosure and selfexploration that are too overwhelming early in the treatment process. Ensembles may address goals such as increasing social interaction, improving attention span and focus, improving physical symptoms through breathing and relaxation, developing leisure skills, increasing self-expression, improving selfesteem, etc. As symptoms improve, individuals can use participation in music ensembles to build social support networks, to regularly practice stress reduction, and to engage in future-directed activity. These types of experiences are implemented at the augmentative level of practice. They tend to be appropriate for clients at any degree of illness, even those who may be in or recently have been in an acute crisis. In inpatient units where groups may be composed of individuals with depression and anxiety as well as other types of mental health diagnoses, this type of experience can meet varied client needs simultaneously, and can be implemented in ways that address multiple levels of functioning within the group. Vocal ensembles do not necessarily require any special music skills on the client’s part, and instrumental ensembles can be adjusted to incorporate those clients who have little or no music training. Preparation. In preparation for the session, consider the level of music experience of the clients who will be in the group. Select music that will suit the clients’ level of music skill, including tonal range, rhythmic demands, and complexity of the arrangement. Also, it is vital to select music that will suit the groups’ musical preferences and will be appealing to them so that their motivation to participate is increased. More often than not, the music will need to be adapted to meet the needs of the group. This may include developing an understandable system of notation other than the traditional treble/bass staff notation; simplifying rhythms and harmonies while maintaining the integrity of the original piece; adapting a piece for nontraditional instruments such as Orff instruments or choir chimes; transcribing vocal pieces to suit the voice distribution and vocal range of the group; or being prepared to teach a piece and/or individual parts by rote. For instrumental ensembles, adaptations will need to meet the demands of the instrumentarium that is available for the group. Also consider the type of musical support that the group will need. Will they need the structure of a therapist-provided piano or guitar accompaniment? Is a recorded accompaniment necessary so that the clients can be actively assisted in performing their parts? Arrange the physical space so that the clients have plenty of personal space and room to move if playing instruments. Semicircular formation is often most effective so that the clients can see and hear each other as well as the conductor. If using piano as an accompaniment instrument, arrange the piano in front of the group so that eye contact can be maintained with the group and so they can see directions, cues, etc. Prepare song sheets in large, clear print with one copy for each group member. If using music or another notation system, make large, clear copies for each group member, or easily read, poster-size sheets to display in front of the group on stands or easels. If using notation or words on poster board, have a pointer stick or laser pointer ready to help direct the clients’ attention accordingly. What to observe. Active participation is primary in music ensembles and indicates that the client is focused in the here-and-now and is not in a state of withdrawal. Ability to follow directions, to stay in sync with the group, and to accurately perform assigned parts are indicators that the client is attending to the task at hand, and that he is aware of self and others in order to adjust musical responses. Watch affect, eye contact, and initiation of interactions with others, as these are signs of increased social interaction and communication. Also watch the quality of client engagement and make adjustments to ensure that they are being challenged at an appropriate level and that they are being motivated and are enjoying the participation. Procedures. Begin the session by getting the group warmed up. This might be done several ways. For vocal groups, stretching and yawning and doing simple vocal warm-up exercises can be effective. For instrumental groups, long, sustained tones or chords and tuning may be a good choice for traditional instruments, and doing a short, simple rhythmic imitation exercise can work for Orff and percussion

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instruments. Creating an opening ritual can also help warm up the group and get them focused. For instrumental groups, this can be playing a particular favorite piece that the group already knows to start the session. For vocal groups, it can be singing a specific song selected by the group as the opening for the session, or it might involve the group picking and singing a favorite song from a songbook. Present new pieces to the group, taking into consideration the level of support they will need to learn. If teaching by rote, work on small sections at a time and repeat until the group feels comfortable. Add small sections together and, again, repeat several times. For groups who are able to use adapted or regular notation, break down the piece into manageable sections. Do not attempt to sing through a piece the first time it is introduced unless the group has advanced music skills. Motivate clients by creating a successful and enjoyable experience. Challenge the group only to the extent that it motivates them and increases their perception of adequacy. On the other hand, assuming that the group cannot handle challenge will not be useful for addressing their feelings of helplessness and hopelessness. This is a fine line that will continually need to be assessed. After working on challenging new material, follow up with a piece or song that the group knows and enjoys as a reward. Maintaining focus and active engagement is the priority. Be sensitive to fatigue and the clients’ general level of energy, and adjust either the length of the session or the demands within the session accordingly. Review with the group prior to ending the session. This may be a verbal review, or it may be useful to do a run-through of what was learned. Provide time for client feedback, including ideas they might have for future sessions and music that they are interested in learning. If the group has worked particularly hard in the session, the clients may want to talk about how they felt during the work or how they are feeling at the conclusion. It is as important to call to attention enjoyment that was experienced during the session as it is to talk through any concerns or frustrations. Those who are depressed or anxious will always be able to identify negative experiences, but they may not always be aware of feeling happy or content, or experiencing a sense of accomplishment or enjoyment. Highlight these moments as they happen during the session as well as in review at the end. Consider a closing ritual for the group, such as singing or playing a specific, group-chosen piece or song. Adaptations. Many adaptations are already involved in the preparation for a client ensemble, and these are usually determined by the clients’ skills and needs, as well as progress that they make both musically and in relation to their depression and anxiety. For groups in inpatient facilities in which the client turnover is quick, or for groups whose level of functioning is very low, using songbooks with a wide selection of popular songs from various genres and allowing clients to pick what they wish to sing can be effective for encouraging active engagement and social interaction. Accompany with an instrument you are comfortable with in order to provide a quality musical experience for the clients. Clients might be asked to say a few words about why they like the song they picked, or what about the song they especially like. For higher-functioning groups with cohesion, preparing to perform can be an effective way to increase the clients’ sense of self-esteem and efficacy. This can also provide opportunities to deal with anxiety and fears in a socially supportive environment, and to build skill in an enjoyable leisure time activity. Performing for other units in a facility or traveling to places like long-term care facilities or classes for special-needs children can provide experiences with interpersonal interactions that encourage the clients to focus outside of themselves in order to connect with and help others. Preparing songs or pieces that allow for solos within the group can address emotional expressiveness and increase selfesteem. For long-term groups, such as outpatient groups, allowing the clients to take responsibility for selecting music, directing the music-making, and making future group plans can increase goal-directed activity, increase sense of worth and responsibility for self and others, and help to build lasting relationships between group members that can serve as a support system for maintenance of good mental health.

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Therapeutic Lessons Overview. Therapeutic lessons involve engagement of the client in vocal or instrumental lessons that focus on working on a therapeutic issue through the learning and performing of musical repertoire. Therapeutic lessons differ from traditional music lessons in that the focus on learning musical skills on an instrument or with the voice is of secondary concern, while the thoughts, feelings, and behaviors that surface during the learning process are of primary concern. Therapeutic lessons provide many opportunities for growth for the individual with depression and or anxiety. Goals might include increasing physical and emotional self-awareness; increasing expressiveness; working through feelings of anxiety, fear, frustration, and anger; increasing self-esteem and sense of self-efficacy; etc. Clients who can best benefit from therapeutic lessons are those who are past any acute crisis, have resolved any major cognitive issues related to depression (e.g., psychosis, confusion, etc.), have the desire to engage in an expressive learning process, and have the energy and are ready to withstand confronting negatively experienced emotion. Clients who are seriously withdrawn or exhibit more acute physical and emotional symptoms of depression and anxiety typically need a less confrontational intervention, such as participation in a vocal or instrumental ensemble. The therapist must be proficient enough on the instrument or with voice to reasonably teach it and select therapeutically appropriate repertoire for the client. In other words, the music therapist who is an accomplished soprano will probably not engage the client in therapeutic lessons on the saxophone, unless she is also accomplished on that instrument. It is vitally important for the client’s success that the therapist stays within his or her areas of musical competence. The exception to this is when the client is already a proficient musician, in which case the therapist can focus mainly on the expressive, emotive qualities of performing and the subsequent issues that arise. This experience can be implemented at the augmentative level of practice for those clients who are addressing behavioral problems such as frustration tolerance, poor attention and focus, inappropriate expression of emotion, and emotional issues such as poor self-esteem and anhedonia. At the intensive level, the therapist will use the music process to help the client explore deeper emotional issues related to dysfunctional feeling states, behaviors, and relationships that become evident through the client’s projections onto the music and the music process and through the client’s manner of expression. Preparation. Preparation of the environment is much the same as preparing for a traditional music lesson, including music stands and armless chairs if appropriate, a piano, and access to a mirror of reasonable size. In addition, have instruments and other materials immediately available for processing of feelings and emotions that might arise during the session. Having a variety of pitched and nonpitched percussive instruments is useful, as are paper, pencil, and drawing materials. A recording device for immediate playback can be useful. A small digital voice recorder works well, and can be immediately erased at the conclusion of the session to protect the client’s confidentiality. The space should be quiet and private so that the client feels free to work in the lesson without fears or anxiety about being seen or heard. Selection of the appropriate level of music for the lesson should be made ahead of time, but should take into consideration the client’s preferences in genre. Building an appropriate repertoire for instrument or voice is not important, but selecting music that is likely to touch upon troublesome feelings and behaviors of the client is. So, for example, if the client has difficulty with perseverance in daily life because of frustration and self-doubt, select music that the client would especially like to sing or play that is at a level of difficulty that will present a reasonable challenge. A reasonable challenge early on in the process may be something as simple as a new note to learn, or an extension in range by one step. Then as

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the fearful doubtful feelings arise and are worked through in the sessions, the level of difficulty in the challenges can be increased. What to observe. During the lesson, look for signs of emotion and behavioral patterns that are indicative of a problem for the client. These might manifest in any number of ways, such as becoming easily frustrated and wanting to quit; becoming angry or tearful; being unable to play through a piece without stopping for every mistake; never stopping to correct any mistake; poor posture, shallow breathing, and other physical blocks that may be the result of held emotion; etc. On an augmentative level, these are indications that the client needs redirection or needs to explore more functional behaviors that can be applied. On an intensive level, they are indications that the music is touching deeper issues that need to be expressed, explored, and resolved. Procedures. Discuss the purpose of therapeutic lessons and how they are different from traditional music lessons so that the client understands what to expect during the process and as an outcome. Give the client a choice between several songs or pieces that have been preselected to address the goals for treatment. Engage the client in the music lesson, looking for signs that troublesome feelings and emotions have being activated, or that dysfunctional behavioral patterns are occurring. Bring these observations to the client’s attention (e.g., “I notice that you skip over this part every time. Can you tell me about that?”), and allow the client to talk about thoughts and feelings. Use the process of learning the music to practice functional ways to address the issues. Using the example noted, talk about why the client is avoiding that particular point in the music. Make suggestions for working through the phrase or measure, and practice it with the client. If the feelings that arise in the client become overwhelming, move away from the lesson momentarily and use another expressive form to release them, such as instrumental or vocal improvisation (see experiences in improvisation above). Use of writing and drawing can put feelings into concrete form that can then be further expressed and explored through improvisation. Then, the client can be returned to the lesson material to practice more functional means of dealing with those feelings within the context of the repertoire. Use recordings of the client’s lessons to help increase the client’s awareness of his behaviors and expressions. Listening together and discussing what is heard in the performance is a good way to increase the client’s self-awareness and to help him understand how musical behaviors are related to other behaviors in daily life. Recordings are also helpful for keeping a record of the client’s improvement both musically and nonmusically. Some clients may benefit from keeping recordings of successful performances of repertoire. These recordings can be compiled onto a CD or transferred to a personal MP3 device so that they can enjoy and share their accomplishments with others outside of the therapy session. Adaptations. Therapeutic lessons can be an effective means for preparing a client for in-depth, long-term work in a psychodynamic approach like vocal psychotherapy or Analytical Music Therapy. As the client increases in self-awareness and ability to connect with and express deeper emotion, deeply repressed or traumatic issues may begin to come to the surface. The music therapist who is not properly trained can, at this point, refer the client to an experienced practitioner in one of these in-depth music therapy approaches and facilitate the client’s transition to the new therapist. The therapeutic lesson experience can be adapted to the instrumental or vocal ensemble experience described above. In this case, the repertoire will be chosen according to its potential to highlight issues that are common to the group members. Clients in this type of group need to be capable of tolerating expression of emotion and interpersonal conflict, and have the cognitive ability to collaboratively problem-solve. Those who are withdrawn, in acute crisis, cognitively impacted by depression, or have not developed self-control when experiencing strong emotion should be involved in a less demanding music experience. Applying instruction to an ensemble experience is an intervention on the intensive level that will provide opportunities for thoughts, feelings, and behaviors to be expressed, explored, and resolved through group process. The therapist must be prepared with musical and verbal

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skills that will facilitate management of the group process and provide adequate support for each of the group members.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting Overview. Songwriting involves the creation of original music and lyrics, resulting in a composition that can be performed repeatedly by the composer or others, or can be recorded and shared through listening. Songwriting provides an avenue for self-exploration, self-expression, communication, personal empowerment, and problem-solving that is highly adaptable to client needs and functioning levels in both individual and group formats (Wigram & Baker, 2005). For depressed and anxious clients, songwriting affords a process of expressing and working through difficult feelings, emotions, and experiences, as well as a final product that can serve as a record of the work that can be performed repeatedly, shared with others, or stored away (Rolvsjord, 2005). This intervention can be implemented at either the augmentative or the intensive level, depending on the needs of the client and the skills of the therapist. Because goals commonly associated with this intervention are directly related to the specific songwriting approach that is implemented by the therapist and the level of practice at which it is implemented, these will be included for each type of songwriting described below. Fill-in-the-blank makes use of a precomposed song that lends itself to having words or phrases removed and replaced. The clients then fill in the removed words or phrases with their own words, creating a “new” song that pertains directly to the clients. This highly structured approach to songwriting is effective for clients who are experiencing acute crisis symptoms of depression and anxiety and who may be demonstrating resulting cognitive impacts, psychomotor slowing, and withdrawal. Engagement in this experience does not require abstraction ability, does not make high demands on the clients, and is a good opportunity to help clients who are unfamiliar with working in music to feel comfortable with the process by having a successful experience. This experience is at the augmentative level of practice. Goals that can be addressed with this experience might include increasing reality-based behavior in the present moment; increasing self-expression; increasing social interaction; and identification of feelings and emotions. Song parody also uses a precomposed song, but instead of replacing a few words or phrases, new words are written for most or all of the song. This approach to songwriting allows the clients to more freely express their thoughts and feelings, but still provides the structure of the style, melody, and harmony of the original song. Clients who are verbally communicative and who are more familiar with the process of working in music will find this approach to be beneficial. It is a good way to begin selfexpression exploration without placing too many demands on the client that might cause feelings of inadequacy or anxiety. Song parody can address goals such as increasing self-expression; exploring feelings and emotions; problem-solving; increasing self-esteem and self-efficacy; increasing assertiveness; etc. Like fill-in-the-blank, song parody is an intervention on the augmentative level of practice. Free-composed song is an approach that utilizes both original words and original music. This approach places more demands upon the client, usually requiring a solid therapeutic relationship between therapist and client, and some comfort with self-disclosure and working through problems on the part of the client. For this reason, it is usually implemented at the intensive level of practice. Free-composed song is often done in individual therapy, but can also be effective in a group setting when the group is cohesive and the therapist provides appropriate direction and structure to facilitate group decision-making. Goals for free-composed songwriting might include developing insight into thoughts, feelings, and experiences; allowing expression of unconscious aspects of the self through creativity; working through and resolving

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difficult experiences of the past; exploring issues related to identity; sharing and witnessing common experiences; etc. Preparation. To prepare for fill-in-the-blank experiences, choose a song that is well known to the clients and is in a preferred style. It should be highly periodic, with short verses and a short chorus that will easily change meaning when words are changed. Make song sheets that have the desired words or phrases removed and replaced with a blank line. Make the print large and clear so that it is easy to see, and use a single sheet of paper on one side. Make copies for all group members. If clients will be asked to fill words in on their own copies, bring pencils. Otherwise, increase the song sheet to poster size, or write it on a white board. When presenting song parody, choose a song with a clear melodic and harmonic structure and that lends itself to the creation of words that are focused on a specific therapeutic topic. Simple songs with four stanzas tend to be comfortable for clients, such as songs with a 12-bar blues structure. Prepare song sheets that present the structure of the song to assist the clients in creating phrases that fit. For a free-composed song, clients will need space to brainstorm and write. This can be done individually, in small groups, or as a large group. Plenty of paper and writing utensils should be on hand if the songwriting will be done by individuals or small groups. For a large group, it is useful to utilize large, flipchart-style paper on an easel or a white board for brainstorming. Write with a dark marker so that it can easily be read by all group members. The group can continue to work together to shape and arrange their thoughts into lyrics, or small groups can be formed to each write a verse using paper and pen or pencil. What to observe. Listen for and draw attention to thoughts and ideas that clients express that are especially expressive of shared and meaningful experiences. Help the clients to draw parallels between ideas that are expressed that may seem unrelated on the surface. Be mindful of group members who are quiet or who are not as assertive as others to ensure that they have a chance to share their thoughts, feelings, and opinions. Musically, listen with care to the inflections and the expressive qualities of the words and phrases being used by the clients. This often will help to suggest melodies and harmonies that will feel natural to the clients, and will most easily express the intentions of the words that they ultimately choose as lyrics. Procedures. When presenting the fill in the blank song experience, perform the original song for the group and urge them to sing along if they know it. Explain the purpose of replacing the words or phrases in the song (e.g., “… give the song words that express something important to you”). Adapt the demands to the functioning level of the group. If it is very low, provide a list of appropriate words or phrases from which the clients can choose to fill in the blanks. For higher-functioning patients, urge them to come up with their own words and phrases. The clients can be asked to each fill in one spot in the song, to each complete a verse and chorus on their own, or to work together as a group to fill in the blanks. Or, each individual can complete a verse, and the group can complete the chorus together. When completed, perform the “new” song together. The procedure for song parody, as well, begins by presenting the original song by performing it for and/or with the group. Then give the clients the directive related to the intent of the experience (e.g., “The original song is about favorite things. Think about the things that are important to you, and make a new song about them using the original melody”). To facilitate the creation of lyrics for the song, the group can brainstorm ideas together or in small groups. Small groups can each write a stanza, or individuals can each write their own stanza, relative to the ability level of the group. Then perform the song using the new words. Encourage the group to talk about the words they have written, capitalizing on opportunities to increase clients’ awareness of self and others, to problem-solve around a common theme, or discuss similarities and differences between group members. If they are comfortable doing so, each individual or small group can sing their own words to the song.

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When facilitating a free-composed songwriting experience, the topic of the song can be identified in a discussion, or the theme can come from work that has already been started in some previous session, from a statement of insight or revelation by the client, or from a communication to someone else that the client wishes to make. Choose the amount of structure that the client needs in order to expressively shape the words. This might include providing a list of words or phrases; having the client develop a list of words or phrases; brainstorming in a free-association manner and writing down words and phrases; allowing the client to tell a story from which to extract ideas and phrases; or using creative writing that the client has composed previously. Decide with the client what style of musical accompaniment will best suit the intent and the emotion of the song’s theme. To the extent possible, encourage the client to make decisions and take ownership of the process and the song product. To create the music accompaniment for the words, the melody can be created as the words are developed, either by the therapist or cocreated by the therapist and client, or can be composed between sessions and presented to the client. Again, it is most effective to encourage the client to take responsibility for whatever portions of the composition process they are capable of doing, providing help with only those aspects that the client cannot realistically complete at an acceptable level to create a quality musical product. Even when the therapist completes the entire music composition, the client can still take responsibility for working with the therapist for the sound quality and style that is desired and that accurately expresses the intention of the song. Because free-composed song is frequently a process that takes more than one session to complete, it is good to plan to record a quality performance of the song when it is complete. This compositional process will involve a good deal of personal investment on the part of the client, and the experiences, thoughts, and feelings that the song expresses should be honored as an meaningful expression of who the client is, as well as a record of the therapeutic work accomplished in the process. Arrange to make the recording using the best recording equipment that can be accessed, and transfer it to a CD and to the client’s personal MP3 player if they have one. Present the client with the CD in a protective sleeve or case and with a printed sheet of the song lyrics. Adaptations. As previously mentioned, this experience can also be used in a group format. The material for the song can come from group discussion, from group brainstorming on a topic of their or the therapist’s choosing, or from sharing of common experiences and personal stories around a common theme. The group should take responsibility for creating as much of the song as possible, ensuring that all voices of the group are heard in its content and that decisions are made within a group process. The songwriting process can serve as a means to create and strengthen group cohesion, and can help group members to work through interpersonal difficulties they may have, such as expressing thoughts and feelings to others, appropriately asserting oneself within the group, taking responsibility for group roles, etc. Songwriting is often an effective way of processing thoughts, feelings, memories, and issues that come out of other musical experiences. For example, during vocal or instrumental improvisation, a client may have a meaningful moment of insight or may access a repressed memory. Expressing and working through that information in the improvisation may lead to content that is appropriate to continue to process through the composition of a song. Vocal improvisation can very naturally lead to song material that can be completed in a compositional process (Austin, 2008; Montello, 2003). Another example is the composition of a song that is stimulated by the process of creating a musical audiobiography (see musical audiobiography, described below). For example, as the client selects and arranges sounds and recordings into a biographical soundscape, thoughts and feelings from this process may lead to a songwriting process that can be included as the culmination of the musical audiobiography. Similarly, the song composition process may stimulate the other sound exploration around the theme or topic that develops into a biographical soundscape that includes the composed song.

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Musical Audiobiography Overview. Musical audiobiography is a compositional approach that involves an individual client selecting and compiling music and sounds into a music product that reflects an important aspect of or important events and experiences in the client’s life related to treatment issues. Prerecorded music and sound, recordings of the client’s performance of precomposed or original music, recordings of improvisations from the client’s therapy sessions, and client’s recordings of other sounds can all be used as material for the final product. Clients who are accomplished musicians can also compose a musical audiobiography in traditional musical notation, although few clients will have this level of musical skill. On an augmentative level of practice, the therapist assists the client in expressing thoughts and feelings and increasing self-awareness related to the identified issue, and problem-solving around the behavioral aspects of working on an extended project, like dealing with frustration tolerance, and working out relationship issues and social behaviors with other clients with whom equipment and resources must be shared. It can be implemented in an individual or a group format. On an intensive level of practice, the expression of thoughts and feelings through sound and music representations allows the client to view the issue from new perspectives, to problem-solve around it, and to define it in terms of its meaning within his or her identity or life experiences. This process may lead to the uncovering of blocked emotions or repressed memories. The functional aspects of seeking out appropriate materials, working with various media and equipment, and successfully expressing oneself through the final product can also uncover issues related to competency, survival, and self-worth. The therapist facilitates the client’s workingthough of deep issues related to the depression or anxiety in order to resolve them and integrate them into the client’s sense of self through the verbal and musical process of selecting and compiling the music and sounds. This type of deep exploration is appropriate for clients who are invested in a long-term therapy process, and usually occurs in an individual therapy format. Preparation. Prepare for facilitating this experience by collecting a wide variety of recordings that the client can access. These might include records, cassettes, CDs, and electronic music library sources. Use of electronic recording and processing programs is highly advantageous in assisting the client in making a product that sounds accurate and properly reflects the client’s thoughts, feelings, and intended communications. A computer with sound processing and editing software (e.g., Audacity, WavePad, MAGIX Music Maker, etc.) will make it possible for the client to do much of the creation with limited assistance from the therapist. Turntables and cassette decks that feed into the computer for transfer of music from nondigital formats are desirable. A small digital voice recorder that easily transfers to the computer (through USB, preferably) will make it possible for the client to record environmental and other nonmusic sounds to incorporate into the soundscape. Naturally, a good knowledge of working with these electronic programs and equipment is necessary in order to facilitate the client’s use of them. Because the process of creating a musical audiobiography can be a long-term one, it is useful to have an external hard drive or a flash drive of sufficient size to store the client’s project in a manner that it can be securely stored to ensure confidentiality of the client’s therapy process. Paper and pencil for planning and keeping notes on ideas and music throughout the process will be helpful to the client in making choices and keeping track of resources that are found in searches. These, too, should be kept securely between sessions. What to observe. On the augmentative level, watch for signs that the client is connecting with the expressive nature of the chosen music and sounds, and encourage elaboration of that expression. Help identify the client’s dysfunctional social and coping behaviors that become evident in carrying out the project, and assist in learning and practicing more functional behaviors. On the intensive level, watch and listen for the client’s projections and transferences onto the music product as it is created, and use these

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to facilitate the client’s exploration and working-through of the related issues. Encourage elaboration on expressive aspects of the process, helping the client to increase self-awareness and to recognize both the strengths and the problems that the process reflects about the client. Note changes in the client’s perspective on the content of the project from week to week, as this will often be a good indicator of where the client is in relation to working through the internal issues and integrating what is gained from the process. Another indicator of progress is a deepened investment in finding “just the right” music and sounds and in working to make the final product sound a very specific way or clearly communicate a specific message. This often will reflect a client’s sense of empowerment in defining his or her own identity or life experience. Procedures. Describe the intent of the project to the client and verify that the client is willing to invest time over a number of sessions to carry out the process. Give the client a specific directive for the content of the audiobiography (e.g., How did life in your family feel in the past, how does it feel now, and how would you like it to feel in the future?) or decide together with the client what the focus of the audiobiography should be. Exploring an event, wishes and dreams, one’s identity, a relationship over time, etc., are examples of useful topics for a musical audiobiography. Then assist the client in planning the movement of the project from beginning to end and in exploring potential music choices. Allow the client access to the electronic equipment (for example, allowing the digital voice recorder to be borrowed between sessions) to assist in collecting desired music and sound, and encourage the client to bring in personal music resources (e.g., CDs, music files from iTunes or eMusic, etc.). Assist the client in loading the various sound and music resources that are selected into the computer program and in working with those resources until the product accurately reflects what the client wants it to express. Process the client’s feelings and emotions that come up within the process, and help the client to develop and practice functional coping and interactive skills in the process as dysfunctional behavioral patterns are recognized. Sometimes on the intensive level of practice and usually on the primary level of practice, it is effective to make use of other types of music experiences to help the client to explore a feeling or behavior more deeply. For example, of a conflict in a relationship is identified as an important part of the biographical content of the project, the client may benefit from exploration of the feelings and emotions related to that conflict through improvisation. Or, a story that the client relates in relation to the biographical might prove to be rich material for songwriting. Recordings should be made of other music experiences that are implemented in relation to the project so that these can be choices for the client for inclusion in the musical audiobiography. Inclusion of the client’s own musical products into the audiobiography can result in additional depth to the meaning of the final product, and can greatly increase the value that the client places on the therapeutic endeavor. It may also increase the effectiveness of the intervention if the client is instructed to keep a journal of some sort to record the thoughts, feelings, images, and memories that arise in response to the process of forming the audiobiography. This can serve as a tool for identifying meaning and as a record of how the process evolved for the client. When the client has worked with the sounds and music so that they have been formed into a whole expression, a permanent recording should be made of the project for the client to keep. Take time to listen to the recording together with the client, preferably multiple times, and allow the client to explain the content and express feelings and emotions about both the content and the process. Remember that a long-term project deserves sufficient time for integration, as well as witnessing of its content and honoring the gains that the client has made in the process. The client may want to share the audiobiography with others. Assist the client in setting up a formal “performance” of the audiobiography if it is therapeutically useful for the client to do this. Adaptations. An abbreviated version of the musical audiobiography can be useful for clients who have limited time in music therapy, or who do not have the cognitive skill to engage in a deeper exploration of self. Choose one topic and allow the client to use recorded music to find selections that

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express something about it. For example, topics like “my most important relationship,” “the best day of my life,” or “the thing about myself that I like the best” can be helpful in assisting the client in focusing on personal strengths, attributes, and experiences that can bolster coping skills and increase feelings of selfworth. Compile the recording into a mini-album for the client. This type of experience also works well for a group that is working on goals such as increasing social interactions or expressing feelings and emotions. Give the group a related topic (e.g., “how I deal with anger”) and assist the group members in selecting a piece of music that represents each. Compile the selections as an album for the group, and encourage each group member to share their thoughts and feelings about their selection with the others. Incorporating other expressive arts (see music and expressive arts, described above) can add to the depth and breadth of the final product and provide additional means for expressing feelings, making communications, and defining the meaning of what is contained in the audiobiography. Useful additions might include creating cover art for the project; incorporating pictures of important people and places and things, or video footage of nature; writing poetry to accompany the music; etc. Similar to songwriting, musical audiobiography can also be effective with a group when it focuses on common experiences or a theme shared in common. Use group discussion or group brainstorming to develop the plan for the audiobiography. Each group member can add a personal selection or part to the audiobiography, or the group can make decisions about content and arrangement together to produce an audiobiography that expresses their common experience. Each group member may have a different level of musical skill and knowledge, as well as a differing level of comfort in self-expression. The therapist needs to provide assistance to both the group as a whole in creating the final product and to the individual group members based on their needs in order to ensure that each is appropriately reflected in the final product. Encourage the group to take as much responsibility for decision-making and implementation as they are capable of.

CLOSING REMARKS ON METHODOLOGY A number of the experiences detailed above indicate that they may be useful both for the individual client and for groups. The decision to provide treatment in one or the other format should be based on a number of variables. First, the treatment needs of the client must be considered. As examples, the natural choice is a group format if the focus of treatment is on decreasing social withdrawal or improving the appropriate communication of emotion, while the individual format is better if exploring the unconscious influences leading to self-destructive behavior. The nature of the client’s issues may also have bearing on the chosen format. Those who have deeply personal and emotional issues that are in need of resolution may not feel safe expressing and exploring thoughts and feelings in a group format. Likewise, in cases where topics of exploration may include personal or health information that should remain confidential (e.g., HIV status), the individual format may be a more appropriate choice. The level of practice being implemented will have an impact on the choice of format. Treatment provided at the auxiliary and augmentative levels often lends itself well to group formats, while intensive and primary levels of practice that utilize in-depth therapy approaches tend to be more appropriate for individual formats. The group format may be appropriate for treatment at the intensive level when the group is cohesive and able to utilize the relationships inherent in group process as part of the impetus for change. These are, of course, very general statements that should not be construed as “rules”; each client and each situation will have its own constellation of variables that help to determine the most appropriate format for treatment. It is understood that sometimes the choice of group or individual format is made for the therapist by the constraints of the facility, case management, or other factors that are beyond the therapist’s control. In these cases, decisions about methodology will necessarily be based on what is most appropriate for

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addressing the clients’ needs within the given circumstances, while providing adequate consideration for their safety and confidentiality. The size of the group and the frequency and duration of sessions will also be determined by the needs of the clients. A group size of six to eight clients seems to generally be effective for most situations. This size is small enough to allow for individual attention to and the full engagement of each client, but large enough to provide a variety of opinions and enough interaction for a group process to occur. A smaller group may be beneficial when the focus is very specific and deeply personal. A larger group is rarely effective, except in cases of vocal or instrumental ensembles that might benefit from the inclusion of more voices or more instrumental parts. Music at the auxiliary level of practice (often not meeting the definition of therapy, per se) that focuses on leisure skills and socialization may also effectively use a larger group, such as in various music game activities or sing-a-longs. For both group and individual formats, the duration of a session should be based on the tolerance level of the clients and the amount of time that is reasonable to complete a therapeutic exchange. Sessions typically last 45 minutes to an hour, although individual sessions utilizing in-depth approaches like BMGIM may last as long as two hours. The frequency of sessions is typically once a week for many situations. In inpatient or day-program situations, groups or individuals may be seen more frequently. In the case of BMGIM, sessions may occur only once a month or every six weeks in order to give the client time to process and integrate the information from each session. As noted above, the constraints of facilities and agencies may dictate the frequency and duration of sessions. The choice of methodology will be responsive to frequency and duration to ensure that the clients will have a complete experience and not be left with unresolved feelings and issues because of an incomplete music therapy process. So, for example, if a client will be present for two sessions in a week’s time before impending discharge from a facility, the therapist will not engage that client in an experience that requires extended interaction over time (e.g., musical autobiography, or BMGIM), but instead will choose experiences that can provide a complete experience within the course of a session (e.g., improvisation or song parody). In each methods section above, the various experiences are generally arranged from those less demanding on the client to those that are more in-depth or require more developed skill on the part of the client. For example, a fill-in-the-blank songwriting experience places far fewer demands upon the client than free-composed songwriting. In some cases, this arrangement may also reflect the level of skill necessary on the part of the therapist. A less experienced therapist may be able to conduct a highly useful and effective session utilizing a receptive music and imagery experience for relaxation, but would not be able to engage a client in a BMGIM session without extensive additional training. Again, these are general statements that describe the order of experiences as they are presented, but are not meant to imply that any given experience is more useful or more effective than any other. In fact, when the client is appropriately engaged in music by a highly skilled music therapist, the simplest of music experiences, such as the fill-in-the-blank songwriting experience mentioned above, can have a deep and lasting impact on the client. It is also important to understand that in any given session, any number of music experiences might be used, including experiences from more than one method. Because a notable part of the effectiveness of music engagement comes from the capability of molding the music experience to the client need as it is made manifest in the moment, it stands to reason that the therapist will naturally allow the client’s process to lead the course of the session. One music experience may provide all that is needed for the client to make sufficient therapeutic progress in a session. Many times, though, once the client is engaged in the music, the process itself will suggest a logical progression of music experiences. One typical progression might be described in this way: The therapist engages the client in an experience that allows recognition of prevalent feelings and emotions, followed by another experience that allows a deeper exploration and expression of those feelings and emotions, and perhaps a last experience that helps the client to integrate and concretize any insights that were gained through that exploration. As an example of

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this, the therapist might lead a discussion of lyrics from a song that the client has selected (song discussion), then engage the client in an improvisation focused on the exploring the emotional content of the song that the client felt related to personal experience (musical feelings exploration), and then, afterward, engage the client in poetry composition that is supported and inspired by listening to a recording of the improvisation (emotion exploration with creative arts). It would be impossible to give a thorough list of examples for logical progressions of experiences within this chapter, since there are an infinite number of choices that might be made; however, as a general rule, an effective logical progression will include experiences that will (1) identify, (2) explore and express, and (3) resolve, integrate, and/or concretize. It is also not unusual that, when this progression has been completed, a new focus will have been identified that will lead to the next progression of experiences, whether in that session or in sessions to come.

RESEARCH EVIDENCE Depression and anxiety are frequently mentioned throughout the music therapy literature, but interestingly, there is limited literature that focuses specifically on depression and/or anxiety, and even less that focuses on the clinical diagnoses of depression and anxiety. This may be due to the fact that both depression and anxiety are normal and natural responses to situations and events in daily life, and are therefore addressed in relation to those events and situations. A significant percentage of the literature considers depression and/or anxiety in relation to physical illnesses and injuries, such as in oncology, cardiac care, or pediatrics. Detailed information about this research can be found in Volumes Two (Pediatric Care) and Four (Medical Care of Adults) of this series. The literature and research that follows has been limited to that which specifically addresses the use of the four methods of music therapy for depression and anxiety as they pertain to mental health. A very recent study by Mössler, Assmus, Heldal, Fuchs, and Gold (in press) examined which methods of music therapy might be most predictive of change in mental health care. They found that recreative methods are best suited for individuals who have difficulty with engagement in verbal therapy, and that they lead to improvement in clients who have low motivation and social withdrawal. These findings support the research and case studies of others who identify the benefits of re-creative music experiences as increased socialization and sense of belonging (Baines, 2000; Choi, Lee, & Lim, 2008; de l’Etoile, 2002; Iliya, 2011) and general improvement in symptoms of depression and anxiety (Choi, Lee, & Lim, 2008; Cooke et al., 2010). A larger amount of literature supports the use of various receptive methods for improving symptoms of depression and anxiety and addressing underlying causes. Several explore receptive music and relaxation for symptoms of depression and anxiety. A Cochrane Review by Maratos et al. (2008) examined the effectiveness of receptive music therapy for depression, although too few methodologically sound studies were found to allow the authors to perform a meta-analysis of the data. Review of included articles led to the conclusion, however, that receptive music therapy shows enough promise as an effective treatment for depression to warrant more extensive research. A controlled clinical trial of receptive music therapy for depression was carried out in response to the Cochrane Review (Brandes et al., 2010), which concluded that receptive music therapy treatment, indeed, reduced depressive symptoms and increased treatment compliance. Receptive music and relaxation has also been found to decrease anxiety and improve sleep patterns of abused women in shelters (Hernandez-Ruiz, 2005) and to effect a significant decrease in depressive symptoms in adults when compared with traditional psychotherapy (Castillo-Perez et al., 2010). The positive effects of GIM have been reported in research and case studies on multiple occasions. In two foundational studies (McKinney, Antoni, & Kumar, 1995; McKinney, Tims, Kumar, & Kumar,

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1997), GIM interventions were shown to decrease plasma β-endorphin levels in healthy individuals. Plasma β-endorphin, a hormone released into the bloodstream in response to stress, is believed to play a role in mood dysregulation. In another study, McKinney, Antoni, Kumar, Tims, and McCabe (1997) found that, in healthy adults, GIM sessions led to the decrease of depressive symptoms, fatigue, and blood levels of cortisol, another hormone released into the blood in response to stress. These studies suggest that GIM may have important implications as a treatment for disordered mood states and physiological changes resulting from stress. Additional literature on GIM and depression reported increases in selfunderstanding in depressed individuals (Lin et al., 2010) and decreases in standardized measurements of depression (Murphy, 2008), as well as cases of resolution of issues related to trauma and abuse (Rinker, 1991) and to the dual diagnosis of depression and addictions (Pickett, 1991). Two studies examined the efficacy of improvisational music therapy for decreasing symptoms of depression. Erkkilä et al. (2011) found that individual improvisational music therapy resulted in significant improvements in depression symptoms, anxiety symptoms, and general functioning when compared to standard care in a randomized controlled trial. Albornoz (2009) studied the effects of group improvisational music therapy on the depressive symptoms of adults and adolescents with substance abuse in a randomized control trial. While the results of this study were contradictory, possibly due to the confounding influence of substance abuse, there was an indication of decreased symptoms of depression in the improvisation group compared to the control group. These results do suggest that further study is warranted. Case studies relate the successful use of improvisation in individual therapy for resolving dysthymia and improving interpersonal relationships (Nolan, 2003), for improvement of anxiety and psychosomatic symptoms (Jahn-Langenberg, 2003), and, in a group setting, for decreasing depression and anxiety while increasing coping skills (Murphy, 1991). In these cases, improvisational music therapy was implemented within a psychodynamic orientation, which exploits the uncovering nature of music and its ability to bring about the resolution of unconscious issues that underlie the symptoms of depression and anxiety. One case study, by Smith (1991), described the use of songwriting with a woman with depression and suicidal ideations. The woman was engaged in songwriting in group music therapy sessions, but also wrote songs individually. The process of creating song lyrics provided the woman with an outlet for thoughts and feelings that she had been unable to easily disclose otherwise, and helped to highlight important events and relationships in her life that she needed to explore and resolve. Sharing these original songs with the music therapy group helped the woman to build a supportive peer group that validated her feelings and emotions and improved her sense of self-worth. In addition, the content of the original songs became the evidence of the woman’s therapeutic journey, reflecting her inner life as she explored and worked through some of the difficult life experiences that had impacted her feelings of depression and hopelessness. No other research or case studies on the use of the creative, or compositional, method of music therapy specifically for treatment of depression and anxiety in a mental health context are available at this time. This should not be construed to mean that music therapists do not use this method for this treatment population, but only that those who use it are not formally studying or writing about their clinical experiences with this method. Based on this lack of literature, and the limited amount of literature focusing on the other three methods, it is safe to say that the profession would greatly benefit from a significant increase in the formal study of and clinical writing about the music therapy treatment of clients who suffer from depression and anxiety.

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SUMMARY Depression is a normal human response to tragic or traumatic experiences in life, but becomes a mental illness when the response is out of proportion to precipitating events, does not resolve after a reasonable time, or occurs without cause. It can cause dysfunction in many aspects of life, from school and work, to self-care, to relationships with others. Anxiety commonly occurs with depression and adds fears, worry, and agitation to the extensive list of depressive symptoms. Clients with depression and anxiety often present with markedly decreased ability to express thoughts and feelings and with difficulty in accessing their own creative resources to address the issues that keep them stuck in a static state of depressed mood. Music can provide many avenues for the depressed client to experience a mobilization of thoughts and feelings, to explore, work through, and resolve difficult experiences and issues, and to reconnect with that which provides value and meaning in daily life. Receptive music therapy methods provide opportunities for relaxation and stress reduction, the exploration of thoughts and feelings through use of songs and the combination of music with other creative arts, and even deeper exploration and potential resolution of inner conflict related to depression and anxiety through music and imagery. Improvisational music therapy methods can stimulate mobilization of affect, increase awareness of thoughts and feelings, increase active expression of emotion, and provide a vehicle for exploration of issues that are represented by and embodied in the musical expressions of the client, as well as providing an outlet for cathartic release. Re-creative music therapy methods involve clients in expressive music-making with the opportunity not only to explore their own feelings and emotions, but also to have them heard, validated, and shared by others. Compositional music therapy methods can stimulate the client’s creative resources in order to understand the thoughts, feelings, and behaviors associated with a depressed and anxious mood state, can engage in problemsolving and communication, and can lead to experiences that bolster self-esteem. While depression and anxiety can have a devastating effect on the client’s life and the lives of family and loved ones, with proper treatment they can be successfully resolved and the client can return to life with renewed vigor and new tools to cope with the hills and valleys that are encountered from day to day. Music can play a primary role in this treatment process because of its ability to speak to and for the individual, to provide avenues for one to move forward when stuck in the experience of illness, to connect one to others and build relationships, and to reconnect the individual to that which has value and meaning. It can return the individual to an experience of the richness of being fully human.

REFERENCES Albornoz, Y. (2009). The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse. Doctoral dissertation. Temple University. ProQuest Dissertations and Theses, http://ezproxy.lib.ipfw.edu/login?url=http://search.proquest.com/docview/305004505?account id=11649 American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). (DSM-IV-TR). Arlington, VA: Author. American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(Nov.), 1–60. American Psychiatric Association (APA). (2012a). Depressive Disorders. In DSM-5 Development. Retrieved from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=167# American Psychiatric Association (APA). (2012b). Anxiety Disorders. In DSM-5 Development. Retrieved from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=167#

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Austin, D. (2008). The theory and practice of vocal psychotherapy: Songs of the self. Philadelphia, PA: Jessica Kingsley. Baines, S. (2000). A consumer-directed and partnered community mental health music therapy program: Program development and evaluation. Canadian Journal of Music Therapy, 7(1), 51–70. Brandes, V., Terris, D. D., Fischer, C., Loerbroks, A., Jarkzoc, M. N., Ottowitz, G., Titscher, G., Fischer, J. E., & Thayer, J. F. (2010). Efficacy of a newly developed method of receptive music therapy for the treatment of depression. European Psychiatry, 25(1), 234. Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas. Bruscia, K. E. (1998). The dynamics of music psychotherapy. Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (2002). The boundaries of Guided Imagery and Music (GIM) and the Bonny method. In K. E. Bruscia & D. E. Grocke (Eds.), Guided Imagery and Music: The Bonny method and beyond (pp. 37–61). Gilsum, NH: Barcelona. Castillo-Pérez, S., Gómez-Pérez, V., Velasco, M., Pérez-Campos, E., & Mayoral, M. (2010). Effects of music therapy on depression compared with psychotherapy. The Arts in Psychotherapy, 37(5), 387– 390. DOI: 10.1016/j.aip.2010.07.001. Choi, A., Lee, M., & Lim, H. (2008). Effects of group music intervention on depression, anxiety, and relationships in psychiatric patients: A pilot study. Journal of Alternative & Complementary Medicine, 14(5), 567–570. DOI: 10.1089/acm.2008.0006. Cooke, M., Moyle, W., Shum, D., Harrison, S., & Murfield, J. (2010). A randomized controlled trial exploring the effect of music on quality of life and depression in older people with dementia. Journal of Health Psychology, 15(5), 765–776. DOI: 10.1177/1359105310368188. d l’Etoile, S. K. (2002). The effectiveness of music therapy in group psychotherapy for adults with mental illness. The Arts in Psychotherapy, 29(1), 69–78. Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi, M., Vanhala, M., & Gold, C. (2011). Individual music therapy for depression: Randomized controlled trial. British Journal of Psychiatry, 199, 132–139. DOI: 10.1192/bjp.bp.110.085431. Gardstrom, S. C. (2007). Music therapy for groups: Essential leadership competencies. Gilsum, NH: Barcelona. Gardstrom, S. C., & Hiller, J. (2010). Song discussion as music psychotherapy. Music Therapy Perspectives, 28(2), 147–156. Hernandez-Ruiz, E. (2005). Effect of music therapy on the anxiety levels and sleep patterns of abused women in shelters. Journal of Music Therapy, 42(2), 140–158. Hills, P. J., & Lewis, M. B. (2011). Sad people avoid the eyes or happy people focus on the eyes? Mood induction affects facial feature discrimination. British Journal of Psychology, 102(2), 260–274. DOI: 10.1348/000712610X519314. Iliya, Y. A. (2011). Singing for healing and hope: Music therapy models that use the voice with individuals who are homeless and mentally ill. Music Therapy Perspectives, 29(1), 14–22. Jahn-Langenberg, M. (2003). Harmony and dissonance in conflict: Psychoanalytically informed music therapy with a psychosomatic patient. In P. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 357–373). Gilsum, NH: Barcelona. Lin, M., Hsu, M., Chang, H., Hsu, Y., Chou, M., & Crawford, P. (2010). Pivotal moments and changes in the Bonny Method of Guided Imagery and Music for patients with depression. Journal of Clinical Nursing, 19(7/8), 1139–1148. DOI: 10.1111/j.1365-2702.2009.03140.x. Maratos, A., Gold, C., Wang, X., & Crawford, M. (2009). Music therapy for depression. Cochrane Database of Systematic Reviews, CD004517. DOI: 10.1002/14651858.CD004517.pub2. McKinney, C., Antoni, M., & Kumar, M. (1995). The effects of Guided Imagery and Music on depression and beta-endorphin levels. Journal of the Association for Music and Imagery, 4, 67–78.

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McKinney, C. H., Antoni, M. H., Kumar, M., Tims, F. C., & McCabe, P. M. (1997). Effects of Guided Imagery and Music (GIM) therapy on mood and cortisol in healthy adults. Health Psychology, 16(4), 390–400. McKinney, C. H., Tims, F. C., Kumar, A. M., & Kumar, M. (1997). The effect of selected classical music and spontaneous imagery on plasma β-endorphin. Journal of Behavioral Medicine, 20(1), 85–99. Meadows, A., Wheeler, B., Shultis, C., & Polen, D. (2005). Client Assessment (Chapter Four). In B. Wheeler, C. Shultis, & D. Polen (Authors), Clinical training guide for the student music therapist, pp. 27-56. Gilsum, NH: Barcelona Publishers. Montello, L. (2003). Protect this child: Psychodynamic music therapy with a gifted musician. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 299–317). Gilsum, NH: Barcelona Publishers.. Mössler, K., Assmus, J., Heldal, T. O., Fuchs, K., & Gold, C. (2010). Music therapy techniques as predictors of change in mental health care. The Arts in Psychotherapy, 39(4), 333-341. DOI: 10.1016/j.aip.2012.05.002. Murphy, K. M. (2008). The effects of group Guided Imagery and Music on the psychological health of adults in substance abuse treatment. Doctoral dissertation. Temple University. ProQuest Dissertations and Theses, http://ezproxy.lib.ipfw.edu/login?url=http://search.proquest.com/docview/304472 212?accountid=11649 Murphy, M. (1991). Group music therapy in acute psychiatric care: The treatment of a depressed woman following neurological trauma. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 465– 478). Gilsum, NH: Barcelona Publishers. Naranjo, C. C., Kornreich, C. C., Campanella, S. S., Noël, X. X., Vandriette, Y. Y., Gillain, B. B., de Longueville, X., Delatte, B., Verbanck, P., & Constant, E. (2011). Major depression is associated with impaired processing of emotion in music as well as in facial and vocal stimuli. Journal of Affective Disorders, 128(3), 243–251. DOI:10.1016/j.jad.2010.06.039. Nolan, P. (2003). Through music to therapeutic attachment: Psychodynamic music psychotherapy with a musician with dysthymic disorder. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 317–338). Gilsum, NH: Barcelona Publishers. Pickett, E. (1991). Guided Imagery and Music (GIM) with a dually diagnosed woman having multiple addictions. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 497–512). Gilsum, NH: Barcelona Publishers. Priestley, M. (1994). Essays on Analytical Music Therapy. Gilsum, NH: Barcelona Publishers. Punkanen, M., Eerola, T., & Erkkila, J. (2011). Biased emotional recognition in depression: Perception of emotions in music by depressed patients. Journal of Affective Disorders, 30(2), 118–126. DOI: 10.1016/j.jad.2010.10.034. Rider, M. (2005). The rhythmic language of health and disease. Gilsum, NH: Barcelona Publishers. Rinker, R. L. (1991). Guided Imagery and Music (GIM): Healing the wounded healer. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 309–319). Gilsum, NH: Barcelona Publishers. Rolvsjord, R. (2005). Collaborations on songwriting with clients with mental health problems. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques, and clinical applications for music therapy clinicians, educators and students (pp. 97–115). Philadelphia, PA: Jessica Kingsley. Smith, G. H. (1991). The song-writing process: A woman’s struggle against depression and suicide. In K. E. Bruscia, Case studies in music therapy (pp. 479–496). Gilsum, NH: Barcelona Publishers. Wigram, T., & Baker, F. (2005). Introduction: Songwriting as therapy. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques, and clinical applications for music therapy clinicians, educators and students (pp. 11–23). Philadelphia, PA: Jessica Kingsley.

Chapter 12

Adults and Adolescents with Borderline Personality Disorder Janice M. Dvorkin

DIAGNOSTIC INFORMATION Personality Disorders Personality disorders were originally seen as a group of symptoms that described problems in relatedness that produce extreme behaviors and emotional reactions. The cause of the disorder is understood to be a mixture of attachment problems, a degree of distorted perceptions, and the appearance of other acute disorders such as depression, panic attacks, or addictions. However, personality disorders were not seen as the primary problem that required psychiatric help. Persons with personality disorders do not recognize that they have an emotional or behavioral problem. Instead, they often see these ideas and behaviors as an integral part of who they are. A personality disorder is not diagnosed until the age of 18 and older when, it is believed, major emotional and cognitive development is close to completion. Borderline Personality Disorder (BPD), in particular, evolved into a broad definition of an individual who is an impulsive and difficult client. However, clinicians who work with children of a parent who is diagnosed with BPD are able to see the effects of BPD mirrored in the child. The child’s inability to separate from the parent and the resulting problems in emotional and cognitive development may be indications of interpersonal difficulties that might occur in adult relationships. This developmental/emotional delay becomes more obvious when the child begins to attend school and even more so in adulthood (Robson, 1997). As of May 28, 2012, the fifth edition of the Diagnostic and Statistical Manual (DSM-5 Development) (American Psychiatric Association [APA], 2012) proposes to change how the clinician will diagnose personality disorders. The basic difference proposed is the diagnosis of a Personality Disorder Trait Specified (PDTS) and the use of the “Levels of Personality Functioning Scale” as the new diagnostic tool, as opposed to a diagnosis of having a borderline personality disorder or not. This scale proposes to offer a range of six personality disorders and degrees of impairment to functioning, which would be called “personality functioning.” Clinically, a person must have significant impairment in the two areas of personality functioning—self and interpersonal. “Self” is defined as how clients view themselves as well as how they identify and pursue goals in life. “Interpersonal” is defined as whether an individual is able to understand other people’s perspectives and form close relationships. The DSM-5 Development proposes that these personality traits will be rated on a scale ranging from mild to extreme. In addition, the pathological personality trait domain must be present in at least one of five broad areas. These are: (1) negative affectivity (including emotional lability, (2) anxiousness, separation insecurity; (3) depressiveness; (4) disinhibition (including impulsivity and risk-taking); and (5) antagonism (including

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hostility) (APA, Borderline Personality Disorder, 2012). Impairments in personality functioning and pathological personality traits tend to be more stable and consistent over time, regardless of the situation. Under the revisions to the diagnostic criteria, both stability and consistency would be required, and all psychiatric diagnoses would include the functioning level of any co-occurring personality disorder assessed on the Personality Functioning Scale (APA, 2012). An individual who is diagnosed with BPD is described as having an “impairment in self (identity or self-direction) and in interpersonal functioning (empathy or intimacy)” (APA, 2012, Personality Disorders, Diagnostic Criteria). In particular, individuals with BPD will exhibit negative affect: emotional lability, anxiousness, separation insecurity; disinhibition, manifested by impulsivity and risk-taking; and antagonism and/or hostility (APA, 2012). The present DSM IV-TR (APA, 2000) contains similar descriptors, but some of them are compressed into the categories listed above (p. 710).

PSYCHODYNAMIC INTERPRETATION OF BPD There are a variety of theories regarding the etiology of the disorder and the needs of people with BPD. Most of them were initially developed within the British and American object relations theorists (Stone, 1986). An outgrowth of Freudian psychoanalytic theory, object relations theory stated not only that a person develops internally on her own, but also that the relationship of a person (subject) to her caretaker(s) (object) determines whether the person will be able to mature appropriately and develop emotionally. The Psychosocial Scale of Development by Erik Erikson is the stage theory prototype for the steps required to master the abilities and skills needed to function in life (Nevid, 2009, pp. 318–319). According to this theory, the person who is diagnosed with BPD has not completed the second stage of development, i.e., she has not successfully gained autonomy; therefore, she has not separated and individuated. In fact, this person is considered to be at the rapprochement stage of individuation (Mahler, Pine, & Bergman, 1975), meaning that the individual, lacking emotional object permanence, has dependency issues and must be in contact with her caretaker after a period of being on her own for a short time.

Interrelationships Throughout Life The relationship with the primary caretaker is the focus of Masterson’s (1985) theory of the development of BPD. Of particular note is his theory on the generational initiation and prolongation of the borderline relationship. The borderline mother chooses a child, usually the oldest, to be her “caretaker.” Often, as a child, this mother herself had to be her mother’s caretaker. (Psychiatrically, this disorder is traditionally seen as a female malady. Males, however, also exhibit these behaviors and developmental interruptions.) There is an unspoken agreement between the parent and child to meet the emotional needs of the mother. This can be seen in the child’s adherence to the demands of the mother. If there are other children, the father agrees to not interfere with this “mother-child” relationship. Therefore, this parental dyad continues throughout their lifetime. The child’s developmental needs, especially the developmental need to separate and individuate, are never met, and the person remains fixated at the second stage of psychosocial development, unable to develop autonomy. Due to the mother’s own fixation at the second stage of development, abandonment is considered her worst fear. When the child begins to try to separate/individuate as a normal developmental step during childhood and adolescence, the threatened mother prevents this growth. The mother often describes this emotionally unstable relationship by stating, “my daughter is my best friend” and, on the other hand, “my daughter cannot take care of herself and cannot make it on her own; she needs me to function.” Thus, the child is unable to experience separation as a normal part of development and

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becomes fearful of abandonment in relationships as well. These children often form very strong friendships, with the wish that this person will help them to separate from the parent and thus help them to function. When this does not occur, the child will attach to other friends or relationships as a substitute for the caretaker, as she cannot function on her own. Thus friendships may last, but the intensity dwindles as a new caretaker is found. At times, friendships might actually end in aggression, due to disappointment that the friend did not assist in the desired autonomy. Like a two-year-old, the child continues to see the world with dichotomous thinking; a person is either good or bad (including the child herself). During adolescence, this relationship becomes even more limiting. While the child may develop friendships and romantic attachments, she is often unable to move away from the mother/daughter, subject/object dyad. If and when the child becomes a parent, her child also becomes the mother’s emotional caretaker, since her developmental needs were never met. In each case, the child’s options for emotional growth are severely limited. Therapy can address this generational paradigm (Masterson, 1985). Ideally, therapy includes both the mother and child, with the goal to stop the cycle through insight and a creation of ways for the participants to meet their own needs. In order to facilitate the development of both mother and child, the role of the therapist becomes one of “good enough parent” (Winnicott, 1989, p. 196). The therapist nurtures both the parent and child and teaches each of them to develop healthier relationships beyond their own. When the parent is in therapy, the family often states how much “better” the parent is. The therapist provides the empathy that tells the parent that someone understands her difficulties. However, this kind of work involves a great amount of time, with periods of resistance to the therapeutic process and often the cessation of sessions by the parent. When the child is in therapy, the therapist can also take on the role of the parent who encourages the child to learn to function. Eventually, the child’s relationship with the therapist becomes an intense parent/child relationship. This is particularly evident when the client panics at her inability to cope with her “bad self” (perceived failure) or is unable to solve a functional problem and turns to the therapist for calming and comforting. The therapist is asked to create a holding environment (Winnicott, 1989, p. 89) and is frequently tested in terms of availability and ability to support the client in crisis. If the therapist is unprepared for the establishment of this type of relationship, she may experience this client as a demanding burden. At this point, the transference toward the therapist and the therapist’s countertransference reactions toward the client are prominent.

The Role of Trauma Another developmental aspect of the person who has a BPD is the existence of a trauma during the first year of life. This experience changes the threshold of the hypothalamus in the area of emotional regulation (Schore, 2008). The threshold is lowered to the point where even a minimal level of emotional stimulation can produce “diffuse distress” (Schore, p. 161) as the child mirrors the caretaker’s panic reactions. These reactions can be seen as rage directed toward themselves or others due to the feeling of intense vulnerability and the inability to cope with the stimulating situation. The contributing factors include an emotional or physiological trauma. In the face of this trauma, two major psychological events occur. First, the parent is perceived by the child as being unable to adequately empathize with the child’s distress and therefore is no longer able to calm the child, and second, the child’s trauma interferes with the parent’s need for the child to provide emotional gratification. Instead, the parent feels an additional pressure to take care of the child. As with a child who has a difficult or slow to warm temperament, the parent experiences overwhelming stress due to the lack of a caretaker to help her and the feeling of failure in her inability to take care of the infant.

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One of the distinguishing features of the history of the person with BPD is the veracity of the child’s lived experience. While the psychological effect of the child’s history might sound exaggerated, it stems from real trauma and is not a false or created memory. This trauma emanates from a sense of abandonment in the child because the parent was not able to remove the emotional or physiological pain. In fact, the child may have experienced the parent as a contributor to her emotional pain. Often, the psychological abandonment is borne out in reality at some point. For example, an adolescent who was the eldest of two sisters was put in foster care by her mother because of her behavioral problems. She literally experienced abandonment as well as an additional rejection because her younger sister was kept at home while she was sent away (Dvorkin, 1991).

Projective Identification A defense mechanism is an unconscious way of reducing anxiety. The defense mechanism that is often used by people with BPD is projective identification. When a feeling or a situation becomes overwhelming and the person is unable to cope with it, this defense allows the person to transfer the distressing emotion to another person by projecting the intensity of feeling onto the other person or object. Thus, the person communicates the overwhelming emotion to the object and the object experiences the distressing feeling. A therapist, for example, might enter a therapy session in an even and neutral emotional state, yet by the end of the session she experiences a strong negative emotion. This emotion is a projection of the intolerable feeling that the client is experiencing. The unconscious defense operates by giving the emotion to the therapist so that she can both experience and help the client cope with the unregulated feeling (Bruscia, 1998, pp. 39–40; Searles, 1994, pp. 201–202).

Lack of Autonomy The problem with the person’s inability to develop autonomy at the appropriate time results in her shame of not being able to function and master living skills on her own. This shame can lead to extreme emotional pain that is attributed to the other person who is blamed for causing the pain. The overwhelming shame can lead to suicidal ideation or suicidal attempts as a way of eliminating the narcissistic injury (Winnicott, 1989, pp. 74–75). If a therapeutic alliance has been established, this person will contact her therapist/caretaker to stop the destructive thoughts and resultant feelings. As with a twoyear-old, the developmental task of maintaining the image of the parent in her absence, or object constancy, is difficult, and it initially appears with demands for immediate relief, which can lead the person to request and even demand frequent contact outside of the therapeutic sessions. A goal in therapy is to increase frustration tolerance and the ability to hold oneself emotionally between therapeutic sessions. This is similar to delaying gratification for an infant or child. Children who do not separate and individuate do not develop a functioning ego. Theoretically, the ego is the part of the self that helps the person address reality, as opposed to reacting without control or mediation to the immediate urges that have existed since birth. This results in a lack of a sense of having achieved competence and mastery of living skills, which leaves the person with a chronic feeling of emptiness. The person with BPD constantly tries to fill this emotional void. Shoplifting, overeating, and sexual gratification are examples of behaviors that are used to fill the emotional void. The attempts to contain these feelings become increasingly difficult. This is when the therapist, friend, or other person who has the role of caretaker is contacted. However, the emptiness and resultant behaviors eventually return. These acting-out problem behaviors may become the focus of the therapy sessions, preventing the therapist and client from addressing the acute symptoms of the disorder or the deeper pervasive issues of the personality disorder.

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Cognitive Attributes The developmental fixation affects how individuals think, which leads to behaviors that are unique to the person with BPD. Dichotomous thinking: The arrested development of the person with BPD not only remains stuck at the two-year-old stage emotionally, but it also remains stuck at this age cognitively. According to Piaget, the two-year-old is just starting the preoperational stage of cognition. This is the beginning of thinking, when the child takes information and organizes it in a useful way. This includes rudimentary categorizing, which is seen as putting everything and everyone in a good or bad category. Someone who is seen as bad at one point can easily be seen as good in response to a different experience, or individuals in a group can be categorized as good or bad individually. This descriptor can change among individuals in the group at any point in time. The results of this type of thinking are seen in splitting the individuals between good and bad people. This phenomenon of splitting is often seen between two individuals in a certain group who feel obligated to play out these roles assigned by the person with BPD. An example would be members of a treatment team who suddenly begin to argue about the treatment of this client. Once the team recognizes that this is the result of a client with BPD, they can then begin to communicate with each other to circumvent this defensive maneuver on the client’s part. When this communication starts, the BPD client has a harder time isolating individuals so that they are able to challenge her distorted perception of the situation (Masterson & Klein, 1989, pp. 134–139). Many times the other person, who is seen as good or bad, is described as a part object. The other person is always perceived in relation to the BPD individual, not as an individual. A BPD client needs to see her primary therapist as the good therapist in order to trust that this person will take care of her. However, as soon as the client makes a request that the therapist cannot meet, the therapist experiences the shift from good to bad object. This occurs despite all attempts by the therapist to explain why the request cannot be met. The client’s reaction stems from feelings of betrayal and abandonment and results in rage that can be destructive to the therapist’s property and/or self. In this situation, the therapist may have an emotional experience that is similar to what the BPD person is experiencing. Had this behavior been seen when the child was two, the therapist would have considered it a usual tantrum response. The appearance of this behavior in an adolescent has the same function as the temper tantrum, but the adolescent is expected to have developed more mature coping mechanisms and greater control of her emotions. Distortion: Due to emotional need, the BPD person’s perception of situations or of people can appear to be extremely distorted to the point of unreality. Borderline was included in the name of this disorder because it referred to someone who exhibited borderline psychotic thoughts. Unlike someone who is psychotic, however, the person with BPD is constantly reliving her past experiences in the present. Therefore, her interpretation of others’ motives and intentions toward her and her reactions to others are based on her perceptions of the realities of her life history. Because her responses to others are based on reliving the past in the present, these distorted perceptions give others the impression that she is not responding to reality. This is particularly obvious when the client with BPD believes she is unable to cope with a person or situation due to the panic and anxiety that is evoked. The fight-or-flight concept appears as a defensive mechanism from the past, and the client with BPD may become aggressive or self-injurious or leave the situation abruptly. At the same time, a BPD client may remain silent in the group or session to protect herself from the fear of revealing the emptiness inside or presenting her false self to others. The mistrust of others can also be seen in a client who frequently creates dissension in the group or whose attendance in therapy is sporadic. There is an internal pressure or defense mechanism called into play for the client with BPD to help her avoid being aware of her behavior; this avoidance tactic responds to an underlying desire to

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evade relational problems. These behaviors and defenses create much interference with the therapy process. External locus of control: As the child begins to separate from her parents, she develops behaviors and ways of thinking that enable her to cope with experiences that provoke myriad emotions. Generally, during the course of normal development, the child learns coping methods to reduce anxiety. When the child chooses these positive coping strategies, this indicates that she is developing an internal locus of control. Since the person with BPD is not able to separate from her parents, she does not develop an internal, autonomous way of deciding how to behave. Instead, she has to rely on others to guide or direct her as to how to respond to relationships with others. This reliance on others is often described as an external locus of control. This arrested area of development is connected to the continuing merging dyad between parent and child and helps explain the dependent, clinging quality of her relationships in general (Nevid, 2009, p. 470) Thus, therapeutic goals are often focused on helping the client to learn to build a repertoire of reactions and responses that are consciously chosen to self-calm so that she can improve her ability to function in relationships with others. Once the client has some success in achieving this goal, she begins to notice the number of choices she has in other situations as well. Throughout therapy, the client develops the ability to reflect on and question her perception of a person or situation prior to choosing an action. As in therapy with children, a large part of the work with the client with BPD is to help her to delay an action (acting in or acting out) until she is able to think through the experience, expand her interpretation of it, and look at the consequences and alternatives of possible actions.

NEUROBIOLOGICAL PERSPECTIVE Schore (2008) presents a neurobiological perspective of this disorder: “Studies have shown that the orbital frontal system plays a fundamental role in preconscious functions, in the processing of emotionevoking stimuli without conscious awareness, and in controlling the allocation of attention to possible contents of consciousness” (p. 200). Schore continues to state that this part of the brain responds to emotional stimuli and is expected to perceive the stimulus and start the response reactions to the stimulus. This response can include primary process responses, such as crying, yelling, etc., as well as more developed responses to attachment and regulatory processes. He theorized that “the orbitalprefrontal areas undergo a critical period of growth at the end of the first and into the second year of infancy, and that extensive experiences with an affectively misattuned primary caretaker represent a growth-inhibiting environment for a maturing corticolimbic system” (Schore, p. 201). Trauma in the early first to second year also has the same effect: “The recovery deficits of internal reparative mechanisms … in coping with intense affect are most obvious under challenging conditions that call for behavioral flexibility and adaptive responses to socioemotional stress. It is the regulatory dysfunction in the orbitofrontal structure that is centrally involved in the adjustment or correction of emotional responses” (Schore, p. 201). Therefore, therapy is focused on increasing the maturing of the corticolimbic system. This will enable the person to respond in an age-appropriate manner.

DIALECTICAL BEHAVIOR THERAPY TREATMENT The psychodynamic and neurobiological interpretation of BPD provides an indication of the needs of persons with this disorder. In response to these needs and a lack of effective treatment methods for this population, Dr. Marsha Linehan (1993) created Dialectical Behavior Therapy (DBT) to help therapists work with these clients, who were most often being treated in an inpatient setting. DBT is based on the concepts of Cognitive Behavioral Therapy, in that the client is encouraged to be aware of thoughts and

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feelings and to use this awareness to choose appropriate actions. In addition, Dr. Linehan’s theory takes into account the belief that the core problem in BPD is emotion dysregulation, resulting from a combination of biology (e.g., genetic and other biological risk factors) and an emotionally unstable childhood environment (e.g., where caregivers punish, trivialize, or respond erratically to the child’s expression of emotion). The focus of DBT is to help the client learn and apply skills that will decrease emotion dysregulation and unhealthy attempts to cope with strong emotions. Usually, DBT includes a combination of group skills training, individual psychotherapy, and phone coaching, although there are exceptions. Clients in DBT are asked to monitor their symptoms and their use of learned skills daily, while their progress is tracked throughout therapy. Linehan’s book and training manual (1993) are a step-by-step guide to teaching clients four sets of skills that are needed for clients in DBT training. “Emotional regulation, interpersonal effectiveness, distress tolerance, and core mindfulness and self-management skills are actively taught” (p. 20). These skill areas are taught in group sessions. Interpersonal effectiveness skills focus on learning to successfully assert one’s needs and to manage conflict in relationships. Distress tolerance skills promote learning ways to accept and tolerate distress without doing anything that will make the distress worse in the long run (e.g., engaging in self-harm). Emotional regulation skills help clients learn to identify and manage emotional reactions.

NEEDS AND RESOURCES The person with BPD usually does not admit to any problems in her ability to function and relate. She often enters therapy only because of the threat of abandonment of a significant other. Thus, the first and most significant need of a person with BPD is to establish a trusting relationship with the therapist and, by extension, with other persons in her life. After the client has established a trusting relationship with the therapist, she is able to begin to reflect on and listen to comments regarding her problematic behaviors without seeing the therapist as threatening her equilibrium and therefore being perceived as “all bad.” The experience of consistency and safety is created as the therapist demonstrates that she is listening to the client and understands how the client perceives people and situations. In the course of therapy, clients need to develop ambivalence, or the ability to accept people as being both “good” and “bad,” or as evoking both desirable and undesirable feelings. To accomplish this, the client needs to experience the therapist as someone who is able to do things that feel “right” to the client. At the same time, the therapist must also take actions that the patient does not like and help the client to talk about her feelings about this, rather than acting on them by injuring herself or others. These needs are developmental and result in cognitive changes related to the client’s thoughts and perceptions about human relationships. Progress can occur when the therapist can offer alternative ways of perceiving and acting and the client can reflect on these without feeling threatened. Unlike the biological parent, the therapist does not demand that the client take care of her. Instead, the client learns to take what she needs from a parent/therapist who encourages her growth and development. In terms of resources, the BPD client often has an idea of what she wants to have in her life. However, she is unable to understand how to get what she is looking for. An example is a child who is looking in the window of a bakery, but has no idea how to get inside. She sees others getting relationships and experiences that she wants, but has no idea how they were able to achieve them. Therefore, the person with BPD comes to therapy as someone who is desperate to change in order to keep or to get a relationship. This is the attitude the therapist encounters during the first several sessions; however, what the therapist sees is the client’s mask, or false self, that was created by experiences that provided gratification (Masterson, 1989, p. 34). The patient uses this presentation of herself as a higher-functioning person to attract the therapist in the first few sessions, but this false self cannot be sustained.

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One of the advantages this author has found in using music in therapy is that the music can be a container for “good” or “bad” perceptions and experiences related to the world. Music can also be an object on which to project these perceptions and experiences. This frees the therapist to take a supportive role toward the client as she encourages the client to question her perceptions. As the client feels supported and accepted by the therapist, she becomes more willing to look at problems that are making her life difficult, often because of immature cognitive and coping skills. This often leads to a reduction in the conflicts that make life so difficult and puzzling.

LEVELS OF THERAPY Most music therapists do not work in institutions where the reconstructive form of therapy can be used with people with BPD. The only inpatient hospital that offers long-term treatment needed for reconstructive therapy is Cornell Medical Center in New York. However, since this disorder is not uncommon, knowledge of the behaviors associated with it will be helpful to music therapists working in a variety of situations, e.g., when leading music therapy groups in institutions, while affording individual inpatient therapy, when subcontracting with a community health agency music therapist, and/or when working in schools. Understanding the issues of the client with BPD helps music therapists to therapeutically manage the disturbances that these clients may bring to the therapy group or individual session by addressing the client’s basic issues so that the process of therapy can continue. Thus, in shortterm inpatient treatment, the music therapist works at an augmentative level by helping the client to develop coping skills in the present and to relate to others based on the “here and now.” Given the time to establish a process and relational position and with more education in psychotherapy, the music therapist can work at the intensive level where the client’s distorted perceptions and current relationships are addressed.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy •

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Listening to a Song to Prepare to Return to the Outside Environment: Clients listen to a song at the end of the music therapy group to help them to transition to the outside environment. Therapist-Improvised Melody and Song: The client listens while the therapist improvises a melody or a song to match the client’s mood; the client may respond by joining in with the therapist.

Improvisational Music Therapy •

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Agenda-Go-Round Group Improvisation: an opening experience for a group in which each client responds to a question sung by the therapist and/or group by improvising on a chosen instrument and/or singing or verbalizing a response. Communicating and Relating through Instrumental Improvisation: Clients play together with the therapist while establishing a common pulse and connecting with various members of the group through improvising on instruments and with their voices. Music Therapy Group Offering Feedback on a Member’s Behavior: The therapist models and helps group members to give constructive feedback and promote positive interactions

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with a client verbally and musically; this experience provides an opportunity for the client to respond appropriately. Two-Chord Song as a Container: The client and therapist improvise melodies, sounds, and words over the rocking alternation of two chords played by the therapist.

Re-creative Music Therapy •

Group Singing: Clients and therapist sing songs together with a harmonic accompaniment provided by the therapist; this is often followed by a discussion of the lyrics.

Compositional Music Therapy •

Responding to Verbal Feedback through Songwriting: Clients and therapist re-write the lyrics of a song to personalize it and create words that reflect their experiences.

Multiple Methods: Re-creative and Improvisational •

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Song as a Transitional Object: The therapist chooses a song that the client and therapist sing together, and then the therapist guides the client to improvise new lyrics that describe the client’s emotions and significant aspects of her inner life related to abandonment. Creating a Dialogue Using Song: The therapist and client sing the transitional object song, and then they improvise lyrics in a dialogue to express and reflect on significant issues in the client’s life.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Clients with BPD may find listening to music more difficult as they become more deeply involved in therapy. Given that the focus of therapy is to increase their awareness of perceptual distortions in relationships and eventually respond more appropriately, there is high importance placed on therapist authenticity throughout the therapy. The client’s response to feelings evoked by the music is also a relationship. When the client has a difficult emotional reaction to music, panic, followed by rage and/or flight, is often the result. Thus, when a receptive music technique is used, the therapist works to help the client develop tolerance to listening to music and to develop the ability to use words or draw images to describe her emotional experience in the music. For example, a client might respond to a directed imagery experience by having an intense image of being inside a box that is pitch black. The overwhelming anxiety might provoke panic followed by an attempt to stop the experience. At this point, the therapist can help the client by offering her ways to cope, for example, by describing, sounding, or drawing the image/emotions as she stays with the feelings in the moment and allows herself to experience positive support. Negative transference reactions can then be directed toward the image or the music as the therapist supports the client in tolerating her feelings and helps her to change these feelings.

Listening to a Song to Prepare for a Return to the Outside Environment Overview. Clients listen to a song at the end of a music therapy group to help them to transition from an emotional and focused group to the normal environment on the unit or to an everyday

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environment. Goals are to help clients to modulate their emotions, to reinforce their sense of self, and to maintain a state of equilibrium. This experience is practiced at the augmentative level of therapy and there are no contraindications. Preparation. The music therapist plans ahead by choosing to use this particular song to close or wind down the group. The song is chosen because of its ability to calm the clients after the emotional experiences during the group and the emotions related to ending the group. This song can be sung in the same manner and used at the end of every group. What to observe. The therapist observes the client’s reaction to this calm music, e.g., if the client is able to relax and close her eyes. The change from involvement in the group to a more sedate state can be overwhelming and produce a fight-or-flight reaction. Clients with mood disorders as well as BPD may have an emotional response such as becoming tearful. Patients with BPD will often appear to be struggling to not show any emotional response, so as not to become overwhelmed. If the patient leaves the session in an agitated state, nursing staff should be informed. Procedures. At the end of a music therapy group, the music therapist asks the group members to sit back, close their eyes (if they can), and breathe deeply with the song as the music therapist sings it and accompanies herself on a guitar or keyboard with a flowing or repetitive accompaniment that sets a rhythmic respiration pattern. A song about calm or peace is preferable. The group is not encouraged to sing with the therapist, but no comment is made if a client chooses to sing with the therapist.

Therapist-Improvised Melody and Song Overview. The client listens while the therapist improvises a melody or a song to match the client’s mood; the client may respond by joining in with the therapist. The therapist who works with a person with BPD has to remember the importance of the relationship between the client and the therapist. Without this connection, the person with BPD is not able to continue to develop or learn more mature behaviors. Instead, she continues to respond with behaviors that communicate her distress and anticipated abandonment. These behaviors can be dangerous to oneself and to others (which is why such clients are often hospitalized). The BPD client is looking for a “good parent” to help her. This method is particularly helpful when the client is unable to function (e.g., stays in bed, is isolative, or is unable to respond to structured situations). Most clients with BPD have difficulty staying in therapy sessions. One way to help clients tolerate the therapy experience is to provide music mirroring. The goals are to help the client to tolerate therapy, to tolerate her feelings, and to increase the client’s trust in the therapist and in the therapeutic process. This experience is usually one that the client has yearned for, but never received. This method is unusual in a psychiatric setting; therefore, the unit staff might question why the music therapist is working in this way. The most common philosophy of care in a psychiatric unit is that the client should conform to the structure of the unit. However, offering the client the opportunity to experience another person who can be supportive of her needs is developmentally important to her growth. When the music is seen as a supportive entity, the therapist can then begin to help the client change from being oppositional and defiant to looking for more positive choices in her behaviors. The level of therapy is augmentative or intensive and is done only in individual sessions. There are no contraindications for this experience. Should the client respond by rejecting this approach, the therapist needs to continue to attempt this form of communication to remain a constant object in the client’s treatment. Preparation. The therapist may use an accompanying instrument with her voice. The therapist should also prepare herself with centering exercises to be fully present to the client’s mood and energy

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level. If the session is held in the group room, a mat, blanket, and pillow are prepared and lights are dimmed. What to observe. The music therapist constantly observes any changes in the client’s respiration, body movements, and sounds. The therapist’s music changes to reflect changes observed in the client. Procedures. The therapist encourages the client to come to the room where groups are held. However, should the client be unable to do so, the therapist conducts the initial sessions at the client’s bedside. The role of the therapist is to create vocal music in an improvised song structure to reflect the client’s mood and behaviors. The music therapist initially uses a guitar or keyboard to mirror the client’s breathing and energy level. Once the client appears to be able to tolerate this musical mirroring, the therapist adds a melodic line on an open vowel. This offers the client the opportunity to merge with the therapist and experience a feeling of nurturance and holding. As the therapist’s improvisation continues, she encourages the client to add a word or a sound to the music, thereby providing an invitation to respond in a way that is similar to caregiver-infant dialogues. The client is not required to respond, although this is normally the way a parent and infant interact together (Dvorkin, 1991).

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Agenda-Go-Round Group Improvisation Overview. This is an opening experience for a group in which each client responds to a question sung by the therapist and/or group by improvising on a chosen instrument and/or singing or verbalizing a response. It is inspired by Yalom’s (1983) inpatient group therapy process and provides a way of beginning a music therapy group that focuses on the clients’ current concerns through verbal and musical responses. It helps clients orient to the start of the music therapy group by using music at the outset while simultaneously offering them an opportunity to work together to choose the topics on which the group would like to work. It also presents the clients with a structured experience to orient them to the process of self-expression through improvisation. The therapist can use this experience at the start of each group; this consistent opening is also comforting because it becomes familiar and the clients know how to respond appropriately. A client who provokes interactive problems between group members and/or staff or appears to purposefully create sounds that do not blend or fit with the group music might benefit from this experience. The goal would be to show the BPD client that she is able to belong to the group and integrate her sound with them. This is also an opportunity for the client to see the effect of her behavior on others and receive feedback about it from the group. There is no contraindication in using this experience in the psychiatric setting. However, because a person with BPD frequently has a distorted perception of reality, she may have difficulty tolerating the reactions of others and the imagery that is evoked by the improvisation. In extreme cases, such reactions can be strong and lead to undesirable behaviors, in particular, a fight-or-flight response. Involving the client in a verbal or nonverbal response prevents the fight-or-flight urge. In such a situation, the therapist might adapt the therapeutic experiences that follow to meet the relational needs of the client. The level of therapy is augmentative. Preparation. A large assortment of percussion instruments is available on a table for the group members to choose from. These include a variety of drums and percussion instruments that require different ways to make a sound—hitting, rubbing, and scratching. Include instruments with a variety of timbres and dynamics, and loud and soft sounds (e.g., finger cymbals and large cymbals).

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What to observe. The therapist notes the congruence or incongruence of feelings that are expressed musically and verbally. Notice if clients remain silent or if they are responsive; notice the group’s ability to listen to everyone’s response and the level of empathy that clients have for each other. Procedures. The therapist describes this intervention and its purpose and asks the group if they have any questions. Clients are then given some time to choose an instrument or two that they will use to express themselves. When everyone has experimented with and chosen their instruments, the therapist sings a question, such as “Client’s name, what are you feeling today?,” and the client responds to the question by responding verbally and/or playing an instrument in a way that reflects her feelings. The group is also invited to sing the repeated request with the therapist. It is helpful to phrase the question as “what” instead of “how” because this helps the client to respond with a feeling rather than responding “fine” and playing in a superficial manner. The therapist can also increase the group members’ awareness of others by asking each person to choose who will answer the question next. By involving group members in the questions and procedure, group cohesion is created, facilitating members to help solve problems and provide support for each other. Once everyone has responded, the therapist thanks the group members for their responses. The therapist uses this opening experience as an assessment and chooses the next experience based on the group responses. For example, if a number of group members have a similar feeling or problem, then this becomes the focus of the first intervention in this session. This group introduction also provides some power and control that makes the client with BPD feel more comfortable.

Communicating and Relating through Instrumental Improvisation Overview. Clients play together with the therapist while establishing a common pulse and connecting with various members of the group through improvising on instruments and with their voices. This technique demonstrates to the client that when words are not adequate to express feelings, using music as a language is often an excellent way to maintain communication and expression in the music therapy group. The goal is to provide clients with new ways to express all aspects of the self in an appropriate manner, using nonverbal processes followed by verbal expression. This form of musical expression can be quite anxiety-provoking for some clients. The relative lack of structure in the improvisation creates a situation where the client may not be certain how to respond, and therefore she may feel vulnerable. As mentioned earlier, this is a situation is where the Dialectical Behavioral Therapy’s emphasis on learning emotional regulation and social interaction could be applied. Goals are to increase the client’s skills to listen to others, to give nonverbal relational cues to others, to recognize nonverbal interactive cues given by others, and to respond appropriately. This experience is recommended for an inpatient group. There are no contraindications to employing this experience with clients. This experience might be difficult for some clients. In this situation, the therapist can work on improvisational responses with the client in an individual session. If the BPD client trusts the therapist, she might be willing to interact in this unstructured manner with the therapist and, from there, be able to risk interacting in the same way with other members of the group. It is similar to the parent attempting to help the two-year-old to separate and individuate by establishing relationships with others. A description of how to incorporate the sound of the BPD, and how the therapist can help the BPD belong to the group sound without fear of merging, can be found in a chapter on “operant relations supervision” (Dvorkin, 1999). The level of therapy is intensive. Preparation. A variety of musical instruments of various sizes, timbres, and shapes should be available. Set up chairs in a circle so that everyone can easily establish eye contact with each other. What to observe. Observe each individual’s level of participation and interaction with the group members. Note what kinds of sounds the client makes, the variety and variability of sounds and dynamics,

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the ability of the client to express herself through sound, and how each client is able to mirror others and offer imitable sounds to others. The therapist should be prepared for reactions demonstrating that a client is struggling. This might be evident by the client’s puzzled affect regarding playing an instrument with the group or anger or frustration if she misses the affective and interactive cues from other members during the group improvisation. Some clients might experience difficulty interpreting what they hear or see from other group members without help from the therapist (experienced as the parent). Without the therapist’s assistance in increasing nonverbal communication between group members, the person with BPD may hear only a concrete cacophony of sounds, e.g., “It just sounds like noise.” At the same time, the group may see this response by a group member as an antagonistic stance in which the musical offerings of others are diminished. Procedures. The therapist begins by asking clients to take some time to explore the instruments and to choose one that they wish to use for this sound communication experience. She then explains the rules for the group: “You don’t hurt yourself, you don’t hurt anyone else, and you don’t purposefully hurt the instruments.” Next, it would be helpful to have a couple of short introductions to group music making and group improvisation. For example, the Agenda Go-Round described above might precede this experience. Other lead-in experiences might include short, imitative, rhythmic call-and-response activities or establishing a common beat and changing the tempo and/or the dynamics together as a group. The therapist then explains that the purpose of this group is to establish contact musically with each person in the group at some point by looking at them and imitating something they are doing musically or by finding a way to play with them so that their music “fits” together. The therapist can also demonstrate how to use one’s voice and percussion instruments to interact with the group members. The importance of eye contact is stressed. Thus, the client is prepared to look for opportunities for musical and nonverbal interaction with other group members. The therapist begins with a basic beat with a harmonic progression on piano or guitar or another harmonic instrument and invites the group to join the music. As the clients play their respective instruments, the therapist musically holds the group together by maintaining a strong basic beat that is constant for the client and allows them to experience being a part of the group. Where there is a paucity of interaction or connection to the other members of the group, the therapist can model connection by attempting to obtain eye contact and nonverbally creating a dialogue with a particular client by mirroring the client’s music. Once this connection has been established between the isolative client and the music therapist, the therapist can begin to assist in helping the client connect with other members of the group. For example, the therapist might say, “Can you look at someone across from you in the group and try to play/talk to her?” After the improvisation, the therapist leads the clients in a discussion about their reactions and feelings related to connecting with others musically and in other nonverbal ways. Adaptations. Helen Odell-Miller (2011) presented other possible responses by a music therapy group member with BPD and demonstrated how the musical expression can be used to lead the group to greater emotional awareness. She described how additional individual sessions helped a client with BPD learn to question “rigid patterns of thought” (p. 35) and helped her to explore the differences in her perception from that of the group. Odell-Miller stated that the particular therapeutic value of music is that it is affect-based and can be structured or unstructured to various degrees. These aspects of music can help the client learn what her music-making tells her about “memories of childhood abuse,” for example. As the client’s insight increases, she is able to learn about her destructive behaviors and how to overcome them. As with this method, verbal review of what the individual client and group members experienced is essential.

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Music Therapy Group Offering Feedback on a Member’s Behavior Overview. The music therapist models and helps group members to give constructive feedback and promote positive interactions with a client verbally and musically; this experience provides an opportunity for the client to respond appropriately. During group process, the BPD client may be unable to interact verbally with other group members in an appropriate way, or she may verbally express distorted perceptions of what is occurring in the group, particularly when the focus is not on her. A nonverbal manifestation of this distorted perception might occur when the client joins in with the group instrumental playing but is unable to blend with the group sound. When such a situation occurs, the group members may respond defensively or with hostility. However, the therapist can set the norm for the group by modeling an appropriate and constructive way to give feedback to the client. As with a DBT group, this type of group offers an opportunity for the client with BPD to hear and respond to an individual’s problematic behavior. This group is possible when its members are able to offer feedback to the individual who displays behaviors that interrupt group process. The therapist focuses on encouraging the group to help the client to gain insight, while at the same time helping the group express their needs and confront another in a constructive, supportive way. The goal, therefore, is to assist the members in being supportive, even though they may experience the individual’s behavior as a problem. Another goal is to provide ways to cope with anxiety and depression related to poor interpersonal relations. The goal for the person with BPD who is being inappropriate is to help the client to accept the comments as helpful and, in so doing, to develop her ego strength. The level of therapy is intensive. However, a client might perceive these comments from the group as betrayal and be unable to accept that they are given in a positive, constructive manner. Such a client would become very angry when she senses that the therapist is not able or willing to protect her. In an attempt to stop the other group members from expressing their thoughts, the client might react by acting out in a negative, even more disruptive fashion. Thus, this experience is contraindicated if the client does not have the minimum of ego strength needed to be able to accept the feedback in a positive, growth-enhancing manner. Preparation. The music therapist concretely organizes the group in the same consistent manner as always (a circle of chairs for clients and a variety of musical instruments available to the group members placed within reach). A large assortment of percussion instruments is available on a table for the group members to choose from. Include a variety of drums and percussion instruments that require different ways to make a sound, for example, hitting, rubbing, and scratching, and instruments that create loud and soft sounds (e.g., drum and finger cymbals). What to observe. The music therapist must strive to keep the group members from projecting their anger and personal issues onto the disruptive client and using this client as a scapegoat. Before this occurs, the music therapist must focus on helping all the group members to cope with their feelings, which can range from disappointment, helplessness, and frustration, to anger and rage. Observe how clients express their feelings, their tone of voice, their ability to make “I” statements rather than to blame, and their ability to listen to others and attempt to understand others’ points of view. Observe how clients handle their emotional states and if they are able to cope with the feelings they experience. Observe how clients are able to learn how to assimilate good communication skills and respond empathetically to build better interpersonal relationships both verbally and in the music. Procedure: What is significant about this group is the music therapist’s response to a BPD client’s negative acting-out behaviors and/or verbal comments in the group. Instead of viewing problematic responses as evidence of the need to eject the client from the group, the therapist encourages the group and the client herself to understand why she might be responding in this way. The therapist also models how clients might cope with difficult feelings.

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For example, the music therapist begins the “hello” song to open the group. Following the greeting, the group and therapist decide to do an improvisation. This is a small improvisation group held in a circle, with instruments available for communication. When describing the purpose of the group, the therapist creates a safe environment where the group members are encouraged to be authentic with other members. While the group members improvise music according to the set theme or agenda and work together on therapeutic issues in the music, the BPD client either ignores the interaction between members or creates participation that is unconnected to the sound of the group, causing a disruption to the group’s goal for music-making. The therapist first attempts to help the BPD client to match the group sound by trying to create interactive musical communication with the client or by verbally reminding the client what the goal, theme, or sound is that the group is trying to achieve together. When the improvisation is finished, the therapist encourages the group members to honestly express how they feel about the music-making. As the group’s disappointment and difficulties emerge, the therapist must tread a fine line between being supportive of the group’s concerns and not appearing to abandon the client with BPD regarding her behaviors in the group. The therapist also has to make sure that the client does not become a scapegoat when she becomes the focus of the group’s concern. This is accomplished by modeling how to communicate in a supportive rather than critical manner and by modeling how the group can process their concerns and nurture each other musically. The therapist would naturally want to understand what the perceptions of the client with BPD were regarding the improvisation and draw her attention to the effect that she had on others. The best way to then process these feelings and interpersonal difficulties is to return immediately to the music, having group members model and practice how to play with others in a supportive, empathetic way. The group therapy process is emphasized, in that the members are responsible for group functioning as the session continues. This is accomplished by the therapist turning to the group members to make decisions such as what kind of music would help an individual or the group as a whole at this moment. This strategy might be familiar to some members, having been used in past group interventions to help a group member in crisis. In such a situation where a group member becomes visibly distressed, the music therapist directs the group to accompany the therapist as she musically matches the client’s sounds and guides the client to slow down and become calmer. This models to the group a way to offer words or music that can help someone who is upset. The client with BPD is also supported and encouraged to find an instrument to express her feelings about receiving verbal feedback and to “selfsoothe,.” The group is encouraged to support her to do so. In a case study by Murphy (1991), this resulted in the client being “totally involved” (pp. 471–472). Adaptations. Any song that enables the person with BPD to learn about herself is appropriate. Examples include “Blowin’ in the Wind” (Bob Dylan), which musically addresses coping with situations that do not have a definitive answer or plan; “This Little Light of Mine” (Harry Dixon Loes), which can be rewritten to address what there is about the client that she would like to allow to shine; “Joy to the World” (traditional Christmas carol), which can be the basis of lyrics that answer the question, “If you were the king of the world, what would you do?”; and “Time in a Bottle” (Jim Croce), which could be used to respond to the proposition, “If you could put time in a bottle, what part of your life would you keep?” Thus, using this technique of supportive feedback, both the group members and the client with BPD benefit by developing skills and insight.

Two-Chord Song as a Container Overview. The individual client and therapist improvise melodies, sounds, and words over the rocking alternation of two chords played by the therapist. This technique is often used as the basis for a

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lullaby or “song” that will be used for immediate calming and reduction of distress. Once established, the melody and harmony may be used repeatedly for this purpose during the therapeutic process, particularly when the client is on the verge of a fight-or-flight response. The repetitive use of comforting music is similar to playing or singing to a baby music that the baby has heard in the womb. It begins the process of maturing the corticolimbic parts of the brain that are responsible for connecting the thinking parts of the brain to the emotional parts (Nunn, Hanstock, & Lask, 2008, p. 236). It enables the client to arrest the process of misattunement and open up to considering another response to the difficult emotional stimuli. The goal is for the client to increase her tolerance of difficult feelings. In so doing, the client may begin to use this song as a means of preventing inappropriate behaviors (Meichenbaum, 2003). This intervention is particularly effective with the BPD client because it reenacts or introduces a positive, attuned, caretaker/infant relationship, thereby facilitating the client’s development toward maturity. Any use of music that exemplifies its conscious use for calming and restoring control is a biologically and cognitively effective intervention. The use of the therapist’s voice as a way of helping the client contain, tolerate, and verbalize the experience of the positive, attuned feeling is created as a basis for the vocal interaction (Austin, 2009). In addition, the therapist also has an opportunity to work on transference issues. The only contraindication would be the client’s adamant resistance to using this music therapy intervention because past relationship failures make it difficult for the client to tolerate this level of intimacy and/or the therapeutic relationship has not yet built up enough trust. This level of therapy is augmentative or intensive when working on transference issues. Preparation. The music therapist often has to work quickly to introduce this improvised song as a vehicle for quickly reducing a client’s panic and dangerous behaviors as soon as the client begins to experience these out of control feelings. Thus, practicing song improvisation in various keys and in 6/8 meter is a necessary preparation. What to observe. During this intervention, the therapist is constantly checking on the response of the client while she listens to the song. This includes breathing patterns, skin color, and body language, such as a frozen body position or agitated movements, in addition to verbal or musical responses. Procedures. This is suitable for individual therapy during a regular session and can also be used as a “PRN” (from the Latin Pro re nata, meaning “in the circumstances”). It might also be initiated when a client approaches the music therapist to ask to use an instrument to calm herself down. At this time, the music therapist can offer to use this technique with the client. The therapist can also use this procedure to calm a client who is in a crisis and has been placed in a seclusion room or restrained in camisole. The therapist begins by improvising a melody purposely in duple meter in a 6/8 rhythm pattern. In the beginning, the therapist needs to provide constant direction to support the client to use the music to help her. Initially, the therapist uses open vowel sounds followed by sung directions to the client inviting her to breathe with the melody. The therapist continues to match the breathing of the client with a melody, tempo, and dynamic range that is consistent with the client’s mood while singing on an open vowel sound. When the client appears to be aware of the therapist, she is asked how she wants the therapist to change the music to more accurately reflect what the client is feeling, e.g., faster or louder. The client is then encouraged to add a word or join in by singing with the open sound. The therapeutic depth is increased when the client can use her voice to improvise words to tell the therapist what happened to create these feelings. Since the person with BPD is often at a developmental two-year-old stage, having the experience of connecting with the therapist nonverbally leads to a feeling of safety. The client may be then ready to verbalize more of her trauma experiences. The song can also be recorded for the client’s use when the therapist is not in the unit.

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GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Group Singing Overview. The clients and therapist sing songs together with harmonic accompaniment provided by the therapist; this is often followed by a discussion of the lyrics. The discussion is continued until the music therapist or member of the group finds another song that relates to feelings that are being experienced in the group. Goals are to develop group cohesion, self-expression, empathy, and insight. The level of therapy is augmentative or intensive and there are no contraindications. However, once again, the BPD patient may disrupt the group due to the anxiety evoked by having less structure in the group. Thus, a client might interfere with the opportunity for other group members to creatively explore coping with uncertainty as they try to find a song that is appropriate to express the changes in feelings or thoughts that they are experiencing. This disruption can be seen as the patient actively insisting on the therapist providing increased group structure. Preparation. Because this is still a music therapy group and not a sing-along, the group is composed of 8 to 10 members, seated in a circle. During the “hello” song, the music therapist listens for commonalities in feelings and concerns expressed by the group members and thinks about which music would reflect the current issue and then where to take the issue after the first song. It is also recommended to ask the opinions of the group members regarding which songs might reflect their feelings/issues or which songs might meet their needs to experience certain feelings. What to observe. Notice whether group members are able to recall songs that match their feelings. Notice how clients cope with the feelings that are being expressed in the group. Notice if clients are able to trust the therapist to help them cope with finding a way to have the experience they need in the moment. The therapist carefully observes for members who may become more agitated as the group attempts to initiate their own problem-solving mechanism. Procedures. The therapist may choose a song or songs based on what has emerged thus far in the group. For example, if the group began with the Agenda-Go-Round described above, and some of the clients brought up issues that dealt with anxiety, then the therapist might decide to have the group sing a composed song that could serve as a bridge to the topic of anxiety. Going home is often a reason for anxiety for clients with BPD. So, a song like “Sloop John B” (an English-Caribbean sailing folk song) is a musical way to address the issue of anxiety related to going home. The therapist can also ask clients if they have ideas about a song that would express something about their anxiety. After suggesting the song to the clients or choosing a song together, the therapist passes out lyric sheets and sings it with the group while accompanying them on guitar or piano. Clients may also choose to play along with instruments. This would be followed by a discussion on what feelings and thoughts the lyrics evoked for individuals in the group. Throughout, the therapist listens carefully for opportunities to connect feelings and thoughts that clients share to facilitate cohesion and connections among the clients in the group. This discussion may suggest another theme or call to mind another song that has lyrical content that relates to what is being discussed, which would lead to singing another song. Songs chosen by clients can be an integral part of this group. For example, a member of the group may suggest singing a song that always calms her down when she is nervous. When the group and therapist accept her suggestion to sing this song, it demonstrates that they value her feelings and ideas. Client song choice is also a way of helping the group learn to regulate their emotions by finding a song that meets their expressive and emotional needs. Adaptations. If a client asks for a song that the group doesn’t know, the therapist can request that the group accompany this member by supporting the song with a basic beat on instruments while the therapist sings it with the client. In this way, the therapist demonstrates that the client belongs in the

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group and compliments the client for accepting the musical support of the group. The group also validates the appropriate behavior of the client. While some music therapists use songbooks, this often limits the choice of the patients. The focus of this method is to learn about the patients based on their past in music. Singing can also be done with an individual client to establish trust and intimacy and to help the client to identify and express feelings. The therapist and client might choose the song together, or the client might express a desire for a particular song, or the therapist might suggest one based on how the song theme relates to the client in the moment.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Responding to Verbal Feedback through Songwriting Overview. The client and therapist rewrite the lyrics of a song to personalize it and create words that reflect the clients’ feelings about receiving verbal feedback from others. Goals are to increase the client’s ability to tolerate positive and negative feedback, to increase trust of therapist and others, and to gain insight into one’s behavior. The level of therapy is intensive. There are some contraindications to using the method, however. Clients who are in the first stages of therapy and have not established trust with the therapist should not be introduced to this method. Clients who are labile in behavior and have distorted perceptions of people and situations are not suitable for such a group, as this songwriting procedure may be perceived as confrontational and would likely increase these symptoms. Preparation. The music therapist should be able to offer a variety of musical styles that mirror the client’s feelings in music. To do this, the therapist needs to have a songbook with a number of choices of styles and songs and be able to sing and accompany these songs. What to observe. Notice how the client is able to tolerate receiving feedback and how the songwriting process helps the client to express and regulate her emotions. Notice if the client is becoming more agitated or is developing feelings of mistrust toward the therapist as the session progresses. Notice if the client needs to take time away from the songwriting to calm herself or to express herself on another instrument such as a drum. Procedures. In a situation where a client has received verbal feedback from a peer in a music group or from another therapist, the music therapist can help the client to express her feelings about this in a song during an individual session. The client and therapist can choose a song together that expresses how the client feels about this feedback. Together, they sing the song and discuss the client’s feelings. The therapist then helps the client to choose which lines she would like to change to express her particular feelings, and then they sing it together. Another song can be chosen to express what the client would like to say to the person or persons who have given her the feedback. The therapist helps the client to use the feedback in a positive way and to develop her ability to communicate her internal experience through the song. While it is common to use the structure of a composed song, a genre such as a harmonic sequence based on the blues can be used, and the client can create a new melody and lyrics or recite spoken words over the blues accompaniment played by the therapist. This procedure may also be used to help an individual client to express her difficulties in relating to others. Adaptations. This can be particularly helpful when the client, with the emotional and musical support of the therapist, can sing the song to the group or the person who provided the feedback. Smith (1991) describes a case study where this method was used with an individual client with BPD who was also a member of a group that met twice a week (pp. 481–496). The BPD client had enormous difficulty in expressing herself verbally and musically, but she had the ability and motivation to put her thoughts into songs. The client and therapist wrote songs in her individual sessions and brought

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them into the group to address the group’s expressed concerns. By bringing her songs into the group, she was able to communicate to the group in an appropriate way and to improve her trust of others. The group’s openness to this type of expression was facilitated by the music therapist’s encouragement of this type of communication. Another adaptation occurs in a group where group members may use the process to describe a quality about each person in the group or to give constructive feedback to each other. This would only be used with a group that is high-functioning, meets regularly, and has established a basic level of trust with each other. The procedure would follow that of the individual session.

GUIDELINES FOR MULTIPLE METHODS: RE-CREATIVE AND IMPROVISATIONAL METHODS Song as a Transitional Object Overview. The therapist chooses a song that the client and therapist sing together, and then the therapist guides the client to improvise new lyrics that describe the client’s emotions and significant aspects of her inner life related to abandonment. The client uses this song similarly to how a two-year-old might use a transitional object to reduce anxiety when the caretaker is not there. The transitional object represents the safe feeling of being with a caretaker. Not only is this inanimate object loved and hugged, but also, in some circumstances, it can become the recipient of abuse from the child. This often occurs as a result of the child’s anger, fear, and despair toward the absent caretaker. Because the child has not developed object constancy, the object is used to absorb the intense feelings that the child experiences when the caretaker leaves. Through a process of projection, the object bears the brunt of the child’s feelings and therefore appears (or feels) battered from this displacement. Working with a client with BPD is unique because of the client’s fixation at an infant to two-yearold stage of development. The client is unable to cope with the daily difficulties of life without the presence of an empathetic, attuned, parental or protective figure, though the client is often unaware of what makes her emotional life so difficult. When a child grows up, she no longer has a material object on which to project her feelings, and other human beings (therapist, friend, and spouse) become the object’s replacement. As an adult, the client can make limited choices on how to express her emotional distress. She can proceed into a panic mode, which causes the fight-or-flight response, or she can safely contain her feelings in a song that expresses what she is experiencing and why. Working with music as an essential component of the therapy process, the therapist can offer a song as a transitional object, and the song becomes the recipient of these intense feelings. Songs provide a structured container in which the client can safely express her feelings, leaving the music therapist free to take a “good” caretaker role rather than having to fend off or cope with the client’s negative projections. The therapist’s goal is to demonstrate to the BPD client that she is able to direct her destructive impulses into singing a song. The goal for the client is to seek appropriate support from the therapist in order to reflect on and express her feelings in the song, and to recognize how she can assuage her emotional distress by directing her unbearable feelings into the song. The possible contraindications to this experience can be the inability of the client to develop trust with anyone in authority. Therefore, the therapist needs to work on nurturing the client to establish trust through helping her to tolerate the emotions that cause panic and helplessness before attempting this method. The level of therapy can be augmentative or primary, depending on the time available to work with the client. This method is practiced only in individual sessions. Preparation. The therapist must reflect on which song (container) can serve as a vehicle for recognizing the perceptions that evoke strong, emotional reactions in the client. Other considerations might be which song can be used to continue the process of self-awareness, how the song might be used to

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do so, and how the song might be used as a vehicle to help the client to learn how to problem-solve in that situation. In order to choose a transitional object song, assessment techniques, such as a test for a range of emotions or knowledge about family history, can facilitate this process. The therapist might need a book of song lyrics and accompaniments and a harmonic instrument to support singing the song. What to observe. The music therapist observes whether or not the client is using the song as a vehicle for containing emotional expression. When the therapist sees the client choosing to direct her emotions toward a person through bullying or verbal or physical assaults, the client is encouraged to go back and put her feelings into the transitional object song. The issue of abandonment is a frequent one for BPD patients. Therefore, songs that address being alone, being abandoned, or being an orphan are good selections. Procedures. As stated above, it is essential that the therapist have a good knowledge of the client’s problems related to emotions and her family dynamics. Preliminary experiences can be used to assess the client in these areas. For example, the therapist can ask the client to divide a keyboard into sections and label the feelings that each section represents from low to high, and then to explain why they are placed in a particular section. The therapist can also ask the client to choose resonator bells to represent members of her family and arrange them in categories such as relative closeness to the client or the person’s role as a positive/negative person in her life. With insight gained from this preliminary experience, the therapist might choose a song for the client and she and the client sing the song as it is written, while the therapist provides vocal and instrumental support for the song. After the patient is comfortable singing this song, she is encouraged to improvise words and phrases that express personal information to replace the lyrics of the original song. The patient can then choose to sing the original or personal version of the song, in order to put her feelings into the song as it is sung. When the client describes behaviors that she finds difficult, she is directed to put these episodes into the song. The words are not written down, but take on a new theme as the patient uses the song during every music therapy session. As the client raises new issues, events, and problems in the therapy sessions, motifs in the song are used repeatedly to transform the spoken narrative into music. The dialogue is literally an ongoing musical conversation between therapist and client that is shaped within the different parts of the song. There may be times when music is not used until what is said can be organized by the therapist to fit into the song. The integration of words and music in the song is based on what the client has said, but it is reframed in the song. The song that can be used as a transitional object in this manner is usually reflective of how the client sees herself, e.g., victim or orphan. An example of a song that is meaningful to many clients with BPD is “Maybe,” from the Broadway musical Annie. While I prefer for the client to choose the song, this particular song directly addresses the longing that a BPD person has for parental support that will meet her emotional needs. The therapist may also provide instruments (such as claves for rage) that have been used by the client in previous sessions. The client is encouraged to find a physical space where she feels secure as this process unfolds, e.g., against the wall or behind the piano. As new feelings and thoughts are expressed, the therapist interprets these in light of unmet developmental issues, listening for verbal clues that bring to mind a song that matches some essential element the client is describing; the therapist then considers songs that would best reflect the client’s experience. At times, the client herself may provide a song to address these forthcoming issues. Once the client begins to recognize that putting her words into the song reduces the intensity of her destructive urges, she begins to use the song as a transitional object. This development increases the likelihood of the client bringing her problems to the session to put in the song. The therapist can then put additional appropriate ideas into the song that increase the awareness of the client’s feelings of abandonment and fear of autonomy. These songs can be taped to use as a coping mechanism, thereby

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maintaining their function as a transitional object, particularly when the client does not have access to the therapist. Depending on the topics that arise, more songs may be used to address different feelings related to past experiences and present perceptions (Dvorkin, 1991).

Creating a Dialogue Using Song Overview. Therapist and client sing the transitional object song described above, and then they improvise lyrics in a dialogue to express and reflect on significant issues in the client’s life; thus, this intervention is an extension of the use of the transitional object song. This song dialogue continues the process of working on increasing personal insight for the person with BPD. This method focuses on expanding a song that represents the issues of the client. The words of the song are altered in an improvisatory manner by both therapist and client to increase the client’s awareness and insight. This type of intervention cannot occur unless there is an established positive relationship with the therapist. Thus, the level of therapy is intensive. This experience might also be used to assess the client’s understanding of her condition and reason for hospitalization. This experience is particularly attractive to the BPD person. It encourages the narcissistic needs of this individual—to be special to someone in authority. This stage is also a change to a more mature stage of development. What is particularly helpful about using song for therapist-client communication is the possibility that the song can become an object for the client. When the song is perceived as a bad or good object, the therapist is free to take whatever role would be the most helpful to the therapy at the time. An example would be encouraging the client to express her anger into the song, rather than direct it at the therapist. The contraindications would be not having established a safe, trusting relationship with the therapist; the reluctance of the client to communicate meaningful experiences in the song; or the client’s rigid reliance on denial as a defense to avoid the shame and fear of exposing the real self. Preparation. The therapist needs to be secure musically with the transitional object song so that she can easily reproduce the musical motives when improvising. The musical dialogue will lag after the drama has played itself out, and the therapist must know how to sense this ending. What to observe. The therapist observes the client’s facility in learning the song as well as her ability to use healthy breathing and phrasing while singing. Most importantly, the therapist observes the client’s ability to express her feelings in words in the song, to be spontaneously connected to her feelings as she does so, and to take in ideas and feelings the therapist offers her through her sung dialogue. Ultimately, the therapist is observant of the client’s ability to derive insight from the song dialogue. Procedures. The client is encouraged to sing the original transitional object song repeatedly until she is able to add her own experiences associated to the lyrics of this song. When the patient demonstrates her desire and ability to express problems and behaviors in music, the therapist models how to do this by introducing improvised dialogue into the song, inserting her images and knowledge of the client into the chorus or verses. The therapist uses words and phrases she has heard the client express and improvises them in the song, thereby expressing caring and nurturance. The client is encouraged to respond in sung dialogue with the therapist, and the dialogue becomes the vehicle through which therapy issues are accessed and processed. Once the client is comfortable substituting lyrics, the therapist can begin to ask questions using the same musical phrases in sung dialogue while continuing to explore the client’s statements in greater depth. The greater the music therapist’s experience and willingness to develop a particular song, the more the client sees music as a way of expressing her history, her anger, and other problems that brought her into the hospital (Dvorkin, 1991). This helps the client to express feelings about her past experiences and connect them to her present situation in the hospital. In addition, encouraging the client to

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incorporate her own words into the song is an example of a parent who is caring but not standing in the way of emotional expression. This prevents the formation of a symbiotic relationship between the therapist and client and encourages the client’s autonomy. This technique is often more popular with adolescents than adults.

CLOSING REMARKS ON METHODOLOGY All of the examples of methods that tend to work with patients with BPD are possible to incorporate into music therapy groups or with individual sessions. The clinical judgment of the therapist is used to decide which of these interventions will work best at the client’s developmental level. In other words, the choice of how to use music is dependent on the functioning level of the person with BPD. This includes her level of awareness of her own behavior and insight, the level of acting out, the degree of difficulty in interacting with others, and the degree of distortions in her perceptions of situations and people.

RESEARCH EVIDENCE Case studies and clinical analyses present other approaches and techniques that are useful when working with persons with BPD. For example, Burns and Woolrich (2008) describe Lisa Summer’s ideas about choosing music “based on Winnicott’s (1989) Good Enough Mothering Principle” (pp. 51–52). The therapist takes the role of the “good enough mother” by encouraging the client to increase her ability to self-soothe during the imagery and music experience, thereby reducing to an appropriate level the amount of contact with the therapist that the client needs between sessions. This approach demonstrates the developmental step of the rapprochement stage of separation/individuation. GIM is another approach that may be used with high-functioning adults with BPD. A description of how a GIM session is conducted is described by Bonny (1978). Paul Nolan (1983) has also written about using receptive music in a forensic setting with a male client who had borderline features. The GIM method was used as a means of achieving insight-oriented outcomes. Nolan described the stages used in a GIM session as well as “the criteria for the suitability of this patient for insight-oriented therapy (awareness of his feelings and an ability to verbalize them); basic trust of the therapist; a high degree of motivation; … an awareness of a recurring pattern [that] places the responsibility on him; and a reasonable amount of physical and psychic energies” (pp. 46–47). This description of the case includes a detailed description of six sessions and the behavioral and developmental changes that occurred due to the use of this intensive level of treatment. Montello (2002) described a technique using receptive music therapy with persons with BPD with which she provided familiar music that matched the client’s developmental level. One client chose an exercise called “Magical Musical Imagery,” which set up an environment for exploring feelings (p. 164). Montello asked the client to choose an image or situation that could lead to further exploration of what was creating problems for the client, e.g., an argument at work, at home, or with someone significant to the client. The music intervention focused on the client’s self-reflection of her behaviors and issues. This technique offered the client an opportunity for increased awareness of sensations in specific areas of her body that were related to an emotional problem; the client experienced a heightened activation of visual or kinesthetic sensations in an altered state of consciousness. Schwartz and Fouts (2003) described the type of “heavy” music that is often preferred by adolescents with borderline features in their behaviors, attitudes, and issues. These authors described “heavy” music as containing “themes of rejection of authority, hyper individualism, and acceptance of antisocial behavior. It is also likely that heavy music matches the qualities and the intensity of their feelings (e.g., tough, wild, angry) associated with the themes through its pounding rhythms, fast pace, and

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its discordant sounds” (p. 206). In general, the authors indicated that adolescents who have more problems behaviorally or developmentally tend to use this music as a distraction. Adolescents who do not have severe developmental delays or behavioral problems tend to choose “lighter” music. So if a music therapist is planning on working with an adolescent on developmental issues at a fixated stage of early childhood, the “heavy” kind of music described in this article should be offered for listening and instrumental expression. It is evident that there is little research in the literature regarding music therapy and persons with BPD. What exists is based on individual clinical case studies. Since music therapy seems to have good results with this population in the case studies, it is important to begin to conduct research with this population.

SUMMARY Like any syndrome, BPD has many different symptoms that need to be considered in order to determine whether the client has this disorder. The basic therapy issues are often complicated by other problems. Many persons with BPD have addictions; substances are used impulsively to alter feelings of internal emptiness and depression, while cutting and suicidal ideations are attempts to end the emotional pain that exists due to difficulties in attachment and ego development. The BPD client often observes other people maturing and has no idea how that occurs and why it’s difficult for her. Very often in a hospital setting, the music therapist may be working with a client who has not been identified with this diagnosis. Instead, the individual behaviors may be identified as Axis I or major mental illnesses and treated as such, e.g., depression. The role of the effective therapist, regardless of the type of therapy practiced, is to address the lack of parental support and to develop the ability to relate to others and to build a functional, independent sense of self. In other words, the client significantly increases her ability to tolerate and problem-solve difficult situations and feelings experienced during life. Like the rudder on a boat, the therapist maintains the role of a stabilizer, container, or “good enough parent” who provides a sense of trust that the child has the ability to function. This type of development usually requires several years to obtain. The total therapeutic process, therefore, requires significant time, usually two to three years. In the inpatient setting, the client with BPD will seek a “good” caretaker who is usually the primary therapist who has control over her stay in the hospital. At times, the client who is frequently admitted to the same hospital for destructive acting out can develop a maternal transference to the hospital or the unit staff. The music therapist on the treatment team also participates in creating an environment to encourage developmental change. Working with a person with BPD also requires additional training in music therapy and/or counseling. The therapist’s recognition of the symptoms of BPD can reduce the tendency for this client to act out in groups, individual therapy sessions, or in the unit. Knowledge of typical transference and countertransference reactions is also important to help the BPD individual continue to develop, rather than reinforcing the maladjustment and rigid defenses of BPD thinking and behaviors. In group work, the therapist’s knowledge about symptoms and defenses used by persons with BPD can also increase the group members’ abilities to help the client develop more mature coping mechanisms. In addition, the client who has had a good inpatient experience with therapy may be able to tolerate outpatient therapy following her inpatient experiences.

REFERENCES American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). (DSM-IV-TR). Arlington, VA: Author.

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American Psychiatric Association (APA). (2012). Personality and personality disorders. In DSM-5 Development. Text subject to change. Retrieved March 18, 2012, from http://www.dsm5.org/proposedrevision/Pages/PersonalityandPersonalityDisorders.aspx Austin, D. (2009). The theory & practice of vocal psychotherapy: Songs of the self. Philadelphia, PA: Jessica Kingsley. Bonny, H. L. (1978). Facilitating Guided Imagery and Music sessions. Baltimore, MD: ICM Books. Bruscia, K. (Ed.). (1998). The dynamics of music psychotherapy. Gilsum, NH: Barcelona Publishers. Burns, D., & Woolrich, J. (2008). The Bonny method of Guided Imagery and Music. In A. Darrow (Ed.), Introduction to approaches in music therapy (2nd ed.; pp. 56–60). Silver Spring, MD: American Music Therapy Association. Dvorkin, J. (1991). Individual music therapy with an adolescent with a borderline personality disorder: An object relations approach. In K. Bruscia (Ed.), Case studies in music therapy (pp. 251–268). Gilsum, NH: Barcelona Publishers. Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: The Guilford Press. Mahler, M., Pine, F., & Bergman, A. (1975). Psychological birth of the human infant. New York: Basic Books. Masterson, J. (1985). Treatment of the borderline adolescent. New York: Brunner-Mazel. Masterson, J., & Klein, R. (1989). Psychotherapy of the disorders of the self: The Masterson approach. New York: Brunner-Mazel. Meichenbaum, D. (2003). Treatment of individuals with anger-control problems and aggressive behavior: A clinical handbook. Williston, VT: Crown House. Montello, L. (2002). Essential musical intelligence. Wheaton, IL: Theosophical Publishing. Murphy, M. (1991). Group music therapy in acute psychiatric care: The treatment of a depressed woman. In K. Bruscia (Ed.), Case studies in music therapy (pp. 451–464). Gilsum, NH: Barcelona Publishers. Nevid, J. (2009). Essentials of psychology: Concepts & applications (2nd ed.). Boston: Houghton Mifflin. Nolan, P. (1983). Insight therapy: Guided Imagery and Music in a forensic psychiatric setting. Music Therapy, 3(1), 43–51. Nunn, K., Hanstock, T., & Lask, B. (2008). Who’s who of the brain: A guide to its inhabitants, where they live and what they do. Philadelphia, PA: Jessica Kingsley. Odell-Miller, H. (2011). Value of music therapy for people with personality disorders. Mental Health Practice, 14(10), 34–35. Robson, K. (Ed.). (1997). The borderline child. Northvale, NJ: Jason Aronson. Schwarz, K. & Fouts, G. (2003). Music preferences, personality style and developmental issues of adolescents. Journal of Youth and Adolescence, 32(3), 205–213. Searles, H. (1994). My work with borderline clients. Northvale, NJ: Jason Aronson. Shore, A. (2008). Affect regulation and the repair of the self. New York: Norton. Smith, G. H. (1991). The song-writing process: A woman’s struggle against depression and suicide. In K. Bruscia (Ed.), Case studies in music therapy (pp. 479–496). Gilsum, NH: Barcelona Publishers. Stone, M. (Ed.). (1986). Essential papers on borderline personality disorder. New York: New York University. Winnicott, D. W. (1989). Psycho-analytic explorations. Cambridge, MA: Harvard University Press. Yalom, I. (1983). In-patient group therapy. New York: Basic Books.

Chapter 13

Adults and Adolescents with Eating Disorders Peggy Tileston _____________________________________________ DIAGNOSTIC INFORMATION The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association [APA], 2000) lists the major eating disorders in adolescents and adults as Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Classified (EDNOS), and proposes that Binge-Eating Disorder (BED) be moved from the appendix into a freestanding diagnosis of its own for the upcoming edition, the DSM-V. The following diagnostic criteria are from the DSM-IV-TR. Diagnostic criteria for Anorexia Nervosa include refusal to maintain body weight at or above a minimally normal weight for age and height, intense fear of gaining weight or becoming fat even though underweight, disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, denial of the seriousness of the current low body weight, and the absence of at least three consecutive menstrual cycles. Two types of Anorexia Nervosa are specified. The Restricting Type occurs when “weight loss is accomplished primarily through dieting, fasting, or excessive exercising” and “during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge eating or purging behavior” (APA, 2000, p. 585). The Binge-Eating/Purging Type occurs when “the person has regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)” (APA, 2000, p. 589) during their current episode of Anorexia Nervosa. Diagnostic features for Bulimia Nervosa include: 1) recurrent episodes of binge eating characterized by both eating, within a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; 2) a sense of lack of control over eating during the episode; recurrent inappropriate compensatory behavior to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise); 3) episodes of binge eating and inappropriate compensatory behavior occurring on average, at least twice a week for three months; 4) self-evaluation unduly influenced by body shape and weight; 5) above disturbances not occurring exclusively during episodes of Anorexia Nervosa. Bulimia Nervosa also has two types. The Purging Type occurs when “during the current episode of Bulimia Nervosa the person has regularly engaged in self-induced vomiting or the misuse of laxatives,

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diuretics, or enemas” (APA, 2000, p. 591). A person with the Nonpurging Type does not engage in those specific behaviors. Diagnostic criteria for Binge-Eating Disorder include recurrent episodes of binge eating characterized by eating within any two-hour period an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances and a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). The binge-eating episodes are associated with three (or more) of the following: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of being embarrassed by how much one is eating, and feeling disgusted with oneself, depressed, or very guilty after overeating. Additional characteristics of BED are marked distress regarding binge eating and the occurrence of binge eating, on average, at least two days a week for six months. The DSM-IV-TR states that an EDNOS diagnosis is for disorders that do not meet the above criteria for any specific eating disorder and can include cases where all of the criteria for AN are met, except that the female individual has regular menses, and/or despite significant weight loss, the individual’s current weight is in the normal range. Another example is when all of the criteria for BN are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than three months. Also included under this diagnosis is the regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies) and repeatedly chewing and spitting out, but not swallowing, large amounts of food (APA, 2000, p. 594). According to information on the website of the National Alliance on Mental Illness (NAMI), “far more individuals suffer from EDNOS than from bulimia and anorexia combined, and the risks associated with having EDNOS are often just as profound as with anorexia or bulimia because many people with EDNOS engage in the same risky, damaging behaviors seen in other eating disorders.” (“Mental Illnesses, Eating Disorder Not Otherwise Specified,” n.d., para. 3). Three more conditions merit mentioning when speaking of eating disorders, though they are not formally classified as eating disorders: excessive exercising, orthorexia, and Night Eating Syndrome (NES). Excessive exercising can herald the onset of an eating disorder and is often one of the behaviors seen in the acute phase of the disease, especially anorexia (Davis et al., 1997), yet it is a condition that also has distinct characteristics. Dr. Theodore Weltzin, Medical Director of Eating Disorder Services at Rogers Memorial Hospital in Wisconsin, writes: Excessive exercise is frequently a daily activity in which the person reports intense anxiety if they are unable to engage in the exercise activity. Those engaging in excessive exercise may plan out their day prominently focusing on exercise, scheduling other activities around their exercise goals. Those engaged in excessive exercise may reduce their social, school, and work activities in order to exercise. Patients who engage excessive exercise often have significant problems with interpersonal, occupational, and academic functioning (Weltzin, 2008, Eating Disorder Hope, “Causes, Diagnosis & Treatment of Excessive Exercise,” para. 2). Orthorexia is characterized by an obsession with eating only healthy foods. Dr. Karin Kratina, a nutritionist specializing in eating-disorder treatment, writes that orthorexia: starts out as an innocent attempt to eat more healthfully, but the orthorexic becomes fixated on food quality and purity. They become more and more

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consumed with what and how much to eat, and how to deal with “slip-ups.” An ironclad will is needed to maintain this rigid eating style. Every day is a day to eat right, be “good,” rise above others in dietary prowess, and self-punish if temptation wins (usually stricter eating, fasts, and exercise). Self-esteem becomes wrapped up in the purity of their diet, and they often feel superior to others, especially in regard to food intake. Eventually, food choices become so restrictive, with both variety and calories, that health suffers—an ironic twist for a person so completely dedicated to healthy eating. Eventually, the obsession with healthy eating can crowd out other activities and interests, impair relationships, and become physically dangerous. (Kratina, 2006, National Eating Disorders Association, “Orthorexia Nervosa,” para. 1) NES is diagnosed when a person limits eating during the day, eats excessive amounts of food during the night, and often wakes at night to eat (O’Reardon, Peshek, & Allison, 2005). One treatment program’s fact sheet describes it as having symptoms and consequences similar to those of an eating disorder, including compulsive eating, food obsession, feelings of guilt and shame, and physical and mental health issues (Casa Palmera, 2009, “How to treat Night Eating Syndrome”). Obesity, depression, and low self-esteem are also associated with NES (Gluck, Geliebter, & Satov, 2001). It is very common for those diagnosed with eating disorders to have co-occurring psychiatric symptoms and diagnoses. A position paper by the Society of Adolescent Medicine reports on research showing that for both AN and BN there is a 50% to 80% chance of being diagnosed with an affective disorder, especially depression. There is a 30% to 65% incidence of anxiety disorders, especially obsessive-compulsive disorder and social phobia, in both populations. The rate of substance abuse in AN is 12% to 21%; it falls between 9% and 55% in BN. The estimates for a diagnosis of a co-occurring personality disorder are 20% to 80% (Golden et al., 2003, p. 497). In addition to the diagnoses just mentioned, the music therapist may also encounter clients diagnosed with posttraumatic stress disorder (PTSD), bipolar disorder, or dissociative disorder. Some clients may engage in self-harming behaviors such as cutting, burning, or using an eraser to inflict pain (Paul, Schroeter, Dahme, & Nutzinger, 2002). There is also a correlation between the incidence of childhood sexual abuse and ED, especially in BN and BED (Brewerton, 2004, 2007; Dalle Grave, Oliosi, Todisco, & Bartocci, 1996). According to one study, 50% of the anorexic and bulimic clients had suffered sexual abuse, compared to only 28% of patients admitted with other eating-disorder diagnoses; this was a significant difference. Of the four types of abuse surveyed, only those patients suffering rape were likely to have sought help from caregivers prior to admission (Hall, Tice, Beresford, Wooley, & Hall, 1989). Another factor of which the therapist needs to be cognizant is the presence of a number of medical conditions that can accompany eating disorders. This can aid in assessing and determining what forms of therapy and types of sessions would be appropriate or contraindicated for an individual. Symptoms can range from fatigue, fainting, muscle weakness, and cognitive impairment to heart problems, osteoporosis, kidney failure, and gastric and esophageal conditions. A recent meta-analysis of 36 studies on the topic found that mortality rates in patients with eating disorders are high, and that in some cases (especially those involving AN), they are much higher than for other psychiatric disorders (Arcelus, Mitchell, Wales, & Nielsen, 2011). According to the website of the Eating Disorders Coalition, eating disorders have the highest mortality rate of any mental illness, from 5% to 20% (Sullivan, 1995; Zerbe, 1995). There is a dangerous misconception that eating disorders are found only among young, heterosexual, Caucasian females. While it is true that most studies have been conducted with this population, there is a growing amount of evidence that disordered eating is found across the cultural and sexual spectrum. The danger associated with this popular misconception is that among other populations,

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ignorance and lack of awareness result in poor prevention efforts and a reluctance to enter treatment. There are also standards and pressures in certain career choices that may contribute to the development of an eating disorder, such as those of model, dancer, gymnast, ice skater, and cycler. Two major studies confirm that young African-American women are as likely to report binge eating and vomiting behaviors, and more likely to report fasting and abusing laxatives or diuretics, as young Caucasian women (StriegelMoore et al., 2000; Striegel-Moore, et al., 2003). A 1995 study reported that a growing number of Asian and Asian-American women professed a desire for thinness and that body dissatisfaction was increasing (Hall, 1995). A review of literature examining the prevalence of eating disorders and negative body image among Asian-American women conducted in 2007 reported that “there is a similar prevalence of eating disorders and their symptoms, especially body dissatisfaction, among Asian-American girls and women” as compared to their Caucasian peers (Cummins & Lehman, 2007, p. 217). A similar study that same year noted that: “Latinos have elevated rates of any binge eating and binge-eating disorder but low prevalence of anorexia nervosa and bulimia nervosa. The U.S.-born and those living a greater percentage of their lifetime in the U.S. evidenced higher risk for certain eating disorders while severe obesity and low levels of education were significant correlates” (Alegria et al., 2007, p. 15). Another 2011 study found that the problems affecting Native American women in regard to eating disorders mirrored those among ethnically white women. The groups were similar in reporting binge eating, purging, and ever having been diagnosed with an eating disorder. The authors state: “That eating disorders are diagnosed as frequently among AI/NA women as white women in the U.S. is a striking finding given known ethnic disparities in access to mental health care in the U.S.” (Striegel-Moore et al., 2011, p. 565). Although eating disorders are most common in the United States and Western European countries, they are on the increase globally (Makino, Tsuboi, & Dennerstein, 2004). An estimated 10% of reported cases of individuals with eating disorders are male, though the number may be low because of underreporting (Fairburn & Beglin, 1990; Wolf, 1991). In fact, a 2007 Harvard study of 3,000 people with anorexia and bulimia reported that 25% were men, with 40% having a binge-eating disorder (Hudson, Hiripi, Pope, & Kessler, 2007). A 2011 study of adolescents found that binge eating and bulimia were indeed more prevalent among adolescent girls than boys, but that the prevalence of anorexia nervosa was exactly the same (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). A BBC report on eating disorders in men reported that according to the National Health Service, there has been a 66% increase in hospital admissions in England for male eating disorders over the last 10 years (Knowles, 2011). Disordered eating and problems with body image are also found among lesbian, gay, bisexual, and transgender clients. One study found that the prevalence of EDs among lesbians and bisexual women is comparable to that among heterosexual women (Feldman & Meyer, 2007). Results from the same study showed that gay and bisexual men had a significantly higher prevalence of eating disorders than heterosexual men. In one of the few studies done in the transgender community, male-to-female subjects showed higher scores on restrained eating, eating concerns, weight concerns, shape concerns, drive for thinness, bulimia, body dissatisfaction, and body checking than male controls, and concerning some variables also when compared to female controls. Female-to-male subjects displayed a higher degree of restrained eating, weight concerns, shape concerns, body dissatisfaction, and body checking than male controls (Vocks, Stahn, Loenser, & Legenbauer, 2009). There seems to be no one causal factor for developing an eating disorder. Genetics and biochemistry, cultural influences and pressure from the media, family and psychological dynamics, and individual life experiences all play their part. A multipronged approach that includes medical, nutritional, behavioral, family systems, psychodynamic, and psychosocial treatment seems to be the most beneficial. For some clients, the addition of spiritual, 12-Step, or feminist models of treatment is also helpful.

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NEEDS AND RESOURCES There are similarities and differences worth noting between adolescents and adults with eating disorders. One often hears professionals who work in the field echo the observation of Dr. Michael Berrett that “many adult eating-disorder clients are in some ways teenagers developmentally, and adolescent eatingdisorder clients are often ‘parentified’ children or premature adults” (Berrett, 2009, para. 13). As in addiction, when an individual develops an eating disorder in childhood or, more likely, in adolescence, the normal course of mastering age-appropriate physical, cognitive, psychological, and psychosocial developmental milestones is often disrupted or arrested. In this sense, many of the psychological and interpersonal issues that arise in therapy will actually be similar. Differences can become obvious in terms of life experience. An adult may be struggling with marriage, career, financial, child-rearing, or caregiving concerns, very few of which an adolescent will relate to. On the other hand, Berrett agrees that adolescents have more acute needs than adults, and suggests that adolescents need more structure, more behavioral and experiential approaches, more encouragement, positive feedback, and praise, more explicit directives and guidance, more family involvement, more short-term and achievable goals, more education and opportunities to learn, and more assignments between sessions to keep the work going. The music therapist will find that some treatment programs are specifically geared to either children and adolescents or adults, others combine adolescents and adults, and still others offer a combination of services in which there are common groups and age-specific groups. In addition to having a dysfunctional relationship with their bodies and preoccupation with weight, appearance, and food, people of any age group with an eating disorder may have common characteristics that include negative self-worth, cognitive distortions, difficult family and interpersonal relationships, problems with emotional and behavioral self-regulation and soothing, and varying levels of depression and anxiety (Brewerton, 2004; Costin, 2007; National Eating Disorders Association, 2005). Characteristics more common in AN than in other forms of the disorder can include a grossly distorted body image, perfectionism, highly restrictive and ritualistic behaviors with exercising, food, and appearance, and either shutting down and isolating or acting overly compliant and approval-seeking. Sexuality is often rigidly repressed or numbed. Clients with AN may be gifted, high achievers with selfesteem and confidence in several areas of their lives, but their self-worth can still be at zero. Characteristics seen more often in BN or BED can include emotional and behavioral lability, an uncontrollable compulsion to engage in the binge and/or purge ritual, sexual acting out behaviors, and addiction (Brewerton, 2004; Costin, 2007; Diaz-Marsa, 2000; National Eating Disorders Association, 2005). People who struggle with eating disorders are often extremely creative, talented, intelligent, and resourceful. They have had to be, in order to survive and to maintain their eating disorder. When the psychological characteristics such as rigidity or lability and the behaviors of bingeing, purging, and restricting are viewed as maladaptive survival mechanisms for coping with internal and external challenges, then treatment can address the underlying needs that those behaviors are trying to meet. Costin (2007) has listed several adaptive functions that eating-disorder behaviors serve: to soothe and nurture, numb or distract, get attention, discharge problematic feelings, provide a sense of predictability and a sense of self-identity, serve as self-punishment, protect or give feelings of safety, discourage intimacy, and give proof of self-blame (p. 79). Eating-disorder behaviors and rituals also provide a sense of control over internal feelings or external experiences that feel too overwhelming or threatening, and offer a way of communicating messages directly and symbolically when all other avenues are blocked. The illness can provide a haven from growing up, being sexual, or assuming accountability for one’s life in the face of perceived threats associated with those occurrences.

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When interacting with clients in the acute phase of their illness, the music therapist should generally refrain from making statements such as “You look good today” or “You look so much healthier.” Avoid and discourage discussions of weight, numbers, and amounts of time spent exercising. Comments that focus on appearance and weight can reinforce an unhealthy preoccupation or trigger anxiety. In the same vein, it is best to stay away from comments that evaluate or pass judgment on a performance or task. Instead, ask about how someone is affected and encourage the practice of self-reflection and awareness.

REFERRAL AND ASSESSMENT Most music therapists serve clients with eating disorders on medical or psychiatric inpatient units, inpatient units specific to eating disorders, and residential treatment programs that specifically address eating disorders. In most cases, the music therapist will know the diagnosis of the client prior to working with them. Many of these facilities have a strong expressive therapy component, with music therapy offered as an integral part of the treatment milieu. Some programs mandate attendance in music therapy groups. Others offer music therapy as part of a menu of choices, and participants may be self-referred or in attendance because a member of the treatment team referred them. Referrals for individual sessions usually come from a member of the client’s treatment team, as a request from the client themselves, or as a recommendation from the music therapist. Some intensive outpatient or day programs may also offer music therapy services, though this seems to be less common. Music therapists in private practice receive clients through self-referral or from a medical professional working with the client. There are no music therapy assessment procedures that specifically address eating disorders. The Improvisation Assessment Profiles (Bruscia, 1987) and Loewy’s (2000) 13 Areas of Inquiry can be used when conducting individual improvisational and music psychotherapy sessions, and familiarity with the tools can inform the therapist’s observations during group improvisational sessions.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • • •

Relaxation and Guided Imagery to Music: involves use of scripted imagery and music designed to evoke a relaxation response. Song Lyric Discussion: Clients listen to songs and discuss song themes based on therapeutic issues. Responding to Music Through Art, Writing, or Movement: Clients listen to recorded music and express themselves through art, writing, movement, or a combination of media.

Improvisational Music Therapy • • • •

Group Instrumental Improvisation: Clients spontaneously make up music together, using simple instruments within their capabilities and preferences. Drum Circles: Clients spontaneously make music together oriented around drums and rhythm-based playing for the purpose of promoting social unity and enjoyment. Group Vocal Improvisation Session: Clients use their voices extemporaneously to create a group piece of music. Group Improvised Role-Plays: Clients play roles with one another using instrumental (and sometimes vocal) music improvisation.

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Group Instrumental Improvisation: One or more clients in the group improvise instrumental pieces to express what they have difficulty expressing verbally.

Re-creative Music Therapy • • •

Sing-Along: Clients choose a song with personal meaning from a list of songs and sing it with the group and/or therapist. Group Singing: This experience differs from the sing-along in that it involves the group in choral singing. Individual Music Lessons with a Therapeutic Focus: This involves teaching the client how to play an instrument in order to access and work through therapeutic issues.

Compositional Music Therapy •

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Group/Individual Songwriting: In this two- to three-session exercise, the client and/or group look over the lyrics of several songs about eating disorders and then, with the help of the therapist, write a song using their own lyrics. Group/Individual Songwriting: Guided by the therapist, the client(s) write a song about emotional self-care.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Relaxation and Guided Imagery to Music: Soothing the Soul Overview. This procedure involves the use of scripted imagery with music designed to evoke a relaxation response. The level of therapy is augmentative. Relaxation and guided imagery are included here under one heading, though they can be taught as two distinct group sessions. One could focus solely on learning how to use breathing and physical relaxation practices without going into any imagery beyond that used for encouraging physical relaxation. It is also possible to conduct guided imagery sessions without a long physical relaxation segment, though most therapists begin with some form of relaxation. High levels of anxiety usually come with an eating disorder (Bulik, 2002), so sessions that enable clients to learn and develop positive coping skills for managing stress and anxiety are extremely beneficial. Beyond the teaching of basic relaxation skills such as breathing, progressive muscle relaxation, or autogenic training, sessions can be tailored to specific goals such as moving from physical disconnection toward the development of a nonjudgmental, mindful awareness of the body. Other general goals for physically oriented sessions include learning skills for self-soothing. When guided imagery or guided visualization is added to the session, goals could then include increased self-awareness and sense of identity. Despite the contraindications below, relaxation and guided imagery are frequently used with this population because this type of session can provide powerfully transformative experiences. It is important to note that many of the traditional methods of physical breathing and relaxation training present a minefield of triggers for the client with an eating disorder, since in ED, the body is the battlefield. A phrase such as “bring your awareness to your stomach and allow your belly to be soft” can set off a firestorm of anxious responses! Clients have reported that they “immediately zoned out” or wanted to jump out of their skin when certain body parts were mentioned or particular words were used. Clients new to these practices and those with AN will usually have the strongest reactions. One way to approach this is to initially keep language more general than specific, as in “soften the tension in the middle of your body” rather than “soften your belly.” If a client is extremely anxious, stay with safer areas

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of the body such as hands, arms, feet, legs, neck, shoulders, face, and jaw. As they become more comfortable with increasing levels of physical sensation and awareness, it may be possible to add more specific words and areas of the body. The therapist needs to be sensitive not only to vocabulary, but also to the timing of the session: Clients tend to be even more anxious and resistant to noticing their bodies immediately before or after a meal. So although these aren’t the best times for a relaxation session, if it’s the only available time, then “name the elephant in the room” and address the fact that anxiety may be higher because of the meal. The script can also specifically address pre- or postmeal anxiety. If the session is before a meal, helping clients stay in the present moment is helpful, but so is imagery that helps them practice relaxing at the meal table. Weaving phrases into the script such as “and let this sense of ease and comfort accompany you as you leave the room” and “while you are sitting at the table, you can take a breath and remember this peace whenever you feel the need to” can support carrying the practices learned in the session into the dining room. Helping clients to relax and replace negative thinking with positive and soothing self-talk after a meal could sound like: “My breathing is slowing and deepening, and I am learning how to allow myself to be nourished on all levels.” Care must be taken when working with clients who have a history of physical and/or sexual trauma. Since there is a high correlation between a trauma history and ED, especially in BN, you can assume that when leading relaxation groups, anywhere from 30% to 50% of the group members have had past trauma (Brewerton, 2007; Conners & Morse, 1993). Here is another case where the body is the battlefield and has armored itself against feeling or remembering through muscular tension and the numbing of physical awareness. When we ask a client to relax or release that armor during a relaxation session, we are asking them to let go of a major coping skill. They may not be psychologically ready to do that. Therefore, creating conditions that foster safety and personal choice are of paramount importance. Phrases such as “you only need to release as much tension as you feel comfortable releasing right now” and “you can open your eyes at any time, and close and open them again as you choose” support those conditions. In a group setting, I always give participants the option to read, journal, or sketch quietly if they don’t feel comfortable with the session, especially if I know there are clients with Post-Traumatic Stress Disorder (PTSD) or trauma present. Other clients have said that when there are too many silences in the script, their minds go to scary places. For them, the therapist’s voice helps anchor them to the present moment. It is best if relaxation and guided imagery sessions are conducted by therapists with training in trauma-informed care or have some experience working with survivors of trauma. Relaxation and guided imagery sessions may be contraindicated for clients who have co-occurring thought or dissociative disorders; however, when they are clinically indicated, the script must be kept very concrete (progressive relaxation, for example), the clients should keep their eyes open, and any imaginative or metaphorical references should be avoided. Summer (1988) reported that patients experiencing psychosis should never participate in music-assisted relaxation when it involves imagery. Preparation. For the novice therapist, the use of a relaxation script is recommended, as is rehearsing the script with the music before conducting the session. There are many books and online resources that offer such scripts, and these can be adapted to meet the needs of an ED population (Grocke & Wigram, 2007; Hanser & Mandel, 2010). Writing a script specifically tailored to a particular issue for a client or group is another option. The therapist may also ask for input from the group or individual and then weave their suggestions into the script. When one has conducted many relaxation sessions and feels more comfortable with the process, improvising a script and responding to the needs of the clients in the moment can be very effective. Vocabulary words suggestive of visual, auditory, kinesthetic and olfactory sensory imagery should be included in the script; however, stay away from the sense of taste, due to the obvious triggering association with food. When leading a guided visualization that will bring clients to a specific place such as a meadow, beach, or mountain, be sure to ask before starting the visualization if

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everyone is agreeable with going to that place. A client once had a panic attack during a guided imagery session involving a trip to the beach because of a past experience of almost drowning at the seaside. The choice of music is important, as is the decision to play live or recorded music. Using recorded music facilitates careful observation of the clients during every phase of the visualization; thus, when using live music, it is best to work with a second therapist or performer who is playing live, so that the guide can concentrate on the script and observe the client’s reactions from moment to moment. In general, the music for a relaxation session should be instrumental, have a slow and steady tempo, have few dynamic changes, and contain predictable melodic and harmonic characteristics (Grocke & Wigram, 2007; Hanser, 1985; Labbe, Schmidt, Babin, & Pharr, 2007). When conducting a guided relaxation session with imagery, the music also needs to be relaxing, but can have more variation to help evoke more imagery. For a more detailed discussion of how to select music, see Grocke and Wigram (2007, pp. 46, 108–111). When using a widely known piece, it is a good idea to check whether anyone has any strong associations with the piece. Pachebel’s “Canon in D” caused a recently divorced client to leave the room in tears because that had been the sound track for her wedding march! The ideal physical setting for a relaxation session is a quiet room with the least amount of potential disturbance possible. If you know that there may be interruptions, place a sign on the door along the lines of Relaxation Session in Progress. Please Enter and Leave Quietly. Have clients lie down on their backs on a comfortable surface such as a carpeted floor or yoga mat, or sit in a reclining chair. Ideal options are not always available, so adaptations can be made for any setting. Sometimes relaxation sessions can even be done with clients sitting in hard-backed chairs or in the midst of the continual coming and going of staff and other patients! Some clients, especially those with a trauma history, may feel too vulnerable when lying down and prefer to remain seated. It is important to allow them that choice. The space has to have a sense of comfort and safety. Pay attention to privacy; lighting; the closing or opening of blinds, curtains, and doors; the presence or absence of a blanket to cover the body; and where in the room the client wants to position herself. For some anorexic clients, having adequate padding underneath them is important for their comfort. What to observe. Watch the breathing patterns of clients to discern if they are relaxing or becoming more anxious. If the breath deepens and slows, it indicates increasing relaxation. Breathing that increases in rate and becomes more shallow suggests rising levels of anxiety. As bodies relax, different muscles may jerk suddenly in release, and this is okay. Watch for when and if eyes open and close, as this can point to attention span issues or level of anxiety. If a client is becoming more and more anxious, add reminders into your script to “take a deep breath, remember that you can open your eyes or sit up if you want to increase your comfort.” If the client continues to appear anxious, move closer to them, softly say their name, and give them permission to sit up. Never touch a client when they are lying down or extremely anxious unless you ask permission first (“Would holding on to my hand be helpful to you?”). Touch can be useful for grounding and connection to the present moment and comfort, but it can also be a trigger. The safest rule is: If there is any doubt, don’t touch. Even when the space and script are as safe as they can be, a client may still have a flashback. That is the nature of flashbacks—they come without warning. The DSM-IV TR defines a flashback as “acting or feeling as if the traumatic event were recurring” (APA, 2000, p. 468). There are many variations, from completely reliving a past traumatic event to having sensory manifestations such as body sensations, images, sounds, tastes, or smells. Sometimes no conscious memories come, but the client experiences feelings of confusion, panic, being trapped, or helplessness. As mentioned above, the therapist may need to assist the client with coming into the present moment. Speak in a gentle, steady voice, say their name, say who you are. Don’t shout, but make sure the sound of your voice is firm enough to cut through any sounds they are making or may be hearing internally. Encourage them to use their senses to come into the present moment. “Sally, Sally. This is Peggy. I’m right here with you. Sally, I want you to open your eyes

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now. You’re here with me and you’re safe. You’re here at the center, you’re safe, open your eyes, hear my voice, look at Linda’s red shirt, see her smiling at you? Sally, you’re safe. Would you like to hold my hand?” In a group setting, you may have to stop the session to address the situation, especially if the client is having an obviously severe episode. It is important to offer the opportunity for both client and group to name and process what just happened. If you are in an inpatient unit or residential program and staff is available, an option would be to ask a staff member to process with the client outside of the room while you tend to the rest of the group. There are no hard-and-fast rules for responding to a flashback, since it depends on the client, your knowledge of the client, and the nature of their flashback. Clients can easily fall asleep during the session. They either need the sleep, or falling asleep has become an escape from awareness for them. When a client falls asleep in an individual session, let them rest for 5 to 10 minutes before waking them up. In a group setting, unless their snoring is disturbing the group, let them sleep. If the snoring is disruptive, move closer and whisper their name to wake them up. If that doesn’t work, gently touch or shake them on a place lower down on their body, such as the calf or foot. If it’s appropriate to the session, you may also choose to process the reasons for falling asleep. It may be as simple as “I didn’t get much sleep last night,” or it could be “I zoned out when you got to the thighs.” Either way, there is usually material to discuss. Procedures. Begin by introducing the topic and goals for the session. At this point, participants may let you know that they are unable or unwilling to participate. Encourage participation while offering quiet alternatives. Make any needed adjustments to the physical environment and ask participants to make themselves comfortable. It is best for physical relaxation that no limbs, such as legs, are crossed. If the client is seated on a chair, suggest that both feet be flat on the ground and that they allow the chair to support the back. The arms can rest on the thighs, lap, or arms of the chair. If the client is on the floor, ask them to lie on their back with arms at the sides, palms face up and a little bit away from the body (about four to six inches away from the side of the body at the elbows). Legs are stretched out, with the feet naturally splaying out to the sides. (Feet are about 12 inches, or hip width, apart, but don’t use the phrase “hip width.”) Again, this is a vulnerable position, so some clients may want to use a blanket, and others may choose to sit. Encourage those who want to curl on their sides in a fetal position to try the blanket or remain seated. Position yourself and the source of music so that all in the room will be able to hear you. Begin the music, adjust the volume as needed for the room, and start your script. Speak in a relaxed, steady, calm tone of voice when leading relaxation. Make sure to breathe! When leading visualization with imagery, your voice can have more animation to it. When the script ends, encourage stretching, rolling to one side before sitting up, wiggling toes, looking around, making eye contact with others. People are often so relaxed that they don’t feel like speaking immediately. Offer opportunities to journal or draw (see possible adaptations) or encourage individuals to take a few minutes to notice how they were affected. After the session, facilitate discussion and processing of how they were affected, the sharing of experiences and imagery, any difficulties encountered, what was helpful and what was not, what they are learning, how this can be useful, and in what situations they could apply it. Ask open-ended questions such as: “What was that like for you?” or “What can you say about your experience?” Ask participants to notice if they feel any different from when they first walked into the room. Listen for any common themes or patterns that arise and mention them in your closing statements. The session can close there, or with a go-around asking each person to state in one word or short phrase how they are feeling. Adaptations. Relaxation and guided imagery sessions can be easily adapted for individual work, and offer more of an opportunity to address specific therapeutic concerns in that setting. Therapists trained in the Bonny Method of Guided Imagery and Music (GIM) will find that this approach can be very effective for both individual and group work. If there is enough time, the clients can write, draw, move or create sound/music right after the relaxation/guided imagery experience, which can help them to integrate and express how they responded to the session in a variety of nonverbal ways. Verbal processing

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may or may not follow. This option is more easily done in individual sessions, but can be done in groups as well. As mentioned above, scripts can be customized to address a wide variety specific issues, such as befriending your inner child, meeting an inner ally or advisor, developing a nonjudgmental awareness of the body, or staying centered in a potentially stressful situation.

Song Lyric Discussion: OMG—That’s So Me! Overview. In song lyric discussion, clients listen to songs and discuss song themes based on therapeutic issues. This session is primarily at the augmentative level of therapy, but can also move into the intensive level when the therapist and client(s) process in such a way that the focus shifts from the song to the therapeutic needs of the client. This experience tends to be very popular and effective with all ages of this population because it provides an enjoyable and nonthreatening method for clients to express themselves and to begin discussing and processing their feelings and experiences. Clients can choose their level of response by staying on the surface and talking about why they like the song or about the artist rather than themselves. Grocke and Wigram (2007) refer to this as “a projective technique whereby difficult emotions can be expressed via projection onto the artist, or the lyrics of the song” (p. 164). Clients more able to work on a deeper psychological level would be able to respond to the songs and to the therapist’s facilitation with more personal sharing. When the client is asked to choose or bring a song that reflects who they are and what they feel, this can augment their sense of control and validation. General goals for this type of session include increasing insight, self-awareness, emotional awareness, and the ability to process and verbalize thoughts, feelings, and experiences; facilitating an awareness of and connection to others; promoting a realistic and positive sense of identity; and providing opportunities for enjoyment. The only contraindications for this session are for clients who are not able to process cognitively or express themselves verbally. Preparation. Materials needed are a selection of recorded songs (a minimum of 10) appropriate to the ages, issues, and cultures of the clients and a method to play the songs that will provide high-quality sound. Though not necessary, lyrics sheets can be a huge benefit when discussing specific lines or sections of a song. Have the clients sit in a circle or as close to a circle as possible, with the source of the music placed so that all can comfortably hear the music. What to observe. While the song is playing, observe not only the client who chose the song, but others in the group as well. Look for nonverbal body and facial cues that indicate various feelings as well as anxiety, agreement, or withdrawal. If side conversations start up, remind participants to show respect through silence. Procedures. Start with a warm-up, such as an explanation of what to expect and the therapeutic goals of the session. An alternative warm-up is to facilitate a simple discussion of the role music plays in our lives, how certain songs and artists are like companions on the journey, how they often speak the words and feelings we can’t or don’t express. The question “What role does music play in your life?” is usually enough to get a discussion like this going. Grocke and Wigram (2007) have an excellent chapter on leading song lyric discussions in their book Receptive Methods in Music Therapy. Pass out the lyrics packets and ask participants to choose one song with which they resonate, a song that seems to speak to them or for them in some way. Either ask for volunteers to share “their song” or conduct a more formal “go-around” of the group, where one person starts and the sharing proceeds around the circle in order. There is a good chance that more than one person has chosen the same song, so these participants can share together after the song is played, and you can direct your questions to all of them. Ask the group for a respectful silence as each song is played.

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After the song has played, facilitate sharing and discussion through asking open questions (Egan, 1998; Grocke & Wigram, 2007; Nolan, 2005) such as “What was it that inspired you to choose this song?” “What do you imagine the artist was thinking or feeling?” “How do you relate to that?” “What part of the song speaks the loudest to you?” “Has anyone else here thought or felt that way?” When so indicated, these open questions can be followed with ones that probe deeper or further (Egan, 1998; Grocke & Wigram, 2007). The number and depth of questions should be determined by time constraints, the number of participants, and the individual client’s or group’s ability for insight and willingness to selfdisclose. This group can often extend to more than one session, depending on the above variables. Suggested questions for closing the session are: How were you affected? Did you notice any patterns or common themes? Can you name something you learned? Questions and discussions that offer participants an opportunity to integrate and “digest” the session before they move on to their next experience are encouraged. Adaptations. There are many variations of Song Lyric Discussion. This session can be easily adapted for individual work, because the basic procedures are the same. Whether one is working with a group or individual, the therapist can focus the session on specific themes through the choice of songs the therapist brings or requests the clients to bring. Empowerment, self-esteem, family issues, songs directly addressing ED, how women are portrayed in popular music, and the effects of isolation are but a few possible topics. If working with an ongoing group or individual, ask them to “bring in a song that describes what it was like for you growing up” or “for next week, bring in a song that echoes your belief of having to be perfect.” Other topics can include songs that depict their past, present, and future; a problem and a solution; a dream or goal. If there is Internet access (through iPhone or computer) in the session room, this can provide the opportunity to immediately access songs, their videos, and their lyrics through sites like YouTube and Lyrics.com. This allows for clients to choose a more personal song rather than select from choices the therapist has brought in. If choosing this approach, be aware that visuals could add a whole new dimension to your discussion, such as how women are portrayed in the video. The disadvantage is that unless you have a printer readily available, you won’t have lyrics sheets. Another adaptation is for the therapist to choose one or two songs that address a specific issue, hand out lyrics sheets, play the song(s), and conduct a discussion based on the song. If you have a client or group that is uncomfortable with or resistant to talking out loud, an option is to make up a sheet of written questions. These questions can be geared to the depth level of therapy you are working with. The client(s) can take their time to reflect on the questions and their answers as they write. For some, writing is more comfortable than talking out loud, and reading what they’ve written is easier than speaking off the cuff. Writing can become a gateway to voicing their thoughts and feelings. When a group lacks cohesiveness or trust, their written responses can be collected and read anonymously to illustrate the threads of commonality that join them. Another suggestion to build group cohesiveness and connection is to ask pairs or small groups to choose one song together and present it to the whole group. This approach also works if the group size is large and time is short. Song lyric discussion is an effective technique when working with couples or families, and the approaches are similar: Ask each member to select a song, discuss one particular song, choose a song together, choose a song that is the family’s theme song. Song lyric discussions can be used to teach specific skills, such as those offered by Dialectical Behavioral Therapy (DBT) (Spiegel, 2010) or Cognitive Behavioral Therapy (CBT) (Hilliard, 2001). The clients themselves tend to be the best source for songs, and it is advisable to have them submit lists of songs that are meaningful to them. Other resources for finding songs are the Internet, using search engine topics such as songs about anorexia, songs about recovering from an eating disorder, songs of empowerment, or songs about denial.

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Responding to Music Through Art, Writing, or Movement: Tuning In Overview. There are many variations of receptive music therapy sessions in which clients respond to a piece of music with art, writing, movement, a combination of any two, or even all three. The piece of music acts as the catalyst, the key that opens the door into their inner worlds and invites them to subsequently explore and express what is found there through art, writing, or movement. The levels of therapy here are thus both augmentative and intensive, since although music serves to open the door, its importance fades as the experience unfolds. If one takes into account the individual perceptual learning and information processing styles of participants (visual, auditory, and kinesthetic), then one can tailor the session to address all three modes or focus primarily on one (Markova, 1996). Because of its nonverbal nature, it is an effective tool for clients struggling to find positive ways to express themselves; because of its creative nature, it provides that safe doorway into conscious and unconscious processes. Goals for these sessions can include the facilitation of creative and verbal self-expression, increased self-awareness and insight, the development of empathy and connection with self and others, the practice of positive coping skills for expressing feelings, and building community and increased interpersonal social skills. Participants with a thought disorder or psychosis would not benefit from this session. Participants in fragile physical health may need to refrain from movement or dance. Preparation. Decide which and how many of the three modalities (art, writing, movement) to use. Consider the length of the session. If the session is 45 minutes to an hour long, stay with one modality; if it is 90 minutes or more, two or more modalities may be included, depending on group size. As with music for guided imagery, if the session is 45 to 60 minutes long, select a piece of music lasting 10 to 15 minutes that contains enough movement and variation to be interesting to listeners. Consider the ages and cultures of the participants. Classical music often works well with adults, but younger clients may prefer electronic, New Age, modern classical, movie sound track, or world music. A program or sound track can also be created before the session, linking together two or three shorter pieces of music. The sound equipment must be able to produce high-quality sound for the size of room. Art supplies for free drawing can include paper (no smaller than 11 inches x 17 inches or 297mm x 420mm, if possible), oil and chalk pastels, Magic Markers, colored pencils, tempera paint, watercolors, brushes, and sponges. When creating collages, have on hand enough magazines, scissors and glue sticks or glue to accommodate the size of the group. Also include Magic Markers in collage work in case participants want to add in words or details. A heavier stock of paper is advisable for collage work, but not necessary. If clients will be writing, have pens and paper available. Place the art supplies within reach of participants. Consider whether desks, tables and chairs, or clipboards will be needed for doing art and writing. Sessions can be done on a hardwood, tile, or industrial-carpeted (very thin) floor if tables are not available. When doing movement and dance, the room must be large enough for the group to move around freely. (See Adaptations for an option that includes kinesthetic expression in a smaller room.) What to observe. Some clients may feel stuck and need your help to get started. If someone is sitting for more than 5 minutes in front of a blank piece of paper or standing frozen in the corner of the room, quietly approach the person and ask what’s happening. Respond accordingly, while also offering encouragement, support, and alternatives. Never force a person to participate or produce. In the art tasks, notice what materials are being used (messy paint or precise colored pencils?), how much of the paper is being used (one tiny corner or requesting more paper?), and how a person is working (slowly, methodically, quickly, messily, tearing it up and starting again?). When scissors are being used, know where each pair is at all times. If you know there are participants present who may engage in self-harming behaviors, you may want to refrain from providing the temptation of scissors. Teach participants how to make a collage by carefully tearing the paper.

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Similar dynamics can be observed with movement. Movement is often harder than artwork or writing for many people, so encourage individuals to spread out and find their own safe space. Tell them that it’s okay to start small (just move one arm), to have eyes closed, to focus on themselves and not others. Clients may want to talk with one another during the process, especially if they are anxious, so encourage silence and a focus on themselves. Procedures. Welcome the group into the room and invite them to find a place to be seated. Describe what the session will entail with words similar to: “Today we are going to listen to a piece of music and explore what happens when we listen deeply and allow the music to suggest images [or movements, words] to us. We’ll respond to the music through creating visual images with the materials you see here [or moving in the room, starting to write whatever words come to us]. Then those who are willing will share their experiences with each other at the end.” When doing a collage, explain that the process of creating a collage involves looking through magazines, cutting or tearing out images and words that catch their eye and seem to fit with the music, and arranging them on a piece of paper. Begin with leading the group through a short breathing practice to help them relax, focus, and come into the present moment. Put the music on, and after a few minutes invite the group to start responding through the medium chosen. When the music ends, ask people to stop for a moment in the silence and take a few breaths. If movement is the modality, when the music ends, ask clients to sit or lie down, lead them through a few breaths, and ask them to notice how they are feeling in their bodies. For art or writing tasks, give participants about 10 minutes to add finishing touches to their work and, if necessary, play the piece again. Fade the music out when you are ready to begin the sharing of work. If a second modality will be used, don’t play the piece while they are putting on finishing touches. When ready to move into the second modality, play the piece again and instruct participants to respond to both the music and their artwork (or their experience of moving, the words they have written). As the music ends, again ask for a breath or two in silence and a few minutes to add finishing touches. Begin the sharing process by asking the group to bring their art or writing with them as they form a circle. Ask open-ended questions such as: “What was that like for you?” “Is there anything else you’d like to share with us?” “What’s going on in that corner?” “What was going on when you made that big leap?” You may be asked to make interpretations, but doing so is not advisable. Leave that to trained art therapists, and reinforce the notion that their interpretation is the one that carries the most meaning for them. Close the session by summarizing some of your observations or with a go-around that asks each person to say one word (or phrase) that describes how the experience was for them. Adaptations. This session can easily be adapted for individual work. Leave the topic open and help the client to formulate a specific theme or focus for the session. Based on that, the piece of music can be chosen by client, therapist, or both. Give the client time and space to create without “hovering” over them, and discourage conversation while they are creating unless they ask for or seem to need assistance. Joanna Booth, who is trained in the Bonny Method of Guided Imagery (BMGIM), has a specific protocol for using music, art, and writing with groups and individuals that she calls Music, Drawing, and Narrative (MDN). She has even designed 14 specific sequences of music for thematic sessions (see Grocke & Wigram, 2007, pp. 211–213). Although it’s advisable to stay away from music with words, lyrics in a foreign language can sometimes add to the colors of the music, and clients can be invited to write their own “translations” as part of the task. In addition, explore instrumental music written by South American (Villa-Lobos), African (Lebo Morake), Asian (Tan Dun), Arab (Omar Khairat), and Indian (Niten Sawney) composers for a wealth of different sounds! This session can also be adapted for participants working together to create a joint mural, collage, story, poem, movement, or dance. Butcher paper comes in a big roll that can be cut to desired lengths and placed on the floor, wall, or table. This can be helpful when a group needs to work on building trust and

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cohesion, or if a common theme or concern is occurring for them all. It can also be adapted for dyads or small groups of three to five people together. If a movement activity is needed but there is insufficient space, encourage exploring movements in their seats using just upper-body, arm, and hand movements or gestures.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Since more has been written on the use of music improvisation in individual work than on its use in group work, this section concentrates on group work. Individual work is addressed in the Adaptations section of each activity.

Group Instrumental Improvisation Session: Sounding It Out Overview. In group instrumental improvisation sessions, the clients spontaneously make up music together, using simple instruments within their capabilities and preferences. Music improvisation sessions can remain on an augmentative level of therapy and can also be conducted at both intensive and primary levels, especially when working with smaller groups or individually. Because creating improvisational music can so quickly tap into deeper emotional and unconscious processes as well as echo the ways participants have of interacting with themselves, others, and the world, it can be a powerful diagnostic and therapeutic tool. Bruscia (1998) lists at least 10 different models of improvisational music therapy and suggests that there are two basic types of improvisational sessions: structured and freeflowing. Both styles can be used with ED. Music improvisation can be geared to all levels of therapy, from the more concrete goals of having fun, building community, and releasing stress to more psychodynamic goals of exploring and expressing feelings, memories, relationships, and experiences. Improvisation can also be used to encourage the development of mindfulness skills such as an orientation to the present moment and nonjudgmental listening. Bruscia (1998) lists the following goals for music improvisation, all of which are applicable to clients with eating disorders: to establish a nonverbal channel of communication and a bridge to verbal communication; provide a fulfilling means of self-expression and identity formation; explore various aspects of self in relation to others and develop the capacity for interpersonal intimacy; develop group skills; develop creativity, expressive freedom, and playfulness with various degrees of structure; stimulate and develop the senses; play, on the spot, with a decisiveness that invites clarity of intention; and develop perceptual and cognitive skills. The most obvious contraindication is a fragile or poor physical condition. Some anorexic clients, especially in inpatient settings, may be too weak or physically compromised to play certain instruments. Some anorexics with fragile bones may need to use mallets instead of their bare hands on drums. Still others may want to play a certain instrument with the covert intention of moving and burning as many calories as possible. You can choose or replace instruments for these clients as you see the need. If it’s appropriate, bring up possible concerns for their safety, which may result in a fruitful discussion. Some clients are not able to tolerate the louder levels of music that may occur in groups and would benefit more from individual sessions. If clients are unable to engage in verbal processing, this would also make participation difficult. Preparation. It is best to have at least as many instruments as group members and offer a diverse range of percussion and a few melodic instruments. When working with a group new to this type of session, keep the melodic instruments to prepared xylophones and other success-oriented instruments that sound pleasing together. You may also choose to play a melodic instrument yourself, such as piano/keyboards, flute/recorder, or a stringed instrument.

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A circle, either on the floor, in chairs, or as a combination of both, is the usual seating format. Either place an instrument at each seat or place them in the middle of the circle or somewhere outside the circle and ask participants to choose an instrument to bring to their seat. Plan to introduce several warmup activities that enable clients to explore and play within the safety of structured exercises before they move into less-structured improvisations, especially if the group is new to improvising together. Decide whether each improvisation will be referential and structured around a theme, or a nonreferential improvisation where the music guides the course of the improvisation (Bruscia, 1987). Although it’s not essential, recording the improvisation and playing it back for the group can yield material for later discussion. If a recording device with good-quality sound is unavailable, it’s best to not record. Clients with eating disorders tend to have ferocious inner critics that will use any opportunity to find fault with something about the session. The room should feel as safe and private as possible, with little chance of observers, listeners, or interruptions. What to observe. Expect resistance from some clients new to this activity! It is the therapist’s job to educate, encourage, and entice clients to engage in something that initially may elicit anxiety and fear, which will often be masked by scorn, derision, or even a flat refusal to participate. Building trust and a therapeutic alliance with your clients over time will help. Loth (2002) introduces new clients individually to music therapy and the instruments prior to the group session. Humor, an easy attitude of playfulness, and the invitation to “experiment and explore” can help ease anxieties. Active participation in the initial structured exercises may also help dispel some of the resistance. Honoring a person’s “No” and allowing them to be silent might also ease their initial resistance and they may choose to join in later, when they are ready. Offer those who are adamant about not participating alternatives such as the role of observer-witness, creative writing, or art-making in response to the music. You can then invite them to share during the processing at the end of the group. A lot can be learned about each individual client from the instruments they initially choose, the ones they discard quickly or never touch, and the ones toward which they gravitate again and again. From a psychodynamic point of view, the physical instrument and their relationship with it is symbolic of psychological processes, and may be viewed and heard in this context. How a person responds in the group session is often indicative of how they respond in life. Also notice how participants hold and play their instruments: tentatively, halfheartedly, gently, quietly, heartily, intently, effusively, ferociously, and so on. Listen for how musical parameters such as rhythm, tone, tempo, timbre, and style are used. Look at facial expressions, which may show emotions and levels of absorption. Be aware of body movements and how a person is or isn’t involving their body. Watch for those who close down, withdraw, and barely play, as well as for those who attempt to control the group with their playing, play impulsively, or are unaware that their playing is dominating the sound. Based on my own experience, participants with AN tend to be more emotionally constricted, quiet, and tentative in their playing, while those with BN or BED diagnoses may exhibit more uncontrolled and impulsive playing. At the group level, notice whether the group is listening to and playing with each other, or playing in a chaotic and disjointed way. The dynamics of any of the above situations can be changed by encouraging everyone to change instruments, gently switching the instrument a particular client is playing, encouraging more balance or listening to each other, and other similar interventions used in drum circle facilitation. The improvisation can also be influenced by musical interventions, such as grounding the piece with rhythm and structure. If intervention is not indicated, it may be better to let the group finish the improvisation and then, depending upon the level of therapy, verbally process the session by offering your own observations and encouraging participants to share their own thoughts and reactions. Watch for a “backlash” effect that can happen when a client has left their controlled comfort zone and offered raw or unfettered expressions of their innermost feelings. The backlash may come later in the

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session, or even afterward—when clients begin to close down, have urges to self-harm, or try to regain control by reinstituting ED behaviors. One way to approach this is to keep in mind that the need to create a safety zone can be addressed through music. Often it is very helpful to use a simple heartbeat rhythm as a way to create a musical “home base” to which individuals and the group can return. Procedures. There are as many ways to open and conduct a group improvisation as there are therapists who conduct them! Have the instruments in the center of the circle as people enter, and invite participants to take a seat in the circle. Briefly explain that the intention of the group is to explore nonverbal ways of expressing ourselves and communicating with each other, and that the idea is not to make pretty sounds or play perfectly, but to explore expressing themselves through sound. “Just as there are colors on an artist’s palette that can convey so much through shading and shape, there are many sounds in this collection of instruments that can help us to communicate with each other.” Have participants remove rings and hard bracelets, both for their safety and the protection of the instruments. Ask them to respect the instruments and treat them gently. Invite participants to choose an instrument from the center of the circle and return to their seats. Give them a few minutes to explore the sounds of their instruments and the various ways they can be played, and to exchange them for another if they want to. You may go around and assist, such as letting djembe drummers know to tilt the drum to allow for a fuller sound. If the group is new to the activity, ask for silence and for a brief go-around where each individual demonstrates the sound of their instrument and different ways to play it for the group. If your group is familiar with the instruments and improvising together, you may be able to move from the centering exercise mentioned below directly into improvising through an instruction to “Begin to sound out how you’re doing today,” or you can choose to introduce one or two warm-ups. The therapist has to play it by ear and by the level of therapy of which the group is capable. If the group seems fragmented, introduce a warm-up or two to encourage listening and resonating together. On the other hand, processing with a group that helps members to discuss their fragmented condition could be very beneficial. If the group is new, I suggest using three or four short, simple, warm-ups. A call-and-response exercise, where the group imitates a rhythm that you or other participants set; sounding the lub-dub of a heartbeat in unison for a few minutes; exploring different parameters such as fast, slow, loud, and soft; giving instructions to “make silly/sad/irritating/happy sounds”; or introducing musical “as if” scenes such as “play as if you’re trying to soothe a baby” or “play as if you’re walking barefoot on hot sand” are examples. When the group is ready to move into the improvisation, explain that returning an instrument to the center of the circle is an option if someone would like to try a different instrument or be in silence for a while. Lead a brief centering meditation that includes sitting in silence while taking a mindful breath or two, tuning in to ourselves, and then looking around to make eye contact with the group or one or two people. If the group is familiar with improvising together, you might give the simple instruction to “Begin now, as you feel it.” Newer groups or groups that lack cohesion initially benefit from more direction and structure than this, so an invitation to “Begin to sound out and express how you’re feeling today” or “Begin to create a sound track for what’s going on inside” would be appropriate. You can also introduce a more structured session by making specific suggestions such as: “Start playing with a focus on yourself and your sound and then gradually start to listen to and interact with others in the room.” This author’s preference when working with group improvisation is to play minimally to increase the focus on listening and observing. There may be times when the therapist will join the group to model, reflect, rhythmically ground, harmonize, or gently guide, and at other times she may be observing. Depending upon how long the improvisation lasts and how much time there is, the therapist may be able to facilitate more than one improvisation and vary the instructions for each one. The therapist might start with an open improvisation, go into a theme on which the group decides, and close with a theme on which she decides. Improvisations often come to a close organically, but the therapist may need to facilitate a closing if it

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extends into the time for processing. As with a drum circle, catch people’s eyes and attention and use hand signals to slow down, fade out, or come to a sudden stop. Or speak instructions over the music to “start to become aware of each other and find your way into ending this piece.” Immediately after the piece ends, ask the group to sit in silence and to notice how they were affected by the experience. I often encourage writing in a journal or making art if there is time for that and for verbal processing. If not, move right into facilitating a discussion. The questions you ask and how deep they go in terms of probing or eliciting more material will depend on your skills, the ego strength of individual clients, and the group as a whole, and how much time you have. Questions such as “How were you affected?,” “How was the group affected?,” “What did you notice about yourself [the music, the group, someone in the group]?,” “Did anything surprise you?,” “Which part did you really resonate with?,” or “Did you learn anything?” are good starters. If the improvisation was recorded, you can play it either immediately afterward or after some preliminary discussion. This author prefers to play it back after having talked about it for a while, because hearing what was played can call up perfectionism and selfcriticism, which tends to overshadow other experiences. On the other hand, hearing what was created can also stimulate delight and self-esteem. As part of the closure, help the group to summarize the session, including major themes that arose and applications for their lives outside of the group. Adaptations. Much of the literature on using music improvisation with eating-disordered clients describes therapists working individually with clients. When working one-on-one with a client, there will necessarily be more interaction between the client and therapist during the improvisation and processing sections of the session. Bruscia (1987) and Wigram (2004) both describe a variety of musical techniques that the therapist can employ when working with clients, such as imitating, reflecting, rhythmic grounding, dialoguing, and accompanying. Approaches to reviewing and processing the improvisation vary according to one’s psychological treatment model and the approach of the team working with the client. Here, too, moving from music into written, danced, or artistic expression can yield more material for assessment and verbal processing. As mentioned earlier, there are two major ways to structure the improvisation, from allowing the music to guide the session (nonreferential) to the therapist and/or participants choosing a theme (referential). Themes can emerge from a check-in at the beginning of the group, as in: “Many people are saying they are pretty frustrated right now, so let’s explore our individual and collective experiences of frustration as we cocreate the ‘Song of Frustration’ together” or “Sally said she’s learning to ask for what she needs, and is asking for support and comfort. Sally, would you be willing to receive and listen to us create support and comfort through music?” Themes for a second improvisation often emerge after verbally processing the first one. What makes music improvisation such a wonderful tool is that so many treatment themes can be addressed! Whether working with an individual or group, the option of adding vocal sounds and singing is highly recommended, especially with clients who are struggling to express themselves verbally. When indicated, remind participants that the voice is also an instrument and is welcome in the improvisation; model it by adding your voice, or get things started by introducing a call-and-response section. There is more on vocal techniques in the Liberate Your Voice session below. Music improvisations can be created without using any instruments. There are vocal and/or body percussion improvisations, which juxtapose making cool, fun, or playful music with an instrument that carries so much charged psychological material—the body. One participant commented that thinking of her body as a musical instrument was “certainly a new and different relationship.” Another noninstrumental improvisation can follow instructions to “Find something in the room with which you can make a sound” or “Return to the room in 10 minutes with something that makes a sound you resonate with.” Other improvisations can be created to accompany a client’s poetry, rap, spoken story, or piece of art. As mentioned earlier, clients can respond to their own improvisations through writing and/or artwork before verbal processing. If the clients are

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physically and clinically able to engage in movement, replaying a recorded improvisation and adding dance/movement can also be very effective.

Group Drum Circle: Sound and Spirit Overview. In drum circles, clients spontaneously make music together oriented around drums and rhythm-based playing for the purpose of promoting social unity and enjoyment (Gardstrom, 2007, p. 21). Although drum circles are at the augmentative level of therapy, they are similar to group instrumental improvisation sessions in terms of the overall goals, structure of the session, and role of facilitator. Sample goals include encouraging creative self-expression; fostering community-building, enjoyment, and fun; learning emotional expressive and regulation skills; practicing mindfulness and present moment awareness; stress reduction; and increasing self-awareness and insight. As with the improvisation sessions, a drum circle can be thematically oriented and tailored to meet specific goals that the group or therapist identify. Contraindications are the same as for instrumental improvisation sessions: physical weakness and, especially in a drum circle, headaches or a hypersensitivity to loud sound. Sessions are prepared in the same manner as group instrumental improvisation; please see the section above. Drum circles tend to use less of the more melodic instruments such as guitar or piano. What to observe. Again, the information in the section on the group instrumental improvisation session also applies to drum circles. Drum circles tend to speed up over time, so, when necessary, either allow and encourage it as part of the piece or intervene through conducting or playing an instrument like claves that will cut through the drumming and ground the rhythm. Procedures. The major difference between facilitating a drum circle and facilitating an instrumental improvisation group is that the therapist may do more actual conducting of structured activities like the ones mentioned as warm-ups for the musical improvisation groups and others mentioned below. Here are some suggestions for leading the drum circle: •

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Begin the group with an introduction to the goals and procedures of the session if the group is new to drum circles, or with a brief verbal check-in if your group is familiar with drum circles. Review guidelines such as the removal of rings and bracelets and the sound, care, and handling of the various instruments. Encourage self-expression as well as listening to the group as a whole. Remind them if that they can’t hear the people next to them, they are probably playing too loudly. Set up hand signals for starting, stopping, and continuing as a group, for individual players to start and stop, and for volume and tempo. Many drum circles make use of the “rumble” hand signal of arms stretched up above the head and hands shaking rapidly to indicate a transition into playing as fast as possible, which usually precedes a group stop. Introduce a few warm-ups and structured rhythmic activities, such as drumming in unison, drumming a heartbeat rhythm, passing a rhythm around the circle, call-andresponse drumming, or drumming and saying your name three times as the group echoes it back three times. Try assigning different rhythms to sections of the group or individuals. Demonstrate the rhythm for them or give them a word or chant to think as they play, such as “base-ball,” “Lit-tle Loo-py Loo,” or “shave and a hair cut—two bits.” Needless to say, do not use food words or references. An option here is to let players know that once they are comfortable, they can drop their assigned rhythms and play what seems to fit with the musical groove.

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Once the group is warmed up, either assign rhythms again or begin a simple 4/4, 3/4, or 6/8 rhythm and ask players to come in as they hear a place for themselves. Conduct the group through variations of starting, stopping, changing dynamics, or bringing in and highlighting or silencing certain sections. Bring the piece to an end, and encourage a few moments of silence and breathing. If you have the time, continue on with any of the suggested activities below in the Adaptations section. If not, facilitate a closing discussion that encourages participants to notice how they were affected, what they may have observed and learned, and how they might apply this learning to any aspect of their lives.

Adaptations. With the proliferation of drum circles and drum circle facilitator trainings in recent years, there are many local and national resources within and outside the field of music therapy that offer tips and exercises. Any number of these can be adapted for this population. The reader is strongly encouraged to follow up on receiving training in drum circle facilitation. The Remo Drum company sponsors national training programs in HealthRhythms Group Empowerment Drumming, developed by music therapist Christine Stevens (2012) and physician Dr. Barry Bittman (Remo.com). Two very effective drum circle facilitator-trainers active at the time of publication are Kalani Das, MT-BC (2011) and Arthur Hull (2010). Basic adaptations include: •

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If there is time, offer volunteers the opportunity to conduct. A single person could conduct a shorter piece, or each conductor could pass the role on to another within the context of a longer piece. If the group and their music sound connected and strong, lie back as the conductor and allow the music to unfold. A piece can be built by having one person start a rhythm, and then, one-by-one around the circle, having others join. Decide on specific themes to play, such as various emotions (anger, serenity), makebelieve scenarios (warriors preparing for battle), or real situations (let’s mindfully release our stress out through our hands and voices as we play). An effective circle task taught by James Borling, Director of Music Therapy at Radford University, is to set a theme such as “how I feel about X” or “what I want to say to X.” Have the group establish resonance by playing a heartbeat rhythm in unison. Set up one drum in the circle that acts as the solo drum. As members of the circle want to express themselves, they move to the solo drum one at a time. As the group sees this, they continue playing the heartbeat rhythm, but softer. The group provides a sound-bed and safety net of support, containment, and companionship as the soloists express themselves. When finished, the soloists move back to their seats and the group heartbeat rhythm resumes at a medium pitch. Assign positive affirmations to sections of players to chant silently or aloud as they play the rhythm on their instruments, and layer several rhythmic affirmations together: Healing, healing, I am healing/One day at a time/I may be scared but I’m also strong. Ask players to come up with their own affirmations.

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Group Vocal Improvisation Session: Liberate Your Voice Overview. In group vocal improvisations, clients use their voices extemporaneously to create a group piece of music. As with instrumental improvisation sessions, vocal work can be conducted solely at an augmentative level of therapy or can become more intensive if it focuses on the deeper needs and processes of participants. When working individually, core issues can be addressed on a primary level of therapy. Many clients with eating disorders find it a real challenge to find their own voice or speak their own truth. This is especially true for clients who are emotionally shut down or who are using their physical symptoms and behaviors as their mouthpieces. On a basic level, group vocal improvisations can provide experiences of having fun, connecting with others, and breathing deeply while exploring the voice as a means of creative self-expression. On a deeper level, interpersonal and intrapersonal issues can be explored through vocal practices and improvisations. Increased self-awareness and insight, improved relationships and communication skills, and emotional expression and regulation are further goals. Participants have remarked that as they become more comfortable and freer with their voices in this group, it has generalized into other areas of their lives. This kind of session is contraindicated for anyone who would react detrimentally to deep breathing exercises, as well as anyone who is actively purging or whose vocal cords and esophagus are medically compromised. Preparation. Although voice is the primary medium, various props such as puppets, balls, hats, bubbles, scarves, percussion instruments, pens, art supplies, and paper for drawing or writing can be useful. The Indian “shruti box,” an accordionlike instrument that provides a drone, can create an ostinato to sing over (Shrutibox.com). Place chairs or pillows in a circle on the floor for seating and make whatever adjustments for safety and comfort the room seems to need, such as drawing the curtains if there is a public window or placing a “Session in Progress” sign on the door. Leave enough time at the end of the session for discussion and processing. What to observe. For many people, using their voice is much more frightening and personal than playing an instrument. The instrument is a step away from us, whereas the voice originates from within us. Clients may immediately say that they do not want to use their voices, or that they are uncomfortable doing so, or they may react with various manifestations of rising anxiety: giggling and laughing, derision and scorn, panic attacks or withdrawal into silence. The therapist’s reassuring, nonjudgmental, playful approach and the warm-up exercises can help to ease this initial anxiety. The voice often echoes with the inner dynamics of the one making sound. Listen for when vocal expression is shaky, constricted, tentative, lifeless, uncontrolled, messy, or overpowering. Listen and watch for those who are leaders and those who are followers, those who are exhibiting genuine spontaneity as opposed to a forced quality in their participation. Listen for when and during what activity someone shuts down or loses access to their voice, as well as for when someone is able to “really let go.” Observe how people are holding and using their bodies. Afterward, sharing these behavioral observations during the closing process discussion can be very useful. “Fred, I noticed that in the partner exercise with Emily, as her voice became louder, faster, and higher-pitched, you started hunching your shoulders and got quieter. What was happening for you?” Since vocal, breathing, and laughter work can be quite strenuous, keep an eye on more physically fragile participants or those with breathing conditions such as asthma. If they seem to be overdoing it or look breathless, invite them to tone it down or even to sit quietly for a while. Procedures. This session can be led as a one-time group, though it is most beneficial when it occurs weekly. The ongoing group situation allows for the introduction of new practices sandwiched in between familiar, safe, opening and closing activities (appropriate rituals). When introducing the session for the first time or if there are new participants in the group, facilitate an opening discussion about the

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value of learning how to feel comfortable and empowered when using our voices. Questions such as “Who here has a hard time speaking their truth—what is it like for you when you keep something inside that you need to say?” or “Who here loves to sing in the shower or the car but wouldn’t be caught dead having someone hear them—what’s that about?” are usually enough to get a discussion rolling. Explain that the practices in this session are designed to help loosen their voices, silence or rehabilitate their inner critics, encourage enjoyment and fun, build a sense of community, and make it easier for them to use their voices when they need to express themselves. Begin with breathing warm-ups, such as inhaling arms up and exhaling them down, and doing it again several times while having fun groaning out the stresses of the day on the exhales. Groaning out a sound is healthier than purging. You can encourage taking turns naming the stress out loud just before the exhale, as long as it doesn’t trigger others. Specific references to food or weight can be triggers. “The casserole we ate for lunch” is not okay. “How I felt after lunch” is okay. Lead a yawning exercise to loosen jaws and inhibitions, and explain that yawning is one of the most effective ways to release stress, lower anxiety, and create empathy (Newburg, 2009). Point out that it’s highly contagious. Ask them to fake a couple of yawns while looking around, and soon they will benefit from a genuine and very satisfying yawn. Introduce a focusing exercise such as passing a clap around the circle. In this activity, passer and receiver must clap at the same time and keep trying until both clap simultaneously, or get “close enough.” (Getting “close enough” and having that be okay in a room full of perfectionists is quite a feat!) This can be done several times, reversing direction or getting faster. A variation is to simultaneously say something together, such as “Yes!” or a nonsense word like “Gooflackle.” The clap exercise can be followed by a vowel toning with laughter exercise, a call-and-response exercise, or both. The laughter/toning practice can become quite aerobic, so if there are physically fragile or asthmatic individuals in the group, this may not be advisable. For the laughter/toning exercise, explain that the group will be warming up their vocal cords and imaginations. Tell them that laughter, like yawning, is contagious, so it’s very important that everyone maintain eye contact. There are many health benefits to laughter and toning, but avoid saying so, as some clients don’t want to hear anything resembling “It’s good for you.” Let them know that in the beginning we are faking the sounds, but that keeping eye contact will help release real laughter. Start with “Uh” and vocalize the syllable on an ascending scale as everyone raises their arms up above their heads, then add an “H” to form “Huh” and laugh deeply—“Huh huh huh huh”—as everyone lowers their arms. (See Adaptations for adding imagination and more movement.) Then move to “Ooh/Hooh,” “Oh/Hoh,” “Aw/Haw,” “Ahh/Hah,” “Eh/Heh,” “Ai(I)/Haiyaiyaiyai,” and “Eee/Hee.” End with an ascending sweep-up combining the sounds— “Uhh-ooh-ohh-aww-ahh-ehh-eee” (which sounds like a drawn out “why”)—and a descending sweepdown—“Eee-ehh-ahh-aww-ohh-ooh-uhh” (which sounds like a drawn out “yeow” with an “uhhh” at the end). If the energy in the room needs to be calmer, repeat the descending scale along with arms moving downward several times while getting softer, until the second-to-last one is a whisper and the last one is thought silently inside. Introduce a call-and-response exercise, with the therapist leading the call and the group echoing. Use all kinds of sounds while varying pitch, rhythm, and volume: animal sounds, singing a line from a song, body and mouth percussion, gibberish/nonsense/scat syllables, and spoken word phrases. Model a few examples, and then either have a go-around where the person next to you leads the next sound and it passes around the circle or throw a ball (stuffed animal, pillow, etc.) to the person who will lead the next call-and-response sound. They then throw it to the next person, until everyone has had an opportunity. Sometimes group members will just shake their head silently or say: “I can’t.” I always allow a person to “pass,” though often group members will encourage their peer and a sound will emerge. Or I’ll request permission from the person and have the group remember the feeling of “I can’t” as we nonjudgmentally

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echo it. These practices form the basis of the warm-up phase of the session. The next phase can be structured or more improvisational. As with instrumental improvisation, the newer or less comfortable with improvisation, the more the group will need structured exercises, which can even continue through the entire session when necessary. Examples are teaching each other old camp songs; blowing soap bubbles and laughing or sounding until the last bubble pops; and passing a Very Important Message (sometimes accompanied by an object that becomes part of the message) around the circle in gibberish, nonsense syllables, or sounds (instruct that they may not speak in any known language spoken on Earth). Passing a gibberish-speaking hand puppet or stuffed animal is also enjoyable. I have found that learning how to speak in gibberish can lead to a greater willingness and ability to verbalize what has previously been silent or silenced. “You can say anything you want, express any idea or emotion, without fear of being judged or criticized. With gibberish, since you cannot be understood, there’s no danger of being misunderstood” (Briar, 2012 [DVD]). There are more suggestions for structured practices under Adaptations. With a group that is able to go deeper, the call-and-response exercise makes a nice transition into the main part of the group: “Now that we’re loosened up, does anyone have a sound they really want to make, or something you would like to practice saying—in gibberish or English—while having the group support and companion you by echoing it back to you?” This one invitation can carry the group to the end of the session, depending upon how many people volunteer and where each person goes with it. (If nobody volunteers, simply move on to another structured practice.) For example, someone may want to explore saying “No” in a variety of ways, which might end there, or another volunteer might be invited to continue. Or after practicing saying “No,” it might be helpful to inquire to whom or in what situation each member wants to say “No.” This in turn could lead to more sounding or a process discussion. Make sure when doing individual work in a group that you find opportunities to include the group through connecting them with the person working and the issue being addressed. “Raise your hand if you also have this difficulty in saying no” or “Anyone else in the room …?” Another way to connect the group with the person working is through various members playing roles: of a supportive chorus, vocal backups, an inner voice, another person, and so on. (This gets into the realm of musical psychodrama, which is addressed in another section.) When the session is near the end, take some time to explore the effects the different exercises have had on the group and to share observations and insights. The questions asked and the observations shared during the closing discussion will be determined by the level of therapy appropriate to the group. Asking “What do you notice about how you and the group have been affected?” and “How might you be able to use this experience in your life?” can be enough for most groups, and can also lead to additional process questions. End with a closing exercise of sounding voices together while making eye contact. One by one, ask people to sound and hold a steady tone, taking breaths when needed, until the whole group is sounding. Let them know that they can change their tone and begin to blend, harmonize, or improvise as they want. Ask them to close their eyes and listen. With eyes closed or open, ask the group to gradually get softer until there is silence, take a mindful breath, and smile. Adaptations. There are many adaptations of this group. Individual Liberate Your Voice sessions can be very therapeutic and address specific themes the client is working on. They can be structured like the group sessions: opening discussion and check-in, warm-up practices, main part of session, process discussion, closing sound practice. The themes for the main part of the session can arise from the check-in with the clients, from something that is touched off in the warm-up phase, introduced by you, or mutually agreed upon between you and the client. When doing individual sessions, it is more common to incorporate instruments, such as vocalizing with piano accompaniment or chanting to a drum. The

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writings of Diane Austin (2008) and Lisa Sokolov (2009), music therapist/singers who practice vocal psychotherapy, are excellent resources for individual sessions. Additional ideas for individuals and groups can be found in the books Free Your Voice by Silvia Nakkach (2012) and Singing the Body into Being (2012) by Francesca Genco. Although the numbers of warm-up and thematic activities are virtually limitless, additional practices are: singing your name (with or without a gesture or movement) and having the group echo it back; sounding out different emotions as well as moving from one emotion to another (from confusion to clarity); humming together (ascending and descending, for example); sounding imaginary situations (you are putting a baby to sleep); passing out index cards with gibberish, nonsense, or scat phrases on them (good for when the client or group is having difficulty generating them); conducting sounding, gibberish, or singing conversations in dyads (one of you is trying to convince the other one, who is skeptical and doubting, one of you is the parent ...); taking on different characters or aspects of the self (sound/sing like a whiny child, your inner critic); and assigning parts to create three- to four-part chants and choral pieces (or doo-wop choruses). For instance, a group created a three-part piece in 4/4 as follows: Singers of part 1 repeated the phrase “I Am” on the downbeat, singers of part 2 repeated the words “taking … claiming … making … aiming” on the “and” after the fourth beat and sometimes after the second beat, and various group members improvised a solo or rapped the verses: “My dreams, my voice, my pain, my joy, my life, my choice/My truth, my voice, my heart, my joy, my mind, my choice/My power, my voice, my body, my joy, my self, my choice.” Additional activities include free vocal improvising that starts with one person, moves around the circle until all are sounding (and moving as an option), body and mouth percussion behind someone doing a rap in gibberish or a language, creating and using a “singing stick” (similar to a “talking stick” in that whoever has the stick has the floor), the group creating a vocal sound track as someone tells a story, shares a poem, or moves. As in musical improvisation, the whole session can be centered on one theme, such as connection, transformation, empowerment, or conflict resolution. You would then design vocal exercises and practices that address some aspect of the theme. Participants can also be encouraged to write poems or chants reflecting the theme, either in small groups or with the whole group. Yoga offers a wealth of practices that music therapists may find useful, from chanting to sounding the chakras (energy centers) and breathing (“pranayama”) exercises. Specific breathing practices to try are the three-part yogic breath for full-body breathing, 2:1 breathing for relaxing, alternate nostril breathing for balancing, and the ujayii and brahmari breaths (Rama, Ballentine, & Hymes, 1979). In her book Essential Musical Intelligence (2002), music therapist Dr. Louise Montello offers several yoga-based exercises. If clients are able to participate in light exercise, adding movement to sound when it seems appropriate can contribute information and awareness that comes from including more of the body. An example is the vowel and laughter exercise mentioned above. The sound “Huh” seems to suggest a deep, low-to-the-ground, perhaps heavy and lumbering sound, while the sound “Aahhh,” with its “Ha ha ha” laugh is a big-heart-and-arms-wide-open kind of sound. “Heh heh heh” can be likened to a witch cackling, and giggling “hee hee hee” in a high register sounds like munchkins skipping around.

Group Improvised Role-Plays: Hearing Me, Hearing You Overview. In this exercise, the clients play roles with one another using instrumental (and sometimes vocal) music improvisation. The level of therapy is usually intensive, though when the core issues of clients are addressed and processed with the therapist, it enters the primary level of therapy. The term “musical psychodrama” was first coined by Joseph Moreno (1980, 2005) to describe how he applies aspects of music therapy and psychodrama to the group therapeutic process. Montello calls the music therapy sessions where she works with clients to reconcile and resolve polarized aspects of the self

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“musical tantra.” Both terms refer to role-plays that are enacted nonverbally through musical improvisation. These types of sessions are effective for clients who are uncomfortable or unwilling to express themselves verbally; for those who are stuck in one polarity of their personality (the “good girl,” for example) or polarized thinking (good-bad, perfect-failure, control-chaos); for exploring and working on family, group, or other relationship dynamics; and for working on one’s relationship with different aspects of the self (the voice of my eating disorder, the part of me who wants to get better, my 7-year-old self). Goals for this group include increased creative self-expression, awareness, and insight; the building of group cohesion and empathy; and working toward resolving intra- and interpersonal conflicts. This activity requires just as much improvisation from the therapist as it does of the group. There are many choice points along the way for therapist intervention, such as when or if to switch players in their roles or pull a player out and replace them with a substitute, or in making suggestions as responses to what is happening in the moment. The main contraindication for participation in group role-plays is the presence of a thought disorder or the inability to think symbolically. Preparation. A selection of percussion and melodic instruments will be needed, and optional recording equipment. Place chairs or pillows in a circle, with the instruments in the center of the circle. What to observe. Watch body language and behavior for any signs of anxiety or dissociation such as restlessness, rapid breathing, withdrawing, closing down, curling into self, and poor eye contact. Procedures. The session can proceed as follows: 1) Welcome the group. Invite them to be seated and lead them in a short, guided meditation of breathing and coming into the present moment. Explain that today’s session will involve exploring issues nonverbally through allowing the instruments to express what we are feeling and what we want to say. 2) Do musical warm-up(s). If the group is new to playing instruments, lead a brief warm-up activity with the instruments (and voices, if you want to add a singing/sounding component) that allows members to hear how each instrument sounds when played softly, loudly, slowly, and rapidly. Encourage players to experiment with all the different sounds their instrument can make. Continue with this second warm-up activity: If the group is familiar with playing instruments, conduct a few simple role-play situations by dividing the group in half and having sides explore playing and dialoguing between polarities such as Yes-No, (everybody play Maybe), Good Girl-Bad Girl (everybody play I’m Both Girls), or Anxious-Serene. 3) Process the musical warm-up. Ask the group to think about any conflicts they are currently experiencing, either inside themselves or with another person, and to verbally share. (If there is resistance to sharing out loud, verbalize that observation and offer the option of anonymously writing the conflicts on pieces of paper and then drawing from a hat one conflict at a time to work out. Ask for volunteers to be the players. Often, the author of the conflict will reveal themselves and act as conductor, especially if one of the players “isn’t playing it right.”) 4) Ask for a volunteer who is willing to explore their conflict through music. Have them identify the roles, briefly describe the conflict, pick an instrument for each role, and demonstrate how each instrument is played by making a “musical statement” (Moreno, 1980). The volunteer can then choose people from the group to play each role/instrument in the way that was demonstrated. If a group member does not want to play, the volunteer can simply choose another. Have the volunteer choose someone to play his or her role, too, in case you want to pull them out of the musical piece so that they can conduct/direct

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the improvisation, or sit back and get a larger perspective. This person sits next to the volunteer at all times, except for when they are sitting in for the volunteer. 5) Place the players in the center of the circle. Remind the rest of the group that their silent support will create a container of safety for the players, and encourage them to listen deeply. If there will be enough time later, record the piece so that you can play it back just before you process with the group. 6) Ask the volunteer to start the piece by designating which role starts the typical interaction. The piece can play out to a natural end or you can pause the improvisation to see whether the volunteer thinks it is an accurate depiction; whether any changes are needed in the sounds, instruments, or roles; or to ask players to switch roles. Possible questions for the volunteer include “How would you like this to sound?,” “What changes would you make in order to bring this piece to closure?,” “What needs to happen for this conflict to be resolved?,” or a simple “What needs to happen here?” 7) When the piece is finished, ask the group to sit silently for a moment and notice how they were affected. Begin the process section with the volunteer first, then do the players, then those who were listening and watching. Ask open-ended questions such as: “What was that like for you?,” “What did you feel, hear, see happening here?,” “Do you have any observations or thoughts about your interactions with …?,” or “Did you learn anything from the piece?” Ask players for their impressions in the role, if they personally resonated with the experience, and if they learned anything. Ask listeners to share their observations and anything they personally related to or learned. Adaptations. This session can be adapted for individual work. The therapist can take one of the roles, or the therapist can assist the client in switching between roles. Other themes for exploration are the Karpman Triangle roles (Victim-Rescuer-Persecutor), dialogues with the Eating Disorder, A Typical Interaction with X That I’d Like to Change, My Musical Family Portrait, and Wanting to Get Better and Not Wanting to Get Better. The possibilities are limitless.

Group Instrumental Improvisation: If You Could Hear What I Cannot Say Overview. In this exercise, one or more clients in the group improvise(s) on instrumental pieces to express what they have great difficulty expressing. The title of this activity is suggested by the book of the same name by Branden (1983). As with musical role-plays, the level of therapy is intensive and, especially in smaller groups or it can be primary with individuals. It appears as the last experience in the Improvisational Music Therapy section because it has strong ties to Compositional Music Therapy, the next area addressed. Clients can take pieces that emerge from these sessions and use them as seeds for longer or more formal compositions. If we remember that most people who suffer from an eating disorder have not learned how to process and express both internal and external events in a healthy way, then providing opportunities to learn a variety of positive and creative methods is essential. This session invites participants to nonverbally explore and ultimately express what they may not feel comfortable with or able to put into words. As clients select the sounds they want and instruct their peers how to play, they are exercising healthy control and experiencing their ability to contain, modulate, and creatively express what may feel frightening or chaotic. When clients hear their music played back, it is as if they are listening to an auditory mirror to their inner selves, and the subsequent discussions can yield many new insights. Their musical expressions often become gateways to writing, drawing, and even verbalizing what was previously unsaid, and the resulting pieces can also stand on their own as valid forms of communication. The session helps to create group cohesion, mutual support, and empathy through involving members in each other’s improvisations. This group requires participants who are capable of insight-oriented process

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discussions. Participants who have had some experience with group improvisation or drum circles will more easily participate in this session, with less need for opening warm-up exercises. Do not conduct this session with anyone who is actively psychotic, suffering from a thought disorder, or would not be able to engage in a process discussion. Preparation. A wide array of percussion and melodic instruments will be needed. The therapist may record the pieces and include time to listen to them as part of the process discussion. A recording can aid in the assessment of the clients, and it can be used as the basis for a later composition or further exploration through writing, art, movement, or spoken/sung word. However, a recording is not necessary to the session. One benefit of not having a recording is that group members may become even more involved in the discussion as they offer observations and feedback. Have your instruments accessible to the participants, either in the center of the circle or to one side. A circle of chairs or pillows on the floor is the starting arrangement; as pieces are created, the seating will change and one area of the circle will usually end up as the area for musicians. What to observe. As in other improvisational music sessions, be aware of the symbolic or metaphoric meanings of the instruments chosen. Because the client-as-composer/conductor also chooses who in the group plays, you may want to ask what motivated their choices during the processing discussion. (If you choose the option of group members volunteering to play, ask them what made them volunteer.) Notice how the client guides his players (interpersonal interactions) as well as how he instructs them to play the instruments (musical and emotional characteristics). Once the piece is in progress and/or during playback of the recording, observe not only the composer’s body and face for nonverbal responses, but also the rest of the group. Look for signs of increasing tension and anxiety as well as for relief or catharsis. Pieces titled “To the Person Who Abused Me” or “To My Grandmother Who Died” will certainly resonate with at least several others in the group. Procedures. There are two options for opening the group session. The first is to welcome participants and then play (live or recorded) the John Mayer song “Say” (or one that expresses a similar message). Then encourage a brief discussion about the difficulties we experience when we can’t or don’t say what we need to say. The second is to lead participants through a few mindful, relaxing breaths and then ask them to silently imagine saying something they have never allowed themselves to say out loud. Introduce the title of the group, If You Could Hear What I Cannot Say, and explain that the group will be exploring how to express what we have difficulty putting into words or have no words for through the instruments and even our voices. Explain that the different sounds the instruments make are like the colors on an artist’s palette or the different movements in a dancer’s repertoire. Reassure them that this is less about creating great music than it is about exploring self-expression through sound. Have participants choose an instrument and conduct a quick go-around where the sound of each instrument can be heard playing loudly, softly, quickly, slowly. If there are still instruments in the center of the circle, demonstrate their sounds. If the group is familiar with improvising or drum circles, you can go directly into the main part of the session. If not, then lead them through this warm-up: Start a heartbeat rhythm, and while the whole group continues the ostinato of the rhythm, conduct groups of two to four players (those sitting next to each other) in and out with instructions such as “play anger,” “play sadness,” “play as if your dearest wish came true,” “play you didn’t get the job.” If the group is very tentative or constricted, try handing out humorous situations such as: “play an unstoppable laughing fit” or “play your adorable puppy just peed on your new Prada shoes.” Give instructions for the task at this point. Ask the group to think about how they would say what they cannot say if they could do it through the sounds available in the room. Explain that the therapist will act as their sound consultant if they have questions. As in a musical psychodrama, not all members of the group will have an opportunity to conduct a piece, unless the group is small or scheduled to meet again, so

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make that clear to the group. Suggest to those who will be listening that they listen with their hearts for what resonates with them, and imagine what is being said. Tell them that if they are chosen to play a sound, they are giving a gift of support to one of their peers who is trying to sound out something in their life. Ask for a volunteer willing to explore “the unsayable.” If no volunteer emerges, use the written alternative described in Adaptations. Guide them through setting up hand signals for musical dynamics, including start and stop. Guide them to choose the instruments they want, and who will play them (“I want that scrapy sound. Angela, will you play it? A little faster, but softer. No, don’t keep a steady beat. Yes! Like that”). As they layer in each instrument, ask them to notice if that sounds complete, or if they want to add another sound. Once they have their ensemble together, give them an opportunity to conduct the piece for a few minutes. If you are not recording, indicate to the players to continue playing while you ask the conductor to step away (other side of the circle) and “just listen.” Then have them step back closer and bring their piece to a close. If someone’s piece is getting too long, you may need to suggest that the conductor; “Find a way to bring what you are saying to a close now.” When the piece is over, ask the group to notice, in silence, how they have been affected. Ask the composer to give the piece a title. If you recorded the piece, play it now with the same instruction to notice how they are affected. Begin your process discussion by first inviting the composer to share, then members of the ensemble, and finally listeners. Ask the composer to talk about how they are affected, what they liked, what surprised them, what they may have learned about their resistance to verbalizing, if they are willing to share any of the words they couldn’t say before, and if not, if they could write or draw them at some point. Ask players and listeners how they were affected, what they felt and observed when playing or listening. Sometimes someone who played or listened says the words in their feedback, or will say what they thought was being said, and the composer will respond in agreement or “No, that’s not at all what I was saying, I was saying ….” The questions asked, how deeply the therapist probes, and how she conducts the process discussion are determined by the amount of time that remains and the level of therapy that the therapist and the group are comfortable with. In general, asking how participants are affected, what they can learn, and what a possible next step is are useful questions. If there is time, another volunteer can go. Otherwise, conduct a short closing activity, such as the group playing a heartbeat rhythm together, a one-word go-around of how they feel, or a closing of your choice. Adaptations. This is easily adapted for individual sessions. The client chooses either one instrument or several that are set up for easy access, and then improvises. An alternative is for the client to conduct the therapist in making the music. When doing this with groups, instead of asking the conductor to choose people, the conductor can ask for volunteers. When no one volunteers in a group session, an option is to have each person anonymously write on a piece of paper what they cannot say aloud, or describe the situation in which they are having trouble. Ask them to fold the papers, place them in a hat or box, and choose one at random. The therapist can ask for volunteers to play or assign members to play, or the whole group can be involved in discussing which instruments to include and how they are played, and improvise from there.

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GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Sing-Along: Pick a Song You Resonate With Overview. Clients choose a song with personal meaning from a list of songs and sing it with the group and/or therapist. The level of therapy is augmentative. The sing-along is a staple activity for many music therapists because it addresses so many therapeutic goals and can be adapted to a diverse range of populations and abilities. At its simplest, a sing-along offers clients opportunities for engaging with others in a nonthreatening way, enjoying music, having fun, building community, releasing stress, and expressing emotions in a safe way. The sing-along can also be aimed at specific treatment goals such as increasing insight, self-awareness, and identity; teaching coping skills; or encouraging the identification and naming of emotions. All levels of therapy can be addressed through this activity. There are some contraindications specific to eating disorders. Clients who purge may experience irritated or damaged vocal cords and throats. Depending upon the severity of the damage, they should not strain their voices or, in serious cases, should not be singing at all until their vocal cords and throats have had a chance to heal. Preparation. The therapist will need either a piano/keyboard or guitar, music for the songs being used, and song sheets/booklets for the singers. If playing a keyboard, be sure to face the group. The choice of songs should reflect the age group, musical tastes, and psychological issues this population is working through. Songs about families (“Family Portrait” by Pink, “Perfect” by Alanis Morissette or Pink), empowerment (“Courage” by Orianthi, “Just Stand Up” by Beyoncé et al.), identity (“Me” by Paula Cole, “Unwritten” by Natasha Beddingfield), being in pain (“These Times” by Safety Suit, “Stand in the Rain” by Superchick, “Would It Matter?” by Skillet), and hope (“Swim” by Jack’s Mannequin, “There’s Hope” by India.Arie) are but a few examples. There are also many songs about eating disorders, such as “Invisible” by Skylar Grey, “Remember the Tin Man” by Tracy Chapman, or “Ana” by Silverchair. Lists of songs about eating disorders can be found on the Internet, but be careful of the ones that may glorify eating disorders. Ask group members for suggestions of songs and compile songbooks from those lists. A minimum number of songs to carry this session is 8 to 10. The therapist should be comfortable enough with the songs to be able to read the music, play, and observe the group at the same time. What to observe. Be alert for any signs of emotion during the singing, and bring up any observations in the postsong discussion: “Sandy, I noticed that you got a little teary-eyed when we sang that last verse. What was going on for you?” Notice who seems comfortable using his voice and who does not. Listen and watch for holding the breath and tensing in the chest, throat, and jaw. Procedures. Welcome the group into the room, and begin the session with a short breathing and centering practice that encourages awareness of breath and coming into the present moment: “Close your eyes, take a deep breath in through your nose, blow it out through your mouths in a long, extended, letting-it-all-go kind of exhale. Once again, but this time breathe in and out through your nose. A third and final time, open your eyes, look around the room, breathe in and out through your nose as you make eye contact with at least two other people in the circle.” Explain to participants that a collection of songs will be distributed, and they are to choose one song they resonate with, a song they can relate to because it says something about them or their experience. Let them know that they are invited to sing the songs together as a way of supporting each other and enjoying the benefits of singing. If there is time, start with a few minutes of fun vocal warm-ups to loosen voices and inhibitions. Lighthearted humming or call-and-response sounds and scales work well. Pass out the song sheets and give participants a few minutes to choose a song. Ask for a volunteer to start, or conduct a go-around and proceed around the circle. Sing the song and then allow time for

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processing. It is likely that more than one person will pick the same song, so include everyone who chose it in the discussion. Ask open-ended questions of the person or people who chose the song, and gear questions to the level of therapy the group can handle. “What was it that drew you to this song? How does this song reflect something about you or your experience? What lyrics really speak to you? What can this song teach you about yourself or your life right now?” As closure for the group, ask questions that help participants integrate the experience. “How were you affected by this session? Did you learn anything about yourself or others in the group? What will you take with you when you leave?” If there is time, end with an uplifting song to sing together or one from the session that seems appropriate. Adaptations. This session is applicable to individual work, and additional tasks can be added. Ask the client to write another verse and sing that version. Ask the client questions that require responding with another song you then sing together. Ask about family dynamics, friendships, dreams, and fears. When working with a large group or under time constraints, divide into small groups and have each small group choose a song they all agree on. This can provide fodder for processing group dynamics such as how the song was chosen, who felt heard, who took over, who didn’t care, and how this reflects behaviors outside of the group room. If a group is working on a particular theme such as anger, self-esteem, or shame, create sets of songs categorized by topic and use those in sessions. Have an array of percussion instruments available for color and depth, but make sure they are played in a supportive way and don’t take over.

Group Singing and Choral Work: Sing Out Overview. This experience differs from the sing-along in that it involves the group in singing different parts at the same time. The level of therapy is augmentative. The benefits of singing are widely documented. One meta-analysis of 54 quantitative and qualitative studies conducted through the Sydney De Haan Research Centre for Arts and Health (Clift, Hancox, Staricoff, & Whitmore, 2008) identified recurrent themes in the perceived or reported benefits of singing. These include: • • • • • • • • •

Relaxation and release of physical and emotional tension A greater sense of well-being and positive mood Increased energy Cognitive stimulation A sense of collective bonding, belonging, and personal contact with others A sense of being a contributor to a product that has many values Increase of self-confidence and self-esteem Awareness of how the body is engaged in singing Being engaged in a valued, meaningful, worthwhile activity that gives a sense of purpose and motivation

Almost all of the benefits listed above are directly relevant to the needs of people with eating disorders. Pavlakou (2009) conducted a six-session choral program in the community for women self-identified with eating disorders and wrote: The workshop participants consistently expressed during the interviews that through the singing activity they experienced a reconnection with bodily

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sensations, which provided physical relaxation and awareness of their body, mental engagement, which helped them to distance themselves from their everyday problems, and emotional release through the performance of music .(p. 36) In order to create and sustain a choral program, the therapist must work in a setting where a sense of continuity and community can develop. This can include a long-term inpatient hospital, a residential facility, an outpatient clinic that offers groups, or a community workshop. This activity can be adapted to all levels of therapy, depending upon the treatment goals for the group. Contraindications include clients who are actively purging or who are in recovery but with compromised vocal cords and throats; they should not engage in this activity. What to observe. Some clients are tense and constricted when it comes to using their voices, while some will be impulsive and unrestrained. For tense participants, use vocal warm-ups that encourage loosening and playfulness, such as rolling the shoulders and neck; moving the jaw, mouth, and tongue; and call-and-response exercises that induce laughter. With those who need more practice with self-control and building their listening skills, use calland-response vocal warm-ups that focus on developing accuracy in rhythm, dynamics, balance, pitch, and tone. Either polarity will benefit from your guidance in helping them come to the middle, so start with loosening warm-ups and progress to exercises that require more awareness and precision. Listen for group members who are struggling with tone deafness or an inability to keep a rhythm, and include ear training and rhythm exercises as part of the group warm-ups. Musicians in the group can become section leaders and mentors for less musically inclined participants. Be alert to issues that perfectionism creates, especially if your group will be performing for others. From psychodynamic and systems theory standpoints, the ways participants behave in the choral group can reflect how they behave in other groups. If your focus is therapeutic in nature, you can observe the roles that participants take on, such as leader, follower, class clown, the rebel, the responsible one, or the acting-out one. Watch for projections or transference issues with you as leader and with peers. “You always give her the solo part to sing” or “This song is stupid and I don’t want to sing it” may be statements with deeper roots in the speaker’s family of origin. This is all material that may come up in the closing process discussions. Preparation. This group can use instruments for accompaniment or be led as an a capella experience. Keep a melodic instrument or pitch pipe handy for establishing pitch accuracy. Have several warm-ups, rounds, songs, and chants prepared. The more musically sophisticated the participants, the greater the possibility of using three- and four-part arrangements. Stay with rounds, unison, and simple harmonies or two- or three-part arrangements for beginners. Songs that are familiar to participants will ensure a higher success rate than new songs. Nevertheless, assume that the majority of participants do not read music, so have lyrics sheets available and be prepared to teach songs that are new to participants by repetition and call-and-response methods. Therapists familiar with Kodaly hand signals for guiding pitch may find the method helpful for teaching new songs, but it is not necessary. Be prepared to teach simple hand signals for starting, stopping, keeping tempo, dynamic, and rhythmic changes, bringing in and taking out sections of the group. There are many online resources from which you can draw exercises and inspiration for choral warm-ups. Procedures. Welcome participants into a circle of chairs or floor seating. When teaching parts later in the session, you will break the group up into different sections. If this is the first session or there are many new people, talk briefly about the goals and group guidelines for the session. If this is a therapeutic group, stress the value of goals such as increasing self-expression, building self-esteem and

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confidence, reducing tension, finding and using one’s voice, and learning how to connect with others through music. If this is primarily a recreational group, stress goals such as fun, the enjoyment of music, developing leisure interests, and building community. Ask participants for a list of songs they would like to sing together, and tell them the lists will be reviewed for any songs that have the potential to be sung as a chorus. Begin with warm-ups that bring them into the present moment and foster connection with themselves and their breath, and move them into awareness of and connection with each other. The following are examples: Ask participants to close their eyes, take in a deep breath through the nose and blow it out the mouth through pursed lips or while groaning on the exhale. This can be accompanied by raising the arms up on the inhalation, bending over on the exhalation. Ask participants to stand; guide and encourage good posture as the exercise is repeated. Ask them to make eye contact with each other while inhaling and smiling, exhaling, and laughing, or yawning out loud while stretching and loosening jaw and facial muscles. Move from breathing exercises to vocal warm-ups such as humming, vibrating different consonants (mmmm, zzzz, eeee, nnnn, thththth, vvvv), vowels, scale singing, and even tongue twisters to practice enunciation. Introduce a simple and familiar round to sing first in unison and then in parts. Rounds are a great introduction to hearing and singing harmony. Group members are often delighted to share old camp songs and rounds with each other. Then introduce chants or songs with an ostinato or simple harmonies with intervals of thirds and fifths. Teach each part to everyone, then divide along alto and soprano lines and practice the song a few times. If this is a chorus that is just forming, be mindful of when the group is ready to move to the next level of learning a full piece. If they are struggling with singing in harmony, spend another session or two practicing rounds and short chants with simple harmonies. When a majority of members are able to sing in tune and hold their parts, introduce a full-length piece for the group to learn. This could be an arrangement of one of the songs from the list of songs you collected from group members, or a song of your choosing. Examples of songs are “Just Stand Up” by Beyoncé et al., “How Can I Keep From Singing” (traditional), or “You’re Not Alone” by Mavis Staples. I highly recommend the songs of India.Arie for their uplifting messages. The music of the vocal group Sweet Honey in the Rock and the repertoires of women’s choruses are also good sources for songs. If you have a recording of the piece, play it for the group and hand out lyrics sheets. As with the simpler rounds and chants, teach each part separately and then put them together when you feel each section is strong enough to work in concert with the others. It is beyond the scope of this chapter to go into detail about methods of choral conducting, but keeping it simple and remaining open to adapting to the needs and abilities of the singers will produce positive results. Even if the chorus will not be performing for others, take time to discuss and rehearse placement and any movement or dance steps. This will add enjoyment and creativity to the experience. If the group has a therapeutic focus, put aside 15 minutes at the end for processing the experience. Return to a circle and ask questions geared to the level of therapy of the participants. Start with general questions that encourage participants to comment on what they enjoyed about the session or what they thought about the music, to more probing questions that encourage them to express how they were affected and what they are learning, what they noticed about themselves and their peers’ interactions, or how the music relates to their lives. Again, depending upon the level of therapy of your group, you can also share your observations: “Mary, I noticed that when your group was working on the second section, you were getting more and more anxious. What was going on for you?” For groups with a more recreational orientation, close the session with a short go-around of a word or short phrase in response to a question such as “How are you doing now?” Adaptations. With an ongoing group, it is possible to open and close with the same consistent welcoming and closing songs, which provide a reassuring sense of consistency. A chorus naturally lends

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itself to movement, from swaying together in rhythm to more elaborate dance steps. Include poems and songs written by group members or composed by the group in your repertoire.

Individual Music Lessons with a Therapeutic Focus: The Music Lesson Overview. This involves teaching the client how to play an instrument in order to access and work through therapeutic issues. Therapy may remain on an augmentative level or taken to an intensive level. As every music student knows, individual music lessons offer an excellent arena within which a multitude of physical, psychological, social, and spiritual concerns play out. For the student with an eating disorder, many of these concerns are amplified. On one end of the spectrum, their inner music critic is often a brutal taskmaster demanding perfection. On the other end may live the impulsive and undisciplined rebel who refuses to practice. A client’s musical talent may be the one area of her life that offers freedom and self-reliance, or it can be the battleground upon which numerous family expectations and dramas have occurred. The positive effects of learning and mastering a new skill or piece of music can be tremendously therapeutic when the music teacher is aware that the lesson offers multiple opportunities for learning on many levels. The therapist can discuss choices and assess the abilities of the client to match new students with the instruments most suited to their interests and needs. The individual music lesson is distinguished from an individual music therapy session only through the explicit agreement with the client that one of the major goals of the lesson is to learn the instrument. Other than a state of ill health that would limit or preclude playing an instrument or singing, there are no contraindications to this type of session. In addition to the primary goal of teaching the instrument, secondary treatment goals are tailored to the client’s specific needs. These may range from increasing self-confidence, providing a means of creative self-expression, and improving impulse control to developing body awareness and transforming the voice of a harsh inner critic into that of a supportive inner mentor. Preparation. Most clients prefer a room in a location that feels safe from prying ears and eyes, so do whatever is possible to ensure safety from interruptions and observation by others if sessions are held in a residential or inpatient setting. Will the client have access to an instrument in between lessons in order to practice? If not, become creative about between-lesson assignments to ensure that material and skills learned in the lesson are reinforced through some form of practice. It is important that the experience be success-oriented rather than a lesson in boredom and frustration because they are not progressing from one lesson to the next. Music lessons tend to be shorter than therapy sessions, from 30 to 45 minutes. What to observe. Whatever your specific goals, watch for opportunities that arise in the teaching of the instrument that create windows through which you can address those concerns. Many instruments require the development of physical awareness and connection in order to effectively play, from diaphragmatic breathing and breath control to posture, stance, and muscle relaxation. Notice areas of holding, tension, and numbness in the body, and look for opportunities to deepen awareness, relaxation, and positive connection. Listen for comments the client makes that offer clues to unrealistic or limiting beliefs and judgments they hold about themselves and the world. Observe and listen for emotional reactions to tasks assigned, skills being worked on, and musical passages, and issues of transference arising in interactions with the therapist. In many cases, you and your client will have discussed both musical and treatment goals, so they will also be alert to issues that arise, as in “You’ll never believe what just ran through my head. I remembered overhearing my father say that it’s a good thing I’m musically talented, because I’m not as pretty as my sister.” Procedures. Welcome the client and check in with him, and then conduct a brief guided meditation designed to bring him into the present moment, increase awareness of his breath and body,

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remind him of his reasons for being in the lesson, and establish his connection with the therapist. This can be as simple as talking them through a few conscious breaths. With repetition, the short meditation will become a reassuring ritual that signals the beginning of a special time. If this is the client’s first lesson, much of it will be spent gathering musical and psychological information, assessing, discussing and setting musical and psychological goals, establishing rapport, and, for some students, being introduced to the instrument for the first time. For subsequent sessions, create musical lesson plans that teach musical skills while also addressing therapeutic goals. An example might be “Practice switching between D, A, and E chords, note on a piece of paper the number of times X calls herself stupid, ask X to come up with supportive words to say when she is struggling to learn something.” Let the student know what the plan is for the day, and if appropriate and therapeutic, ask them for their input. As the music lesson progresses, therapeutic issues will surface. If the issue is being felt intensely by the student or it is determined that the best course of action is to stop the music lesson and address the issue, then do so. Other concerns can be noted or briefly commented upon and then brought up at the end of the session. Save time at the end of the lesson to process with the client. The depth of the discussion is determined by the level of therapy of which the client is capable. The open-ended question “What was that like for you?” will usually indicate how far to go with subsequent questions and which observations the therapist would bring up. The closing discussion should also cover any practice assignments. Adaptations. It’s possible to teach group music lessons if there is access to a number of the same instrument, or if one is forming and rehearsing a band that will make use of different instruments. Social issues and group dynamics would necessarily be added to the list of therapeutic concerns and benefits. One can also lead drum circles in which participants are taught specific techniques, rhythmic parts, and songs.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Group/Individual Songwriting: Good-bye Song to Ed I have never been married, but I am happily divorced. Ed and I lived together for more than twenty years. He was abusive, controlling, and never hesitated to tell me what he thought, how I was doing it wrong, and what I should be doing instead ... Ed is not a high school sweetheart. Ed is not some creep that I started dating in college ... Ed’s name comes from the initials E.D., as in eating disorder. Ed is my eating disorder. From the Introduction to Life Without Ed by Jenni Schaefer

Overview. In this two- or three-session exercise, the client and/or group looks over the lyrics of several songs about eating disorders, and then, with the help of the therapist, writes a song using their own lyrics. The aim of the song is to help clients to disidentify with their eating disorder, seeing it as a part of themselves but not all of who they are. The level of therapy is primarily intensive. Author, musician, and speaker Jenni Schaefer sees herself as “fully recovered” from an eating disorder. In her books, Life Without Ed (2003) and Goodbye Ed, Hello Me (2009), she chronicles her work with therapist Thom Rutledge, who helped her personify her eating disorder as “Ed” and frame her

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recovery in terms of leaving a dysfunctional relationship. When viewed this way, we ask the person suffering from an eating disorder to disidentify from the disorder—to step back and observe the ways in which it is operating in their lives and to work toward finding new coping skills and ways of relating to themselves and the world. A similar idea is to ask clients to view the eating disorder as a part of them, but not all of who they are. For some, especially those who have been in treatment for a while, these ideas can be liberating and empowering. With those for whom the eating disorder forms the sole basis of their identity or their protective armor and way of relating in the world, these are terrifying ideas that will elicit much resistance. For that reason, this activity should only be introduced when at least some of the members of the group will be open to the concept. The main goals of this group are to explore the idea of disidentifying with the eating disorder, increase insight into the role the eating disorder is playing in one’s life and the effects it has, encourage creative expression and a sense of empowerment, and build a sense community and connection among group members. Even those participants who are far from considering letting go of the eating disorder will engage in discussion and contribute to the songwriting. Sometimes it’s a “fake-it-till-you-make-it” approach, with members pretending or imagining what it would be like to declare their aversion to or independence from “Ed.” That’s fine, because at minimum they are still being exposed to the ideas. This group usually spans two or three sessions, since the first group covers the introduction and discussion of the ideas, and the following groups(s) are used for the songwriting process. There is quicker version in the Adaptations section. The main contraindication is lack of readiness. As mentioned above, at least some of the members of the group must be at a point in their recovery where they can be open to the idea that “I am not the eating disorder” and that breaking free is a desired and possible outcome. Participants need to be able to verbally process in the group, so this group is not appropriate for anyone with a thought disorder. Procedures. It is recommended to read Schaefer’s books and spend time on her website (jennischaefer.com) or read more about disidentification and the concept of disengaging from one’s eating disorder. The distinction between “I am anorexic” and ‘I have anorexia” is significant. The idea is addressed in many eating-disorder recovery blogs and websites (e.g., something-fishy.org, eatingdisorderrecovery.com, eatingdisorderhope.com) and in numerous books such as 8 Keys to Recovery from an Eating Disorder (Costin & Grabbe, 2011). For the first session, make a one-page handout with a few excerpts from Schaefer’s books, such as the one above and the following one from Goodbye Ed, Hello Me: Who am I without Ed? We have been together for so long that I am afraid of what my life might look like without him. What if my life is actually worse without him? Sure, things are not exactly great with him. Okay, I admit that things are horribly miserable with Ed, but at least I’m thin. I would definitely rather be thin and miserable than fat and miserable. What if being recovered just means that I’m going to gain weight and be fat and miserable? Excerpts from anonymous bloggers found on the websites mentioned above might also be included to stimulate responses and discussion. Find a song that illustrates being trapped by the ED or caught in a dysfunctional relationship, and one that illustrates breaking free. To the extent possible, choose songs that are current and relevant to the ages and cultures in your group. Here are some classics that describe ED:

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“Ana’s Song” by Silverchair “Me and MIA” by Ted Leo and The Pharmacists “Mary Jane” by Alanis Morissette Here are some that address hope and breaking up: “Courage” by Superchick “Quasimodo” by Lifehouse “Survivor” by Destiny’s Child Jenni Schaefer also has a song, “Life Without Ed,” that covers it all. Have lyrics sheets to pass out, and a method of playing the songs. This first group will consist of reading the excerpts, listening to the songs, discussing the idea of disidentifying from the eating disorder, and processing the feelings that arise. A circle of chairs or pillows is the best arrangement. The second session will make use of a piano, keyboard or guitar, optional percussion instruments, sheets of paper, pens, and a method of recording the music. Access to a white board, an easel and chart paper, or butcher paper that can be taped to a wall will aid in the group songwriting process. For the third session, copies of the new song’s lyrics, instruments, and a recording device are needed. What to observe. Keep in mind that the eating disorder has been, for many, a means of survival. The idea is not to rip away defense mechanisms, but to gently invite inquiry and awareness, which may open the door to a different way of relating to oneself and the eating disorder. By its very nature, this group will produce a variety of anxious responses that might manifest as resistance, mockery, anger, withdrawal into silence, restlessness, and an inability to focus. Ask open-ended questions such as “What’s your response to that?” or “Can you talk more about how you think it’s stupid?” Remind participants that just because they are looking at this from a different perspective, it doesn’t mean they have to adopt it. Many times, those who strongly resist the idea will still admit to a love-hate, dysfunctional relationship with their eating disorder and be able to authentically participate from that position. Watch for those who tend to take over the songwriting task and those who remain silent or passive, and assist them with toning down and collaborating or piping up and participating. The process of songwriting can also bring some participants’ inner music critics and perfectionists out in full force, as well as their tendency to focus on the flawless finished product rather than the fun process of collaboration and creative expression. If this happens, gently point it out and invite the client to take a deep breath, to laugh, or to thank their inner critic for “sharing.”

Procedures. First session (warm-up): Welcome the group and lead a short meditation that encourages breath awareness and coming into the present moment. Pass out lyrics sheets and play the song you have chosen that illustrates life with the eating disorder. Facilitate discussion with open-ended questions like “What is your response to the song?” Pass out the sheet with excerpts from Jenni Schaefer’s books, say a few words about Schaefer’s journey, and ask for volunteers to read the excerpt out loud. “What do you think of this approach?” is one of the simplest ways to get the discussion going, and “Can you imagine divorcing your eating disorder?” may keep it going. The depth to which you go in your discussions will be up to you and the group. Explain that over the next group or two, you will be working together to create a “Good-bye, Ed” song. As a practice and to generate ideas for the song, ask the group to write a “Dear John” letter to “Ed” that covers ideas such as the damage he caused, why the break-up is happening, how it happens, and how it will feel to be free. This is where the white board, easel or butcher paper comes in handy.

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When the letter is done, take turns reading it or ask for a volunteer to read it aloud once. Divide a large group into smaller groups and have each small group share their letter. Allow for discussion and processing of responses and feelings about the letter writing, again by asking open-ended questions. Close the group by playing either the empowering song you chose for the session or Jenni Schaefer’s Life Without Ed, with lyrics sheets. Collect and make copies of the letter(s) for participants to use in the next session. Second session (action): Welcome the group and lead a short breathing and centering meditation. Ask if there were any experiences, thoughts, or feelings related to the last group, and allow time for sharing. Pass out the copies of the letter(s) from the previous session, take turns reading them aloud, and tell the group that the ideas in the letters will be the seeds for the song. Facilitate a discussion and decision process about the style of music the song will be in. Demonstrate on keyboard or guitar several chord progressions and melodies from the blues, jazz, pop, rock, hip-hop, and country styles of music. One group chose to rap the song with percussion, mouth and body percussion, and Beatbox sound effects! For larger groups, a democratic vote to settle on a final choice saves time, while with smaller groups you may be able to arrive at consensus. The therapist can come up with the melody and structure of the song to save time. (It’s always good to have some prepared progressions and melodies to demonstrate for this type of group.) There are two choices here: to run through the song several times, with the group singing “la la la” so that all get a feel for it and can write their parts, or to decide on the rhythmic structure of the chorus and verses with the group and then come up with the melody as they are working on the words. Another alternative is for the group to come up with general ideas of what they want, and the therapist then solidifies the ideas into a song in the session or before the next session. On the occasions when there are musicians and songwriters in the group who are willing to contribute to composing the music, by all means include them. Once, a group member “donated” the music to one of her original songs. Guide the verbal songwriting by suggesting that the song requires a chorus plus at least three verses to illustrate the ideas previously brought up in the letter(s): the negative effects and damage caused, why and how the break-up happens, and how it will feel to be free. A smaller group can all work on the full song together, and a larger group can work on the chorus together but break up into smaller groups to write verses based on one of the ideas (group A writes a verse about the damage, group B about why the break up is happening, and so on). With a small group that works quickly, the group may be able to finish the song, record it, and listen to it within the second session. Make sure there are at least 15 to 20 minutes to discuss and process how participants were affected by the whole experience, how they might use the song, and anything else they want to share. If using a third session to finish up, close the second session with 10 to 15 minutes of discussion and sharing of their experiences by asking open-ended questions. Third session (closure): Welcome the group and lead a short centering and breathing practice. Remind participants that this is the final session of three, in which the song is finished and recorded. Pass around the words to the song and perform what has been completed so far, encouraging all to take part. Work together as a group to add the finishing touches to the song in terms of instrumentation, soloists, and other musical details. Record the song and then listen to it. The rest of the group will be devoted to discussion and processing. Open the discussion by reminding participants of the first session and asking for comments or observations about the journey from then to now, both on a personal and community level. Ask open-ended questions in response to what participants are sharing. Close the group with either a live performance or by listening to the recorded version.

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Adaptations. This group can be adapted to individual sessions. The process would be the same: Introduce the concept, write a good-bye letter, craft a song. Another option is for the group to rewrite the lyrics to a preexisting song they all know. Once the song is agreed upon, assist the participants in matching their lyrics to the structure and the rhythm of the song. An Internet connection may be needed to a site where you can listen to music, and a site that gives you chords/music in case the group opts for rewriting words to a song that you do not know. Rewriting lyrics to a song is the easier and quicker option, and the one to go with if you do not have three sessions with which to work. Examples of preexisting songs that groups have used are Ray Charles’s “Hit the Road, Jack,” “Firework” by Katy Perry, Lynyrd Skynyrd’s “Freebird,” “Brave” by Idina Menzel, and “Hope” by India.Arie. Songwriting is a versatile activity that can address countless themes and treatment goals, so enjoy adapting the basic session to meet your clients’ needs. If you have the means to offer participants MP3s or CDs of their song, it is always appreciated.

Group/Individual Songwriting: Comfort Chant Overview. Guided by the therapist, the client(s) writes a song about emotional self-care. Marsha Linehan (1993a, 1993b) has made a tremendous contribution to the field of mental health by introducing the principles and practices of Dialectical Behavioral Therapy, which can be used very effectively with clients with eating disorders. Deborah Spiegel, a music therapist from Colorado, is leading the way in combining music therapy and DBT (2010). Another music therapist who has done extensive work with clients in creating self-soothing songs and chants is Louise Montello, who works with clients to create lullabies and “safe place songs” (Montello, 2002, pp. 100–102, 204–206). The Comfort Chant session addresses the development of mindfulness, emotional regulation, and distress tolerance, three of the four skill areas addressed in DBT. Many people who live with an eating disorder have never learned how to regulate their emotions or self-soothe in healthy ways, and consequently use self-harming addictions or eating-disorder behaviors to do so. This exercise teaches clients to become aware of a situation or trigger that causes distress; to witness, name, and disidentify from resultant overwhelming emotions; and then to self-soothe in the presence of the distressing trigger or emotion. This activity can be adapted to any level of therapy. The activity can be conducted as an entire group, small group, or individually. As for contraindications, participants should have enough of an ability to contain difficult emotions so that they would not be disruptive to the group. If they are too emotionally labile and attention-seeking, then individual sessions are advised until they are more able to work in a group setting. Preparation. Have an array of percussion and melodic instruments available on one side of the room. Participants can sit in chairs or on the floor in a circle. If working individually in a group setting, the room must be large enough so that participants can create physical and auditory space for themselves, or the situation is such that they are allowed to leave the group room or wander outside. Otherwise, work in small groups or with the group as a whole. Have pens and paper available for individuals and small groups, or a white board/standing flip chart if working with the whole group. Also, have simple art supplies available but not obviously evident. They are to be used only for those participants who genuinely experience difficulty expressing themselves musically. What to observe. As with any collaborative effort, watch for participants who tend to take over the songwriting task and those who remain silent or passive. Direct questions to and invite comments from the more quiet clients, and acknowledge the contributions made by active clients while encouraging them to allow space for others to voice ideas. The specific instrument chosen by an individual, how they play it, and how the singer uses their voice may offer clues to symbolic or psychodynamic processes.

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Please see the Group Improvisation “What to observe” section above for a more thorough discussion of these ideas. Procedures. Welcome participants into the room, hand out lyrics sheets, and play the songs “Ooh Child,” sung by Marirose (one of many versions of this old classic), and/or “Gentle With Myself” by Karen Drucker. If you can’t obtain these songs, find a song that addresses the concept of offering comfort to oneself. Lead a discussion by asking what the two songs have in common, and highlight any comments made about how the songs are soothing. Ask for other examples of songs that offer comfort, such as lullabies, and stress how even a few lines of a song can carry us through a difficult time. Steer the conversation toward a discussion about what one would say to soothe a child, loved one, or dear friend who was feeling scared, lonely, angry, hopeless, or confused or suffering in some way. Ask participants to identify one specific situation or emotion for which they would appreciate having a simple, soothing song. Ask them to describe how they are affected when the emotion or situation arises and to begin to think about what they would say “to that part of you that is suffering.” Introduce the task, which is to write a four-line Comfort Song for the emotion or situation they just identified. Hand out paper and pens to each participant if they will be working individually, and if dividing into small groups, do so by common themes. If staying as one large group, come to a consensus or vote democratically for the theme of the song. Examples of themes might be “for when I’m feeling hopeless” or “for when I’m getting really anxious.” Ask individual participants to then select one instrument that will become their cocreator and companion for the song. Small groups or one large group can discuss which instrumentation they want to use, and not everyone needs to play an instrument. Tell participants that they can spend time first exploring the sound of their instruments and allow the words and melody to come later, or they can compose the words first and then explore how their instruments can support the lyrics through rhythm and melody. Stress that there is no “right way.” Model an example (preferably with words drawn from the previous discussion) of playing an instrument for a while, finding a “groove” or repeated pattern, and then beginning to sing simple words over it. Let participants know how much time they have to work on the song and, if they will be leaving the room, what locations are permissible. Fifteen to twenty minutes is usually enough time to complete the task, though some participants will finish more quickly than others. Encourage those who finish early to practice their songs quietly or to spend the time imagining themselves singing their songs in future situations. Give slower participants 10- and 5-minute warnings as the songwriting period comes to a close. Check in with individuals and small groups while they work to offer assistance with navigating through stuck periods, settling creative conflicts, or providing musical suggestions. Occasionally, an individual will be unable or unwilling to work musically, so give them the option to spend the time drawing a soothing image, writing themselves a letter of comfort, or exploring how they can move in ways that invite increasing levels of comfort. When leading one large group, decide as a group whether to begin with music or lyrics. Elicit suggestions for words and phrases, write them on the board, and facilitate the crafting of four lines of lyrics. Make sure to check in with the quiet ones, even if just to ask if they approve of choices. Ask the group to begin exploring what a musical sound track for the theme of the song would sound like; facilitate finding a rhythm and a repeating pattern into which the whole group settles. If there is no melody coming through in the improvisation, ask for suggestions for a simple melody. If nobody offers ideas, come up with a simple one and offer it to the group. Play through the completed song several times. If the group works quickly, an additional four lines may be written. Gather the group in a circle for processing and closure. Ask small groups and invite individuals to share their songs with the larger group. Occasionally, an individual will not want to share a song that feels very personal, and it’s important to respect their choice not to share. If the therapist determines that for clinical reasons (the client may be suicidal, for an example) she needs to discuss the song or the client’s

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unwillingness to share, do so individually after the group ends. As clients share, encourage them to notice how both the creative process and the final product affected them, and invite them to consider how they can use the process and the song in the future. Listen for opportunities to reinforce the concepts of identifying a distressing state, witnessing how one is affected, and disengaging enough to comfort oneself. When processing sessions that occurred with the smaller groups or the full group, you can also ask participants to notice how they worked with others in the group process, what role(s) they played, and if this reflects how they interact in other settings. If working with one group, close with a final rendition of the song. For all other groups, ask participants to close their eyes and hear their comfort song inside. When they open their eyes, remind them of the importance of learning how to self-soothe and congratulate them for their efforts. Adaptations. In addition to songs of comfort, individuals and groups can write songs or chants of courage and empowerment. Music therapist Christine Stevens’s chant “Tower of Strength” from her CD Diva: Empowering Rhythms & Chants for Women’s Spirit, works well as a warm-up song to this theme, and participants can join in (Stevens, 2009). Another adaptation is to compose songs that create and anchor participants to feelings and even places of serenity and safety. The song “Peace” by Norah Jones is a beautiful example that could be played as a warm-up. As mentioned above, the concept of learning and practicing the art of self-soothing can also be explored through art, writing, and movement or dance for a full, multimodal experience.

CLOSING REMARKS ON METHODOLOGY When planning the treatment goals and methods for any session, the music therapist must take into account the length of time available for the session and the ages, acuity, diagnoses, and size of the group. Although most of the articles written about music therapy and eating disorders focus on individual sessions, group work is very effective with this population. In broad terms, groups are conducive for working on interpersonal issues, and individual sessions, for working on intrapsychic issues. Certain facilities may offer only groups and others may include both. Factors to consider when deciding to offer group or individual sessions are the psychological stability and ability of clients. If they are too emotionally labile, consistently exhibit behaviors that would be disruptive to the group process, or are unable to cognitively process at the level of other members of the group, then they would benefit from individual work that helps them develop stability, self-control, and cognitive skills before they join a group. Physical health, especially in inpatient and medical settings, can also determine eligibility for group work. Some clients who are bedridden or too ill for group may still benefit from individual sessions. As mentioned earlier in the chapter, there are some programs that keep adolescent and adult groups separate, others that don’t, and still others that offer a combination of the two. The same can be said of groups composed of participants diagnosed with anorexia versus those with bulimia and bingeeating disorder. There are enough differences that groups with a focus on issues and concerns specific to each diagnosis can be helpful, and there are enough similarities that groups addressing those similarities are also beneficial. The music therapist should take into account the ages and diagnoses of participants when planning the session, and gear treatment goals and methods accordingly. The optimal size for groups with a psychodynamic focus and for adolescent groups is from 3 to 12 participants. Larger groups are best suited for psychoeducational material and therapeutic goals addressing the development of interpersonal, communication, and self-expression skills. Unless the therapist is in private practice, it is often the institution that determines the length of a session, which can range from 45 to 90 minutes for groups and 30 to 60 minutes for individual appointments. An hour to 90 minutes is optimal for most sessions, and weekly or semiweekly sessions

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provide the continuity necessary to build therapeutic rapport and momentum. Anything less would tend to negatively influence the depth to which participants are willing to go with each other and the therapist. It can be helpful to think in terms three sections or phases when designing a music therapy session: the initial warm-up or introduction, the action phase, and the closure. In addition to providing an effective model for planning sessions, this format helps to reduce anxiety in participants by providing structure and consistency. The warm-up phase can take up to a quarter of the allotted time for the session, and serves the following purposes: •

• • • •

To nonverbally articulate that participants are entering a physical space and time designated for working therapeutically and to bring participants into an awareness of themselves and the present moment so they are more receptive to the therapeutic experience. Activities such as breathing techniques, grounding, and mindfulness practices are useful here (Shapiro et al., 2008). Some groups, especially those that have continuity to them, may even benefit from creating their own opening and closing rituals. To teach basic skills needed for the task in the action phase. To reduce anxiety levels by offering a success-oriented experience. To introduce the theme(s) of the session. To facilitate a sense of group cohesion, community, and trust.

Examples of tasks that address the above objectives are simple instrumental or vocal activities such as playing a heartbeat rhythm together or call-and-response exercises. Themes can be introduced through a song, poem, reading, or discussion. Encouraging a discussion of the theme by asking questions such as “How many of you have ever …?” can also build group cohesion. The purpose of the action phase is to involve the individual or group in a treatment-oriented experience; it should last for approximately one-half to three-quarters of the session. This is the section where the therapist introduces the music therapy task(s) designed to address specific goals and objectives. Examples of this might be songwriting, playing and discussing a specific song chosen for lyric discussion, or improvising on the theme of anger. The therapist can introduce breathing, centering, grounding, or mindfulness practices if an individual experiences extreme anxiety or PTSD symptoms, if the group loses its focus or the therapist loses control of the group, and if the therapist feels it would be beneficial to the group or individual to stop and reorient to the task or themselves. The closure phase takes up the final quarter of session time. If the group is large, if strong feelings or conflicts arose, or if the subject matter is heavily charged, you may need to allot more time for closure. Experiential tasks bring up nonverbal physical and emotional responses, as well as unconscious material. The two main purposes of this section are: 1) To give participants time to integrate, “digest,” and make sense of their experience. Verbally processing the experience uses the prefrontal cortex of the brain to facilitate this awareness and understanding. The level of therapy the individual or group is capable of will determine the type and depth of the verbal processing. When there is time, nonverbal techniques for processing, such as writing and drawing, can also be used. They can then be shared with the therapist or group. Basic themes for discussion include noticing how participants have been affected, what they are aware of, and what aspects of the experience can be applied to their lives in terms of past, current or future challenges. Participants can also be encouraged to identify behaviors or practices to engage in as a result of their experience. Closing discussions in groups also meet the goals of building connection, cohesion, empathy, and verbal and communication skills.

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2) To mark the end of the session as a special therapeutic time. The playing of a closing song or the reading of a poem that ties together the theme of the session and members’ experiences can be used here. The final playing of a recording made in the session, of the song discussed in the session, or a final jam can close out the session. Once again, a simple breathing, centering, or mindfulness practice can be very effective as a closing ritual.

WORKING WITH CAREGIVERS Family therapy is an essential treatment component for this population, so it is surprising that there is no literature currently available on the use of music therapy in the treatment of families with a member diagnosed with an eating disorder. There are also no eating-disorder treatment centers that advertise the use of music therapy in family work. Music therapist Lee Anna Rasar suggests that “Music is very useful in both family and marital therapy since music is a medium for communication. … Watching the family while they are making music together gives the therapist an inside look at who takes on what role and how the family works together.” (http://people.uwec.edu/rasarla/research/familytherapy/index.htm)

RESEARCH EVIDENCE There are many skilled and dedicated music therapy professionals working with clients who have eating disorders. The music therapy literature on eating disorders is growing; however, most of the writings are of a clinical nature, falling primarily into the category of case studies. See the reference section below. No research studies have been found on music therapy for eating disorders except for one by McFerran, Baker, Patton, and Sawyer (2006). They did a retrospective analysis of the lyrics written by clients with eating disorders and found these themes to be most prevalent: relationships with significant other (17.4%), identity issues (28.2%), aspirations and hopes (16.6%), eating disorders (15.2%), emotional awareness (17.2%), and finding support (2.4%). No research has been found documenting the effectiveness of music therapy with this population. Much research is needed, especially clinical trials.

SUMMARY AND CONCLUSIONS Our understanding of how to use music therapy for eating disorders is based primarily on clinical experience and clinical writings. Little is known about how to use music therapy with caregivers and families, and no efficacy research is available at this time. Based on my own clinical experience, music therapy shows great promise as a very effective treatment modality for eating disorders; however, research is sorely needed.

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Feldman, M., & Meyer, I. (2007). Eating disorders in diverse lesbian, gay, and bisexual populations. International Journal of Eating Disorders, 40(3), 218–226. DOI: 10.1002/eat.20360. Gardstrom, S. (2007). Music therapy improvisation for groups: Essential leadership competencies. Gilsum, NH: Barcelona Publishers. Genco, F. (2012). Singing the body into being: Healing yourself and community through song. Berkeley, CA: self-published. Available from http://songofthebody.com/ Gluck, M., Geliebter, A., & Satov, T. (2001). Night Eating Syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obesity Research, 9(4), 264–267. Retrieved from http://onlinelibrary.wiley.com/doi/10.1038/oby.2001.31/full Golden, N., Katzman, D., Kreipe, R., Stevens, S., Sawyer, S., Rees, J., & Rome, E. (2003). Eating disorders in adolescents: Position paper for the Society for Adolescent Medicine. Journal of Adolescent Health, 33, 496–503. Grocke, D., & Wigram, T. (2007). Receptive methods in music therapy. . Philadelphia, PA: Jessica Kingsley. Hall, C. C. (1995). Asian eyes: Body image and eating disorders of Asian and Asian American women. Eating Disorders, 3(1), 8–19. Hall, R., Tice, L., Beresford, T. P., Wooley, B., & Hall, A. K. (1989). Sexual abuse in patients with anorexia nervosa and bulimia. Psychosomatics, 30, 73–79. Hanser, S. B. (1985). Music therapy and stress reduction research. Journal of Music Therapy, 22(4), 193– 206. Hanser, S. B., & Mandel, S. E. (2010). Manage your stress and pain through music. Boston: Berklee Press. Hilliard, R. (2001). The use of cognitive-behavioral music therapy in the treatment of women with eating disorders. Music Therapy Perspectives, 19(2), 109–113. Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892232/ Hull, A. (2010). Drum circle facilitation. Milwaukee, WI: Hal Leonard Corporation. Knowles, R. (2011, July 13). Rise in men suffering from eating disorders, say GPs. Retrieved from http://www.bbc.co.uk/newsbeat/14051772 Kratina, K. (2006). Orthorexia Nervosa. [pdf download]. Retrieved from http://www.nationaleatingdisorders.org/information-resources/general information.php Labbé, E., Schmidt, N., Babin, J., & Pharr, M. (2007). Coping with stress: The effectiveness of different types of music. Applied Psychophysiological Biofeedback, 32, 163–168. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treatment of borderline personality disorder. New York: Guilford Press. Loewy, J. (2000). Music psychotherapy assessment. Music Therapy Perspectives, 18(3), 47–58. Loth, H. (2002). “There’s no getting away from anything in here”: A music therapy group within an inpatient programme for adults with eating disorders. In A. Davies & E. Richards (Eds.), Music therapy and group work: Sound company (pp. 90–104). . Philadelphia, PA: Jessica Kingsley. Makino, M., Tsuboi, K., & Dennerstein, L. (2004). Prevalence of eating disorders: A comparison of western and non-western countries. Medscape General Medicine Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1435625/ Markova, D. (1996). The open mind: Exploring the 6 patterns of natural intelligence. York Beach, ME: Redwheel/Weiser.

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McFerran, K., Baker, F., Patton, G., & Sawyer, S. (2006). A retrospective lyrical analysis of songs written by adolescents with anorexia nervosa. European Eating Disorders Review, 14, 397–403. Montello, L. (2002). Essential musical intelligence. Wheaton, IL: Quest Books. Moreno, J. J. (1980). Musical psychodrama: A new direction in music therapy. Journal of Music Therapy, 27(1), 34–42. Moreno, J. J. (2005). Acting your inner music: Music therapy and psychodrama. Gilsum, NH: Barcelona Publishers. Nackach, S. (2012). Free your voice: Awaken to life through singing. Louisville, CO: Sounds True. See http://www.voxmundiproject.com/ National Alliance on Mental Illness (NAMI). (n.d.). Mental Illness, Eating Disorder Not Otherwise Specified. Retrieved from http://www.nami.org/ Template.cfm? National Eating Disorders Association. (2005). http://www.nationaleatingdisorders.org/ Newberg, A. (2009). Yawn. It’s one of the best things you can do for your brain. The Pennsylvania Gazette, Nov/Dec. Retrieved from: http://www.upenn.edu/ gazette/1109/expert.html Nolan, P. (2005). Verbal processing within the music therapy relationship. Music Therapy Perspectives, 23(1), 18–28. O’Reardon, J., Peshek, A., & Allison, K. (2005). Night Eating Syndrome: Diagnosis, epidemiology and management. [Abstract]. CNS Drugs, 19(12), 997–1008. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16332142 Paul, T., Schroeter, K., Dahme, B., & Nutzinger, D. (2002). Self-injurious behavior in women with eating disorders. American Journal of Psychiatry, 159(3), 408–411. Pavlakou, M. (2009). Benefits of group singing for people with eating disorders: Preliminary findings from a non-clinical study. Approaches: Music Therapy & Special Music Education, 1(1). Retrieved from http://approaches.primarymusic.gr/approaches/content/view/19/37/lang,en/ Rama, S., Ballentine, R., & Hymes, A. (1979). Science of breath. Honesdale, PA: The Himalayan Institute Press. Schaefer, J. (2003). Life Without Ed. New York: McGraw-Hill. Schaefer, J. (2009). Goodbye Ed, hello me. New York: McGraw-Hill. Shapiro, S. L., Oman, D., Thoresen, C. E., Plante, T. G., & Flinders, T. (2008). Cultivating mindfulness: Effects on well-being. [Abstract]. Journal of Clinical Psychology, 64(7), 840–862. Sokolov, L. (2009). Opening to breath: An examination of breath and process in embodied voice work. In R. Azoulay & J. Loewy (Eds.), Music, the breath and health: Advances in integrative music therapy (pp. 43–53). New York: Satchnote Press. Spiegel, D. (2010). Music activities and more for teaching DBT skills and enhancing any therapy: Even for the non-musician. Bloomington, IN: Authorhouse. Stevens, C. (2009). Tower of strength. On Drumming Up Diva [CD]. Portland, OR: CD Baby. Stevens, C. (2012). Music medicine. Louisville, CO: Sounds True. Striegel-Moore, R., Schreiber, G., Lo, A., Crawford, P., Obarzanek, E., & Rodin, J. (2000). Eating disorder symptoms in a sample of 11- to 16-year-old black girls and white girls. International Journal of Eating Disorders, 27, 49–66. Striegel-Moore, R., Dohm, F., Kraemer, H., Taylor, C., Daniels, S., Crawford, P., & Schreiber, G. (2003). Eating disorders in black and white young women. American Journal of Psychiatry, 160, 1326– 1331. Striegel-Moore, R., Rosselli, F., Holtzman, N., Dierker, L., Becker, A., & Swaney, G. (2011). Behavioral symptoms of eating disorders in Native Americans: Results from the add health survey wave lll. International Journal of Eating Disorders, 44(6), 561–566. Sullivan, P. (1995) Mortality in anorexia nervosa. The American Journal of Psychiatry, 152(7), 1073– 1074.

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Summer, L. (1988). Guided Imagery and Music in the institutional setting. St. Louis, MO: MMB Music, Inc. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714–723. DOI: 10.1001/archgenpsychiatry.2011.22. Vocks S, Stahn C., Loenser, K., & Legenbauer, T. (2009). Eating and body image disturbances in male-tofemale and female-to-male transexuals. [Abstract]. Archives of Sexual Behavior, 38(3), 364–377. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/19030979 Weltzin, T. (2008). Causes, diagnosis & treatment options of excessive exercise. Retrieved from http://www.eatingdisorderhope.com/information/orthorexiaexcessiveexercise/diagnosisevaluation-causes-treatment Wigram, T. (2004) Improvisation: Methods and techniques for music therapy clinicians, educators, and students. . Philadelphia, PA: Jessica Kingsley. Wolf, N. (1991). The beauty myth. New York: William Morrow. Zerbe, K. J. (1995). The body betrayed. Carlsbad, CA: Gürze Books.

ADDITIONAL MUSIC THERAPY ARTICLES Bauer, S. (2010). Music therapy and eating disorders—A single case study about the sound of human needs. Voices: A World Forum For Music Therapy, 10(2). Retrieved from https://normt.uib.no/index.php/voices/article/view/258 Bobilin, M. (2008). Music therapy in the treatment of eating disorders. In S. L. Brooke (Ed.), The Creative Therapies and Eating Disorders (pp. 142–158). Springfield, IL: Charles C. Thomas Publishers. Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa and the person within. New York: Basic Books. Dvorkin, J. (1996). Perspectives on music therapy with people suffering from anorexia nervosa. British Association for Music Therapy, 10(2), 7–14. Frederiksen, B. (1999). Analysis of musical improvisations to understand and work with elements of resistance in a client with anorexia nervosa. In T. Wigram & J. De Backer (Eds.) Clinical applications of music therapy in psychiatry (pp. 211–231). . Philadelphia, PA: Jessica Kingsley. Goiricelaya, F. (1988). The role of music therapy in the eating disorders programme at St. Mary’s Hill Psychiatric Hospital, Milwaukee, Wisconsin, U.S.A. In Proceedings of the National Conference of the Australian Music Therapy Association, 14, 57–61. Retrieved from http://trove.nla.gov.au/work/39523760 Heal, M., & O’Hara, J. (1993). The music therapy of an anorectic mentally handicapped adult. British Journal of Medical Psychology, 66(1), 33–41. Heiderscheit, A. (2008). Discovery and recovery through music: An overview of music therapy with adults in eating disorder treatment. In S. L. Brooke (Ed.), The creative therapies and eating disorders (pp. 122–141). Springfield, IL: Charles C. Thomas Publishers. Justice, R. (1994). Music therapy interventions for people with eating disorders in an inpatient setting. Music Therapy Perspectives, 12(2), 104–110. Lejonclou, A., & Trondalen, G. (2009). “I’ve started to move into my own body”: Music therapy with women suffering from eating disorders. Nordic Journal of Music Therapy, 18(1), 79–92. McFerran, K. (2005). Dangerous liaisons: Group work for adolescent girls who have anorexia nervosa. Voices: A World Forum For Music Therapy, 5(1). Retrieved from https://normt.uib.no/index.php/voices/article/view/215/159

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McFerran, K., Baker, F., Kildea, C., Patton, G., & Sawyer, S. M. (2008). Avoiding conflict: What do adolescents with disordered eating say about their mothers in music therapy? British Journal of Music Therapy, 22(1), 16–23. Nolan, P. (1989a). Music as a transitional object in the treatment of bulimia. Music Therapy Perspectives, 6, 49–51. Nolan, P. (1989b). Music therapy improvisation techniques with bulimic patients. In L. M. Hornyak & E. K. Baker (Eds.), Experiential therapies for eating disorders (pp. 167–187). New York: Guilford Press. Parente, A. (1989a). Feeding the hungry soul: Music as a therapeutic modality in the treatment of anorexia nervosa. Music Therapy Perspectives, 6, 44–48. Parente, A. (1989b). Music as a therapeutic tool in treating anorexia nervosa. In L. M. Hornyak & E. K. Baker (Eds.), Experiential therapies for eating disorders (pp. 305–328). New York: Guilford Press. Reynaga-Abiko, G. (2008). Culturally competent group therapy with Latina adolescents and young adults with eating disturbance: The use of poetry and music. In S. L. Brooke (Ed.), The creative therapies and eating disorders (pp. 159–172). Springfield, IL: Charles C. Thomas Publishers. Robarts, J. (1994). Towards autonomy and a sense of self: Music therapy and the individuation process in relation to children and adolescents with early onset anorexia nervosa. In D. Dokter (Ed.), Arts therapies and clients with eating disorders: Fragile board (pp. 229–246). . Philadelphia, PA: Jessica Kingsley. Robarts, J. (2000). Music therapy and adolescents with anorexia nervosa (poetic processes in music therapy). Nordic Journal of Music Therapy, 9(1), 3–12. Robarts, J., & Sloboda, A. (1994). Perspectives on music therapy with people suffering from anorexia nervosa. British Journal of Music Therapy, 8(1), 7–14. Rogers, P. J. (1994). Sexual abuse and eating disorders: A possible connection indicated through music therapy? In D. Dokter (Ed.), Arts therapies and clients with eating disorders: Fragile board (pp. 262–278. Philadelphia, PA: Jessica Kingsley. Sloboda, A. (1993). Individual therapy with a man who has an eating disorder. In M. Heal & T. Wigram (Eds.), Music therapy in health and education (pp. 103–111. Philadelphia, PA: Jessica Kingsley. Sloboda, A. (1994). Individual music therapy with anorexic and bulimic patients. In D. Dokter (Ed.), Arts therapies and clients with eating disorders: Fragile board (pp. 247–261). . Philadelphia, PA: Jessica Kingsley. Smeijsters, H., van den Hurk, J., & van der Veer, M. (1993). Research in practice in the music therapeutic treatment of a client with symptoms of anorexia nervosa. In M. Heal & T. Wigram (Eds.), Music therapy in health and education (pp. 235–263). . Philadelphia, PA: Jessica Kingsley. Smeijsters, H. (1996). Music therapy with anorexia nervosa: An integrated theoretical and methodological perspective. British Journal of Music Therapy, 10(2), 3–13. Taylor, L., & Schaefer, J. (2007). Music as the healer: The power of music in recovery. Eating Disorders Review, 5(3). Retrieved from http://www.eatingdisordersreview.com/nl/nl_edt_5_3_11.html Trondalen, G. (2003). “Self-listening” in music therapy with a young woman suffering from anorexia nervosa. Nordic Journal of Music Therapy, 12(1), 3–17. Trondalen, G. (2005). “Significant moments” in music therapy with young persons suffering from anorexia nervosa. Music Therapy Today, VI(3), 396–429. Retrieved from www.wfmt.info/Musictherapyworld/.../MTT6_3_Trondalen.pdf

Chapter 14

Adults with Substance Use Disorders Kathleen M. Murphy _____________________________________________ DIAGNOSTIC INFORMATION According to the National Institute on Drug Abuse (2010), addiction is considered to be “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences” (p. 5). Research has shown that addiction disrupts the healthy functioning of the brain resulting in serious consequences if left untreated. These structural changes in the brain lead to destructive behaviors that can cost those with addictions their family, job, self-respect, and ultimately their life (NIDA, 2010). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR), a diagnosis of Substance-Related Disorder is given when the individual has an intense need to use alcohol or drugs, which gradually takes over his life (American Psychiatric Association [APA], 2000). “The Substance-Related Disorders include disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure” (DSM-IV TR, 2000, p. 191). There are 11 classes of substances included in this group of disorders, including alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidines, and sedatives, hypnotics, or anxiolytics.

NEEDS AND RESOURCES Persistent substance misuse affects the body, mind, and spirit of those who become addicted. Therefore, music therapy treatment needs to focus on physical, mental, emotional, and spiritual needs that arise as an individual moves from addiction to recovery. While each will be discussed separately, recovery does not follow a linear path. Symptoms related to use or insights related to recovery may appear, be resolved, and then reappear throughout the treatment process. During detoxification, the body and the brain have to learn to function without the substance, making physical recovery the first challenge those in treatment have to overcome (Borling, 2011a). During this adjustment period, individuals may experience both physical and emotional withdrawal symptoms (see Table 1). Disordered sleep is a common symptom of withdrawal and, if not treated, may have a negative impact on recovery. As the physical symptoms subside, clients may begin to experience emotional distress as feelings begin to surface, and familiar coping strategies become an impediment to recovery (Borling, 2011a). During early phases of recovery, thinking tends to be rigid and problem-solving skills are limited (Center for Substance Abuse Treatment [CSAT], 2005a), adding another level of challenge to the recovery process. Additionally, those who misuse substances may have a co-occurring disorder, the symptoms of which begin to emerge once drug and/or alcohol use has stopped (CSAT, 2005b). (Co-occurring disorder is the

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term used to describe the occurrence of a mental disorder such as schizophrenia, bipolar disorder, depression, or generalized anxiety disorder along with a substance use disorder.) Table 1. Physical and Emotional Withdrawal Symptoms

Physical Symptoms Sweating Racing heart Palpitation Muscle tension Tightness in the chest Difficulty breathing Tremor Nausea, vomiting, diarrhea

Emotional Symptoms Anxiety Restlessness Irritability Insomnia Headaches Poor concentration Depression Social isolation

Bill W (cofounder of Alcoholics Anonymous) notes that addicted individuals are “spiritually sick” and that mental and physical healing will occur when the “spiritual malady” is overcome (Alcoholics Anonymous, 2001). Spiritual sickness is a reference not to religiosity, but to the lack of a connection to something outside of oneself. Many of those who struggle with addictions have difficulty finding fulfillment and meaning in their lives, misusing substances to numb feelings of despair and hopelessness (Hagedorn & Moorhead, 2010). Individuals who abuse drugs and/or alcohol often lack the social and personal resources that are known to prevent substance abuse (Moos, 2007). These include self-efficacy and coping skills, healthy relationships, financial stability, moderate levels of structure and goal-directedness, engagement in work, active leisure and spiritual pursuits, and sober role models (Oetting & Donnermeyer, 1998). In addition to addressing the physical, mental, emotional, and spiritual needs of individuals in recovery, effective treatment of substance use disorders should also develop and/or strengthen protective resources (Moos & Moos, 2007). Individuals with substance use disorders often come into treatment as “broken” and depleted. Participation in music therapy may bring to light inner resources of which clients may not have been previously aware or able to tap into. Research has demonstrated that most individuals in recovery will have emotional and cognitive responses to music experiences (e.g., Baker, Dingle, & Gleadhill, 2012; Baker, Gleadhill, & Dingle, 2007). Additionally, engagement in music experiences can stimulate the imagination, helping clients to find solutions or gain insights. Within a group setting, clients have the ability to learn how to connect with others.

CULTURAL CONSIDERATIONS Alcohol and drug use are often influenced by cultural attitudes and values (Amodeo et al., 2004). Castro and Garfinkle (2003) astutely note that most substance abuse treatment programs are blind to these cultural variables. In fact, most treatment programs are based on the principles of Alcoholics Anonymous (AA), which evolved from a Western European view of addiction (Krestan, 2000); ethnically specific treatment models are limited (Amodeo et al., 2004). Therefore, it is important for clinicians to be aware of the beliefs, values, norms, and behaviors that reflect the life experiences of their clients (Castro & Alarcón, 2002) and develop interventions that are culturally compatible. In addition, music therapists need to understand the role of music in various cultures (Moreno, 1995) and be able to incorporate diverse music genres into their clinical practice (Moreno, 1988). Understanding both the cultural norms and music will help the music therapist communicate in a culturally respectful manner (Shapiro, 2005) and develop

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culturally sensitive music therapy experiences. Dougherty (1984) provides brief examples of music therapy groups that were offered for special populations within an inpatient substance abuse treatment facility. Suggestions for further reading may be found at the end of this chapter.

ASSESSMENT AND REFERRAL PROCEDURES In order for treatment to be effective, it must address medical, psychological, social, and legal problems related to the substance use disorder (NIDA, 2009). One of the most widely used assessments in addiction treatment is the Addiction Severity Index (McLellan, Luborsky, Woody, & O’Brien, 1980). The ASI is a semistructured interview designed to collect data on immediate (within 30 days) and long-term difficulties of substance abusers in seven clinical areas: (1) medical status, (2) employment/support status, (3) alcohol use, (4) drug use, (5) legal status, (6) family/social relationships, and (7) psychiatric status (McLellan, Luborsky, & O’Brien, 1986). At this time, there are not any specific music therapy assessments that have been developed for use with individuals who are in treatment for substance abuse disorders (Soshensky, 2007). However, there are theoretical models from which music therapists can draw to assess where clients are in the recovery process and determine treatment needs. Two such models are the Stages of Change as developed by Prochaska and DiClemente (1986) and the Developmental Recovery Process formulated by Gorski (2003). Each of these models identifies therapeutic issues that can be addressed within the context of a music therapy session. As with assessment, there are not standardized referral procedures. In most cases, clients either are assigned to attend (Murphy, 1983; Ross et al., 2008) or elect to participate in (Dingle, Gleadhill, & Baker, 2008) music therapy groups as part of their treatment program. Clients who have difficulty expressing thoughts and emotions may be referred to music therapy as well (Abdollahnejad, 2006a). In some cases, individuals with substance use disorders may self-refer to a music therapist for ongoing treatment (Pickett, 1991).

GENERAL GUIDELINES FOR MUSIC THERAPY IN SUBSTANCE ABUSE TREATMENT There are several general guidelines of which music therapists should be cognizant when planning music experiences for use in substance abuse treatment. Group members who are in detoxification or early recovery may still be experiencing withdrawal symptoms. These clients may exhibit symptoms of withdrawal, including chills, sweats, nausea, and fatigue. Additionally, they may have difficulty attending and remaining focused for an entire session. Lastly, individuals in substance abuse treatment may experience symptoms related to postacute withdrawal (e.g., increased anxiety, palpitations, mood swings, and tiredness). Therapists who observe any of these symptoms should bring them to the attention of the medical staff. Some of the music therapy methods described in this section require the client to go into an “altered state of consciousness,” meaning a shift in normal consciousness to a more “dreamlike” or qualitatively different means of perception (Tart, 1972). Therefore, individuals who have a history of schizophrenia or are actively experiencing hallucinations or delusions should be assessed to determine if altered-state work is safe and appropriate (Summer, 1988). Verbal discourse may be used to help process the music experience. It can be a challenge to keep the discussion focused on the therapeutic issue(s) being addressed and not allow it to become a distraction. Therefore, music therapists should be familiar with verbal techniques such as probes, clarifications, highlighting inconsistencies, reflections, and summaries. Gardstrom (2007) as well as Grocke and Wigram (2007) provide an overview of these techniques and their use within the context of music therapy sessions.

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Receptive Music Therapy: Songs and Music • • • •

•

• •

Active Music Listening and Writing: Clients listen to short musical excerpts and complete a structured writing exercise. Music Discussion: Clients discuss the style/genre of music and the role music plays in an individual’s life as opposed to a discussion centered on the content of the lyrics. Song Choice: Group members are directed to select a song based on a directive from the therapist. Song (Lyric) Discussion: The therapist chooses a song in which the lyrics center on a theme relevant to the therapeutic issues related to addiction, recovery, and/or relapse and client(s) and therapist discuss its meaning. Song Communication: Clients communicate or share something about themselves with the group and/or therapist by choosing a song and describing why it is meaningful to them; also called song sharing. Song Sensitation: The therapist selects a song, then clients listen to it in a relaxed mode, listen to it with the lyrics, reflect on it and give feedback, then re-create the song together. Focused Listening: The therapist or a client brings a song to the group that explores an issue related to addiction and recovery such as powerlessness, unmanageability, selfesteem, self-identity, or anger.

Receptive Music Therapy: Movement • • •

Exercise to Music: Clients move or do exercise while listening to music. Affirmation Creation: Clients move to music to release physical tension while creating personal affirmations for daily use. Movement to Music: The therapist creates a sequence of movements to an instrumental or vocal music composition that the group members perform together.

Receptive Music Therapy: Imagery • •

• • •

Music-Assisted Relaxation (MAR): Clients physically relax while listening to music; this may include progressive muscle relaxation, autogenic relaxation, or breathing techniques. Physioacoustic Method with Music Listening: Low-frequency sound combined with specially selected music is transmitted to different areas of the body through an acoustic system that is embedded in an adjustable chair. Structured Imagery: Clients focus on imagery evoked by music in a structured relaxation experience guided by the therapist. Group Guided Imagery and Music: Clients listen and image to music in an altered state of consciousness in a group setting. The Bonny Method of Guided Imagery and Music (BMGIM): Clients listen to a program of classical music program in an altered state of consciousness while reporting their images to a qualified guide.

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Improvisational Music Therapy • •

• •

• •

•

• •

• • • •

Guitar Improvisation: Clients improvise solo in a free manner on a guitar prepared with open tuning. Referential and Nonreferential Group Improvisation: Clients choose an instrument or voice and improvise freely, either without reference to any idea outside the music (nonreferential) or with reference to an idea or image external to the music (referential). Nonverbal Music Improvisation: Clients improvise freely with a focus on music-making and limited verbal discussion. Adult Improvisational Therapy: Clients discuss pertinent issues in their lives and improvise to explore these issues; verbal and musical techniques are combined throughout the improvisational music therapy session. Analytical Music Therapy (AMT): Client and therapist improvise music together and discuss the symbolic meaning of the music based on analytical concepts. Stories, Myths, and Music: Clients add improvised and predetermined instrumental and vocal accompaniments to stories and myths that have messages relevant to addiction and recovery. Artistic Music Therapy (ArMT): Clients play referential and nonreferential improvisations and work with various other art forms (art, dance/movement, drama); therapeutic work may culminate in a public performance. Song Improvisation: Clients create lyrics and melodies extemporaneously. Vocal Psychotherapy: Clients use “… breath, sounds, vocal improvisation, songs, and dialogue within a client-therapist relationship to promote intrapsychic and interpersonal growth and change” (Austin, 2008, p. 13). Group Drumming: Clients improvise primarily on drums in structured and free musicmaking. Catch Phrase Drum Circle: Clients drum together in a group, improvising rhythms based on AA/NA slogans. Rhythmic Drum-Circle Assignments: Clients play structured rhythmic improvisations on drums; this is used to assess coping skills and rigidity. Conscious Drumming: Clients alternate between improvisational group drumming and playing a group “heartbeat” rhythm to accompany participants who wish to share their response to focus questions.

Re-creative Music Therapy • • •

Vocal Re-creation: Clients choose and sing precomposed songs. Instrumental Re-creation: Clients re-create an instrumental piece or song, or accompany a recording with percussion instruments. Musical Games: Clients play traditional games, such as Jeopardy!, Name That Tune, or Bingo, that are structured to use music or include topics related to music.

Compositional Music Therapy • •

Songwriting: Clients compose an original song within the context of a therapeutic relationship. Song Collage: Clients create two complementary collages: one made from masks, the other from song lyrics.

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GUIDELINES FOR RECEPTIVE MUSIC THERAPY: SONG- AND MUSIC-BASED RECEPTIVE METHODS Songs are the most frequently reported receptive music therapy method in the treatment of substance abuse. They are also often connected to substance use; listening may trigger drug memories or cravings (Fachner, 2010). Music therapists should be aware of this possibility when using songs and have the skill to help clients process a memory or craving so it does not lead to relapse (Horesch, 2010, 2006). When using songs, clients should be assessed for their ability to participate in a music therapy experience that may bring up repressed and/or traumatic memories, and engage in an insight-oriented discussion.

Active Music Listening and Writing Overview. This method involves listening to short musical excerpts and completing a structured writing exercise. Its use in addiction treatment is described by Lesiuk (2010). Active music listening and writing (AMLW) can be used in all stages of recovery with individuals who do not have difficulties with abstract thought. It is designed to improve executive functioning (Lesiuk, 2010). Typical goals include (1) improving attention and concentration, (2) improving verbal memory, and (3) preventing relapse. AMLW is typically used at the augmentative level of music therapy practice. Preparation. Prior to the session, the music therapist should select several short excerpts of different types of music (approximately 2 minutes) and burn them to a CD or upload to an iPod/MP3 player. A structured writing exercise should be created for each excerpt (e.g., write down the musical elements that were heard, write down a memory or image that came to mind). Supplies include pens, pencils, and paper. What to observe. The therapist should observe group members’ attentiveness as well as ability to complete writing assignment and participate in verbal discussion. Procedures. The therapist tells group members that they are going to listen to several short musical excerpts of various genres. After each excerpt, they will be asked to write down their responses to the therapist-prepared questions (see above) related to the music. The therapist checks in with group members to ensure that everyone understands and then plays the first excerpt. The group members listen and complete the structured writing exercise. This process continues until the last excerpt has been played. The therapist may offer assistance to group members as needed. The therapist plays snippets of each excerpt to stimulate group members’ memories and then asks them to share their written answers. Information on the importance of sustained attention in recovery and relapse prevention may be presented if deemed appropriate by the therapist (Lesiuk, 2010).

Music Discussion Overview. Clients discuss the style/genre of music and the role music plays in an individual’s life as opposed to a discussion centered on the content of the lyrics. The therapist facilitates a discussion with clients about their music preferences, how music is used in leisure time, and how preferred music can be used for relaxation (Bednarz & Nikkel, 1992). Music discussion is used with individuals in various stages of recovery in order to develop rapport and discuss the role music plays in one’s life. Typical goals include (1) establishment of rapport using music as a common interest, (2) observing and discussing the role of music in crisis and coping, (3) exploring the relationship between music and alcohol/drug use, (4) recognition of music triggers, (5) relapse prevention, and (6) discussing the role of music in long-term recovery (Bednarz & Nikkel, 1992, p. 22). Music discussion is used at the augmentative level of music therapy practice.

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Preparation. The therapist should familiarize herself with the benefits and dangers of listening to music in recovery. This information could be used to prepare an informational handout for group members. What to observe. During the discussion, the music therapist should make note of the client’s manner of responding to the discussion as well as his attentiveness, alertness, interaction with therapist and group members, willingness to share from one’s life experiences, ability to give and receive feedback, physical tension, affect, mood, and breathing. Procedures. The therapist can begin the discussion in several ways, depending upon the stage of recovery of the group members. In early recovery, the therapist may want to start the discussion by asking members to share their music preferences (genres, artists, instrumentation, etc.) as a way of building rapport. Other topics can be introduced as treatment progresses, such as the use of music as a coping skill, the role of music listening and relapse, and ways of using music in long-term recovery. Once the topic is introduced, the therapist can use verbal techniques to help facilitate the discussion. The therapist may provide a psychoeducational discussion on the benefits and risks of music listening/performing in recovery. Adaptations. This method can be a stand-alone group experience or can be incorporated into other methods as deemed appropriate by the therapist. Song Choice Overview. Group members are directed to select a song based on a directive from the therapist (Dougherty, 1984). Song choice is typically used in a group setting as a means for clients to practice social skills and elicit feelings and memories (Dougherty, 1984). It is appropriate for use in all stages of recovery. Typical goals include (1) impulse control, (2) respect for others, (3) getting to know others (Dijkstra & Hakvoort, 2010), (4) identification of feelings (Dougherty, 1984), (5) reminiscence (Dougherty, 1984), and (6) connecting the addiction to problems of living (Treder-Wolff, 1990a). Clients should be assessed for their ability to participate in a music therapy experience that requires group interaction and tolerance for others. This intervention may not be appropriate for those clients who have limited cognitive abilities. Song Choice may be used at either the augmentative or intensive level of music therapy practice, depending upon the needs of the clients or level of training of the music therapist. This method has been described by Dougherty (1984) and by Dijkstra and Hakvoort (2010). Preparation. The therapist should prepare a list of songs with accompanying lyric sheets and recordings or sheet music (if the song is to be sung live). What to observe. In addition to the general guidelines above, the music therapist should be attentive to mood, affect, participation level, interaction with other group members, willingness to share, ability to give and receive feedback, and inconsistencies between thoughts, feelings, and behaviors (both in the present and during discussions of the past). Procedures. The therapist should pass out the list of song titles. Each client is asked to choose one song to be played based on a directive from the therapist. The therapist should use information from the check-in as well as knowledge of client needs when formulating questions. Dougherty (1984) offers the following as suggestions: “Choose a song to express and enhance the way you are feeling right now; choose a song to change your mood; choose a song to bring back memories; or choose a song for someone else in the group” (pp. 49–50). Play the selection. When it is finished, ask the client to share with the group his reason for choosing that particular song and how it related to the directive given. For example, if the directive given was “choose a song to change your mood,” the therapist may ask the client to share whether the song had the desired effect. Group members would be encouraged to offer supportive feedback noting changes in affect, demeanor, and/or body language. The therapist may then encourage other group members to comment on the effect the song had on their mood as well. If appropriate,

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incorporate an educational discussion on the benefits/risks of music listening in recovery. The therapist should summarize the group discussion. Clients can be asked to contribute to the summary and/or to identify what they are taking away from the group session.

Song (Lyric) Discussion Overview. The therapist chooses a song in which the lyrics center on a theme relevant to the therapeutic issues related to addiction, recovery, and/or relapse (e.g., denial, forgiveness, self-image) and discusses the song’s meaning with client(s). Suggested songs may be found in Appendix A. After listening to the song, the client is given the opportunity to reflect on the meaning of the lyrics (Borling, 2011a; Bruscia, 1998a). This method is often referred to as lyric analysis or discussion and has been described by several authors, including Abdollahnejad (2006a, 2006b); Baker, Gleadhill, and Dingle (2007); Bednarz & Nikkel (1992); Borczon (1997); Borling (2011b); Dingle, Gleadhill, and Baker (2008); Ficken (2010); Gallagher and Steele (2002); Gardstrom, Carlini, Josefczyk, and Love (2012); Jones (2005); Punkanen (2010); Reitman (2011); Silverman (2009a, 2010, 2011a); Treder-Wolff (1999b); and Walker (1995). Song (lyric) discussion is used within all stages of addiction treatment to “… assist the client in exploring effective and/or ineffective coping strategies (cognitive-behavioral), making contact with, and developing awareness of, emotional states (gestalt), as well as allowing the music the meet the internal need for validation, support, and connection (humanistic)” (Borling, 2011b). It can be used in all stages of recovery. Typical goals may be considered in four categories: (1) identification of, exploration of, and working through thoughts, feelings, memories, and behaviors related to addiction and recovery, (2) fostering group cohesion and social skills development, (3) identifying, understanding, and working through maladaptive coping strategies and developing healthy coping strategies, and (4) identifying, understanding, and correcting misinformation about substance use in popular songs and commercial jingles. Additionally, Reitman (2011) provides an extensive list of goals and objectives that can be addressed through song discussion. In addition to the above-stated considerations, clients should be assessed for their ability to participate in an insight-oriented discussion. Song discussion may be used at all levels of music therapy practice, depending upon the setting, needs, and abilities of the clients and skill level of the therapist. Preparation. The therapist should prepare a list of songs with accompanying recordings or sheet music (if the song is to be sung live). Gardstrom and Hiller (2010) have outlined the advantages and disadvantages for each type of song presentation (live or recorded). Music therapists are encouraged to review these guidelines to help inform their decision. Lyric sheets should also be prepared ahead of time. Prior to the start of the group, the therapist may choose to check in with program staff to identify possible themes/issues for lyric discussion. What to observe. In addition to the considerations stated above, music therapists should note group members’ ability to give and receive feedback, and inconsistencies between thoughts, feelings, and behaviors—both in the present and during discussions of the past. Procedures. The therapist hands out lyric sheets for the selected song and provides a focus for the listening experience (Gardstrom & Hiller, 2010). This may be highly directive (e.g., providing group members with a predetermined set of questions, such as: Which lyrics describe powerlessness? What stage of change do you think these lyrics describe?). Or the questions may be nondirective (As you are listening, notice any thoughts, images, or feelings that come into your awareness). The therapist either performs the song live or plays a recorded version. The group members may also sing along. There are various ways to proceed with the discussion, based on the needs of the group, the goals for the experience, the skill of the therapist, and the level of therapy. The therapist may take a highly directive approach and ask a set of predetermined questions. Reitman (2011) and Silverman (2010) provide examples of questions they have developed for specific songs. Alternatively, the therapist may choose a more nondirective approach and ask group members to comment on a part of the song that was most

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meaningful or stood out for them (Borling, 2011a). For example, if powerlessness and unmanageability were being explored, clients would be asked to share which parts of the song represent their experience of powerlessness or unmanageability. If appropriate, incorporate an educational discussion on the benefits/risks of music listening in recovery. The song may be played again after the discussion is concluded, depending upon the needs of the group members. Adaptations. Silverman (2011a) and Treder-Wolff (1999b) also include information on the life, struggles, challenges, and recovery of artists who have a history of substance misuse in the context of song (lyric) discussions.

Song Communication Overview. In song communication or song-sharing (Hedigan, 2005, 2010), clients communicate or share something about themselves with the group and/or therapist by choosing a song and describing why it is meaningful to them. It is a means of communicating what a client is consciously aware of and, at times, that of which he is not cognizant (Heiderscheit, 2009). Song communication is appropriate for use in the middle and late stages of recovery. Its use has been described by several authors, including Abdollahnjad (2006a, 2006b, 2010), Gallagher and Steele (2002), Gardstrom et al. (2012), Hedigan (2005, 2010), Heiderscheit (2009), and Treder-Wolff (1990a, 1990b). Typical goals include (1) identity formation (Hedigan, 2005); (2) recalling significant life events (Hedigan, 2005); (3) communicating or sharing something about oneself with the group (Heiderscheit, 2009); (4) sending a message to another group member, family member, or significant other (Borling & Murphy, 2012); (5) sending a message of encouragement to a group member who is being discharged (Borling & Murphy, 2012; Gardstrom et al., 2012); (6) developing group cohesion (Gallagher & Steele, 2002); and (7) promoting a sense of safety (Gardstrom et al., 2012). Song communication is typically used at the intensive and primary levels of music therapy practice. Preparation. Clients should be reminded to bring in a song they want to share with the group prior to the music therapy session. Alternatively, the music therapist can have a list of available song titles that clients can select from during a group session. Therapists may choose to have prepared lyric sheets for the selected songs. What to observe. As the clients are listening, the music therapist should be observant of changes in physical tension, affect, mood, and breathing. During the discussion, the therapist should be attentive to mood, affect, participation level, willingness to share, ability to give and receive feedback, and inconsistencies between thoughts, feelings, and behaviors—both in the present and during discussions of the past. Throughout the session, the therapist should attend to the way in which group members are interacting with each other and the content of verbal discussions. Procedures. Group members are asked to bring in a song that communicates something about them that they would like to share with the group or contains a message that they would like to share with a specific member. For example, group members may be asked to be bring in a song that contains a message of hope for a client who is about to be discharged. Before playing the song, the group member may choose to share reasons for its choice. Lyric sheets, if being used, are passed out, and a recording of the song is played. After listening, the client who brought in the song can begin the discussion, adding to what was said at the beginning of the group or sharing any other thoughts, feelings, or reactions that may have come up while listening. Group members can be asked to participate in the discussion as appropriate. The therapist may choose to summarize the discussion as a means of bringing closure. If time permits, another group member can share his song, following the same procedure. To close, the therapist may provide a summary of the entire group experience, or the group may end with a musical or imagery experience depending upon the client needs. Adaptations. Hedigan (2010) uses a group improvisation based on Adult Improvisation Therapy (Bruscia, 1987) as a warm-up or opening method prior to introducing Song Communication. The

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improvisation lasts between 8 and 12 minutes. The improvisation may or may not serve as the impetus for the song selection.

Song Sensitation Overview. The song sensitation technique (Loewy, 2002) is composed of four steps: song selection, relaxation and listening twice, feedback-reflection, and a live rendition of the song. This technique was modified by Staub (2006) for use in detoxification/early recovery. In detoxification/early recovery, the song sensitation technique is used to bring awareness to themes and emotions underlying the group members’ substance use. In later stages, it can be used to identify and work through issues related to addiction and recovery. Typical goals include (1) exploration of thoughts, feelings, memories, and behaviors related to addiction and recovery; (2) identification of metaphors that can be used to describe addiction and explore recovery; (3) experiencing and providing support for others; and (4) providing opportunities for creativity and self-expression. This intervention would not be appropriate for individuals who have difficulty with abstract thought and/or limited cognitive abilities or for whom altered-state work is contraindicated. Therapists who use this method should have advanced training in music psychotherapy. Song sensitation is typically used at the intensive and primary levels of music therapy practice. Preparation. Prior to the session, the therapist should select and prepare lyric sheets for several songs that address issues related to addiction and recovery. The lighting in the room will change for each phase of the song sensitation technique. Supplies include pens, pencils, colored pencils, lyric sheets, guitar and/or keyboard, ocean drum, and assorted handheld percussion instruments. What to observe. During the first listening, the music therapist should be observant of changes in observable physical tension, affect, and breathing. For the second listening, the music therapist should make note of the client’s manner of responding to the song as well as physical tension, affect, and breathing. Throughout the session, the therapist should attend to the way in which group members are interacting with each other and the content of verbal discussion, as well being attentive to mood, affect, participation level, willingness to share, ability to give and receive feedback, and inconsistencies between thoughts, feelings, and behaviors—both in the present and during discussions of the past. Procedures. The therapist selects and brings in a song for use in the session. The lights are turned down and group members are encouraged to allow themselves to relax as much as possible. The therapist, accompanying herself with arpeggiated guitar chords or the ocean drum, leads the group members through a music-guided induction focusing on the breath. The music may be used to provide a calming background and/or to structure breathing. At the completion of the relaxation induction, the song is turned on and the group members are invited to listen. When the song has ended, the therapist guides group members back to a more alert state. Lyric sheets and colored pencils are passed out. Group members are invited to follow along with the lyrics during the second listening, using the colored pencils to write down any thoughts, to circle or underline any words or phrases they connected with, or to draw. When everyone has finished writing/drawing, the therapist leads a discussion centering on each person’s experience of the song. Group members are invited to share what they underlined, circled, wrote, or drew. Following the discussion, group members are invited to re-create the song based on what was shared. Group members may choose to sing, play a percussion instrument, or actively listen (Staub, 2006).

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Focused Listening Overview. In focused listening (Murphy, 2012), the therapist or a client brings a song to the group that explores an issue related to addiction and recovery, such as powerlessness, unmanageability, self-esteem, self-identity, or anger. This technique was adapted from the song sensitation technique described by Loewy (2002). The clients listen to and then respond to the song either in writing or by drawing a mandala (free circle drawing). This receptive method is used to assist clients in the identification and exploration of issues related to their addiction and use. It can also be used as a means to explore common themes (see Appendix A) related to the 12 Steps of AA/NA (see Appendix B). Focused listening can be used in all stages of addiction treatment. However, it would not be appropriate for individuals who have difficulty with abstract thought or who have limited cognitive abilities or for whom altered-state work is contraindicated. Typical goals include (1) developing a personal definition of powerlessness, unmanageability, surrender, or other 12-Step concept; (2) exploration of the effects of one’s addiction on his life and that of significant others; (3) exploration of thoughts, feelings, memories, and behaviors related to addiction and recovery; (4) working through denial; and (5) identifying metaphors that can be used to describe addiction and support recovery. Therapists who use focused listening should have advanced training in music psychotherapy, as it is used at the intensive and primary levels of music therapy practice. Preparation. Prior to the session, the therapist should select and prepare lyric sheets for several songs that address issues related to addiction and recovery. The lighting in the room will change for each phase of the focused listening experience. Supplies include pens, pencils, and lyric sheets. What to observe. During the first listening, the music therapist should be observant of changes in physical tension, affect, and breathing. For the second listening, the music therapist should make note of the client’s manner of responding to the song, as well as physical tension, affect, mood, breathing, attentiveness, and alertness. During the discussion, the therapist should be attentive to mood, affect, participation level, interaction with other group members, willingness to share, and ability to give and receive feedback and inconsistencies between thoughts, feelings, and behaviors—both in the present and during discussions of the past. Procedures. To select a song, the therapist identifies a recovery-related theme based on the check-in. The clients are asked to define the theme from their perspective. For example, if the theme is powerlessness, each client is asked to describe his experience of powerlessness. Upon completion of the discussion, the therapist selects a song that is related to the identified theme. The therapist then gives the following directions: “We are going to listen to a song. The first time, I will invite you to lie down on the floor and close your eyes and just listen, noticing any part of the song that stands out. The second time, I will invite you to return to your chairs, and I will pass out the lyric sheets. During the second listening, I would like you to underline two or three of the lyrics that stand out for you today. Then write a paragraph that describes why the underlined lyrics are important for you today. I would ask that you respect the silence until everyone has finished writing and we return to the group. Does anyone have any questions?” Once all questions are answered, invite the clients to lie down on the floor, getting as comfortable as they can. Remind clients that they can also remain in their seats if they so choose. Additionally, they can open their eyes and sit up at any time during the music listening. The listening component follows the directions. Once the clients are all situated, lead them through a brief relaxation induction. When the group appears to be relaxed, turn the music on, gradually turning up the volume and using the following or similar: “As the music comes into your awareness, draw your attention to the sounds and the words. Notice any physical, mental, emotional, or spiritual responses you may have. Notice which of the lyrics or sounds stand out. If your mind begins to wander or you experience an intruding thought, bring your focus back to the music.” When the music has ended, bring the group back to a normal conscious state using the following or a similar script: “The music has ended. Take a moment to collect any thoughts and notice any feelings or sensations … slowly take in a deep

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breath, hold it for a moment, and let it go … then let your breath fall into its own natural rhythm coming in and going out. Become aware of your body against the floor or the chair; move your hands and your feet, and whenever you are ready, you may open your eyes and sit up, respecting the silence.” Pass out the lyric sheets and review the instructions: “This time when you are listening, underline one or two lines that really stand out for you today. Then take some time to write a paragraph describing why you chose those lines.” Once everyone has their lyric sheet and a pen, play the song a second time. When the song has ended, let group members know they can have a few more minutes to finish writing up their thoughts and reactions. The postlistening discussion can be facilitated in a variety of ways, depending upon the group. The therapist can ask each client to share his reactions, using verbal techniques identified above. Those who chose similar lines could be asked to share among each other and bring a summary statement back to the group. Throughout the discussion, the therapist should be looking for opportunities to discuss the theme and deepen the client’s awareness and understanding of it. To close the group, the therapist asks each person to go around and make any changes (if needed) to their definition of the theme and to identify what they will take from the group that will help them in their recovery. Adaptations. Prior to the closing, the focused listening experience may be followed by another music therapy experience such as songwriting, Group Guided Imagery and Music, structured imagery, and/or mandala (free circle) drawing. These additional experiences can be used to further explore material that was brought up by the listening. All of these methods are described within this chapter.

MOVEMENT-BASED RECEPTIVE METHODS Clients should be assessed for their ability to participate in a movement experience. Those in early withdrawal and detoxification should have permission from their physician to participate in any physical activities. Additionally, clients who are in detoxification may not have the stamina to participate in movement-based methods. Chairs should be available should anyone need to sit down before the experience has ended.

Exercise to Music Overview. Clients move and do exercise while listening to music. The music therapist works with physical/recreation therapists to develop music programs to accompany these exercise routines (Ficken, 2010). Exercise to music has been used with clients in all stages of recovery. The music is used to make the workouts more effective and increase motivation to continue exercising postdischarge. Ficken (2010) identifies the following goals: (1) promotion, maintenance, or improvement in physical stamina; (2) structure and increased motivation for exercise; (3) challenging and increasing stamina; and (4) introducing exercise concepts. Exercise to music is used at the augmentative level of music therapy practice. Preparation. The music therapist determines client-preferred music and creates a list of songs that could be used in an exercise program. The music therapist meets with the physical/recreation therapist to determine what musical selections will complement the recommended exercises. The selected music is prerecorded onto a CD or iPod/MP3 Player for use in an exercise to music group. The group should be held in a space where there is enough room for the participants to perform the exercises without infringing upon one another’s person space. Chairs should be available for those who may need to rest during the exercise routine. What to observe. The therapist should observe the clients’ willingness and motivation to participate and ability to perform the exercises as directed. Additionally, the therapist should be attentive to fatigue levels, especially of those participants who are still experiencing symptoms of withdrawal. Procedures. The therapist invites the group members to stand up and find a space allowing enough room so that they do not impinge on the personal space of others. The therapist turns on the

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music and begins demonstrating the exercises that have been prescribed by the physical or recreational therapist, inviting the participants to follow. When the routine is finished, the therapist turns the music off and invites participants to return to their seats. The therapist should begin and end the session with deep breathing and stretching. Adaptations. The therapist may want to facilitate a discussion allowing participants to comment on the experience or share any other thoughts or feelings. Additionally, the therapist can provide a psychoeducational lecture on the importance of exercise to recovery.

Affirmation Creation Overview. Movement to music is used to facilitate the release of physical tension while creating personal affirmations for daily use (Murphy, 2011). This receptive method has been used with clients who are in detoxification or early recovery as a means of reducing physical tension and creating personal affirmations focused on the benefits of walking away from people, places, things, behaviors, and thoughts that will hinder recovery. Typical goals include (1) identification of people, places, things, behaviors, and thoughts that will hinder recovery; (2) decreasing physical tension through gentle movement; (3) offering support to group members; and (4) learning how to create and use affirmations as a healthy coping strategy. This method can be used at all levels of music therapy practice. Preparation. The therapist should select instrumental music with a “walking beat” for use with this intervention (e.g., “Pastorale” by Ray Lynch). It is important that the therapist is familiar with the phrasing, mood, and contour of the composition so as to pair the movements and breathing with the musical structure. Copies of the affirmation worksheet should be prepared prior to the group (Appendix C). The chairs should be set up in a circle, with enough space for the clients to stand up and participate in the movements without hitting or bumping into the person next to them. Supplies include pencils, pens, markers, colored pencils, and affirmation worksheets. What to observe. During the movement portion, the therapist should be attentive to fatigue levels, especially of those participants who are still experiencing symptoms of withdrawal. The therapist should also note which group members are able to share the people, places, things, and behaviors from which they need to walk away. Encourage those who do not feel comfortable sharing with the group to make a mental list for use later in the session. Procedures. The therapist asks if anyone in the group knows what affirmations are and what they are used for. Once the clients have responded, the therapist fills in any additional information. The therapist states that the purpose of this group is to create personal affirmations that will identify what each client needs to move away from and toward in order to maintain his sobriety. The therapist reviews the procedure and asks if there are any questions. The participants are invited to stand up in front of their chairs. The therapist reviews the instructions: “When the music comes on, I will invite you to move in various ways. Each movement will be paired with a question. Once you have thought of an answer, say it out loud. The group will repeat it back to you. For example, when we start stepping to the music, I will ask: ‘What are you walking away from?’ Someone may answer, ‘Heroin.’ The group will then respond: ‘You are walking away from heroin.’” Ask if there are any questions before turning the music on and remind clients that they can sit down if they begin to feel fatigued. Turn on the music and begin by leading the group in some deep breathing, using the music to structure in-and-out breaths. Next, ask the group members to step to the beat, as if they were walking. Once everyone is walking, ask the question: “What are you walking away from?” As group members respond, lead the group in echoing back the response. When those who want to contribute have finished, begin shaking your arms and hands and invite group members to do the same. Then ask the question: “What are you shaking off?” Follow the same procedure as for walking. The next movement is pushing the arms into the center of the circle, followed by the question, “What are you

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pushing away?” When all have finished responding to this question, lead the group in some deep breathing, using the music to structure in-and-out breaths. Then ask the group members to reach up, followed by the question: “What are you reaching for?” This movement is followed by extending arms out in front and bringing them, in accompanied by the question: “What are you taking in?” Finally, return to stepping in place, asking: “What are you walking towards?” As the music comes to an end, guide the group through some deep breathing. When the music ends, invite the group members to sit down. Pass out the affirmation worksheets and ask the group members to complete it using the ideas they came up with during the movement. Clients with limited reading and/or writing abilities may need assistance to complete the worksheet. Once everyone has completed their sheet, group members are invited to stand up one at a time and share their affirmations. After each line, the group will echo back what was shared as a means of support. Each person should remain standing until everyone has shared. Once everyone has shared, lead the group in the Serenity Prayer (found on the bottom of the affirmation worksheet). Ask group members to share what they will be taking away from this experience and how they can use affirmations in their recovery.

Movement to Music Overview. The therapist creates a sequence of movements to a music composition (either instrumental or vocal) that the group members perform together (Borling, 2011a; Borling & Murphy, 2012). This receptive method has been used with clients in various stages of recovery and has been described by Borling (2011); Cevasco, Kennedy, and Generally (2005); and Gardstrom et al. (2012). Typical goals include (1) reducing physical tension (Borling, 2011a), (2) decreasing feelings of stress and anxiety (Cevasco, Kennedy, & Generally, 2005), (3) risk-taking (Borling & Murphy, 2012), (4) experiencing non-drug-induced feelings of pleasure or fun (Borling & Murphy, 2012), (5) attention to task, and (6) working within a given structure. Movement to Music is used at all levels of music therapy practice. Preparation. The therapist should select a musical composition that has a “dance feel” or strong, steady rhythm and create a movement or dance pattern (similar to a line dance). The dance moves should not be very complicated, and the pattern should be short enough for group members to remember. Movements can include locomotor and nonlocomotor movements, body percussion, and stretching. Movement to Music requires a space that is large enough for each group member to stand up and perform the choreographed movements without infringing upon one another’s personal space. What to observe. Throughout the movement experience, the therapist should be aware of physical fatigue, ending the music early if necessary. Additionally, the therapist should be attentive to mood, affect, participation level, interactions between group members, willingness to share, and inconsistencies between thoughts, feelings, and behaviors. Procedures. Group members are asked to stand. The therapist demonstrates the “dance moves” one or two at a time, asking the group members to repeat them. The moves are chained together to complete the entire “dance.” Once the group members have repeated the entire dance at least once without the music, the therapist turns the music on and the entire group performs the dance. The therapist should be mindful of the energy levels of the group members, turning down the music when most members seem fatigued. When the music has stopped, the group members should be asked to return to their seats. The therapist may facilitate a discussion by asking open-ended questions that help group members reflect on the experience and what effect it had on them physically (e.g., How is your body feeling? How would you rate your tension physically, mentally (e.g., What thoughts were running through your head?), and emotionally (How did this experience effect your mood? Did you perform the dance perfectly? If not, what was that like?)? 12-Step principles may be incorporated into the discussion where appropriate. The discussion can be followed with a brief psychoeducational presentation on the benefits of exercise and having fun in recovery (Borling, 2011a).

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Adaptations. Gardstrom et al. (2012) describe the use of expressive movements to explore feelings of embarrassment, shame, guilt, sadness, and other feelings that are burdensome. The clients are asked to move to different styles of music that represent the weight of carrying negative emotions. The music is followed by another composition that encourages more playful movements. This method is designed to help clients feel the difference between being weighted down and being playful and unburdened in their bodies. Mirroring movements can also be used. In this method, clients are paired up. One client initiates various movements that his partner imitates as if he were a mirror image. Roles are then reversed. This can be a very intimate experience and may not be appropriate for individuals in early recovery. Beanbag Toss Overview. Beanbag toss is a receptive method in which rhythmic music (e.g., drumming) is used to structure and accompany an interactive experience (Borling & Murphy, 2012). This receptive method has been used with clients in various stages of recovery. Typical goals include (1) reducing physical tension, (2) decreasing feelings of stress and anxiety, (3) working cooperatively with others, (4) experiencing non-drug-induced feelings of pleasure or fun, (5) attention to task, and (6) working within a given structure. Beanbag toss is typically used at the augmentative or intensive level of music therapy treatment, depending on the goals and skill level of the therapist. Preparation. The therapist should select a rhythmic musical composition. Recorded drumming works well with this method. Beanbag toss requires a space that is large enough for each group member to stand up and form a circle. Supplies needed include four to six beanbags, depending upon the size of the group. What to observe. Throughout the movement experience, the therapist should be aware of physical fatigue, ending the music early if necessary. Additionally, the therapist should be attentive to mood, affect, participation level, interaction with other group members, willingness to share, and inconsistencies between thoughts, feelings, and behaviors. Procedures. Group members are asked to stand and to form a circle. The therapist gives the following directions: “You are to toss the beanbag to one of the group members. The individual who catches the beanbag should then toss it to another group member who has not caught it before. Go around the circle until the only person left to catch the beanbag is the person who tossed it first. When that person has caught the beanbag, he will throw it to the same person he tossed it to originally. Each person should toss the beanbag to the same person and catch the bean bag from the same person.” The therapist then will give a beanbag to a group member who will begin the process. The group should go through the process a couple of times so that the therapist can ensure that everyone understands the directions. When the beanbag is back to the group member who started the sequence, the therapist can turn on the music. After the group members seem to have the tossing/catching pattern down, the therapist can introduce another beanbag into the experience, reminding the group members that they should continue tossing to/catching from the same person. Once the group seems comfortable with two beanbags, a third can be introduced. The therapist can continue to introduce beanbags (up to five or six) as the experience continues. Once the maximum number of beanbags is going around in the circle, the therapist can start to remove beanbags one at a time, by gently stepping in to catch a beanbag ahead of the intended receiver. The therapist should turn down the music when all the beanbags have been taken out of circulation and facilitate a discussion about the experience that will help group members to explore the physical (e.g., reduced physical tension, increased energy) and psychological (e.g., reduced stress/anxiety, feelings of having fun, experience of risk-taking, not having to be perfect) benefits of participating in this exercise. Twelve-Step principles may be incorporated into the discussion where appropriate. The discussion can be followed by a brief psychoeducational presentation on the benefits of exercise and having fun in recovery (Borling, 2011a).

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IMAGERY-BASED RECEPTIVE METHODS During these experiences, individuals move from a normal waking state to one that is more dreamlike or qualitatively different from ordinary functioning (Tart, 1972). Clients who have co-occurring mental illness such as schizophrenia or bipolar disorder with psychotic features should be assessed for their ability to engage in these imagery-based receptive methods.

Music-Assisted Relaxation Overview. Music-assisted relaxation (MAR) combines music listening with a variety of relaxation techniques, including progressive muscle relaxation (Jacobson, 1938), autogenic relaxation (Grocke & Wigram, 2007), or breathing techniques (Austin, 2007). New Age or ambient music is typically used to help facilitate and maintain a relaxed state. Research has indicated that client-preferred music is most effective in facilitating a relaxation response (Batt-Rawden, 2010; Thaut & Davis, 1993). The typical MAR session can last from 5 to 20 minutes depending upon the needs of the client. The use of MAR in addiction treatment has been described by Borling (2011), Gallagher and Steele (2002), James (1988), and Walker (1995). In addiction treatment, MAR is indicated when clients need to learn how to manage symptoms of stress and anxiety, and it can be used in all stages of recovery. It may also be indicated during detoxification to help manage withdrawal symptoms. Typical goals include (1) increasing awareness of physical tension and its relationship to substance misuse (Murphy, 2011), (2) learning how to manage physical tension, stress, anxiety, and/or withdrawal symptoms in order to prevent relapse (Borling, 2011a), and (3) using MAR outside of the clinical setting (Borling, 2011b). MAR is used at all levels of music therapy practice. Relaxation inductions often begin by inviting participants to close their eyes. This can bring up feelings of vulnerability and fear (Grocke & Wigram, 2007). Therapists should give participants the option of closing their eyes, with assurance that it is okay to open their eyes at any point in the relaxation experience. Justice (2007) has developed guidelines for the use of MAR with individuals who have psychiatric disorders. The guidelines are appropriate for use with individuals who have a co-occurring substance use disorder and mental illness. Preparation. The music therapist should take time to familiarize herself with both the music and the relaxation induction that will be used. The induction, the process used to help quiet the body and mind, can be done in several ways. The most familiar technique is progressive muscle relaxation. Examples may be found in Grocke and Wigram (2007), Jacobsen (1938), and Justice (2007). In early recovery, short inductions are recommended. New Age instrumental or ambient music with minimal tempo, dynamic, and harmonic changes that is 50 and 72 beats per minute is recommended for use with MAR in addictions treatment. It is important to practice the relaxation script with various instrumental compositions so that the words and music flow together, thereby creating an aesthetic environment that is conducive to relaxation. MAR sessions should be conducted in a quiet and comfortable room. While the technique works best if individuals are able to lie down, benefit can still be derived if clients prefer to sit. Mats or chairs should be spaced so that each client has their own “personal” space. Lighting should be dim. Music selection should be cued up and turned on once the clients have found their comfortable position. What to observe. During the MAR exercise, the music therapist should be observant of changes in physical tension, affect, and breathing. Procedures. Invite clients to find a comfortable position either lying on a mat or sitting in their chair. Remind them that they can adjust their position at any time in order to maintain maximum comfort. Invite clients to close their eyes if they feel comfortable doing so and to become aware of their breath. Turn the music on and invite the clients to become aware of the music as it fills the room. Begin

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reciting the selected relaxation induction. When the relaxation induction is completed, invite the clients to remain in this relaxed state that they have created, noticing their breathing or the music. As the music comes to an end, begin to prepare the clients for a return to a normal conscious state, using the following or similar language: “The music is coming to end. Take a moment to scan your body from the top of your head to the tip of your feet, noticing what it feels like to be in a relaxed state … slowly take a deep breath in, hold, and release … become aware of the mat (chair) underneath you … become aware of the ambient sounds in the room … slowly take a deep breath in, hold, and release … move your hands and your feet … and whenever you feel ready, open your eyes and slowly sit up.” Group members are encouraged to share their experience with the group, noting any changes in physical tension, stress or anxiety, reaction to the music, and positive or negative feelings. Suggestions for how to use MAR during recovery are elicited from group members. Adaptations. Imagery can be added to MAR (Music and Imagery–Assisted Relaxation). The therapist directs the client to imagine a very peaceful and relaxing place at the completion of the relaxation script that is being used (Hammer, 1996). Mandel, Hanser, and Ryan (2010) have developed a music and imagery relaxation script that can be adapted for use in substance abuse treatment. This method has been used is substance abuse treatment by Hammer (1996).

Physioacoustic Method with Music Listening Overview. The physioacoustic method is a Finnish application in which low-frequency sound combined with specially selected music is transmitted to different areas of the body through an acoustic system that is embedded in an adjustable chair (Lehikoinen, 1997). This method is used to produce physical sensations and images that are explored by the therapist and client (Punkanen, 2006). Use of this method in addictions treatment has been described by Erkkilä and Eerola (2010), Punkanen (2006, 2007), and Punkanen and Ala-Ruona (2011). This method has been used with individuals who have both substance and process addictions (e.g., gambling) in all stages of substance abuse treatment. Typical goals include (1) withdrawal symptom management and stabilization (Punkanen, 2007); (2) evocation of sensations, images, emotions, and memories (Punkanen, 2006); (3) reducing anxiety and tension (Erkillä & Eerola, 2010); and (4) producing a form of alternative substitute pleasure (Erkillä & Eerola, 2010). The physioacoustic method with music listening is used at the intensive or primary level of music therapy practice. Preparation. This method requires the use of a recliner equipped with the physioacoustic device, an audio system, and transformer. Access to an electrical outlet is also needed. The therapist should be familiar with a wide variety of music that is appropriate for this method. What to observe. Lehikoinen (1997) has identified the following side effects that have been reported by clients during their first few physioacoustic therapy sessions: “slight drowsiness, vertigo, or feelings of nausea” (p. 213). Additionally, therapists should be attentive to mood, affect, physical tension, and ability to image. Procedures. The client sits in the recliner. The therapist turns on the physioacoustic device that has been programmed at the proper frequencies as well as the audio device. The music listening lasts approximately 20 minutes. In early recovery, the music chosen should facilitate a relaxing and enjoyable experience (Punkanen, 2007). In later stages, the music can be used to evoke thoughts, feelings, sensations, and images that will be processed when the listening phase has ended (Punkanen & AlaRuona, 2011). The music listening is followed by a therapeutic discussion in which the therapist helps the client integrate the images, sensations, thoughts, and feelings into his life situation and understanding of his addiction. Adaptations. Erkkilä and Eerola (2010) do not focus as much on the imagery that may be produced, but rather advocate use of this method as a means of producing a pleasure sensation that could replace the one obtained from gambling.

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Structured Imagery Overview. Clients focus on imagery evoked by music in a structured relaxation experience guided by the therapist. This technique allows clients the opportunity to explore an area of recovery that lies just below their waking consciousness. The imagery may be scripted or nonscripted, with the therapist giving clients a “seed image” for further exploration (Borling, 2011a, 2011b). The use of structured imagery has been described by Borling (2011a, 2011b) and Gardstrom et al. (2012); Gardstrom et al. (2012) use the term “scripted music and imagery exercise” to describe this method. Structured Imagery may be used with individuals for whom the effects of withdrawal are subsiding and physical recovery is under way (Borling, 2011a). Typical goals include (1) identifying areas of emotional challenge and growth (Borling, 2011a ), (2) connecting with and experiencing emotional states that are uncomfortable (Borling, 2011b), (3) improving self-awareness (Bruscia, 1998b), (4) providing opportunities for emotional release (Bruscia, 1998b), (5) developing insight into substance use (Bruscia, 1998b), (6) spiritual development (Borling, 2011a; Bruscia, 1998b), (7) exploring a personal relationship with a “power greater than oneself” (Borling, 2011b), and (8) exploring personal qualities that contribute to the recovery process (Borling, 2011b). Structured Imagery is used at the intensive and primary levels of music therapy practice. As this method takes its roots from the Bonny Method of Guided Imagery and Music (BMGIM), therapists should have completed at least Level I of the training. Additionally, those music therapists who have not completed their BMGIM training should be working under the supervision of a qualified supervisor. Clients should be assessed for their ability to participate in a music therapy experience that may bring up repressed and/or traumatic memories and their ability to engage in an insight-oriented discussion. Additionally, this intervention would not be appropriate for individuals who have difficulty with abstract thought and/or limited cognitive abilities. Preparation. The therapist should be familiar with music that is appropriate for this type of imagery work. Typically, music used is of the classical, New Age, or ambient genres, and is stable and supportive without drastic melodic, harmonic, dynamic, or tempo changes (Borling, 2011b). Therapists should also be familiar with a variety of relaxation inductions and be able to create “seed images” or imagery scripts based on the presenting needs of the group. The group room should have ample space for chairs to be set up in a circle and for group members to lie down (during the music listening portion of the group). The CD player/iPod/mp3 Player dock should be positioned for easy access to on/off switch and volume controls. Supplies needed include pillows, blankets, writing and drawing paper, pens, pencils, colored pencils, and pastels. What to observe. Throughout the session, the music therapist should be attentive to mood, affect, participation level, interactions with other group members, willingness to share, and inconsistencies between thoughts, feelings, and behaviors. This information can be incorporated into the postimagery discussion if appropriate. Procedures. The imagery focus may be predetermined by the therapist or chosen based on the content of the check-in discussion. For example, the following imagery focus may be used in a group that is exploring connections with a higher power: “Begin to imagine yourself walking down a path, until you come to an image representing a higher power; sit with this image and listen for a message.” The therapist selects music that matches the imagery focus and needs of the group. The relaxation induction is used to quiet both the body and the mind, preparing the client to move into an altered state of consciousness (Ventre, 2002). The therapist invites group members to find a spot to lie down, providing pillows and blankets if requested. The therapist then invites the group members to close their eyes and guides them through a relaxation induction. The type of induction used will be based on participant need, therapist training and expertise, and stage of recovery. Typical inductions include use of the breath, ball of light, or progressive muscle relaxation. Others may be found in Bonny (2002a), Grocke and Wigram (2007), and Skaggs (n.d).

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At the conclusion of the relaxation induction, the therapist introduces the imagery focus and then begins the music. The therapist may choose to direct the experience by providing imagery suggestions at spaced intervals during the music. Imagery suggestions should fit in with the overall flow and form of the music and are provided to help clients remain focused or to draw them deeper into the experience. For example, an additional suggestion that could be used with the imagery focus above might be: “Take a few moments to notice what it feels like to be with this image of your higher power.” When the music has ended, the therapist guides the group members back to waking consciousness. The therapist invites the participants to either write or create a mandala (free circle drawing) in response to their imagery experience. When the group members have finished writing/drawing, the therapist facilitates a discussion in which participants can share their experiences with the group. Throughout the discussion, the therapist should be responding to opportunities to deepen the participant’s awareness and understanding of the imagery experience. Concepts from the 12 Steps and AA/NA such as surrender or connecting with a higher power can be used as well.

Group Guided Imagery and Music Overview. Group Guided Imagery and Music (Bonny, 2002a) involves listening and imaging to music in an altered state of consciousness in a group setting. The typical sessions last 60 to 90 minutes. Its use in addiction treatment has been reported by Erkkilä and Eerola (2010), Gardstrom et al. (2012), Murphy (2009), Murphy and Ziedonis (2012), and Skaggs (1997). Group Guided Imagery and Music (GIM) may be indicated when individuals in recovery need to gain insight into their addiction, clarify feelings about themselves, and understand their behaviors (Skaggs, 1997). Therapists utilizing this method should have completed their training in the Bonny Method of Guided Imagery and Music. Skaggs (1997) identifies the following goals: (1) view life from different perspectives, (2) access and build a trust in the inner helper, (3) take moral and personal inventory of self in its deepest nature, (4) resolve internal conflicts, (5) heal old hurts, (6) provide an ongoing support system independent of external sources, (7) bring together fragmented pieces of life, (8) serve as a model of healthy responses, and (9) improve moods (p. 28). Group Guided Imagery and Music is used at the intensive and primary level of music therapy practice. Preparation. The music used in the group format of GIM is drawn from the classical repertoire. Skaggs (n.d.) provides guidelines for music use during group GIM. Therapists should also be familiar with a variety of relaxation inductions and be able to create “seed images” based on the presenting needs of the group. The group room should have ample space for chairs to be set up in a circle and for group members to lie down (during the music listening portion of the group). Supplies needed include pillows, blankets, writing and drawing paper, pens, pencils, colored pencils, and pastels. What to observe. Throughout the session, the music therapist should be attentive to participation level, interaction with other group members, willingness to share, mood, affect, and inconsistencies between thoughts, feelings, and behaviors. This information can be incorporated into the postimagery discussion if appropriate. Procedures. Skaggs (1997) outlines the following procedural steps for group GIM in addictions treatment: (1) A conversational period between therapist and group members: This serves as a check-in for the participants. It is used to determine the impact that recent life events have had on the life of each group member. It is also used to determine feeling states, and assists with the selection of a relaxation induction and imagery focus. (2) An induction, which helps the clients transition into “… a state of focused concentration” (p. 24). Typical inductions include progressive muscle relaxation, focused breathing, or imagery. Bonny and Savary (2005) provide guidelines for inductions that have been used successfully in the group setting. When the therapist has assessed that group members have shifted their attention to an internal focus, a “seed” image is presented (Skaggs, 1997, p. 24). The seed image should be connected to

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the session goal (e.g., exploring powerlessness) and may be based on a metaphor gleaned from the opening conversation (walking down a path, coming across an obstacle). (3) In the Music listening and imaging phase, the participants are invited to explore the seed image as the music is turned on, using this or similar instructions: “As you become aware of the sounds, let the music help you explore this image. If you become aware of distracting thoughts or external sounds, let the music help you refocus your attention on the starting image.” The music selection should be four to seven minutes in length. (4) When the music has ended, the therapist guides the participants to a more alert state and facilitates a discussion in which the meaning of participants’ imagery is shared and discussed. Throughout the discussion, the therapist should be responding to opportunities to deepen the participant’s awareness and understanding of the imagery experience. Concepts from the 12 Steps and AA/NA such as powerlessness, unmanageability, surrender, and the lengths to which one is willing to go for one’s recovery can be used as well. Adaptations. Summer (2002) describes a task-oriented induction that may be more appropriate for use with individuals in early recovery. She suggests asking group members to create a poem about a feeling or a visual image that is relaxing rather than using an image that encourages exploration while they are listening to the music. Borczon (1997) has created a music and imagery program that is similar to the Bonny method of Group Guided Imagery and Music, with two notable exceptions. First, he does not use a specific imagery focus; rather, participants are invited to let their mind wander to wherever the music takes them. The second difference is that he has created a music program made up of five two-minute excerpts of various styles of instrumental music. At the end of each excerpt, the participants are asked to report on any images, feelings, or sensations they may have experienced. The therapist records the participants’ comments and uses them in the postimagery discussion. Music-painting is a three-stage process in which the client listens to prerecorded music and creates a painting to reflect his inner experience. This technique has been described by Erkkilä and Eerola (2010) and can be used in both individual and group formats. Erkkilä and Eerola (2010) outline the following procedural steps: (1) the client is invited to focus on his own mental contents with music guided by the therapist, using the following or similar language: The mind … is allowed to wander freely without any concrete anchor point. Gradually something more concrete, such as single words, a feeling, a color, or a symbol, emerges from the free associational flow; (2) creating a painting where the still-fragmented mental contents are spontaneously transferred onto paper; and (3) discussion based on the imagery process during which the participants talk about the personal meanings they ascribe to their images (pp. 146–147).

Bonny Method of Guided Imagery and Music Overview. The Bonny Method of Guided Imagery and Music (BMGIM) is a depth-oriented approach to psychotherapy that involves listening to a program of classical music in an altered state of consciousness and reporting images to a qualified guide. Helen Bonny developed BMGIM in the 1970s as a result of her work at the Maryland Psychiatric Center, where it was initially used to accompany hallucinogenic drug therapy. BMGIM is used in individual therapy with sessions lasting 1½ to 2 hours. The use of BMGIM has been described for use in addictions by Borling (1992), Bonny and Tansill (2002), Heiderscheit (2006), Heiderscheit (2009), and Pickett (1991). BMGIM is useful when clients in substance abuse treatment are trying to understand more about themselves and the issues surrounding their substance misuse (Bonny & Tansill, 2002). In addition to the goals listed under Group GIM, additional goals for BMGIM in addiction treatment reported in the literature include (1) establishment of rapport (Bonny, 2002a), (2) affective expression and release (Bonny, 2002b), (3) facilitation of positive experiences (Bonny, 2002a), and (4) uncovering, working through, and resolving issues related to grief (Pickett, 1991). BMGIM is used at the intensive and primary

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levels of music therapy practice. Music therapists who are interested in using the BMGIM in their practice can consult the website of the Association for Music and Imagery (http://ami-bonnymethod.org/) for more information on training. Procedures are specified in the BMGIM training.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Improvisations can be overstimulating, lead to an altered state of consciousness, or bring up repressed emotional material. Group members should be assessed for their ability to work in this way. Those with limited cognitive abilities or difficulties with abstract thought may have difficulty understanding and/or discussing the experience. Group members who are still in the detoxification phase may have difficulty attending and participating secondary to withdrawal symptoms. If used within the first year of recovery, the therapist should watch for symptoms associated with postacute withdrawal (e.g., increased anxiety, palpitations, mood swings, tiredness) and assess clients for their ability and energy for an in-depth music therapy experience. Group members should also be assessed for their ability to play tuned and nontuned percussion instruments; adaptations to the instruments (e.g., stands, built-up handles on mallets) should be made when possible.

Guitar Improvisation Overview. Clients improvise solo in a free manner on a guitar prepared with open tuning. This improvisational method focuses on (1) the experience of playing while others are listening and (2) being attentive to one another’s performance. Its use in addiction treatment is described by Treder-Wolff (1990a). This method is used in the early stages of treatment typified by denial, resistance to group interaction, and difficulties with creative expression (Treder-Wolff, 1990a). Typical goals include (1) making choices within established structure and limits, (2) sharing aspects of the self that are accessed through the experience, (3) raising awareness of addictive attitudes and behaviors, (4) exploration of denial system, and (5) establishment of connections with other group members. Guitar improvisations are used at the augmentative level of music therapy practice. Preparation. The therapist uses open tuning to tune a guitar to a D chord prior to the group. Chairs, preferably, should be arranged in a circle. What to observe. The therapist should be observant of the manner in which each participant follows directions, improvises, attends to others’ playing, and participates in the discussion. Additionally, the participants’ mood, affect, physical tension levels, and behaviors should be noted. Procedures. Treder-Wolff (1990a) outlines the following procedure: (1) The therapist gives the following instructions: “Play for as long as you like, any way you like, before passing to the next person.” Group members are asked to remain silent until everyone has had a turn to play. (2) The therapist gives the guitar to a group member, who plays and when finished hands it to the person next to him. (3) When everyone has played, the therapist facilitates a discussion focusing on the experience of responding to open-ended instructions, feelings about playing with others listening, and the connections to recovery.

Referential and Nonreferential Group Improvisation Overview. Clients choose an instrument or voice and improvise freely either without reference to any idea outside the music (nonreferential) or with reference to an idea or image external to the music (referential). Referential improvisations are those in which “the music is organized in reference to something other than itself” (Bruscia, 1987). The therapist or a group member suggests a title, theme, image, or other referent as the basis for the referential improvisation. The use of referential

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improvisations in addiction treatment has been reported on by Adelman and Castricone (1986), Gallagher and Steele (2002), Ross et al. (2008), and Scheiby (1999). Improvisations that are organized according to musical considerations are referred to as nonreferential improvisations. These improvisations do not rely on a predetermined theme or focus (Bruscia, 1987). Referential and nonreferential improvisations may be vocal or instrumental. The uses of nonreferential improvisations are reported on by Soshensky (2001, 2007) and Treder-Wolff (1990a). Referential and nonreferential group improvisations may be used to help those in substance abuse treatment access their personal creative power (Soshensky, 2007) as they work to address the issues underlying their addiction. They are used in all stages of recovery. Typical goals include (1) increasing self-awareness (Ross et al., 2008), (2) providing a means of nonverbal communication (Ross et al., 2008), (3) increasing self-esteem (Ross et al., 2008), (4) improving interpersonal communication and socialization skills (Ross et al., 2008), (5) decreasing isolative behaviors (Ross et al., 2008), (6) expression of feelings (Gallagher & Steele, 2002), (7) controlling automatic or impulsive responses (Lesiuk, 2010), and (8) increasing awareness of behavioral responses to underlying emotions (Ghetti, 2004). Referential and nonreferential improvisations can be used at all three levels of music therapy practice, based on the needs of the clients and education and training of the therapist. Therapists using improvisational methods should have some basic training in percussion, piano (or other melodic instrument), and voice. Additionally, they should be comfortable using these in an improvisatory manner. Preparation. Chairs should be set up in a circle. A variety of tuned and nontuned percussion instruments are placed either inside the circle or just outside of the circle. What to observe. The therapist should be observant of the energy and participation level as well as interactions among group members, intensity of feelings, and manner of communicating with others. Additionally, the therapist should be aware of denial, resistance, transference, and countertransference that may manifest verbally, musically, or both. Procedures. If the group members are unfamiliar with improvisation, the therapist may want to discuss the purpose of improvisation and review playing techniques for the instruments. The therapist may or may not choose to use a referent to structure the improvisation. Referents may be related to the 12 Steps (e.g., create a musical representation of powerlessness) or recovery (e.g., create a musical representation of your recovery journey). Bruscia (1987) offers guidelines to consider when selecting referents. If a referent is used, it should be explained in as concise a manner as possible (Gardstrom, 2007). Group members are asked to select an instrument for the improvisation. The therapist should allow some time for the participants to experiment with the instruments before asking them to return to their seats. The therapist invites the participants to close their eyes (if they feel comfortable) and take a few deep breaths as a means of centering and focusing themselves for the improvisation. The referent (if being used) may be restated by the therapist. The therapist may begin the improvisation with a grounding rhythm, or she may invite participants to begin playing whenever they feel ready. Bruscia (1987) has developed a comprehensive taxonomy of clinical techniques used in improvisation that music therapists may draw from when facilitating an improvisation. When the improvisation has ended, the therapist may facilitate a discussion using verbal facilitation techniques such as probes, clarifications, reflections, questioning inconsistencies, and summarization. The depth of the discussion should be related to the level of clinical practice, skill of the therapist, and ego strength of the participants. At the augmentative level, the therapist should focus the discussion on the here-and-now experience of the improvisation, noting any relationships or contradictions between what the client shares and what was observed in the group, and 12-Step concepts such as powerlessness (e.g., What was it like to not be able to control another group member’s playing? What does that have to do with your recovery?). Moving into the intensive and primary level, the discussion can focus on observed behavioral patterns in the music that mirror ways of being when one is “living the life of an addict.”

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Nonverbal Music Improvisation Overview. Clients improvise freely with a focus on music-making and limited verbal discussion. It is described by Murphy (1983) and incorporated into the group work described by Staub (2006). Nonverbal music improvisations work especially well with those individuals who have difficulty with verbal interactions. The primary reason for using this method is to confront resistance and foster feelings of acceptance (Murphy, 1983). It may be used in all stages of recovery. Typical goals include (1) expression of here-and-now feelings, (2) exploration of anger and frustration related to treatment, (3) development of leadership skills, and (4) fostering group cohesion. Nonverbal music improvisation is typically used at the intensive level of music therapy practice. Preparation. Prior to the session, the therapist should gather tuned and nontuned percussion instruments. Chairs should be in a circle. The instruments can be placed in the center or just outside the circle. The music therapist should review the names of and ways of playing the various instruments that are available prior to the start of the group improvisation experience. What to observe. During the session, the therapist should be observant of therapeutic behavior patterns such as (1) confrontation of low frustration tolerance, (2) conformity through a creative experience, (3) interaction to combat isolation, (4) validation of self-esteem, and (5) release of tension to support treatment in rehabilitation (Murphy, 1983). Procedures. The session begins with a warm-up. After a verbal introduction, the clients play an improvisation, usually initiated by the therapist on the piano. Group members begin to play as they feel ready. A group member who has the desire to play how he is feeling may take on the leadership role instead of the therapist. In this case, the client leader selects the players and instruments he would like to use. The rest of the group listens as the subgroup plays. This continues until all who wanted the opportunity to lead have had a turn. The entire group listens to each of the improvisations. The session ends with a musical closing and verbal acknowledgement of each member’s contribution (Murphy, 1983). Adult Improvisational Therapy Overview. Clients discuss pertinent issues in their lives and improvise to explore these issues; verbal and musical techniques are combined throughout the improvisational music therapy session (Bruscia, 1987). Originally developed for use with adult psychiatric patients, the model has been adapted for use with adults in substance use treatment (Hedigan, 2010; S. C. Gardstrom, personal communication, June 4, 2012). Adult improvisational therapy may be used across all stages of treatment; however, it is not recommended for those in detoxification. It can be used to help group members explore issues related to addiction and recovery, to find one’s voice, and to explore social interaction. The role of the therapist is to initiate, support, and guide the improvisation (Bruscia, 1987). Therefore, music therapists using this method should have some training in facilitating and verbally processing improvisations as well as the ability to improvise on tuned (e.g., piano) and nontuned percussion. Typical goals include (1) exploring thoughts, feelings, and relationships; (2) fostering group cohesion; (3) developing communication and listening skills; (4) risk-taking; and (5) creative self-expression. Adult improvisational therapy is practiced at the intensive and primary level of music therapy practice. Preparation. Prior to the session, the therapist should be familiar with group members’ goals and progress in treatment. The room should be set up with chairs in a circle, with various tuned and nontuned percussion in the middle or just outside of the circle. Prior to the start of the group improvisation experience, the therapist should review the names of and ways of playing the various instruments that are available. What to observe. Please refer to guidelines for referential and nonreferential improvisations. Procedures. Bruscia (1987) outlines the following procedural steps:

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Murphy 1) Warm-up: The warm-up consists of a nonreferential improvisation lasting from five to ten minutes. 2) Verbal Discussion: The therapist checks in with group members to learn what has been going on during the week and what they would like to work on. A theme or focus for the group is developed based on this discussion (e.g., need for support). 3) Working Through: This part of the session uses discussion and/or improvisation to explore and work through the identified theme/topic. The therapist may choose to move into a discussion about support followed by an improvisation, or she may opt to start with the improvisation. Using support as a theme, the therapist may ask one group member to begin playing alone, and cue other members to come in as the improvisation progresses. The ensuing discussion would focus on the experience of playing alone, vs. with others, and how that parallels the use of support in recovery. Music techniques used by the therapist in this phase include modeling, leading, mirroring, supportive mirroring, roleplaying, grounding, and stimulating. 4) Closing: The session ends with a brief experience such as singing, stretching, improvising, or silence.

Analytical Music Therapy Overview. Analytical Music Therapy (AMT) was developed by Mary Priestley in the 1970s. It is defined as “the analytically informed symbolic use of improvised music by the music therapist and client. It is used as a creative tool with which to explore the client’s inner life so as to provide the way forward for growth and greater self-knowledge” (Priestley, 1994, p. 3). Its use in substance abuse treatment in described by Scheiby (1999). AMT is useful in helping clients remove obstacles that prevent the achievement of personal goals and self-actualization (Scheiby, 1999). It is used in the mid- to late stages of recovery. AMT makes use of live improvised music; therefore, the music therapist must be able to improvise on tuned (e.g., piano) and nontuned (e.g., drums, handheld percussion) instruments. The therapist should also be comfortable with verbal techniques. Additionally the therapist should understand the concepts of transference, countertransference, and resistance, and their manifestation both verbally and musically. Scheiby (1999) identifies the following goals: (1) reliving emotions attached to trauma, (2) rebuilding self-esteem, (3) facilitating emotional and physical growth, and (4) facilitating insight into the conscious and unconscious to stimulate desired changes. AMT is typically used at the intensive and primary levels of music therapy practice. The therapist should assess clients for hearing, symbolic thinking, and verbal skills. Those who have deficits in these areas will need a modified approach (Bruscia, 1987). If used within the first year of recovery, the therapist should watch for symptoms associated with postacute withdrawal (e.g., increased anxiety, palpitations, mood swings, tiredness) and assess client for ability and energy for in-depth music therapy experiences. Analytical Music Therapy requires specialized training beyond the master’s degree. Music therapists interested in learning more about this training should contact the Institute for Analytical Music Therapy, 20 West 20th Street, Suite #803, New York, NY. Procedures are described in the training.

Stories, Myths, and Music Overview. Clients add improvised and predetermined instrumental and vocal accompaniments to stories and myths that have messages relevant to addiction and recovery. Its use in addiction treatment is described by Borczon (1997). This method is appropriate for use in mid- to late recovery with clients who are capable of abstract thought, do not have any cognitive limitations, and for whom altered-state work is not contraindicated. Therapists who use this method should have advanced training in music psychotherapy. Typical goals include to (1) access conscious and unconscious feelings, images, and

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associations; (2) identify unconscious elements or archetypes that need to be expressed; and (3) express that which is difficult to communicate verbally. Stories, myths, and music are typically used at the intensive and primary levels of music therapy practice. Preparation. This method uses stories/myths that embody metaphors for addiction, recovery, or relapse. Sources for stories/myths may be found throughout folk literature and anthologies of myths and fables. Once an appropriate story/myth has been identified, the therapist should practice reciting the story, paying attention to voice tone and pacing. Additionally, the therapist needs to determine how best to incorporate elements of music. The music should have some meaning for the story such as music to accompany a chant or song, resting music, or traveling music (R. Borczon, personal communication, June 18, 2012). The therapist should plan the instrumentation for the story prior to its use. Background music can be played as group members enter the room (R. Borczon, 1997). What to observe. The therapist should be observant of the energy and participation level of each participant, interactions among group members, intensity of feelings, and changes in affect, mood, and physical tension. Procedures. A warm-up experience such as a group improvisation is used to prepare the group for the story/myth that will be used. The therapist begins with a centering or focusing exercise such as deep breathing. If an instrumental improvisation is used, the therapist invites group members to select an instrument and explore it for a few minutes. The therapist then leads a structured, nonreferential improvisation. She may choose to begin by playing a basic beat inviting group members to join in as they feel ready. Once the basic beat is stable, group members may be encouraged to play around the beat, adding divisions, subdivisions, or rhythmic motifs. When the improvisation is completed, the therapist facilitates a brief discussion. The therapist then demonstrates how and when the instruments should be played in the story/myth. The therapist begins telling the story/myth, cuing participants to play their instruments at the appropriate time. At the conclusion of the story, the therapist facilitates a discussion about the experience. She may ask group members which, if any, of the characters in the story they identified with and to share why they are able to relate. Group members may be asked to posit the relationship between the story/myth and recovery or to comment on their role/participation in the experience. During this discussion, the therapist is listening for and responding to parallels between themes and actions in the story/myth and each client’s recovery journey. The therapist may summarize the verbal discussion and move into closure by asking each person to share what he is taking from the group. Group members are thanked for their participation and reminded to reflect on the experience and the insights gained (Borczon, 1997).

Artistic Music Therapy Overview. Artistic music therapy (ArMT) is a multi-expressive improvisational approach to individual and group therapy developed by Albornoz (2009). It involves the use of referential and nonreferential improvisations along with various other art forms (art, dance/movement, drama) and may culminate in a public performance. Albornoz (2009, 2011) is the only music therapist who reports on the use of this method in addictions treatment. This method has been used to treat adults with substance use disorders who are experiencing symptoms of depression. It may be used in all phases of recovery. The therapist should have advanced training in music therapy with an emphasis on psychotherapy, along with coursework on clinical improvisation. ArMT makes use of various expressive mediums; therefore, the therapist should be comfortable in working with multiple modalities. Typical goals include (1) reducing depressive symptoms and (2) exploring and expressing emotions (Albornoz, 2009, 2011). ArMT is used at the intensive and primary levels of music therapy practice. The therapist should assess clients for hearing, symbolic thinking, and verbal skills. This is an intensive or primary level of therapy. Preparation. Prior to the session, the therapist should gather instruments, art materials, and any other manipulatives or props that might be necessary, pens, pencils and writing paper.

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What to observe. If used within the first year of recovery, the therapist should watch for symptoms associated with postacute withdrawal (e.g., increased anxiety, palpitations, mood swings, tiredness) and assess the client for ability and energy for an in-depth music therapy experience. In addition, please refer to guidelines for referential and nonreferential improvisations. Procedures. Albornoz (2009, 2011) outlines the following procedural steps: (1) the ArMT session begins with a free music improvisation or a discussion; (2) if the session begins with a free music improvisation, group members may react verbally, musically, or with another artistic medium; (3) if the session begins with a discussion, themes are identified for use in a music improvisation or exploration with other expressive media; (4) therapeutic issues that arise in either the improvisation or the discussion are further explored through music, verbal processing, or use of other expressive media; (5) the session continues with identification and exploration of issues. In some instances, clients may decide to rehearse and perform artistic products that are developed within the context of an ArMT session. Clients select the audience for performances. Song Improvisation Overview. Song improvisations are the extemporaneous creation of lyrics and melodies. The harmonic structure and song form may be predictable (e.g., 12-bar blues; scat singing) or improvised. This method can be used in both group and individual settings. The use of improvised songs in substance abuse treatment has been described by Adelman and Castricone (1986), Smith (2007), Soshensky (2001, 2007), and Treder-Wolff (1990a). Song improvisation can be used in all phases of substance abuse treatment. In early recovery, more structured methods are recommended. The therapist should be able to play various musical structures that would support song improvisation, including 12-bar blues, modal accompaniment patterns, and song forms that lend themselves to spontaneous lyric creation or vocalizations, as well as computer programs that can produce rhythmic and harmonic sequences. Additionally, the therapist should be comfortable using her voice to demonstrate and/or lead a vocal improvisation. Additional training in using the voice for improvisation is recommended. Typical goals include (1) sustaining participation in a group (Treder-Wolff, 1990a), (2) risk-taking (Adelman & Castricone, 1986), (3) giving form to and enhancing emotional expression (Soshensky, 2007), (4) safely containing disturbing or opposing emotions and ambivalence (Soshensky, 2007), (5) validating and communicating inner experiences (Soshensky, 2007), (6) stimulating emotional identification and selfawareness, and (7) facilitating group cohesion. Song improvisation is typically used at the intensive and primary levels of music therapy practice. Preparation. Prior to the session, the therapist should gather the necessary instruments and technology. Chairs should be set up in a circle with the instruments within easy access. What to observe. Please refer to guidelines for referential and nonreferential improvisations. Procedures. Based on the check-in, the therapist may want to begin with some deep breathing as a means of centering and focusing the group. Warm-up exercises may also be helpful (see Austin [2007] for some examples). The therapist selects an appropriate format for the song improvisation. More structured approaches would be based on a 12-bar blues progression. The therapist or a group member suggests a starting phrase (e.g., “woke up this morning”), and group members spontaneously create a response (e.g., “was feeling pretty low”) (see Austin, 2007; Treder-Wolff, 1990b). The therapist may lead the group in singing a short precomposed song and encourage participants to improvise lyrics for subsequent verses (Gardstrom et al., 2012). For example, the therapist may sing a verse of “Three Little Birds,” and the clients may follow with improvised words focusing on worry or anxiety. Song improvisations can be used as a means of reflecting on or responding to a precomposed song (Smith, 2007). On the other end of the continuum, a client may start singing and the therapist and/or group members would create the accompaniment (see Soshensky, 2001, 2007). Accompaniments can be created on acoustic or electronic instruments. Computer programs can also be used to create harmonic and

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rhythmic accompaniments. Following the song improvisation, the therapist may choose to facilitate a discussion about the experience of singing and/or content of the improvised lyrics, using verbal techniques such as probes, reflections, and clarifications. The discussion may be followed by another song improvisation or other music therapy experience such as songwriting, imagery work, or relaxation. Adaptations. Adelman and Castricone (1986) describe a “choral-like” vocal improvisation. Each group member is asked to create a phrase or sentence to describe the essence of an experience. The therapist cues each group member to enter by chanting his/her phrase using a dynamic level and tempo that reflects its emotional weight.

Vocal Psychotherapy Overview. “Vocal psychotherapy is the use of the breath, sounds, vocal improvisation, songs, and dialogue within a client-therapist relationship to promote intrapsychic and interpersonal growth and change” (Austin, 2008, p. 13). Vocal psychotherapy is typically used in individual therapy, but the interventions can be adapted for group work (Austin, 2008). Vocal psychotherapy can be used in the middle to late stages of recovery. It is used to help individuals connect to their authentic self and to provide corrective emotional experiences. Vocal psychotherapy requires training beyond the master’s degree; therefore, therapists using this method should have completed the Vocal Psychotherapy training course. This method makes use of vocal improvisation and songs. Therefore, the therapist must be comfortable and able to use her voice (e.g., singing, chanting, vocalizing, improvising). Additionally, the therapist should be familiar with a large repertoire of songs of different genres, spanning several generations. Sample goals include (Austin, 2008): (1) building a trusting relationship; (2) encouraging playfulness and spontaneity; (3) working through denial and resistance; (4) accessing and working through conscious and unconscious feelings, images, and associations; and (5) releasing feelings. Vocal psychotherapy should only be used at the primary level of music therapy practice. Vocal psychotherapy is not appropriate for individuals in detoxification or early withdrawal. Clients should be assessed for their ability to participate in and gain meaning from participation in an in-depth music therapy experience. For more information, music therapists can visit http://dianeaustin.com/music. DRUMMING The substance abuse literature contains numerous references to the use of drumming, both in the context of a music therapy session (Dijkstra & Hakvoort, 2010; Hedigan, 2005) and for recreational purposes (Mikenas, 1999; Winkleman, 2003). Therefore, the drumming methods are being described separately from other forms of improvisation as they use mainly drums and are used solely in a group setting. The use of drum circles or community drumming is beyond the scope of this chapter and will not be included. The reader is referred to Gardstrom (2007) for a discussion of the differences between the use of drumming as a music therapy method and drum circles. Drumming can be overstimulating and lead to an altered state of consciousness, especially if it goes on for an extended period (Matney, 2007). Therefore, individuals who are experiencing psychosis should not participate in group drumming. Clients who have a history of schizophrenia or are actively experiencing hallucinations or delusions should be assessed prior to participation (Summer, 1988).

Group Drumming Overview. Drumming may be considered an improvisation method, which uses primarily drums in structured and free music-making. The use of drumming as an improvisational music therapy method in addictions treatment has been described by Borling (2011a, 2011b), Gallagher and Steele (2002), Gardstrom et al. (2012), Hedigan (2005), Heiderscheit (2009), Ross et al. (2008), and Soshensky (2007).

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This improvisational method is used for stress reduction, socialization, and community-building across all stages of recovery. Music therapists who use drumming should have a rudimentary understanding of and ability to play various “grounding rhythms” (Ross et al., p. 44). A grounding rhythm is a repetitive rhythmic pattern that is used as a basis for the group improvisation. Typical goals include (1) releasing energy and connecting with the physical nature of the body (Borling, 2011b), (2) increasing group cohesion (Ross et al., 2008), (3) increasing creative self-expression (Ross et al., 2008), (4) development of coping skills (Gallagher & Steele, 2002), (5) improving self-esteem (Hedigan, 2005), and (6) increasing confidence (Hedigan, 2005). Group drumming is typically practiced at the augmentative level of music therapy practice. Group members who are still in the detoxification phase may have difficulty attending and participating secondary to withdrawal symptoms. Those in detoxification may not be able to withstand the volume or “tribal sound.” Preparation. Chairs should be placed in a circle with a variety of drums in the center. What to observe. The therapist should observe how the group members work together, as well as energy level, mood, and affect. When followed by verbal processing, the therapist should attend to participation in the discussion and ability to listen to others, as well as give and receive feedback. Procedures. Group members are asked to select a drum and bring it back to their seats. The therapist may give a brief explanation of drumming and its benefits to addiction treatment (Ross et al., 2008), or she may move immediately into playing. The therapist usually starts the group by providing a rhythmic foundation. Group members are encouraged to join in as they feel ready. They may be instructed to play the same or different rhythm. The therapist may “conduct” by directing group members to change dynamics or tempi, assigning subgroups unique rhythm patterns, or leading a call-and-response exercise. The types of interventions the therapist makes are based on the needs and goals of the group members. When the drumming has finished, the therapist may choose to facilitate a discussion regarding the experience, using traditional verbal therapy techniques. The discussion may be focused on the physical, mental, emotional, or spiritual effects clients experienced as a result of participating in the drumming experience. The therapist may choose to bring the experience to a close by inviting group members to share one word or short phrase that sums up their experience, reciting the Serenity Prayer, or singing a simple folk song.

Catch Phrase Drum Circle Overview. This is a group drumming method based on improvised rhythms created to reflect AA/NA slogans (Ficken, 2010). This improvisational method is used to reinforce recovery concepts. It can be used in all stages of recovery. Typical goals include (1) introducing AA/NA slogans and concepts, (2) social interaction and cooperation with others, (3) facilitation of a group process, (4) identification and expression of thoughts and feelings related to treatment, and (5) identification and sharing of hopes (Ficken, 2010). The catch phrase drum circle is typically used at the augmentative level of practice. This method may be intimidating for individuals who have extreme difficulties in working with others or have a very low frustration tolerance. Preparation. Prior to the group the therapist should write out common AA/NA slogans one a piece of paper (one to a page). Common slogans include “One Day at a Time,” “Stinkin’ Thinkin’,” “Let Go and Let God,” “Just for Today,” and “Fake It Till You Make It.” There are over 400 different slogans that can be found at http://webpages.charter.net/jlbond/slogans.htm. Supplies needed are various drums. What to observe. The therapist should observe how the group members work together, decision-making skills, and roles within the group. During the discussion, the therapist should attend to participation in the discussion, as well as the ability to listen to others give and receive feedback and make connections between behaviors in group and real life.

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Procedures. Ficken (2010) recommends the following procedural steps: (1) divide the group into pairs, giving each one of the slogans and asking them to create a rhythm to fit their slogan; (2) allow time for participants to experiment and come up with a rhythm; (3) invite each pair to play their rhythm, one at a time, around the circle in an additive manner (e.g., first plays their rhythm, they continue to play, and the second pair adds their rhythm and continues to play, as the third pair adds their rhythm until all the pairs are playing); and (4) bring the drumming to a close and facilitate a discussion by asking group members to comment on their experience and their thoughts about the slogans. Adaptations. This improvisation can be used as the basis for a songwriting, music-assisted relaxation, or imagery experience. Rhythmic Drum-Circle Assignments Overview. Rhythmic drum-circle assignments are directive rhythmic improvisations in which drums are used to assess coping skills and rigidity of clients in substance abuse treatment. This method was developed and described by Dijkstra and Hakvoort (2010). It is introduced after rapport has been established and may be used in all stages of recovery. The goals are (1) assessment of coping strategies and ability to set boundaries, (2) identification of personal coping strategies, (3) raising awareness of alternative (nondrug) coping strategies, and (4) stimulation of group cohesion. Additionally, each assignment has specific objectives related to one of the above-stated goals. This method is used at the intensive level of music therapy practice. Clients who are sensitive to loud sounds or are in early recovery may find group drumming to be “too loud.” Participants need to be able to understand the directions and be able to participate in a group drumming experience. Those with limited ability for abstract thought or who are still in detoxification may have difficulty comparing their musical behavior with their nonmusical behavior. Preparation. Prior to the session, the therapist should gather the drums needed and audiovisual recording equipment. Chairs should be set up in a circle with drums placed in the middle. What to observe. The therapist should observe participants’ reactions to the assignment and the music as well as interactions with other group members. Procedures. Dijkstra and Hakvoort (2010) outline the following procedure: (1) Each group member and the therapist choose a drum. The therapist selects one of ten different rhythmic drumming assignments, such as working as a group to create a steady pulse or increasing/decreasing volume and/or tempo in responses to changes initiated by the therapist (see pp. 96–98 for the complete list). (2) The therapist observes and videotapes the clients’ reactions to the improvisations. The observations are analyzed and discussed with the group members. Coping strategies that were observed during the improvisation (e.g., adjusting to another person’s playing) are brought to the client’s attention and discussed. Analogies are made between the clients’ musical and nonmusical behaviors.

Conscious Drumming Overview. Conscious drumming is improvisational group drumming alternating with a group “heartbeat” drumming pattern to accompany participants who wish to share their response to focus questions. It is a structured improvisational method that “… makes use of contemporary drum circle techniques while honoring the long history and process of ritual” (Borling & Miller, 2007, p. 226). Conscious drumming has been used in both community and therapeutic settings in which a communal opportunity to express feelings and emotions is needed. It is most appropriately used in middle and late stages of recovery. In order to facilitate conscious drumming, the therapist needs to have a strong foundation and experience with group drumming (Borling & Miller, 2007). Borling and Miller (2007, p. 228) have identified the following goals or foci: (1) community-building, (2) existential exploration, (3)

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emotional expression around a specific topic, and (4) 12-Step work. Conscious drumming is used at the intensive and primary level of music therapy practice. Preparation. The therapist will need to decide on a focus and prepare readings and a set of related questions. Chairs should be arranged in a circle. The session room should have ample space for all participants to sit and comfortably play a drum. Depending upon the size of the group, a microphone may be needed. Supplies needed include a variety of drums and a talking stick. What to observe. Group drumming may access emotional material that may need to be processed outside to the session. Therefore, the therapist should be observant of participants’ mood, affect, physical tension levels, and behaviors. Procedures. Borling and Miller (2007) outline the following procedural steps. 1) Warm-up: Participants play group rhythms and familiarize themselves with the instruments. This lasts 10 to 15 minutes. 2) Quiet down: The therapist brings the volume of the drumming down and plays a rhythm that resembles a heartbeat. Depending upon the skill of the therapist, she may continue the heartbeat rhythm while explaining the fundamentals of conscious drumming. This explanation can also be given without the underlying rhythmic heartbeat. 3) Educate: The therapist provides group members with an overview of the principle components of the experience, including the impact of rhythm and group drumming, the role, the purpose and use of the talking stick, and the meaning of ritual. 4) Focus: The therapist may read some material (e.g., a poem or short reading) to help focus the group so individual members may discuss the issue(s) from a “heartfelt space” (Borling & Miller, 2007, p. 230). This may be followed by a set of questions that individuals may respond to when using the talking stick. 5) Action: The therapist begins a rhythm, inviting group members to join in. This is sustained for a period of time, and then individuals are invited to come up, pick up the talking stick, and share their thoughts, feelings, and/or views on the focus. When a group member gets up to speak, the therapist brings the group drumming into a unified “heartbeat” rhythm. When the individual speaking returns to his seat, the therapist facilitates a return to improvisatory drumming. It is important to remember that speaking during this type of drum circle is voluntary. The therapist may have to model use of the talking stick. 6) Wrap-up: Oftentimes the drum circle will come to a natural end. It is important to provide a “last opportunity” for participants to speak before facilitating the ending, which can be done using a variety of drumming techniques. When the drumming has ended, the therapist may ask each group member to share one word to sum up his experience or may lead the group in a toning experience or a simple song.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Vocal Re-creation Overview. Vocal re-creation, or the singing of precomposed songs (Bruscia, 1998), may be used as a stand-alone method or in combination with others such as song discussion, songwriting, or song communication. It is frequently used in substance abuse treatment, although it is described by different names, including therapeutic singing (Gardstrom et al., 2012), song singing or sing-a-long (Baker, Gleadhill, & Dingle, 2007; Dougherty, 1984; Soshensky, 2007), and participatory group music (Bednarz & Nikkel, 1992). Vocal re-creation can be used in all stages of substance abuse treatment. In early recovery, vocal re-creation offers a “safe” musical experience that may be used to foster social interaction and develop group cohesion. In later stages, it may be used to help identify and communicate feelings. Typical

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goals include (1) increasing proactive, hopeful attitudes (Soshensky, 2007); (2) improving social/collaboration skills (Soshensky, 2007); (3) developing a sense of community and unity (Dougherty, 1984; Gardstrom et al., 2012); (4) having fun while sober (Dougherty, 1984); (5) increasing awareness of others; and (6) peer interaction (Bednarz & Nikkel, 1992). Vocal re-creation is used at all levels of music therapy practice. Singing may be threatening to some clients; the therapist should be sensitive to this and encourage participation, respecting an individual’s right to refuse. Preparation. Prior to the session, the therapist may want to gather lyric sheets, sheet music, and/or song collections. The therapist may also want to prepare song lists based on specific themes related to addiction and recovery. The therapist should tune her guitar just prior to the start of the group if being used. All technology (e.g., iPods, DVD players, karaoke machines) should be checked to be sure they are in good working order. Chairs should be set up in a circle. There should be adequate lighting so that participants can read the lyrics if needed. If percussion instruments are being used, they should be placed in the middle or just outside of the circle for easy access. What to observe. As the songs are being played, the therapist should be observant of the manner in which group members are participating. Specifically, the therapist may want to note if group members are singing with a full voice, as opposed to quietly mouthing the words or just listening. Throughout the group, changes in observable physical tension, affect, mood, and breathing should be noted. Procedures. The therapist hands out a list of songs from which group members can choose and invites group members to select songs that they would like to sing. (See Appendix A for suggestions.) Group members may be invited to select a handheld percussion instrument to play while singing. The therapist leads the group in singing the song. When the song is finished, the therapist may facilitate a brief discussion, asking why the member chose that particular song or if they would like to share the significance attached to it. The process continues until the group ends. Adaptations. Members of the group who are musicians may want to play their instrument to accompany the song. Some music therapists may also want to make use of karaoke recordings if they are unable to reproduce electronic accompaniments. Hedigan (2005) reports on the benefits of a therapeutic choir. The choir should have a regular rehearsal schedule and be involved in the selection of music to be sung. Participation in a choir can be used to work on goals related to performance anxiety in addition to having social, emotional, and physiological benefits (Hedigan).

Instrumental Re-creation Overview. Clients play or perform a precomposed instrumental piece or accompany a recording or song with percussion instruments. Instrumental re-creation or playing precomposed music (Bruscia, 1998a) may be used individually or in a group setting. The use of instrumental re-creation is common in substance abuse treatment and has been reported on in the literature by Bednarz and Nikkel (1992); Cevasco, Kennedy, and Generally (2005); Lesiuk (2010); and van der Lann and Janssen (1996). Instrumental re-creation can be used during all stages of recovery. In early recovery, it can be used as means of establishing trust and group cohesion. In later recovery, instrumental re-creation provides opportunities to work on socialization and leisure skills. Bednarz and Nikkel (1992) report the following goals: (1) interaction and acceptance among peers, (2) development of social skills, and (3) creative selfexpression. Instrumental re-creation can be overstimulating. The therapist should be mindful of this, as clients in early recovery may have a negative reaction to the music. It is typically used at the augmentative level of music therapy practice. Preparation. Prior to the session, the therapist should check the instruments to be sure they are in good working order. Guitars and pianos should be in tune. Battery life should be checked on electronic instruments. Extension cords, if needed, should be easily accessible for use when needed. The therapist

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may need to provide sheet music for the clients to use during the music therapy session. Chairs should be in a circle near an electrical outlet if necessary. What to observe. During the session, the therapist should be observant of group members’ playing style and ability to listen to others, and interaction among group members. Additionally, the therapist should be attentive to changes in mood, affect, and physical tension. Procedures. The therapist may choose one of the following ways to proceed (this list is not meant to be inclusive): (1) Each group member is given an opportunity to perform a solo while the rest of the group listens. The therapist may model verbal encouragement and support. (2) The group works together to re-create a song—some group members may play guitar or piano, while other group members accompany it using tuned, nontuned, and/or body percussion. (3) The therapist may teach group members a rhythmic accompaniment for use with live or recorded music. There can be a time for sharing at the conclusion of each song. Adaptations. Instrumental and vocal recreation may be combined within the same group experience. It may also be followed up by another music therapy method such as song discussion, composition, or music-assisted relaxation. The use of music lessons, another type of instrumental re-creation, in substance abuse treatment has been described by Bednarz and Nikkel (1992), Miller (1970), and van der Lann and Janssen (1996). Goals cited include increasing self-esteem and developing self-discipline and leisure skills (Bednarz & Nikkel, 1992). The format is similar to traditional instrumental lessons and may be offered in group or individual settings. Performance groups can offer a safe and motivating setting in which to practice new behaviors and engage in a socially acceptable leisure skill. Brooks (1973), Miller (1970), and Van Stone (1973) advocate for the inclusion of performance groups in substance abuse treatment.

Musical Games Overview. Traditional games such as Jeopardy!, Name That Tune, or Bingo are structured using music or include topics related to music (Bruscia, 1998a; Plach, 1996). Musical games may be based on nonmusical games, or the therapist may create a game such as identifying song lyrics that relate to drug use (Cevasco, Kennedy, & Generally, 2005). Musical games are typically used during detoxification and early recovery. They are also used in settings where clients may have co-occurring disorders (Gallagher & Steele, 2002). The use of musical games in addiction treatment has been reported on by Cevasco, Kennedy, and Generally (2005) and Gallagher and Steele (2002). Typical goals include (1) developing group cohesion; (2) education about addiction, relapse, and recovery; (3) improving social skills; and (4) improving mood and decreasing stress. Musical games are typically used at the augmentative level of music therapy practice. Individuals who are highly competitive or have poor impulse control and low frustration tolerance may have difficulty participating in musical games. Preparation. Preparation prior to the session will depend on the requirements of the game. For example, Musical Jeopardy would require the identification of appropriate categories and creation of several questions, the answers to which should be written down and ordered in a hierarchy from easiest to most difficult. Initially chairs may be set up in a circle to facilitate the check-in. If teams are going to be created, the chairs may be moved to create teams. The musical game chosen will determine the materials and supplies that will be needed. What to observe. During the session, the therapist should be observant of the interactions between team members and among teams. The therapist may want to note the role each participant takes in his group, social skills (e.g., turn-taking, waiting), impulse control, and frustration tolerance. Procedures. The therapist should review the procedure for the musical games and all rules. The therapist should divide group members into teams (if applicable). The musical game should begin, and

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continue until one team has won (if applicable) or time and/or interest have run out. The group should conclude with a discussion in which members can share their experience and give/receive feedback from group members. The therapist may want to offer her observations of each group member’s participation level and make connections between what was observed during the group session and real-life behaviors.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting Overview. Songwriting, or the process of composing an original song within the context of a therapeutic relationship, is used in addiction treatment to address the psychosocial, emotional, spiritual, cognitive, and communication needs of clients. There are a myriad of songwriting methods, several of which are described by Wigram (2005). Songwriting may be used as a stand-alone method or in response to another music therapy experience (e.g., lyric discussion). It can be used in all stages of treatment. Reitman (2011) incorporates songwriting methods into his music therapy protocols and offers the following general goals: (1) learning to work together in a productive manner, (2) increased selfexpression, (3) increased frustration tolerance, (4) following through with tasks to completion, and (5) increased problem-solving skills (p. 4). Other goals include (1) creating a response to songs to offer a differing point of view (Ficken, 2010), (2) becoming more insightful about the need for inpatient treatment (Murphy, 1983), (3) confronting personal issues related to addiction (Gallant, Holosko, & Siegel, 1997), (4) increasing personal insights that will lead to growth (Gallant, Holosko, & Siegel, 1997), (5) promoting group cohesion (Walker, 1995), (6) expression of thoughts and feelings in a creative and healthy manner, and (7) exploration of treatment related issues (powerless, unmanageability, surrender). Songwriting can be used at all levels of music therapy practice. The level at which it is used should correspond to the needs of the client and education/training level of the therapist. At the augmentative level, songwriting may be used to facilitate group cohesion and develop frustration tolerance. At the intensive or primary level, it may be used to work through conscious or unconscious thoughts and feelings, self-expression, or communication with parts of the self (e.g., inner child) or others. Clients should be assessed for their ability to participate in a music therapy experience that may require group interaction, tolerance for others, and the ability to give and receive feedback. Clients in detoxification may have difficulty remaining focused during the songwriting process. More structured approaches may be suitable for those patients in early recovery. Preparation. In general, music therapists should have some competence in basic songwriting including song forms (rondos, verse/chorus), and harmonic progressions (12-bar blues, ’50s rock, ’40s swing). Each type of songwriting method may require additional skills or preparation, and these are included in the descriptions that follow. The session room should be organized, chairs set up in a circle. Guitars and/or keyboards and tuned and nontuned percussion instruments should be available for use. A flip chart or dry-erase board may be used to record and refine lyrics. Audio/audiovisual equipment should be available if the intent is to record the finished composition. What to observe. During the songwriting process, the therapist should be observant of the group process, including who is contributing and who is sitting back, as well as who has the ability to withstand and give feedback, listen, share, and work with others. Depending upon the songwriting variation used, the therapist should be attentive to group members’ ability to remember and follow directions and work within a given framework. Procedures. There are several songwriting procedures reported on the literature or used by the author. Regardless of method, all music therapy sessions should start with a check to determine if songwriting will be appropriate for any given group. The check-in may also provide a theme or focus for the songwriting experience. Once it has been determined that songwriting is appropriate. the therapist may opt to select one of these methods:

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(a) Individual songwriting within a group setting. Each member of the group writes his own song based on the following guidelines (Treder-Wolff, 1990a): (1) Each group member selects a song style and length from those suggested by the therapist (styles: blues, country, jazz, pop; length: four lines, six lines). (2) Each group member identifies a feeling and then writes lyrics to describe it using the style/length that was chosen. The group member identifies the song style but does not include his name on the lyric sheet. (3) The therapist collects the lyric sheets and sings each song in the style indicated (either improvising or selecting a precomposed melody). (4) The therapist facilitates a discussion after each song in which group members try to discern the composer. (5) The lyricist reveals himself, and the therapist processes group members’ responses and reactions. Steps 3 to 5 are repeated until all the lyrics have been set to music and performed. Adaptations: Clients may bring lyrics to individual or group music therapy sessions. The therapist may assist the client in the creation of appropriate music. Therapists may compose songs (lyrics and music) based on their reflections of a particular client or group. (b) Group songwriting. An original song is written, with members of the group contributing equally to the creation of the lyrics and/or the musical framework. The use of group songwriting in addictions treatment has been described by Ficken (2010), Heiderscheit (2009), and Murphy (1983). Ficken (2010) describes the following procedure, which may require several sessions to complete: (1) select a song that describes the life of an addict/alcoholic; (2) hand out lyric sheets and play the song, encouraging group members to follow along; (3) at the conclusion of the song, solicit feedback from group members as to the authenticity of the lyrics based on their life experience; (4) ask the group members to work together and create their own song as a response, creating lyrics to accurately reflect their life experience (note: group members may work on the lyrics outside of group time); (5) the therapist may assist with lyric writing by reviewing what the clients have written and/or offering suggestions to help with the overall flow; (6) assistance may be given with the creation of a musical framework or new melody (the therapist may play some chord progressions or transcribe a client-created melody); and (7) the group members may want to make a recording of the finished song. Heiderscheit (2009) and Murphy (1983) suggest the following procedure: (1) The group starts with brainstorming, during which each participant contributes his ideas, thoughts, and/or feelings related to a recovery- or treatment-related theme or topic. The contributions are then used to create song lines. (2) The group decides, with input from the therapist if necessary, what type of music should be used for the lyrics and whether the song should be in a major or minor key. (3) The lyrics are set to music and the group performs the song. The group may choose to record the song as well. Reitman (2011) and Silverman (2011b) suggest the use of a blues format for group songwriting. Both use predetermined questions based on themes related to recovery (e.g., coping skills, consequences of addiction) to stimulate discussion leading to the creation of lyrics. Reitman (2011) also suggests the use of a fill-in-the-blank format or sample first line to assist group members in the creation of their blues song. The lyrics are set to a melody and blues harmonization created by the therapist. The newly created song is sung by group members, accompanied by the therapist. (c) Rap creation. Rap is a form of vocal music characterized by “… semispoken rhymes declaimed over a rhythmic musical backing, drawn from the sampling of preexisting recordings and the use of DJ mixing techniques” (Toot, 2012). Raps are not sung (Adams, 2008), potentially making this song form more palatable to clients. The use of rap creation in substance abuse treatment has been reported on by Baker, Dingle, and Gleadhill (2012); Heiderscheit (2009); Reitman (2011); Treder-Wolff (1990b); and Walker (1995). Reitman (2011) suggests the following procedure for the creation of rap: (1) Group members are divided into smaller groups (three or four people each). (2) Group members are asked to select an appropriate rap beat from a predetermined selection (e.g., loops on GarageBand or other software programs; therapist-created loops that have been prerecorded). They may also choose to create a rap beat of their own. (3) A rap chorus or “hook” (Walker, 1995) created by the therapist is shared with the group. (4) Group members are asked to create verses that would go along with the chorus. The verses are based on material from a song discussion in the early part of the group session. (5) Group members are

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asked to perform the rap. Adaptations: Treder-Wolff (199b) suggests asking each group to write a fourline rap on their experience in treatment or other relevant theme. After each group performs their rap, the therapist facilitates a discussion that explores perfectionistic tendencies, expectations of self and others during the process, and control-oriented attitudes. The therapist should make connections between addict behaviors that may have manifested themselves during the process (e.g., the need for perfection) vs. healthy behaviors (e.g., the ability to receive feedback from others). (d) Song parodies. Group members “… change the words, phrases, or the entire lyrics of an existing song, while maintaining the melody and standard accompaniment” (Bruscia, 1998a, p. 120). Also known as “lyric substitution,” this is the most common songwriting method used in substance abuse treatment (Silverman, 2009b). There are three ways in which to structure a song parody: fill-in-the blank, creating a new verse, and creating new words for a preexisting melody. • Cloze procedure (fill-in-the-blank) or song transformation (Gardstrom et al., 2012) has been reported on in the substance abuse literature by Freed (1987), Borling (2011b), Borling and Murphy (2012), Jones (2005), Reitman (2011), and Walker (1995). This is a structured songwriting method in which the therapist provides group members with sentence stems taken from a precomposed song that are followed by a blank line. Group members working collectively or individually fill in the blanks so that the lyrics relate to issues in addiction, recovery, or relapse. The completed song is then sung by the group collectively or individual members with the therapist providing an accompaniment. • Creating a new verse has been reported on in the literature by Borling (2011), Borling and Murphy (2012), and Freed (1987). Group members listen to a song related to the group goal, topic, and theme. After a brief discussion, group members collectively or individually write the next verse based on their reactions to the song and/or the content of the group discussion. • New words to preexisting melodies is an unstructured songwriting method in which group members write lyrics to preexisting melodies. The use of this songwriting method is reported on in the literature by Freed (1987), Reitman (2011), and Walker (1995). Freed (1987) suggests the following procedural steps: (1) Divide the group into smaller groups. (2) A precomposed melody that is known to all group members is selected. (3) Members of each small group work together to create new lyrics based on the topic, theme, or goal of the group. The therapist may want to provide a theme for each verse (Reitman, 2011). For example, if the song is about Identifying Denial, the first verse might focus on reasons for denial, the second on perceived benefits of denial, the third on the consequences of denial, and the fourth on healthier behaviors. (4) Each small group’s song will be sung (therapist assisting with accompaniment and/or singing). This is followed by a discussion of the new lyrics. (e) Jingle parodies are described by Treder-Wolff (1990a) and Gallagher and Steele (2002). In this songwriting method, group members work to change the lyrics of jingles used in commercials promoting alcohol or other addicting products (cigarettes, sleeping pills, caffeine). The new lyrics may focus on topics such as the need to be aware of social messages that may come from advertising (TrederWolff, 1990a) or the benefits of a sober lifestyle (Gallagher & Steele, 2002).

Song Collage Overview. Clients create two complementary collages: one made from masks, the other from song lyrics. This is a compositional method used by the author in a 90-day substance abuse treatment program for women. It is used to help clients identify and explore their internal self-representations (e.g., addicted self, spiritual self, idealized self, current self) in order to develop an integrated self (Avants & Margolin, 1995). This method is not appropriate for use with clients who are in detoxification or the early

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stage of recovery. Typical goals include (1) to identify and name internal self-representations and (2) to uncover and work through negative messages and unrealistic expectations. Therapists who use this method should have advanced training in music psychotherapy as well as an understanding of selfschema theory. Song collage is used at the intensive and primary levels of music therapy practice. This compositional method requires the listener to go into an altered state. Therefore, this intervention should not be used with patients/clients who have a history of schizophrenia or are actively experiencing hallucinations or delusions (Summer, 1988). Clients should be assessed for their ability to (1) participate in and gain meaning from participation in an in-depth music therapy experience and (2) engage in an insight-oriented discussion. This intervention would not be appropriate for individuals who have difficulty with abstract thought and/or limited cognitive abilities. Preparation. The therapist may want to have two spaces in the session room: one for discussion and sharing, the other for working on the collage. The discussion space should have chairs or large beanbag pillows set up in a circle. Tables and chairs can be set up in another part of the room for clients to use while creating their collages. Art materials and other supplies should be kept at a central location in the room for easy client access. The CD player/iPod dock should be positioned for easy access to on/off switch and volume controls. The therapist should prepare background music as well as music for the initial focusing exercise prior to the group session. What to observe. Throughout the session, the therapist should be observing the client’s energy level, mood, affect, motivation, and intensity of feelings. Additionally, the therapist should be aware of denial, resistance, transference, and countertransference reactions that may manifest verbally, musically, or both. Procedures. Song collages will take more than one session to complete. Therapists using this method will need to pace the procedural steps, according to their time constraints. 1. Opening: After the check-in, the therapist facilitates a discussion on internal selfrepresentations (e.g., addict self, sober self, ideal self, current self, ought self, spiritual self). Group members are given some time to journal about each of their internal selfrepresentations. The therapist facilitates a structured imagery experience in which participants are asked to visualize their internal selves one at a time. The structured imagery experience is followed by a group discussion in which participants are invited to share their imagery experience as it relates to their internal self-representations. 2. Mask-making: (a) The participants are then invited to make a mask representing each of their self-representations, using any of the available art materials. (b) On the back of the mask, they are invited to list all the qualities or characteristics (both positive and negative) associated with each. 3. Song selection: (a) Once the masks are completed, group members are invited to select a song that best represents the qualities and characteristics of each self-representation. Group members may work on this step outside of group. (b) The therapist invites participants to underline the lyrics in each song that are especially relevant to its corresponding mask. (c) The participants are invited to share their masks and songs with the group. The therapist facilitates a discussion, using verbal techniques such as probes, reflecting, and clarification. 4. Putting it all together: (a) The therapist invites each participant to combine all the masks into one. This can be done in a manner that feels comfortable for each participant. (b) The therapist invites each participant to create a new song for the integrated mask. This is done by taking the significant lyrics from each song and integrating them into a new composition. Clients may choose to combine melodic/harmonic phrases from each song or may create an entirely new musical structure. The client may choose to perform his song a capella, or the therapist may accompany. The therapist may help the client transcribe a newly created melody as well. Work on this step may occur outside of the

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group session. (c) The therapist invites each group member to share the new mask and song. In the performance of the song, participants may ask other group members to assist with the accompaniment. (d) The therapist facilitates a discussion throughout this process to help participants integrate what they discovered about themselves and their recovery. Adaptations: The therapist may choose to focus on roles (e.g., mother, sister, wife, daughter, employee) rather than self-representations.

CLOSING REMARKS ON METHODOLOGY The majority of treatments for substance use disorders, regardless of discipline, occur in a group setting (Brook, 2003; Stinchfield, Owen, & Winters, 1994). This certainly is the case for music therapy. With the exception of the individual form of the Bonny Method of Guided Imagery and Music, Analytical Music Therapy, and Vocal Psychotherapy, all the methods described above have been used primarily in group settings. Group music therapy has many advantages; it provides opportunities for positive peer support and constructive feedback, decreases isolation, and allows for sharing of strength and hope. Ideally, groups should consist of six to eight members, although groups can range anywhere from 2 to 20, depending on the treatment facility. Frequency of sessions is usually determined by the treatment setting as well. Individuals with substance use disorders may participate in only one music therapy session while in treatment; others may receive music therapy weekly, daily, or somewhere in between. Again, this is usually determined by the treatment facility and program schedule. The therapist should prepare the therapeutic space before the session begins. The room should be neat and organized, with adequate lighting. Chairs, beanbags, or mats should be positioned to make a circle. Audio playback equipment should be positioned for easy access to on/off switch and volume controls. The therapist should have easy access to the light switches. Background music and subdued lighting can be used at the therapist’s discretion. It is recommended that each session begin with a general check-in during which clients are asked to assess themselves physically, mentally, emotionally, and spiritually. The therapist then summarizes the check-in and uses that information to select a music experience that will meet the needs of the group members. The check-in may be followed with a warm-up exercise. Warm-ups are described above in several of the methods. Some are indigenous to the method (e.g., Adult Improvisation Therapy); others are more generic and can be used with a variety of methods (e.g., breathing exercises). The warm-up should set the stage for the main experience in that it helps to quiet and focus the clients, or it clarifies the issues to be worked on during the session. At the conclusion of the warm-up, the therapist should help facilitate the transition into the next music experience. This may begin with a brief check-in to assess the effects of the warm-up experience, or the therapist can explain what will be happening next. Choice of method should be related to the needs of the clients and education and training of the therapist. Songwriting and song discussion can be used to explore recovery issues with a focus on the hereand-now. Imagery and improvisation can be used to deepen the experience, helping clients to gain insight into their addiction, identify obstacles to recovery, or explore connections with a higher power. The session should end with a closing experience that completes the session. There are several ways to bring a session to an end; group members can be asked to share one word that describes how they are feeling or a few sentences explaining what they will be taking from the music experience(s). Chants (defined here as short songs with simple melodies, often composed by the music therapist) may be used as a means of bringing the group to an end, using words that reflect the theme/topic of the group. The Serenity Prayer is often said at the conclusion of the group as well. Appendix D provides a sample session that demonstrates how music experiences can be sequenced to address recovery themes. Additionally, Borczon (1997) includes several examples of how to move through a session, along with case examples. Throughout the session, the therapist should be attentive to changes in mood, affect, interaction with others, and physical tension, providing feedback as it relates to the individual’s participation and the

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group experience. The pacing and sequencing of music experiences should be based on clients’ mood, affect, and energy level. For example, if the group seems lethargic, the therapist may want to consider using a movement or drumming experience to energize participants. Conversely, if the group seems very agitated or anxious, an improvisation or imagery experience may be more appropriate. The music therapy methods described in the section move from those used primarily at the augmentative level of music therapy practice to those employed at the primary level.

RESEARCH EVIDENCE There is a small but promising body of research demonstrating the efficacy of music therapy methods in addiction treatment. The research is not focused in any one area of addictions treatment, nor is it tied to any particular treatment theory or model of treatment. As can be seen in Table 2, the majority of studies investigating music therapy interventions used in a group setting examined the effect on emotional change, anxiety, or participation and motivation. Table 2. Music Therapy and Addictions Research AUTHOR

YEAR

MT METHOD

Abdollahnejad

2006a 2006b 2011 2007

RESEARCH METHOD Quantitative

INDEPENDENT VARIABLE/FOCUS Insomnia

Quantitative Quantitative

Depression Mood, exploration of emotions

Quantitative

Depression, stress, anxiety, anger Motivation, enjoyment, continued attendance Question generation and hypothesis formation

Cevasco, Kennedy, & Generally Dingle, Gleadhill, & Baker Gallant, Gallant, Gorey, Holosko, & Siegel

2005

Receptive: Music Listening Improvisation Multiple Methods Receptive & Recreative Multiple Methods

2008

Multiple Methods

Quantitative

1998

Receptive: Song Discussion

Qualitative

Gallant, Holosko, Gorey & Lesiuk

1997

Receptive: Song Discussion

Quantitative

Gardstrom & Diestelkamp Hammer

2013

Multiple

Quantitative

Marital satisfaction, loneliness/isolation, psychosocial problems Anxiety

1996

Quantitative

State and trait anxiety

Hedigan

2010

Receptive: Music and Imagery-Assisted Relaxation Multiple

Qualitative

Heiderscheit

2006

Receptive: BMGIM

Quantitative

Jones

2005

Multiple Methods

Quantitative

Essential features of the experience of music therapy Interpersonal problems, sense of coherence, salivary immunoglobulin A Emotional change

Albornoz Baker, Gleadhill, & Dingle

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Table 2 (Continued) AUTHOR

YEAR

MT METHOD

Murphy

2009

Murphy & Ziedonis Rio Ross et al.

2012

Receptive: Group GIM Receptive: Group GIM Improvisation Multiple Methods

Silverman

2009a

Silverman

2010

Silverman

2011a

Silverman

2011b

Wheeler

1985

2005 2008

RESEARCH METHOD Quantitative Quantitative Qualitative Quantitative

Receptive: Song Discussion Receptive: Song Discussion Receptive: Song Discussion Receptive: Songwriting

Quantitative

Multiple Methods

Quantitative

Quantitative Quantitative Quantitative

INDEPENDENT VARIABLE/FOCUS Sense of coherence, depression, motivation Sense of coherence, depression, motivation Identify themes of therapy Motivation, global functioning, psychiatric symptoms, adherence to aftercare plan Treatment eagerness, working alliance Withdrawal symptoms, locus of control Change readiness, craving Readiness to change, depression, treatment perceptions Responses in music therapy

Receptive Music Therapy As can be seen in Table 2, receptive music therapy methods have been researched more than the others. Within receptive methods, song discussion has been studied most frequently. This is not surprising in that it is the most common method used by music therapists working with individuals who are in substance abuse treatment (Silverman, 2009b). Other receptive methods that have been researched include music listening (Abdollahnejad, 2006a, 2006b), music and imagery–assisted relaxation (Hammer, 1996), individual BMGIM (Heiderscheit, 2006), and group GIM (Murphy, 2009; Murphy & Ziedonis, 2012). Song Discussion. Silverman (2009a, 2010, 2011a) conducted a series of single-session studies examining the efficacy of scripted song discussions on treatment eagerness (2009a), working alliance (2009a), withdrawal symptoms (2010), locus of control (2010), change readiness (2011a, 2011b), depression (2011b), and craving (2011a). With the exception of readiness to change, lyric analysis was found to be equally effective as verbal therapy on all dependent measures. Readiness to change scores were significantly higher in the music therapy group as compared to verbal therapy group. Song discussion was also found to significantly decrease feelings of loneliness in women participating in a 12week, music-based social work group (Gallant, Holosko, Gorey, & Lesiuk, 1997). Qualitative studies undertaken by Abdollahnejad (2006a, 2006b) and Gallant, Gallant, Gorey, Holosko, and Siegel (1997) focused on participants’ experiences of song discussion in therapy. Content analyses of participant responses suggest that song discussion may encourage discussion of important issues that were not as readily accessible in verbal therapy (Abdollahnejad, 2006a, 2006b) as well as facilitate the group problem-solving process (Gallant, Gallant, Gorey, Holosko, & Siegal, 1997).

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Music Listening. Abdollahnejad (2006a, 2006b) compared the use of music listening to standard treatment for sleep difficulties in men residing in a therapeutic community. There was a significant difference between pretest and posttest scores for the music listening group as compared with the control group. These results suggest that listening to relaxing music before going to bed may help to alleviate sleep difficulties among males residing in a therapeutic community. Music and Imagery. Three quantitative studies have investigated the use of music and imagery in addictions treatment. Hammer (1996) found that music and imagery–assisted relaxation significantly decreased state anxiety in adults diagnosed with a substance use disorder. Individual BMGIM was found to significantly decrease the level of interpersonal problems and increase feelings of manageability (Heiderscheit, 2006). The effect of group GIM on coping, mood, and motivation was examined by Murphy and Ziedonis (2012). While there were no significant findings, it is interesting to note that the experimental group (group GIM) had a higher retention rate than the control group. Improvisational Music Therapy Improvisation as a stand-alone method within a music therapy session has been studied by Albornoz (2011) and Rio (2005). Albornoz (2011) examined the effect of Artistic Music Therapy (ArMT) on depression in adolescents and adults diagnosed with a substance use disorder who also met the criteria for depression. Study participants were randomly assigned to either the experimental group (improvisation) or standard treatment. Those in the experimental group attended two-hour ArMT sessions for three months. Participants in the music therapy group had significantly greater improvements in psychologist-rated depression than those in the control group. This suggests that improvisational music therapy may be effective in treating depression in adults and adolescents who have a substance use disorder. Rio (2005) completed a systematic review and analysis of the progress homeless men made on issues related to recovery while participating in an improvisation-based music therapy group. Her analysis identified several themes, including emotional expression, beauty/spirituality, relationship, story, structure, create/risk, and health, that were addressed through participation in the improvisational music therapy group. Rio’s analysis further suggests that music therapy is an effective means of addressing the aesthetic and spiritual needs of homeless men in recovery.

Compositional Music Therapy There has only been one study that has examined the efficacy of songwriting in substance abuse treatment. Silverman (2011b) studied the effect of a single songwriting session using a blues format on readiness to change, depression, and treatment perceptions of individuals residing on an adult detoxification unit. Immediate results suggested that those participating in the songwriting group had higher perceptions of helpfulness and enjoyment. Significant differences were not found for readiness to change or depression.

Multiple Methods Participation in music therapy groups in which multiple music therapy methods are used seems to result in positive outcomes. Descriptive data indicates that adults with substance use disorders report high levels of engagement, motivation, and enjoyment after attending a music therapy session regardless of substance used (Dingle, Gleadhill, & Baker, 2007). Those participating in music therapy sessions reported a noticeable decrease in anxiety (Gardstrom, 2013) and the ability to express emotions without the use of substances (Baker, Gleadhill, & Dingle, 2007). Wheeler (1985) also noted that music therapy sessions that

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incorporated art led to an increase in the expression of feelings, whereas the incorporation of movement led to increased tension. Ross et al. (2008) evaluated how participation in music therapy affected treatment outcomes, specifically motivation, general functioning, and adherence to aftercare. Study participants attended daily one-hour music therapy sessions for the duration of their hospital stay. Results indicate that an increase in appreciation for music therapy was related to an improvement in general functioning. Additionally, attendance at music therapy was predictive of compliance with the first aftercare appointment postdischarge.

Comparison of Methods Two studies have been done that have compared two or more music therapy methods on treatment outcomes. Jones (2005) reported that songwriting and lyric analysis were equally effective in evoking emotional change in adults residing in a detoxification unit. A comparison of movement-to-music, rhythm activities, and competitive games yielded similar results in that they were all equally effective in decreasing stress, anxiety, and anger (Cevasco, Kennedy, & Generally, 2005).

SUMMARY AND CONCLUSIONS Substance use disorders affect individuals physically, mentally, emotionally, and spiritually. Additionally, each stage of treatment will have a different set of goals. Music therapists should be cognizant of these two facts and use them to help plan and implement music therapy. In early recovery, the focus is often on physical goals (Borling, 2011a; Punanken, 2007) and motivation for change (Ghetti, 2004), whereas in later recovery the focus may shift to emotional/spiritual goals (Borling, 2011a) and maintaining newly learned behaviors (Ghetti, 2004). Music therapy methods described in this chapter run the gamut from very structured supportive experiences to less structured in-depth processes. This continuum makes music therapy a very attractive modality for use with individuals who may present with various levels of cognitive, emotional, and physical functioning (Ghetti, 2004). It is incumbent upon the music therapist to assess each client and select the method that most appropriately meets his motivational and functional level. Additionally, the protocols included in this chapter should serve merely as a guide; it is the responsibility of the music therapist to adapt and modify as necessary. While music therapy can be extremely beneficial in substance abuse treatment, the use of music can be potentially harmful. As noted in the contraindication sections of several methods, songs used in treatment can induce memories of use, change mood, and induce cravings. Within the context of a supportive music therapy group led by a skilled music therapist, these responses can become “therapeutic grist for the mill.” Outside of this context, these responses can lead to relapse. Lastly, it is important to consider that music listening, while helpful for stress reduction and anxiety management, can also lead to isolation and cutting oneself off from social supports. As noted by Brooks (1973), “Music … can be a door to healthy human interaction or a block to communication, an excuse not to communicate” (p. 4). He further recommends that when used in treatment, music therapy experiences should involve active engagement rather than passive participation, regardless of the method. Effective music therapy treatment, then, should be based on an assessment of the client’s physical, mental, emotional, and spiritual needs; stage of recovery; and motivation for change. Music therapists should select music therapy methods based on these factors and strive to actively engage their clients in the therapeutic process. Lastly, a discussion of both the benefits and dangers of music in recovery should be incorporated into a comprehensive music therapy treatment program.

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Abdollahnejad, M. R. (2006a). The use of music therapy with substance abusers. Music Therapy Today (online), 7, 318–332. Retrieved July 17, 2006, from http://musictherapyworld.net Abdollahnejad, M. R. (2006b). Music therapy in the Tehran therapeutic community. International Journal of Therapeutic Communities, 27, 147–158. Abdollahnejad, M. R. (2010). The role of music therapy in helping drug dependants [sic]. In D. Aldridge & F. Fachner (Eds.), Music therapy and addictions (pp. 75–87). ). Philadelphia, PA: Jessica Kingsley. Adams, K. (2008). Aspects of the music/text relationship in rap. Music Theory Online, 14(2). Retrieved from http://www.mtosmt.org/issues/mto.08.14.2/mto.08.14.2.adams.html Adelman, E. J., & Castricone, L. (1986). An expressive arts model for substance abuse group training and treatment. The Arts in Psychotherapy, 13(1), 53–59. Albornoz, Y. (2009). The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse: A randomized controlled trial. Dissertation Abstracts International: Section B: The Sciences and Engineering, 70(6-B), 3773. Albornoz, Y. (2011). The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse: A randomized controlled trial. Nordic Journal of Music Therapy, 20, 208–224. Alcoholic Anonymous World Services. (2001). Alcoholics Anonymous (4th ed.). New York: Author. American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—Text revision (4th ed.). (DSM-IV-TR). Arlington, VA: Author. Amodeo, M., Peou, S., Grigg-Saito, D., Berke, H., Pin-Riebe, S., & Jones, L. K. (2004). Providing culturally specific substance abuse services in refugee and immigrant communities: Lessons from a Cambodian treatment and demonstration project. Journal of Social Work Practice in the Addictions, 4(3), 23–46. Austin, D. (2007). Vocal psychotherapy. In B. J. Crowe & C. Colwell (Eds.), Music therapy for children, adolescents, and adults with mental disorders (pp. 76–93). Silver Spring, MD: American Music Therapy Association. Austin, D. (2008). The theory and practice of vocal psychotherapy: Songs of the self. ).

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Bonny, H., & Savary, L. M. (2005). Music and your mind: Listening with a new consciousness. Gilsum, NH: Barcelona Publishers. Bonny, H., & Tansill, R. (2002). Music therapy: A legal high. In L. Summer (Ed.), Music consciousness: The evolution of Guided Imagery and Music (pp. 185–204). Gilsum, NH: Barcelona Publishers. Borczon, R. M. (1997). Music therapy: Group vignettes. Gilsum, NH: Barcelona Publishers. Borling, J. (1992). Guided imagery and music in recovery: A rationale for GIM with addiction. Unpublished manuscript. Borling, J. (2011). Music therapy and addiction: Addressing essential components of the recovery process. In A. Meadows (Ed.), Developments in music therapy practice: Case study perspectives (pp. 334–349). Gilsum, NH: Barcelona Publishers. Borling, J. (2012). Considerations in treatment planning for addictions. In A. L. Gadberry (Ed.), Treatment planning for music therapy cases. Denton, TX: Sarsen Publishing. Borling, J., & Murphy, K. (2012). Music therapy in addictions treatment. Continuing Education Course presented at the annual conference of the Mid-Atlantic Region of the American Music Therapy Association, Baltimore, MD. Borling, J. E., & Miller, R. G. (2007). Conscious drumming: Drumming from the heart. In B. Matney, Tataku: The use of percussion in music therapy (pp. 226–232). Denton, TX: Sarsen Publishing. Brook, D. W. (2003). Exploring group therapies. Psychiatric Times, 20(2), 1–6. Retrieved from http://www.psychiatrictimes.com/display/article/10168/47221# Brooks, H. B. (1973). The role of music in a community drug abuse prevention program. Journal of Music Therapy, 10, 3–6. Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas Publisher. Bruscia, K. E. (1998a). Defining music therapy (2nd ed.). Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (1998b). An introduction to music psychotherapy. In K. E. Bruscia (Ed.), The dynamics of music psychotherapy (pp. 1–15). Gilsum, NH: Barcelona Publishers. Castro, F., & Alarcón, E. H. (2002). Integrating cultural variables into drug abuse prevention and treatment with racial/ethnic minorities. Journal of Drug Issues, 32, 783–810. Castro, F., & Garfinkle, J. (2003). Critical issues in the development of culturally relevant substance abuse treatments for specific minority groups. Alcoholism: Clinical and Experimental Research, 27, 1381–1388. Center for Substance Abuse Treatment (CSAT). (2005a). Substance abuse treatment: Group therapy. Treatment Improvement Protocol (TIP), Series 41. DHHS Publication No. (SMA) 05-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment (CSAT). (2005b). Substance abuse treatment for persons with cooccurring disorders. Treatment Improvement Protocol (TIP), Series 41. DHHS Publication No. (SMA) 05-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration. Cevasco, A. M., Kennedy, R., & Generally, N. R. (2005). Comparison of movement-to-music, rhythmic activities, and competitive games on depression, stress, anxiety, and anger of females in substance abuse rehabilitation. Journal of Music Therapy, 42(1), 64–80. Dijkstra, T. F., & Hakvoort, L. G. (2010). “How to deal music?” Music therapy with clients suffering from addiction problems: Enhancing coping strategies. In D. Aldridge & F. Fachner (Eds.), Music therapy and addictions (pp. 88–102). ). Philadelphia, PA: Jessica Kingsley. Dingle, G., Gleadhill, L., & Baker, F. (2008). Can music therapy engage patients in group cognitive behaviour therapy for substance abuse treatment? Drug & Alcohol Review, 27(2), 190–196. Dougherty, K. M. (1984). Music therapy in the treatment of the alcoholic client. Music Therapy: The Journal of the American Music Therapy Association, 4, 47–54.

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Heiderscheit, A. (2009). Songs, music and sobriety: An overview of music therapy in substance abuse. In S. L. Brooke (Ed.), The use of creative therapies with chemical dependency issues (pp. 136–161). Springfield, IL: Charles C Thomas Publisher. Horesh, T. (2006). “Music is my whole life”—The many meanings of music in addicts’ lives. Music Therapy Today (online), 7, 299–319. Retrieved July 16, 2006, from http://www.musictherapyworld.net Horesch, T. (2010). Drug addicts and their music: A story of a complex relationship. In D. Aldridge & F. Fachner (Eds.), Music therapy and addictions (pp. 57–74). ). Philadelphia, PA: Jessica Kingsley. Jacobson, E. (1938). Progressive relaxation (2nd ed.). Chicago: University of Chicago Press. James, M. R. (1988). Music therapy and alcoholism: Part II—Treatment services. Music Therapy Perspectives, 5, 64–68. Jones, J. D. (2005). A comparison of songwriting and lyric analysis techniques to evoke emotional change in a single session with people who are chemically dependent. Journal of Music Therapy, 42(2), 94–110. Justice, R. W. (2007). Relaxation techniques. In B. Crowe & C. Colwell (Eds.), Music therapy for adults, adolescents and children with mental disorders (pp. 36–39). Silver Spring, MD: American Music Therapy Association. Krestan, J. (2000). Addiction, power and powerlessness. In J. Krestan (Ed.), Bridges to recovery: Addiction, family therapy, and multicultural treatment (pp. 15–44). New York: The Free Press. Lehikoinen, P. (1997). The physioacoustic method. In T. Wigram & C. Dileo (Eds.), Music, vibration and health (pp. 209–215). Cherry Hill, NJ: Jeffrey Books. Lesiuk, T. L. (2010). A rationale for music-based cognitive rehabilitation toward prevention of relapse in drug addiction. Music Therapy Perspectives, 28(2), 124–130. Loewy, J. V. (2002). Song sensitation: How fragile we are. In J. V. Loewy & A. F. Hara (Eds), Caring for the caregiver: The use of music and music therapy in grief and trauma (pp. 33–42). Silver Spring, MD: American Music Therapy Association, Inc. Mandel, S. E., Hanser, S. B., & Ryan, L. J. (2010). Effects of a music-assisted relaxation and imagery compact disc recording on health-related outcomes in cardiac rehabilitation. Music Therapy Perspectives, 28(1), 11–21. Matney, B. (2007). Tataku: The use of percussion in music therapy. Denton, TX: Sarsen Publishing. McLellan, A. T., Luborsky, L., & O’Brien, C. P. (1986). Alcohol and drug abuse treatment in three different populations: Is there improvement and is it predictable? American Journal of Drug & Alcohol Abuse, 12, 101–120. McLellan, A. T., Luborsky, L., Woody, G. E., & O’Brien, C. P. (1980). An improved diagnostic evaluation instrument for substance abuse patients. Journal of Nervous and Mental Disease, 168, 26–33. Mikenas, E. E. (1999). Drumming, not drugs. Percussive Notes, 37, 62–63. Miller, A. S. (1970). Music therapy for alcoholics at a Salvation Army Center. Journal of Music Therapy, 7, 136–138. Moos, R. H. (2007). Theory-based active ingredients of effective treatments for substance use disorders. Drug and Alcohol Dependence, 88, 109–121. Moos, R. H., & Moos, B. S. (2007). Protective resources and long-term recovery from alcohol use disorders. Drug and Alcohol Dependence, 88, 46–54. Moreno, J. (1988). Multicultural music therapy: The world music connection. Journal of Music Therapy, 25, 17–27. Moreno, J. (1995). Ethnomusic therapy: An interdisciplinary approach to music and healing. The Arts in Psychotherapy, 22, 239–338. Murphy, K. M. (2009). The effects of group guided imagery and music on the psychological health of adults in substance abuse treatment. Dissertation Abstracts International Section A: Humanities and Social Sciences, 69(8-A), 29–39.

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Murphy, K. M. (2011). Creative approaches to stress management in substance abuse treatment. Paper presented at the annual conference of the American Music Therapy Association, Atlanta, GA. Murphy, K. M. (2012). Music therapy in detoxification. Manuscript in preparation. Murphy, K. M., & Ziedonis, D. M. (2012). Group Guided Imagery and Music (GIM) for adults in addiction treatment: A randomized controlled pilot study. Manuscript submitted for publication. Murphy, M. (1983). Music therapy: A self-help group experience for substance abuse patients. Music Therapy: Journal of the American Association for Music Therapy, 3, 52–62. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide. Washington, DC: National Institutes of Health. National Institute on Drug Abuse (2010). Drugs, brains, and behavior: The science of addiction. Washington, DC: National Institutes of Health. Oetting, E. R., & Donnermeyer, J. F. (1998). Primary socialization theory: The etiology of drug use and deviance. Substance Use and Misuse, 33, 995–1026. Pickett, E. (1991). Guided Imagery and Music with a dually diagnosed woman having multiple addictions. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 497–512). Gilsum, NH: Barcelona Publishers. Plach, T. (1996). The creative use of music in group therapy (2nd ed.). Springfield, IL: Charles C. Thomas. Priestley, M. (1994). Essays on Analytical Music Therapy. Gilsum, NH: Barcelona Publishers. Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Process of change (pp. 3–27). New York: Plenum Press. Punkanen, M. (2006). On a journey to somatic memory: Theoretical and clinical approaches for the treatment of traumatic memories in music therapy-based drug rehabilitation. In D. Aldridge & J. Fachner (Eds.), Music and altered states: Consciousness, transcendence, therapy and addictions (pp. 140–154). ). Philadelphia, PA: Jessica Kingsley. Punkanen, M. (2007). Music therapy as part of drug rehabilitation. Music Therapy Today, 8(3). Available at http://www.musictherapyworld.net Punkanen, M. (2010). Music therapy as a part of drug rehabilitation: From adhering to treatment to integrating the levels of experience. In D. Aldridge & F. Fachner (Eds.), Music therapy and addictions (pp. 123–131). ). Philadelphia, PA: Jessica Kingsley. Punkanen, M., & Ala-Ruona, E. (2011). Making my body a safe place to stay: A psychotherapeutically oriented approach to vibroacoustic therapy in drug rehabilitation. In A. Meadows (Ed.), Developments in music therapy practice: Case study perspectives (pp. 350–367). Gilsum, NH: Barcelona Publishers. Reitman, A. D. (2011). Songs in group psychotherapy for chemical dependence. Gilsum, NH: Barcelona Publishers. Rio, R. (2005). Adults in recovery: A year with members of the Choirhouse. Nordic Journal of Music Therapy, 14(2), 107–119. Ross, S., Cidambi, I., Dermatis, H., Weinstein, J., Ziedonis, D., Roth, S., & Galanter, M. (2008). Music therapy: A novel motivational approach for dually diagnosed patients. Journal of Addictive Disorders, 27, 41–53. Scheiby, B. (1999). Music as symbolic expression: Analytical music therapy. In D. J. Weiner (Ed.), Beyond talk therapy: Using movement and expressive techniques in clinical practice (pp. 263–285). Washington, DC: American Psychological Association. Shapiro, N. (2005). Sounds in the world: Multicultural influences in music therapy in clinical practice and training. Music Therapy Perspectives, 23, 29–35.

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Silverman, M. J. (2009a). The effect of lyric analysis on treatment eagerness and working alliance in consumers who are in detoxification: A randomized clinical effectiveness study. Music Therapy Perspectives, 27(2), 115–121. Silverman, M. J. (2009b). A descriptive analysis of music therapists working with consumers in substance abuse rehabilitation: Current clinical practice to guide future research. The Arts in Psychotherapy, 36(3), 123–130. Silverman, M. J. (2010). The effect of a lyric analysis intervention on withdrawal symptoms and locus of control in patients on a detoxification unit: A randomized effectiveness study. The Arts in Psychotherapy, 37, 197–201. Silverman, M. J. (2011a). Effects of music therapy on change readiness and craving in patients on a detoxification unit. Journal of Music Therapy, 48, 509–531. Silverman, M. J. (2011b). Effects of music therapy on change and depression on clients in detoxification. Journal of Addictions Nursing, 22, 185–192. Skaggs, R. (1997). Finishing strong: Treating chemical addictions with music and imagery. St. Louis, MO: MMB Music. Skaggs, R. (n.d). Music and imagery: An innovative addition to substance abuse treatment. Atlanta, GA: Author. Smith, J. G. (2007). Creating a “Circle of Song” within Canada’s poorest postal code. Canadian Journal of Music Therapy, 13(2), 103–114. Soshensky, R. (2001). Music therapy and addiction. Music Therapy Perspectives, 19, 45–52. Soshensky, R. (2007). Music therapy for clients with substance use disorders. In B. J. Crowe & C. Colwell (Eds.), Music therapy for children, adolescents, and adults with mental disorders: Using music to maximize mental health (pp. 149–164). Silver Spring, MD: American Music Therapy Association, Inc. Staub, A. J. (2006). The road to recovery: The use of group improvisation and the song sensitation technique with chemically dependent adults in detox/early recovery. New York: New York University. Stinchfield, R. D., Owen, P. L., & Winters, K. C. (1994). Group therapy for substance abuse: A review of the empirical literature. In A. Fuhriman & G. M. Burlingame (Eds.), Handbook of group psychotherapy: An empirical and clinical synthesis (p. 458–488). New York: Wiley. Summer, L. (1988). Guided imagery and music in the institutional setting. St. Louis, MO: MMB Music, Inc. Summer, L. (2002). Group music and imagery therapy: Emergent receptive techniques in music therapy practice. In K. E. Bruscia & D. E. Grocke (Eds.), Guided imagery and music: The Bonny method and beyond (pp. 297–306). Gilsum, NH: Barcelona Publishers. Tart, C. T. (1972). States of consciousness and state-specific sciences. Science, 175, 1203–1210. Thaut, M. H., & Davis, W. B. (1993). The influence of subject-selected versus experimenter-chosen music on affect, anxiety, and relaxation. Journal of Music Therapy, 30, 210–223. Toot, D. (2012). Rap. In D. Root (Ed.), Oxford music online. Retrieved from http://www.oxfordmusiconline.com/subscriber/article/grove/music/46867?q=Rap&search=quic k&pos=1&_start=1#firsthit Treder-Wolff, J. (1990a). Music therapy as a facilitator of creative process in addictions treatment. The Arts in Psychotherapy, 17, 319–324. Treder-Wolff, J. (1990b). Affecting attitudes: Music therapy in addictions treatment. Music Therapy Perspectives, 8, 67–71. van der Lann, M. C., & Janssen, M. G. P. (1996). Addressing drug abuse in a Dutch forensic hospital. Criminal Behaviour and Mental Health, 6, 157–166. Van Stone, W. W. (1973). Peer groups and drug rehabilitation. Journal of Music Therapy, 10, 7–12.

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Ventre, M. (2002). The individual form of the Bonny method of guided imagery and music. In K. E. Bruscia & D. E. Grocke (Eds), Guided imagery and music: The Bonny method and beyond (pp. 29–36). Gilsum, NH: Barcelona Publishers. Walker, J. (1995). Music therapy, spirituality and chemically dependent clients. In R. J. Kus (Ed.), Spirituality and chemical dependency (pp. 145–166). New York: Harrington Park Press/Haworth Press. Wheeler, B. L. (1985). The relationship between musical and activity elements of music therapy sessions and client responses: An exploratory study. Music Therapy: Journal of the American Association for Music Therapy, 5, 52–60. Wigram, T. (2005). Songwriting methods—Similarities and differences: Developing a working model. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques and clinical applications for music therapy clinicians, educators and students (pp. 246–264). Philadelphia, PA: Jessica Kingsley. Winkelman, M. (2003). Complementary therapy for addiction: “Drumming out drugs.” American Journal of Public Health, 93, 647–651.

FOR FURTHER READING Thurman, P. J., Swaim, R., & Plested, B. (1995). Intervention and treatment of ethnic minority substance abusers. In J. F. Aponte, R. Y. Rivers, & J. Wohl (Eds.), Psychological interventions and cultural diversity (pp. 215–233). Boston: Allyn and Bacon. Xueqin, G., & Henderson, G. (2002). Ethnicity and substance abuse: Prevention and intervention. Springfield, IL: Charles C. Thomas Publishers.

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APPENDIX A SONGS USED IN SUBSTANCE ABUSE TREATMENT

Theme: Change • Alive Again: Matt Sevier • Change: Tracy Chapman • Everything must change: Nina Simone • I want a new drug: Huey Lewis • Landslide: Stevie Nicks and Fleetwood Mac • Who I am hates who I’ve been: Jon Vezner and Don Henry Theme: Coping Skills • Don’t worry, be happy: Bobby McFerran • Three Little Birds: Bob Marley Theme: Decision-Making/Choices • Best of you: Foo Fighters • Breakaway: Kelly Clarkson • I am changing: Jennifer Hudson • I choose: Indie.Arie Theme: Denial • Not an Addict: Jane’s Addiction

Theme: Depression • Under the bridge: Red Hot Chili Peppers • You’re only human: Billy Joel • Motherless child: Spiritual Theme: Escape • Cocaine: Eric Clapton • Comfortably Numb: Pink Floyd • Crystal Ship: The Doors • I feel like dying: L’il Wayne • Have another drink: The Kinks • When the work is over: Johnny Cash Theme: Family Issues • Alcohol: The Kinks • Nobody drinks alone: Keith Urban

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Please, Daddy: John Denver

Theme: Forgiveness • Healing of the heart: Ken Medema

Theme: Hopes/Dream • I hope you dance: LeeAnn Womack • The River: Garth Brooks

Theme: Life on life’s terms: • Life’s a dance: John Montgomery • Life ain’t always beautiful: Gary Allen

Theme: Powerlessness and Unmanageability • Addicted: Kelly Clarkson • Devil Inside: INXS • Disturbia: Rihanna • Master of Puppets: Metallica

Theme: Regret • In the journey: Martin Sexton • Sunday morning coming down: Johnny Cash • Wasted on the way: Crosby Stills, Nash, & Young Theme: Self-esteem/Belief in Oneself • Beautiful: Christine Aguilera • Hero: Mariah Carey • I believe I can fly: R. Kelly

Theme: Support • Stand by me: R. Kelly • A little help from my friends: The Beatles • I will carry you: Clay Aiken • I will not take these things for granted: Toad, the wet Sprocket Lean on me: Bill Withers • Stand by Me: Ben King Theme: Surrender • Let it be: The Beatles • Sweet surrender: Sarah McLachlan

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APPENDIX B THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS 1) We admitted we were powerless over alcohol—that our lives had become unmanageable. 2) Came to believe that a Power greater than ourselves could restore us to sanity. 3) Made a decision to turn our will and our lives over to the care of God as we understood Him. 4) Made a searching and fearless moral inventory of ourselves. 5) Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6) Were entirely ready to have God remove all these defects of character. 7) Humbly asked Him to remove our shortcomings. 8) Made a list of all persons we had harmed, and became willing to make amends to them all. 9) Made direct amends to such people wherever possible, except when to do so would injure them or others. 10) Continued to take personal inventory, and when we were wrong, promptly admitted it. 11) Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12) Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs. See: www.aa.org/en_pdfs/smf-121_en.pdf

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APPENDIX C AFFIRMATION CREATION WORKSHOP Just For Today I am walking away from

and walking toward

I am pushing away

and bringing in

I am shaking off

and reaching toward

I need

and I can God, grant me the Serenity to accept the things I cannot change; Courage to change the things I can Wisdom to know the difference

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APPENDIX D SAMPLE MUSIC THERAPY SESSION FOR ADULTS IN SUBSTANCE ABUSE TREATMENT Check-in for Theme Identification

Warm-up Personal Definition of the Theme OR Share 3 words to describe theme

Focused Listening Members need to: Reflect on the theme Use the music to explore the theme Connect with the message of the song

Song Discussion Structured approach to explore theme Altered-state work contraindicated Therapist does not have advanced training

Songwriting Structured approach to synthesizes ideas from song discussion Altered-state work contraindicated Therapist does not have advanced training

Group Guided Imagery & Music Deepen the clients’ understanding of the theme Gain new insights

Wrap-up Share what will be taking from group Three words to describe experience

Closure Chant Serenity Prayer

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Chapter 15

Adolescents with Substance Use Disorders Katrina Skewes McFerran _____________________________________________ DIAGNOSTIC INFORMATION Adolescence is defined by the World Health Organization (WHO) as the period of time between childhood and adulthood (WHO, 2012). It is essentially a transition between different roles assigned by society, one which is assumed to be dependent on the care of others, and the other which is based on civic participation through working and caring. The in-between of adolescence has historically been characterized as a time of selfishness and rebellion (Hall, 1916), but this construction is tenuous and “Sturm und Drang” has been found to be largely a Western construction (Phinney & Baldelomar, 2011). In cultures where adolescents are given adult liberties and are expected to make a contribution to their community, the concept of adolescent rebelliousness is not widespread. There is nothing inherent about the teenage years that demand “breaking free.” In contrast, it is the restrictions that are placed on adolescents at a time in their life when they are reaching full maturity, physically, cognitively and emotionally, that create the restraints from which teenagers strain to free themselves. In a book called The case against adolescence: Rediscovering the adult in every teen, Epstein (2007) provides powerful examples of adults whose emotional maturity is far less than the average teenager, or alternately, whose self-serving behaviors and refusal to follow rules have led to a role as a company CEO. Hormonal fluctuations do begin with the onset of puberty and the unfamiliarity of these variations in the biological system may lead to some confusion for a young person at times. But Epstein argues that making assumptions about emotional maturity based simply on age is flawed, and it is individual people who have more or less emotional capacity that emerges, but does necessarily change, after adolescence. Within this chapter, the use of substances will be considered in relation to developmental stage. Using substances is certainly not unique to adolescence (see Chapter 14, “Adults with Substance Use Disorders”), and statistics suggest that the highest levels of substance use occur after 18 years of age (“Statistics on drug use in Australia 2006,” 2007). Although substance abuse is more common in adulthood, patterns of behavior that lead to habitual use often begin during the teenage years. The Diagnostic and Statistical Manual (DSM)-IIIR (American Psychiatric Association [APA] 1987) used the phrase substance “abuse” to describe “a maladaptive pattern of use indicated by … continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem that is caused or exacerbated by use or by recurrent use in situations in which it is physically hazardous” (p.453). However, DSM-IV (1994) and the World Health Organization (“Lexicon of alcohol and drug terms,)” have moved to the use of “dependence” to indicate the physical reliance on substances, since there is a tendency to use the phrase “abuse” as a form of disapproving judgment. They suggest “harmful” or “hazardous” use as preferred terminology. The key point is that substance use is not always hazardous

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and that the context surrounding young people’s abuse/misuse/dependence is usually the reason for engaging in music therapy. Once substance use is understood as being distinct from substance abuse, the question is raised of what contextual factors lead to harmful use. The most common understandings separate purposes for substance use into distinct categories of sensation-seeking or self-medicating, with the first being related to recreational intentions and the second to more complex contextual factors. This is illustrated by a group of British multisubstance users who report appropriating substances for relaxation purposes, alleviating a depressed mood, becoming intoxicated, staying awake at night while socializing, and enhancing an activity (Boys, Marsden, & Strang, 2001). Clearly some of these uses are more likely to be connected to vulnerable contexts (self-medicating), while others may be more sensation-seeking. Researchers have been active in studying the comorbidity of substance use and mental health problems, with one international review (Merikangas et al., 1998) clearly showing that mood and anxiety disorders are likely to precede substance use. This can be seen to support commonly held beliefs that substances are often used by vulnerable young people in an attempt to manage or avoid dealing with mental health problems. This is confirmed in a study of people with comorbid substance abuse and mood disorders (Bizzarria et al., 2007), where self-medication was more common, and an increased “substance sensitivity” was found in comparison to a control group whose focus was more on sensation-seeking. Doak (2003) has helpfully linked adolescent drug use, musical preferences, and mental health problems together, identifying some significant patterns of connection. Although her study did not find any significant correlation between adolescents’ reasons for using music and their diagnosis, she did find relationships between diagnosis and type of preferred music. “Clinically depressed adolescents tended to prefer rap, heavy metal, and techno. Adolescents with a mood disorder tended to prefer rap, classic rock, hard rock, heavy metal, and alternative music. Those with oppositional defiant disorder tended to prefer only rap and some techno” (p. 71). These kinds of connections between music preference and diagnosis have frequently been identified in the literature. Baker and Bor (2008) have also highlighted the links between a preference for heavy metal and rap music and antisocial behaviors that have been identified in several studies (North & Hargreaves, 2006). However, other studies have found listening to preferred music (which might include heavy metal and rap) can lead to positive outcomes (Walworth, 2003). The relationship is complex, and the earliest work of Miranda and Claes (2004) identified a link between deviant behaviors and rap music (2004); however, it is critical to realize that there is no evidence suggesting that particular genres of music cause mental health problems or lead to particular substance use. It is a postfacto connection, a simple correlation that suggests that young people who use amphetamines are more likely to prefer techno music and those who use crack to prefer metal and rock music. It does not suggest that liking metal music leads to a particular kind of substance use. Metal music has received particular attention in relation to the mental health of young people and has most often been connected with substance misuse and suicide (Lacourse, Claes, & Villeneuve, 2001; North & Hargreaves, 2006; Scheel, 1999; Stack, 1998), as well as depression and isolation (North & Hargreaves, 2012; Reddick & Beresin, 2002). In the 1980s, this resulted in some wild claims about metal music causing particular behaviors, and despite the fact that these claims were unsubstantiated, this movement did lead to the introduction of the “Explicit Lyrics” sticker that can now be found on many store-bought audio CDs. The connection between metal and “problem behaviors” (as they are labeled by North & Hargreaves, 2008) is more conspicuous than for any other music genre, even rap, which is equally preferred. If we accept that particular types of music do not cause certain behaviors, but are related, then it becomes pertinent to consider what reasons young people have for engaging with certain types of music. At a theoretical level, the functions of music during adolescence have been broadly described as supporting adolescent identity by engaging identity, interpersonal relationships, agency, and emotions (Gold, Saarikallio, & McFerran, 2010). More specifically, Miranda and Claes (2009) have illuminated

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specific relationships between different ways of using music listening for coping and positive and negative outcomes, and these differ depending on the gender of the young person. The results of his study highlight that girls who listen to music to grapple with their problems achieve better outcomes than when they use music to avoid their problems. He suggests that using music to avoid thinking about problems may distract them from taking actions that are needed. In contrast, his findings suggest that boys who use music listening to focus on their problems are more likely to use it for venting, but not for successful emotion regulation. Boys’ music listening was linked to positive outcomes when they did use it for avoiding or distracting themselves from the problem. Therefore, the idea of engaging with music to relax and distract from problems, which is commonly described by young people, may be more complex than is acknowledged. As music therapists, we should be particularly attentive to the descriptions of musical engagement provided by young people with mental health problems, since a disconnection with reality already lies at the core of their mental illness. For young people with mental illness, bad situations seem worse, dangerous situations are not recognized, and, at worst, the distinction between auditory hallucinations and sounds perceived in the world may be unclear. Similar to the use of substances, music use can be appropriated in order to achieve a distance from reality, which may be unproblematic for some, but dangerous for others. As usual, the most vulnerable are the most at risk. Therefore, the potentially diagnostic information provided by the relationships young people have with music should not be ignored in relation to understanding their abuse of substances, but neither should the relationships be exaggerated as causative.

NEEDS AND RESOURCES In discussion, many young people simply describe their most significant need as “to be happy.” It is common for adolescents to report their needs in groups as “I just want to feel better,” and it is this desire that feeds most therapeutic encounters. Music is often seen as a resource for addressing that need, and the relationship between young people who misuse substances and music is a powerful one. Although Doak’s (2003) study is the only one to connect music genres, substance misuse, and mental health explicitly, this is an important combination, and the reasons that young people turn to music when they are struggling can be very similar to their reasons for turning to substances. However, substances are clearly linked to negative health outcomes (addiction/abuse), where music has not yet been shown to cause health problems—with the very important exception of hearing impairment. (The increasing use of MP3 players with in-ear buds on public transport is predicted to lead to a major health problem if current listening trends continue [Vogel, Verschuure, Ploeg, Brug & Raat, 2010]). One way of addressing young people’s need to feel good is fostering a healthy sense of belonging, and many commentators describe peer affiliations as the primary developmental task of this stage of life. With reference to ego development, Jane Loevinger (1987, in Kroger, 2004) uses the phrase “conformity with the beliefs of others” to label the need young people have to appear similar to their peers, which is often seen in the formation of subgroups during adolescence. Eric Erikson’s (1965) foundational contribution to developmental understandings of adolescence also highlighted the importance of the opinions of others, describing adolescent identity as a negotiation between internal beliefs about personal identity and the feedback received from others that either confirms or confuses those inbuilt assumptions about self. Even cognitive psychologists describe adolescent development in relation to others and emphasize the importance of social interaction in increasing cognitive ability (Kegan, 1982). Another way of addressing the need to feel better is through emotional experience, and the pleasure-seeking dimensions of both musical engagement and substance use are in the forefront for young people. The latest figures estimating the amount of hours spent listening to music suggest

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approximately 2.5 hours per day, with the total amount of time spent multitasking with various media being around 7.5 hours (Rideout, Foehr, & Roberts, 2010). Even more interesting is that the amount of time increases when young people are struggling (McFerran, 2010a; North & Hargreaves, 2006). Saarikallio and Erkkila (2007) attribute this increase to attempts at emotion and mood regulation, describing how adolescents have a sense of what they “need” to listen to in any given mood. Studies of the MP3 listening habits of adults confirm these notions, with adults describing using music to intentionally adjust their energy levels and “administer” their emotions being described (Skanland, 2011). Both music and drugs are powerful resources in building connectedness and working with emotions during adolescence. Levitin (2008) has described the neurochemicals that are released during musical participation and highlighted the similarities to those induced by synthetic and designer drugs. He explains that dopamine levels are modulated when playing music, leading to an elevated mood, and this is mirrored in synthetic amphetamines and cocaine. Endorphins are released when we sing, and these natural pain relievers are equivalent to the semisynthetic variants of heroin, morphine, and even alcohol. Serotonin increases during listening to pleasant (but not unpleasant) music and is important for mental relaxation and going to sleep, having effects similar to those of certain sleeping pills. And finally, oxytocin levels are known to increase significantly after singing with others, and this is the brain drug for building trust, also released during the intimate and bonding acts of breast-feeding and sexual encounter. Early research on Guided Imagery and Music (GIM) drew on these similarities to enhance the experience of imaging by pairing LSD and specific music programs, but Helen Bonny soon discovered that music was powerful enough on its own (Bruscia & Grocke, 2002). While some young people have anecdotally described the need to stop listening to music in order to break their drug habit, an alternative is to bring Bonny’s learning to the attention of young people who misuse substances.

ASSESSING MUSICAL INTEREST Young people who misuse substances may access music therapy in a range of settings, from substancespecific services to schools, hospitals, and community programs. Depending on the context, different approaches to assessment and referral will be appropriate. Assuming that organizations provide relevant information about the challenges being faced by the young person and his personal context, the role of the music therapist will be to complement this by focusing on his relationship with music. This can often be elicited through a casual conversation, beginning with “So, what kind of music do you like?” (McFerran, 2010, p. 88). The music therapist then draws on her active listening skills to draw out a response from the young person, since it is not always an easy question to answer. The information that is heard will tend to fit into one of the following categories of responses.

Young People with Absolute or Loyal Music Preferences Some young people may express a loyalty to a particular genre of music, such as hard core or hip-hop, and this can then lead to a request from the music therapist to hear some of their favorite tracks. Since most young people carry music on their phones or have access to a computer and YouTube, this can often happen immediately and provides a wonderful opportunity to listen deeply to the young person, expressing a serious interest in attending to the entire track and then asking afterward, “So what is it you like about that song?” It is important not to make any assumptions about what the music is expressing until the young person has the opportunity to offer their explanation. Common mistakes in assessment at this stage include assuming that the young person is angry because his musical choice is loud, or depressed because the music is slow. These are overly simplistic, and the nuance of a young person’s commitment to a particular type of music is what the music therapist is seeking: “When did you start

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liking this kind of music? How often do you listen? When do you turn to this kind of music? How do you feel after listening? Is that how you expected to feel?” The aim of these questions is not only for the music therapist to “extract” the information, but also for the young person to increase his conscious awareness of his own relationship with music. This relationship can sometimes be based on unconscious assumptions about the healing power of music, and the young person’s experience may not always be positive since music can prime for negative states of mind as much as positive ones. Most young people have not considered the possibility that their music might not be helpful for them, so this discussion is critical with young people who have absolute or loyal preferences.

Young People with Unclear or Eclectic Music Preferences Although a particular young person may enjoy listening to and playing music, he may not have one band or one genre to which he is deeply committed. In this case, the general assessment question may be difficult to answer and may lead to the young person feeling insecure because he is not representing himself authentically. In this case, the role of the music therapist is to ask helpful questions that will gradually allow him to recall favorite songs and artists. Questions such as “Do you listen to the radio/buy compilation CDs/listen to your friends’ music?” may help the young person to remember that he does listen to music, but that he doesn’t always know what he is listening to. The music therapist may also name some pop music bands or singers and help the young person to express his musical identity by reflecting reactions to them. A common example would be to ask whether the young person likes the latest boy band at the top of the charts, and this will often either elicit a clear “No way” or a “Oh, yeah, totally.” Helping a young person to establish his musical identity within a music therapy assessment is a critical dimension to the conversation with these young people, since it will shape what opportunities are offered in subsequent encounters and will establish the young person, and his identity, as central to the therapeutic encounter.

Young People with Disguised or Unpopular Music Preferences Some young people may actually have a clear sense of musical preferences, but be undecided about whether they trust the music therapist enough to share that information. Musical identity has significant currency in peer interactions, so young people may have had negative experiences of sharing the music they like, making them cautious about doing so again. They may also have a clear understanding that their musical identity is unusual for an adolescent and have made a conscious decision not to share that information. This is often the case for young people who either play instruments in the Western tradition of classical music or have strong connections with the music of their cultural origins. Another reason for disguising musical taste may be that the associations and meanings of the song are private and sharing them may lead to a real sense of vulnerability. This can usually be ascertained by asking about what music the young person listened to last and commenting that their iPod can actually help them identify most frequently played songs, or their most recent ones. Careful observation of the young person’s reaction will help the music therapist decide how to proceed from here, and respect for musical privacy should always be balanced by the music therapist’s expression of deep interest and care in the young person’s musical choices.

Identifying Unhealthy Aspects in Young People’s Relationships with Music After assessing the musical preferences of young people in this way, the music therapist is able to make initial decisions about what kind of music therapy process might be suggested. Due consideration needs to

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be given to the information that has been gathered in response to the question about “What kind of music do you like?” It would be a mistake to assume that all young people have healthy relationships with music, and important to notice whether the relationship might be characterized as high-risk and/or highly protective. Emerging research (Gold et al., 2010) suggests that young people are not always conscious of the consequences of their relationship with music. There is a tendency (in both music therapists and youth) to assume that music is always helpful, even when engagement is characterized by aspects that may be problematic. A critical analysis of the literature identified four characteristics of a young person’s relationship with music that may have risk and protective factors. The interpersonal nature of the relationship may vary from engaging with music in a way that promotes connectedness with others to, at the other end of the spectrum, engaging with it in a way that isolates the young person from others. The nature of the musical relationship may have a positive or a negative impact on mood. Young people may use music to cope either by avoiding thoughts and feelings or by engaging in emotional processing. Consciousness is also seen as a critical characteristic, since some young people have ritualized and repetitive uses of music that do not engage conscious consideration, whereas others are more contemplative and considered in their engagement. Each individual will vary along the spectrum of these four characteristics of interpersonal, mood, coping, and consciousness dimensions at different times, but a common grouping that may trigger the music therapist’s interest is the young person who habitually listens to the same music alone at lunchtime as a way of avoiding contact with others and reconnecting with a negative experience associated with the song. These factors should not be understood in isolation, since some young people have relationships with music that may be characterized by all of the risk factors, but they do not experience negative consequences because their social networks are strong. This means that they may choose to isolate themselves, but friends or family will interrupt and encourage interaction, or a song they listen to repetitively might impact negatively on their mood, but their best friend may become aware of that and convince them to remove the song from their iPod. The resilience conferred by their social network (Ungar, 2004) therefore means that moments of intense musical engagement are eventually moderated and do not remain habitual and harmful. However, if a young person has a problem with substance misuse, their relationship with music may well be associated with a more complex personal context. Habit-forming behaviors that easily become rigid rather than temporary may be more typical, and mental health problems that are reflected in an inclination to ruminate rather than reflect on emotionally charged issues (Trapnell & Campbell, 1999) may be prevalent. In addition, the resilience conferred upon a well-connected young person through their friendships and family support may be missing, and although music may feel like a friend that understands, it actually lacks the dynamic qualities of friends who may disagree, develop new perspectives, or encourage the young person to try something different. The role of the music therapist is to consider the qualities of the young person’s relationship with music as he interweaves with the broader context of his life. The risk or protective aspects cannot be understood without being located appropriately, but nor should they be ignored based on the assumption that music is always a force for good. The music therapist’s assessment of the quality of the young person’s relationship with music should contribute to decision-making about where to begin the music therapy processes described below. Equally, young people struggling with substance misuse should be empowered to articulate how they would like to engage in music therapy and be given enough information about their options. Since the development of personal resources is a critical dimension of recovery for these young people, a resource-oriented approach that generates mutually empowering encounters where genuinely shared decision-making occurs is appropriate (Rolvsjord, 2006; Rolvsjord, 2010). Adopting an “expert” stance, where the music therapist considers herself responsible for determining the “best treatment for the client” could be disempowering, even if it is well-intentioned. Together, the young person and the music therapist can choose where they would like to begin.

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OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • •

Individual Playlist Creation: involves selecting preferred songs with the young person to create a playlist. Music for Individual Mood Management: The music therapist guides the young person to develop a playlist that is carefully altered to move from one mood state to another.

Improvisational Music Therapy •

Expressive Group Improvisations: Young people play tuned and nontuned percussion instruments together in a group to express themselves.

Re-creative Music Therapy •

Group Song Playing: involves learning to play a preferred song as a group.

Compositional Music Therapy •

Group Lyric Substitution: The clients and therapist work together to change the lyrics of an existing song to reflect their personal experience.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Since most young people have existing music preferences, working with music listening is a common starting place for the development of a mutually empowering therapeutic relationship. The act of music listening with young people can involve sharing a set of ear buds plugged into the young person’s mobile phone or listening through the speakers of the music therapist’s iPad or tablet, or it can involve huddling in front of a computer screen selecting YouTube clips to share. The enormous benefit of the MP3 revolution is that the music therapist need no longer be the supplier of all music for listening, since most young people carry a long list of music with them at all times, leaving the music therapist to complement and expand an existing music repertoire.

Individual Playlist Creation Overview. Selecting preferred songs to be included in a playlist can be a powerful exercise for individual young people who have not consciously considered their musical choices before. Whether the therapist focuses on lyric analysis (McFerran, 2010, p. 89) or associations with personal history (DeNora, 2000) influences the specific outcomes that are achieved. Increasing the degree of intentionality in musical engagement is an important therapeutic goal at the augmentative level for young people who seem to be engaging with music in powerful but unconscious ways. Frequent reliance on the “shuffle” function as the default mode for listening is an indicator of the possible value of Playlist Creation as a starting point for therapy. Playlist Creation does require the capacity for reflection and some young people who have been abusing substances may not be able to focus on this task or to make meaningful decisions. Since the music therapist is not responsible for programming the playlists, the young person’s

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commitment to, and interest in this process is necessary. Preparation. No external resources are required for this process, since it involves working with the existing repertoire of the young person. Some young people may wish to physically create the playlists in their MP3 player together with the music therapist, while others may want to think about different possibilities for creating the playlist but do the manual work at home on their computer, depending on the type of MP3 player they have. Some young people may not have access to their music because of the rules of the institution, and in this case, the music therapist may illustrate the process using the songs she has available and then support the young person to consider how he might use the same strategy at home. This would then take place at the music therapist’s computer, where they have access to a music library or by using an iPad or tablet. What to observe. The degree of consciousness about the ways that musical choices impact on personal experience is the focus for the music therapist. Noticing how challenging this is will influence the pace and the number of playlists that are created. The young person’s cognitive capacity may be poor due to his habitual substance use, and therefore playlist creation may initially happen at a very concrete level. Alternately, it may be a profound experience of reorganization if the young person is ready to make a change. Observing where the young person is able to engage, and working at that level, is essential. Procedures. Having negotiated the creation of playlists, the music therapist and young person need to undertake two processes, and the order of these might vary depending on how conscious music use is already. One part of the process is to decide the labels for the playlists, which might indicate different mood states (Happy Playlist, Sad Playlist). Alternatively, the playlist titles might refer to the existing associations that the young person has with particular styles of listening (The Day You Went Away, Pumping Up, Best Eva). The second process is to group together the tracks that are associated with the event/mood/activity. The order of the songs is of secondary importance compared to assisting the young person to really think about why they listen to particular songs. This includes both what intentions they have when they choose the song and, importantly, what consequences they experience when they actually listen. The music therapist works to make these dimensions of the experience conscious, which may be quite challenging for some. Adaptations. Australian music therapists Carmen Cheong-Clinch and Cherry Hense have promoted this idea as a public health strategy on a local youth website found at http://www.tuneinnotout.com/music/. Addressing consciousness-raising at an institutional or global level is an alternative to working through this process with individuals.

Music for Individual Mood Management Overview. The music therapist guides the young person to develop a playlist that is carefully altered to move from one mood state to another. The Iso principle provides the beginning point (what mood is the young person in now) and Hevner’s mood wheel (1936) provides a guide for selecting nearby mood states that move toward the positive. This is carefully combined with reflection on the distinction between how the young person has been using music to influence their mood and whether those strategies have been effective or not. If the young person is capable of engaging in conscious contemplation of the ways that music can influence his mood, it is feasible to consider a more intensive level of therapeutic approach to playlist creation that targets mood management. This is a cognitive process that requires the capacity for focusing and decision-making. The goal is to create a sequence of music that mirrors and matches one’s initial mood state and then moves gently toward a preferred mood using the Iso principle. The benefits of cognitively structuring otherwise natural processes of mood modulation are particularly important for young people whose substance abuse is associated with ruminative thinking, since this can result in

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unconscious and harmful music listening habits that reinforce negative mood states. Young people whose cognitive capacity has been impacted by their substance use may not be able to reflect on their uses of music at an abstract level. This process involves meta-thinking because the young person needs to consider how they think music influences their mood and then determine whether the actual consequences of listening resulted in their expected mood change. In addition, they need to be aware of some qualities of the music and the ways that the music impacts their mood. If this level of thinking is not feasible, then the approach is not suitable. Preparation. It is possible that the young person’s existing repertoire of songs may need to be supplemented with new pieces in order to generate a smooth sequence of songs. Therefore, the music therapist will need to have access to a library of repertoire that includes a good range of age-appropriate songs, as well as tracks from other genres such as classical music, folk music, world music, religious pieces, and New Age music. What to observe. It is important that the young person drives this process, and therefore the therapist should attend to the degree of focus that the young person is able to offer and conclude the session when attention levels diminish. The therapist should also be attentive to the music choices being made and engage in discussions about the relationship between how effective the music actually is in achieving the goals that are being targeted by the young person. It is easy for a playlist to be created that is not actually effective because it is based on the young person fulfilling the therapist’s ideals for the process, rather than actively engaging and committing to selecting songs that work for them. This can easily happen because of the mental focus required for working with this process. Procedures. The young person needs to identify mood states that he frequently encounters and with which he would like assistance in leaving. These are typically moods such as depressed, stressed (anxious), and angry. The therapist then helps him to identify songs associated with each of those states that will be used initially to match his mood. The more challenging part of the procedure is to identify songs that are associated with a step-wise movement away from the initial state and toward a more positive mood. Setting realistic expectations is important, since angry may not progress to happy, but rather to energetic. Or depressed may move to peaceful, rather than joyous. (Hevner’s (1936) mood wheel [1936] provides an old but very useful explanation of the different ways in which mood can be connected to music and the two can be interconnected to one another).The movement needs to be dynamic but not rushed, so each playlist should contain five or six songs that serve to engage the young person’s interest, and either increase in tempo, change in lyric content, or simply progress through associated meanings. This will vary for each young person. Adaptations. Although managing mood is an individual process, it may be feasible to share these strategies in a group context. The benefits of group occur when the group participants have the opportunity to hear others describe their uses of music to manage mood. Although discussion with the therapist can be illuminating, peer-to-peer learning is invaluable and can lead to the identification of both novel and dysfunctional strategies of music use through hearing one’s own actions being described by another (Yalom & Leszcz, 2005). Managing the group dynamics can be the priority for the therapist as she ensures that participants are not overly critical of the ideas proposed by other group members, particularly because social skills may have been impacted by years of substance use. The music therapist needs to model tolerance and encourage authentic sharing, being sure to avoid young people fabricating stories for their own amusement and to build their status in the group. Whether the process results in the creation of a group mood management list or encourages individual group members to develop their own playlists at home, the dynamics elicited by these discussions should contribute to therapeutic progress if managed well.

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GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Expressive Group Improvisations Overview. In this method, young people play tuned and nontuned percussion instruments in a group to create a piece of music based on a chosen theme or referent. Playing instruments together is a powerful way of expressing self within a group and experiencing the intimacy of personal contact that this requires. This is most appropriate within an ongoing group process rather than in single group sessions because it is the patterns that emerge over time which are likely to be most therapeutically revealing, and therefore potent. Verbal processing is not necessary if the therapist is able to listen skillfully to the musical material and work with music as therapy (McFerran, 2005, p. 42). This method is indicated when the group members are not able or willing to use cognitive approaches that require them to think about how they use the music and make intentional decisions about using it differently. The goal of expressive group improvisations is to aid expression of self and emotions in a way that does not require verbal processing. Even when young people are unable to verbally reflect on the expressive nature of their playing in discussions immediately after playing, they can still be experiencing benefit from the process. Young people who have been unable to process expressive group improvisations within a group have later described the process as providing a sense of release that leads to relief, using phrases like “it broke the seal on the fridge and my emotions rushed out” (McFerran-Skewes, 2000, p. 17) and “it feels better than keeping it bottled up” (McFerran, 2010b, p. 21). Despite the importance of cognitive processing advocated by psychotherapy gurus such as Irvin Yalom (Yalom & Leszcz, 2005), musical processing is considered to be powerful at the primary level of therapy, where the therapeutic benefits of musical expression and group dynamics interplay at a subconscious level. The results can be life-changing, although this may not be apparent in the nature of the musical material or in the behavior of the group members. But the value of playing out feelings and experiences on the instruments in a contained group environment has been described as leading to “feeling better” and “helping a lot” (McFerran, 2010b, p. 19). Young people who are not able to function in group contexts are unlikely to benefit from participating in expressive group improvisations and may impact negatively on the experience for all involved. The benefits of group work cannot be accessed without foundational social skills and basic respect for the values of others. The level of therapy is intensive. Preparation. A good range and quality of instruments is required for expressive group improvisations since these will impact on what possibilities for musical expression are available. Percussion instruments such as hand drums, tambourines, triangles, shakers, guiros, cabassas, wood sticks, and wind chimes are fundamental and will hold symbolic meaning for the participants, although it may not be conscious. In addition, melodic possibilities should be available in the form or xylophones, metallaphones, marimbas, tone blocks, and glockenspiels. A range of sizes in instruments should be represented so that young people are able to choose inconspicuous roles and dominating roles at the level of taking up space, as well as be able to make choices influenced by the timbre and volume of the instrument selected. The instruments should be placed in the middle of the circle so that the group members are able to observe the possible choices prior to choosing. When beginning the first improvisation, it is important for the music therapist to model how each instrument is played so that the young people are more

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empowered in their choices and able to access the potential of the instrument they choose. Avoiding harmonically complex instruments (such as guitars) is useful in expressive group improvisations with young people, because these require a higher level of skill and practice that is not necessary when playing percussion and simple melodic instruments. What to observe. Although the physical behaviors of the young people can be observed within the group context, it is the auditory observations that will bring the greatest insights. Listening to the ways that young people play, particularly over time, reveals many aspects of their personality in relation to those of others. Discerning patterns in the roles that group members take on is particularly revealing and may lead the music therapist to bring a particular interpersonal dynamic into the consciousness of the group. For example, some young people may always choose a small and soft instrument and then be dissatisfied that nobody seemed to notice their playing. Bringing this to the attention of the individual and the group can lead to significant changes in group dynamics, even if no further discussion results from the insight. Attending to the degree of congruence between the playing of group members is also helpful, since conspicuous differences that are repeated can be an indicator of a degree of disconnection. The IAPs (Bruscia, 1987; Gardstrom, 2007) provide an excellent foundation for this kind of listening, but what is most important is to not make generalizations from only one improvisation. The observation of patterns over a number of free group improvisations is the most critical focus for the music therapist. Procedures. The expressive group improvisations should be incorporated into an existing group structure and can serve as the pinnacle of a session that occurs after introductory and warm-up activities and is followed by warm-down and closure activities (see Achenbach, 1997, for examples of such activities). Once the instruments have been placed in the center of the circle and the music therapist has demonstrated how each might be played, the young people are invited to choose an instrument that appeals to them. The music therapist should encourage them not to take too long in deciding on their instrument and remind group members that someone else might take their preferred choice if they do not take action. Adolescents have an additional hurdle of self-consciousness to get over in being the first to start this process, so a number of verbal strategies can be used to ensure that it does not stall before it begins. Asking more enthusiastic members to choose first is another option, or walking around and holding up instruments for young people who seem to be struggling to find the motivation to leave their chair is another. Once group members have taken instruments that appeal to them, the music therapist reassures them that there is no right and wrong in a group improvisation, and that even being silent at times is a powerful contribution, since this is so important in music. The music therapist may use a verbal cue like “1, 2, 3, go” for the first improvisation, and then reduce the directedness for further improvisations once the group has a sense of what is expected. Many young people require a referent for expressive group improvisations, and the discrete emotions of happy, sad, and angry provide a sufficiently concrete range of emotions to express. Using more complex emotions such as guilty or annoying or stressed as referents for the improvisation can lead to confusion, whereas the distinctions between these three (happy/angry/sad) seem to be clear for young people. The sequence of emotions for the expressive group improvisations is important, since many young people need to progress gradually into the more negative states through happiness, and usually appreciate being returned to happy to conclude the series. Although discussion may not be forthcoming immediately after the improvisations, young people may be willing to discuss the experience by the end of the session, by the next session, or in final evaluations, and these opportunities for processing should be actively sought but not required. It can be helpful to start conversations by referring to previous groups and their experience of improvisations, or the music therapist can briefly describe her own reaction as a way of modeling what is expected. Alternately, asking specific group members for their input can be more comfortable than creating a long silence, which is usually ineffective for encouraging discussion with groups of adolescents.

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Adaptations. Although emotions are one part of expressive improvisations, any kind of referent can be effective in providing the group with some structure that will encourage them to express themselves musically. The more open these are, the more profound the musical experience can be, since cognitive processes will not distract players. But it may be helpful to provide frameworks such as “moving toward feeling better,” or more substance-related topics such as “trying to say no.” These ideas are best when suggested by group members, but some examples might be necessary so that the young people understand what is being requested.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Group Song Playing Overview. In this method, young people practice alone and in a group to master the skills involved in learning to play and perform a preferred song. Learning to play a song as a group introduces a number of mechanical challenges that need to be grappled with by group members but this is of secondary interest to the intra- and interpersonal dynamics that result from the process. The focus of the music therapist is divided between identifying and facilitating the playing of appropriate songs and working with the issues that arise for group members, and when the time comes, also considering any audience members who witness the song (McFerran, 2010. p. 253). Having group members choose songs for playing in the group is indicated in the early stages of group process when the goal is to foster group cohesion by increasing group members’ connection to one another. This process is at the augmentative level of practice, where song playing is used to foster group bonding and to promote the experience of participation. This method can be unexpectedly powerful in the field of substance misuse, since sitting around and playing songs with other people may be strongly associated with habits of using drugs and may trigger desires and memories. If a young person is working on a establishing a new identity in order to break the habit, it is important not to reinforce powerful dimensions of old ways of being. The method does not have to be avoided, but the individual may need to take up a new instrument or role in musicmaking, or he may need to be clear about what genres he wishes to engage with. Open discussion is very helpful in bringing these habits of identity to consciousness. Preparation. A number of resources are required for re-creating songs for group participation. Electric guitars, bass guitars, drum kits, keyboards, technology that has beats, microphones, and hand percussion will all be helpful, and a PA system will be necessary in order for the softer and electronic instruments to be heard. It may be important to involve the young people in setting up the instruments, rather than having everything ready to go, since this is a critical dimension in being able to play electronic instruments and will provide them with the skills they need to take this resource into their life beyond the music therapy sessions. The use of amplified instruments means that the volume of music-making will be high, and therefore due consideration needs to be paid to others in close vicinity. Finding a room that is soundproof enough for this method is unlikely, so the emphasis is more on finding the right time as well as the right place for the session. What to observe. When working on playing songs together that have been suggested by the group, the music therapist is focused on the musical contributions that each young person is able to make. There will be musical skills that each participant needs to develop, and these will need to be identified

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through observation and constantly attended to during the process. In addition, there are often egorelated issues that emerge during song playing, with feelings of incompetence and failure as well as overinflated egos, particularly when substance use has resulted in some degree of cognitive deficit or beliefs about one’s musical abilities that were formed in an altered state that have not been questioned by the young person. A careful monitoring of all individuals is therefore required throughout the process, as these dimensions can be more or less prominent at different times. Procedures. Learning to play and sing a song together will take some time and usually requires a commitment of more than one session. Working together on songs over time can be one of the most powerful aspects of the process, since the reality of music-making demands a long-term commitment in order to learn a song successfully. It is often helpful for the music therapist to have been a strong influence in choosing what song will be played, since musical discrimination is required to determine whether the song is within the capacities of the group. Many pop and rock songs have only three chords, making it feasible for group members to learn if these are transposed into the easiest key for chordplaying. Rap and hip-hop songs will rely on computer skills more than instrument-playing skills, but in most ways the process is very similar, since beats will need to be identified and then re-created within the form of the song. The music therapist facilitates the acquisition of all the required skills in the session, often moving around between different people individually while the rest of the group continues to practice their parts and mess about on the instruments. This can be a very noisy process, and the auditory chaos is a critical part of the experimentation with different sounds. The music therapist should regularly call the group together to practice running through the song as a band. This may literally involve calling out for everyone to stop playing for a moment and then counting the group in and actively conducting different group members to play on cue and to move to the next section of the song. As time passes and some members are able to conquer their parts more easily than others, it is important to engage those young people in supporting the musical development of other group members by asking them to work together and cuing them to be encouraging and supportive of those who have steeper learning curves. The peak moment of this method is usually recording or performing the song for an audience. Recording can easily be facilitated within the session itself, and the music therapist can use her iPad or portable recording device to pick up the entire song being played on a single track or single video recording. This is the easiest way to document progress and achievements and is usually very rewarding for group members whose capacity to discriminate good-quality recordings may not be high. For some groups, it may be important to get a good-quality, multitrack recording, which will require access to either a studio or a very portable set of good-quality microphones, a mixing desk, and recording software that can be bought into the space. This involves a lot of work, but may well be justified if the group’s identity is related to the quality of the material produced. Working toward the performance of songs can be equally time-consuming, since it is critical to ensure that the song quality is adequate for the audience that will be invited to hear the performance. In many ways, the role of the music therapist is to identify and prepare the right audience for this kind of performance, since not all people are sympathetic to the amount of time it takes to learn to play a song, and an unprepared audience may make unfair comparisons to professional musicians who have been developing their musical skills over a lifetime. In this way, preparation for a performance is critical and involves equal attention to the performing group members and the audience participants. Adaptations. While some young people may be interested in playing instruments, others might be more focused on singing. Young women, in particular, often desire to sing their favorite songs more than to play them on instruments. This concept can easily be adapted to singing and may require as much time in preparation, despite the voice being a naturally existing instrument. Young people who have abused substances frequently have an untuneful way of singing, and vocal warm-ups and gentle vocal

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training exercises may be helpful. The music therapist should be very careful in giving feedback about the vocal quality of the young person, since most people are extremely sensitive to criticism about their voice.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Group Lyric Substitution Overview. In this method, the young people and therapist work together to change the lyrics of an existing song to reflect the group’s personal experience. Writing new lyrics for songs with groups of young people often elicits a deep commitment from group members who, though possibly hesitant at first in the group context and nervous about getting it wrong, will soon become enthusiastic and determined. This is primarily a verbal and cognitive process that draws out discussions between group members, but another aspect of the process is unconscious, since young people often reveal important issues in the material they share for the song. The music therapist needs to juggle the different needs of the group for discussion and music playing to maintain focus and try to marry the different expectations about song quality that exist in the group (McFerran, 2011a, p. 262). Changing the lyrics of an existing song can be used to focus the group on a relevant topic and is indicated when music therapy is operating at an intensive level, assisting young people to discover new ways of functioning. Verbal capacity is essential to this process, since the primary musical element is the lyrics, while the instrumental parts serve to maintain focus and motivation while issues and behaviors are processed. Lyric substitution is particularly helpful when the goals of the group are to reflect on past experiences or, alternately, to aspire toward a better future. The process encourages putting language to experience without becoming too distracted by the musical requirements. Young people whose cognitive process is compromised may struggle with the imaginative aspects of this process, since it challenges the previous literal use of the song. The selection of the song needs to be carefully made, since changing the words to a song that has existing meaning for a young person can be counterproductive (Gleadhill, 2009). If the song lyrics are already important and helpful, then this technique can effectively disrupt an existing association that may not result in the best therapeutic outcome. Alternately, if the associations are with the pleasure of substance use, then the song may reactivate a desire for using substances and even strengthen that desire. Awareness about existing associations is therefore required in order to consider contraindications. Preparation. In order to brainstorm the lyrics for the song, at least two pieces of large white paper are required, or a board for writing on so that the whole group is able to participate. If only one board is available, it will be important to split the board in two parts—one for brainstorming ideas and the other for developing lyrics. If this does not happen, then the ideas can take up all the space and will need to be rubbed off in order to have somewhere to write the lyrics, which can be counterproductive. A range of colors in the markers being used can also be helpful, so that different ideas can be highlighted and creativity is inspired. Selecting the song for substitution can be collaborative, or it can be preplanned by the music therapist. If collaborative decision-making is being promoted, then the music therapist will need to bring a set of songs along that she is able to re-create, as well as provide original recordings for inspiration. Depending on the time frames for the process, the decision about which song to choose can take a whole

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session that includes music listening, or it can take less than five minutes to choose between a limited number of options provided by the therapist. Once the song has been written, it is valuable to be able to re-create it using live instruments, and the group members may wish to have instrumental as well as vocal roles. In this case, a selection of hand percussion instruments should be made available, as well as accompanying instruments if music skills exist in the group. The group may wish to record the song, and the music therapist should have the equipment available to do so, while being aware that relistening could be very disappointing for young people, since the song is unlikely to sound like the original. Participants should be actively prepared for this if they choose to record and listen to the song. What to observe. The verbal material contributed for this process is the focus. The music therapist should be very conscious of what is being offered by young people and should ask questions about hidden and disguised meanings if there is a lack of clarity. This is particularly important if “user” code is being shared—many people who have used substances have sets of words with double meanings that refer to the various aspects of picking up drugs, using drugs, and being under the influence. This can quickly become complicated if some young people are committed to getting clean, while others are using the opportunity to playfully reconnect with their habits through the language they are using. Therapeutic inquiry is required in order to promote group processes, but can be challenging in the moment. If the young people use the process for health-oriented meaning-making, the music therapist will be able to observe the hopes and dreams of different individuals. The aspirations can often be surprisingly optimistic, and lyric substitution provides a powerful vehicle for these fantasies to be articulated and then remembered through the re-creation of the song. Observing these lyrics can provide a great deal of insight into the inner world of group members, and sharing this information with the team can enhance treatment by providing a different picture of the young people than what is evident to other professionals. In both the verbal and nonverbal processes, the music therapist should remain observant of group dynamics. Although the music is motivating, it does create a context that is socially complex, requiring teamwork, personal sharing, and being able to tolerate the ideas of others. The music therapist will need to respond to and work with these dynamics, since ignoring the interpersonal encounters is counterproductive within a group process. Procedures. The idea of lyric substitution can be introduced quite easily by giving an example of how it works. The music therapist might play the first couple of lines of a known song and then illustrate how she can change the words entirely to give a new meaning, or just change some of the words to more simply alter the existing meaning. It is often helpful to provide some historical context for this process by noting how common it was in times gone by to change the words to popular songs, before the musicianas-expert became a tradition. A number of steps can then be undertaken that involve choosing the song, brainstorming ideas for new lyrics, reshaping those ideas to fit in the rhythmic and melodic shape of the existing lyrics, and practicing the song. These steps are broadly related to the Guided Original Lyric Method GOLM documented by O’Brien (2005). Of these steps, brainstorming and reshaping are the most timeconsuming. To facilitate a brainstorming process, the music therapist needs to be committed to accepting all contributions by group members and writing them up so that they are documented. Any judgment made by the music therapist of ideas being shared could stymie the group process, since generating an environment of shared creativity induces a sense of vulnerability. The music therapist should be secure in knowing that editing of ideas will happen in the subsequent process, and the two stages should not be blended. Group members may need to be taught about this also, since they can make negative comments about the quality of someone else’s, or their own, ideas.

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The music therapist begins by writing the main topic or idea at the top of the page and then asking people to suggest any words or ideas that they associate with the topic. Topics relevant for this group may include: a new beginning; loss and grief; my aspirations; feeling excluded; don’t judge me; struggling; or whatever other issue is being processed within the program supporting the young people. Ideas may require active solicitation in the first few minutes to get the process rolling. The music therapist may ask specific group members directly, carefully choosing those that usually say more than others. Once the ideas are rolling, it can be difficult to keep up, and the music therapist may need to slow the process down so that all ideas can be documented (sometimes abbreviated) and to ensure that quiet members have the opportunity to be heard. Once the board is covered in ideas, the editing process can begin. The music therapist should ask the group to identify the most important ideas and circle these using another color. She may ask quiet members directly about the ideas that they want included, since energy is often created by this process and the extraverts in the group can be very dominating and need to be actively supplemented. Once this process is completed, a key idea can be chosen for the chorus, and the music therapist may offer an example of how that idea can be fit into the existing melodic and rhythmic framework. In some groups, a simple illustration is all that is required for at least one group member to grasp the process and start making well-formed contributions. In this case, that person should be allowed to take a strong role in contributing, as not all people have this talent for shaping ideas into existing rhythms, and the lyric creations will be grounded in the ideas of the whole group, so this can be very powerful. If no one in the group is forthcoming, then the music therapist may need to be more active in helping the group to shape the key ideas into lyrics that fit in the song. Group members may be able to contribute some lines, which should again be accepted whenever possible, and the music therapist can pick up key ideas from the brainstorming process and ensure that they are included. Once the lyrics have been documented, there is opportunity for further editing, and different group members may be better at perfecting the rhythms of individual lines or ensuring that the combination of ideas makes sense overall. This is an important part of the process. Practicing the song may be more or less important, depending on what the group has decided about the life of the song. If there is no intention to record or perform the song, the group may simply sing it through a small number of times in order to experience how powerful their creation is. If some kind of performance is desired, this process will need to be expanded and roles found for each group member. This process could then become similar to the Group Song Playing experience noted above. Adaptations. Original songs can be created rather than lyric substitutions. Original songs can alter by degree from lyric substitutions, since it is helpful to choose a song for inspiration when facilitating a group to write a song for the first time. Rather than changing the lyrics only, the group can be encouraged to find a beat on the keyboard that they like as much as their identified song, and to use a form, melody, and/or harmony similar to that of the song. The more original the song, the greater the number of decisions that will need to be made by the group and the longer the time that will be required. Where a lyric substitution can happen in one session if necessary, an original song is rarely produced as quickly. The group will need to make musical decisions about the following elements, where lyric construction is just one part. 1) Song Structure—does this material have one core idea that would suit a chorus, and the rest can be fitted into verses/bridge, or is it through-composed? 2) To Rhyme or Not to Rhyme—an important decision because of people’s preconceived ideas of how a good song “should” sound; 3) Creating Lyrics—involving group in the process of creating lyrics and making decisions about length of phrases and meter;

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4) Creating Melody and Harmony—asking group to “sing” or “rap” the words as they hear them. Alternately, offering choices of melodies or rhythms for group to choose from; and 5) Finalizing Musical Features—checking tempo, accompaniment styles, musical roles, dynamics, and other musical nuance (McFerran, 2004, pp. 154–155).

CLOSING REMARKS ON METHODOLOGY Working with groups of adolescents who have substance use disorders generates a number of interpersonal challenges for the young people involved. While many adolescents have a passionate relationship with music, each is an individual, and therefore sharing these preferences and abilities is bound to evoke strong reactions. Some young people may not be ready for these kinds of challenges to their identity and would benefit from individual work in the early stages in order to build up their musical identity and to develop some confidence in the value of their musical contributions. The ideas for playlist creation can facilitate this process successfully by drawing on the young person’s existing resources in relation to music. Once this has been established, it will be easier to work with the group dynamics that will undoubtedly emerge when working with others. This is as true of adolescents struggling with trauma (McFerran & Teggelove, 2011), as it is with young people who are classified by their attempted coping strategy (substance abuse). The order of the methods presented above moves from those that are easiest to introduce quickly and effectively to those that may require more time and more commitment. However, it is often necessary to combine a number of methods in each group to create a shape for the session. When working in a group process over time, it is helpful to use a repeating process, so that the shape becomes familiar and predictable to the young people, providing a sense of safety and security. Expressive group improvisations are a powerful welcome into the beginning of sessions, since it requires authentic expression and provides a clear indication that it is time for musicking and not only talking. This can also be used as a form of closure at the end of the session, where group members have the opportunity to reflect on the session and provide feedback to the music therapist and to their peers. Songs can engage young people for longer periods of time, providing a balance of structure and creativity that meets their needs for stimulation while also allowing plenty of space for individual and group processes. Whether Group Song Playing or Group Lyric Substitution is the best method to begin with can be determined by the group members’ capacity for both verbal and musical expression. Groups of young women are often interested in the dialogue that is required for lyric creation and commit themselves to sharing honestly and authentically through the discussion of lyric content. Groups of young men are often inspired by the possibility of playing instruments together and are willing to grapple with the complex dynamics that emerge for themselves and with others in order to take this opportunity for playing. The gender divide is not always so simple (McFerran & Teggelove, 2011), but the social expectations of men and women from the outside world are often (but not always) reenacted in music therapy groups, with women taking roles as singers and men as instrument players. It can take a different kind of courage for men to choose to sing or women to play the drums in mixed groups, particularly with the identity negotiations that will be required to end an abusive relationship with substances (McFerran, 2011a). When working in intensive workshops with groups of young people, rather than in a process of regular sessions over time, all of these processes can be incorporated into a one- or two-day frame. An example is provided here and further detailed in relation to Grief and Loss workshops elsewhere (McFerran, 2010, p. 230). This is often a very powerful way of working with young people who have substance use disorder, and workers who spend regular time with group members should be available to support in facilitating the group members since issues may come up, having been triggered by the music and associations with it.

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Table 1. Session Structure for 1-Day Workshop 10:00 a.m.

Ice Breakers

Guess my favourite performer Selecting Photographic Cards

10:30

Song Contributions

Playing an important song for the group that says “Who I Am”

11:30

Group Improvisations

Introduction to instruments Free improvisation with rhythmic ground Emotion-Based Themes

12:30 p.m.

Lunch

1:30

Song Writing

Identify song Improvise Brainstorm words and stories

3:00

Break

3:30

Song creation and

Fill-in lyrics

recording

Practice song and record

4:30

Jam Session

Rhythm-based and Free Improvisation

5:00

Close

WORKING WITH PARENTS When working with parents of adolescents, it is important to consider them as allies unless there is reason to think otherwise. This chapter has not focused on the family or support systems that surround the young person, nor does it deny the importance of family networks for young people. Songwriting frequently elicits material about the family unit (e.g., McFerran, Baker, Kildea, Patton, & Sawyer, 2008) that should be understood as the young person’s perspective on the dynamics of the relationship, rather than believed as literal truths. This does not suggest that the young person’s contribution is not true; rather, it acknowledges that parent-child dynamics are complex and historically rooted and that each person will have their own stories about how things happen between them that will have been established over time. Until there is reason to doubt the honesty of one party, it can be assumed that both parent and adolescent are telling the truth, and yet their stories may be completely contrasting. The music therapist needs to be conscious of this and not to take sides while working with young people, but rather recognize that a healthy parent-child relationship is the best support for a young person. Practically speaking, this may involve providing parents with broad information about what happened in music therapy sessions. It does not break confidentiality to say that the young person worked on writing a song, or played instruments to express their feelings, or shared songs that were important to them. The music therapist is also able to offer general statements about the nature of the session, such as “your child seemed positive today” or “your child wasn’t very involved today.” It is not appropriate to share details about what songs were shared, or why a particular song was described as meaningful. More complex interpretations of behavior and mood should also be avoided, since this begins to impact the privacy and safety of the young person in the session. However, it is important to remember that young people are still under the care of their parents, and to refuse to pass over any information about how a

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child is coping is effectively reinforcing a split in the dyad and should not happen unless indicated by specific evidence or requirements.

RESEARCH EVIDENCE The field of music therapy and adolescents is constantly evolving, with increasing literature being published. In a review conducted of the existing literature to 2009, it became clear that the most common and unifying goal addressed by music therapists was identity formation by assisting young people in answering the question of “Who am I?” in music therapy (McFerran, 2010). Various authors use different language to describe this process, usually influenced by the theoretical frameworks that inform their work. Many music therapy authors use terms such as self-expression (e.g., Kennelly, 1999; Viega, 2008), self-concept (e.g., Clarkson & Robey, 2000; Johnson, 1981), self-esteem (e.g., Sausser & Waller, 2006; Tervo, 2001), and self-awareness (e.g., McIntyre, 2007; Trondalen, 2003). Less comon is the use of the words self-confidence (e.g., Abad & Williams, 2006; Schotsmans, 2007), self-knowledge (e.g., Ruutel, Ratnik, Tamm, & Zilensk, 2004), self-regulation (e.g., Robarts, 2006) or sense of self (e.g., Rio & Tenney, 2002; Smeijsters, 1996). Despite a reasonable volume of literature, there are few outcome studies describing music therapy with adolescents. The current author has conducted a number of qualitative investigations of young people’s experiences in group music therapy in which the methods described above have been integrated, most commonly combining group songwriting with group song playing, and expressive group improvisations. While these studies have been specifically focused on coping with bereavement, loss and grief can be seen to underpin the experiences of most young people who are struggling. The first study adopted a psychodynamic lens with an emphasis on group song sharing and expressive improvisations. The young people described the value of the opportunities for fun, freedom, and control within the group and considered them essential for developing an enhanced sense of personal identity while simultaneously addressing emotions in music therapy grief and loss groups (McFerran, 2011b; McFerranSkewes & Erdonmez-Grocke, 2000). A follow-up study utilized a more outward-facing approach, informed by community music therapy theory, and as such focused on songwriting alongside group song playing. The descriptions of the young people were similar, but a different approach to analysis revealed indications of therapeutic change. The group members described being “bottled up” before the group and “hiding away” their grief so that people wouldn’t be disturbed by their angst. They then described “releasing my feelings” within the group and “letting it all out” and, resultantly, being able to “move on,” “get over it,” and “let it go.” Finally, they said they “felt better” (McFerran, 2010b, p. 19). These descriptive outcomes have been supported by controlled investigations of young people in music therapy bereavement support groups. A study by Russell Hilliard produced significant improvements in measures of behavior and grief symptoms before and after eight weeks of music therapy within a cognitive behavioral framework (2009). Another study used a structured, cognitive behavioral approach over eight weeks to address different grief-related topics through songwriting, and again, noticeable improvements in grief processing were found as compared to a wait-list control group whose status remained relatively unchanged (Dalton & Krout, 2005). A meta-analysis of music therapy intervention studies with young people who have psychopathology also identified evidence of the effectiveness of music therapy, although this was based primarily on individual work (Gold, Voracek, & Wigram, 2004). Six studies with adolescents were identified, three of which adopted a cognitive behavioral lens, while three were more eclectic in both their theoretical approach and the combination of methods used. Statistical analysis showed clinically relevant outcomes on psychological measures. A further experimental study of 136 young people with mental health problems (developmental, behavioral, or adjustment/emotional disorders) receiving individual

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music therapy was then conducted by Gold, Wigram, and Voracek (2007), with results showing improvements in parent-rated perception of symptoms and quality of life. Improvisation was the primary method used by clinicians in this study, and individual mood management and playlist creation have not been investigated for effectiveness of outcomes within the literature.

SUMMARY AND CONCLUSIONS Music therapy practice with adolescents who have substance use disorders is sparsely documented in the literature; however, a good amount of practice knowledge can be garnered from descriptions of music therapy with adolescents across a range of contexts. Both group and individual work is relevant for this age group, with the importance of peer affiliations bringing group work to the fore more than for any other age. The popularity of music with youth is also an important influence, since music plays an enormous role in the everyday lives of young people—even more so when they are vulnerable as a result of facing personal or interpersonal challenges. Music therapists have an important role to play in encouraging more informed and intentional everyday music use by adolescents, particularly those who are relying on it as a “best friend” or “daily vitamin dose,” as many young people describe their relationship with music. Apart from raising consciousness about existing relationships with music using receptive methods, music therapists also offer opportunities for active music-making, through an eclectic combination of compositional, re-creative, and improvisational methods. Gold’s (2009) systematic review of effectiveness suggests that eclectic combinations of methods and theoretical approaches are most helpful, and this practice knowledge is reflected in the literature, where more than two goals and two methods are typically described (Gold, Solli, Kruger, & Lie, 2010). This makes good sense, since adolescents are transitioning between child and adult roles in the world, and eclectic music therapy approaches provide a flexible and potent way of bridging these two worlds due to its combination of verbal (lyrical) and nonverbal (musical) properties. More outcome studies will strengthen the evidence base for the field; however, practice understandings are strong and music therapy is regularly reported as a popular and relevant approach for the promotion of adolescent health in the face of many challenges such as substance misuse.

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Chapter 16

Adult Males in Forensic Settings Vaughn Kaser _____________________________________________ ACKNOWLEDGMENT The author would like to thank Erin Bullard, MMT, MT-BC, for contributing the research references, some adaptations to various methods, and her section on Research Evidence. The author would also like to thank Tara Brinkman, MT-BC, for her contribution of the Receptive Music Therapy Method section and her contributions to the Compositional Music Therapy section.

DIAGNOSTIC INFORMATION Forensic mental health is a term used to identify mentally ill incarcerated individuals. In most cases, these are adults suffering from a serious psychiatric illness who have also been convicted of some type of criminal behavior that is often directly related to the symptoms of their mental illness. These patients will have been diagnosed with some type of Diagnostic and Statistical Manual (DSM) Axis I major mental illness that plays a major role in the individual’s criminal behavior. For example many patients suffering from schizophrenia, delusional disorders, or psychotic disorders have symptoms that include hearing voices telling the individual to harm others (command hallucinations), a belief that others are going to harm them, being suspicious or fearful of others, or some type of delusional thinking which may lead them to commit a criminal offense of some type (American Psychiatric Association [APA], 2012b, DSM-5 Development, B 08 Schizophrenia). Not all individuals with these mental disorders experience symptoms that cause them to act out in some criminal manner. All six specific personality disorders (antisocial, avoidant, borderline, narcissistic, schizotypal, and obsessive–compulsive) are defined by “criteria based on typical impairments in personality functioning and pathological personality traits in one or more trait domains” (APA, 2012a, DSM-5 Development, “Personality Disorders,” para. 3). All the personality disorders involve some type of impairment in the individual’s identity and self-image. Antisocial, borderline, and narcissistic personalities all exhibit difficulties with empathy, being able to recognize or identify with the feelings of others. A problem with intimacy in being able to form close and meaningful relationships with others is a characteristic shared by these three personality disorders. Common to both antisocial and borderline personalities are risk-taking behavior and impulsivity. The antisocial personality tends to be the most common Axis II diagnosis in forensic facilities. Patents with antisocial personalities may also find it more difficult to live in a therapeutic hospital environment and do not always respond well to treatment. A closer look at the criteria an individual must meet before being diagnosed with an antisocial personality disorder may help explain why this is often the case. The diagnosis of antisocial personality includes impairment in interpersonal functioning with lack of empathy or the incapacity for mutually intimate relationships. Persons with this disorder have pathological personality traits including manipulativeness, deceitfulness, hostility, irresponsibility,

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impulsivity, and risk-taking. The impairment in personality tends to be chronic, with little change over time (APA, 2012a, DSM-5 Development, T 04 Antisocial Personality Disorder/Dyssocial Personality Disorder). Another dimension not included in the DSM that is often used to define a particular group of criminals is psychopath or sociopath. According to Hare (1993), this group “is defined by a cluster of both personality traits and socially deviant behaviors” (p. 25). Key symptoms include being glib and superficial, egocentric and grandiose, having a lack of remorse or guilt, lack of empathy, being deceitful and manipulative, having poor behavior controls, early behavior problems, and adult antisocial behavior. Most criminals are not defined as being psychopaths; however, those who are tend to respond very poorly to a therapeutic setting. A true psychopath does not feel he has psychological problems and sees nothing wrong with his behavior; he tends to blame others for his problems and often, when confronted, sees himself as the victim. One study of psychopathic patients released from a therapeutic community program showed they were four times more likely to commit a violent crime than the other patients; therapy may have actually made them worse because psychopaths who did not participate in the therapy program were less violent following release than the psychopaths who did participate (Hare, 1993). Since a psychopath does not feel he has any problems and no reason to change, he often views a psychotherapy program as on opportunity to learn how to trick others into believing he has changed. The advantage creative arts and recreational therapies have when compared to traditional psychotherapy methods when working with psychopathic patients is related to the emphasis on spontaneous social interaction behaviors that can be observed as opposed to relying on what the patients say. They are often more naturally skilled at verbal manipulation and lying during discussion as opposed to changing their behavior and actions, which are directly affected by their egocentricity, lack of empathy, shallow emotions, impulsiveness, and poor behavioral controls.

Types of Treatment Facilities The type of facility where mentally ill offenders reside for treatment varies from state to state. Variations in the states’ legal codes often determine where convicted offenders will eventually reside. One very important determining factor related to where convicted mentally ill adults will be treated is related to their overall security risk for assaultive behavior. Forensic mental health facilities house and treat the most dangerous and potentially assaultive patients and are constructed as maximum-security facilities. A maximum-security facility usually has two security fences surround the facility and strictly controlled entrances containing sally ports for egress purposes for all employees. The level of security measures within the facility will vary. Some adult psychiatric facilities have separate locked housing units for forensic patients as well. Other states have large maximum-security hospitals designed for psychiatric treatment purposes as opposed to prisons, which are designated for behavioral rehabilitation. Offenders who are committed under the “Not Guilty by Reason of Insanity” (NGI) defense (California Penal Code, 2012, PC §1026) may be sent to regular psychiatric hospitals for treatment. Other states have forensic state hospitals where these individuals can be sent directly for treatment and thus will not have to spend time in a regular prison. Patients found NGI are usually given an indeterminate sentence, which means that they can be released as soon as the clinical treatment team and the courts agree that sanity has been restored and they are no longer a threat to the safety of others in the community. Another common type of forensic patient is called “Incompetent to Stand Trial” (California Penal Code, PC §1370). This type of patient has been arrested and accused of a criminal act. If the court determines that his mental condition makes him unable to understand the legal proceedings or he is unable to participate in his own defense, he is found incompetent. The individual is then placed in a

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forensic treatment facility or unit, often in the county jail, where he can receive mental health treatment. The objective of this type of treatment is to help restore the individual to competency so that he can go to trial for the crime for which he is accused. In some states, such as California, laws have been passed to evaluate mentally ill offenders who were originally convicted and sentenced to incarceration in state correctional facilities (California Penal Code, PC §2962). After completing their time in prison and before being paroled, these individuals are psychiatrically evaluated. In states with this law, the evaluation is related specifically to these points: The individual was convicted of a violent crime; he has a mental illness that is not in remission; the mental illness was a factor in their criminal behavior; and the mental health professional doing the evaluation certifies that he presents a substantial danger to others as a result of his disorder. If so determined by the courts to meet the criteria of the Mentally Disordered Offender (MDO) law (California Department of Mental Health, n.d.), these individuals are paroled to a forensic state hospital for treatment.

NEEDS AND RESOURCES Persons in forensic settings are often very musical, with a desire to listen, play, and express themselves (Sloboda & Bolton, 2002). The impediments to expression are defenses of resistance and denial, strongly felt and expressed negative emotions such as anger and frustration, and poor coping skills and anger management, leading to acting out behavior such as aggression (Loth, 1996). Most forensic patients have difficulty in dealing with anger and sadness or depression in particular. They are often impulsive and need to learn how to manage their behavior and emotions. The combinations of mental health problems often encountered simultaneously in many forensic patients may respond more favorably to music therapy, as there is an opportunity to address multiple therapy issues simultaneously in music therapy groups. Patients with a combination of Axis I (major mental illness), Axis II (personality disorders), and substance abuse problems benefit greatly from therapy directed toward grounding and supporting reality testing done in a social setting that requires cooperation and cohesive interaction. Music helps to support the expression of feelings for those who have difficulty expressing themselves verbally. It is their inability to express their frustration and anger sufficiently and appropriately that often contributes to their aggressive acts (Kaser, 1993). Forensic patients also encounter the double stigma of having both a mental illness and a criminal record. Both present considerable challenges to their self-image and confidence in their ability to become successful productive members of society. When structured and presented properly, music therapy playing groups can offer an opportunity for patients to be successful at accomplishing a tangible task. Perhaps more importantly, the patients have the opportunity to have fun as well and distance themselves from their problems for a while. The connection to music that many patients in this setting already possess is a personal resource for them. Living in a forensic institution can be very stressful and regimented, with little opportunity for freedom and choice. Restrictions related to security and safety are more stringent in forensic settings than in some correctional facilities due to the more unpredictable and violent nature of some mentally ill offenders. As a result of being in this type of sterile and restrictive environment for long periods, these individuals may find the opportunity to listen and play music to be very meaningful and comforting, providing them with a way of coping with emotions, becoming oriented to reality, and interacting in a socially appropriate manner (Codding, 2002; Glyn, 2002; Nolan, 1983; Thaut, 1987, 1989). Some patients who already possess musical skills may have access to an instrument for their own use that can help them in their daily struggles.

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REFERRAL AND ASSESSMENT PROCEDURE There is no specific published music therapy assessment written for forensic mental health facilities (Codding, 2002). A general assessment, standard to the treatment facility, often includes information about interests and past experiences with arts and leisure activities. Based on outcomes from initial screenings and assessments from the interdisciplinary treatment team, the patient is assigned or referred to a music therapy group designed to address problematic behaviors specific to that patient’s treatment plan. In many cases, patients get involved in a music therapy treatment group based on their interest in expressing themselves musically. Another factor is the patient’s mental health symptoms or his barrier to discharge. The team encourages patients to get involved in therapies that will address the individual’s primary problems, such as social skills and aggression groups. The music therapy assessment can take place in a group or individual setting. It typically covers functioning levels across all domains: social skills, emotional skills, cognitive skills, communication, leisure skills, motor functioning, and musical functioning (Codding, 2002; Fulford, 2002). Types of music therapy assessment include group improvisation (Boone, 1991), individual improvisation (Sloboda, 1997), and questionnaire (Gallagher & Steele, 2002). Though assessment is generally focused on nonmusic behaviors (Codding, 2002), assessment of patients’ rhythm skills is helpful prior to placement in a group involving improvisation methods. Some patients who may not initially appear to be capable of organizing their playing well enough for this type of group may develop the required skills by participating in structured rhythmic activities. Medication issues, learning how to move and play the instruments properly, lack of interest and motivation, depression, and other factors may all affect a patient’s initial rhythmic skill level. Patients are often referred to a music group primarily based on their interest in expressing themselves musically and their willingness to do so in a therapeutic setting. Since patients are assigned to groups by treatment teams, the therapist must assess each patient’s skill level in the group. Once in the group, the patients are informally assessed for their ability to establish a steady pulse independently, to be able to follow a pulse established by others, and to spontaneously alter basic musical elements of their playing, such as rhythm, tempo, level of volume, and timbre, in order to match what others are playing. The individual’s mental health symptoms, personality issues, movement coordination skills, and knowledge of music often affect these particular musical skills.

OVERVIEW OF METHODS AND PROCEDURES The following methods and procedures are used most commonly with forensic patients.

Receptive Music Therapy •

•

Emotion Management Through Lyric Discussion: This group employs a combination of music listening, lyric analysis, and eventually songwriting to assist patients in recognizing and coping with various emotions. Music-Assisted Relaxation Group: This type of group involves practicing relaxation techniques such as deep breathing, progressive muscle relaxation, meditation, and guided imagery with music.

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Improvisational Music Therapy •

•

Interacting Through Music Improvisation Group: The therapist facilitates participation in a series of simple structured improvisation exercises and culminates with a free improvisation experience with a focus on listening and interacting musically with others in the group. Anger Management Through Music Improvisation Group: The therapist facilitates a 30minute rhythmically structured improvisation that builds to an intense climax and then becomes slower and calmer in order to help patients with anger management.

Re-creative Music Therapy •

• •

Structured Improvisation with Song Singing: Patients and therapist sing a chosen song and create instrumental extensions on a variety of percussion instruments while the therapist accompanies on the piano or the guitar. Performance Band Group: Patients learn music and perform it for others. Karaoke Performance Group: Patients sing popular songs using a microphone with a prerecorded song accompaniment.

Compositional Music Therapy • Songwriting in the Exploring Music and Emotions Group: This intervention involves creating new lyrics for an existing song or composing a new song.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Emotion Management Through Lyric Discussion Overview. This group employs a combination of music listening, lyric analysis, and eventually songwriting to assist patients in recognizing and coping with various emotions from anger, sadness, and jealousy to hope, happiness, and love. There is a range of emotional functionality addressed in this group. Some patients are not able or willing to identify symptoms and emotions in themselves. Others can determine times in the past when they have not coped well with a particular emotion and are able to develop a plan for dealing more effectively with that emotion in the future. Some patients need to focus on the basics, while others are able to process complicated information. Oftentimes, forensic psychiatric patients have had trouble in school and do not like the feeling of being in a classroom environment. This process group can feel safe and nonthreatening to them. For some patients, the only opportunity they have to hear songs is during groups if they do not have a radio or a cassette player (the least dangerous options for patients in this type of setting). Thus, this group serves an important function in the lives of the patients. The level of therapy is intensive, as it is aimed at helping the patients to learn new ways of coping and achieving a higher level of functioning. Well-developed skills in verbal processing are needed to conduct this group. Goals for this group include defining a particular emotion, identifying symptoms of an emotion, identifying personal triggers for an emotion, and learning coping skills to deal with a particular emotion. Patients who prefer attending a process group as opposed to a purely didactic group are good candidates. It is also important that the interdisciplinary team provides support for the patients to attend. Some patients have been enrolled in traditional therapy groups related to emotion management and

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already have some knowledge about different emotions, triggers, and coping skills. Others are not interested in didactic treatment or find it difficult to learn in those situations, preferring a process group. Both types of patients are appropriate for this process group. It is helpful if patients know how to read and write, but this is not essential. Special procedures should be followed if there are patients in the group with language barriers, cognitive limitations, or severe psychotic symptoms. It is important to make each group member feel included. Thus, the music therapist can use questions with “yes” or “no” answers when talking to these patients. An interpreter can be used if a patient does not understand English but wants to participate in the group. Music therapists should use visual aids and simple sentences to ensure that the majority of the patients understand. Patients who are very vocal about their delusions or hallucinations are not appropriate for this type of group because they can be distracting to their peers and the process of the group. Everyone in the group needs to feel safe in order for it to be productive. Patients do not need to acknowledge that they have trouble managing emotions, but they need to be able to communicate with the therapist and their peers. It is contraindicated for a person who is in an enraged state to participate in this group. Due to the security of the facility, patients should not attend groups if they are angry or unsafe. Preparation. This group should be held in a room with a white board or other means of writing information so that all the patients can see it. There should be chairs in a semicircle around the board with enough space between each chair so that the patients are less likely to feel paranoid or anxious in their seats. It helps if there is a table in the room or other hard surfaces available in case the patients are asked to write. The music therapist should have a CD player, CDs, white board markers, patient pens, paper, and a portable instrument such as a guitar or keyboard available for the session. What to observe. The therapist should observe the patients’ nonverbal reactions to the music (facial cues, posture, etc.) as well as their verbal responses. It is important to note whether the patients are being genuine in their responses. The group provider should also be aware of any recent problems the patients may have had related to managing emotions and should allow the patients the opportunity to discuss those situations in the group if they are comfortable doing so. Procedures. The group is designed to examine one topic at a time by means of music listening, lyric analysis, and songwriting. This process occurs over several sessions. The receptive methods will be discussed here, and the songwriting process will be discussed in the section on Compositional Music Therapy. The topic can be an emotion or another topic that is related to emotions such as stress, relationships, or communication. The therapist will introduce the topic through a variety of songs. These can be live or recorded, but live music is preferred when possible. Some examples of songs used to discuss anger are “Burn It Down” by Avenged Sevenfold, “Nobody’s Listening” by Linkin Park, “Break Stuff” by Limp Bizkit, “Bust Your Windows” by Jazmine Sullivan, and “Not Ready to Make Nice” by the Dixie Chicks. The therapist should check with the group members before playing songs with foul language to ensure that they will not be offended. Some of the songs about anger in particular use cursing. Some songs that can be used to present the topic of jealousy include “Jealousy” by Queen, “Jealous Guy” by John Lennon, “Jessie’s Girl” by Rick Springfield, “Jealous” by Jasmine V, “Jealousy” by Natalie Merchant, and “Hey Jealousy” by the Gin Blossoms. The music therapist will choose songs based on their lyrics and the musical preferences of the group members. It is important to present songs from a variety of musical genres so that patients of all ages, cultures, and backgrounds feel included and remain interested. After the songs, the therapist will ask the group members questions in order to discuss triggers, symptoms, and coping skills related to the emotion or topic. Open-ended questions will often bring about the greatest variety of responses. However, for some patients, closed-ended questions are easier to understand and may appear safer for them to answer. The discussions after the songs will provide information about the given topic. If the topic is jealousy, the therapist can use the song “Jealousy” by Queen to ask the patients which other emotions are related to jealousy as presented in the song. The song

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mentions other emotions such as love, surprise, suspicion, pride, and sorrow. The song “Jealous Guy” by John Lennon can be used to ask about what symptoms of jealousy are in the song. Then the conversation can move to other symptoms of jealousy experienced by the various group members. Processing can bring the patients back to a state of mind which will allow them to behave appropriately regardless of the thoughts and feelings elicited by the music (Nolan, 2002). The music will likely bring about emotional responses in some patients. However, patients are expected to manage their emotions and behave appropriately throughout the day in this type of setting. The music therapist must ensure that they have been brought out of those emotional states before they return to their housing units after the group. Therapists are advised to review Nolan’s (2002) article for verbal processing guidelines and hazards. The music therapist will also present information about the emotions through different mediums such as teaching, writing on the board, worksheets, or videos. Once the group has discussed several songs (the number depends on the theme, the group’s grasp of the emotion, and available songs), the therapist moves on to the songwriting portion of the group. Songwriting about the theme provides the patients with another way to remember the information, while at the same time allowing the therapist to evaluate what information the patients retained. Adaptations. An adaptation of this receptive music experience is one in which the primary goal is to help the patients become aware of the effect of certain types of music on their moods. This experience demonstrates how listening to music can help them cope with certain emotions, particularly stress or anger. The therapist chooses songs of different genres, tempi, volumes, and melodic content and plays them for the patients. He also designs a worksheet with a Likert scale from 1 to 5 that ranges from relaxed to stressed or from calm to angry. It helps to leave a space for the patients to write comments while listening to the songs if they choose to do so. For patients who cannot read or who have language barriers and would nevertheless find this group valuable, the therapist can include pictures of different facial expressions corresponding to the numbers on the form. In this way, all patients who might benefit can participate in the activity. The therapist instructs the patients to circle the number or face that describes how they feel after listening to each song. The patients will also be invited to write down information about how they feel, memories evoked, and anything else that comes to mind while listening to the songs. The names of the songs and artists will be written on a master copy for future reference. The therapist will lead a discussion about which styles of music created strong reactions in each of the patients (either low scores or high scores) and encourage them to listen to the songs or styles which helped them feel relaxed or calm (low scores) when they are experiencing stress or anger. Forensic clients sometimes give verbal responses based on what they believe the therapist wants to hear rather than based on their own feelings or opinions (Hakvoort, 2002b). Therapists should stress the importance of honesty when rating the songs and assure the patients that this will be used as a tool for them to help improve their moods when they feel angry or under a lot of stress. This activity can be repeated as often as necessary and can be used to show the patients which styles of music can improve their moods as well as which styles can make them feel worse. Some forensic patients have difficulty connecting what they have learned in groups to their own lives, and this is a great way to provide them with specific songs and genres that can help them reduce their stress or anger levels. Another option in this group is to allow the patients to choose songs that relate to the emotion being discussed rather than leave the song choice to the therapist. For example, if anger is being discussed, the patients might choose a song that helps them calm down when they are angry. If the theme is hope and hopelessness, the patients may be asked to choose a song that gives them hope. They could also be permitted simply to choose a song that makes them feel good. This type of activity allows the patients to have some autonomy by making choices about what is played in the group. After each song is played, the therapist will engage the patients in a brief discussion about why they picked their particular song and how it related to the topic. Some patients will give superficial answers, while others can be

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guided to a more insightful response. It is up to the therapist to use his clinical judgment to know whether to prompt the patient for more information. A different version of this group would be to use this structure to address any area that is a concern for patients in this type of setting. For example, these procedures could be used to teach patients about mental illnesses in general and how to cope with symptoms. The approach would be similar, but the topics would relate to different diagnoses, triggers, warning signs, and coping skills. The music therapist would still use recorded or live music as well as various worksheets and visual aids to help the patients learn about their mental illnesses and how to manage them. Other areas of concern may be social skills or substance abuse. Music therapists can use lyric analysis and music listening to address several problem areas with forensic patients. Wyatt (2002) stresses the importance of choosing songs for lyric analysis that are goal-focused and can help the clients modify their thinking. She lists several songs for reference that can lead to discussion topics such as life struggles, hope, personal growth, strengths, grief, relationships, and substance abuse. Her work involves juvenile offenders, but these songs and topics also relate to the adult forensic population. Thaut (1987) describes a group music therapy format he used in corrections in which the music therapist orients the patients and asks them to develop personal agendas for the session. He gives examples of personal agendas toward which the therapist can lead the patients at the beginning of the group if the patients need assistance. He then allows the patients to choose songs to help them accomplish their personal agendas for the day. He uses verbal processing about their experiences and personal agendas and then concludes the session. Receptive music listening was used by Spang (1997) to prepare patients to eventually participate in improvisation. Spang used prerecorded music selected by the patients in the group to build rapport and provide a means for projecting emotions and discussing shared life experiences within the group. Through music listening and lyric discussion, the patients became more open to using instruments and expressing feelings in improvisations that followed the music listening and discussion portion of the group. Over time, the use of prerecorded music diminished to the point where the group became exclusively improvisation-based.

Music-Assisted Relaxation Group Overview. This group involves learning and practicing relaxation techniques such as deep breathing, progressive muscle relaxation, meditation, and guided imagery with music. Forensic patients often have trouble relaxing and benefit from learning relaxation techniques (Fulford, 2002; Gallagher & Steele, 2002). The goals of this group are to increase relaxation skills, decrease stress and anxiety, and learn to differentiate between tension and relaxation. Patients who recognize the benefits of relaxation as well as patients who are experiencing high levels of stress and may not recognize its negative impact on their lives are excellent candidates for this group. Patients who are psychotic should not be asked to close their eyes during any form of relaxation. Summer (1988) reported that patients experiencing psychosis should never participate in music-assisted relaxation when it involves imagery. The level of therapy used is augmentative or intensive. While specialized training is not needed to implement this procedure, experience with relaxation methods is necessary to use it successfully with this population. Preparation. This group should occur in a room or location without a lot of visual stimuli that can be distracting. There should be chairs set up in a single circle or semicircle with ample space between them. The therapist will bring a variety of recorded music choices ranging in tempo and intensity from different genres such as jazz, New Age, and classical. It would be helpful to make CDs for each style of relaxation technique. The therapist may also wish to have a relaxation script prepared so that the

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experience is consistent each time for the patients. Davis, Eschelman, and McKay (2000) provide examples of relaxation exercises and scripts that can be used. What to observe. The therapist should pay attention to the volume and rate of speech of the patients. These can indicate whether a patient is truly feeling relaxed. The therapist should also watch for evidence of muscle tension in the patients, particularly in their faces. The patients should be observed as they breathe to determine how shallow or deep their breaths are as well as the rate of breathing. Finally, the patients should be engaged in discussions about how they feel after the different relaxation methods to determine whether their verbal responses match their nonverbal reactions. Procedures. To begin, the therapist should check in with the patients by asking how they are doing and whether they have experienced high levels of stress since the last group. The therapist may want to develop a tool with a consistent scale to determine how the patients are doing in each session and over a longer period of time. The patients can be encouraged to discuss any stressful events that occurred and how they handled them. Next, the therapist will introduce the relaxation technique being used in the session. Some choices include deep breathing, progressive muscle relaxation, meditation, and guided imagery through music. Deep breathing is an excellent relaxation experience with which to begin because it is important to have a strong foundation of proper breathing technique before exploring other methods of relaxation. The patients should be asked to put their left hand on their chest and their right hand on their abdomen and to breathe normally, taking note of which hand moves. The therapist will then discuss and demonstrate proper diaphragmatic breathing technique. A handout illustrating the parts of the body involved in breathing may be helpful. The patients should be instructed to inhale through the nose and exhale through the mouth. The therapist can have the patients breathe in for a certain number of counts and breathe out for a certain number of counts. Once the patients have mastered the technique without music, the therapist will play music that can assist them in beginning each inhalation based on the musical phrases. The therapist should use the iso principle to choose songs that meet where the patients in the group are in terms of relaxation and slowly bring them to a more relaxed state with successive music choices. For this to work, it is beneficial for the music therapist to have a few CDs that start at different levels of intensity and tempi and slowly become more relaxing. The therapist chooses a CD (or song) based on the verbal and nonverbal cues from the patients about how much stress they may be experiencing. The therapist will guide the patients to a deeper level of relaxation by going through the progression of songs. It is important to note that some patients may get light-headed if they breathe rapidly or deeply for a long period of time, particularly if they are new to the technique. The therapist should constantly observe the patients to determine whether they need to take a break. After the deep breathing exercises, the therapist will engage the patients in a discussion about the relaxation exercise. They can talk about how it felt, which music felt most relaxing, and any negative experiences they may have had. Adaptations. Progressive muscle relaxation is another relaxation technique that is beneficial to use with this population. It allows patients to feel the difference between tense and relaxed muscles. It helps to use the same format each time, and a script can ensure that the same order is followed. First, the therapist will encourage the patients to sit up in their chairs with both feet on the floor and to make sure they feel comfortable. Then, the therapist will lead the patients through a series of muscle groups. The patients will be encouraged to tense their muscles, one at a time, and to notice how it feels when their muscles are tense. Then, they will be instructed to relax those muscles and to notice how it feels when their muscles are relaxed. The patients will be encouraged to breathe deeply after all of the muscles have been tensed and relaxed.

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The therapist can play music during this activity. It can be challenging to find appropriate pieces because it works best if it includes both tension and resolution. It is helpful to use instrumental pieces so as not to distract from the relaxation instructions. Some genres that may suit this style of relaxation include classical, New Age, and jazz. The music therapist may want to create his own piece of music to accompany the progressive muscle relaxation process. The therapist could also record his voice giving the instructions onto a CD for the group or onto a cassette that patients can use during their own time (if allowed in the facility). Patients should be encouraged to practice this technique on their own and to report their experiences to the group. Thaut (1989) allowed his patients to choose the slow songs for progressive muscle relaxation themselves. His study demonstrated that patients felt significantly more relaxed after the progressive muscle relaxation with music session than before the session. Therapists may also want to incorporate meditation into their music-assisted relaxation groups. A variety of relaxation techniques can be used with music in order to enhance the relaxation effects. Music therapists can teach basic principles of meditation and add music to the experience. Meditation involves the act of focusing on one thing. Some people use chanting, while others focus on their breath. Some people choose to count and to start over when another thought enters their mind. Patients can be instructed to focus on one particular aspect of the song, such as a particular instrument or the melody. The music therapist should introduce different ways to focus one’s mind, allow the patients to practice, and discuss the experiences with the patients. Zwerling (1979) discussed how guided imagery and music was used with a patient in a forensic setting to address his emotional conflict and to increase his level of independence. During each session, the music therapist first assessed the patient’s mental status, then led the patient to a relaxed state, and finally used music listening to create a conversation about the “images, feeling states, and thought patterns that were aroused by music” (p. 844). Guided imagery through music can be an effective way to assist forensic patients on an individual basis but must only be performed by therapists who have been thoroughly trained in the method and have experience with this population. Relaxation techniques can be taught alongside both music improvisation and receptive techniques (Fulford, 2002). Hakvoort (2002a) described a five-phase program incorporating a variety of listening and active instrumental playing interventions. The phases occur through learning objectives as a focused treatment approach with the forensic psychiatric population. Examples of the types of music therapy interventions used included listening to music to “provoke feelings of irritation and relaxation in the patient” (p. 129), teaching relaxation skills through listening to music, using recorded music to arouse feelings of anger in order to discover triggers for anger, and drumming techniques.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Interacting Through Music Improvisation Group

Overview. In this group, the therapist facilitates participation in a series of simple structured improvisation exercises and culminates with a free improvisation experience with a focus on listening and interacting musically with others in the group. This is a symptom-focused group designed to address patients’ social skills development by providing the opportunity for meaningful music experiences during which the patients are learning social skills, self-expression, reality orientation, and building self-esteem (Fulford, 2002; Gallagher & Steele, 2002; Reed, 2002). The therapist may concentrate on any number of primary goals depending on the individual’s particular treatment plan. These goals include increasing attention, the ability to focus in a shared reality with others, orientation to reality through interpersonal connection, the ability to communicate and share one’s feelings with others, social interaction skills,

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problem-solving skills, and empathy. The level of therapy is augmentative or intensive, depending on the patient’s level of insight. Most patients in a forensic mental health facility can derive therapeutic benefit from playing percussion instruments in an improvisational music group. The primary indication of appropriateness for the group is the patient’s voluntary wish to join the group and his motivation to participate regularly in it. Some resistance is normal, however, mostly because improvising with percussion instruments is a new activity to most patients. Dealing with initial resistance is a very important role of the therapist. One approach is to present the improvisation group as an opportunity for the patients to do something enjoyable and different from their usual experience of talk therapy (Loth, 1996). Patients who are suspicious or paranoid are more likely to get involved if they feel the music group will be less of a threat than the verbal therapy group. Recommendations and encouragement by the treatment team to become involved in the improvisation group will also contribute to helping patients to overcome their resistance. Contraindications for participation in the small improvisation group include patients who have an antisocial personality disorder, especially when they have previously spent time in a regular prison or correctional facility. Patients who have cognitive impairments which affect their ability to organize their playing sufficiently to meet the basic demands of interacting successfully in the improvisational setting would also be contraindicated for the small improvisation group. Preparation. A large, soundproofed room is ideal, but it is still possible to facilitate an effective group in less favorable circumstances. Minimally, the room should be free of interruption and should have enough space for all patients to sit comfortably with a few inches of space between them. Set up the instruments in a circle in the center of the room, providing as much space as possible around the circle. This will allow patients to move around or even leave the room if they feel anxious, while at the same time affording them the possibility of changing instruments during the improvisation without disturbing the group. If the group size is two to four patients, arrange the instruments closer together in front of fewer chairs. In this way, it is possible for one person to use a variety of instruments without changing his or her seat. One of the primary concerns in all forensic mental health settings is the safety and security of staff and patients. For that reason, it is always best to have a coleader (another music therapist, if possible) in every group, along with other staff assigned nearby—for example, just outside the room where the group is held. Many facilities, such as the one in which this author works, have a security alarm system. Every room has a sensor that can be activated by an alarm device carried at all times by each staff person in the facility. In some cases, it may be possible for the therapist to remain between the patients and the exit from the room. However, this may not always be possible in an improvisation group where the therapist is changing his position to play various instruments. It will be necessary to make sure all the instruments being used are constantly checked for any parts that might be loose or in need of repair. Any metal or sharp pieces that are potentially removable need to be closely monitored for tampering. Ideally there would be two therapists to colead the group so that one therapist can keep track of the instruments and help with any potential security issues. Percussion instruments have unique tones and timbres that can be associated with different feelings, memories, and images. Thus, the range of expressive possibilities increases with the variety of instruments available. Include instruments from materials that are wood, skin (drums), metal, and plastic; include instruments that are handheld and that are freestanding; consider size so that there is a range of small and large in each category; provide a number of different shakers; provide a number of different shapes. Many interesting good-quality instruments from world cultures can also be purchased on a moderate budget. Look for quality instruments so that the timbre is more evocative and reminiscent of instruments played by adults. Many forensic patients are often reluctant to participate in a group when they feel it is not “macho” enough for them. Using high-quality instruments can help reduce resistance.

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Nevertheless, if instruments are not available, it is still possible to offer instrumental improvisation by using handmade percussion instruments and inexpensive or free items such as plastic paint buckets, a sturdy cardboard box and a set of brushes, empty water bottles, and cans filled with rice. An example of instruments used in an ideal setting would include the following set up in a circle: large bass xylophone on rolling stand, djembe, Gibraltar percussion workstation table (includes tambourine, cowbell, two sets of agogo bells, Latin percussion super guiro, LP afuche cabasa, sleigh bells, LP pro maracas, LP dual surface multi-guiro shaker, two egg shakers, wooden tongue drum with four tones, mounted crash cymbal, and mounted bar chime), 16-inch floor tom drum, tenor xylophone on chair, set of temple blocks on stand, crash cymbal on stand, djembe along with tongue drum, full rock drum set (includes two mounted toms, two cymbals, hi-hat, one floor tom), large Brazilian surdo drum, set of LP fiberglass congas, and mounted LP bongos. Next to each xylophone is a choice of hand percussion instruments such as tambourines, maracas, afuche cabasa, and shakers. Additional melodic xylophones can be included. Mallets for the xylophones may also be used to play the floor tom, the mounted cymbals, or the woodblocks. The patients are instructed not to use mallets or sticks on the congas, bongos, or djembes. Group cohesiveness is facilitated through musical parameters. The xylophone scales can all be altered to create a particular tonality or modality so that they support cohesiveness within the group. Depending on the individual members in the group, the therapist may need to refrain from playing a tuned instrument such as guitar or piano because some patients will challenge the therapist to allow them to play these instruments as well, potentially causing problems in establishing group cohesion. Though there may be skilled guitar or piano players in the group, they are rarely capable of free improvisation using only the same notes as the xylophones, and they are rarely able to play in a way that accommodates the sounds of the other group members. Reed (2002) also noted that some patients are unaware that they may be playing something different from the group and appear to be unable to hear this difference. What to observe. During the improvisation, the therapist identifies how well each individual patient is able to organize his own playing and focus on the improvisation in order to engage and interact musically with others. After the improvisation ends, the therapist leads a discussion about what the patients experienced while playing, and he or she relates these responses to the primary therapeutic goals for the group and for each individual (Fulford, 2002; Glyn, 2002; Hakvoort, 2002a; Hoskyns, 1988; Sloboda & Bolton, 2002). During the verbal processing, the therapist focuses on two main areas of observation: the patients’ insight and their ability to understand the connection between their musical expressions and their individual objectives. In the course of the verbal discussion, the therapist might also provide patients with a brief assessment of how they are doing. The therapist working in a forensic mental health setting should realize that many patients with antisocial personality disorder, and patients who have spent time in a prison environment, do not like to be confronted with their poor behavior, particularly in a group setting. Criminal-minded patients might view any negative comment that the therapist might intend to be therapeutic feedback as being criticized or disrespected. Patients whose eventual discharge hinges on achieving near-perfect behavior tend to avoid groups in which they fear their actions are going to be documented and used against them. When possible, it would be best for the therapist to address playing behavior issues in a general way without drawing attention to a particular patient. If, however, the behavior is felt to be more serious and needs to be addressed with the individual, the therapist might try discussing the problem with the patient after the group individually or with another team member present. Procedures. Patients are given the first opportunity to sit where they would like as they enter the room. Many patients gravitate to a particular instrument after they become familiar with it. The therapist should decide in advance if he or she is going to impose a rotation system for sharing instruments. When empty seats are available, the patients are given the option of moving to another spot in the circle at any

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time. Once the group is seated, new patients are introduced and announcements are made. This is followed by discussion about how the group has been doing since the last meeting. The group process is explained, and new patients who are unfamiliar with the instruments are given brief instruction, which serves as a review for the rest of the group. Before the patients begin to play, the therapist reviews the primary goals and objectives with the group. Whether developing social skills, stress and anger management skills, problem-solving skills, or emotional management skills, it is important to remind the group of the treatment focus. Three basic instructions will help the group to achieve a therapeutic music experience: to listen to each other, to attempt to engage and interact with each other, and to alter their playing to achieve a cohesive, synchronized sound. Instruct the members that once the group begins playing, there is no talking or hand signaling allowed. At the beginning of the group, introductory rhythm exercises are presented to prepare the group to play together. One of the main challenges to conducting an improvisation group is what to do when the group is struggling to listen and play together. A new group will often have this difficulty before they begin to learn how to incorporate some of the feedback and suggestions for how they can improve their playing. The mental illness of the patient sometimes impacts his ability to organize his rhythm, and this can have a great influence on the success of the improvisation. The more acute the level of mental illness, the fewer patients the therapist might want to allow in the group. Patients who have difficulty being able to organize their own playing or have difficulty playing on the same beat with others may require additional attention. To work with this, the therapist first helps the group to keep the same steady beat together. Some individuals may find that tapping their foot while playing helps them to keep the beat. If using mallets or drumsticks, they may have more success using only one hand to keep a beat. For those who continue to have difficulty, another intervention is to encourage them to play the xylophones during the improvisations. Staying on pulse in rhythm with others is less important for a melodic instrument such as the xylophone. Another introductory exercise to help keep the beat is to give each individual a mallet to play the pulse together simultaneously on a floor tom drum. Following this, the therapist helps each member to subdivide the beat equally in order to alter the rhythm spontaneously while keeping the pulse with the rest of the group. This can be achieved by demonstrating and practicing playing whole notes, half notes, quarter notes, and eighth notes and then combining them in various ways so that group members are playing different values while maintaining a steady pulse. An important concept to teach the patients is that of silence and space, especially when there are more than four members in the group. Demonstrate how leaving space allows others to fit their playing into the group sound. Tempo is another key element in rhythmic organization. In addition to demonstrating how individuals can play as fast as they need to as long as they keep the same basic pulse as the group, the therapist can practice changing the tempo of the basic pulse with the group as a whole. The ability of the group to manage simultaneous changes in tempo is an indication of a healthy, well-functioning group. One of the primary ways the group members can demonstrate they are listening to others and attempting to engage others is in the way they alter their playing rhythmically to imitate the rhythms of others, or by playing a rhythm that can be easily picked up by others. The therapist can demonstrate playing simple combinations to create rhythmic motives and ask the group to repeat them. Individuals can also play motives that they create and have the group play them back. This will prepare them for the main improvisation. When using xylophones, group members should be encouraged to organize their playing in short, memorable, rhythmic phrases as well. The therapist can demonstrate how to play a brief melodic phrase and to pause between phrases to imitate the speaking process. It may also help to instruct the patient to play only single notes with one hand. Others can imitate these melodic phrases on percussion instruments, and this supports the cohesiveness of the group. Playing in this manner demonstrates that one is listening and seeking to engage others.

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Another warm-up exercise is to use the tone or timbre of various percussion instruments as a way to organize the improvisation. Members might play metallic-sounding instruments, or wood, or bell sounds, or any other combination that group members or the therapist might propose. Group members can engage others by imitating the tone quality of the instruments that another is playing. After these warm-up rhythm exercises have been played, the group is ready to begin to improvise freely. The therapist reminds group members to listen to each other and to attempt to alter their playing in order to engage others with their music. The therapist can inform the group members that he will model this behavior during the improvisation by responding musically to each individual in the group during music-making. Before beginning to play, the therapist asks the group members to pause briefly for a moment of quiet. This allows them to be open to listening. During the improvisation, the therapist does not set the beat, but instead refrains from taking a strong leadership role in order to allow the patients the opportunity to determine how to make the improvisation experience a positive one. Allow the group to play until the improvisation comes to a natural ending musically and nonverbally with no other method of direction. Following the improvisation, there is a verbal discussion to help patients to develop insight by understanding how to develop musical social skills through organized interactive playing. Important topics to address in this discussion are related to five primary musical elements: dynamics or volume, rhythm, tempo, melody, and tone. For example, to address rhythm, the therapist might ask the group members if they were able to play together on the same beat during the improvisation; if they managed to subdivide the beat; if they ever lost the feeling of the pulse, and how they found it again; if they heard someone imitate their rhythm; or if they imitated anyone else’s rhythm. The volume is often directly related to the patient’s diagnosis. A patient with antisocial traits experiencing mania will often be the loudest in the group, while a patient with depression or low self-esteem will usually play quietly. The therapist may want to ask the group if everyone could be heard during the improvisation. Asking this question suggests to the group that everyone should have the opportunity to be heard and will encourage someone who is playing too loud to try to play softer next time. Another focus for discussion centers on the patient’s ability to interact and engage others during the improvisation. The therapist can help patients make connections between the skills they used to relate to others in the music and the skills they need to make any social encounter a meaningful experience. Typical subjects might include staying focused and listening to what others are saying and playing, following transitions in the music and in verbal discussions, taking both a leading role and a supportive role in the group verbally and musically, and being respectful of others’ feelings and musical expressions even if they feel or play differently. Adaptations. In a way similar to the rhythmic exercises previously described, Reed (2002) used chord progressions, such as the 12-bar blues pattern, as a semi-improvisation. The therapist provided a chord progression for the patients to learn and play each week. As a measure of functioning, the therapist could assess how much was retained from the previous week. The chord progressions and other riffs were also used within the improvisation as an evaluation tool for learning and adaptation. The music improvisation group’s organization can range from very low structure with no indication or initiation from the therapist (Compton Dickinson, 2006; Glyn, 2002; Hakvoort, 2002a; Sloboda, 1997; Sloboda & Bolton, 2002; Spang, 1997; Watson, 2002) to high structure, wherein chords and instruction are provided (Hakvoort, 2002a; Hoskyns, 1995; Reed, 2000, 2002).

Anger Management Through Music Improvisation Group Overview. In this group, the therapist facilitates a 30-minute rhythmically structured improvisation that builds to an intense climax and then gradually becomes slower and calmer in order to

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help patients with anger management. It is designed for patients with acute issues related to aggressive acting out when they are angry. Improvising on percussion instruments is one of the best methods for providing a direct cathartic emotional outlet for releasing negative visceral content related to aggression and anger. The experience of expressing, releasing, channeling, resolving, and sublimating can dissipate such angry and aggressive feelings. Learning to control volume and intensity in the improvisation can help the patients to internalize this way of controlling themselves from acting out physically when they get angry. This group addresses the patient’s needs at the augmentative or intensive levels of therapy. The primary focus is to help reduce the patient’s tension, frustration, and visceral energy related to aggression. The goal is to help the patient to be more successful in controlling his anger by providing him with the opportunity to release intense aggressive feelings through a safe and controlled musical experience (Hakvoort, 2002a). Due to the intense cathartic level of playing and the chaotic sound quality that sometimes occurs in this type of music group, the therapist should be very careful not to include patients who may be too unstable or fragile to participate. Patients who are experiencing an acute stage of anger and frustration should be monitored carefully as well, because this type of activity might have the reverse effect of causing them to escalate further and even lose control of their aggression. Preparation. Expressing feelings freely on any percussion instrument can be a stress-reducing experience. However, this group is designed to encourage the patients to extend the range of their expression from very intense and powerful to soft and gentle. An ideal combination of instruments for this group would include four large, powerful drums (e.g., two Surdos and two drum set floor toms), two small crash cymbals placed in a circle in the center of the room, two congas, two djembes, a set of bongos, and a bass xylophone placed within reach of everyone. Other instruments include maracas, sleigh bells, agogo bells, ocean drum, rain stick, egg shakers, and selected tone chimes. Provide as many large drums to be played with sticks or mallets as possible for this style of group. What to observe. It is important for the therapist to take note of anyone in the group who may appear disoriented or uncomfortable in any way during and after the playing. It should be explained at some point that there is a difference between intense group drumming, which is cohesive, organized, and goal-directed, and intense overt pounding behavior. As soon as the therapist observes a patient appear to be detached, not on pulse, and pounding hard on any instrument, he should attempt to redirect the individual back to trying to play along with the group. It is important to encourage the group to maintain a cohesive supportive sound throughout the playing experience. Procedures. At the beginning of the group, there is a brief discussion with instructions related to the improvisation. It is helpful for the therapist to lead the group in playing various simple yet common drum patterns for the group to both dialogue with and imitate. Some preliminary rhythm exercises from the Interacting Through Music Improvisation group can be used here as well. For the main improvisation, group members are given instructions to keep the group pulse, but they are also encouraged to express themselves through the subdivision of the beat. The rhythmic layers help to create a phrase structure and encourage the patients to be musical as opposed to simply pounding the instruments. It should be noted that due to the level of volume this group can attain depending on the number of patients involved and the intensity level of their playing, earplugs should be made available before the playing begins during each group. The patients are also counseled regarding the potential for hearing problems related to the level of volume of the group. The group begins playing together at a moderate loudness and intensity level. The therapist leads the group to gradually increase the intensity to become louder and faster. The amount of time from beginning to the most intense level of playing lasts about 10 minutes. The patients should be encouraged to play as intensely as they feel comfortable doing. At this point, the therapist begins to lead the group to a

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gradual reduction in both volume and tempo for approximately 10 minutes, while maintaining the pulse with the drum. As the playing gradually slows down, the group members are encouraged to use deep breathing techniques to increase their feelings of relaxation. When the pulse reaches a very slow tempo similar to a resting heartbeat, the group is instructed to stop drumming and to switch to playing instruments that can create soft sustaining sounds such as the ocean drums, bass xylophone (with soft mallets), rain sticks, wind chimes, tone chimes, and the cymbals with soft mallets. The therapist puts on a relaxation CD as background music that creates an interesting sound environment along with the sounds made by the group. The tone chimes selected by the therapist are selected beforehand to match the pitch of the recorded music. The group method for anger management described here involves one long improvisation approximately 30 minutes in duration. Though the patients are given the opportunity to express very aggressive feelings during this playing experience, they are also encouraged to learn how to gradually calm themselves and to increase their ability to express tender, quiet feelings that they might not otherwise feel comfortable doing. Time is given at the end of the playing experience for discussion. The group should be asked to comment on how they are feeling after the playing is completed. Do they feel more relaxed? Do they feel they were able to release tension and feeling related to aggression and/or anger? The therapist should discuss how sharing the release of intense feelings supports the individual’s release of aggression as a natural positive process. The intense drumming followed by a steady decline into more tender expressions is a reflection of how the strength they possess can be controlled and used in a positive way. After participating in this experience a few times the patients are asked to keep track of situations the might occur during the rest of the week when they experience feeling frustrated and angry for any reason. Explain that the objective of the group is to help reduce the intensity of their anger to an appropriate level, and to help them to handle their anger without acting out physically. As a music therapist participating actively in this process twice a week for over a year, this author’s experience has been that it does. Adaptations. Adaptations for this group would include introducing the group members to cognitive behavioral concepts to help them to better understand their anger problems. The therapist can also use discussion time in this group for psychoeducation regarding diet, medication, sleep, exercise, and other stress-reducing activities.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Structured Improvisation with Song Singing Overview. Patients and therapist sing a chosen song and create instrumental extensions on a variety of percussion instruments, while the therapist accompanies on the piano or the guitar. Popular songs or familiar song forms such as the blues progression can be used as the basis of this structured improvisation experience. Singing songs is an excellent way to help patients who are disorganized, have difficulty expressing themselves, or have trouble staying grounded in reality. This is for two reasons: (1) the structure provided by the steady rhythm and the lyrics of a familiar song helps patients with internal and external structure (Reed, 2002; Sears, 1968; Thaut, 2005) and (2) singing is an integrative musical experience that simultaneously activates multiple areas of the brain (Jeffries, Fritz, & Braun, 2003; Thaut, 2005). The music therapy treatment focus is to provide an opportunity for the patients to improvise and interact musically with others spontaneously and freely (Codding, 2002; Reed, 2000, 2002). There are a number of unique therapeutic possibilities in this group. In addition to leadership, expressive, and social

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goals, this group provides patients with the opportunity to improve communication. Patients diagnosed with various thought disorders often have difficulty organizing meaningful melodic thoughts; playing improvised melodies on the xylophone mimics the process of speech, helping them to develop conversational skills. Goals for this group are numerous, including to reduce resistance to music therapy, improve reality orientation, establish a connection with peers, reduce stress, increase self-organization, improve one’s ability to play in a common pulse, increase one’s direct expression of feelings, increase one’s self-awareness, improve communication, and develop a more positive attitude toward group therapy. This group addresses the patient’s needs at the augmentative or intensive level of therapy. Many forensic patients who are reluctant to become involved in a music therapy group may be more likely to participate in a group that uses familiar songs they enjoy and to which they relate. In singing, they can express feelings indirectly, make a connection with others through a shared song, and release stress. In addition, patients who have difficulty keeping a beat may be placed in this group because singing has a neurologically integrative effect on some individuals with mental illness and/or brainimpairment. While there are no contraindications for this group, the therapist should be aware that patients often react negatively to the song choices made by others in the group. Songs chosen at random by the patients from an available list will have an impact upon the mood of the patients as well as the overall mood tone of the group. To facilitate ending the group with a positive relaxed mood, the therapist may suggest that the group members try to select songs that will reflect these feelings as the group draws to a close. Preparation. The room setup and instruments used can be exactly the same as for the free improvisation group. The main addition is a piano or guitar for the therapist to help lead the songs and, if possible, a drum set to help structure the instrumental improvisation segment of the songs. Two alto or soprano xylophones and one bass xylophone are also used. When using xylophones, the therapist should prepare them before each song by using the scale best suited for the chord progression. With basic threechord songs, it may be possible for the patient playing the bass xylophone to play the root note of the chords. Patients playing the alto xylophones should be instructed to play any of the notes while the song is being played. Individual group members are also encouraged to lead songs, and for this purpose, a microphone and amplifier are provided. Although the therapist can accompany the group with the guitar, the piano is preferred for several reasons. It is much easier to hear the piano when all the instruments are being played, the therapist has more flexibility with volume depending on the needs of the group, and the bass notes of the piano can be used as a bass guitar to re-create the original sound of the songs. Another main reason for the therapist to use the piano is that not having a guitar in the room makes it easier to justify not allowing the patients to use it in the group. Often, group members may have some skill on the guitar, but they are not able to maintain awareness of the group while playing, and this can create a less pleasing experience for everyone. Some members may know how to play the guitar but they do not know a particular song, and they are reluctant to give up the guitar, thus bringing the group process to a halt. What to observe. If there are resistant patients participating in the group for the first time, the therapist should take note of how they respond while the group is playing. If they simply do not play and instead remain passive, the therapist should explain that they are encouraged to join in, as they will not experience the positive benefits of the music unless they participate in the playing. If they do participate, the therapist should note whether they appeared to be invested in the experience or whether their playing appeared robotic or superficial. The therapist should keep in mind that some patients may be both resistant and opposed to playing instruments. If they were at least willing to participate to see what the experience was like and honest about how they felt about it, they should be given positive feedback for doing so.

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Familiar songs are often easier to organize and play in this type of music therapy group; however, since they are so familiar, some patients are sensitive to the fact that the song didn’t sound anything like the original recording. The therapist should explain that they are not professional musicians and that the songs are simply being used to help structure a therapeutic musical experience in which any patient can participate, regardless of their musical skill level. The therapist should be prepared for the possibility of critical comments directed toward patients who have more difficulty successfully organizing their playing. The therapist may consider having a rule that patients will be encouraged to provide supportive feedback for how the group can improve but critical comments directed at individuals should be avoided. The therapist should particularly take note of how well-organized patient playing behaviors are when related to the different types of playing or singing in which they participate. For example, are patients who have difficulty playing a steady pulse with their hands on a drum able to sing in rhythm with the therapist playing the piano? The additional grounding support from singing familiar songs can help some patients to focus in reality at least while the song is being played. This supportive quality related to playing familiar songs also encourages patients with personality disorders (antisocial or narcissistic in particular) to adjust their personal playing in such a way as to support the successful playing of the song by the entire group. It has been observed that patients who are skilled musicians with an antisocial personality disorder are more likely to listen to and support others more if it means that the song (and they as well) will sound better. Procedures. As the patients enter the room, they are given the opportunity to choose which instruments they wish to play. Songbooks with lyrics for a variety of songs and a table of contents of song titles are provided, along with music stands, so the group can play while singing the lyrics or following the song format. After the group selects a song, patients who wish to play a different instrument are given the opportunity to do so. One patient who is interested in leading the song is given the microphone, while the others are instructed to sing along with him. The therapist should also be prepared to alter his or her playing in response to the soloist and to lead with the patient if he needs additional support. The therapist provides a brief explanation of the basic format of the song. The basic format for a structured improvisation using songs is similar to how a jazz or blues band performs a song. There is an introduction section, and then part or all of the song is sung with instrumental accompaniment, followed by improvised solos played by individual instruments while the rest of the group plays the chord progression. The therapist and the group members decide in advance which parts of the song are going to be played as solos and who will play the xylophone solos. The song can be repeated in whole or in part, instrumentally or vocally or both, finishing with the coda to end the song. More than one patient might play during the solo section, or two group members may dialogue with shorter solos as is often done in jazz groups. The therapist sets the tempo and the rhythm in the instrumental introduction, while group members improvise on the various instruments provided, and then the therapist cues in the singing. The therapist also provides support with rhythmic chording to help capture the basic feel of the song style and keep the beat, while singing the melody to support the leader and the group as a whole. During the xylophone solo, only one alto xylophone should be played. The bass xylophone and other percussion instruments should continue to improvise a rhythmic accompaniment, being aware that they must support the soloist, while the therapist continues to play the song’s harmonic and rhythmic structure. After the solos and singing have been completed, the therapist may want to continue playing the chords while the group continues to improvise. Encourage the singers to improvise on the lyrics, spontaneously make up their own words, or vocalize freely as in scat singing. The therapist may also want to try altering the chord progression as well. After the song has ended, the therapist should allow for a brief discussion of how the group thought they sounded and/or what their experience was like during the playing. The therapist should

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provide positive feedback for positive musical behaviors observed during the playing in order to encourage similar playing behaviors from all the patients during every playing experience. Use the discussion period to give feedback related to how well they were able to follow the method of playing the song. Did they sing the verses and then the chorus in the right order? Did the singers follow the therapist accompaniment on the piano? Was everyone on the same beat? Could everyone hear the soloists on the xylophones? Adaptations. One adaptation is to facilitate a percussion jam at some point during the song. Many Latin jazz/rock groups will often deviate in this manner and feature the percussion players in the group. The therapist can join in on a drum or percussion instrument as well. Another adaptation is to have the group improvise freely as an introduction section to a song. This method helps introduce the group to what it is like to improvise freely and can act as a good transition when attempting to make free improvisation a regular part of the group. Some songs have parts that are fairly easy to teach the group to play while singing the lyrics to the song. Bass lines can be played on a xylophone, and some vocal lines can be echoed to create harmony. For example, “You’ve Lost That Loving Feeling” begins with a bass pedal tone on one note for most of the verse. Small reusable, self-adhesive, colored-plastic Post-it flags can be used to mark the xylophone bars to be played. This song also has a part where words sung by the lead singer are repeated by the backup singers, like an echo. Many songs offer unique vocal and/or written parts that the group might try to reproduce. In cases where a patient requests a song with which the therapist is not familiar, ask him to sing the song a cappella, with the rest of the group improvising the beat on percussion instruments. Patients who like to rap can do so with the rest of the group improvising on percussion instruments as well. Many rap beats are often very similar to basic rock-and-roll or rhythm-and-blues beats. If the therapist is not familiar with rap, he can listen to recordings to get ideas for basic rap patterns. The therapist may have the group invent their own raps or work on rap lyrics as part of the group.

Performance Band Group Overview. In this group, patients learn music and perform it for others. Therapists will often encounter creative, artistic individuals in forensic mental health facilities who have various levels of skill in playing instruments. There are also opportunities for patients to sing and/or play hand percussion instruments without too much training. Some patients are very motivated to be part of a performance group, and doing so can be a therapeutic boost to their self-image, particularly when the group has an opportunity to play in front of an audience. The therapist must use his discretion as to whether a band group is feasible given the level of skills and number of instrumentalists available. In some larger institutions, there may be enough patients with skills to form more than one band group. In most cases, it is likely to be easiest to form a rock-and-roll, pop-style band group, as many of the patients tend to know songs in this style on their instruments. For less skilled players, there are popular songs that are not difficult to learn. A basic rock or pop band can be formed using four instruments: electric guitar, electric bass, drum set, and piano. Rap groups are also becoming more popular and can be formed using even fewer instruments. An important goal for many antisocial, criminal-minded patients is to help them to reduce resistance to treatment and develop a more positive attitude to the therapeutic milieu. A performance group may be more acceptable to antisocial patients who are resistant to participate in regular talk therapy groups. The opportunity to perform the styles of music they enjoy for a live audience becomes a positive reinforcement for their willingness to engage in a therapeutic music group. One of the primary goals for the performance group is to encourage empathetic (i.e., awareness and concern for others)

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responses from patients with personality disorders. When using songs in a structured improvisation experience, some patients with personality disorders who are also skilled musicians may be more willing to consider others if it means the band of which they are part will sound better. The main concern that such a patient has in almost all his interactions with others is related to power and control. In a band group, however, the primary concern is not necessarily with the group interactions as much as it is with the sound of the music. Though success is based on successful group musical interactions, a patient with antisocial or narcissistic personality disorder, in spite of his natural disregard for others, can be successful in a performance group when he is willing to put the musical product above his individual concerns. Thus, forensic patients with Axis II disorders, particularly the antisocial personality disorder, may benefit greatly from this group. Ultimately, personal success is more likely when all the individuals involved learn how to be more empathetic toward others. The main goal of this group is to encourage the patients to learn how to work in tandem with others toward a group goal so that they can feel better about themselves while also helping the group succeed in playing music as best they can. The therapist addresses various issues related to each patient’s symptoms of mental illness while helping the patients to prepare the music for performance. In the process of creating a satisfying artistic product, patients are able to improve their social skills and problem-solving skills. There are also significant therapeutic and personal rewards gained through the experience of working together as a group preparing for a performance. In what is often a very depressing institutional environment, through the performance group, patients can experience a sense of accomplishment, develop interpersonal bonds through group collaboration, and share the experience of helping to create something positive and good for others to enjoy. Patients with little or no previous musical training on instruments which require considerable training, such as piano, electric guitar, or any orchestral instruments besides percussion, in most cases would not be suitable for a performance group. Patients with poor rhythm skills may not be appropriate for playing percussion instruments either. Basically, a performance group is primarily for musicians; patients interested in expressing themselves musically with no previous experience on an instrument will have a more meaningful therapeutic experience from participating in more structured improvisation groups. This group addresses the patient’s needs at the augmentative level of therapy. The therapist should have advanced performance skills in popular music genres on the guitar or piano and functional knowledge of lead guitar, bass, and percussion. Preparation. The first necessity is the availability of suitable instruments for a rock, blues, pop, jazz, and/or Latin band group. The primary instruments are electric guitar, piano, and bass guitar, with proper amplifiers for each. In most cases, a full drum set is ideal. The first additional percussion instrument would be congas and a variety of hand percussion instruments. A suitable sound system for the vocals would be nice to have when other instruments are amplified. Any other instrument the facility may have (brass and wind instruments, harmonica, etc.) could be added to the group, particularly if there is a patient skilled enough to play it. If the facility does not have electronic instruments and a full drum set, a performance group can still be organized using the instruments that are available. Use what is available even if it is only one acoustic guitar and a tambourine. A sturdy cardboard box with a pair of brushes makes an acceptable drum sound. If you have a limited budget, purchase a Cajon instead of a snare drum, cymbal, and stands. A CD player is useful for the group to listen to previously recorded songs they have chosen. Alternately, the therapist might use a computer with Internet capability (or an iPad) to listen to songs and gather information related to them. The therapist might also prepare a collection of songs in a variety of musical styles that he or she is familiar playing from which the group can choose. One of the main concerns of a performance group is having an opportunity to perform the music. It is much less rewarding for a group simply to practice all the time without being able to play for an

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audience. In most cases, it will be up to the therapist to find a suitable opportunity for the group to perform. This is something they may want to consider before starting a performance group. Some facilities organize hospital wide events in which patients can perform in a talent show–type production (Fulford, 2002; O’Grady, 2011; Reed, 2002). Another concern is that the therapist must consider the amount of music the group can prepare within the time frame before a performance is scheduled. From experience, a performance group practicing twice a week for 50 minutes in each rehearsal was able to learn between six and eight songs within 12 weeks. These songs took approximately 30 minutes to perform during a hospital wide concert held along with several other performance groups in a large auditorium. What to observe. One issue that often has to be dealt with when using amplified instruments, particularly for patients with some type of personality disorder, is the loudness level of the group. Electrified band groups can get very loud, and the therapist is likely to have to deal with the issue of balance at some point. It is important that every instrument in the group can be heard and that the sound level is not in a range that can be harmful to patient hearing. Patients who play too loudly all the time may have to be confronted because this is a therapeutic issue for the group. Another common issue is related to the variable skill levels of the patients in the group. It can be frustrating for both less skilled and advanced musicians to be in the same group together. Depending on circumstances, it may not always be possible to have both beginner and advanced-level performance groups in the therapy setting (Reed, 2002). In some cases, this issue can be handled as part of the therapeutic process for the patients involved. Is the skilled musician an antisocial patient who makes negative comments about less-skilled patients? If so, the therapist may want this individual to work on helping others during the group rehearsals. Adjustments to the choice of songs can be made so that easier songs are integrated with more challenging material. In this way, the therapist can suggest another instrument that the less skilled musician can play for the more challenging songs, or give the option of singing the song with others. In some institutions, there may be opportunities for the individual to practice his instrument privately during the rest of the week. While many patients are eager to have access to an instrument to practice on whenever possible, most institutions limit access to instruments due to contraband and safety issues related to the instruments. Procedures. During the first group session, the music therapist will meet with the group to find out what type of music and songs they would like to learn. Suggest that each individual in the group choose a few songs for the group. The therapist should bring his collection of music and other resources such as popular CDs or songs on an iPod for the group to consider. Once the therapist begins to get a sense of the type of music his patients are familiar with, he might want to make suggestions from the list of songs the therapist knows how to play. Songs the patients select that are not readily available can be found on the Internet before the next group is held. Having CD recordings available for the group to select from is helpful when they are not familiar with the songs being considered. Later on, it will also be helpful to have the recording when the group is trying to learn the song. The group does not necessarily have to select every song they plan to learn and perform during this first session. Having a few songs for the next group will be enough to get started. This type of selection meeting for a first group allows the patients the opportunity get to know each other and to learn about the type of music they like, what instruments they can play, and who likes to sing. It will be important in this first session for the music therapist to assess the skill level on each participant’s instrument of choice; this will guide the music therapist in the song selection process. Songs that are particularly challenging for beginners may not be good choices considering the amount of time the group will have to invest before attempting a performance. After a few years of experience in facilitating this type of group, the music therapist will find he has accumulated a library of suitable songs in a variety of styles

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that many patients enjoy playing, and which are not too complicated to learn and perform in a short period of time. For the second group, the therapist should prepare a written copy of the song for the patients to follow. The basic format is to list the chord name or the actual tab over the lyrics where the chords change. Mark the sections of the song, such as verse, chorus, and bridge. If possible, put all this information on one page. Most songs can be found in this format on the Internet, and copyrighted piano parts for many songs can also be downloaded for a small fee. In addition to written material for the patients, it is advisable to make a CD copy of the songs. Some patients might actually prefer to hear the song and play it by ear without looking at a written part. During the first rehearsal, the patients will set up their equipment and tune the guitars. The therapist will distribute the written materials and select one of the songs to begin working on. When beginning a new song that the group members are not all familiar with, it helps to have them look at their written “music” while listening to the recording. One of the most important musical challenges for the group is to have the guitar, bass, and keyboard musicians play the proper chords or notes and make chord changes at the same time together. This is the first skill set the group will have to master. When there is a patient with advanced skills, the group will be able to learn songs more quickly. Where appropriate, skilled musicians/patients can help others learn their parts. For the therapist who is not familiar with modern playing styles, guitar lessons with a teacher who is knowledgeable about current styles are highly recommended. Familiarity with the harmonic language in various styles (rock, blues, jazz, R&B) will also be very helpful, as chords played on original recordings are not always indicated correctly on the materials found on the Internet. Once the chord progression (including the bass guitar’s) is fairly organized, help the group to perform part of the song together while singing. Begin with one section of the song such as the verse, chorus, or bridge, and repeat it until the group has a good grasp of the rhythm and harmony. After finishing a section, be sure to solicit the group’s input and feedback regarding how they think it sounds and what they think they need to do to improve it. For some songs, it might be helpful to play part of the recording again after they have had a chance to practice it, and then have them play it again. Continue this method until the group has had a chance to play the entire song if time allows. Some songs are easier than others and may not take the group much time to learn. It will be up to the therapist to decide how many songs the group might want to work on during one group. As the group begins to learn each song, there will be more time during each group to rehearse more songs. The therapist may want to keep in mind, and inform the group as well, that there is a major difference between a professional-sounding recording produced by highly skilled musicians and their group. They should be encouraged to appreciate their own unique sound and arrangement of the songs they are learning to play. The song may not always sound so good at first, but with practice they will get better. Taking on the challenge of learning songs as a group, developing individual musical skills, and overcoming the frustration of the learning process are all part of what can make a performance group therapeutic for the patients involved. Adaptations. The performance group can be a chorus. Singing is one of the most therapeutic music activities, and it does not necessarily require musical training. A chorus group can be composed of patient singers and led by the music therapist on either guitar or the piano, or the group can perform a cappella. Alternately, one can include patient musicians who have advanced skills that enable them to play the material with little or no assistance from the therapist. A chorus group can also serve the function of a choir for religious services held in the facility. Chaplains working in forensic facilities often organize choirs for their services, and they usually appreciate the help of the music therapist. The advantage for a choir group is that they have a place to perform on a regular basis, as long as the therapist does not mind putting in work hours on the weekend.

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Reed (2002) outlined how she structured and taught a gospel choir group to sing only “contemporary black gospel songs” in an adult forensic state hospital (p. 101). Patients with all levels of musical skill were accepted into her group. Basic musical rhythm, melody, and harmony skills were taught along with the songs the group performed. This gospel choir performed at various hospital wide concerts as well as during hospital religious services on Sundays (Reed, 2002). Another adaptation of a performance group is to form a rap group (Hadley & Yancy, 2011). There are often patients who are familiar with the rap style of singing or performing “mouth percussion” sounds. Many of the patients who enjoy rapping often write their own lyrics, although the lyrics for popular rap recordings are available as well. In addition to the rap vocalists, this type of group could also include other patients playing a variety of drums and percussion instruments imitating rap-style beats. In some cases, keyboard parts could be added without too much difficulty as well. An additional adaptation for a rap group would be to have the patients compose original lyrics together during the group to be learned and performed. The procedure for conducting the sessions would be the same as for the band performance group already discussed.

Karaoke Performance Group Overview. Patients sing popular songs using a microphone with a prerecorded song accompaniment. Singing is perhaps one of the single most therapeutic musical activities there is; it stimulates deep breathing and can help reduce tension and anxiety (Haan, Clift, Hancox, Staricoff, & Whitmore, 2008). It involves both the right and left hemispheres of the brain as well as the brain stem and midbrain centers. Singing a familiar song involves simultaneous stimulation of multiple areas of the brain, which creates an integration of parts involved related to memory, movements, and feelings (Koelsch, Offermanns, & Franzke, 2010). This type of music experience is indicated for patients suffering from even the most severe mental health symptoms. A karaoke group encourages patients to sing, particularly when there is a wide variety of songs from which to choose. When karaoke is made available as an informal leisure drop-in activity, it can also have the goal of helping to reduce resistance to treatment for patients who have refused to get involved in therapy programs. Patients may perceive the karaoke group to be an enjoyable and informal music group. This can be especially helpful when dealing with a resistant patient who might feel less intimidated and possibly more comfortable interacting with others in this group. A primary goal that is addressed when singing songs in a karaoke group is to facilitate grounding and reality orientation. Karaoke is an excellent musical activity for patients with affective disorders and for those who have difficulty with controlling their aggression and need an enjoyable and nonthreatening way to reduce frustration and anger. An informal karaoke group is intended to be for any and all patients willing to attend. Active participation is not always necessary, because patients often enjoy the experience of watching others and contributing verbally in spontaneous song discussions. Unless a patient is very familiar with a song and has the lyrics memorized, karaoke requires the patients to be able to read. Some patients who do not read may not feel comfortable in this group unless they do know the lyrics of songs or enjoy singing along to parts of songs they already know or can learn quickly. Some patients who read slowly may find it frustrating to try to sing a favorite song when the lyrics are shown too quickly for them to follow. This group addresses the patient’s needs at the augmentative level of therapy. Preparation. The music therapist must have a suitable karaoke machine and a set of karaoke CDs with a variety of music styles available. Most inexpensive karaoke machines are fairly compact and usually only require a television set or monitor which has connections for the standard RCA video cable (usually three plugs: white, red, and yellow). Most karaoke machines come equipped with the cables and a

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microphone for singing. However, the CD collection of songs may have to be purchased separately. Try to provide as many copies of the song lists as possible so that several patients in the group can look at the song choices at the same time. The chairs in the room should be arranged in front of the TV monitor where the lyrics will be displayed. Usually, the person singing will have to sit near the front to be able to read the lyrics and use the microphone. One of the most convenient aspects of a karaoke group is the setup, as there is very little equipment involved. If the facility has a TV monitor that can be placed on a cart and rolled from room to room, this group can be held just about anywhere. What to observe. The therapist should always be ready to offer assistance to help the patients sing the song they have chosen. Karaoke arrangements are often different from the original recordings. The patients usually choose songs they enjoy listening to, but they may not realize how challenging these songs may be to sing. Sometimes, the patients need help finding the proper key to sing in or some assistance in following the words in the proper rhythm. Encourage the group to support and help each other with their songs, but keep in mind that some patients do not like to be helped. Keep the group fun but also keep it well structured. Antisocial patients who enjoy this type of activity often have behavior problems that can affect the group. They may have difficulty waiting their turn while others sing or they might sing along at a high volume, drowning out the lead singer. They may make fun of patients who are less skilled at singing. None of these behaviors should be allowed in the group. Some patients are reluctant to try singing a song using the microphone and prefer to sing with the group or simply to watch. It’s up to the therapist to decide if this will be acceptable in their group. Some patients may need more time before they are willing to try singing alone. Procedures. After everything is set up and the patients are in the room, the therapist explains how he intends to select the order of the singers. The easiest way is to start with the patients who already know which song they want to sing; be sure to write down the order so that after each patient has sung his first song, he can go in the same order for his next choice if there is time. The therapist should let the group know that it will be up to the lead singer to decide if he wants others sing along with him. Explain that there are often chorus sections for everyone in the group to sing along with the lead singer. The therapist should also announce that he will select songs for the entire group to sing together. When there are guitar solos or saxophone solos on the recordings, it is fun to provide a plastic blow up instrument for someone to use to pretend they are doing the solo … air guitar style. Adaptations. The karaoke group described above did not specify a particular group size. The same procedure for conducting the group can be used no matter what the group size. Karaoke can be used for a large, drop-in, leisure dayroom group as well as for a smaller room with fewer patients. The length of time the group is held will determine how many songs can be played. On average, there is usually time for 10 to 12 songs in one hour. The nice thing about a leisure drop-in–style group when held in the unit is that patients who might not normally get involved in other activities in the unit, or who have not shown an interest in other types of music groups, may be willing to get involved. Karaoke can also be designed as a small, process-oriented group for six to eight patients. Finally, karaoke can be used in a performance concert setting by inviting various patients to sing for an audience in a large room or auditorium. This type of activity works best when the karaoke DVDs can be shown on a larger screen.

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GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting in the Exploring Music and Emotions Group The section below will discuss the songwriting component of the Exploring Music and Emotions group presented in the Receptive Music Therapy section. Fill-in-the-blank songwriting is an appropriate introduction to songwriting because it does not appear as daunting to patients who are experiencing songwriting for the first time. It can also be the easiest method for the therapist if he does not have a lot of songwriting experience. Songwriting can be a popular music experience in the forensic setting because it does not require equipment that may pose a risk for contraband. There are often difficulties in providing quality music therapy interventions in a maximum-security setting due to equipment restrictions, staff attitudes toward the benefits of music therapy, and other security measures (Fulford, 2002; Langan, Williams, & Athanasou, 1998). Overview. This group involves creating new lyrics for an existing song or composing a new song. Therapists in forensic settings often use songwriting with their clients in order to accomplish goals such as working together, expressing emotions, and improving communication. Jones (2006) reviewed several sources and found that common goals of process songwriting include improving verbal communication, socialization, self-esteem, expression of feelings, group cohesion, and coping skills. In this songwriting group, the particular goals are to identify and define various emotions as well as the patients’ triggers and symptoms related to emotions. Some songwriting groups also work on coping skills for various emotions. As with the lyric analysis portion of this group, it is beneficial if the patients are interested in processing as a part of the group and willing to participate actively. It is helpful if the patients can read and write, but it is not necessary because the songwriting generally occurs as a group with the therapist writing the words. The patients enrolled in the group should have an adequate grasp of verbal communication so that they can participate in the songwriting process. This group is contraindicated for a patient experiencing active hallucinations because he may not be able to concentrate or participate meaningfully, and this may lead to increased internal chaos. Patients who have narcissistic tendencies and believe that their ideas are the only correct ones may experience some frustration in this group since everyone in the group is expected to contribute their opinions and all opinions are considered valid. The level of therapy for the songwriting experience is augmentative or intensive. Preparation. The therapist chooses the topic and the level of structure that will work best for the patients in the group. If the group includes patients who are concrete or have cognitive deficits, a fill-inthe-blank songwriting activity is often the best option. If the members of the group have adequate writing skills and have a good grasp of the emotion being discussed, they may be able to handle more independence in the songwriting process. For a fill-in-the-blank songwriting experience, the therapist will choose a song that suits the emotion being discussed, taking into consideration the tempo, dynamics, length of phrases, and other important elements of the song. The therapist should choose a popular song so that more patients are likely to know the melody and song structure. The therapist will design a template for the activity. Some words will be written by the therapist to assist the patients in reaching the goal of the activity, and there will be blanks for the patients to complete. The blanks can range from one word to complete lines or phrases. The patients should all be seated in a room in a semicircle around a white board. White board markers, handouts, patient pens, and a guitar or keyboard should be readily available before beginning the session. The environment should allow for each patient to have a hard surface to write on, such as a table, in the event that they are required to write their lyrics.

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What to observe. The music therapist should observe the patients’ verbal responses as well as their nonverbal responses to the group. When patients write down their own ideas, the therapist may want to read what they have written to gain insight into their level of understanding, current emotional state, and experiences related to the given topic. The interactions among the group members are also noteworthy to determine whether they are improving in the areas of communication or group cohesion. Procedures. This group uses a combination of lyric analysis, music listening, and psychoeducation to instruct the patients about various emotions. The group focuses on various emotions, including anger, sadness, hope, and jealousy. Often, the therapist will choose the emotion based on the patients in the group and the emotions that give them trouble. Also, the therapist can ask the patients which emotions they would like to address. The therapist teaches about the triggers, symptoms, and coping skills for the emotion through the lyric analysis portion of the group and didactic methods when necessary. Once the group has reviewed a particular emotion, the therapist will lead the patients in a songwriting activity. The therapist will play and sing the original song being used for the fill-in-the-blank songwriting activity. The therapist can choose the song based on musical qualities such as the key, tempo, and melody that reflect the given emotion in sound. The therapist can also invite the patients to make decisions about whether the song is in a major or minor key, whether to use guitar or keyboard, and which chord progressions will work best. The patients will either be given a handout with blanks to fill in or the basic format will be written on the board. Throughout this process, the therapist gives clear instructions to the patients. Since the goal of this particular group is to teach the patients about the emotions and coping skills, the songwriting process remains structured so that these goals are accomplished. The therapist works with the group to write new lyrics that define and describe the emotion and its symptoms as well as ways to cope with it. The therapist will guide the patients throughout the process, making sure to include every patient. If a patient is hesitant to participate, he can be given a choice between two words or phrases, or he can be asked simpler questions. It is important to include lyrical input from every patient because each one is in the group to learn about emotion management skills, and including something specific from each patient will instill a sense of ownership in the song. Once the words are written, the therapist will sing and play the song, inviting the group members to sing along if they are comfortable. Oftentimes, the group chooses to modify the song after hearing it the first time. They can change words to better suit the musical phrases. They should also be encouraged to create a title for their song. It may take several sessions before the song is complete, depending on the number of verses and the patients in the group. The therapist will bring typed copies of the song to the next session for all of the group members to keep. The song can be performed again at this time, with or without instruments. A discussion should take place with the patients about their experiences during the songwriting process and ways to improve the process for the future. The song can be sung in subsequent sessions to reinforce the information contained in it and, periodically, the therapist can test the group members’ retention of the material. Adaptations. While the fill-in-the-blank style of songwriting offers structure that many forensic patients need, it is limiting because clients may feel the need to fit the words to the phrases rather than staying true to their intentions (McFerran, Baker, & Krout, 2011). The style of songwriting can be modified when needed. Patients can rewrite the lyrics completely by using a familiar song as the melody, otherwise known as a song parody. Another option would be to have patients write lyrics in a poem form. Then the therapist can either write the music for the song independently or can include the patients in making choices about the style and various elements of the song. These choices will vary based on the capabilities of the patients in the group, the amount of time allotted for the songwriting activity, and the comfort level of the therapist.

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Patients could also write their own verses or songs related to the given topic so that they have more of an opportunity to share their thoughts and express themselves rather than just contributing a few lines. Sometimes the patients who seem like they are not paying attention during a group songwriting experience write insightful verses on their own but do not feel comfortable sharing them with the group. While their lines may not be included in the song, it can be a cathartic experience for them to express their feelings in writing. Another adaptation is to use the songwriting process to work on therapeutic issues other than emotion management. This might include themes that focus on symptom management, social skills, and substance abuse. Songwriting can address each of those areas using the above procedures. Songwriting can also be used in individual sessions that allow for more creativity. Patients may be more open and honest if they work individually with the music therapist rather than in a group setting. The goals are modified for the individual patient’s treatment, allowing him more freedom to explore his past, feelings, and ideas. After building rapport, an individual client even may be willing to explore his crime and ways to reduce his chances of recidivism. Boone (1991) gives an example of how a forensic patient was able to increase his interactions with others, build rapport with staff members, and express his feelings through individual songwriting sessions with music therapy interns. Another adaptation is a hip-hop writing group. There are many patients in forensic settings who may identify with rap and the hip-hop culture. At this author’s facility, songwriting is used to help these individuals discover personal values, explore conflicts between personal goals, and identify skills needed to secure a good life. The patients create their own songs based on the guidelines given to them in the group and perform them for each other. Some guidelines include using respect, allowing each member to introduce himself musically without censoring his lyrics, and using constructive criticism to point out incompatible themes. Each new participant is asked to create a list of at least five personal values to be developed as themes in subsequent sessions. The group members are invited to suggest rhythmic or melodic motifs, and these are then developed into a musical accompaniment using live instruments. Songwriting in the style of rap creates an opportunity for these patients to share their culture, identify their strengths, determine personal values, and develop a vision for their future. Rio and Tenney (2002) describe a case study in which rap writing was used to help a client express himself appropriately. The client originally wrote a song with a lot of cursing, and the music therapist asked him to write another song with a more positive outlook and with clean language. Therapists can impose guidelines such as the type of content or language that is acceptable. Rap music often has expletives and negative content, but patients can be guided to create more appropriate compositions in order to advance in their treatment. Music therapists can also write original songs outside of group and bring them into their groups to accomplish various therapeutic goals. However, Jones (2006) reported that most clinicians working in mental health settings did not compose original songs for their groups. Some therapists feel that the patients’ preferred music is more valuable than original songs in other styles (Jones, 2006)). Patients in forensic settings appear to take more from the experience if they have input in the creation of the song, regardless of the style.

CLOSING REMARKS ON METHODOLOGY Many of the methods outlined in this chapter could be applied to a variety of patient populations. However, in most forensic settings, the importance of safety and security should always be taken into careful consideration no matter what type of activity is taking place. For this reason, it is recommended that the therapist work primarily in groups composed of 5 to 8 patients. Groups of this size provide the social interaction challenges that most forensic patients need in order to be successful in the community. Such groups provide treatment that educates patients on how to communicate, compromise, and solve

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problems in order to get along with others. In addition, the therapist will be less susceptible to manipulative behavior and boundary issues when working with groups of patients as opposed to individuals in forensic facilities. Whenever multiple diagnostic issues related to antisocial personality disorders, criminal-mindedness, mental illness symptoms, and cognitive disorders are combined in a patient population, the smaller group has an advantage in addressing the multitude of behavioral issues the therapist may need to manage. In addition, smaller groups tend to be easier to manage and more productive therapeutically, particularly when the patients are playing instruments. Individual work is only rarely recommended for treatment for this reason. The overall behavioral and cognitive level of functioning will always be the primary determining factor in the choice of methods and clinical process of a particular group in order to render it successful. In the setting presented in this chapter, groups are often held twice a week for 50 minutes to an hour for 12-week quarters. There is a one- to two-week break at the end of each quarter. The patients are assessed by their individual treatment teams, which decide if they are to remain in the same group or be referred to another treatment group. At the beginning of each new series of groups, patients are given specific information that pertains to the psychoeducational goals of that group. While this is primarily for the benefit of new patients, those members who are repeating a group have the opportunity to both review the information and perhaps be called on to explain to the new patients what the group is about. For the most part, the methods presented in this chapter present a procedure for a complete session because music therapy groups are often organized by method and patients are assigned to the group or groups that best suit their needs at the particular time of their treatment. Thus, receptive, improvisational, re-creative and compositional group methods are not combined within the same group, although there is one notable exception. The re-creative method of playing instruments to accompany familiar songs is often used during an improvisation group. The Exploring Music and Emotions group uses receptive and compositional methods. The structure inherent in the song form is helpful in improvisation groups when a group is struggling with grounding and attention issues. Because some patients are limited by mental illness and cognitive impairments, they are unable to successfully improvise on melodic instruments such as the xylophones, and their expression is often limited. These patients may find satisfaction in expression by playing nontuned percussion instruments in an improvisatory manner, using songs to structure their playing. This helps them to hear, pay attention to, and organize their expression by playing shorter melodic phrases in the song. In this way, they can experience success, thereby raising their self-esteem and preparing themselves for freer improvisations. Although combining group methods is not often used by the authors in the forensic facility discussed in this chapter, others may want to experiment and discover what might work well for them.

RESEARCH EVIDENCE Few studies exist in the music therapy literature concerning the forensic psychiatric population. All four methods of music therapy have been used in research, although improvisation is used most frequently, appearing in six out of eight studies.

Improvisational Music Therapy Hoskyns (1988) used Personal Construct Theory to study men and women offenders in group music therapy. Groups met once per week in 12-week sessions and typically used instrumental improvisation. The purpose of this research was to devise a strategy for studying this population. Findings reveal the importance of the therapist as a researcher in gaining trust during interviews and the need to balance rational, verbal responses to therapeutic outcomes with nonverbal, emotional responses. This study

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helped to inform a 1995 study by Hoskyns in which she developed rating scales to assess changes in group activity with the same population. Preliminary findings show observable changes in behavior among two of the 22 participants following 12 weeks of group music therapy sessions. In the only qualitative study of arts therapists working with forensic psychiatric patients, Smeijsters and Cleven (2006) interviewed participants to identify key behavior issues among this population and how this was addressed through the therapists’ modality. Findings show consensus-based rationales for using music therapy to address aggression through expression and regulation. All participants reported using forms of improvisation, such as playing musical instruments, drumming, musical role-playing, and discussing improvisations as related to aggression and anger.

Receptive Music Therapy While improvisational and re-creative methods were occasionally used in treatment groups with female inmates, a study by Chambers (2008) found the importance of song in prerecorded form. The researcher chose one group member for a naturalistic qualitative case study. The study focused on the use of metaphors through emergent design and inductive narrative analysis of 136 group sessions the participant attended. The author found that the use of songs served as vehicles for expression as well as developing song images (metaphors) whereby a transformative capacity was obtained. This allowed both client and therapist (participant and researcher) to explore and develop feelings associated with the music and relationships formed therein.

Multiple Methods of Music Therapy Thaut compared three music methods in a 1989 study. With a sample size of 50 male prisoner-patients with a mental illness, he found that music group therapy consisting of song selection and discussion, instrumental improvisation, and music and relaxation all produced significant changes (p < 0.05) in selfperceived ratings in thought/insight, mood/emotion, and relaxation. A small study by Langan, Williams, and Athanasou (1998) used singing and playing familiar songs, instrumental improvisation, and songwriting to measure participation levels. Four male inmates with psychiatric conditions attended six 40-minute music therapy sessions. Data was gathered through a process of researcher observation, audio recordings, and analysis of researcher notes. Rating scales based on six categories of behavior were used to measure overall responses to the various interventions in the treatment group. Response ratings taken repeatedly over a four-week period showed significant differences in levels of participation for the group [F(5,18) = 2.9, p < 0.05]. Daveson and Edwards (2001) conducted a descriptive study of five women in a prison setting using music listening, instrumental improvisation, songwriting, lyric discussion, song parody or lyric substitution, and singing familiar songs over 12 sessions. Based on self-report measures, the researchers found the various methods used in music therapy helpful in reducing tension and anxiety and increasing motivation and ties with reality. A qualitative study by O’Grady (2009) used the compositional and re-creative methods of songwriting and musical performance as a therapeutic tool for seven female inmates. O’Grady found that the process of working toward the performance served as a “bridge” from inside (prison, isolation, emotions) to the outside (typical life, sharing with others, interpersonal relationships).

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SUMMARY AND CONCLUSIONS In no other mental health setting is the efficacy of music therapy as important on so many levels as in a forensic mental health setting. The music therapy experiences presented in this chapter address the following primary therapeutic concerns: the patients’ major mental illnesses and the impact symptoms can have on their criminal behavior, personality problems affecting their social interactions with and empathy for others, and their difficulties controlling their hostility and aggression. Playing instruments and singing is a very grounding experience that supports a patient’s focus and attention in reality with others. Simply listening to music and learning how to use music to relax and to cope with emotion can help in this regard as well. All music activities conducted in groups support cohesiveness among group members. Music and sound have an effect on all who are present. Common physiological responses and feelings are experienced. When patients are motivated to produce a successful musical product, it is reflective of their willingness to be cooperative and empathetic. This type of cohesive social interaction involving intellectual, physiological, and emotional aspects can be one of the most therapeutic music therapy experiences. Any active music-making experience has the potential for providing an important visceral expression of feelings, which can be beneficial in reducing aggression. This is the primary objective for most of the patients being treated in forensic facilities. For some, a leisure-oriented karaoke group can be just as effective in reducing hostility as playing drums in an improvisational anger management through music group. Music improvisation is a direct expression of the patient’s own feelings and is a therapeutic process allowing for the release of a range of visceral content. This is particularly true for patients who are unwilling and/or unable to effectively express their feelings in a verbal manner. For some patients, the opportunity to express themselves musically can be an enjoyable experience in which they are motivated to participate. For resistant and paranoid patients, music therapy can be a bridge to developing a more positive attitude toward the therapeutic process or a more natural and rewarding way of coping with their problems. The less active receptive music therapy groups are particularly effective for resistant patients. Many are depressed, have physical limitations, or enjoy music but have less interest in playing an instrument. For these patients, the power of music to communicate and express emotions can help them better understand the negative impact of their illness and problems dealing with others. Lyric analysis can be used to work with patients with little to no insight about their mental illnesses and behaviors. The patients can discuss how people in the song might be feeling and what they may be experiencing without needing to recognize their own issues. It can also be used with patients with good insight about their illnesses and behaviors. Songwriting can be another way to build group cohesion while evaluating what the group has learned. Music and certain songs often speak to the universal connections and similarities among all people. Thus, music is an indispensable therapy for some of the most difficult patients in the forensic setting. A critical examination of literature regarding forensic mental health reveals a significant number of clinical examples and applications of music therapy research from the mental health field. While current forensic psychiatric research is lacking in areas of assessment and long-term effects of music therapy, it does provide a strong base for the use of all four methods of music therapy in the forensic mental health setting. The research is balanced between qualitative and quantitative studies, suggesting that both play an important role understanding how best to work with this population. While the quantitative studies tend to focus on the effectiveness of one or more methods on a specific behavior, the qualitative studies have helped to reveal the complexity of the therapist-client relationship and insight into the challenges and opportunities in working with the population as discussed herein.

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To provide effective delivery of music therapy services with this population, it is essential to understand disorders and issues related to mental health as well as the unique conditions, considerations, and environment that must be taken into account when working with the forensic patient. These considerations include the role of music therapy and the music therapist within the culture of the corrections institution and its security procedures, as well as an awareness of how to maintain security and safety for both forensic clients and the therapist.

REFERENCES American Psychiatric Association. (APA). (June 11, 2012a). DSM-5 Development. Personality disorders. Retrieved from http://www.dsm5.org/Pages/Default.aspx Material in revision and subject to change. American Psychiatric Association (APA). (June 11, 2012b). DSM-5 Development. Schizophrenia spectrum and other psychotic disorders. Retrieved from: http://www.dsm5.org/Defaultaspx. Material in revision and subject to change. Boone, P. (1991). Composition, improvisation and poetry in the psychiatric treatment of a forensic patient. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 433–450). Gilsum, NH: Barcelona Publishers. California Department of Mental Health. (n.d.). Mentally disordered offenders program. Retrieved May 13, 2012, from http://www.dmh.ca.gov/services_and_programs/Forensic_Services/MDO/default.asp California Penal Codes: With Selected Provisions from Other Codes and Rules of Court. (2012). New York: West A Thompson Reuters Business Publishers. Chambers, C. (2008). Song and metaphoric imagery in forensic music therapy. Dissertation. University of Nottingham. Codding, P. (2002). A comprehensive survey of music therapists practicing in correctional psychiatry: Demographics, conditions of employment, service provision, assessment, therapeutic objectives, and related values of the therapist. Music Therapy Perspectives, 20(2), 56–68. Compton Dickinson, S. (2006) Beyond body, beyond words: Cognitive analytic music therapy in forensic psychiatry—new approaches in the treatment of Personality Disordered Offenders. Music Therapy Today,, VII(4), 839–875. Retrieved from: http://www.wfmt.info/Musictherapyworld/modules/mmmagizine/showarticle.php?articletosho w=187 Daveson, B. A., & Edwards, J. (2001). A descriptive study exploring the role of music therapy in prisons. The Arts in Psychotherapy, 28(2), 137–141. doi: 10.1016/S0197-4556(00)00089-7. Davis, M., Eschelman, E. R., & McKay, M. (2000). The relaxation & stress reduction workbook (5th ed.). Oakland, CA: New Harbinger Publications, Inc. Fulford, M. (2002). Overview of a music therapy program at a maximum-security unit of a state psychiatric facility. Music Therapy Perspectives, 20(2), 112–116. Gallagher, L. M., & Steele, A. L. (2002). Music therapy with offenders in a substance abuse/mental illness treatment program. Music Therapy Perspectives, 20(2), 117–122. Glyn, J. (2002). Drummed out of mind: A music therapy group with forensic patients. In A. Davies & E. Richards (Eds.), Music therapy and group work: Sound company (pp. 43–62). Philadelphia, PA: Jessica Kingsley.

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Haan, S., Clift, S., Hancox, G., Staricoff, R., & Whitmore, C. (2008). Singing and Health: Summary of a Systematic Mapping and Review of Non-Clinical Research. Sidney De Haan Reports 5, Sidney De Haan Research Centre for Arts and Health. Retrieved from. http://www.wlu.ca/documents/32033/Singing_and_Health.pdf Hadley, S., & Yancy, G. (Eds.). (2011). Therapeutic uses of rap and hip-hop. London: Routledge/Taylor & Francis Group. Hakvoort, L. (2002a). A music therapy anger management program for forensic offenders. Music Therapy Perspectives, 20(2), 123–132. Hakvoort, L. (2002b). Observation and treatment criteria in music therapy for forensic patients. In J. Fachner & D. Aldridge (Eds.), Dialogue and Debate-Conference Proceedings of the 10th World Congress on Music Therapy (pp. 723–744). Witten, Germany: MusicTherapyWorld.Net. Retrieved from: http://wfmt.info/WFMT/2011_World_Congress_files/Proceedings%20Oxford_2002.pdf Hare, R. D. (1993). Without conscience: The disturbing world of the psychopaths among us. Published 1999. New York: Guilford Press. Hoskyns, S. (1988). Studying group music therapy with adult offenders: Research in progress. Psychology of Music, 16(1), 25–41. doi: 10.1177/0305735688161003. Hoskyns, S. (1995). Observing offenders: The use of simple rating scales to assess changes in activity during group music therapy. In A. Gilroy & C. Lee (Eds.), Art and music, therapy and research. London: Routledge. Jeffries, K. J., Fritz, J. B., & Braun, A. R. (2003). Words in melody: an H (2) 150 PET study of brain activation during singing and speaking. Neuroreport, 14(5), 749–754. Jones, J. D. (2006). Songs composed for use in music therapy: A survey of original songwriting practices of music therapists. Journal of Music Therapy, XLIII(2), 94–110. Koelsch, S., Offermanns, K., & Franzke, P. (2010). Music in the Treatment of Affective Disorders: An Exploratory Investigation of a New Method For Music-Therapeutic Research. Music Perception, 27(4), 307–316. Langan, D., Williams, P., & Athanasou, J. A. (1998). Outcomes of a music therapy intervention in a psychiatric ward within a correctional services institution. In R. R. Pratt & D. E. Grocke (Eds.), MusicMedicine 3: MusicMedicine and music therapy: Expanding horizons (pp. 275–284). St. Louis, MO: MMB Music, Inc. Loth, H. (1996). Music therapy. In Forensic psychotherapy: Crime, psychodynamics and the offender patient (pp. 561–566). London: J. Kingsley Publishers. McFerran, K., Baker, F., & Krout, R. (2011). What’s in the lyrics? A discussion paper describing the complexities of systematically analyzing lyrics composed in music therapy. Canadian Journal of Music Therapy, 17(1), 34–54. Nilsen, V. (1996). Music in prison and freedom. Nordic Journal of Music Therapy, 5(2), 113–118. Nolan, P. (1983). Insight therapy: Guided imagery and music in a forensic psychiatric setting. Music Therapy, 3(1), 43–51. Nolan, P. (2002). Verbal processing in music therapy. In J. Fachner & D. Aldridge (Eds.), Dialogue and Debate-Conference Proceedings of the 10th World Congress on Music Therapy (pp. 1153–1167). Witten, Germany: MusicTherapyWorld.Net. Retrieved from: http://wfmt.info/WFMT/2011_World_Congress_files/Proceedings%20Oxford_2002.pdf O’Grady, L. (2011). The therapeutic potentials of creating and performing music with women in prison: A qualitative case study. In S. Gardstrom (Ed.), Qualitative inquiries in music therapy: A monograph series (pp. 122-152). Retrieved from: http://www.barcelonapublishers.com/onlineperiodicals/ Reed, K. J. (2000). Music is the master key. Orlando, FL: Rivercross.

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Reed, K. J. (2002). Music therapy treatment groups for mentally disordered offenders (MDO) in a state hospital setting. Music Therapy Perspectives, 20(2), 98–104. Rio, R. E., & Tenney, K. S. (2002). Music therapy for juvenile offenders in residential treatment. Music Therapy Perspectives, 20(2), 89–97. Sears, W. W. (1968). Processes in music therapy. In E. T. Gaston (Ed.), Music in therapy (pp. 30–44). New York: Macmillan Publishing Co., Inc. Sloboda, A. (1997). Music therapy and psychotic violence. In E. V. Welldon & C. Van Velsen (Eds.), A practical guide to forensic psychotherapy (pp. 121–129). Philadelphia, PA: Jessica Kingsley. Sloboda, A., & Bolton, R. (2002). Music therapy in forensic psychiatry: A case study with musical commentary. In L. Bunt & S. Hoskyns (Eds.), The handbook of music therapy (pp. 132–148). New York: Brunner-Routledge. Smeijsters, H. , & Cleven, G. (2006). The treatment of aggression using arts therapies in forensic psychiatry: Results of a qualitative inquiry. The Arts in Psychotherapy, 33(1), 37–58. doi: 10.1016/j.aip.2005.07.001. Spang, S. (1997). Forensic psychiatry and music therapy. Annual Journal of the New Zealand Society for Music Therapy, 17–28. Summer, L. (1988). Guided Imagery and Music in the institutional setting. St. Louis, MO: MMB Music, Inc. Thaut, M. H. (1987). A new challenge for music therapy: The correctional setting. Music Therapy Perspectives, 4, 44–50. Thaut, M. H. (1989). The influence of music therapy interventions on self-rated changes in relaxation, affect, and thought in psychiatric prisoner-patients. Journal of Music Therapy, 26(3), 155–166. Thaut, M. H. (2005). Rhythm, music, and the brain: Scientific foundations and clinical applications. New York: Routledge. Watson, D. M. (2002). Drumming and improvisation with adult male sexual offenders. Music Therapy Perspectives, 20(2), 105–111. Wyatt, J. G. (2002). From the field: Clinical resources for music therapy with juvenile offenders. Music Therapy Perspectives, 20(2), 80–88. Zwerling, I. (1979). The creative arts therapies as “real therapies.” Hospital and Community Psychiatry, 20(12), 841–844.

Chapter 17

Adult Females in Correctional Facilities Karen Anne Litecky Melendez

DIAGNOSTIC INFORMATION This section provides basic criteria for correctional placement and mental health classification of incarcerated adult females and identifies mental health diagnoses most common to this population and symptoms related to the diagnoses that impact treatment. (Note: The terms adult women, patient, member, and group member are used interchangeably throughout this chapter.) Correctional mental health is a term used to identify individuals with mental illness who reside in a prison environment and who have been convicted and sentenced for criminal behavior by state or federal court. Sentence length is often 365 days or longer, a basic requirement for placement in a state prison (vs. county jail, which is less than 365 days). Upon admission, the offender is assessed for mental health issues that may require treatment. Depending on the severity of the symptoms and diagnosis, they may be placed on a mental health roster and treated while living in the general population housing units or housed in a segregated part of the prison specific to mental health care (Codding, 2002). These segregated units often involve a multidisciplinary level of care including a team of psychologists, social workers, licensed professional counselors, nurses, occupational therapists, creative arts therapists and/or recreational therapists. If mental health symptoms arise during incarceration, the offender may be referred for assessment and appropriate placement and treatment. If the offender is housed in a segregated mental health unit but continues to decompensate and requires more intense services, she may be temporarily placed in an affiliated hospital’s forensic psychiatric unit until she demonstrates enough progress to return. Adult female inmates on the roster for mental health care (sometimes referred to as special needs) are diagnosed based on criteria from the American Psychiatry Association’s (APA) Diagnostic and Statistical Manual (DSM). Most common among this population are the following diagnoses: Substance Use Disorder, Antisocial/Psychopathic Personality Disorder, Borderline Personality Disorder, Adjustment Disorder, Mood Disorders, Post Traumatic Stress Disorder (PTSD), Malingering, and Chronic Mental Illness. What follows is a brief overview of these diagnoses and symptoms of each disorder that often appear in the adult female correctional mental health setting. This description is heavily drawn from the DSM-5 Development (APA, 2012). Substance Use Disorder: Seventy percent of incarcerated women have been found to be under the influence of illegal substances when committing their crime or to have engaged in criminal behavior related to illegal substances. Substance-related issues are an integral part of therapeutic treatment in most Correctional rehabilitative programs, and have been described by some as the key issue blocking an inmate’s success in society. Often the inmate has arrived from county jail or another unit with several weeks or months of abstinence, but sometimes the transfer to state prison from society is shorter. If the

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latter is the case, withdrawal signs may be evident and confused with symptoms of more serious mental health problems. Time and observation are of utmost importance to determine symptom validity and correct classification. Other addictive traits include: obsessive thinking and behaviors (e.g., preoccupation with and excessive use of substitute items such as coffee or medications), all-or-nothing thinking (limited insight and ability to compromise), self-centeredness, somatic complaints, glorification of substance use (grandiosity), limited knowledge of recreation without substance use, and a reduction in interests. One can sometimes sense the seriousness of an inmate’s addiction by learning what she gave up for drugs (e.g., treasured instruments, children, etc.). It is important to remember that abstinence from substance use may be due only to being in a controlled environment (i.e., prison). Therapeutic intervention during incarceration may be one of few times when a troubled adult female can constructively reflect on herself and choose a better way of living. “Many individuals who abuse drugs and alcohol also have some form of mental illness … [and] many of those who are diagnosed with substance abuse and mental illness are also criminal offenders” (Gallagher & Steele, 2002, p. 117). Personality disorders are highly prevalent among special needs adult females in Corrections. Most common are Borderline and/or Antisocial/Psychopathic Personality Disorders. Both include a tendency toward anger/agitation, resistance to authority, and unstable personal relations. These symptoms, if unchecked and unaddressed, may lead to dangerous situations of escalating violence, boundary violations, and undue familiarity between inmates and correctional officers, other inmates, or civilian staff. Frequent irritability and displays of anger decrease safety and increase stress levels on housing units. Symptoms commonly associated with these disorders may contribute to the incarcerated female’s reputation of having a strong propensity for cat fights and drama. Antisocial/Psychopathic Personality Disorder: In his work with males in a medium-secure forensic psychiatric unit, Glyn (2002) notes the importance of staff awareness of “relating to the patients as just vulnerable and failing to recognize the hidden aggressive sides” (p. 61). He comments on the therapist’s “tendency to relate to forensic patients as if they are much less ill than they actually are,” especially when patients “superficially present as relatively undisturbed” (2008, p. 68). While treating adult females in Corrections, it is similarly important to keep a healthy balance between empathy for symptoms of mental illness and awareness of criminal and/or sociopathic tendencies. In her writings on adult male sex offenders in a residential treatment center, Watson (2002) notes that “psychopathy is characterized by pathological lying, conning or manipulation, lack of remorse or guilt, failure to accept responsibility, impulsivity and need for stimulation” (p. 107). Traits that directly affect therapeutic work include disregard for others; narcissistic and grandiose tendencies; superficiality; resistance to authority; exhibiting control of others and/or the group; little to no capacity for self-reflection; lack of empathy and/or emotional connection to self and others; an irritable, angry, and/or aggressive disposition; low frustration tolerance with a tendency for impulsivity without regard to others; poor social/relational skills; lack of self-discipline; and motivation for self-interest and personal power only, with no regard for appropriate social mores (APA, 2012, T04). Of the many diagnoses, working with adult females suffering from Borderline Personality Disorder can be most challenging. Symptoms include very low self-worth (tendency for depression); difficulty determining and following through with personal goals; hypersensitivity; a limited ability to recognize the needs of others; very unstable and intense personal relations; unstable emotions and rapid mood changes; a high degree of anxiety around personal stressors; intense fears of rejection and/or abandonment/separation; impulsivity and self-harming behaviors (e.g., self-mutilation, substance use, etc.); and frequent display of irritability, anger, and/or hostility (APA, 2012, T00). Inside prison walls, these traits sometimes take on an even more serious dimension than those found in society. The degree of self-mutilation can be quite severe and horrific. A tendency to get caught in the downward spiral of tumultuous and unstable relations with other adult females may lead to increased disciplinary infractions

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and increased sentence length. Extremely low self-esteem and worthlessness are often a constant no matter how much external progress the female demonstrates. This makes therapeutic work exhausting. Close to symptoms of psychopathy is evidence of Malingering. Malingering is a condition whose manifestation results in “the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives” (APA, 2000, p. 739). It is important to remain aware of the possibility of malingering, as some inmates will go to any length to exaggerate symptoms to create the appearance of a more severe diagnosis, deceive others in an effort to reduce or change their prison sentence, and/or fabricate symptoms for any number of external incentives (Conroy & Kwartner, 2006). Examples of external incentives include receiving more medication to feed their own addictions or to sell them for money to other inmates; to prey on the weak, more vulnerable inmates (like the mentally ill); to receive attention (other personality traits may be at work here); to receive more privacy by being housed on a unit with individual cells; or to stay at a location and avoid moving forward into general population, grounds, or society. Malingering commonly takes the form of feigning psychotic symptoms such as reporting auditory or visual hallucinations, or limitations in physical movement like unsteady gait or false seizures. Detection includes reports of manipulative behavior with officers and other inmates. Adjustment Disorder: It is common for adult females first entering the prison system to be placed on special needs status due to the overwhelming stress of adjusting to life in prison. Within the first few weeks of arrival, a significant impairment in social, job-related, or other important areas of functioning is sometimes noted, often accompanied by a depressed mood and/or anxiety (APA, 2012, G04). Adult females sometimes verbalize a deep sense of hopelessness and/or nervousness when coping with separation from loved ones and children, the stark reality of their crime and its resultant consequences, and what is often the abrupt adjustment to coping with the inmate and Corrections environment (Codding, 2002). Mood Disorders: Strongly prevalent among adult females, mood disorders are often associated with substance use and a life of poverty, abuse, and neglect. Mood Disorder refers to “disorders that have a disturbance in mood as the predominant feature” (APA, 2012, Chapter 6). Symptoms often appear as episodes, with identified degrees of depression, mania, and/or both (APA, Chapter 6). Symptoms of Depression in adult females in Corrections may include extreme fatigue (inability to stay awake or pay attention); preoccupation or difficulty concentrating; intense feelings of sadness/hopelessness; little interest in anything; low physical energy (limited active involvement, psychomotor retardation); psychotic symptoms; and/or suicidality. In the prison setting, suicides and attempted suicides are of particular concern. Specific protocols are often in place to keep the suicidal inmate safe and to maintain safety precautions against suicide on all units. These protocols grew from research supporting a reduction in the risk of successful attempts. Precautions include the elimination of single-inmate cells in favor of double-bunk cells, even in long-term administrative segregation units (i.e., detention). Symptoms of Mania appear as irritability or overly elated mood, dominance of group, and/or disruption to the group process. Inmate behavior during a manic episode may include rapid or pressured speech, a limited ability to focus, constant flight of ideas (tangential at times), very loud verbal and creative expression (e.g., with the voice or an instrument such as the drum or cowbell), an inability to remain seated, and/or an inability to wait or pause (APA, 2012, Mood Disorders). Listed under Anxiety Disorders in the DSM IV-TR are anxiety, panic, agoraphobia, and PTSD (APA, 2012, Chapter 7). Symptoms may include a preoccupation with worry (like an inmate constantly talking about her next date before the Corrections panel, an anticipated move from the unit, or an issue with medication); physical symptoms of distress (such as chest pressure or feeling like she is going crazy); an inability to concentrate or tolerate the group setting; hypervigilance (especially toward Corrections, institutional interruptions or other inmates); and/or repeated statements of inability to cope (sometimes accompanied by very constricted affect or ongoing tearfulness).

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A large percentage of incarcerated women are victims of emotional, physical and/or sexual abuse and have a history of exposure to violence. As such, it is common for many of them to suffer from symptoms of PTSD. Symptoms may include dissociative reactions (shutting down, blanking out, withdrawing from a group), sudden tearfulness or mood changes, recurrent invasive thoughts, inhibiting ability to participate or trust, negativity, limited capacity for emotions and emotional expression, exaggerated startle response, and difficulty concentrating. Sometimes adult females suffering from PTSD report a hypersensitivity to particular musical instruments like the triangle or drum, so caution must be used when engaging in musical improvisation or instrument playing. Chronic Mental Illness: Perhaps the most tragic of adult female inmates to work with are those who fall under the umbrella of “Criminalization of the Mentally Ill.” These are individuals who become trapped within correctional systems due to inadequate care and treatment (Ficken & Gardstrom, 2002). Their crimes often occur while they are actively psychotic, for survival (out of desperation), or due to victimization. Factors precipitating incarceration often include homelessness, lack of social/family support, lack of medical/psychiatric care, treatment noncompliance, and complications of substance use/abuse. Common symptoms of Schizophrenia include active psychosis; fixed delusions; negative symptoms such as diminished emotional expression, withdrawal, and flat affect; and/or disorganized and/or bizarre thoughts and behavior. Interpersonal relations are often difficult; emotions are unstable, absent, or inappropriate (APA, 2012, B08). Sometimes paranoia is evident, putting the inmate and others at risk for increased violent/assaultive behavior. Medication compliance and insight into the need for medical care is often greatly limited. Limited secondary processing; poor activities of daily living (ADLs), such as proper hygiene; and poor social relations make these adult females particularly vulnerable to others. Even if they are successfully stabilized while in prison, most adult females with chronic mental illness are released to society with minimal supportive services. Only the most acute cases are courtcommitted to a state mental health facility for psychiatric treatment following their release. Next to Schizophrenia, Schizoaffective Disorder is common among incarcerated adult females. This disorder includes symptoms of a major mood episode such as mania and/or depression in addition to the presence of delusions and/or hallucinations (APA, 2012, B07). Individuals with chronic mental illness are difficult to treat; socialization and motivation for self-improvement is limited, and dependence on the system and others is quite common.

NEEDS This section provides information on specific needs of adult females in Corrections. It includes a profile of the average adult female in Corrections, discusses key stressors, and notes differences in adult female inmates (vs. males) that impact mental health care. The average age of the incarcerated adult female is 35, with a three-year length of sentence. If tried and sentenced as an adult, females younger than 18 years of age may be included in the category of “adult female.” At least half of today’s incarcerated adult females are African-American, one third are Caucasian, and about one tenth are Hispanic; African-American and Hispanic populations are growing the fastest (Braithwaite, Treadwell, & Arriola, 2005). Key stressors leading to incarceration include substance use, poor representation and support, the challenges of child care, limited education, poverty, and poor mental and medical health (Braithwaite et al., 2005). As noted, drug-related offenses predominate. A history of exposure to harm, violence, poverty, and isolation is common, which may accelerate the fall into criminal behavior (Anderson, 2001; Braithwaite et al., 2005). Though many struggle with issues related to insecure attachment, the majority of adult females are parents of children under the age of 18, with African-American and Hispanic women having “more children than their White counterparts, [which] … makes them more likely to resort to

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criminal activities to make ends meet” (Braithwaite et al., p. 3). Education for more than half the total population is limited (i.e., no high school diploma); job skills and training are minimal, and about 60% are unemployed prior to incarceration. Close to one tenth of adult females are homeless (Correctional Association of New York, 2009). This factor, coupled with mental illness and/or substance misuse, may lead to longer periods of incarceration, complicating placement following release (McNeil et al., 2005). A co-morbidity of two or more disorders is common among inmates with mental health issues. Homelessness is correlated with an increase in violent behavior and in medical issues (Greenberg & Rosenheck, 2008). Most adult females entering Corrections present with a number of medical concerns. Those who are survivors of physical and/or sexual abuse are at “greater-than-average risk for high-risk pregnancies and life-threatening illnesses like HIV/AIDS, hepatitis C, and human papillomavirus infection” (Braithwaite et al., 2005, p. 1680). Providing supportive mental health and medical services, especially to those with multiple incarcerations, is costly; but failure to address these needs during incarceration can adversely affect our society (McNeil, Binder, & Robinson, 2005; Braithwaite et al., 2005). Insensitivity to differences in gender and the needs of females (as opposed to males) has been identified as an additional source of stress for adult females in Corrections. These differences are reflected in her representation and placement in society, need for public assistance, receipt of punitive sanctions, relational dynamics with loved ones and with other inmates, child care responsibilities, medical needs, and mental health needs. Criminal justice has been described as a system created by males for males (Braithwaite et al., 2005). Add to this the belief that women are among the most disadvantaged of our society, and their “concerns … are often downplayed by all segments … including health care professionals” (Braithwaite et al., p. 1681). Historically, adult females have been “underrepresented at all levels” of the criminal justice system (Braithwaite et al., p. 1679). This is reflected in everything from poor legal representation to minimal paper products (such as toilet paper and sanitary napkins)—the latter due to administrative decisions on rations based on the needs of males. While serving a prison sentence might elevate the status of a male criminal (particularly if gangaffiliated), adult females who have been incarcerated have less status. In drug- and gang-related crimes, adult females generally play smaller parts, “but they often receive longer prison sentences than men because their limited knowledge of the drug operations leaves them without the means to negotiate deals or because they are afraid to testify against the violent male leaders of the rings” (Braithwaite et al., 2005, p. 1681). A larger percentage of adult females than males is dependent on public assistance prior to incarceration (Correctional Association of New York, 2009); this may lead to more dependent tendencies on mental health and Correctional services. Disciplinary citations issued to adult females who commit infractions while in prison are often pettier in nature and more prevalent than those of males (Braithwaite et al., 2005). While males generally fight to kill, females often engage in violations that are not terminal but instead violent and dramatic (e.g., hot oil on face, lock in a sock, etc.). Due to the number of individuals sentenced to prison, each state commonly has multiple facilities which house inmates by type of offense committed and/or sentence length. While the number of incarcerated adult females has greatly increased over the years, the overall number of adult females is significantly lower than that of males (Braithwaite et al., 2005). As such, a minimal number of facilities in each state (often one or two) are usually designated for adult female offenders. These facilities have traditionally been located “far from … major urban center[s],” isolating the adult female from what little social supports she has, making it expensive and difficult for children and loved ones to visit (Braithwaite et al., p. 1681). The mixture of criminals all housed in one location contributes to a more volatile environment where weaker, more vulnerable, adult females with minor crime histories are at the mercy of more manipulative and aggressive criminals (Braithwaite et al., 2005). Personal relations and emotional expression are of greater significance to adult females than to males. Unique to adult female correctional settings, often surrogate-like families are formed among

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inmates. Close attachments, some of which have romantic and/or motherly overtones, are so strong that adult females who get involved have been known to sacrifice their release dates by accruing more charges and longer sentences for the sake of the relationship. Unlike males, almost two-thirds of incarcerated adult females who are mothers lived with their children prior to sentencing; many were solely responsible for their children’s care (Correctional Association of New York, 2009). “Many incarcerated women have lacked health care prior to their imprisonment” (Braithwaite et al., 2005, p. 1680). In New York State, the rates of Hepatitis C and HIV for adult females were reported as double those of males, and “14 times higher than the general public” (Correctional Association of New York, 2009). Adult females were more likely than males to have histories of physical and sexual abuse (Women in Prison, 2009). In addition, Blitz, Wolff, and Paap (2006) found that “relative to their male counterparts, women incarcerated in state prisons are more likely to have psychiatric disorders” (p. 356). From this backdrop of key stressors in and out of the Corrections environment, the most prevalent needs of incarcerated adult females include the need for safety, for supportive relationshipbuilding, for access to mental health and medical services, and for opportunities that educate, empower, and motivate them toward effective self-care and care of others. Translated into the therapeutic setting, of paramount importance are individual and group opportunities that identify personal strengths and build autonomy; support identification and healthy expression of emotions beyond anger and aggression; teach and give the chance to practice effective coping skills; foster a healthy social environment based on mutual respect and effective relationship-building; educate on improved quality of life without the use of selfdestructive substances or self-defeating behaviors; and expose adult females to effective role models and supportive community-building—fostering hope and motivation for their future.

RESOURCES Rio and Tenney (2002), in their work with male and female juveniles in detention, note that adapting musical experiences to the individual strengths and needs of each patient is important to program success. Similarly, individualizing treatment with adult females in Corrections helps to identify and utilize each person’s unique inner resources, which promotes success. Inner resources include her openness to arts-oriented approaches, desire to learn, ability to adapt, longing for self-improvement, strong emotional nature, tendency toward relationships and relationship-building, motivations for the future, and yearning for escape and release from stress. Female offenders have been found to be more open to arts-oriented approaches than males (Silber, 2005). They are often eager to learn and to practice new skills. The forensics/Corrections population in general has been found to respond more effectively to action-oriented, nonverbal approaches (Nolan, 1983). Engaging the senses—from auditory (listening), to visual (observing), to tactile/physical (playing/singing/moving)—involves the whole person, allowing for active creative exploration and retraining on a multisensory level. Finding a creative way to explore, discover, and rebuild an adult female’s ability to cope is a refreshing alternative and a complement to verbally oriented approaches employed by other modalities in mental health care in Corrections. While living in prison is extremely difficult and depressing, it often forces the adult female to tap into her ability to adapt in order to survive. Examples exist every day where adult females use limited resources to creatively get their needs met—from innovative cooking and artwork to hair-braiding styles and journaling. These demonstrations are evidence of the adult female’s desire to improve her environment and quality of life. This creative drive makes her a good candidate for alternative methods like music therapy. Acting-out behavior is usually at a minimum during creative arts therapy. From her work with males in an anger management program for forensic offenders, Hakvoort (2002) notes that the therapist’s

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role is to provide a “containing musical environment, which makes the patient feel safe” (p. 124). In their work with males in a forensic psychiatry regional secure unit, Sloboda and Bolton (2002) describe this role as having “a responsibility to help the patient communicate verbally, as well as through the art medium, about his or her mental state” (p. 134). Once the patient realizes the music therapy environment is supportive and helpful rather than punitive, she often responds positively and relies on the therapy for effective release, exploration, and personal growth. Emotional expression is of greater significance to females than males (Silber, 2006). However, through stressful life experiences, a female’s connection with her emotions is sometimes lost or damaged. “Music is strong in stirring emotions” (Hakvoort, 2002, p. 126). The very essence of music involves the emotions and can be used to support exploration and relearning of emotional identification and expression. Music’s vibratory nature resonates within the being, allowing for an awareness of feeling in the body, supporting a connection to self. This can be cathartic, validating, and empowering (Buschong, 2002). Exploring emotions through music happens with engagement of the imagination and can allow for release of negative feelings. Introducing ways to safely channel negative emotions such as anger, frustration, and aggression is an important part of effective therapy with incarcerated adult females suffering from trauma, depression, and substance and personality disorders. Personal relationships have been found to be of greater significance to females than males (Silber, 2005). In their work with adolescent females, Rio and Tenney (2002) note that the “ability to listen and empathize with other clients in group process seemed to come naturally for the girls” (p. 92). A displayed hunger for relationships is evident in their tendency to “seek surrogate family relationships” (Silber, 2005, p. 255). “Developing relationships using music as a catalyst offers … new opportunities to form healthy attachments” (Rio & Tenney, 2002, p. 90), preparing the adult female for building supportive relations in her own life in and out of prison. Adult females find common bonds through shared musical preferences, experiences, and discussion (Rio & Tenney, 2002). The tendency for many inmates to idolize the lifestyles of popular musicians (Hakvoort, 2002) allows for further investment in the use of music in therapy. Bringing together groups of females to participate in a creative effort like a choir is a great way to develop interdependence and build supportive community (Rio & Tenney, 2002), a healthy alternative to the Corrections environment of criminal behavior (Silber, 2005). Added benefits of community-building include a reduction in stress in the units, a focus on receiving attention for positive behavior (instead of from negative acting-out behaviors), and the opportunity to be recognized for one’s achievements in a supportive environment. This latter point is something many adult females in Corrections missed out on in their youth and early adult years. A key motivating force for many adult females in Corrections is the dream of attachment or reunion, particularly with their children. Closely in line with this is a desire to be a better mother and a better partner and to have a happy life. This dream is not to be crushed but used to open the door to hope. An abundance of life stressors and the reality of survival in “institutionalized spaces experienced within the prison walls” (O’Grady, 2011, p. 134) foster a strong desire to escape. Prior to incarceration, many adult females found little relief from stress beyond the experience of getting high. Introducing healthy forms of escape through music therapy activities plants the seed for drug-free effective coping. Nearly every adult female has access to music in and out of prison, whether through commonly purchased handheld radios on the inside or similar items plus venues such as church and community choirs on the outside. Consciously applying relaxation, visualization, quiet listening, active music-making, and community-based performance methods allows for an experience that is satisfying, healing, and safe. Supporting an adult female’s exploration of healthy and fun ways to escape helps to meet her needs; promotes a safe, therapeutic prison environment; and fosters her connection to reality beyond prison.

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REFERRAL AND ASSESSMENT PROCEDURES There are no specific published music therapy assessments written for adult females in Corrections. However, the first step is always to assess for safety risk. In outlining individual music therapy sessions for adults in maximum security, Fulford (2002) defines a music therapy assessment as gathering “information in the following skill areas: gross and fine motor, cognitive, communication, social, emotional, and musical assessment of functioning” (p. 115). She notes that in her location, the unit’s occupational therapist and music therapist complete a dual assessment; both reports are compared and combined. Gallagher and Steele (2002) use an assessment in the form of a questionnaire in an outpatient substance abuse/mental illness treatment program with offenders. “Questions include: (1) musical preference, (2) musical background, (3) responsiveness to/use of music, (4) favorite song, (5) favorite singer or group, (6) musical triggers, (7) former drug of choice, (8) reason for participation in SA/MI program, and (9) methods utilized for relaxation. The assessment is repeated every three months, giving the therapist the opportunity to identify changes in the client’s outlook on treatment” (p. 118). They also suggest the use of the Rogers’s (1981) Happy/Sad Face Assessment Tool at the start and end of each session to determine patient mood and mood changes during the session (p. 118). Hakvoort (2002) notes the importance of a “collaborative assessment” (p. 125) between therapist and patient, outlining an eightquestion before-and-after test. In their study of females in Corrections, Daveson and Edwards (2001) note using two surveys that use self-report measures and the “evaluation of musical and verbal material shared” (p. 139) during a 12-session study. However, these measures are discussed without the details of specific methods used (Daveson & Edwards, 2001). In addition to assessment typically including “a patient’s interaction, communication, and selfexpression, as indicated by the way a patient plays a musical instrument, or musical parameters like dynamics and articulation” (p. 133), Sloboda and Bolton (2002) describe a detailed commentary of “various aspects” of improvisations (or “musical events”) (p. 145). This includes noting the resemblance of a piece to a particular genre; key variance or stability; dissonance and/or consonance; subdivisions and overall structure; chord progressions; identification of instruments that dictate harmonic movement; chord lengthening; resolution; musical embellishments; harmony; accompaniment style (example: arpeggio movement, doubling, etc.), including textural strategies; rhythmic cadence (includes stability or fluidity); use of syncopation; movement of melodic line(s); interaction between instruments and dynamics; and then comparison of musical events to each other as reflective of patient changes over time. Bolton (2002) notes that “general clinical practice does not allow time to do” such detailed commentaries (p. 147). While laborious, their analysis seemed to support the therapist’s view of the nature of changes in the patient over time (Sloboda & Bolton, 2002). In support of analyzing behavior, Hoskyns (1988), researching music therapy with male and female adult recidivist offenders, noted the effectiveness of using video footage. This was used for group process observation and for patient self-evaluation. In their study of music therapy interventions with males in a psychiatric ward within a correctional services institution, Langan, Williams, and Athanasou (1999) examined levels of responses in six categories (emotional response, musical awareness, musical initiations, musical participation, movement response, and musical sharing). From this, they suggest a long-term study of the differences in these responses and recommend the development of an assessment for entry into music therapy programming and/or a “baseline or expected normal level of music behavior” to determine client progress within a music therapy intervention (p. 281). Although Glyn (2008) notes completing an assessment following team recommendation of a patient to individual music therapy, no details of the assessment process are given. Writing about his work with males in a psychiatric hospital inside a closed custody state prison, Thaut (1987) does not outline an initial assessment but shares questions related to the completion of short- and long-term evaluations (p. 48). Short-term evaluations combine an evaluation of individual “subjective

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verbal reports” with assessment of “nonverbal behavior” and individual “actions”; long-term evaluations assess “short-term observations in music therapy, comparing them to behavior criteria defined throughout individual treatment plan goals … adding this composite evaluation to the total treatment team evaluation” (p. 48). A general psychological/medical assessment is required upon admission to prison. If an inmate is classified as special needs and referred for treatment, a licensed psychologist completes a more detailed assessment. A nursing/medical intake assessment is also completed if the inmate is admitted to a mental health unit. Once the adult female is on the special needs roster, she may be referred to as patient. If team members note continued concern regarding a patient’s medical, mental, and/or behavioral status, additional testing may be requested which assists with more effective treatment, even placement following release from prison (Fulford, 2002). Testing may include a rule-out of behaviors such as malingering, IQ level assessment, neuropsychological assessment, etc.

SPECIAL CONSIDERATIONS IN CORRECTIONS This section highlights special considerations for the therapist working in the correctional setting with adult females. Areas covered include equipment and supplies; conducting sessions; privacy; unit dynamics, resistance, and patient involvement; the therapeutic relationship; and correctional officers.

Equipment and Supplies In Corrections, the use of music equipment may be limited or restricted by the level of security. While instruments and props like music CDs and stereos are beneficial to treatment, their inclusion is also a security risk. Policies often require written administrative approval prior to equipment purchase; supervision of equipment while in use; and safe storage in a locked location. All supplies must be accounted for at all times. The best method to accomplish this is by keeping a regular inventory of supplies at the start and end of each session before inmates are dismissed from the room, reporting immediately to correctional officers any items that are missing or misplaced. Some units require the therapist to carry a copy of the approved list of items with administrative signature; this list is reviewed each time the therapist goes through a security checkpoint. If any supplies (music or other) specified for music therapy use are found in a patient’s possession outside the session, disciplinary sanctions may be issued to the patient and the therapist may be denied the opportunity to use the supplies in the future. In accordance with these provisions, the therapist may have a wealth of resources at her disposal, including music CDs and CD players (minus radio antenna or recording device), karaoke machines (without camera or recorder), electronic keyboard with pedal; acoustic guitar, capo, pick and strap, tuner and metronome, and various tuned and nontuned percussive instruments such as bongos, buffalo drum, cabasa, claves, conga, djembe, egg shakers, guiro, kokiriko, slit drums, tambourine, tone chimes, triangle, maracas, jingle bells, rain stick, and xylophone. Soft mallets and drumsticks may be included, but use of hands is preferred in groups focused on drumming or anger management (Fulford, 2002). Equipment may include other items like an electronic musical instrument or drum machine (Gallagher & Steele, 2002), electric guitar (with distortion), electric bass and/or wah-wah pedal (Fulford, 2002), resonator bells (Schmidt, 1983), steel drums, vibraphone (Glyn, 2002), and portable sound system with cables, speakers, and speaker stands. However, these require additional safety measures such as the regular counting of strings (Fulford, 2002) and/or wires. Drums without rims or lug nuts are recommended (Fulford, 2002). Metal items are discouraged; care must be taken to ensure safe disposal of worn items like guitar strings and equipment (Fulford, 2002). Wind instruments that require more advanced cleaning to avoid germ contamination are discouraged. Electronic storage devices such as portable media players

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(or digital audio players) and Universal Serial Bus (USB) flash drives are often not permitted, as they may put the therapist at risk for undue familiarity or a security breach. Safety measures often limit patient handling of equipment. For example, the therapist may be the only individual allowed to operate a CD player or to play the guitar. Some units may support the use of recording or video equipment (Fulford, 2002); the therapist must check with Correctional policies first. During therapeutic games, material prizes are discouraged in favor of nonmaterial positive reinforcers. In her work with juvenile offenders, Wyatt (2002) encouraged patient “focus on the internal gratification earned from participating in a positive … experience” (p. 85). Examples of “intrinsic rewards” (p. 83) include choosing a favorite selection of music for the group to listen to (Wyatt, 2002); receiving a standing ovation, words of praise and/or compliments; and helping to choose the next week’s activity. The adult female correctional setting comes with its risk of exposure to a number of communicable institutional diseases like Hepatitis C and Methicillin-Resistant Staphylococcus Aureus (MRSA). In more recent years, many state correctional budgets have tightened, affecting the availability of items such as cleaning supplies. If inmates are the ones cleaning, their housekeeping routine may be minimal at best. With this in mind, the therapist is strongly encouraged to sanitize instruments and equipment after each use with an approved disinfectant. If a patient is contagious, the therapist might excuse her from therapy to avoid the spreading of communicable germs. Care must be taken when disposing disinfectants containing alcohol, as patients with addictive tendencies might be inclined to ingest them. In addition to musical equipment, art supplies and writing implements are commonly used in therapy, following similar security guidelines. Some units prohibit the use of specific items, such as lead pencils; black, blue, and yellow markers; spring-loaded pens; paintbrushes; and child-proof scissors.

Conducting Sessions Conducting music therapy sessions in Corrections is challenging. Group rooms are often cramped and dirty, with limited heat or air-conditioning (Silber, 2005). When units are on lockdown or limited officers are available, inmate movement to group is not allowed. Patients who are concerned about their personal property may miss group to protect their “territory” (Silber, 2005, p. 257). If patients have limited investment in treatment, they may resist attendance. In her writing on mentally disordered male offenders in a state hospital, Reed (2002) notes that “the amount of psychotropic medications and changes in dosage also affects … the patient’s level of involvement and alertness” (p. 102). Groups often start late or end early; times sometimes conflict with other programming like work assignments, medical and court appointments, educational programming, visitations, religious services, other mental health services, and officer shift changes. Correctional activities are the first priority; the safety of inmates, civilians, and staff always comes before therapeutic work. Without the support of Corrections, mental health services would never take place in a safe and organized manner.

Privacy Therapeutic privacy remains a challenge in Corrections. At least one officer is always present, often within earshot. Patients may be less inclined to self-disclose due to this close proximity and due to their level of trust of other patients in attendance. To guard against the dangers of too much self-disclosure, Thaut (1987) recommends a “personal agenda technique” where individual goals centered on the “here-andnow” of each session are utilized in lieu of long-term group goals (p. 48). Most group rooms have observation windows or doors with open grates in place of windows. When group space is limited, public areas in the units are used. In these cases, interruptions are frequent. Unit sounds invade privacy and can

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be very distracting. When a music therapy session is conducted with good attendance and minimal interruptions, it is the exception to the rule.

Unit Dynamics, Resistance, and Patient Involvement A music therapist can function effectively only if she understands the dynamics of the Corrections setting (Wyatt, 2002) and is familiar with individual patient criminal records (Thaut, 1987). Dynamics of the Corrections society include “codes of prisoner behaviors, power hierarchies, manipulative games, jargon, and different personality types formed during incarceration” (Thaut, 1987, p. 47), all of which directly affect the group process. If a romantic or other interest occurs between patients, it may be reflected in a group and interfere with the process. When an ulterior motive to attendance is suspected, the therapist is wise to quickly identify and address the patient’s appropriateness for session inclusion. As with any therapeutic intervention, resistance may occur unrelated to Corrections setting dynamics. Examples include a patient refusing to choose a song, being openly critical of others, asking questions at inappropriate times, attempting to split the therapist from other staff, or becoming openly hostile. Being prepared for resistance and setting consistent and clear limits at the start is important. This includes outlining rules for the safety of group members and staff (Wyatt, 2002) and the proper use of equipment. “If behavioral rules are presented with a positive connotation, i.e., as necessary to help everybody to be treated with respect and fairly, the inmates will, in most cases, adopt these rules and even develop some peer control once they see their usefulness” (Thaut, 1987, p. 47). The therapist should always place herself in the officer’s line of sight, calling on the officer immediately if disruptions occur. The therapist must carefully select the most appropriate music therapy method for each situation. For example, Glyn (2008) notes that less structured methods such as free improvisation may open the door to an enactment of offense-related behaviors. Thus, prior to each session’s start, he encourages careful consideration of individual patient circumstances, the likelihood of these behaviors emerging, and the therapist’s approach to handling such a situation should it occur. Spang (1997) similarly stresses the importance of taking “cues from [patients] … as to the content and depth … reached during music therapy sessions” (p. 21). If, in this situation, countertherapeutic behavior continues, Fulford (2002) suggests providing “more structure and exert[ing] greater control quickly and effectively” (p. 114). In her work on a forensic psychiatry hospital unit, Spang (1997) explains the importance of respect of confidentiality within the therapy session. Developing enough trust to self-disclose when sharing takes time and is especially difficult to develop with adult women in Corrections. As with any therapeutic group, one patient’s willingness to actively engage can open the door for others. Although active involvement is the ideal, patients may be given the option to pass and sit quietly if they clearly do not want to engage in a task or discussion. Sometimes just listening to music is all that is required to effect a change.

The Therapeutic Relationship Building the right relations is vital to the success of adult women in Corrections. One of the greatest influences a therapist can have on her patients is achieved simply by her presence and example. Demonstrating consistency in attendance, setting clear and fair limits, staying within the framework of Corrections policies, collaborating with patients and staff, providing structure based on patient needs, offering interpretive guidance, speaking honestly and respectfully, using a vocabulary reflective of the average inmate’s intellectual level: These are all building blocks for the development of trust and successful role modeling (Thaut, 1987; Wyatt, 2002).

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Correctional Officers Correctional facilities first and foremost are the home of correctional officers, who “serve society by confining inmates” (Appelbaum, Hickey, & Packer, 2001, p. 1344). Everyone else in the facility, including civilian staff like therapists, is considered a guest. In their review of literature on correctional officers, Schaufeli and Peeters (2000) note that Corrections culture is known for its high level of long-term stress on officers. Negative attitudes, a sense of alienation, job dissatisfaction, an increase in psychosomatic diseases, boredom coupled with the constant threat of violence, and work overload lead to high levels of burnout, absenteeism, and depersonalization (Schaufeli & Peters, 2000). In the best-case scenario, effective correctional officers secure our safety and have the “authority to provide discipline and apply sanctions” to manage and curtail “maladaptive behaviors of inmates on the residential treatment unit” (Appelbaum et al., p. 1345). In the worst-case scenario, an officer’s behavior may include an array of demeaning and punitive measures, such as writing charges for petty behavior, inflicting physical or verbal harm, and denying patient access to supportive care, all of which damage an adult female’s sense of self (Silber, 2005). In their article on the role of correctional officers in prison mental health care, Appelbaum et al. (2001) note that inmates with mental disorders increase the degree of stress on a unit due to their impaired ability to cope with and to adapt to prison life. To counteract this increased stress, Appelbaum et al. (2001) emphasize the importance of building a “foundation of mutual respect, shared training, and ongoing communication and cooperation” between Correctional and Mental Health staff to ensure “successful collaboration” (p. 1343). A therapist’s supportive approach toward unit officers may be the determining factor in having access to patients and providing effective treatment. Sometimes correctional officers observe or sit in on sessions out of curiosity about what takes place, their own love of music, or a personal need for mental health care. It is important to take the time to politely educate them on the purpose of music therapy while encouraging appropriate privacy boundaries, welcoming their contributions to more community-based methods like unit concerts and karaoke.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • • • •

Breath Awareness with Music: Patients practice focused breathing in time with rhythmic drumming to increase awareness of their breath. Creative Movement with Music: Patients engage in gentle movement and stretching exercises with music. Song Listening with Lyric Discussion: Patients listen to and discuss how song lyrics relate to one’s life. Supportive Directed Imagery and Music: Patients listen to music in a relaxed state, focusing on supportive imagery while drawing a mandala.

Improvisational Music Therapy •

Group Improvisation: Patients engage in live, in-the-moment, musical creation through the use of instruments in an interactive group environment.

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Re-creative Music Therapy • • • • •

•

Vocal Warm-up: Patients imitate vocal exercises modeled by the therapist to warm up the voice and to learn care and proper use of the voice. Sing-Along: Patients sing a precomposed song or songs in a group or individual session with the therapist. Karaoke Singing: Individuals and/or groups of patients sing familiar songs with the use of a karaoke machine, with or without a microphone. Learning a New Song: Patients learn new songs and pieces of music through a step-bystep process facilitated by the therapist. Didactic Music Lessons: Individuals and/or groups of patients learn to play an instrument such as keyboard or guitar in a structured lesson format with a focus on therapeutic issues that emerge in the learning process. The Concert Performance: Patients and therapist choose, practice, and execute a group concert program which may include choral, small ensemble, and/or solo performances.

Compositional Music Therapy • •

Lyric Writing: Patients work independently or with the therapist to create songs by rewriting existing lyrics or by creating new lyrics. Melody Writing: Patients work independently or with the therapist to create original melodies and melodic structures as a complement to poems and lyrics or as original instrumental compositions.

Multiple Methods of Music Therapy • • •

Expression of Feelings: Patients create artwork and improvise on instruments to assist with exploration of healthy ways to identify and creatively express feelings. Musical Trust Walk: Patients follow directions represented by instrument sounds to search for a hidden object with eyes closed. Special Guest: Individuals and/or ensembles of patients share music, an interest, or talent that is personally meaningful with other members of the community.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Breath Awareness with Music Overview. In this method, patients practice focused breathing in time with rhythmic drumming to increase awareness of their breath. This is used for stress management and centering, supporting the common need for patient assistance with relaxation and anger management in the Corrections environment. Fulford (2002) recommends full breathing exercises prior to drumming and vocal activities to help with release of feelings and tension related to those feelings (p. 114). Patients who struggle with anxiety, panic, addictions, insomnia, and/or depression are appropriate. Patients who demonstrate highly acute symptoms (like active psychosis, a high degree of mania, agitation, dissociative symptoms, paranoia, or religious preoccupation) or who are unable to tolerate sitting quietly are not appropriate. Patients who are highly antisocial may not be appropriate.

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Goals for breath awareness include to increase focus on the here-and-now, promote self-awareness, learn relaxation and more effective creative coping skills, foster self-control, decrease aggressive behavior, and make positive changes in mood states. The level of therapy is augmentative. The therapist would benefit from additional training in relaxation techniques. Preparation. The group may take place in a room where interruptions are minimal. Room setup includes chairs, exercise/yoga mats, and tables; a hand drum; and a CD player and collection of CD music that is supportive in nature. Chairs may be set up in a circle at the start of the group with mats and tables placed to the side. As the group progresses, patients may be given the option of lying on exercise mats. When selecting a technique, it is important to note patient comfort with closing their eyes and with visualization. If patients are more comfortable with eyes opened, one might suggest that the patient soften their gaze and find a spot before them to focus on. If the patient shows any signs of limited secondary processing or psychosis, a closed-eye technique or guided visualization is not encouraged. In these cases, it is better to employ something with eyes opened that is very concrete in nature (such as progressive muscle relaxation). Be wary of recorded music containing background wildlife noises, as the odd sounds may increase paranoia. What to observe. Note patient responses, including attentiveness; ability to concentrate on the music and group process; changes in mood or behavior; and physical changes evident in posture, breath rate, and/or restlessness. Procedures. The therapist begins by asking group members to share any experiences they’ve had with the use of mindful breathing techniques. Invite each member to place one hand above her chest, just below the collarbone. Encourage awareness of the movement of this hand on the upper chest as one breathes in and out, noting that this is where most breathing occurs during daily activities. Then invite patients to place a second hand below their ribcage on the diaphragm. Briefly describe the diaphragm (example: a horizontal muscle similar to a tire tube), noting how it expands like a balloon as one breathes in and contracts as a balloon would as one breathes out and releases air. Invite patients to sit noticing the movement of this air as they breathe in and out, slowly and deeply. As the patients participate in this breathing exercise, observe the pace at which the patients are breathing and use this pace to determine the tempo of the drumming in the next step. Once the patients are aware of breathing, introduce a simple four-beat drumming pattern (example: 1, 2 and 3, hit the rim of the drum on 4). Invite patients to follow the drum pattern with their breath, breathing in for 4, out for 4. (Note: The therapist may speak the beat out loud as the synchronized breathing and drumming begins (example: INHALE, 2 and 3, 4; EXHALE, 2 and 3, 4, etc.) As patients learn the pattern and follow along while breathing to the drumbeat, the therapist may speak less (e.g., IN [silent while playing the rest of the pattern on the drum]; and OUT [silent while playing the rest of the pattern]). A cycle of 4 or 5 simultaneous inhale/exhale patterns is usually enough to demonstrate the technique. It is important to start with a faster beat, so as not to extend the breath too far beyond patient lung capacity. In between practicing each step, be sure to allow patients to return to a normal pace of breathing, so as to avoid anything like hyperventilation. After the deeper breathing is practiced, continue with a review of how to apply this method to daily life. This may include discussion of when to use deep breathing (examples: before falling asleep at night; during count or private time in one’s cell; when anxiety or stress levels are increased and one is aware of shallow breathing) or other adaptations (example: connecting four-beat breaths to walking or other movement). Adaptations. Practice walking and breathing to the beat in the group room to live or recorded music. As patients become comfortable with the technique, increase the number of beats for breathing in and out to support improved lung capacity. Follow the same directives in a supine position, with patients

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resting on exercise mats. Lying down often increases awareness of lung capacity and is specific to how the technique may be applied while resting on one’s cot.

Creative Movement with Music Overview. Patients engage in gentle movement and stretching exercises with music. The experience of music can be very kinesthetic, and this method gives patients the chance to explore the connection between music and the physical self while supporting exercise and healthy release of stress. It helps with concentration and may bring up issues related to intimacy and sexuality (Rio & Tenney, 2002). Patients who are invested in the creative arts and expression and who enjoy movement are appropriate. Patients with medical concerns that limit physical stability, who have difficulty maintaining appropriate physical boundaries, or who demonstrate highly acute symptoms (like active psychosis, a high degree of mania, agitation, dissociative symptoms, or paranoia) are not appropriate. Those hesitant to actively engage in the method may have limited benefit. Goals include to increase self-awareness and awareness of others (including physical/spatial awareness), increase control of the environment, learn relaxation and effective creative coping skills, support creative self-expression, support healthy release of tension and anxiety, foster self-control, develop effective leisure skills, support connectedness to others, and make positive changes in mood states. These procedures are practiced at the augmentative and intensive levels of therapy. Preparation. The group may take place in a room where there is space to move. Room setup includes chairs, a CD player, and a collection of CD music. A wide variety of supportive and/or popular music is recommended. Songs with a steady rhythm and that are repetitive in nature are recommended for the method described in this section. See the music of artists such as Bob Marley, Sade, Seal, or Al Green for examples (with the exception of “I Shot the Sheriff”). What to observe. Note patient responses, including attentiveness, changes in mood or behavior, physical comfort (i.e., steadiness of gait, breath rate, affect, signs of fatigue, etc.), level of involvement, ability to focus on the music and group process, creative expression (i.e., movement), and identified rate of stress and/or relaxation response at the group’s start and finish. Procedures. Creative Movement may begin with the therapist facilitating a discussion on ways one may hold stress in the body. Specific examples include noticing clenched teeth, stiff neck or shoulders, biting of nails, shaking legs, etc. Members are then asked to stand as selected background music is turned on. When the music starts to play, one at a time each member is invited to demonstrate a simple stretch or movement for patients to complete together to help release tension in the body. Examples include head rolls from shoulder to shoulder, arms stretching up to the ceiling, etc. The therapist may want to begin by demonstrating the first stretch. After the demonstration, group members are invited to try the stretch all together. The patient to the right of the therapist is then invited to demonstrate a stretch with the group trying it out; then another member does one, until all members have had the chance to lead. Following completion by the group, members are asked to return to their seats. The music’s volume is lowered to silent and/or turned off. Pausing is helpful, allowing patients to reflect on the effects of the movement and the music on the body, mind, and emotions. Adaptations. The stretches may be completed from a seated position or while lying on mats. Appropriate dance movements or yoga or tai chi postures can be incorporated. Patients can form a circle, with one or more patients moving or dancing in the center, or patients may be encouraged to clap to the music if it is energetic. Patients may be invited to move freely to the music, respecting each other’s physical space, or they may be divided into pairs and take turns mirroring creative movement in slow motion. Patients may be encouraged to release a vocal sound while completing a stretch or movement (rather than playing background music). The group can then reflect this sound in their movement.

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Other adaptations include inviting one or more patients to select the music or having the therapist perform a live song during patient movement. As a cognitive goal, patients may be challenged to remember and review each of the stretches or movements in order of completion.

Song Listening with Lyric Discussion Overview. In this method, patients listen to and discuss how song lyrics relate to one’s life. While listening, memories connected to familiar songs are often reawakened or discovered, triggering an array of emotions. Sometimes these emotions are positive; sometimes they are painful and need a supportive, safe environment to be experienced. Patients who demonstrate a high level of investment in music and music listening and who are able to engage in turn-taking are appropriate. Patients resistant to music, personal reflection, and discussion of self; whose cognitive ability is limited to primary processing; who demonstrate active psychosis or a high degree of mania or other symptoms that limit their ability to sit quietly; or who cannot tolerate the group setting are not appropriate. Patients who are very antisocial, narcissistic, or grandiose may tend to dominate the group and limit shared group discussion. Goals include to promote self-awareness, promote personal development, promote social skills development, enhance listening skills, promote healing, support healthy release of emotions, promote empathic connection to others, support the development of healthy leisure activities, increase control of the environment; increase knowledge of music and music history, increase repertoire of preferred music, and make positive changes in mood states. These procedures are practiced at the augmentative, intensive, and primary levels of therapy. The therapist would benefit from having some historical and background knowledge of the music, musical genres, and specific artists included in the session. Preparation. One important tool for the therapist in Corrections is a collection of music CDs from different musical genres that reflects adult female preferences. Some Corrections facilities are very particular about what music is allowed, especially if songs in any way reference or are associated with gangs. Recordings with a lot of profanity or strong sexual content are discouraged. Sometimes administrative review and approval of lyric sheets is required in advance. The therapist is encouraged to use her best professional judgment in censoring song lyrics and content prior to music purchase and inclusion in a collection, and when supporting patient song choice. The wrong song played at the wrong time may have a negative impact on an individual and/or group (Wyatt, 2002). Accompanying the collection is a list of song choices. This list may be generally organized in a manner easy for patient and therapist use (i.e., alphabetically by genre, artist, or CD title). Within each category, the CD list may include CD name, artist name(s), track number, song name, and length of song. If the list of CDs and CD content is large, it may be held together by approved material (example: six-inch pieces of yarn through three-hole-punched paper copies). It is helpful to have more than one copy of the master list of each collection on hand, as patients can pick their selections simultaneously without slowing down the group process. This group requires a CD player and a collection of CDs with a CD collection list, lyric sheets, a wall board, writing implements, art supplies, paper, and floor mats, and possibly a karaoke machine and instruments. If lyric sheets are used, the Internet is a valuable resource in locating lyrics for analysis (Wyatt, 2002, p. 85). What to observe. Note patient responses, including her ability to attend to the music; changes in mood or behavior; changes in physical demeanor (like posture, breath rate, and ability to remain seated); degree of involvement in discussion; literary proficiency; knowledge of music and music history; awareness of the group process; relatedness to other group members and the therapist, including her attitude toward them and their selections; and her own music preferences. Procedures. The therapist may open with a discussion of songs patients have heard or thought of recently to get a sense of current focus and interests and then introduce the topic or order of the

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listening activity. This may or may not be related to the opening discussion. Music selections for the session are chosen. They may be selected by the therapist or patient(s), based on a group-related referential theme, such as love or loss, predetermined from past discussions or spontaneously chosen within the course of the session. Patients are then guided to sit or lie comfortably and reminded to remain quiet, respectful, and attentive as each selection is played. If available, patients may be directed to take a lyric sheet and writing implement. The music selection is played, and patients are given the chance to make notes on the song and then directed to return to their seats. Discussion of the song may include directives to: 1) share specific lines that stood out; 2) share individual interpretations of the song’s meaning and the songwriter’s intention(s) in writing it; 3) note ways in which they relate to the song or its message; 4) review ways in which it reflects their own life experience, memories, hopes, or dreams; 5) identify and discuss feelings evoked while listening (Gallagher & Steele, 2002); 6) discuss the song’s musical elements (i.e., structure, dynamics, tempo, instrumentation, length, melodic line, key, etc.); 7) discuss its lyric writing elements (i.e., theme, rhyme scheme, and lyric rhythms) (Edgerton, 1990); 8) discuss the song’s genre classification; 9) determine the form of communication reflected in the lyrics and/or style (i.e., passive, aggressive and/or assertive) (Gallagher & Steele, 2002); 10) discuss the song’s effectiveness; 11) identify personal levels of like or dislike of the song; 12) note any kinesthetic response(s) to the song; 13) note relaxation response(s); 14) discuss the song’s history.

Adaptations. Patients may write down “thoughts triggered by the music” on a separate piece of paper (Spang, 1997, p. 22) or rate a number of “selections … to identify musical likes and dislikes” (Gallagher & Steele, 2002, p. 119). Patients may be invited to use other forms of creative expression while listening, like drawing or moving to the music. Those with who are illiterate may be directed to use artwork (Wyatt, 2002). Questions may be created in advance for verbal discourse (Wyatt, 2002). Wyatt suggests that the therapist “predetermine several issues to center the group discussion around, and facilitate exploration of these issues” (p. 85). For example, Gallagher & Steele (2002) use Billy Joel’s song “Pressure” to discuss anger and stress management, and recommend that group members “complete a handout identifying personal pressures and stress management techniques” (p. 120). In her work with chemically dependent individuals, Freed (1987, p. 15) notes specific questions that the therapist may ask to encourage discussion of the Eagles song “Life in the Fast Lane”: “What type of lifestyle is described ... What feelings are associated [with it?] ... What are the steps to changing one’s lifestyle?” Wyatt (2002, pp. 85–86) and Plach (1996, pp. 37–42) provide sample song lists organized by relevant therapeutic topics. Song Sets: These are chosen by the therapist to introduce a set of songs with similar content—for example, on the subject of self-love and self-acceptance, Mary J. Blige’s “Take Me As I Am,” India Arie’s “Because I Am a Queen,” and Mariah Carey’s “Hero.” The group is then facilitated to promote personal sharing and to strengthen cohesion. To begin, patients are directed to sit in pairs with lyric sheets. After the first selection is played, the pairs are encouraged to discuss the song’s meaning and their response(s).

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Pairs are then expanded to teams of four, and similar discussion is encouraged within each quartet after the second selection is played. Quartets are then expanded to include the entire group, which listens to the last selection, noting similarities and differences across all three songs. This adaptation works particularly well with groups of patients of differing ages and backgrounds when songs reflective of differing genres are included. Sharing Songs: The therapist invites patients to take turns selecting and sharing favorite songs. This gives them an opportunity to self-disclose via personal music preferences. Spang (1997) notes that this adaptation helps to “build a working relationship with the group” (p. 19). Discussion of preferences allows for the identification of common interests and differences among members. When stress is high, hearing the right song often leads to a positive shift in mood and attitude. In this adaptation, patients may be encouraged to choose one song each from a CD Collection list. Selections may include a song with lyrics or a recorded instrumental composition. If a patient is illiterate, the therapist may assist by asking after favorite styles, narrowing the selection down by her own knowledge of artists and genres included in the collection. When everyone who wishes has selected a song, the therapist notes patient choices on paper or a wall board. Gathering the CD Collection list at this point allows for better focus during music listening. The first selection is played, and the patient who chose the song is invited to discuss it. The therapist may help focus the discussion by asking about the patient’s experience of the song (see discussion directives listed above). Other group members are invited to add constructive comments. This procedure continues until all selections have been heard and discussed. Spang (1997) notes a simpler version where patients are asked to select a piece of music they are happy to share with the group. “Along with their selection, each member [is] … required to give a reason for their choice” (p. 19). Thaut (1987) suggests that the therapist start by writing down each patient’s individual goal or agenda for the day’s session, inviting them to select a song or instrumental composition that relates to that personal goal. See Thaut (1987, pp. 49–50) for helpful specifics on verbal processing related to this adaptation. If group membership is large and time is limited, the therapist may opt to play only part of each song. Two minutes or the length of a verse and chorus work well. Another option is to share only a certain number of songs from the list, continuing with the rest at the following week’s session. A third consideration is to devote an entire session to one patient’s selection. A fourth is to take turns sharing a set of selections reflective of each patient’s life journey. Related to this idea, Plach (1996) suggests an experience called Parts of My Personality (p. 53). In this adaptation, the patient designs an original CD cover including a list of song titles that reflect personal interests and life experiences. Music Appreciation: Patients listen to and discuss music of specific genres. To prepare, the therapist should possess information about the musical genre and have a collection of songs in that genre. It is important to include music to which patients can relate—for example, music indicative of life struggles that carries a positive message of hope, endurance or empowerment. The list of artists from whom to choose is endless and may include everyone from J. S. Bach, who was imprisoned at one point in his life, to Mary J. Blige, who survived addiction and gang involvement and developed a strong faith. Begin with discussion of a specific musical genre chosen by the therapist and/or patient(s). Members listen to recorded selections and then contribute any information they know about the artist, the piece, the genre of music, or events in history that took place during the popularity of the piece. Prominent elements of the musical style may be identified and discussed, including instrumentation, tempo, dynamics, overall mood, lyrics, melody, key, and song structure. Patients end the session by summarizing their response to the music and what they learned from the experience. An adaptation might include using preapproved videos or movies demonstrating the life of an artist or particular music or musical genre. Name That Tune: Patients listen to music as an element of an interactive game. This is great for stimulating conversation and cognitive thought processes in a shared and supportive environment,

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encourages participation and increased motivation (Gallagher & Steele, 2002), and is useful in the assessment of new patients (Wyatt, 2002). In preparation, the therapist is equipped with a list of 10 to 12 songs from various genres, tempos, and periods. Prior to starting the music, the therapist lists patient names on a wall board with room for scoring. Patients are directed to listen to the selection. If they know anything about the piece—the name of the song, the artist or composer, the musical style, or any trivia about it or the singer—they can share this. For each correct fact, a patient receives one point. Points are tallied, and those with the highest scores are recognized. Sometimes more dominant personalities or those highly invested in the group may attempt to answer all the questions. It is at the discretion of the therapist to decide the order of answering questions. Quieter patients may require additional encouragement to participate. Selections may be narrowed to specific referential categories such as specific genres or artists or countries of origin. Questions may be prepared in advance focusing on these categories, keeping score of correct answers. Music trivia may be included, such as an artist’s real name, old and new examples of a specific genre, or music video/movie information (Wyatt, 2002, pp. 83–84). The format of the session may be arranged to reflect a popular show such as Jeopardy!, with topics like “music, mental health, and substance abuse recovery questions” (Gallagher & Steele, 2002, pp. 119–120). Adaptations may include patient-selected of music; patients may also be invited to facilitate the music listening, questioning, and answering, or to help with scoring the game. Patients may be divided into teams (Gallagher & Steele, 2002). Gallagher and Steele (2002) describe a re-creative adaptation, the Mystery Song method, which is a form of Name That Tune in which tone chimes are used: “Each client plays a choir chime when pointed to by the therapist in order to produce a melody line. Clients work together to identify the song” (p. 120). Songwriting Awareness: Patients listen to songs with a focus on learning about songwriting. Goals include to increase patient awareness of the components of effective songwriting and to learn about different songwriting techniques through listening and discussion. This may greatly benefit patients who are invested in creative writing, who are experiencing writer’s block, or who wish to write a song in a particular style. Reading and writing skills are a necessity. Additional goals include to increase awareness of the creative songwriting process, develop knowledge of songwriting elements, and prepare for creative skill development. During the session, the therapist may also note the patient’s ability to understand and apply songwriting techniques and concepts. To facilitate this adaptation, patients are given song lyric sheets at the start of the session. After listening to the identified song, the therapist discusses a particular aspect of the song that relates to effective songwriting, like the placement of the title in the body of the song. Patients are directed to identify the song’s title and to note each occurrence of the title during a second listening of the song. Discussion follows on the title’s effectiveness and the importance of title placement. Similar adaptations include the identification and discussion of other structural parts or elements in a song, such as the chorus, verse, bridge, etc. (i.e., review their placement, length, similarity, and differences); the lyrics (i.e., review of the title or hook, the opening line, style of words selected, flow and simplicity of words chosen, and rhyming); the theme (i.e., review the underlying idea, the writer’s approach to that idea, whether it is clear or muddled, whether it is believable); the melody (i.e., review how the melody and lyrics complement each other, the established feeling of the song as reflected in rhythm and tempo, the effectiveness of the hook, melodic changes between song parts, like the chorus vs. the bridge, etc.); and the overall effect (i.e., review the song’s flow from start to finish, the message of each verse, emotions that may be released in the listening, the story line, any resolution by the song’s end, and whether it is satisfactory to the listener) (Nashville Songwriters Association, 2006). Regarding examination of a song’s elements, in her work with emotionally impaired adolescents, Edgerton (1990) notes discussing the lyric

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theme (feelings expressed, “examples which validate” it, “symbolic words or phrases” that describe it, “stories” told which relate to it, and questions answered about it), the lyric rhyme scheme (including imperfect, perfect, and internal rhymes and patterns used, speaking or clapping them out during discussion), the lyric’s “melodic, harmonic, and rhythmic elements,” repetitions in melody, instruments used (including each instrument’s role), and “any word-painting techniques used in matching the character of the lyrics to that of the music” (pp. 16–17).

Supportive Directed Imagery and Music Overview. Patients listen to music in a relaxed state, focusing on supportive imagery while drawing a mandala. In their work with offenders in a substance use program, Gallagher and Steele (2002) note that “music-assisted relaxation teaches the clients various ways to relax or achieve an altered state without the use of chemicals” (p. 119). Patients are introduced to a deepening personal awareness via relaxation combined with music listening and active imagery; this is inspired by the Level I Bonny Method of Guided Imagery and Music’s (BMGIM) Supportive Imagery and Music Experience. From a Corrections mental health perspective, the goals of mental health services are to address acute symptoms (i.e., stabilization to support a return to general population or to a safe level of functioning) rather than to include depth-oriented therapy practice. The level of trauma and PTSD experienced by many adult females in Corrections is sometimes quite significant. Supportive directed imagery and music methods are recommended as they focus on assisting the patient with awareness of self, awareness of self in response to music, development of positive inner resources, and development of trust. Advanced levels of BMGIM are used minimally due to the limitations of the environment (i.e., privacy), the limited length of time appropriate patients have to complete deeper work, and the amount of trauma that may be awakened should deeper methods be initiated. Patients who are capable of self-reflection and secondary processing; invested in personal growth; struggle with anxiety, panic, addictions, insomnia, and/or depression; and/or are invested in art and/or music listening with a desire to build effective creative coping skills are appropriate. Patients who have experienced severe trauma may attend, but with caution and close supervision by the therapist. Patients who are not invested in active group involvement or personal growth, demonstrate highly acute symptoms (such as active psychosis, a high degree of mania, agitation, dissociation, paranoid or delusional thinking), are unable to remain still for a period of time, are highly antisocial, or demonstrate limited secondary processing are not appropriate. Goals include to increase self-awareness, support adjustment, increase control of the environment, learn more effective creative coping skills, encourage emotion management, support healthy release of tension and anxiety, foster self-control, develop effective leisure skills, develop trust, decrease defenses, decrease aggressive behavior, support emotional development, and make positive changes in mood states. These procedures are practiced at the augmentative, intensive, and primary levels of therapy. The therapist would benefit from additional training in Level I BMGIM. Preparation. For this method, using music that conveys a sense of being “held” or “contained” is more important than that which conveys a deeper, emotionally stimulating experience. In her chapter on supportive group music and imagery therapy in institutional settings, Summer (2002) notes that “the role of music … is to provide a common esthetic experience; a musically bound common denominator which will engender a feeling of group unity” (p. 301). Summer (2002) defines supportive music for this experience as “classical or nonclassical music, of five to ten minutes’ duration, with minimal musical development and considerable repetition,” noting that this “helps clients to keep focused upon one image” (p. 301). In this light, music that is supportive would have little dissonance and few dynamic shifts, might be in a major key (rather than minor), and have a repetitive, predictable melody. Selections should be

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reviewed and examined by the therapist prior to their inclusion in a collection and may be categorized under such headings as predominant mood states or types of images evoked while listening. Examples this writer has used include: Warlock’s “Pieds en L’Air,” R. Vaughan Williams’s “Rhosymedre,” and Paul Winter’s “River Run.” If these offer too much tension, selections like Joanne Shenandoah’s “When Eyes Meet” that are extremely repetitive with almost no dynamic movement may be more appropriate. The group takes place in a room where interruptions are minimal. Setup includes chairs and tables; paper (with a paper plate–size circle drawn in the center) and art supplies (such as oil pastels and chalk pastels); and a CD player and collection of supportive CD music. As the group progresses, patients may be given the option of lying on exercise/yoga mats instead of sitting in chairs. What to observe. Note patient responses to the music and relaxation techniques, including attentiveness, changes in mood or behavior, physical changes (i.e., posture, breath rate, affect, restlessness, etc.), ability to attend to the music, awareness and degree of involvement in the group process, creative expression (i.e., artwork), and identified stress and/or relaxation response at the group’s start and finish. Procedures. The therapist begins by briefly explaining that the session will focus on helping patients develop a greater awareness of positive strengths within themselves. She shares an outline the entire procedure: identification of a supportive image (which will serve as an induction), selection of music, a short centering or relaxation and directive to the image (i.e., the induction), the addition of music, and an invitation to open their eyes and engage in a mandala drawing as the music continues. Discussion of experiences will follow. In the first step, the therapist begins by facilitating a brief discussion of positive resources that group members can identify in their lives. One group member might be asked to share a personal example of something from her life that she recognizes as a source of strength or support. If it is a place, the therapist may ask the patient to be specific in describing it, making reference to the different senses (examples: “What does this place look like? What colors/objects do you see when you think of this place? Is there a certain smell you associate with this place? Is there anything you hear when you think of this place? How do you feel as you imagine yourself being there?”). If it is a person or object, apply similar questions around appropriate senses. The therapist then explains to other group members that the specifics are being discussed to show how detailed they can be as they imagine this positive resource in their own minds. The more detailed the experience, the greater the patient’s ability to be fully present to it in the music. Based on the previous discussion of patients’ current mood states and positive resources, the therapist picks three musical selections of varying styles (e.g., a piece with predominant guitar, another with piano, a third with symphony). A sample of each selection is played. Patients are then directed to vote on one for the group experience. Allowing patients to be a part of the music selection process increases investment in the group experience and allows for a small amount of control within the restricted environment. Once the music is selected, patients are invited to sit or lie down comfortably in the room. It is helpful to acknowledge the potential for outside distractions at the start, inviting patients to stay focused on themselves if any noises are present. The therapist then guides patients through a short centering or relaxation experience (such as Breath Awareness). Following the centering/relaxation, the induction continues when patients begin to imagine the positive resource identified at the start of the session. They are directed to experience this place/thing on many sense levels, with the therapist using questions such as those noted above regarding sight, sound, taste, smell, and feel. Patients are then offered a directive like “as the music begins, allow it to take you deeper into this experience.” The therapist then starts the selected piece of music. After several seconds of the music unfolding, the therapist may invite patients to open their eyes with statements such as: “When you are ready, allow your eyes to open. See if there is something from this experience that you might place

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on the paper.” Depending on the length of the piece and patient progress, the music selection may need to be repeated until drawing time comes to an end. If this is the case, be sure to allow time for discussion and closure before session close. When the drawing time and the music stops, the therapist may want to verbally acknowledge the end of the music, to invite group members to title their drawings and to discuss their experiences. Discussion may include comments on the overall process (i.e., centering/relaxation, induction, and music), sharing of mandalas, and a review of the experience’s similarities and differences among patients. Adaptations. The therapist may choose the music selection herself or she may use a piece of music requested by a patient(s). Those requested from this writer have included songs from such popular artists as Kenny G and Enya. The selected piece of music may be played throughout the experience rather than starting after the induction. Additionally, individual parts of the method can be used as a unique experience, such as a centering and relaxation to music without imagery or a centering, relaxation, and induction with music and no art, etc. Other relaxation methods, such as Jacobson’s Progressive Muscle Relaxation and Benson and Proctor’s Relaxation Response, may be used (Gallagher & Steele, 2002) If used in its entirety, the relaxation method might take up the whole session. With selected background music, this adaptation might be considered Music and Relaxation. Summer (2002) suggests that during the induction of a supportive group music and imagery experience, the leader or group “develop a simple induction to frame the music experience. The induction can be a feeling, a concept, a word, or a visual image that provides a topic upon which group members will focus during the music” (p. 300). Summer (2002) encourages “task-oriented” inductions at the start like “create a short poem about a feeling … or … draw a visual image that is ‘relaxing’”—something very “simple and concrete” to hold the patients “in a common, positive feeling that will establish a sense of group unity during and after the music is played” (p. 301). After the music, she suggests, the therapist should work to “reinforce any positive feelings that have emerged from the music and imagery experience” by employing “music-making techniques such as spontaneous songwriting, structured improvisation, or singing” (p. 302).

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY This section is composed of a number of improvisation experiences that proceed from basic preparatory exercises to very structured ones to those that encourage greater freedom of expression. Each lends itself well to building onto the next and is meant to be a guide to possibilities of creative expression through supportive music-making and improvisation with adult females in Corrections. As the examples progress, more leadership and ownership of the improvisational process is in the hands of the patients. However, during the process, the therapist must be prepared to vary structure in both the musical or verbal discussion parts to support patients getting “maximum benefit from the interactions” (Fulford, 2002, p. 115). Any time structure can be decreased without compromising the quality of the group or the successful participation of a particular patient, more freedom of expression will be encouraged and allowed for in the music. However, any amount of successful participation, no matter how small, has been shown to be effective in improving communication skills and improving mood and/or behaviors (Fulford, 2002, p. 114). Watson (2002, p. 108) provides additional suggestions on the breakdown of beginner, intermediate, and advanced methods.

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Within each submethod, the therapist may choose to verbally process the music the group made together. Processing questions may include those that relate to the patient’s feelings or thoughts during the music, her awareness of other group members, and her sense of musical attunement to others (Wyatt, 2002). Attunement may include discussion of the “dynamics of the musical relationship, for example, who has been taking the leading or supporting role and which [person] … initiated changes in the music, like getting louder or faster” (Sloboda & Bolton, 2002, p. 139). Follow-up sessions may include a review of progress from previous sessions to determine patient retention and the pace of group advancement (Reed, 2002). As improvisation progresses and if Corrections policy permits, the therapist may use a recording of sections for group discussion and analysis (Fulford, 2002).

Group Improvisation Overview. Patients engage in live, in-the-moment musical creation through the use of instruments in an interactive group environment. While most adult females in Corrections listen to music, few have experienced hands-on playing of musical instruments. The benefits of drumming and improvisation are manifold (Fulford, 2002; Watson, 2002), rendering it an optimal experience for this population. Improvisation experiences prepare offenders for skill development in the areas of creative self-expression, socialization, and interpersonal relations (Reed, 2002). They help with the appropriate expression of strong emotions such as anger (Wyatt, 2002), providing enough distance between patient emotions and the therapist to ensure mutual safety (Hakvoort, 2002). They allow for the release of stress and tension and increased attention span (Fulford, 2002), and are recommended for depression management (Gallagher & Steele, 2002) and for increasing self-esteem (Spang, 1979). Taking the time to let the therapeutic relationship develop while familiarizing patients with instruments and spontaneous creative expression may help to increase musical awareness and responses (Langan et al., 1999). When placed at the week’s end, activities like drumming were reported by Watson to help “release tensions, stress, negative emotions, and provide closure to their week in treatment” (p. 109). Watson (2002) recommends, “care in selection of group members” for drumming and improvisational experiences (p. 110). Patients who are invested in music and who have a positive response to instruments and live musical interaction are appropriate. Those who tend to be less verbal and those having difficulty orienting to the present moment may be included, as active music-making often assists with orientation to the present moment and nonverbal methods may effectively address the needs of the cognitively impaired (Watson, 2002). Patients with no interest in musical instruments, who may be overstimulated by instrument sounds, or who are resistant to active involvement are not appropriate. Patients with serious medical concerns (such as neck or back pain) may be limited in their participation due to an inability to play an instrument. Goals include to develop a “sound vocabulary” (i.e., familiarity with instruments and basic playing techniques) (Gardstrom, 2004, p. 83), increase focus on the here-and-now, improve attention span, support creative self-expression, develop and improve interpersonal and intrapersonal nonverbal communication skills, develop effective leisure skills, increase socialization, improve self-esteem, appropriately release stress and tension, increase respect for authority, improve teamwork, promote spontaneity, and promote decision-making. These procedures are practiced at the augmentative and intensive levels of therapy. Preparation. The group is held in a room with chairs arranged in a circle. A table with a variety of percussive instruments, including melodic instruments like tone chimes and xylophone, is placed in the center or off to one side. A guitar and/or keyboard are needed for the therapist, as well as a wall board and/or cue cards. When appropriate, it can be noted that voice (such as words, phrases, rap or scat

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singing, humming, or sounds) and body parts (like hand claps, tapping the thigh, or stomping the feet) may be included in the instrumentation (Fulford, 2002; Rio & Tenney, 2002). What to observe. Note patient responses, including ability to focus; level of involvement and interest in the instruments; ability to follow directives and handle instruments appropriately; mood or behavior changes; awareness of and connectedness to others, including authority figures; and response to taking on a leadership role. Procedures. Patients must first be introduced to instruments and become familiar with them to prepare for improvisations. The therapist may begin by introducing one or more percussive instruments from the table, playing it, and then passing it around the circle for patients to play. Patients may also be invited to choose and play the first instrument(s) without the therapist’s demonstration. Patients may identify which instruments appeal to them and discuss why, demonstrating the sound of the instrument before or after their sharing. Once familiar with the instruments, patients may be directed to create a sound for their current mood state using the instrument or to improvise on it in turn in their own way (Glyn, 2002). In his work with males in an improvisational group setting, Glyn notes that the passing of an instrument “highlights the issue of how the individual can retain a sense of autonomy and self in the face of intense pressure to surrender to forces generated by the group” (p. 49). Instruments may also be used to close a session, e.g., a final individual expression on the chosen instrument may be followed by brief comments about the day’s group experience. Members may also choose to take turns playing their own selected instruments or complete the session with a final shared group sound. Structured Rhythmic Improvisation: This prepares the patients for more advanced forms of improvisation by getting them familiar with independent, creative music-making using the support of a predetermined rhythmic or melodic structure. Goals include to improve music skills and ability, including rhythm and creativity, and to increase perceptual-motor coordination (Reed, 2002). One example of a good beginning experience starts with the therapist introducing a familiar spoken rhythmic verse or chant such as the familiar children’s singing game and nursery rhyme Peas Porridge Hot. Each patient is assigned a word or phrase from the short verse. After the verse is spoken more than once and patients can remember it, they are asked to simultaneously clap and sing their part as they go around the circle. Patients are then invited to choose an instrument to play instead of clapping. Eventually, the spoken word is eliminated and patients play their instruments in time with the original spoken verse. Once patients succeed in completing a full round of the rhythmic verse with instruments, they may pass their instrument to the patient on their right or trade instruments with another member in the group, completing the verse once again using a new instrument. This may be done until each patient has the chance to try out each instrument. Ostinatos: These may be introduced as group members demonstrate competency in their ability play and maintain a simple rhythmic beat with the music. One example is to invite members to tap their hands on their lap in a pattern similar to walking (i.e., left, right, left, right). The therapist notes how everyone tapping in time to this pattern creates a connected sound. They then each choose an instrument and play the same pattern as a group instead of tapping their thighs. A method of stopping playing is determined—for example, speaking the word “stop” loudly when it is time to end, fading out, stopping suddenly, slowing down until reaching a halt, building up to a crescendo, or counting backward to the beat (Sloboda & Bolton, 2002). An example of the latter is to say in time with the rhythm “5 … 4 … 3 … 2 … 1 (silence).” Another example of an ostinato is described by Wyatt (2002) in the “echo” technique, where “the therapist plays a simple two-beat rhythm and the group mimics the rhythm together in tempo to form a four-beat phrase” (p. 86). Patients can then develop their own rhythmic motives and play them as an ostinato together in the group.

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Playing to the Beat of a Familiar Song: This is another procedure that supports the development of the ability to play a common group beat. The therapist plays and sings the song on the guitar or keyboard as patients play their instruments together, keeping the beat. Once patients have achieved playing on the beat together, they can develop their creativity and spontaneity by playing rhythmic motives within the common beat. More than one rhythmic ostinato may be taught and used in the same song. “This process continues until the facilitator feels that most of the group has learned the rhythms” (Wyatt, 2002, p. 86). The therapist may vamp on a particular song during a re-creative song experience to include moments of instrument playing without singing the familiar melody. These musical spaces allow for increased awareness of active music-making. One example of a musical space is for the therapist to vamp on a short chord progression like bVII-IV-I in the same key and rhythm as Johnny Nash’s song “I Can See Clearly Now” just after the chorus hook. Rhythmic Ostinato Layering: This technique may be introduced and played simultaneously by different patients or different teams of patients. An example includes two patients playing instruments on beats 1, 3, and 4; another pair playing theirs on beats 2 and 4. A code name may be applied to familiar or popular rhythmic ostinatos. An example is playing on beats 1 and 2, silent on 3 and 4, calling this pattern “heartbeat.” The therapist may then call out the pattern name for group members to return to at certain points in the improvisation to assist with refocusing the group. Using cue cards or a wall board with the patterns written out in large print educates patients on basic rhythmic notation and serves as a visual reminder of which pattern to follow. Wyatt (2002, p. 86) provides a list of additional drumming resources. Solos and Small Ensembles: As patients gain confidence in using the instruments, opportunities for short solos and small ensembles (i.e., duets, trios, etc.) may be supported by the therapist’s musical accompaniment. For example, using “I Can See Clearly Now,” when everyone stops playing and singing at end of the song, the therapist may call on certain patients to start to play. The therapist picks up the accompaniment again as she cues the selected patients to begin, directing them when to stop, usually after four to six measures. She then cues another group or individual to play. There are many ways to cue patients to take turns in this manner. Some of them include calling out: • • • •

individual instrument names such as the tambourine, maracas, etc.; all those playing a certain type of instrument (like drums, instruments you can shake, instruments you can tap, etc.); specific patients by name(s); or those patients sitting on a certain side of the room.

The experience ends with everyone being invited to play together once again, singing a final round of the song’s chorus. Conducting an Improvisation: Conducting is an excellent way to develop leadership abilities. In this procedure, members choose from a variety of small handheld instruments while the therapist plays a dominant percussive instrument such as the conga, modeling a simple rhythmic ostinato and maintaining it for the duration of the experience. While playing, she invites group members to join in all together or one by one with the conga playing (Fulford, 2002). Next, the therapist facilitates individual leadership by requesting that another patient volunteer to take the lead on the conga. The new leader is asked to demonstrate and verbalize how she will invite other patients to join in on their instruments and how she will direct the group to end the drumming experience. The leader then begins with an ostinato and maintains it throughout the improvisation. Following leading the group on an instrument, patients can practice conducting to indicate other musical elements like tempo and dynamics (Fulford, 2002). A review of conducting basics may include

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hand/arm movements for such directives as start/stop, slow/fast, and loud/soft. As patients become familiar with the cues, they may take turns standing in front of the group to conduct, using gestures and/or a drumstick (as baton) during the improvisation. Conducting may include learning to point out specific individuals or parts of the group to complete solos, trios, duets, etc., or directing a particular type of instrument to play, such as drums, shakers, bells, etc. Group members may limit the overall selection of instruments used, for example, choosing only those items that make up an effective drum circle. Review of conducting and playing styles may be expanded to include a discussion and demonstration of passive, aggressive, and/or assertive styles, relating the experience of playing to effective communication (Gallagher & Steele, 2002). Patients who demonstrate an interest, aptitude, and investment in conducting may be given the opportunity to use these skills in other groups or special events. Discussion after the experience may include “naming the improvisation, discussing musical roles, and comparing those roles to social roles of individuals; identifying musical styles associated with the improvisation; comparing general feelings associated with the improvisation; and/or discussing how the music, mood, or social climate would have changed with a different leader” (Fulford, 2002, p. 114). Improvisation with Melodic Instruments: This begins by introducing patients to melodic instruments of different timbres. The use of melodic instruments may allow for the development of a greater sense of identity and of an expressive “voice.” Preparation includes placing one melodic instrument in the group space for easy access, for example, a xylophone. It helps to begin with a melodic instrument that is easy to play and has a limited range, continuing with more complex instruments (like the piano or guitar) over time. The therapist adds musical support by playing a progression of chords as accompaniment as patients take turns with the instrument. Major chord progressions that are predictable and return to the tonic (such as for 12-bar blues) lend themselves well to this practice. Limiting the number of tones on the xylophone to something like a pentatonic scale (in the key of C, it would include C, D, E, G, and A) or preparing the instrument in the same key as the accompaniment allows for a more consonant sound. This is particularly important at the start of this type of creative improvisation, where too many dissonant sounds may be harsh or unpleasant. As different members take turns, the therapist may want to vary her style of playing to reflect each player’s approach—for example, strumming strongly to the beat in a repetitive pattern, loosely strumming an occasional chord, or finger-picking. If a guitar is used as the shared instrument, the therapist may begin with the guitar set to an alternative open tuning. If a keyboard is used, notes may be limited to the white or black keys (Fulford, 2002). If the patient is skilled in musical ability, a key may be agreed upon prior to the improvisation (Sloboda & Bolton, 2002). Relational Improvisation: This approach focuses on relationship development. Patients may be assigned to work in pairs, taking turns listening, playing, and responding to each other’s musical communication via instrument-playing. This method can be particularly helpful to patients who have difficulty with effective relationship-building and/or communication limitations or deficits. Each patient chooses a drum, and the therapist asks one of the patients to silently identify in her mind something she would like to share with her partner in the activity. Instead of speaking it out loud, she is directed to make a creative sound on the drum representing what she would like to say. The patient’s partner is then asked to reflect back what she heard by playing it on her own drum, and then to make up a reply. This creative interchange continues with the original partner reflecting back what she heard and then starting a new interchange. The process continues until the musical conversation is complete. Afterward, the basics of effective communication may be discussed, including the importance of listening, of making eye contact, and of noting facial expression. Communication styles may also be discussed and explored, such as passive, aggressive, and assertive. The interchange may be followed by another musical conversation. Other instruments besides the drum may be used. The therapist may demonstrate the method with a group member acting as her partner. The method may be adapted to include a group of patients responding to a leader in a similar call-and-response fashion.

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Relational Improvisation may occur in an individual session when deeper personal issues are addressed. Hakvoort (2002) describes Musical Confrontation, where interventions such as “contrasting, intervening, splitting, and shifting” (p. 124) are used as triggers to work on issues of anger. She notes that “musical confrontation is the careful combination of the situation with a specific musical intervention. Sometimes, the therapy is processed … verbally … other times more musically … [E]ffective therapy needs a proper balance between … containment in the musical environment and the confrontation” (p. 124). Careful consideration must be made on the part of the therapist and/or other team members to ensure the appropriateness of this technique for specific patients. Free Improvisation: This approach may be the most challenging for this population. Living in the confines of an untrusting, punitive, controlling environment, the notion of spontaneous creation may seem alien, but the rewards are great. Through the improvisational process of stepping back from a more “directive approach,” Spang (1997) notes the importance of the development of the patient’s personal space, the chance for active problem-solving among group members with such issues as tension over singular dominance and inequality, and the use of music as the main ingredient of communication. An example of free improvisation may begin with each patient selecting one instrument and taking the time to explore its sound (Rio & Tenney, 2002). The therapist explains that the group is to work together to create a new sound—something that unfolds over time and that they can make up as they go along. They are informed that as the music-making progresses, instruments may be changed or exchanged. The floor is then “open for anyone to begin the music-making” (Rio & Tenney, p. 93). Others are invited to join in on their instruments, as they feel inspired. In her study of improvisational music with adolescents, Gardstrom (2002) notes that patients are “encouraged to begin and end at will, with no restriction on the length of each piece beyond that imposed by the structure of the site schedule or the allotted session time” (p. 84). The free improvisation may be short or long depending on patient interests, the ability to focus, and the direction the music takes. When the improvisation ends, patients may discuss their experience of the music—the sounds, feelings, general mood, flow, and connection with others. The therapist has many options regarding her involvement in the free improvisation. She can choose an instrument and “join in with the playing, trying to notice and follow different strands, and to comment occasionally on what … [she] think[s] is happening” (Glyn, 2002, p. 49). She can also support the music by reinforcing and developing what the patients are playing” (Glyn, 2002, p. 51). If patients are hesitant to begin, she might give a demonstration or initiate a first sound. She can choose to include melodic instruments like the keyboard, guitar, or xylophone to add to the richness of the sound. In her work in a day program for male and female adult recidivist offenders, Hoskyns (1988) describes her role in Rogerian terms as being “‘client-centered’ … while maintaining the boundaries of the session … [T]his usually means early stages of proposing and negotiating structures and ideas, and gradually working toward the goal of clients taking a fully active part in decision-making, organizing, and commenting within the session” (p. 31). Glyn (2002) notes that “sessions move between improvised playing and periods of discussion, with the balance varying from week to week” (p. 49). To provide imaginative and musical structure, a referential theme such as a mood, a feeling, or a color may be selected by the group or therapist. For example, if the feeling “loneliness” is chosen, the therapist could ask, “If loneliness had a sound, what would it be like?” Patients would then be directed to simply play “loneliness.” Spang (1997) discusses exploring emotions through instruments and how she chose one emotion per weekly session for the group focus. The use of this method is recommended early in the therapeutic process, supporting the “idea of group sharing” and patient cooperation throughout treatment (Spang, 1997, p. 20). It allows for patient contributions (and emotions) to be heard and validated (Spang, 1997).

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GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Vocal Warm-up Overview. Patients imitate vocal exercises modeled by the therapist to warm up the voice to learn the care and proper use of the voice. This is a good opening for Sing-Along and other vocal experiences. In general, singing activities assist patients with “intensity, rate, and pitch difficulties” (Fulford, 2002, p. 115). Goals include to increase awareness of the physical self and the importance of selfcare and to help “increase breath support and improve voice tone for speaking” (Fulford, 2002, p. 115). Reed (2002) notes other goals: in a choral group, the Warm-up can “get the individuals prepared to focus on learning and to ease the initial tension. The warm-up also prepared the individual to listen to the group leader, follow the rhythm, and pay attention to verbal cues” (p. 101). There are no contraindications for this group, and therapy is practiced at the augmentative level. Preparation. Chairs are placed in a circle, with the therapist at the front. A keyboard or guitar may be used for harmonic support, and a music stand may be helpful. What to observe. Note patient responses, including degree of comfort with vocalizing and the vocal range of the exercise, ability to focus and to sing in time with others, investment in the process, depth of breathing, dynamic range, and musical limitations like tone deafness or severe vocal gruffness. Procedures. Begin the first session by explaining that the vocal cords are similar to other muscles in the body, benefiting from warm-up prior to use. Members may be guided to sit on the edge of their chairs while completing simple exercises such as stretching the neck, mouth, and jaw. Methods like Breath Awareness or those outlined in Creative Relaxation Group may be utilized. Review of musical scales such as those in recommended vocal techniques may be employed with the use of vowels or simple phrases. Many special needs inmates have a history of heavy smoking, so lung capacity may be limited. If some patients with cognitive deficits are present, their memory may be limited. It is better to start off with shorter scales than long, involved ones. A description of mouth placement for proper vowel pronunciation and use of the diaphragm for deeper breathing is helpful. One simple warm-up that works well is that of the siren, so called because it sounds like a firehouse siren. The music therapist may demonstrate the exercise before inviting patients to join in. Patients sing “oo,” starting with a low note, and move up through their register until they reach their highest pitch. A pause at the top of the sound allows time to take a breath before initiating the downward sound. The Warm-up phase may end with comments or questions about caring for the voice. Adaptations. These include giving invested patients the chance to lead the exercises; using the keyboard or guitar to musically support members when singing scales; making the session more psychoeducational by offering information on proper breath and vocalization and the damaging effects of smoking on the lungs, voice, and body; and providing recorded examples of vocal exercises and styles of singing. Reed (2002) and Silber (2005) both recommend the use of a call-and-response song as part of the group’s warm-up. Reed (2002), who led a gospel choir group with mentally ill offenders, suggests, “a … congregational song … where the leader first sings a lyric and the group members answer back the same … structured on an upbeat-tempo 12-bar-blues pattern” (p. 101). Silber (2005) notes the effectiveness of a “bouncy three-word song, in two-part harmony, which became the ‘anchoring’ piece that we sang at the beginning and end of each of our sessions. Significantly, the song was entitled … ‘Be Strong’ … a theme … that was extremely important to the choir members, given their experience of the world as a place in which only the strong survive” (p. 260).

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Sing-Along Overview. Patients sing a precomposed song or songs in a group or individual session with the therapist. Under its heading are three important adaptations: Vocal Warm-up, Karaoke, and Learning a New Song, along with a description of creating a Songbook. The live music experience affirms active listening and engagement in the present moment. Though an effective introductory method, Sing-Along may be utilized throughout treatment, supporting the building of community and shared connection through music. Patients with an interest in music, who are literate, and who are isolated or depressed and in need of social stimulation are most appropriate; those who are illiterate may still benefit. Patients with physical injuries to the voice, medical conditions that discourage deep breathing like asthma or emphysema, a high level of acuity, a high degree of impatience, strong antisocial traits such as lack of tolerance for varying musical preferences, who become overstimulated, or who demonstrate difficulty with turn-taking are not appropriate. This procedure is practiced at the augmentative level of therapy. Goals include to increase self-awareness, increase reality-testing, develop healthy social interaction skills, increase control of the environment, learn coping skills, develop effective leisure skills, support healthy release of tension, decrease destructive/aggressive behavior, improve respect for others, support creative self-expression, support emotional development, improve self-care, improve physical conditioning, support cognitive stimulation, and make positive changes in mood states. The levels of therapy are augmentative or intensive. Preparation. Chairs are arranged in a circle, with the therapist at the front. Close to the therapist are a keyboard and/or guitar, adequate copies of a unit Songbook and its corresponding Lead Sheet Songbook. A Songbook is a collection of a variety of song lyrics from popular and classic genres, reflective of patient preferences. It includes a table of contents which may be organized around themes, genres, or in alphabetical order to facilitate locating each song quickly. Songbooks develop over time based on patient preferences and therapeutic work. Include songs that lend themselves well to songwriting and a few popular songs in the Spanish language. To accommodate patients with poor eyesight, lyric sheets should be typed in a large, bold font with the chorus and bridge indented as a visual separation from the verses. In Corrections, it is important to bind songbooks together only with approved material like yarn. The therapist should create an accompanying Lead Sheet Songbook for herself, which contains lead sheets for all songs in the songbook. These are transposed into keys that are compatible with the patients’ vocal range and are most effective when they include a short instrumental introduction to the song. Additional equipment may include wall board or paper and writing utensil to list patient selections in advance; karaoke machine with or without microphones; music stand; microphone stand; CD player, CDs, and CD Collection Lists (including those for karaoke CDs); and other musical instruments. What to observe. Note patient responses, including literary proficiency, response to the learning process, comfort with the vocal range of the song or exercise, rate of memorization (if applicable), ability to follow directions for musical elements (including tempo, style, and dynamics), investment in the music choice, musical preferences, connectedness to other group members and the therapist, ability to focus, degree of active engagement during the music, comfort with vocalizing, depth of breathing, dynamic range, ability to tolerate different song styles, ability to sing in time with others, and musical limitations such as tone deafness or severe vocal gruffness. Procedures. Begin with a vocal warm-up (see method Vocal Warm-up for details). Afterward, patients are encouraged to choose one song each from the songbook for the session. It is important to be aware of member involvement, as patients with dominant personality traits may attempt to control music selections of other patients. The therapist then plays the selection live, encouraging group members to join in with the singing. Discussion may take place in between songs or at the session’s end. If patients

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have limited cognitive abilities, then staying in the moment in the music may be more effective than attempting to engage group members in verbal processing. Adaptations. If time allows and the group size is small, patients may each choose more than one selection. Group members may be encouraged to work collaboratively when choosing selections (i.e., vote with a show of hands or ballots, discuss preferences, etc.). Where appropriate, instruments may be added for patient use; song selection may be based on a referential theme like personal preference or current mood state; and patients may be encouraged to sing from a standing position, which allows for deeper breathing, improved physical conditioning, and preparation for performance.

Karaoke Singing Overview. In this method, individuals and/or groups of patients sing familiar songs using a karaoke machine, with or without a microphone. The Karaoke experience encourages active involvement; even patients who prefer to observe are frequently inspired to move and sing along to the words on the screen. In a regimented institutional setting (such as prison), the experience of Karaoke can be normalizing, even humanizing. Goals include to increase relaxation, release tension and strong emotions, increase active involvement, foster independent decision-making, increase socialization, and promote independent decision-making. In some units, activities like Karaoke are built into a behavior modification system and used as a reward at the end of the week for the attainment of behavioral objectives (Fulford, 2002). In these cases, attendance is limited to patients who demonstrate sustained treatment compliance and to those who are compliant and in need of social stimulation. Karaoke is often a time of positive interaction between correctional officers and inmates. Onlookers are frequent. While this may appear as a violation of privacy, making room for positive interchanges during a music experience can improve communication between the subcultures, foster respect, and help to build a supportive community. Patients demonstrating highly acute symptoms, who cannot tolerate the group setting, who are overly dominant, or who do not like music are not appropriate. This procedure is practiced at the augmentative and intensive levels of therapy. Preparation. A karaoke machine and corresponding karaoke CD music is required, along with karaoke CD collection lists. For security reasons, the therapist should handle the machine and changing of CDs. What to observe. Observations are identical to Sing-Along, noted above. Procedures. As patients enter the room, they are directed to sign in; this determines the order of singers. Once seated, they review the Karaoke CD Collection List, choosing one song each for the session. If new group members are present, take time to review group rules. These include the need to be respectful toward each singer, to not engage in side conversations during the music, and to handle equipment appropriately. If necessary, include instruction on microphone use. Discourage blowing into the microphone, as this adds germs to the equipment; discourage twirling the microphone, as this breaks the wire inside the cord. Remind members to hold the microphone close to their mouth without touching their lips to it, and to turn it off after their performance to avoid feedback. Openings may consist of a Vocal Warm-up and passing the microphone around for each patient to share briefly on a topic or question. The latter allows group members to practice using a microphone, to become familiar with the sound of their amplified voices, and to prepare for this shared experience. One example of an opening question would be: “What would you like to get from today’s group?” Sometimes the response to this question helps focus the group and gives the therapist a sense of group members’ needs.

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Patients then take turns using the microphone to perform the song each has chosen, starting with the patient at the top of the sign-in sheet and continuing in order. This is important, as those with more dominant personality traits or those highly invested in the music tend to want to go first and to have more than one turn, often appearing oblivious to the needs of other group members. If Corrections officers or other staff are present and time allows, they may be invited to sing a song. The level of therapist involvement is based on individual patient needs; this may include anything from singing quietly beside the patient to cuing them on when to begin to sing to clapping with the group during an energetic performance. The method ends with a Closing similar to the Opening, where the microphone is passed and thoughts about this day’s experience are shared. Sometimes patients are asked to answer another questions, such as “What song had the most meaning for you today?” or “Did the group meet your goals mentioned earlier in the session?,” or they are asked to share a final comment to end the group. Adaptations. Patients may be inspired to dance or move appropriately to the music (within unit guidelines). Group dance numbers may be included, such as DJ Casper’s “Cha Cha Slide”; the Moody Brothers’ version of the popular American song “Cotton Eye Joe”; “The Electric Slide” (set to Marcia Griffiths’s song “Electric Boogie”); Los del Rio’s “Macarena”; or Henri Belolo, Jacques Morali, and Victor Willis’s “Y.M.C.A.” Patients may choose a song for the group to sing together or opt to sign as a duet or small ensemble. They may also share something other than songs from the Karaoke Collection (such as songs or poetry from other sources, short skits, raps, or stand-up comic routines). These may include the use of other musical instruments and props. Patients may use their turn to practice a performance they are preparing for an upcoming concert or special event. The therapist may assign the role of master of ceremonies (or “MC”) to a group member. Patients generally placed in this role are those with limited social interaction or those exhibiting low self-esteem who would benefit from the added attention.

Learning a New Song Overview. Patients learn new songs and pieces of music through a step-by-step process facilitated by the therapist. If a song with which patients are not familiar is used during group or for a special event, it is important to facilitate learning of the new material. Goals include to increase cognitive skills, improve ability to learn, and increase self-esteem. Reed (2002) notes that “through singing, reading music, and following directions, the patient also makes gains in memory, tactile/sensory stimulation, and reality-ordered behavior” (p. 101). While the process may be considered slow or boring for higherfunctioning or more antisocial patients, often the majority respond well to simple, slow learning. This allows for the implementation and use of effective coping skills over time. Patients who are illiterate or who have learning disorders may require more time before demonstrating progress. Patients with memory impairment may show little improvement and may be contraindicated for the group. This procedure is practiced at the augmentative level of therapy. Preparation. The same preparation and observations as seen in the Sing-Along are used here. Procedures. Begin by identifying the song to be worked on and play it in its entirety either as a live performance or via recording, encouraging everyone to listen closely. Following along with a printed lyric sheet may assist with patient focus. The active learning process begins by breaking the song down into small parts. First, focus on the chorus or a recurring part of the song. This grounds the patient in the heart of the song, and its repetitive nature may make it easier to learn. Sing one line or phrase of the designated part, asking patients to sing it back to you. This call-and-response style helps with rhythmic and melodic uniformity. Words of encouragement are helpful, as is constructive feedback and taking the

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time to correct mistakes. If patients start out learning the song incorrectly, they may remember the piece this way, and it will be harder to reteach it correctly. After patients demonstrate competence with the line, the therapist may move on to the next, eventually connecting lines into larger sections. In general, reviewing each section three times is enough to aid memory without creating boredom. After mastering one section, provide a break from what may be intense cognitive effort by putting the song aside in favor of more familiar pieces, discussion, or other tasks. When the therapist teaches too much new material at once, patients may appear to be zoning out, tired, bored, frustrated, or discouraged. It may take more than one session before members begin to demonstrate confidence with the new song. Adaptations. Patients may benefit by hearing the new song in its entirety more than once at the start. Other group members familiar with the song may sing it and help teach it. Reed (2002) recommends starting with a copy of the lyric sheet with the therapist guiding the group to read through the song, followed by a demonstration of “the rhythms, melody, pitches, harmony, and overall musical structure” (p. 101). The music therapist may use a karaoke recording as well, in which case patients sing along with the song as it is played. With this adaptation or when she is not providing instrumental accompaniment, the therapist may conduct each phrase with arm gestures, encouraging eye contact in lieu of reading off the lyric sheet. The learning process may be repeated for more than one session until a piece is mastered. Reed (2002) recommends that in consecutive sessions patients are “asked to sing without the lyric sheets to assess what was retained from the previous session. After an assessment was completed, the group leader … [reviews] the lyrics by phrases or entire chorus, having the group repeat the words until the entire group … [is] able to retain the song from one week to the next” (p. 101).

Didactic Music Lessons Overview. Individual and/or groups of patients learn to play an instrument like a keyboard or guitar in structured lesson format with a focus on therapeutic issues that emerge in the learning process. Patients with an interest and motivation are most appropriate. Patients with cognitive deficits, physical limitations, or learning disorders may be limited in their ability to succeed. In the group setting, the music therapist may need to adjust the level of teaching to accommodate patients with limited skill and ability. Goals for didactic music lessons include to develop effective leisure skills, support creative selfexpression, improve self-esteem, make positive changes in mood states, increase self-awareness, increase control of the environment, improve physical conditioning, increase perceptual-motor coordination, and improve existing musical skills. These procedures are practiced at the augmentative and intensive levels of therapy. Preparation. Music Lessons may take place as individual or group sessions. A method of turntaking is best suited to the group. If patient skills are notably varied in ability, the therapist can provide beginner and advanced sessions. Sessions may be held in a group room with enough chairs for each of the patients and with the following equipment: For guitar, include a minimum of one guitar, preferably nylon stringed, at least one chair that has no arms, guitar strap, picks, guitar slide, capo, tuner, writing utensil, and music stand. Include paper for tablature, chord, and standard music notation, and lead sheets. The therapist may write out melodies and/or chords of popular songs, or method books may be used. She should be familiar with alternative open tunings, particularly in the keys of D (DADF#AD) and G (DGDGBD). When teaching keyboard, include one keyboard with wall adapter and foot pedal, a chair or piano stool, writing utensil and paper, and music method books from beginner to advanced. If the chord organ method is employed, make a paper grid to place above the keys denoting the numbering system (example:

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middle C = 1, D above middle C = 2, etc.). Many published chord organ sheets show these corresponding numbers above their notation. Using this technique, basic keyboard lessons may begin with one melodic line of a song written as a series of numbers. The patient reads the numbers from left to right, playing the corresponding notes on the keyboard. If sharps or flats are used, they may be represented by a plus (+) or minus (-) sign next to the number of the note being played. It is helpful to highlight these sharps and flats in a bright color for easy reading. Patients are often more invested in the didactic learning process if music they enjoy and are familiar with is included in the lesson. While pre-existing method books may be helpful, it is beneficial to have a repertoire of simply written popular songs both in guitar tablature and chord organ methods. It is also helpful to begin with the more familiar chorus or hook rather than the verse. What to observe. Note patient responses, including ability to focus, memory capacity, hand coordination, literary proficiency, ability to follow directives, tolerance for frustration, and mood or behavior changes over time. Procedures. Following are general guidelines on simple methods that have been found to be effective with this population. For either instrument, four areas may be covered in initial music lessons. These are: (1) an assessment of patient familiarity with the instrument and skill level. This includes a discussion of past music lessons and/or experience with the instrument. Various pieces of music may be presented to check patient level of playing and reading music. (2) If the patient is a beginner, review of instrument parts, proper hand and body positioning, and playing. (3) Suggestions for hand-strengthening exercises. This is particularly important with the guitar, where strength is required in the left hand to press down on strings. As lessons progress, patients may be given a drawing of a guitar neck on a piece of card stock paper—something they can safely take back to their cell and practice with to familiarize themselves with proper hand placement. (4) A method of learning, the easiest of which this writer has found to be tablature and chord charts for the guitar, and chord organ for keyboard. More advanced methods of reading music may be employed if patients demonstrate aptitude, higher frustration tolerance, and investment in the process. Guitar: If a patient is new to the guitar, lessons may begin with basic technique review (i.e., strumming vs. plucking one string, single notes vs. chords, using fingers vs. a pick, etc.). The therapist teaches the patient to read tablature, showing how each line relates to a string on the guitar, noting how the number on the string corresponds to the number of the fret. A song such as the traditional French nursery melody “Brother John” played solely on one string may be introduced. The therapist writes it out on the tab paper using the first string of the guitar, then demonstrates how it is played, giving the patient the opportunity to try. Songs played on one string are effective because they can be practiced on all strings, building hand strength when played on the heavier strings. Songs whose melodies are played on two strings are then presented. As the patient demonstrates a clearer sound and more fluid movements, pieces employing more strings may be added. Sometimes patients are more interested in strumming the guitar while they sing than in learning how to play individual notes. Chord diagrams and education on proper finger placement are helpful. Published lead sheets or those from the Internet may be used, or the therapist may draw out her own chord diagrams next to a lead sheet of lyrics. As hand strength, familiarity with chords and patient comfort with chord changes progresses, introduce specific strumming patterns to be employed while practicing. One example is ↓↓↑↓↑ in 4/4 time. If patients are limited in their ability to coordinate proper finger placement or lack finger strength, lessons may be simplified. An example of simplification is to change the guitar strings to an alternative open tuning in G or D and use a guitar slide. Music selection should be limited to songs using no more than three chords (i.e., I, IV, and V). The therapist may demonstrate strumming and show the

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patient how to alternate between strumming on the open strings and strumming with the guitar slide placed on the 5th and 7th frets, denoting the I, IV, and V chords, respectively. One example is to start with an open downward strum (↓↓↓↓), singing the English language nursery rhyme “Row, Row, Row Your Boat.” After the patient masters the downward strum, practice the song adding the slide on the 7th fret for the placement of the V chord on the words life is but a, returning to an open position for the I chord on the word dream. Eventually, more songs may be applied that utilize the I, IV, and V chords in this positioning. Many blues and rock songs lend themselves well to this method. Keyboard: Lessons may begin with a discussion of proper hand placement (i.e., awareness of wrist positioning, finger attack on the keys, etc.). Songs with a limited melodic range are appropriate to start with. If the chord organ method is used, the numbering system is explained and demonstrated. If the patient is comfortable with the chord organ method and demonstrates ability for more advanced learning, then a beginner’s method book may be used to teach traditional notation. The latter method generally takes longer to learn correctly and is harder to execute in a group setting if patients of varying acuity levels are included. One important advantage to the latter is that reading music correctly is a skill more readily transferrable to the outside world and may be employed wherever a keyboard and music are available. Adaptations. Patients sometimes arrive with knowledge and ability on their instrument of choice. Lessons are adjusted accordingly if they are prepared for more advanced training. Didactic Music Lessons may include voice, percussion, or other instruments like tone chimes, and may lead to the development of a musical ensemble (such as drums, guitar, and voice). Patients demonstrating musical skill may share their talents with others as a Special Guest during a special event like a Concert Performance or in Karaoke.

The Concert Performance Overview. In this method, patients and therapist choose, practice, and execute a group concert program, which may include choral, small ensemble, and/or solo performances. “The choir is a community with rules, relationships, and purpose. When located in a prison, it takes on the therapeutic function of providing a protected space for expression” (Silber, 2005, p. 251). In their work with adolescent girls, Rio and Tenney (2002) note that “singing provided the most cohesion and trust among members” (p. 92) and “elicited the greatest demonstration of unity” (p. 93). Concerts allow special needs patients to contribute in a positive, constructive manner to building supportive community within Corrections. They provide a rare chance for individual patients and patient progress to be recognized in a positive light by others including unit inmates, civilian staff, Corrections staff, and administrators. Reed (2002) describes concerts as “opportunities for transcendent experiences where they were able to move beyond their cognitive, emotional, and social limitations” (p. 102). O’Grady (2011), who completed a study with females in a maximum security prison, discussed the community element of a musical performance, which emphasizes an outward, “sociocultural” shift, allowing the inner (private) individual a way to prepare and integrate into the outside world (p. 126). The size of the audience is not as important as the chance for patients to work together to achieve a common goal, recognizing each other’s contributions to that end. In this sense, Reed (2002) notes that the choir group affords mentally ill offenders a chance to come “to terms with past antisocial behavior … [and to] think about change … [impacting] a patient’s psychiatric, social, emotional, physical, perceptual, and environmental adjustment, providing treatment in all areas important to biopsychosocial rehabilitation” (p. 102). While the demonstration of talent and musical skills may make for a more enjoyable performance, the therapist’s carefully planned support and preparation is the foundation of a concert’s

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success. Observation by administrators and key Corrections officers, while not a necessity, may greatly impact a patient’s self-esteem (Silber, 2005). Completing more than two shows a year may not be practical, but performances on a smaller scale might be more frequent (Reed, 2002). Building on personal strengths and interests through the use of the choir, the therapist facilitates the constructive use of time and offers a healthy form of escape and release, while helping to build effective social skills. The structure and form of the choir helps patients with dominant personality traits to temper their behaviors to reflect more reciprocal human interaction; guidance on proper tonal balance helps with patient awareness and attention to balance in human interactions (Reed, 2002). “The choir also offers a venue for learning to navigate a relationship with an authority figure, in this case the conductor … the singer-conductor relationship shifts the focus from conflict or power struggle to a focus on the common goal of successful execution of the music” (Silber, 2005, p. 254). Patients with musical or creative skills are most appropriate; however, pre-existing musical skills are not required. Patients who are willing to share, learn, and try new methods and who would benefit from increased opportunities for healthy socialization, creative self-expression, and teamwork are appropriate. This may include patients who are withdrawn or limited in confidence or functioning to the group. Patients with severe social phobia or with acute mental health symptoms that limit their ability to follow directives, to remain seated, to complete tasks, and/or to collaborate with others; those who dislike music; and those who demonstrate strong resistance to authority are not appropriate. Patients who are highly narcissistic and/or grandiose or hypomanic are generally eager to be included. However, the therapist must be prepared to provide clear boundaries, regular redirection, and extra support to manage behaviors that can easily dominate or negate a group or performance. Goals include to develop healthy social interaction skills, support adjustment, maintain focus on the here-and-now, increase control of the environment, learn effective creative coping skills, support healthy release of tension and anxiety, foster motivation, decrease destructive/aggressive behavior, improve respect for others (including peers and authority figures), demonstrate increased tolerance and acceptance of structured activities, develop effective leisure skills, support emotional development, improve self-esteem, support creative self-expression, make positive changes in mood states, and increase one’s sense of connection with the outside world. These procedures are practiced at the augmentative and intensive levels of therapy. It greatly benefits the music therapist to have performance experience herself, as this enhances her effectiveness as a resource and facilitator. Preparation. This may be broken down into a number of stages that take place over the course of several weeks. These include: Permission and Recruitment, Choosing the Concert Repertoire, Rehearsals, Dress Rehearsal, Concert Performance, and Post-Concert Group. What follows is a brief description of preparations for each stage. Permission and Recruitment: Approval for the concert and dress rehearsal must be cleared with Corrections and mental health administrators before the therapist may begin to recruit patients as concert participants. Once approval is given, a sign-up sheet may be posted in the unit. Participant roles include: • • • •

singing a solo or duet or singing in the choir; playing an instrument or playing in an ensemble; acting as MC, speaking about a song before or after it is performed, or reading the introductory or closing speeches; and helping roles, such as turning lead sheet pages; equipment and room setup and breakdown; laundering choir robes; designing and/or creating decorations, artwork and favors; distributing programs and favors.

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Other clinical team members may also be encouraged to recommend and refer patients for active involvement in the concert. Choosing the Concert Repertoire: This takes place in the first preparatory session. Chairs are set in a large circle, with a table available for songbooks and CDs. A device to play the selections and the therapist’s accompanying instrument are also available. The therapist brings a writing utensil and pad, a list of CD collections, songbooks, karaoke CD collections, and the posted sheet with names of patients who signed up for the event. Rehearsals: These begin in subsequent sessions. For all rehearsal and song practice sessions, the therapist prepares: • • • • • • •

sign-in sheet or predetermined set-list identifying order of performers; sheet music for song selections with live accompaniment, writing utensil, and paper; copies of large-print lyric sheets for all songs included in the event; music CDs and CD player or karaoke machine and microphones for recorded music accompaniment; music and microphone stands; musical instruments used for accompaniment; and two binders with music arranged in order of performers for the show: The first binder is for the therapist and contains lead sheets for all the music that will be performed; the second contains copies of song lyrics for the performers. As rehearsals progress, the introductory speech and closing speech may be added to the front and back of each binder, respectively.

Chairs may be arranged in a “U” formation, with the opening designated as the “stage” at the front. On the “stage” is a music stand and microphone stand; beside the “stage” are any musical instruments used in the performance; behind the “stage” is the sound system, CD player, and/or karaoke machine. At this point, the performer sings facing the seated group. As rehearsals progress, seating may be moved behind the performer and be assigned to facilitate group entry and exit. Performers using a karaoke recording may be eager to read lyrics on the television screen rather than use the written lyric sheet. This may be done for the first few rehearsal groups but is discouraged over time, as the performer usually has her back to an audience when using the screen and the television is not usually used for the final performance. Rehearsal sessions may be organized as a group or as individual practice sessions with the performer(s) of each song having a private window of time with the therapist. This is helpful if a patient needs extra musical help, is anxious, has difficulty focusing, or demonstrates some paranoia in the group setting. Rehearsal sessions may be split up by patient commonalities, for example, including those with limited cognitive functioning in a morning session and those with higher cognitive functioning in an afternoon session. If the number of participants is large, breaking the group into two or more sessions makes for a more manageable rehearsal. Eventually, the rehearsal set list is finalized and lyric sheets may be grouped into booklets and used by patients performing in the show. As rehearsals progress, it is important to make note of details from each performance in preparation for the final show. These may include: microphone volume, type of musical introduction (if accompanying), any verbal introductions, equipment setup (i.e., placement of stands, etc.), key of song and first musical note; tempo; instrument adjustment (like alternate tuning on guitar or programmed setting on electronic keyboard); and special directives (such as “conduct this,” “stand with the guitar,” “invite others to join in,” etc.).

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Other preparations include completing complementary art such as favors, decorations, and a concert flier. Complementary art items are often reflective of the concert’s theme, may be created by patients, and may be assembled in a separate group led by the music therapist or by other mental health clinicians. Complementary art is important; it demonstrates respect for individuality and provides an opportunity to include patients with differing interests and talents who might otherwise decline active involvement. The more involved each patient on a unit is in the production of a concert, the more invested the community is as a whole. When rehearsals are nearly complete, several additional patients are recruited to distribute the concert programs and other items like favors, and to read the Opening and Closing Speeches on the day of the show. Patients reading the speeches may be provided with a copy in advance and are included in the Dress Rehearsal. Introductory and closing speeches help to open and close a concert. They provide additional opportunities for patient involvement and are an effective way to politely review safety guidelines during the concert. The introductory speech may include welcoming everyone in attendance to the show, acknowledging the hard work of all participants, reminding those in attendance to refrain from side conversations and to be respectful of each performer, and introducing the MC. The Closing Speech may include thanking everyone for their attendance, recognizing administrators and staff whose support and contributions were significant to the concert’s success, inviting a head administrator to say a few supportive words to the group, and directing civilians, staff, and inmates on how to safely exit the room. The concert program is a great way to publicly acknowledge and support patient success. It places attention on the patient for positive action and is often a source of pride. Before it is completed, the therapist must check with administrators on the printing of patient names (i.e., their privacy policy). The program content may include: • • • • •

basic concert information like the show’s date, title or theme, time, and location; the set list, including each song’s title and the performer’s name(s); a breakdown of all who contributed to the concert, including patients who helped with Complementary Art, room setup, speeches, etc.; a section which recognizes the support of individuals such as key administrators, Corrections officers, and mental health staff; and meaningful lyrics from songs highlighted in the show (this may include all or part of songs where audience participation is requested) or meaningful prose or poetry.

Dress Rehearsal: The room where the concert will take place is arranged as it is for the rehearsal sessions, with the exception of assigned seating for performers beside the stage and the addition of seats in front of the stage for a small audience. Inclusion of a small audience helps the performer to mentally prepare for the addition of an audience during the concert. Equipment and instruments used in the show are arranged appropriately in the stage area. Other preparations before the Concert Performance include hanging decorations in the concert room. On the day of the concert, additional chairs are added in the audience to accommodate a larger crowd. Check with Corrections staff on the need for seating segregation. If permitted, taking photos, recording, or videotaping the show may be included. Post-Concert Group. This session takes place in a group therapy room with chairs in a circle. The therapist may bring certificates, writing utensils, and paper or a concert feedback form. Instruments and music are optional. What to observe. Note patient responses, including ability to focus and to follow directives, degree of investment, ability to collaborate with others, preparedness for each session, ability to wait her

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turn, mood or behavior changes, literary proficiency, and ability to follow along with the music or designated performance. Procedures. This is an experience that takes several weeks to prepare and has various phases. These include Choosing the Concert Repertoire, Rehearsals, the Dress Rehearsal, Concert Performance, and Post-Concert Group. Suggested procedures for each are described below. Choosing the Concert Repertoire: Patients are welcomed and reminded of the different opportunities available for the concert. Those who have been in previous concerts are invited to briefly share their experience. Each patient is then encouraged to identify how she would like to contribute to the concert while the therapist makes a new list of patient names and planned involvement. If patients are undecided about what song to sing, they may be directed to the various collections of songbooks and CDs for review and encouraged to listen to the radio or television for popular song ideas. Songs from the songwriting group may be included. The therapist may also suggest songs for individuals and/or the group. Performances other than music and singing may be included (i.e., appropriate movement/dance; a theatrical skit; recitation of a poem, song lyrics, or short prose; presentation of artwork, etc.) (Fulford, 2002). Whatever assistance the music therapist offers, Silber (2005) suggests working to cultivate a “sense of ownership” in the group, considering the performer’s “musical tastes and preferences,” and “being flexible about interpretive matters that might affect the degree of emotional meaning the song would have for the participants” (p. 266). This includes adjusting songs to suit patient preferences (like tempo, accompaniment, etc.), working to musically support the performer in a way that her feelings about the music are validated and communicated in the performance (Silber, 2005). The therapist discusses possible show themes and identifies songs that patients might like to sing as a group. As selections are chosen over the first couple of rehearsals, a theme usually emerges. Sometimes this theme is the title of a group song. Often it is reflective of hope, strength, or inspiration. Ultimately, the decision for the show’s title rests with the music therapist/director and administration. Nonsecular titles are discouraged to respect religious and cultural differences among patients. An example of this would be “Winter Concert” instead of “Christmas Concert.” Rehearsals: These begin once the repertoire has been chosen. Rehearsal groups are at the heart of a concert experience, giving the patient an opportunity to learn about discipline, accountability, perseverance, collaboration, teamwork, and the benefits of practice and community. The group’s opening includes a review of the day’s goals, directives about the show, and time for questions and answers. The order of performers and set list is determined or shared, and copies of song lyrics sheets are distributed. The therapist leads a vocal warm-up, which may include singing a group song. Following this, practice begins with the first performer on the set list. If patients are unfamiliar with the microphone, a review of microphone etiquette is included (see Procedures section under Karaoke Singing for details). When group songs are rehearsed, all performers are encouraged to sing, thus becoming the “choir.” Methods discussed in Learning a New Song are used as a rehearsal technique. If any patient resists this level of involvement, she may be seated at the end of a row in the performance so as not to stand out. When rehearsing songs, the therapist may teach patients ordered behaviors such as clapping together in time with the music and/or moving in unison to the music by swaying from side to side. Reed (2002) notes that clapping may assist with time orientation, particularly for those patients with reality disturbances (p. 101). Used at peak points, it gives strength and direction to a song, may help to outwardly unify a choir, and assists with memory retention of the song during performance. As practice continues, it will become clear that different patients need different levels of musical and emotional support to perform successfully. Levels of support include:

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providing live musical accompaniment using guitar, keyboard, percussion, drum beats, etc. The music therapist or other adept patients may be chosen to play the accompaniment; providing a karaoke recording of the selected song as accompaniment; providing the original CD recording of the selected song as accompaniment; singing quietly alongside the patient; encouraging her to select another performer, group of performers, or the music therapist to sing with her for all or parts of the song, including singing harmony; allowing another patient to stand close by for support; allowing her to sing from a seated position; and having the music therapist or another adept performer stand in front and conduct.

The group’s closing may include a recap of what was practiced, repeating some of the songs worked on in the session (Reed, 2002). If listening is a challenge, Silber (2005) suggests the employment of “listening games” to help develop social skills and educate members on how to “sing and listen simultaneously” (p. 260). For example, “two participants spoke different sentences at the same time and then were asked to relate what the other had said” (Silber, 2002, p. 260). If, when singing in unison, one or more choir members have a tendency to dominate the sound, Silber (2005) suggests asking them “both to hear and look at each other, in order to produce a sound of one voice” (p. 261). If choir members exhibit a tendency toward angry outbursts during rehearsals, Silber (2005) recommends working with them on “breath control,” and the “activation of diaphragm as a means of achieving the steady flow of air necessary for proper singing. … Since proper breathing is an excellent tool for anger control, I suggested that the participants exhale and then take deep breaths whenever they felt anger” (p. 261). She also introduced members to “the higher voice register, which is a gentler and [has] softer head-tone quality” (p. 261), giving them the chance to understand and become accustomed to their “nonaggressive voice” (p. 261) as a new source of strength. This was employed by including in their repertoire a popular song to be sung in a higher register. Working on the development of “musical trust,” helping the choir members to connect with their “own singing voices and to draw a connection between those voices and their underlying emotions,” Silber (2005) “encouraged them to create mental images of the song texts and communicate (principally through volume changes) those images in their singing” (p. 262). Dress Rehearsal: This prepares patients for the upcoming concert, giving them a sense of what the show will be like. After openings, performers may ask any questions they have related to the show. Several items may be reviewed during this session: • • • •

procedures for entering and exiting the concert room in an orderly fashion; how and where to stand up and sit down in unison for songs with the choir (this can be accomplished with designated hand signals and eye contact); proper attire and placement of prison ID (often a specific uniform is designated for more public or formal appearances); and the draft concert program with the participants.

Patients are guided to sit in assigned seats; booklets and instruments are distributed. Individuals in the audience are encouraged to be seated, and a full run through of the show takes place, including introductory and closing speeches. Patients assigned to the opening and closing speeches sit with the audience rather than with performers.

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Concert Performance: This is the culmination of all the preceding procedures and preparations. About 30 minutes before the show, performers are assembled. Attendance and proper attire are checked; booklets and handheld instruments may be distributed if they are needed for the entrance. Patients giving the opening and closing speeches and those distributing programs and favors are directed to their respective places. A vocal warm-up is completed and words of inspiration may be spoken as performers are lined up and prepare for the show’s start. After the audience arrives, performers are guided into the concert area. The patient giving the opening speech is welcomed to the stage and the show begins as planned. When the show is complete, the music therapist follows Corrections guidelines on audience removal, inmate exit, room clean-up and the packing and securing of all instruments and equipment. Inmates may be assigned to assist with clean-up. Post-Concert Group: This provides closure after the event, giving patients the chance to acknowledge their accomplishments and to discuss how to incorporate the lessons learned into daily life. An important part of any performance is the opportunity to reflect on the process after its completion. Taking time for closure helps with the after-show letdown and transition back to a regular schedule; it is a model as well for effective adjustment to the highs and lows of daily life. The group begins with a review of the show’s success. Patients are given the chance to share their impressions of the show. Discussion may include a review of parts of the show that went well; areas of the show that might be improved; plans for future concerts; lessons learned; and ways in which the concert process reflects life challenges and opportunities. Special emphasis should be placed on patient success, including collaboration with others and support of others involved in the show. If permitted, the PostConcert Group may include a viewing and review of pictures, the recording, and/or videotaping of the show. If patients are slow to openly share their impressions, a written form may be distributed where they can anonymously rate the show and their involvement, sharing any feedback on show highlights, areas of improvement, and suggestions for future special events. If time allows, the session may close with the final sharing of a favorite song from the show. The therapist may want to distribute certificates of achievement for concert involvement. If most of the unit community is involved, it is nice to complete this activity during a community meeting time. Other staff may want to attend to provide feedback and support to the patients. Adaptations. To build an atmosphere of “acceptance, openness, and support” (p. 261), during rehearsals Silber (2005) gave each choir member a chance to sing a solo, even if they did not perform the solo in the show. “The group, as she sang, provided harmonic back-up” (p. 262). Similar to the effectiveness of call-and-response to build cohesion, Silber (2005) noted, “arrangements in which a soloist is followed by harmonic vocal support can also create a positive dynamic” (p. 263). To assist with selfcontrol, Silber (2005) stressed a basic technique in choral singing [and anger management], explaining that, Impulsive behavior would have to be curtailed if the choir was to have any chance of success. … I … stressed that the sounds they produce have consequences and that, in order to produce beautiful ones, they needed to think before beginning to articulate. … I asked them to think of the opening tone of a song before producing it, to be mindful at all times about the need to take breaths together, and to remember where the consonant sounds were to be articulated so that their singing would be in tune and unified (p. 264). To assist with patience and improved tolerance for delayed gratification, Silber (2005) noted the deeper satisfaction gained from several weeks or months’ preparation where the choir engaged in a “cycle of

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review, improvement, and refinement” during rehearsals and began to learn the “harmonies of songs, and not just the basic melody” (p. 265). The music therapist may allow patients who are interested but hesitant to sit in on the Introductory Group and Rehearsals, getting them to help with tasks like song selection, setup, and breakdown of chairs and equipment. Sometimes these same patients become a part of the show by the rehearsal’s end. At other times, patients are actively involved in the process but decline the final performance. O’Grady (2011) notes that not everyone has a “performance personality” (p. 143) and suggests collaborative discussion between music therapist and patient of the decision to sit out or quit. Reasons may include anything from a patient not being ready to having a tendency toward stagnation, being concerned about the threat of exposure and need for privacy, having fear and discomfort with performance, needing “space and time to reflect and ingest new experiences,” or needing a rest (pp. 140– 143). She recommends that the therapist support the patient’s need to stay in her “comfort zone” and draw upon the “comforting and soothing capacities of music, for example, by facilitating vocal improvisations that are structured to emulate the mother-baby dyad or focusing on techniques of receptive music therapy” (p. 143). Patients who help with rehearsal groups may be allowed to announce the order of performers. Eventually this role may become that of master of ceremonies (MC) for the show. These patients may be included in other music therapy groups, such as Songwriting, where pieces for the concert are created or worked on, giving members an indirect chance for inclusion in the concert. If they are insistent on not performing in the show, their contributions to stage management may still be recognized. Special Events might be planned that are shorter in length and simpler in preparation, like a group of patients singing a special song during a community meeting. In some institutions, Corrections religious ministries may provide choir robes for patients to wear for the actual performance. Sometimes complementary art projects include a simple decorative piece such as a flower to be worn on the shirt collar by way of the patient’s ID clip. Clinical staff may “participate in some performances with the patients or for the patients” (Fulford, 2002, p. 115). During the last of three choral performances, Silber (2005) noted arranging for an outside student choir to enter the prison and sing with the female inmate choir, noting the striking significance of this collaboration. O’Grady (2011) notes five phases of creation of a musical performance: “play, transformation, reflection, negotiation, and collaboration” (p. 129). Her detailed method begins with songwriting and incorporates original music into a scripted show.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting This method involves the creation of songs to support the exploration, discovery, and development of self and community. Songwriting provides a powerful voice for adult women, fostering inner strength and empowerment, “facilitating the recovery of repressed material” (Schmidt, 1983, p. 4) while validating personal expression. In their work with offenders with substance abuse and mental health issues, Gallagher and Steele (2002) describe how songwriting “has been shown to enhance self-expression and the communication of feelings, thoughts, and attitudes, and encourage socially acceptable behaviors and a sense of community belonging” (p. 119). The primary focus of this method is on supporting patient goals through creative self-expression. In Freed’s (1987) words, “The song does not have to be perfect to have value or to be therapeutic. The focus should be on the person and not the product” (p. 14). Once songwriting is chosen as a therapeutic method, the therapist must decide where to begin. Schmidt (1983) notes that the choices include whether to begin by focusing on lyric writing or melody

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creation, and to determine the specific roles played by therapist and patient in crafting the song. Edgerton (1990) suggests starting with the creation of a musical hook or “germinal idea,” harmony, a “rhythm/riff,” improvisation, and/or a combination of all of the above (p. 16). Key to making this choice is considering the needs, goals, and skills of the patient (Edgerton, 1990). The degree of support the therapist provides using her own songwriting skills should complement this choice. The following examples demonstrate techniques used to compose songs with adult females in Corrections. Taking into consideration the adult female’s tendency for limited literary proficiency, suppressed personal expression, and limited musical experience, it is important to start with structured experiences that are less intimidating before proceeding to freer creative expression with less structure. Schmidt’s (1983) suggestion is to begin with “pre-existent melodies or to have the therapist suggest melodic material, simply because most of the people with whom music therapists work are probably unfamiliar with the manipulation of musical and melodic components” (p. 5). Throughout this process, having exposure to improvisational experiences and listening to songs reflective of different writing styles are helpful (Schmidt, 1983). (See Songwriting Awareness in the Song Listening with Lyric Discussion, and the Improvisation Experiences sections of this chapter.) After a new song is completed, the therapist or a skilled patient may play an accompaniment; and other instruments may be added to create a fuller musical experience. If it is of therapeutic value to the patient(s), the song may be shared with others, including performance in a special event; the song may be included as a regular part of the group’s repertoire; the unit may allow a recording of the new song, used for group discussion or special events; and Complementary Art may be made which supports the recording or performance. Examples of artwork include a CD cover design or a mural depicting the mood of the song. See Fulford (2002, p. 115) for more details on recording and complementary art. Entire songs may be written by individual patients; by individual patients and the therapist; by collaborative groups of patients; or by collaborative groups of patients and the therapist. In the final stages of creative songwriting, Edgerton (1990) recommends discussing the songwriting process “with regard to issues that surfaced, progress made both by individuals and within the group, and generalization that occurred outside of the music therapy setting” (p. 18). Comparison of the song’s beginning (i.e., early lyrics, improvisation, etc.) with the final product may lead to recognition of patient progress and collaboration (Edgerton, 1990).

Lyric Writing Overview. Patients work independently or with the therapist to create songs by rewriting existing lyric or by creating new lyrics. Patients who are open to and invested in creative expression in the form of writing and who are capable of being honest are appropriate. Those with literacy deficiencies may benefit with support. Patients who are very antisocial, narcissistic, or grandiose may enjoy the process but tend to dominate a group and demonstrate limited compassion for others’ musical preferences and interests. Patients who are resistant to active involvement, incapable of secondary processing or personal reflection, dislike music, or demonstrate acute symptoms which limit their ability to focus are not appropriate. Goals include to support creative self-expression, increase insight into feelings and needs of self and others, increase/improve self-esteem and self-confidence, support healthy release and expression of feelings, encourage anger management and a decrease in destructive/aggressive behavior, increase control of the environment, improve group cohesion, accept responsibility for thoughts and feelings, learn coping skills and effective leisure skills, support emotional exploration and development, make positive changes in mood states, support the development of healthy social skills, and promote more socially acceptable behavior. These procedures are practiced at the augmentative, intensive, and primary levels of

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therapy. Therapists benefit greatly from having the ability to remain flexible and spontaneous in the process (Freed, 1987) and having skills and personal experience in the art of songwriting. Preparation. The session may take place in a room with chairs and tables, keyboard and/or guitar, a wall board, writing paper, music notation paper, and writing implements. Additional supplies may include other instruments like the xylophone and handheld percussion, lyric sheets, the karaoke machine, and microphones. Chairs may be arranged in a circle around tables. All other equipment may be placed outside the circle within reach of the therapist. Freed (1987) encourages the practice of “self-expression” and use of “lead-in” activities before patients are ready for “primary songwriting experiences” (p. 15). Some of these are included in submethods that follow; others are suggested in the Closing Remarks on Methodology section of this chapter. What to observe. Note patient responses, including degree of involvement, investment in songwriting and creative expression, ability to focus, comfort level with sharing and creative expression, ability to understand and apply songwriting techniques and concepts, ability to organize thoughts and melody into a rhythmic pattern, literacy proficiency, musical ability, willingness to work with others, response to constructive feedback, and attitude toward others. including the therapist.

Procedures. Fill-in-the-Blank: This method of lyric writing, also identified as the cloze procedure (Freed, 1987; Gallagher & Steele, 2002), involves filling in purposeful blanks of a pre-existing song lyric. It is a simple, nonthreatening method that lends itself well to beginning songwriting. To prepare, develop a list of popular songs that reflect patient musical preferences and that lend themselves well to this procedure [i.e., “how appropriately blanks can be substituted for original lyrics, thus providing a framework which will aid personal disclosure” (Freed, 1987, p. 15)]. Advantages of using familiar songs include a decreased need for the patient’s “compositional skills,” the ability to complete a song within one session, and the ease with which a rewrite can be “performed … for immediate reinforcement” (Freed, 1987, p. 16). One example is to use a song such as John Stewart’s “Little Road and a Stone to Roll.” The therapist begins by passing out original lyric sheets of the song and engages the group in singing it using the guitar or keyboard for accompaniment. She then encourages discussion of the song’s meaning and lyric content. This particular song uses its title to signify the road of life, and the metaphor of stones (or obstacles in life) that one rolls (or deals with) as they move along that road. Patients are invited to share their interpretation of the song’s meaning, drawing particular attention to the chorus and then the verses. In this case, it may be noted that the verses identify what everybody needs to help them roll their stones down the road of life. Patients are then asked to think of and discuss current life challenges and the resources they need to help face and cope with those challenges. Next, the therapist explains she is going to guide patients to write their own version of the verses by filling in noted blanks in the lyric to create a song “about themselves, their situations, and their feelings” (Freed, 1987, p. 15). Freed (1987) suggests encouraging spontaneity by “instructing individuals to write the first thought that comes to mind, followed by assurance that the lyrics can be changed if the authors are not satisfied”; emphasizing the method is “only a framework, and the individual is free to change the words” in the song; noting individuals “need not be concerned with how well their versions will fit the original melody” (p. 15). The therapist prepares a wall board using the lead-in sentence technique where the first part of a line is predetermined and the patients make up the rest of the line (Freed, 1987, p. 15). In this example, the therapist writes Everybody needs, followed by a blank line (_____). She writes this same lead-in sentence three times on the board, ending with the verse’s closing line, Everybody has a stone to roll. As patients identify specific resources they need to help with their life challenges, the therapist fills one

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resource in for each of the three blank lines on the board. If more than three resources are noted, additional verses are added in similar format. Once the verses are complete, the therapist invites the group to sing the new version of the song to her accompaniment. Patients then discuss any responses to this new version. Freed (1987) notes the importance of lyric analysis after song creation to become aware of feelings expressed and “pertinent topics of discussion as they surface” (p. 16). Discussion can be facilitated with the use of “open-ended questions” and the therapist’s awareness of the “possible symbolic representations of feelings through the use of metaphors as well as themes” (p. 16). Applied to the above example, questions may include: “How would these needs make a difference in your life? What needs not listed in the song are also important? Are there any changes you would make to the new verses? Are there any needs listed by other patients that you identify with? If you were to change the title of the rewritten song, what would you call it?” The session ends with closing thoughts and the group singing one more round of the new version. After the session, Freed (1987) notes the importance of sharing a typed copy of the new lyrics for “reinforcement, future reference” and “analysis” in upcoming sessions (p. 17). Adaptations. During the song’s introduction, the therapist may start with a music recording of the song being discussed. However, in her review of effective therapeutic songwriting methods, Schmidt (1983) notes that “[w]hen using ‘fill-in-the-blank’ songs which call for deeper emotional involvement and expression, it may be more beneficial to have the people in the group fill in their own phrases before hearing the original lyrics” (p. 5). The therapist may distribute paper and writing implements, inviting patients to write ideas on paper rather than listing them on the wall board, or she may type the format in advance and distribute copies during the session for patients or teams of patients. If using teams, each team may be encouraged to create a new verse, sharing it when the group reunites. Schmidt (1983) notes that handouts are helpful when rewrites involve filling in more than one word; they allow time for patients to “process the material,” supporting the inclusion of those who may initially feel too threatened to openly share their ideas with a group (p. 5). When patients demonstrate greater comfort with this method, the therapist may use adaptations that become progressively less structured. These include allowing patients to help with original song selection; directing patients to fill in more than one blank each, eventually leading to the completion of one or more verses per person; the therapist constructing new lead-in words based on group goals or a focus different from those of the original song (Freed, 1987); supporting patients in writing entirely new parts of a song, like a rap or a whole verse outside of the Everybody format; and having patients write new words for the entire song (Freed, 1987). Future sessions may include the use of similar fill-in songs such as The BoDeans’ “Closer to Free” and Carrie Underwood’s “Temporary Home,” which lends itself well to entire verse rewrites. See Schmidt (1983) for additional song suggestions. Full parodies of songs like “The Twelve Days of Christmas” or familiar commercial jingles may be created (Gallagher & Steele, 2002; Schmidt, 1983). With this in mind, an original song’s meaning does not have to be discussed in connection with the rewrite; the therapist simply uses the song’s framework as a supportive guide. The therapist may also write an original song, inviting patients to assist with filling in the verses or the entire lyric content. Question-and-Answer Lyrics: Another adaptation involves using simple predetermined melodies to support a conversation-style question/answer format where patients create the lyric response. A basic melodic and/or harmonic structure is repeated, with lines or verses contributed alternately by the therapist and group members. “Where Is Thumbkin?” (Berg, 1966), “Billy Boy” (Goodwin, 1961), and “Skip to My Lou” (Goodwin, 1961) are common examples of songs using a question-and-answer format. Initial experiences might use these familiar melodies with the words varied slightly to fit the therapeutic

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situation, encouraging individuals to state feelings, suggest answers to problems, and the like. (Schmidt, 1983, p. 5) Lyrics Based on Blues Form. An additional adaptation involves the use of a predetermined musical form such as 12-bar blues, which lends itself well to variations on degrees of structure based on the patient’s skill (Schmidt, 1983). “Certain phrases may be provided to aid … in writing lyrics.” As the patient gains confidence, she “can be encouraged to write lyrics without specific guidance” (Schmidt, 1983, p. 6). Traditionally, there are “three lines or phrases with a ‘break’ or instrumental interlude between each phrase. The words of the first phrase are usually repeated for the second phrase, while the third phrase has different words” (Schmidt, 1983, p. 6). Schmidt (1983) further suggests the following model as a guide: Hey, ev’rybody, I’m feeling ________________ today. Hey, ev’rybody, I’m feeling ________________ today. It seems like __________________________________. In setting the lyrics to music, the therapist plays a 12-bar blues chord progression (e.g., E-E-E-E7 / A7-A7-E-E7 / B7-A7-E-E7) to provide the harmonic background while the person with whom one is working sets the tempo and provides the melodic and rhythmic setting for the lyrics. Initially, group members may be given the option of just speaking the words in order to reduce self-consciousness about solo singing. Later they are encouraged to improvise a melody over the harmonic background. Depending on the level of the group, the content of the lyrics and the choices of tempo, rhythm, and dynamics might be discussed. (p. 7) Another adaptation is to use the karaoke track of a pre-existing song as an accompaniment to the composition. Song Collage: This adaptation is helpful when patients have difficulty generating their own lyrics. Schmidt (1983) describes this method of combining parts of favorite songs into a unified whole as an effective way for patients to “gain experience in formulating lyrics” (p. 5). Each person picks a phrase from a favorite song or from a group of songs dealing with a central theme. The group then works on combining these fragments to form a new lyric. (A hint: If each person’s phrase is written on a separate strip of paper, it will be easier to manipulate the order of the phrases as the group works on the new lyric.) Melodic material for the new lyric may come from the original songs or be newly composed (Schmidt, 1983, p. 5)

Original Lyric Writing: Original lyrics can be developed using one of three primary exercises: Free Writing, Brainstorming, or Poetry Writing Techniques. When a patient demonstrates increased comfort and investment in structured lyric writing, she may be encouraged to use more freedom in personal expression. Songwriters use writing exercises to stimulate new ideas for songs and to help with writer’s block. In the Corrections setting, these exercises may be completed during a session or as homework. Advantages of group songwriting include promoting and improving group cohesion and personal relations and developing a deeper sense of security (Edgerton, 1990). Although the examples that follow describe individual experiences, most work well with groups of patients. As a group, patients may be directed to each complete a section individually, to collaborate with others on constructing each

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line or section, to take turns contributing individual lines to build the song into a uniform whole, or a combination of any of these. Edgerton (1990) provides a detailed description of the Creative Group Songwriting technique, outlining a systematic six-step process. Free Writing: This occurs when a writing implement is placed on a piece of paper and the patient is directed to write down whatever comes to mind during a specified amount of time without censure. When the time is up, the patient is directed to put her writing implement down and review what she has completed, looking for common themes or ideas for songs. These may be discussed or shared and used as the backbone of new song development. Sometimes the process of independent free writing is intimidating. If this is the case, the therapist might play a preselected, short instrumental piece while the patient completes the exercise. In this case, the patient is directed to write whatever comes to mind as the music is played. Similarly, a directive to draw or creatively move to a piece of music may lead to discussion and the identification of descriptive words for lyric content. It must be noted that the general mood or feel of the music will potentially influence the writing. Another option includes the use of a work of art as a starting point for the free writing exercise. Brainstorming: This involves the rapid and spontaneous identification of ideas for songs through active discussion or reflection. During the process, these ideas are written on a wall board or on paper. When brainstorming ends, the list is reviewed and narrowed down to a referential theme for the focus of the song. Next, the patient is directed to write on the identified theme, like a mood such as loneliness or an important issue like surviving abuse. From this writing, ideas for a poem or lyric begin to form. It may be helpful for the therapist to initially choose the topic until patients become comfortable with the process. Sometimes, a common theme takes the form of a story (for example, my boyfriend left and I am all alone). In this case, the patient is directed to create a poem or prose from the story, which is developed into an original song. Schmidt (1983) suggests directing patients to “focus on a particular person or event that meant a lot to him or her, quickly write down all the phrases that come to mind, pick out the more interesting phrases and expand on them, and gradually refine these phrases into a shape” (p. 6). Poetry Writing Techniques: These may help to get patients started with original lyric writing (Schmidt, 1983). These may lead to increased attention to details such as different writing styles, rhyme scheme possibilities, and the refining of original lyric content. Regarding the latter, Schmidt (1983) notes the importance of placing “value judgments” and criticism aside due to the extreme vulnerability of the “self” in this “creative process” (p. 5). As a complement to poetry, free writing, and brainstorming, independent journal writing may be encouraged. When this occurs, patients must be made aware that saved personal writings may be subject to correctional review at any time should shakedowns, investigations, or movement of personal property take place. Adaptations. In addition to brainstorming for song themes, the patient may brainstorm and engage in discussion to determine the musical style of a song and the overall mood of a song (Edgerton, 1990). As confidence in this process increases, a more open-ended, spontaneous approach might be to distribute writing implements and paper, asking, “If you were to write a song, what would it say?” Patients are given a set amount of time to write down their thoughts and then are invited to share. From this sharing grows the seed of a new song(s). When assembling the actual lyric, Edgerton (1990) suggests ensuring that the chorus “is written by first identifying and subsequently combining the major thoughts concerning the theme. The remainder of the ideas are then reworded to form the verses and, if applicable, the bridge. Rhyme and lyric rhythms are discussed throughout” (p. 17).

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Melody Writing Overview. Patients work independently or with the therapist to create original melodies and melodic structures as a complement to poems and lyrics or as original instrumental compositions. This method supports patient focus on melody writing. On occasion, a patient will enter a session with an entire original song stored in her memory, requesting the therapist’s help in notating and/or completing it. More often, guidance and direction are required to support skill development. Similar to lyric writing, this process can be “approached gradually through successive steps of approximation” (Schmidt, 1983, p. 6). Melodic ideas may grow from many avenues, including spontaneous expression, a moment of inspiration, and reflection on a particular focus like a referential theme or work of art, a situation on a unit, or an issue in a patient’s personal life. Approaches to melody composition are numerous. In this section, three techniques with adaptations are discussed, from most to least structured: the composition of melody from a pre-existing musical structure, the composition of melody from pre-existing lyric, and the composition of melody from improvisation. For the adult female who is withdrawn and silent, finding a new voice through melody can be very freeing. Patients open to and invested in expression in the form of musical creation are most appropriate. Contraindications, goals, level of therapy, and what to observe are the same as those outlined in Lyric Writing, with the exception that there is less emphasis placed on literary proficiency and more on the potential for instrument-playing to assist with focus on the present moment. Preparation is similar, with primary emphasis placed on the use of instruments, including the voice.

Procedures. Melody from a Pre-existing Musical Structure: This technique involves the development of melody from a predetermined harmonic or rhythmic structure. The therapist begins by introducing a repetitive, predictable musical form such as a 12-bar blues progression, playing it on the guitar or keyboard. The patient is then invited to play along to the accompaniment on a melodic instrument (for example, a xylophone), which is set in the same key as the therapist’s instrument. As the music-making continues, the patient is directed to pay close attention to any lyrical phrases or patterns that stand out in her playing or are repeated. These then serve as the basis of melody creation and are developed into a melodic form. The patient may then work collaboratively with the therapist to fill out the song (see below). Adaptations. While the therapist plays this musical form or style, patients may be invited to vocally sing, speak, or scat to create a melody (Schmidt, 1983, p. 6). In this instance, it is common for spontaneous lyrics to naturally follow. It may be helpful for the therapist to introduce ideas for “licks” to get things started; as the creative juices flow, the patient is then encouraged to develop her own melodic lines (Schmidt, 1983). Adaptations may include the identification and use of other chord progressions. These may be as simple as vacillating between two chords (like Gm and Cm as used in Akon’s “Locked Up”) or a four-chord pattern (such as Am, G, Em, and F as used in Mariah Carey’s “We Belong Together”). Melody from a Pre-existing Lyric: This involves the addition of an original melody to lyrics. “For lyrics to make the transition from poetry to song, they must be set to music. The musical setting serves to underscore, clarify, and intensify the thoughts and feelings embodied in the lyrics” (Schmidt, 1983, p. 6). Lyrics may be in the form of a pre-existing poem (Wyatt, 2002) or original composition. This technique works well subsequent to lyric creation as outlined above in Original Lyric Writing. With lyrics written out, the patient is asked if she has an idea of how she would like the song’s melody to sound. If she notes a preference, she is invited to sit near the therapist and to freely sing

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through the lyric. The therapist echoes the sung melody on voice, keyboard, or guitar. As the melody is developed, the patient may work collaboratively with the therapist to fill out the song (see below). Regarding singing the lyric, in this writer’s experience it is quite common for adult females to be eager to sing but to have a limited vocal range or to be tone deaf. This may lead to difficulty distinguishing a clear melody line. In these cases, the therapist is encouraged to use her best judgment to assist with melody creation, working to blend the patient’s preferences into a more substantial form. Adaptations. If the patient does not have an idea of the melody and is unsure how to proceed, she may be given one or a combination of several options: • • • •

•

•

•

Ask the therapist, another patient or group of patients who are more musically inclined to assist with melody creation. Choose from “several alternate suggestions of melodies for each phrase” offered by the therapist (Schmidt, 1983, p. 6). Select and assign a random note for each word, writing the notes on paper by placing dots on a musical staff or by identifying letter names (i.e., A, B, C, etc.). Start with a predetermined instrument order like a specific number of resonator bells on a table. The bells are lined up; “the tune is played simply by beginning with the bell on the left and moving to the right, striking each bell once” (Schmidt, 1983, p. 6). Experiment with a melodic instrument. Starting with the first written line, the patient is directed to try out the instrument and choose a note for each word to make up a melody. If the number of notes on an instrument seems daunting, they may be reduced; for example, using an Orff-style activity such as a “simple ostinati or pentatonic scales” (Schmidt, 1983, p. 6) on the xylophone or using only the black keys on a keyboard. To avoid a melody that is too random or erratic, the patient may be directed to utilize a limited range of notes (like a single octave) or to begin and end on the same note. Read the lyric aloud, remaining aware of the “natural speech inflections and rhythms” of the written word (Schmidt, 1983, p. 6). From speaking the “lyrics rhythmically,” she may then clap them out and “‘orchestrate” them with percussion and/or melody instruments” (Schmidt, 1983, p. 6) or overemphasize the spoken movement until she playfully begins to sing a melody line in a manner reflective of the same movement in song. Engage in a progressive group music experience which includes the layering of instruments to determine “basic rhythm, harmonic progression, and melody,” respectively. See Edgerton’s detailed account of Creative Group Songwriting (1990), which includes developing lyric writing into active collaborative group music-making.

These processes often take time; the patient may need to explore a series of options before determining the final progression of notes. For options involving instruments, patient comfort with the instrument is important. As each melody is developed, the therapist may echo it on voice, keyboard, and/or guitar. The therapist notates the melody on paper (staff, tablature, or by note letter) or on a wall board with corresponding lyrics under each note. When the process is complete, the therapist reviews the entire lyric and melody with the patient, making changes as requested. They then may collaboratively work to fill out the song (see below). Melody from Improvisation: In this technique, the original melody grows out of active musicmaking. (See Free Improvisation in the Improvisational Experiences section for an example of starting such an experience in a group setting.) If the improvisation grows from a specific theme or focus, the patient may be directed “to explore ways in which the expressive content of music can be varied by

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changes in dynamics, articulation, tempo, or timbre” (Schmidt, 1983, p. 6) to reflect that theme or focus. As the experience unfolds, the therapist may encourage the patient to note specific elements such as “rhythmic organization, melodic contours, and phrasing” (Schmidt, 1983, p. 6), particularly those which are repeated or stand out. Awareness and review of these sections may then lead to the solidification of a melody and song idea. Melodies and musical structures that grow from improvisation may remain strictly instrumental or evolve to include song lyrics. Lyrics may be developed through spontaneous vocalizing and singing during the improvisation or through conscious lyric writing following determination of the melody. Adaptations. Patients may be challenged to develop an improvised song idea to fit a specific songwriting structure (like ABA, AABA, etc.) or musical style. As the improvisation develops, Schmidt (1983) suggests the use of “graphic scoring, using pictures to represent instruments, dynamics, and other musical elements)” to “aid in discussing and patterning the composition” (p. 6). Filling Out a Song: In this process, the song’s melody and lyrics are expanded and arranged to become a more substantial composition. When this process begins, it may be helpful to educate the patient on the fact that original songs often naturally change over time. What starts as an idea sometimes sounds very different in its final form and is influenced by the refinement of each musical element, as well as continued practice and performance. Filling Out a Song is completed by the patient, therapist or often a collaboration of the two and may include: • •

• • • • •

a decision about the key and supportive chord progression; identification of the song’s genre or style (this is easily accomplished with the use of a keyboard that includes preprogrammed styles and drumbeats—each may be sampled and tested until the patient is happy with the result; if the patient notes difficulty in choosing a style, it may be helpful to first identify a favorite artist and/or specific popular song the patient would like to model their writing after, modeling choices based on personal preference); further refinement of musical elements, including the determination of tempo, dynamics, harmony, and instrumentation (Schmidt, 1983); a restructuring or rewriting of any part of the song; more detailed cleanup of note value and melodic rhythms; practice and performance of the song, working out problem spots (Edgerton, 1990); and the completion of a lead sheet, which is definitive enough to ensure accurate replication of the song’s intent by another musician.

Adaptations. Patients familiar with notation may write the song out themselves. Songs may be transcribed using a simpler form of notation such as tablature for guitar or the chord organ method for keyboard. Patients with musical skills may elect to play the song as they present it on a guitar or keyboard. If in a group setting, members may be encouraged to offer constructive feedback or suggestions to strengthen the song. GUIDELINES FOR MULTIPLE METHODS OF MUSIC THERAPY Expression of Feelings Overview. Patients create artwork and improvise on instruments to assist with exploration of healthy ways to identify and creatively express feelings. It may lead to an increased awareness of others:

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their different ways of thinking, feeling, and creatively expressing emotions. Patients who are invested in personal growth and self-reflection are most appropriate; those with the ability for secondary processing are appropriate. Patients with limited secondary processing; active acute symptoms like psychosis; and/or high degrees of mania, agitation, or antisocial behavior, or who are not invested in active group involvement and/or personal growth are not appropriate. Goals include to increase awareness of self and others, improve empathy and respect toward self and others, support healthy release of emotions, explore creative nonverbal expression, support adjustment, increase control of the environment, learn coping skills, and make positive changes in mood states. These procedures are practiced at the augmentative and intensive levels of therapy. Preparation. A room with adequate tables and chairs is required. Chairs may be placed around tables with paper and art supplies, including colored pencils, crayons, pastels, and/or markers. Another table set to the side may hold a variety of percussive and melodic music instruments with an additional chair. The therapist may have copies of a list of feelings. What to observe. Note patient responses, including changes in mood or behavior, level of relatedness to other group members, ability to empathize with and support others, response to the therapist, and level of engagement. Procedures. The therapist begins with a discussion of feelings, including what they are, how to identify and express them, and that they are a natural part of the human experience. Sometimes adult females in Corrections have a limited knowledge of feelings beyond anger or sadness. If this is the case, it would benefit the therapist to review a variety of emotions with the group, using the list of feelings. This may include a discussion of the differences between thoughts and feelings, which are often confused. Patients are each offered a piece of paper and art supplies, then directed to take a few minutes to draw a picture reflective of one feeling they are experiencing in this moment or of a recent feeling they experienced strongly. It may be helpful to explain that the art task is not about artistic talent or skill, but merely a creative way to express a feeling, and that there is no right or wrong, good or bad way to express a feeling in a drawing. The therapist tells patients the drawings are not to contain any identifying information (i.e., names). When the drawing is complete, pictures are collected and displayed for easy viewing. Patients are reminded to show respect for each other’s creative expression and feeling states as the process unfolds. Next, one patient is invited to choose a picture that is not her own and to examine it and create a sound using the instruments which represents her interpretation of the feeling depicted in the picture. Discussion follows of the patient’s and group’s interpretation of the picture, focusing on possible feelings experienced while listening to the instrument sounds. It is optional for the therapist to invite the patient who drew the picture to disclose herself and to share about it. Another patient is invited to choose the next picture, and the process repeats itself until the session’s end or until all willing group members have had their turn. At the session’s close, patients may conclude by discussing differences among their experiences (including different interpretations and different ways feelings are experienced and expressed), commonalities among group members, and the benefits of emotional expression through appropriate creative processes. Adaptations. Gallagher and Steele (2002) recommend the use of Rogers’s (1981) “Happy/Sad Face Assessment Tool” (p. 118), suggesting that the patient choose the face that best represents their mood at the time. They recommend this tool’s use as an opening and closing at the start of each group. Happy/Sad Faces may be used in lieu of drawn pictures or written words at the start of this method. Similar to the Happy/Sad Faces, circles on pieces of paper can be distributed with the instruction to create an individual face reflective of a current mood state. Patients may write the name of one feeling they are experiencing (or have experienced) on the paper instead of drawing it.

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Members may be invited to work together in a dyad or small group to express a feeling artistically and/or musically. The art portion of the task can be eliminated; patients then go directly to choosing instruments to play a sound for their current mood state, with members guessing and discussing their interpretations (Gallagher & Steele, 2002). The group as a whole may be invited to improvise on one feeling. This is particularly effective when more than one group member shares the same feeling. In lieu of instruments, group members may be invited to create a vocal sound or movement or other appropriate expression for the drawing.

Musical Trust Walk Overview. Patients follow directions represented by instrument sounds to search for a hidden object with eyes closed. It is excellent for developing teamwork and listening skills as well as trust among group members. While members may be hesitant at first, often their investment and involvement increases with practice of the activity. Patients who are oriented to the here-and-now and who are eager for active involvement are most appropriate. Patients who are not comfortable closing their eyes, who demonstrate symptoms of paranoia, who demonstrate poor physical boundaries and/or a high level of antisocial personality traits, or who have a limited investment in teamwork, active involvement, or personal growth are not appropriate. Goals include to develop trust, improve respect for others, improve problem-solving skills, develop healthy nonverbal communication skills, and develop healthy social interaction skills. This procedure is practiced at the augmentative and intensive levels of therapy. Preparation. A room with chairs and five handheld instruments, each of different timbre, are required. What to observe. Note patient responses, including level of involvement in the activity, ability to complete the trust walk, reaction to other group members and to the therapist, and changes in affect or behavior. Procedures. This method begins with an opening discussion focused on “trust” and may include questions such as “What does it mean to be trusting? How do you know if you can trust someone? How might you develop trust in a relationship?” The therapist then explains that this activity involves teamwork, the development of trust, and the use of silent (i.e., nonverbal) communication. Five instruments of different timbre are introduced (example: buffalo drum, triangle, claves, jingle bells, egg shaker). It is then explained that the sound of each instrument will be the cue for a specific movement. For example, a beat of the buffalo drum means “step forward”; a strike of the triangle means “turn”; the tapping of claves means to “reach up”; the jingling of bells means to “reach down”; and the egg shaker is the object which is hidden and must be found. Six patients are requested as volunteers. Four volunteers will play one of the first four instruments, respectively; one volunteer will hide the egg shaker somewhere in the room that is within sight and easy reach and not on top of another person; the final volunteer will be the first contestant of the Musical Trust Walk. The first contestant is led out of the room by the therapist with her back to the room as the volunteer with the egg shaker hides it. The first contestant is directed to keep her eyes closed during the experience, using her ears to listen to each musical sound, which determines her movements. The sounds played one at a time help to guide the first contestant to the egg shaker. In other environments, it might be appropriate for the first contestant to wear something over her eyes to keep from looking. A modified version where the patient agrees to close her eyes is the best way to complete the task safely while adhering to Correctional guidelines. When patients with the instruments announce they are ready, the first contestant is guided to turn around, facing the front entrance of the room, and the activity begins. Patients with the instruments are challenged to use their playing to guide the first contestant to find the egg shaker. Once she does, she

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opens her eyes and all participants share in a discussion that may include review of any challenges the patients or the group as a whole faced during the task, a review of basic communication and leadership skills that make for a successful experience, and identification of actions that support goal attainment by the first contestant. Group members are encouraged to complete the process again, with different patients playing different instruments and with a new contestant for the Trust Walk. The process continues for the length of the group or until patients who are willing all get the chance to be a contestant. The session may close with discussion of the activity’s purpose and of the benefits of the activity and how it might apply to everyday life. Basic elements of effective communication and teamwork may be summarized (i.e., the importance of looking and listening, turn-taking, how to support others toward positive goal attainment, etc.). Adaptations. Discussion of the process may be saved for the end, rather than after each contestant’s turn. If the group is small, patients may opt to play more than one instrument at a time. The therapist may volunteer to take a turn at the start of the session to demonstrate how it works and to support the development of trust within the group.

Special Guest Overview. Individual and/or ensembles of patients share music, an interest, or a talent that is personally meaningful with other members of the community. It gives patients in a unit the chance to recognize and appreciate each other’s talents. Sharing a talent introduces the patient to a supportive community, gives her the chance to act as a positive role model, and allows her to consider active participation in similar venues like a future concert or special event. Patients invested in creative expression of any form are appropriate. Patients who are not interested or are uncomfortable with sharing before a group; who demonstrate an inability to tolerate remaining seated and/or listening without interrupting; and who demonstrate antisocial traits, including investment in socially inappropriate behavior, are not appropriate. Goals include to increase self-confidence, increase self-awareness, support creative selfexpression, increase control of environment, develop healthy social skills, improve self-esteem, develop effective leisure skills, and learn effective coping skills. This procedure is practiced at the augmentative and intensive levels of therapy. Preparation. The method takes place in a group setting. The Special Guest is placed in the front of the room. Required equipment is based on selected performance and may include karaoke machine, microphone, and cable; music stand; chairs; handouts; musical instruments; karaoke or CD collection CDs; and songbooks. What to observe. Note patient responses, including degree of relatedness to others and to the therapist during and after the performance, changes in mood or behavior, ability to focus, and ability to complete the performance. Procedures. Patients in the unit involved in therapeutic programming are invited to share a socially appropriate personal talent with the community. The therapist meets individually with the patient prior to the session to discuss, plan out, and practice what will be included. Examples include: • • •

reciting a favorite creative writing (original or printed), such as a poem, prayer, scripture, or prose; sharing an appropriate dance (see Group Dynamics and Patient Conduct under Special Considerations in Corrections in this chapter); sharing a favorite song (by recording or live performance);

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playing a solo on a musical instrument; sharing a piece of artwork; sharing a theatrical skit; and verbally describing a favorite musical movie or video (if approved and available in the unit).

At the start of the designated group, the therapist introduces the Special Guest, encouraging patient support and respect for the performer. The performer is given the opportunity to share their talent. After the performance, applause, appropriate questions, and discussion of the patient’s contribution may follow. Discussion may include noting the performance’s effect on the community and on other group members. The Special Guest is given the option to stay for the remainder of the group or to leave. The group continues as planned. Adaptations. More than one patient may engage in a performance together. A group may be devoted solely to Special Guest performances. Staff members may be invited as Special Guests. The performance may take place during other events in the unit, such as a community meeting. The performance may be the center of a group topic and discussion for a particular session. The performance may be related to a particular theme such as a holiday, a season, or an awareness week or day such as for breast cancer or domestic violence.

CLOSING REMARKS ON METHODOLOGY This section offers suggestions on the successful facilitation of music therapy methods outlined in this chapter with adult females in Corrections. General guidelines are noted first. Most music therapy sessions with adult females in Corrections take the form of groups, are scheduled in advance around correctional movement, and are included as a regular part of mental health programming. Attendance may be mandatory. Some units require a formal list of attendees submitted in advance, which is disseminated to confirm inmate movement. Group size and composition vary depending on method content, target population, and patient availability. On average, the music therapist leads two or three sessions a day. Prior to session facilitation, the therapist should know if any patients are on restriction from involvement in certain groups. This is important, as manipulative patients may attempt to participate. Groups composed of more cognitively impaired or limited patients often emphasize nonverbal, concrete methods, while those composed of higher-functioning patients often emphasize more advanced techniques and discussion. What follows is a suggested outline of groups that support the effective use of methods noted in this chapter. Groups are listed from introductory to advanced. Method selection should always be based on patient needs, taking into account patient abilities and preferences. With demonstration of increased investment and progress in music therapy, movement to more advanced versions of each method often occurs naturally. The following sections describe how groups may be structured, beginning with techniques to use to open and close groups, offer guidelines on facilitating individual sessions, and identify which methods are combined to create particular groups.

Openings and Closings Having experienced more loss than stability, it is common for adult females to enter therapy very defensive. This makes the use of Openings and Closings important. Openings and Closings need not be long but should affirm each session’s beginning and end. Openings help with focus (Watson, 2002) and

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are a good time to complete therapist introductions and to review behavioral group rules (Thaut, 1987), to acknowledge patients, to discuss session goals and objectives, to follow up on previous session items, and to set the stage for new methods. Thaut (1987) suggests the following for a first session: I am (_______) and am the music therapist. … This is one of our music therapy groups, where we will basically be listening to music and talking. This group meets three times a week on (_____) at (__) o’clock. This is the room we will meet in every time. This group will run for (__) minutes, and basically we are trying to develop an enjoyable and positive experience for everybody. This is a time for yourself to make yourself feel better and to work on goals that help you with that. For example, to relax, to change your mood and lift your spirits, to bring back memories that can strengthen you, to share thoughts and feelings to get them off your chest, to think and feel good about yourself, to get your mind off the daily tension, or to clear your thoughts. The music is a powerful tool that can help you accomplish these goals because it can bring back feelings, it can help you express feelings and thoughts, it can calm you down or pick you up, depending on what you need. Therefore, I want you to pick the music carefully and put some thought into it so that you really get out of it what you need. This is your time and I will help and guide you with questions, suggestions, and explanations to reach your goal for this group time (p. 47). Once the purpose of the group is discussed, Thaut (1987) recommends asking “each group member how he feels that day” keeping the focus on individual goal-setting by “immediately ask[ing] him to formulate a brief personal agenda on which to work during group” (p. 48). Closings refocus a group (Watson, 2002); are a good time to summarize content and overall effects of a session; may serve to encourage patient understanding of music therapy related to individual care (Watson, 2002); and provide a chance for supportive feedback, review of goal attainment, review of session highlights, and for setting future goals (Rio & Tenney, 2002). Thaut (1987) refers to these as wrap-ups, noting that they should be supportive, emphasizing successful experiences and appropriate behavior, and validating that identified individual patient goals and music selections were “worthwhile” (p. 50). If a group has been loud and/or stimulating, providing a calming method of closing assists with patient balance of emotion and decreased heart and regulatory rate prior to their return to the unit (Watson, 2002). In addition to the abovementioned guidelines, specific music therapy methods that work well as Openings or Closings include the improvisational Openings and Closings outlined in Improvisation Experiences and the receptive Breath Awareness with Music. The use of before-and-after measurements (as described below in Creative Relaxation) or the Happy/Sad Faces (as described in the Adaptations section of the multiple method Expression of Feelings) can be used as an assessment in the opening and/or closing of a session. Openings may also include the re-creative Vocal Warm-up and the improvisational Familiarity with Instruments.

Individual Music Therapy A set number of individual music therapy sessions may be added to the schedule when specific needs are identified that cannot be met in the group setting (Fulford, 2002). The decision for individual therapy to address identified goals may be based on team referral, observation of patient behavior and response to music therapy, and/or patient request. Patients diagnosed with malingering, who exhibit severe antisocial

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traits, or who are resistant to therapy are not appropriate. If the patient is eager for individual attention (which is often the case), she may be hesitant to show or share improvement. Feedback from other team members and/or close observation of patient behavior in and out of the session is helpful to determine goal attainment and continued appropriateness. Skills that are worked on may be encouraged in other unit programming. For example, a patient may become a Special Guest in a Therapeutic Music Recreation group or perform in the next concert, or a patient demonstrating progress by managing anxiety more effectively after a series of supportive individual GIM sessions may be placed in the Creative Relaxation group. Methods employed are specific to patient need and identified goals. First session openings may include the completion of a questionnaire similar to that noted by Gallagher and Steele (2002); see Assessment and Referral Procedures.

Introductory Music Therapy Some mental health programs in Corrections include an introductory music therapy group for patients new or returning to the unit. This group provides the adult female with basic guidelines on the group process and on how music therapy is used to support personal care. It gives the therapist a chance to evaluate and assess musical, cognitive, intellectual, physical, and mental abilities, assisting with future group placement. Contraindicated are those patients whose symptoms are so acute as to limit their ability to function in the group setting. Goals include to support adjustment to prison and to the program. During the opening, members may be encouraged to share feelings/thoughts related to being in the program. Methods that lend themselves well in this introductory group include the receptive Song Listening with Lyric Discussion (particularly with tasks such as Favorite Song and Parts of My Personality); the re-creative Sing-Along; the improvisational Improvisation Experiences (starting with Openings and Closings); simple compositional methods of Songwriting, like Lyric Substitution/Fill-inthe-Blank; and the receptive Breath Awareness with Music. Until trust and comfort with this medium is developed, patients may be self-conscious about playing musical instruments. If, however, they demonstrate investment in instruments, the re-creative Didactic Music Lessons; and the improvisational Structured Rhythmic Improvisation, Rhythmic Advancement, Structured Rhythmic Accompaniment to Familiar Song, and/or Structured Rhythmic Improvisation may be considered. A similar group topic may be called “How to Get the Most Out of Group” (Gallagher & Steele, 2002).

Therapeutic Music Recreation This group is designed to support the use of recreationally based music activities with patients who would benefit from therapeutic play. Experiencing healthy forms of leisure activity within the social environment supports the development of more effective ways of relating to others and of coping in society. Openings may begin with a general check-in on patient status and needs for the session, followed by those noted in the Openings section above. Methods that lend themselves well to this group include the multiple-method Special Guest; the receptive Song Listening with Lyric Discussion (particularly Favorite Song, Parts of My Personality, Music Appreciation, and games such as Name That Tune); the re-creative Vocal Warmup with Sing-Along or Karaoke Singing or Learning a New Song; the re-creative Creative Movement with Music; the compositional Songwriting (particularly simple Lyric Substitution/Fill-in-the-Blank or the adaptations Conversation-Style Question/Answer and Predetermined 12-Bar Blues Musical Form); the improvisational Improvisation Experiences: Familiarity with Instruments, followed by the mixed Expression of Feelings or Musical Trust Walk. If group members are part of a re-creative Concert Performance in the unit, then group methods may include Rehearsal of Individual and Group Songs and/or the completion of

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Complementary Art. Patients may take turns choosing group activities. For example, those celebrating a birthday during that week might choose a favorite method. Closings may include any of the methods described above under Openings and Closings or those noted under the specific methods. This group may be titled and adapted to reflect other therapeutic topics like Healthy Leisure Skills, Socialization or Relationship-Building, or Relapse Prevention (Gallagher & Steele, 2002). Wyatt (2002) describes groups involving musical games titled “Music Trivia” and “Name That Jam” (pp. 83–84). The re-creative method Karaoke Singing works well as its own therapeutic music recreation group. In some units, groups such as Karaoke Singing are built into a behavior modification system and used as a reward at week’s end for treatment compliance and the attainment of goals and/or objectives (Fulford, 2002). Details including openings, closings, and adaptations are outlined in the Karaoke Singing method.

Creative Coping: Instruments and Song This group is designed to explore and develop the use of musical instruments (including the voice) for healthy creative expression, effective communication, feeling identification and management, and building community. Openings may include any experiences described in the Openings and Closings section. Methods employed include all those listed under the improvisational Improvisation Experiences, the re-creative Sing-Along, and the mixed Expression of Feelings. Improvisations that develop may lead to the compositional Songwriting, Creative Movement to Music, or involvement in the re-creative Concert Performance or Special Guest. Closings may include any experiences described in the Openings and Closings section. Similar groups may be titled and reflect the topics Leisure Skills, Communication, Relationship-Building, or Decision-Making. Group content can be included for Relapse Prevention (Gallagher & Steele, 2002) as well.

The Concert Performance The Concert Performance is a method and series of groups in and of itself. Once practice is under way, Openings may include the receptive Breath Awareness with Music and the re-creative Vocal Warm-up. The re-creative Learning a New Song, Sing-Along, and Creative Movement to Music may be utilized. Improvisation Experiences (from Structured Rhythmic Accompaniment to Familiar Songs to Solos, Duets, and Trios) may be employed if playing of instruments is included in the concert. Concert details could be worked on during complementary groups like Creative Coping: Instruments and Song, Karaoke Singing, Songwriting, Therapeutic Music Recreation, and Individual Music Therapy. Closings may include improvisations found in Improvisational Experiences/Closings, as well as the receptive Breath Awareness with Music or discussion. Reed (2002) describes another concert group titled “Gospel Choir” (p. 100).

Songwriting This group is designed to help adult females who have difficulty with self-expression but are open to the creative process. Those with symptoms of anxiety and depression often respond well. Openings may include questions such as “Did you hear or think of a song recently that stood out for you? How did you experience that song? If your life were a song what would the title be?” Openings may begin as well with the sharing of a song written or reviewed in a previous session, or with the spontaneous use of a simple recreative Songwriting method like Lyrics Based on Blues Form. Referential methods that work well as “lead-ins” to compositional songwriting include Song Listening with Lyric Discussion (in particular, the

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adaptation Songwriting Awareness). As patient familiarity and comfort with this medium increases, other compositional methods listed under Songwriting: Lyric Writing and Melody Writing may be employed. Compositions may be included in the Concert Performance or shared during a Special Guest performance. Closings may include a review of material created in the session or any of those listed in the Openings and Closings section described above.

Creative Relaxation This group is designed for adult females who have difficulty coping with stress. It provides an opportunity for personal reflection, increased attunement to self, and identification of supportive inner resources. “Training the patients in music selection, muscle relaxation, simple imaging, and physical responses of stress aids them in learning techniques they can use on their own, whether in the unit or after discharge” (Fulford, 2002, p. 114). Patients who demonstrate a capacity for personal reflection and secondary processing, who are invested in personal growth and artistic expression, and who desire to build effective creative coping skills benefit most from this group. Those who have experienced severe trauma may attend but with caution and close supervision by the therapist. Patients who are highly antisocial are not appropriate. Openings may include patient sharing of recent stressors, ways they cope with the stress, and/or effective relaxation techniques they practiced. Fulford (2002) recommends using “rate of respirations and subjective response … to measure relaxation” (p. 114), discussing physical and mental anger triggers to “measure anger management skills,” and discussing “alternate methods of expression” (p. 114). As such, Openings and Closings may include before-and-after measurements of anger, stress, and/or relaxation levels in addition to other experiences described in the Opening and Closings section above. Following openings, methods may include the receptive Song Listening with Lyric Discussion (with particular focus on relaxation response to the music), Creative Movement to Music, and Supportive Directed Imagery and Music. Alternative methods may include the improvisational Improvisation Experiences, the re-creative Vocal Warm-up and Sing-Along, and the mixed Expression of Feelings. Closings may include a return to the receptive Breath Awareness with Music or to the Improvisational Experiences with relaxation/stress/anger measurements afterward. A group with similar content may be titled Stress Management or Depression Management.

Anger Management While a group specific to anger has not been used by this writer, Hakvoort (2002) presents a model for use with male forensic offenders worth considering for future research with adult females (pp. 123–132). The model is designed to help patients learn to identify, “regulate and control … aggressive impulses arising from increasing irritation and anger” (p. 126). Group content follows five phases over approximately 15 sessions. Methods include the receptive Song Listening with Discussion and the recreative Sing-Along to increase awareness of anger and situational anger triggers; adaptations from the receptive Supportive Directed Imagery and Music in combination with Song Listening with Discussion to encourage the use of music and relaxation to regulate emotions; adaptations from Supportive Directed Imagery and Music in combination with the improvisational Improvisation Experiences to confront negative emotional states, directly applying more effective coping mechanisms; and then the practice and integration of new skills. For specifics, refer directly to Hakvoort’s article (2002).

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CARING FOR THE CAREGIVER The high degree of need among adult women in Corrections could easily warrant extended sessions and extra attention. Despite our best efforts to promote wellness, sometimes criminal behavior persists and patients act out or reoffend. With the limited resources of time and high risk of burnout among mental health clinicians, learning to maintain appropriate professional boundaries and to cope with patient setbacks is vital to the therapist’s success. To this end, Daveson and Edwards (2001) strongly encourage regular supervision while Glyn (2008), illustrating his work with violent mentally ill offenders, considers supervision “an absolute necessity” (p. 72). Thaut (1987) also supports the use of “brief, time-limited interventions with clearly defined goals for treatment” and group therapy over individual sessions (p. 46). An effective therapist benefits from close, regular communication and collaboration with her treatment team and from awareness of her own personal “beliefs and biases that relate to criminal activity; mental health issues; differing forms of abuse including substance, physical, emotional, and sexual abuse; sexuality; and the role of the individual and society in responding to criminal activity” (Daveson & Edwards, 2001). Self-care, attention to personal responses, and attention to countertransference issues guard against two pitfalls: that of becoming overly sympathetic to patients, losing sight of criminal intent or psychopathy, or, conversely, that of becoming “dismissive and superior” (Glyn, 2002, p. 61). Such responses indicate symptoms of burnout. Falling into these pitfalls and lack of self-care significantly limit the therapist’s ability to support patient development (Daveson & Edwards, 2001).

RESEARCH EVIDENCE This section reviews research literature that includes music therapy with females in Corrections. The seven references listed in this section involved direct work with females; research literature exclusive to working with males or unspecific to Corrections/Offenders was not included. The first three reference summaries that follow are specific to adult females in Corrections; the fourth contains a section specific to female juvenile offenders in a residential facility; the fifth involved females and males in a forensic psychiatry unit; the sixth and seventh involve female and male offenders in community settings. Daveson and Edwards (2001) engaged in a descriptive study which took place in a female correctional facility to investigate the role of music therapy in prisons, using two surveys that evaluate self-report measures and by evaluating musical and verbal material shared during a 12-week program over a 14-week period. Receptive methods (music selection and listening), compositional methods (songwriting and song parody); improvisational methods (vocal and instrumental recreation), and recreative methods of music therapy (singing) were employed. Participant attendance was small; however, participants noted a reduction in stress and levels of anger and frustration, particularly with the use of recreative, compositional, and receptive methods. In an effort to examine the therapeutic potential of creating and performing music, O’Grady (2011) directed and researched a 10-week collaboration in a maximum security female prison between several inmates and female artists from an outside theatre company. This led to a musical show. Methods utilized included compositional (songwriting) in combination with mixed music therapy (singing, writing scripts, and community theatre). O’Grady (2011) discusses the benefits of community music therapy, shares how creating and performing music can bridge the gap between the inside and outside on multiple levels (i.e., within oneself, between oneself and the outside world, etc.), and emphasizes the need for “inward-focused approaches to the music experience” (p. 144). Although Silber (2005) is a choir conductor and educator, not a board-certified music therapist, this writer found her work significant enough to be included in this chapter. Silber examines many aspects

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of a multivocal choir created for female inmates in prison. The re-creative music therapy method of directing a choir was employed. Attention is given to the application of specifics such as hand signals, musical concepts, increased looking/listening, and harmonic backup to assist with skill development and improved social outcomes specific to incarcerated women (i.e., empowerment, self-esteem, group cohesion, cooperation, etc.). Rio and Tenney (2002) discussed their development of a group music therapy program for juvenile offenders in a residential treatment setting. Girls were segregated from boys; it was noted how client groups evolved differently. Treatment stages emphasized focus, trust, leadership and identity, group cohesion, and closure. Methods employed included receptive (music selection and listening), re-creative (singing as a group and as soloists, movement to music, and performance), improvisational (group improvisations, drumming), and compositional music therapy (lyric- and songwriting). Regarding adolescent girl groups, it was noted that movement was important for helping with focus and that singing elicited “the greatest demonstration of unity” (p. 93). Spang (1997) discussed her two years of music therapy experience in a forensic psychiatric unit with very hostile, mentally ill patients (including three adult females). Methods utilized were receptive (music listening and discussion), improvisational (exploring emotions via group and individual instrument playing), and compositional music therapy (writing). She describes her observations of the slow group progression from receptive to active music-making; the opportunities and challenges provided from supporting music-evoked emotions; the cycle of environmental demands leading to criminal acts by mentally ill individuals; the importance of therapist qualities like acceptance, affirmation, validation, and nonjudgment; and the importance of teamwork when treating severely mentally ill offenders. Spang (1997) also notes issues addressed in music therapy and patient changes, which included decreased somatic complaints, increased self-esteem and responsibility toward self and others, and staff reports of increased constructive use of time outside of group. Hoskyns (1988) outlined the development of a “music therapy grid … designed to investigate how group members perceive music therapy and if their perceptions changed over time (p. 25). Her research was conducted at a center run in connection with a probation after-care service, which provides an alternative to custody for male and female offenders over 21 years of age and encourages client responsibility for change. Music therapy groups took place weekly over a 12-week period and included a small sample of clients, with the therapist and student assistant utilizing the method of improvisational music therapy. Correctional staff and clients were given questionnaires and clients reviewed videotapes of sessions. Regarding client buy-in and cooperation, Hoskyns (1988) noted the benefits of actively including the human subjects of investigation in the research planning and execution. Gallagher and Steele (2002) outlined a group music therapy program in a community-based setting for dually diagnosed clients (substance abuse and mental illness), the majority of whom were criminal offenders. Written assessments were issued quarterly; Rogers’s Happy/Sad Faces Assessment Tool (p. 118) was utilized before and after each group. Methods employed included receptive (music listening, music-assisted relaxation, lyric analysis, music games, rating of music preferences), improvisational (instrument-playing, setting feelings to music), compositional (lyric- and songwriting, including cloze and parodies), re-creative (singing), and multiple media and methods (sharing of favorite items, including recordings, writings, videos, etc.; storytelling; combining drama and music to produce a music video). Music therapy was found to be an effective and important component of the treatment of clients with dual disorders. In summary, five of the seven references noted the use of multiple methods (Daveson & Edwards, 2001; Gallagher & Steele, 2002; O’Grady, 2011; Rio & Tenney, 2002; Spang, 1997), a sixth was limited to improvisation (Hoskyns, 1988), and a seventh was limited to re-creative in the form of a choir (Silber, 2005). Of the five mentioned above, one focused on the incorporation of music into a musical (O’Grady, 2011). Five of the seven references included the re-creative method of singing (Daveson & Edwards, 2001;

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Gallagher & Steele, 2002; O’Grady, 2011; Rio & Tenney, 2002; Silber, 2005); three of these five noted increased unity and group cohesion when members engaged in this method (O’Grady, 2011; Rio & Tenney, 2002; Silber, 2005); and two of these five directly involved community performance (O’Grady, 2011; Silber, 2005). Five of the seven references included compositional methods (Daveson & Edwards, 2001; Gallagher & Steele, 2002; O’Grady, 2011; Rio & Tenney, 2002; Spang, 1997); five included improvisational methods (Daveson & Edwards, 2001; Gallagher & Steele, 2002; Hoskyns, 1998; Rio & Tenney, 2002; Spang, 1997); four included the receptive method of music listening (Daveson & Edwards, 2001; Gallagher & Steele, 2002; Rio & Tenney, 2002; Spang, 1997); and one included the re-creative method of movement to music (Rio & Tenney, 2002). Music therapy research specific to this population is still in its infancy; there is much need for continued investigation. Research to date includes recommendations for future study and development of formalized assessment measures related to identified goal areas (Watson, 2002); methods that take into account the adult offender’s difficulty with trust and the dangers of sharing sensitive information, and that foster effective collaboration by encouraging active offender involvement and self-evaluation (Hoskyns, 1988, p. 40); a comparison of treatment programs for “offenders who received music therapy and those who did not” (Watson, 2002, p. 110); longitudinal research that examines the impact of music therapy on recidivism rates (Watson, 2002); and long-term studies that examine the implications of exercising self-control in a choir context on overall social functioning (Silber, 2005). In addition, this writer recommends studies that investigate a possible link between increased empathy and emotional growth through musical expression and those that might identify specific methods that most effectively foster independence and empowerment, promote increased motivation, and support long-term success with emotion/anger management and self-care.

SUMMARY AND CONCLUSIONS This chapter has provided an introduction to and examples of how music therapy may be utilized to make a difference in the survival, adaptation, and improved well-being of adult females in Corrections. While the needs of this population are many, confounding variables of the correctional environment make effective therapy practices all the more important to a female’s successful social integration. Valuable music therapy methods have been introduced that promote insight, support personal growth, improve self-esteem, encourage appropriate expression and management of emotions, improve stress management, promote the development of healthy leisure skills and healthy relationship-building, and foster a sense of belonging. Continuing to help adult females translate these interventions into effective coping outside of the protective therapy environment is necessary. This requires more active music therapy involvement not only in multidisciplinary treatment teams, but also in discharge planning and continuums of care for females leaving prison. It is this writer’s hope that this chapter plants the seed of inspiration in other music therapists to enrich the lives of this unique and chronically underserved population.

DEDICATION This chapter is dedicated to all individuals who strive, against all odds, to build community. Special thanks go to Dr. Lillian Eyre, for this opportunity and her unending guidance and patience; to Tricia Higgins, Nicole Masceri, and Dr. Jerlym Porter for their inspiration; and to my family, my husband Freddie, and Dr. Deborah Skibbee for their unending faith in me.

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REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Arlington, VA: Author. American Psychiatric Association. (2000). DSM IV-TR, Chapter 6. Mood Disorders. DSM Library. psychiatryonline. Retrieved September 2, 2012, from http://psychiatryonline.org/content.aspx?bookid=22§ionid=1890370#2016 American Psychiatric Association. (2000). DSM IV-TR, Chapter 7. Anxiety Disorders. DSM Library. psychiatryonline. Retrieved September 2, 2012, from http://dsm.psychiatryonline.org//content.aspx?bookid=22§ionid=1890929 American Psychiatric Association. (APA). (April 30, 2012). DSM-5 Development, Proposed Revisions. B 07 Schizoaffective disorder. Retrieved July 28, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=144 American Psychiatric Association. (APA). (April 30, 2012). DSM-5 Development, Proposed Revisions. B 08 Schizophrenia. Retrieved July 28, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=411 American Psychiatric Association. (APA). (2012). DSM-5 Development, Proposed Revisions. G 03 Posttraumatic stress disorder. Retrieved June 25, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165 American Psychiatric Association. (APA). (April 30, 2012). DSM-5 Development, Proposed Revisions. G 04 Adjustment disorders. Retrieved June 25, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=367 American Psychiatric Association. (APA). (May 11, 2012). DSM-5 Development, Proposed Revisions. T 00 Mood disorders. Retrieved July 12, 2012, from http://www.dsm5.org/meetus/pages/mooddisorders.aspx American Psychiatric Association. (APA). (2012). DSM-5 Development, Proposed Revisions. Substance use disorder. Retrieved June 23, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=431 American Psychiatric Association. (APA). (June 21, 2011). DSM-5 Development, Proposed Revisions. Borderline personality disorder. Retrieved June 24, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=17 American Psychiatric Association. (APA). (2012). DSM-5 Development, Proposed Revisions. T 04 Antisocial/Psychopathic personality disorder type. Retrieved June 25, 2012, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=438 Anderson, E. (2001, January). Going straight: The story of a young inner-city ex-convict. Punishment & Society, 3(1), 135–152. http://pun.sagepub.com Appelbaum, K. L., Hickey, J. M., & Packer, I. (2001, October). Multidisciplinary roles in the 21st century: The role of correctional officers in multidisciplinary mental health care in prisons. Psychiatric Services, 52(10), 1343–1347. Blitz, C. L., Wolff, N., & Paap, K. (2006, March). Availability of behavioral health treatment for women in prison. Psychiatric Services, 57(3), 356–360. http://ps.Psychiatryonline.org Boone, P. (1991). Composition, improvisation and poetry in the psychiatric treatment of a forensic patient. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 433–450). Phoenixville, PA: Barcelona Publishers. Braithwaite, R. L., Treadwell, H. M., & Arriola, K. R. J. (2005, October). Health disparities and incarcerated women: A population ignored. American Journal of Public Health, 95(10), 1679– 1681. Ovid.

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Buschong, D. J. (2002). Good music/bad music: Extant literature on popular music media and antisocial behavior. Music Therapy Perspectives, 20(2), 69–79. Codding, P. A. (2002). A comprehensive survey of music therapists practicing in correctional psychiatry: Demographics, conditions of employment, service provision, assessment, therapeutic objectives, and related values of the therapist. Music Therapy Perspectives, 20(2), 56–68. Conroy, M. A., & Kwartner, P. P. (2006). Malingering. Applied Psychology in Criminal Justice, 2(3), 29– 51. Sam Houston State University. Retrieved September 3, 2012, from http://www.apcj.org/documents/2_3_Malingering.pdf Correctional Association of New York. (2009, April 1). Women in prison fact sheet, United States. Retrieved June 1, 2012, from http://www.correctionalassociation.org/resource/women-in-prison-fact-sheet Daveson, B.A. & Edwards, J. (2001). A descriptive study exploring the role of music therapy in prisons. The Arts in Psychotherapy, 28, 137-141. Edgerton, C. D. (1990). Creative group songwriting. Music Therapy Perspectives, 8, 15–19. Farlex, Inc. (2012). Mood disorder. The free dictionary by Farlex. Retrieved July 12, 2012, from http://medical-dictionary.thefreedictionary.com/mood+disorder Ficken, T., & Gardstrom, S. (2002). Guest editorial. Music Therapy Perspectives, 20(2), 53–55. Freed, B. S. (1987). Songwriting with the chemically dependent. Music Therapy Perspectives, 4, 13–18. Fulford, M. (2002). Overview of a music therapy program at a maximum security unit of a state psychiatric facility. Music Therapy Perspectives, 20(2), 112–116. Gallagher, L. M., & Steele, A. L. (2002). Music therapy with offenders in a substance abuse/mental illness treatment program. Music Therapy Perspectives, 20(2), 117–122. Gardstrom, S. C. (2004). An investigation of meaning in clinical improvisation with troubled adolescents. In B. Abrams (Ed.), Qualitative Inquiries in Music Therapy: A Monograph Series, 1 (pp. 77– 160). Gilsum, NH: Barcelona Publishers. Glyn, J. (2002). Drummed out of mind: A music therapy group with forensic patients. In A. Davies & E. Richards (Ed.), Music therapy and group work: Sound company, 3 (pp. 43–62). London & Philadelphia, PA: Jessica Kingsley. Glyn, J. (2009). Two’s company, three’s a crowd: Hatred of triangulation in music therapy, and its supervision in a forensic setting. In H. Odell-Miller and E. Richards (Eds.), Supervision of music therapy: A theoretical and practical handbook, 4 (pp. 67-82). London: Routledge. Greenberg, G. A., & Rosenheck, R. A. (2008, February 1). Jail incarceration, homelessness, and mental health: A national study. Psychiatric Services, 59(2), 170–177. http://www.ps.psychiatryonline.org Hakvoort, L. (2002). A music therapy anger management program for forensic offenders. Music Therapy Perspectives, 20(2), 123–132. Hoskyns, S. (1988). Studying group music therapy with adult offenders: Research in progress. Psychology of Music, 16, 25–41. Langan, D., Williams, P., & Athanasou, J. A. (1999). Outcomes of a music therapy intervention in a psychiatric ward within a correctional services institution. MusicMedicine, 3, 275–284. McNeil, D. E., Binder, R.L., & Robinson, J.C. (2005, July). Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse. Psychiatric Services, 56(7), 840–846. http://ps.psychiatryonline.org Nashville Songwriters Association International (NSAI). (2006). Song checklist. The NSAI Guide, 5. Nolan, P. (1983). Insight therapy: Guided imagery and music in a forensic psychiatric setting. Music Therapy, 3(1), 43–51. O’Grady, L. (2011). The therapeutic potentials of creating and performing music with women in prison: A qualitative case study. Qualitative Inquiries in Music Therapy: A Monograph Series, 6, 122–152.

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Plach, T. (1996). The creative use of music in group therapy. Springfield, IL: Charles C Thomas Publisher. Reed, K. J. (2002). Music therapy treatment groups for mentally disordered offenders (MDO) in a state hospital setting. Music Therapy Perspectives, 20(2), 98–104. Rio, R. E., & Tenney, K. S. (2002). Music therapy for juvenile offenders in residential treatment. Music Therapy Perspectives, 20(2), 89–97. Rogers, A. (1981, September 4-11). Third World Congress on Pain of the International Association for the Study of Pain. Edinburgh, Scotland. Abstracts. Pain— Supplement, 1. 51-319. Salekin, R. T., Rodgers, R., & Sewell, K. W. (1997). Construct validity of psychopathy in a female offender sample: A multitrait-multimethod evaluation. Journal of Abnormal Psychology, 106(4), 576– 585.http://ovidsp.tx.ovid.com.libproxy2.umdnj.edu/spb/ovidweb.cgi?&S=CBNLFPBHNGDDMA PINCHLFCCKEPNGAA00&Li Schaufeli, W. B., & Peeters, M. C. W. (2000, January). Job stress and burnout among correctional officers: A literature review. International Journal of Stress Management, 7(1), 19–48. Schmidt, J.A. (1983). Songwriting as a therapeutic procedure. Music Therapy Perspectives, 1(2), 4–7. Silber, L. (2005, July). Bars behind bars: The impact of a women’s prison choir on social harmony. Music Education Research, 7(2), 251–271. Sloboda, A., & Bolton, R. (2002). Music therapy in forensic psychiatry: A case study with musical commentary. L. Bunt and S. Hoskyns (Eds.), The handbook of music therapy, 8, pp. 132–148. London: Routledge. Spang, S. (1997). Forensic psychiatry and music therapy. Annual Journal of the New Zealand Society for Music Therapy, 17-28. Summer, L. (2002). Group music and imagery therapy: Emergent receptive techniques in music therapy practice. In K. E. Bruscia & D. E. Grocke (Eds.), Guided imagery and music: The Bonny method and beyond, 16 (pp. 297–306). Gilsum, NH: Barcelona. Thaut, M. H. (1987). A new challenge for music therapy: The correctional setting. Music Therapy Perspectives, 4, 44–50. Watson, D. M. (2002). Drumming and improvisation with adult male sexual offenders. Music Therapy Perspectives, 20(2), 105–111. Wyatt, J. G. (2002). From the field: Clinical resources for music therapy with juvenile offenders. Music Therapy Perspectives, 20(2), 80–88.

Chapter 18

Adjudicated Adolescents Susan C. Gardstrom _____________________________________________ INTRODUCTION This chapter highlights music therapy practice with adjudicated adolescents, also referred to as juvenile offenders or delinquents. In 2008 alone (the most recent year for which statistics are available), juvenile courts in the U.S. took action on more than 1.6 million petitions of delinquency. Some of these cases were dismissed; some were waived to adult, or criminal, court; still others resulted in adjudication (a determination of guilt) with subsequent dispositions of community service, restitution, fines, probation, and/or mandatory placement in treatment programs of varying levels of security (National Center for Juvenile Justice, 2009). The American Music Therapy Association (AMTA, 2010) reports that 18.5% of its members are employed in mental health settings and that 13.4% serve teens, which could include delinquent youth. A smaller percentage (less than 2%) report working in corrections, although it is unclear whether this means adult or adolescent correctional facilities. Thus, at this time, the percentage of credentialed music therapists in this country who treat adjudicated adolescents (as opposed to adult criminals or adolescent clients of a different demographic) is unknown. Definitions of terms and descriptions of judicial processes related to delinquency are offered in the following section. These are intended to provide a context for the information in this chapter and to help the reader delineate between adjudicated adolescents and other adolescent clientele described in another chapter in this same volume. (Note: The clinical profiles and treatment needs of juvenile sex offenders are thought to differ notably from those of non–sex offenders. Thus, music therapy with young sex offenders is addressed separately in another chapter of this volume.)

Juveniles and Delinquency According to the Office of Juvenile Justice and Delinquency Prevention (OJJDP) within the U.S. Justice Department, juveniles, or minors, are commonly thought of as individuals under the age of 18 years. However, the legal definition of juvenile—and thus the upper age of juvenile court jurisdiction (vs. criminal court jurisdiction)—differs depending on the state. Whereas most states consider the upper age to be 17 years, at the time of this writing, 16- and 17-year-olds in some states may be tried in criminal court for all offenses committed. On the other hand, one state extends the upper age to 18 (OJJDP, 2011a). From a legal standpoint, a juvenile is said to be delinquent when found to have engaged in behavior that, were she or he considered an adult in the state in which the act was performed, would have been tried in criminal court. Examples of delinquent acts include offenses against persons (e.g., assault), property (e.g., larceny-theft), and public order (e.g., disorderly conduct) and drug offenses (e.g.,

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possession of narcotics). Only 3% of all juvenile arrests in 2008 were related to violent offenses, such as homicide, rape, robbery, and aggravated assault (Puzzanchera, Adams, & Kang, 2009). Status offenses refer to acts that are illegal for juveniles but not for adults, such as consumption of alcohol, violation of curfew, and truancy from school (OJJDP, 2011a).

Juvenile Justice Processes and Treatment Options Terminology, policies, and procedures pertaining to the U.S. juvenile justice system have changed considerably over time and presently vary from state to state, as is neatly chronicled by Barton (2011a). In general, though, when a juvenile is alleged to have committed a delinquent act or status offense, a petition is filed with the juvenile court in the proper jurisdiction. Once the allegation has been made, the case is referred to a probation department, where a predisposition report is prepared. This report typically contains a summary of the facts related to the case and a recommendation for corrective measures (Barton, 2011a). A judge reviews the report and, in a disposition hearing, may adjudicate and then render a decision regarding correction. The particular disposition imposed usually depends upon the nature and severity of the adolescent’s offense(s), his or her criminal history (including prior dispositions), the philosophy of the juvenile court in which the individual is tried, and the options available for remediation, among other factors. Often, after arrest and during court proceedings, youth may be sent to reside in local or regional jails or, increasingly, in temporary, secure detention centers. Nonsecure, interim shelters may also be employed for adolescents who pose low social risk or who have no other safe place to stay while they await adjudication, disposition, or another placement (Barton, 2011b; Puzzanchera, 2009). In this country, adolescents are not typically incarcerated for status offenses alone. Serious and repeat offenders receive the most severe sanction—commitment to a residential program. Some examples are training schools/long-term secure facilities, group homes/halfway houses, boot camps, and ranch/wilderness therapies. OJJDP custody data for 2007 indicated that nearly 87,000 detained and committed juveniles under the age of 21 years were held in residential placements around the country, 86% of whom were male residents (OJJDP, 2011b). Most of these programs are privately operated and small (20 or fewer youth), yet about 70% of all juvenile offenders reside in large, stateoperated facilities (OJJDP, 2011c). Some are same-sex and some are coeducational, and they vary in level of security. If published materials are any indication, most music therapists who work with adjudicated adolescents do so in some type of residential program.

Treatment Approaches Since its inception in the early 20th century, the juvenile justice system has struggled with the tension created by the need to punish young offenders for their actions and the need to rehabilitate them. The demonstrable outcome of this struggle has been a vacillation between lenient policies and programs and the “zero tolerance” and “get tough” stance of the 1990s, prompted by unprecedented high rates of youth violence and recidivism (a return to offending after a period of intervention). Since that time, principles of risk, protection, and resilience have emerged and figured prominently in the vocabulary of policy-makers and providers. In spite of these ever-shifting perspectives, traditional policies and programs have been consistently deficit-based, that is, the emphasis has been on identification and reduction of a young person’s deficits or problem behaviors through incarceration (to protect public safety), imposition of sanctions, and rehabilitation designed to reduce recidivism (Barton & Butts, 2008). The effectiveness of this problem-based model of juvenile justice, with its “one size fits all” approach to programming, has been questioned, however. Barton and Butts (2008) write,

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[Practitioners] are adopting a perspective that focuses on what is right with youth rather than on what is wrong with youth. This approach involves working with families and communities to enhance the positive social supports and opportunities that may improve a youth’s chances of developing to his or her fullest potential. The new perspective arises from two innovative frameworks for working with youth—positive youth development and strength-based practice (p. 1). In spite of organizational resistance and myriad challenges of implementation, strength-based practices, which tailor treatment to individual profiles, needs, and interests, are beginning to take hold in juvenile justice settings around the country (Barton & Butts, 2008). Some jurisdictions have adopted positive youth development and strength-based practices based on the managed care system model developed for children and adolescents in mental health, special education, and welfare systems. The term wraparound services has been used to describe a highly individualized and interagency approach to prevention, treatment, and aftercare of youth who are in or at risk for residential placement. At the heart of the wrap-around approach is a supportive care team, as depicted in the following description of one such best-practice, strength-based program in Indiana: If the child meets eligibility criteria and is accepted, a service coordinator is assigned to organize and facilitate a Child and Family Team (CFT) that includes natural supports in the community. The team develops and implements an individualized service plan using a wrap-around approach focused on the needs of the child and building on the strengths of the family. At the service-delivery level, the team works across agencies to integrate school plans, court orders, probation requirements, and mental health plans into one coordinated plan that is manageable for families. Utilizing the full array of community resources, the service plan is specific to the child and is flexible, evolving with the child’s progress. The Dawn Project’s philosophy is that “families don’t fail, plans do” (National Center for Education, Disability and Juvenile Justice [NCEDJJ], 2007, p. 9). One compelling argument for individualized, synchronized care is that wrap-around services appear to be more effective in reducing typically high levels of recidivism than coordinated, interagency treatment (Barton & Butts, 2008). Cost-sharing by multiple agencies is clearly a financial advantage.

CLIENT PROFILES AND NEEDS Adjudicated adolescents face myriad challenges, owing to a complex constellation of biological/genetic, psychological, familial, peer-related, school-oriented, and societal factors and risks. Underlying psychiatric disorders, neglectful and abusive family systems, gang involvement, repeated conflicts and failures in academic and social relationships and tasks, and poverty are just some of the customary features of the lives of many young offenders. (The reader is directed to Barton [2011a] for a comprehensive, referenced list of internal and external risk factors for and predictors of delinquency.) Delinquent youth present for treatment with a plethora of needs, perhaps the most salient and urgent of which orbit around their emotional functioning. Compared to nondelinquent youth, young offenders have been shown to exhibit more negative and less positive trait and state emotion (Plattner et al., 2007). Whereas some youth are able to regulate even frequent and intense feelings, others are unable

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to do so; this incapacity is thought to contribute to the development of internalizing disorders (e.g., anxiety, depression, and somatic complaints) or maladaptive externalization of emotion, in which high levels of anger and impulsivity lead to antisocial behaviors and, often, diagnoses of oppositional defiant disorder or conduct disorder. Emotional self-awareness and regulation, including opportunities for healthy externalization of potent traumatogenic feelings, common among these youth (Carrion & Steiner, 2000), are thus critical needs of juvenile offenders. In this way—by virtue of similar early life circumstances, events, and experiences that mold who they become as teens—adjudicated adolescents resemble other clientele described in this volume, such as youth in inpatient treatment for psychiatric disorders. The relationship between delinquency and long-standing and serious mental disorders is, in fact, well established. Abram and colleagues (2003) and Marker (2006) discovered significantly elevated rates of several psychiatric illnesses and a wide variety of symptoms among detained and incarcerated adolescents. Such illnesses include not only oppositional defiant and conduct disorders, but also mood and anxiety disorders, ADHD, substance use and addictive disorders, and in a minority of cases, psychoses. In a more recent multi-state prevalence study, Shufelt and Cocozza (2006) found that over 70% of youth in the juvenile justice system—female and male—met criteria for at least one psychiatric disorder and that 79% of these individuals met criteria for two or more disorders. Girls appear to be differentially affected by certain risk factors, such as early onset of puberty, sexual abuse and related trauma, substance abuse problems, and depression and anxiety (Hubbard & Pratt, 2002; OJJDP, 2010). Rio and Tenney (2002), in a rare article describing music therapy programming for young female offenders, noted in their clients high incidences of depression, dissociative reactions, and intrusive somatic symptoms and complaints, suggesting the presence of posttraumatic stress disorder (American Psychiatric Association [APA], 2013). In addition to mental health services, youth may require special education services. While it is a thorny task to establish accurate rates, it is estimated that more than one in three adolescents in correctional facilities has a disability that warrants special instructional services. The most frequently reported disabilities are emotional or behavioral disorders, ADHD, learning disabilities, and mild mental retardation (NCEDJJ, 2007). Interpersonal issues among young offenders can be quite complex. Many adolescents “generalize deep-seated fear and mistrust to relationships outside the family system” (Gardstrom, 2002, p. 185) and thus find it difficult to establish positive and meaningful connections with others. Relationships with peers, adults, relatives, and community members—some of whom may have been victims of the offenders’ criminal activities—are often strained. Trust, healthy boundaries, communication, conflict resolution, and intimacy are just some of the multifarious interpersonal needs to be considered. Systematic inquiry regarding the connection between low self-esteem and delinquency has produced mixed results. Some researchers have suggested that, rather than acting on feelings related to low self-regard, delinquents are driven by antisocial attitudes/characteristics such as a lack of empathy, sense of entitlement, and egotism, which suggest an inflated rather than a diminished perception of the self (Costello & Dunaway, 2003). On the other hand, outcomes of a series of interrelated and rigorous studies (Donnellan et al., 2005) support a positive correlation between poor self-regard and externalizing responses such as the aggression that, more often than not, is a core feature of delinquency. Whether or not low self-esteem figures prominently in the etiology of antisocial behavior, by the time adolescents enter a residential placement—and sometimes as a result of their interactions with the juvenile justice system and subsequent treatment—most delinquent youth will have accrued a host of personal and social failures which, when combined with poor personal resilience and/or a lack of external support, may contribute to low self-regard. The need for opportunities to succeed in meaningful endeavors, develop interpersonal/social confidence, and form realistic perceptions of self-efficacy thus should not be overlooked.

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Juvenile offenders may present for treatment with a variety of physical needs as well. Serious medical and/or dental complications and conditions stem from physical abuse (e.g., substance use, sexual abuse, etc.) and neglect of fundamental health needs (Gardstrom, 2002). In particular, female offenders often have unique somatic issues related to their experiences with sexual victimization, prostitution, and pregnancy. While similarities between adjudicated and nonadjudicated adolescents have been noted above, juvenile delinquents have a handful of needs that do not necessarily overlap with other adolescent groups. For instance, a young offender who has committed serious crimes against other people may already have a heavy dose of guilt and/or shame, or these adverse feelings may surface during the “work” of treatment. Issues of remorse and forgiveness—both the victim’s exoneration of the offender and the offender’s own exoneration of other perpetrators—may need to be explored. Restitution for criminal and hurtful acts, whether mandated by the court or not, may help to restore emotional and interpersonal balance and allow the adolescent to move forward. Regardless of the specific philosophy undergirding delinquency programming, effective treatment for adjudicated adolescents must include a robust mental health component in order to accommodate the needs of young offenders with concomitant psychiatric illnesses. Pharmacological intervention, group, individual, and family counseling, and drug/alcohol education and treatment are just some of the services that could mean the difference between success and failure—or even life and death—for a young offender with serious mental health needs.

CLIENT RESOURCES It stands to reason that identification of clients’ resources and strengths at intake and throughout their residence can assist treatment providers in setting a course for change and in helping youth to engage fully with the treatment process. Toward this end, increased interest in and knowledge about protective factors and resilience among young offenders has come about in the last few decades. Protective factors can be conceptualized as those personal, familial, and environmental factors that “shield” an individual from certain risks and thus help her or him bypass or break free from a delinquent trajectory. Personal protective factors include having an easy temperament, a high IQ, and highly developed social skills, for instance. Familial protectors include factors such as positive parental discipline, strong extended relationships, and racial pride. Environmental factors relate to things like prosocial peers, low crime neighborhoods, and academic success. Many of these factors are malleable (either before or during treatment), while others are not (Barton, 2011a). Identification and fortification of protective factors may help the adolescent develop greater overall resilience, defined in this context as “the ability to recover strength and spirit under adversity in both internal (self) and external (family, school, community, and peer relation) domains for a positive outcome” (NCEDJJ, 2011, Resilience, para. 2). Some adolescents in custody have qualities that could be viewed as protective factors, in a sense, but that, ironically, seem to have developed as a result of the very life circumstances that one would hope these youth are able to circumvent upon their release. For example, this author encountered some of the most creative individuals she has ever known while employed to run an intergenerational music program at a state-operated training school. The youth involved in the program had come from extremely chaotic— even lethal—homes, schools, and neighborhoods in which they needed to be able to generate new ideas and do so quickly in order to stay alive. The challenge for staff at the training school was to find ways to help these adolescents channel their creativity toward constructive endeavors, for, as Spooner (2008) notes,

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Creativity can be employed for socially positive or socially negative outcomes. Creative people can use their creative minds to generate positive, as well as negative, ideas that may be channeled to good or to sinister outcomes. To a large extent, it is where, when, and how one chooses to apply one’s creative thinking, together with who is making the judgments on them, that determines the nature of one’s creative offerings and how they are perceived (p. 129). Closely related to the concept of creativity is resourcefulness, defined here as being able to make something of value out of “next to nothing.” Youth who come from the most severely impoverished families and communities seem the most able to fashion a workable product from very few material resources. An example that comes to mind for this author are the beautiful, gossamer dance skirts that one 15-year-old girl made for a choreographed performance of Tracy Chapman’s “Mountains o’ Things” from a box of old, sheer window panels that had been placed by training school staff at the back door dumpster. A discussion about the resources and strengths of adjudicated adolescents would not be complete without mention of their profound curiosity about and personal connection to music and the arts. To be sure, not all youth share a passion for music, but most seem motivated to experience the arts and produce artistic works, and most use music listening on a daily basis. Even youth who have had little experience and/or training in artistic production can use their interest as a positive resource—not only as a channel for creativity, but also for emotional expression, as one form of healthy recreation/leisure, to develop interpersonal relationships, as an outlet for psychophysiological energy, and as a way to make positive and meaningful connections in and contributions to their home communities upon their release.

MULTICULTURAL CONSIDERATIONS In that delinquency is found among all types of people, it is critical that the music therapist give careful attention to diverse cultural traditions in his or her manner of working and in the selection of music and music interventions. In general, the music therapist should work to foster a safe, respectful, and interculturally responsive clinical environment. In particular, music selection for receptive and re-creative experiences should demonstrate sensitivity not only for client musical preferences but also for gender, race, ethnicity, socioeconomic class, physical abilities or qualities, sexual orientation, religion, etc. As Gardstrom and Hiller (2010) note, “With access to the Internet, a therapist can locate a varied and everincreasing supply of recorded music selections from around the globe” (p. 150), which makes it is easier than ever to accommodate and honor diverse identities and characteristics.

MUSIC THERAPY TREATMENT The author has drawn heavily upon her own and her colleagues’ experiences in composing this chapter because, although music therapists are known to have worked with adjudicated adolescents in a variety of settings, including court diversion programs, detention facilities, shelters, and short- and long-term residential treatment programs, published literature about the use of music therapy with young offenders is extremely scarce in comparison with that about other clientele. That which does exist mostly depicts small group music therapy as one component of residential programming. Same-sex groups are common, in keeping with configurations of living units (e.g., cottages or halls). A few examples of coed groups also are presented in this chapter. Treatment duration varies, but it appears as though multiple sessions (vs. single sessions) are the norm, as would be expected in long-term residential treatment.

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In some residential facilities, music therapy is viewed as a component of academic programming and, in this case, may resemble adaptive music education. In others, it may be aligned more with treatment programming, for example, as one of several expressive arts or experiential therapies. In still other facilities, music therapy may be viewed as part of the recreational or recreational therapy offerings, or as a separate entity, with no formal affiliation with other services.

REFERRAL AND ASSESSMENT PROCEDURES Naturally, how referrals for music therapy are made and who makes them is largely dependent upon the role and function of music therapy in the treatment facility. In some settings, music therapy is seen as a required component of treatment, that is, no referral is necessary because all youth experience music therapy as a routine feature of their care and rehabilitation. In other facilities, music therapy is viewed as a privilege to be earned by youth, that is, only adolescents who have met and can sustain some predetermined standard (e.g., level of trust or behavioral stability or competence) are allowed to participate in individual or group music therapy. When referrals for music therapy are made, they may come from a variety of sources, including teachers, other therapists, or program administrators. For individual treatment, an adolescent may self-refer according to facility policies and procedures (e.g., request adaptive music lessons, ask his or her treatment team for permission to work with the therapist to complete an original song, etc.). One or more team members may refer an adolescent for music therapy in order to target some aspect of that youth’s individualized care plan. Teachers who work at the facility may ask for the music therapist’s help with a particular individual in order to engender academic motivation and/or achievement. When whole residential groups are referred, referrals typically come from one or more members of a treatment team because they perceive that group members could benefit in some way from the structure, processes, or products afforded by music therapy. An extensive search revealed no published music therapy assessment protocols or tools for young offenders. However, although developed for and implemented with adolescents in an inpatient psychiatric facility, Wells’s (1988) protocol works well for the assessment of delinquent youth. In fact, Wells notes that conduct and oppositional disorders—established above as prevalent among delinquent youth in residential placement—are chief diagnoses among the youth for whom her assessment was designed. The assessment protocol consists of a series of music-related, projective tasks that, when completed, provide the therapist with insight to the adolescent’s assets, deficits, and overall functioning in a variety of domains, such as anxiety, frustration tolerance, self-image, and ego boundaries, among others. In Task One, the youth selects a song from a list generated by the therapist and discusses it (called song choice). In Task Two, the individual is asked to choose an instrumental piece from a list of titles, listen for a moment, and then begin composing a written story with the music in the background. The individual then reads the story to the therapist. Task Three consists of a multipart instrumental improvisation, which includes as one feature a symbolic representation of the youth’s family members and their communication patterns. A dyadic improvisation or singing a song with the therapist provides for insight into comfort with interpersonal intimacy and for closure of the assessment process. With minor adaptations, these tasks can be implemented with individuals within a group treatment setting.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy •

Song Discussion: involves the client and therapist listening to a song together and finding its meaning and relevance to the client’s life.

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Song Communication: involves a client and/or therapist choosing a song to share with others as a way to express or disclose something about self or about the therapeutic relationship or process. Music-Assisted Relaxation (MAR): Two basic types of MAR are presented. Autogenic relaxation involves suggestions of mental and sensorial imagery to support deep breathing and total relaxation, and progressive muscle relaxation involves alternately tensing and releasing tension in various muscle groups toward physical relaxation. Eurhythmic Listening: is the use of music listening to rhythmically organize motor behaviors, e.g., structured and creative/free movement or aerobic exercise routines.

Improvisational Music Therapy • •

Individual Improvisation: involves one client and a therapist or therapists creating sounds and music extemporaneously together or alone. Group Improvisation: involves clients creating music together extemporaneously as a group with or without the therapist.

Re-creative Music Therapy • •

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Individual Lessons: involve teaching a client how to play an instrument in order to evoke and work through therapeutic issues. Small Performance Ensembles: consist of small vocal and instrumental groups that are formed for the purpose of choosing, practicing, and performing repertoire to work through therapeutic issues. Large Performance Groups: engage 12 or more adolescents in practicing and performing music in formats such as choirs and instrumental ensembles in order to address therapeutic goals. Group Percussion-Based Experiences: Adolescents collectively learn, internalize, memorize, and re-create discrete rhythmic/motoric patterns and sequences using drums and other percussion instruments.

Compositional Music Therapy • •

Individual Songwriting: involves the client creating new lyrics in whole or in part to existing songs or composing original music and lyrics with the therapist’s help. Group Songwriting: Clients collaborate to create new lyrics in whole or in part to an existing song or compose an original song with assistance from the therapist.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Although adolescents spend a great deal of time listening to music, the use of receptive, or listening, methods in music therapy appears to have been chronicled less often than the other three methods. Two of the most popular receptive variations are Song Discussion and Song Communication. Examples of Eurhythmic Listening and Music Relaxation, less frequently mentioned, also will be presented herein.

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Song Discussion Overview. Song discussion (Bruscia, 1998a) and related experiences—referred to in the literature by various names (e.g., lyric analysis, lyric discussion, etc.)—essentially involves the client and therapist listening to a song together and finding its meaning and relevance to the client’s life. Song discussion has been used as a music therapy method with teens in both individual and group therapy (Cassity & Cassity, 1994; Clendenon-Wallen, 1991; Dvorkin, 1991; Frisch, 1990; Gardstrom, 2002; Mark, 1988; Skewes McFerran, 2000; Skaggs, 1997; Wyatt, 2002). One rationale for using song discussion with adolescents is that nearly all teens listen to popular songs on a daily basis (Christenson & Roberts, 1998; McFerran, 2011), and the familiarity of this genre may decrease the sense of alienation experienced during this difficult developmental phase (Mark, 1988). Obviously, because song discussion involves listening to and discussing song material, the clients need to be able to hear and to use some form of language to express and communicate their thoughts and feelings. Additionally, their capacity to abstract from language (e.g., understand metaphor and other literary devices, which, according to Piaget, begins to appear at around age 12) and to relate musical and lyrical material to aspects of the self will greatly assist the process. Clients in the concrete operational stage of development will fare better with literal presentation of ideas and themes and palpable connections between lyrical material and the clients’ life circumstances. Song discussion targets a variety of clinical aims, such as “the identification and authentic expression of difficult feelings, increased self-insight, the exploration of beliefs and values, and improved communication and group cohesion” (Gardstrom & Hiller, 2010, p. 148). Gardstrom (1990) notes that song discussion promotes self-disclosure among adolescent offenders while exploring risky topics, such as their criminal behaviors, sexuality, relationships with others, and drug and alcohol use and abuse. Wyatt (2002) states that the purpose of this intervention within cognitive behavioral treatment for young offenders is “to challenge the clients to think differently and to make connections between their experiences and their feelings, thoughts, and behaviors” (p. 85). Edgerton (1990) used song discussion as a precursor to song composition with adjudicated youth with emotional impairments. In this case, the intervention was didactic rather than psychotherapeutic in nature, that is, clients analyzed lyrics in order to understand how a songwriter communicates and how to create various rhyme schemes. Song discussion as described herein aligns with Bruscia’s (1998a) augmentative level of practice, in which the music adds to existing services and programming, and the relationship formed between client and therapist is based on the music/activity, rather than seen as a primary agent of change. Preparation. Sharing out loud can be difficult for adolescents for a number of reasons. Even some “typical” adolescents—perhaps boys more than girls—resist sharing personal thoughts and feelings with peers for fear of being ridiculed or ostracized in some way. Add to this the fact that many offenders carry guilt and shame related to their crimes, as well as fear and anxiety from having been badly or repeatedly abused and betrayed by others. These feelings lead to a tendency to withdraw or to maintain a “tough guy” façade, rather than expose their vulnerabilities and thereby risk being negatively judged or hurt emotionally. It is thus critical that the therapist adequately prepare the environment and the client(s) for song discussion in order to minimize resistance stemming from this overly self-protective demeanor. The physical environment should be free of external disruptions. It should be private, in the sense that no one outside the room/group would be able to hear what is shared. A circle seating formation allows for eye contact, a sense of equality, and the potential for “we-ness” to develop. If used, lyric sheets should be prepared in advance. In readying the clients for self-disclosure, it is important to thoroughly explain the purpose and process of song discussion and to mention that they will not (and cannot) be forced to share. It may be important to stress certain “group rules” pertaining to the experience in order to promote freedom and

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authenticity of expression. Consequences for disregarding group rules should be clear, fair, and consistently applied. In this author’s experience, when the clients themselves create three or four meaningful rules and consequences (with the therapist’s guidance, perhaps), the rules are more likely to be respected. Some examples of these behavioral parameters may include maintaining confidentiality outside of the group session and avoiding “put-downs,” ridicule, and verbal interruptions. What to observe. Regardless of the level of structure or song material used, during the listening and discussion phases, it is important for the therapist to take note of emergent paraverbal and nonverbal reactions that can provide clues to the teens’ inner experiences, such as tone of voice, breathing, shifts in posture, changes in facial affect, etc. In particular, emotional responses should be noted. The author has learned that the obvious presence of a box of tissues can promote the healthy release of tears during the intervention. Procedures. Procedural steps for the facilitation of song discussion with young offenders, in particular, have not been fleshed out in the literature. However, song discussion typically involves a series of sequential decisions about (1) song choice, (2) song and lyric sheet preparation, (3) introduction of the experience, (4) establishment of a “listening set,” (5) listening and observing, (6) verbal processing, and (7) closure. The reader is referred to an article by Gardstrom and Hiller (2010) in which clinical decisions pertaining to the preparation and facilitation of song discussion are outlined in highly detailed fashion. Some of the decisions surrounding song choice include who chooses the song and what type of genre is selected. When working in delinquency programs, the music therapist may need to align with agency/facility rules pertaining to the use of so-called controversial music styles and lyrics or may need to educate staff and administrators about the value of such media (Gardstrom, 2000). Regarding song and lyric preparation, the therapist must consider a variety of factors, such as whether she or he can re-create the song well and confidently enough to facilitate a solid listening experience and whether lyric sheets will hamper or enhance the clients’ experience and response. It is this author’s experience, for example, that listening without a lyric sheet helps to bypass resistance from individuals who have difficulty reading and puts all listeners on a more equal footing. Song discussion—what it is, why it is being used, and how it typically unfolds—should be explained. A listening set is issued prior to the listening and springs from the established clinical aim(s) of the experience. Examples include, “As you listen to this song, take notice of your emotions” or “Listen and then be ready to talk about if and how this song relates to your own life story.” The level of structure imposed before and after the listening depends on the goal(s), the dynamics of the group, and the therapist’s approach to treatment. Wyatt (2002) describes her behavioral approach to “lyric analysis” with small groups of six to eight delinquents in a residential treatment program. She advocates for a highly structured facilitation in which preestablished questions function as the listening set and clients write or— in the case of those who have difficulty with written language—illustrate their answers prior to discussing them with other group members. Edgerton describes her use of a structured listening set to heighten awareness of interpersonal and racial dynamics within cottage groups of adjudicated boys (personal communication, February 10, 2012). Using the song “Across the Lines” by Tracy Chapman, Edgerton directed the boys to answer questions such as “How do you feel as you listen to the song?,” “What is the theme of the song?,” “How do you think Tracy feels?,” “What are the ‘lines’ in the song?,” and “How can your group cross their ‘lines’?” The boys were encouraged to think, write, and then discuss their responses. Sometimes the youth will request to hear a song again after having discussed its relevance to their lives or treatment issues. A second hearing can spur further discussion or serve as closure of the intervention or session. Adaptations. Song discussion may be used at the intensive level of therapy as a form of music psychotherapy (Bruscia, 1998b) in which the client receives support to learn new ways to solve problems

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and in which verbal communication is an important dimension of the intervention and the clienttherapist relationship. Song discussion has been described as a projective experience within music psychotherapy (Bruscia, 1998b; Gardstrom & Hiller, 2010; Nolan, 1983) through which unconscious material may surface and promote insight and self-discovery. When song discussion is used as music psychotherapy, the ambiguity of music and the written word are valued; clients can imbue their own meaning into the characters, objects, events, feelings, etc., portrayed in the song through the formation of unique identifications and objects of empathy. In this sense, a more relaxed and client-driven approach to facilitation may be used, based on the notion that such flexibility may diminish resistance and assist individualized projection. Gardstrom and Hiller (2010) point to one example with delinquent boys, in which misogynistic raps were used to stimulate the uncovering of unconscious material, which led to emotionally potent realizations and disclosures surrounding the clients’ own and others’ victimization.

Song Communication Overview. Song communication involves a client and/or therapist choosing a song to share with others as a way to express or disclose something about self or about the therapeutic relationship or process. In the section that follows, the focus is on client song communications within the context of group therapy. It is important that the client understand that his or her song choice could be but may be more than a favorite song; most importantly, it should somehow represent something about the adolescent’s life, past or present, which he or she wants to convey to the therapist and his or her peers. Song communication in a group setting is indicated when clients are perceived as being able to benefit from personal sharing and receiving, through which several therapeutic mechanisms may be activated, the most central being cohesiveness (Yalom & Leszcz, 2005). Clients need to have access to prerecorded music or be able to re-create or rely on the therapist to re-create the selected piece. They also need to be able to articulate why they chose their song and what they intended to convey about themselves with their selection. At one group home for delinquent boys in which the author has supervised undergraduate students, song communication was introduced in the inaugural sessions as a way for the therapists to gently initiate the process of personal sharing in a music therapy group, to learn about the clients and assess their musical proclivities, and to convey interest in the boys’ musical offerings as a way to build rapport. In keeping with this last aim, Rio and Tenney (2002), who worked with adolescents in residential treatment, reflect that “Having youth choose music that was important to them was an almost certain way of developing rapport; it allowed them to share part of themselves with others in the group” (p. 91). In this author’s experience, song communication is typically used with adjudicated adolescents in the same way as song discussion, at the augmentative level of practice (Bruscia, 1998a). Preparation. Preparation for song communication entails the same considerations as for song discussion, that is, the environment should be private and free of interruption. All clients should be assisted in feeling comfortable sharing at whatever breadth or depth they are able, and all relevant contributions should be valued. Equipment necessary for song communication may include some or all of the following: CDs and/or MP3 player and playback system, accompaniment instrument, and sheet music (for live re-creation, if needed). What to observe. As with song discussion, the therapist needs to pay close attention not only to the client’s verbalizations, but also to paraverbal and nonverbal actions during the music listening. Additionally, the therapist may listen for congruence or a lack thereof between what the song seems to reveal and how the client draws a connection between the song and self. Procedures. Each client is invited to select a song to play in the present or a subsequent session. Again, clients are reminded that the song is to communicate something about themselves or about the

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therapeutic relationship or process. If a “library” (playlist) of prerecorded music is available and the adolescents are willing, they may be invited to look through the selections and choose a song in the moment. If a music collection is not available, or if the clients need time to consider their selections, song communication can occur in the following session, in a more planned way. During the intervention, each person takes a turn at will, speaking either before or after the listening period (or both) about the personal significance of the song. No lyric sheets need be used; in fact, it is often impossible to provide lyrics on short notice. Other clients in the group may be asked to offer their opinions and insights about and associations with each song and, at times, to make their own personal connections with the meaning that was disclosed by the individual who shared the song. If possible, audio versions of songs should be used, as video versions may direct the sharer and the listeners away from the individualized meaning of the song. Adaptations. In addition to the “typical” use of song communication, as described above, this author has used the intervention as a way for groups of young female offenders to say good-bye to individuals who have “graduated” from the program and were returning to their home communities or starting new lives in other places. A song was selected by the individual’s peers and shared in live or recorded fashion during the graduate’s final group therapy session or cottage meeting with accompanying verbal sentiments. In similar fashion, this author has used song communication to help young male and female offenders communicate something of importance to a deceased loved one in a carefully orchestrated memorial service involving a music therapist, chaplain or spiritual guide, group therapist, family member, and/or trusted peer. In this way, the music functioned as a container for feelings (Hiller, 2011) such as grief, anger, love, and forgiveness.

Music-Assisted Relaxation (MAR) Overview. Two basic types of MAR are presented here: autogenic relaxation (AR) and progressive muscle relaxation (PMR). AR involves suggestions of mental and sensorial imagery to support deep breathing and total relaxation, whereas PMR involves alternately tensing and releasing tension in various muscle groups toward physical relaxation that may, in turn, lead to psychological comfort. Gladfelter (1992) asserts that “adjudicated adolescents with behavior disorders, such as those in a residential treatment setting, need to be exposed to techniques which will help them to decrease their anxiety so they can function more effectively in life” and notes that “much research has been done using relaxation techniques to reduce anxiety, although very little has focused on the adolescent population” (pp. 1–2). Indeed, the use of music relaxation with delinquent youth is mentioned only sparingly in the literature. MAR is indicated when clients self-report or are observed to have distressing or intrusive levels of anxiety, when they need opportunities to relax after particularly anxious events or circumstances (e.g., a difficult family therapy session or court appearance), and when it seems that they could benefit from learning relaxation techniques to implement as part of a self-care plan. Occasionally, clients are too agitated to participate due to a clinical condition or diagnosis (such as PTSD or hyperactivity) or medication effects. In these cases, psychophysiological energy might be better directed into music therapy methods with the potential for physical catharsis, such as drumming, improvisation, or music-supported movement. The primary goal of MAR, as the name implies, is to induce deep physical and psychological relaxation. MAR is ordinarily used at the augmentative level of practice (Bruscia, 1998a) and is addressed herein as a group intervention. Ideal group size ranges from 3 to 10 members. Depending on the size of the group, it may be wise to conduct this intervention with a cofacilitator (see below). In this author’s experience, same-sex groups are more effective in that clients are less defended and thus more likely to

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relax deeply.

Preparation. The physical space for MAR should be quiet and comfortable, with the possibility of dimming the lights. Interruptions and external noise should be kept to a minimum. Floor mats should be made available. Clients may bring blankets and pillows for added comfort. In this author’s experience, younger or regressed clients would often ask and were allowed to bring a stuffed animal or similar comforting object. MAR typically requires a relaxation script and prerecorded, instrumental music to support the script. Commercial scripts are available, or the therapist may craft a script that takes into consideration the idiosyncratic needs and vocabulary of the adolescents. The music selections should be static rather than dynamic, that is, the music should be repetitive and highly predictable, as abrupt changes in rhythmic, tonal, expressive, and formal elements can serve to arouse, rather than relax, the listener and may elicit traumatogenic reactions (American Music Therapy Association, 2012). The sound source should be as centralized as possible, and the therapist should have immediate access to the volume control during the experience. What to observe. While the clients are engaged in the experience, it is helpful to watch them carefully in order to adjust the pace of the therapist’s verbalizations, moving more quickly or lingering in response to perceived needs. It is also crucial that the therapist watches and listens intently for possible signs of client distress, such as facial grimaces, tears, constant physical shifting, and anguished vocalizations or verbalizations. Often, clients who are sleep-deprived or depressed will fall asleep early in the procedure. While viewed as the ultimate, conscious state of relaxation, sleeping may not be desirable, as it will prevent the client from learning relaxation techniques. If such learning is one aim of the experience, these clients may be encouraged to sit upright rather than recline on the floor mat. Procedures. Sessions generally last between 30 and 45 minutes. To begin, the therapist may conduct an introductory discussion with the group (5 to 8 minutes), wherein she assesses the clients and describes for them the expectations of the relaxation experience. Assessment should be geared toward identifying any emotional issues that may be immediately important for any individual or that may impede an adolescent’s ability to participate fully or safely in the relaxation experience. If any contraindication is identified, the therapist should suggest that the client not participate. The introductory phase is also a time to develop rapport with the clients, to begin establishing a peaceful and positive environment for the experience—using an engaging tone of voice and comfortable pace of speech—and to answer any client queries. The clients should be told that, although not a focus of the experience, vivid imagery may occur in response to the music and that opening one’s eyes can usually halt the disturbing imagery. If troubling imagery persists, a client can beckon for support from the therapist or cofacilitator and may be ushered out of the room or asked to sit upright next to the therapist or cofacilitator. After the introductory phase, the clients are instructed to assume a comfortable position on the floor mat and to close their eyes as they are able. The lights may be dimmed to enhance relaxation. A brief (3- to 5-minute) verbal induction follows; this may be the presentation of focal imagery (AR) or a guided breathing exercise designed to help the client focus on internal, bodily experiences (PMR). After the induction, the therapist begins the core phase, during which the music plays and the relaxation script, whether AR or PMR, is recited (10 to 12 minutes). Once the script and music have ended, a period of silence may ensue prior to the reentry phase, which is when the therapist guides the adolescents to return their attention to the surrounding environment, move their bodies gently, open their eyes, and prepare to discuss the relaxation experience. Verbal processing should first include the clients’ reflections on their own experiences followed by the therapist’s feedback and guidance. Adaptations. Adolescents who have been sexually molested or traumatized may have difficulty relaxing in a reclining position. In this case, comfortable chairs may be substituted for floor mats. Additionally, some teens find that closing their eyes puts in them in a more vulnerable state than they are

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ready to experience. Although perhaps not as effective, PMR can be conducted with the client’s eyes open and is, in this case, a preferred alternative to autogenic, or imagery-based, relaxation. Additionally, the suggested time frames for each procedural phase may be shortened or lengthened, depending on client need. For instance, some clients may need to practice MAR repeatedly, with a gradually increasing number of minutes devoted to the induction and core phases.

Eurhythmic Listening Overview. Eurhythmic listening, defined as the use of music listening to rhythmically organize motor behaviors (Bruscia, 1998a), can be used with adolescent offenders toward a wide variety of clinical aims. Experiences addressed here include structured and creative/free movement and others such as aerobic exercise routines. Eurhythmic listening experiences can enhance the identification and healthy expression of emotions, improve self-esteem (especially body image), improve physical health (e.g., strength, endurance, coordination, and balance), and promote cognitive development (Gardstrom, 2002). Movement may also address adolescents’ needs for increased cardiovascular exercise aimed at weight control (a concern in residential facilities) and increased comfort in their bodies (Brooks, 1989). As with all movement protocol, caution should be taken to minimize the risk of physical injury. Clients who have serious or chronic illnesses or those with obesity or physical challenges should be screened for participation and monitored closely during the intervention. The eurhythmic listening interventions described here occur at the augmentative level of therapy (Bruscia, 1998a), as an adjunct to other services and programs. Same-sex grouping may help to minimize inhibitions associated with movement. Preparation. Movement requires dedicated space, which could be a gymnasium, empty classroom or clinic, or outdoor area. It is important to consider that a private space for the group may help reduce embarrassment and shame attached to moving one’s body. Recorded music is used. Typically, the therapist selects the music, but clients may also suggest musical material; this can aid in their motivation to participate. Instrumental or song material should be selected based on its specific elemental properties. For instance, if the desired movement is rhythmic in nature and stability is important, a pulse must be clearly discernible throughout the piece. Above all, the music used must support the desired energy level and intended movement sequences. Careful attention should be paid to tempo, phrasing, and meter, all of which should match and support the desired procedural phases (see below). Music with a clear formal structure (e.g., ABAB) can assist in the recall of choreographed movement sequences that are paired with each musical section. The music playback system should be powerful enough to “fill the space.” Digital music media is preferred, as this facilitates precise cuing for modeling or repetition of movement sequences. What to observe. In that groups of adolescents will come to a movement experience with varying levels of motor skill and comfort, it is imperative that the therapist carefully observe their reactions to the movement directives. Some youth may have difficulty with directionality (left vs. right), balance, endurance, or strength, suggesting that certain accommodations must be made in order that the youth can be successful. Adolescents who “give up” and stop moving with the group may be voicing resistance that stems from feelings of embarrassment or bodily shame and may need to process what is happening in the moment in order to move forward. Procedures. Described here are suggested procedures for music-supported group movement based on the author’s leadership of eight-week modules of biweekly sessions with adjudicated girls. The author has facilitated three different types of modules, dependent on identified educational and clinical aims: aerobic exercise, structured choreography to preselected pieces, and creative/free movement. Sessions generally last 30 to 45 minutes.

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Regardless of the type of movement—aerobic, choreographed, or creative/free—sessions should adhere to the following procedural sequence: (1) gentle movement (walking, reaching, bending, etc.) for warming up the large muscle groups; (2) stretching of major muscle groups (legs, arms, torso, neck and shoulders) to avoid subsequent strain or injury; (3) working phase, composed of movement sequences of increasing aerobic or motoric demand (depending on the type of movement); (4) cool down with a gradual lessening of energy output; (5) final stretching of major muscle groups; (6) verbal processing of the experience; and, when indicated, (7) summary and future planning. Verbal processing of eurhythmic listening experiences may focus on any and all related treatment issues, such as bodily or sensorial experiences, emotions that surface during the intervention, group dynamics, learning points, future aims, and so forth. Adaptations. Movement sequences can be adapted to accommodate client idiosyncrasies and capabilities. Adaptations include simplifying patterns (e.g., removing fancy footwork and concentrating on upper-body movements only, or vice versa), “halving” the tempo (e.g., presenting a sequence over 16 rather than 8 beats), and “featuring” (e.g., relying on certain clients to perform difficult sequences while other clients perform simpler sequences or step to the beat). Most structured and creative/free movement experiences can be adapted for a seated position in the event that clients are unable to stand and move through space.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Improvisational Music Therapy, or Clinical Improvisation, has been defined in numerous ways in the professional literature. In this chapter, this method is viewed as the extemporaneous creation of sounds and music for purposes of assessment or treatment. The sounds and music are created by the client(s) or the client(s) and the therapist(s) together, using the body, voice, and musical instruments or other objects that are capable of producing sound. An important distinction between clinical music improvisation and music improvisation—the latter referring to the type of improvisation found in jazz genres, Baroque music, Orff Schulwerk activities, etc.—is the relational essence of clinical improvisation; in clinical improvisation, client(s) and therapist(s) create and develop relationships with self (intrapersonal), with others (interpersonal), with their own music (intramusical), and with the music of others (intermusical). It is in and through these relationships that personal transformation occurs. Also, in clinical improvisation, both the processes of creating and the products that result assume value, whereas in music improvisation, the salient aim is most often to create a product of aesthetic value (Hiller, 2009). The method of clinical improvisation, hereafter referred to simply as improvisation, revolves around the use of two types of improvisation, often categorized as referential and nonreferential. Referential improvisation is extemporaneous music that refers to or depicts something outside of the music, such as an emotion, a life event, or a relationship. Nonreferential, on the other hand, is improvisation without a theme; the music is created “for music’s sake” without referring to anything outside of itself. Improvisation may be applied in individual or group formats and from a variety of theoretical models and practical approaches. The improvisations themselves can be structured in multiple ways through the use of various “givens” (Bruscia, 1987) or play rules that help to focus the experience of improvising. Three types of givens are vocabulary givens (which specify the musical/sound media used or the theme to be portrayed), procedural givens (which refer to the procedures or time elements of the improvisational process), and interpersonal givens (which specify roles and relationships between players). For a detailed compendium of improvisational models, the reader is referred to Bruscia’s Improvisational Models of Music Therapy (1987).

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Individual Improvisation Overview. Individual improvisation involves one client and a therapist or therapists creating music extemporaneously. Typically, the client and therapist(s) improvise together, although the client may also improvise alone, depending on the clinical aim. Although most adolescent offenders are housed and treated in group settings, certain individual treatment modalities may be indicated, particularly if a teen needs to develop dependence on a reliable adult, having been denied this essential relationship in his or her childhood within the family of origin. Additionally, some teens have a deep fear or distrust of peers, and others find that social situations produce unbearable anxiety. Individual improvisation may be used at the intensive level of therapy as a form of music psychotherapy (Bruscia, 1998b) in which the adolescent receives support to learn new ways to solve problems and in which verbal communication is an important dimension of the process. Improvisation may also be used at the reconstructive, or Primary Level of practice (Bruscia, 1998a), with a focus on “altering basic structures within the client and between the client and the environment” (p. 162), and getting to the “core” of the client’s condition. Improvisation can support an abundance of clinical aims: help a young person modify behaviors, find an authentic “voice,” release “toxic” emotions and resolve past trauma, reflect on and learn about self through improvisational products and processes, develop intimacy through a musical relationship with the therapist(s), tap into creative potential, and develop a stronger and more positive self-image. Preparation. Preparation for the session is based on an intentional assessment of what the client needs at the particular time of treatment. As available, a wide variety of percussion and tonal instruments should be arranged for easy access. If sessions are to be audio- or video-recorded for playback and reflection, recording equipment should be ready to operate. What to observe. What the therapist observes during individual improvisation is, of course, filtered through the therapist’s theoretical approach and the expectations placed upon him or her by the employer. For example, from a behavioral perspective—many residential facilities for young offenders adopt the mission of altering delinquents’ maladaptive behaviors through the use of behavioral principles of modeling, reinforcement, punishment, and so forth—the therapist will watch for how well the individual’s responses match stated or implicit expectations for use of the musical instruments, relating to the therapist, and following the rules peripheral to the experience (e.g., arriving on time to the session, respecting the meeting space, etc.). From a humanistic perspective, the therapist will be concerned about how to help the client actualize personal potential within the improvisation experience. From an existential perspective, the therapist will attempt to understand the client’s inner experiences, watching and listening for clues into the physical, psychological, and social “worlds” of the client. From a psychoanalytic perspective, what emerges as important is how the client’s improvised music serves as a symbol or projection of aspects of the self that are hidden, such as feelings, impulses, and conflicts buried in the unconscious. Transference, countertransference, and resistance become important dynamics to observe within the musical and personal relationships that emerge in the session. Specific protocols for the process of listening to, analyzing, and interpreting client improvisations have been described elsewhere (e.g., Arnason, 2002; Bruscia, 1987, 2000; Lee; 2000); descriptions of these protocols lie beyond the scope of this chapter. Again, the reader may find Bruscia’s Improvisational Models of Music Therapy (1987) to be useful—in particular, the information about the Improvisation Assessment Profiles. Procedures. In that individual improvisation typically is geared toward meeting the immediate and emergent needs of the client, it is difficult to specify procedures ahead of time that would apply to every client and every improvisational experience. However, in general, the following steps will occur, either as predetermined by the therapist before the meeting or by the therapist and client at the time of

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the session: (1) play or talk as a way to elucidate client need and determine a focus or theme for the session; (2) determine parameters for the ensuing improvisation, including musical media, thematic focus (optional), and whether the client will improvise alone or with the therapist; (3) decide whether or not to record the improvisation, securing necessary permission to do so; (4) decide whether or not to process the improvisation verbally or through some other modality, such as art or movement; (5) improvise; and (6) process the improvisation in the predetermined manner (optional), which may involve listening to and reflecting upon the recorded improvisation. Adaptations. In a sense, each improvisation experience is itself an adaptation. The freedom and flexibility afforded by not having to rely on any prescribed or preselected music opens the door to infinite possibilities for ongoing modification to whatever is occurring at any given moment. And, through the use of in-the-moment musical, verbal, and gestural facilitation techniques (Bruscia, 1987; Gardstrom, 2007), the therapist can make adjustments, accommodations, and alterations in the course of action at any point during an actual improvisation.

Group Improvisation Overview. Group improvisation involves clients creating music together extemporaneously as a group with or without the therapist. It is indicated when the peer culture is seen as the primary agent of therapeutic change (Gardstrom, 1987) or when youth need opportunities for positive leadership and healthy interaction with peers. As with individual improvisation, group improvisation can aid adjudicated adolescents in altering counterproductive behaviors, expressing their thoughts, feelings, and creativity; learning about themselves (particularly in relationship to others); and developing confidence and a sense of self-worth. In this country, group improvisation is used at the augmentative level of practice, as an addition to other services and treatment modalities. Preparation. Preparation for group improvisation sessions begins with the question, “How can I best structure this time in order to meet the immediate and emergent needs of the youth?” The structure of the session may refer to the “big” picture of what to do when throughout the entire session or to the “little” picture of which parameters or givens to use in facilitating specific improvisational experiences as discrete but interrelated components of the session. The types of structures that are clinically indicated should inform the therapist’s decision about which particular instruments and equipment will be necessary to arrange in advance of the clients’ arrival (vs. the other way around). A general guideline for the setup of the physical space is to arrange chairs in a circle with instruments in the center. A circle can convey a sense of equality and “we-ness” and enable group members to see and hear one another. In that improvisation can call forth the “raw” expression of internal experience, it is crucial that the participants are prepared for this possibility, using whatever language and preparatory experiences are developmentally appropriate. The use of structured rhythmic activities such as Guided Interactive Drumming or Traditional Drumming (see below) may be used as a way to introduce the notion of being in musical community with others and employing instruments as a form of personal self-expression. As with other interventions, it may be useful to establish group rules so that members feel free to share authentically without fear of derision. What to observe. As group members enter the playing space, check in musically, and engage in music improvisation with others, the therapist may become overwhelmed by the sheer number of clinically relevant responses that are occurring at any given time. This is because each client in the group is likely simultaneously responding to his or her own music (intramusical relationship) and his or her own nonmusical experiences (intrapersonal relationships), as well as the connections between his or her music and the music of others (intermusical relationships) and his or her nonmusical experiences and those of others (interpersonal relationships). As a guiding principle, then, the concept of salience can help the

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therapist to attend to the most critical aspects of a group improvisation processes and products (Bruscia, 1987). Salience refers to the most prominent or commanding feature of an improvisation, and may include a musical element that dominates the improvisation, such as meter or volume, or a profile that “jumps out” as significant, such as the degree to which the group’s rhythms integrate with an underlying pulse (rhythmic integration), the degree to which volume changes over time (volume variability), or the role that each player assumes in relationship to other players (autonomy). Other important observations may include which instruments the members select (if given a choice), how well the teens work together to depict a given theme (in referential improvisation), and what they reveal about the processes and products after the fact (if processed). Procedures. While it is impossible in this chapter to outline all of the possible procedures that may emerge as useful in the facilitation of group improvisation, one general procedure has proven to have great utility in this author’s experience with percussion-based improvisation with adjudicated adolescents. The essential steps of this procedure are as follows: (1) Greeting—Clients and therapist greet one another and settle into their seats; (2) Check-in—A drum is passed around the circle/room and all are asked to (a) say, “This is how I am feeling right now” (as a way to help identify and take both personal and public ownership for present emotional state), (b) play a brief improvisation that depicts inner experience, and (c)(optional) put a word or phrase to the feelings; (3) Review and Rules—The therapist and clients discuss (a) the “gist” of improvisation (i.e., what it is and why it is used), (b) the importance and acceptance of authenticity of expression, (c) the expectation that all authentic expression (musical and verbal) will be valued, and (d) rules about instrument use, interactions, etc.; (4) Exploration (optional, as needed)—The therapist introduces the available instruments by name and demonstrates both conventional and nonconventional ways to play them, and the clients are encouraged to freely explore several instruments; (5) Givens—Helpful parameters for the group improvisation are stated by the therapist or created by the group and affirmed by the therapist, with attention to clinical issues that may have been made apparent during the check-in; (6) Improvisation—The group improvises according to the preestablished parameters; and (7) Processing—The therapist makes opportunities for verbal processing or processing using other modalities, such as art or movement. Steps (5) through (7) are repeated, according to group goals, individual client needs, interests, remaining time, etc. Edgerton (personal communication, February 10, 2012) shares a specific structure that she used to facilitate tonal improvisation with small groups of youth, employing bass guitar, electronic keyboard, and other instruments capable of harmonic or melodic renderings. She began by introducing drums and other percussion instruments. Players established a beat and added unique rhythmic figures. A bass guitar joined the beat, with strings tuned to E-A-E-A. Keyboard players were then encouraged to improvise freely on the white keys, using just two or three designated, consonant pitches at first and gradually expanding the melodic possibilities. With the aim of promoting awareness of group “issues,” improvisations were recorded and members of the improvisation ensemble listened to the recording, selfreflected, and provided feedback to other members. Edgerton believes that troublesome or healthy group dynamics became apparent to the therapist and the improvisers while listening to the recording, stating, “It all came out in the music. It wasn’t me telling them what was going on in the group; they heard it in their own music!” Adaptations. One adaptation of the author’s procedure (above) includes varying the check-in prompt from “This is how I am feeling right now” to “This is how I want to feel right now,” or “This is how I feel about myself right now,” or even “This is how I feel about the group right now” or “This is what I would like to say to my victim[s] right now.” Obviously, the choice of which prompt to use should be considered carefully, as this has the potential to influence the tenor of the session. Additionally, although group improvisation most often means that all or most members of a group are creating music simultaneously, sometimes an individual may improvise in solo fashion for the group as a way to have his

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or her expressions heard, communicate something of a personal or individual nature, develop confidence among peers, and so forth.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY At the core of re-creative experiences in music therapy is the vocal or instrumental performance of precomposed music. In residential settings for juvenile offenders, this may take the form of individual lessons, individual performance, or small and large ensembles, such as a chorus, handbell group, popular music “combo” (guitar, bass guitar, keyboard, drums, vocals), or any number of other performance ensembles (Edgerton, personal communication; Gardstrom, 2002; Johnston, personal communication; Rio & Tenney, 2002; Wyatt, 2002). Small- or large-group drumming, which does not have a performance focus, is another common re-creative intervention. When adjudicated youth are detained in school programs, they may have opportunities to perform music in school assemblies or other similar venues; these individual and ensemble performances may or may not involve the music therapist. Examples of individual, small-group, and large-group re-creative experiences are described below.

Individual Music Lessons Overview. Individual lessons involve teaching a client how to play an instrument in order to evoke and work through therapeutic issues. One of the responsibilities of this author and a colleague (Edgerton, personal communication, February 10, 2012) in a residential school for male felons was to provide individual music instruction to select adolescents. Weekly, 30-minute lessons were given to boys who had successfully petitioned their treatment team for the privilege and whom the team believed could make specific clinical or educational gains through music instruction. As supported by findings of a meta-analysis by Gold, Voracek, and Wigram (2004), treatment personnel may see individual music therapy as a way to bolster the adolescent’s self-esteem through individual, adult attention and musical mastery. They may refer youth who need opportunities for positive self-expression through active music-making. Individual music therapy also may improve an offender’s ability to form and sustain interpersonal relationships: In individual therapy, the music therapist is likely to be “working toward building a positive, caring, reciprocal relationship with the youth in hope that relationship-building skills will generalize to other authority relationships, such as parents or teachers” (Gardstrom, 1987, p. 22). Gardstrom (2002) writes, “Besides learning care, maintenance, and basic playing technique on a particular instrument, a sense of responsibility and cooperation is fostered …. Finally, music is a viable leisure pursuit for students who have few nondelinquent interests” (p. 188). Sometimes youth are referred not because they are trustworthy, but so that they might learn and demonstrate trustworthiness (Gardstrom, 1987). To that end, certain clients may need support, accountability, or supervision in the form of a specific behavioral contract or a staff member or trusted peer who accompanies them to their individual lessons. Adolescents who are an immediate danger to self or others may not be indicated for individual lessons unless these lessons can take place in a setting in which such a risk can be appropriately managed. Lessons are provided at the augmentative level. Preparation. Drum set, acoustic and electric 6-string guitar, bass guitar, piano or electronic keyboard, and voice tend to be the most requested instruments in individual music lessons. In rarer cases, students may have had prior training on band and orchestral instruments (e.g., violin, saxophone, trumpet, flute, etc.) and may express their desire to continue with these. Ideally, the music therapist would have access to these instruments and a comfortable space in which to work individually. Some students may be able to understand traditional music notation, in which case the therapist should have access to an array of conventional beginning and intermediate instructional materials. (Many of these

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resources are now available free of charge on the Internet.) Other students may need special adaptations (see below); these should be prepared in advance, as the therapist is able. What to observe. During the assessment phase, the therapist will want to establish the teen’s musical interests and prior experiences and abilities. During the lessons, signs of frustration or boredom may indicate a need for alteration of the lesson content or the pedagogical methods or pace. Clients who do not progress as expected or in comparison to their peers may have a learning disability or similar difficulty that requires additional attention or testing. Clients who progress rapidly or show unusual determination may be good candidates for typical music lessons or ensemble participation upon return to their home communities. Procedures. Because each client has idiosyncratic needs and abilities, it is difficult to “prescribe” a sequence of procedures for individual music lessons. However, the therapist would likely (1) welcome the client; (2) introduce or review any and all expectations for the individual session; (3) establish at least one learning objective for the lesson, with or without the client’s input; (4) begin the music instruction with a review of material covered in the previous session; (5) move forward in the learning sequence, offering guidance, correction, and encouragement as fitting; (6) assign “homework” (practice material), if relevant; and (7) close the session with a brief summary and confirmation of the next lesson day and time. Adaptations. Numerous instructional adaptations may need to be applied in an attempt to meet teens’ unique needs and capabilities. Adaptive lessons are designed to maximize the adolescent’s abilities and minimize learning deficits. Some students learn best by rote/imitation or via some form of modified notational system, for example, using colors or numbers to indicate certain concepts. Free or improvisatory play may be used as a “jumping off point” for instruction. Often, simplified chords and riffs will be used on guitar and piano. And, as is common in music therapists’ work with other clientele, experiences need to be structured for immediate, small successes upon which the adolescents can build sequentially and over time. This author has found it helpful for youth who have difficulty engaging or for whom learning is problematic to build in opportunities for “mini-performances” for peers or staff (e.g., “Can you demonstrate for Mr. Grant what you accomplished today?”) in order to stress a sense of accountability for the learning process and, at the same time, bolster confidence that can come from taking small risks and succeeding.

Small Performance Ensembles Overview. Small performance ensembles consist of small vocal and instrumental groups that are formed for the purpose of choosing, practicing, and performing repertoire to work through therapeutic issues. Such groups can assist the juvenile offender in developing a number of personal and interpersonal skills. As outlined by Gardstrom (2002), “Youths learn to give and accept constructive feedback about their playing from their peers. A successful performance in the community may help the young offender and the citizens of that community feel more positively toward one another” (p. 188). Case in point: Edgerton (personal communication, February 10, 2012) and Gardstrom (1993) describe the use of handbells with adjudicated adolescents in residential treatment. Cottage groups of 10 to 12 boys rehearsed on a weekly basis and performed in Sunday chapel services and for special events, both on the residential campus and in the surrounding communities. Community members who attended these events were appreciative and complimentary; this provided some redress for the youth, who experienced a fair amount of shame attached to the delinquent acts that they had perpetrated in those communities. This author also rehearsed with small groups of delinquent youth in residential treatment toward a special performance in a historic theater in the community in which the treatment facility was located. Musical drama, small instrumental combos, cottage choirs, and other “acts” were included in a culminating production, which was open to the public. While the inherent challenges of the preparation

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(e.g., learning and memorizing music and scripts, cooperating with other group members, overcoming performance anxiety, etc.) were the focus of treatment, the product—in this case, the public performance—provided added value for the youth, contributing to their individual and collective sense of accomplishment. There are many responsibilities that run peripheral to, yet enhance, the musical performance. Designing printed programs, making costumes, operating the sound system and stage lights—all of these tasks provide additional opportunities for youth to assume and carry out important responsibilities, as well as develop new skills or demonstrate existing nonmusical yet equally valued skills. Youth who feel overwhelmed in large groups but who need social experiences with peers may benefit from small group involvement. Re-creative experiences such as those described above can promote identification and empathy and enhance interactional skills (Bruscia, 1998a). Additionally, successful performance in a group can lead to an understanding and acceptance of one’s role in the greater endeavor, improved group cohesion, and a sense of group pride. Students who physically aggress toward others or who have severe impulsivity may not be well suited for small performance groups, especially if formal presentations for external or public audiences are planned. Performance groups would be considered an augmentative level of practice (Bruscia, 1998a), employed in tandem with other therapeutic and academic programming. Preparation. With both instrumental and vocal performance groups, musical repertoire needs to be selected and scores (if used)—whether commercially prepared or created/adapted by the music therapist—need to be prepared ahead of time so that rehearsals run smoothly. The rehearsal room must have adequate space for the task at hand. Requisite equipment could include music stands, music folders, tables, chairs, etc. A recording and playback device may help clients more efficiently learn their parts or refine their collective renderings. With instrumental groups, high-quality instruments should be available to the clients. Gardstrom (2007) writes, “Well-constructed instruments tend to be more durable and predictable over time. Perhaps most importantly, the investment in well-manufactured instruments conveys an attitude of respect for one’s self as a professional, for the client as a musical human being, and for the music itself” (p. 35). Depending on the nature of the performance, special costumes or attire may be indicated. What to observe. As with any ensemble, the members of a small performance group of adjudicated adolescents will assume certain roles and affects during rehearsal sessions: Who assumes responsibility and who avoids it? Who comes prepared for the work and who is ill-prepared? Who appears curious and engaged in the learning and rehearsal process and who seems bored or disengaged? Interpersonal relationships will also emerge: Who assumes leadership, and in what way? How do others relate to this leadership? Who is supportive and who is diminutive of others’ contributions? How well do the players listen to and “groove” with one another’s playing? How well do they cooperate with one another in peripheral activities such as selecting repertoire and giving verbal feedback? Procedures. Specific procedural steps depend on the type and size of the performance group. In general, though, sessions might include (1) a welcome and review of what was accomplished in the prior session, (2) a verbal overview of the rehearsal plan or strategy, (3) a warm-up period (vocal or instrumental), (4) focused rehearsal of performance repertoire, including troubleshooting or “finessing” of certain sections, (5) verbal feedback about the performance from the therapist and other listeners, and (6) an opportunity for questions or comments from group members. If possible, a “dress rehearsal” in the performance space is recommended so that the actual performance runs more smoothly; this also may alleviate some of the anxiety that many youth experience when displaying their talents for public consumption. Adaptations. Cornhill (personal communication, September 4, 2012) provides beginning and advanced levels of adaptive guitar lessons to same-sex groups of four to six adjudicated youth. Teens

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petition their treatment teams and are rewarded for solid academic performance and effort with the weekly lessons. After a brief “check-in” with group members about the events of the day, Cornhill begins the lesson, purposely using tunes with lyrics that may spark meaningful discussion about clinical themes. Charts are used to teach open chords in the beginning group; advanced players may learn some barre chords and a bit about tablature notation. The groups aim for performances at facility events, such as Family Days. Many adjudicated adolescents will not have had enough prior music instruction or experience to embrace traditional notational systems. As with adaptive music lessons, then, rote instruction or simplified written systems are often used in order to accommodate the disparate levels of music ability among group members. Video-recorded performances may be used in place of live music performances in certain situations. For example, this author recorded a cottage band in advance of a school assembly because (1) there would not have been enough room on the stage for all of the instruments and players involved, and (2) two of the teens were planning their release from the program just prior to the assembly, and none of the other boys were equipped to assume their parts. Watching oneself perform, while quite different from performing live, affords different benefits, such as being able to relax and enjoy the moment, critique one’s singular performance, and notice aspects of the ensemble that are overlooked when one is focused on a particular part.

Large Performance Ensembles Overview. Large performance groups engage 12 or more adolescents in practicing and performing music in formats such as choirs and instrumental ensembles in order to address therapeutic goals. Such groups are popular in residential programs that have an educational focus. In these programs, funds permitting, administrators often attempt to offer academic and arts training on par with typical school systems. Not only does this provide for “normalizing” experiences for the adjudicated youth, but it also makes for an easier transition to regular schools upon release. Additionally, some program administrators choose to involve bands and choirs in their public relations endeavors as a way to showcase program benefits or demonstrate funding needs. In these cases, performance standards may be dictated by administrators rather than emerge organically from within the group itself. It takes a skilled music therapist to manage such externally imposed expectations and the complex logistics and dynamics of a large ensemble—particularly if it includes both male and female clients—while maintaining a clinical focus. As one example of a large performance ensemble at the augmentative level, Cornhill (personal communication, September 4, 2012) describes his work with a coeducational choir of 25 to 30 adolescents from a variety of educational/treatment programs operating under one umbrella agency. The agency serves troubled preteens and teens, many of whom have been adjudicated. The youth audition for the choir, just as they might in a typical school system. Cornhill states that choir participants experience a boost in self-esteem but, more importantly, report an unprecedented “sense of belonging to a group” and “feelings of normalcy that they so desperately need.” He states that some clients—no matter how musically talented or eager—are not ready to be placed in a coeducational group; on the other hand, the customary challenges of blending girls and boys in this age range seem to diminish when music-making is the primary focus; furthermore, youth need opportunities to practice healthy interaction with the opposite sex. Preparation. With a large ensemble, the therapist needs to be as musically prepared as possible before the session, which may be called a rehearsal, begins. Warm-ups should be preselected. Music should be chosen with consideration given to the teens’ abilities and interests. Cornhill (personal communication, September 4, 2012) takes care to select songs for his choir with lyrics that have a

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therapeutic message. If published/copyrighted songs will be performed or rearranged (unison vs. parts, solo vs. tutti, etc.), the therapist may need to secure necessary permission. Keys may need to be altered to accommodate the awkwardness of changing male adolescent voices. Once musical selections are finalized, the accompanist(s) will need to rehearse and, perhaps, memorize the parts. This is particularly important if the therapist is also an accompanist; a therapist whose eyes are riveted to the musical score will overlook important signals from the group and will not be able to provide visual cues for the ensemble. For groups involving girls and boys, some forethought should be given to seating/standing arrangements. Rules pertaining to interaction between boys and girls and consequences for violation of the rules should be clear and in concordance with facility rules. What to observe. Roles and affects are important here (as with small performance ensembles; see above), but the intricacies of interactions among large groups are, naturally, more difficult to observe. In most cases, a music therapist who works with a large group will have staff assistance so that responsibility for certain aspects of behavior management—which can be a critical corequisite of musical and interpersonal development—is shared. Procedures. Depending on the type of group and the clinical aims, social activities may be built into the beginning or ending of a rehearsal. Instrumental or vocal warm-ups are introduced to gather the group together, stimulate musical sensibilities, and, particularly in the case of a choral ensemble, avoid vocal strain or injury. The therapist or clients may state hopes for what the group might accomplish during the session. The “core” of the rehearsal follows, with the use of traditional notation, adapted notation, or (in most cases) rote instruction. During this phase of the rehearsal, the therapist may use techniques such as modeling of musical lines, error detection and correction, repetition, verbal praise, and small sectional rehearsal. After rehearsing each song or at the end of the session, clients should have an opportunity for private or public self-appraisal: What went well? What problems were encountered and how were they addressed? What needs further attention or improvement? What was learned or gained through the experience? Adaptations. Cornhill takes his choir into the community to perform for various audiences. Song material is interspersed or even strategically linked together with scripted or impromptu individual testimony from youth about their criminal history and their processes of change.

Group Percussion-Based Experiences: Guided Interactive Drumming, Traditional Drumming, and Drum Circle Overview. Adolescents collectively learn, internalize/memorize, and re-create discrete rhythmic/motoric patterns and sequences using drums and other percussion instruments as a way to develop in physical, cognitive, interpersonal, and affective domains of functioning. Several different types of percussion-based experiences have been used with adjudicated adolescents. Percussion instruments have great appeal and seem to be highly valued by adolescents (Gardstrom, 2004). Additionally, these are instruments on which teens with little or no prior musical training can be successful with relatively little instruction. Three percussion-based experiences will be highlighted in this section. Note: The term drumming, used here and elsewhere in the literature, actually refers to the use of drums and a variety of other percussion instruments. (A helpful taxonomy of percussion-based experiences used in clinical practice is found at the following site: http://musictherapydrumming.com/a-taxonomy-of-drummingexperiences-2/.) Percussion-based exercises demand that teens work together as a musical ensemble in the production of rhythmic patterns, thereby providing occasions for the strengthening of group ties. Other relevant clinical goals of such exercises include lengthening attention span, decreasing impulsivity and improving frustration tolerance, and increasing personal sense of mastery through musical success. And,

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while distinctions are made between Recreational Music-Making (RMM) with adolescents (Bittman, Dickson, & Coddington, 2009) and music therapy, it is important to note that a music therapist may design percussion-based experiences as a way to help adjudicated adolescents to have “good, clean fun” together—something that many of them need to learn or relearn. Such interventions are typically indicative of the augmentative level of practice. Preparation. It is important to have a variety of hand drums, such as tubanos, djembes, doumbeks, gathering drums, and so on. Auxiliary and so-called ambient percussion instruments, including shakers, tambourines, agogos, ocean drums, and others are also recommended. Space for drumming is necessary, and ideally the group should be arranged in a circle formation, either standing or sitting as the experience requires; if sitting, use armless chairs. When groups of teens are playing percussion instruments together, the cumulative volume demands consideration; the sound may need to be contained somehow. Depending upon the particular experience, the therapist may need to predetermine the specific rhythmic patterns that will be used, and written notation may need to be prepared ahead of time. What to observe. Percussion-based experiences give the therapist a chance to assess sensorimotor skills, handedness, auditory discrimination, rhythmic memory, and a host of other aspects of motoric and cognitive functioning. As with other instrumental interventions, it is important to be on the lookout for clients who have difficulty with coordination. Clients who are unable to synchronize with a steady beat or repeat a simple rhythmic pattern—even without prior drumming experience—may be delayed in some way. Such exercises also enable the therapist to learn about dynamics in the group: Who is engaged? Who emerges as a leader? How does the group as a whole deal with the “outliers” who struggle with the exercises? Adolescents who do not blend in with the group’s musical tempi or dynamics but rather “do their own thing” may be demonstrating problems with structure or authority or may be attempting to call attention to themselves. On the other hand, clients who stop playing prematurely, blend into the background, or refuse to take a leadership role in the circle, no matter how small a part, may be struggling with low self-esteem or social anxiety. Procedures. In one example of Guided Interactive Drumming, the group members stand in a circle, shoulder to shoulder, holding a frame drum in the left hand and a soft-headed mallet in the right. The therapist first directs the teens to synchronize their own drums with a pulse that she provides. The pulse is then organized into a measure of 4/4 time, and players are instructed to count out loud and place an accent on beat 1. Once the group is able to accomplish this, beat 2 is moved to the drumheads of the players to the right. With success at this task, the players are directed to place beat 4 on the drumheads on their left, resulting in a center-right-center-left pattern. From here, simple patterns (including subdivisions) can be sequenced for greater challenge and interest. Once simple patterns have been mastered, increased tempi and progressively more complex rhythmic figures can be introduced, as well as more sophisticated playing configurations involving each player and his or her “neighbor.” In this author’s experience, clients draw great satisfaction from creating and contributing their own rhythms to the mix. In the Traditional Drumming experience, adolescents are introduced to and re-create established “grooves” from a variety of music traditions such as Afro-Cuban (e.g., salsa), Brazilian (e.g., bossa nova), American jazz (e.g., boogie-woogie), etc. The following general procedures assist with this intervention: (1) introduce the groove using recorded examples; (2) demonstrate basic playing techniques on each of the instrumental components that will be used in the re-creation; (3) distribute instruments according to interest and skill; (4) arrange the players in small groups according to instrument or instrument group; (5) instruct each of the small groups, troubleshooting and rehearsing difficult parts; and (6) layer parts together and sustain the “groove.” Song material may be added once the rhythmic foundation is secure.

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Verbal processing is often a feature of this experience as well; questions may be oriented around difficulties overcome, moments of pride, lessons learned, etc. Dal and Matney (2010) describe a Drum Circle as a “group interactive process where individuals use a variety of drums and percussion instruments with the intent of producing a musical product of recreational and community value” (http://musictherapydrumming.com/a-taxonomy-of-drummingexperiences-2/). In the last decade—parallel to increased interest and involvement in community-based drum circles—the use of facilitated drumming with various music therapy clientele has grown in popularity. In that the motivation and ability to choose, participate in, and derive enjoyment from social and community activities is a valid clinical aim for adjudicated adolescents, a drum circle (also called community drumming) may be considered a legitimate intervention. In treatment programs espousing the primacy of the peer group, especially, such community-building activities are highly valued. The role of the therapist (or facilitator) is to help the youth “form, express, and share ideas and impulses that support the goals of the group” (Dal & Matney, 2010, n.p.). While a drum circle may have improvisational components, it is essentially re-creative in that the players are re-creating rhythmic patterns that are suggested, assigned, or directed by the facilitator. Often the process of community drumming begins with the facilitator establishing the pulse (and, hence, the tempo), the meter (which is usually duple), and the dynamic level. Synchronized playing is common at first, although drum circle facilitators may also engage the players in rhythmic imitation and call-response forms in which one player or subgroup of players will initiate a rhythmic pattern or phrase and the other players will imitate or respond in kind. An ostinato may serve as undergirding during rhythmic exploration and improvisational moments within the larger, structured experience. Adaptations. Thanks to performing artists such as Stomp and Blue Man Group, youth are well familiar with and may even be drawn to alternative ways to create percussive sounds using various household items such as milk jugs, trash can lids, and so forth. With a bit of creativity, objects found in residential facilities can serve as viable substitutes for percussion instruments. Likewise, body percussion may be used; with the right technique, certain body sounds can approximate conventional percussion instruments (e.g., foot stomp for a bass drum, hand clap for a snare drum, etc.). In this author’s experience, groups of adolescents appreciate the chance to create a meaningful musical product using the resources at hand, are additionally pleased to see a video recording of their creation, and can gain critical insights from watching it.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY The use of composition with adjudicated adolescents is frequently noted in the literature. Both individual and group songwriting is described, and some detail relating to goals and procedures is provided. No examples of instrumental composition with delinquent youth were located in this author’s search. Songwriting can be accomplished in a number of ways. In this day and age, many compositional tasks are completed with the help of technology. Products such as Smart Touch™, GarageBand™, and Finale™, have opened up a world of possibilities for clients with little or no musical “language” or skill.

Individual Songwriting Overview. Individual songwriting involves the client creating new lyrics in whole or in part to existing songs or composing original music and lyrics with the therapist’s help. In educational programs for delinquent youth, one may see the blending of clinical and educational aims. For example, this author and a language arts teacher at a residential school for delinquent boys worked together on a unique grant project involving individual songwriting. Clinical goals of the project were to enhance each boy’s creative

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self-expression and to improve a sense of mastery through completion of an original composition. Educational aims were to decrease resistance to creative writing and to improve each client’s understanding and use of certain literary structures and techniques. (Grant monies supported several trips to a local recording studio in which each boy had the chance to work with a sound engineer to arrange and eventually record his song.) The aforementioned program was not unlike that of Genuine Voices, a not-for-profit organization in Boston, MA, whose mission is “to teach music, musical composition, and computer-based music ‘sequencing’ to youths in juvenile detention centers and other educational and institutional settings” (Genuine Voices, www.genuinevoices.com). Volunteer musicians meet with program participants once per week to assist them in creating, arranging, and recording their original material. Although this is not music therapy, per se, music therapy students and faculty from Berklee College of Music appear to have been directly and peripherally involved in the program. As an augmentative practice, individual composition can be one of many ways to help access and release feelings associated with adolescents’ criminal histories and the familial, sociopolitical, interpersonal, and personal factors that may have contributed to their delinquency. For example, her treatment team referred one young woman to this author in order to complete a song she had begun about her grandfather, whose death had spiraled her into a period of intense grief that was manifested in angry gestures and illegal acts. Preparation. One advantage of composition is that it can be a beneficial treatment intervention without the need for extensive resources. In fact, it is quite possible to lead individual composition experiences with adjudicated youth with nothing but a voice. If more sophisticated instrumentation is desired, the environment must be prepared accordingly. This may mean having a portable keyboard on a stand or a guitar at the ready to support melodic and harmonic exploration and accompaniment. In the case of computer-assisted composition with the use of commercial tools (e.g., GarageBand™), the necessary electronic components will need to be set up and in working order. If music listening is incorporated as a way to stimulate and refine ideas (see procedures, below), a suitable playback system must be accessible. The environment should be private and free of distractions and the therapist’s demeanor accepting of whatever material the client initially presents. What to observe. Individual composition—particularly song composition—can provide useful data about a client’s cognitive and emotional functioning, particularly in that lyrics may reveal the composer’s personal ideas, beliefs, attitudes, values, fantasies, feelings, and so forth. The structure of creative output is also telling; youth who are unable to synthesize their expressions into a coherent lyrical or musical package may be revealing internal disorganization. The therapist may gather important information not only from viewing the products, but also from observing the process—that is, the “how” of composition, or the manner in which the client moves through the various tasks associated with the method. A teen who is unable to complete a certain section of a song may be revealing resistance or instability. It is important in any individual music therapy with adjudicated adolescents to watch for “splitting” and manipulation that can easily occur in the intimacy of a one-on-one musical relationship. As with song discussion and song communication, the therapist should be knowledgeable about the types of themes/lyrics that are allowed expression within the facility and should communicate frequently with other staff about the individual sessions. Case in point: This author recalls nearly being “duped” by Timmy, who requested that she help him compose a song about his rage toward a sexual perpetrator, a topic that the verbal psychotherapists had denied expression in group sessions on the grounds that Timmy was using the victim role as a defense against the shame associated with his own incarceration for predatorial and pedophilic offenses.

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Procedures. As with other individual music therapy interventions, it is difficult to pinpoint a specific sequence of procedures for composition. However, a general protocol might encompass helping the youth to: (1) choose a personalized theme for the song; (2) decide on a song style and form; (3) construct lyrics; (4) craft melodies and harmonic accompaniment for the different formal components; and (5) determine instrumentation. In that the task of melodic and harmonic construction may be quite challenging for someone with little or no music training, the therapist may employ a variety of assistive techniques, three of which are music listening (i.e., the client and therapist listen to song examples in order to generate ideas), modeling (i.e., the therapist presents several different options from which the client may choose or which the client can modify), and improvisation (i.e., the client creates spontaneous music and subsequently shapes these creations). In some cases, “homework” on a particular song might be assigned or encouraged between scheduled sessions. One extension of the composition process is the recording of the client’s original song, as described above, a process that may interface with re-creative variations. Adaptations. In some cases, teens may elect to perform an original song for others or share a recording as a gift or communicative gesture. Potential audiences may be peers, members of a treatment group, family members, or people who have been victims of the teens’ criminal activity. The music therapist may suggest this additional step in the compositional process when a topic of clinical significance arises and suggests further development. Careful preparation for the performance or sharing of an original song involves not only rehearsing the song itself, but also readying the clients for a variety of responses from the receivers, including the unfortunate but real possibilities of rejection and ridicule.

Group Songwriting Overview. In group songwriting, clients collaborate to create new lyrics in whole or in part to an existing song or compose an original song with assistance from the therapist. In relevant publications, one finds reference to goals that can be accomplished through the use of songwriting with adolescents, such as to increase self-expression, develop group cohesion, improve self-esteem, and develop decision-making skills (Edgerton, 1990). No contraindications are noted. The literature describes group songwriting as what would be considered an intervention at the augmentative level. Preparation. Before adolescents arrive at a group composition session, the therapist must prepare several musical and nonmusical materials. For Edgerton’s procedure, described below, this involves (at the least) (1) selecting a song for lyric analysis as the first step in the process and preparing a lyric sheet, as relevant, (2) providing a large, visible surface upon which to record group members’ verbal contributions, and (3) arranging musical instruments and equipment so that the music composition process can be aptly facilitated. Additionally, students may need instruction in the care, tuning, and manipulation of the instruments in order to be successful. What to observe. Group members’ roles and relationships will become evident in the process of creating a song in collaborative fashion. The therapist might take note of which teens take charge of certain pertinent tasks and whether their leadership is positive (i.e., supportive, productive) or negative (i.e., critical, bossy, counterproductive). Which members are easily able to identify and verbally express their reactions as the process unfolds? Which members seem reluctant to share or appear to have difficulty organizing the expression of thoughts, feelings, and creative ideas? How do the clients work through creative lulls or the negotiation that is a necessary feature of any collaborative endeavor? Ideally, the music therapist will be on the lookout for opportunities to “draw out” less verbal members and, in general, ensure that all members have an opportunity to contribute to and feel some sense of accomplishment in the compositional process and product, no matter what the typical role relationships and interpersonal relationships within the group.

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Procedures. Edgerton (1990) describes her original procedure, called “Creative Group Songwriting,” which she used to help adjudicated youth with emotional impairments increase selfexpression, develop group cohesion, and improve self-esteem. Six procedural steps comprise the procedure. During Lyric Analysis, the clients listen to and discuss a song selected by the therapist, with attention to the overall form, techniques used by the songwriter to communicate the theme, and thoughts and feelings elicited by the song. In the second step, Music Analysis, the listeners review the form and focus on compositional techniques, identifying the “hooks,” instrumentation, and creative techniques such as word painting. In Theme and Style Selection (as the name implies), the group members choose a theme for the song and agree upon the overall style and mood. The fourth procedural step is Lyricwriting, in which brainstorming by all members is encouraged and the various sections of the song (i.e., chorus, verses, and bridge) are fleshed out by combining multiple ideas related to the selected theme. Music Composition occurs next. In this important step, group members assign instruments and vocals and then improvise or “add on.” In adding on, the drum machine lays down a beat, and then the rhythm guitar, trap set, lead guitar, other instruments, and voices add on, each in turn. The therapist provides foundational music instruction at this point—for example, demonstrating open tuning barre chords and teaching single note names on the frets. After a period of exploration and improvisation, the group’s creation is recorded, played, and discussed until the clients agree on the musical construction for each of the sections of the song. In the final step, Culmination, the song is rehearsed in preparation for recording or performance, and the adolescents are given an opportunity to reflect on and converse about the entire compositional process. Adaptations. A useful format for group composition is the 12-bar blues, in which three lyrical lines make up one verse. After listening to live and/or recorded examples of blues songs, a theme for the group composition is determined through majority or consensus, and clients brainstorm words and phrases pertaining to the theme. One group member may serve as scribe. The first lyrical line of each verse is selected by the teens or suggested by the therapist (e.g., “When I woke up this morning, I was feeling ___”). This first line is then repeated (occasionally with slight modification) for the second line; the third line relates to or “finishes” the idea from the previous lines and may rhyme. Once the group has completed the entire blues, which can be as short or as long as desired, the song can be fairly easily recreated with bass guitar (three different pitches), keyboard or 6-string guitar (three simplified chords), and a vocalist, with optional percussion.

CLOSING REMARKS ON METHODOLOGY Whether delinquent youth receive individual or group music therapy (or both) depends upon factors too numerous to list in their entirety, the most obvious of these being the type of setting and program philosophy. Both treatment options have advantages for these youth. But if a residential facility espouses the primacy of the peer group, as some do, there likely will be few opportunities for individual therapeutic intervention. Or, if a program operates on a levels system in which “good” behavior is rewarded and music therapy is viewed as a reward, only certain groups or individuals will be “eligible” for treatment. Other factors that may influence the provision of treatment include affordability, safety, and feasibility issues, such as the available space and personnel or material resources. When individual sessions are an option, in the best-case scenario, one or more treatment team members will refer an adolescent for music therapy in order to target some aspect of that youth’s individualized care plan. In some circumstances, an adolescent may be allowed to self-refer according to facility policies and procedures (e.g., request music lessons, ask his or her treatment team for permission to work with the therapist to complete an original song, etc.). Finally, teachers and other professionals who work at the facility may ask for the music therapist’s help with a particular individual in order to

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engender academic motivation and/or achievement or to address another problematic area of functioning. Group treatment is indicated when group members could benefit in some way from the structure, processes, or products afforded by group music therapy. In their theoretical treatise, Yalom and Leczsz (2005) outline curative factors that are unique to group psychotherapy, such as altruism and universality; although originally applied to verbal therapy, these principles pertain to creative arts therapies as well. As stated in the introductory comments, if music therapy is viewed as a regular feature of an academic program, it is likely that music therapy will be group-oriented, with group size determined by classroom or “cottage” census. In this author’s experience in residential facilities, group treatment (sessions lasting 50 to 60 minutes) occurred during the school day and individual or dyadic sessions (lasting 30 minutes) were considered a privilege that was earned through responsible behavior and that took place at the end of the school day or in the evenings, much like music lessons for teens in regular education programs. Whether one intervention or multiple interventions are used during each individual or group session will also depend upon a multiplicity of factors. At the very heart of this decision are the clinical aims of the session: It may be that certain therapeutic goals can be addressed with only one method (e.g., receptive) or one variation (e.g., song communication), whereas others may require a combination of methods or variations, in that each variation poses unique challenges and opportunities befitting of certain aims. Time is also a consideration, in that shorter session durations will naturally allow for fewer music experiences. Whether or not verbal processing is indicated—and, if so, to what extent—will also influence the configuration of methods and variations within a single session. Music therapists who work with adolescent offenders generally report that a flexible approach to session planning and facilitation is necessary and that this flexibility must extend to both the number and sequence of session events. There is no magic session format for delinquent youth! That said, in general, this author has found that the 4-phase session structure suggested by Stephens (in Bruscia, 1987) for improvisation has benefitted her work with many male and female adolescent groups, even when improvisation is not employed: warm-up, verbal discussion (during which areas of potential therapeutic focus are determined), working through (“core” music experiences), and closure. Any of the aforementioned methods and variations may serve as a warm-up or working through (core) experience. Again, the decision of what methods or variations to use when stems from the session aim(s). Warm-ups should be relatively brief, do not necessarily need to be processed (verbally or otherwise), and should bring the group members together somehow and “warm them up” to the content of the core experience. During the working through phase, music experiences are used to more fully explore the treatment issues identified in the discussion, generate solutions, release physical and psychic energy, and collect insights. Closure may be musical or verbal in nature and should be a time to acknowledge what has occurred in the group. Following is one sample session structure designed to target the identification and healthy release of emotions, a common focus of treatment for young offenders: Session 1 •

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Warm-up: Clients collectively imitate therapist’s rhythm patterns on tubano drums to warm up their hands, arouse their senses, and bolster their musical/expressive confidence. Discussion: Each group member will say, “Right now, I feel (emotion) and this relates to (circumstance, person).” She may choose to follow this statement with a musical statement on her drum.

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Core: Using the tubanos, the group will improvise collectively, exploring preestablished referents based on feelings shared during the discussion (e.g., anger, loneliness, pride, etc.). Closure: Each group member will share one thing they learned about their own emotions or the emotional lives of other members.

RESEARCH EVIDENCE Receptive Music Therapy Using a three-group comparison design with pretest and posttest measures, Gladfelter (1992)—a music therapist who worked in a private, residential school for male offenders, ages 15 to 18 years—researched the impact of progressive muscle relaxation (PMR) only, music listening only, and PMR with music listening on state and trait anxiety of 65 residents at his place of employment. Residents were asked to lie down in a reclining chair. Prerecorded classical (instrumental acoustic), New Age (instrumental electronic), and jazz (accompanied saxophone) selections were used in the music conditions. The State Trait Anxiety Inventory (STAI, Spielberger, 1983) and a subjective numerical measure of discomfort were used to collect data pertaining to the dependent variable. Gladfelter found that both the PMR and the music listening conditions significantly reduced the boys’ self-reported state anxiety. The combination of the two techniques, however, did not yield consistent or significant pretest-posttest changes in state anxiety. Trait anxiety was unaffected by PMR and the combined techniques but was significantly reduced in the music listening condition. There was a positive correlation between enjoyment of the music selections and self-reported relaxation. Jazz was the most preferred genre. Contact with Gladfelter confirmed this author’s hunch that music relaxation was not used as a feature of treatment but, rather, was unique to this particular research protocol (personal communication, February 9, 2012). In a case study within a descriptive article about their work with delinquents in residential treatment, Rio and Tenney (2002) cursorily illustrate their use of music-assisted relaxation with Cody, a 16-year-old with a criminal, gang, and substance abuse history. The authors indicate that one of Cody’s goals was to learn ways to relax and meditate. Tenney met with Cody for multiple individual sessions, and “[s]ome form of relaxation with music took place during almost every session” (p. 95). Progressive muscle relaxation (PMR) with music was used as a precursor to song composition. Initially, therapist-selected solo piano music was paired with PMR, which led to some degree of self-reported relaxation. When Cody chose his own music (rap), he reported feeling even more relaxed. He also indicated that, upon termination of treatment, he would continue to use MAR techniques when his anger flared up. In a pilot program with one cottage group of 12 delinquent girls at a state training school, this author (Gardstrom, unpublished) used eurhythmic listening for increased cardiovascular exercise aimed at the girls’ weight control and improved body image. At the start of the eight-week program, the movement experiences were met with resistance from many of the girls. Issues uncovered during the verbal processing included fear and embarrassment related to obesity and a perceived lack of coordination, and the triggering of potent emotions related to physical and sexual abuse. In time, and with encouragement from the author, certain residents in this author’s group emerged as motivational leaders who were able to help other girls break through defenses. Confidence increased and a sense of group pride surfaced. Eventually, the group requested permission to perform a choreographed piece for other male and female residents at a school assembly, which was met with great praise from staff and peers alike, contributing to the girls’ reported feelings of mastery and gratification. Rio and Tenney (2002) describe their use of structured movement to music with girls in a residential treatment facility as a way to help them focus and to heighten body awareness. Similarly, they

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found that movement to music for their client, “Caroline,” revealed inhibition and discomfort related to her history of promiscuity and prostitution—feelings that were subsequently explored through instrumental improvisation. This author was able to unearth just one example of projective listening with juvenile offenders. As part of a larger creative project involving lyric interpretation and video interpretation, Edgerton (personal communication, February 20, 2012) played instrumental music for delinquent boys in a residential school program and asked them to respond to multiple, open-ended questions about the music, such as “What name would you give the piece?,” “What would the piece be about?,” and “What colors, feelings, adjectives, etc., would you use to describe the music?” Working in tandem with an art therapist, Edgerton helped the boys interpret what they heard using various art media. Eventually this projective handiwork became part of a group collage that was shared during a special “family day” at the school.

Improvisational Music Therapy Edgerton (personal communication, February 10, 2012) describes the use of improvisation with young male offenders as part of a larger group documentary project involving music and art media. Cottage groups of 10 to 12 youth created sketches that were eventually sequenced as slides with music accompaniment. The boys could select instrumental music to accompany the presentation of their slides or could improvise a “sound track.” In order to introduce the concept of improvisation and build improvisational fluency, Edgerton asked half of the cottage residents to improvise together using the referent of a particular emotion (e.g., anger, joy, loneliness, etc.). A variety of instruments were used, including electronic keyboards with certain scales and arpeggios (e.g., Middle Eastern, natural minor) marked with tape for easy recognition. The other half of the cottage group, through discussion, guessed the referent and talked about how the improvised music reflected the referent. Edgerton describes this experience as developing verbal and nonverbal communication skills, promoting group cohesion, and unleashing creative potential.

Re-creative Music Therapy In one of the earliest published examples of the behavioral application of music in delinquency treatment, Madsen and Madsen (1968) write about the procedures they used to extinguish one young man’s abusive and antisocial behaviors. Individual guitar lessons were provided, contingent upon the client’s completion of short work tasks. No specific information was provided as to the length or content of these lessons. Gardstrom (1993) writes about the use of handbells with male and female delinquents in an intergenerational music-based program. In this program, youth from a state training school and older adults in community “senior centers” served as participants. Rehearsals occurred weekly for two hours, with youth taking responsibility for transporting all necessary equipment to the center (i.e., bells, gloves, tables, foam pads, sheet music, etc.), setup, and teardown. The youth and their senior “partners” worked side by side to re-create simple hymns, patriotic songs, and folk songs. Snacks and socializing concluded each session. Culminating performances in nursing homes and other community venues allowed all participants to experience the joy of working together and giving to others, as well as the pride that accompanies a job well done and enthusiastically applauded. A somewhat unexpected but welcomed byproduct of this particular program was the exposition and working through of the offenders’ feelings of guilt, shame, and remorse attached to their prior victimization of vulnerable older adults in their home communities. Using a randomized controlled crossover design, Bittman, Dickson, and Coddington (2009)

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explored the impact of the HealthRHYTHMS adolescent drumming protocol on quality of life of youth from a secure residential treatment facility. This protocol is a 6- or 12-week program that blends Recreational Music-Making and counseling techniques and targets “at-risk” youth in residential treatment and community programs, including court-referred adolescents with histories of trauma, substance abuse, gang-related activity, and mental health diagnoses. Participants in HealthRHYTHMS programs are youth between the ages of 12 and 18. The protocol is publicized as having myriad biological and psychosocial benefits, as demonstrated in preliminary systematic studies (HealthRHYTHMS website, 2012). The adolescent program is designed to facilitate communication and personal expression toward improved quality of life. No contraindications are identified. While not conducted by a certified music therapist, music therapy faculty from Berklee School of Music appear to have been peripherally involved in the project. Participants in the study were status offenders, and many had mental health diagnoses. Intervention groups of 6 to 12 male and female participants were involved in a specific sequence of expressive activities, including unstructured jam sessions on drums and handheld percussion instruments, structured rhythmic activities, nonverbal/musical portrayal of responses to specific questions, a shaker pass activity, and a “wellness” activity involving breathing, movement, and a tactile object, and performed to acoustic Clavinova music. Open and supportive discussion was a regular feature of every one of the sessions during the six-week intervention period. Treatment and control groups differed significantly and in desired directions in school/work performance, anhedonia/negative affect, negative self-evaluation, and instrumental anger (i.e., delayed emotional responses including revenge and retaliation), as reflected through standardized dependent measures.

Compositional Music Therapy Neforos and Willenbrink (2012) describe group songwriting with five or six clients in a group home for atrisk and adjudicated boys, ages 15 to 18. The therapists used this method to address identified needs among the clients: emotional expression, creative control, supportive peer relationships, identification of personal strengths, and recognition of opportunities for positive life changes. Originally, Neforos and Willenbrink planned a single session built around individual compositions within a 12-bar blues structure, using open-ended lyric stems. However, the group members rejected this structure as musically unfamiliar and restrictive of their creativity. At this point, individual composition was abandoned for a group process, which spanned several sessions. The group composition procedure was fluid and reflexive. Clients made decisions about the title, lyrics, music, and form of the piece; the therapists facilitated the experience primarily by asking questions to help clients refine their ideas and by suggesting and modeling harmonic and melodic material that could be incorporated into the end product. Therapists also provided encouragement for participation, “ran interference” when communication became strained, and praised group members who made valuable contributions and who demonstrated desirable traits and behaviors during the process. Lyrics were constructed first and, without a doubt, the lyric writing emerged as the core focus of the experience. Subsequent musical decisions regarding style, rhythm, and instrumentation were made by means of group discussion and negotiation. The resulting product was a two-verse rap with a melodic chorus, based on the theme of overcoming struggles and making positive life changes. The clients recorded the rap and had an opportunity to listen to and critique their creation. The level of involvement differed from member to member, depending on individual cognitive and social functioning and maturity. Neforos and Willenbrink note that the experience seemed most beneficial for the group members who invested fully in the process, sharing meaningful personal experiences (including traumatogenic material from their past) and providing emotional support for others when this type of sharing occurred (personal communication, February 3, 2012). While the compositional product was a

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necessary focus and provided ongoing motivation for the group members, the therapists identify the primary agent of change as “the evolution of group dynamics through this working process,” from a place of isolation and conflict to a cohesive unit, in which all members felt a sense of belonging and validation, as described by Yalom and Leczsz (2005).

SUMMARY AND CONCLUSION The purpose of this chapter was to provide guidelines for the selection and facilitation of music experiences with adjudicated adolescents. Group and individual experiences within each the four music therapy methods were identified and sequential procedures offered. The author drew from her own history as a clinician, her colleagues’ expertise, and published literature about music therapy with adjudicated youth, the last of which is limited in comparison to publications about certain other adolescent clientele. The process of adjudication ultimately involves a disposition hearing during which a court representative passes judgment on an adolescent’s behavior and renders a decision regarding corrective action. In the case of severe or repeat offenders, residential placements (e.g., training schools, boot camps, group homes, etc.) are often mandated. Whether residential placement serves as incarceration toward guaranteeing public safety, as punishment or retribution for criminal behavior, or as an opportunity for rehabilitation and a welcome return to society depends on the national zeitgeist and, in some cases, on the particular jurisdiction in which the adolescent is adjudicated. Without a doubt, young offenders—while often demonstrating profound resilience—typically come into residential treatment with a host of significant deficits, challenges, and needs: Many have been witnesses to and victims of abuse; other youth have been neglected, abandoned, or invalidated at critical points in their development; some teens have psychiatric and substance use disorders that have gone undetected or unaddressed; and still others have learning difficulties that have led to failure in typical educational systems. Dysfunctional peer groups (e.g., gangs), family systems, and communities contribute to the myriad challenges of rehabilitation. These complex issues demand a team approach. Music therapists who work with adjudicated youth most often share the responsibilities of rehabilitation with several other clinical personnel, such as counselors, social workers, psychologists, residential staff, and—in the best of circumstances—other creative arts therapists. Each team member makes unique contributions to the treatment process. The music therapist with knowledge about and working facility within the four music therapy methods— receptive, improvisational, re-creative, and compositional—will be able to offer an attractive, experiential modality through which adjudicated adolescents can experience personal growth, with the prospect of enduring change.

REFERENCES Abram, K., Teplin, L., McClelland, G., & Dulcan, M. (2003). Co-morbid psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 60(12), 1097–1108. American Music Therapy Association. (2010). Member sourcebook. Silver Spring, MD: AMTA. American Music Therapy Association. (2012). Fact Sheet: Music Therapy Interventions in Trauma, Depression, & Substance Abuse: Selected References and Key Findings. Silver Spring, MD: AMTA. Retrieved from www.musictherapy.org American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-5). Arlington, VA: Author.

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Arnason, C. (2002). An eclectic approach to the analysis of improvisations in music therapy sessions. Music Therapy Perspectives, 20, 4–12. Barton, W. H. (2011a). Juvenile justice policies and programs. In J. M. Jenson & M. W. Fraser (Eds.), Social policy for children & families: A risk and resilience perspective (2nd ed., pp. 306–352). Thousand Oaks, CA: Sage Publications. Barton, W. H. (2011b). Detention. In B. Feld & D. Bishop (Eds.), The handbook of juvenile crime and juvenile justice (pp. 636–663). New York: Oxford University Press. Barton, W. H., & Butts, J. A. (2008). Building on strength: Positive youth development in juvenile justice programs. Chicago: Chapin Hall Center for Children at the University of Chicago. Bittman, B., Dickson, L., & Coddington, K. (2009). Creative musical expression as a catalyst for quality-oflife improvement in inner-city adolescents placed in a court-referred residential treatment program. Advances in Mind-Body Medicine, 24(1), 8–19. Brooks, D. M. (1989). Music therapy enhances treatment with adolescents. Music Therapy Perspectives, 6, 37–39. Bruscia, K. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas. Bruscia, K. (1998a). Defining music therapy. Gilsum, NH: Barcelona Publishers. Bruscia, K. (1998b). (Ed.). The dynamics of music psychotherapy. Gilsum, NH: Barcelona Publishers. Carrion, V., & Steiner, H. (2000). Trauma and dissociation in delinquent adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 353–359. Cassity, M., & Cassity, J. (1994). Psychiatric music therapy assessment and treatment in clinical training facilities with adults, adolescents, and children. Journal of Music Therapy, 31(1), 2–30. Christenson, P., & Roberts, D. (1998). It’s not only rock ’n’ roll. Cresskill, NJ: Hampton Press. Clendenon-Wallen, J. (1991). The use of music therapy to increase the self-confidence and self-esteem of adolescents who are sexually abused. Music Therapy Perspectives, 9, 73–81. Costello, B., & Dunaway, R. (2003). Egotism and delinquent behavior. Journal of Interpersonal Violence, 18, 572–590. Dal, K., & Matney, W. (2010). A taxonomy of drumming experiences. Music therapy drumming. Retrieved from http://musictherapydrumming.com/a-taxonomy-of-drumming-experiences-2/ Donnellan, M., Trzesniewski, K., Robins, R., Moffit, T., & Caspi, A. (2005). Low self-esteem is related to aggression, antisocial behavior, and delinquency. Psychological Science, 16(4), 328–335. DOI: 03616-01210.1111/j.0956-7976.2005.01535. Dvorkin, J. (1991). Individual music therapy for an adolescent with Borderline Personality Disorder. In K. Bruscia (Ed.), Case studies in music therapy (pp. 251–268). Gilsum, NH: Barcelona Publishers. Edgerton, C. D. (1990). Creative group songwriting. Music Therapy Perspectives, 8, 15–19. Frisch, A. (1990). Symbol and structure: Music therapy for the adolescent psychiatric inpatient. Music Therapy, 9(1), 16–34. Gardstrom, S. (1987). Positive Peer Culture: A working definition for the music therapist. Music Therapy Perspectives, 4, 19–23. Gardstrom, S. (1993). Partners: Intergenerational music therapy. Music Therapy Perspectives, 11(2), 66. Gardstrom, S. (2000). Controversial music styles. Triad (official publication of the Ohio Music Education Association), 66(5), 21–22. Gardstrom, S. (2002). Music therapy with juvenile offenders. In B. Wilson (Ed.), Models of Music Therapy Intervention in School Settings (2nd ed., pp. 183–195). Silver Spring, MD: American Music Therapy Association. Gardstrom, S. (2004). An investigation of meaning in clinical music improvisation with troubled adolescents. In B. Abrams (Ed.), Qualitative Inquiries in Music Therapy: Monograph Series, Volume One (pp. 77–160).

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Gardstrom, S. (2007). Music therapy improvisation for groups: Essential leadership competencies. Gilsum, NH: Barcelona Publishers. Gardstrom, S., & Hiller, J. (2010). Song discussion as music psychotherapy. Music Therapy Perspectives, 28(2), 147–156. Gladfelter, N. (1992). The effects of music listening and progressive muscle relaxation on the anxiety level of adjudicated adolescent males in a residential treatment setting. Unpublished master’s thesis. Western Michigan University, Kalamazoo, MI. Gold, C., Voracek, M., & Wigram, T. (2004). Effects of music therapy for children and adolescents with psychopathology: A meta-analysis. Journal of Child Psychology and Psychiatry, 45(6), 1054– 1063. Hiller, J. (2009). Use of and training in clinical improvisation. Music Therapy Perspectives, 27(1), 25–32. Hiller, J. (2011). Theoretical foundations for understanding the meaning potentials of rhythm in improvisation. Doctoral dissertation. Retrieved from UMI ProQuest Dissertations and Theses (#3457829). Hubbard, D. J., & Pratt, T. C. (2002). A meta-analysis of the predictors of delinquency among girls. Journal of Offender Rehabilitation, 34, 1–13. Lee, C. (2000). A method of analyzing improvisations in music therapy. Journal of Music Therapy, 37, 147–167. Madsen, C. K., & Madsen, C. H. (1968). Music as a behavior modification technique with a juvenile delinquent. Journal of Music Therapy, 5(3), 72–76. Mark, A. (1988). Metaphoric lyrics as a bridge to the adolescent’s world. Adolescence, 23(90), 313–323. Marker, M. (2006). DSM symptom clusters among juvenile offenders. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(12-B), 6930. ProQuest Information & Learning, US. McFerran, K. (2011). Moving out of your comfort zone: Music therapy with adolescents who have misused drugs. In A. Meadows (Ed.), Developments in music therapy clinical practice: Case studies (pp. 248–267). Gilsum, NH: Barcelona Publishers. National Center for Juvenile Justice. (2009). Juvenile court statistics, annual. Pittsburgh, PA. National Center on Education, Disability and Juvenile Justice. (2007). Tools for promoting educational success and reducing delinquency. Step 7. Court-involved youth. Retrieved from http://www.edjj.org/focus/prevention/JJSE/TOOLS%20Step%207%20(2- 28-07).pdf National Center on Education, Disability and Juvenile Justice. (2011). Prevention. Retrieved from http://www.edjj.org/prevention/resiliency.html Neforos, J., & Willenbrink, J. (2012). Music therapy and evolving sense of hope among at-risk adolescent boys: A descriptive group case study based on Yalom’s principles of group psychotherapy. Great Lakes Region AMTA Conference, Grand Rapids, MI. April 14, 2012. Research poster session. Nolan, P. (1983). Insight therapy: Guided Imagery and Music in a forensic psychiatric setting. Music Therapy, 3(1), 43–51. Office of Juvenile Justice and Delinquency Prevention. (2010). In focus: Girls’ delinquency. Retrieved from: www.ncjrs.gov/pdffiles1/ojjdp/228414.pdf Office of Juvenile Justice and Delinquency Prevention. (2011a). Statistical briefing book: Frequently asked questions about juveniles in corrections. Retrieved from http://www.ojjdp.gov/ojstatbb/corrections/faqs.asp Office of Juvenile Justice and Delinquency Prevention. (2011b). Statistical briefing book: One day count of juveniles in residential placement facilities, 1997-2010. Retrieved from http://www.ojjdp.gov/ojstatbb/corrections/qa08201.asp?

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Office of Juvenile Justice and Delinquency Prevention. (2011c). Juvenile residential facility census, 2008: Selected findings, in Juvenile offenders and victims: National report series. Retrieved from www.ncjrs.gov/pdffiles1/ojjdp/231683.pdf Plattner, B., Karnik, N., Jo, B., Hall, R., Schallauer, A., Carrion, V., Faucht, M., & Steiner, H. (2007). Child Psychiatry and Human Development, 38, 155–169. DOI: 10.1007/s10578-007-0050-0. Puzzanchera, C. (2009). Juvenile arrests, 2007. Juvenile Justice Bulletin. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Puzzanchera, C., Adams, B., & Kang, W. (2009). Easy access to FBI arrest statistics, 1994–2007. Online. Retrieved from http://www.ojjdp.gov/ojstatbb/ezaucr/ Rio, R., & Tenney, K. (2002). Music therapy for juvenile offenders in residential treatment. Music Therapy Perspectives, 20(2), 89–97. Shufelt, J. & Cocozza, J. (2006). Youth with mental health disorders in the juvenile justice system: Results from a multi-state prevalence study. Research and Program Brief. National Center for Mental Health and Juvenile Justice. Retrieved from http://www.ncmhjj.com/pdfs/publications/PrevalenceRPB.pdf Skaggs, R. (1997). Music-centered creative arts in a sex offender treatment program for male juveniles. Music Therapy Perspectives, 15, 73–78. Spielberger, C. D. (1983). Manual for the State–Trait Anxiety Inventory (Form Y). Palo Alto, CA: Mind Garden. Spooner, M. (2008). Creativity Research Journal, 20(2), 128–129. DOI: 10.1080/10400410802059689. Steele, A. L. (1975). Three-year study of a music therapy program in a residential treatment center. Journal of Music Therapy, 12(2), 67–83. Wells, N. F. (1998). An individual music therapy assessment procedure for emotionally disturbed young adolescents. The Arts in Psychotherapy, 15(1), 47–54. Wyatt, J. (2002). From the field: Clinical resources for music therapy with juvenile offenders. Music Therapy Perspectives, 20, 80–88. Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.

Chapter 19

Juvenile Male Sex Offenders Lori L. De Rea-Kolb ____________________________________________ DIAGNOSTIC INFORMATION Of the wide variety of criminal activity and offending that occurs in society, few offenses are viewed with such vitriol as sexual-related ones. Among the subgroups of individuals who make up the term “sex offender,” juvenile males comprise a significant number. According to Davis and Leitenberg (1987), adolescents were found to be accountable for 20% of rapes and up to 50% of all child sexual molestation in the United States. Furthermore, males represent 90% of the overall juvenile offender demographic. Thus, male juvenile sex offenders are responsible for a significant portion of all reported cases. The term “Juvenile Sex Offender” (JSO) is defined as any “minor who commits any sexual act with a person of any age (1) against the victim’s will, (2) without consent, or (3) in an aggressive, exploitive, or threatening manner” (Ryan, 1991, p. 3). This type of behavior can include pedophilia, rape, exhibitionism, voyeurism, harassment, frottage, and paraphilias such as bestiality or sadism. It is important to understand that there is a difference between juvenile and adult offenders. The Center for Sex Offender Management (CSOM) (2012a) notes that “juvenile sex offenders are not just younger versions of adult offenders” (p. 6) and that “juvenile sex offenders appear to respond better to treatment and reoffend less frequently than adult sex offenders” (p. 7). Although many juvenile offenders may not continue to offend into adulthood, research has found that “most adult offenders committed their first offense during early adolescence” and that “between 60% and 90% of adult sex offenders committed their first sexual offense between 13 and 15 years of age” (Bremmer, 1992; Skaggs, 1997). Because sexual offending can be viewed primarily as sexual behavioral issues, it is important to understand the etiology of such behaviors. According to the CSOM (2012b), “The onset of sexual offending behavior in these youth can be linked to numerous factors reflected in their experiences, exposure, and/or developmental deficits” (p. 1). A history of trauma is common with this population. Research shows that 20% to 50% of juvenile sex offenders have a history of experiencing physical abuse, while 40% to 80% of these youth have experienced sexual abuse. Accordingly, “symptoms of Post Traumatic Stress Disorder (PTSD) have been observed in a number of youth with sexual behavior disorder” (p. 2). Other common characteristics include high rates of learning disabilities and academic dysfunction, the presence of other behavioral health issues (substance abuse and conduct disorder), and difficulties with impulse control and impaired judgment. These factors alone do not cause the development of sexual behavioral issues, but are important in understanding what needs are common to the male juvenile sex offender. The CSOM states: “The most effective type of treatment approach involves helping offenders change unhealthy thinking patterns, understand factors that are linked to their offending, and develop effective coping skills” (2012, p. 4). This type of treatment can take many forms: psychological therapy, behavioral therapy, and even biological treatment. Most programs for male juvenile sex offenders report using relapse prevention and cognitive-behavioral models of intervention (McGrath, Cumming, &

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Burchard, 2003). How and where they receive these services is often determined by the justice system. Although many juvenile sex offenders can be safely managed in the community with specialized supervision and treatment (CSOM, 2012), failure to comply with community treatment or cases that are unique, severe, or repeat may lead to referral to a higher level of care such as a residential treatment program. Still other serious cases may be committed to a detention facility. In addition, the juvenile may be subject to laws that require specific sex offender registration and/or community notification. These are often different for juveniles than adults and vary greatly from state to state. This author is aware of music therapists providing treatment to adjudicated or troubled adolescents in a wide variety of settings. Personal experience, as well as a review of existing literature, provides insight only into the residential and detention center levels of treatment as they relate specifically to male juvenile sex offenders. In addition, it is not uncommon for a music therapist to treat clients presenting with alternate primary issues who may have a known or unknown history of sex offense. Sexual offending behaviors in juveniles may be unreported, dismissed, or overlooked. Therefore, a client who may be in treatment for his or her own trauma, PTSD, or other behavioral health issues may also have a history of sexually offending behavior.

NEEDS AND RESOURCES Watson (2002) cites Abel et al. (1987) in that “while sexual offenders are diverse in their demographics (all ages, races, socioeconomic levels, religions, and educational levels), they exhibit similar needs” (p. 105). Treatment needs can be understood through identifying categories of risk for offending or reoffending. These categories include: intimacy deficits, negative peer influences, attitudes tolerant of sexual offending, problems with emotional/sexual self-regulation or general self-regulation (poor impulse control, lack of respect, and empathy for others), or lack of ability to follow laws/rules/guidelines or generally accepted behavior in society (Hanson, 2000). Understanding these needs, and how they interact with other mental health issues that are commonly present in the male juvenile sex offender, can create a clearer picture for creating music therapy treatment with this population. Skaggs (1997) offers a convincing rationale for creative arts as a part of offender treatment: Since many sex offenders were also abused, often early in their formative years, their learning about offending occurred before cognitive abilities were well developed. Many cognitive distortions were learned through experiences imprinted heavily with images, emotions, and bodily sensations; therefore, relearning through experiential methods can be very effective. … Creative arts therapies address the multifaceted needs of juvenile sex offenders from a level deeper and more expansive than words alone can provide (p. 74). The music therapist has the opportunity to provide interventions that support the juvenile’s needs in relation to these risk factors. For example, group music therapy can provide an excellent venue to address social needs and deficits related to lack of intimacy or empathy. Treatment in a group format can also reduce the secrecy and shame that often comes along with committing a sexual offense. The inherent structure created by music can support development of understanding of structure or impulse control. Using popular music within treatment can aid in the discussion of societal influences such as negative peer influences or attitudes tolerant of sexual offending. These clients are naturally drawn to music, as are most adolescents. When they are invested, they are creative and enthusiastic. Many clients have learning disabilities or academic struggles and may

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struggle with verbal self-expression, which allows a nonverbal modality of therapy to be extremely effective. Adolescents are young, and their brains are still pliable, so one can still modify their behavioral patterns, making them very amenable to treatment. They are also worried about “fitting in” and “being cool,” so may hesitate to try something new, or be vulnerable in any way, especially in front of a group. This makes group development and dynamics important when working in this setting. Groups can also be challenging because many clients in this population struggle with healthy social skills in many ways. Some may be socially awkward and isolative, while other clients may have extremely poor boundaries. However, this is also the same reason why group work with the population is important and rewarding.

REFERRAL AND ASSESSMENT As previously discussed, there currently have been no references in existing music therapy research that are specific to referral or assessment in providing music therapy to those who have a history of sex offense, both on the adult and juvenile level. Typically, the client will be receiving treatment as part of the adjudication process, which varies from state to state. Common treatment includes some type of cognitive behavioral therapy, and music therapy may be offered in conjunction to this treatment. As music therapy assessment procedures have not been specifically addressed in current literature, it has been this author’s experience that music therapy assessment is often individualized as to practitioner and client, keeping in mind that “the focus in the assessment and treatment of sexual offenders is on dynamic (changeable) factors that can be demonstrated to reduce their risk to recidivate” (Watson, 2002, p. 105). Beyond the music therapy community, there are standardized assessments frequently used by practitioners to provide information about the sexual offender’s current needs and levels of functioning. Tools that are commonly used to assess juveniles include the Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR; Worling & Curwen, 2001) and the Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II; Prentky & Righthand, 2003). In addition, psychiatrists and clinicians commonly perform BioPsychoSocial and BioPsychoSexual assessments to determine history, risk factors and likelihood to reoffend. Adjunctive assessments that measure physical responses such as the plethysmograph (used to measure the level of physical arousal) and polygraph (commonly referred to as the “lie detector”) assessments may also be utilized, as appropriate. Musically, it is important to assess a variety of areas, and this can be performed in many different ways. Information such as musical preferences, musical history, and musical interests can be gained from a questionnaire type of format. Because it is not uncommon for this population to have learning disabilities, it may also be useful to do a short verbal follow-up or interview based on this questionnaire. Musically, short improvisations on preferred instruments such as drums or piano can allow for the therapist to assess impulse control, motor function, attention span, and the ability to imitate and follow directions as well as general musical receptivity.

MULTICULTURAL CONSIDERATIONS When engaging in a discussion of culture and sexual offending behaviors, one must be careful not to suggest that certain ethnic or socioeconomic cultures promote sexual offending due to variations in acceptable sexual behavior. In fact, it has been widely recognized that “although racial and socioeconomic differences may be overrepresented in certain settings … juveniles referred for treatment in a variety of environments reflect the same racial, religious, and socioeconomic distributions as the general population of the United States” (CSOM, 2012b). Rather, the purpose of this discussion of culture and sex offending is to bring to light cultural considerations that are salient to working with this population and how these cultural differences may affect understanding and reporting of sexually abusive behaviors.

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Many of the risk factors of offense or reoffense can be associated with variations in cultural norms. Deficits in intimacy, negative peer influences, attitudes which are tolerant of sexual offending, and an understanding of emotions within the self are all strongly affected by culture or deviation therefrom. Certain attitudes regarding sex, emotions, and personal boundaries can affect the development of healthy sexual attitudes, especially when other risk factors are also present. As with all therapy, when trying to eliminate risk factors or restructure cognitive distortions, it is important to understand how they developed and are understood from the client’s point of view. In any cultural context, there are expectations for how gender roles could and should be fulfilled. In the Latino culture, males are expected to exhibit a machismo attitude (Bourdeau, Thomas, & Long, 2008), while for African-American males, being in therapy itself may be stigmatizing as “not masculine.” Still, for Asian males, discussion of sex may be taboo (Kennedy & Gorzalka, 2002), which can create difficulties for the client truly engaging in the therapeutic process in a meaningful way.

OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • • •

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Breathing and Autogenic Relaxation: promotes relaxation using the breath, music, and relaxation exercises, based on repeated suggestions for body sensation. Relaxation and Directed Imagery with Music: involves listening to music and using directed imagery to develop the relaxation response. Guided Imagery and Music (GIM): involves using carefully selected recordings of instrumental music to elicit images, thoughts, feelings, and sensations from the listener for a therapeutic purpose. Therapeutic Song Discussion: involves listening to and verbally discussing a prerecorded song or songs to address a wide variety of therapeutic goals.

Improvisational Music Therapy • •

Group Drumming: Clients drum together, entraining to a common beat and variable dynamic level while creating individual rhythmic figures within the common beat. Individual Musical Autobiography: a referential musical improvisation or multiple improvisations created by the client within individual sessions to provide a narrative of some aspect of his life.

Re-creative Music Therapy • •

•

Therapeutic Instrumental Instruction: involves teaching an instrument of choice to a client in individual sessions to achieve therapeutic goals. Individual Therapeutic Music Performance: Client participates in a musical performance with therapeutic goals in mind, giving the client an opportunity to experience the role of performer. Structured Community Music Experiences—Creating a Band: involves creating music with others with the goal of performance, while achieving therapeutic goals throughout the process.

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Compositional Music Therapy • • •

Group Songwriting: Clients work together in a group or individually in the group to create new lyrics or a newly composed lyrics and music. Creating a Group Music Video: The therapist assists the group of clients in creating a finished music video product. Creating a Therapeutic Playlist: Clients choose various songs to create a playlist with a therapeutic purpose.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Breathing and Autogenic Relaxation Overview. These techniques promote relaxation using the breath, music, and relaxation exercises based on repeated suggestions for body sensation. Goals include improved relaxation, stress and anxiety management, and increasing impulse control. Not only does this experience provide the client with an opportunity to practice relaxation, but also it reinforces the ability of the mind to influence the state of the body. In other words, although the client may be feeling one particular way (angry, stressed, anxious), he can learn to alter that feeling and help his body to feel differently. Feeling in control of your own mind and body is an important concept when dealing with gaining a sense of control over arousal. Because this exercise is meant to be brief in nature (2 to 10 minutes), it is appropriate for many different lengths of attention spans. It can also be adapted to many levels of cognitive needs. Most notably, this task would be contraindicated for clients who have a history of psychosis. The level of practice is augmentative. Preparation. The session environment should be quiet and with minimal distractions. Chairs may be set up in a circle or in any arrangement in which the therapist can observe all the clients and the clients feel comfortable. It is best for the clients to sit in their chairs, but added materials such as footrests and pillows may help them be more comfortable. The therapist must also prepare music to last the duration of the exercise (2 to 10 minutes). Because the goal of the intervention is relaxation, music should have a tempo similar to a resting heart rate (62 beats a minute), and the music should not be overly loud, or have intense or rapidly changing dynamics. The melodic line should be somewhat smooth, with conjunct melodic intervals and predictable harmonies, and the overall mood of the music should suggest support. Finally, the therapist should have a plan for which relaxation prompts and imagery she will use with the client. The verbal directions should be clear and easy to understand. Anything too abstract will be difficult for this population to process and may cause anxiety or distress rather than relaxation. The verbal directions should also avoid referencing very specific body sensations (e.g., tighten your leg muscle), as this may be perceived by the client as sexual in nature and may cause arousal. What to observe. Observe the clients for signs of relaxation, such as relaxed affect, relaxed muscle tone in the face and posture, and deep, regular breathing. It is possible that some clients may have a negative reaction to this experience. Therefore, the therapist must also observe for signs of distress, such as grimacing, clenching fists, or tightening of muscles. Finally, observe for signs of arousal, which may be more difficult to notice. The client typically may become nervous, agitated, or unfocused. Procedures. Invite the clients to sit down and find a position in which they are comfortable. Explain the procedure to them and emphasize that they should only do what they feel comfortable doing. Suggest closing their eyes, but realize that some clients may not feel comfortable doing so. Instead of closing their eyes, clients may choose to unfocus their eyes, which can be described as similar to “zoning

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out” or “daydreaming.” Instruct the clients to take a few deep breaths, and begin the music selection while they are doing so. Begin with breathing prompts, which traditionally are structured as such: “Breathe in … 2 … 3 … 4 …” “Breathe out … 2 … 3 … 4 …” Repeat these prompts 2 to 4 times, as seems necessary. The clients should then seem settled and beginning to relax. Next, prompt the client with relaxing imagery. Some examples of this are: “As you relax, imagine that you are being covered by a heavy blanket. The blanket begins at your toes, and slowly covers your body until you are safe and relaxed under a nice, warm, blanket. “As you continue to relax, imagine a color. This can be any color, perhaps one that feels important to you right now. Imagine this color is filling your body, starting at the top of your head, and continuing down through your toes. “You are relaxed. You can feel the support of the chair underneath you. Feel the support of the floor under the chair. Feel the support of the ground under the building.” Providing prompts that reference sensations of being supported, feeling relaxed, “heavy,” or grounded are all ways to aid in the relaxation process. The therapist’s tones should be relaxing and the speech should be at a moderate rate. Allow brief pauses (2 to 4 seconds) for the clients to respond to the prompts, but not such a long time that the clients become distracted or feel lost or abandoned. The therapist should also be aware of the role of the music within this process. Timing prompts to coincide with phrases of the music allows the music to be most effective. After the therapist has concluded the guided relaxation, a prompt such as “listen to the music and you continue to feel this sense of calm and peace” can alert the clients that you will no longer be verbally guided them, but that they should continue to relax and listen to the music provided. When the music has ended, the therapist should alert the group to this fact and guide them to begin to become aware of their surroundings. Many clients will feel sleepy or “out of it” because of their deepened state of relaxation. Allow them time to walk around, drink some water, rub their face, and generally become more oriented to space and time. Processing for this task may vary. This experience is often used in conjunction with, or as a beginning to other types of interventions, and may be processed within the context of the experience as a whole. Also, if the therapist assesses that the clients have had a positive experience, it may not be necessary to process, allowing each client to have his personal experience as a special memory for himself. Other times, clients will be unable to relax, or may have had a negative experience. Although processing this within the group may be helpful for the client or other group members, it may also be more appropriate for the therapist to follow up with this client individually after the group. Also verbal processing is appropriate, a creative arts approach such as journaling, writing poetry, or creating art may help the client better express and integrate his experience. Adaptations. This experience can be adapted by changing the length of the task, the music used, and the imagery and prompts, which are suggested. Different therapists will have different experiences with various types of deep breathing and relaxation imagery prompts, and most of these are appropriate. It should also be adapted to the specific needs of the group. Feedback is important, and learning that a group likes the imagery of a heavy blanket but does not like the imagery of filling up with a color is important information, which can be adapted for the next session. Finally, this intervention can be used without music. It is also commonly used before music and imagery types of experiences, such as relaxation and directed imagery with music, and Guided Imagery and Music. It may also be used before other, nonimagery tasks as a method of centering and focusing before the music therapy session.

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Relaxation and Directed Imagery with Music Overview. These experiences involve listening to music and using directed imagery to develop the relaxation response. When interviewing a client about his coping skills, it is very common for the client to respond that “listening to music” is a major source of relaxation. These experiences build upon the client’s affinity for music and provide him with structured opportunities to use music that is carefully selected by the therapist in combination with a structured relaxation script to promote relaxed state. Music and relaxation addresses the client’s ability to self-regulate, a concept that is typically introduced early in treatment for sexually offending behaviors. Thus, this method is typically appropriate for many clients. Because this intervention in highly structured and guided, it can be adapted for most needs within this setting. It is noteworthy, though, that attention span, impulse control, and ability to maintain a sense of safety will all affect the client’s level of engagement. This method may be contraindicated for clients who struggle with highly intrusive sexual fantasies, or those clients with severe cognitive issues who may not be able to process or benefit from the experience. Music and relaxation exercises address augmentative or intensive goals in the male JSO’s treatment, including developing coping skills, improving self-regulation, developing relaxation techniques, and addressing issues related to anxiety, depression, and stress. There are some contraindications regarding the method of relaxation used with this population. For example, Jacobson’s progressive muscle relaxation method uses prompts such as “tighten your muscles and hold, hold, hold … now release.” This may be useful to the client (as it is to many people); however, the language used to promote connection to the body may evoke inappropriate sensual arousal. Thus, deep breathing exercises or autogenic relaxation prompts are more appropriate for this population. Preparation. The environment should be quiet with minimal distractions. Additional comforts such as pillows or blankets may be made available. The therapist should have music appropriate for client’s attention span and needs. Clients on the younger end of the age spectrum (12 to 15 years) may only be able to work on music selections that are about 3 to 10 minutes long. As the client’s age progresses toward adulthood, he may be able to work within a longer time frame. The music itself should support the material of the imagery script or directives that will be utilized during the session. For example, a piece of music that has a moderate tempo and a steady bass line and limited melodic range might suggest a hiking or walking trip. It would not make sense to suggest extremely dynamic imagery such as a spirited dance or rafting down a raging river. Skaggs (1997) suggests that appropriate music would “provide containment which supports the emergence of imagery and, at the same time, elicits a sense of being grounded” (p. 75). Musical elements that can suggest a sense of being grounded might include a strong, steady cadence or full harmonies. Another example might be a melodic line which is smooth and flowing with conjunct intervals, as opposed to a spirited and jumpy melody with many disjunct intervals. The script or verbal prompts should use clear wording, appropriate for the client’s intellectual level. Any language that is too abstract may cause confusion for the adolescent and distract from the process. The script and music should also provide a clear “story” or structure. It is not uncommon for clients to experience feelings of loss or abandonment if they are unable to resolve their relaxation experiences. Because of sexual implications, clients should avoid lying down, especially in a group setting. Have the clients sit in comfortable chairs. Finally, be aware of the body sensations that may be referenced. Modifying progressive muscle relaxation or other types of relaxation scripts with awareness of possible body arousal is key. What to observe. The therapist should continuously observe and assess the client’s affect and body language for signs of relaxation, as well as emotional distress or arousal. A client who is in emotional distress may display physical signs such as tightening of muscles, clenching of fists, facial expressions or

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grimaces, or shaking. There may also be observable changes such as flushing of the skin, sweating, or crying. Beginning signs of arousal may be less obvious, but clients will typically exhibit similar signs to being nervous or agitated (e.g., flushed face, clenching fists, unable to focus). In any situation, open and honest discussion about the factors leading up to the reaction should be explored. Procedures. The therapist should begin the activity with a short relaxation exercise, which then can transition into a longer task or scripted relaxation journey, if appropriate. Choosing the relaxation prompts and exercises for this population should be done with care and sensitivity. It is best to use autogenic or deep breathing exercises. Another type of relaxation exercise may include imagining a “safe place” for the client. In the example of a “safe place” imagery, allow the clients a few moments to become comfortable in their space, and suggest closing their eyes. Some clients will be highly resistant to this, especially if they have a history of trauma. In these cases, suggest defocusing their eyes or “zoning out,” similar to “daydreaming.” This is often more comfortable for the client, especially in the beginning sessions. Leave a few seconds of silence, and then suggest that the clients imagine a place where they feel completely safe and relaxed. Depending on the cognitive abilities of the clients, the therapist may need to suggest ideas, such as a beach or park. Allow the clients time to imagine being in this place. Have them notice how they feel, what they notice, what they are doing, and their favorite things about this place. Remind them that this is their safe place, and they can return to this place in their mind any time they need to feel safe and relaxed. Skaggs (1997) prompted her clients to “close their eyes (if they felt comfortable), take a few deeps breaths, and imagine themselves in a place that felt safe” (p. 75). The therapist may choose to have the clients do this to music, then end the experience here, or move on to a longer relaxation “journey.” The “script” that is used for the relaxation journey should have a clear beginning, middle, and end to provide containment for the relaxation experience. It should be no longer than 5 to 7 minutes. Typically, a concrete experience, such as taking a walk through a park or going to a beach, is successful. Direct the imagery in a way that engages the clients’ senses of vision, smell, hearing, touch, and even taste. Incorporate scenes where there are others present. Choosing public or open settings, rather than isolative places such as the client’s room or a hidden forest, provides fewer opportunities to trigger the client’s sexual fantasies. Keep a steady pace for the script to help the clients remain engaged and on task. Allowing too much nonguided music time (over 20 to 30 seconds at a time) could lead to distraction or sexual fantasies. Also, be aware of the sensory words employed to describe the surroundings. Providing sensory cues helps establish a relaxed state of mind, but using words that may also have a sexual connotation may not be beneficial. Finally, it is important to process and reinforce the experience. With this intervention, this author typically asks that each client share something with the group verbally; however, it is not a requirement that each person share the full story of his personal experience. Some clients struggle to visualize, while others may have had intrusive or inappropriate thoughts, which would be beneficial to process in an individual setting, but may be disruptive to the group setting. Adaptations. This type of session may be done as a whole session, or the therapist may prefer to break it into steps to allow the client to learn each skill at a time. For example, it may be best to introduce and practice various short relaxation exercises of 1 to 2 minutes for a few sessions, or integrate these experiences with other activities. This will provide some familiarity for clients who may be hesitant to fully participate in longer relaxation journeys. It will also provide a way to focus clients for the remainder of the session. Finally, practicing a variety of relaxation exercises will help the therapist to assess which types of imagery and language are best for the clients. Skaggs (1997) reported practicing relaxation exercises which taught her residents to “find a place of safety” (p. 75) in order to teach them how to deal with feelings that became very intense. She concluded that instilling this sense of safety allowed the clients to more fully engage in the task, as evidenced by the group closing their eyes and becoming quiet.

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Additionally, processing of the group may be done in a variety of ways, including traditional verbal methods or using art and other expressive methods. Writing about the experience in a journal or creating art are just some of the ways one could process this journey. Because the therapist is suggesting the client visualize through the process, it is natural that some clients will be most drawn to a visual representation of their experiences. Clients may also feel compelled to create an “artifact” from their relaxation journey. Using clay or other art materials, have the clients re-create something that was important from their journey. For example, if the journey involved a walk on the beach, have the clients create a seashell out of clay. This shell may be useful in helping the client access this skill on his own when needed.

Guided Imagery and Music Overview. Guided Imagery and Music (GIM) involves listening to carefully selected recordings of instrumental music to elicit images, thoughts, feelings, and sensations from the listener for a therapeutic purpose. Most commonly done individually, GIM can be a valuable intervention for clients who are developing coping skills, developing relaxation techniques, and addressing issues related to anxiety, depression, stress, and trauma. Clients who do well with music relaxation techniques may benefit from this type of intervention. This technique would be contraindicated for those clients who struggle with fantasy versus reality, especially those struggling with intrusive sexual fantasies. Accordingly, those clients who struggle with mental health issues which impair their reality orientation, cognitive issues which impair their ability to process the experience, or the emotional stability to experience the feelings and images that may occur during the session are generally not appropriate for this intervention. GIM is an intensive or primary therapy, and the therapist should have appropriate GIM training to provide this intervention. Preparations. For the session, the therapist should have available a number of musical selections appropriate for Guided Imagery and the goal of the specific session. Special awareness should be given to the length of the selection when considering the client’s attention span. The environment should be quiet and free from distractions or disruptions. Additional comforts such as pillows or blankets may be made available. What to observe. While conducting this session, the therapist should be aware of the client’s level of engagement and physical responses to the task, as well as verbal responses. If the client becomes disengaged from the process (e.g., extremely alert state, eyes open, non–music-related discussion, extreme difficulty reporting imagery), it may be best to discontinue the session or continue as a music listening and response session. Procedures. The traditional components of a GIM session, as outlined by Bonny (1978), include a preliminary conversation, a relaxation and induction, a music imaging experience, a return to an alert state, and a closing conversation or processing of the images. This basic structure should be followed, but it can also be modified to appropriate delivery to the adolescent population. In the preliminary conversation, the therapist and client discuss issues that are important to the client. The therapist assesses the client in this conversation, and together, the therapist and client decide on an intention or focus for the session. In the assessment, the therapist addresses the following concerns: the type of music that would best support this client, adaptations to the length of the music that may needed, and what starting image would best support the session focus. Next, the client sits in a comfortable chair and begins to relax. The therapist aids in this process by guiding the client in techniques such as deep breathing or autogenic relaxation exercises. As noted in the previous section (breathing and relaxation exercises), care should be taken when using Jacobson’s progressive muscle relaxation due to the description of the body and possibility for arousal. Along with

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aiding in the client’s relaxation, the therapist may remind the client of any important intentions or topics the client would like to explore during the session. After the induction, the therapist gives the client a starting image and begins the music program. The therapist verbally guides the client through his imagery experience for the duration of the music while recording verbatim what the client describes. When the music selections are finished, the therapist verbally prompts the client to return to an alert state. Help the client to feel grounded by calling attention to his breathing and suggesting movements such as putting one’s feet flat on the ground, moving the arms, and rubbing one’s face. Often, the client will still be in an altered state and feel “sleepy,” “fuzzy,” or “out of it.” Sometimes a drink of water or small stretching exercises can help return the client to a “normal” state of mind. In the closing conversation, the client and therapist will process and discuss the experience, noting imagery that seemed important or emotionally charged. The goal is to help the client to understand his imagery experiences in relation to his treatment. Adaptations. The basic structure of the session remains constant, but the therapist may make modifications such as music choice, length of selection, and nature of verbal prompts appropriately for the client’s treatment process. As a group process, it is best to refer to the process used in “Music and Relaxation Exercises.” Skaggs (1997) outlines a procedure which she refers to as GIM wherein she modified this structure for group use and provided only one piece of music due to time constraints. She provided art materials and had her clients create art pieces to aid with the closing conversation where the experience was processed.

Therapeutic Song Discussion Overview. This experience involves listening to and verbally discussing a prerecorded song or songs to address a wide variety of therapeutic goals. This experience is most often conducted in a group, but can also be used in individual sessions. Songs may be chosen prior to or during the session by the therapist or the client(s). Depending on the structure of the intervention, therapeutic song discussion can address a variety of needs to address intimacy deficits, explore cognitive distortions, and increase selfregulation. Developing social skills and increasing empathy and understanding of others is addressed in the group setting. Song discussion is generally able to engage most clients, even those who may be showing resistance in other parts of treatment, and there are no contraindications aside from careful choice and monitoring of the song lyrics used. Because clients in this population have a wide range of cognitive abilities and insight, it is important for the therapist to have a strong rapport and understanding of the client(s) before engaging in this experience. For some clients, listening to music with themes of anger and violence may reinforce this type of behavior. Other clients may have a more developed level of insight so that listening to music with these themes can aid in processing past experiences or identifying negative thought patterns. The level of therapy is augmentative. Preparations. The environment should be appropriate for music listening and analysis: quiet with minimal distractions. Chairs should be placed in a circle formation, in order to encourage group cohesiveness and discussion. Materials include a variety of recordings of music and copies of the lyrics for each client. Music may be played with CDs, MP3 players, or other technology that is available to the therapist. It may also be useful to give each client a list of the songs that will be covered in the session or that are available to play. In general, the therapist will choose the selections on the song list, because of the importance of selecting appropriate music that will stimulate treatment-related discussion. Integrating the clients’ preferences and suggestions when creating this list may help create a heightened sense of investment in the process. The therapist must carefully review each selection to be presented before the session to ensure the lyrics are appropriate, paying special regard to any topics in the song that may be contraindicated to the

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process of the group or individual’s treatment. Examples of this might be objectification of a person, sexual acts or promiscuity, substance abuse, reinforcement of immediate gratification, violence, and aggression. The use of these topics may not be inappropriate for every client, but should be weighed in regard to his overall triggers, needs, insight, and progress. An example of a song that can be effective in this intervention is Akon’s “Sorry, Put the Blame on Me,” which can spark a discussion about taking responsibility for one’s actions. Alicia Keys’s “Fallin’” may bring up the topic of healthy relationships, while Carrie Underwood’s “Before He Cheats” can address negative coping skills and anger management as well as communication and relationship issues. What to observe. During the listening phase, be aware of the client’s body language to assess the client’s reactions to the music. This might be manifested in expressions of relaxation or enjoyment, such as pleasant or calm facial expressions or movement in tandem with the music. The music may also provoke responses such as anxiety, anger, or arousal that would be evident by body reactions such as fidgeting or clenched fists. Note any spontaneous verbal or vocal responses to the music. Procedures. Begin the session by welcoming the clients; introduce the experience by telling them that everyone will listen to a song together and then discuss it. If the therapist has chosen the song in advance, pass out the lyric sheets; if she has created a song list from which clients may choose, pass out the list. When clients make their own choices from the options available, it creates a sense of “ownership” or connection to the song, and this helps to segue into analysis. A song chosen by the therapist can provide a new experience for the client or stimulate discussion on a particular topic that may be pertinent for group discussion. At this point, group rules or expectations should be discussed. Are the clients allowed to sing along, or should they listen quietly? Should clients offer feedback in a free-flowing fashion, or should they raise their hands to speak? The therapist will want to make this clear. Other topics that frequently need to be addressed include emphasizing respect for peers and their music choices, as well as what to do if a song “triggers” the client or provides overwhelming memories. If a client is having difficulty with a particular piece of music, it is always best to allow him to remove himself from the group and take a “time out” or time to process it with a supportive figure, if possible. A general expectation is that the client will return to group once he has been able to regain his composure, if possible. At times, the client will want to share his reaction with the group; at other times, the client may return to group withdrawn and isolative. Still other clients will want to move on and not address the reaction at all. It is the therapist’s discretion about the situation and how to address this within the group; however, is it always recommended that the therapist follow up with the client individually in order to process and explore the reaction. After each song is played, the therapist facilitates a discussion of the clients’ perceptions and experiences of the song. Verbal processing and analysis will vary greatly due to client insight, observation, personal experiences, and associations. Questions such as “Why did you pick this song?” and “What is this song about?” are general open questions that stimulate group conversation. Discussion of treatmentrelated themes such as healthy versus unhealthy relationships, self-esteem, coping skills, “thinking errors,” or cognitive distortions are typically integrated into the analysis. Clients who are at the beginning of their treatment or who are unfamiliar with this type of intervention may need more direct questions to stimulate analysis. For example, the therapist might ask what coping skills are being used in the song and whether they are healthy or unhealthy. Next, the therapist may prompt a discussion about the clients’ personal coping skills or how they might cope given the same situation. Adaptations. It is common for adolescents to “stick to what they know,” especially in a group session. They may be hesitant or even negative about listening to music that is outside of the genre with which they identify themselves. Creative ideas related to music selection within the session can provide opportunities for clients to think of the material of the session in differing ways. For example, presenting

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the song list options simply as lyrics from the songs, a summary of the song, or just by artist can expose the clients to new music they may not have chosen or aid in breaking down preconceived notions about artists, songs, or genres. In this author’s experience, music video analysis has also been successful and motivating to this population. This task is structured in much the same as lyric analysis; however, the media presented is visual as well as musical. This is highly motivating for adolescents, as music videos are a large part of the typical adolescent culture. It can evoke a high investment from clients who may otherwise be difficult to engage and adds a visual expressive element. Because of the multimodal expression, careful selection and review of material is, again, of very high importance. Although music videos are readily available on YouTube and on iTunes, the therapist must preview the material before the session in order to ensure that the visual material is appropriate for the clients and where they are in their treatment.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Instrumental Improvisation: Group Drumming Overview. In this experience, clients drum together, entraining to a common beat and variable dynamic level while creating individual rhythmic figures within the common beat. Improvising on drum and other percussion instruments is documented liberally in music therapy literature as an effective intervention for adolescents. This intervention is endlessly adaptable to the needs of the client and can be facilitated in a group or individual setting. Although there are many benefits to drumming with male JSO clients, this intervention will not be productive with certain clients. For example, clients with conditions related to the auditory system such as auditory processing problems, auditory hallucinations, or musicogenic epilepsy may not be appropriate to participate in this intervention. If the client responds to the task in a counterproductive way (e.g., withdrawal, compulsions, overstimulation), this task may also be contraindicated (Bruscia, 1987). In particular, a lack of impulse control and ability to process stimuli in a productive manner is common in this population, and drumming may be contraindicated for these clients until they have developed or are beginning to develop strong enough impulse control skills to benefit from this intervention. Percussion-specific improvisation provides an opportunity for the male JSO to address goals such as increasing self-esteem, increasing self-expression, increasing impulse control, and increasing or developing a healthy re-creation skill. In a group setting, the additional challenges of improving social interactions can provide a valuable experiential piece to treatment. Improvisation with a group requires understanding of the individual’s role within a group, positive interactions, and even developing empathy and social understanding. Physiological health benefits such as reduction of stress hormones have also been associated with active participation in this task. There are two warm-up and three drumming experiences, each with specific goals that are described in this section. Drumming is practiced at the augmentative or intensive level of therapy. Preparation. Group drumming can take place in any space that is large enough to handle the acoustics of the group. Rooms that are too small will quickly create a loud, overstimulating environment that is counterproductive to the session. The therapist should provide instruments with a wide range of pitches and sounds. Materials might include a variety of drums (such as congas, djembes, hand drums, and bongos) and other percussion instruments (such as cabasas, triangles, claves, shakers, guirros, and tambourines). The amount should enough so that group members may have many options and the ability to switch instruments. What to observe. It is important to be aware of the individual’s experience within the group, as well as the group experience, and how they may relate to one another. Observation may include the music

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structure that is created, and how clients respond to this structure, or lack thereof; how clients interact with each other and the instruments, both behaviorally and musically; and body language, which may communicate relaxation, frustration, difficulties with impulse control, or other important information. Because many clients have a history of aggression, loud noises may become a trigger for trauma-related flashbacks or behaviors. Any behavior that seems unusual (crying, shallow breathing, shallow affect, inability to focus or orient) should be addressed. Procedures. Improvisational drumming groups can be structured in a variety of ways; however, the most common format includes these elements: a brief warm-up or opening activity to acclimate the clients to the instruments and/or each other, the improvisation, possible verbal processing, and a closing. For the initial meeting of the group, or if there are new members, a primary objective is to introduce the clients to the instruments. Name and describe each one, outlining any safety or care instructions (e.g., do not use anything other than hands to play the djembe), and have a client demonstrate how to play the instrument. Also discuss group rules and rituals. Examples of rules include: no drumming while someone is talking, how members will chose instruments, when members will be able to switch instruments, and signals or how members will know when to do things like start/stop, change dynamics, etc. In each session, providing a warm-up activity allows the clients to orient to group and transition into the mind-set to focus for the upcoming group time. Two examples of warm-up experiences are Call and Response and the Welcome Song. In Call and Response, the leader, either the therapist or a group member, plays a simple rhythmic pattern and the remainder of the group immediately plays this pattern back to the leader. The leader may change throughout the activity. This provides an opportunity to take on a leadership role as well as to learn to play as a group and listen to others. In the Welcome Song, the group chooses one consistent format as an opening drumming experience every week. This might be a song that the group sings while drumming, a particular beat that is played, or something prerecorded that the group plays along with. The repetition each week provides a sense of structure and familiarity, as well as creating a ritual that the clients will be able to depend on session to session. After the warm-up experience, the main drumming experience, which takes on one of three basic forms, is introduced. In the Referential Improvisation, a leader, either the therapist or a member of the group, is designated. The leader or group decides on a topic or title to think about or reference while drumming. The topic might be something that is important to the group (how the group is functioning, loss of a group member) or an open idea or concept (anger, happiness, or peace). The leader is also in charge of providing a way to begin the improvisation, as well as providing a closure to the improvisation. If the group is struggling, the leader maintains structure. After the improvisation, the therapist leads the verbal processing. Referential improvisation typically provides a great deal of focus for group verbal discussion afterward and can be helpful in exploring topics that clients may struggle to express. How did the music sound? How would you describe the music? How did it relate to the topic? Do you think this piece of music represented the topic well? What would you name this piece of music? How did it feel to play about this topic? How did your part in the music relate to the topic? In the Structured Improvisation, a leader is designated to provide a beat and set the tone for the improvisation, while group members invent their own rhythms within the beat. The leader’s role is to lead the beginning and end of the improvisation, and to indicate musical elements such as dynamics and tempo. Although the therapist may allow the group to create their music spontaneously, there are times when the therapist may want to create situations for the clients to experience. For example, the therapist may cue a quieter group member to increase his dynamics to experience having a stronger voice within the group. Another example would be the therapist who plays a tempo that is slightly slower than the clients might normally play, in an attempt to work on impulse control.

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When the improvisation is completed, the therapist processes it verbally. Topics to process might include: How did the group member feel about the piece of music? What words describe this piece of music? What would they name this piece of music? How did it feel to be a group member? Any reactions or experiences the group members want to share about playing? Were there any group members who stood out, and in what way? Do any of these behaviors relate to behaviors outside of group, or in daily life? Structured improvisation provides a container and support for clients who may struggle with impulse control or focus. It addresses group dynamics, although in a relatively safe manner, because the leader maintains that role throughout. In Open Improvisation, the group begins in silence and creates music freely. There is no formal leader or structure, and the piece is played as long as the members continue to play. Open improvisation is difficult for clients who struggle with impulse control or lack of focus. It is a strong indicator or group functioning and dynamics, and there is no leader to “rescue” the group or keep it on track. This type of intervention can be challenging with adolescents who are, developmentally, struggling to separate and define themselves. It can also be very beneficial to clients who are able to process the musical material appropriately. During the group drumming processes, if a client is having an adverse reaction to the improvisation, it may be best to excuse him from the task, either for a “time out” with a later return to group, or perhaps for the remainder for the group. Always provide support for the client immediately; this can be a staff member, parent, or other support person. In addition, it is very important to follow up with the client individually after the session to process the adverse reaction. Was there a specific sound or instrument that caused the reaction? Can the client describe their experience? How does the client feel about the experience? How does the client feel about further group improvisation? The therapist will also want to note how the client reacted and how the group reacted. The therapist should do her utmost to ensure that the client does not feel ashamed about his reaction, and he should be encouraged to return to group if it is clinically appropriate. As stated above, after each of these drumming experiences, the therapist facilitates verbal processing and closure. The therapist leads an in-depth discussion about the improvisation, asking questions about how the group played together, what they thought about the piece, how they felt about their role in the piece, how that relates to their role within the group, what they expressed through the music, etc. It might also be appropriate to have a shorter discussion where each member of the group says a word that describes how they feel, what the improvisational piece sounded like, or what it felt like to be in the group that day. The group then ends with verbal closure, a chant, or a short music-making experience. Adaptations. As noted before, this group intervention can easily be adapted and may be practiced in many variations based upon the style of the therapist. Adapting this task for individual intervention follows many of the same concepts discussed above, but would be geared less toward functionality within a group setting and more toward individual musical expression and structuring.

Referential Improvisation: Individual Musical Autobiography Overview. An individual music autobiography is a referential musical improvisation or multiple improvisations created by the client within individual sessions. It is based on the instrumental depiction of various periods in the client’s life. Creating an improvisation based on a specific idea or theme can provide a more focused structure as well as address treatment specific goals such as increased selfexpression and self-reflection and improved self-esteem. Creating a musical autobiography provides the client with the opportunity to safely explore past trauma, relationships, and familial issues, and allows the therapist to process cognitive distortions in the client’s attitude to himself and his life experience. This

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autobiography requires that the client is willing and able to reflect on his life and is open to sharing this with the therapist. It may be contraindicated for clients who have impaired cognitive abilities and who are not able to process or assign meaning to the music symbology. The level of therapy is intensive. Preparation. Sessions should be conducted in a quiet, familiar environment. Materials include appropriate instruments for improvisation: drums, Orff instruments, various percussion, piano or keyboard. Recording equipment, such as a computer or digital voice recorder, may also be necessary, if the session is to be recorded for later analytical purposes. What to observe. As with improvisation with drumming and percussion instruments, depending on the specific needs and goals of the individual, observation may include the music structure that is created, and how the client responds to this structure, or lack thereof; instrument choice and how that relates to the topic; how the client interacts with the instruments, both behaviorally and musically; what instrument the client chooses to express specific emotion or events and why; and body language, which may communicate relaxation, frustration, difficulties with impulse control, or other important information. Because the client is telling his personal story, it is also important to note the topics of the story, what areas were given attention or ignored, if the story is fluid or disjunct, the congruence of the mood and dynamics of the music being used to tell the story, and how he represents his story in sound. Procedures. To begin, give the client an opportunity to familiarize himself with the variety of instruments. Clients may shy away from instruments if they feel uncomfortable with how to work them or what they may sound like. A short experience with each instrument may increase the client’s “toolbox” for telling his story. Encourage the client to pick up and feel each instrument and to explore the sounds it can create. Some instruction on how to play certain instruments might be necessary. Explaining the task to the client may be challenging, as the idea of representing your life story musically can be quite abstract to teenagers, who are often concrete thinkers. Referencing familiar pieces of music that use the instruments to convey strong emotions or providing an example such as a movie or video game soundtrack can help illustrate this concept. It may also be helpful to have the client “practice” by using instruments to play simple emotions like happy or sad. Next, have a discussion with the client wherein he chooses a stage of his life to represent musically. Some clients would like to play their entire life song and, in this case, helping the client organize his life into thematic sections of themes may facilitate the greatest success. Therapist involvement in the improvisation should be left to clinical discretion, although it is important to be aware of the clinical implications of “helping” someone “tell” his life story. Once the therapist begins creating music with the client, the therapist becomes an “other” who is telling the client’s life story. It is important that the therapist assist the client in telling his story and not tell the story through her own interpretation. In this situation, the client may project feelings onto the therapist or cast her in a role within his life story, which could be positive, negative, or neutral. The therapist should be in a role where she is helping the client express his story, not expressing the story for the client. Depending on the length of the improvisation(s), after the client has finished a section or the whole of his autobiography, the therapist processes the experience verbally with the client. Have the client explain what he just played, perhaps retelling the story in words instead of music. How does he currently feel? Were there any sections that were particularly meaningful, and if so, why? Much of the processing will depend on the material brought up by the improvisation. Additionally, the therapist might have the client create a piece of art or writing in conjunction with the music. If the improvisations occur in a series over more than one session, a creative arts journal might be created. Adaptations. This task may be modified to examine specific life events, such as a musical reenactment of trauma or offense(s). The therapist’s level of involvement during these tasks may vary and may be more appropriate if the client is “working through” these issues, not simply expressing or presenting them. This task may also be helpful to complete at various points in treatment, as an indicator

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of how feelings, perceptions or attitudes may have shifted. It may also be beneficial to record the “performance” for playback and analysis. With this type of processing, the therapist records the autobiography. After the improvisation is completed, the client and therapist play the recording and the client discusses his reactions to the music or thought process while creating it. Clients often react differently to hearing the music they created than when they are experiencing the creation. A recording can also be an important artifact for the client to keep. Within a group setting, the concept of a musical autobiography can be employed in various ways. A client may take turns improvising in front of the group as a way of sharing certain aspects of himself. Another idea would be to have a client who may have recorded his autobiography bring and play this for the larger group. Finally, a group that has grown and evolved together may want to create a musical autobiography telling the story of how they have progressed together.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Therapeutic Instrumental Instruction Overview. This experience involves teaching an instrument of choice to a client in individual sessions to achieve therapeutic goals. Many clients mistake music therapists for music teachers, as that is what they have most likely encountered in the past. In this author’s experience, this familiarity often leads the adolescent to be interested in learning to play an instrument. Despite the differences between professions, instruction on a music instrument can be a significant therapeutic tool with this population. Clients who would be contraindicated for this task would have severely poor impulse control or intellectual abilities that are too impaired to complete this task. The goals for instrumental instruction include increased self-expression and self-esteem, improved impulse control and frustration tolerance, and the development or improvement of coping skills and leisure skills. The level of therapy is augmentative or intensive, depending on the client’s level of involvement and duration of study of the instrument. Preparations. The session can be conducted in any soundproofed space where the client will have minimal distractions. Sheet music at appropriate level, the instrument being taught, and any appropriate teaching aids should be present. Music and instrument selection should take into account cognitive abilities, ability to control impulses, and personal interests of client. Choosing the instrument that the client will learn is important. Client preference naturally plays a large role in instrument selection, but the therapist should also consider what the goals for the sessions may be. Learning to play the drums would not be compatible with a client who wants to play an instrument to be able to write his own songs. Similarly, a client who may need to increase his ability to follow rules and structure may do best on an instrument like a drum set because of the precision needed to play correctly and in a structured manner. What to observe. Throughout these sessions, it is important to be aware of how the client is interacting with the music. Does he seem frustrated? Is he trying to rush the process, or is he stuck, perseverating on one particular aspect of the music? Is he able to recognize what he has accomplished, or does he often look for the negatives? Some clients are able to increase impulse control when working within the structure of a song. Others will rush the tempo, or not notice many mistakes. Adolescents, especially those with low self-esteem, will often make self-derogatory statements as an “excuse” for why they are not immediately successful. Procedures. This type of session would take place similarly to an educational instrumental lesson. The therapist assists the client in learning to play an instrument, of which there are many different methods. Because the goals of therapeutic instrumental instruction are different than teaching a client to

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perform on an instrument, modifications and teaching aids may be used more liberally. For example, writing note names on the keyboard or in music is one way that a client can achieve success. The therapist may also adapt the order in which concepts are traditionally introduced. One example is teaching the client basic chords to a favorite song, even if those chords are not traditionally introduced early in a guitarist’s career. Giving the client tools in which he can be successful at an early stage can instill a sense of self-esteem and accomplishment. This may allow him to feel more confident and motivated in this task going forward and in other areas of his life. Similarly, the concept of “delayed gratification” is related to controlling impulses associated with sexually offending behaviors, and often comes up when the client wishes he could progress at a faster rate than he is. Processing this with the client is important. It can help to work with the client to create realistic goals to accomplish each session, so that the client sees the small progress he is making each session. Within this intervention, emphasis should be placed on controlling frustration and building selfesteem.

Individual Therapeutic Music Performance Overview. In therapeutic music performance, the client participates in a musical performance with therapeutic goals in mind, giving himself an opportunity to experience the role of performer. In this author’s experience, many adolescents are motivated to get up in front of peers and sing, dance, or express themselves; thus, exploiting this natural inclination for therapeutic ends can create an atmosphere of positive support and a feeling of community as each member shares his performance. The actual “performance” session may take place at the culmination of therapeutic instrumental instruction sessions or a songwriting session. It can also be impromptu, such as an improvisation or “karaoke”-style performance. It is only necessary that the client is able to perform meaningful material for therapeutic outcomes. This intervention may be contraindicated for those who lack sufficient ego strength or emotional stability to cope with the anxiety and emotions of performance. However, as noted below, roles within this task can be adjusted or created for a variety of needs. The therapist may utilize this type of intervention when the client is working on goals such as increased self-expression, self-esteem, and positive social skills, and improved coping skills and frustration tolerance. One caveat to the spontaneous performance group is that because nothing is rehearsed, there may be less overall group participation because some members may not feel “prepared” or “good enough” to perform. The level of therapy is augmentative or intensive. Preparation. The rehearsal as well as the performance can take place in whatever setting is large enough to hold the members and musical space. For these types of performances, a karaoke machine, as well as instruments with which clients are familiar, such as piano or drums, are very useful materials. What to observe. Actions and reactions during the performance should be monitored, including response to receiving attention, the ability to be attentive to others, appropriate social reactions to performances, ability to engage oneself in performance, and any physical indications of frustration, nervousness, or low self-esteem. Procedures. Music therapy performances can be carefully rehearsed and planned, or quite impromptu. The procedure for conducting these types of session will vary greatly within the treatment setting. In a residential setting, setting up a quarterly talent show or “café” type of setting allows the clients to rehearse and plan toward a performance date. The therapist sets up opportunities to develop a performance in an “open studio” group. This is a group session where clients are able to work on acts and rehearse or develop roles for themselves for the café performance. In addition, clients who are not comfortable in performing a musical piece are allowed

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to emcee or perform as part of the stage crew. That way, every group member has a role in the performance, even if it is nonmusical in nature. Within the open studio, the therapist assists the clients in developing their role for the café. The therapist might help the client to choose a song or instrument to play. The therapist might also teach the client a piece of music to perform or modify an arrangement to make the music easier to perform. The therapist might also suggest small groupings of clients to perform together, or pair up students who have similar acts to practice together. The process culminates with the performance, when all of the clients have a chance to perform for staff, peers, and others, as appropriate. Other details not directly related to the therapeutic process that go into planning a performance might include procuring and setting/cleaning up equipment, food (if you would like to serve refreshments), and creating supplemental materials such as flyers and programs. Adaptations. Variations and adaptations of this intervention will be based upon the clinical needs of the clients. As noted above, performances can vary in nature, from planned to unplanned, with a variety of audiences. Impromptu performances can occur at any time. They may occur during downtime in the programming or on holidays or special occasions. This author has also taken select groups of clients outside of the treatment facility to perform within the community. When working within the residential setting, care and attention must be given to the selection of clients for this type of group, with consideration for the client’s readiness to engage in community settings. Particulars of the performance will vary based on the specific venue and arrangements, but the preparation is structured similarly to an instrumental group practice (which will be discussed below). The benefits for this type of performance are many—most notably, the sense of hope and pride that the clients experience.

Structured Community Music Experiences: Creating a Band Overview. Creating a band involves selecting a group of clients who will work closely together to create music with the goal of performance, while achieving therapeutic goals throughout the process. Many long-term clients in a residential setting who come to music therapy with prior musical skills, or those who develop these skills during the course of therapy, often wish to create “a band.” Clients included in such an endeavor should be able to communicate and work cooperatively with peers, and follow basic directions. This experience would be contraindicated for those clients who have severe difficulty interacting cooperatively within a group setting due to its inherently social nature. Goals addressed in this intervention may be increased self-expression, self-esteem, pro-social behavior, coping skills, and frustration tolerance. The level of therapy is augmentative. Preparation. “Practice” sessions should take place weekly in the same place, in an area that is able to hold all members and equipment comfortably. Regular practices help to create a sense of predictability for the members and are key to the musical development of clients as a group. The structure of the practice groups will vary based on the type of performance group that has assembled. In general, the session structure should include a warm-up, practice, learning of new music, and closing. For example, a drumming performance group might start off with a short improvisation or call-and-response warm-up. The session may then transition into practice of pieces worked on in previous weeks. Next, the group would learn new music. Finally, the group would participate in a closing drumming activity, perhaps a favorite piece or a short jam session. The overall goal of a performance group is to perform. Performances may take place when and wherever the therapist deems clinically appropriate. The level of therapy is augmentative. What to observe. As with individual performances, observation for the performance phase of the intervention might include the client’s actions and reactions during both the practice and the

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performance, his ability to maintain attention, ability to engage oneself in the performance, and any physical indications of feelings of frustration, nervousness, or low self-esteem. Procedures. Similarly to the process noted for individual music therapy performances, the band can be carefully rehearsed and planned, or quite impromptu. The procedure for conducting these sessions will vary greatly within the treatment setting. The type of performance, personal investment of the client, and venue will also play a large role in how sessions are structured. One difference between individual and group performances is the amount of time spent practicing and developing group cohesion. These “practice” sessions should have a typical structure to provide predictability and a feeling of safety within the group. One example might be: warm-up task, working on learning and shaping material, and then a closing task/processing. Initial sessions should focus on deciding roles within the group (who should play which instruments or sing what parts) and the direction of the group (what type of music, specific songs to play, how many songs to learn, etc.). The therapist may want to create the group with specific members in mind for specific roles. For example, the therapist may want to choose a group consisting of a member who has some experience in drumming, a member who has been learning guitar in individual sessions, and a member who is proficient in keyboard. The choice of repertoire and the method used to present or teach it will depend on the amount of experience and musical abilities of the group members. Once the sessions are established, each practice session should begin with a group warm-up. This might be an easy song that each member knows how to play, or a short improvisation. This warm-up is to allow the clients time to play together and begin to focus on the tasks ahead. Learning and shaping material might occur as a group, or with each group member learning and practicing their parts individually, with help from the therapist. Here, the therapist would assist in the learning and technique of musical parts, and guide the group in putting each part together. At the end of the session, the therapist leads the group in verbal processing. How did the group do today? What did the group do well? What should the group work on for next time? After this piece, the group may end, or may want to make music together one last time, for a closing task. Throughout the process, the therapist maintains the structure and provides feedback. She also observes and supports individual processes and social interactions, as well as provides musical instruction when needed. Adaptations. Any time a group is created and rehearses for the purpose of making music together, it could fall under this category of intervention. This author has facilitated a variety of performance groups, including a punk band, a chorus, and a drum team, within this population. Each has its own specific implications for treatment; for example, a chorus can particularly powerful in giving many of the clients a “voice.” The punk band was effective in aiding self-expression, since this type of music was particularly meaningful to those specific clients. Specific implications of each group should be considered when creating the membership and structure of the group.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Group Songwriting Overview. Group songwriting is the creation of new lyrics or a newly composed song, both lyrics and music. Songwriting interventions are effective with and appealing to the adolescent population, perhaps because adolescents are constantly struggling to he heard and to have their own unique voice. This is evident by the common practice of keeping a diary or of documenting their daily lives using technology such as Facebook, blogs, or Twitter. Many clients who wish to express themselves also write poetry or songs. In an individual type of format, goals might include increased self-expression, improved

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understanding of emotions, and the ability to process personal material such as trauma history. In a group setting, this task can address those same goals as well as promote positive social skills, decreased isolation, and promote a feeling of intimacy and understanding. This type of songwriting works with all clients. Because can be structured, clients with lower-functioning capabilities can be successful. The level of therapy is augmentative or intensive. Preparation. The session should take place in a setting that is quiet with minimal distractions. Depending on the structure of the task, the therapist may need to provide instruments, recordings, or other materials that will support the songwriting process, such as a white board, flip chart, or paper and pencils. What to observe. The therapist will be working closely with the clients throughout the session. Because the group is working together to create one song, the therapist will be able to observe the role the client plays within the group (e.g., positive leader, negative follower, scapegoat), as well as the development of social skills being used. Within the client’s offerings to the group, the therapist can assess the client’s ability to express himself, the congruence of those thoughts within the group process, and his ability to think abstractly and problem-solve. Group songwriting also highlights the client’s ability to empathize with and process others’ experiences. Procedures. Songwriting with male juvenile sex offenders can be approached in a variety of ways, as discussed further in adaptations. The most accessible format is the cloze or fill-in–the-blank method. In this type of songwriting, the therapist would provide a song that was already composed, both lyrically and musically. Certain words in the lyrics would be missing and the client’s role is to fill these in. Although the song used may be decided upon by either the group or the therapist, it would be the therapist’s role to decide on the structure and prepare the song, choosing which words or phrases for the group to rewrite. Here, the therapist must also decide if the group will be rewriting the whole song, a verse, or maybe just the chorus. This might be different depending on the song, size of the group, or time constraints. Finally, the therapist must decide if each ‘blank’ will be filled in by the group as a whole, by small groups, or whether each group member might take turns having their own song to complete. Ideally, the song would be familiar to the majority of members within the group. Its musical structure should be somewhat easy to follow, so that tackling a difficult melody or complicated rhythm does not become more important than the songwriting itself. When deciding which words to leave out or rewrite, the therapist should choose words that seem key to the song itself, words that describe emotion or major thoughts. When the therapist presents the song and structure to the group, it might be best to familiarize the group with the original song by singing it together and leading a small discussion. What is the song about? What was the author trying to express? Why did the author choose certain words or key phrases? Next, present the song with the words or phrases taken out and discuss, as a group, what the new song should express. From here, the therapist works closely with the group to develop a new song. At the end, allow the group time to sing or present their song as one cohesive piece. Discuss with the group how they feel about the piece, what parts some members might change, other topics they could have explored, how they worked as a group, and/or how each group member felt represented (or not). Some examples of songs that lend themselves to this style of writing follow. In the verse of “Sorry, Put the Blame on Me,” by Akon, he repeatedly states “Sorry for …” and clients fill in the remainder of the phrase. Although the rhythms used can be complicated at times, many clients have things that they would like to say “sorry for,” ranging from their offense to relationships with family members or other behavioral issues. Although some adolescent clients may not be familiar with “Imagine,” by the Beatles, the idea of imagining a different, better life appeals to many group members. Each client can contribute something to

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“imagine” and explain how things would be different if that were true. These often range from silly— “Imagine there’s unlimited cake”—to poignant—“Imagine there’s no trauma.” Clients often enjoy singing “I Believe I Can Fly,” by R Kelly. Its inspirational theme lends itself well to create a personalized, uplifting song. By filling in “I believe I can …,” or changing the phrase to “I believe I AM …,” the clients can discuss what they are working on or how they aspire to change. Adaptations. Adaptations with this task (as discussed above) are key, as each client has a different comfort level with his self-expression. For clients who may be “stuck” in creating music or avoiding a specific area of treatment, providing a prompt (“Write a song about your relationship with your siblings”) or fill-in-the-blank might be more appropriate. However, personal expression in the form of improvisation has also been useful in providing a deep level of insight. A format that leaves more choice for the client and is somewhat more demanding is the Piggyback or Parody Song. In this format, the melody and harmony from a familiar song are used, but all or most of the words to the melody are changed. This format is successful with teenagers with a moderate level of creativity and writing abilities; it still provides a strong musical structure, but allows for a large range of lyric expression. This type of structure could work in both an individual and group setting, but may take more than one session to complete, especially in a large group format. Small groups or individual may be best. When using this type of format, the song to be parodied should be very familiar to the client. Often, the client will have an idea of a song to parody, but the song could also be chosen by listening to familiar or favorite music. The therapist and client should listen to the song together and discuss important themes or structure. Once the topic of the parody is established, the client typically works with the lyrics to change and replace words to the song. One example of this format is “Fight for Your Right,” by the Beastie Boys. This song embodies a classic teenage struggle with authority to be able to express oneself and live life in the way one sees fit. Many of the clients are struggling in a variety of ways, whether it is to understand trauma that they themselves have experienced, struggling with relationships with family members or friends as a result of their offense, or even struggling to acclimate to a residential or treatment program. In these situations, many clients feel that they are “fighting” and are able to meaningfully parody this song. A more demanding format is the original song composition in which the client composes both the lyrics and melody while the therapist composes the harmonic structure. It is best in a small group (2 or 3 clients) or individual session because it may require close work with the therapist to create the desired piece. Usually done over many sessions, this format has a looser structure than the previous formats, but allows for a wide range of expression. The client typically composes one component of the piece first (melody, harmony, or lyrics) and the therapist supports the client in the further development of that component, as well as the other part. Which component is created first depends greatly on the strengths and abilities of the client, as well as what they are comfortable doing. If a client is comfortable creating lyrics, the therapist might take those lyrics and suggest a melody to pair with it. Other components, such as harmony, dynamics, and tempo, would then be decided upon. Similarly, a client may have an idea for a melody for a piece and would further work on lyrics and other musical aspects. Finally, Rio and Tenney (2002) discussed an intervention where they provided lyrical structure as prompts to access particular feelings, and had the client fill in his answers for the lyrics. In one example, the client had no prior experience or familiarity with the song, but filled in the rest of the phrase, as in “When I’m ….” Then, the client listened to the original song and processed with the therapists. This method was used later to write a rap song, with the therapist providing prompts such as “And I’ve tried …,” while the client finished the phrase. This aided the client in developing an original composition that he performed, successfully, to a group of peers.

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Creating a Group Music Video Overview. The therapist assists the group of clients in creating a finished music video product. Creating a group music video allows the clients to express their creativity both musically and visually. As previously mentioned, technology is an integral part of the adolescent’s musical world. Many clients have expressed their desire to create a music video, and many technology programs available make this a viable project. Clients should be able to work within a goal-directed environment over a number of sessions, verbally express ideas and thoughts, and work collaboratively with his therapist or other members of the project. Goals for this project are increased self-expression and increased self-awareness and improved social functioning and organizational skills. This intervention can be adapted to address a variety of needs. The therapist may take a more active or passive of role as necessary; there are no contraindications. The level of therapy is augmentative or intensive. Preparations. When preparing for this session, the client should be aware that this intervention might take many sessions to complete. Depending on the specific structure of how the music video will be created, the sessions may take place in one room or in a variety of locations. This will be determined by the project itself. The therapist should be familiar with the specific equipment and/or software being used. What to observe. Throughout the project, the therapist should observe the client’s ability to express himself in a variety of ways: verbally to the therapist or group members and musically, as well as noting how this is expressed in the added dimension of visual expression. Are the client’s ideas congruent with the process and product? Does one medium (music, verbal) express one thing, while another (visual) projects a different meaning? Also, the therapist should be aware of the client’s ability to plan and execute, as well as impulse control. Because this project is often easy to imagine and difficult to execute, how does the client deal with frustration, disappointment, or limits? Finally, social skills and interaction with the therapist and other group members should be assessed. Procedures. The available resources, such as technology, and the time frame often determine the structure of the sessions or intervention as a whole. This is a time-consuming project, and the therapist should manage this time wisely, or it may become overwhelming. Typically, the first session addressing this intervention will be a “planning” type of session. In this session, the clients will decide what music to use and how they would like to visually represent this music. A timeline should also be established. For example, if the therapist would like to devote eight sessions to a project where the group would like to use a prerecorded song and be the actors in the music video, the timeline might look as follows: Session One: Initial Planning Session Session Two: Creating Props/Planning Scenes Session Three: Practicing Scenes Session Four: Recording Scenes 1–3 Session Five: Recording Scenes 4–6 Session Six: Editing Session Seven: Final Editing Session Eight: Project Processing and Viewing Party The sessions that follow will adhere to this timeline, adjusting as needed. Planning and practicing scenes are very important, so that recording can be done as efficiently as possible. Some therapists prefer to do the editing themselves, as this can often be a long and meticulous process, which becomes more difficult in a group format. Once the project is completed, a viewing party is a positive way to view the final project and process it with the clients.

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Adaptations. This intervention can be adapted to be as advanced or simple as desired. A simple form of this task might involve picking a prerecorded song and coordinating it to a PowerPoint of pictures that the clients think relate to the song. It can also be as complex as the client writing and recording his own music and then videotaping scenes and visual representations to express his song. The latter project, of course, requires significant time and experience with recording and video equipment, while the first type of project can be completed with a lesser amount of technological savvy and time.

Creating a Therapeutic Playlist Overview. Clients choose various songs to create a playlist with a therapeutic purpose. Adolescents assign increased value to music and often have strong emotional associations with popular music. This variation on creating a “mix tape” has therapeutic value for clients who are deeply invested in using music as a method of communicating their emotional world. It is nonthreatening in the sense that the client is using others’ words and music to express himself; therefore, this task has been effective in engaging clients, even if a large amount of resistance is present. This intervention can be adapted to address a variety of needs, and the therapist may also take as active or passive a role as necessary; there are no contraindications. Goals include increased self-esteem, self-expression, self-awareness, and creating an artifact. The level of therapy is augmentative. Preparation. This intervention can be conducted in many environments; however, it requires the use of technology that allows the therapist and client to have access to a variety of music, and possibly creating an artifact (MP3 player playlist, CD, etc.) of this intervention. To conduct this session, the therapist may want to provide a list of songs from which to choose. Providing a list may give ideas or suggestions to clients who are struggling to think of songs to put on their playlist. This list could be a comprehensive list of the music the therapist has available, a list of top 100 popular songs, or a list of titles of songs from artists the client prefers. What to observe. While creating the playlist, the therapist should pay attention to the client’s process in choosing songs. Does he choose the first song that sounds like it would fit the playlist theme? Does he choose songs that don’t fit the topic, or does he have difficulty making any choice at all? Observations during processing are similar to those suggested in Therapeutic Lyric Analysis. Procedures. To conduct this session, the therapist should present the task to the client and then allow time for him to create the playlist on his own. The therapist should be available for support or processing, but it is important to remind the client of the personal nature of the project. If the client struggles, it may help to have him write a list of favorite songs and the personal meaning behind them. Presenting the client with an MP3 player or a master playlist of a great number of songs (100+) can help suggest songs if the client struggles to identify songs independently. Depending on the client and his investment, this intervention may take one session, or it may span across many. Processing should include listening to the CD or playlist in its entirety and discussing the significant factors of each song. Adaptations. This intervention can be modified in countless ways to maximize the therapeutic value throughout the client’s treatment. Grouping the playlist around therapeutic themes such as those presented below will provide an opportunity for the client to work on personal goals or explore areas of his treatment. “Who I Am” involves creating a playlist of personally meaningful songs that present the client’s perception of his identity and allow the adolescent to “introduce” himself to the therapist or group. This can be helpful with the client who is shy about other expressive means of therapy, and provides a “safe” way of introduction, using others’ words and music. “Old Me/New Me” allows the client to express how he has changed over the course of his treatment by creating a musical comparison between the “old” and “new” selves. This can be done in

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conjunction with discharge sessions. Music may be prerecorded or a compilation of recordings the client has created over his time in therapy, if possible. The “My Offense Cycle” playlist is typically created during or after the part of treatment when a client is actively looking at the behaviors that lead to his sexual offense. The client must be at a stage in the treatment where he is willing to analyze and take responsibility for his actions and behavior. Special awareness should be taken when assigning a musical representation to the actual offending behavior. It is important not to glorify or create a positive association between the two items. A “Personal Dedication” playlist may be created if a client is working through relational issues with significant people in his life. This relationship could be positive or negative in nature and allows the client to express a variety of feelings relating to this person. This topic could be further modified to specific feelings such as “Empathy playlist for my victim,” “Apology remix for my family,” or “Anger remix for my abuser.” These playlists will not actually be given to the person they are dedicated to (especially when dealing with offender/victim relationships), but used as a therapy tool to assess and explore the issues surrounding these relationships.

CLOSING REMARKS ON METHODOLOGY When offering treatment to clients, there are a number of factors to consider. Music therapists have documented their work with groups of all sizes, as well as individuals. For safety, the therapist should be aware of the client’s offending and behavioral history, and make any adjustments accordingly. The therapist may want to do very small groups or individual sessions in an area with other staff or clients present, such as a quiet corner of a common room, or perhaps on office with the door left open. Cotreating with another professional or staff member provides effective, appropriate treatment while being aware of the therapist’s personal safety and needs. Depending on the therapist’s treatment site, group size, duration, frequency, and length of treatment may be predetermined. It is not uncommon for facilities to have a minimum requirement, e.g., each client receives one hour of music therapy in a group setting weekly for the duration of their time in treatment. Typically, small group and individual sessions are offered at the discretion of the music therapist, or by recommendation of other members of the client’s treatment team. The length and duration of session should be appropriate for the client’s developmental age and attention span. Adolescents at the youngest part of the age spectrum may be able have meaningful interaction for only 30 to 45 minutes, especially if they also have attention disorders. Group treatment has been well documented with this population. The primary justification for this setting asserts that group therapy reduces the isolation that is so common to offending behaviors and provides a sense of support and community. Ideally, groups would have 7 to 10 group members. Groups of this size do best with experiences such as breathing and autogenic relaxation to music, relaxation-directed imagery and music, therapeutic song analysis, group drumming, and group songwriting. Smaller groups (two to six members) are appropriate to work on more specialized, similar goals. Groups of this size do well with many of the interventions that are appropriate for larger groups, even if some adaptations need to be made. Within a smaller, specialized group, it may also be possible to work on therapeutic instrumental instruction, structured community music-making experiences, and creating a group music video. Selection of clients for individual sessions should be done with careful consideration. Often, these clients are not currently focused on social skills types of goals, which could be met in group settings, but are exploring more personal goals, such as exploring trauma or empathy.

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Within the setting, experiences can be sequenced in a number of ways. Providing an opening, focus, and closing to the session is a simple and common structure that works well with this population. More than one focus per session can be too lengthy or too scattered for the client to process. Although it is common to focus on one type of experience per session, types of music therapy experiences can also be combined. For example, breathing and autogenic relaxation to music can be an opening experience for almost any session focus. It provides relaxation and orientation to the music therapy setting and sets the stage for other interventions to follow. Experiences such as GIM or therapeutic instrumental instruction may take a great deal of time or effort, and are best as the focus of the session. To end, a group improvisation may create a positive sense of group, unity, or self-expression.

CARING FOR THE FAMILY A review of the literature has provided no evidence of how or if music therapy has been used with caregivers for this population. The role of the family/caregivers varies greatly within each unique family structure; however, it is well documented that family therapy is effective in preventing recidivism within this population, where appropriate.

RESEARCH EVIDENCE The existing published work regarding music therapy and male juvenile sex offenders is qualitative. The nature of the material speaks to the nature of working with the population; with so many factors that play a role in risk and recidivism, it is difficult to translate these behaviors into quantitative measures. Because sexually offending behaviors are multifaceted and complex, it should be noted that research regarding mental health issues which are prevalent to this population (trauma, PTSD, cognitive deficits, substance abuse, conduct disorder) may be applicable to specific clients or situations, and should be researched and utilized on a case-by-case basis. The following is a review of the existing music therapy research relevant to work with male juvenile sex offenders.

Receptive Music Therapy Skaggs (1997) reported her use of lyric analysis with this population. The music therapist allowed the youths to bring their favorite music to group to share with their peers. Emphasis was placed on lyrics awareness and the pulse and tempo of the music, as well as learning to use music for behavior management. Group members “learned how music can be a resource for managing behavior and preventing relapse” (p. 76). In the same publication, Skaggs discussed the use of GIM techniques within sessions. She presented an adapted GIM experience in a group format, with only one short piece of music. Processing occurred as a group, often with art materials as an aid. The youth were able to develop valuable relaxation and coping skills that were applied in their relapse prevention treatment. Skaggs also reported several experiences in which youth were able to use art to process their experiences in a way that brought about release of emotions. Rio and Tenney (2002) also refer to using relaxation exercises with an individual client. Initially, the therapists performed music that they deemed relaxing while a progressive muscle relaxation script was read. Although the client reported feeling somewhat relaxed afterward, he reported a greater relaxation response when the script was read over his preferred music, rap.

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Improvisational Music Therapy Watson (2002) clearly defines her use of improvisational drumming with male adult sex offenders. She developed a three-tiered protocol providing beginning-, intermediate-, and advanced-level improvisation on drums in a structured group setting. The structure was similar to the outline provided in the previous section. The purpose of this group was to use these methods “to provide opportunities for nonverbal selfexpression, positive group/social experiences, leadership opportunities, cooperation, confrontation, and a safe environment to release intense emotions” (p. 107). The outcomes were positive, as evidenced by client and staff verbal feedback. Watson reported that the group was able to address the goal areas of the design adequately. Rio and Tenney (2002) discussed their improvisational work with male juvenile sex offenders in a residential treatment facility. They developed a system of stages to organize their music therapy treatment: focus, trust, leadership and identity, group cohesion, and closure. Goals for the sex offenders included providing a social area in which the youths could practice newly learned social skills, develop expressive skills and relate to each other as individuals, and develop a more balanced image of self, as well as develop their attention level, new skills, and expression using sound and movement and relaxation. Skaggs’s (1997) use of improvisational music therapy was more referential in nature. Encouraging each resident to pick an instrument and improvise a feeling provided a framework for focused listening and “respect and validation from peers” (p. 76). Skaggs asserted that these skills could be generalized to increased socialization and developing victim empathy; both are major components of treatment.

Re-creative Music Therapy There is currently little literature published regarding re-creative music therapy and male juvenile sex offenders; however, Rio and Tenney (2002) described the performance of a personal piece of songwriting that was developed throughout individual sessions. They reported that the client was successful in managing his emotions after the performance.

Compositional Music Therapy A case study presented by Rio and Tenney (2002) discussed their individual work with an adolescent male sex offender. Although other interventions were used, the primary technique explored was structured songwriting using the fill–in-the-blank method, which supported their long-term goals of increasing selfcontrol and developing self-esteem.

SUMMARY AND CONCLUSIONS Working with this specialized population is clearly challenging and multifaceted, but has large benefits for the safety of society as a whole. The inherent connection between the adolescent culture and music is prevalent in many different ways. As Gardstrom (1999) states, “Particularly for adolescents, involvement with music satisfied a curiosity about and a need to explore life values and issues” (p. 211). Exploring those particular issues is an important part of treating a juvenile sex offender. Therefore, music provides a motivating and meaningful way to process these topics. It is clear that those music therapists currently working in the field must continue their efforts to publish and enrich the current knowledge of their practice with this population. The existing music therapy literature is able to discuss music therapy treatment with male JSOs only at a residential level. Still, other literature provides insight into treatment with “juvenile offenders,” which is a term for all

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adolescents who have been through the adjudication process, and may include the specialized category of Juvenile Sex Offender. It is unclear how many of these clients may have fit the male JSO label, and these resources may be valuable when working with particular clients in this population.

REFERENCES Abel, G., Becker, J., Mittelman, M., Cunningham-Rather, J., Rouleau, J. L., & Murphy, W. D. (1987). Selfreported sex crimes of nonincarcerated paraphiliacs. Journal of Interpersonal Violence, 2, 3–25. Bonny, H. (1978) Facilitating GIM Sessions. Baltimore: ICM Publications. Bourdeau, B., Thomas, V., & Long, J. (2008). Latino sexual styles: Developing a nuanced understanding of risk. Journal of Sex Research, 45(1), 71–81. Bremmer, J. (1992). Serious juvenile sex offenders: Treatment and long-term follow- up. Psychiatric Annals, 22, 326–332. Bruscia, K. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas. Center for Sex Offender Management (CSOM). (2012a). Fact sheet: What you need to know about sex offenders, 2008. Retrieved from http://www.csom.org/pubs/needtoknow_fs.pdf Center for Sex Offender Management (CSOM). (2012b). Understanding juvenile sexual offending behavior: Emerging research, treatment approaches, and management practices, 1999. Retrieved from http://www.csom.org/pubs/juvbrf10.pdf Davis, G. E., & Leitenberg, H. (1987). Adolescent sex offenders. Psychological Bulletin, 101(3), 417–427. Gardstrom, S. C. (1999). Music exposure and criminal behavior: Perceptions of juvenile offenders. Journal of Music Therapy, 36(3), 207–221. Hanson, R. K. (2000). Risk assessment. Beaverton, OR: Association for the Treatment of Sexual Abusers. Kennedy, M. A., & Gorzalka, B. B. (2002). Asian and non-Asian attitudes toward rape, sexual harassment, and sexuality. Sex Roles, 46, 227–238. McGrath, R. J., Cumming, G. F., & Burchard, B. L. (2003). Current practices and trends in sexual abuser management: The Safer Society 2002 nationwide survey. Brandon, VT: Safer Society. Prentky, R., & Righthand, S. (2003). Juvenile Sex Offender Assessment Protocol-II: Manual. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Rio, R., & Tenney, K. (2002). Music Therapy for juvenile offenders in residential treatment. Music Therapy Perspectives, 20(2), 89–97. Ryan, G. (1991). Juvenile sex offenders: Defining the population. In G. D. Ryan & S. L. Lane (Eds.), Juvenile sexual offending (pp. 3–7). Lexington, MA: Lexington Books. Skaggs, R. (1997). Music-centered creative arts in a sex offender treatment program for male juveniles. Music Therapy Perspectives, 15(2), 73–78. Watson, D. M. (2002). Drumming and improvisation with adult male sexual offenders. Music Therapy Perspectives, 20(2), 105–111. Worling, J. R., & Curwen, T. (2001). The ERASOR: Estimate of Risk of Adolescent Sexual Offense Recidivism. Toronto, ON: SAFE-T Program.

RESOURCES The Association for the Treatment of Sexual Abusers (ATSA): www.atsa.com The Center for Sex Offender Management (COSM): www.csom.org The National Adolescent Perpetration Network (NAPN): www.kempe.org/napn/ The Office of Juvenile Justice and Delinquency Prevention (OJJDP): www.ojjdp.gov/juvsexoff

Chapter 20

Elderly Residents in Nursing Facilities Elaine A. Abbott _____________________________________________ This chapter is written to support music therapists’ work with elderly residents in nursing facilities who are alert in at least two, if not three, spheres (person, place, and time). When using the methods described below, session length, whether with a group or an individual, is typically 30 to 50 minutes. The session schedule is weekly or biweekly.

DIAGNOSTIC INFORMATION The residents of nursing facilities are often frail elderly people receiving custodial care. Frail elderly persons typically have “medical, nutritional, cognitive, emotional, or activity impairments” (frail elderly, 2009). Such deficits can limit residents’ “ability to live independently and predispose them to illnesses and the side effects of treatment” (frail elderly, 2009). Custodial care is “nonskilled personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops” (U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, 2007, p. 43). Some residents of nursing facilities receive skilled care. This level of care “requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy” (p. 45). Often, frail elderly people must meet specific criteria for admission to a nursing facility. For example, to receive Medicaid in the state of Alabama, a prospective resident must have a physician’s certification of need for admission, a need for daily nursing care, and a need for at least two of many listed specific services (Alabama Medicaid Agency Administrative Code, 1982). The list includes services like “the administration of a potent and dangerous injectable medication” (p. 10-13), “use of oxygen on a regular or continuing basis” (p. 10-14), and assistance with at least one of several listed activities of daily living on an ongoing basis.

NEEDS AND RESOURCES Personal Characteristics Aging is a “multifaceted process in which bodily structures and functions undergo a negative deviation from the optimum” (aging, 2002). The aging process brings on significant changes in all human developmental domains. Frail elderly people who reside in nursing facilities cope with challenges related to their cognitive functioning, perceptual motor-functioning, psychospiritual health, physical health, and social health.

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Aging can change a person’s cognitive functioning, including one’s judgment, reasoning, comprehension of information, and memory (Weissman, 1983). This process can impede decision-making (Bright, 1996) and slow reaction times (Pedersen, 1986). In order to maintain or increase cognitive skills, frail elderly people need opportunities to think, problem-solve, and learn (Smith & Lipe, 1991). Music therapists must remember that cognitive processes for the elderly will require adequate rehearsal, visual cues, and clear and simple communication. Residents will also need auditory and motoric modeling, allowance for reaction time, and repetition of instructions with different words (Reuer, Crowe, & Bernstein, 2007). Music therapists must pace and time their instructions to allow residents to cognitively integrate concepts and process information (Pedersen, 1986). Aging may also effect a person’s perceptual-motor functioning. Residents may experience losses related to balance, physical endurance, flexibility, strength, and agility (Clair & Memmott, 2008), as well as their ability to respond to sensory stimuli (Weissman, 1983). To cope with aural losses, residents need music therapists to speak clearly and slowly and face group members while speaking. Music therapists also need to get group members’ attention before speaking or demonstrating and lower the pitch of their voices. Limiting extraneous background noise (Reuer, Crowe, & Bernstein, 2007) and timing instructions to allow residents to motor-plan (Pedersen, 1986) are also helpful. To cope with visual losses, music therapists must provide residents with large-print reading materials and nonglare lighting (Reuer, Crowe, & Bernstein, 2007). Frail elderly people who reside in nursing facilities may struggle with their psychospiritual health. As people age, they contend with personal issues that may result in withdrawal and depression (Bright, 1972). Past and unresolved losses can complicate present grief related to the death of family and friends (Bright, 1997). Present losses related to one’s inability to maintain independence can bring feelings of powerlessness, uselessness, and indignity (Bright, 1997; Kitamoto, 2003). The loss of “the future” must also be dealt with as one faces the reality of unrealized dreams (Bright, 1997). Elderly residents can have significant needs as they work to cope with these losses. They need opportunities to acknowledge and communicate about their life experiences, maintain their self-identity, grieve their losses, and gain realistic expectations of themselves (Weissman, 1983). They need to express their creativity, affirm their spirituality (Kitamoto, 2003; Smith & Lipe, 1991), and experience a sense of control (Clair & Memmott, 2008). They need motivation to reengage in life (Reuer, Crowe, & Bernstein, 2007). The aging process can bring about physical health problems. Residents may experience acute and/or chronic illnesses (Clair & Memmott, 2008). As a result, they may need to be placed in sessions so that they can see and hear appropriately. They may need adaptive equipment, a helper partner (Bright, 1972), and warmer room temperatures (Reuer, Crowe, & Bernstein, 2007). Nursing facility residents can also experience social health issues. As cognitive functioning, perceptual-motor functioning, psychospiritual health, and physical health problems trigger loss of autonomy (Bright, 1997), a resident’s role in society will change. One goes gradually (or quickly) from caregiver to caregivee; from independent to dependent; from a member of a large social group to one of a few remaining. This change in role may result in decreased social interaction (Weissman, 1983) and loneliness. Residents may lose their sense of legacy (Bright, 1997). Additionally, loss of family members and friends may cause an absence of caregivers (Clair & Memmott, 2008). In these situations, residents need to feel others’ concern and support for them, to engage in meaningful group activities, and to express their concern and support for others (Bright 1997; Weissman, 1983). Meaning can be found through discovery of common interests with others, working together toward a common goal (Bright 1997), and feeling a sense of social belonging (Clair & Memmott, 2008).

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Musical Characteristics As a group, elderly people display some specific musical characteristics. The power of their voices can diminish over time (Bruhn, 2002). Their voice ranges may decrease. The average vocal range for women (ages 60–99) may be from F3 to C5; men’s range may be almost an octave lower (Moore, Staum, & Brotons, 1992). Gibbons (1983a) found that musical aptitude does not seem to deteriorate with age. She (1983b) also discovered that elderly people “may have difficulty learning or performing music which requires discrimination of small interval changes, duration changes, or complex rhythm patterns” (p. 201). She suggests that music with distinct pitch changes and simple rhythm patterns might make participation in music experiences more successful for elderly persons. Clair (1991) suggests that the rhythmic auditory discrimination skills of the elderly might be better than their rhythmic imitation skills and that successful musical experiences would be more likely when they involved simple and redundant rhythmic patterns. The music preference of elderly people has long been considered the popular music of their young adult years (Gibbons, 1977; Holbrook & Schindler, 1989; Schulkind, Hennis, & Rubin, 1999); however, as younger generations have access to larger bodies of music repertoire throughout their lives, it may be that the music preferences of elderly people shift to encompass those larger repertoires. It seems clear that music is most effective when connected to the individual taste of each person (Bruhn, 2002). With this in mind, it is most advantageous for music therapists to possess a broad repertoire of popular music, both sacred and secular, that crosses several decades. Cevasco and VanWeelden (2010) and VanWeelden and Cevasco (2007, 2009, 2010) list, in great detail, specific popular songs across several decades and cite resources for the repertoire.

Personal Resources Although aging is, essentially, a subtractive process, elderly people continue to have many strengths and resources. They have “innate capacities for musical development” that “are maintained with age whether or not the individual is frail enough for nursing home care” (Gibbons, 1988, p. 33). Each individual has a personal musical history that can be related to life events and important relationships from the past. This history can also be used to support here-and-now, inter- and intrapersonal interactions. While a resident may be coping with significant deficits in one or more domains of human development, abilities in other domains may continue to be resources. In addition, all residents have engaged in rich life learning, which has contributed to their personal development. Connecting to the wisdom gained from their life experience allows each resident access to the integrity of his/her personhood.

MULTICULTURAL ISSUES All cultures have stated and unstated expectations regarding the role of music in people’s lives and regarding the social roles played by members of the culture. In nursing facilities, music therapists will find that the institution may have a cultural affiliation that needs to be observed and that individual residents may have cultural affiliations that need to be respected. Religion is an important cultural affiliation of which to be aware. If the nursing facility has a specific religious affiliation, the music therapist should contact the facility chaplain or make an appointment to meet with visiting clergy. This will help the music therapist learn the extent of the facility’s affiliation with the religion, how to support residents’ observation of that religion, and the repertoire associated with it. It will also be important, with new admissions to the music therapist’s caseload, to become aware of and respect each resident’s religious affiliation.

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Music therapists may also find that a nursing facility has a music culture of its own. The facility may use music to support specific social gatherings (e.g., holiday events) and secular ceremonies (e.g., birthday celebrations). It is important to remember that these traditions are part of the life-of-the-facility and to respect the rituals the facility has developed. Ethnicity is another important cultural affiliation of which to be aware. A resident may strongly associate with his ancestry (e.g., Italian-American, Hmong, Bantu, etc.) and its common culture (including language, religion, music, food, beliefs, etc.). Different ethnicities have different customs of which to be aware. The elderly may play a specific role in the ethnic society, men and women may have specific roles, and social interactions may require the observation of certain rules. Music therapists must inform themselves and/or ask individual residents to inform them about the ethnic traditions residents wish to observe. Music therapists must also become aware of the music of residents’ observed ethnic traditions. They should understand the ways in which music is and is not used in the culture, e.g., to play ceremonial music out of context while expecting it to perform the same ceremonial function has the potential to be ineffective (Aluede & Stevenson, 2010), offensive, or, in contrast, completely acceptable.

REFERRAL AND ASSESSMENT Music therapists who work in nursing facilities may assess residents’ functioning using the Activity Pursuit Patterns area of the Minimum Data Set and/or a short, one-page, facility-developed activity assessment. The Minimum Data Set (MDS) is a federally mandated process of assessment for all residents in certified Medicare and Medicaid nursing facilities (MDS Applicability). The Activity Pursuit Patterns section of the MDS is used to record the amount and types of general interests and activities each resident pursues. The facility-developed assessments are typically used to record each resident’s specific past and present activity interests. Two music therapy assessments for nursing facility residents were developed and published for public access. In 1993, Raijmaekers described specific tools to address the areas of emotion, cognition, and communication. In 2000, Hintz described specific tools to assess a resident’s expressive musical skills, receptive musical skills, behavioral/psychosocial skills, motor skills, and cognitive memory skills. Hintz’s assessment tools can also be used to gather information about a resident’s “tendencies to organize and process sensory data into meaningful information while engaging in musical experiences” (p. 31). Both authors provide sample forms and detailed discussion of each assessment process.

OVERVIEW OF METHODS AND PROCEDURES The following methods and procedures are used most commonly with elderly residents in nursing homes.

Receptive Music Therapy • • •

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Eurhythmics involves moving to music and matching the movement to the energy and flow of the music. Music Appreciation involves learning about and listening to familiar and unfamiliar music of different genres. Reflective Music Listening involves selecting recorded music that relates to the residents’ here-and-now psychospiritual needs, listening to it with them and discussing themes that are evoked while listening. Music and Imagery involves listening to prerecorded music while imaging; the starting image is based on a theme that is chosen by the participants.

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Individual Reflective Music Listening involves working one-on-one with a client to address here-and-now psychospiritual needs. Music Reminiscence is listening to music for the purpose of reflecting on memories. Environmental Music is live or recorded music that is programmed by the music therapist for the purpose of creating a therapeutic sound environment for residents.

Improvisational Music Therapy • •

Cooperative Group Improvisation involves playing rhythm instruments to accompany familiar songs while singing them or as instrumental interludes. Individual Instrumental Improvisation involves learning to play and improvise on a selected instrument(s) in a musical dyad with the therapist.

Re-creative Music Therapy • • • • • •

• • •

Community Singing involves singing familiar and unfamiliar songs together in a group. Reflective Group Singing involves selecting, singing, and discussing music that relates to the residents’ here-and-now psychospiritual needs. Community Choir involves residents learning songs together to perform for an audience. Intergenerational Music Programs provide residents and youths an opportunity to interact and create relationships through engagement in music. Therapeutic Music Lessons involve teaching an instrument to attain therapeutic goals. Percussion Ensemble involves residents being divided into percussion instrument sections, learning specific parts to accompany a program of music selections, and perhaps performing the program for audiences. Tone Chime Choir involves the therapist conducting residents who play songs on tone chimes. Talent Show involves residents, staff, and family members practicing and performing a musical selection as a soloist or as a member of a small or large group. Musical Games are quizzes and guessing games related to music that are used to involve the participants in active music-making.

Compositional Music Therapy • •

Cooperative Songwriting involves the group in creating new lyrics for familiar songs. Individual Songwriting involves individual residents in composing new lyrics and music to express themselves in a song.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Several receptive music therapy methods are described below. The use of quality sound and sound production equipment (e.g., CD player, MP3 player with speakers) for prerecorded music is, as always, important.

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Eurhythmics Overview. Eurhythmics involves moving to music and matching the movement to the energy and flow of the music. It is indicated for residents who enjoy music and need motivation to participate in physical exercise (B. K. Sutton, May 17, 2012, personal communication). It is also indicated for residents who need redirection from discomfort and anxiety related to movement and for those who need cues to begin and complete movements (LaRocque & Compagna, 1983). The method described here is related to the maintenance of physical movement; for more information regarding the use of music in rehabilitation, refer to the Neurologic Music Therapy Training Institute (see “Resources”). This method is contraindicated for residents who are unwilling to participate, are disruptive to the group process, and/or are too physically frail to participate. Goals for residents are to maintain physical movement, to maintain muscle strength, to increase engagement in activities, and/or to increase social interaction. The level of therapy is augmentative. No special training is required to use this method. Preparation. To prepare to lead eurhythmics, make an appointment with the physical therapist in the facility. Discuss with the physical therapist the movement abilities of the residents who will be included in the group, as well as any contraindicated movements (Bright, 1997). Also discuss physical indicators that would inform the music therapist to adapt a resident’s movements or stop a resident’s participation (B. K. Sutton, May 17, 2012, personal communication). When selecting music for eurhythmics, choose pieces of short duration (approximately 3 minutes) (Liederman, 1967) and relate the tempo and meter of each piece to the phase of session (see “Session Procedures,” below). Select slow tempos for stretching and faster tempos for active movements (Clair & Memmott, 2008). Ensure that the music has a prominent pulse and that rhythm patterns are short and repetitious (Liederman, 1967). While some music therapists recommend changing the music regularly from group to group to retain resident interest (Bright, 1981), others suggest repeating tunes so the group can develop favorites (Liederman, 1967). Doing some of each is also effective. The music may or may not have lyrics. Either way, plan for the music to help cue movement. Use familiar, repeated lyrics as a cue (e.g., twist to “Let’s Twist Again”) or use distinctive meters and rhythms as a cue (e.g., raise knees to a Sousa March, sway to “Sentimental Journey”). The music may be live or recorded. The music therapist might use live music when musical prompts will be enough to cue resident movement; she might use recorded music when she needs to use her body to physically and verbally prompt resident movement and to model movements for the group (B. K. Sutton, May 17, 2012, personal communication). The space in which the eurhythmics group is conducted should allow all residents enough room to stretch and move without hitting one another. It should be a space with limited disruptions and in which residents are able to hear instructions and music. Include from 4 to 12 residents in the group. Play music using a CD player, or an MP3 player with speakers, to ensure quality sound production. What to observe. As residents participate in eurhythmics, watch for the moment when people drop out, determine the cause (e.g., distraction, pain, boredom), and take action as needed. For example, the therapist might demonstrate adaptations for residents unable to complete full movements, cue distracted residents, provide physical support or assistance, or model movements. Notice whether the volume of recorded music needs adjusting so residents can hear instructions, hear the music, and tolerate the loudness of the environment (Clair & Memmott, 2008; LaRocque & Compagna, 1983; Palmer, 1983). Procedures. Open a eurhythmics session with a peer greeting. Invite residents to say hello to one another and remind them to encourage each other throughout the exercise routine. Begin a deep breathing routine to music with a moderate to slow tempo and phrasing appropriate to the length of a deep breath. Time the cue to the beginning of a musical phrase and ask residents to take in a deep breath,

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to fill their lungs, and to feel their rib cage expand. Instruct them to let out the breath when they are ready. Wait for all members to release the deep breath and resume a typical breathing pattern. Again, time the cue to the beginning of a musical phrase and ask the residents to take in a second deep breath. Repeat a third time. Continue the session with warm-up exercises. Live or recorded music should be changed at this point to cue residents to begin the new phase of the session. The music should, however, continue at a moderate to slow tempo. Ask residents to gently move their bodies at each joint, shifting to a different joint when the phrasing changes in the music. Examples of movements include: turn the head from side to side, lift the shoulders, bend the elbows, bend the wrists, wiggle the fingers, lift the knees to move the hips, lift the feet to move the knees, rotate the feet to move the ankles, and wiggle the toes (LaRocque & Compagna, 1983). During these warm-up movements, integrate social interaction into the movement, e.g., say to residents, “As you turn your head, say ‘Hello’ to your neighbor, now shake hands with your neighbor,” etc. (B. K. Sutton, May 17, 2012, personal communication). Begin the working phase of the session by changing the music to pieces with an increased tempo and shorter musical phrases. Changes in timbre and texture (e.g., from strings to brass, from piano solo to quartet) may help residents to move to the faster tempo. Introduce props (e.g., lightweight wooden dowels, towels, balls, and scarves) to encourage repetitions of gross motor movements and work on range of motion. Examples of these movements are to move the hands from head to knees and back to the head; to reach the arms left and right, crossing midline and twisting the trunk; to lift and lower the feet and extend the knees; to tap the toes on the left and right. Use props to encourage fine motor movements as well, e.g., grasping scarves with fingers while waving them up and down; grasping dowels with fingers while turning them like a steering wheel; and squeezing balls with hands (LaRocque & Compagna, 1983). Repeat each movement three to five times before changing to a different movement. Use two or three music pieces during the working phase of the session. Change the meter and style of each music piece to retain resident interest and cue specific types of movement. Encourage clients throughout to continue moving, to adapt movement as needed, and to move to the tempo of the music. Model the movements for residents who have difficulty following verbal directions. Close the session with slow stretching and relaxation (LaRocque & Compagna, 1983). Select music with a slow tempo and longer phrases and remind residents to move gently and slowly. Cue residents to turn the head from side to side, drop the chin to the chest and raise it again, reach the right arm to the left while holding the upper arm against the chest with the left arm, and then to do the same with the left arm. Residents who are able to can stretch their backs by placing their hands on their knees and leaning forward as far as is comfortable for a count of two or three and then pushing against the legs with the arms to lean back again. Cue residents to stretch each arm by reaching up to the ceiling, one at a time, as far as possible and then relax each arm so the hand comes back into the lap; stretch the legs out as far as possible while pointing the toes at the music therapist, and then return the feet to a resting position. Time all the instructions to the phrasing of the music. End the session as it began, with deep breathing to the phrasing of the music with a slow tempo and longer phrasing. Adaptations. Eurhythmics groups can be adapted in many ways. If the group of residents is fairly physically able, movements can be done while standing behind a chair for support. Movements can be encouraged through the use of a parachute, egg shaker passing games, stretch bands large enough for each member of the group to hold, top hats, feather boas, disco taps, etc. (B. K. Sutton, May 17, 2012, personal communication). Additionally, themes can be used to select props and music based on the time of year or holidays, for example, Mardi Gras eurhythmics might involve Mardi Gras music, bead necklaces, and boas.

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Music Appreciation Overview. Music appreciation involves learning about and listening to familiar and unfamiliar music of different genres. It is indicated for residents who are alert, able to participate in group conversations, and interested in learning about music. This group provides residents with opportunities to express their preferences for and ideas about music. The method is contraindicated for residents who are unwilling to participate and may be disruptive to the group process. Goals for residents are to increase intellectual stimulation and social interaction. The level of therapy is augmentative. No special training is required to use this method. Preparation. Keeping in mind that the purpose of music appreciation is didactic, prepare for an initial session by selecting musical compositions from three or four genres (e.g., classical, folk, rock, country). Choose three pieces that the music therapist believes the group may like and one that may stretch the limits of their preferences. This will provide an opportunity for the group to understand the possibilities for the breadth of learning that the sessions might allow without alienating them with an overload of disliked music. Research the history and theory of each piece, including such facts as the composer’s nationality and inspiration for the piece, the year the piece was composed, its form, and anything else of interest. When researching music pieces, the music therapist need not be an expert on a given piece, but can use this group as an opportunity to increase the repertoire of music with which she is familiar. This “new learner” approach is an attitude that can be modeled and shared with the residents to help them to reduce any anxiety they might have. Create a paper program of the three or four pieces chosen for review to pass out to the group members. On the program, list the pieces to be played, the composer of each piece, the artist who played each piece and any historical or theoretical information about the pieces that the residents might find interesting. Lyrics to songs might also be included in the program. The program should be two to three pages long. The font should be large (14- to 16-point), and easy to read. Recruit six to eight group members by soliciting referrals from staff and talking with residents. Hold the group in a fairly quiet space with minimal disruptions. The group will be difficult to guide if residents are unable to hear the music or one another converse. Seat the group around a table. What to observe. As the music is played and discussed, watch resident responses to it and the conversational interactions between residents. If a music piece elicits unhappy memories or sadness over happy memories (Clair & Memmott, 2008), guide the conversation so that the resident has an opportunity to talk about his experiences to the extent he is willing or able. If interactions between residents become overly tense, act as a moderator and encourage members to agree to disagree on topics. Direct the conversation back to the didactic content of the group. Watch for residents who have difficulty expressing their own dislike for music selections (Towse, 1995). These residents may be trying to avoid interpersonal tension and need sensitively delivered encouragement to express their opinions in a safe place. Throughout the group, watch for residents who need intervention from the therapist to participate in discussion (Towse, 1995), for example, those who may need help understanding another resident or who may have difficulty making themselves understood. Procedures. Open the initial session by asking group members to introduce themselves, checking in with each group member’s well-being and explaining that the group is for people who are interested in listening to and talking about music. Pass out the music program for the session. During the working phase of the session, play each piece and review the program content related to each piece before and after playing it. Residents might read parts of the program aloud to each other. Encourage conversation about the music by asking questions like, “What did you most like about the piece? What did you least like about it? How would you rate the piece on a scale of 1 to 10? What did you find interesting about the history of the piece?” Close the session by taking comments from the members about the group

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process (What might they like to do again? What might they like to try next time?). Ask members about their genre preferences based on their personal music histories and on the pieces they listened to that session. Ask for requests for the next session’s program and support group decision-making about a listening program for the next session. Allow time for residents to consider their preferences while also being willing to create or contribute to the next session’s program. Suggest possibilities for areas of learning (see “Possible Adaptations”) and support the group’s preferences. Ask members to consider preferences for group process and music selection between the present meeting and the next. After checkin at the next group meeting, encourage residents to share any ideas for the group about which they may have thought. Adaptations. Residents might listen to and study music from different cultures, periods of time, and genres. They might take on research assignments and bring information about the history of composers and pieces of music back to the group. The group might organize to attend on- or off-campus music concerts together.

Reflective Music Listening Overview. Reflective music listening involves selecting recorded music that relates to the residents’ here-and-now psychospiritual needs, listening to it with them and discussing themes that are evoked while listening. The therapist guides the group through soliciting information about each member’s psychospiritual state and selecting, or supporting the group to select, music that supports the group’s needs. It is indicated for residents who are isolated or withdrawn, who may need social support, or who are interested in relating to music on a more personal level. The method is contraindicated for residents who are unable to relate to music on a personal level, are unable to participate in group conversations, or would disrupt the group process. Goals for residents may be to connect with one’s own integrity, to have an aesthetic experience, to engage in decision- and choice-making, and to increase social support (Towse, 1995). The level of therapy is augmentative. No special training is required to use this method, although an interest or specialization in music psychotherapy would be helpful. Preparation. Create a collection of many recorded music pieces from a broad range of styles and eras. Ensure that the collection includes pieces that are of short duration (2 to 4 minutes); include some that are familiar and others that are unfamiliar to the group members, and select from both vocal and instrumental repertoire (Towse, 1995). The music therapist should be familiar with the music played for this group and understand its therapeutic indications and contraindications as they may relate to the group members’ psychospiritual states. Hold the group in a quiet space, preferably in a room with a closed door. Group cohesion will be difficult to develop if sessions are subject to significant disruption or if the residents are unable to hear the music or each other. Seat the group of five or six residents around a table or in a circle. What to observe. Continually observe residents who may need the therapist’s help to participate in the discussion (Towse, 1995). They may need to have another resident repeat something or they may have difficulty speaking clearly. Listen for psychotherapeutic material to arise. For example, residents may be dealing with feelings like loneliness, joy, bitterness, fear, helplessness, hopelessness, anger, and resentment. These feelings may relate to family events (births, deaths, illnesses, etc.), their own increasing dependency, the creation of new interpersonal connections, the inability to escape from other residents, the experience of having a crippling condition, powerful authority figures (doctors, nurses), or memories of incidents or events (“positive” and “negative”), etc. (Towse). Additionally, be aware of the effect of the music on each person. Note when pieces of music have particular effects on specific residents and when a particular piece of music is special to a group member (Towse). Procedures. Open the session with a brief social conversation lasting 15 minutes or less.

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Throughout the conversation, solicit information about each member’s well-being and psychospiritual state. Ask questions like, “How are you feeling today? What is happening in your life? How is your roommate? How is your family?” Encourage group members to ask questions of each other. Listen for themes related to their psychospiritual well-being to arise. Begin the working phase of the session by selecting a piece of music related to a theme that has emerged in the conversation. For example, if two or three residents have mentioned difficulties with illness, the music therapist might select the song “Standin’ in the Need of Prayer.” As the residents listen to the music, ask them to consider how it may relate to them or to the group as a whole. After listening, encourage a discussion that relates the residents’ psychospiritual states to their experiences of the music. Ask questions like, “How did the piece relate to our conversation today? How did you feel as you listened to that piece of music? Did that piece of music remind you of anything?” Even as you ask questions, follow, rather than lead, the discussion (Towse, 1995). Let the psychotherapeutic material that arises from the residents shape the conversation and inform the next piece of music that the music therapist plays. If residents make music requests, take those that are appropriate to the group process. If requests are not appropriate to the group process, e.g., if a resident requests “Sweet Rosie O’Grady” when the group discussion focused on illness, then sensitively redirect the request to a song more closely related to the therapeutic issue—for example, “Oh! I love that song, but I’m hearing that John and Sarah are worried about their health today. Could we listen to a song that might be less about romantic love and more about comforting love? Is there are song you listen to when you want to feel comforted?” If the resident has difficulty selecting a different song, provide some song titles from which to choose, e.g., “Amazing Grace” or “He’s Got the Whole World in His Hands.” As residents make music requests, encourage them to be tolerant of one another’s musical preferences. Play two or three pieces for each group. Close the group with a broad, thematic statement about the content of the session. Ask group members to comment on their experiences of the group. Summarize the topics covered and acknowledge each resident’s contribution to the group. Adaptations. Reflective music listening and music appreciation methods may be used together in a single group as a holistic response to residents’ needs. Although the primary method of a group may be music appreciation, residents’ experiences of the music may be more psychospiritual than educational. The opposite may be true as well; if the primary method of a group is reflective music listening, residents may have more educational experiences of the music than psychospiritual. In each case, opportunity is presented for the music therapist to respond to the residents’ in-the-moment needs by moving fluidly between these two methods or by combining them to create a “reflective music appreciation” method.

Music and Imagery Overview. Music and imagery involves listening to prerecorded music while imaging; the starting image is based on a theme that is chosen by the participants. Indications for music and imagery include interest in self-exploration and a need to cope with issues related to aging. Other indications include a need for social support while working to cope with changes and rumination over specific thoughts or memories (Short, 1992). Contraindications include hearing deficits severe enough to impede music listening, inability to be quiet and inner-focused during the session, and inability to use reliable communication skills. Additional contraindications include difficulty following instructions, unstable ego structure, and unwillingness to participate (Short, 1992). Goals for residents are to engage in decision- and choice-making and to discuss personal issues (Short, 1992). Other goals may be to increase awareness of life accomplishments, to engage in new ways of thinking, and to have new experiences. Additional goals may involve increasing self-awareness and increasing self-acceptance (Summer, 1981). The level of therapy is augmentative. Training in the use of

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supportive music and imagery methods or advanced skills in music and imagery is recommended. Preparation. Create a collection of music compositions (start with five to eight) that are 4 to 12 minutes in length (Short, 1992). The pieces should vary in style and genre (e.g., classical, new age, ethnic) and be of a supportive or re-educative nature. Music of a supportive nature is “reliable and has little tension: Melodies are simple, repetitive and do not develop; tempos are steady; dynamics are moderate; and instrumental orchestration is not overly complex (e.g., Puccini’s Humming Chorus from Madame Butterfly)” (Abbott, 2010, p. 2). Music of a re-educative nature is “less reliable, e.g., tempo may increase or decrease; meter may shift; melody and harmony may briefly develop but then return to the home theme; timbres may shift between soft and sharp or mellow and edgy; and/or dynamics may change within a moderate range. Overall, however, re-educative music still remains rather reliable (e.g., the Andantino movement of Debussy’s String Quartet)” (Abbott, 2010, p. 3). Include four to six residents in the group. Hold the session in a quiet space, preferably with a closed door. Seat the residents around a small table or in a circle. The group process will be difficult to develop if the sessions are subject to disruption and the residents are unable to hear the music or each other. What to observe. Throughout the session, listen for manifestation of psychological issues related to aging and disability (Short, 1992). Watch for indications of physical and/or psychospiritual pain and provide support as needed. Indications may be delivered through verbal conversation, but may also be noticed in facial expressions and body language. While the music is playing, watch the residents for changes in rate of breathing, coughing, restlessness, and changes in facial expression (Short, 1992). Procedures. Open the session with a general discussion. Explain the music and imagery process and how the session will be structured. Answer any questions about the process. Ask the group members how they are feeling that day and identify themes in the conversation. If more than one theme arises from the group conversation, list two or three, e.g., “I’ve heard different people say they would like to go on an imaginary trip; they are feeling relaxed and they are feeling frustrated.” As the group talks, watch for splits in the group’s mood (e.g., frustrated vs. relaxed). Support the group in “brainstorming” about images that might relate to each theme, e.g., we could imagine we are in Hawaii, we could imagine we are having a picnic, we could imagine we are listening carefully to our frustrations and letting the music help us take care of them. Support the group in choosing an opening image for the session (Short, 1992). Select music with qualities that will relate to the group’s starting image (Short, 1992). For example, if the image is about caring for frustrations, select a piece with a moderate tempo and a gentle melodic theme written in a major key and in 3/4 time. A piece with these qualities might be suggestive of a lullaby and might support the residents in imagining themselves putting their arms around their frustrations, or rocking them in a hammock, or sitting with them in an easy chair, etc. Begin the working phase of the session with an induction that will help the residents shift the focus of their attention from the outside world to their here-and-now experiences of themselves. Invite clients to become physically comfortable in their seats and, if comfortable in doing so, to close their eyes. Ask the clients to notice their feet, to feel them resting on the ground (or footrests), and to let the muscles in them relax. Ask them to feel their legs and to let the muscles in them relax. Continue the process through their hips, middle, chest, shoulders, arms, neck, and head. Use the same phrases throughout the induction to allow the residents to focus on their experiences rather than on following the music therapist’s directions. End all inductions that ask residents to notice different areas of the body by asking them to become aware of their whole body. In the case of this induction, ask the residents to notice how the muscles in their whole body can relax. If the suggestion to relax puts group members to sleep, suggest that the muscles feel energized as well as relaxed (Summer, 1981). Use different inductions for different starting images. For example, if the starting image relates to feeling the summer sun, use an autogenic induction, e.g., invite the residents to feel warmth in each area of the body. If the starting image relates to

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letting go of worries, use a progressive muscle relaxation induction that supports letting go of tension, e.g., invite the residents to tense and then release the muscles in each area of the body (Short, 1992). Verbally describe for the residents the opening image agreed upon by the group and then relate the music to that image just before turning on the music. Say, for example, “As the music begins, let yourself imagine that your frustrations are being carefully listened to and cared for. Let the music help you imagine what this might look like, what this might feel like, and how this might happen.” Then begin the music (perhaps, in this case, William Walton’s “Touch Her Soft Lips and Part”), allowing it to play for 4 to 12 minutes. If the residents seem engaged in the experience (i.e., are not falling asleep) and the piece is short (e.g., four minutes), repeat it two or three times. If one or more residents seem upset, quietly approach them while the music is playing, softly ask how they are doing, whether they would like to open their eyes, and whether it is okay to continue playing the music. If the residents would like the music to be turned off, slowly fade it out. With the music turned off, help the residents refocus from their internal involvement with imagery back to an external awareness of the group (Short, 1992). Do this by letting the residents know that the music has finished and it is time to return to the session room. Ask them to remember their imagery, even as they become more and more aware of the room and the people around them. Use an everyday tone and volume of voice to invite the residents to feel themselves in their seats and prepare to open their eyes. Ask them, after a moment or two, to open their eyes. Continue the group with a conversation about the residents’ experiences of the music and their imagery. Ask questions like, “Will you describe your imagery? How did the music sound to you? Did your imagery have anything to do with our opening image? If so, how?” Ensure that the group hears from each member, even if just to say, “No, thank you, I’d prefer not to share.” Help the group members support each other’s positive and more difficult memories, thoughts, and feelings (Summer, 1981). After hearing from each resident, allow the conversation to become more group-oriented than individual-oriented (Short, 1992). This may happen naturally, or encourage the residents to help one another consider how they might use their music-imagery experiences in their lives. Ask open questions like, “How will your imagery affect the rest of your day? If you remind yourself of your imagery later in the week, what will it bring to you?” Thank the residents for attending the group and allow it to disperse. If a resident seemed to have an experience that was particularly intense or upsetting, follow up later in the day to ask how he is feeling and whether he would like to talk more about the experience (Short, 1992). Adaptations. Rather than allowing the group to decide the opening image or “theme” of the music and imagery experience, provide the residents with an image or thought on which to focus their attention, e.g., an especially pleasant family memory or a favorite vacation spot (Summer, 1981). For further specific procedures, see Summer (1981) and Short (1992).

Individual Reflective Music Listening Overview. Individual reflective music listening involves working one-on-one with a client to address here-and-now psychospiritual needs. The music is used to reflect overt and underlying feelings the resident may be having, but is unable to satisfactorily express through verbal conversation. This method is indicated for residents who need to recognize repressed emotions and/or who are experiencing a loss of personal integrity (Bright, 1997). It is also indicated for residents who are coping with change (Clair & Memmott, 2008). It is contraindicated for residents who are unwilling, or unable, to participate. Goals for the resident may be to acknowledge past difficulties and to validate emotional responses to past difficulties. Other goals may be to increase acceptance of self and life circumstances, to engage in choice-making (Bright, 1997), and to increase the ability to cope with change (Clair & Memmott, 2008). The level of therapy is augmentative. No special training is required to use this method, although training

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in music psychotherapy is recommended. Preparation. As the session is intended for an individual resident, find a private space with a closed door to conduct the session. The resident’s room may be an option. Bring a range of melodic (e.g., keyboard, small metallophone, guitar) and rhythmic (e.g., jingle bells, egg shakers, small hand drum) instruments. Be able to improvise on guitar or keyboard in several keys and styles (e.g., country, rock, sacred, blues, etc.). What to observe. Throughout the session, watch for the resident’s ability to tolerate having his emotional state reflected in the music. Monitor the resident’s ability to have and express feelings (consciously and unconsciously) in constructive ways, e.g., using words and through feedback about adjusting the music therapist’s improvisation. Be aware of the resident’s facial expressions, body language, and verbal language. Assess the resident’s willingness to engage in choice-making processes and in a relationship with the therapist. Procedures. Open the session with a verbal check-in (Bright, 1997). Probe enough to assess the resident’s overt and underlying psychospiritual state. Ask questions like, “How are you feeling? How is your day going? What is on your mind? How was breakfast today? Who has visited you recently?” Specific and general open-ended questions will encourage the resident to talk about his responses to, and experiences of, the events in his life. Begin the working phase of the session by playing a short improvisational piece (one to two minutes or shorter) to express for the client his underlying emotions. Check in with the client verbally to assess the level at which the music meets the resident’s here-and-now experience (Bright, 1997). Ask questions like, “How does the music sound you? Does it say anything about how you are feeling right now? Should it be faster/slower? More minor/major? Louder/softer?” Use the questions to help the resident describe changes to the music that would allow it to be a more accurate reflection of his hereand-now psychospiritual state. Incorporate the adjustments into the improvisation and play a longer piece (three to five minutes) (Bright, 1997). Close the session with another verbal check-in. Assess the resident’s current state and selfunderstanding. Ask questions like, “How did you feel while you were listening to the music? What did you hear in the music? Did the music have a message for you? What were you thinking as you listened to the music? What did you notice about the music?” If the client is able to answer the assessment questions, support his/her self-expression by reflecting main thoughts or ideas back to him or using other active listening techniques. Reflect back to the resident any insights he may have gained as a result of hearing his emotional stated reflected in the music (Bright, 1997). Adaptations. Rather than improvising for the resident, come prepared with a large-print list of song titles through which the resident can browse (Bright, 1997). Have a medium through which the resident can access the song lyrics (large-print songbook, electronic documents, or Internet access). Include in the list songs that are sacred and secular and songs that are from multiple genres and eras (25 to 30 songs per list). The music therapist should able to accompany herself on keyboard or guitar while singing all the songs from the list of song titles. Encourage the resident to select a song(s) he would like to hear. Play and sing the song for the resident or access an original performance of the song on an iPad or computer. Encourage the resident to reflect on the meaning of the song(s) as it relates to his life. Ask questions like, “How was it that you came to choose that song? Are there any lyrics in the song that are particularly meaningful to you? Does this phrase of the lyrics [read a phrase] relate to you in any way?” Another adaptation might involve the music therapist or a family member playing the resident’s favorite instrumental pieces. Yet another variation might occur if the resident requests to hear spiritual or religious music and to engage in prayer (Clair & Memmott, 2008). In a spiritually focused reflective music listening session, the resident might meditate on a text while listening to the music therapist improvise or play a precomposed song, or the resident might choose a song for the music therapist to play that relates

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to the purpose of the resident’s prayer. If the resident would like a text on which to meditate but does not have access to one, ask the facility chaplain for resources. When closing the session, leave the resident with a copy of the music and/or text so that he might reflect on it until the next session (Clair & Memmott), if doing so is supportive of the resident’s needs. Refrain from providing the resident with spiritual counseling or direction. Be an open, active listener for the resident. Be of musical support to the resident’s psychospiritual needs. Refer requests for spiritual direction to the facility chaplain or visiting clergy.

Music Reminiscence Music Reminiscence is listening to music for the purpose of reflecting on memories. Please see Young’s chapter 21 of this book on Alzheimer’s for use of music reminiscence methods. The methods are easily adaptable to a group of alert yet fragile elderly residents (rather than residents with dementia).

Environmental Music Environmental music is live or recorded music that is programmed by the music therapist for the purpose of creating a therapeutic sound environment for residents. Please see chapter by Young in this book for use of environmental music methods. The methods are easily adaptable to a group of alert yet fragile elderly residents (rather than residents with dementia).

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Cooperative Group Improvisation Overview. Cooperative group improvisation involves playing rhythm instruments to accompany familiar songs while singing them or as instrumental interludes. Residents who are coping with losses and have a limited social group may benefit from cooperative group improvisation. The only contraindication is an unwillingness to participate. Resident goals are to engage in building a group culture, to express self, to interact with others, and to make choices (Darnley-Smith, 2002; M. Zulauf, personal communication, May 19, 2012). The level of therapy is augmentative. No special training is required to use this method. Preparation. Be able to sing a repertoire of six to eight songs that are familiar to the residents while accompanying oneself on keyboard or guitar or with a rhythmic ostinato. Be able to vamp on the chord structure of the familiar songs. Gather 10 to 15 easy-to-play rhythm instruments of good quality, e.g., small maraca, jingle bells, small hand drum, small shekere, tree chime on stand, etc. Gather an accompanying instrument, e.g., keyboard, guitar, hand drum. Find a space in which a group of 8 to 10 residents are able to sit in a circle. The space need not be secluded and may allow for residents to “drop in” when they are able. Encourage the participation of resident’s family, friends, and other visitors. Solicit volunteers to assist residents with playing instruments. What to observe. Throughout the group, watch for residents who need cues or motivation to engage, or remain engaged, in playing (M. Zulauf, personal communication, May 19, 2012). Be aware that group members may have doubts about their musical skill and worry that they are not making “real music” (Darnley-Smith, 2002). Procedures. To open the session, pass out a rhythm instrument to each group member. Allow each member to choose a preferred instrument and model playing the instrument for the members as needed. Pair any residents in need of assistance with a partner. The partner may be another resident, another staff member, a family member, a volunteer, etc. To begin the working phase of the session, sing

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and play a familiar song. Encourage residents to sing along and/or play along. Encourage and respond to song requests. Toward the middle of the group, if using a keyboard or guitar to support the music-making, create an instrumental section and encourage residents to improvise on their rhythm instruments during it. Do this by verbally and musically cuing residents to stop singing and only play their instruments. At the end of the section, cue the residents to begin singing again. During breaks between songs, encourage residents to exchange instruments. Sing some songs only with a rhythmic pulse as accompaniment (Darnley-Smith, 2002; M. Zulauf, personal communication, May 19, 2012). Play six to eight songs during the session. Establish a ritual closing song for the group. Play and sing it at the end of each group. Adaptations. The intention of the method is for residents to become engaged in an enjoyable, cooperative, group music-making experience. In each session, respond creatively to the residents’ needs and requests for music. For example: Introduce unfamiliar songs that the group may learn and to which they can improvise; encourage solos, duets, and other groupings during improvisation (B. K. Sutton, personal communication, May 18, 2012); encourage free improvisation to a basic, rhythmic ostinato (maintain a steady beat to support the group); or prepare a pentatonic scale on xylophones or metallophones for residents to play over a rhythmic ground (M. Zulauf, personal communication, May 19, 2012).

Individual Instrumental Improvisation Overview. This involves learning to play and improvise on a selected instrument(s) in a musical dyad with the therapist. The improvisation is discussed as an expression of the resident’s self. Indications for this method include a perceived lack of autonomy and loss of integrity (Bright, 1997). The contraindication is an unwillingness to participate. Goals are to make choices (Bright, 1997), to remember the contributions the resident has made to the world, and to connect with his personal values. The level of therapy is augmentative. No special training is required to use this method, although training in music psychotherapy is recommended. Preparation. Be able to use an accompanying instrument to vamp on different harmonic progressions in a few different styles. Gather several different lightweight, quality melodic and rhythmic instruments, e.g., tambourine, slit drum with adapted mallets, jingle bells, mini-maraca, chime bars (Bright, 1997). Gather an accompanying instrument, e.g., portable keyboard, guitar, autoharp (Bright). Find a private space, preferably with a closed door, in which to conduct the session. The resident’s room may be an option. What to observe. Throughout the session, observe the resident’s willingness to work with the instruments and his verbal communication, body language, and facial expressions. Additionally, be aware of any indications of discomfort, either physical or emotional. Procedures. To open the session, let the resident know who the music therapist is and what she does. Engage the resident in a brief conversation about his circumstances. Ask questions such as, “How are you today? Who has been to visit you recently?” Assess the resident’s overt and underlying psychospiritual state. Ask the resident if he would like to try playing an instrument with the music therapist. Support the resident’s selection of a preferred instrument by showing him different instrument choices and how to play each one. Help the resident learn to play his preferred instrument. Encourage the resident to play freely and to continue playing as the music therapist begins to harmonically accompany his playing. The music therapist should support the resident’s playing with the musical qualities of the accompaniment, e.g., tempo, meter, phrasing, rhythm, dynamics, etc. Allow the improvisation to continue until the resident stops playing. Close the session by supporting conversation related to events in the resident’s life and the music-making. Help the client make connections between his life and the music, i.e., to hear the music as a metaphor for self. Ask questions like, “How was it to make music like that?

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What did you feel as we played together? What did you hear as we played together? How did the music sound to you? How do you feel after playing the music together? What were you thinking about as we played together? How are you feeling now? If you remember our playing later in the day, how might it help you?” Adaptations. Time allowing, ask the resident whether he would like to do more than one improvisation and/or try improvising on a different instrument. If the resident chooses to improvise on chime bars, sing a melody with the resident’s playing (Bright, 1977).

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Community Singing Overview. Community singing involves singing familiar and unfamiliar songs together in a group. Indications include enjoyment of singing or listening to singing. They also include limited access to stimulation or community engagement. Contraindications include unwillingness to attend and behavior that is consistently disruptive to the group process. Goals for residents are to increase sensory stimulation and to increase cognitive stimulation. Other goals may be to increase community involvement and to increase a sense of community belonging. The level of therapy is augmentative. No special training is required to use this method. Preparation. The music therapist should be able to accompany herself on guitar or keyboard while singing a broad repertoire of sacred and secular songs familiar to the residents. Have available large-print lyric sheets for the residents. Make enough copies so that each member of the group may have a sheet. Solicit volunteers to assist with the group. Gather lyric sheets and an accompaniment instrument. Find a space in which 6 to 20 residents can gather and be seated in rows. The space may be open and allow for residents to join the group when they are able. Leave enough room between rows for volunteers to collect and distribute lyric sheets. What to observe. Be aware of residents who need help in holding lyric sheets or prompting to remain engaged. Procedures. Open the session by asking for a request from the group or with a regularly used, familiar song that indicates to the group that it has gathered and it is time to begin (e.g., “Hail, Hail, the Gang’s All Here”). Continue into the working phase of the session by asking volunteers to help distribute lyric sheets for the next song. Select songs based on resident requests or the music therapist’s assessment of the group’s energy level. If the group is unsettled, select a moderately paced song with well-known, often repeated lyrics. If the group is low-energy and having difficulty attending to the session, select an up-tempo song with well-known, often repeated lyrics. When the group seems engaged and has enough energy, select a song with more challenging, less often repeated, or less well-known lyrics. Continually evaluate the group’s level of energy and level of engagement in the music-making process; make song selections based on this evaluation. Have a volunteer collect and distribute lyric sheets between each song. Sing 8 to 15 songs before closing the session with a regularly used, familiar song that indicates the group has concluded (e.g., “Bye, Bye, Blackbird”). Adaptations. Base repertoire for community singing on different themes, e.g., seasons, holidays, or song titles with particular words in them. Develop a repertoire of sacred songs familiar to the residents for a regularly scheduled hymn sing.

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Reflective Group Singing Overview. Reflective group singing involves selecting, singing, and discussing music that relates to the residents’ here-and-now psychospiritual needs. The therapist solicits information about each member’s psychospiritual state and selects, or guides the group to select, music that meets the group’s needs. This method is indicated for residents who may need social support and opportunities to reflect on personal issues and their experiences of them. The method is contraindicated for residents unwilling to attend and who are consistently disruptive during group conversations. Goals for residents are to recognize, integrate, and accept feelings and to find ways of coping with personal issues (Short, 1995). Goals may also be to increase tolerance of feelings and experience feelings fully (Short). The level of therapy is augmentative. Preparation. Educate staff regarding the purpose of the group. Let them know that the music therapist would like referrals for a group of four to eight residents with similar levels of functioning and who may need social support and an opportunity to reflect on personal issues. The therapist should be able to accompany herself while singing a broad repertoire of sacred and secular songs. Find a space in which the residents can sit comfortably in a circle or around a table. Ensure that the group will not typically be disrupted in the space. Prepare large-print lyric sheets for group use (Short, 1995). What to observe. Throughout the group, observe each resident’s verbal communication, body language, and facial expressions. Watch for evidence of physical and/or emotional pain. Watch for denial of feelings through song choices that do not match verbal and/or nonverbal expressions of emotion. Watch for coherence (or lack thereof) among each resident’s words, body language, and facial expression (Short, 1995). Procedures. Open the session by soliciting information from each resident about how he is feeling. Ask questions like, “How are you coming to group today? How is your physical self feeling? How is your emotional self feeling? How is your spiritual self feeling?” Allow ample time and opportunity for each resident to respond. Use the residents’ responses to assess their underlying and overt psychospiritual states. Select a familiar song to match the general mood state of the group. Hand out lyric sheets to support the residents’ singing. Encourage the residents to sing along. Accompany the group while leading its singing. After singing the first song, assess again the group’s general mood state and preferences for musical qualities. Ask the group questions like, “How was it to sing that song? Would you like to sing a song that is more, or less, quiet than the last piece?” Encourage the residents to respond to each other’s verbal ideas by asking questions like, “What do you all think about Mr. Smith’s idea?” Listen for an emerging theme in the residents’ verbal and nonverbal responses to the music. Themes may be quite concrete, e.g., family, or somewhat abstract, e.g., feeling relaxed. During the working phase of the session, support a main theme by selecting a related song or by verbalizing the theme and asking the residents to select a related song. For example, “It sounds like everyone is feeling pretty relaxed today. What songs come to mind when you think about feeling relaxed?” If a resident’s song suggestion does not match the theme, use sensitivity to gently redirect the group and encourage authentic acknowledgement of the group’s mood/theme. Once a second song is selected, lead group singing of the song in a musical style that matches the group’s mood and issues, e.g., if needed, play a typically up-tempo song at slower tempo. After singing, allow time for verbal and nonverbal responses to the song. Support the residents in consciously expressing and processing underlying issues and feelings. Follow the above process to select two or three more songs to sing. Close the session by summarizing its theme in words or through a closing song selection. Verbally encourage residents to see issues from a different perspective, to recognize the shared nature of their individual issues, or to increase their understanding of themselves (Short, 1995). The same method can be used in a one-on-one setting (Bright, 1997).

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Community Choir Overview. In a community choir, residents learn songs together to perform for an audience. Indications for resident participation in a community choir may include a loss of role in the community, enjoyment of singing, and previous choir membership. The method is contraindicated for residents unwilling to participate in a community choir or who might be consistently disruptive to rehearsals (B. K. Sutton, personal communication, May 18, 2012). Goals of therapy for residents are to increase personal fulfillment, to increase self-awareness, and to increase engagement in interpersonal relationships (Zanini & Leao, 2006). Goals may also be to make a purposeful contribution to the community and to feel responsible for, and to, a community (B. K. Sutton, personal communication, May 18, 2012). Additional goals might be to increase intellectual stimulation and to engage in choice-making. The level of therapy is augmentative. No special training is required to use this method. Preparation. Solicit a group of at least eight residents to participate in the choir. Allow membership to grow as large as there are resources to support the choir. Prepare a possible selection of songs for a performance program (perhaps based on a theme). Select a variety of familiar and unfamiliar songs. Create a checklist of prospective songs for the residents. Take the checklist to the first rehearsal. Once the program music has been selected, transpose songs into keys appropriate for the group’s vocal range when needed. Create music sheets for each song. Music sheets may include lyrics only or both lyrics and melody. Enlarge and darken any melody lines. The music therapist may solicit a volunteer to accompany the choir or accompany the choir herself; in either instance, prepare music for the accompaniment. In rehearsal, be prepared to work with residents on musicality of performance, but also come to the group with an accepting attitude toward the musical product. Singing in harmony may be difficult for the group; singing melody in unison may create the most aesthetic experience for the residents (B. K. Sutton, personal communication, May 18, 2012). What to observe. During rehearsals, watch to ensure that each group member receives a music sheet, that each member has the correct music sheet, and that group members remain engaged. Observe the interpersonal dynamics of the group. Notice the learning needs of individuals. Assess individual resident’s musical skills, e.g., ability to sing on pitch, ability to sing in time. Use the assessments to support resident participation with helpful musical (through accompaniment) and nonmusical (through conducting) cues (B. K. Sutton, personal communication, May 18, 2012). Procedures. The selection of performance program is the first step in the procedures. Bring the prospective performance program song checklist (see “Preparation of Session and Environment”) and pencils to the first rehearsal. Distribute the checklists to the choir members. Play through each song to familiarize the group with their options. Ask each member to select three to five favorite songs. After rehearsal, rank the group members’ selections by popularity. Announce the performance program songs at the next rehearsal. Support the group in selecting the order of the program through group conversation (B. K. Sutton, personal communication, May 18, 2012) Next, at the beginning and/or end of rehearsals, communicate announcements to the group. Give reminders regarding performance preparations or feedback from the community about recent performances. Ask individuals to make personal good and welfare announcements (B. K. Sutton, personal communication, May 18, 2012). The rehearsal warm-up begins with physical warm-ups. Lead the group in taking two or three slow, deep breaths together. Model and talk through facial exercise repetitions (2 to 3 per exercise), e.g., scrunch the entire face, then release, scrunch, then release; smile wide, release; frown low, release, etc. Model and talk through slow, gentle movements at each joint, e.g., toe circles, knee lifts, kicks, wrist

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circles, arm reaches (out/up, high/low), finger movements, arm circles, shoulder circles, shoulder scrunches, chin to chest. Verbally reinforce careful, purposeful movement as the group stretches. Explain how a stretch should feel, e.g., “Feel a slight pull on your neck as you gently move your chin toward your chest. Nothing painful, nothing tight, just a gentle stretch” (B. K. Sutton, personal communication, May 18, 2012). Lead the group in three or four singing-related warm-ups. Lead breath support awareness warmups, e.g., repeat the syllable “ha” on six single pitched eighth notes, sing a seventh “ha” on a quarter note, move up a half-step and repeat; hold a single pitch on “ah” for two measures of 4/4. Lead vocal warm-ups, e.g., sing up and down a fifth using solfeggio syllables (do, re, me, fa, sol, fa, me, re, do), move down a half-step, and repeat; sing “police sirens”—start low and slide the voice up the scale, then slide the voice back down the scale. Lead articulation warm-ups, e.g., repeat, in 3/3 time, the word “bumblebee” four times; sing “mee, may, mah, moe, moo” on a single pitch in 4/4, move up a half-step, and repeat. Support any pitched warm-ups with accompaniment (B. K. Sutton, personal communication, May 18, 2012). The warm-up is followed by the song rehearsal. During song rehearsal, pair members of the choir together so that one member may assist a less able member with passing music sheets, following music, staying alert, etc. Hand out and collect music sheets one at a time. Sing through each piece with accompaniment. Encourage and support engagement in the social expectations of a musical ensemble, e.g., before starting a music piece, the choir members make eye contact with the director. After singing each piece, provide specific feedback on the rehearsal and elicit feedback from group members on the musical interpretation of songs. Run through a song again to incorporate any changes. Over time, allow role development to occur, e.g., identify residents able to take charge of collecting and distributing music sheets, identify soloists, etc. (B. K. Sutton, personal communication, May 18, 2012). Shaping the performance is an important aspect of the rehearsal. Take time during the opening or closing of rehearsals to talk with the choir about shaping upcoming performances. Solicit group opinions on details of dress, e.g., select specific colors of clothing to wear or select prop to attach to wheelchairs and walkers. Enhance the theme of concerts by deciding on program notes for choir members to read between songs (this also gives the music therapist time to change music, hand out props, etc., between songs). Decide which group members will read program notes during the performance. Select a date for the performance. Plan the reception or intermission menu. Remind choir members to invite friends and family (B. K. Sutton, personal communication, May 18, 2012). To close the rehearsal, review the choir’s accomplishments during the rehearsal. Sing a ritual closing song. Thank the residents for attending the rehearsal and orient them to the next activity on the schedule, e.g., “Thanks for coming. Lunch is in 10 minutes. We’ll help you get to the dining room. See you for the next rehearsal on Thursday” (B. K. Sutton, personal communication, May 18, 2012). Adaptations. Invite a group of youth from the community to join rehearsals to form an intergenerational choir. Support facility religious services by performing at church once a month. Invite facility staff members to join in a performance. Start a church choir; end each rehearsal with a short prayer (B. K. Sutton, personal communication, May 18, 2012).

Intergenerational Music Program Overview. Intergenerational music programs provide residents and youths an opportunity to interact and create relationships through engagement in music. Indications for resident participation in an intergenerational program include need for meaning and purpose within the community, enjoyment of youth, and enjoyment of music (Clair & Memmott, 2008). Contraindications include an unwillingness to participate. Goals for residents are to improve quality of life, increase meaningful interpersonal interactions, and build relationships with others (M. Zulauf, personal communication, May 19, 2012). The

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level of therapy is augmentative. No special training is required to use this method. Preparation. Create a liaison with a community youth program, e.g., specific classrooms or grade levels in a local school system, Girl Scouts, Cub Scouts, church-affiliated youth groups, 4-H, etc. Youth may be preschool, elementary, high school, or college-age students (Clair & Memmott, 2008). If possible, engage the group in regular visits to the nursing facility; consistent participation is helpful for building relationships. Ensure that the youth are aware of the problems and needs of the residents with whom they will interact. Visit the youth group to provide a program on successful strategies for interacting with the residents. Find a space in which a large group can meet (the dining hall or a large meeting space in the facility could work). Adapt one of the music therapy methods described in this chapter for intergenerational participation. The group may be of any size and need be limited only by the resources available to support member participation. What to observe. Throughout each session, observe the interactions between the group members and support interactions between the residents and the youths. Procedures. Adapt the procedures from one of the music therapy methods described in this chapter for intergenerational participation. Choose methods that encourage interaction between group members, e.g., musical games, reminiscing (see Young, Chapter 21), rhythm ensemble, talent show, choir, or community singing. Pair individual youths with individual residents during sessions when the music therapy method allows. Develop ritual greeting and closing songs for the group. Use a different music therapy method in each session or develop an ensemble and schedule an intergenerational performance for it (M. Zulauf, personal communication, May 19, 2012).

Therapeutic Music Lessons Overview. Therapeutic music lessons involve teaching an instrument to attain therapeutic goals. Indications for resident participation in therapeutic lessons may include a desire to learn an instrument, a need for the physical exercise related to playing a specific instrument, limited social interaction, and boredom (Clair & Memmott, 2008). Contraindications may include a lack of desire to participate (Zelazny, 2001) or an inability to complete fine motor tasks. Goals for residents are to increase cognitive stimulation, increase muscle strength, and increase fine motor dexterity. Other goals may be to improve range of motion, increase remembrance of positive life events and experiences, and increase opportunity for social interaction. Additional goals may be to develop a role in a social community, increase self-expression, increase the structure of leisure time, and increase activity level. Residents may also work to improve mood through engagement in a desired activity (M. Zulauf, personal communication, May 19, 2012). The level of therapy is augmentative. No special training is required to use this method. Preparation. If the goal of therapeutic music lessons is to improve physical functioning, coordinate with a physical therapist to select appropriate instrument(s) and exercises to ensure optimal outcomes. To measure change, see the methods followed by Zelazny (2001). When preparing to engage a resident in therapeutic music lessons for all goals, assess the resident’s preferred music, physical abilities, learning styles, and musical skills. Use the assessment results to adapt lessons to the resident’s interests and abilities. Determine a method of teaching (e.g., through numbers on keys, through reading music, through modeling). Combine visual, aural, and tactile teaching methods when creating lessons. Select music with the resident. Adapt the music to the abilities of the resident. Enlarge and darken music sheets for the resident (Zelazny, 2001; M. Zulauf, personal communication, May 19, 2012). Lessons may be taught one-on-one or in a small group (4 to 6 residents). What to observe. While the resident is receiving lessons, watch for a decrease in participation related to lack of motivation or discomfort (Zelazny, 2001) and be aware of the emotional reactions

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triggered by songs (M. Zulauf, personal communication, May 19, 2012). Observe for increased alertness and willingness to interact with others. Procedures. Set up a time to meet with the resident. Discuss the time with nursing staff to ensure that the resident is available to attend the lesson. Implement any adaptations required for the resident to play the instrument and learn the music. Provide motivation and support for the resident to attend lessons and work through difficulties with the learning process. Continually evaluate the resident’s abilities and make changes to lessons as needed to meet the client at his level of ability. Support the client’s development of a repertoire book over time (M. Zulauf, personal communication, May 19, 2012). Adaptations. The resident may learn an instrument, relearn an instrument, or learn to sing. Lessons may be in groups or on an individual basis. Lessons may take place in sectional rehearsals for an ensemble. The resident may prepare to participate in a music ensemble of other learners, to play in a talent show, or to join in an ensemble preparing for a talent show performance (Glassman, 1983). The resident may prepare to play a performance for a religious service (Palmer, 1983).

Percussion Ensemble Overview. In a percussion ensemble, residents are divided into percussion instrument sections, learn specific parts to accompany a program of music selections, and may perform the program for audiences. Indications for resident participation in a percussion ensemble may include loss of role in society, limited social interaction, and a need for physical movement. Contraindications include limited tolerance for high levels of sound and unwillingness to participate. Goals for residents are to maintain fine and gross motor control, and to maintain hand-eye coordination. Other goals may be to increase social interaction and to increase one’s sense of role in the community (Reuer, Crowe, & Bernstein, 2007). Additional goals may be to increase quality of life, to increase self-esteem, and to stimulate short-term memory (Schweinsberg, 1981). The level of therapy is augmentative. No special training is required to use this method. Preparation. Create a collection of small, lightweight, quality rhythm instruments, e.g., cymbals, maracas, claves, bells, etc. Collect adaptive instruments as needed. The music therapist may solicit a volunteer accompanist or plan to accompany the group herself on piano or guitar (Reuer, Crowe, & Bernstein, 2007). Solicit one to three volunteer assistants for the group. Select music pieces for the group that have a strong pulse (Schweinsberg, 1981) and are two to four minutes in length. The music pieces may be of any genre, familiar or unfamiliar, and with or without lyrics. The pieces maybe similar to those sung in choir or in a community singing group, or they may different (e.g., Sousa marches and ragtime melodies). Make music selections based on residents’ abilities to multitask (e.g., play while singing familiar music) and respond to conducting cues (familiar music may prompt more playing than unfamiliar music). Arrange the music for the group. While doing so, remember that simple and redundant rhythmic patterns may create more successful music experiences for the residents (Clair, 1991). Consider whether or not the residents will sing, when they will sing, and whether or not they will sing while playing. Consider dividing the group into instrumental sections and/or creating opportunities for solos, small ensembles, and accent parts. Create music sheets or books for residents. If dividing the group into sections, create separate sheets for each section and use the sheets to indicate when each section starts and stops playing. This may be done most easily in relation to song lyrics (Schweinsberg, 1981). Likewise, create separate music sheets for soloists or small ensembles within the group. Find a large space in which 10 to 20 residents can be seated in rows. If using music sheets or books, have a music stand for every two residents.

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What to observe. Throughout rehearsals, ensure that residents are seated so that they can see, hear, and receive assistance as needed (Reuer, Crowe, & Bernstein, 2007). For example, place residents who need physical cues to start and stop playing in the front row (Schweinsberg, 1981). Assess the cognitive, physical, and musical abilities of individual participants (Reuer, Crowe, & Bernstein, 2007). Ensure that residents have the correct music sheet. Procedures. As with the community choir, make announcements at the opening or closing of rehearsal, work with the group to select a performance program, and engage the group in rehearsal warmups. When shaping a rhythm ensemble performance, follow community choir procedures, but also take volunteers for, or assign willing residents to, solos, small ensembles, and/or accent parts. Ensure that parts assigned to individuals or small groups match residents’ cognitive, physical, and musical ability levels. Use a portion of the rehearsal to develop the residents’ rhythm skills. Have participants play a pulse while singing a familiar song at the same time. Have residents clap to word phrases that match basic rhythm patterns, then drop out the word phrases, and then play the rhythm pattern on an instrument. When rehearsing performance pieces, follow community choir procedures, but also assign volunteers to assist with section leading and with cuing and prompting participation. Rehearse two or three pieces per session with accompaniment. Ensure that musical cues from the accompanist and physical cues from the conductor are communicated clearly to the group. Continually evaluate the residents’ musical, cognitive, and physical abilities as they relate to participating in the ensemble. Shift musical and physical cues to meet any changes in residents’ abilities. Adaptations. See Reuer, Crowe, and Bernstein (2007) for further, detailed warm-up and skill development ideas.

Tone Chime Choir Overview. In the tone chime choir, the therapist conducts residents in playing songs on tone chimes. Indications for resident participation in tone chime choir include ability to follow visual cues, ability to hold and manipulate a hand chime, and interest in music. Contraindications include unwillingness to participate, a decline in cognitive status, and behavior disruptive to the group (B. K. Sutton & M. Zulauf, personal communication, May 18, 2012). Goals for residents are to increase awareness of membership in a community, increase engagement in decision-making, and increase responsibility for, and to, a community. Additional goals may be to increase cognitive stimulation and increase engagement in activities (B. K. Sutton & M. Zulauf, personal communication, May 18, 2012). The level of therapy is augmentative. No special training is required to use this method. Preparation. Solicit referrals from staff and talk with residents who might be interested in, and are indicated for, joining a tone chime choir. Acquire or borrow one chromatic, two-octave set of hand chimes. Have a music stand for the conductor. Solicit a volunteer to accompany the group on guitar or piano. Solicit additional volunteers to help hand out bells, to provide one-to-one assistance to residents, and/or to sit in for residents unable to make rehearsal. Find a space in which 8 to 12 residents can sit comfortably in a half-circle while facing a conductor. Ensure enough space for the accompanist and the accompanying instrument as well. Set a weekly, consistent time for the group to meet (B. K. Sutton & M. Zulauf, personal communication, May 18, 2012). Select a repertoire of music familiar to the residents and with simple harmonic progressions. Arrange the music so that the accompanist plays melody and harmony and the choir members play I, IV, and V chords (the choir can drop out while the accompanist plays non-I, -IV, -V chords). Create a performance program; list the songs on the program based on the organization of the bells the residents play. Assign choir members to one of the three chords (or two, if the resident is able). Remember to assign

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heavier chimes to stronger residents and lighter chimes to more fragile residents. Create a seating chart for the residents and the bells they play for each song. Seat residents according to the chord groups in which they play. Prepare lyric sheets for each part that indicate to residents when and how to ring their bells (lyrics highlighted in bright colors may work well). Prepare a master lyric sheet for the conductor. Memorize chord changes in each song or follow the master lyric sheet so that the music therapist is able to observe and cue the chime players as needed. What to observe. During rehearsals, watch for residents to make eye contact when cuing chord groups to play. Observe residents’ facial expressions and body language for level of enjoyment, level of participation, and accuracy of participation. Watch residents’ arm movements to ensure their chimes are ringing. Assess each individual resident’s strength, handedness, and level of understanding of the process. Identify which residents need more or different cuing and the types of cues that are most helpful (eye contact, versus hand gesture). Be aware of whether residents are on the correct lyric sheet or who has dropped a music sheet. Procedures. As with the community choir and rhythm ensemble, make announcements at the opening or closing of rehearsal and engage the group in physical warm-ups. Tone chime choir performance pieces may need to be selected and ordered in the program by the music therapist because of the preparation required for a performance to run smoothly. Involve the choir members as much as possible in these decisions, e.g., selecting specific colors of clothing to wear, choosing an overall theme for the performance, selecting program notes and who will read which notes. Seat the residents and pass out the hand chimes according to the master seating chart prepared earlier. Engage the group in musical warm-ups. Have each chord group play alone and practice starting and stopping together. Encourage the residents to listen to each other as they play. Have each individual ring his chime alone. Have the group play individually, in time, around the half-circle. Introduce the accompanist and play one or two well-rehearsed pieces together. Begin work on less well-rehearsed songs. Pass out individual lyric sheets or lyric books. Play through each piece while cuing the chord groups with hand gestures. Indicate to each group when to start and stop playing. Gently encourage the group to play attentively so as to improve their musicianship, but also be accepting of the level of musicianship they are able to attain. Encourage the residents to evaluate their playing, but guide them to do so in constructive and supportive ways. Close the rehearsal with a random, group playing of all chimes (i.e., self-applause). Have the residents pass in their bells according to the master seating chart. Engage residents in gentle hand stretches, e.g., using the left hand to pull the fingers of the right hand back toward the top of the lower arm, making and releasing fists. Pass out written reminders of an upcoming performance as appropriate. Adaptations. Rather than arranging the music so that group members play in chords, arrange the music so that members play song melodies with harmonic accompaniment by another instrument. Have the members play harmonic accompaniment while singing songs. Have members improvise over harmonic accompaniment from another instrument (e.g., use a pentatonic scale and point to random choir members to play while a volunteer plays a regular harmonic progression on piano). Incorporate other instruments to pieces as appropriate, e.g., jingle bells for “Jingle Bells.” Between performances, or on a regular basis, bring trivia about the songs the group is playing or encourage reminiscence (see Young, Chapter 21). Bring residents who would rather listen than participate to rehearsal. Rather than providing individual lyric sheets for each choir member, prepare a large chart from which the whole group can read. Assign each choir member or chord group a number and notate which number plays when on the chart. Conduct the group by pointing to the chart.

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Talent Show Overview. In the talent show, residents, staff, and family members practice and perform a musical selection as a soloist or as a member of a small or large group. Participation in a talent show is indicated by a desire to be involved in the community, a desire to contribute to the community, and a desire for recognition. Contraindications include an unwillingness to participate or inability to perform due to fragile health. Goals for residents are to increase positive self-concept, to increase a sense of belonging, and to increase a sense of productivity. Other goals may be to gain a role in the community and to enhance the quality of a relationship with a family member. The level of therapy is augmentative. No special training is required to use this method. Preparation. Ask residents, family members, and staff members to participate in the talent show. Solicit enough performances for an hour-long show. Develop and prepare a performance program. Find a space that will accommodate a small stage and room for an audience. Acquire, and learn to operate, a sound system appropriate for the room. Prepare an advertising flyer and post it throughout the facility. Invite residents’ friends and families to attend. Prepare program notes. Solicit an emcee for the performance. Prepare notes for the emcee to use to introduce each performance and the performers. Work with other departments (maintenance, dining services) to organize decorations for the space and a reception after the show. What to observe. Among the group of performers, identify who is able to rehearse independently and who is not. Be aware of performers who need encouragement and support to rehearse and perform. Be aware of any personality conflicts and rivalry. Procedures. Meet with separate “acts” for rehearsal, e.g., choir, solos, duets. Some performers (particularly staff and family members) may not need to rehearse with the music therapist; others may need to rehearse only once before the show, while others may need to meet weekly. On the day of the performance, set up the sound system, decorate the space, and check in with other departments to coordinate work. Organize the performers and their instruments. Provide all performers with the program. Have the emcee introduce each performance (or the music therapist can emcee the program) before it goes on stage. Adopt an accepting attitude throughout; troubleshoot when able and encourage the performers and the audience to enjoy the show. Adaptations. For a significantly able group of residents, see Glassman’s procedures and techniques (1983).

Musical Games Overview. Musical games are quizzes and guessing games related to music that are used to involve the participants in active music-making. Indications for resident participation in musical games include willingness to participate. Contraindications include unwillingness to participate. Goals for residents are to increase social interaction, to increase activity level, and to increase cognitive stimulation. The level of therapy is augmentative. No special training is required to use this method. Preparation. Create or purchase supplies needed for specific musical games. These may include a large dry-erase board, lyric sheets, music bingo cards, bingo chips or markers, and an accompaniment instrument such as guitar or piano. Use songs familiar to the residents as the basis for the games, e.g., replace bingo numbers with songs titles or use song titles or lyric phrases as the words in music Hangman. Solicit volunteers to assist residents. Organize a space so that six to eight residents can sit in a semicircle or circle or around a table and participate with limited disruptions. What to observe. Watch residents’ interactions with each other. Observe residents’ verbal communication, body language, and facial expressions for level of engagement. Watch for residents who

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need assistance to participate. Procedures. Ensure that each resident has the materials required to participate in the game. Be supportive of all responses offered by residents; gently redirect inappropriate answers using therapeutic skills. Use the game as a catalyst to engage in active music-making. For example, during music Hangman, have the residents guess the letters to a song title or the phrase of a song and then sing the song together. Possible games to play include: music Hangman, Name That Tune, and music bingo.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Cooperative Songwriting Overview. Cooperative songwriting involves the group in creating new lyrics for familiar songs. Indications for cooperative songwriting may include needs for relief from boredom, constructive use of leisure time, enjoyment, and community-building (Clair & Memmott, 2008). Contraindications include unwillingness to participate, behavior disruptive to the group, and an inability to participate in group conversation. Goals for residents are to increase activity level and to increase cognitive stimulation. Other goals may be to increase self-expression and to increase social support. The level of therapy is augmentative. No special training is required to use this method. Preparation. From a broad repertoire of sacred and secular songs, make a list of songs that are familiar to residents and have reliable, repeating forms, e.g., “I’ve Got Rhythm,” “My Favorite Things,” and “I Love the Mountains.” The music therapist should able to accompany herself on piano or guitar while playing songs from the list. Gather a dry-erase board, dry-erase marker, and a keyboard or guitar (M. Zulauf, personal communication, May 18, 2012). Find a quiet space in which six to eight residents can gather in a semicircle in front of the dry-erase board. What to observe. Throughout the session, be aware of all comments from residents. Be willing to accept all comments and creatively integrate them into the song lyrics (M. Zulauf, personal communication, May 18, 2012). Procedures. Open the session by explaining to the group that they will be working on writing their own lyrics to a familiar song (Clair & Memmott, 2008; Rio, 2002). Provide the residents with a list of topics or songs from which to choose. Topics may relate to the weather, to a holiday, to their mood state, etc. Songs should be from the list the music therapist generated before the session. Support the group to select one topic or song with which to work. If the group selects a topic, use the song that best fits the topic for the session (M. Zulauf, personal communication, May 18, 2012). Move into the working phase of the session by eliciting ideas related to the topic or the song from the group. When several group members respond simultaneously, be sure to hear from each resident. Elicit ideas from less active participants by asking questions like, “What do you think, Mrs. Johnson? What is your favorite season? Why is it your favorite? What do you love?” Write all of the residents’ ideas on the board. Work from verse to verse of the familiar song and exchange the original words for the residents’ words, e.g., “I love the mountains” becomes “I love my grandkids.” Take time to sing each section of the new lyrics before moving on to the next section. Listen to how it sounds and make adjustments as needed. Close the group by singing the whole song through two or three times. Make plans to share the song with the community, e.g., have the lyrics printed in the newsletter or display them on a bulletin board (M. Zulauf, personal communication, May 18, 2012). Adaptations. Perform the song for staff, residents and/or family immediately available in the area. Write a song for the bell choir or the community choir to perform. Write a song for a staff member on holiday; display the lyrics as a Welcome Back message to the staff member (B. K. Sutton & M. Zulauf,

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personal communication, May 18, 2012). Use the same method to address personal topics in a more private, group setting (Palmer, 1983). For example, gently guide residents to express feelings about a new living situation or the difficulty of rehabilitation after an acute health crisis. Be aware of residents’ needs to express difficult experiences and desires, i.e., Living is too difficult; I want to die. Support residents to express their experiences related to their circumstances, become more accepting of them, and reengage in living.

Individual Songwriting Overview. Individual songwriting involves the resident in composing new lyrics and music to express himself in a song. Indications for resident involvement in individual composition may include needs to review life events or to deal with issues related to life and death (Bright, 1997). Another indication may be grief related to losses (Bright, 2002). Contraindications include unwillingness to participate or inability to participate related to psychological decompensation. Goals for residents are to remember past and present life experiences and put them in the context of one’s entire life (Karras, 1987), to express uncomfortable experiences, and to create reminders of personal integrity (Bright, 2002). The level of therapy is augmentative. No special training is required to use this method, although an interest or specialization in music psychotherapy is recommended. Preparation. Gather a pencil, staff paper (or a computer with appropriate software), audio recorder, and keyboard or guitar (Bright, 2002). Find a quiet, private space in which the music therapist can meet one-on-one with the resident. What to observe. While working with the resident, be aware of his body language, tone of voice, and use of language (Bright, 2002). Watch for his level of comfort/discomfort with the process. Procedures. The song composition process may happen quickly in one session or need to develop over several sessions. Either way, begin the process with a general social conversation, e.g., “Hi, how are you today?” Encourage the resident to talk about the events of his life. Listen, as the resident talks, to hear a main theme in the conversation, e.g., particular feeling states, a need to reminisce, a need for psychosocial support, etc. Verbally reflect, to the resident, the theme(s) heard in the conversation. Ask the resident if he would be willing, with the music therapist’s support, to try to write a song about that theme(s). The music therapist should explain that she knows how to write songs and can cowrite the song with the resident or be of great support through the writing process. In the face of a resident’s uncertainty, encourage him to “just try,” to “enjoy working and spending time together,” and to “see what happens.” Support the resident in writing lyrics for the song. Encourage him to talk about the theme. If the resident needs to express uncomfortable experiences, ask questions like, “Have you felt this way before? What was it like then? What is it like now? Can you use a metaphor to describe the experience?” If the resident needs a concrete reminder of his personal integrity, ask questions like, “What is important to you? What do you believe in? What do you like most about yourself?” If the resident needs to place experiences in the context of his life, ask questions like, “Who are the people most important to you? What moments, good and bad, come to mind when you think over your life?” As the client talks, write down salient phrases from the conversation. Allow space and time for ideas to come forward. Follow up the resident’s answers with questions that encourage him to describe further detail about specific experiences. Show him the written phrases and ask him which phrases should go in the song, which phrases should make up the chorus, which phrases might be repeated, and in what order the phrases should go. Ask the client to “fill in” words between phrases where needed. Remember to allow space and time for ideas to come forward. If the resident is willing, provide suggestions from which he may choose. Help the resident to set the lyrics to music and reflect the qualities of the lyrics in the qualities of the music. Discuss different tempos with the resident. Ask questions like, “Does this seem like a song that

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moves slowly along, walks briskly along, or runs?” Play familiar types of chord progressions from which the client can choose to set the verses and the chorus, e.g., I-IV-V or I-ii-IV-V. Consider dynamics. Ask a question like, “Are there places in the song that should be louder or softer than others?” Once the music therapist has determined the chord tempo and chord progressions and dynamics, play them repeatedly and begin to improvise a melody over them. If the client is willing, ask him/her to sing along. Keep the phrases of the chorus in mind, and when a melody line seems to fit a phrase, sing the words to the melodic line. Ask the client to join if he has not already. Record the product, play it back to the resident, and ask for feedback. Follow the same process to complete the melody. Develop a melody that is comfortable for the resident to sing, i.e., is within the range of the resident’s voice and is composed of singable intervals (Bright, 2002). The music therapist should keep the song short when she wants the resident to remember it easily (Bright, 2002). When the song is completely written, ask the resident to title it. Print the song for the resident with his name as the composer. Record the final version of the song with the resident. Adaptations. As with cooperative songwriting, change the words to a familiar song. Write a chant rather than a song with melody and harmony. Another adaptation is to create an audio biography with the resident. Bring a large-print list of song titles through which the resident can browse and have accessible a large repertoire of prerecorded music pieces (see “Receptive Methods: Individual Reflective Music Listening”). Support the resident to select prerecorded music pieces that represent different persons or periods in the resident’s life. To prompt the resident’s selection of music pieces, ask questions like, “What is your earliest memory of music in your life? How did your family participate in music? What music do you remember from church or synagogue? Did you take music lessons? Did you go to concerts? What song reminds you most of your spouse, brother, sister, mother, etc.? What is your favorite song? What songs were played at your wedding?” (Karras, 1987). Record the pieces on a compact disc or save them on an MP3 player, so that the resident might play them for himself and his community of friends/family. The music therapist might also encourage the resident to select photographs that relate to each piece of music and work with him to construct a PowerPoint presentation that sets the photos to music. The resident might also write text for the presentation or include song lyrics or poetry in it.

CLOSING REMARKS ON METHODOLOGY When selecting methods for use with residents, the music therapist should take into consideration the following: different options for using the methods within sessions, whether to offer group or individual sessions, the number of residents to involve in a particular method, the length of sessions, and the frequency at which to offer sessions. While the methods presented in this chapter are described as full sessions, the therapist might consider combining different methods in a single session. For example, the opening of a session might involve the community singing of a ritual song, the working phase might involve a short eurhythmic warm-up and two cooperative group improvisations, and the closing phase might involve the community singing of a ritual song. The therapist is free to use the methods to create sessions that respond to the assessed needs and interests of the residents. Group and individual sessions are typically offered for different reasons. Individual sessions are required when residents are unable or unwilling to leave their rooms. They also may be required if the residents need to work with experiences they are uncomfortable sharing with a group of people. In these cases, methods such as Individual Song Composition, Personal Instrumental Improvisation, or Individual Reflective Music Listening might be effective. Group sessions are indicated when residents are able and willing to leave their rooms and would benefit from the interaction and stimulation involved in

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joining a community of people. As noted in the methods section, music therapy groups can be planned to meet a diverse set of needs. When offering group sessions, the membership size should vary based on the purpose of the session. Methods such as Reflective Group Singing and Music and Imagery should involve smaller groups of residents (e.g., five to eight); the intention of the method is to encourage intimate sharing of personal information. Methods such as Eurhythmics and Therapeutic Music Lessons should also involve smaller groups of residents (e.g., five to eight); the intention of the method is to provide guidance for effective participation and may require that residents receive individual attention. Methods such as Cooperative Group Improvisation and Intergenerational Music Programs may involve a moderate group of residents (e.g., 8 to 15); the intention of the method is to encourage interaction with others, although not necessarily on an intimate level. Methods such as Community Singing and Community Choir may involve larger groups of residents (e.g., 8 to 40); the intention of the method may be to involve the residents in an experience of community membership. In sum, when selecting group size, consider the level of intimacy to be fostered in the group, the amount of individual attention the residents will require, and the environment that the music experience is intended to create. The length and frequency of sessions will vary, depending on the residents involved. Some residents will be able to sustain the energy required to participate in a 50-minute session, while others will be able to manage a 15- or 30-minute session. Consider the psychospiritual and physical health states of the residents involved when planning session lengths. Sessions may be scheduled as the residents’ interests indicate and the music therapist’s time allows. Typically, sessions are run on a weekly or biweekly basis.

WORKING WITH CAREGIVERS The Administration on Aging (Vincent & Velkoff, 2010) reports that by the year 2050, the number of Americans 65 and older will be over 80 million (more than double the population of 2010). Those 85 and over may account for 4.3 percent of the American population (an increase in 2.3 percent from 2030 projections). MetLife (2011) reports that “nearly 10 million adult children over the age of 50 care for their aging parents” (p. 2). Additionally, the caregivers of older people are often themselves older adults. The average age of caregivers is 63 years, and one-third of those caregivers are in fair to poor health (Administration on Aging, 2011). MetLife (2011) found that adult children who work and care for a parent are more likely to have fair or poor health than those adult children who do not care for their parents. Adult children and spouses, through the process of caregiving, may experience profound loss, depression, social isolation, and hopelessness (Clair & Memmott, 2008). Placement of a caregivee into resident care may bring feelings of guilt, failure, helplessness, and emptiness when the individual’s role changes from constant caregiver to visitor (Clair & Memmott, 2008). All caregivers, including family and facility staff, have significant needs. New and difficult experiences require that they learn techniques for stress management, for constructive emotional expression, and for interacting with caregivees. They need to find ways to interact and connect with others and experience psychospiritual support. They also need respite from caregiving. Clair & Memmott (2008) have found that music can allow “caregivers to share something that goes beyond the fulfillment of day-to-day physical needs with the people for whom they provide care” (p. 287). They describe how caregivers can use music with caregivees. Such experiences might include singing favorite songs together, dancing together, reminiscing while listening to music, or leaving recorded music behind for the caregivee. The authors also describe how caregivers can use music for self-care, including playing an instrument, writing songs, listening to music, or practicing music and relaxation techniques. Music therapists can support all caregivers, including children, grandchildren, spouses, and facility staff, in using music with caregivees and for self-care.

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RESEARCH EVIDENCE Receptive Music Therapy Researchers have studied the effect of residents’ music listening on exercise repetitions. Bernard (1992) found that the differences between music listening and non–music listening exercise groups approached significance and suggested that music listening may increase motivation to exercise. Johnson, Otto, and Clair (2001) compared the effect of live music (instrumental and vocal) and no music on residents’ repetition of prescribed physical therapy exercises. While participants indicated preference for music over nonmusic conditions while exercising, the researchers found that singing distracted participants from their exercise program. They concluded that unfamiliar music, suitable to the speed and range of specific movements, would most likely encourage the best engagement in and adherence to exercises. Thaut and McIntosh (1999) found that elderly individuals with Parkinson’s Disease could synchronize their step patterns to auditory rhythms and that doing so created an “entrainment effect” that resulted in significant improvements in gait velocity, cadence, and stride lengths when not listening to the rhythms. They concluded that auditory rhythm might be an accessible sensory stimulus that can help improve the mobility of elderly patients with movement disorders. Bennett and Maas (1988) investigated the effects of music-based life review versus discussionbased life review on life satisfaction and ego integrity. During the music-based life review sessions, subjects were asked to listen to a song and then participate in a discussion after its completion. The researcher facilitated exploration of thoughts and feelings related to the piece of music played and asked further questions to stimulate recall of memories. It was found that the music program promoted more life satisfaction than the discussion program, but the results did not show differences in ego integrity.

Re-creative Music Therapy Two researchers studied the impact of re-creative music therapy methods on elderly individuals. Byrne (1982) wrote a case study on a depressed woman attending day care. After seven reminiscence-throughmusic groups, the woman’s Global Depression Score decreased from 17 to 8, indicating relief from depression. Zelazny (2001) studied the effect of therapeutic keyboard lessons on the management of hand osteoarthritis. After receiving lessons four days a week for 30 minutes for four weeks, residents’ finger pinch meter and range of motion were positively increased. Additionally, two of four participants recorded significant decreases in arthritic discomfort, and three participants showed significant improvement in finger velocity and, hence, finger strength/dexterity. The researcher concluded that playing the keyboard might be an effective means to help manage hand osteoarthritis in older adults by increasing finger muscle strength/dexterity and decreasing perceived arthritic discomfort.

Multiple Methods Several researchers have examined the impact on residents of music therapy sessions that involved multiple music therapy methods. Chen, Lin, and Jane (2009) used qualitative focus group interviews to examine elderly nursing home residents’ experiences of music therapy. Each music therapy session was subdivided into eight sections: an initial phase (saying hello), a warm up (hand massage), dancing (moving upper bodies to music), group play with percussion instruments, group play without instruments, listening to relaxing music, listening to a musical performance, and a concluding phase (thanking for their participation, saying good-bye, asking for preferred music for next session). In the

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interviews, the residents described ways in which they derived strength from the group dynamic (including a sense of energy, distraction from suffering, and confirmation as a person) and ways in which the sessions enhanced their quality of life (including the addition of variety to their lives, motivation to exercise, learning of positive behavior, and feeling greater life satisfaction). Redinbaugh (1988) published a case study that demonstrated the use of music therapy techniques to increase the verbal and nonverbal communication of a withdrawn, depressed, older adult female in a long-term care facility. Through moving to music, singing, and instrument-playing, the client learned to communicate through music and was then able to increase her participation in social activity groups and form a social support system. Suzuki (1998) worked with depressed long-term care residents to identify the effects of music therapy on mood changes and on the accessibility of positive and negative memories. Each group therapy session consisted of three segments: (1) a sing-along; (2) music-making, including instrumental playing or lyric writing; and (3) relaxation or movement to music. The study results showed a significant decrease in negative mood and recall of significantly fewer unpleasant past events after participation in music therapy. VanderArk, Newman, and Bell (1983) assessed the self-concepts, life satisfaction, socialization, music attitudes, and self-concepts in music of nursing home residents who participated in music therapy. Residents participated in two sessions per week for five weeks. Each session lasted approximately 45 minutes and consisted of group participation in various music activities (e.g., singing familiar songs and learning simple accompaniment patterns to the songs). Significant improvement in the life satisfaction, music attitude, and music self-concept of the program participants was found. While socialization and self-concept scores showed improvement, they were not considered statistically significant.

SUMMARY AND CONCLUSIONS Frail elderly persons who live in nursing facilities cope with significant health challenges. The aging process effects their cognition, perceptual-motor functioning, psychospiritual health, physical health and social health. Even while dealing with significant challenges, nursing home residents can draw upon their innate musicality, life history, interests and abilities to engage in meaningful activity. Music therapy provides residents an avenue for such engagement. Different music therapy methods offer residents different types of opportunities. For example, Eurhythmics and Therapeutic Music Lessons can motivate physical exercise. Community Choir, Percussion Ensemble and Tone Chime Choir can engender a sense of purpose in residents; they can also provide residents with a community in which they can to belong and to which they can contribute. Music Appreciation and Musical Games can stimulate residents’ cognitive thinking. Music and Imagery and Personal Instrumental Improvisation can allow residents to connect with their inner worlds and share the contents of those worlds with others. Clearly, the benefits of resident participation in therapeutic music experiences are many and diverse. The present research literature provides evidence of the benefits of resident participation in music therapy. In particular, receptive and re-creative methods have been investigated in relation to their effect on exercise repetitions, gait patterns, life satisfaction, depression and arthritis. Several researchers have also studied the effects of multiple method sessions on variables such as resident engagement in communication, mood change and self-concept. It appears, however, that researchers have yet to publish studies that systematically examine resident participation in composition and improvisation methods. Although there are gaps in the literature on music therapy with residents of nursing facilities, the current body of publications is significant and describes effective clinical methods. These methods provide music therapists a solid foundation on which to base, and from which to expand, their clinical work.

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REFERENCES Abbott, E. (2010). The Bonny method: Training innovations at Anna Maria College. Voices: A World Forum for Music Therapy, 10(3). Retrieved from https://normt.uib.no/index.php/voices/article/view/501/424 Administration on Aging. (2011, October). Who are caregivers in the U. S.? Selected caregiver statistics. Retrieved from http://www.aoa.gov/AoARoot/Press_Room/Social_Media/Widget/Statistical_Profile/2011/10.a spx#citation Aging. (2002). In McGraw-Hill Concise Dictionary of Modern Medicine. New York: The McGraw-Hill Companies. Alabama Medicaid Agency Administrative Code, Chapter 560-x-10-.10, Long Term Care, Admission Criteria (1982 & Supp. 2011). Retrieved from http://www.alabamaadministrativecode.state.al.us/docs/med/560-X-10.pdf Aluede, C. O., & Stevenson Omoera, O. (2010). Learning from the past in organising music therapy activities for the elderly in Esan, Edo state of Nigeria. Voices: A World Forum for Music Therapy, 10(1). Retrieved from https://normt.uib.no/index.php/voices/article/view/30/243 Bennett, S. L., & Maas, F. (1988). The effect of music-based life review on the life satisfaction and ego integrity of elderly people. British Journal of Occupational Therapy, 51(12), 433–436. Bernard, A. (1992). The use of music as purposeful activity: A preliminary investigation. Physical & Occupational Therapy in Geriatrics, 10(3), 35–45. Beube, M. (1980). Movement and the elderly. Seventh Annual Conference of the Canadian Association for Music Therapy, Regina, Saskatchewan, 2, 34–39. Bright, R. (1972). Music in geriatric care. Sydney, Australia: Angus and Robertson. Bright, R. (1981). Practical planning in music therapy for the aged. Lynbrook, NY: Musicgraphics. Bright, R. (1996). Grief and powerlessness: Helping people regain control of their lives. London: J. Kingsley Publishers. Bright, R. (1997). Wholeness in later life. Philadelphia, PA: Jessica Kingsley. Bright, R. (2002). Supportive eclectic music therapy for grief and loss: A practical handbook for professionals. St. Louis, MO: MMB. Bruhn, H. (2002). Musical development of elderly people. Psychomusicology, 18, 59–75. Byrne, L. A. (1982). Music therapy and reminiscence: A case study. Clinical Gerontologist, 1(2), 76–77. Cevasco, A. M., & VanWeelden, K. (2010). An analysis of songbook series for older adult populations. Music Therapy Perspectives, 28(1), 37–78. Chen, S., Lin, H., & Jane, S. (2009). Perceptions of group music therapy among elderly nursing home residents in Taiwan. Complementary Therapies in Medicine, 17(4), 190–195. Clair, A. (1991). Rhythmic responses in the elderly and their implications for music programming. Journal of the International Association of Music for the Handicapped, 6(1), 3–11. Clair, A. A., & Memmott, J. (2008). Therapeutic uses of music with older adults (2nd ed.). Silver Spring, MD: American Music Therapy Association. Darnley-Smith, R. (2002). Music therapy with elderly adults. In A. Davies & E. Richards (Eds.), Music therapy and group work: Sound company (pp. 77–89). Philadelphia, PA: Jessica Kingsley. Frail Elderly. (2009). In Taber’s cyclopedic medical dictionary. Retrieved from http://literati.credoreference.com.authenticate.library.duq.edu/content/entry/tcmd/frail_elderl y/0

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Gibbons, A. C. (1977). Popular music preferences of elderly people. Journal of Music Therapy, 14(4), 180–189. Gibbons, A. C. (1983a). Primary measures of music audiation scores in an institutionalized elderly population. Journal of Music Therapy, 20(1), 21–29. Gibbons, A. C. (1983b). Item analysis of the primary measures of music audiation in elderly care home residents. Journal of Music Therapy, 20(4), 201–209. Gibbons, A. C. (1988). A review of literature for music development/education and music therapy with the elderly. Music Therapy Perspectives, 5, 33–40. Glassman, L. A. (1983). The talent show: Meeting the needs of the healthy elderly. Music Therapy, 3(1), 82–93. Hintz, M. R. (2000). Geriatric music therapy clinical assessment: Assessment of music skills and related behaviors. Music Therapy Perspectives, 18(1), 31–40. Holbrook, M. B., & Schindler, R. M. (1989). Some exploratory findings on the development of musical tastes. Journal of Consumer Research, 16, 119–124. Johnson, G., Otto, D., & Clair, A. (2001). The effect of instrumental and vocal music on adherence to a physical rehabilitation exercise program with persons who are elderly. Journal of Music Therapy, 38(2), 82–96. Karras, B. (1987). “You bring out the music in me”: Music in nursing homes. Binghamton, NY: Haworth Press. Kitamoto, F. (2003). Psycho-social aims of music therapy for elderly persons. Voices: A World Forum for Music Therapy, 3(2). Retrieved June 29, 2011, from https://normt.uib.no/index.php/voices/article/viewArticle/128/104 LaRocque, P., & Campagna, P. D. (1983). Physical activity through rhythmic exercise for elderly persons living in a senior citizen residence. Activities, Adaptation & Aging, 4(1), 77–81. Liederman, P. C. (1967). Music and rhythm group therapy for geriatric patients. Journal of Music Therapy, 4(4), 126–127. MDS Applicability. Retrieved from http://www.cms.gov/Research-Statistics-Data-andSystems/Computer-Data-and-Systems/MinimumDataSets20/MDSApplicability.html MetLife (2011). The MetLife study of caregiving costs to working caregivers. Retrieved from http://www.metlife.com/assets/cao/mmi/publications/studies/2011/mmi-caregiving-costsworking-caregivers.pdf Moore, R. S. , Staum, M. J., & Brotons, M. (1992). Music preferences of the elderly: Repertoire, vocal ranges, tempos, and accompaniments for singing. Journal of Music Therapy, 29(4), 236–252. Palmer, M. D. (1983). Music therapy in a comprehensive program of treatment and rehabilitation for the geriatric resident. Activities, Adaptation & Aging, 3(3), 53–59. Pedersen, I. D. (1986). Treatment of depression in institutionalized older persons. Physical and Occupational Therapy in Geriatrics, 5(1), 77–78. Raijmaekers, J. (1993). Music therapy’s role in the diagnosis of psycho-geriatric patients in the Hague. In M. H. Heal & T. Wigram (Eds.), Music therapy in health and education (pp. 126–134). Philadelphia, PA: Jessica Kingsley. Redinbaugh, E. M. (1988). The use of music therapy in developing a communication system in a withdrawn, depressed older adult resident: A case study. Music Therapy Perspectives, 5, 82–85. Reuer, B., Crowe, B., & Bernstein, B. (Ed.). (2007). Group rhythm and drumming with older adults: Music therapy techniques and multimedia training guide. Silver Spring, MD: American Music Therapy Association. Rio, R. (2002). Improvisation with the elderly: Moving from creative activities to process-oriented therapy. The Arts in Psychotherapy, 29(4), 191–201. DOI: 10.1016/S0197-4556(02)00156-9

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Schulkind, M. D., Hennis, L. K., & Rubin, D. C. (1999). Music, emotion, and autobiographical memory: They’re playing your song. Memory & Cognition, 27(6), 948–955. Schweinsberg, M. (1981). Rhythm bands in the nursing home. Activities, Adaptation & Aging, 1(3), 37– 41. Short, A. (1995). Insight-oriented music therapy with residents. Australian Journal of Music Therapy, 6, 4–18. Short, A. E. (1992). Music and imagery with physically disabled elderly residents: A GIM adaptation. Music Therapy, 11(1), 65–98. Smith, D. S., & Lipe, A. W. (1991). Music therapy practices in gerontology. Journal of Music Therapy, 28(4), 193–210. Summer, L. (1981). Guided imagery and music with the elderly. Music Therapy, 1(1), 39–42. Suzuki, A. I. (1998). The effects of music therapy on mood and congruent memory of elderly adults with depressive symptoms. Music Therapy Perspectives, 16(2), 75–80. Thaut, M., & McIntosh, G. (1999). Music therapy in mobility training with the elderly: A review of current research. Care Management Journals: Journal of Case Management; The Journal of Long Term Home Health Care, 1(1), 71–74. Towse, E. (1995). Listening and accepting. In T. Wigram, B. Saperston, & R. West (Eds.), The art and science of music therapy: A handbook (pp. 324–341). England: Harwood Academic Publishers. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (HHS, CMS). (2007). Medicare coverage of skilled nursing facility care (CMS Publication No. 10153). Retrieved from http://www.medicare.gov/publications/pubs/pdf/10153.pdf VanderArk, S., Newman, I., & Bell, S. (1983). The effects of music participation on quality of life of the elderly. Music Therapy, 3(1), 71–81. VanWeelden, K., & Cevasco, A. M. (2007). Repertoire recommendations by music therapists for geriatric clients during singing activities. Music Therapy Perspectives, 25(1), 4–12. VanWeelden, K., & Cevasco, A. M. (2009). Geriatric clients’ preferences for specific popular songs to use during singing activities. Journal of Music Therapy, 46(2), 147–159. VanWeelden, K., & Cevasco, A. M. (2010). Recognition of geriatric popular song repertoire: A comparison of geriatric clients and music therapy students. Journal of Music Therapy, 47(1), 84–99. Vincent, G. K., & Velkoff, V. A. (2010). The next four decades: The older population in the United States: 2010 to 2050. Retrieved from http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/DOCS/p25-1138.pdf Weissman, J. A. (1983). Planning music activities to meet needs and treatment goals of aged individuals in long-term care facilities. Music Therapy, 3(1), 63–70. Zanini, C. R. O., & Leao, E. (2006). Therapeutic choir — A music therapist looks at the new millennium elderly. Voices: A World Forum for Music Therapy, 6(2). Retrieved June 29, 2011, from https://normt.uib.no/index.php/voices/article/view/249/193 Zelazny, C. (2001). Therapeutic instrumental music playing in hand rehabilitation for older adults with osteoarthritis: Four case studies. Journal of Music Therapy, 38(2), 97–113. RESOURCE Neurologic Music Therapy Training Institute. http://www.colostate.edu/dept/cbrm/institute.htm

Chapter 21

Persons with Alzheimer’s Disease and Other Dementias Laurel Young

This chapter provides music therapists with fundamental information on how to work with persons who have mild to moderate and severe dementia (stages defined below). This work may take place in longterm care, hospital, or community contexts (e.g., day programs, hospice, or at the client’s home). The reader should note that Chapter 20 (Abbott) also contains some methods that may be modified for this clinical population.

DIAGNOSTIC INFORMATION Dementia is not a disease but a term used to indicate a range of symptoms associated with a decline in memory and other cognitive skills which in turn affects one’s ability to perform the activities of daily living (ADL) (Alzheimer’s Association, 2012, July 31.). It is caused by irreversible physiological changes in the brain that vary according to the type of disorder. When brain cells die or are not functioning properly, cognition, behavior, and emotions can be affected. Alzheimer’s disease (AD) is the most common form of dementia and accounts for 60% to 80% of cases. It is the sixth leading cause of death in the United States and the fifth leading cause of death in Americans over the age of 65 (Alzheimer’s Association, 2012; Miniño, Murphy, Xu, & Kochanek, 2011). Due to an increase in the number of people over the age of 65, the annual incidence of AD and other dementias is projected to double by 2050 (from 5.2 million to 11–16 million people) unless a way is found to prevent, slow, or stop the disease (Hebert, Beckett, Scherr, & Evans, 2001). Other disorders commonly associated with dementia include vascular dementia, dementia with Lewy bodies (DLB), frontotemporal lobar degeneration (FTLD), Creutzfeldt-Jakob disease, Wernicke-Korsakoff Syndrome, Huntington’s disease, Parkinson’s disease, normal pressure hydrocephalus, and mixed dementia (a combination of AD and vascular dementia). Researchers do not know how many people diagnosed with dementia actually have mixed dementia, but autopsy studies indicate that the condition may be more common than previously realized. Additionally, the combination of these two diseases may have a greater impact on the brain than either one alone (Alzheimer’s Association, 2012, August 1). There is no one definitive test to determine if someone has dementia. The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) contains detailed diagnostic criteria for a variety of major and mild neurocognitive disorders, including AD. The DSM-5 contains some revisions to these criteria. (It is beyond the scope of this chapter to review all of the diagnostic criteria contained in the DSM-IV-TR and DSM-5. Please consult these publications for additional information; also see American Psychiatric Association, 2012, July 1.) Doctors often make a diagnosis based on medical history, family history, physical and neurologic examinations, and laboratory tests, as well as on the characteristic changes in thinking, daily functioning, and behavior

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that are associated with each disorder (Alzheimer’s Association, 2012). Commonly used brief cognitive screening instruments include the Mini-Mental State Examination (MMSE), the Mini-Cog, and the Memory Impairment Screen (MIS) (Holsinger et al., 2012). Some conditions (e.g., depression, thyroid problems, etc.) have symptoms that mimic dementia but, unlike as with dementia, these can be reversed with treatment. Although doctors can diagnose irreversible dementia with a high level of certainty, it can be difficult to determine the exact type, as symptoms of different disorders often overlap. In some cases, a doctor may simply apply a label of dementia and not specify a particular type. According to the Alzheimer’s Association (2012, based on DSM-IV-TR criteria), to be considered dementia, symptoms must include a decline in memory and in at least one of the following abilities: (a) ability to generate coherent speech or understand spoken or written language, (b) ability to recognize or identify objects, assuming intact sensory function; (c) ability to execute motor activities, assuming intact motor abilities and sensory function, and comprehension of the required task; and (d) ability to think abstractly, make sound judgments, and plan and carry out complex tasks (p. 132). Currently, there is no cure for Alzheimer’s disease or most other dementias, and no proven treatment that significantly slows or stops the progression of these diseases. There are pharmacological treatments that may temporarily improve some symptoms, but these must be used with caution as elderly people often have a heightened sensitivity to the effects of drugs (American Psychiatric Association, 2010). Ultimately, persons with dementia require individualized and multimodal treatment plans that change over time to suit their needs as the disease progresses (American Psychiatric Association, 2010; Alzheimer’s Association, 2012).

NEEDS AND RESOURCES General Characteristics As the majority of persons with AD or other dementias are over the age of 65 (Alzheimer’s Association, 2012), they will experience many of the typical aging processes outlined by Abbott in Chapter 20. However, persons with AD and other dementias also “display a wide range of cognitive impairments and neuropsychiatric symptoms that can cause significant stress to themselves and caregivers” (American Psychiatric Association, 2010, p. 11). Cognitive symptoms include impairments in memory, executive function, language, judgment, and spatial abilities. Neuropsychiatric symptoms may include depression, suicidal ideation or behavior, hallucinations, delusions, agitation, aggressive behavior, disinhibition, sexually inappropriate behavior, anxiety, apathy, wandering, social withdrawal, and disturbances of appetite and sleep. Some individuals experience a peak period of agitation, referred to as sundowning, as the evening hours approach (American Psychiatric Association, 2010). Although cognitive decline is generally not reversible, neuropsychiatric symptoms can often be improved with treatment, including music therapy intervention. Many dementias are progressive, meaning that symptoms gradually worsen over time. Studies indicate that persons over 65 have a mean survival rate of four to eight years after diagnosis, but some can live as long as 20 years (Brookmeyer, Corrada, Curriero, & Kawas, 2002; Ganguli, Dodge, Shen, Pandav, & DeKosky, 2005; Helzner et al., 2008; Larson et al., 2004; Xie, Brayne, & Matthews, 2008). Additionally, more of these years are generally spent in the most severe stage of the disease (Arrighi, Neumann, Lieberburg, & Townsend, 2010). Although the scientific validity of staging criteria has been called into question (American Psychiatric Association, 2010; Olde Rikkert et al., 2011), it is helpful to delineate general stages of dementia so that the rationale for particular music therapy methods and adaptations can be understood and applied in a manner that best suits the needs of each client. The American Psychiatric Practice Guideline (American Psychiatric Association, 2010) also notes that “whatever the intervention, it

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is critical to match the level of demand on the patient with his or her current capacity, avoiding both infantilization and frustration” (p. 19). The Clinical Dementia Rating Scale (CDR) is commonly used to stage the severity of dementia (Morris, 1993) and is currently the best-evidenced scale (Olde Rikkert et al., 2011). Stages of dementia presented in this chapter are overarching summaries of stages contained in the CDR. For more information, see http://alzheimer.wustl.edu/cdr/downloadselectionpage.htm. Persons with questionable dementia have slight but consistent memory problems and may exhibit mild functional impairment. Symptoms are subtle and are often consistent with those of normal aging (see Chapter 20). Persons with mild dementia have moderate memory loss, especially for recent events, and have difficulty with daily activities such as balancing a checkbook or preparing a complex meal. They may experience difficulty in functioning independently at social events. Persons with moderate dementia experience more profound memory loss and retain only highly learned material. They are disoriented with respect to time and place, lack judgment, and have difficulty handling problems. They have little or no ability to function independently. Persons with severe dementia are not oriented with respect to time or place and require total assistance with personal care. However, research indicates that some measurable cognitive abilities remain (Auer, Sclan, Yaffee, & Reisberg, 1994). In the terminal phase, individuals become bed-bound, require constant care, and are susceptible to accidents and infectious diseases that may prove fatal (American Psychiatric Association, 2010). After reviewing the above characteristics, one may feel that the prognosis of persons diagnosed with dementia is rather bleak and hopeless. However, it is crucial for health care providers, caregivers, and loved ones to understand that aspects of one’s essential character, of personality and personhood, of self, survive—along with certain, almost indestructible forms of memory—even in very advanced dementia. It is as if identity has such a robust, widespread neural basis, as if personal style is so deeply engrained in the nervous system, that it is never wholly lost (Sacks, 2007, p. 336). This means that we must do more than simply control or treat the textbook symptoms of dementia. As a society, we have a moral obligation to support the unique identity that still exists within each person and help millions of people (who may include our friends, neighbors, community leaders, and loved ones) to maintain their dignity and have a reasonably good quality of life. Music therapy is an essential part of this mission.

Musical Characteristics Music therapists work under the premise that all persons, regardless of musical experience or background, have a fundamental ability to perceive, enjoy, and/or respond to music. An exception to this may be persons who have neurological issues that affect musical functioning, such as congenital amusia. Persons with this condition have extreme difficulties appreciating, perceiving, and memorizing music. This is possibly due to a deficit in fine-grained pitch discrimination that prevents the normal development of neural networks that ascribe musical function to pitch (Peretz & Hyde, 2003). However, areas of musical functioning are very often preserved in persons with dementia and, in fact, musical perception, sensibility, emotion, and memory can survive and may even be heightened long after other forms of memory have disappeared (Cuddy et al., 2012; Gagnon, Gosselin, Provencher, & Bier, 2012; Sacks, 2007). The ability to play a musical instrument (procedural musical memory) is often spared in persons with AD (Baird & Samson, 2009; Beatty et al., 1999). Studies have shown that new musical learning can occur in both musicians (Crystal, Grober, & Masur, 1989; Fornazzari et al., 2006) and nonmusicians (Cevasco & Grant, 2006; Prickett & Moore, 1991) who have dementia. All of these findings support the hypothesis that the brain has a memory system for music that is wholly or partially unaffected by most dementias and that this system may be functionally and physiologically distinct from other domains such as verbal and visual memory (Peretz, 1996; Peretz & Coltheart, 2003; York, 1994). Assessing musical memory and other

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musical functions in persons with dementia may provide insight into preserved cognitive skills that can be used to design therapeutic interventions that target both musical and nonmusical domains of functioning (see the section below on assessment). As noted by neurologist and author Oliver Sacks, “music is no luxury [to persons with dementia], but a necessity” (2007, p. 347). Music therapists are in a unique position to provide theoretically informed and skillfully designed music programs and interventions that address the complex needs of persons with dementia.

MULTICULTURAL CONSIDERATIONS In the present chapter, the term multicultural is being defined to include significant reference groups such as those related to race, ethnicity, religion, sexual orientation, gender, age, disability, and socioeconomic status (Sue & Sue, 2003). All music therapists, regardless of the clinical population, must develop appropriate, relevant, and sensitive intervention strategies that take a wide range of multicultural issues into account. Moreno (1988) stressed the need for music therapists to not only have a basic working knowledge of world music genres, but also gain understanding of the cultural implications of clients’ musical traditions. Unfortunately, very little has been written to address multicultural considerations that are specific to music therapy intervention with clients who have dementia. The following paragraphs contain a brief overview on this topic. As outlined by Abbott in Chapter 20, it is essential for music therapists to use music in a way that respects individuals’ cultural affiliations as well as the cultural norms of particular contexts. However, it may often be the case that an individual with dementia is unable to verbally articulate his musical preferences and/or cultural practices. In these situations, the music therapist should use all available means to find out as much as she can about a client’s cultural background, personal history, and personal music preferences before engaging that client in music experiences. This may be done by speaking to family members or friends, reviewing information contained in the client’s chart, speaking to relevant health professionals (e.g., primary nurse, family doctor, social worker, etc.), or, when possible, noting the potential cultural significance of personal objects displayed in the client’s personal living space. If cultural information is limited, it may be best for the music therapist to begin by using improvised music or original compositions to assess a potential client’s responses to music in general. In this way, the music therapist is less likely to use music that inadvertently disrespects a client’s cultural norms or use music that may elicit an abreactive response (e.g., when music triggers memories of a past trauma such as war). It may also be necessary for music therapists to educate professional and volunteer caregivers about cultural issues related to music. The current author has observed occasions when well-meaning persons were singing hymns or Christmas carols to persons with dementia who were not of the Christian faith. Other instances involved facility staff using music (live or recorded) to comfort or stimulate clients during times that contradicted these individuals’ cultural/spiritual traditions. For example, there are designated holy days when persons who adhere to particular Jewish traditions are prohibited from playing or listening to music. In situations observed by the current author, the individuals with dementia were unable to articulate their beliefs or preferences and were most likely not oriented to time and place. Furthermore, some of these individuals exhibited positive responses to the music (smiling, clapping, singing along, etc.), which further reinforced those who were providing the music. However, these positive responses were most likely a reaction to the music stimulus in and of itself, and these individuals were unable to consciously comprehend the cultural content or implications of the music. It is essential to consider what the individual with dementia would want if he were able to make an informed choice. Family members may also become quite upset if they discover that their loved one is participating in activities that contradict his cultural traditions or religious beliefs.

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In addition to musical considerations, a multicultural approach to music therapy encompasses a vast array of cultural issues (Young, 2009). When working with clients who have dementia, music therapists must also consider the following: 1) Race and ethnicity. As ethnic diversity increases in the general population, so too will it increase in the population of persons diagnosed with dementia. Cultural background may influence the ways in which symptoms present in persons with dementia as well as the ways in which their families respond to and interpret these symptoms (American Psychiatric Association, 2010). In contexts where persons with dementia interact, individuals may exhibit disrespectful behavior toward one another. These behaviors may be an expression of individuals’ belief systems, but it may also be the case that socially inappropriate behaviors are occurring due to physiological changes in the brain that affect personality. In either case, reasoning with these individuals is usually not effective as they are unable to process and/or retain the information. The music therapist must redirect these behaviors or find ways to prevent them from occurring in the first place. Programs and interventions must be designed in ways that embrace and respect the values and needs of persons from all ethnic backgrounds. Music therapists also need to become aware of their own values and assumptions and understand how these may affect their work with culturally different clients. 2) Needs of different age cohorts. Although the vast majority of persons with dementia are over the age of 65, they do not all belong to one single age cohort. As older people often respond positively to the popular music of their youth (Cohen, Bailey, & Nilsson, 2002), music therapists must consider the musical preferences (and other relevant historical aspects) of several generations—not just one or two. Additionally, the younger-onset population (under the age of 65) is growing and is often associated with a more rapid rate of decline (Alzheimer’s Association, 2012; Swearer, O’Donnell, Ingram, & Drachman, 1996). Programs and interventions must be designed in ways that recognize the life experiences and needs of various age cohorts. 3) Gender-specific needs. More women than men have dementia, which is most likely due to the fact that on average, women live longer than men (Alzheimer’s Association, 2012). This, in addition to the fact that significantly more music therapists (and frontline caregivers overall) in North America are women (American Music Therapy Association, 2012; Centers for Disease Control and Prevention, 2012, October 1), suggests the possibility of unintentional gender bias when it comes to dementia care. Programs and interventions must be designed in ways that meet the gender-specific interests and needs of both men and women. 4) Sexual orientation. Lesbian, gay, and bisexual (LGB) people with dementia face many unique challenges. They are more likely than heterosexual people to be single and less likely to have children and receive regular family support (Alzheimer’s Society, 2013, March 31). They may be fearful due to discrimination experienced in the past and may even unintentionally out themselves, as sexuality can be more overtly expressed in all persons with dementia due to reduced inhibition (Alzheimer’s Society, 2013, March 31). Programs and interventions must be designed in ways that promote a nonjudgmental environment where all individuals feel a sense of safety, acceptance, and respect. 5) Social class. People with fewer years of education appear to be at higher risk for developing dementia than those with more years of education. One theory proposes that more educated individuals have a cognitive reserve that enables them to compensate for changes in the brain or that persons in lower socioeconomic groups are at increased risk

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for disease in general and have less access to medical care (American Psychiatric Association, 2010). Programs and interventions must be designed in ways that recognize the life experiences and needs of persons from different socioeconomic backgrounds.

CONTEXTUAL CONSIDERATIONS Approaches to treatment are influenced by context—as certain issues are unique to particular care settings (American Psychiatric Association, 2010). Therefore, not all of the music therapy interventions presented in this chapter will be appropriate for all contexts. Additionally, the level of care or types of interventions used may change over time as persons with dementia often move from one level of care (or location) to another during the course of their disease. Approximately two-thirds of persons with dementia live at home and receive care on an outpatient basis—often in conjunction with family support (American Psychiatric Association, 2010). Although exact numbers are not known, it is estimated that approximately 800,000 (15.4% of 5.4 million) Americans with dementia live alone in the community. Although these persons are most often in the early stages of dementia, these individuals are at increased risk in terms of health and safety issues (Alzheimer’s Association, 2012). Music therapists who see clients in their homes may focus on providing positive stimulation and/or emotional support, or on alleviating a specific problem (e.g., the use of music to promote cooperation during personal care). They may engage caregivers in music experiences with their loved ones (see examples throughout this chapter) or, conversely, this time may provide caregivers with a short break. End-of-life care for persons with dementia may also happen in the home, and this often involves unique stressors (Patrick & Avins, 2005). Persons with dementia who live at home may attend day programs designed to provide social stimulation in a safe environment. These programs may also be a source of much-needed respite for caregivers, and sometimes they also offer them various kinds of psychoeducational support. Because overstimulation can be an issue for some individuals with dementia, social activities must be thoughtfully designed and implemented with care. Problems may also arise when persons with different levels of dementia are expected to participate together in the same activities (American Psychiatric Association, 2010). Some day programs separate attendees into different groups according to level of functioning (Chavin, 1991). It is the current author’s experience, however, that persons of varying levels of functioning can successfully participate in certain types of group music therapy intervention or skillfully executed sing-along–type programs. This may be due (at least in part) to the fact that some if not all of the musical functions of the brain remain intact throughout the various stages of dementia (as described above). Furthermore, some individuals’ level of musical participation seems to increase when others in the group (peers, volunteers, or staff) model an active level of participation (Christie, 1995). Therefore, persons at various stages of dementia may be on a relatively level playing field (so to speak) when placed in appropriately structured musical contexts. Music therapists may utilize a wide range of interventions in day programs although the scope of practice normally aligns with the overall goals of the program—which generally address social, recreational, cognitive, behavioral, and sensory domains of functioning (AhonenEerikainen, Rippin, Sibille, Koch, & Dalby, 2007; Jennings & Vance, 2002; Kelleher, 2001; MercadalBrotons, 2011). Many persons with dementia will ultimately require placement in long-term care. Approximately two-thirds of residents in long-term–care facilities have dementia (American Psychiatric Association, 2010; Magaziner et al., 2000). “Placement is usually due to progression of the illness, the emergence of behavioral problems, the development of intercurrent medical illness, or the loss of social support” (American Psychiatric Association, 2010, p. 40). Although it is not always the case, persons with dementia

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may be assigned to designated units/areas in long-term–care facilities where accommodations are made to meet their needs. The extent of these accommodations, however, can vary widely from facility to facility. Some focus largely on addressing basic safety and physical care needs, whereas others provide specialized programs in carefully designed environments. For an example of a state-of-the-art dementia care facility, where music and art therapy are an integral part of the program, please see: http://sunnybrook.ca/content/?page=veterans_dementia_care_dorothy_macham_home. A music therapist’s scope of practice in a long-term–care context can depend greatly on the nature of her position at the facility. Many music therapists work on a contractual basis through which they provide a few hours of music therapy services a week (group and/or individual) at a particular facility. Often, these music therapists have limited access to information about their clients and interactions with other staff, and may not be permitted to read or write in residents’ health care charts. Although these programs can greatly improve the quality of life of persons with dementia, goals are often designed to address clients’ needs in the moment since other information is unknown or limited. Conversely, music therapists who hold facility positions and are integrated into multidisciplinary care teams are able to design programs and implement interventions that align with residents’ care plans and overall treatment goals. They may have the opportunity to colead or design programs in conjunction with other professionals, such as speech therapists (Bolton, 2012), physical therapists (Johnson, Otto, & Clair, 2001; Pacchetti et al., 2000), or spiritual care practitioners (Kirkland & McIlveen, 1999). Music therapists may also assist staff in learning how to effectively use music in conjunction with various activities of daily living (ADL; e.g., bathing) (Thomas, Heitman, & Alexander, 1997). There may be opportunities to educate staff about the potential breadth of services (i.e., that music therapy is not limited to social or recreational goals) and thus receive a wide variety of suitable referrals for persons who could truly benefit from music therapy intervention. They may be called upon to train or oversee musical entertainers or volunteers to ensure that these individuals provide suitable musical programming. Finally, they may serve in a consultant role by helping to design and/or implement policies and procedures that enhance facility sound environments. These may focus on various issues such as the reduction of extraneous sound (e.g., turning off televisions that people are not watching) or monitoring the use of music in common areas (e.g., the dining room) to ensure that it meets the unique needs of persons with dementia (Campbell & Young, November, 2010; Mazer, 2010; Mercado & Mercado, 2006; Whitcomb, 1994). While living at home or in long-term care, persons with dementia may need to be admitted to an inpatient facility (e.g., general medicine or psychiatric unit) for the treatment of psychotic, affective, or behavioral symptoms as well as for general medical conditions. Persons with dementia who are admitted to inpatient units are at particular risk in three areas: (a) behavioral problems due to fear, lack of comprehension, and lack of memory of what they have been told; (b) delirium, especially due to medications; and (c) difficulty in understanding and communicating pain, hunger, and other uncomfortable states (American Psychiatric Association, 2010, pp. 41–42). In short-term inpatient treatment contexts, music therapists may use interventions that help to calm patients’ anxiety, reduce agitation, facilitate cooperation with ADL/medical procedures, promote relaxation/sleep, and enhance the environment and overall quality of their stay. At the end of life, persons with dementia may be cared for in a long-term–care facility, hospital, or hospice program, or at home. On occasion, a hospice music therapist will be called upon to provide services to individuals who reside in long-term care (Patrick & Avins, 2005). Persons who are in the early stages of dementia will have at least some awareness regarding their prognosis, and in these cases, approaches to music therapy are similar to those outlined by Clement-Cortés on end-of-life care in Chapter 12, Volume 4, of this series (Guidelines for Music Therapy Practice in Adult Medical Care). As always, the music therapist would adjust the methods to meet the specific needs of the individual. For those who are unable to cognitively understand, retain, or process what is happening, music therapists

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need to provide interventions that elicit feelings of comfort and safety for that individual and not use language that could elicit fear or anxiety (Bright, 1997). Music elements utilized should be chosen with great care, as the quality of voice, instruments chosen, tempo, etc., can have particular impact on a person with dementia who is also in a palliative care context. “These decisions are best grounded in the music therapist’s training and intuition” (Patrick & Avins, 2005, p. 80). The music therapist must also listen carefully to what may seem like incoherent verbalizations as the individual may be trying to communicate an important message. The music therapist can validate and acknowledge this message through words and/or music as well as communicate this message to caregivers and/or loved ones (Patrick & Avins, 2005). Caregivers and loved ones of persons with dementia often experience conflicting feelings about their loved one’s impending death that include emotions such as relief, sadness, guilt, helplessness, etc., Music therapists can provide overarching support to family members/caregivers but can also help them to cope with these feelings by involving them in bedside music interventions with their loved ones—allowing them to feel involved and useful during the last days of care and helping them to work through some of their own feelings through the music (Bright, 1997; Patrick & Avins, 2005). Personalized music experiences can be a particularly effective and intimate way for loved ones to say good-bye or achieve a sense of closure when words are not possible. Overall, it is important to remember that persons with dementia gradually lose the ability to effectively cope with various aspects of their environment—especially if that environment is unfamiliar. Some exhibit what appears to be an acute decline in functioning when they move from their home into a long-term–care facility (e.g., increased withdrawal, confusion, anxiety, agitation, aggression, and/or disinhibition). However, it may simply be the case that the individual was better able to compensate for his deficits in a familiar home environment. When interacting with clients who have dementia, there are some simple guidelines that music therapists can follow to help clients feel more at ease in their environment and thus increase their potential to benefit from music therapy (and other) interventions. These guidelines emerged from the current author’s own knowledge and experience but are also informed by Bright (1997) and Chavin (1991): 1) Use simple and clear language/directions. Establish eye contact so that the person knows you are communicating with him. Provide frequent reminders as well as sensory and gestural cues when needed. Avoid asking too many questions and especially ones that are open-ended (e.g., rather than “What kind of music do you like?,” ask “Do you prefer classical music or country music?”). Use a calm and reassuring tone of voice. Use humor and praise when appropriate. Slow down and be patient. Too much information can overwhelm the client. 2) Redirect a client’s attention (using words, music, gestures, another activity, etc.) when he becomes fixated on something negative or when he exhibits difficult behaviors. Do not correct or reprimand a client for inappropriate behavior. If a client cannot be redirected, music therapy may be contraindicated at that time. Try again later. 3) Listen for the meaning behind a client’s words even if they do not make sense (e.g., if an elderly client indicates that he is looking for his mother, he may be feeling lonely, lost, worried, etc.). 4) Do not argue, correct, or try to reason with a client about his perception of reality. Either redirect the conversation or validate the client’s perspective and move on to another activity or topic. 5) Do not take socially inappropriate comments or negative reactions personally. Remain calm and use redirection.

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6) Do not share upsetting information with a client that he is unable to process and/or retain (e.g., do not tell a client that his mother passed away many years ago if he believes that she is alive; gently redirect the conversation). 7) Do not talk about a client in front of him and/or assume that he cannot understand what you are saying. 8) Do not approach clients from behind, and avoid sudden movements. Explain and/or demonstrate what you are about to do (e.g., “I am going to move your chair nearer to the drum”). 9) Present instruments (or other objects) in a nonthreatening manner. Use hand-over-hand (when culturally acceptable) to help initiate participation but not necessarily to maintain it. 10) Some clients may have visual agnosia (i.e., they are unable to recognize the intended function of an object) or they may use instruments in a perseverative rather than a musically meaningful manner. Instrument-playing may be contraindicated for these clients. 11) Some clients are sensitive to particular timbres or may become overstimulated by too many sounds happening at once. Limit sound stimuli accordingly (e.g., too many percussion instruments may result in chaos and be countertherapeutic). Individual rather than group music therapy sessions may be indicated for persons who are particularly sensitive to sound. 12) Clients may appear not to recognize you from week to week, but over time, their actions may seem to imply a sense of familiarity. Be aware of clients’ intuitive sense of knowing and build upon this potential when designing interventions. Do not ask a client if he remembers you or what he did in his last session. 13) Generally, the more advanced the stage of dementia, the smaller the group must be. If one has to work alone (i.e., no assistants), it may be more beneficial to spend five minutes with ten individuals than to try to have a one-hour group session with ten people. If working in a group, seat people in circles or semicircles (not rows) to facilitate maximum interaction with the therapist. 14) Sometimes, it is better to work with clients in their unit or in their room rather than taking them out of their unit (e.g., to a designated music therapy space) where surroundings feel unfamiliar. Furthermore, there may be multiple safety issues to consider (e.g., toileting, wandering, aggressive behavior due to confusion, etc.). On the other hand, music therapy sessions held in spaces that are designated for other activities (e.g., a dining area) may be confusing for some clients. 15) Finally, assess the client’s environment to try to determine what may be causing a particular negative reaction or behavior. It is possible that adjustments may be made in the environment, which may help to support each client’s potentials (strengths) rather than highlight/exacerbate his deficits.

ASSESSMENT AND REFERRAL As noted above, a diagnosis of dementia “is [primarily] based on behavioral assessments and cognitive tests that highlight quantitative and qualitative changes in cognitive functions and activities of daily living, which are characteristic of the dementia syndrome and its underlying diseases” (Olde Rikkert et al., 2011, p. 357). Staging scales (e.g., the Clinical Dementia Rating [CDR] scale, Morris, 1993) or standardized tools to assess behaviors (e.g., the Cohen-Mansfield Agitation Inventory; Olde Rikkert et al.,

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2011; Weiner et al., 2002) may be used to describe and monitor clinical changes over time (American Psychological Association, 2013, January 30). Music therapy researchers have suggested that ongoing assessment of musical functioning would also provide a noninvasive and effective approach to monitoring clinical changes (Aldridge, 1998; Aldridge, 2000; Aldridge & Aldridge, 1992; Aldridge & Brandt, 1991; Lipe, 1995; Lipe, York, & Jensen, 2007; York, 1994). However, based on a review of the literature and the current author’s experience, it appears that these procedures are used more commonly in research than in day-to-day practice. Typically, assessment procedures (especially in long-term care or other inpatient settings) involve the collection of profession-specific data by various multidisciplinary health professionals that is entered into an official health care record or chart. These data may be documented as progress notes (e.g., SOAP: Subject, Object, Assessment, and Plan, or DART: Description, Assessment, Responses, Treatment). Formal assessment procedures may also be used. These include tools such as the Minimum Data Set (MDS; van der Steen et al., 2006), which provides a comprehensive interprofessional evaluation of an individual’s functional abilities, or PointClickCare®, a form of electronic documentation commonly used in long-term–care facilities by the health professional team to manage the entire life cycle of each resident’s care (PointClickCare®, 2013, April 18). The information obtained from the assessment is subsequently used to develop a care plan, which addresses the identified medical, practical, and/or psychosocial needs of each individual. Music therapists often contribute to these interprofessional forms of documentation by entering a summary of the results of their own assessment. However, they may or may not be able to include a copy of the music therapy assessment tool that they used in clients’ health care records/charts. Many facilities allow only approved forms in these charts, and there are various legal, philosophical, and logistical reasons as to why this is the case. When music therapists complete clinical documentation that is not included in clients’ official health care charts, they need to adhere to the privacy policies of their institution (or state/province/country/professional regulatory body) and store their documentation accordingly. Depending on the context and/or on the procedures of a particular facility or program, referrals to music therapy may be made informally (e.g., through a verbal request) or may involve a formal procedure (e.g., a referral/request for consult form). Music therapists follow up on referrals by conducting a global music therapy assessment which determines how music experiences or interventions may be used to maintain or improve various domains of functioning (e.g., psychosocial, emotional, behavioral, cognitive, sensory, etc.). This assessment often occurs over the course of two or more sessions. Additionally, pertinent background information is gathered (including information about musical preferences and experiences) by reviewing the client’s chart and, when possible, by speaking to persons who know the client (e.g., family, other health care professionals, etc.) or the client himself. The music therapy assessment tools identified by Abbott in Chapter 20 may be adapted for use with clients who have mild to moderate dementia (Hintz, 2000; Raijmaekers, 1993). A brief assessment protocol and tool created by Norman (2012) is suitable for use with various clients in long-term care—including those who have mild to moderate dementia. A descriptive music therapy assessment model formulated by MunkMadsen (2001) may be adapted for use with clients who have mild, moderate, or severe dementia. This author suggests that the assessment sessions be video recorded or an outside observer be used in order to gather the necessary detailed information. Music therapists will often create original assessment protocols and templates based on their own practical experience, knowledge, and philosophical orientation. Some music therapists may use a musicbased assessment protocol to assess clients’ music skills (e.g., rhythmic skills, melody/pitch recognition, etc.) and preferences. As noted above, these music-based assessments may reveal diagnostic information related to general cognition (Aldridge, 1998; Aldridge, 2000; Aldridge & Aldridge, 1992; Aldridge & Brandt, 1991; Lipe, 1995; Lipe, York, & Jensen, 2007). However, information pertaining to various domains of musical functioning may also help to determine the types of music experiences or

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interventions that may be most effective in assisting a client to achieve nonmusical clinical goals or optimal musical engagement (Bright, 1997; Clair, Mathews, & Kosloski, 2005). Published music-based assessment protocols for persons with dementia include Music Skills Assessment (Bright, 1997); Residual Music Skills Test (York, 1994); and Music-Based Evaluation of Cognitive Functioning (Lipe, 1995). No matter which assessment tool or approach is used, unless music therapy is contraindicated, music therapists ultimately establish goals for clients based on the results of their assessment. Broad, overarching goals for persons with dementia typically include improving quality of life, maximizing potential or functions within the context of existing deficits, and improving or maintaining cognitive skills, social skills, motor skills, mood, and/or behavior (American Psychiatric Association, 2010). An individualized music therapy treatment/intervention plan is formulated to determine how these goal areas (and emergent goal areas) will be addressed (e.g., in open-group, closed-group, and/or individual sessions; the time, location, frequency, and duration of sessions; the types of music interventions/experiences/ methods to be utilized, etc.). This plan may also indicate how progress is operationally defined and subsequently measured for each goal over time (e.g., through quantitative ratings, qualitative observations, frequency recording, etc.). When implementing treatment plans, it is important to note that some persons with dementia may not have the capacity to fully understand what is being offered when they are invited to attend music therapy. Furthermore, their ability to make an informed decision can fluctuate according to time and circumstances. Music therapists must learn how to most effectively present the option of participating in music therapy to each client (i.e., in an individualized way) and provide him with ongoing opportunities to give implied consent (e.g., the therapist can note how the individual actually responds to a brief music intervention as opposed to a direct question) and informed expressed consent (when possible). If an individual’s authentic wishes reveal that he does not want to participate in music therapy, these wishes should be respected and not overruled by what the therapist, other staff, and/or family feel is best (Mitty, 2012). These wishes should be reassessed over time as the individual’s circumstances and needs change.

OVERVIEW OF METHODS AND PROCEDURES An extensive literature review highlighted considerable diversity in the ways in which music therapy methods are described and utilized with persons who have dementia. In an attempt to organize, synthesize, and clarify these methods, the current author grouped similar music therapy interventions into categories. She then created a comprehensive description of each overarching method (i.e., category), integrating additional information derived from her clinical knowledge and experiences. Sources used to help formulate the guidelines are cited at the end of each method and where relevant, unique contributions from specific sources are noted. A music therapy session may be limited to one method, or alternatively, one session may contain several methods/interventions. Although some methods/interventions may be adapted for use by non–music therapists (as indicated throughout when applicable), the guidelines contained in this chapter were compiled for use in practice by professional music therapists or music therapy students/interns who are receiving clinical supervision.

Receptive Music Therapy •

Moving/Exercise to Music: Participants move their bodies in response to live or recorded music provided by the music therapist in combination with verbal, visual, gestural, and/or sensory cues.

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Dancing with Spouse/Loved One: The music therapist helps to facilitate engagement between a client and a spouse/loved one through the use of dancing in a group and/or private session context. Environmental Music: The music therapist designs recorded music programs that are used to create a supportive or therapeutic sound environment for a group of clients in a particular context (e.g., dining area). Music-Supported Personal Care: The music therapist provides personalized live or recorded music programs for individual clients during care activities such as bathing, toileting, dressing, and administration of medication. Relaxation through Music Listening and Imagery: The client listens to specially programmed live or recorded music in an individual private session to evoke peaceful and relaxing imagery experiences. Music-Assisted Life Review: The music therapist uses personalized music experiences with a client to evoke significant life memories, facilitate a sense of connection to one’s self/identity, and/or provide closure at the end of life. Loved ones may also participate in some or all of the sessions. Therapeutic Singing for Individuals with Severe Dementia: individual sessions where the music therapist sings preferred songs to (or vocalizes with) individuals who have severe dementia. This intervention can involve a wide variety of therapeutic goals. Music-Assisted Sensory Stimulation Theme Groups: small group sessions for persons with severe dementia, where the music therapist helps to stimulate clients’ senses within a structured and supportive environment. Sensory Stimulation Using Instruments/Vibrotactile Stimulation: The music therapist uses tactile stimulation and vibrations produced by musical instruments to elicit a sensory response. Vibroacoustic Stimulation with Music: The client reclines on a specially designed mat, bed, or chair that is embedded with speakers that convert specific frequencies into vibrations while listening to live or recorded music that is programmed by the music therapist.

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Small Group Improvisation: The music therapist creates an improvised musical structure based on sounds and/or music expressed by group members (4–6 participants). Playing Percussion Instruments: Clients play percussion instruments in response to a musical and/or rhythmic structure provided by the music therapist. Nordoff Robbins Music Therapy—Individual Improvisation: the development of a musical relationship between therapist and client through improvisation, which is considered to be the vehicle of therapy. Soundbeam® Improvisation: The Soundbeam® is programmed by the music therapist and uses motion sensors to translate body movements into musical sounds of varying pitch and intensity, which in turn provides clients with an accessible avenue for creative self-expression.

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Re-creative Music Therapy •

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Group Sing-Along: The music therapist sings precomposed songs in a group setting with live musical accompaniment to address a diverse range of general and/or specific therapeutic goals. Music Reminiscence Groups: The music therapist uses live and/or recorded precomposed music to enhance and/or promote participation in reminiscence discussion groups. Community Music Therapy Performance: The music therapist facilitates opportunities for clients (individual or group) to experience the joy of performing with and for others in a supportive and accepting environment. Intergenerational Music Therapy Programs: see Chapter 20. Lyric Analysis: The music therapist uses lyrics from familiar songs (verbally and musically) to convey a positive message or to validate a client’s feelings. Playing a Familiar (Known) Instrument: The music therapist provides the client (also a musician) with resources, support, and/or adaptations needed to play a preferred (known) musical instrument.

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Group Songwriting: The music therapist composes lyrics for clients or provides a directed structure wherein clients can compose lyrics related to a relevant group theme. The music therapist sets these lyrics to music using a pre-existing or original melody. Recorded Music Collages: In collaboration with the client, the music therapist compiles a collage (collection) of music recordings that are significant or meaningful for the client. This may include recordings of music made during the client’s own music therapy sessions.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Receptive methods described in Chapter 20 that require comprehension of language and/or verbal response may be utilized or adapted for persons with mild dementia. However, these methods are used less frequently or may even be contraindicated for persons who have moderate to severe dementia. Receptive methods contained in the current chapter may also need to be adjusted according to individuals’ receptive and expressive language abilities as well as their ability to retain and/or process information. If an individual with moderate to severe dementia responds verbally to a receptive music therapy experience, the therapist needs to validate the client’s response in a way that best meets his needs and abilities. If the response is constructive (e.g., the client shares meaningful memories or feelings) and/or aligns with the established therapeutic goals, the therapist can encourage the client to stay with that feeling, work through that feeling, and/or build upon this response. If the response is negative (e.g., the client becomes fixated on feelings of sadness, fear, anger, anxiety, etc.), the therapist needs to acknowledge the client’s feelings, allow a brief period for expression of these feelings (unless the client is extremely agitated), and then gradually redirect him toward another topic, activity, and/or intervention that better meets his current needs. Like everyone, persons with dementia have a right and a need to express a broad spectrum of emotions. However, the music therapist must assess the extent to which each individual is able to cognitively process difficult emotions and, if clinically indicated, determine the most suitable modality through which he can express these emotions (verbal and/or nonverbal).

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Moving/Exercise to Music Overview. Participants move their bodies in response to live or recorded music provided by the music therapist in combination with verbal, visual, gestural, and/or sensory cues. This method usually occurs in a group setting where individuals sit in chairs or wheelchairs, although some may prefer to stand depending upon their physical condition, therapeutic needs, and/or the nature of a particular movement activity. Group size depends upon the needs of the clients and the amount of staff/volunteer support available. Duration is approximately 30–45 minutes but can vary depending upon clients’ needs and abilities. This intervention is indicated for individuals with mild to moderate dementia who are at risk of physical deterioration and/or loss of skills because they do not initiate independent movement, as well as for those who need a constructive outlet for agitation, restlessness, and/or self-expression. This intervention is contraindicated for individuals who are too physically frail or exhausted from pacing, do not willingly move in response to the stimuli or cues provided, and/or may become overstimulated by this experience. The main goals for the clients are to maintain or improve physical condition or abilities, decrease agitation or disruptive behaviors by focusing attention on a structured activity, discharge anxiety or tension, increase self-expression through purposeful movement, improve mood, increase socialization, and/or stimulate cognitive function. The level of therapy is augmentative. Preparation. Determine individuals who may be appropriate for this program through an assessment and/or referral process. Secure an open space where interruptions will be minimal. Design movement programs that are supported by live or recorded instrumental music, taking the stylistic preferences of the clients into consideration (see program structure described below in Procedures). Although song lyrics may be used to prompt specific movements, participants will often stop moving and sing along, so songs (i.e., music with lyrics) should be used sparingly, if at all (Cevasco & Grant, 2003; Johnson, Otto, & Clair, 2001). If possible, consult with an appropriate professional (a physical therapist or a dance movement therapist) to ensure that particular movements are safe for clients and/or to discuss ideas for movement programs in general. If using live music, one group leader is needed to play the music (often on piano) and another is needed to cue the movements (e.g., a health care professional or trained volunteer). Depending upon the size of the group and the needs of the clients, it may be helpful to have volunteers, other staff members, or higher functioning peers participate in the group to provide additional modeling, cuing, and motivation for the clients (Christie, 1995) as well as for safety considerations. What to observe. Notice unique movements initiated by individuals and incorporate these into the program. Provide additional cuing for those who are not responding. Look for early signs of anxiety (e.g., body language, facial expression, etc.) to prevent clients from becoming agitated or overstimulated. Procedures. Arrange clients in a circle or semicircle (seated). For ambulatory persons, use straight-back chairs that accommodate individuals’ needs (some with arms, some without). As long as there are no safety concerns, persons in wheelchairs may benefit from having the foot pedals removed. The group leader stands or sits in a visible location and verbally orients the clients to the program. Begin with a warm-up activity (breathing/stretching) supported by slow to medium-tempo music. This is followed by several movement activities—each of which is supported by music with a strong pulse played at a medium to upbeat tempo at a medium volume (i.e., loud enough to motivate participation but not too loud as this may agitate some clients). Ensure that clients have enough time to complete the movements. Model movements that involve the shoulders, hands, arms, head, neck, legs, ankles, and feet—using actions that come naturally/easily (e.g., shoulder shrugs, clapping, finger-snapping, waving, stamping feet, kicking, etc.). If using live music, adjust musical elements and styles to meet clients’ needs as they

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emerge and maximize participation. If individuals cannot follow the moves being demonstrated, encourage them to move to the music in their own unique way. Close the session with a cooldown activity (breathing/stretching) supported by slow to medium-tempo music. Thank clients for their participation and verbally orient them to what is happening next (e.g., they are going to lunch, back to their room, attending another activity, etc.). Adaptations. Props may be used to elicit or maximize movements, although this may be confusing for some clients (Cevasco & Grant, 2003). These can include small percussion instruments, balloons, scarves/small towels, or a parachute/large sheet. Simple folk dances in a circle or familiar dance moves remembered by clients may be incorporated into programs (Bright, 1997). Improvised live music may also be used if the music therapist is adept at improvising in distinct styles/structures and able to adjust music in the moment to meet clients’ needs. It should also be noted that some persons with dementia feel a strong desire to pace. It may be helpful (or satisfying) for these individuals to engage in music experiences while they pace (e.g., singing or playing a small instrument) (Chavin, 1991) or to redirect their energy into music and movement activities that inherently feel more structured and purposeful. Other Sources. Belgrave, Darrow, Walworth, and Wlodarczyk (2011), Bright (1997), Cevasco and Grant (2003), Shively and Henkin (1986), and Wade (1987) suggested/implied various goal areas for this method and provided some directions on how to facilitate movement/exercise to music programs for persons with dementia. Clair and Memmott (2008) outlined considerations on using music in exercise programs for older adults who have various needs—including those related to dementia. These considerations were integrated into the above description. Note: Readers may also want to consult Movercise—a DVD and training manual designed for use in exercise programs for persons with dementia (Schellin & Gemeiner, 2003).

Dancing with Spouse/Loved One Overview. The music therapist helps to facilitate engagement between a client and a spouse/loved one through dancing. This may take place in a group and/or in a private session context. This intervention is indicated for couples/loved ones who have a close relationship or for those who had a close relationship prior to the onset of dementia. This intervention is contraindicated for persons (client or loved one) who may be uncomfortable with this level of physical closeness (for personal, cultural, or religious reasons) (Clair & Memmott, 2008) or who may have physical limitations that make this activity inaccessible or unsafe. The main goals for the client(s) are to maintain/regain emotional intimacy with a loved one, increase loved ones’ satisfaction with time spent together, re-initiate participation in a previously enjoyed activity, and elicit reminiscence. The level of therapy is augmentative. Preparation. When possible, interview the client (may be part of a music therapy assessment process) and/or a spouse/loved one to discuss meaningful musical selections (e.g., a wedding song) and shared memories (Belgrave et al., 2011). Create a personalized music list. Gather recordings of these musical selections and/or learn live arrangements. Either schedule a session time for the spouse/loved one to come and dance with the client or be prepared to initiate this method in music therapy sessions when a loved one happens to be present. What to observe. Notice if the client exhibits any signs of discomfort or pulls away when physical closeness is attempted (Clair & Memmott, 2008). Ensure that the area is safe so the couple(s) can move as freely as possible.

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Procedures. Provide live and/or recorded music for dancing based on personalized music lists. Use verbal encouragement or other types of support/cues to elicit participation. When appropriate, engage the couple(s) in reminiscence between musical selections. Adaptations. When standing up is not possible due to physical limitations, safety issues, or severe dementia, loved ones may sit with the client and initiate touch and/or movement (e.g., holding hands, moving arms in time to the music, putting arm around loved one’s shoulders and swaying, etc.). When appropriate, clients may be encouraged to dance with each other to improve/increase social interactions between peers. The music therapist may compile personalized recorded music programs for couples to use on their own. Other Sources. Belgrave et al. (2011), Clair (2002a, 2002b), and Clair and Memmott (2008) suggested/implied various goal areas for this method and provided some directions on how to facilitate dancing experiences. Chavin (1991) and Clair and Memmott (2008) proposed adaptations for this method as outlined above.

Environmental Music Overview. The music therapist programs recorded music used to create a supportive or therapeutic sound environment for a group of clients in a particular context (e.g., dining area). This may not only improve clients’ quality of life but also lead to decreased frustration for caregivers or staff. This intervention is indicated for persons with mild, moderate, or severe dementia who engage more constructively in a specific task or context in response to specially programmed music. This intervention is contraindicated for those who respond negatively to recorded music programs and/or who are particularly sensitive to environmental sound stimulation. Recordings that include nature sounds may be contraindicated for persons with dementia, as they can become confused by sounds that do not fit with their environment (Grocke & Wigram, 2007). The main goals for the client(s) are to reduce negative behaviors and/or increase constructive behaviors in a particular context, experience an aesthetically enhanced environment, and regulate time spent on a task (such as eating). The level of therapy is augmentative. Preparation. Schedule specific times for environmental music programs to occur. This may be determined by noting clients’ responses to music at certain times of day and/or by noting their behavior patterns in particular contexts. Determine the general/common musical preferences of the client(s) involved. Preferred music of staff/caregivers should not be used unless it is the same as the clients’ preferred music. Create a variety of recorded programs from which to choose based on clients’ needs at the time of implementation. Music utilized must not be overly sedative so as not to induce drowsiness or inactivity or overly stimulating, as it may cause people to stand up, move, and/or sing along rather than perform the desired task (e.g., eating). What to observe. While the music is playing, look for signs of agitation, and if these occur, either stop the music or remove the affected individual(s) from the environment. Notice if a client stops responding to the music. Music can become ineffective if overused or tedious for individuals who cannot turn it off when they no longer wish to hear it (Clair & Memmott, 2008). Procedures. During scheduled times only, play designated music programs at an audible level on high-quality sound equipment. The music therapist or another trained individual should always be present in order to observe responses and/or adjust the music experience as needed (e.g., change the volume, change the music program, stop the music, move a client away from the sound source, etc.). Adaptations. The music therapist may provide live environmental music, which can be adjusted to meet clients’ needs in the moment as they emerge. The music therapist can train caregivers/staff how to effectively use recorded environmental music programs that he/she has designed for particular

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contexts. This method may be adapted for use with individuals (Janata, 2012), similar to the MusicSupported Personal Care method described below. Other Sources. Aldridge (2007), Chang, Huang, Lin, and Lin (2010), and Clair and Memmott (2008) suggested/implied various goal areas for this method and provided information on the use of music in dining contexts. Mercado and Mercado (2006) and Ziv, Granot, Hai, Dassa, and Haimov (2007) provided information on how to use music to create better sound environments for persons with dementia in order to increase positive and decrease negative behaviors.

Music-Supported Personal Care Overview. The music therapist provides personalized live or recorded music programs for individual clients during care activities (bathing, toileting, dressing, administration of medication, etc.). This intervention is indicated for clients with moderate to severe dementia who have difficulty participating or cooperating during care activities (e.g., demonstrate resistance, aggression, confusion, lack of motivation, etc.) and respond positively to musical stimuli in the care context. This method is contraindicated for persons who become more agitated or confused by music when it is incorporated into the care environment. The main goals for the client are to reduce anxiety, reduce aggression, improve cooperation with activities of daily living (ADL), improve orientation to task, improve awareness (sensory and environmental), maintain (feelings of) independence, and/or improve communication/relationship between the client and care provider. The level of therapy is augmentative but could be considered intensive if the music therapist is working in tandem with other treatment modalities as an equal partner or as the main therapist. Preparation. Meet with care providers to better understand the issues, plan logistics, and educate them with regard to how music can help in this context. Meet with the client and/or family members (if possible) to assess/determine the client’s preferred musical selections. If using live music, memorize the client’s preferred musical selections or styles—vocal and/or instrumental. If using recorded music, create a variety of personalized music programs from which to choose based on the client’s needs on a given day. Preferred music of the care provider(s) should not be used unless it is the same as the client’s preferred music. It may also be appropriate to observe the client in the care context before providing music in order to get a better sense of the issues. What to observe. Watch for signs of cooperation and other constructive interactions with the care provider as well as for signs of increased anxiety or agitation. Procedures. Arrange the music source (live or recorded) in a way that will not interfere with the care activity procedure but at the same time will provide the client with optimal support (based on needs identified through the music therapy assessment process). Initiate the music either just before the care activity begins (to set the mood or relax the client) or as the activity begins. Adjust musical elements (e.g., volume, tempo, style, etc.) according to the client’s responses (positive or negative). The music should fade gradually as the procedure ends or shortly thereafter. If the music is not helpful (after trying several adjustments), it should not be utilized. Adaptations. The music therapist may train care providers on how to sing or use recorded personalized music programs while providing care (consult the sources listed below). The music therapist may utilize improvised live music during care and adjust music in the moment to meet the client’s needs. If a client who has not had a music therapy assessment becomes extremely agitated during a caregiving activity, with the permission of the care provider, a music therapist may attempt a spontaneous live music intervention. If this is successful, the music therapist may design and implement an ongoing, personalized, music-supported care program as outlined above. The music therapist may also intentionally hold a session with a client just before a planned procedure or care activity. This may relax

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(i.e., reduce anxiety, agitation, or wandering behavior), positively stimulate, and/or orient the client so that he will subsequently be more willing or able to engage in that procedure or activity (e.g., eating, taking medications, etc.) (McHugh, Gardstrom, Hiller, Brewer, & Diestelkamp, 2012). Other Sources. Brown, Götell, and Ekman, (2001a, 2001b), Chatterton, Baker, and Morgan (2010), Clair, (2002c), Clair and Memmott, (2008), Engström, Hammar, Williams, and Götell (2011), Gerdner (2005), Götell, Brown, and Ekman (2000, 2002, 2003, 2009), Götell, Thunborg, Söderlund, & von Heideken Wågert (2012), Hammar, Emami, Engström, and Götell (2011a, 2011b), Hammar, Götell, Emami, and Engström (2011), Hammar, Götell, and Engström (2011), Hanser, Butterfield-Whitcomb, and Kawata (2011), and Thomas, Heitman, and Alexander (1997) suggested/implied various goals for the use of live/recorded music during personal care activities of persons with dementia. These sources also provided some information on how to use music during these personal care experiences. Chatterton, Baker, and Morgan (2010), Rio (2009), and the current author clarified roles for music therapists within this method—which may include having music therapists train care providers on how to use particular aspects of this method.

Relaxation through Music Listening and Imagery Overview. The client listens to specially programmed live or recorded music in an individual private session to evoke peaceful and relaxing imagery experiences. Imagery experiences may include visions, thoughts, feelings, memories, fantasies, and/or body sensations (Grocke, 2005). This intervention is indicated for clients with mild dementia who are experiencing mild anxiety/agitation and who are able stay focused during brief, therapist-supported, music listening and imagery experiences. This method is contraindicated for clients who experience hallucinations, have negative imagery in response to music listening experiences, and/or are unable to stay focused on the music experience even with support of the therapist. The main goals for the client are to reduce anxiety, increase feelings of well-being, experience a peaceful environment, promote rest or sleep, and/or reduce perception of physical pain or discomfort. The level of therapy is augmentative. Preparation. Conduct an individual assessment to determine if this method might be appropriate for a particular client. If so, secure a private space where interruptions will not occur. The room should be dimly lit but not too dark. If using recorded music, speakers should be portable so that they can be placed in the best position for a particular client (head, feet, or on a particular side). Compile a variety of brief, relaxing music selections (live or recorded) from which to choose. These selections may include the client’s preferred music. What to observe. Notice subtle responses (e.g., respiration rate, facial expression, body tension, etc.) to ensure that the client is having a positive experience. Procedures. Situate the client in a reclining chair or on a bed. Encourage the client to relax by using a very brief relaxation induction that may consist of a few single words combined with gestural cues (e.g., the therapist demonstrates relaxed breathing and posture). The therapist may provide the client with a starting image (e.g., a relaxing place or feeling). Start music (live or recorded). If using live music, the therapist may repeatedly sing comforting phrases or words, sing a relaxing song, vocalize (improvise without words) over instrumental accompaniment, or use instrumental music with no voice. The instrument utilized should have a gentle timbre (e.g., classical guitar, Native American flute, harp, cello, etc.). If vocalizing a cappella or if using recorded music, the therapist might stroke the client’s arm or use hand massage to help him/her relax (if appropriate). The duration of the music should not exceed 10 minutes to ensure that the client does not enter into a deep altered state of consciousness. When the music ends, gently bring the client back to a present state of awareness by using clear verbal directions (e.g., “The music has ended and it is time to open your eyes”). The client may or may not want to discuss

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his experience. The overarching point of the experience is to leave the client feeling relaxed and safe, and the therapist should facilitate the post imagery conversation accordingly. If the client falls asleep during the music and imagery experience, the therapist may quietly leave the room and check back at a later time. Adaptations. The therapist may use a spoken relaxation script while recorded music is playing. Sources. Grocke and Wigram (2007) was the primary source utilized to compile this method. This material was combined and integrated with information based on the author’s knowledge and experience as a certified Guided Imagery and Music practitioner.

Music-Assisted Life Review Overview. The music therapist uses personalized music experiences in individual sessions with a client to evoke significant life memories or facilitate a sense of connection to one’s self/identity. When appropriate and possible, the client’s loved ones may also participate in some or all of the sessions. (Please note that aspects of this method are also re-creative or compositional.) This intervention is indicated for individuals with mild to moderate dementia who enjoy reminiscing, respond constructively (verbally or nonverbally) to personally significant musical selections, and would benefit from increased meaningful interactions with loved ones. This intervention is contraindicated for individuals who fixate on negative memories or who may become emotionally overwhelmed by the process. The main goals for the client are to affirm that one’s life has had value and meaning, increase self-esteem, maintain sense of self, facilitate bonding/resolution with loved ones, and have a safe forum through which to express complex emotions, and/or achieve closure at the end of life. The level of therapy is usually augmentative but could also occur at the intensive or primary level if the client’s main treatment goals are palliative. Preparation. Conduct an assessment with the client and/or interviews with loved ones/caregivers (when possible) to learn about important life events, memories, personality traits, preferred music of the client, etc. Plan music experiences based on this information. This may involve learning repertoire and/or gathering recordings. If loved ones are attending the sessions, contact them to schedule a convenient session time. Secure a private space for the session(s). If audio or video recording the sessions, obtain the necessary written consent. What to observe. Observe family dynamics and interactions. Notice the music experiences that the client responds most strongly to and the emotional nature of these responses. Procedures. Facilitate individualized music experiences and discussion. In addition to music listening and reminiscence, the client and or loved/ones may actively participate in the music-making (recreative). The therapist may also write songs (using pre-existing or original music) that honor particular aspects of the client’s life (Belgrave et al., 2011). The therapist may write these songs independently, or they may be written during music therapy sessions in collaboration with the client and/or loved ones (compositional). When appropriate, a recording of significant musical moments from sessions may be compiled to give to loved ones (compositional; see Music Collages in Compositional Methods). Continue to use significant musical selections with the client even as his condition deteriorates, as persons with severe and terminal dementia may continue to respond positively and/or be comforted by this music. Adaptations. This method is a process that normally occurs over time but could also be contained within a single session and may even emerge spontaneously within a session. It may also be used in sessions with families/loved ones (the client is not present) in order to help them remember their loved one before dementia, celebrate his/her life, and grieve over losses that have occurred.

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Sources. Belgrave et al. (2011), Patrick and Avins (2005) and Tomaino (2000) suggested/implied various goal areas for this method and provided some directions on how to facilitate music-assisted life review experiences.

Therapeutic Singing for Individuals with Severe Dementia Overview. Individual sessions where the music therapist sings preferred songs to individuals with severe dementia. Songs that have personal meaning may still reach these clients at an emotional level. These songs are often sung without instrumental accompaniment so that the therapist can utilize touch (when appropriate) and maximize response. This intervention may be used for durations of 10–15 minutes, several times a day, or multiple sessions may be held throughout the week. This intervention is indicated for individuals who are withdrawn or agitated, and who are generally unresponsive or respond poorly to other stimuli. This intervention is contraindicated for individuals who do not respond positively to the songs (e.g., the person makes any effort to pull away, tenses muscles in the face or body, turns the head away in a deliberate manner, vocally responds as if in distress, etc.). The main goals for the client are to increase positive stimulation, experience meaningful interaction with another human being, improve awareness of external environment, create feelings of safety, regulate mood/level of arousal, increase cooperation, increase self-expression, experience recognition of his feelings by another, and utilize songs as cues to help orient him to the here-and-now. The level of therapy is augmentative, although it could also be considered primary if the method is used on a regular and ongoing basis to regulate mood/level of arousal. Preparation. If possible, interview loved ones to gather information on the client’s preferred music. Memorize words and melodies of the client’s preferred music as well as words and melodies of music that the client is likely to know (based on age, culture, etc.). When possible and applicable, secure a space where there will be limited interruptions or other distractions. The first session may be used as a music-based assessment session. What to observe. Carefully observe the individual before, during, and after singing to determine the effect(s) of the method. Observe very subtle responses (e.g., change in respiration rate; opening eyes; brief eye contact; moving head in the direction of the therapist/music/sound source; vocal sounds or changes in vocal sounds; moving arms, hands, legs, and/or feet, etc.) (Clair, 2000). Procedures. Sit with the client at bedside or bedside chair. Consider proximity and use of touch based on the client’s needs and known/implied preferences. Begin the session by singing a song that matches client’s demeanor and/or energy level (Iso principle). This could be an opening song that incorporates the client’s name. Adjust elements of music that appear to positively affect the client’s responses (e.g., vocal timbre, tempo, use of rubato, with or without lyrics, etc.). End the session when the desired state is achieved (e.g., the client appears to be content, satisfied, calm, etc.). The final intervention should provide a sense of closure. Adaptations. Caregivers/loved ones may be taught to use aspects of the above intervention. The music therapist may use improvised songs/vocalizations instead of or in addition to precomposed songs, depending upon the needs and responses of the client. Improvised vocalization may also be used (in or outside of a formal session context) to regulate clients who are agitated. Here, the music therapist matches the client’s level of vocal arousal with her voice (Iso principle) and then gradually modifies musical elements of these vocalizations to help the client achieve a more optimal state of being. It should be noted that this method could be considered a form of entrainment––which, depending on how it is used, may require advanced training. Musical entrainment is a process whereby physiological rhythms of the body are synchronized with external rhythmical stimuli created through music (Dileo & Bradt, 1999; Patrick & Avins, 2005; Ridder, 2011; Wigram, Pederson, & Bonde, 2002).

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Other Sources. Clair (1996, 2000), Clair and Memmott (2008), Gaertner (1999), Ridder (2005, 2011), Ridder and Aldridge (2005), and Robertson-Gillam (2011) suggested/implied various goal areas for this method and all sources provided some directions on how to facilitate individual therapeutic singing experiences for persons with severe dementia. This information was combined to form the above method.

Music-Assisted Sensory Stimulation Theme Groups Overview. This method is used in small group sessions (approximately four participants) for clients with severe dementia. The music therapist helps to stimulate clients’ senses within a structured and supportive environment. Music may be used as the stimulation in and of itself, or it may be used to support the theme of the session and/or the presentation of various stimuli. These groups are approximately 15–30 minutes in duration based on the clients’ level of fatigue and/or attention span. However, these groups may take place several times a week. This intervention is indicated for individuals with moderate to severe dementia who are withdrawn, depressed, and/or lack stimulation. The method is contraindicated for individuals who respond negatively to any of the stimuli presented or for those who have visual agnosia. The main goals for the clients are to stimulate one or more senses during the session (e.g., aural, visual, tactile, and olfactory), improve mood, improve engagement with others, and improve engagement with their immediate environment. Given the dietary restrictions and swallowing disorders that often exist in this population, gustatory stimulation may be contraindicated. The level of therapy is augmentative. Preparation. Determine the appropriateness of the method for particular clients based on an assessment and/or referral process. Secure a space where interruptions will be minimal. Choose a simple theme (e.g., colors, trip to the beach, flowers, holidays, seasons, etc.) around which a number of simple sensory activities can be designed. Gather props for sensory activities. Learn and memorize simple music selections that reflect the theme and/or support particular sensory activities. For example, one might sing a song about the ocean while helping a client to hold or play an ocean drum. The therapist should keep all materials within arm’s reach so that she can stay within close proximity of each individual. What to observe. Carefully observe individuals before, during, and after each session to determine the effect of the method and to understand which sensory interventions work best for particular individuals. Be aware of very subtle responses (e.g., change in respiration rate, brief eye contact, slight change in body posture or facial expression, etc.). The intervention should be discontinued if an individual makes any effort to pull away, tenses muscles in the face or body, turns the head away in a deliberate manner, and/or vocally responds as if in distress. Procedures. Seat participants in a small circle or around a small table. Orient individuals to the context by singing a greeting song that contains each individual’s name and by singing a song that introduces the theme (e.g., “My Bonnie Lies Over the Ocean”). Offer each individual a chance to experience each sensory activity, verbally/vocally reiterating the theme topic several times during each activity. Adjust each activity according to each individual’s potential for response. At least one activity should involve vibrotactile stimulation (e.g., have the client hold or place hand on a drum while the therapist plays it). Verbally encourage individuals in the group to look at each other or to experience stimuli at the same time (e.g., have two clients hold the drum while the therapist plays it). At the end, thank each individual for participating in the group. Sing a song to reinforce that the group is over for the time being but that it is not a final good-bye (e.g., “Till We Meet Again”). Adaptations. Each activity contained in a group session may be used on its own as a short intervention. The intervention can be adapted for individual sessions where loved ones/caregivers may also be involved.

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Source. Chavin (1991) was the primary source utilized to compile this method. This material was combined and integrated with additional information based on the author’s knowledge and experience.

Sensory Stimulation Using Instruments/Vibrotactile Stimulation Overview. The music therapist uses tactile stimulation and vibrations produced by musical instruments to elicit a sensory response. This method is usually one activity within a small group music therapy session that contains other interventions. This intervention is indicated for individuals with severe dementia who respond overtly and positively when they perceive and feel sound vibrations. This intervention may be contraindicated for persons who become agitated by this type of stimulation. The timbre of certain musical instruments may be disturbing or painful for some individuals or some individuals may perseverate when playing certain instruments, thereby negating the potential for positive stimulation. The main goals for the client(s) are to increase creative self-expression through an accessible medium, increase sensory stimulation, increase engagement with others, and improve engagement with/orientation to their immediate environment. The level of therapy is augmentative. Preparation. Collect instruments of various shapes, textures, and timbres (e.g., ocean drum, rain stick, triangle, cabasa, etc.). Avoid instruments with loud or startling sounds. Instruments that can be placed on the client’s lap while being played (e.g., autoharp, omnichord, iPad) may also be effective. What to observe. Be aware of very subtle responses (e.g., change in respiration rate, brief eye contact, slight change in body posture or facial expression, etc.). The intervention should be discontinued if the person makes any effort to pull away, tenses muscles in the face or body, turns the head away in a deliberate manner, and/or vocally responds as if in distress. Procedures. Tell the group that they are going to hear a sound. Demonstrate an instrument sound a few times, allowing the sound to resonate. Approach each client individually and demonstrate the sound again. Encourage each client to touch the instrument and/or hold the instrument while the therapist plays it. If necessary and appropriate, use hand-over-hand cuing to facilitate contact with the instrument or to help an individual play an instrument. Ask each client simple questions about the sound or the feel of the instrument (e.g., do you like that sound?; is it a wet sound or a dry sound?; is it a dark sound or a light sound?; does the instrument feel rough or smooth?; etc.). Reverse choices when posing the questions to help determine if a client’s answer is meaningful or echolalic. In a group setting, ask group members to bring their attention to a particular client when he is playing a sound. Thank each client. Move on to the next person and repeat the exercise, adjusting to the needs/responses of each client until everyone has had an opportunity to participate. Adaptations. Use a variety of instruments in a session and compare the client’s individual responses as well as responses among the group members. This intervention may be adapted for use in individual sessions. Sources. Belgrave, (2009), Chavin, (1991), and Clair and Bernstein, (1990) suggested/implied various goal areas for this method. Chavin (1991) provided some directions on how to facilitate sensory stimulation experiences using instruments. This material was combined and integrated with additional information based on the author’s knowledge and experience.

Vibroacoustic Stimulation with Music Overview. The client reclines on a specially designed mat, bed, or chair that is embedded with speakers that convert specific frequencies into vibrations while listening to recorded music specially programmed by the music therapist (free-field listening, as opposed to headphones/ear buds, is usually better for clients with dementia).

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This intervention is indicated for clients with mild to moderate dementia who are experiencing anxiety and/or respond positively to vibrotactile stimulation. This intervention is contraindicated for clients who are agitated by this type of stimulation, have experienced past psychotic episodes or suffer from PTSD, have pacemakers, and/or cannot lie down or sit still long enough to engage in the experience. The main goals for the client are to reduce anxiety/agitation and/or increase positive sensory stimulation. The level of therapy is augmentative. Preparation. Secure a dedicated quiet space for the therapy equipment. The music therapist should receive practical and theoretical training on this equipment before using it with clients. Conduct an assessment with the client and carefully research his background information in consideration of the above contraindications. If therapy is potentially indicated, schedule sessions with the client during a time of day when he/she is typically most anxious or agitated. Ensure that the session will be uninterrupted (e.g., place a “Do Not Disturb” sign on the door). Program relaxing recorded music selections. These may be based on client’s preferences as determined through the music therapy assessment. Unfamiliar music may be more effective with some clients as it elicits fewer associations. It may also be helpful to consult Grocke and Wigram (2007) for guidelines on choosing music to be used during vibroacoustic treatments (pp. 226–227). However, it is important to note that these are general guidelines and do not account for the unique needs of persons with dementia. What to observe. Be aware of very subtle responses (e.g., change in respiration rate, facial expression, muscle tension, etc.). Some clients may have difficulty verbally expressing their responses to this intervention (i.e., they may not be able to articulate if it is a pleasant experience or not). This intervention should be discontinued if the person shows any signs of distress. Procedures. Assist the client to sit or lie down and find a comfortable position. Encourage him to relax by using verbal or gestural cues or a brief but more formal relaxation induction. Initiate the appropriate (indicated) vibroacoustic stimulation and music. Monitor the client’s responses. Make adjustments to the stimulation and/or music if needed. The length of the session may vary based on client’s responses. Adaptations. The music therapist may provide live music during the vibroacoustic experience. Sources. Chavin, (1991), Clair and Bernstein, (1990, 1993), Vibroacoustics for Seniors, (2012) and Grocke and Wigram (2007) suggested/implied various goal areas for this method. Vibroacoustics for Seniors, (2012) and Grocke and Wigram (2007) provided some directions on how to facilitate vibroacoustic stimulation experiences with music and also outlined contraindications for this method. This material was combined and integrated with additional information based on the author’s knowledge and experience.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Small Group Improvisation Overview. The music therapist creates an improvised musical structure based on sounds and/or music expressed by group members. The group should contain no more than 4–6 participants so that the therapist can hear and develop individuals’ musical contributions. This method is indicated for individuals with mild to moderate dementia who have difficulty with self-expression (verbal or other) and who find satisfaction through participation in shared musical experiences. This method is contraindicated for clients who may become overstimulated and/or are unable to use instruments in a musically meaningful way. This would be indicated when the client plays in a perseverative manner and/or does not recognize the function of instruments/objects (visual agnosia); becomes agitated if he cannot recognize the music (i.e., responds positively to familiar music only); or is

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physically incapable of manipulating instruments or using the voice. The main goals for the client(s) are to increase social interaction, increase awareness of self within a group environment, increase creative self-expression, and participate in an aesthetically satisfying experience. The level of therapy is augmentative. Preparation. Conduct individual music therapy assessments to determine if this intervention is suitable for particular clients. Secure a private space where participants can make music and/or vocalize freely without interruption. The therapist must have strong improvisational skills on at least one pitched instrument (or voice) to provide the necessary musical structure and direction. What to observe. Listen to individual clients’ musical/sound contributions. Watch for signs of agitation and/or overstimulation. Assess clients’ feelings and the overall mood of the group by observing their body language, gestures, facial expressions, and overall appearance. Procedures. Verbally orient clients to the music therapy context. Distribute various percussion instruments based on clients’ intuitive skills and/or preferences (identified through individual assessments). Demonstrate how to play each instrument as necessary. Clients may choose to not play an instrument. Listen for spontaneous sounds or vocalizations made by clients and use these as the starting point for the improvisation or, if necessary, provide a musical starting point. Listen for each individual client’s sound contributions and develop these musically. The therapist’s musical decisions are based upon what she thinks might be helpful for individual participants (e.g., encourage a socially withdrawn client to play louder). Encourage solo, dyad, and full-group improvisations. Provide closure at the end of the session by using a structured singing or listening activity. Adaptations. This intervention may be adapted for use in individual sessions (similar to the Nordoff Robbins Music Therapy—Individual Improvisation method outlined below). It may also be appropriate to have an opening/warm-up activity or ritual before implementing this intervention (e.g., a greeting song). Opening and closing rituals offer form and familiarity, especially for group members who may not consciously remember the group from week to week. Sources. Odell-Miller (2002) and Rio (2002) were the primary sources utilized to compile this method. This material was combined and integrated with additional information based on the author’s knowledge and experience.

Playing Percussion Instruments Overview. Clients play percussion instruments in response to a musical and/or rhythmic structure provided by the music therapist. This structure may be improvised or precomposed. In a group setting, individuals with mild to moderate dementia are often able to entrain their playing with others and interact rhythmically even though they may be unable to interact in other ways. In order to avoid overstimulation or chaos, group size should be limited to 6–8 people. This method may be used as the main intervention in a session along with an opening and closing intervention for an approximate duration of 30–45 minutes. Alternatively, it may be one activity in a music therapy session that contains other interventions. This method is indicated for individuals with mild to moderate dementia who enjoy playing percussion instruments and who exhibit overt (often spontaneous) positive responses to rhythmic stimulation. This method is contraindicated for individuals who do not like percussion instruments— some may feel it is age-inappropriate (Bright, 1997) or find loud sounds physically painful (Clair & Memmott, 2008). It is also contraindicated for those individuals who consistently play instruments in a perseverative manner, do not recognize the function of the instruments (visual agnosia), and/or become agitated or overstimulated by the experience (Clair & Memmott, 2008). The main goals for the client(s) are to maintain fine and/or gross motor skills, maintain attention to task, participate in a satisfying “here-

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and-now” experience, increase self-expression, increase vibrotactile stimulation, and find a constructive outlet for anxiety or agitation. The level of therapy is augmentative. Preparation. Conduct individual music therapy assessments or observe individuals in other music contexts to determine the potential suitability of this intervention for particular clients. Secure a designated space where participants can play percussion instruments freely without experiencing other distractions or having to worry about disturbing others. Although a variety of percussion instruments may be used (e.g., drums, claves, temple blocks, suspended triangle, etc.), it is best to use high-quality, ageappropriate instruments that make a clear or distinct sound when struck so that participants can feel/create the rhythmic pulse. It is also helpful to determine which instruments are most suitable for individuals based on their preferences and capabilities. Some instruments may need to be adapted for particular individuals (e.g., special stands, clamps, holders, grips for mallets, etc.). If using melodic percussion (e.g., xylophones, glockenspiels, etc.), the therapist needs to design interventions that will incorporate these instruments in an aesthetically pleasing way (i.e., consider tonality). The therapist should prepare a variety of rhythm activities and instrumental musical selections from which to choose in order to respond to clients’ needs and responses as they emerge. What to observe. Watch for signs of agitation and/or overstimulation. Assess clients’ feelings and the overall mood of the group by observing body language, gestures, facial expressions, and the nature of their rhythmic contributions (e.g., aggressive, gentle, disorganized, syncopated, etc.). Clients who become agitated should be removed from the group (by a staff or volunteer assistant if possible). The current author and others have also noticed that as some clients progress from a mild to a moderate stage of dementia, their tendency to play more complex and syncopated rhythms may increase (Clair, Bernstein, & Johnson, 1995; Clair & Ebberts, 1997). Procedures. Arrange participants in a circle or semicircle (seated). For ambulatory persons, use straight-back chairs that accommodate individuals’ needs (some with arms, some without). Verbally orient clients to the activity or context. Distribute instruments to clients based on their predetermined preferences and needs. Some clients will need a brief demonstration or reminder on how to play their instrument. The therapist should stand or sit in a visible location and play a distinct-sounding percussion instrument (such as a drum or a cowbell) to encourage clients to participate in directed rhythm activities (e.g., call-and-response, stopping and starting, exploring different tempos and volumes, etc.). She may also play instrumental selections (usually on piano/keyboard) and encourage clients to play along in various ways. The therapist must provide structure and guidance through visual/gestural, verbal, and musical cues to maintain participation. Some individuals may need a personal assistant to help with cuing, hold an instrument, and/or accompany them back to a familiar/quiet space if they become agitated. Although simple rhythmic patterns may help to create successful experiences, some groups may be able to intuitively learn more complex patterns over time. Adaptations. Groups may focus on a particular kind of percussion instrument (e.g., drums–see “Therapeutic Drumming” in Belgrave et al., 2011, p. 46) rather than use a variety of instruments. This intervention may be adapted for use in individual sessions for those who respond strongly to rhythm but may be overwhelmed by the group setting. There may be some clients who enjoy the group experience but have trouble maintaining a beat, which in turn may affect the group’s overall rhythmic cohesiveness. These clients may still participate if they are amenable to playing a softer instrument (such as an egg shaker or a small maraca) that will not impact on the group’s ability to maintain the pulse. Although live music or rhythmic stimuli are usually more effective and flexible, clients may play percussion instruments along with carefully chosen recorded music that aligns with participants’ preferences and/or naturally evokes strong rhythmic responses (e.g., Big Band music, military marches, symphonic music, etc.).

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Other Sources. Cevasco and Grant (2006), Clair, Bernstein, and Johnson (1995), Bright, (1997), and Clair and Memmott (2008) suggested/implied various goal areas for this method as well as some directions on how to facilitate percussion playing experiences for persons with dementia.

Nordoff Robbins Music Therapy—Individual Improvisation Overview. Individual improvisation within the Nordoff Robbins Music Therapy model involves the development of a musical relationship between therapist and client through improvisation, which is considered to be the vehicle of therapy. Developed by Paul Nordoff and Clive Robbins in the 1950s (Nordoff, Robbins, & Marcus, 2007), it was originally designed for children with special needs but is now used with various populations, including adults with dementia. The frequency and length of sessions is flexible, based on a client’s needs. This intervention is indicated for clients with mild to moderate dementia who have the capacity and desire to express themselves through cocreated improvisational music experiences. This intervention is contraindicated for clients who express or imply a preference for other kinds of musical experiences. The main goals for the client are to engage in a musical and interpersonal relationship, increase creative self-expression, increase sense of identity, and/or increase orientation to musical experiences that are happening in the “here-and-now.” The level of therapy is augmentative, or it may be considered primary depending upon the main therapeutic needs of the client and the nature of the therapeutic change. Preparation. Secure a private space with a piano and variety of percussion instruments. If audio or video recording the sessions, obtain the necessary written consent. Although all music therapists may utilize the aspects of the Nordoff Robbins Music Therapy model, it is important to note that music therapists who use this model as their main approach have completed certification in this method. What to observe. Sessions are often audio or video recorded and then indexed afterward (i.e., time and corresponding clinical and musical details are carefully noted and reviewed to assess the moment-to-moment experience of each session). Procedures. Play the piano along with the client who may use a range of percussion instruments and/or voice. Provide a variety of musical, verbal, gestural, and sensory cues to help the client engage with the instruments. Exploratory sessions usually begin with drum and cymbal. In a therapy process that occurs over time, the client may use other rhythmic/melodic instruments (tone bars, xylophone, piano, voice, etc.). Listen for the client’s sound contributions and try to develop these musically. The emphasis is on creating one or more improvisations per session. Adaptations. The therapist may support the client using instruments other than piano (including voice). Within a session or over a course of sessions, therapists may use other methods/interventions in combination with this method. Sources. Aldridge and Aldridge (1992), Aldridge and Brandt (1991), and Simpson (2000) were the primary sources utilized to compile this method. This material was combined and integrated with additional information based on the author’s knowledge and experience. Soundbeam® Improvisation Overview. The Soundbeam® uses motion sensors to translate body movements into musical sounds of varying pitch and intensity, which in turn provides clients with an accessible avenue for creative self-expression. This intervention is indicated for clients with mild, moderate, or severe dementia who respond with interest and engage with the Soundbeam® through voluntary, purposeful (responsive) movements as

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well as for clients who have limited mobility and/or communication deficits. This intervention is contraindicated for clients who are negatively stimulated or confused by the Soundbeam® or who do not overtly respond to it. The main goals for the client are to enhance posture, balance, and/or trunk control; increase creative self-expression; increase sensory stimulation; and motivate purposeful movement and active participation. The level of therapy is augmentative. Preparation. The MIDI module that is connected to the Soundbeam® can be programmed by the therapist to contain personalized sound stimuli that are meaningful, appealing, or stimulating for a particular client. These preferences may be determined through a music therapy assessment process or may be known to the therapist if she works with the client in another music therapy context. What to observe. Be aware of very subtle responses (e.g., change in respiration rate, slight change in body posture or facial expression, etc.). The intervention should be discontinued if the person demonstrates a negative response (e.g., moves away from the beam, vocally responds as if in distress, etc.). Procedures. The first session may be used as an assessment session. Position the beam so that when the client moves, sound is triggered. Experiment with different sounds to determine client’s preferences. Use gestural and verbal cues when necessary to encourage and validate client’s participation. Adaptations. The therapist may play the Soundbeam® in conjunction with the client or use another instrument to support the client while he plays the Soundbeam®. Sources. Gaertner, (1999) and Soundbeam®, (2013, January 30) were the primary sources utilized to compile this method. This material was combined and integrated with additional information based on the author’s knowledge and experience.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY A significant amount of literature supports the idea of using preferred, precomposed music for clients with dementia as it generally yields positive therapeutic outcomes (Bright, 1997; Clair, 2000; Clair & Memmott, 2008; Lesta & Petocz, 2006; Tomaino, 2000). As noted earlier in this chapter, musical memories and skills are often retained by persons with dementia—even as other areas of memory deteriorate. Furthermore, using a client’s preferred music demonstrates respect for the individual’s expressed or implied preferences. However, some research has indicated that persons with frontal temporal lobe dementia may experience changes in their music preferences (Geroldi et al., 2000; Mell, Howard, & Miller, 2003; Ridder & Aldridge, 2005). It is also important to note that using a client’s preferred music in a music therapy context goes far beyond simply replicating favorite selections and also involves changing the music as needed to meet the needs of the client as they emerge (Ridder & Aldridge, 2005). These factors should be taken into consideration when executing all interventions that utilize precomposed music—this point is especially relevant to the methods/interventions contained in this section.

Group Sing-Along Overview. The music therapist sings precomposed songs in a group setting with live musical accompaniment (piano, guitar, accordion, or other). Some songs may be sung a capella or with a percussion instrument such as a hand drum. It is similar in nature to the Community Singing intervention described in Chapter 20, but when working with persons who have dementia in a group-singing context, the therapist needs to be more directive and provide very structured opportunities for choice. The group may be open (e.g., drop-in group where attendees may vary from session to session; therapeutic goals are general and not targeted toward individual needs) or closed (e.g., same participants every week; goals

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target specific therapeutic needs of individuals). The group may be quite large (up to 15 people), but only if there is at least one staff or trained volunteer assistant for every 3–5 persons. Under the guidance of the therapist, these assistants may help to maximize clients’ participation though modeling or cuing. The duration of the group is approximately 45–60 minutes and can be held one or more times a week. Although some individuals with severe dementia may benefit from this program, this intervention is generally indicated for individuals with mild to moderate dementia who enjoy singing and who thrive in social settings. It may also be held later in the day in order to address issues associated with “sundowning”—increased agitation that occurs in some people with dementia during late afternoon and evening hours (see Adaptations below). This intervention is contraindicated for individuals who may become overstimulated by this experience, respond more positively in small group or individual contexts, and/or do not enjoy the styles/genres of music that are being utilized. The main goals for the clients are to increase creative self-expression; maintain expressive language abilities; increase awareness of self and others; participate in constructive social interactions; make choices through song requests; increase selfesteem through successful participation; improve mood; stimulate deep breathing and physical relaxation; participate in a purposeful activity; elicit feelings of control, self-efficacy, and a sense of coherence; improve general orientation (time of day, season, etc.); and experience a safe environment within which the inherent therapeutic benefits of singing can occur. The level of therapy is augmentative. Preparation. Learn how to sing and accompany a wide range of repertoire that is stylistically and culturally appropriate for the age cohort(s) attending the program. The therapist should memorize as much of this repertoire as possible or create lead sheets so that she can focus on interacting with the participants. Transpose music into an appropriate vocal range (in general, F below middle C to C above middle C for women and an octave lower for men) (Moore, Staum, & Brotons, 1992). Keep accompaniments simple, although not too simple as clients may disengage (Groene, 2001), and use accompanying instruments that can be adjusted easily with regard to pitch, tempo, and volume, such as guitar, keyboard, autoharp, accordion, etc. Prepare lyrics for projection onto an overhead screen (use an overhead or LCD projector if needed and appropriate; song sheets/books tend to cause distraction or confusion that hinders participation) (Bright, 1997; Chavin, 1991). Secure a space that is large enough so that the maximum number of anticipated participants can sit in a circle or semicircle (rows should be avoided) (Bright, 1997). Volunteer or staff assistants may be needed to model participation, assist with individual participants’ needs, and/or for safety purposes, depending upon the size of the group. These persons may need guidelines/training from the music therapist so that they have a clear understanding of their role. Depending upon the size of the group, the therapist might want to use a wireless amplification system (headset) to maintain clients’ attention and to avoid vocal fatigue. What to observe. Look for emerging signs of anxiety (e.g., body language, facial expression, etc.) to prevent clients from becoming agitated or overstimulated. Notice if certain clients do not get along— plan seating arrangements and assistance accordingly. Notice clients who are not participating and determine if they might benefit from additional cuing or assistance. Some clients may indicate that they cannot sing or that they have a poor singing voice. These individuals will usually end up singing if they are reassured that singing is not “required” and that listening is also an acceptable form of participation. Procedures. Have recorded music playing at a low volume as clients enter the room to help orient them to the context. Ensure that individuals are seated in their assigned locations (if applicable). Welcome clients and verbally orient them to the group singing context. Start with an opening song that further orients the clients to the context and also matches their current mood/energy level (Iso principle). This song may include clients’ names. Play a variety of precomposed songs at tempos with which participants are able to sing along (usually a bit slower than usual). In order to maintain clients’ attention and elicit maximum response, do not play more than two songs in a row that are in the same key and do not play too many fast or slow songs in succession. In order to accommodate those who may have trouble

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singing the lyrics, repeat well-known verses at least twice and sing some verses on a neutral syllable (e.g., la, la). Elicit responses by slowing phrases down and allowing the participants to complete the line, use call-and-response lyric techniques, sing some verses a cappella, and clap hands. Use imitation and modeling to support, extend, and reinforce participants’ responses. Use verbal, gestural, and musical cues to encourage clients to look at one another and notice what others are doing. When transitioning between songs, clients often enjoy brief, therapist-directed discussions about relevant music history, trivia, or other reminiscence topics. End the session with a medium tempo or slow closing song that indicates that the session is over. In order to avoid an escalation in anxiety, it is also important to let the clients know what is happening next. For example, the current author has often closed sessions using a song with a familiar tune that states several times “Music time is over and now it’s time for [fill in the blank with an appropriate activity].” Adaptations. There are many variations on this method. Clients may choose songs by taking a slip of paper from a hat or drum that contains a song title. Song choices may also be contained within the context of games such as “Musical Bingo” or “Spin the Music Wheel” (Belgrave et al., 2011). A Sing-Along Group session may be composed of repertoire that adheres to a relevant theme (e.g., holidays, seasons, cultural practices, etc.). Familiar objects or photographs that are linked to a theme or a song may be used to elicit song ideas, memories, and/or social interaction. Clients may play percussion instruments during this activity. However, to avoid overstimulation and/or chaos, instruments should not be used for the duration of the group (Bright, 1997). Rather, focus on one or a particular set of instruments to complement a specific song in a meaningful way. For example, it may be appropriate to use drums during a marching song. Not everyone has to play an instrument, and individuals can take turns on particular instruments. A client may want to lead/conduct a particular song or have a solo vocal part, and the therapist can provide the structure to ensure that this happens in an appropriate and successful way. The general principles of this method may be adapted for individuals (or dyads) that enjoy singing but prefer to sing alone or find the group setting too overwhelming. For clients with mild to moderate dementia, Darnley-Smith (2002) proposed the concept of “acoustic dreaming.” Here, precomposed songs occur freely in the group through suggestion or spontaneous singing of clients or therapist. Free improvisation is incorporated into the song structures using instruments and voice. The author suggested that this combination allows space for unconscious material to emerge, thus resulting in more authentic self-expression. When running a sing-a-long group specifically to address issues related to sundowning, consider the following adaptations (modified from Whitcomb, 1994; Lesta & Petocz, 2006): (a) create a comfortable and protected environment by eliminating unnecessary stimulation (e.g., dim bright lights, draw curtains, secure a private space, seat clients strategically, etc.), (b) focus on relaxation and anxiety reduction rather than stimulation, (c) provide ongoing reassurance and redirection of attention to the music context, (d) do not include individuals whose anxiety cannot be ameliorated by the group as this will agitate others in the group, (e) use a gentle song to facilitate closure, and (f) orient clients to the next activity (e.g., meal, bed, television, etc.) Other Sources. Bright (1997), Cevasco and Grant (2006), Chavin (1991), Clair (2000), Clair and Memmott (2008), and Robertson-Gillam (2011) all suggested/implied various goal areas for this method and provided some directions on how to facilitate group sing-alongs.

Music Reminiscence Groups Overview. The music therapist uses live and/or recorded precomposed music to enhance and/or promote participation in reminiscence discussion groups.

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This method is indicated for clients with mild to moderate dementia who enjoy discussing memories and events from the past. The group should be limited to 6–8 people, depending on clients’ level of functioning and needs. The duration of the group is approximately one hour, and usually takes place once a week. This method is contraindicated for clients who have expressive and/or receptive language deficits, do not enjoy reminiscing, find this activity childish (due to the music and/or props used) (Bright, 1997), or become agitated or confused when discussing the past. The main goals for the client(s) are to express opinions and feelings, experience memories through extramusical associations, increase self-esteem and enhance sense of self by remembering personal and historical events, participate in life review, have meaningful interactions with others who have had similar life experiences, increase verbalization through singing and recitation, maintain long-term memory, maintain attending skills, improve mood, and increase cognitive and sensory stimulation. The level of therapy is augmentative. Preparation. Clients are referred to this group based on needs or interests identified though a music therapy assessment process. The therapist should familiarize herself with the lifestyles and events of the decades in which the group participants were adolescents and young adults (Karras, 1987). Determine a topic prior to session (e.g., weddings, vacations, fashion, pets, etc.). Select music that is relevant to the topic and also likely to be familiar to the group members. Use original recordings, live music, or a combination of both. Prepare questions about the topic that will prompt reminiscence. Gather relevant objects or sensory props (e.g., photographs, old sheet music, scented oils, a variety of percussion instruments, etc.). Secure a private space for the session. What to observe. Observe interactions between group members to ensure that interactions are supportive and positive. It may be appropriate to seat clients strategically based on personality characteristics. Observe levels and types of participation in order to cue clients as needed and to assess levels of functioning. It may be necessary to remove a client from the group if he is no longer benefiting due to a change in cognitive status (Karras, 1987). It may be appropriate for some clients to be transferred into a Music-Assisted Sensory Stimulation Theme Group (described above under Receptive Methods). Note future ideas for themes that may emerge during group discussions. Procedures. Have relevant recorded background music playing as clients enter the room. Have clients sit in a circle along with the therapist. When ready to begin, stop the recorded music, welcome clients to the group, and orient them to the topic using words, a musical selection (e.g., an opening song), and/or tactile props. Promote further discussion using music listening, interactive singing, and questions. Acknowledge clients’ feelings and provide support if difficult memories emerge. To end the session, thank group members for their participation and sing a closing song. This song may be the same from week to week (to create a sense of group identity), or it may be a song that somehow provides closure to the theme for that session. Adaptations. Musical games may be used in Music Reminiscence Groups (e.g., “Name that Tune/Vocalist/Musician,” “Fill in the Missing Lyrics,” “Music Trivia,” etc.). Consult Belgrave et al. (2011), Bright (1997), Chavin (1991), Cordrey (1994), Karras (1987), Shaw (1993), and Wenrick (1996) for information on discussion topics, themes, and musical games. Smith (1986) also contains a list of songs and corresponding questions that can be used when facilitating a music reminiscence group. Other Sources. Ashida, (2000), Chavin (1991), and Karras (1987) suggested/implied various goal areas for this method provided some directions on how to facilitate music reminiscence groups.

Community Music Therapy Performance Overview. The music therapist facilitates opportunities for clients (individual or group) to experience the joy of performing with and for others in a supportive and accepting environment. The therapeutic focus is on the performance process and not on the performance product in and of itself.

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This method is indicated for clients with mild to moderate dementia who have had past positive experiences with performing and/or who seem to enjoy performance activities (Young & Nicol, 2011). This method is contraindicated for persons who may experience increased anxiety or overstimulation as the result of a performance activity or for persons who are unable to effectively execute a desired level of performance even with adaptations and/or the support of the therapist (Young & Nicol, 2011). The main goals for the client are to rekindle previously enjoyed musical practices, increase feelings of self-worth or validation through the capacity to contribute, increase or maintain one’s sense of identity, experience a sense of belonging (to a group and/or community), experience feelings of accomplishment, create a sense of community, change the community environment, and improve relationships with others by highlighting the client’s potentials (changes others’ perceptions of the client). The level of therapy is augmentative. Preparation. Each client participates in closed individual and/or group music therapy sessions prior to participating in any open performance activities. This helps the therapist to assess if open performance would be beneficial for a particular client or group and understand the kind of supports or modifications the client(s) might need. The individual client or group should participate in performanceoriented musical experiences during closed therapy contexts before participating in an open performance. For example, a client may assume the role of performing a particular song each week in a closed music therapy group. Open performances usually occur within the clients’ day program or long-term care facility. Audiences are generally limited to facility staff, other long-term–care residents/day program participants, family members, and friends. Open performances may be scheduled ahead of time or they may occur spontaneously during an open music therapy group (such as a Group Sing-Along). What to observe. Prior to and during a performance, watch for signs of anxiety. Note any positive social behaviors that are generally not otherwise observed in particular individuals. Clients who enjoy performing often exhibit an improved level of social functioning during a performance experience. Other clients, however, may overestimate their own performance abilities or try to dominate a particular performance context. The therapist needs to establish appropriate boundaries and maintain a directive role to ensure that all participants have a successful and rewarding experience. Procedures. During open music therapy groups or formally scheduled performances, provide clients with structured opportunities to perform. Provide musical or logistical support as needed to ensure that all performances are a successful experience for the performer(s). For example, a client may play a solo on the harmonica while a volunteer holds a microphone and the therapist provides verbal prompts and/or musical accompaniment. An open music therapy group or formal performance may be guided by a theme (e.g., Valentine’s Day, a season, etc.). Spontaneous responses may be incorporated into the performance (e.g., stories and songs that emerge). The performance should culminate with a public acknowledgement of each performer and an appropriate closing song/music activity based on the theme. Adaptations. Individual clients’ past musical practices may need to be adjusted to accommodate each client’s current level of functioning (e.g., the therapist can open-tune a client’s guitar and play along with the client). Staff and family members may participate by performing with clients or by performing on their own (at the discretion of the therapist). Although performances often consist of precomposed music, improvisation may also be employed, depending upon client’s needs and musical strengths. Sources. Powell (2004) was the primary source utilized to compile this method. This material was integrated with information based on the author’s knowledge and experience.

Intergenerational Music Therapy Programs Please see the description contained in Chapter 20. Very little has been written on intergenerational

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music therapy programs for persons with dementia. However, research has indicated that the presence of children during structured music activities for persons with dementia appeared to stimulate increased responsiveness and involvement as compared to these same activities when the children were not present (Newman & Ward, 1992–1993). Furthermore, participation in music activities with young children appeared to lower agitation levels (Ward, Kamp, & Newman, 1996). There is potential for further development of specific intergenerational music therapy methods for persons with dementia.

Lyric Analysis Overview. The music therapist uses lyrics from familiar songs and discussions about those lyrics to convey a positive message to clients or to validate a client’s feelings. This method may be one intervention in an individual music therapy session that contains other interventions or it may be used for the duration of a session. This method is indicated for clients with mild to moderate dementia who respond constructively to messages or “feeling” words contained in songs. This method is contraindicated for clients who are unable to cognitively process difficult emotions or cannot understand song lyrics due to receptive communication deficits. The main goals for the client are to improve mood, increase self-expression, increased coping skills, reduce anxiety, maintain sense of self, and increase reminiscence. The level of therapy is augmentative. Preparation. Compile and learn songs that contain words that either convey specific feelings or communicate positive messages. Have these songs ready to use when feelings emerge in sessions or when it is appropriate to communicate a positive message to clients. For clients who are able to read (some lose this ability as their dementia progresses), it may be helpful to have typed copies of lyrics in order to be able to visually refer the client to specific words or phrases. What to observe. In order to provide validation and the appropriate level of support, carefully observe emotional responses, facial expressions, body language, etc. Procedures. During an individual session, the music therapist tells the client that she has a song that seems appropriate for the moment. Sing the song for the client and encourage him to sing along or listen carefully. Musically emphasize relevant lines or words. Facilitate a discussion with the client about his feelings and how these may relate to the message or feelings contained in the song, focusing on relevant lines or words and providing verbal cues/structure as needed. If appropriate, the therapist and the client may finish the activity by singing the song together (may be sung more than once). Adaptations. The client may choose to change the lyrics of the song to better suit his feelings or perspectives (see Lyric Substitution in the Compositional Methods section below). This activity may be adapted for a group session, although it may be more appropriate to focus on positive messages rather than complex emotions, as it may be difficult to effectively facilitate this type of conversation with several clients who have diverse needs due to dementia. Source. Belgrave et al. (2011) suggested some goal areas for this method and provided some directions on how to facilitate a lyric analysis intervention (“Lyric Analysis for Depression” p. 49).

Playing a Familiar (Known) Instrument Overview. The music therapist provides the client (who is also a musician) with resources and/or support needed to play a known musical instrument. The therapeutic focus is on the enjoyment and sense of fulfillment that the client receives from participation in a familiar musical practice rather than on the quality of the musical product per se.

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This intervention is indicated for clients with mild to moderate dementia who have maintained at least some of their personal musical knowledge/skills and who enjoy participating in this activity. This method is contraindicated for clients who are no longer able to play their instrument at a level that is personally satisfying or who may become upset by a realization that their musical abilities have deteriorated (if this is the case). This realization could also occur repeatedly from session to session if the client cannot retain this information. Music therapy in general may be contraindicated for these clients if the music therapy context consistently triggers a strong sense of musical loss that is unable to be resolved. The main goals for the client are to rekindle or maintain a previously enjoyed musical skill or practice; maintain a sense of musical and/or personal identity; form a musical relationship with another musician (the music therapist); and experience feelings of accomplishment, confidence, and self-esteem. The level of therapy is augmentative but could also be considered intensive depending upon how the therapy process unfolds and the needs that are being addressed by the intervention. Preparation. Interview the client (may be part of a music therapy assessment process) and/or spouse/loved one about the client’s past musical practices and assess the client’s desire and potential ability to play a preferred instrument. Investigate logistical issues such as access to the preferred instrument and storage. Secure a private space where the sessions can take place. If everything seems feasible, arrange for a time to meet with the client to assess his ability to play his preferred instrument. It would be helpful for the therapist to find out about particular musical selections that the client used to play and have this available in some way at the session (e.g., scores or recordings). If the therapist has limited knowledge of the client’s preferred instrument, it would also be helpful for her to look up some practical information (e.g., tuning, playing techniques, instrument maintenance, etc.) and listen to some recorded examples prior to the first session. What to observe. Observe the ways in which the client plays or manipulates the instrument and provide support (cues or encouragement) as needed. Watch for signs of frustration or distress. If difficulties cannot be rectified, end the session or move on to another activity. Procedures. If the client is able to play the instrument to his satisfaction, arrange for him to have weekly individual sessions. This provides the client with the motivation, structure, and musical context needed to sustain this practice. The therapist may participate in the musical experiences by playing a similar or different instrument along with the client. If appropriate, the therapist and client may assume “soloist” and/or “accompanist” roles. Ultimately, structure each session to ensure that the individual has a satisfying experience with his chosen musical instrument. If appropriate, the client may want to participate in a Community Music Therapy Performance (as described above). Adaptations. If it is amenable to the client, the therapist may be able to adapt an instrument to meet the client’s current abilities (e.g., open-tune a guitar). Some clients may be willing to try other (more accessible) instruments if they are unable to play their primary instrument. In some cases, it may be possible to have dyad sessions with two clients who are musicians if their skills and personalities complement one another. Adaptations may need to occur over time as the client’s dementia progresses. If the client is no longer able to participate in this type of session, the music therapist may be able to implement another kind of music therapy intervention that will better meet his current needs. The client may be able to transition effectively to a new type of intervention not only because of his musical interest but also because of the musical relationship/bond that he has formed with the therapist.

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GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Group Songwriting Overview. The music therapist helps clients with mild to moderate dementia to create song lyrics related to a relevant theme. This method may be used as the main intervention in a small group session (4–6 participants if working alone) for an approximate total duration of 30–60 minutes. This method is indicated for clients who are isolated and would benefit from interactive experiences that involve music and discussion. This method is contraindicated for persons who have expressive and/or receptive language difficulties or for those who have difficulties with focus/concentration/orientation in this context. The mains goals for clients are to increase social interaction and awareness of others, increase feelings of belonging/community, increase self-expression and self-awareness, maintain communication skills, focus attention on a “here-and-now” context/activity, and improve mood. The level of therapy is augmentative. Preparation. Clients are referred to this group based on needs and potentials identified though a music therapy assessment process. A consistent opening and closing music therapy intervention should be planned in conjunction with this method for each session. This provides a sense of predictable structure and orients clients to the context. The therapist may prepare a predetermined theme for each session (e.g., based on a season, a holiday, etc.) or she may allow the theme to emerge from the group discussion. Either way, she needs to have several musical ideas in mind (or prepared) that can be used immediately as a structure for the song lyrics. What to observe. Notice clients who do not participate in the discussion and/or who appear to have trouble focusing on the discussion topic. Provide structured opportunities (verbal cues, questions, choices, etc.) for these clients to contribute and/or stay focused on the activity. Procedures. Arrange participants in a semicircle (seated) facing a flip chart or whiteboard. Orient participants to the context with an opening song. Rather than tell clients that they are going to write a song, engage clients in either an open discussion that leads to a theme or a discussion that involves a predetermined theme. Write down ideas (on a personal notepad) that pertain to the theme as the discussion progresses. Tell the clients that their ideas can be made into a song. The therapist may sing one line to provide a tangible example. Ask clients for ideas on what kind of music might best fit the theme, giving concrete examples of musical concepts [e.g., fast, slow, happy (major), sad (minor), pre-existing melody, etc.]. If this is too confusing for clients, the therapist may independently decide on a musical structure that best reflects the theme. Take the ideas that emerged from the discussion and write them on the flip chart/white board, adjusting the text to fit the musical structure. Sing the song to the participants, encouraging them to sing along using various cues and techniques (lining out, pointing to the lyrics, etc.). Ask the participants if they have suggestions for improvement and, if possible, incorporate these into the song. Provide clients with choices, such as adding some percussion instruments or sound effects that reflect the theme. The whole song should be sung (at least once), and this may or may not be used as the closing activity for the session. Given the memory difficulties of these clients, the song needs to be completed in one session in order for the participants to experience the intervention as a complete process. However, the song may be used again in future sessions for a variety of therapeutic purposes. Adaptations. This method can be adapted for use in individual sessions. Lyrics could be organized into a poem (rather than a song) that is read by group members and/or the therapist while thematic instrumental music is played in the background (live or recorded) (Silber & Hes, 1995). A lyric substitution method can also be used in which new words are substituted for the original words of a familiar song (Chavin, 1991) (e.g., use the tune of “My Favorite Things” from the movie musical The

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Sound of Music). However, some clients find lyric substitution confusing and will revert back to the original lyrics when singing the song. Other Sources. Belgrave et al. (2011, p. 48 & p. 50) and Silber and Hes (1995) were the primary sources utilized to compile this method. This material was combined and integrated with information based on the author’s own knowledge and experience.

Recorded Music Collages Overview. The music therapist compiles and arranges a collage (collection) of music recordings that are significant or meaningful for the client. This may include recordings of live music from the client’s own music therapy sessions, commercially recorded selections, or a combination of both. This method is indicated for clients with mild to moderate dementia who have strong musical associations. This method is contraindicated for clients who are not interested in this process, are unable to participate due to cognitive deficits, or have abreactive responses to music that trigger associations with past trauma (e.g., war, death of a loved one, a painful separation, abuse, etc.). The main goals for the client are to participate in a life review process, increase cognitive stimulation, maintain a sense of identity, increase creative self-expression, increase self-esteem, and create a forum for interaction with loved ones. The level of therapy is usually augmentative but could also occur at the intensive or primary level if the client’s treatment goals are palliative. Preparation. This method generally emerges out of interactions that the music therapist has had with the client in individual music therapy sessions. The music therapist needs to have the necessary recording equipment and computer software to create the final product (CD or audio file). If live music from music therapy sessions is being used as part of the recorded collage, ensure that the necessary written consent is obtained. Copyright laws also need to be considered when using commercially recorded music as part of this method. What to observe. During individual music therapy sessions, notice musical selections or music experiences that appear to be particularly meaningful for the client. If possible, facilitate discussions with the client about the relevance of these meaningful moments and assess the potential therapeutic benefits of making a recorded music collage. Procedures. The therapist works with the client to determine the content and order of the musical selections to be contained in the collage. This may include favorite musical selections of the client or musical selections that in some way represent meaningful moments, events, or stages in a client’s life (i.e., a musical autobiography—see Music-Assisted Life Review in Receptive Methods. Record live renditions, listen to relevant commercial recordings, and/or facilitate discussions. Although this method would normally be implemented with persons who have mild to moderate dementia, the recorded music collage and the knowledge gained from the process may be used to aid in facilitating music therapy sessions as the client’s dementia continues to progress. Adaptations. A recorded music collage may be made for loved ones as a legacy gift from the client (Belgrave et al., 2011; Patrick & Avins, 2005). The music therapist may also provide family members or caregivers with a recorded music collage that is tailored specifically to suit the needs and preferences of the client (Clair & Memmott, 2008). The purpose of this recording would be to facilitate meaningful, shared experiences. Recorded music collages may also be made using a video format. Note: Wigram and Grocke (2007) used the term “individual music collage” (p.200) for a method where the client uses pictures from magazines to create an artistic collage with the support of the therapist while listening to preferred recorded music. This is a receptive rather than a compositional method. The authors also indicated that although this method may be helpful for some clients with dementia, it is contraindicated for those who are not constructively stimulated by visual images and/or become confused by the activity.

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WORKING WITH CAREGIVERS As noted in the methods described above, family caregivers often participate in their loved one’s music therapy sessions. This may not only enhance the session for the client, but also be a positive experience for family members as they interact with their loved one through musical media in meaningful ways. Music therapists may also provide music interventions during caregiving activities, which may help to facilitate the caregiving process and/or make the experience more positive for both the family/professional caregivers and the care recipient. As persons with dementia tend to respond strongly to music in general, it can be helpful for the music therapist to teach individually tailored music techniques to both family and professional caregivers. These techniques may be used to enhance the caregiver/care recipient relationship, facilitate cooperation with ADL, and/or improve the day-to-day quality of life for persons with dementia. It is beyond the scope of this chapter to describe specific techniques in detail, but the literature contains many resources and further discussions on this topic (see Brotons & Marti, 2003; Brown, Götell, & Ekman, 2001a, 2001b; Chatterton, Baker, & Morgan, 2010; Clair, 2002a, 2002b, 2002c; Clair & Ebberts, 1997; Clair et al., 2005; Clair and Memmott, 2008; Clair, Tebb, & Bernstein, 1993; Engström, Hammar, Williams, & Götell, 2011; Gardner, 1999; Gerdner, 2005; Götell, Brown, & Ekman 2000, 2002, 2003, 2009; Götell, Thunborg, Söderlund, & von Heideken Wågert, 2012; Hammar, Emami, Engström, & Götell, 2011a, 2011b; Hammar, Götell, Emami, & Engström, 2011; Hammar, Götell, & Engström, 2011; Hanser, Butterfield-Whitcomb, & Kawata, 2011; Hanser & Clair, 1995; Matthews & Kosloski, 2000; Rio, 2009; Thomas, Heitman, & Alexander, 1997). It is important to note that although these techniques may be beneficial, they are not music therapy per se nor do they replace the need for a music therapist. Music therapists understand the clinical applications of music (which are far more diverse and require more skill and knowledge than most people realize) as well contraindications for the use of music. These contraindications are especially important to consider when working with a vulnerable population that may have increased sensitivity to sound stimulation, may not be able to clearly communicate when music/sound is having a negative impact, and/or may become immune to the positive effects of music if it is overused. It is also the current author’s experience that caregivers (both professional and family) often need help in understanding that the ways in which they perceive music to be helpful may or may not be helpful for another person. Music therapists can ensure that caregivers are using music in a constructive way for particular individuals, and they can personally provide skillfully executed clinical music therapy interventions that are adjusted over time (or in the moment) to help alleviate various symptoms/consequences of dementia. Instead of seeing music therapy as an additional expense, one could argue that a professionally designed music program for persons with dementia that includes clinical music therapy and consultation with music therapists as core components could increase efficiency. Used in this manner, music could possibly facilitate the caregiving process, prevent the need for more time-consuming interventions, and reduce costs (e.g., through less need for medications). More research is needed to investigate the potential cost-effectiveness and efficiency outcomes of comprehensive music therapy–based programs in dementia care.

Overview on Music Therapy for Caregivers of Persons with Dementia More than 15 million Americans provide unpaid care for persons with AD or other dementias; this includes immediate family, other relatives, friends, etc. (Alzheimer’s Association, 2012). Family caregivers may experience high levels of personal and financial stress, which in turn may have negative impacts on health and well-being. “Signs of caregiver distress include increased anger, social withdrawal, anxiety, depression, exhaustion, sleeplessness, irritability, poor concentration, increased health problems, and

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denial” (American Psychiatric Association, 2010, p. 23). Professional caregivers of persons with dementia can also experience significant levels of stress and burnout as they deal with challenging client behaviors, physical demands of their job, staffing shortages, high staff turnover rates, a perceived lack of workplace support, and complex interactions with family members (Duffy, Oyebode, & Allen, 2009; Mackenzie & Peragine, 2003; Todd & Watts, 2005). It can also be the case that some of these professionals have received little to no training in issues specific to dementia care, which can also lead to increased feelings of stress and frustration. As noted above, there is a growing amount of literature on teaching caregivers how to use music for persons with dementia and increased involvement of caregivers in clients’ music therapy sessions, which may also have benefits for the caregivers themselves (Clair & Ebberts, 1997; Hanser, Butterfield-Whitcomb, & Kawata, 2011). However, there is a limited amount of literature on how music therapy may be used to more directly address the caregivers’ needs. The following two sections provide a brief summary of what is known about music therapy intervention for family and professional caregivers of persons with dementia.

Family Caregivers Two studies were found which describe music therapy interventions for family caregivers alone. A pilot study conducted by Brotons and Marti (2003) contained three conditions: (a) seven group music therapy sessions for persons with dementia and their family caregivers, (b) 10 group music therapy sessions for persons with dementia without their family caregivers, and (c) four group music therapy sessions for the caregivers alone. Interventions in the “caregivers alone” condition included singing, music listening, music relaxation exercises, musical games, and songwriting. No significant results were found using the Caregiver Burden Questionnaire and the Beck Depression Scale. However, the posttest mean scores on the State Trait Anxiety Inventory (STAI-S) were significantly lower than the pretest scores, indicating a reduction in anxiety immediately after the project and also two months after the project began. Furthermore, all participants indicated that the “caregivers alone” sessions helped them to relax and “66.7% indicated that it offered them a pleasant and enjoyable space where they could share and express feelings that [they] had not been able to express before” (Brotons & Marti, 2003, p. 144). In a study conducted by Klein and Silverman (2012), a songwriting intervention (one 45-minute session) and a psychoeducational discussion (one 45-minute session) were compared as methods for teaching self-care to family caregivers of persons with dementia. Analysis of participants’ written feedback indicated that both interventions yielded positive results. However, themes related to “fun” and “appreciation” were present in the songwriting condition only. In both of these studies, the sample sizes were small and the duration of the intervention period was limited. More research is needed to better understand the ways in which music therapy intervention can most effectively address the unique needs of family caregivers of persons with dementia.

Professional Caregivers Professional caregivers of persons with dementia include a wide spectrum of health care workers (nurses, allied health, mental health professionals, health care aides, etc.). For reasons noted above, stress levels and burnout among these individuals can be quite high. Research has also indicated that staff burnout in dementia care may also be associated with low optimism, negative emotional responses to behavior, and low self-efficacy (Duffy, Oyebode, & Allen, 2009; Mackenzie & Peragine, 2003; Todd & Watts, 2005). Other publications suggest that staff may receive some respite or inadvertent aesthetic benefit from clients’ participation in music therapy—which in turn may help to decrease staff burnout (Olderog-Millard & Smith, 1989). However, very little has been written on the use of music therapy intervention to directly

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address the needs of professional caregivers of persons with dementia. A study by Bittman, Bruhn, Stevens, Westengard, and Umbach (2003) found that a six-session re-creational music-making protocol that focused on building support, communication, and interdisciplinary respect had a statistically significant positive impact on burnout and mood dimensions of the participants—all of whom worked in long-term care. Presumably, some of these participants were working in dementia care. The authors also projected that the implementation of this type of program would result in less staff turnover and subsequent cost savings. Results of an exploratory pilot program for staff members who worked on a dementia unit indicated that music relaxation techniques had a positive impact on participants’ perceived levels of relaxation (McCarthy, 1992). More research is needed to better understand how music therapy intervention may be used to address the unique needs of professionals who work in dementia care. For music therapists and other mental health professionals, it should also be noted that professional supervision provided by a music therapist could also be a helpful means of support. Although it is not music therapy, music may be utilized in these supervision sessions to facilitate insight and professional growth, which in turn may result in reduced stress and prevention of burnout.

RESEARCH EVIDENCE Based on the literature, popular media, and the current author’s personal experience, the past 20 years has seen a growing widespread public recognition that music can be used to help persons with dementia. Documentaries, television shows, news articles, and textbooks on the subject of dementia invariably make positive claims about the use of music in some way. However, it is often the case that little differentiation is made between the use of music for enjoyment and the clinical use of music to alleviate the symptoms of dementia (i.e., music therapy). Furthermore, adaptations or contraindications for the use of music with this population are rarely acknowledged. It is the current author’s opinion that the dissemination and application of methodologically sound music therapy research (qualitative and quantitative) is one way to effectively promote increased understanding of the role and need for evidence-based music therapy intervention in dementia care. The literature contains many studies that explore the efficacy of music therapy with persons who have dementia. (Please see Chapter 2 in Belgrave et al., 2011, for a concise review of music therapy research pertaining to therapeutic outcomes with this clinical population.) However, various methodological issues have limited the generalizability or transferability of these results. Researchers have attempted to organize and analyze this diverse body of music therapy research through literature reviews, systematic reviews, and/or meta analyses (Brotons, Koger, & Pickett-Cooper, 1997; Dileo & Bradt, 2005; Koger, Chapin, & Brotons, 1999; McDermott, Crellin, Ridder, & Orrell, 2012; Nugent, 2002; Raglio et al., 2012; Sherratt, Thornton, & Hatton, 2004; Ueda, Suzukamo, Sato, & Izumi (2013, in press); Vink, 2000; Vink, Bruinsma, & Scholten, 2011). Although some of these reviews have indicated positive effects (e.g., that music therapy may help persons with dementia to maintain or improve cognitive skills; decrease behaviors related to anxiety, agitation, and aggression; improve psychosocial and emotional functioning; maintain language skills; increase active engagement; decrease isolation; improve social interaction; and improve quality of relationship with caregivers), these results must be interpreted with caution due to methodological limitations of the studies that were included in the analyses. Furthermore, there is a limited amount of research that explores the efficacy of specific methods or interventions. A systematic review was conducted through the Cochrane Collaboration “to assess the effects of music therapy in the treatment of behavioral, social, cognitive, and emotional problems of older people with dementia, in relation to the type of music therapy intervention” (Vink et al., 2011, p. 2). (Cochrane Reviews report the combined results of high-quality research studies and are recognized by many as the gold standard in evidence-based health care.) Only 10 studies (Randomized Controlled Trials, or RCTs)

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met the criteria for inclusion in the analysis. The researchers concluded that “the methodological quality of the studies was generally poor and the study results could not be validated or pooled for further analyses” (p. 2). Therefore, this review provided no evidence to support or refute the use of music therapy with persons who have dementia. However, other researchers have argued that controlled trials (CTs) should have been included in the Cochrane analysis, as this research design is often used in music therapy (Ueda et al., 2013, in press). These researchers conducted a systematic review and meta-analysis that included both RCTs and CTs to evaluate the effect of music therapy on behavioral and psychological symptoms of dementia (BPSD), activities of daily living (ADL), and cognitive function in patients with dementia. Additionally, they investigated the differences in effect size based on the kinds of interventions, the type of disease, and the intervention period. The results indicated that music therapy had moderate effects on anxiety and small effects on behavioral symptoms. In studies that were less than three months in duration, music therapy had large effects on anxiety. However, almost all studies included in the analysis used a combination of methods (such as singing, playing musical instruments, and/or listening to live music), thus making it virtually impossible to determine the effectiveness of specific interventions or methods. Furthermore, professional music therapists were not always involved in the intervention protocols, leading one to question if certain studies should have been included in the analysis. Although standardized systematic reviews and quantitative meta-analyses can provide important information, they exclude qualitative research that may also contain relevant evidence. A systematic qualitative literature review conducted by Ridder (2005) examined the clinical music therapeutic strategies used for persons with dementia contained in 92 studies (various paradigms) published between 1980 and August 2004. As in the current chapter, she attempted to create generalized descriptions of interventions. Ultimately, she identified 17 different therapeutic initiatives, although procedures on how to execute these initiatives are not described in detail. However, she created four categories to describe the functions of music within the identified therapeutic initiatives. These included: (a) Evaluative—the use of music initiatives for assessment purposes, (b) Regulative—musical elements are used to change behavior or mood, (c) Stimulative—music is used to motivate and engage clients for the purpose of maintaining various domains of functioning, and (d) Communicative—initiatives focus on the “whole” person and take psychosocial, emotional, and cultural needs into account. Various receptive, improvisational, re-creative, and compositional initiatives were contained in each category. However, limitations of the studies included in the review—including lack of information with regard to the type of music intervention being used and the exact purpose of specific music initiatives—made it difficult to draw definitive conclusions about the effectiveness of particular methods or interventions. In order to explore the “mechanisms” of music therapy interventions used in dementia care, McDermott et al. (2012) conducted a narrative synthesis (NS) systematic review. This involved a systematic evaluation of both process-based and outcome-based music therapy studies using four interactive elements: (a) theory development, (b) preliminary synthesis of findings, (c) exploration of relationships between studies, and (d) assessment of the robustness of the synthesis (p. 2). Only 18 studies (15 quantitative and three qualitative/mixed methods) out of 263 potentially relevant titles identified in the initial search met the full inclusion criteria (refer to the article for a complete description of these criteria). Although some evidence was found to support short-term improvements in behavioral and psychological disturbances as a result of music therapy interventions, it was not possible to attribute these positive results to a particular method or intervention. Singing (which may be used as a receptive, improvisational, and/or re-creative method) was employed in seven of the studies. “However, it was not possible to consolidate enough evidence to develop a new theory because of the heterogeneity of the musical interventions of different qualities, the diversity of research designs, and the limited explanations of the study findings and clinical implications” (p. 12). Chatterton et al. (2010) also examined the use of individual singing (receptive method) for persons who have dementia through a systematic review of the literature (note: Inclusion criteria for the studies were far less stringent than in the McDermott et al.,

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2012, study). The “singers” in the studies included music therapists, nurses/other professional caregivers, and family members. Overall, results indicated that individual singing for persons with dementia can improve their quality of life, regardless of the qualifications of the singer. However, the authors also concluded that the effectiveness of individual singing interventions likely depends on the goals of the person providing the intervention and on the perceptions of the client. Goals employed by music therapists were specific and addressed cognitive, behavioral, and social areas, whereas goals of other professional or family caregivers were general and focused on building connections and improving the caregiving experience. The authors recommended that music therapists focus some of their efforts on empowering professional and nonprofessional caregivers to sing to persons with dementia, thereby multiplying the benefits music can bring. In spite of a relatively large body of research on music therapy and dementia, there is limited satisfactory evidence on the efficacy of specific music therapy methods or interventions for persons with dementia. Based on recommendations from the reviews outlined above and on the present author’s perspectives, the following points should be considered when one is conducting research on music therapy in dementia care: (a) the type and stage of dementia must be identified, (b) the specific needs being addressed by the method or intervention and/or the purpose of the must be clearly stated, (c) the protocol and/or the type of music therapy method or intervention used must be clearly identified and described (see also Ridder, Wigram, & Ottsen, 2009), (d) the research methodology employed should be the best “fit” for the method/intervention/research question being investigated, (e) in quantitative research, reliable and valid measurement tools that are relevant for the clinical population should be used [also, check the reliability of the measures used in relation to each study’s sample (e.g., Cronbach’s alphas)], (f) adhere to high-quality reporting standards (e.g., for quantitative research, report all necessary statistics; for qualitative research, clearly outline the researcher’s epistemological stance), (g) use longitudinal research designs and/or mixed-method designs when logistically feasible and methodologically appropriate (see also Ledger & Baker, 2005), and (h) contraindications or negative outcomes related to music therapy intervention for persons with dementia must also be investigated and reported.

SUMMARY AND CONCLUSIONS Dementia is not a disease but a term used to indicate a range of symptoms associated with a decline in memory and other cognitive skills, which in turn affects one’s ability to perform the activities of daily living. Persons with dementia display a wide range of cognitive impairments and other symptoms that can cause significant stress to themselves and caregivers. However, areas of the brain associated with musical functioning are very often preserved in persons with dementia. Therefore, music therapists are in a unique position to provide theoretically informed and skillfully designed music programs and interventions that address the complex needs of persons with dementia. A variety of receptive, improvisational, re-creative, and compositional music therapy methods and interventions may be used to highlight potentials and address a diverse spectrum of needs of persons with dementia. Family members and professional or volunteer caregivers may also participate in the client’s music therapy sessions. In some cases, the music therapist may instruct family members, volunteers, and/or professional caregivers on how to apply particular music techniques or principles. Family members and professional caregivers may themselves benefit from music therapy interventions designed to meet their own unique needs. Although a substantial amount of research and anecdotal literature contains positive results with regard to the efficacy of music therapy for persons with dementia, these results must be interpreted with caution due to a number of limitations. Methodologically sound qualitative and quantitative research is needed in order to draw more definitive conclusions about the effectiveness of particular music therapy

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methods/interventions for this clinical population as well as to expand perspectives on the role of music therapy in dementia care. The current author was inspired to enter the field of music therapy over 20 years ago due in large part to experiences that she had with this population as a university music student. My subsequent clinical, educational, research, teaching, and life experiences have served to strengthen my commitment and belief in the necessity of advocating for high-quality music therapy services for persons with dementia. Music therapy is not a frill—it is a lifeline to these individuals’ dignity and surviving sense of self.

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Todd, S. J., & Watts, S. C. (2005). Staff responses to challenging behavior shown by people with dementia: An application of an attribution-emotional model of helping behaviour. Aging and Mental Health, 9(1), 71–81. Tomaino, C. (2000). Working with images and recollection with elderly patients. In D. Aldridge (Ed.), Music therapy in dementia care (pp. 195–211). Philadelphia, PA: Jessica Kingsley. Ueda, T., Suzukamo, Y., Sato, M., & Izumi, S.-I. (in press). Effects of music therapy on behavioral and psychological symptoms of dementia: A systematic review and meta-analysis. Ageing Research Reviews (2013), http://dx.doi.org/10.1016/j.arr.2013.02.003 van der Steen, J. T., Volicer, L., Gerritsen, D. L., Kruse, R. L., Ribbe, M.W., & Mehr, D. R. (2006). Defining severe dementia with the Minimum Data Set. International Journal of Geriatric Psychiatry, 21(11), 1099–1106. Vibroacoustics for Seniors. (2012, December 12). [Website]. Retrieved from http://www.vibroacoustictherapy.com/vibroacoustics-for-seniors Vink, A. (2000). A survey of music therapy practice with elderly people in the Netherlands. In D. Aldridge (Ed.), Music therapy in dementia care (pp. 119–138). Philadelphia, PA: Jessica Kingsley. Vink, A. C., Birks, J. S., Bruinsma, M. S., & Scholten, R. J. (2011). Music therapy for people with dementia. Cochrane Database of Systematic Reviews, 4. Art. No.: CD003477. DOI: 10.1002/14651858.CD003477.pub2. Vink, A. C., Bruinsma, M. S., & Scholten, R. J. P. M. (2011). Music therapy for people with dementia. Cochrane Database of Systematic Reviews 2003, Issue 4,. Art. No.: CD003477. DOI: 10.1002/14651858.CD003477.pub2. Wade, F. L. (1987). Music and movement for the geriatric resident. In B. Karras (Ed.), You bring out the music in me: Music in nursing homes (pp. 37–62). New York: Haworth Press. Ward, C. R., Kamp, L. L., & Newman, S. (1996). The effects of participation in an intergenerational program on the behavior of residents with dementia. Activities, Adaptation & Aging, 20(4), 61– 76. Weiner, M. F., Tractenberg, R. E., Jin, S., Gamst, A., Thomas, R. G., Koss, E., & Thal, L. J. (2002). Assessing Alzheimer’s disease patients with the Cohen-Mansfield Agitation Inventory: scoring and clinical implications. Journal of Psychiatric Research, 36, 19–25. Wenrick, N. A. (1996). So much more than a sing-a-long: Creative activities for groups. St. Louis, MO: MMB Music. Whitcomb, J. B. (1994). “I would weave a song for you”: Therapeutic music and milieu for dementia residents. Activities, Adaptation & Aging, 18(2), 57–74. Wigram, T., Pedersen, I. N., & Bonde, L. O. (2002). A comprehensive guide to music therapy: Theory, clinical practice, research and training. Philadelphia, PA: Jessica Kingsley. Xie, J., Brayne, C., & Matthews, F. E. (2008). Survival times in people with dementia: Analysis from a population-based cohort study with 14-year follow-up. BMJ (British Medical Journal), 336, 258– 262. doi: http://dx.doi.org/10.1136/bmj.39433.616678.25 York, E. (1994). The development of a quantitative music skills test for patients with Alzheimer’s Disease. Journal of Music Therapy, 31(4), 280–296. Young, L. (2009). Multicultural issues encountered in the supervision of music therapy internships in the USA and Canada. The Arts in Psychotherapy, 36, 191–201. Young, L., & Nicol, J. J. (2011). Perspectives on singing and performance in music therapy. International Symposium on Performance Science, 129–134. Retrieved from http://www.legacyweb.rcm.ac.uk/cache/fl0026688.pdf Ziv, N., Granot, A., Hai, S., Dassa, A., & Haimov, I. (2007). The effect of background stimulative music on behavior in Alzheimer’s patients. Journal of Music Therapy, 44(4), 329–343.

Chapter 22

Professional Burnout Darlene M. Brooks

DIAGNOSTIC INFORMATION The “bottom line” has become a way of life for most employers, whether in business and industry or in education and health care. The demand for more and better is the constant theme of institutions around the world, and at the same time, these same institutions downsize their employees, add more responsibility, or switch to technology that requires fewer employees. The result of such high demands is employee burnout. Who suffers from burnout? Interestingly it is a phenomenon that affects factory workers, clerical workers, teachers, students, administrators, pharmacists, psychiatrists, mental health workers, social workers, psychotherapists, creative arts therapists, and music therapists (Figley, 2002; Fortney & Taylor, 2010; Kertz-Weizel, 2009; Lahoz & Mason, 1990; Maslach & Leiter, 1997; Najjar, Davis, Beck-Coon, & Doebbeling, 2009; O’Halloran & Linton, 2000). Burnout reaches across all disciplines and across all environments, but it is most prevalent in the work environment. It affects all ages; however, it has been noted that young, highly motivated individuals often experience “conflicts between their expectations and the reality” of their jobs, which often leads to burnout (Espeland, 2006, p. 179). There are several factors that enhance the propensity for burnout. “Individuals who display low levels of hardiness, who depend on external events to attest to their worthiness, who have poor coping styles and who are Type A personalities and are perfectionists” tend to be candidates for burnout (Espeland, 2006, p. 179). Role conflict and role ambiguity also contribute to burnout in employees. Often employees are asked or expected to take on roles for which there has not been proper training. When mistakes occur, there is reprimand for poor work, and the employee’s sense of self-worth is compromised. For many years, burnout was perceived as an individual problem, i.e., the employee was not adequate for the job. These burned-out employees may have exhibited such behaviors as constant complaints about the job, they may often have been ill, and they may have been suspended or even terminated from the job. As demands for services expanded in work environments, however, demands for employee productivity also increased, and more employees began to display similar behaviors and symptoms until this syndrome began to permeate the work environment (Halbesleben & Buckley, 2004; Schaufeli, Leiter, & Maslach, 2009). Symptoms of burnout seen in employees include negative emotions where the person appears to be angry, frustrated, stuck, bored, or helpless. In some cases, compulsive behaviors may also be displayed. For example, employees may become workaholics, over- or undereat, smoke, drink excessive caffeine, use pain medications excessively, or become underachievers and do the bare minimum in work, often neglecting duties (Maslach, as cited in Angerer, 2003). These behaviors impact performance at work and affect the employees’ relationships both at work and at home. There may be angry outbursts, hostility, or paranoia. Often physical symptoms begin to appear, which may include insomnia, headaches, backaches, nausea, etc. (Brock & Grady, as cited in Angerer, 2003).The person may begin to withdraw from others

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and lose the capacity for compassion and empathy. According to Brill (1984),“Organizations have begun to recognize the contribution of psychosocial factors to health, productivity, worker satisfaction, morale, communications, and motivations” (p. 13). When the environment becomes toxic, productivity, customer relations, and patient care are all compromised. A study by Weber and Jackel-Reinhard (2000) indicated that many industrialized countries have begun to recognize that the reduction in productivity and poor customer relations may be because of burnout. Understanding the triggers and searching for ways to prevent burnout in their employees while continuing to increase productivity is a goal for employers everywhere. It is apparent that burnout has far-reaching consequences in many work environments. To better understand this phenomenon, it is necessary to define it.

Defining Burnout Defining burnout is a challenging task. It has been researched and discussed in the literature since the early 1970s. Brill (1984) defined burnout as: An expectationally mediated, job-related, dysphoric and dysfunctional state in an individual without major psychopathology who has (1) functioned for a time at adequate performance and affectual levels in the same job situation and who (2) will not recover to the previous level without outside help or environmental rearrangement (p. 15). The most widely accepted definitions of burnout, however, are the ones proposed by Maslach and Jackson (1981), “Burnout is a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do ‘people-work’ of some kind” (p. 99), and Maslach, Schaufeli, and Leiter (2001), who further describe burnout as “a prolonged response to chronic emotional and interpersonal stressors on the job, and [it] is defined by three dimensions of exhaustion, cynicism and inefficacy” (p. 397). The dimensions of burnout are important in this definition. According to Angerer (2003), exhaustion occurs when the individual is overextended on the job. The overextension can be imposed on the employee by either the employer or the employee himself. Often, individuals take on more responsibility than they should, and instead of admitting they are overextended, they work harder. When the extra work efforts are not rewarded, the employee is disappointed, and to protect himself from the disappointment, he becomes cynical. Thus, the second dimension of cynicism is manifested. The individual becomes jaded about the facility, his coworkers, the policies, the administration, and occasionally about the persons to whom he is providing a service. If others do not share that jaded feeling, the third dimension of inefficacy is manifested. The individual begins to feel inadequate, “accomplishments seem trivial, and projects seem overwhelming” (p. 101). The individual has decreased job satisfaction, has diminished energy, and becomes unproductive and ineffective in his duties. The consequences of exhaustion, cynicism and inefficacy are injurious to the individual, to the facility, to coworkers and, in some cases, to those persons who receive services. Accompanying these feelings are physical symptoms like body aches, insomnia, the tendency to catch frequent colds and viruses, headaches, unusual startle responses, (O’Halloran & Linton, 2000), and other physical maladies (Angerer, 2003). Weber and Jackel-Reinhard (2000) suggested that in extreme cases, abuse of drugs and alcohol accompany burnout. When burnout becomes chronic and untreated, other symptoms appear. Concentration becomes a problem, along with memory problems, and the person may become aggressive. The individual is disorganized and becomes anxious over his constant mistakes. His social and family relationships may be impacted, and often he becomes depressed. Several other authors have tried to understand burnout and ways to further define it. After closely observing the work of teachers and discussing the phenomenon with psychotherapists, Farber (2000)

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concluded that burnout is “marked by individuals’ complaints of multiple obligations, increasing external pressures, inadequate financial rewards, and insufficient opportunities for personal advancement” (p. 592). He further argued that all individuals do not present the same symptoms and etiology. Farber proposed that burnout is also based more on the individual’s failure to meet his own self-imposed, often unrealistic goals, and suggested that a differentiation of the burnout syndrome should be based on three clinical profiles of employees: frenetic, underchallenged, and worn-out. In a 2009 study, Montero-Marin, Garcia-Campayo, Mera, and del Hoyo further defined Farber’s clinical profiles. The frenetic employee works until exhausted and seeks success that equals the invested efforts. The underchallenged employee lacks motivation, and the worn-out type often gives up when presented with too much stress. The authors hypothesized a way of integrating the burnout subtypes based on Farber’s proposal. Based on grounded theory, they used a content analysis of a qualitative, vertical, and interpretative nature to construct conceptual categories. Their results provided clinical properties of Farber’s burnout syndrome subtypes as follows: 1) Frenetic type • • • • •

Involvement in work (tenacious and energetic persons) Ambition and need for achievements (needs external approval from operations) Inability to acknowledge failure and difficult situations (do not tolerate failure, strong belief that their work reflects personal worth) Neglecting own needs (risk health and personal life) Anxiety and irritability (don’t acknowledge limitations and increase stress)

2) Underchallenged type • • • • •

3)

Indifference and superficiality in tasks (work is not appealing) Lack of personal development (feel dissatisfied and feel they are not developing) Contemplating another job (question the suitability of their current job) Monotony and boredom (lack of stimulus and performing tasks perfunctorily) Absence of overload-induced stress (no perception of difficulties performing their tasks)

Worn-out type • • • • •

Neglecting responsibilities (lack of personal involvement in tasks) Absence of control over result Problems with organization and reward system Difficulties in performing tasks Depressive symptomatology (emotional exhaustion leading to depressive symptoms)

These subtypes are useful in helping to understand what the person may be manifesting during burnout syndrome. While these authors and many others who have offered definitions of burnout present

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variations to the original definition proposed by Maslach and Jackson (1981), the primary emphasis for them is on the general population and the stressful jobs performed in industry and education. There is another area of importance when discussing burnout that relates directly to the care of persons who are physically or mentally ill or have experienced some type of trauma and those who are dying. Because of the unique demands of this work, persons who work directly with these populations experience burnout in a more acute manner. Another term, compassion fatigue, has been coined to identify the type of burnout that these caregivers experience. According to Figley (2002), compassion fatigue puts therapists and caregivers at risk. He often uses the term “compassion stress,” and defines it as “the residue of emotional energy from the empathic response to the client, and […] the ongoing demand for action to relieve the suffering of a client” (p. 1437). Figley (2003) and others often refer to compassion fatigue as secondary traumatic stress syndrome. Therapists listen to the traumas that clients experience, try to help clients with the pain, and often have their own traumatic recollections when they think about what the client has endured (Keidel, 2002; Najjar et al., 2009). The irony of compassion fatigue is that the very characteristics that one needs to have to care for persons who are ill are also what often lead to the disorder. Those characteristics include compassion, emotional energy, and empathy (Figley, 2002). Unfortunately, the person’s capacity to bear the suffering of others is often overtaxed, and his work efficiency is compromised. There are two types of compassion fatigue identified. In the first, the caretaker identifies with the patient and absorbs the patient’s trauma. In the second type, the caretaker has experiences similar to flashbacks through the patient’s descriptions of his trauma, which is referred to as secondary posttraumatic stress disorder (McHolm, 2006). As in the case with burnout, if compassion fatigue is not addressed, the therapist, the therapist’s family, the organization, and, most importantly, the client can experience its negative impact. Tests have been developed for burnout in the Maslach Burnout Inventory (MBI) (Maslach & Jackson, 1981), which is designed to measure emotional exhaustion, depersonalization, and personal accomplishment, and in the Professional Quality of Life Scale (Pro-QOL) for compassion fatigue, which was designed to measure risk of burnout, compassion fatigue, and the degree of satisfaction derived from helping others (Figley & Stamm, 1996). For purposes of this chapter, the two terms will be combined and addressed as burnout/compassion fatigue.

NEEDS The primary need of individuals who suffer burnout/compassion fatigue is to eliminate it. Unfortunately, employees will go to any lengths to hide the burnout/compassion fatigue symptoms that they experience. Rather, they address somatic complaints and viruses as the excuses for their developing apathy. Various authors have listed needs they feel would benefit persons suffering from burnout/compassion fatigue. Those range from the need to communicate sadness and grief, care for the self, and a good support team (Najjar et al., 2009) to cutting back on work hours, establishing balance between work and life, planning stress reducing vacations, altering diet, exercise, and relaxation habits (Hamann & Gordon, 2000). Duffy, Oyebode, and Allan (2009) suggest reducing anxiety, self-efficacy, reciprocity, and commitment as ways to address burnout/compassion fatigue. It seems clear that many of these needs revolve around the work environment. Maslach and Goldberg (1998) state, “A work setting that is designed to support the positive development of the three core qualities of energy, involvement, and effectiveness should be successful in promoting the well-being and productivity of its employees” (p. 66). Their emphasis is on changing the work environment to provide opportunities for employees to better function with the demands of the job. They recommend changing work patterns, utilization of social resources, developing a more relaxed lifestyle, and self-analysis as personal approaches to reducing burnout, and suggest that employers consider the risk of burnout with certain job responsibilities and evaluate the risks and benefits of placing employees in particular situations. Another important factor they address is the work environment in

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terms of employee overload and the sense of community in the work environment. O’Halloran and Linton (2000) report that in the case of compassion fatigue from secondary post-traumatic stress disorder (reliving the trauma that the client reports), it is better to focus on coping strategies rather than on preventing the disorder from occurring, implying that the work environment will not necessarily change, that is, clients with trauma will continue to be the focus of the institution. He then provides a list of selfhelp resources that are characterized as social, emotional, cognitive, physical, spiritual, and vocational.

RESOURCES When examining ways to implement these recommendations, several authors offer suggestions to address them. Farber (2000) suggests that the therapist working with persons who have burnout align herself with the person experiencing burnout, and then address four aspects of treatment that are significant. Those four aspects are: • • • •

Getting the individual to adjust his or her expectations of what work (and others at work) can and cannot provide in terms of meaning and fulfillment; Getting the individual to focus on the positive aspects of work, and not just the oppressive, onerous parts; Getting the individual to build a stronger support network to mediate the inevitable stressors of work; Working with individuals to take better care of themselves and others in domains outside of work such that the stressors of work are not always in the foreground (p. 593).

It should be noted here that persons seeking treatment for burnout/compassion fatigue also come to the music therapist with a number of personal resources. It is important that the music therapist explore those resources with the client during the assessment period. For example, their cognitive abilities are most often intact. They recognize that there is a problem and willingly seek help for that problem. They are generally problem-solvers, which is another excellent strength. This particular strength helps them be receptive to seeking solutions for the burnout/compassion fatigue that they experience. Even though burnout/compassion fatigue may cause friction between people, there are support systems readily available for them, for example, family, friends, and coworkers. Most persons suffering with burnout/compassion fatigue, while exhausted, have emotional maturity, demonstrated through the very nature of the work they do. This emotional maturity is an excellent resource that the client possesses that will enable him to confront the issues related to burnout/compassion fatigue. Generally, communication skills are also an asset that these clients possess. They are able to communicate verbally and nonverbally. Many clients also have spirituality as an asset. They have made sense of the world they live in and found meaningfulness in the work they do and in the relationships they form. Each of these personal resources is helpful in guiding the client through the difficulties they experience from burnout/compassion fatigue. Occasionally, clients who are suffering from burnout/compassion fatigue may lose sight of those resources.

MULTICULTURAL ISSUES Today’s work world is a multicultural one. Employers seek the best employees they can find, and these often include persons from different cultures. In many cultures, serving others is more important than taking care of oneself. Adjusting to the work environment and demands, the differences between cultures, and stigmas associated with difference may all lead to acculturative stress (Kim, 2010). For many

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nationalities or cultural groups, however, there is such a sense of “others first and me last” that they tend to burn out without realizing it themselves. Because of their willingness to work beyond expectations, employees will push themselves further than what is considered normal, and only stop when burnout has reached a critical stage. In other cultures, working for the family is more important than the demands of the job. Employees are working to provide for their families, and the more they work, the better they are able to provide. What neither they nor their employers recognize is that the demands of the job are interfering with the employee’s ability to successfully do the tasks needed. In other words, the employee continues to do everything asked of him, even tasks beyond his abilities, and the employer continues to ask more. Neither recognizes that the overtime hours, successful completion of tasks without error, or changes in employee attitude may be related to employee burnout, because the employee’s focus is on providing for his family, while the employer’s focus is the bottom line. Yet, these employees don’t complain, because the end justifies the means. Unfortunately, the ability to work at the demanding pace often comes with physical, emotional, and social ramifications. Work becomes sloppy, and the employee becomes forgetful, blames himself for not being able to do more, may become paranoid or physically ill, and may be eventually dismissed because his extra efforts have caused him and the company more harm than good. The family is affected because the income has stopped. It is therefore vital when encouraging treatment for burnout/compassion fatigue that the person offering such services is culturally aware so that the appropriate support can be offered. Possibly the most important goal for referring a client to treatment for burnout/compassion fatigue is self-empowerment, where the client can discover strategies that will help him deal with the feelings associated with burnout/compassion fatigue in healthier ways than demonstrated prior to treatment. Who, then, would benefit from music therapy to treat burnout/compassion fatigue? Factory workers, clerical workers, teachers, students, administrators, pharmacists, psychiatrists, mental health workers, social workers, psychotherapists, creative arts therapists, and music therapists would all benefit from music therapy to treat burnout/compassion fatigue. It should be noted, however, that clients who have a history of psychiatric problems or who have auditory or visual hallucinations are not recommended for this type of music therapy treatment. Generally, these sessions are not conducted in an environment where immediate assistance can be offered to clients having a psychotic episode; therefore, persons with major psychiatric problems are contraindicated.

REFERRAL AND ASSESSMENT Individuals who suffer burnout/compassion fatigue are often unaware that this is the problem they are experiencing, but instead seek treatment for somatic symptoms that manifest as a result of the burnout/compassion fatigue, believing that medication will take care of the problem. Unfortunately, in more cases than not, the burnout/compassion fatigue continues. Those working in hospice, palliative care, nursing homes, or hospitals may be aware of the music therapist, and they may have even offhandedly remarked that they might need music therapy. They recognize that they are tired and may seek music therapy to help them. Some facilities offer employee assistance programs that are designed to help the stressed employee. Friends or coworkers may suggest that the person get help with his burnout. For whatever reason, the person seeks treatment for his burnout/compassion fatigue, it is important for the therapist to conduct an assessment of the client to determine the level of burnout manifested, to determine if he is able to work individually or in a group, and, most importantly, to determine if he is appropriate for music therapy. To begin this assessment, it is recommended that the therapist discuss the reasons that the client is experiencing burnout/compassion fatigue, so that both the therapist and the client have some understanding of what led to the problems. The therapist might ask a series of questions to gain this

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information. For example: Is the problem the number of clients they are expected to see in a given day? Is it the administrative responsibilities they have to balance along with patient care? Is it the feeling of inadequacy related to preventing the suffering of the client? Is it the work environment, e.g., in palliative and hospice care, going into the homes of the client, the number of clients lost because of their disease? Is it the clinically detached nature of the environment? Is it working alone? Is it the lack of supervision or support? The therapist should avoid closed-ended or leading questions, but instead allow the information to come naturally from the participant. Sometimes people cannot tell the reasons for their burnout/compassion fatigue because they don't recognize this as something that may be happening to them. In this case, it is recommended that the participant discuss his typical workday. This may provide insightful information. It is important as well in this first meeting to discuss the types of music the client prefers and reasons for those choices. Discuss favorite listening experiences, preferred genres, messages in songs that he finds meaningful, and the client’s reasons for selecting the types of music being discussed. This information is important for future sessions where the therapist may guide the client in the use of preferred music. Also, knowing how the client uses certain types of music helps the therapist to avoid exacerbating the negative emotions associated with that type of music in a session. For example, the client may use a particular kind of music when he feels angry and full of negative emotions related to his job. In the music therapy session, the therapist would want to avoid this particular type of music. This same discussion can be conducted when working with a group of participants. Here, the therapist is looking for similarities and differences in music preferences, which may be very useful in future sessions. After each client has been assessed, the therapist can determine if the client needs individual treatment or can benefit from group work. Generally, this is based on the severity of the burnout/compassion fatigue presented and on the uniqueness of the client’s symptoms. If the therapist has a number of clients who are experiencing burnout/compassion fatigue, group work would be more beneficial for most clients because of the support received from others who are experiencing the same issues. Once assessments have been completed on all clients, the therapist can then determine if she can divide the group into smaller homogeneous groups based on the symptoms they are experiencing, for example, emotional exhaustion vs. depersonalization. Group sessions are contraindicated for clients unable to tolerate working in groups or those with hearing sensitivity.

OVERVIEW OF METHODS AND PROCEDURES There are four main methods employed in music therapy. Each method has variations aimed at enhancing the client’s therapeutic experience and working on specific goals. The four methods are receptive, improvisational, re-creative, and compositional. Applications of these methods that the author feels best address the issues of burnout/compassion fatigue will be addressed.

Receptive Music Therapy • • •

Music Listening for Relaxation: Clients listen to relaxing music while bringing their awareness to how the music feels in their bodies to help them relax. Directed Music Imagery: The client, in an altered state of consciousness, creates images to a scene evoked by the music and directed by the therapist. Music Imagery, Mandala Drawings, and Logs: The therapist guides clients in physical relaxation and scripted imagery experiences, after which clients create mandala drawings and write about the experience.

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Improvisational Music Therapy • • • •

Nonreferential Instrumental Improvisation: The therapist guides clients in making music on a variety of melodic and rhythmic instruments. Referential Instrumental Improvisation: The therapist guides clients in making music based on specific themes or ideas. Referential Vocal Improvisation: The therapist guides clients in creating a syllabic vocal improvisation based on the sound of stress in order to reduce stress. Referential Song Improvisation: The therapist guides the clients in extemporizing lyrics to express current emotional states.

Re-creative Music Therapy • •

Song Singing: Clients and therapist sing precomposed songs with live accompaniment. Musical Games: The therapist guides the clients in musical games, such as Name That Tune or Musical Charades.

Compositional Music Therapy • •

Song Parody: The clients change lyrics or phrases of songs to create original songs and sing them with the therapist. Songwriting: The therapist guides clients in song composition from rhythm to melody to lyrics.

For this chapter, all activities will be presented focusing on group work, but each can be done in individual sessions.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Music Relaxation: “Purposeful Listening” Overview. In music relaxation, clients listen to relaxing music while bringing their awareness to how the music feels in their bodies to help them to relax. One of the more appealing methods to use with persons suffering from burnout/compassion fatigue is the receptive method. It is well received by most individuals because it doesn’t require them to do anything except take the music in, and most clients will already have a relationship with music and may have some experience using music in this way. The primary goals for this activity are (1) to introduce clients to listening activities in a therapeutic way, (2) to help clients learn to listen with intent, (3) to identify and develop an awareness of what happens to their bodies as they listen, and (4) to help clients learn to relax. The level of therapy is augmentative. Preparation. This listening activity is generally done with recorded music selected by the therapist. The therapist should have a CD player and a number of CDs or an MP3 player for the session. The length of time for the music listening should not exceed 10 minutes. Have a variety of music selections available and be certain that the volume is appropriate for the exercise. Whenever possible, nonreferential music should be used for the session to avoid possible distractions. Suggestions might include music by such artists as Ciani, Kitaro, Enya, Lynch, or Kobialka. Depending on the ability of the therapist to speak over the music in a calm and soothing way, the therapist may choose to either sit so that she closes the circle or stand so that she can move around and be prepared to assist any client in crisis.

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The room should be set up with ambient light. In many cases, office or therapy spaces are filled with fluorescent lighting. To provide ambient light, it is suggested that a lamp or two be purchased so that the fluorescent light is not on. In cases where this is impossible, try having only one row of lights on. For this activity, chairs or floor mats may be used and placed in a semicircle. The chairs or mats should be placed at least a foot or two apart to provide sufficient distance between each so that clients have a sense of their personal space. If mats are not available, however, comfortable chairs can be used, since this activity is short and does not require listening with eyes closed. Whether they are sitting or lying on mats, it is of significant importance that the therapist creates an environment where clients are comfortable within the space. What to observe. The first thing to observe is the client’s comfort level, that is, how much movement it takes for the client to be still and how shallow or deep the breathing is. It may be necessary to verbally encourage deep, slow breathing until the clients become more still. Observe focus, that is, does the client have a focus on the wall or on his/her lap, or is the client looking around at other clients? Notice nonverbal communication between clients, which will give some indication of each client’s willingness to engage in the activity. Observe any signs of tension in the client’s body and his/her affect after the listening session, as they verbalize the experience of their bodies. Procedures. Once clients are seated, talk about the purpose of the session. The purpose of this activity is to introduce clients to listening while increasing self-awareness, in particular, awareness of the body’s response to music listening. Explain to them that in the first session they will be listening to music, and they can do so with their eyes open or closed, as they become comfortable with the procedures, the therapist, and the environment. Reassure clients that there is no right or wrong way to listen. Let them know that the only expectation is that they allow the music to come into themselves as they listen and bring into their awareness the way their body responds to the music. Inform them that if they find their attention shifting to unwanted thoughts, first concentrate on their breathing, then become aware of the music, and identify the instruments if they can, listening to the flow of the melody and the tempo of the music. To begin, give clients the opportunity to get comfortable. This will involve some shifting in their chairs, legs crossing and uncrossing, moving head, and stretching neck, arms, and legs. Generally, when clients become still, this is an indication that they are comfortable and ready to proceed. Once clients seem comfortable, ask them first get in a position they can remain in for the duration of the music listening. Then have them focus on each body part to notice how that body part feels. This is done by helping them become aware of their limbs, hips, back, torso, arms, neck, and head. Then shift the focus to their heartbeat and pulse. With this internal awareness (heart and pulse), guide their awareness to their muscles—ask them to become aware if muscles are more or less tense as they breathe. Have the clients take in regular breaths, but with awareness. Encourage them to notice how frequently and how deeply they inhale and exhale. This should go on for a few minutes. Then have the clients take deep, full breaths, holding the inhalation for a brief period and then exhaling deeply. Do this a few times. Let them know that as the music begins, they are free to close their eyes if they wish to help them maintain their awareness, but it is also acceptable to keep their eyes open. Inform the clients that the music is beginning and, as they listen to the music, to become more aware of their bodies in this space and time, first with awareness of their bodies in the chair or on the mat, then of their inhalation and exhalation, their heartbeat/pulse, and finally their muscles. Let them know that staying in one position may be uncomfortable, and if the need arises, they are free to shift positions in their chairs or on their mats, but they cannot leave their places until the music is finished. When the music listening ends, a moment or two of silence should be allowed. Then slowly help clients shift their conscious awareness by focusing on their breaths, the sounds next to them, and the sounds in the room and outside of the room. Have them open their eyes if closed, and shift positions, stretching, sitting up, or standing for a moment. This is followed by a discussion about the experience,

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when clients have the opportunity to talk about what they were aware of in their bodies. The therapist should talk to the clients about the ways they may be able to use this type of music listening experience for themselves, and explain that this listening with intent can be a first step in reducing burnout. Share with the clients how and why the music was selected, focusing on how particular music is helpful to generate the relaxation response. Adaptations. The environment may be made more comfortable by using mats on the floor rather than chairs. Another adaptation would be to have the clients close their eyes at the onset of the relaxation so that awareness of the body response can be more acute.

Directed Music Imagery: “The Gift” Overview. In directed music imagery, the client, in an altered state of consciousness, creates images to a scene evoked by the music and directed by the therapist. This receptive method is a good session with clients who have burnout/compassion fatigue, after rapport and trust have been established with the therapist. It allows clients to find gifts within themselves that can be used during periods of daily stress, while also engaging in a deeper form of imagery. Clients should be able to comfortably engage in an imagery experience for 20 to 30 minutes. This session is done with eyes closed so that it allows clients to drift into a relaxed state where they experience an altered state of consciousness. The goal of this imagery experience is to give clients a resource in the form of something they can visualize to use outside of the music therapy session; this internal resource will help them cope with difficult emotions and bring them calm and peace. This session is practiced at the augmentative or intensive level of therapy. This session is contraindicated for clients who have difficulty remaining still with eyes closed for the allotted time to complete the session, or those who are too restless to engage in the activity. Therapists who use the first listening experience would have information on the appropriateness of this session for clients who have difficulties with sustained attention. Preparation. For this session, mats should be placed on the floor approximately one foot apart. Ambient lighting is required, and the space should be as free from noise as possible. The therapist should have a CD player and CD or MP3 player ready to play the selection. Here again, the therapist should choose the music. It is recommended for this session that the therapist select music similar to that used in the previous activity, nonreferential New Age music that has some movement, but not enough to be distracting for the experience, for example, music by Kitaro or Kobialka. The therapist should prepare a script if doing this exercise for the first time. It is also helpful for the therapist to audio record him/herself guiding this session to have an idea of pacing, where pauses and voice inflection are needed, and how the music supports the imagery exercise. What to observe. This session requires clients to close their eyes and focus within. Observe clients closely to determine the pacing of the relaxation exercise. It may be necessary to slow down or speed up the body relaxation depending on client’s apparent relaxation. Often this is determined by the amount that the client is moving and the pace of his breathing. Fidgety movement might indicate discomfort. It may be necessary to place a pillow under the knees of a client who seems to be having difficulty with lying on his/her back with legs extended. Be aware that some clients may fall asleep during the body relaxation. At the end of the session, observe clients as they share their imagery experiences. Are they able to look at the therapist or other clients? Do they seem comfortable or uncomfortable in sharing? Notice what kinds of images they report. Ask the client what he thinks the image means. Notice if the client’s report of the symbolism is related to his burnout/compassion fatigue or is helpful in his efforts to combat the burnout/compassion fatigue.

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Procedures. Once clients have come into the room, encourage them to find a mat. As they sit on the mat, begin with a check-in to find out how they are. Do a check-in on their burnout/compassion fatigue states since the last session. Clients are then instructed to lie on the mat and get as comfortable as possible. Once clients seem still, the therapist begins with a relaxation procedure. The relaxation may be a breathing exercise or progressive muscle relaxation. An example is Breathing in Color. This exercise begins with clients taking deep breaths with focused exhalations. After several of these, have the clients imagine a color. With the next inhalation, imagine the color coming into the body and making its way down to the feet. Imagine that the color surrounds the feet, taking away tension from the feet, leaving the feet relaxed and weightless. Proceed to the legs, knees, and thighs, repeating the same instructions. Next, proceed to the stomach, back, chest, shoulders, arms, and fingers. The color moves to the neck and head, taking away tension, leaving that part of the body relaxed and weightless. With the next inhalation, have the client imagine that the color has become cooler. Allow the color to go over and through the head and face, taking away worries, concerns, and thoughts of the day until the head and face are free from tension, relaxed and weightless. This should not be rushed, but paced based on what the therapist is observing. In some cases, it may be necessary to repeat an instruction until all clients seem relaxed. Once physically relaxed, the therapist reads from the prepared script. For example: Imagine you are on a path in the woods. These are safe woods, with beautiful fall foliage all around you. Take time to notice the colors, notice the trees, what kind of trees are on your path. What do you see in the distance? Do you notice any animals? What kind? Notice how friendly these animals are. As you continue down this path, you notice that the path becomes wider and veers to the right. Continue to the right, feeling the warmth of the sun and the clean scents of nature around you. You notice a boulder. Take a moment or two and sit on the boulder. Feel the energy of the earth coming through your body as you sit on the boulder. Feel the total relaxation that enters your body. Take a few moments to look around and take in everything you see. As you look to the left, you notice a small box. Pick up the box and notice what material it’s made of. Notice the color of the box, and the smoothness or roughness of the box. Feel its weight in your hand. Smell the box. Now notice the clasp in the front of the box. Open the box and see what’s inside. There is a gift just for you. Pull it out of the box. Notice its color, shape, and weight. Notice how it feels to have this gift. Know that this gift is yours and yours only. You can choose to put it back in the box or hold it in your hand. Become aware of the energy around you from the boulder, from the sun and all the life around you. It’s time to leave this place. Before leaving, take some time to notice everything you can about this place. Notice the animals, flowers, trees, and water, everything you can put in your memory. Know that this is a place you can go whenever you need to. Also know that you can take your gift with you so that whenever you need it, you simply have to close your eyes for a moment and it is there for you. After the imagery experience, the therapist should slowly bring the clients back to normal consciousness by having the clients focus on the body, beginning with the feet and moving up to the head. Once fully conscious, have the clients remain on the mats for a few minutes to get them oriented to place and time. Check in with the clients to make sure they are ready to sit up and continue with their day. If there is time, and clients are motivated, a discussion can follow this activity. Clients should not be forced to share what their gift was.

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Adaptations. The therapist may choose to use a music piece to take clients through the physical relaxation, then have no music as the imagery is presented, and then follow by having music to help them move along in the imagery. Music Imagery, Mandala Drawings, and Logs: “Finding My Place” Overview. In music imagery, mandala drawings, and logs, the therapist guides clients in physical relaxation and scripted imagery experiences, and then clients create mandala drawings and write about the experience. Because clients return to the environments that cause burnout/compassion fatigue, there are times when clients need more than the music experience to sustain them after the session has ended. This four-step procedure is based on a study completed by Brooks, Bradt, Eyre, Hunt, and Dileo (2001). It involves autogenic relaxation (Luthe & Schultz, 1969), directed imagery chosen by the therapist, logs written by the clients, and mandala drawings (Kellogg, 1987). The goals of this session are to: (1) engage clients in psychical relaxation, (2) help clients find a place where burnout/compassion fatigue are minimized, (3) provide opportunities to log about their experiences to gain insight, and (4) complete a drawing that represents their experience to gain insight. This is practiced at the intensive level of therapy. Preparation. The room should have mats where clients can lie down. The mats should be spaced about two feet apart in a semicircle. There should also be chairs available, placed against the wall for clients who are not comfortable lying on the mats. The therapist will need a CD player with speakers or an iPod with iPod speakers that are spaced to allow for “surround sound” if possible. The decibel level should be set so that the music is loud enough evoke feelings and imagery, but also allows clients to hear the directions of the therapist. Ambient light is required. Generally, lamps are sufficient. Drapes should be drawn to close off outside lights. If possible, have the room temperature at around 72 degrees. If not, have a few pillows and blankets or sheets available, should a client become too uncomfortable. Drawing paper with a circle drawn on it the size of a dinner plate should be available for each client, along with a variety of pastels. Writing paper and pens should be provided for clients to log about their experience. Carefully chosen contemporary music should be used for this session, for example, the music of Daniel Kobialka, Susan Ciani, or Steven Halpern. It is recommended that the therapist write the script and time it with the music selection so that there is enough music. What to observe. Observe the clients’ ability to physically relax. If needed, repeat instructions until clients are able to complete the relaxation. Observe the clients’ breathing, spending time to help them breathe in a relaxed way if needed. Be aware of clients’ movements throughout the imagery. If a client seems restless, it may be necessary to go to that client and reassure them that they are safe and should focus on breathing. Also be aware that this experience may be emotional for some clients, and it is not unusual to see a client wiping his eyes. Procedures. As clients enter the room, ask them to find a mat to sit on, or sit and lean against the wall if that is more comfortable. Explain that they are going to engage in a relaxation exercise in a safe environment. Have clients recline on their mats if possible. Check to see that each client is comfortable. Offer pillows, blankets, or sheets if requested. Tell the clients that you will dim the lights so they are not bothered by the brightness. After clients are settled, have them concentrate on their breathing, noticing how rapidly they breathe, encouraging them to allow their breathing to gradually slow down. Have clients take a deep breath, holding the breath and exhaling audibly. Repeat this until the therapist notices that clients are breathing much more slowly. Have them focus on their feet and imagine that their feet are getting warm and heavy. Proceed to the legs, the thighs, the back, the stomach, the arms, the neck, and the head. Note: At the face, have them feel the warmth, but stress that the warmth of the face is at a perfect temperature, not too hot, nor too cold. Have them scan their bodies, feeling equal warmth

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throughout their bodies. At this point, begin the music listening and directed imagery. A sample script follows: Imagine yourself in front of a house. It’s a beautiful house. Take some time to walk around the house, noticing everything there. Notice what the house is made of. Notice the shrubs around it; notice the flowers. Allow yourself to enter the house. Notice the feeling of warmth in the house. Notice the furniture. Allow yourself to explore each room. [There should be a pause here to allow the music to help the client explore.] Find yourself at the kitchen door looking out. You see a path, but cannot tell where it goes. See yourself walking out the kitchen door to take the path. Notice the plants, flowers, and wildlife on either side of the path. Let this path take you to a special place, just for you. As you arrive at this special place, take everything in about it. Notice how your body feels in this special place. Be aware of the special warmth of this place and the relaxation you feel. As you relish in this place, look around, remembering everything you see. Find something in this place you can take with you. [Pause to let the music help the clients to find something they can take.] And now, it is time to leave this special place just for you. Notice the path, and say good-bye to this place. Know it is there for you. Know you can return to this special place whenever you need to. You simply have to look at the object you took with you to go there. As you return to the path, notice the plants, flowers and wildlife. Feel the warmth and feelings you have gained on this journey. It’s time to leave this space. As you leave this beautiful space, turn around and see the house. Allow yourself to enter the house, back into the kitchen. Breathe in its welcoming sight. Thank it for allowing you to visit. Go to the front of the house, take one more look around, and then open the door to exit the house. Find yourself on the steps that take you away from the house. Look around and breathe in the sights. And begin to bring this image to a close. Allow it to gently fade away, keeping any feelings that you want inside of you. Become aware of your body on the mat, or in the chair. Listen to the sounds in the room. Become aware of your breathing and begin to move your body. Become aware of your environment. Stretch your body, and when you’re ready, open your eyes. After all of the clients have opened their eyes, allow a few moments of silence. Have the clients sit up if on the mats, and bend and stretch if against the wall. Pass the paper and pens out and give the clients instructions to log about their experience. In the log, ask them to put as much detail about their experience as they can. When logs are completed, pass out the paper with a large circle drawn in the center and pastels. Ask the clients to draw anything they would like that represents this experience. Assure them that there is no right or wrong representation. When mandala drawings are complete, begin the verbal discussion. Clients are free to share or not share their experience and their drawings. Tell the clients that their logs and mandala drawings are for them to take and use whenever they need to.

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Nonreferential Instrumental Improvisation: “Letting Go and Having Fun” Overview. In nonreferential instrumental improvisation, the therapist guides clients in making music on a variety of melodic and rhythmic instruments. This is a method that is best employed in groups, but can be used in individual sessions in dyadic improvisations with the therapist. Discomfort, denial. and perhaps even anger accompany clients when they first come into music therapy. The idea of making up music on instruments they have never played understandably creates discomfort for many clients. In addition, clients often feel inadequate because of work difficulties that may be further exacerbated if they don’t possess music skills. Most will immediately state that they cannot sing or play an instrument, and begin to question how this might be of help to them in any way. Therapists should keep in mind that clients who are experiencing burnout/compassion fatigue are not eager to add a new task to their full and overworked lives. It is therefore very important that the therapist introduce the improvisation activity as a relaxing, enjoyable exercise designed to relieve, rather than to overburden. The use of nonreferential improvisation is a nice introduction to music therapy that enables the client to engage musically without feeling anxious or intimidated. This instrumental improvisation is practiced at the augmentative level of therapy. Clients who are sensitive to loud noises are contraindicated for this session. The goals of the session are to: (1) provide a musical means of expression, (2) use music as a means of communication with others, (3) develop awareness of others, (4) develop creativity, and (5) experience having fun and connecting with one’s spontaneity. Preparation. The room should be set up with chairs in a circle. In the middle of the circle, there should be a variety of percussion instruments including drums, marimbas, various xylophones, tone bars, ocean drums, rain sticks, and a guitar. If possible, two of each instrument would be ideal to avoid conflicts over choices. What to observe. Observe the client’s choice of instrument and how he explores the potential of that instrument. Does a client choose an instrument that barely makes a sound and express concern afterward about not being able to hear himself? Or does he choose the loudest instrument available and play it very loudly or very softly? This may give some information on the client’s level of comfort with expressing himself. Notice how the client explores the instrument. Does he hold the instrument close to his body as if to shield himself? Does he hold it at a distance as if fearful of it? Does he establish eye contact with anyone when playing? Is his playing at the appropriate volume for his instrument and for the volume of the group sound? Does he appear aware of other group members? Does the client appear anxious as the activity continues? Does he stop playing before other group members? Procedures. As clients enter the therapy room, encourage each to find a seat in the circle. Once everyone is seated, the therapist should take the remaining chair, also in the circle. Check in with the clients. Ask about their day and how they are feeling. Talk about improvisation, and how it can be used as a vehicle to reduce stress, and to enable participants to have fun. Then describe each instrument and demonstrate how each is played. After demonstrating, encourage clients to also try out each instrument. When they have successfully done this, ask them to choose the instrument that feels the most comfortable to them. After all clients have selected their instruments, the therapist should let them know that they are free to change instruments should they choose to. The only rule is that everyone has an instrument. The therapist should begin by playing her instrument, while encouraging the clients to play theirs as well. It is recommended that the therapist select a nonmelodic instrument, such as a drum or a small gong. This will provide grounding should the clients need it, rather than a melody that clients would depend on to harmonize with in some way to make the sounds more aesthetically pleasing. Initially, it is

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permissible for the therapist to play the loudest, but as soon as clients begin to play, the therapist’s instrument should be softer, and remain that way unless it appears the clients are disintegrating prematurely. In this case, the therapist serves as the ground. Caution should be taken in this role, because the intent is for this to become the clients’ undirected improvisation. The improvisation should continue until it comes naturally to an end. After the improvisation ends, allow a few moments of silence. Then begin with an open-ended question, for example, How was this experience? Clients are encouraged to share their thoughts about playing their instruments. Ask what they were aware of while playing, and whether that awareness influenced the way they played. Ask if there was any other instrument they would have liked to play. Ask how they are feeling at this moment, compared to when they came in. If clients indicate a preference for another instrument, suggest an additional improvisation. Adaptations. This improvisational activity can be done with an individual client. The client would have a variety of instruments to play, be encouraged to switch instruments whenever the desire occurred, and in some cases play several instruments at the same time. The therapist would also play with the client for support.

Referential Instrumental Improvisation: “Finding the Theme” Overview. In referential instrumental improvisation, the therapist guides clients in making music based on specific themes or ideas. This is most often used in a group experience. Clients who experience burnout/compassion fatigue are often unaware of why they feel the way they do. It is difficult for them to verbalize what they are experiencing. This session is one way to help clients begin to identify what they are experiencing that has led to their burnout/compassion fatigue, yet does not require verbalization about those feelings as they relate to burnout/compassion fatigue. After clients have been introduced to music therapy, possibly through the nonreferential music therapy experience, they are usually more comfortable and are willing to explore other aspects of music therapy. This referential improvisation is designed so that the emphasis of the improvisation is a topical theme generally shared by the group. The topics are group-oriented rather than focused on the individual, which provides security to the individual members of the group who are struggling with verbalization about their burnout/compassion fatigue. Goals of this session include the facilitation of (1) nonverbal channels of communication, (2) increased ability for clients to identify emotions that they have been unable to name, (3) the ability to confront the cause of burnout/compassion fatigue without naming it, (4) group cohesion, and (5) self-expression. This improvisation is practiced at the augmentative level of therapy. Preparation. Chairs should be set up in a circle. A variety of melodic and percussive instruments should be placed in the center of the circle. What to observe. It is important to observe clients for signs of undue anxiety such as avoidance of eye contact, fidgeting in the seat, talking too loudly or whispering, hand wringing, or labored breathing. It is recommended that should a client become overly anxious, the therapist should help the client by doing some slow breathing exercises with him and invite the client to sit quietly until he feels able to begin to participate again. Observe overly aggressive playing and the impact of that playing on other group members. Here again, being able to pause and breathe is a recommended way of helping the client control the aggression. Also observe timid, withdrawn playing, as this may be an indicator of the client’s fears around admitting burnout/compassion fatigue. Notice how clients play and hold their instruments. Be aware of the group as a whole. Look for any connection between clients. Look for avoidance of playing or lack of eye contact. Listen for connections between clients as they play. Is there a leader? How do other clients respond to that leader?

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Procedures. As clients come into the room, encourage them to find a seat in the circle. The therapist should initially check in with clients to find out how they are. After the check-in, the therapist should ask if they noticed common themes that seem to come from the group. Allow the group time to discuss what themes may have emerged from their check-in. If they are unable to find common themes, the therapist may suggest some that she heard during the check-ins. It is important that clients agree with these possible themes. Then the group should decide on the theme they would like to explore. Once the theme has been determined and agreed upon by the group, the therapist invites each client to choose an instrument that he feels comfortable playing and to demonstrate what the theme may sound like on his instrument. Once everyone has chosen his instrument and has a sense of how to play it, the therapist asks the clients to begin playing the theme together. The therapist also tells the group that she may play a little at the beginning, but they should continue to play as long as they wish even if she is not playing. The therapist should play only if clients have difficulty getting started with the improvisation, and she should stop as other clients join in. The reason for the therapist not being actively involved in playing is to allow the clients the freedom to express their theme without interference from a perceived authority figure. Again, reassure them that they can continue to play even if the therapist stops playing. It is important, however, that the therapist display her support through affect and body language. As in the previous improvisations, allow this one to end organically. Once the improvisation has ended, allow a moment of silence. After the silence, encourage clients to take a few deep breaths, because clients will often hold their breath when focusing on a particular theme or topic while improvising. This should be followed by a discussion on the experience. Questions related to each client’s ability to comfortably express what he was feeling during the playing should be discussed. The therapist leads a discussion on how the theme was experienced in the music, along with issues related to the roles of leading and following each other’s music. The therapist can also discuss how the improvisation allowed clients to express various body sensations and emotions in the music, and to note any body or mood changes as a result. Notice that the clients are not asked to relate the theme to their specific feelings around burnout/compassion fatigue. Adaptations. A possible adaptation would be to choose a rhythmic pattern that sounds like the theme determined by the group and to have clients play that rhythm slowly and then with increased speed, loudly or softly. Referential Vocal Improvisation: “Sounding It Out” Overview. In a referential vocal improvisation, the therapist guides clients in creating a syllabic vocal improvisation based on the sound of stress in order to both reduce stress and begin to externalize the feelings associated with burnout/compassion fatigue. It is often difficult for clients to verbalize the emotions they are experiencing, either because of fear of reprisal or because to do so would appear ungrateful to their employers or disrespectful to their clients. This referential improvisation activity provides an opportunity for clients to express those emotions safely through vocalization. The goal of this intensive or primary level of therapy is to offer clients a vocal venue for dealing with the feelings associated with burnout/compassion fatigue. Clients may be naturally uncomfortable with this activity for many of the same reasons they are hesitant to play instruments. Another factor here is that the use of the voice is often very revealing, and this may also cause some discomfort. This activity is contraindicated for persons who are very inhibited about making sounds and would become more anxious or stressed by being asked to do so. It is practiced at the augmentative or intensive level of therapy. Preparation. For this experience, the only requirement is a room that has some soundproofing if possible and chairs for the clients to sit in, should they choose to sit.

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What to observe. Notice which clients are making audible sounds or tones and which are not; notice the nature of these sounds. Encourage clients to sing louder if they are comfortable enough to do so. Notice any undue anxiety demonstrated by a lowered head, the inability to make eye contact, fidgeting, or nervous laughter. As the experience progresses, notice if those behaviors continue. Should this become problematic, encourage the client to stop singing, focus on relaxing breaths, and sit quietly. Procedures. The therapist should do a verbal check-in to see how the clients are feeling. Once they have verbalized their feelings, she asks each client to find a syllable or sound that accurately describes his feelings about burnout/compassion fatigue. The sound can be a grunt, groan, whisper, hiss, yell, or anything else that the client feels represents his feelings about burnout/compassion fatigue. Have the clients explore where in their bodies they have that feeling, so that it can be amplified through sound. The therapist should also choose a sound to describe what she is feeling. It might be necessary for the therapist to demonstrate putting her feeling to sound so that the clients can try it as well. Once each client has found his sound, the therapist will instruct clients that what they’re going to do is start a vocal improvisation using those sounds or syllables. The therapist should accompany those sounds, using piano with a moving bass that varies slightly with each client, but not enough to be confusing. Clients should also be told that they are free to walk around the room, make the sound with their eyes closed, or make it with their back to the group. Let them know that you will also be walking around as the group improvises. Clients will be encouraged to begin softly, and as they begin to experience the feelings in their bodies, to become louder. As they gain comfort with producing those sounds or syllables, they may decrease the volume or allow the volume to remain where it is until they feel they have expressed the feelings and are comfortable that the sounds they made represent the feelings they have. It is important that clients find a sound or syllable, because this is the beginning of verbally expressing their internal experiences of burnout/compassion fatigue. Allow the improvisation to end organically. Once the improvisation has ended, allow a moment of silence. After the silence, encourage clients to take a few deep breaths, because clients will often hold their breath when focusing on a particular theme while improvising. This should be followed by a discussion on the experience. Questions related to the clients’ ability to comfortably express what they were feeling should be discussed. Here again, it is not necessary for clients to name their feeling, but only to comment on the vocalizations. A discussion on this type of experience to address the theme should occur, along with an indication of who became the leader in the improvisation if a leader was recognized. Discussion on improvisation as a method to explore various themes is also recommended. Adaptations. A possible adaptation would be to record the session so that clients can listen to their vocal representations and have the opportunity to change their sound if it did not accurately represent what they wanted it to. It is recommended that each sound be recorded individually; then record the group improvisation, so that clients can identify themselves as they listen to the group improvisation. Referential Song Improvisation: “Now I Can Say It” Overview. In referential song improvisation, the therapist guides the clients in extemporizing lyrics to express current emotional states. For many patients, getting to the point of being able to verbalize thoughts and feelings is as important as stating them. Yet this verbalization comes with hesitancy because of perceptions about self-worth, employee expectations, client expectations, and fear that this admission will minimize their value as caretakers. To begin addressing the issues of burnout/compassion fatigue, there is a need for clients to recognize what is happening to them and to state it. This activity provides such an opportunity without censorship. This experience is at the augmentative or intensive level and has the following goals: (1) to define burnout, (2) to express feelings surrounding burnout/compassion fatigue

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without guilt, and (3) to release emotions. Note: This session should not be done until clients have engaged in several music therapy sessions and trust and comfort with music therapy and the music therapist have been established. Preparation. The room should be set up with chairs in a semicircle. No instruments are needed for this activity, except a piano or guitar played by the therapist. What to observe. This may be one of the more difficult sessions that clients experience in music therapy. With that in mind, it’s important to be very vigilant during the session. Observe clients for breathing difficulties, tears, signs of embarrassment, and signs of anger. If any of these become excessive, stop the activity and engage in breathing activities and discussion about what the clients may be experiencing. Procedures. After greetings and the check-in, ask clients what they believe are the definitions of burnout and compassion fatigue. Using those client definitions, the therapist helps the clients to create a musical expression of the definition. For example, if a client defines burnout as “an excuse not to work,” then the therapist provides chord accompaniment and melody to that definition and asks all the clients to sing along with her. Another client may say, “It’s exhausting.” This accompaniment and melody should have the same chords but be played and sung differently, with emphasis matching the way the client stated the definition. Clients would repeat this melody as well, until all clients have defined burnout/compassion fatigue. After all definitions have been given and sung, the therapist asks the clients to begin singing the definitions that best match how they feel about burnout/compassion fatigue, feeling free to add words as they need to, as the therapist accompanies the clients harmonically. Let them know they are free to walk around the room if they feel more comfortable. Encourage clients to increase volume, tempo, and rhythm until they feel they have been able to comfortably express their thoughts and feelings about burnout. This improvisation should continue until clients end it naturally. When the singing ends, allow a few moments for clients to quiet themselves and settle down. Conduct deep breathing with the clients. Then engage them in a discussion about the experience. Ask how it felt to sing those words. Ask how it felt singing their own words as others were singing theirs. Then ask if any of them experienced those feelings in their work. Talk about the shared experience and how it currently feels to sing about those feelings of burnout/compassion fatigue. Adaptations. An adaptation to this session might be to have instruments available so that clients can play while singing.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Song Singing: “Tempting the Temptations” Overview. In song singing, clients and therapist sing precomposed songs with live accompaniment. In the process of taking care of persons who are ill or disabled, there is little time for caretakers to relax and enjoy themselves. In many cases, they leave the caretaking of their employment and go home to take care of their families. Yet to successfully carry out their work, there exists a need to have outlets from the stressors of the job. Vocal re-creation, often referred to as song singing or the singalong, provides such an option. This activity is practiced at the augmentative level. Goals are to promote relaxation, enjoyment, group cohesion, and reminiscence. Preparation. The room can be set up either in a circle, if the therapist is using a guitar, or in a semicircle, if the therapist is using a keyboard. There should be a variety of songbooks available and, if possible, song sheets with lyrics to a variety of songs from the ’60s through the present so that the clients have words to the songs they choose.

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What to observe. Notice clients’ comfort with choosing songs and which clients are singing and which are only listening. Maintain awareness of the song titles and lyrics chosen, and personal meanings that any songs may have for individuals. Be aware of client animation as certain songs are selected. Procedures. After welcoming clients, do a check-in to find out how clients are feeling. Discuss the purpose of the session, which is primarily fun and reminiscence. Pass out song sheets, and tell clients they are free to look through songbooks in addition to the song sheets. After a period of time, ask someone to choose a song. The therapist accompanies as clients sing along. Once completed, ask for another selection, and repeat this until each client has selected a song. Where appropriate, divide the clients up so that one group is singing just the chorus and the other group is singing verses. Reverse with the next song. If comfortable, ask for a volunteer who might want to be lead singer, with the rest of the group being background and chorus. Suggest that clients stand, take the positions of the artists who originally sang the songs, and do the movements the artists did while singing. At the end of the selections, talk about the songs and memories surrounding those songs, and ask clients to report how this experience felt to them. Adaptations. An adaptation to this session would be to choose music that had similar themes, possibly those related to freedom, escape, etc., and have clients relate their present work experiences to the sentiments expressed in the songs. Musical Games: “Name That Tune” Overview. In musical games, the therapist guides the clients in musical games such as Name That Tune or Musical Charades. Loosely based on the game shows of the ’50s–’80s, games provide a healthy music experience for clients that encourage them to have fun and relax. They can be set up such that the group competes with the therapist or such that the group is divided and competes against one another. Games may be played at the beginning or end of the session to increase relaxation, or they may be used in the first sessions to promote group cohesiveness. The level of therapy is augmentative. Goals for this session include diversion from everyday stressors, relaxation, healthy competition, and having the experience of fun. Preparation. The therapist should prepare a varied genre of songs, and gather information on the person who wrote the song, when it was popular, the singer, and other information that can be used as a cue. The therapist should have either guitar or piano to play the songs. Song sheets should also be available for the clients. The room should be set up so that clients are in a semicircle that can easily be separated into two teams. What to observe. The main observation in this session is clients’ participation. Observe changes in affect, smiles, and leadership within the groups. If divided, notice which client becomes the spokesman for the group, and the level of participation from other clients. Procedures. Discuss the need to have fun in a relaxing way, and talk about the opportunity to do that in this session. Talk about Name That Tune and how interesting, educational and fun it can be. The therapist begins by telling the clients that she will give a few clues about a song and the group can guess the title. After a few attempts, divide the group in half, and play according to the rules. Based on the television series, clients can choose to say they can name the tune in 4 to 10 notes or as many as are necessary when clues about the song are given to help their team gain points. Encourage all clients to participate. After the session, ask clients how the experience was. Comment on their interaction and the smiles and groans that came from the group. End the session with a reminder that finding relaxing, fun ways to release stress is important, and that this is an activity they may be able to duplicate with their families.

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Adaptations. A possible adaptation might be to change leaders after every round so that each client has a turn as the spokesman for the group. Another adaptation is a “Jeopardy!” version of Name That Tune, where the therapist gives a definition of the song’s meaning or information about the artist who recorded the song. Another adaptation would be to play charades to Name That Tune, where the clients act out the song title. GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Song Parodies: “What I Really Want to Say” Overview. In song parodies, the clients change lyrics or phrases of songs to create original songs and sing them with the therapist. Burnout/compassion fatigue is a very serious condition if not addressed in a timely way. Clients who suffer from these disorders are hesitant to admit the condition because they fear that admission means they are unable to do the job, they are concerned about losing their job, or they are concerned that admission may mean there are other problems existing within them. The song parody provides a way for clients to discuss their experience of burnout through song. Because it is a group activity, there is less focus on the individual client and more focus on the group. This is an augmentative music therapy experience that provides a method of expression in a safe manner. Preparation. The therapist should have a song available for clients to sing and be familiar enough with the music that she can play it. The song should have an easy refrain that may or may not need to be changed, but this is essential for the goal of the activity. There should be a lyric sheet for each client to follow and with which to sing along. A separate sheet should be provided with blank lines for the clients to fill in on their own. An additional sheet with blank lines should be provided to fill in the words that the group makes up. Pencils or pens should also be provided. If possible, the therapist should have a blackboard available on which to write new lyrics as the clients fill in the blanks. If a blackboard is not available, a large poster board or butcher-block paper should be available to write the lyrics, and tape should be available to put the finished song on the wall so all clients can see it. If possible, chairs with writing attachments should be available. Otherwise, some kind of hard surface should be available, if not a table, then cardboard for each client. What to observe. Be aware of the level of participation by the group. Which clients are comfortable and which are silent during the session? Encourage all to participate, and stress that this is a group song. Also stress the confidential nature of music therapy sessions, ensuring clients that nothing discussed in music therapy would impede in any way on their jobs. Observe affect as clients sing the song, and notice which ones sing and which ones avoid singing. Procedures. After greeting the clients, discuss the activity. The therapist talks about song parodies and explains the session. Explain that they are going to substitute words to make the song “their” song. The song can be serious or funny. That decision will come from the group as the lyrics proceed. It might be necessary to provide a simple song parody to demonstrate what the therapist is hoping to achieve. For example: Are you sleeping? Are you sleeping? Brother John, Brother John? Morning bells are ringing, Morning bells are ringing, Ding, dang, dong. Ding, dang, dong! becomes:

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Are you hungry? Are you hungry? Yes, I am. Yes, I am. When will it be lunchtime? When will it be dinner? Sing it again! Sing it again! The therapist may choose to initially have the clients engage in this simple repeatable melody to get a feel for song parody. After clients have participated in this simple version, pass out sheets that will be used in the session that have entire lyrics to the chosen song written on them, and have clients sing along with the original lyrics. Then give them a sheet with some of the lyrics removed. An example of a more serious song might be “With A little Help from My Friends” by the Beatles. Key words are omitted in the following manner: What would you do if ___ ______ _______ ______ _____ Would you stand up and _______ _______ ______ ____ Lend me your ____ and I’ll ______ ____ ___ ______ And I’ll ___ __ __ ___ ____ __ ___ Oh, I’ll get by … (continue with original chorus). Have clients fill in the blanks until the song is completed. Clients should be in agreement with the words used to fill in the blanks as the therapist writes the words on a blackboard or poster board. The therapist then goes to the piano or guitar and sings the new song, inviting the group to sing along with her. After the song is sung once, ask the group if they are satisfied with the final version or would like to change any words. This continues until the entire group is pleased with the song. When the singing has come to an end, talk to the group about their work and compliment the clients on their engagement in the activity. Ask questions about how it feels to work collectively with the group, and how it feels to be sharing something that may have significance to them.

Songwriting: “My Anthem” Overview. In songwriting, the therapist guides clients in song composition from rhythm to melody to lyrics. Clients who suffer with burnout/compassion fatigue inevitably feel very alone, mainly because sharing these feelings comes at a perceived cost that is more frightening than the burnout/compassion fatigue itself. While very helpful, some clients are unable to take the benefits of therapy with them when they leave the therapy session. Songwriting is an activity that provides a tangible object that clients can take with them and use whenever the need arises. This is practiced at the augmentative or intensive level of therapy. The goals of this session are to: (1) fully engage the clients in the creation of a song; (2) promote creativity; (3) promote ownership of the lyrics, melody, and rhythm; (4) recognize the positive aspects of self; and (5) give clients a gift that might be useful to them outside of the music therapy sessions. Preparation. Songwriting can be done in a number of ways. For this session, the clients will use percussion instruments, electric keyboard, melodic instruments, acoustic piano, guitar, microphone, and CDs for recording the completed song. What to observe. Notice which instruments clients gravitate toward. Encourage exploration as clients examine various materials available for them. For the client who chooses to sit out the session, be sensitive to this, and encourage that person to observe and offer suggestions. Notice change in affect and level of participation as the process continues.

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Procedures. Greet and check in with the clients. Have a discussion with the clients about songwriting and the purpose of the session. They should also be informed that this project may take several sessions to complete. After the discussion, have clients explore instruments. Have the clients explore various rhythms until the group has decided that the rhythm that feels comfortable to them. The therapist should then play a variety of modes for the clients, incorporating their rhythms and some simple improvisation around each of the modes. Have the clients select the mode they feel would best accompany their rhythm. Once mode and rhythm have been selected, have clients play their rhythms on various instruments while the therapist accompanies that rhythm in the mode chosen, simply by playing the scale of that mode, until the group is satisfied. The scale is recommended so that the therapist does not unduly influence the client’s melody selection. It is suggested that this be recorded so that clients have the opportunity to listen to their creation as often as needed to complete their song. Following the selection of rhythm and mode, the therapist returns to the discussion about the song composition and its purpose. At this point, the therapist asks each client what, if given the opportunity, he would say to his burnout/compassion fatigue if given the opportunity to confront it. Each client is given the chance to provide one sentence. The therapist writes those sentences on the blackboard or on poster board. Once everyone has contributed, this becomes the lyrics for the song. The therapist guides the clients in choosing the sentences that could be repeated and would best serve as the chorus for their song. Without providing specific notes, the therapist then plays the audio recording of their rhythmic/modal rendition made earlier. As clients listen to this, the therapist asks them to chant the repeated chorus lyrics until the group determines where they will fit in the song. Once there is agreement, the therapist asks the clients to look at the remaining sentences and decide as a group to rank them and indicate where the chorus should appear in this ranking. The new order of sentences is then written on the board for all to see. Once again, the therapist plays the recorded rhythmic and modal recording from earlier, having the clients chant the entire song. Ask the clients if they are satisfied with the rhythms they played, now that they have lyrics, and if they are satisfied with order of the sentences. Allow the clients to make changes on which that the entire group agrees. If the group wants to change the rhythms or the musical modes, this should be audio recorded as well. It’s also possible at this point in time that a client would like to reword his contribution. This should be permitted, but it is important that there is agreement on the changed words. It is possible that within the group there are clients who have musical abilities. Encourage those musicians to assist with either the basic rhythmic pattern chosen or the melodic patterns chosen by the group. The next step in the songwriting process is to determine the melody that will best accompany the words and rhythms. The therapist should begin with the chorus, playing the mode and scale chosen by the group. Have the group decide the pitch direction of the chorus melody and the motion, i.e., where a conjunct melody would be best and where to use intervallic leaps. This process should continue until the group has selected the melody for their chorus. Using either the recording or the assistance of the musician clients, the new melody is played until everyone is satisfied with it. Then the group sings the chorus a number of times until the melody is ingrained. Once comfortable with the chorus, other clients are invited to play their instruments and sing along with the therapist. Time should be allowed for slight changes in rhythm, and the entire chorus with rhythm, melody, and singing should be recorded. This process should be continued with the verses until the song is complete, after which the therapist should have the clients sing the song through several times. At the end of the songwriting, ask clients to discuss the process of songwriting and their involvement. Ask the clients to discuss ways they might use their song. Have a CD of the song that clients created available for them at the next session. Adaptation. A possible adaptation that might shorten the process of songwriting is to use a piece of music from the classical or popular music genre to serve as the melody for the song.

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CLOSING REMARKS ON METHODOLOGY Considering the demands placed on employees at the workplace, this burnout/compassion fatigue chapter is designed to be a six- to nine-week sequence that can be repeated if there is a need. As stated, all of the experiences described here can be used in either group or individual sessions. Groups have the advantage of decreasing the sense of alienation that persons with burnout/compassion fatigue often feel, and help to release them from the burden of the solitary suffering of silence. Individual sessions have the advantage of working at a deeper level to provide a unique treatment for the individual. While peers offer great comfort in the group sessions, there is greater depth possible in individual sessions. The methods presented in this chapter can also be used in individual sessions for work with burnout/compassion fatigue clients. What follows is a possible sequence that might be used in working with burnout/compassion fatigue. It should be pointed out, however, that therapists are free to combine and vary these suggested methods based on the needs and responsiveness of their clients. Each session should begin with a greeting, allowing clients to talk about their day and their emotional state. This greeting is important because it lets the clients know that their feelings are important, it helps to establish rapport and trust between the client and therapist, and this acknowledgment of feelings often opens clients to try new experiences. It is also important that the checkin not be rushed. Make sure that clients have said all they need to say before proceeding to the session itself. Each check-in should be followed by a few minutes of some type of breathing exercise to help relax and center the client. Each activity should be explained to clients, reassuring them there is no right or wrong way to participate in the sessions, and they are encouraged to do the best they can. The receptive methods that began this chapter are a very good way to introduce the clients to music therapy. Many times when persons suffer burnout/compassion fatigue, they state that all they need is some relaxation. Providing a session like “Purposeful Listening,” in which clients focus only on their bodies as they listen to music, offers much needed relaxation to these clients. In addition, this experience demonstrates the willingness of the therapist to hear and respond to the clients’ stated needs by demanding nothing more from them than to listen and relax. This activity also helps establish rapport and trust between the therapist and clients. After this activity, or at the next session, the therapist may choose a nonreferential improvisation. Simply letting go and having fun can help clients connect, with little focus on the problems at hand. Instead of focusing on problems, the music-making helps relieve tension and releases endorphins that stimulate a relaxation response for the client. Also, because the focus of the activity is not on the cause of their burnout/compassion fatigue, clients are more apt to share freely. Here again, the nonreferential improvisation is nondemanding; encourages group awareness and rapport between and among therapist and clients; and serves as a door-opener for clients to use to explore their burnout/compassion fatigue. Even with the door opened for further exploration, the therapist must be mindful that personal feelings about burnout and compassion fatigue are occasionally rejected by the client as a sign of weakness and laziness, as they are surrounded by fear of losing their jobs. With this in mind, approaching those feelings in music therapy should be gradual. Remaining mindful of the clients’ difficulties with the idea of burnout/compassion fatigue, the next session may be a repetition of the first. It is suggested that this session have mats available so that clients can recline on the floor to further experience their bodies in a more physically relaxed state. Following this relaxation exercise, have clients discuss what they noticed in their bodies, and if possible discuss how this relaxation exercise was different from the first one they experienced. As previously stated, it is often difficult for the clients to verbalize their burnout/compassion fatigue because of embarrassment, fear of reprisals, or self-rejection that this may be happening to them. It is recommended that a vocal referential improvisation, “Sounding It Out,” in which clients can give a sound to describe the feelings associated with what they are feeling, burnout/compassion fatigue, may be a way to ease clients into further exploration of burnout/compassion fatigue. Whether a sigh, groan, grunt, or scream, any of

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these expressions offered by the clients represent what burnout/compassion fatigue sounds like to them. It is important here that clients have the freedom to make their sounds in any way that is comfortable to them. It is crucial that all sounds happen simultaneously during the improvisation. In this way, no client is exposed, feels judged, or is made to feel different from others. This can be a very intense session, leaving clients often feeling exhausted from the amount of energy expended in this session. There are two benefits to this referential vocal improvisation. The first is that the clients have been able to find a sound that represents their feelings. The second is that group cohesion may be further established as they use these sounds to express their feelings. A third benefit to this exercise is that clients are gradually able to release these unspoken feelings with sounds. A possible addition to this session is to have all clients repeat the vocal sounds made by each other, allowing them to choose to share the sound made by a peer or use their own sounds when the group begins to make the sounds together. This referential vocal improvisation should continue until clients begin to show evidence that the feelings are no longer held within. Signs of this may be smiles, tears, slower breathing, or more rapid breathing. It is helpful to lead clients in breathing exercises after this session, until a sense of calm is evident. This is followed by a discussion about the experience. It should be noted that these activities are a gentle way to help clients begin to deal with the issues of burnout/compassion fatigue, but with sounds rather than words, and the focus is on the group rather than a specific individual. Trust continues to be established, and awareness of not being alone with these feelings also becomes more apparent. Given the intensity of the vocal improvisation, clients may come into the session a bit wary of what the music therapist has planned. Clients may be experiencing more trepidation than expected because there is unease about what is coming. This is a good time to introduce re-creative methods. Singing songs together—“Tempting the Temptations”—is an excellent activity to have at this point. It is relaxing, offers a respite from dealing with burnout/compassion fatigue, and is enjoyable for the clients. The intent here is to give the clients an enjoyable experience, while demonstrating the sensitivity of the therapist toward the clients’ anxiety levels. This could possibly be followed by a receptive imagery session such as “The Gift.” Placing the receptive activity here gives the clients something that they can use or take with them to use when they are dealing with difficult issues in the workplace. At this point, it is possible to begin a more serious examination of the burnout/compassion fatigue issues that the clients face. The referential song improvisation, “Now I Can Say It,” is recommended. In this session, clients are asked to individually define burnout/compassion fatigue. The therapist provides accompaniment to each of those definitions, encouraging the client who has defined burnout/compassion fatigue to sing those words with the accompaniment until they retain it. This process is continued until each client has sung his words. It is suggested that the therapist provide a moving bass accompaniment that can be varied enough for each client, but not so different as to add confusion. Clients are encouraged to help with their own words, using varied rhythm instruments. This is probably the first time clients have verbalized through song their personal definitions of burnout/compassion fatigue. It is important that the therapist allow time for the clients to deal with this expression. A recommendation after this experience would be to offer a brief imagery activity in which clients can once again find their gifts from previous sessions. Discussions about the sessions should follow. Once again, clients have a need for levity in the music therapy session. Musical games, Name That Tune, a re-creative method followed by a composition method, Song Parody: “What I Really Want to Say,” would be a nice combination. Name That Tune provides healthy, playful competition among clients, providing opportunities for them to enjoy themselves. After playing the musical game, clients are generally laughing, relaxed, and enjoying the time in music therapy. At this stage in music therapy treatment, the clients should have begun to understand and appreciate the value of music as a helpful therapeutic treatment to help them with burnout/compassion fatigue. Because of the rapport established between group members and the therapist, this may be an appropriate time to begin more serious work on addressing their issues related to burnout/compassion fatigue. This would be an excellent time to

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introduce song parodies, where clients substitute words that address their burnout/compassion fatigue for words in a familiar song. This can be a very empowering activity in which clients can begin to take control of their feelings and needs. As with other sessions, following the song parody, time should be allowed for discussion about the session. One of the goals of music therapy with clients experiencing burnout/compassion fatigue is selfempowerment. A method that would help clients achieve self-empowerment would be songwriting. Songwriting, “My Anthem,” can take several sessions and should not be rushed, in that this may mark one of the most empowering experiences in music therapy for these clients. As described in the activity written above, the process of songwriting here is fairly systematic and involves the entire group working within their abilities and desires. The end result is a tangible object that clients can take away with them and use whenever they feel the first stages of burnout/compassion fatigue manifesting. At the culmination of the songwriting sessions, clients are empowered yet often exhausted from the feelings they demonstrated during the process. The therapist should make arrangements to have the CD burned so that at some point they can be delivered to the clients to have a tangible reminder that they have found a voice and place to put their feelings and emotions associated with burnout/compassion fatigue. Another way the therapist can empower the clients as these sessions come to an end is through the receptive method “Finding My Place.” This directed imagery experience generally lasts 20–25 minutes. It is intended to take the clients to a place where they can find self-empowerment and a safe place. Even though this session is provided to the group, the uniqueness of the session is that the imagery is directed enough to move the clients along, but vague enough that each individual sees a house of his choosing and a garden of his choosing and has an experience that is unique to the individual. Following the imagery experience, clients are invited to complete a mandala drawing. This drawing may be lines, shapes, colors, or any representation of the client’s experiences and imagery. After completing the mandala drawing, clients are given an opportunity to write logs about their experience in the imagery and mandala session. This can be done in reverse order, where the clients log first, then complete the mandala drawing. Both the mandala and logs are gifts that the clients can take with them when the session is over. The therapist should encourage the clients to keep the mandala drawing somewhere prominent so that when they feel overwhelmed by job pressures, they can use their mandala drawing as a way to bring them back to that place of peace and beauty they experienced in the imagery session. In the ideal world, a music therapist would have as many opportunities to work with a client with burnout/compassion fatigue as needed. In more cases than not, this may not be possible; consequently, any of these methods may be done independently of each other or in concert with each other. Choosing which method to employ should be based on the needs of the client and the amount of time allocated for the sessions. The information provided in this conclusion should be considered regardless of the number of sessions available.

RESEARCH EVIDENCE Art Therapy and Burnout/Compassion Fatigue Research There has been a plethora of research done on the treatment of burnout, and more appearing in the literature on compassion fatigue. Authors such as Alexander (1980); Angerer (2003); Doyle (2007); Duffy et al., (2009); Figley (1995, 2002); Maslach and Goldberg (1998); Maslach et al. (2001); Maytum, Heimen, and Garwick (2004); Najjar et al. (2009); Pickett, Walsh-Brennan, Greenberg, Licht, and Worrell (1994); and van Dierendonock, Garssen, and Visser (2005) have all suggested stress management techniques such as breathing exercises, yoga, reducing workload, providing support for persons suffering from burnout, learning leisure activities, debriefing after difficult patient encounters, and changes to the work environment.

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Other authors have suggested specific techniques to address burnout/compassion fatigue. For example, stress management, self-soothing, and desensitization techniques are recommended by Figley (2002). In contrast, Taormina and Law (2000) suggest that finding techniques for stress management causes added stress because often the individual has to find his own resources to get the stress management training. Mathieu (2007) suggests changing work patterns, developing preventive coping skills and a relaxed lifestyle, self-analysis, asking for help, learning to say no, and rebalancing the workload, while Hamann and Gordon (2000) suggest balanced breathing and imagery relaxation. Fortney and Taylor (2010) are advocates of meditation as a means of reducing burnout/compassion fatigue. Specifically, the authors indicate that mindfulness meditation “cultivates clear thinking, equanimity, compassion, and openheartedness” (p. 81). Meditation is considered self-empowering, as it draws on inner resources to help the therapist become more present for her clients. Salyers et al. (2011) offered a one-day retreat designed to reduce burnout among mental health professionals. Their workshop included lecture, meditation, tools to develop support networks, cognitive restructuring and values clarification. Using a randomized trial with a wait list control group, a pretest was administered, as well as a posttest six weeks later. Results indicated that depersonalization and emotional exhaustion were significantly lower than baseline measures. There was also an increase in consumer optimism. Meesters and Waslander (2010) conducted a study to determine the effects of light treatment on the reduction of burnout. Findings indicated that the light treatment group experienced improvement in emotional exhaustion. They recommended that a 20-minute light treatment therapy be included with other treatment protocols for the reduction of burnout. A significant amount of research has looked at the effects of creative arts media in the treatment of burnout/compassion fatigue. Art therapy as a new language to help staff express their experiences in carrying out their duties was studied by Belfiore (1994). The objectives of the study were to provide a means for the group to serve as its own container, to provide opportunities for grieving both verbally and nonverbally, to understand aspects of self and others, and to have a playful and expressive means of being in relationship with others. The study showed that imagery and other experiences enable access to emotional materials, and often help participants relate to each other. In a review of the literature on burnout and the college music major, Christian (2005) found recommendations for guided imagery, tai chi chaun, self-defense classes, mind-body interventions, and relaxation exercises to be effective interventions in treating burnout. Italia, Favara-Scacco, Cataldo, and Russo (2008) examined art therapy treatment in oncology units using a pre- and posttest design. The study included 65 doctors and nurses in an adult and pediatric oncology unit. After examining the results of the Italian version of the Maslach Burnout Inventory (MBI) during the diagnostic phase of the study, the authors divided the participants into two groups. The second group participated in a four-month program that included psychodrama techniques to promote communicative exchanges, play therapy to stimulate comfort and nonverbal communication, Ericksonian relaxation techniques to reduce anxiety, and videos that showed techniques to support children during painful procedures. The results of the study showed a decrease in emotional exhaustion and depersonalization dimensions among these participants and an increase in personal accomplishment. Salzano, Lindermann, and Tronsky (2012) studied a collaborative art-making experience on stress reduction in hospice caregivers. A randomized sample of social workers and arts department staff participated in the study. The study used both pre- and posttest measures to determine if there was a difference between those who participated in collaborative work and those who simply attended team meetings. The collaborative work included consensus at team meetings and consensus first in dyads on art designs and then consensus with the entire group on placement of art projects. Results indicated a statistically significant decrease in burnout as a result of the collaborative art projects.

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Music Therapy Evidence Cheek, Bradley, Parr, and Lan (2003) studied the effects of music therapy techniques added to cognitive behavioral techniques to reduce burnout in elementary school teachers. Fifty-one participants were randomly assigned to two groups—the cognitive behavioral group with music therapy techniques and a cognitive behavioral group only. The specific music therapy techniques used included listening to clientselected meaningful songs and relaxation. Results indicated a decrease in depersonalization levels. The authors stated that music techniques could easily be integrated into other forms of treatment for stress reduction. Bittman et al. (2004) examined recreational music-making protocol on burnout and mood issues with nursing students. Specifically, they used improvisational methods and group support. Results indicated significant statistical differences in reductions of multiple burnout and mood dimensions in subjects. Hilliard (2006) studied the effects of two music therapy techniques on compassion fatigue and the team-building of professional hospice caregivers. Two groups were formed, and music therapy occurred at the home office where the participants were located. Pre- and posttests of a subscale of Figley’s (2002) Compassion Satisfaction/Fatigue Self-Test for Helpers Scale (CFS) were also administered. All music therapy sessions involved live music. The first group involved the therapist planning each session, but provided open and spontaneous responses from the participants. Following Bruscia’s (1998) ecological area of practice, Hilliard (2006) used improvisational methods with this group. The second group was based on Bruscia’s didactic area of practice, where the intent was to focus on gaining knowledge to function independently. With this group, Hilliard used receptive, improvisational, and re-creative methods. Results indicated that participants in both groups improved in team-building and their sense of team-building. The didactic music therapy group, however, improved significantly more in terms of team-building. Hilliard stated that in the ecological group his role was more a supportive one, but in the didactic group, his role was that of the leader, implying that the music therapist is essential in enhancing team-building. Brandes et al. (2009) examined specifically designed music programs to determine if they would reduce burnout symptoms. The authors designed specific programs using the receptive methods for one group and nature sounds for the second. Results after the five-week period of the study showed that those who participated in the receptive method programs had a reduction of burnout symptoms. They conducted interviews with the participants “every 3 months since the study’s end. To date, all the participants have reported a sustained degree of stabilization and were able to maintain their level of psychological resilience” (p. 424). Brooks et al. (2010) studied creative approaches for reducing burnout in medical personnel. Sixty-five medical personnel who worked with cancer, cardiac, and psychiatric units at an urban university-affiliated hospital were recruited for the study. Using receptive methods, specifically musicdirected imagery, mandala drawings, and logs, the authors conducted a two-arm, randomized, controlled, mixed methods trial. Results showed a discrepancy between quantitative and qualitative results. There were no statistically significant differences between the experimental and control groups, yet the qualitative results indicated that participants themselves found the music imagery and creative mandala drawing to be very effective. The music imagery sessions evoked positive emotions and activated memories and associations that provided a sense of well-being for all participants. There has been extensive research on the effects of music therapy methods in reducing burnout/compassion fatigue, and the studies presented offer promise for future research on this important topic.

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The treatment of burnout/compassion fatigue is of great concern for administrators and for those who provide treatment. Finding effective and sustainable ways of offering treatment to these individuals is a challenge because persons who suffer from burnout/compassion fatigue rarely have any relief from their symptoms because the nature of their work requires that they be patient-focused at all times. Music therapy is one method that may offer continued success in combating burnout/compassion fatigue. The nonthreatening nature of music therapy makes it a preferred treatment method for many people with burnout/compassion fatigue because it allows expression without censure and equips clients with outcomes that may extend beyond the session itself. The music therapy methods described above are one way in which clients can benefit from therapy while continuing to work, offering opportunities for more effective interactions among peers, consumers, clients, and employers. These activities can be done with groups or with individual clients. Each activity can be done alone or can follow in any sequence chosen by the therapist.

REFERENCES Alexander, C. J. (1980). Counteracting burnout. AORN: Association of Perioperative Registered Nurses, 32(4), 597–604. Angerer, J. M. (2003). Job burnout. Journal of Employment Counseling 40(3), 98–107. Belfiore, M. (1994). The group takes care of itself: Art therapy to prevent burnout. The Arts in Psychotherapy, 21(2), 119–126. Bittman, B. B., Snyder, C., Bruhn, K. T., Liebfreid, F., Stevens, C. K., Westengard, J., & Umbach, P. O. (2004). Recreational music making: An integrative group intervention for reducing burnout and improving mood states in first year associate degree nursing students: Insights and economic impact. International Journal of Nursing Education Scholarship, 1(1); http://www.bepress.com/ijnes/vol 1/iss1/art 12 Brandes, V., Terris, D., Fischer, C., Schuessler, M., Ottowitz, G., Titscher, G., Fischer, J., & Thayer, J. (2009). Music programs designed to remedy burnout symptoms show significant effects after five weeks. Annals of the New York Academy of Science, 1169, 422–425. Brill, P. (1984). The need for an operational definition of burnout. Family and Community Health, 6(4), 12–24. Brooks, D. M., Bradt, J., Eyre, L., Hunt, A., & Dileo, C. (2010). Creative approaches for reducing burnout in medical personnel. The Arts in Psychotherapy, 37, 255–263. Bruscia, K. (1998). Defining music therapy. Gilsum, NH: Barcelona Publishers. Cheek, J. R., Bradley, L., Parr, G., & Lan, W. (2003). Using music therapy techniques to treat teacher burnout. Journal of Mental Health Counseling, 25(3), 204–217. Christian, B. (2005). Burnout and the college music education major. Journal of Music Teacher Education, 15(1), 43–51. Doyle, M. (2007). Burnout: The impact of psychosocial interventions training. Mental Health Practice, 10(7), 16–21. Duffy, B., Oyebode, J., & Allan, J. (2009). Burnout among care staff for older adults with dementia. Dementia: The International Journal of Social Research and Practice, 8(4), 515–541. Espeland, K. E. (2006). Overcoming burnout: How to revitalize your career. The Journal of Continuing Education in Nursing, 37(7), 178–184. Farber, B. A. (2000). Subtypes of burnout: Theory, research and practice. Paper presented at the Annual Conference, American Psychological Association. San Francisco.

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Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorders in those who treat the traumatized. London: Brunner-Routledge. Figley, C. R. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self-care. Journal of Clinical Psychology, 58(1), 1433–1441. Figley, C. R. (2003). Compassion fatigue: An introduction. Prevention & Treatment—PTSD Resource. http://www.giftfromwithin.org/html/What-is-Compassion-Fatigue-Dr-Charles-Figley.html. Camden, ME: Gift from Within. Figley, C. R., & Stamm, B. (1996). Psychometric review of compassion fatigue self-test. In B. Stamm (Ed.), Measurement of stress, trauma and adaptation (pp. 127–128). Lutherville MD: Sidran Press. Fortney, L., & Taylor, M. (2010). Meditation in medical practice: A review of the evidence and practice. Primary Care, 37(1), 81–84. Halbesleben, J., & Buckley, M. R. (2004). Burnout in organizational Life. Journal of Management, 30(6), 859–879. Hamann, D. L., & Gordon, D. G. (2000). Burnout: An occupational hazard. Music Educators Journal, 87(3), 34–39. Hilliard, R. (2006). The effect of music therapy sessions on compassion fatigue and team building of professional hospice caregivers. The Arts in Psychotherapy, 33, 395–401. Italia, S., Favara-Scacco, C., Cataldo, A., & Russo, G. (2008). Evaluation and art therapy treatment of the burnout syndrome in oncology units. Psycho-Oncology, 7, 676–680. Keidel, G. C. (2002). Burnout and compassion fatigue among hospice caregivers. American Journal of Hospice and Palliative Medicine, 19(3), 200–205. Kellogg, J. (1987). Mandala: Path of beauty. Clearwater, FL: MARI. Kertz-Weizel, A. (2009). Philosophy of music education and the burnout syndrome: Female viewpoints on a male school world. Philosophy of Music Education Review, 17(2), 144–161. Kim, S. (2010). Predictors of acculturative stress among international music therapy students in the United States. Unpublished doctoral dissertation. Temple University. Lahoz, M., & Mason, H. (1990). Burnout among pharmacists. American Pharmacy, 8, 28–32. Luthe, W., & Schultz, J. H. (1969). Autogenic therapy. New York: Grune & Stratton. Maslach, C., & Goldberg, J. (1998). Prevention of burnout: New Perspectives. Applied and Preventive Psychology, 7, 63–74. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2, 99–113. Maslach, C., & Leiter, M. (1997). The truth about burnout: How organizations cause personal stress and what to do about it. San Francisco: Jossey-Bass. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Reviews of Psychology, 52, 397–422. Mathieu, F. (2007). Overcoming compassion fatigue: Eight tips for professionals. Shoppers Home Health Care Clinical Notes, Fall 2007, 1, 12. Retrieved from http://home.cogeco.ca/~cmc/ClinNotes_FALL07.pdf Maytum, J. C., Heimen, M. B., & Garwick, A. W. (2004). Compassion fatigue and burnout in nurses who work with children with chronic conditions and their families. Journal of Pediatric Health Care: Official Publication of National Association of Pediatric Nurse Associates and Practitioners, 18(4), 171–179. McHolm, F. (2006). Rx for compassion fatigue. Journal of Christian Nursing, 23(4), 12– 19. Meesters, Y., & Waslander, M. (2010). Burnout and light treatment. Stress and Health, 26(1), 13–20. Montero-Marin, J., Garcia-Campayo, J., Mera, D. M., & del Hoyo, Y. L. (2009). A new definition of burnout syndrome based on Farber’s proposal. Journal of Occupational Medicine and Toxicology, 4, 31. DOI:10.1186/1745-6673-4-31. http://www.occup-med.com/content/4/1/31

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Najjar, N., Davis, L., Beck-Coon, C., & Doebbeling, C. (2009). Compassion fatigue: A review of the research to data and relevance to cancer care providers. Journal of Health Psychology, 14(2), 267–277. O’Halloran, T. M., & Linton, J. M. (2000). Stress on the job: Self-care resources for counselors. Journal of Mental Health Counseling, 22(4), 354–364. Pickett, M., Walsh Brennan, A. M., Greenberg, H., Licht, L., & Worrell, J. D. (1994). Use of debriefing techniques to prevent compassion fatigue in research teams. Nursing Research, 43(4), 250–252. Salyers, M. P., Hudson, C., Morse, G., Rollins, A. L., Monroe-DeVita, M., Wilson, C., & Freeland, L. (2011). Breathe: A pilot study of a one-day retreat to reduce burnout among mental health professionals. Psychiatric Services (Washington, DC), 62(2), 214–217. Salzano, A. T., Lindermann, E., & Tronsky, L. (2012). The effectiveness of a collaborative art-making task on reducing stress in hospice caregivers. The Arts in Psychotherapy, 40, 45–52. Schaufeli, W., Leiter, M., & Maslach, C. (2009). Burnout: 35 years of research and practice. Career Development International, 14(3), 204–220. Taormina, R., & Law, C. (2000). Approaches to preventing burnout: The effects of personal stress management and organizational socialization. Journal of Nursing Management, 8(2), 89–99. van Dierendonock, D., Garssen, B., & Visser, A. (2005). Burnout prevention through personal growth. International Journal of Stress Management, 12(1), 62–77 Weber, A., & Jackel-Reinhard, A. (2000). Burnout syndrome: A disease of modern societies? Occupational Medicine, 50(7), 512–517.

Chapter 23

Stress Reduction and Wellness Seung-A Kim

DIAGNOSTIC INFORMATION Daily Life Stress Modern society has induced a plethora of new media through which people of all ages can be affected by stress, including life stress (Holmes & Rahe, 1967), academic stress (Misra & Castilo, 2004), occupational stress (McClenahan, Giles, & Mallett, 2007), music performance anxiety stress (Kenny, 2005), social stress (Meyer, 2003), traumatic stress (Sutton, 2002) and acculturative stress (S. Kim, 2011). The complex nature of modern society is responsible for increasing levels of stress in our daily lives (Edlin & Golanty, 2010). The Annual Stress Report (2012), conducted by the American Psychology Association (APA), found that 44% of respondents felt that the degree of stress in their lives had increased over the past five years. Moreover, one in five respondents were identified as suffering from chronic stress. Stress includes psychological and physiological manifestations (Fink, 2000; Lovallo, 2005). The effects of stress can be significant, as stress can result in serious illnesses such as depression, insomnia, heart disease, cancer, weight problems, or, in extreme cases, suicide (McEwen & Stellar, 1993; McGrady, 2007; Walker, Wingate, Obasi, & Joiner, 2008). Although there have been efforts to increase awareness of the effects of stress on health, only 31% of the respondents indicated that their own stress level could cause poor health conditions. The first step in increasing awareness of stress is to understand the mechanisms of stress.

What Is Stress? There are three major perspectives in the development of stress theory (McGrady, 2007; Lovallo, 2005), known as the general adaptation syndrome (GAS) (Selye, 1956), appraisal and coping model (Lazarus & Folkman, 1984), and allostasis theory (McEwen & Stellar, 1993). Hans Selye, the father of stress research (Lovallo, 2005), observed that the stress response is “nonspecific,” meaning that it has a consistent pattern known as the general adaptation syndrome (GAS). He identified three stages of the stress response—alarm reaction, stage of resistance, and stage of exhaustion. When homeostasis—or the ability of the body and mind to regulate itself—is threatened by physical or psychological challenges, we experience tension. Our body automatically responds to the stress with a counterreaction known as fight or flight, which is the alarm reaction. The entire sympathetic nervous system (SNS) is activated, while the activity under the parasympathetic nervous system (PSNS) is reduced. Blood starts to flow toward the muscles, forcing the heart to beat faster to compensate for the extra oxygen the body needs. The pituitary gland, which controls bodily hormonal functions, starts to secrete hormones such as adrenocorticotrophic hormone (ACTH). This leads to the stimulation of the adrenal glands, which then release the stress hormones cortisol, epinephrine (adrenaline), and norepinephrine. These hormones are responsible for anxiety, stress, and feelings of helplessness (Krout, 2007). This emotional state is also known as the stage

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of resistance, and is the stage where we are susceptible to disease. If this stage is prolonged, it may be possible to exhaust all of the resources needed for the body to return to homeostasis (Cannon, 1929). Eventually, the functions may stop and approach the stage of exhaustion. Although Selye’s theory described the impact of physical stressors on our bodies, it does not sufficiently explain the cognitive processes that are involved in the stress response. Thus, stress is viewed as an ongoing relationship between individuals and their environments, especially since individuals do not react in the same way to different stressors. Based on the cognitive stress theory, Lazarus and Folkman (1984) discussed the psychological process of stress. They proposed two important concepts to illustrate the stress response—appraisal (evaluating the event based on one’s resources, possible consequences, and their meanings) and coping (how an individual manages this event). Within this framework, stress is defined as: “A relationship with the environment that the person appraises as significant for his or her well-being and in which the demands tax or exceed available coping resources” (Lazarus & Folkman, 1986, p. 63). Lazarus (1991) also identified three types of stress: harm, threat, and challenge, and noted that these types of stress elicit different types of emotional responses. Sterling and Eyer (1988) introduced the concept of allostasis, which explained the complex phenomenon of the process of adaptation in response to challenges. This concept is “the idea that when a demand has not been removed or neutralized, maintaining homeostasis may be a source of ongoing wear and tear on the system” (Lovallo, 2005, p. 37). When allostasis—or the ability of the body to maintain homeostasis in response to stressors—is functioning well, one’s resilience is strengthened. However, when allostasis is not functioning well, the chronic stress causes allostatic load, which may eventually lead to serious illnesses as described above. Ultimately, an individual will become less capable of coping with new challenges. Moreover, the manner in which an individual reacts to the same stressor differs, depending on his or her relationship with internal and external environments. Thus, social and cultural influences on stress should be considered to understand the whole context under which stress occurs.

Age, Gender, and Stress Age and gender play a significant role in stress (Mroczek & Almeida, 2004). Children have their own stressors relating to schoolwork and peer pressure. Their stress levels can be exacerbated by family conflicts, divorce, and other unfortunate events. Adults may feel stressed as a result of multiple responsibilities, including family, friends, work, and interpersonal relationships. In later stages of life, older adults may encounter lower daily stress levels compared to their younger counterparts. However, older adults may react to stress more emotionally (Mroczek & Almeida, 2004). Thus, “the importance of developmental factors in understanding emotion and well-being” is emphasized (p. 356). In addition, stress responses differ by gender (Hall, Chipperfield, Perry, Ruthig, & Goetz, 2006; Matud, 2004). Women may be more vulnerable to anxiety and stress than men, as they generally score higher on chronic stress assessments. In addition, it is reported that women are more likely to use emotion-focused coping strategies to deal with their stress (Matud, 2004). This trend may occur because women are socially and culturally conditioned to be more emotionally expressive than men.

Personality and Stress Certain personality traits may be susceptible to stress, since personality can influence one’s coping skills and attitudes toward life (John, Naumann, & Soto, 2008; Ward, Leong, & Low, 2004). For example, neuroticism, which is also known as a risk factor for mood and anxiety disorders, is strongly linked to certain levels of stress (S. Kim, 2011). Similarly, individuals who display perfectionistic traits have a tendency to have increased negative reactions to stressful situations as well as poorer coping skills

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compared to individuals who are not perfectionists (Montello, 2008; Wei et al., 2007). On the other hand, although the results have been inconsistent (S. Kim, 2011), other personality traits such as openness are associated with lower levels of stress (Poyrazli, Kavanaugh, Baker, & Al-Timimi, 2004). Individuals who have high openness to experience (John et al., 2008) are most likely to cope with stress better than individuals who are more rigid.

Culture and Stress Although stress is common to all people, the relationship between one’s own culture and stress has been studied (Berry, Kim, Minde, & Mok, 1987; Spector, 2012). As Cuellar (2000) asserts, “culture has been viewed as having a potential impact on numerous aspects of health, illness, and adaptation” (p. 49). For example, African-Americans (Walker et al., 2008) and Hispanic/Latino Americans (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005) experience higher levels of chronic stress than other ethnic and racial groups. This contributes to an increased prevalence of hypertension and diabetes (McCabe, Bostwick, Hughes, West, & Boyd, 2010), as well as substance abuse (Spector, 2012) and other psychological issues (Nadeem, Lange, & Miranda, 2009). Sources of chronic stressors related to culture (e.g., perceived discrimination, neighborhood, socioeconomic conditions, acculturation) may be attributed to neighborhood stress (Meyer, 2003) and acculturative stress (National Institute of Health, 2011).

Acculturative Stress Acculturative stress (Berry et al., 1987) is a unique type of stress in which difficulties with cultural adjustment are manifested in particular symptoms such as anxiety, depression, confusion, low selfesteem, and psychosomatic illnesses (Shin, Antonio, Son, Kim, & Park, 2011; Wilton & Constantine, 2003). At various points in the acculturation process, individuals may experience culture shock, resulting in a wide range of physical, social, and psychological consequences. For example, children and adults of immigrant families may display a high rate of acculturative stress and depression (Lara et al., 2005). Racial and ethnic discrimination are significant sources of acculturative stress (APA, 2012). Acculturation strategies, gender, age of immigration, socioeconomic educational backgrounds and social support may also play a role in acculturative stress (Berry et al., 1987). It is also widely reported that acculturative stress is associated with maladaptive coping skills (Wilton & Constantine, 2003). According to S. Kim’s (2011) study, English proficiency, neuroticism, and academic stress predict acculturative stress among international students studying music therapy. The greater the cultural differences between one’s own culture and the host culture, the higher the degree of acculturative stress. Existing stigmas regarding treatment, as well as language and cultural differences, prevent certain ethnic or race groups from seeking help to cope with these issues (Nadeem, et al., 2009). Thus, music therapists should thoroughly assess the client’s acculturation process and include treatment goals such as maintaining a sense of identity and social support when feeling overwhelmed and stressed. It is important to note that “music therapists must commit themselves to learning about the [client’s] various cultural needs and musical preferences; examine their own personal cultural values and how they may be in conflict with those of the [client]; and develop authentic skills in multicultural empathy” (Dileo & Magill, 2005, p. 228). In addition, a therapeutic approach should be chosen with the client’s culture and degree of acculturation in mind. For example, Asian and Hispanic groups may express their stress somatically. There are various somatic approaches that may be helpful in treating these clients. It should be noted that yoga, Qigong, and meditation have developed in the East, whereas

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progressive relaxation, biofeedback, and cognitive methods are based on Western philosophies which focus more on practical problems rather than one’s inner state (Woolfolk, Lehrer, & Allen, 2007). As discussed above, stress is a complex phenomenon. It is known that the stress response is associated with various factors, such as individuals’ differences including age, gender, personality, ethnicity, race, culture, resources, coping skills, and environment. Thus, stress must be understood within a certain context and in a comprehensive way and effective coping skills and stress reduction strategies must be developed: “If you want to improve your performance of any kind, you must control your rest as well as your work” (Gregorek & Gregorek, 2009, p. 65).

NEEDS AND RESOURCES Types, Symptoms, and Sources of Stress Stress can be classified as positive or negative. For example, when students are assigned to do a project, their reactions to the same task may vary. Eustress, a type of positive stress that some may experience, can be a reaction as a result of the energy and motivation needed to complete the task. Distress, a type of negative stress, can be a reaction as a result of the assignment being mundane, unchallenging, or too overbearing. Whether the individual is experiencing positive or negative stress, the characteristics of the physiological response are the same. Any change to homeostasis can be stressful. Based on frequency, duration, and intensity, stress can also be divided into three categories—acute, episodic acute, and chronic (APA, 2012). In addition, individuals display various symptoms, as well as various sources of stress. Acute stress is a short-term stress that most individuals experience daily. The symptoms are easily recognizable and relatively manageable. The physical symptoms include headache and/or stomach and chest pain. The emotional symptoms include feelings of irritability, worry, anxiousness, depression, and/or lack of concentration. Physiologically, individuals may experience a shortening of breath, a rise in blood pressure, an increase in heart rate, and cold hands and feet. It is important to note that these symptoms may disappear when the source of stress is addressed. However, these symptoms may also be experienced more frequently as episodic acute stress. When an individual experiences episodic acute stress, he or she reacts to stressors intensely. These individuals have a tendency to become impatient, overbearing, and worrisome, and remain hostile to their surroundings. There are overlaps between Type A personalities and individuals experiencing episodic acute stress. In addition, individuals facing episodic acute stress may experience intense headaches, asthma, heart disease, and hypertension. Furthermore, feelings of helplessness, depression, and inadequacies may occur. This in turn weakens the individual’s immune system, increasing the chances of physiological problems such as chronic pain, appearance of ulcers, development of chronic fatigue, and digestive problems. Factors that may cause episodic acute stress are related to poverty, family dysfunctions, feelings of helplessness, and/or traumatic childhood experiences. Therefore, individuals experiencing episodic acute stress may need to seek professional help in order to develop a wellness plan and better coping skills. Chronic stress is an extension of the aforementioned symptoms that can be prolonged and more severe. Chronic stress can lead to suicide or violence and the development of heart attacks, strokes, or cancers. This type of stress may originate from traumatic experiences or early childhood memories that may affect one’s personality. A challenge that mediators face is that people experiencing chronic stress often do not recognize their own symptoms or do not recognize their need for treatment because they are accustomed to these emotions and physiological effects. In order to properly deal with chronic stress, medical care and psychological interventions are required (APA, 2012; Woolfolk et al., 2007).

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The duration and intensity of all the different kinds of stress may be relieved when an individual learns to accept some of his or her challenges, foster meaningful relationships with others, strengthen resilience, and develop positive thoughts. The physical symptoms of stress may be alleviated by regular medical check-ups, regular exercise, and healthy nutrition. Behaviorally, it may be helpful to examine responsibilities, develop time management skills, identify the sources of the stress, and engage in a wellness program regularly. Given all the complexity that accompanies stress, how can music therapy help clients decrease stress? The literature review explains how many of the areas discussed above can be addressed through music therapy. Most importantly, individuals can develop proper coping skills through music therapy sessions. Priestley (1994) notes that “everyone must be aware of the stress caused by the need for constant and often traumatic changes to which one must make readjustment without time for the assimilation of the emotional resonances that they cause” (pp. 188–189) and that the role of the therapist is to “find [the client’s] optimum stimulation level” (p. 189).

Musical Characteristics of Clients with Stress The type of stress and the symptoms being experienced by the client is often manifested musically in sessions. Some examples based on the author’s observation are included here. In the case of acute stress, clients may have difficulty with following directions due to constant ruminations. Clients may move from one activity to another at a faster pace and have difficulty with engaging in relaxation or imagery. In addition, clients may also feel uncomfortable with silence. Further, clients may make constant demands of the therapist during the session or show apathy toward the music and the therapist. Clients with episodic stress may exhibit a restless mind and an incoherent and disorganized attitude; they may express strong emotions by playing an instrument loudly, clashing cymbals, or by abruptly ending their playing. On the other hand, some may exhibit a lack of interest in engaging in a musical activity, be unmotivated to contribute musical ideas, and be unwilling to try a new instrument or an activity. In either case, these clients may inhibit their creativity and flexibility in musical expression and react to any change intensely during the session. Because clients are most likely to be impatient, they can easily fall into conflict with other members in the group. The clients with chronic stress may simply refuse to participate in the sessions as they may not acknowledge or be aware that they are experiencing chronic stress. Even though they agree to come to the session, they may remain inactive during the session because they may feel emotionally stuck or depressed. They may have difficulty expressing and connecting with their own feelings and often seek validation from others. They may demonstrate a lack of expressiveness and can be resistant to certain music or relaxation experiences. It is notable that individual differences among the clients in each type of stress should be considered as their coping skills and environments differ.

Coping Strategies and Music Therapy Lazarus (1991) pointed out that coping with stress is a process that requires a person’s ongoing efforts in willpower and action in order to overcome overwhelming situations. Problem-focused coping focuses on a person’s coping skills in dealing with the environment and the impact of the coping skills on psychological stress. Emotion-focused coping postulates that the way a person perceives and interprets his environment affects the person’s psychological stress. Thus, when identifying the sources of stress and current coping skills, the first method examines what situational factors cause stress and how the person acts in response. The latter method evaluates how a stressful situation makes the person feel and what the person does to feel better (Lazarus & Folkman, 1984). Table 1 illustrates how these coping skills are addressed in

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music therapy. The techniques listed in the table are described in detail in this chapter. Note that (p) denotes problem-focused coping and (e) denotes emotion-focused coping for stress. Both coping methods can be addressed in music therapy sessions. Table 1. Coping Strategies Music Therapy Focus Mind

Goals for Developing Coping Strategies a) Identify stressors (p) b) Examine the client’s value, goals, “optimum stimulation level”(Priestley, 1994, p. 198) (p) c) Identify one’s strengths (p) d) Evaluate current resources and coping skills (p) e) Help the clients prioritize their responsibilities (p) f) Sort out the stressors that can be avoided or altered (p) g) Help the client react to the stressor by adapting to or accepting it (e)

Techniques Used in Music Therapy a) Take care of my cultural being b) Assertiveness training c) Journaling d) Imagery e) Music therapy improvisation and desensitization

Body

a) Promote exercise regularly (p) b) Set aside relaxation time to help reduce the intensity of emotional reactions (e)

a) Music-assisted breathing b) Yoga, tai chi c) Psychodynamic movement

Spirit

a) Spend time and share feelings with a support group, which buffers the person from the negative effects of stress (e) b) Engage in an enjoyable activity daily (p) c) Connect with others (e) d) Utilize community resources (p) e) Keep a sense of humor (e) f) Adopt a perspective to look at challenges as opportunities (e)

a) b) c) d) e) f) g) h)

Chanting Community jam Celebrating life Group work Tai Chi Imagery Expand creativity Use one’s energy in a more productive way

Wellness Development Practiced in many Eastern cultures and ancient societies (Roskam, & Reuer, 1999), the wellness model (Dunn, 1977) advocates a holistic approach that connects the mind, body, and spirit (Grocke, 2009;

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Shoemark, 1987). A state of well-being is defined as “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable. It requires that the individual maintain a continuum of balance and purposeful direction with the environment in which he is functioning” (Dunn, 1977, pp. 4–5). As a preventive intervention as well as a cost-effective method, wellness programs include nutrition, physical exercises, stress reduction, regular medical check-ups, mind-body interventions, and meditations (Belgrave, Darrow, Walworth, & Wlodarczyk, 2011; Ghetti, Hama, & Woolrich, 2003). The wellness model is based on the belief that the individual is capable of affecting one’s health status by actively participating in treatment decisions, promoting a healthier lifestyle, adopting a more optimistic attitude, being more involved in the community, and maintaining preventative measures (Krout, 2007; Scheve, 2004). In other words, the individual takes responsibility for his or her own health. Wellness programs are available in a variety of settings, including educational settings, geriatric workplaces, and community centers (Belgrave et al., 2011; VanWeelden & Whipple, 2004). These settings often include music-assisted wellness programs. The emphasis placed on the wellness program varies depending on where the person is in their stage of life and depending on the needs of the person. Wellness techniques are developed both for therapy sessions and for individuals to reduce stress and increase relaxation. Thus, an individualized wellness program is recommended. However, it is notable that currently group wellness programs are more cost-effective and therefore used more often. Clientele of all age groups can benefit from wellness programs (Grocke, 2009). Children are of an “ideal age” (Ghetti et al., 2003) to learn about what constitutes a healthy lifestyle and proper coping skills. In addition, “music may be a medium to help young people reduce their negative emotions”(Labbé, Schmidt, Babin, & Pharr, 2007, p. 163). Parents, teachers, and members of the community can work together to help promote the well-being of children. For example, using song lyrics and teaching children wellness concepts, (e.g., brushing one’s teeth and eating healthy foods) increases the awareness of health. Employing structured musical activities will help children engage in breathing exercises or other physical exercises and release tension, improving concentration. By participating in a variety of music ensembles, children can further develop social skills and leisure skills. In adulthood, “self-awareness and self-responsibility” (Ghetti et al., 2003, p. 132) are emphasized. Wellness programs can be personalized, depending on the individual’s need. Stress management has been predominantly used in wellness programs for adults. More and more, many workplaces implement wellness programs and promote employees’ health: “Stress is a prevalent mental health problem in the workplace, and having a high level of perceived stress is associated with poor work performance, higher health care costs, and poor quality of life” (Clark et al., 2011). Music-assisted meditation and relaxation, such as joining in a musical ensemble, may help lower their stress levels and develop proper coping strategies. For the elderly, maintaining a state of well-being and effective stress management is important in enabling them to continue their involvement in their community. “Self-responsibility for health, nutrition, exercise, stress management, interpersonal support, self-actualization, and spiritual development” (Ghetti et al., 2003, p. 134) are integrated into wellness programs. Music therapy can be a medium for reducing stress by achieving independence, preventing illness, delaying the normal aging process, continuing social engagements, and developing spirituality (Clair, 1996; Hanser & Mandel, 2010). Well-being means “to remain interested in life and to participate fully in it” (Clair, 1996, p. 33). As reviewed above, stress can better be understood within a wellness model. It is recommended that one become engaged in such a program as early as possible because a healthy lifestyle will affect a person and his or her experiences throughout one’s life span. While various methods are used to manage stress among Americans (e.g., exercising, reading, spending time with friends or family, and napping), listening to music (48%) has been ranked as the most frequent method of stress management (APA, 2012).

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REFERRAL AND ASSESSMENT Guidelines Referrals come from various sources, including self-referral, parents, caretakers, or professionals who work with the clients. Ongoing assessment is necessary to meet the needs of persons with stress because stress levels are often fluctuating. To utilize session time more efficiently, it may be possible in some cases to send out a music therapy assessment form and ask the client to return it prior to the first session. Then, during the assessment session, the therapist will utilize music activities to assess the client’s needs and review the assessment form with him so that pertinent information can be further elicited. An individual assessment session is beneficial, even if brief, because each person understands and experiences stress in a unique way. Guidelines for an initial assessment are as follows: 1) Stress Inventory: Assess the client’s perceived stress level and identify sources of stress, symptoms of stress, and current coping skills. The client’s value and “optimum stimulation level” (Priestley, 1994) are also examined. Standardized stress inventories can be used, such as Holmes-Rahe’s Stress Scale (1967) or Spielberger’s State-Trait Anxiety Inventory (STAI) (Spielberger, Gorssuch, Lushene, Vagg, & Jacobs, 1983). 2) Music Inventory: Ask the client to identify his favorite music and relaxing music, as well as music that could cause stress. 3) History of Music Experiences: Any participation in musical ensembles or musical training as well as the client’s wishes to learn about music or musical instruments are noted. Family musical backgrounds are also helpful information. 4) Medical Information: The client’s medical conditions are noted prior to every session. 5) Psychosocial Information: Any traumatic experiences or personal history relating to stress are noted. Spiritual and religious information are necessary to avoid any conflicts regarding music methods. 6) Music Assessment: During the assessment session, using improvisation and songwriting assess the client’s well-being in the physical, psychological, and spiritual domains in relation to stress and healing. Both the therapist and client together can identify underlying causes and stressors of which the client may not be aware. If the member is open to engaging in songwriting, this method is also helpful in identifying any irrational thoughts and expectations when setting goals, “as original musical lyrics may often reveal aspects of an individual’s belief systems” (Dileo & Bradt, 2007, p. 533). During sessions, the therapist should consider the following: 1) Set realistic goals: Clients often have a tendency to take on more than they can handle, resulting in increased stress levels. It is important for clients to routinely check their daily schedules and make any adjustments to establish realistic daily goals. 2) Help the client to select a preferred music intervention. Ultimately, he should be able to prevent stress outside of sessions through these self-help methods. Homework assignments may be helpful, e.g., providing recorded music and verbal directions for relaxation. 3) Encourage the client to explore combining other creative methods. The root of stress comes from ongoing interactions between an individual’s perception and his

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environment. These methods may enhance the client’s flexibility, openness, and coping skills. Recommend music that research has proven to be helpful in managing stress. 4) Keep in mind that only the client knows what is right for himself. 5) Be resourceful in finding ways to help the client cope (S. Kim, 2011). 6) Utilize group settings for clients to have opportunities for exchanging resources and supporting each other. Having completed the assessment, the therapist designs and implements a treatment plan to manage stress. The following guidelines for music interventions in the treatment of stress are based on the current literature in music therapy and other fields as well as this author’s clinical experiences with a wide range of populations. Although these interventions may be adapted to a clinical setting, they are primarily for people with stress or those who are interested in stress prevention. Most of these methods can be conducted in individual or group sessions with any age group. It is recommended that the therapist implement mind–body integration (Deckro, Ballinger, Hoyt, & Wilcher, 2002) with any of the music interventions for stress reduction. Also, the therapist should experience these methods personally before implementing them with clients. For some members, excessive stress may result from trauma or personality (e.g., Type A, or neurotic traits) and may need to undergo a deeper level of work to resolve the issues causing stress. A client requiring this level of intervention should be referred to a music therapist who is qualified to practice a specific advanced method. Analytical Music Therapy (AMT), Bonny Method of Guided Imagery and Music (BMGIM), or Nordoff-Robbins Music Therapy (NRMT) is recommended. More detailed information about advanced methods can be found in Bruscia (1987).

OVERVIEW OF METHODS AND PROCEDURES All four music therapy methods are used for treating stress, in addition to combinations of music therapy methods.

Receptive Music Therapy • • • • • • • •

Music-Assisted Breathing: Clients learn and practice diaphragmatic breathing using music to cue the deep breathing response. Stress Reduction Through Movement: The client breathes and executes gentle movements to music. Tension and Release Body Relaxation: Clients hold, tense, and relax each muscle group; this procedure is adapted from Jacobsen’s (1938) progressive muscle relaxation. Vibroacoustic Therapy: is the use of the vibratory and acoustic or sound properties of music as a clinical treatment for therapeutic goals. Relaxation for Children: Children improvise live vocal music and/or use prerecorded music to promote relaxation while they are lying down and listening receptively. Music and Imagery—Favorite Place: In a relaxed state while listening to music, the client creates an image of a favorite place that will promote the relaxation response. Entrainment: The client listens to music improvised by the therapist to reduce physical pain. Musical Analytical Meditation (MAM): The client listens to music improvised by the therapist while focusing on breathing and imagery. It is preceded and followed by a verbal discussion to provide focus for the client’s goals.

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Improvisational Music Therapy • •

•

•

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Vocal Toning—Celebrating Your Authentic Voice: Clients engage in vocal toning and improvise vocal phrases to express feelings. Role-Playing to Enhance Assertiveness: Clients improvise lyrics with or without a melody or improvise instrumentally over a structured harmonic accompaniment to affirm one’s needs. Rhythmic Drumming—Connecting to Others: Clients play drums in a structured rhythm using imitative, call-and-response, solo and accompaniment, and free improvisation structures. Psychodynamic Movement: Clients improvise movements based on their experiences of stress while the therapist provides a grounding accompaniment and interprets the movements musically. Clients may also vocalize while moving. Music Therapy Improvisation and Desensitization (MTID): Clients access images, feelings, and sensations related to stress and to relaxation and then improvise relaxing music to replace the stressful experience with a calm and relaxing one.

Re-creative Music Therapy •

Chanting to Liberate Stress: Clients create a sound or chants based on a personal affirmation, a prayer, or a line of a song and sing it repeatedly to release stress.

Compositional Music Therapy •

Song Composition: Clients partially or completely create new lyrics to an existing song or compose a new song.

Multiple Methods of Music Therapy •

•

Singing and Accompanying Songs Across Cultures: Clients sing songs from different cultures and accompany them on instruments. The instrumental accompaniment may develop into an improvisation. Community Jam—Musicking Together: Clients rehearse, perform, improvise, listen, play, and/or sing with others with the intention of enjoying music together.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Music-Assisted Breathing for Groups: Breathing Tension Away Overview. In music-assisted breathing, clients learn and practice diaphragmatic breathing using music to cue the deep breathing response. Diaphragmatic breathing is a healthy and normal breathing pattern during which the client uses the abdominal muscles to breathe, instead of the chest muscles. This assures that ample oxygen is delivered to the lungs and relaxes the autonomic nervous system. As a result, it elicits the relaxation state. Diaphragmatic breathing is essential in calming the mind and body and in preparation for meditation. The goals are to learn how to breathe properly, to release tension, and to be more in touch with one’s own body.

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This method benefits clients who have difficulty relaxing. Such clients may appear anxious, short of breath, easily irritated, and fatigued. Their daily schedule may be hectic. A client with medical conditions such as respiratory problems, cardiovascular problems, or hyperventilation should be monitored carefully. Any client who feels dizzy or light-headed should hold his breath for up to 30 seconds before exhaling. If the symptoms continue, pause the activity and return to it when the symptoms disappear. This method can be used in both individual and group music therapy settings at the augmentative level. It is beneficial for all ages. No specific training is required to implement this method. Preparation. Provide a soothing and comfortable space. The client should be lying down on the floor using a mat or blankets or sitting up straight in a chair. Dim the lights, draw the curtains or blinds, and ensure that the room temperature is comfortable. Precautions must be taken to prevent any distractions (e.g., turn off cellular phone). Inform the client he should wear comfortable clothing and remove eyeglasses and jewelry if appropriate (Clair, 1996). The therapist will need a wide variety of relaxation CDs or music on an iPod or iPad with a good sound system and speakers. Note that commercial music can often be at a relatively fast tempo (Hanser & Mandel, 2010), so it needs to be carefully reviewed prior to the session. The music therapist selects a variety of musical styles for relaxation based on research studies or recommendations from other professionals. The general guideline in selecting relaxing music (Grocke & Wigram, 2007; Hanser & Mandel, 2010) includes a tempo of around 60 beats per minute, which is similar to the average heartbeat; soft volume; long phrases; consistency in dynamics; repetitive, predictable structure and form, and no sudden changes; instrumental music (the lyrics of music are involved with cognitive processing); and avoid heavy metal, punk, and strongly accented rhythmic music. The therapist may also record her own improvised music that closely matches the client’s pace and use the recording in sessions. A hand drum, rain stick, ocean drum, tone bar, woodwind instruments, or synthesizer is recommended. Nature sounds (e.g., water, wind, and waves) may also be incorporated into music. What to observe. The therapist observes the clients’ breathing patterns and their reactions and sensations, and assists them in using their abdominal muscles to breathe rather than their chest muscles. Also, observe whether the clients synchronize their breathing with the rhythm of the music. The music may be changed if it does not seem to work well. Anyone who becomes short of breath or dizzy should be advised to stop breathing deeply and return to a normal breathing pattern. Procedures. This method is usually used at the beginning of the session; if so, it may be preceded by a greeting song that is familiar to the clients. The therapist then describes the mechanics and benefits of diaphragmatic breathing, explaining the connection between one’s emotional state and breathing. The therapist invites clients to sit in a comfortable position with their feet flat on the floor and their eyes closed. This will lessen any distractions. At this time, it may be helpful for the therapist to demonstrate diaphragmatic breathing to the clients and to share what she observes in terms of their breathing patterns when they practice it. She then begins to play music softly and asks the clients to synchronize their breathing with the rhythm of the music while breathing normally and noticing their natural breathing patterns. The therapist may ask, “Is your breath short, fast, or long? Do you breathe with your chest or stomach? What does your breathing tell you?” Clients can then be instructed to put one hand on their chest and the other hand on their abdomen, while slowly inhaling through their noses and then exhaling out of their mouths. This should be continued for several minutes. If the client’s hand moves up and down on his abdomen while he is breathing, he is performing diaphragmatic breathing correctly, enabling him to get more oxygen into his lungs. If a client has difficulty doing so, guide the client to expand his abdomen as though filling a balloon for four counts while inhaling, then four counts while exhaling, and then four counts while relaxing. This should be repeated several times, while reminding the client to breathe evenly and fully. Allow the client to breathe at his own rhythm, keeping mindful of the sensation of breathing while listening to the music. Toward the end of the experience, gradually lower the volume of

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the music. Once the client has finished, guide him to gently massage his face and wiggle his fingers and toes. At the end of the music, the therapist can ask the client or clients to describe their experiences during the exercise. The therapist should take note of client feedback regarding the environment, verbal directions, and the music to help ensure the effectiveness of future sessions. If this activity is used at the end of the session, close the session with a good-bye song. Adaptations. This breathing procedure can be used as an independent activity or at the beginning of every session, and it can be used with individuals as well as groups. If space is available, it should be performed lying down on the floor using mats. Also, the therapist should encourage the clients to practice the technique at home daily as often as they need. The therapist may record the verbal directions with music so that the clients can practice by themselves at home (Clair, 1996; Hanser & Mandel, 2010). Another alternative is adapted from Davis, Eshelman, and McKay (1995). This involves making sounds with the breathing. In this technique, the client is instructed to breathe deeply and pause for a moment. Then, exhaling on a slow and even breath, the client allows a natural vowel sound to issue forth from the abdomen; the sound can be anything from a gentle sigh to a guttural animal sound. If the client wishes, he can make any movement, for example, an arm movement along with the sound. The client is instructed to continue to breathe while exploring different sounds until he finds a sound that he connects with. As above, the therapist will ask him to share his experience verbally.

Stress Reduction through Movement Overview. In this experience, the client breathes and executes gentle movements to music. Clients who experience fatigue, anxiety, restlessness, or depression may need to be energized with gentle movement experiences. When the client’s body is relaxed, he becomes more sensitive to it and more aware of tension and breathing patterns that may be contributing to stress. The goals are to increase flexibility and body awareness, and to integrate mind and body. Some clients may experience pain or aching in their body when they become more attuned to it, or when executing movements. Inform the clients that they should complete movements only within their physical comfort zone. Overstretching or strenuous movements may worsen muscle conditions. This procedure should not be done on a full stomach. Any client who recently received any surgery, has been diagnosed with a heart condition, or has had a prolonged disease is contraindicated for this method unless a doctor has medically cleared him. This method is effective in both individual and group therapy at the augmentative level. It is beneficial for all ages. No specific training is required to implement this method. Preparation. Provide a soothing and comfortable space. The client should begin lying down on the floor using a mat or blankets or sitting up straight in a chair. Prepare the room as in the MusicAssisted Breathing procedure above and inform clients of attire recommendations. Refer to the information in the previous section regarding the characteristics of music that may be used. The therapist should have relaxation-appropriate recorded music, including a wide variety of relaxation CDs. A CD player, iPod or iPad, and good-quality speakers are necessary to play the music. What to observe. Prevent overuse of one side of the body. Encourage clients to freely use their bodies. Observe breathing patterns to determine if clients are breathing productively or holding their breath. Observe the ease or difficulty with which clients execute movements: strength, flexibility, range of motion, and variety of movements. Some older adults may have difficulty due to physical limitations. Assist them as needed. The pace should be flexible. Procedures. This method may begin in a sitting, standing, or lying down position. The client begins by taking long breaths through the nose with the mouth closed using the diaphragmatic breathing technique. Once the client is comfortable breathing in this way, the therapist facilitates deepening the

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breathing by counting. If the client is not already standing, ask him to stand in a relaxed position with his feet slightly apart at shoulder’s distance and to continue breathing in a normal manner. The therapist then plays the selected music and guides the client to make a slow, easy turning movement from side to side, initiated at the level of the hips. Next, the client draws an imaginary circle in the air with his chin moving counterclockwise first, and then moving clockwise. This will prevent the client from stretching the neck too far back and squeezing the vertebrae in the neck. Next, the client begins with his arms at his side, raises them slowly above the head, and then puts them back down to the side. Following this, the arms might be bent at the elbow and swung gently from side to side in front of the body. At this point, the client may lie down. Then, the client should be instructed to bring his right leg closer to the chest to provide a gentle stretch and then to let go. The same should be done with the left leg, and then with both legs together. Then, bringing both knees up to the chest and holding them gently with the arms, the client can gently make a circular motion to relax the lumbar region before stretching the leg out. Finally, the client should be instructed to find a comfortable position and continue to rest on the mat. After a minute or two, the therapist asks the client to slowly and gently roll over on one side and support the body to come back to a sitting position. A brief check-in with the client is necessary to gain understanding regarding each client’s abilities and limitations and to help the client adjust his routine to better meet these needs. It is recommended to practice these exercises for a few minutes each day, preferably in the morning. Adaptations. Yoga (West, Otte, Geher, Johnson, & Mohr, 2004), tai chi, popular line dancing, or other movements can be combined with music to facilitate movement. It is important to encourage the clients to acknowledge their stressors and to attempt to find balance in order to cope with ongoing stress. A beach ball can be utilized as a symbol of a stressor (as a means of letting out aggression). For example, first ask the client to imagine holding a beach ball in his hands. Ask him to describe the shape, size, color, and texture of the ball. In addition, instruct the client to be aware of how the beach ball feels in his hands. Then, the client should be told to do whatever he wants to do with the ball, whether it is throwing it, playing with it, or squeezing it. Eventually, the ball will be thrown away at the conclusion of the imaginative activity.

Tension and Release Body Relaxation Overview. Clients hold, tense, and relax each muscle group; this procedure is adapted from Jacobsen’s (1938) progressive muscle relaxation. The length of the time for squeezing and relaxing is flexible. Clients become more aware of tension and relaxation as they systematically tense and relax each muscle group. This helps them to integrate relaxation for both body and mind (Clair, 1996; Scartelli, 1989). The muscle groups can be divided into a variety of specific groups, depending on the client’s needs. The goals are to identify tense muscles, to release tension and to be more in touch with one’s body. This method can be practiced in both individual and group therapy settings at the augmentative level. It is beneficial for all ages. No specific training is required to implement this method. Clients with muscle tension, bodily pain, somatic symptoms, insomnia, irritability and persistent nervousness would benefit from this method. However, it would not be appropriate for clients with hypertension or myocardial infarction because this exercise may result in raising blood pressure or anxiety for them (Clair, 1996). Thus, it would be advisable if the clients consulted with their physician prior to the session. The therapist must inform the clients regarding the contraindications for this method and verify if they have had any physical injuries recently. This technique should not be practiced right after a meal or before physical exercise. Preparation. Provide a soothing and comfortable space. The client should be lying down on the floor using a mat or blankets or reclining comfortably in a chair. Prepare the room as in the Music-

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Assisted Breathing procedure above and inform clients of attire recommendations. Refer to the information in the previous section regarding the characteristics of music that may be used. What to observe. Monitor clients, making sure they use their muscles within their comfort zone. If any client seems to be in pain, ask him to discontinue the activity. Closely monitor clients who take medication or have medical conditions. If the therapist observes any client sweating profusely, breathing fast, or shivering, give proper assistance. Clients may begin to feel anxious while doing this activity. In this case, assist them in breathing normally. Any client who feels dizzy or uncomfortable should terminate this activity and focus on breathing naturally while relaxing the body. Procedures. The therapist gives a brief introduction to Jacobsen relaxation and explains that she will verbally instruct them to tense and release various muscle groups. Clients should be reminded not to overtense any part of their muscles. If they feel pain or cramps at any time, they should be instructed to simply focus on the relaxation aspect for that muscle group. She then invites the clients to find a comfortable spot in the room. When the clients are settled and ready to begin the activity, the therapist plays the selected music and instructs them to do a preliminary body scan to become aware of any muscles that are tense or in pain, suggesting that as they do this exercise, they can focus on the tensed muscle to soften and relax it. Next, guide the clients to become aware of their natural breathing rhythm as they listen to the music. Diaphragmatic breathing may also be used at this time. The therapist then instructs the clients to contract and release their muscles, systematically focusing on each part of the body. The exercise begins with the first muscle group, the hands and arms, including forearms and upper arms or biceps. Begin with the client’s dominant hand and arm, instructing him to squeeze the muscles for five to seven seconds, and then relax them for 20 to 30 seconds before moving to the nondominant hand and arm. After the arms have been completed, clients should move to the second muscle group—the head, face, throat, and shoulders. They should begin by tensing and then relaxing the forehead. This should also be done with eyes closed. Next, the therapist should instruct clients to clench their whole face, and then relax. The chest, stomach, and lower back are the third muscle group. It can be helpful to instruct clients to make the sound “shhhh” when they exhale. The fourth muscle group, the thighs, buttocks, calves, and feet, are tensed and relaxed in that order. When the therapist reaches the legs, she proceeds with dominant thighs, calves, and feet, and nondominant thighs, calves, and feet. Each muscle group should be repeated once. If the area is still tense, it can be repeated up to five times. Additionally, throughout the process, the suggestion should be made to the clients that they are feeling more and more relaxed. Finally, instruct clients to squeeze their entire body, relax, and remain in position for a few minutes. The therapist turns off the music and tells them the exercise has been completed, gently bringing the clients back to the sounds of the room and an awareness of their bodies, then counts back from five to one, and then turns the light on. The clients are told they can rub their palms together gently a few times and massage their faces gently before opening their eyes and slowly sitting up. Adaptations. As both tension and release are important components frequently used in music, certain musical elements such as pitch, melody, harmony, texture, phrasing, volume, and timbre are utilized to evoke tension and relaxation responses (Bruscia, 1987). Thus, the therapist selects these musical elements to facilitate the client’s physiological responses to help them relax. More detailed information about creating musical tension and release can be found in Bruscia (1987), Robbins and Robbins (1998), and Wigram (2004). Bruscia (1987) specified five levels of tension in improvisation—hypotense, calm, cyclic, tense, and hypertense (pp. 435–436). First, the therapist should consider what degree of tension and relaxation the client needs and should choose the appropriate musical sound using consonance/dissonance and melodies/harmonies. When creating sounds to evoke muscular tension, they should be louder and have more harmonic dissonance than relaxing sounds. For example, sounds that evoke tension might include

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strong accents and syncopations and have harmonies that contain seconds, sevenths, and augmented fourths in their chord structures (Robbins & Robbins, 1998). To release the tension, it is important to use melodic phrases that utilize calm, simple, repetitive, and more predictable sounds in a slower tempo. The use of melodies and simple chords, e.g., triadic, diatonic, octaves, and fifths, can aid in releasing the tension in the body. Pauses in the music and the use of dynamics are also important to consider. The therapist can also reinforce tension or release vocally. The therapist might also record the verbal directions and encourage the clients to practice by themselves twice a day at home at their own pace (Clair, 1996; Hanser & Mandel, 2010). The therapist can also recommend music that may be suitable for this exercise. Because this activity may help to improve the quality of sleep (Clair, 1996), clients may practice this activity before going to bed. Another adaptation is to use a short form of the procedure. Instructions for the short form would be: “First, tighten both fists, biceps, and forearms together and then relax.” Then, the second and third muscle groups described above can be done together. Finally, the fourth muscle group is treated similarly, saying, for example: “Squeeze and release. Take a deep breath. Raise your feet and toes toward your face while tensing your shins. Hold and relax. Tighten your calves, thighs, and buttocks together and then relax” (Clair, 1996, pp. 35–38). Additional procedures are introduced in Clair (pp. 279–295). As an alternative procedure, the therapist can focus on specific physical symptoms of stress as described in Strauss (1984). The author noted that this procedure should be practiced in conjunction with proper medical care. Start with the breathing procedure as in the Music-Assisted Breathing exercise above. Then guide the client in a directed meditation with a focus on body sensation. Using relaxing music with the characteristics described above, ask the client to notice his thoughts in order to let them go. Then direct the client to an awareness of the parts of the body that are in pain or feel tense. Visualize the pain or tension or sensations in those body parts; while listening to the music, ask the clients to use the fingers of both hands to draw the healing energy from the solar plexus. Clients can be instructed as follows: “First, place your fingers on the solar plexus for about ten seconds. Concentrate on it. Then move your fingers to the body parts that feel pain and tension, while listening to the music. Let the music energize the body part” (pp. 95–97). Repeat this procedure until the client’s muscles feel relaxed. Suggest that clients continue to play the same music for at least three months and perform this activity every day in the same location. After practicing exercises at home, clients who are attending a group experience can discuss what relaxation techniques they used, what they learned about themselves, how they will deal with stressors in the future, and how relaxation benefits them (Reuner, 2008).

Vibroacoustic Therapy Overview. Vibroacoustic therapy is the use of the vibratory and acoustic sound properties of music as a clinical treatment for therapeutic goals. First researched and developed by Professor Olav Skille in Norway in the 1980s (Grocke & Wigram, 2007), there are various forms of vibroacoustic therapy practiced by different professionals. However, the description in this chapter is limited to the practice in which music is used for a specific clinical reason. Vibroacoustic equipment is relatively easy to build using a bed or a chair with a low-frequency bass woofer speaker. Although a variety of music styles can be used, sedative music would be best as it contains low frequencies, is rhythmically neutral, is soft in volume, and is “stable, predictable, and consistent” (p. 226). The goals for this method include releasing tension; increasing energy; increasing self-regulation; and identifying unconscious material related to stress. Clients who wish to participate in this activity should consult with a physician prior to the treatment. Some individuals may display stress responses, physical or emotional reactions, dizziness, or discomfort. The client with “acute inflammatory conditions, psychosis, pregnancy, hemorrhaging, and active bleeding, thrombosis, hypotension, or [users of]

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pacemakers” (Grocke & Wigram, 2007, p. 227) cannot receive this treatment due to side effects. Individual therapy at the augmentative level is suitable. This method is used only for adults. No specific training is required to implement this method. Preparation. This method requires a vibroacoustic bed or chair built with low-frequency woofer speakers. To avoid dissonant tones, select music with low frequencies of 44 Hz and lower. Moreover, relaxing sedative music, as well as the pulsed sinusoidal and low-frequency tones (30–80 Hz) are most effective for experiencing vibrations in the body (Grocke & Wigram, 2007). What to observe. If there are any unusual responses (e.g., crying, shaking), gently call the client’s name and check in with him. Also, adjust the volume according to the client’s needs for that day. He may need an additional blanket or pillow to feel more relaxed. Observe his facial expressions and postures for signs of relaxation. If he is not relaxed, ask him if there is anything that the therapist can do. Procedures. First, always review with the client whether he has any health concerns or is taking any medications. Explain the procedures in detail. It is important that the client knows that he or she has control over the situation by stating that the treatment can be stopped at any time. Grocke and Wigram (2007) provide the following explanation to the client regarding the procedure: “This 35-minute rest period is for you to relax and listen to the music you have chosen as your preferred music. I am here just to be with you, but we shouldn’t talk during this time. You can listen to the music and relax, and I will read a book” (p. 222). The client sits in the vibroacaustic bed or chair. The client will begin by engaging in Music-Assisted Breathing. Then begin the music at a low volume and turn the bass tone to zero, gradually increasing it periodically. After the treatment is complete, the client will remain in the seat for about 30 minutes to rest. Adaptations. Depending upon the client’s condition on the day of the session, the frequency and volume may be adjusted accordingly. The time of the treatment is also flexible, depending on the client’s condition.

Relaxation for Children Overview. Children improvise live vocal music and/or use prerecorded music to promote relaxation while they are lying down and listening receptively. The goals are to release tension and stress, to increase relaxation, and to engage creativity. Children who ruminate, are restless, display short attention spans, have short tempers, or have a hard time self-regulating can benefit from this method. Some may have a hard time adjusting to a relaxing environment. The purpose of the activity should be explained first, and care should be taken to guide them step-by-step. This method can be used in both individual and group therapy settings at the augmentative level. No specific training is required to implement this method. Preparation. A comfortable and soothing environment with dimmed lighting is necessary. A comfortable room temperature, mats, and pillows should be provided. Suitable prerecorded music with a good sound system must be available. Lullabies, nursery rhymes, or classical music (e.g., “Twinkle, Twinkle Little Star”; Prelude: Cello Suite No.1 by Bach) that are familiar are recommended. What to observe. The therapist should note which children are having difficulty settling into the experience. Observe if anyone appears uncomfortable. If a child becomes fidgety or attempts to engage with other peers, approach the child quietly and tell him that it is time to rest. If he still has a hard time, gently massage his back or hold his hand until he becomes quiet. Provide support for those clients who need more assurance. If needed, offer pillows or stuffed animals. Procedures. If recorded music is being used, the first step involves choosing music that appeals to the client or group. Play a few seconds of the opening of a couple selections of soothing music and ask the clients about their music preferences. Then ask them to find a comfortable spot in the room and lie

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down on the mats. The therapist informs the clients that she is dimming the lights and begins a relaxation induction that involves a breathing exercise. Soothing music is played, either recorded or improvised: “live music is always very effective because it can be tailored specifically to the [clients], matching their energy closely” (Grocke & Wigram, 2007, pp. 85–88). A 5- to 10-minute session of vocalization by the therapist using a simple harmonic structure may also create a feeling of comfort. Ask the clients to be silent while listening to the music. At times, the children may need to be redirected to the music, for example, “Let’s listen to the music; you will be quieter, quieter, and quieter.” The therapist should state that anyone requiring assistance should raise his or her hand. When the music has stopped, the therapist should inform the children to count down from five to one. Once the countdown ends, the lights should be turned back on. The clients can move their arms, shoulders, and legs, and slowly get up. After a brief verbal check-in, the children should put away their mats. Adaptations. Music and movement may be effective as preparation for relaxation. For example, walking and jumping prior to relaxation will help the children to expend their energy and relax better. As they find a spot to lie down, beginning the relaxation with a lullaby or vocalization while the children close their eyes may be helpful. To help them better relax, while music is playing, the therapist may read a fairytale such as Sleeping Beauty. Seeing a silk fabric being waved gently in the air during music listening is also recommended to create a soothing visual effect. If the group is an older adolescent group, familiar self-selected music is preferable, and other props, such as a flickering candle, can be useful (Grocke & Wigram, 2007, p. 88).

Music and Imagery—Favorite Place Overview. In a relaxed state while listening to music, the client creates an image of a favorite place that will promote the relaxation response. The goals in this music imagery experience are to help the client connect with oneself—in body, mind, and spirit—and to achieve a more relaxed state through imagery and personal associations. This method can be effective when clients display somatic symptoms, are very anxious, or have a hectic daily schedule. Clients who are open to utilizing their imagination may benefit from this procedure. It is not appropriate for any clients who have poor reality orientation to participate in the music and imagery experience, as it may lead to hallucinations and delusions (Clair, 1996). In addition, this method may induce anxiety for clients who are uncomfortable in a meditative state or who experience unpleasant associations to past experiences evoked by the particular music used. This method can be used in both individual and group therapy settings at the augmentative level. It is beneficial for all ages. No specific training is required to implement this method, although advanced training in imagery and relaxation techniques is recommended. Preparation. Provide a soothing and comfortable space. The client should be lying down on the floor using a mat or blankets or sitting up straight in a chair. Prepare the room as in the Music-Assisted Breathing procedure above and inform clients of attire recommendations. Improvised live music or recorded music can be used. Art materials (e.g., crayons, oil pastels, sand, board, pens, markers) may be needed. If the therapist uses improvised live music, the verbal directions can be recorded prior to the session, including breathing procedure and guidance during this experience. See Music-Assisted Breathing for indications regarding music choice. What to observe. Closely observe each client's reactions, including facial expressions, body postures, gestures, and sensations. If they appear to be uncomfortable during the imagery, remind them that they can open their eyes and come out of the imagery whenever they wish. Procedures. Before beginning the imaging experience, the therapist should give instructions and choose the music in collaboration with the clients. Instructions include telling the clients that they are going to enter into a relaxed state, and then they will imagine that they are relaxing in their favorite place

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while listening to music for approximately 15 minutes. Because each client will imagine his unique favorite place, the clients might begin to consider where that will be before the relaxation begins. It is important to encourage clients to use their senses to observe the image they create (Merrit, 1996). They may see shapes, colors, people, and figures in addition to having olfactory and/or tactile sensations (Bonny & Savary, 1990; Bush, 1995). Also, the therapist reminds clients to remain in touch with their senses, sensations, and images. While this experience is most successful when lying down with eyes closed, clients should be instructed that if at any time they become uneasy with the feelings or images evoked, they may open their eyes and feel free to stop imaging. Next, the therapist plays a couple of excerpts from the recorded music and collaborates with the clients in choosing a musical selection that is preferred or acceptable to all in the group. Alternately, if the therapist is comfortable doing so, she may improvise music to accompany the clients’ imagery experience. Appropriate music will enhance the clients’ ability to access imagery related to their favorite places. This activity can be done either sitting down or lying down. The therapist first guides the clients in the procedure described in Music-Assisted Breathing above. Verbal directions should be repeated clearly. To induce a relaxed state, the therapist should use a warm timbre in a medium-range pitch and proceed at a moderate pace to allow the client time to form the image. Note that when working with children in a group, it may be necessary to project the voice with more volume. Immediately following the breathing experience, begin to play the selected music (or improvised music), bringing the clients’ attention to their breath and its natural rhythm, and helping clients relax by suggesting that as each thought appears, they allow it to fall away and bring their attention back to the music. Following the breathing exercise, the therapist states: “Find a relaxing position and let the tension leave your body. Let the music guide you as it takes you to your favorite place. This can be outdoors by a mountain, ocean, or your house, backyard, wherever it would be … [pause] … notice how this place feels. Look around, notice the smells, the temperature. … Do you notice any particular colors or shapes? Do you see anybody, or are there other people around you? If not, are you content to be alone? Take some time to look around and find your favorite place … [pause] … Allow yourself to settle in and feel comfortable in your space. … Notice the relaxing feeling that comes over you here. Notice the sounds, smells, colors. Notice how your body feels. You are content, happy, and relaxed to be here. … If your thoughts wander, gently bring them back to your favorite place ….” Clients should not be left alone to image without verbal guiding for more than 30 seconds at the time. Thus, at various intervals, the therapist might suggest, “Notice what is happening now. Has anything changed? What are you aware of? Notice the relaxed feeling in your body and allow it to deepen.” Allowing intervals of 30 seconds between verbal directions will allow clients to enter more deeply into the music and the sensations it evokes. The therapist should notify the clients one minute before the music ends, saying, “The music will end soon.” When the music ends, direct the clients to a more alert state. Using a normal speaking voice, slowly say, “The music has ended now. Allow the image to fade, while keeping the relaxing, pleasant feelings with you. Know that this is your special private place and that you can return here whenever you need to.” Then instruct the clients to become aware of their breathing and the sounds inside and outside the room. Ask them to wiggle their fingers and toes and gently move their heads around, and then to place their feet flat on the floor and begin to stretch their arms and any other part of the body that needs stretching. Finally, invite them to open their eyes and come to a sitting position when they are ready. Before beginning the verbal processing, be silent for a moment and allow the clients to reflect on what they experienced. If the group is ready, have them share what they experienced, including any visual and sensory experiences, as well as any difficulties or challenges. If clients express that they had a difficult time finding imagery, this should be addressed at this time. Clients should be assured that this is not unusual. Each person has a unique way of experiencing imagery, and for some, the image may be a sensation rather than a picture. It may also take some time to be able to focus on the imagery. Some

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clients might note that their mind wanders or that they are having negative thoughts. If this occurs, they should be told not to avoid these experiences. Instead, the next time they image, they should simply be aware of the thoughts and breathe with them, releasing these thoughts while exhaling. If they are pleasant thoughts, they should be encouraged simply to stay with them and enjoy them. After the imagery experience, other creative arts, e.g., drawing, free writing, or movement, can be incorporated to further process it. The drawing “allows recall, keeps participants entrained in their own process, and may suggest new scenes or avenues of exploration, or expand upon the drawing experience” (Grocke & Wigram, 2007, p. 211). Whatever thoughts, feelings, images, and fantasies come up, clients should feel free to write them down. For young children, provide materials such as crayons or sand. Adaptations. To help the clients’ imagery experiences, props such as pictures and flowers can be used. Music incorporated with natural sounds can be used (e.g., birds, water, wind). The therapist can also play live music. Another method can be to suggest that members create motions along with the music. They can be spontaneous, making motions independently or as a group. When working with children, they might be instructed to play with sand to create a favorite place or write about or draw a favorite place while listening to music.

Entrainment Overview. In this method, the client listens to music improvised by the therapist to reduce physical pain; it is adapted from Dileo and Bradt (1999, 2007). The music improvised by the therapist matches both the client’s perception of pain or discomfort and his perception of healing music that brings relief from pain or discomfort (Dileo & Bradt, 1999). Krout (2007) offers this explanation of the phenomenon, describing entrainment as “the natural predisposition for the human body and its physiologic processes to respond to and synchronize with both its internal and external environments, including sound and rhythm” (p. 137). In the stress relief model, goals of entrainment include reducing stress-related pain, releasing tensions, identifying stressors, increasing self-awareness regarding stress, and achieving relaxation. This method can be used for clients who exhibit any symptoms of stress, but particularly for individuals with chronic stress and their caregivers. Clients with mental illnesses, hearing difficulties, musicogenic epilepsy, or brain dysfunctions are not appropriate. Cathartic reactions may occur as “relaxed states minimize the client’s defenses and allow psychological issues to be more readily evoked by music” (Dileo & Bradt, 2007, p. 527). The success of this experience is dependent on the improvised music’s capacity to accurately represent the client’s experience of pain or discomfort and relief or relaxation in sound. Thus, the entrainment session is done only in individual sessions. The music therapist should receive special training and supervision to utilize this method (Dileo & Bradt, 1999). This method is practiced at the intensive level. Preparation. Provide a soothing and comfortable space. The client should be lying down on the floor using a mat or blankets or reclined in a chair. Prepare the room as in the Music-Assisted Breathing procedure above and inform clients of attire recommendations. A variety of instruments, including instruments from around the world as well as meditative instruments—for example, singing ball, didgeridoo, drums, tone bar, ocean drum, gong, rain stick, shakers, mallets, chime, tone bar, and blowing instruments, such as Indian flutes—should be available to afford the possibility of creating a wide variety of sounds. A synthesizer or an electronic piano, tubular bells, ocean drum, guitar, xylophone, and metallophone are also recommended. What to observe. Closely observe the client’s physical and emotional reactions. In particular, be sensitive about nonverbal expression, e.g., how the client responds to the music. For example, observe the client’s breathing patterns and the level of relaxation or tension in body parts. If the client is relaxed, his

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breathing will also be calm. The client may experience deeper levels of an altered state and thus may require more assistance to return to an alert state at the end of the experience. Procedures. In an initial discussion, the client is asked to use adjectives to describe in detail what the discomfort, stress, or pain feels like in the body. Help the client describe what the stress feels like, what shape or movement it might have, and the sounds, smells, and feelings associated with the stress. Once the therapist has a clear idea of the pain, she and the client collaborate to find a conglomeration and sequence of sounds that aptly depict the sensation of these feelings. Together, they explore the sounds that match the client’s descriptions by using various instruments and adjusting the combinations, intensity, and development of the sounds with the help of the client’s feedback. The same procedure is followed to create the client’s unique relaxing sounds. Once the client is satisfied with the sounds for stress and the sounds for relaxation, the client lies down, the therapist positions all the instruments she will need within easy reach, and the entrainment procedure begins. The client closes his eyes and breathes naturally, then indicates to the therapist when he is ready to have the therapist begin to play the stress sounds. The therapist's playing must resonate with the stress that the client is experiencing. The client uses hand signals to signify changes in the dynamics and intensity of the sound. The client uses a predetermined hand signal to indicate that he is ready to hear the relaxing or healing sounds, and the therapist continues to play these until the client indicates he is feeling relaxed. The therapist allows the client a few moments to return to an alert state, guiding him back to the room and helping him to become aware of his breathing and his body until he is able to open his eyes and sit up. The client and therapist discuss the experience, acknowledging the stressors in the client’s life and their effects, and focus on ways in which music can be helpful in releasing tension and stress. This may help the client to gain further insight into how he can manage stress autonomously. Adaptations. The therapist can record the music that she improvised for the session and allow the client to take it home to use when he feels stress. Another option is to suggest that the client create motions or his own sounds with music the therapist is improvising. The therapist can also join in with her voice to lend support. This might help the client to release anxieties and stress felt in the body. For example, if the client feels tension in one particular area of the body, he can move that area or make a sound that matches it in a way that helps him to release the tension. These motions and sounds can be spontaneous, or the therapist can help the client decide which movements or sounds might help before the music begins.

Musical Analytical Meditation (MAM) Overview. The client listens to music improvised by the therapist while focusing on breathing and imagery. It is preceded and followed by a verbal discussion to provide focus for the client’s goals. This method is adapted from Scheiby’s Analytical Music Therapy Training (AMT) (2005). The goals are to manage symptoms of chronic stress and traumatic stress, to release tension, and to identify unconscious material relating to stress. This method can be effective when clients display somatic symptoms, are very anxious, or have a hectic daily schedule. Caregivers or individuals who are open to utilizing their imaginations may benefit from it. This method may not be appropriate for any clients who have poor reality testing. In addition, this method may induce anxiety for persons who are uncomfortable in a meditative state or who experience unpleasant associations to past experiences evoked by the particular music used. Thus, prior to the experience, the therapist should verify that the music choice is acceptable to the clients by playing an excerpt from it. This method is used in both individual and group therapy settings at the intensive and primary levels and is beneficial for all ages. It requires specialized AMT training and supervision.

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Preparation. Provide a soothing and comfortable space. The client should be lying down on the floor using a mat or blankets or sitting up straight in a chair. Prepare the room as in the Music-Assisted Breathing procedure above and inform clients of attire recommendations. A variety of instruments, including instruments from around the world as well as meditative instruments (singing ball, didgeridoo, North American Indian drums, tone bar, ocean drum, gong, rain stick, shakers, mallets, chime, tone bar, bass resonator bar, and wind instruments such as Indian flute) should be prepared (Scheiby, 2005). A keyboard, marimba, Indian flute, cello, shruti box, tubular bell, ocean drum, guitar, xylimba, and metallophone are also useful. What to observe. Closely observe the clients’ words, breathing, vocal sounds, and bodily responses. Observe what type of music and musical instruments are effective for each individual client. Their physical, verbal, and emotional reactions will demonstrate whether they benefit from this activity. Procedures. There are five steps during the session. They are: 1) Assessment: The therapist gathers significant information on the clients’ physical, cognitive, and spiritual domains. In particular, she listens for themes related to stressors and helps clients to identify the sources of the stress and its effects. Next, the therapist gathers information on the clients’ preferred music styles and preferred sounds of various instruments in order to choose instruments for meditation. She then provides instructions about the meditation procedure, making certain to tell clients that they can open their eyes if they wish to end the experience at any time. To begin the meditation, she asks the clients to set aside their thoughts related to stressors, find a comfortable seated position, and focus on breathing and listening. 2) Facilitation of Deepening the Breath: The therapist accompanies the clients’ breathing with an improvisation using instruments such as the rain stick, ocean drum, gongs, mouth harmonica, or bass wind instruments. 3) Musically Accompanied Travel: While the client is in a relaxed position, the therapist will improvise to create meditative sounds. This is best achieved by providing musical structure, repetitiveness, and holding: “[T]he therapist can musically reflect, support, and reinforce the imagery” (Scheiby, 2005, p. 181). 4) Verbal Processing: Feelings, images, sensations, and thoughts that the clients experienced during the musical meditation are shared in the group or individual session. To increase the clients’ insight, the therapist helps each client to identify stress-causing “blind spots” of which he was previously unaware. For example, the therapist might share her observation regarding a client’s posture while he was listening to the music in a meditative state. Clients might also process their experiences with other modalities such as writing in a journal. 5) Musical Closure Ritual: A very clear, short, musical phrase is played to close the session, such as playing one time on the drum or playing a chord on the keyboard. Some may experience deeper levels of an altered state. The therapist then facilitates the clients’ return to the present place and time, while reminding them that they can re-create the pleasant meditative state at any time.

Adaptations. The therapist can play improvised meditative music led by either her consciousness or by countertransferential reactions (Priestley, 1975). The therapist begins to play a steady holding rhythm or ostinato on a harmonic instrument and invites the client to “let go.” The therapist instructs the client to embrace all of the noise around him and to surrender to the silence. Advise the client that if he has a thought, he should try to let it go repeatedly. If the clients need more structure, the

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therapist may offer more verbal directions. Also, they may discuss their preferences of musical instruments (live music). After the activity, the group may share their experiences or write in a journal.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Vocal Toning—Celebrating Your Authentic Voice Overview. In this method, clients engage in vocal toning and improvisation to express their feelings. The goals are to discover the client’s own voice, to release tension, and to prevent stress. This method can be effective for clients who experience disconnection or imbalance between body and mind or need to release tension, connect with others, or maintain wellness: “Singing and resonating with another, being empathically connected—these are the moments where we can share the different levels of experience with each other” (Uhlig, 2006, p. 83). Although structured vocal improvisation can help relieve stress and tension, it is important for clients to feel in control during improvisation, as they often feel helpless due to the inability to control their stressful situations. Clients with respiratory problems or those who are short of breath may simplify the activity. Clients who have high blood pressure or respiratory problems should also closely observe their physical reactions. This method is practiced in both individual and group therapy settings at the intensive level. This method can be used with both children and adults. No specific training to practice this method is required. Preparation. A quiet and pleasant environment should be provided with chairs in a semicircle. Some melodic instruments (e.g., Tibetan gong, singing balls, tone bar, xylophone, marimba, piano, and guitar) and drums are prepared. What to observe. The therapist observes whether the clients are breathing well to support their voice. Notice if the clients vocalize easily and whether their vocalizations are connected with their emotions. Some clients may need more time than others to fully engage in this activity because they may be uncomfortable or unfamiliar with using their voices. In this case, they may observe what others do and join in when they are ready. Procedures. The clients find a comfortable spot in the room and either sit on a chair or stand in place. The therapist begins with the Music-Assisted Breathing experience. If they are sitting and feel comfortable doing so, clients may close their eyes. When they have completed the warm-up MusicAssisted Breathing exercise, the therapist describes the vocal improvisation to the clients, telling them that they can make any sound that resonates in a place in their body that is comfortable and natural for them. When they have finished, they take another deep breath and sound the same or another tone. The therapist asks them to focus on their internal experience while doing the vocalization. For example, to notice the following: “Is the sound coming out of your abdomen, chest, or throat? Does this sound connect to you physically? How is this making you feel? Are you feeling authentic? Are you feeling tired? Unmotivated? Pleasant? Comfortable or uncomfortable?” Clients are then invited to join in the therapist’s vocalization by imitating what the therapist does or finding a different tone that is comfortable for them. The therapist plays a long note a few times with a steady beat on the Tibetan gong or any tone bar and then vocalizes a low tone of long duration. After breathing, the therapist continues to tone the same tone to support the clients. This continues for approximately 5 to 10 minutes, depending on the energy and participation of the clients. The therapist should ask clients how different tones elicit different physiological responses, if any. The therapist may guide the inquiry by asking clients how their head, neck, chest, stomach, legs, or feet feel after each tone. Each body part should be addressed individually and within reasonable intervals so that the client may have time to evaluate and respond.

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In the next phase of the improvisation, the therapist demonstrates a musical phrase and asks the clients to explore creating one as well. Variations with different rhythms—combinations of short and long tones and ascending and descending melodies—can be explored in the group. Then, the therapist accompanies their vocalization on the piano or guitar. Clients can often express their type of stress through improvisation. As the therapist provides a safe and empathetic environment, they feel that they have control over their own vocalization and that they can express any negative emotions that they may have into their improvisation. When this happens, grounding, holding and containing (Bruscia, 1987; Priestley, 1994; Wigram, 2004) are effective techniques that can be utilized. Some examples of grounding are the use of strong octaves or fifths in the bass of the piano, steady pulsed beats on a bass drum, strong chords of a stable tonal nature using typically dominant and tonic chords, and a simple ostinato. To close the improvisation, the therapist plays the gong a few times, letting the sound resonate and die out each time it is struck. During this time, clients are asked again to focus on their internal experiences before slowly opening their eyes. Afterward, clients may either write down or draw what they experienced. The therapist leads a discussion in which the clients share their thoughts and feelings, with a focus on how this method might be used to release stress in their lives. Adaptations. This activity may be done in dyads while clients harmonize with each other. Clients may sit back-to-back to feel the vocal vibrations and support each other. The therapist can encourage clients to be playful—for example, making babbling sounds that represent the relationship between mother and infant. When working with children, it is necessary for the therapist to give more direction (e.g., soft, loud, an animal sound) to help children be expressive.

Role-Playing to Enhance Assertiveness Overview. Clients improvise lyrics with or without a melody or improvise instrumentally over a structured harmonic accompaniment to affirm one’s needs. This method was adapted from Gregorek and Gregorek (2009) and Priestley (1994). The goals are to increase self-awareness and self-esteem, to be more assertive, and to relieve physical symptoms related to stress. Clients who exhibit somatic symptoms or who experience chronic stress would benefit from this method since the inability to voice their needs may affect their level of stress. Clients lacking in self-esteem would also benefit greatly from engaging in this activity. There are no contraindications. This method is suitable for both individual and group therapy for adults at the intensive and primary level. No specific training is required to implement it. Preparation. Place chairs in a semicircle and include hand drums and mallets, gongs, and cymbals within easy reach. The room should be comfortable and similar to a home environment. Paper and pencils, music sheets, and an accompanying instrument, e.g., piano, guitar, drum, and cymbal, for the therapist are needed. What to observe. Clients will demonstrate how comfortable they are in asserting themselves through their physical and emotional reactions. Some clients will need more encouragement than others. Clients who feel uneasy singing their responses may speak them over the accompaniment. Others may prefer to begin by expressing themselves through playing an instrument. The therapist should note the choice of instrument and the volume with which it is played or the content and expression of the lyrics. Procedures. A greeting song is chosen by the group and sung together to open the session. Following this, group members verbally share situations in which they experienced difficulties in their daily interactions with others, and they discuss their interpersonal goals. The therapist invites each client to write down an example of a difficult social situation, and then asks each one to consider something that is essential about that situation and frame this in a thought, feeling, desire, or need. Based on these examples, the clients create a song improvisation while completing the lyrics: “I think … I feel … I want ….” The therapist provides a simple chord progression, e.g., I-IV-V-I or a blues progression, and

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accompanies their singing or recitation on an instrument. Clients who are not comfortable using words to express their needs can opt to choose instruments instead. The therapist may also use a call-and-response format to structure the improvisation. Afterward, clients may journal or draw to reflect on this experience, and then verbally share what it was like for them to express their needs. They may also share strategies for dealing with difficult interpersonal situations. Adaptations. Drum and cymbal can be incorporated. Clients may support and emphasize the feeling behind their words by playing the rhythm of their speech or a basic beat on the drum. For example, if a client has difficulty saying “No” to others, he may play this very strongly on the drum while repeating “No.” Clients should be encouraged to play in the tempo, rhythm, and volume that match their feelings. Another option is to incorporate role-play based on the issues and needs they wrote about. Other group members may provide instrumental accompaniment to match the words and feelings of the clients acting out the parts. The therapist may work on body language, eye contact, body posture, and tone of voice after the role-play and ask the clients to share their observations.

Rhythmic Drumming—Connecting to Others Overview. Clients play drums in a structured rhythm using imitative, call-and-response, solo and accompaniment, and free improvisation structures. The goals are to relieve stress, to develop coping skills, and to feel a sense of belonging. Clients with stress symptoms that need to be released physically or individuals who feel isolated and are trying to maintain wellness through social contact would benefit from this method. This activity may cause pain for the client with upper-body physical problems. Some elderly clients may also react to loud sounds. Some children may become overstimulated as a result of this method. This method can be practiced in both individual and group therapy settings at the auxiliary level. There are various trainings to facilitate effective drum circles, but no specific training is necessary. It is for all ages. Preparation. Arrange chairs in a semicircle with ample room between them. Provide easy access to a variety of drums and percussion instruments such as hand drums, congas, bongos, djembes, doumbeks, paddle drums, tubanos, shakers, doumbek, tambourines, guiro, cowbells, and gongs along with mallets. Earplugs can be made available for those who are sensitive to loud sounds. What to observe. The therapist carefully observes the clients’ physical and emotional reactions. Some may have unpleasant facial expressions due to the volume of the drum playing. If this happens, offer the client earplugs. Procedures. The therapist leads the Music-Assisted Breathing experience and then invites the clients to choose a drum and introduce themselves by name rhythms on their drums. The therapist demonstrates how to play different drum tones such as the bass tone and high-pitched sounds and introduces techniques such as open, closed, slap, and palm strikes on various drums, asking the clients to experiment with these sounds on their drums. The therapist should begin to play a basic beat in the middle of the drum and then ask the client to imitate the beat on their drums. This leads into a continuous call-and-response where the therapist plays a rhythm that the group imitates and then all return to the basic beat. The alternation from basic beat to call-and-response rhythm continues with different rhythms. Next, while some clients continue to play, the rest will pause their playing and then join in again followed by the therapist’s directions. Alternatively, the therapist can divide the group into two groups and teach each group different rhythmic patterns. While the therapist plays a third rhythmic pattern, she can direct the group to experiment with different dynamics and tempi (e.g., soft, loud, fast, slow), leading with her instrument or predetermined hand signals. Clients can also take turns in being the leader in the call-andresponse activity and in leading the musical elements of tempo and volume. After the drumming, the

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therapist can lead the group in Music-Assisted Breathing, again followed by a short verbal discussion regarding how it felt to focus on the rhythm and drumming, and the effect this had on stress. Adaptations. Chanting a song such as “Fanga Alafia” or any other vocalizations may be incorporated with the drumming (Reuner, 2008). The therapist may vocalize a melody and do a call-andresponse activity with the clients. For visual stimulation, some clients may dance with colored scarves along with the drumming.

Music Therapy Improvisation and Desensitization (MTID) Overview. Clients access images, feelings, and sensations related to stress and to relaxation and then improvise relaxing music to replace the stressful experience with a calm and relaxing one. Y. Kim (2005) developed this method as part of her doctoral study. A short version of her methods is presented here; detailed information can be found in her article. The goals are to identify stressors, to release tension, and to develop coping skills. Musician clients who experience chronic stress may benefit from this method. Also, clients who are not musicians but interested in improving their performance ability may also benefit from this activity. Clients who are unmotivated or resistant to creating improvisations may need assistance or may be contraindicated. This method is designed for adults and practiced in individual music therapy at the intensive level. Preparation. A variety of tuned and nontuned musical instruments, including pianos or keyboards, guitars, xylophones, drums, shakers, wind chimes, cymbals, rain stick, and ocean drum should be provided for clients. If the improvisation will be recorded, then recording and playback equipment is necessary as well. What to observe. The therapist observes how the client describes his stressors and the characteristics of his relaxing music. The therapist carefully observes the client’s physical and emotional reactions and offers any suggestions for selecting music or instruments. Procedures. The therapist should assist the client in identifying stressors and choosing a relaxing sound. First, the therapist will discuss the major stressors in the client’s life and then discuss how the client would ideally like to feel. The therapist and client then choose instruments that produce sounds that help the client get in touch with his images, feelings, and sensations of calm. Together, therapist and client create two or three improvised pieces of music together to evoke the relaxing, calm feelings. This may be recorded and played back afterward. The therapist and client analyze the elements of the music and the feelings, images, and sensations that were experienced while playing. In the discussion, the therapist can invite the client to share memories and associations to the music, including early memories and family experiences. In discussing the feelings of relaxation that issue from the improvisation, the therapist can also guide the client in identifying underlying causes of stress and ways of relieving that stress. The therapist might also suggest that clients create relaxing music at home using one’s own voice or easily available sounds such as wind chimes. The next session should focus on desensitization training. The client is directed to first think about an image related to the stress in his life and note the feelings and sensations he experiences. Following this, the client creates a relaxing image or scene and focuses on the relaxing scene for about 10 to 15 seconds, noting the changes in mind and body. Together, the client and therapist create an improvised musical piece that reflects the relaxing imagery (Y. Kim, 2005, pp. 20–21). Adaptations. The improvisation may be recorded and discussed during the session. It is most effective if the client chooses an instrument that accurately represents his stress. Meditation may also be incorporated with this experience. In meditation, the clients are encouraged to listen to their own rhythms while embracing all of the sounds around them. Those who live with a hectic daily schedule may feel

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uneasy being in silence. As clients practice being in silence, they become more aware of their body and mind, and learn to connect to them with greater ease. As an alternative method, Joanna Booth developed the music, drawing, and narrative (MDN) method adapted from BMGIM (Grocke & Wigram, 2007). In her method, music is used to evoke calm and peaceful imagery, and then it is expressed in both drawing and narrative form. The therapist helps teach the client that he is in control regarding what to draw and write. While listening to this relatable music, the client should express his or her feelings by drawing. When the song is played again for the second time, the client should be encouraged to write a narrative to help “recall” and integrate the relaxing experience.

Psychodynamic Movement Overview. Clients improvise movements based on their experiences of stress while the therapist provides a grounding accompaniment and interprets the movements musically. Clients may also vocalize while moving. This method (improvised movement to improvised music) is adapted from Priestley (1975). Priestley claims that communicating with one’s own body is “the most primitive and natural form: expressive movement” (Priestley, p. 78). It is important that the therapist addresses the client’s selfawareness as a whole when targeting stress reduction. This includes the client’s body, mind, and spirit. Being aware of the client, as a whole, will help make the music more effective when combined with other modalities. Through moving and speaking and relaxing to music, one learns to relax different kinds of tension. One also learns to be aware of tense shoulders and thighs, and of feelings of anger and jealousy, and to investigate their causes and try to do something about them (Priestley, p. 84). The goals are to release tension, to develop coping skills, and to improve connections with one’s mind and body. Clients with somatic symptoms, chronic pain, tensed muscles, fatigue, or depressive symptoms may benefit from this method. Although it is encouraged that all clients participate in the movement at some point, some may prefer to observe others in the first sessions and then gradually participate in making motions. Clients who have heart conditions or who are pregnant should be advised to not engage in this activity. Also, clients with physical problems may need assistance and should be advised to move only within their physical capacities. This method can be practiced in both individual and group music therapy settings at the augmentative level. It is used for all ages. It requires specialized AMT training and supervision (Pedersen, 2002). Preparation. A safe environment and ample space between individuals are necessary. Clients should wear comfortable clothing. Live music requires the availability of a variety of melodic and percussive instruments. In some situations, recorded music may be used, and in this case, CDs and a good-quality sound system are required. What to observe. The therapist should assess the client’s physical functioning prior to implementing this method. Prompts may need to be given to encourage clients who are less active or who are reticent to move. Allow clients to observe before moving if they wish. Others may need a demonstration in terms of making a motion along with music. Sensitively observe what type of music is suitable for each individual client. Procedures. Depending on the client’s needs, this method may work better if the therapist starts with a more a structured activity and then moves to free movement. The therapist begins with the MusicAssisted Breathing procedure as a warm-up. The therapist then asks the clients to find a comfortable spot in the room and to focus on one’s inner self, imagining how stress feels in one’s body. They might be asked to visualize the shape and sounds of stress. The therapist explains that they will express the feelings of stress in movements and that they are also encouraged to express any sounds they feel while moving. First, it is suggested to utilize lively rhythmic recorded music, e.g., Latin music, to help clients get in touch

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with their bodies. While listening to this music, the therapist should encourage clients to make motions in relation to the beats and melodies of the recording (Priestley, 1975). The therapist should then provide an improvisation originating from “a deep and instinctual level,” while the clients are engaged in movements that express what the body feels like under stress (p. 81). “Most important is for the therapist to put his mind and feelings into a condition of limpid contentment and play from there” (p. 82). In order to limit any association to music, atonal improvised music is recommended to match the patient's expression to a given stimulus. To help a client who is reluctant or new to the therapeutic process, the therapist may demonstrate how to make simple motions such as waving their hands or holding their bodies, thereby providing the client with a vocabulary of movements. After the movement comes to an end, the clients participate in Music-Assisted Breathing to center themselves. Following this, they share their experiences verbally. The therapist leads a group discussion, asking questions such as “What did your body feel like during the movement? What sorts of thoughts or ideas did you have that you want to share? What sort of mood were you in?” (Priestley, p. 79). Adaptations. Two music therapists can colead the session, where one leads the activity and the other provides the improvisation for the client. One client may take a leadership role and move to the music, while others imitate the leader in a call-and-response structure. Clients may also practice this method in dyads. While one client creates a movement, the other takes the role of his or her stressor, thus creating a conversation in movement with each other. Another option is to stretch to the music. In order to assist the clients’ movement and stretch as best as they can, use maracas or egg shakers in both hands in either a standing or lying down position. Clients can be instructed to raise their arms high above their shoulders and then high above their heads, as if trying to reach toward the ceiling, and then over and behind their heads. Clients should be instructed to keep breathing deeply, tightening their abdominals, and holding their breath. Next, clients bend toward their feet and touch the ground. They should be instructed to slowly lift their shoulders to their ears, release tension, and return to the normal position while exhaling. Recorded music may be used, and if so, it should have a steady beat and be rhythmically strong. Recorded music or songs may also be chosen based on a theme or according to a client’s preferences. Moving to one’s favorite music can increase enjoyment and pleasure, which may consequently lead to a decrease in anxiety and stress. When clients can share their favorite music with others, they feel accepted and acknowledged, which promotes a positive spirit.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Chanting to Liberate Stress Overview. Clients create a sound or chants based on a personal affirmation, a prayer, or a line of a song and sing it repeatedly to release stress. The goals are to release tension, to build a stronger identity, and to create harmony between mind, body, and spirit. Repetitious chanting may deepen brain wave activity, increase warmth in the hands, and create a feeling of being centered (Campbell, 1992). Clients with tensed muscles or who are fatigued or depressed may benefit from this method. Some clients may be reluctant to try chanting due to unfamiliarity with this method or due to religious beliefs. There are no contraindications. This method is for all ages and is practiced in both individual and group therapy at the intensive level. No specific training is required. Preparation. A quiet, comfortable room with chairs arranged in a circle is required. Instruments such as a drum, Tibetan gong, or singing bowls may also be used as musical support. If the therapist uses a precomposed chant, she should select one that is relatively slow and free-flowing without being sentimental or sad or heavy in mood.

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What to observe. The therapist observes how the clients engage in chanting. If they are engaged, they should be in a comfortable posture and have calm facial expressions. On the other hand, if they are not engaged, they may chant in a soft volume or not join in chanting at all. Some clients may also react to the chanting emotionally. Procedures. The therapist begins with Music-Assisted Breathing to center the clients. She asks the clients to choose an affirmation or word based on personal need, e.g., “I can do it,” “I love myself,” or to use a phrase from a prayer or a meaningful song. Clients then close their eyes, find a tone, and sing the word or phrase, using a simple melody and repeating it. The therapist can add gentle and nonintrusive instrumental accompaniment or provide a soft, steady beat on a drum. Self-produced, repeated sounds are most effective for relaxation. If a client cannot think of a word or phrase, the therapist may demonstrate a sound and ask the client to repeat it. For example, the “m” sound is a connector, “om” can move one from the objective world, and “aum” can be sung for a closure. Humming a melody is soothing and can help the members relax. Chants and words can be sung in call-and-response, with the therapist and group repeating the chant after the client sings. Adaptations. Singing a lullaby or precomposed chants can be useful, particularly in the first sessions when clients are being introduced to this experience. There are also many beautiful chants across cultures, such as American Indian chants, Indian chants, and Tibetan chants. Helpful resources are Circle of Song by Kate Marks and Sacred Circles/Affirhythms by Terry Garthwaite. Both are available from www.ladyslipper.org. Singing or playing spiritual songs (e.g., “Down the Riverside,” “Nobody Knows the Trouble I’ve Seen”) or the client’s favorite songs can also be used for liberating stress.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting is the main approach used in compositional music therapy for stress relief and well-being. Songwriting provides an outlet for a better awareness of stressors as well as self-expression. This is a collaborative activity in which the therapist is equipped with musical knowledge and the clients have their own enriching life experiences as a resource when creating the song. The “product” or song is not the focus, but rather, the focus is on the “creative process.” However, for some members, this creative process may induce stress. The therapist can reduce the stress experienced by some persons in this activity by presenting it in a step-by-step fashion and by adjusting the demands of the task to the comfort level of the participants. Today, music writing computer software programs are also helpful in making this activity more pleasurable.

Song Composition—A Song for Myself and for My Community Overview. Clients partially or completely create new lyrics to an existing song or compose a new song. The goals with songwriting are to identify one’s needs, to increase self-expression through music, to discuss coping skills, and to gain a sense of accomplishment. Clients who have difficulty identifying their stressors, want to increase self-awareness about their life patterns, or want to have an opportunity to selfexpress may benefit from this method. Some clients may feel uncomfortable with the idea of songwriting due to the unfamiliarity of this activity. Thus, the therapist should be sure to demonstrate this method with sensitivity and flexibility; otherwise, it may become another source of stress. This is for adults and is practiced in both individual and group therapy settings at the intensive level. No specific training is required. Preparation. The therapist should prepare a semicircle of comfortable chairs, a board, and markers. A variety of styles of music CDs should be provided, or assistive technology for music composition. This might include an iPod or iPad with speakers, a recording system, Midi keyboard,

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and/or any music-writing software such as GarageBand, Cakewalk, Home Studio (Windows), Protastudio (guitar player), and/or Band-in-a-Box IV (Hanser & Mandel, 2010). Harmonic and accompanying instruments such as piano, guitar, and percussion should also be available to play the new song. What to observe. Be sensitive toward members who seem reluctant to contribute an idea. A client with chronic stress may not be motivated to contribute ideas or may not want to engage in the cognitive process. However, these clients may feel more at ease in the musical process. Also, observe members’ nonverbal expressions, particularly if a client becomes emotional or shows any physical reactions, positive or negative. Appropriate support and attention should be given to those members. Procedures. The group begins by taking a few minutes for each client to center himself through breathing exercises as described in Music-Assisted Breathing. Next, the songwriting experience begins by choosing a topic. For example, the group may discuss precomposed songs that reflect on the chosen theme. If the theme is friendship as a support system, “A Little Help from My Friends” by The Beatles may be selected as inspiration. The therapist might also introduce a song (either recorded or live) that is suitable for the theme. While listening to the song, the clients should be instructed to apply the song to their personal situations and write down any thoughts, feelings, and images that occur as they are listening. The songwriting procedure has many options. The following are presented in order of most accessible to most demanding. Option 1: Filling In Selected Lyrics. This is also called the cloze method. In this method, the clients fill in a few words or create new verses to a chosen song, keeping some of the original song lyrics and melody. Clients who are new to song composition may find this difficult, and the therapist can offer ideas that may make it more accessible. For example, rhyme is not always necessary. If a client cannot think of a word, another member or the therapist can offer a suggestion. Also clients should be encouraged to “pass” when they cannot come up with ideas. It is important to be flexible, so that clients do not feel an increased level of stress while participating in the stress reduction session. To facilitate this procedure, the therapist can write words or phrases that come up for clients while listening to the original song on the left side of the board. On the right side of the board, the therapist writes the original lyrics of the song, while leaving a couple of verses blank or bracketed and color-coded. For example, the therapist may write the line “What would you do if I sang out of tune” and leave a blank for the next line. Once the song has been completed and all the ideas the group wants to express are presented, the therapist accompanies the members in singing the song with the new lyrics. This may be followed by a discussion related to internal experiences of stress and contentment while being involved in the process. Option 2: Creating New Lyrics. Depending on the group stage and readiness of the members, the group may create a song with entirely new lyrics. The same procedure as above is used to select a topic. Once the topic is chosen, the group is broken into two smaller groups to discuss images, feelings, thoughts, or memories related to the topic. Based on the discussions, they will create lyrics to the song. One member in each group takes notes on the members’ contributions. During the discussion, the therapist should spend some time with each group and provide assistance if necessary. When each group has completed their verse, both verses are written on the board. If necessary, the therapist and group may make changes such as rearranging the lyrics to suit the musical structure or lyrical coherence. This is followed by a performance and verbal discussion as above. Option 3: Creating New Lyrics and New Music. Alternatively, the group may follow the procedure for new lyric creation above, and add to this the creation of a new melody. After creating the lyrics, the therapist plays simple chords that are suitable for the theme and the lyrics. She may begin with two simple chords, for example, play I and IV chords alternating in a steady rhythm, which is a structure that often appears in gospel songs. Other chord choices can be offered to the clients, and once two or three chords have been selected, a client can be asked to read the first line and then hum a melody for the line.

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When a client hums the melody, others repeat the same melody. At this point, the therapist and group members may decide to change a few notes in the melody or to continue with the second line in the same manner. This continues until the entire melody is complete. The group may add variations. The clients can discuss a title for the song. When the songwriting is complete, the group sings the song or a volunteer may sing a solo to the group. This is followed by a verbal discussion as above. Adaptations. The themes may include any stressful or unpleasant event or memory, or anything that contributes to stress. For example, clients can be asked to write a letter to their own stress while expressing their feelings, “I feel …,” “I hope….” Any negative thoughts, pressures, and concerns may be expressed. Also, clients may write about something positive. If a client seems to have a hard time finding words or musical ideas, the therapist may suggest that he listen to their spoken words and, based on these words, they may create a rap song instead. To simplify, the group may use the chord progressions of a precomposed song. As the group becomes familiar with the procedure that is described above, the therapist can add more choices of musical styles. It is important to provide balance between structure and allowing members to make choices. The clients can also create a song for their significant others, following the guidelines above. Example: 12-bar blues, a steady rhythm; the 12–bar blues is predictable and the melody repeats, so members are familiar with the three-part structure.

GUIDELINES FOR MULTIPLE METHODS OF MUSIC THERAPY Singing and Accompanying Songs Across Cultures Overview. Clients sing songs from different cultures and accompany them on instruments. The instrumental accompaniment may develop into an improvisation. Thus, this is both a re-creative and improvisational method. This method can be used to help manage acculturative stress (S. Kim, 2011). Acculturative stress occurs when an individual feels caught between two drastically different cultures: the culture of one’s origin and the new culture. Music can be used to increase one’s cultural awareness, enhance cognitive-emotional flexibility, and apprehend other cultures more deeply. The goals are to promote one’s cultural well-being, to resolve internal cultural conflict, and to encourage taking risks and trying new things. Clients who exhibit any symptoms of acculturative stress, such as fatigue or feelings of helplessness, or clients who want to prevent acculturative stress may benefit from this method. Some clients may be reluctant to share their problems because sharing personal problems may not be a part of their cultural norm, or they may be concerned about sharing their issues because of their legal status. The therapist should explain to all clients that they should share only what they wish to share and that all of the information is completely confidential. Also, music may bring out strong emotional reactions when, for example, singing about a missing family member. Check in with clients throughout the session and after the activity with regard to their emotional state. Individual or group therapy is appropriate at the intensive level, and this method is appropriate for all ages. No specific training is required. Preparation. Create a comforting and welcoming environment. A variety of world music CDs and music books, as well as instruments from around the world such as singing bowls, tubular bells, didgeridoo, drums, tone bar, ocean drum, gongs, rain sticks, shakers, mallets, chime, tone bar, xylophones, metallophones, and blowing instruments such as Indian flutes are required. In addition, a guitar, synthesizer, and piano or electronic piano is helpful for the therapist to provide musical accompaniment. The therapist should have a good understanding of multicultural issues and should be knowledgeable about a variety of world music styles. What to observe. The therapist should be knowledgeable regarding the culture of the clients to help anticipate which client may need more prompts or structure to increase participation. Cultural issues

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may come up, and appropriate emotional support should be provided. The therapist should closely observe group dynamics and each client’s interactions with other members. Clients’ experiences with discrimination may emerge in the session. Procedures. For a warm-up, the therapist may sing a familiar American folk song with the group. The song should contain a chorus line with simple words. Following this, each member of the group shares his own folk music or music that is meaningful to him. The therapist and other group members will accompany his singing on their instruments. This may become a group improvisation utilizing the chord structure of the song played by the therapist. The therapist encourages the clients to try new things, such as a song that is outside of their own culture, and a different way of playing during the improvisation. Also, clients may teach the group a song from their culture, and then everyone sings and plays it together. After the musical experience, clients may either take turns expressing their experiences in one word or engage in a group discussion. Adaptations. Some clients may require more structure, e.g., providing detailed musical and verbal directions. This activity can also be combined with receptive or composition methods: “Familiar songs can be rewritten to become personalized reflections of the patients and/or their families. This technique is cross-cultural and can be used with all ages of [clients]” (Dileo & Magill, 2005, p. 232). Culture-related issues can be expressed through music-making. An example of a referential or song composition theme may be: “I miss you.” Clients can also rehearse their songs and present them to family members and friends in a subsequent session.

Community Jam—Musicking Together Overview. Clients rehearse, perform, improvise, listen, play, and/or sing with others with the intention of enjoying music together. The goals are to release tension, to develop coping skills, and to increase a sense of belonging: Musicking is considered to be a “self-healing practice” (Batt-Rawden, DeNora, & Ruud, 2005, p. 131). In the context of a therapeutic process, clients need different levels of assistance based on their previous experience in instrumental play and their musical skills. In addition, since this is a group setting, the music being played may not be everyone’s preferred choice. However, this can become an opportunity to learn to tolerate differences among each other. It is important to encourage the group to be respectful of others’ choices while at the same time expressing one’s needs. This experience is for all ages and is practiced in group therapy at the augmentative level. Preparation. A semicircle of chairs should be provided, with ample room between chairs. A variety of instruments (piano, guitar, drums, xylophones, ocean drum, rain sticks, shakers, mallets and mats), microphone and recording system, music books, and stand should be set up. What to observe. Prompts and encouragements should be given to clients who are inactive, but it may be that some clients will benefit from listening to others and serving in the role of audience. It is important to create a safe and accepting environment, ensuring that the session will not become another source of stress. Procedures. The group greets each other, and members share how they have been doing since the last session. They then discuss which music method they would like to engage in. This might take the form of an improvisation, singing songs with a specific theme and playing with instruments to accompany the song, or rehearsing precomposed music. If they decide to do an improvisation, they can discuss the theme of the improvisation, e.g., title, and choose an instrument that they want to play to express the theme; alternately, they may do a nonreferential improvisation or a drum circle. If, prior to the session, clients give their consent, the therapist may record the clients singing and playing so that they can listen back to their music. The session ends with a closing song chosen by the group. If the group is cohesive and

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develops a strong rapport over time, they might consider inviting friends and family to listen to them perform.

CLOSING REMARKS ON METHODOLOGY The methods described above are in the order of most commonly used in the literature. If it is not specified, the methods are used in either individual or group settings with some modifications. There are benefits to each session format: In individual sessions, the therapist can focus on the client’s individual needs and follow his wellness plan. Thus, the client may be more able to open up and progress at a faster pace. In group sessions, clients may experience a feeling of support and a sense of community, which can also be a therapeutic agent to alleviate stress. In any case, the client’s preference in the session format is also important to consider. The length and frequency of these sessions depends on the client’s individual needs. A small group size, from four to six members, would be preferable. While many of these methods could be used as a complete session, various methods can also be combined in one session. In addition, the particular method used should specifically address the client or clients’ goals. It is therapeutically important for the client to feel in control; therefore, the more choices the client can make during the sessions, the more effective the session will be. However, the music therapist should also assess the client in the beginning of every session. Since stressors are closely related to environmental factors, it is possible that the needs of the client may be different from session to session. The therapist should also be aware whether the client accepts responsibility for his health and whether the client is willing to maintain a certain level of wellness. Thus, choosing a specific method can be done mutually. Also, note that one method is not appropriate for everyone. The therapist should be open to a variety of methods and incorporate them into the sessions to meet the client’s interest. For opening and closing experiences, breathing or toning exercises are particularly beneficial. In most cases, greeting and/or closing songs are also suggested in every session to provide a sense of continuity and stability. For example, sessions might begin with a greeting song followed by musicassisted breathing exercises and the tension and release body relaxation experience. Vocal toning can help clients feel more grounded and might also be indicated at the beginning of a session. These introductory exercises should lead to a more active music experience such as rhythmic drumming, psychodynamic movement, song singing, or song composition. Imagery and other receptive experiences that are less physically active can be coupled with improvisation or singing experiences. Chanting or singing a closing song or doing a group or even doing some breathing with a short imagery exercise can close the session, along with a closing song. In all sessions, the client’s preference for the method of stress reduction must be considered. It may be necessary to modify the procedure, given a client’s needs and energy level. The therapist should regularly discuss these methods with the client in order to assess what the client prefers from a choice of possible methods that the therapist feels best meets the client’s needs.

CARING FOR THE CAREGIVER The concept of allostasis describes how prolonged stress can lead to physiopathology. When an individual is unable to maintain homeostasis due to the intensity of ongoing stressors and has exhausted all the resources that he has, the person experiences an “allostatic overload,” which is the cumulative cost to the person’s well-being. The stress may “not [be] life-threatening stress; however, if they do not manage their stress levels, the ongoing demand of work competes for coping resources, while reducing the ability to cope psychologically or physiologically with new demands that may be imposed by other stressors encountered in daily life” (Lovallo, 2005, p. 37). Caregivers provide care for their loved ones without being paid and often have an outside job as well. They are not necessarily equipped with medical knowledge or

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skills for care. According to the American Psychological Association (APA) Annual Report (2012), caregivers, especially older adults, have been identified as a high-risk group (APA, 2012). Many caregivers reported that they are prone to unhealthy behaviors and less likely to change their lifestyles due to their set life circumstances. It is noteworthy that they are susceptible to chronic illnesses such as depression and obesity. With the increase of this population, health professionals must pay more attention to these individuals and continue to study effective stress management and prevention (Myers, 2010). We as therapists are helping professionals. Taking care of ourselves is an integral part of our job, as the nature of this profession consumes a great deal of our energy and sensitivity (S. Kim, 2011; Scheiby, 2005; Priestley, 1994). ”Psycho-hygiening” (Jahn-Langenberg, 2001) is the process in which we care for our psychological and emotional well-being to ensure that we provide optimal care when serving our clients. Our ability to do this depends on how well we cope with our own existing stress. To reduce and prevent stress, it is recommended that therapists utilize the activities described in this chapter.

RESEARCH EVIDENCE Music and music therapy methods that reduce stress have been found to be effective in promoting wellbeing and bringing out positive physiological (Knight & Rickard, 2001; Krout, 2007; Edwards & Burard, 2003) and psychological (Clair, 1996; Hanser & Mandel, 2010) effects. The gate control theory of pain (Melzack & Wall, 1965) illustrates how music can diminish or prevent negative stimuli, such as stress (Schwoebel, Coslett, Bradt, Friedman, & Dileo, 2002). When stimuli travel from the brain to the spinal cord, they cause neural gates in the spinal cord to open. The amount of stress that one experiences correlates to the number of neural gates that are open. Interestingly, when music passes through the neural gates, the amount of stress that is experienced can diminish. Since music also affects the limbic system, which controls emotional behavior, it is possible to delay or alter negative emotional experiences by utilizing music. A variety of methods of assessing stress have been used (physiological, e.g., levels of muscle activities, skin temperature, and heart rate, and psychological measures, e.g., State-Trait Anxiety Inventory) to demonstrate the impact of music on stress. Stress-inducing tasks have also been used to examine the effects of music listening (Hirokawa & Ohira, 2003). In addition, a variety of music interventions, including receptive, re-creative, improvisational, and compositional music therapy methods have been examined in different settings, e.g., educational (Fernandez, 2004), workplace (Bittman, Bruhn, Stevens, Westengard, & Umbach, 2003), and wellness centers (Bittman, Berk, & Felten, 2001; Bittman et al., 2005). Music, often combined with other methods, e.g., progressive muscle relaxation (Hernandez-Ruiz, 2005; Jacobson, 1938), meditation (Rosenzweig, Reibel, Greenson, Brainard, & Hojat, 2003), yoga (West, Otte, Geher, Johnson, & Mohr, 2004) and creative arts media (Grocke & Wigram, 2007), has been explored.

Receptive Music Therapy Two meta-analyses (Dileo & Bradt, 2005; Pelletier, 2004) present an overview of the effect of music on reducing stress and offer some recommendations for future study. Pelletier (2004) analyzed 22 studies examining the use of music to decrease arousal due to stress. Results suggested that music alone and music-assisted relaxation techniques are effective in enhancing relaxation when subjects are in an aroused condition due to stress. However, due to many variables in stress and the complexity of our mind and body, we do not know the precise nature of the effects of music on relaxation: The effects of music on relaxation are still difficult to identify based on the large number of relaxation techniques combined with differing musical selections,

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the application of music therapy within various populations, different forms and levels of stress, and variations in measurement procedures. It seems a quantitative review of the research is greatly needed and past due (p. 193). Through an examination of 41 studies with nonmedical populations, Dileo and Bradt (2005, 2007) found that self-report measures brought out higher effect sizes than the studies that employed physiological measures. While there have been inconsistent findings regarding whether relaxing music is more effective when chosen by a researcher vs. the client (Labbé, et al., 2007), due to the Iso principle, it seems that whether a specific piece of music creates a sense of calmness and relaxation depends on the client’s preference of (Walworth, 2003) and familiarity with music (Tan, Yowler, Super, & Fratianne, 2012) and personal experience (Hoeft & Kern, 2007). However, familiarity with specific music can also adversely affect relaxation, so it is important to ask clients whether the chosen music has any negative associations. Thus, the therapist uses her training with input from the client to help guide the client in the selection of relaxing music (Dileo & Bradt, 2005). Regardless of the familiarity with the music, predictability of the music and a feeling of security are considered to be significant factors when choosing relaxing music (Grocke & Wigram, 2007). A variety of types of music, such as classical, New Age, jazz, popular, spiritual, and world, have been examined empirically (Pinkerton, 1996; Smith & Joyce, 2004). While some researchers reported that classical music seems to have a greater effect on relaxation than hard rock (Burns et al., 2002) or heavy metal music (Labbé et al., 2007), according to Dileo and Bradt (2007), nonclassical music is more effective in stress reduction. The authors, however, cautioned that these results might be influenced by the fact that many studies did not consider personal preference and music selection. Interestingly, Hoeft and Kern (2007) studied recorded percussion music that had specifically been composed for wellness music to observe the mood, level of relaxation, energy level, and focus of the listener. Their results suggested that recorded percussion music enhances positive moods. They concluded that less referential music seemed to be more effective in relaxation, as the percussion music can “limit cultural or musical preference bias to modes, musical genre, or lyrics” (p. 142). Some researchers also compared relaxation techniques that used music and no music (sitting in silence). While Burns et al. (2002) explained that sitting quietly may be a better way to engage in relaxation compared to listening to Mozart or hard rock, Labbé et al. (2007) found that listening to classical music after a challenging mental task can better relax individuals. Additionally, listening to classical music or self-selected music significantly reduced arousal and lowered stress as compared to sitting in silence or listening to heavy metal music. According to Burns et al. (2002), the type of music does not affect one’s physiological experience of stress because the feeling of “relaxed” is cognitive, not physiological, in nature. Thus, self-selected music can significantly reduce arousal and lower stress. Similarly, listening to relaxing music may bring out more of a psychological or emotional response than a physiological response. Labbé et al. (2007) examined both physiological and psychological measures of stress. Heart rate and respiration decreased in all conditions, and heart rate had a greater reduction when classical music and self-selected music were played. Respiration rate demonstrated a greater decrease when classical music and heavy metal music were played. Classical music appears to lower systolic blood pressure (Chafin, Roy, Gerin, & Christenfeld, 2004). Knight and Rickard (2001) played participants Pachelbel’s “Canon in D” and found that it prevented an increase in anxiety, blood pressure, and heart rate by a cognitive stressor. It did not affect levels of cortisol and ACTH, but increased salivary IgA. The researchers noted that when the same piece is played repeatedly, it creates feeling of stability and familiarity. The researchers concluded that level of stress is related to the individual’s feeling of control over a situation. Elliot, Polman, and McGregor (2011) attempted to define characteristics of relaxing music for anxiety control. In his study, 84 college students were asked to imagine an anxiety-provoking situation

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and then listened to a selection of 30 compositions. They were then asked to identify levels of relaxation in each selection and the musical elements that were helpful in relaxation. Their findings suggest that relaxing music is a personal choice. Tempo is considered to be important, but music that is too slow may be perceived as boring. Similarly, Tan et al. (2012) examined the psychophysical properties of relaxation music and how it relates to music familiarity, preference, and degree of perceived relaxation. The authors concluded: “An individual’s conscious experience of music listening must be considered globally by taking into account the intrinsic musical properties, personal preference, and familiarity with the music” (p. 170). The manner in which an individual perceives relaxing music is related to music preference for both music therapists’ and healthy individuals’ familiarity with and degree of relaxation. Music listening as a relaxation method is often combined with other creative methods, such as breathing, meditation, cognitive restructuring, and movement (Pelletier, 2004). McKinney, Antoni, Kumar, Tims, and McCabe (1997) found music combined with imagery to be effective in reducing stress. Similarly, music-assisted progressive muscle relaxation with abused women has been found to result in improved sleep quality and reduced anxiety (Hernandez-Ruiz, 2005). The impact of music on stress has been examined in several specific groups. When pregnant women (Chang, Chen, & Huang, 2008; Hanser, Larson, & O’Connell, 1983) and pregnant teenagers (Liebman & MacLaren, 1991) participated in music listening, they were able to decrease perceived anxiety and stress (Liebman & MacLaren, 1991). A study by Jespersen and Vuust (2012) in which 15 refugees residing in Denmark, many from Middle Eastern countries, listened to classical sedative music found a significant improvement of sleep quality and well-being.

Improvisational Music Therapy Active music-making involving improvisation with instruments (Kim, 2005) and with voice (Valentine & Evans, 2001) has also been examined empirically. Singing and chanting, for example, can lower heart rates (Rider, Mickey, Weldin, & Hawkinson, 1991). Grape, Sandgren, Hansson, Ericson, and Theorell (2003) examined eight amateur singers with little to no experience and eight professional singers (6 males and 10 females) who had taken at least six months of singing lessons prior to the study, and gave each a 45-minute singing lesson. The authors found that the sympathetic nervous system of the subjects from the professional group was more activated than those of the subjects from the amateur group. Professionals showed more arousal than amateurs because amateurs considered the singing lessons as a means of self-expression. Singing, therefore, enhanced the well-being of the amateurs more than that of the professionals. Females in both groups showed less endocrinological arousal than males. Cortisol and prolactin levels decreased in women and increased in men; thus, the effects of singing were more stressreducing for women than for men in both groups (professional and amateur). There have been studies conducted on the effects of drumming on the immune system of healthy adults (Bittman et al., 2001). Drumming may reduce burnout among health care workers and nursing students (Bittman et al., 2003). For example, Bittman et al. (2001) conducted a study at a mind–body wellness center. Sixty-one subjects were randomly assigned into a total of six groups. There were two control groups (resting while reading and listening to drum music) and four group-drumming experimental models using a variety of drumming music. Drumming experiences in group music therapy showed enhanced specific immunologic measures associated with natural killer cell activity and cellmediated immunity, compared to those of the control groups.

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Re-creative Music Therapy Tims (Wellness, n.d.) reported in AMC Music News that regular group keyboard lessons for elderly people brought a significant increase in immune hormones, increased feelings of control, and increased socialization, while the levels of anxiety, depression, and loneliness were significantly decreased. Tims strongly believed that “abundant health benefits can be achieved by older people learning to play music in a supportive, socially enjoyable setting” (para. 8). Tims’s study is also confirmed by Hanser and Mandel (2010) and Clair (1996). It is evident that participating in a community choir (Kreutz, Bongard, Rohrmann, Hodapp, & Grebe, 2004) or any musical ensemble significantly lowered anxiety, stress, and depressive symptoms in the elderly. Few studies are found on stress in children (Fernandez, 2004; Ierardi & O’Brien, 2007; Pavlicevic, 2001). Mackenzie and Hamlett (2005) created a community music program called “The Music Together Program” and offered it to families with typical children up to age four. The goals for this program were “to strengthen early attachment, to build social supports and increase the resilience of the family unit, and to reduce the potential impact of stress and adversity” (p. 43). They received weekly onehour music group sessions attended by 140 parents and caregivers, who were surveyed and provided positive feedback on the effects of the program. They concluded that this program was beneficial for building social support and managing stressful situations. Similarly, a music intervention group for middle school–age children was formed in Sweden (Lindblad, Hogmark, & Theorell, 2007). One hour of music education was provided each week throughout the school year. The results showed that the subjects in the music intervention group had lower cortisol levels, although not significantly so.

Compositional Music Therapy Studies on treating stress employing compositional music therapy in a nonclinical setting are scarce. However, there are studies that focus on patients and caregivers in hospital settings using song composition methods (O’Callaghan, 2001; O’Callaghan & Grocke, 2009) suggesting that these methods result in lower stress and provided an opportunity for self-expression through songwriting. The findings can be applied to clinical goals related to stress reductions.

Multiple Music Therapy Methods Hernandez-Ruiz (2005) examined music listening combined with progressive muscle relaxation to reduce anxiety and improve sleep patterns among 28 abused women residing in shelters. Thirty-minute music therapy sessions for five consecutive days were offered. During the sessions, 20 minutes of relaxing music chosen by the subjects was found to be effective in reducing anxiety and improving sleep quality. Cevasco, Kennedy, and Generally (2005) conducted a study to compare movement to music, rhythm activities, and competitive games on stress and anger of females with substance abuse. Each intervention was implemented for a total of four sessions, one hour twice a week. Movement intervention addressed locomotor and nonlocomotor hand-eye coordination, body percussion, and stretching. Rhythm activity included African hand drumming, call-and-response, Kodaly experiences, playing resonator bells, participating in Orff rondos, and improvisations. Competitive games included Name That Tune, the aural discrimination of rhythms, playing notated rhythms, and doing lyric analysis. No significant differences among these interventions were found; however, individuals reported decreased levels of depression, stress, anxiety, and anger after the sessions. As reviewed above, future research on this topic is imperative. Suggestions for further research include the following: an examination of each of the three levels of the stress process—stressors,

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moderators, and stress outcomes—and music therapy as an independent treatment so that the effects of music therapy can be clearly understood; recruitment of a variety of ethnic, age, and gender groups; an investigation of a greater variety of music to compare the resulting relaxation effects to better understand the characteristics of stress-relieving music; and an examination of individual differences and sociocultural factors.

SUMMARY AND CONCLUSIONS More and more, we live in a society that induces daily stress due to all the challenges and difficulties in our personal lives. Priestley (1994) suggests a positive way of looking at these aspects of life, pointing out that “times of stress [can be] viewed as opportunities for maturation” (p. 198). Stress can be manageable and can even produce positive outcomes. However, the intensity and duration of a stressful event can adversely affect a person’s well-being when one’s resources have been exhausted. Therefore, stress must be examined within a holistic context—physical, psychological, emotional, cognitive, and spiritual (Lehrer, Woolfolk, & Sime, 2007). The symptoms of stress vary in each individual due to different ages and/or experiences. Accordingly, treatment for stress is a specific and individual matter. One size does not fit all. Thus, an individualized wellness program, even in a group setting, is effective in addressing the needs of the individual. A variety of music interventions has been used in wellness programs to increase awareness of stress, to identify stressors, to reduce stress and tension, and to develop successful coping skills. Without sensitivity and proper training of the therapist, the use of music can also bring adverse results. Music therapists should continue to study effective methods. As Bruscia (1998) noted, “health encompasses and depends upon the entire ecological system, from body, mind, and spirit and their interactions within the individual to the broader contexts of the individual’s relationships with society, culture, and environment” (p. 78). The willingness of the individual to engage in experiences to reduce stress plays an important part in the wellness model. In addition, collaborative work with the individual, music therapist, family members, and community will help the members maintain an optimal state of well-being.

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Chapter 24

Musicians Gro Trondalen _____________________________________________ Musicians have the most wonderful profession: they have the opportunity to create music as an art form for a vibrant audience. However, being trained and working as a musician also means confronting one’s health, i.e., physical, mental, and existential well-being. This chapter addresses music therapy treatment offered to musicians. The rationale and understanding of why and how the different music therapy approaches function is not the main thrust of this text. On the contrary, its focus is closer to procedures and teaching manuals, which in turn may inspire a variety of music therapy approaches within a diversity of contexts. Regardless of the approach or theoretical orientation, be it the client’s or the music therapist’s, ethical issues should be conducted with the utmost respect for the client (Dileo, 2000). The author’s basic assumption is that both the client and the music therapist are semper major: As human beings, we are more than —semper major—personal narratives and observation, as performance in life does not disclose the depths in our existence (Trondalen, 2012).

DIAGNOSTIC INFORMATION Musicians make a variety of contributions to society today, and music institutions demand a great deal from their students by way of preparing them for these responsibilities. Stiff requirements challenge professional performers (who are often teachers at an institution in conjunction with their employment in an orchestra and freelance activities) and push students both mentally and physically (see, e.g., Trondalen, 2011b). Such challenges seem to be similar for all professional musicians independent of musical genre and place of employment. Little attention was given to the scope and nature of the medical problems (performing arts medicine) confronting musicians until late in the 1960s, though this has now changed (James, 2000, in Wynn Parry, 2004, p. 41). An increasing amount of literature has been devoted to performance anxiety and the often-accompanying belief that one is not good enough (polarized perfectionists) (Esplen & Hodnett, 1999; Kenny, 2006; Montello, 2000; Taborsky, 2007; Youngshin, 2005). Other authors address physical injuries such as noise-induced hearing loss (Ostri, Eller, Dahlin, & Skylv, 1989; Sataloff, 1991; Teie, 1998), dystonia and nerve entrapment (Altenmüller & Jabusch, 2010), overuse (Dawson, 2001), depression (Robson & Gillies, 1987), sleep disturbances (Fishbein & Middelstadt, 1988), drug addiction and simple stress (Sternbach, 1993; Sternbach & Woody, 2008), and challenges that may lead to chemical dependency (Tolson & Cuyjet, 2007), among other things (see, e.g., Buller, 2002; Olseng, 2009; Palac, 2005; Williamon, 2004; Zuskin et al., 2005). Given the array of problems experienced, musicians seeking treatment in music therapy most often do not have one diagnosis per se. They often present with a host of problems, including physical, mental and existential challenges (Wynn Parry, 2004). Sometimes injuries may threaten the musician’s career and jeopardize his economic stability (Quentzel & Loewy, 2012a).

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Some studies engage with music therapy in the context of musicians, performance, and selfactualization (Gregg & Clark, 2007; Maranto, 1989, 1994; Montello, 1995; Montello, Coons, & Kantor, 1990; Rider, 1987; Trondalen, 2010); others link Guided Imager and Music (GIM), musicians, and performance anxiety (Grocke, 2005a; Martin, 2007).

NEEDS AND RESOURCES The pleasure and satisfaction to be derived from playing one’s chosen primary instrument are indisputable (Ostwald, 1992). Yet these come with a price: “No pain, no gain” is a mantra that accompanies musicians as well as athletes (Wynn Parry, 2004, p. 41). In a study titled Stress and Professional Popular Musicians in the UK (random sampled, N=246), musicians were found to suffer from above-average levels of psychological anxiety (Willis & Cooper, 2006). Middlestadt and Fishbein (1988) found that stress is not related to the gender of players, but strongly related to age and to the musician’s function within the orchestra, with soloists experiencing the highest levels. Factors affecting prevalence and severity of music performance are also related to experience, performance-setting, and musical instrument. For example, a singer cannot hide his instrument, as it offers a very personal performance. Soloists and members of small orchestras report more anxiety than members of large orchestras, as do brass and wind players (1988), who are more exposed. The authors also report that 27% of the 2,212 respondents had used beta-blockers to control performance anxiety before solo recitals, auditions, concerto performances, and challenging orchestral performances (1988). A comprehensive 1997 survey performed by scholars at the Fédération Internationale de Musiciens (FIM) studied the physical, psychological, and pedagogical factors that might affect the performer. The study included 57 orchestras worldwide, and the results were consistent: 56% of the musicians reported they had suffered physical pain within the last year, and 34% experienced pain more than once a week; 19% had even suffered from pain that was severe enough to halt a performance (James, 2000, in Wynn Parry, 2004, p. 42). Furthermore, 83% responded negatively to this question: “Do you think your training college or academy gave you sufficient help in preparation for the stresses and strains of being an orchestral musician?” On the other hand, of course, most musicians do report overall satisfaction with their jobs and, assuming a minimal level of personal mental and physical fitness, respond as most other people do to standard medical intervention (Willis & Cooper, 2006; Wynn Parry, 2004). Those health challenges that are particular to musicians are usually met with physiotherapy 0r psychomotor therapy and/or medical treatment, which often require drug intervention (Maranto, 1989, 1994). However, there is growing interest in a departure from the “krankheitsorientiert” (focus on illness) (Spahn, 2009, p. 27) approach focusing on diagnosis, in favour of a more resource-oriented approach that emphasizes health promotion and preventive interventions for the general population, including musicians (see, e.g., Cockey, 2000; Martin, 2007; Rolvsjord, 2010; Ruud & Stige, 1994; Trondalen, 2011b; Valla, 2010). Attention is also drawn to the fact that due to their training, musicians have differential responses to music both physically and psychologically. The musician’s brain is different from that of nonmusicians’ functionally and anatomically as a result of their years of musical training (Satoh, Takeda, & Kuzuhara, 2007). Maranto advocates that musicians’ long-term relationship to music allows them to relate and commit themselves to a therapeutic environment supplemented with music. In addition, musicians may be more sensitive to music and respond more intensely to it than nonmusicians. This might indicate that musicians’ “response to music may heighten the effectiveness of music as a therapeutic modality” (Maranto, 1989, p. 278), e.g., to treat performance anxiety in musicians. Similar indications are presented in a study showing that music therapists decoded the emotional content of improvisations more accurately than nontherapists (Gilboa, Bodner, & Amir, 2006). Many music training programs also

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address ancillary subjects like performance physiology and preparation. The most important aspect is the activation of musicians’ personal resources through strategies and techniques for preventing illness and supporting musical development (see, e.g., Fadnes & Leira, 2006; Joukano-Ampuja, 2009; Jørgensen & Lehmann, 1997; Roland, 1998; Sparre, 2009; Williamon, 2004). In spite of documented health challenges at a physical and mental level, musicians go on playing. This may be because the problem is also the solution. Though music performance makes many demands and takes its toll, as the title “Mich macht krank, was ich liebe” (“What I love makes me ill”) (DeckerVoigt, 2012) indicates, musicians benefit from music as a means of self-care at the same time, using music to regulate and improve health and develop personal strength, professional identity, and creativity (Trondalen, 2011b). It may be that music therapists are especially suited to understand challenges that musicians face, as the music therapist can recall her own musical training and the pressure to excel at performances. These experiences are of vital importance to empathically understand and offer a unique form of treatment for performance-related problems (Chungwon, 2008; Rider, 1987).

REFERRAL AND ASSESSMENT Some musicians look up treatment modalities themselves. Others bring referrals from their General Practitioners. Music therapy does not always seem to be easily accessed as a treatment option, and it is often expensive, due to lack of reimbursement. The reason for this is a variety of referral systems and often a lack of recognition of music therapy as a reimbursable treatment method. There are different intake systems, be it a private or officially approved treatment setting. Intake assessments are also related to whether it is an individual clinical practice or an out- or inpatient setting. One assessment form that is inclusive of music medicine and music psychotherapy practices a Bio-Psycho-Musical assessment model of care (Quentzel & Loewy, 2012a, 2012b). The interviewers ask for clear confirmation of data presented, rather than relying on innuendo, while using their sensitive awareness. The intake assessment procedure consists of two parts: both medical (by the medical doctor) and musical interviews (by the music psychotherapist) are performed. The first part of the model is related to etiology, and among the topics are family/social history, medical problems (including where the presenting problem first occurred), the amount of time spent on practicing the instrument, the time of the day when most of the music-making occurs, and the musician’s or performing art patient’s expectations for the intake and ongoing care. The second part, the music psychotherapy evaluation, includes a narrative of the client’s performance history inclusive of frustrations and most critical performances, in addition to an actual playing of a musical piece, chosen by the patient. Inclusive is also playing together with the therapist, where the therapist in such a duet may offer the client extensive psychological selfreflection. These duets may be performed independently of main instruments for both participants (2012a, 2012b). Before a treatment plan is suggested, evaluation of pain and trauma is critical, as the Bio-PsychoMusical assessment integrates mind and emotion, body and spirit, and informs and reveals how music can be implemented as part of the treatment strategy in the mental health care plan. For an extensive review of the assessment procedure, see the Appendix to the article An Integrative Bio-Psycho-musical Assessment Model for the Treatment of Musicians: Part II—Intake and Assessment (Quentzel & Loewy, 2012b, pp. 124–125).

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OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy •

Bonny Method of Guided Imager and Music (GIM): is a music-centered, receptive method using specifically sequenced classical music programs (30 to 45 minutes’ duration) and a set of protocols for conducting a listening session. There are many adaptations to this method included in this chapter.

Improvisational Music Therapy •

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Creative Music Therapy (CMT): Clients use instruments, singing, or both in dyad or group format using a variety of instruments to create music extemporaneously with a focus on the music itself as a means for aesthetic exploration. Analytical Music Therapy (AMT): Clients create music extemporaneously with a focus on the use of symbolic music improvisation and verbal processing to create and interpret the music.

Re-creative Music Therapy •

Singing and Playing Music: The therapist engages the client in reproducing music in different ways, which can involve vocal and/or instrumental performances.

Compositional Music Therapy •

Song Composition: Clients change the lyrics to an existing song to render them more personal or compose an entirely new song. Adaptations include instrumental pieces or the creation of a musical or artistic product.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Most people casually listen to music, but some take it a step further, applying music more actively or purposefully to their moods or energy levels (see, e.g., Bonde, 2009; North, Hargreaves, & Hargreaves, 2004; Sloboda, 2005). This investment in musical self-care impacts one’s musical identity and may even be seen as a way of expressing oneself (Ruud, 1997; Skånland, 2012). The most important procedure offered to a musician in the receptive music therapy method is active music listening. There are different models and procedures within receptive music therapy, such as “Regulative Musiktherapie” (“Music therapy for regulation and coping”) (Schwabe, 1987) and other variations, be it in individual or group settings (Bruscia & Grocke, 2002; Grocke & Wigram, 2007).

Bonny Method of Guided Imagery and Music (GIM) Overview. In its classic, individual format, the Bonny Method of Guided Imagery and Music (hereafter GIM) is a music-centered, receptive method using specifically sequenced classical music programs (30 to 45 minutes’ duration) and a set of protocols for conducting a listening session. This is the most internationally renowned receptive music therapy model to which many musicians have been

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exposed (Bonny, 2002; Bonny & Savary, 1973; Bruscia & Grocke, 2002; Parker, 2010; Summer, 1988). GIM is a music-assisted transformational therapy that offers persons the opportunity to integrate mental, emotional, physical, and spiritual (existential) aspects of themselves. The founder, Helen Lindquist Bonny, states that GIM is a process where imagery is evoked during music listening (Bonny, 1990). In her Ph.D. on Pivotal Moments in GIM, Grocke also favors the alignment with principles of psychotherapy: Guided Imagery and Music [is] a specialized area of music therapy in which clients listens to classical music in a deeply relaxed state and in which visual imagery, changes in mood, and psychological effect in the body are experienced (Grocke, 1999, p. 1). The music is drawn from the Western classical genre and ranges from the baroque period to the 20th century (Bonny, 1976). Twelve of the programs are created by Bonny and are often referred to as “core programs.” In 1995–96, Kenneth Bruscia developed a set of 10 CDs, Music for the Imagination, and he published a manual describing the history of the programs, their revisions, and this new collection based on Naxos recordings. In 2002, there were 66 programs available (Bruscia & Grocke, 2002), and in 2010, over 100 (Bonde, 2009; Meadows, 2010), and new programs are continually being produced. GIM combines listening to music with relaxation, visualization, drawing, and verbal conversation procedures and allows for experiences at different levels of consciousness. In its classical form, a GIM session lasts from 90 minutes to two hours in a one-to-one modality. However, experienced GIM facilitators also make adaptations for group work. There are many reasons to offer receptive music therapy (GIM) as an approach for musicians who are struggling with physical and/or psychological issues. Musicians most often have the ability to concentrate for a long period, which is important because music listening procedures often require the ability to listen to music over a long period. Musicians also seem to be more sensitive to music, which indicates an increased potential for music as a treatment modality (Maranto, 1989). In addition, musicians are creative persons, which is often illustrated through the variety of images they can create (Trondalen, 2010). This variety of images evokes the client’s relationship to both areas of vulnerability and resources in his life. If a musician is physically hurt (e.g., muscle fatigue), music listening can offer a way to work on the injury while the body itself is at rest (Rider, 1987). This means that relating experiences through music may support the client’s resources and strength, which are emerging from the music listening. This author often experiences that musicians can use the music as a way of nurturing themselves in a stressful everyday life (Trondalen, 2011b). Music listening might also be indicated with tinnitus (noise-induced hearing loss or sound), as concentrated listening allows for less volume as in expressive music therapy. There are also some challenges in music listening (GIM) with musicians, as many musicians do not want to verbalize about the music or the music experience. They want the music itself to stand for itself, as an autonomous work of art, with its own aesthetic. Others are mostly occupied with listening to the performing musician, the sound of the instrument, or the performance per se. What the musician identifies as a “bad recording” may destroy the listening experience. In addition, musicians, because of their heightened music discrimination abilities, tend to listen to music with a more analytical process than do nonmusicians (Miller, 1999). From practice, this author recognizes that many musicians have strong preferences for music selections, which means they express liking or disliking the music programs or the composers of the music programs more often than the general population. Many musicians are also very private in nature and find it difficult to express themselves in the presence of a music therapist. Others seem to be afraid to get in touch with—and/or be overwhelmed by—psychological issues, e.g., their performance anxiety. These challenges may be related to shame (Skårderud, 2001), which many

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musicians face in various ways. Some musicians also relate that they are afraid of losing control, which the therapist may observe as an anxiety to surrender to or dwell in the music listening experience. There are also contraindications for offering music listening to musicians. However, these contraindications are, from this author’s experience, not connected to musicians per se, but to aspects related to contraindications of music listening (GIM) at a more general level. Contraindications for this method occur when the client: (1) is not capable of symbolic thinking, (2) cannot differentiate between symbolic thinking and reality (e.g., persons with poor ego boundaries occurring in psychotic conditions, schizophrenia, or schizoid conditions), (3) cannot relate his experience to the therapist (including people being unable to verbalize the experience, including, e.g., those with aphasia), (4) cannot achieve growth through GIM (e.g., cannot understand symbolic or metaphorical images), (5) is in extremely poor physical health with low psychical energy, and (6) is in a terminal stage of illness, unable to address unresolved issues, and is preparing to die (Grocke, 1999; Summer, 1988). There are, however exceptions where GIM is used in a modified form, even in some of the contraindicated situations mentioned above (see, e.g., Bruscia, 1991; Moe, 2000). The aim of GIM is to promote and “sustain a dynamic unfolding of inner experiences” (Association of Music & Imagery, 2012, para. 2) and allow for listening experiences at different levels of consciousness (Bonny, 2002). Listening to music in a relaxed state may help the musician to process difficult life issues and support psychological empowerment at an individual level (Zimmermann, 2000), including changes in behaviour, cognition, and emotions. Examples from transcripts strengthening personal empowerment include statements like “I am playing in the orchestra ... I am performing very well” and “I think everything is inside of me” (Trondalen, 2011b). The goals of music listening may range from self-actualization as a professional musician to reworking a memory lapse at a performance. Nurturing the musician’s strength and resources through music imagery may support musical flow and self-efficacy (Bandura, 1986). For example, a musician may visualize himself on stage through an image that evokes the experience of performance anxiety in the music listening here-and-now. At the same time, he recognizes the image is not reality per se. This experience offers him the possibility to explore a variety of actions and perceptions to address his stage fright and search for new ways of relating to it through the music imagery journey. GIM is a music-centered therapy, hence, music as therapy. In Bruscia’s systematic account of music therapy models, GIM is placed at the intensive level (or primary therapy) because “the music experience is therapeutically transformative and complete in, of, and by itself, independent of any insights gained through verbal exchange” (Bruscia, 1998a, p. 219). To work as a GIM therapist requires specialized GIM training, i.e., additional training. Such training usually includes academic training in music as well as training in therapeutic skills, as both are essential to the professional practice of GIM. Performance experiences with music further enhance the therapist’s sensitivity to and understanding of music in much the same way as clinical experience enhances the understanding of therapeutic theory. These qualifications are of vital importance when working with musicians. Preparation. Preparation is important before the listening session to help the client attain a relaxed state of mind necessary for the music listening. The recording and playing system must be of a high quality, as musicians are extremely sensitive to sound quality. Phones should be set to silent so that there is no interference with the listening experience. A stop sign, or a note on the door saying “music listening is in progress, please do not disturb,” is useful to prevent others from disturbing the music listening. Chairs are needed for the opening conversation (prelude) while a recliner or mat is needed for the traveling segment. For group listening, mats should be placed so that everybody feels they have enough space for themselves, while being in a comfortable distance to the loudspeakers, their fellow

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travelers, and the therapist. The listeners are offered a pillow and blanket, or they may use their own overcoats, as some prefer to do. Crayons, watercolors, and instruments should be ready for use after the listening procedure. Individual sheets of paper with a circle (a “mandala”) drawn in the middle of the paper should be prepared beforehand for mandala work. Do not fold the sheet beforehand, as this might interfere with the visual experience of the drawing. Verify that the stereo system is in good working order prior to the session and make sure there is an ample supply of paper to record the client’s remarks during the journey. These sheets should preferably include a carbon paper, as the client gets the original transcript of his travel when he leaves and the therapist keeps a copy. A variety of music programs or single music pieces should also be available if there is a need to switch music or offer a musical extension to the journey. What to observe. There are many aspects to observe in the initial meeting with the client and in potential changes from session to session regarding the general context and the client’s mental state of mind. During the listening experience itself, it is valuable to be aware of bodily changes, such as alterations in breathing, crying, shivering, sweating, or feelings of numbed limbs (e.g., the fingers of a viola player or the throat/vocal cords of a singer). It is also important to observe psychological changes such as a variety of emotions as the music challenges, supports, contains, further elaborates, and transforms the images (Abbott, 2005). Constructs from psychotherapeutic theory such as transference, countertransference, and projective identification are as present in active music listening as in expressive music therapy, be it connected to the music (“The music understands me and take care of me”), the music instruments (“I am the flute”), or the music therapist (“You are identical to my mother”). Sometimes clients talk as if the music is incongruent with them, or that they are having an undesirable or uncomfortable experience of listening to a “bad” performance. Clients often tend to cast the music and other musicians into a “negative” role. When this happens, the therapist sometimes supports the client’s reaction. Regardless of what kind of feelings emerge, it is important to help the client to engage with them or find enough meaning in the experience to stay and work through it (e.g., “this violin player is an old shivering man, he should be fired from the orchestra, I hate the sound and don’t want to listen to him anymore”). At other times, it might be useful to change to a more complex music program to support the client in his images, which might move him into deeper levels of his experience (e.g., when images moves from “sunny fields” to traumatic experiences). Another aspect to observe is whether the client needs to terminate before the program ends or needs a piece of music as an extension to the actual program. The role of the music therapist is to be aware and attentive as she affectively attunes (Trondalen & Skårderud, 2007) herself to the client, the music, and the images. This is also the case during the closure or postlude phase, when clients may be asked to draw; many clients who are used to high performance standards may say, “I haven’t drawn since primary school. I am not good at drawing.” The therapist’s response should be a supportive one, focusing on the fact that this is not a performance but a personal representation of some selected experiences. Procedures. In GIM, there is a set of protocols—procedures and techniques—for conducting a listening session: (1) prelude; (2) induction, relaxation, and focusing”; (3) music travel; (4) return and drawing; and (5) verbal conversation (Bonny, 2002; Bonde, Pedersen, Wigram, 2001). In the prelude, or preliminary discussion, the music therapist and the client together discuss the focus of the session. Sometimes the client wants to play music himself or together with the therapist, to evoke imagery that may provide a useful point of departure for his musical journey. An example is the male musician who wanted to improvise music to search for an opening image/focus for the music listening. The outcome was an improvised tune focusing on challenges that were occurring in his life: “This is a little song—No one can take it away—No one can ever take it away—From me” (Trondalen,

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2010). Examples of difficulties that clients commonly present are: stage fright, physical constraints (e.g., a throat operation affects a singer), a divorce that influences his musical capacity, and the feeling of being stuck—or not good enough (perfectionism)—as a musician. And for some clients, not least among music students, “ambivalence” related to their choice of profession can be added. With the actual theme (mood/issue) in mind, the therapist draws on knowledge from her training and clinical experience when choosing the music program, taking into consideration the length, moods, and form of the program. For example, the “feeling of being stuck and negative self-talk” was explored with a client through the program Mythic Journey One: The Hero’s Journey (Clark, 1995). This program was used because it includes a diversity of solo instruments, vocals, and orchestral music, in addition to a broad variety of emotional expression in the music itself (Trondalen, 2010). However, it is seldom that only one music program chosen by the therapist is the one and only correct choice. Fortunately, it seems that the musician is able to make use of a variety of music programs. Nevertheless, it is the author’s experience that some choices are indeed better than others in the actual session. The purpose of the induction phase (relaxation-based or autogenic) is to facilitate a transition from ego-dominated consciousness to deeper levels of consciousness and to surrender to a more flexible experience of time and space. The client reclines in a comfortable chair or lies down on a mat and closes his eyes. The therapist improvises an induction, based on the preliminary discussion. For example, if the client is struggling in sessions to connect—and surrender—to the music (which is often the case), a tension-release induction may be useful: “Allow yourself to experience everything that’s inside your abdomen—hold on to what’s inside—and release as much as you would like to let go.” This allows the client to control his state, as the therapist focuses on the release of tension throughout the different muscle groups of the body. From this relaxation phase, the client most often moves into the imagery that had emerged during the prelude as a useful point of departure for his musical journey. The music program lasts from 30 to 45 minutes and ushers in the travel or journey segment. As the induction transitions into the starting image and the music, the therapist turns up the sound slowly from silence to the preferred volume during the first five seconds, so that the client has the opportunity to take in the music at his own pace. The music therapist sits beside the client during the listening procedure while he verbally describes his experience while listening to the music. The therapist listens intently, recording everything the client says during each composition, periodically guiding the client with nondirective verbal interventions to “help the client to describe the experience, to stay close to it, and to feel the full impact of it” (Grocke, 2005b, p. 46). Based on the client’s response to the program and the flow of images emerging in the here-and-now, the therapist may change the music program as the journey proceeds to offer the client appropriate support in his imagery experience. It is not recommended to touch the client, e.g., for the therapist to hold his hand, during the music listening even though he may ask. Because he is in a relaxed state of mind, any touch may be experienced differently than when alert. One way to meet such a request may be to ask whether the client can visualize the therapist together with him within the journey. Such an image may offer him the support he may be seeking. When the music is over, there is a return phase where the therapist guides the client back to an alert state of consciousness. Most often it is useful to help the client by concentrating on sensations in his body saying, e.g., “Be aware of your feet,” followed by a focus on the different parts of the body. The postlude is the last part of the session. Often, the therapist may begin this part of the session by encouraging the client to make a mandala drawing (Kellogg, 1984), model a clay sculpture, write a poem, or create an expressive work of art to capture what stands out as important experiences and images during the music travel. Some clients may wish to play an instrument to process images that may have been important in the musical journey. Afterward, the therapist and client have a verbal conversation using the expressive work as a focal point beginning with what emerges as important for the client in the here-and-now. Finally, the therapist helps the client to connect this experience to his inner life and his

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daily life. An example of a closing question might be: “What do you take with you from this session into your daily life?” The client’s own interpretation of the experience is acknowledged as authoritative. The written transcript is given to the client after each session and the therapist keeps a copy. Adaptations. There are a number of adaptations to classic GIM. The first that will be presented here is Focused, Time-limited GIM. In a focused and time-limited approach, a specific issue is chosen to be the focus of the therapy from the beginning, and the number of sessions and date of the final session is predetermined (inspired by Mann, 1973; Proskauer, 1971). The approach could typically be five sessions distributed over a period of three to four months and divided into four phases. The first phase focuses on forming a relationship and defining the focus (sessions 1–2). A specific issue to be chosen can be “Exploration of my performance anxiety.” This process is characterized by collaboration and focus on the client’s strengths and potentials, while recognizing his competence related to his therapeutic process (cf. Rolvsjord, Gold, & Stige, 2005). The relationship is established verbally and through music listening, e.g., in a program such as Caring (Grocke, 2002, p. 131). The second period concentrates on facilitating change in a limited area of the client’s functioning (session 3). Here the music program used is the most complex one in the time-limited approach, e.g., Mythic journey (Clark, 1995, 2002). The third phase gives attention to termination and stabilization (sessions 4–5). The selected music is more predictable and sustainable, although still presenting musical and psychic challenges, which may be associated with a theme such as standing up on my own (e.g., Relationships, Grocke, 2002, pp. 126–127). In such a themefocused series of sessions, the anxiety—and a possible positive insight—“I am well-prepared and will joyfully give my best in my upcoming performance”—are both explored within the time limit. The GIM therapist may also include elements from coaching techniques, introduced as homework such as: “Be aware of any signs of performance anxiety in your life.” The aim of this first assignment would be to identify and notice the feeling of being unable to act. The aim of the last assignment would be to reflect upon how well the client has achieved his goal, e.g., “Be aware of how you feel and how you behave whenever performance anxiety arises at work, with friends, and when you are alone.” There may also be a fourth phase, termed “a follow-up” (see, e.g., Trondalen, 2009–2010, 2011b). Guided Music Imagery (GMI) is another adaptation to GIM. A specific type of Imaginal listening is referred to as Guided Music Imagery (GMI). GMI is defined in the following way: “[T]he client freely images to music while in an altered state of consciousness and dialoguing with the therapist” (Bruscia, 1998a, p. 125). GMI is similar to focused, time-limited GIM when it comes to standard number of sessions and the phases of acclimatization, build-up, breakthrough, and catharsis, before stabilization and insight (Bonny, 1999/2000). It is also different in that it adds music to imagery techniques carried out in an altered state of consciousness. Following the induction, the starting image is brought to mind and the music is turned on. Examples of such imagery themes that focus on music performance anxiety are: (1) Introduction to GMI (favorite place imagery), (2) What first inspired the participant to become involved with music, (3) Remembering one the best experiences of playing music, (4) Remembering one of the worst experiences of playing music, (5) Present feelings about playing music and plans for the future, and (6) Discussion and closure (Martin, 2007). The GMI sessions follow the general format of BMGIM sessions, although the length of each segment is shortened. Music-centered Guided Imagery and Music (MCGIM) is also an adaptation to GIM. Individual Music-Centered GIM (MCGIM) is a modification of BMGIM (Summer, 2009). There are two elements that are adjusted, compared to a classical GIM session. These modifications are (a) music choice and (b) guiding strategies. MCGIM is characterized first by the use of a music program of repeated pieces of classical music, i.e., one or more pieces within the program are repeated at least once. Second, the client interacts primarily through music-centered verbal guiding interventions. Examples are: “How are you experiencing the music?” “Describe the music.” “Really open to the music.” “Let go into the music.” “Listen more deeply to the music.” “What do you notice about the music?” (2009, p. 126). The MCGIM

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approach is based on the concept of “holding” a client in one piece of music as opposed to a sequential use of music linked together in an “affective contour” (Bonny, 1978/2002, p. 308). The MCGIM piece is usually chosen spontaneously. Summer says (2009, p. 255): The multiple hearings of one piece of music are intended to give the client time to listen more closely to the aesthetic complexities inherent within the classical music selection. Repetition creates the opportunity for a deeper, more intimate, and more differentiated relationship with the given piece of music. The MCGIM session is structured as: prelude (preliminary conversation), induction, guided musicimaging, return, and postlude (mandala drawing and discussion) (2009, p. 128). Examples of useful pieces of music with this approach are Rodrigo’s “Concierto de Aranjuez” and the second movement of Beethoven’s “Piano Concerto #5,” while a vocal piece may be Mozart’s “Laudate Dominum.” It is the author’s experience that a MCGIM approach can be very useful and nurturing to a musician, who most often listens to music in a technical way more than dwelling in it or surrendering into the music itself (Trondalen, 2011b). Short Music Journeys or Korta musikresor (KMR) is the Swedish term used for a receptive method of music therapy adapted from the tradition of The Bonny Method of Guided Imagery and Music (GIM) and the theory and practice of Expressive Arts Therapy (Wärja, 2010). The KMR can be performed individually or in groups (see Group Work). KMR is most often used in therapeutic work with life crisis, limited mental health problems, and/or issues related to work performance. It is also used in supervision and personal development. Compared to GIM practice, KMR uses only short pieces of music, less complex music, and very often music from other genre than the classical repertoire. Another difference is that the client listens to the music in silence, without any dialogue with the therapist. The KMR method starts with a verbal conversation directed toward what is going on in the client’s life in the here-and-now, and makes a starting point on a particular focus, e.g., stress. The therapist gives a very short introduction focusing on the here-and-now. She then chooses music pieces (usually one or two) lasting from two to five minutes, five minutes at the longest. The client may sit down or walk slowly around in the room while listening. A short piece of music that might be used to explore “stress” is Stefan Nilsson’s “No. 2, Aron’s Dream,” lasting for 3:53, from the movie Jerusalem. After the silent listening experience, the client makes an expressive artwork, such as a drawing or clay work. This artwork makes the starting point to process and explore “stress” after the music journey in a reflective and associative conversation with the therapist. Group Work is a variation of receptive music therapy in group settings for clients (for inspiration, procedures, and ideas, see Grocke & Wigram, 2007). The music, lasting a total of five to ten minutes, may be chosen from the classical repertoire or from other genres. Regardless of the music choice, it is important to take into consideration the complexity of the music, which should be short pieces and predicable enough so that they can act as small containers for the imagery experience. A variety of themes may be explored, even though some issues seem more suited for group work, as the examples below illustrate. If the music therapist is not a trained GIM therapist, then the focus should be on a “safe” experience, such as a place in nature or a favorite place. The relaxation, music imagery experience, and closing procedures are similar in all of these group processes. One procedure focuses on the individual within the group. The aim is to prevent loneliness by fostering empowerment at an individual level (which is needed in order to be a successful performing musician) and still experience belonging to a group (self-with-others, Stern, 1985/2000). The group members are asked to find a place in the room that is comfortable for them. The therapist performs a short induction suggesting that each person turn his attention to how his body is feeling. The music therapist focuses on a theme like “imagine you are playing one instrument in this orchestra together with the rest of the group in this room … and as the music begins to play, bring the music into that image,

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allowing the image to change as the music begins to play.” An example of music to use for individual within the group imagery is Mozart, “Serenade, with 12 wind instruments and double-bass.” The music therapist closes the listening experience with a phrase similar to this: The music has come to an end; allow the image to fade away for the moment, knowing you can always return to it whenever you want to … become aware of the room we are in … become aware of the other people in the room … aware of the sounds … move (and stretch) your legs and arms … and return to the room by opening your eyes. The group members share experiences with each other through a drawing and/or verbally. Allow time enough for closing the session. Another procedure consists of a dyad within the group. The aim is to promote the feeling of closeness, although not at the sacrifice of the musician’s necessary individuality. All clients in the group are seated on chairs or lying on mats in groups of two to form a pair. The music therapist begins with a short relaxation focusing on relaxed breathing and physical support from the chair or mat, sometimes with a joint focus. During the music, the two persons in the dyad dialogue with each other, in the role of a guide, the other as a traveler. An example of an appropriate music for such work is Bach’s “Concerto for two violins, Largo” (7:00). The therapist verbally informs the dyad when the music has come to an end, and then indicates that the two travelers will have time to explore their experiences together. They share their experiences and images with each other, and then share this with the larger group. This process is repeated again as the two persons change roles of guide and traveler. Such a joint, however not identical experience seems to represent the individuality a musician needs in order to perform on his own. In addition, such experiences seem to promote the feeling of togetherness by sharing (often similar) images with the primary traveler before opening up to the whole group experience. Accordingly, the experiences offer an experience of individuality, duality, and a belonging to the group. A comment from one male client illustrates joy, appreciation, and surprise of still being able to be surprised: I’ve been a musician for 30 years, and I never knew that such a music listening experience was so powerful—and afforded me with such important images from my life—and I even want to share them with the group. A third procedure involves improvisational listening performed in the group as a whole. The aim is to promote creativity, joy, and the feeling of belonging. The music therapist performs a relaxation, while the clients are seated on chairs or lying on mats. The therapist introduces a supportive image (e.g., “You are sitting on the beach … the sun is setting”) and the clients continue to freely share images verbally in succession. This author has had positive experiences with groups listening to Elgar’s “Enigma Variations,” nos. 8 and 9.

GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Improvisation is inventive, spontaneous, extemporaneous, resourceful, and involves creating and playing music simultaneously on a variety of instruments. It is not always an art, and it does not always result in music per se. Sometimes it is a process that results in very simple sound forms. However, all expressions are welcome in therapy, regardless of their artistic meaning or aesthetic merit.

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Creative Music Therapy (CMT) The term Creative Music Therapy (CMT) is used with reference to Bruscia’s (1987) overview of improvisational models of music therapy. Overview. Improvisations can be performed with a high level of artistic quality, or with a variety of small instruments and voice, resulting in very simple sound forms (Bruscia, 1987, pp. 5). To the author, this includes, for example, single tones out of tune, rhythmic expressions with small instruments, playful vocal glissandi, screams, tearful humming, whispering, and so on. CMT employs instruments, voice, or both to create music extemporaneously. The focus is on the music itself—as an aesthetic exploration, as the meanings of meaning-making lay in the music-making itself. CMT is a useful method to use with musicians because they are creative persons and have a heightened awareness of variations in the music itself. However, many musicians are completely tied up to the written scores or struggle with performance anxiety. An improvisation can contribute to vitality and joyfulness and promote and support expressive freedom, i.e., support one’s fullest potential and foster self-actualization. Feelings related to stress can be explored in CMT, be it of a high artistic quality or through sound forms. Exploring a variety of instruments can support healing of medical problems. An example is playing on the big gong, as the musician is stretching and bowing his vulnerable elbow in his own tempo and within his personal limit of managing. If he is suffering from muscle fatigue, an improvisation using only simple forms of sound can offer a musical space for emotional and physical exploration, with a minimum of physical effort. Both vocal and instrumental improvisations can release, e.g., stress. In such a case it is of vital importance that the music-making is at the forefront for the musician, i.e., that the musician is exploring his stress issues within the flow of the music itself. Some musicians do not want to express—or struggle to find—words that describe feelings. Not being able to connect with emotions verbally may indicate a body/mind split, and this contraindicates an approach mainly based on musical interventions. Improvisational music therapy might also be contraindicated with tinnitus (noise-induced) hearing loss, as the sound may be too loud or harsh to cope with. In CMT, the clinical goals are contained within the musical goals. The relational experience is embedded in the music and promotes expressive freedom and communication. A goal in working with a depressed musician may be to stimulate his vital self-healing and facilitate his sense of creativity. For a musician with physical injury, the goal may be to support vulnerable limbs by finding new ways to carry out actions. Through creative improvisation, the therapist can support the client’s vital existence and expressive freedom in a stressful daily life. In Bruscia’s systematic account of music therapy models, Creative Music Therapy (Nordoff & Robbins, 1977) is placed as “Developmental Music Therapy” or “Music Therapy in Healing” or “Transformative Music Psychotherapy” at the intensive level (Bruscia, 1998a, pp. 189, 210, 219). Thus, CMT can be used for a variety of goals. Preparation. Ideally, the room is equipped with a wide range of high-quality musical instruments, including a tuned piano, xylophones, cymbal, gong, percussion, and wind and string instruments, e.g., harp. The music therapist observes what the musician presents musically and responds creatively in the moment. This means the music therapist must be ready to improvise instrumentally and/or vocally as the situation requires, hence only certain aspects of a session can be planned beforehand. It is usual to tape the session, so informed consent must be obtained and the room should include recording equipment. What to observe. The improvisation is the main means of collecting data related to the musician’s psychological and developmental status and the procedural relationship in the session. The primary focus is on the overall musical expressiveness in the improvisation. In addition, through his

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musical responses, the therapist observes what qualities of the music or musical relationship are stimulating to the musician. The musician’s growth and relationship in the music and his musical communicativeness is evident by his withdrawal and poor concentration or conversely, his engagement and attention. The structural and expressive components and the expression of feelings such as hopelessness or joy are also important to observe. Procedures. Each session is improvised. The first step of the working phase is to meet the musician musically. He freely chooses an instrument and the therapist chooses hers, or the musician may inform her choice. The therapist has to involve herself in the working alliance, as she attunes herself personally and musically toward the musician and his choice of an improvisatorial style, instrumental and/or vocal. Such a style can be structured by Western music styles, tonalities, and meters, or it can be a free, atonal, improvisational approach. The musician may not be familiar with a free improvisation. One approach that may help the musician to meet this challenge is to say: “Play one note and wait for the next one to emerge. Play the next note and continue listening to the succeeding notes. And slowly let the music out.” During this improvisational awakening, the therapist can provide a musical frame, frequently establishing clear rhythm and pulse. She may introduce clinical techniques, e.g., techniques of empathy, structuring, emotional exploration, and holding, etc. (Bruscia, 1987, pp. 533–557). If it feels natural, the therapist may sing about what is happening in the session while they are doing it, in order to bring into focus the experience that is occurring in the here-and-now. Some spontaneous impulses created in the moment can provide a musician with a musical encounter that is physical, emotional, and spiritual. Any musical expression produced by the client, vocal or instrumental, is incorporated into a musical frame, and encouraged. The therapist’s musical stance is nondirective, accepting, predictable, and supportive, and sometimes it is more challenging and confronting. Adaptations. The first adaptation is the use of CMT in a Group setting where the group improvises freely on, e.g., nonpitched instruments. The improvisation usually begins with a silence, which allows everyone to center internally before beginning. The therapist usually participates on equal terms, taking a nondirective role and providing support when necessary. Rhythm or drumming activities may be introduced to promote peer encouragement and to support self-expression, skill development, and closure. One technique is to provide a framed and structured activity such as improvising with instruments to a known song. In a Self-Listening procedure, the musician listens to a recording of his own music or composition and reflects upon himself and the experience (Bruscia, 1998a, p. 124). Such a procedure can release new insight like, “It is as if an empty space is filled inside of me … memories are coming forward … I am a bigger part of the music when I’ve made it myself … this really gives me something” (Trondalen, 2003, p. 8). The author’s experience is that some musicians can benefit greatly from self-listening, while others do indeed not want to enter into such an activity. Sometimes the self-listening includes a composition with lyrics, which makes a starting point for dialogue.

Analytical Music Therapy (AMT) Overview. In AMT, the client or client and therapist create music extemporaneously with a focus on the use of symbolic music improvisation and verbal processing to create and interpret the music. From the early 20th century, there was within psychoanalysis a tradition of exploring music and music experiences (Bonde 2009); also, the Jungian tradition of analytical psychology had some affinity with music (Wärja 1994). However, an analytical tradition in music therapy developed quite late, with Juliette Alvin (Alvin, 1966/1975) i and especially Mary Priestley as contributors. From the early 1970s, Priestley developed Analytical Music Therapy (Priestley, 1975/85) as an expressive, psychotherapeutic method

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based on the symbolic use of musical and nonverbal improvisations followed by an interpretive therapeutic dialogue between therapist and client. The improvisations in AMT may be with instruments (e.g., Decker-Vogt, 2012), voice, or both (e.g., Nolan, 2003; Timmermann, 1983). There are many indications to recommend AMT to musicians, as it offers a unique combination of music and verbal processing to encounter life challenges and promote life fulfillment. Existential thoughts and feelings emanating from one’s sense of a lack of meaning, depression, low self-esteem, or symptoms such as sleep disturbance, poor concentration, inability to make decisions, and other signs of troubles can all be explored through music and words. Connecting the semantic meaning of words and relating one’s experience through music may facilitate an exploration and identification of body/mind issues of separation and integration. Such mind/body issues are especially significant when, e.g., a musician has injuries or illnesses that can affect his ability to perform—and his identity as a musician. For example, if a singer has had abdominal or throat surgery, improvisations that facilitate expression of feelings related to this issue followed by discussions based on a psychoanalytic, existential, or psychosocial theoretical frame may be helpful in working through the musician’s difficulties. One challenge is that some musicians do not want to verbalize about the music or the music experience. They refuse to interpret the music or use music as a means, as they feel this reduces music as an art form. Second, some musicians refuse to make simple improvisations, as they feel that it is beneath one’s dignity. Such a view seems to be connected to not feeling good enough and to perfectionism, and may also be related to shame (Skårderud, 2001). If a musician wants only to talk and refuses to play, he would be contraindicated for AMT, as the music-making and verbal processing are intricately connected. Improvisational music therapy might also be contraindicated with tinnitus (noise-induced) hearing loss, as the sounds may be too harsh or loud to cope with. Goals in AMT are related to outer (daily life) and inner life (mental) changes in a musician’s life. These include bringing previously unknown aspects of self into awareness and working on acceptance of these aspects of self, including both positive and negative parts. In essence, AMT procedures are helpful in order to melt frozen emotions or to release energy blockages. This is achieved by stimulating the client’s self-healing and mental resources through music and verbal dialogue designed to bring about insight and new intrapersonal and interpersonal experiences. Music-making and verbal processing have equal valence in AMT; thus, from a philosophical point of view, it is music in therapy. In Bruscia’s systematic account of music therapy models, AMT could be placed as “Insight Music Therapy” at the intensive level (Bruscia, 1998, p. 219) when it has re-educative goals (behavior change, goal modification, self-actualization) and at the primary level when it has reconstructive goals (in-depth changes in the client’s personality structure). Preparation. It is usual to tape the improvisations and play the music back to the musician during the session. Informed consent must be obtained and the room should include recording equipment. It is, however, not necessary to save and repeat musical ideas or improvisations in AMT because the here-and-now experience provides the essence of the content for emotional investigation, rather than relying on a consistent use of specific musical material repeated from session to session. The music therapist relies on the musician to bring forth an issue or designated area to work on in the session. Information from previous sessions is consequently only used as information and guidance. Ideally, the room is equipped with a wide range of high-quality musical instruments, including a tuned piano. For improvising, the musician usually sits at the piano, or behind a set arrangement of instruments including xylophone, drum, cymbal, gong, and assorted smaller instruments. The therapist very often plays the piano, but could improvise on another chosen instrument or use the voice as his instrument.

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What to observe. The therapist should note the musician’s ability to express and work with significant life issues through improvisation. The therapist will also observe the musician’s use of various instruments and the manner of playing them, including variability and stability as well as the intermusical relatedness created. Equally important is the musician’s capacity for abstraction; this is evident in his ability to draw insight from the discussions with the therapist and to relate aspects of his musical improvisations to his life. AMT most often works at a deep, exploratory level. Therefore, the therapist should observe if the musician is willing and ready to explore these areas of the psyche. These emotional expressions are very personal and can evoke strong feelings. It important to take into consideration how prepared the musician is to play roles related to different parts of self and to investigate unconscious and conscious aspects of these feelings. Procedures. The musician and/or the music therapist verbally identify an emotional issue at the start of the session. If the musician is struggling to find words to express significant thoughts or feelings, the issue can be identified through a preliminary improvisation followed by a discussion. Once an issue has been identified (e.g., a string player identifies an issue with stage fright), it is translated into a programmatic or referential title, or a “playing rule” connected to the music, e.g., play only on black keys, use an ostinato of a quint, perform a 3/4 rhythm. A referential title captures the essence of the issue in such a way that it allows for explorative improvisation. For example, a musician chose the title The question I cannot answer, as an issue for his stage fright. The title was evocative enough to encourage improvisation but open-ended enough to bring forth his feelings and projections. The musician and music therapist took different role when exploring The question I cannot answer; the therapist played the role of “a reviewer in the audience,” while the musician expressed his feelings toward her in the improvisation. To promote external and internal changes, the therapist may use various analytical techniques such as holding and splitting to allow for the expression a variety of emotions, from frozen emotions to positive aspects of self (cf. Priestley, 1975/85). Holding can also be called containing and is used when the client needs musical support from the therapist in order to fully experience an emotion and its climax through sound expression (Bruscia, 1987, pp. 130.; Priestley, 1975/85, p. 121). In clinical practice, the music therapist looks for a way to provide a musical accompaniment that allows for the client to feel held and contained, while at the same time being able to explore and express his emotions. For example, when a musician with fear of singing after years of criticism from a music teacher explores his breathing voice, it may provoke shivering, screaming, and sobbing. Here, the therapist would likely use a holding technique in order for the client to fully explore his emotions and still have the feeling of being taken care of in the music. Priestley’s use of the splitting technique is used to explore experiences or situations that involve polarities and conflicting themes. In clinical practice, this involves a duet improvisation where the client and therapist take turns depicting opposite sides of an intrapsychic conflict—or subject-object split (Bruscia, 1987, pp. 132). An example of splitting would be the musician who is having a conflict with the conductor of the orchestra in which he is employed. The musician might not be able to face his unconscious resentment of a demanding and impolite conductor, so he projects his anger into the conductor and consequently develops a fear for him. In music therapy, the music therapist could play the angry part of the conductor, while the client experiences himself as a victimized orchestral musician. Then they change roles, and gradually the musician has an opportunity to separate his personal anger from his projection of it onto the conductor. After the improvisations have been completed, regardless of techniques used, the client and therapist discuss the symbolic and concrete meaning of the music. When listening to the tape recording, various topics for discussion can arise, including transference and countertransference issues. The

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listening experience and discussion may result in a second improvisation as the issue is further explored. Individual sessions are usually 50 minutes in length. Adaptations. Vocal Psychotherapy was developed by Austin (1999, 2006, 2008) and is based on analytical theories, including different techniques. The vocal holding is a technique involving creating a consistent and stable musical environment, which may be useful, e.g., when confronting emotional trauma. In clinical practice, this can mean that two chords (major, minor, suspended, etc., based on the preferences of the musician) are repeated in sequence in a predictable pulse to provide an experience of the good enough mother who is able to hold the client. In the initial phase, the musician and music therapist sing in unison, while harmonizing is introduced in the second stage. As one pianist expressed: “Seeing your mouth wide open and hearing loud, high-pitched sounds, while also making these sounds myself, opened something up … hurt, that’s when I cried” (Austin, 1999, p. 149). Improvisation and Muscle Relaxation was inspired by Kim Chungwon (2008). It is used to increase physical and muscular relaxation through the use of improvisation and other techniques. The session begins with an opening conversation on, e.g., how performance anxiety affects life, in addition to an interest in how personal and professional background affects the musician’s life. Subsequently rhythmic breathing may be introduced, established at a rhythm of 80 beats per minute. This is followed by free instrumental improvisation with the music therapist and verbal processing. A homework assignment might include free improvisation and rhythmic breathing. The session can be expanded with guided meditation and/or conversation in the middle of the session. Group Improvisation can also be a useful approach. Issues that musicians have in common can be identified at an individual level or as a group issue. The playing rule may be explored in dyads or in the group as a whole. The group can provide opportunities for the individual to become aware of and express inner feelings (Montello, 2000; Montello et al., 1990) that relate particularly to interpersonal issues. In a group, the individual can identify, establish, and defend one’s identity and uniqueness in reference to the group and also build skills in “how-to-be-with-others” (cf. Stern, 1985/2000, e.g., “different roles and positions in the orchestra”).

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Singing and Playing Music Overview. In this method, the therapist engages the client in reproducing music in different ways, which can involve vocal and/or instrumental performances. Many musicians only perform music in professional settings. When confronting difficulties that make it impossible for them to perform on a steady basis, the musician may become isolated and lonely. Performance activities like singing in a choir (in spite of a physical injury) or playing in a band (when using ear plugs due to noise-induced hearing loss), or dancing (because “everybody can dance”), support health benefits at a physical and mental level (Clift, 2012; Murcia & Kreutz, 2012), hence an indication to engage in re-creative music therapy. Another indication to participate in RCM is to prevent isolation and stress by promoting healthy behavior through active participation in a social setting. A contraindication to re-creative music therapy would occur if the musician is in extremely poor physical health with low physical energy, or if he is in a terminal stage of illness, unable to address his needs, and preparing to die. The primary goal for re-creative music therapy is to nurture oneself, i.e., engage in music or any other art, as leisure time or as a social activity. Such a goal is related to the quality of life, pleasurable leisure activities, while also serving as a vehicle for therapeutic change. In re-creative music therapy, lyrics and music-making and music listening have equal weight, thus from a philosophical point of view it is music in therapy. Re-creative music therapy can be used and

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processed at different levels of therapy depending on the therapeutic orientation of the goals (Bruscia, 1998a). At an auxiliary level, the therapist might employ leisure-time activities that are not designed to meet any therapeutic goal per se; settings where this might occur are music re-creation activities in hospitals, community centers, and rehabilitation and day programs for individuals at all ages. The level is augmentative when the therapy is re-creation in a supportive form, and when music is the most desirable leisure-time activity. The level can also be intensive when the focus is to help the musician to understand, express, and deal with feelings about self and significant others, e.g., storytelling about his life supported by music (pp. 226ff.). It is the intensive level that is most often used with musicians in individual therapy. Preparation. The preparation depends on the activity. In general, the therapist or the musician brings an assorted selection of songbooks, lyrics, and/or scores, or a selection of music to which to listen. It might be interesting to tape a performance, e.g., a choir performance, or to record a therapeutic recreative experience and listen to or watch it afterward. If this is done, then informed consent must be obtained and the actual room should include recording equipment. Ideally, the room is equipped with a wide range of high-quality musical instruments, including a tuned piano, xylophone, drum, cymbal, gong, string instruments, and assorted smaller instruments. The musician is also encouraged to bring his personal instrument. What to observe. A musician may have an emotional reaction to a re-creative activity that is, in essence, a performance. Because of the musician’s lifelong engagement with the stage and all the feelings evoked by public performance, playing instruments or singing during therapy may evoke a variety of responses, from experiencing frozen emotions to recognition of positive aspects of self. For example, when a singer with fear of singing after years of criticism from a reviewer sings solo, it may provoke reactions like shivering, screaming, and sobbing or a heightened state of mind. It is important to be sensitive to the cultural and social context of performance that has been experienced by the musician who is being treated and to be aware of the strong feelings that might be evoked. The therapist should assess how prepared the musician is to sing or play solo or with the therapist and what repertoire he is willing to use, and offer the needed support to help the musician to perform and deal with his various feelings. Procedures. There are a variety of procedures for the different experiences. In this author’s opinion, it is of vital importance to focus on resources and strengths in the re-creative music experience instead of permitting negative experiences to impede the therapeutic process. It is worthwhile to offer clinically adapted instruments to the physically impaired musician (Chadwick & Clark, 1980)., as this helps him to maintain some aspects of performing in spite of the injury. Do not avoid problems in leisure activities, but nonetheless, promote positive, pleasurable performance experiences to promote positive emotions and an increased quality of life. As part of the therapeutic process, a musician who is unable to perform professionally can be encouraged to give or take educational lessons on his personal instrument also just for fun, or in another modality, e.g., voice lessons. In such a voice lesson, the musician can also bring his personal preferred songs to sing or discuss with the therapist. Such an approach may elucidate constraints and strengths in the musician, and allow him to explore important themes and feelings evoked in the songs. He can also use his competency as a teacher, thereby fulfilling his need for contact with music and his need to share music with others. In other words, he can find useful ways to stay connected with music, even in a stressful period of life. Another music experience in which an injured or stressed musician can participate is to join a choir. He might also explore different roles as a singer, conductor, musician, and composer or assist the choir as pianist or in the band. Very often, the musician experiences a critical period during illness, or in the transition from employment to retirement (Gembis, 2012). While this might be a good solution for some musicians, it does not meet everyone’s needs. It is not easy for some musicians to accept belonging to a group that has a lower musical standard than that to which he is accustomed. For example, a

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musician who took on the role of piano accompanist for a choir told the author: “I shouldn’t be playing there; they don’t know how excellent I am.” Yet another retired musician was more than happy to conduct an amateur choir, stating that it gave him “tremendous joy.”

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Compositional Music Therapy occurs when the music therapist engages with the musician to write songs, lyrics, or instrumental pieces, or to create a musical or artistic product.

Song Composition Overview. Song Composition involves changing the lyrics to an existing song to render them more personal or composing an entirely new song. Indications to offer songwriting to a musician can be to encourage his creativity and self-actualization and strengthen his personal identity (Baker & Wigram, 2005; Rolvsjord, 2001). Song composition can be fun and musically rewarding, but it can also expose emotional, psychological, and spiritual resources, which allow for new insight. It may reduce stress and address problems in dysthymic disorders, for example. A therapeutic aspect of the use of songs is that they evoke a variety of sides of the musician’s musical personality by integrating lyrics and music, thus bringing together body and mind in an integrated way. If a musician has a medical problem that threatens his musical career, e.g., a double-bass player who has lost a phalanx, songwriting can be a useful way to work on emotional difficulties and to promote a focus on resources and strength; this often comes as a surprise and a relief to musicians in treatment. If the musician is possessed with a driving need for perfectionism that impedes the creative process, songwriting may be contraindicated. Another contraindication may be if the musician is in poor physical health with low physical energy and is in a terminal stage of illness, unable to address unresolved issues, and preparing to die. Goals in song composition are related to outer (daily life) and inner life (mental). Songwriting is about setting words and musical expression to places, people, animals, objects, or spiritual experiences that are important in the musician's life. It can function as a means of expression, fulfilling one’s need for both verbal expression through lyrics and musical achievement. As such, it can be a source of lifeexpanding experiences. Goals for song composition would be related to self-expression of difficult feelings, discovering insights regarding one’s situation, and identifying and developing personal resources. Songwriting can be practiced as insight music therapy at the intensive level (Bruscia, 1998a, p. 219) when it has re-educative goals such as behavior change, goal modification, or self-actualization and at the primary level when it has reconstructive goals such as in-depth changes in the client’s personality structure. Preparation. The therapist can bring an assorted selection of songbooks and lyrics as well as recorded music to use as inspiration. To listen to recorded songs, Spotify, CDs, iPod, iPad, or computer may be used. It may be interesting to record the song and listen to the music during the session. The room should include equipment that can record and play music. Informed consent must be obtained if recordings are made. Ideally, the room is also equipped with a wide range of high-quality musical instruments, including a tuned piano, xylophone, drum, cymbal, gong, and assorted smaller instruments. The musician may also bring in instruments he would like to play. What to observe. It is important to notice if there is a flow in the songwriting experience, or if the musician is stuck in either the creation of lyrics or in the music. The therapist is seen as a fellow traveler (Yalom, 2001, 2002) and may help by suggesting options for words or music, in a gentle and

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empathetic way. As the therapist is selectively attuning herself toward the compositional process and the musician, it is of vital importance not to “steal” the musician’s experience, i.e., consciously or unconsciously “take over” for the musician, be it musically or verbally (Trondalen & Skårderud, 2007). If this happens, the musician loses the chance to experience himself as a competent and resourceful song composer, and the possibility of sharing a relating experience through music is lost for both persons. Therefore, song composition will not be connected to his positive self-esteem. Such a lost change for supporting self-esteem is really a pity, since a belief that one is not good enough inevitably is connected to inner psychological phenomena for many musicians (see, e.g., Kenny, 2006; Montello, 2000; Taborsky, 2007). Procedures. Decide how to start the song composition, be it either with the lyrics or the music, or moving between them. Make a starting point in what stands out as the most important to the musician in the here-and-now. Another point of departure would be to ask the musician to write down keywords and/or lyrics in between the sessions and bring these notes to music therapy. In both approaches, identify themes, ideas, and the intention the musician might have regarding the lyrics. The subject or theme of the song is chosen by the musician or in tandem with the music therapist. Examples of themes are daily life issues, the feeling of failure as a musician, or standing by oneself, acknowledging both failures and successes. The latter is often the hardest. Negotiate how to write the song: tune first or verses first or start with the chorus. Decide on the rhythm, form, or some preliminary chords, some of which may be inspired by some music/melodic lines of which the client is fond. Ideas for the song composition can also be precomposed melodies, familiar chord sequences, chosen keys or modes, or rhythmic beats (for ideas, see Aasgaard, 2002; Baker & Wigram, 2005). It is also possible to allow the musician to lead the process in his own creative way. This might mean that the process is free-flowing, as studies have shown that performing music while being in a state of flow is a desirable experience for musicians (Kirchner & Skutnick-Henley, 2009). Ideas for the song composition may be precomposed melodies and familiar chord sequences, keys, or beats. If starting is difficult, it is helpful to listen to recorded music in order to draw on ideas and inspiration from precomposed music and lyrics. Music improvisation, playing precomposed pieces, or singing precomposed songs or pieces may also help to free up the musician before beginning to write his own song. As lyrics begin to flow, write them down. Create a simple score. Afterward, if the musician wishes, make a recording of the song and then listen to the music together and offer the musician a recording/file/CD to bring with him. Adaptations. One way to deepen the songwriting experience is to use the adaptation Songwriting and Body Toning. The musician and therapist write a song together, locate this song somewhere in the body, and find a tone that resonates with that area (for ideas, see Austin, 2006). The therapist may join in the toning. Toning is the conscious use of sustained vowel sounds for the purpose of restoring the body’s balance (2006). The musician can also bring song compositions, poetry, bits of lyrics, or fragments of compositional ideas from home to be developed in the music therapy session. This may allow for a degree of healthy narcissism (Nolan, 2003) or just a rediscovery of the musician’s creative energy as a composer and pianist. Sharing a personal song composition through a recording/file/CD may allow the performing musician to experience himself in a new role as a composer of music (Aasgaard, 2002). The Musical Audiobiography is another compositional method. It is an autobiography that employs sounds instead of words. It is a recorded musical sound collage of the musician’s life, where each segment is from 5 to 60 seconds long. It can include musical and nonmusical sounds, prerecorded or improvised, and be in any style. Narrated titles and comments may be added (Bruscia, 1998b, p. 108). Life story improvisation is similar to Musical Audiobiography. The client divides his life into stages or periods

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(at least six) and gives them names, and then he creates an improvisation that represents each stage and the experiences therein. The improvisations are arranged chronologically and then recorded. Instrumental Composing may be used as an adaptation to songwriting. Some musicians may prefer to write an instrumental or vocal composition rather than a song. This would proceed in the same way as with the song composition guidelines from above. These approaches, including songwriting, can be applied individually or within groups. Another way to use the compositional method is to create an Original Playlist Program or Original CD Compilation of music used in individual or group therapy that will help the musician when he is outside of the therapy session. For example, if the musician is on a long-term sick leave, he can create his personal CD repertoire or playlist on his MP3 player and use the music as self-care (Skånland, 2012). Research studies show that the reflexive use of music in everyday life can reduce stress and social phobia and promote physical and mental balance (Batt-Rawden, 2007; Ruud, 2002).

GUIDELINES FOR MULTIPLE METHODS A multiple methods approach for musicians in therapy may also be useful. This author suggests the following approach: Form a small group of musicians who share the same interests in singing (sing-along), drumming, or playing in chamber orchestra or band. A young musician said: “Playing in a quartet— that’s the best you can do when you are playing your main instrument. Somebody’s getting an idea: Four people emerge into one unit” (Trondalen, 2011b, p. 117). These groups can join each other at community events, competitions, or festivals. With facilitation from the therapist, some members might wish to form a group to be trained in relaxation and imagery techniques and to create individual relaxation tapes. Musicians can also use methods of assisted relaxation and imagery, following a discussion on stress. Others might like to include family members in song-lyric writing and interpretation of selected song lyrics, while exploring stressors and coping techniques together with their closest family members. The various methods used may be interchanged in the small group of musicians who are eager to share their music-making experiences.

CLOSING REMARKS ON METHODOLOGY Closing remarks on methodology offer more layers of reflection than is previously presented under each method, such as organizing the music therapy session, group size/individual sessions, length and frequency of sessions, necessary equipment, opening and closing procedure, and the use of therapeutic “intuition.” It is this author’s experience that there is seldom one, and only one, method or procedure that is the correct one in a music therapy session. The clients have their own styles and challenges in life and the music therapist has her personal style of performing her profession. Nevertheless, some important aspects should be considered. Opening and closing rituals are important, as predictability offers a safer space than when one doesn’t know what to anticipate. Some clients prefer the same activity/procedure at the opening of every session, e.g., listening to some music or playing/singing a particular song. However, this author’s experience is that most musicians do not want to start with singing a song or using their voice, as this is often connected too strongly to their inner feelings. One female client expressed herself like this: “Singing is giving away myself through my breath.” One solution with a client having such feelings can be to play an easy tune together instead. The closing should be mentally and practically anticipated in a way that the client feels taken care of, and the therapeutic issues that have been touched upon are bearable to deal with outside the therapy room. From a practical point of view, it can be useful to tidy up the room together as a part of the closing ritual. From a musical point of view, music with closed endings is often preferable. As

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far as conversation is concerned, the verbal conversation should indicate that the session is coming to an end. A useful closing question can be: “What will you bring with you from this session into your daily life?” Another way of creating closure is to ask the client to form a word or small symbol or drawing on one line on a lined sheet of paper every session. The sessions should be numbered. Such a sheet becomes a visible sign for the music therapy process (a narrative) and offers the opportunity to talk about process and development on basis of the client’s personal “summing up.” The clients should be met—and attended—before and after the sessions. It is the client who should leave the therapist, not the other way around. While accompanying the client to say good-bye, the room could be ventilated to provide for fresh air for the next session. When returning to the room, the therapist very briefly should make notes, including a reminder on what might be important to follow up on in the next session. Organizing and structuring the session within the time frame is important. To do this, it is often helpful to ask the client what his needs are so that the therapist can plan accordingly. However, clients are not always aware of what they need. In this case, the therapist might suggest two or more musical activities from which the client can choose. Usually, the client will choose activities that give meaning to him, which provides the therapist with a starting point to address the client’s needs as well as his personal resources and interests. Supporting client strengths in such a way helps the client to recognize his strengths and promotes empowerment. Sometimes there will be a flexible transition from one activity to another; at other times, the client and therapist might need to take more time to discuss, e.g., whether to use the voice or create an instrumental composition. Individual or group sessions may vary. Some clients want to participate in both, while others seem to profit more from one than the other. Again, ask the client and introduce different alternatives, providing the client with appropriate information about each. Some clients may also need an individual session to explore physical or mental issues, while at other times in life, connection to others may be therapeutic, and then it is useful to join a group. A useful group size is from six to eight people, which allows a client visibility and safety in withdrawal at the same time. Such a size also takes into account possible absence among the clients. Length and frequency may be from 30 minutes in an individual session to 1½ hours in a group. It is the author’s experience that more than 1½ hours, even if it is a wellfunctioning group, takes too much energy, which in turn lowers concentration and attention. The frequency of individual and group sessions can vary from three times a week to one session every month. The most important criterion is to adapt to the client’s flow, which most often means frequent occurrences of sessions in the beginning of therapy, and a reduction in the number afterward. In some settings, shortterm therapy of three to five sessions is the most useful (cf. Trondalen, 2009–2010), e.g., when a client presents with a goal such as, “I want to explore my anger toward the conductor.” Some clients also want to do some homework, which may speed up the therapy process, while others are not interested in this. An important part of music therapy as it unfolds is the therapist’s reflection upon the methodological issues involved, and the role responsibilities of being a music therapist. Such a philosophical task includes both a systematic process linked to methods and procedures (as previously presented) and an exploration of the lived experience of working as an “intuitive” music therapist. Intuition and rationality may be seen as opposites, but in this author’s opinion, they are not. From a philosophical point of view, the phenomenologist Husserl elucidates that intuition is neither too mysterious nor too difficult to grasp and perceive (in Sokolowski, 1974/89, pp. 26ff.): Intuition is simply consciousness of an object in its direct presence; it is the opposite of intending the object absently. […] There is nothing solipsistic or mysterious about intuitions, and in principle they can be publicly manifest and confirmed.

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Intuition is connected to the concrete musical action in itself, while at the same time directed toward the client and the “sounding relationship” (Trondalen, 2004) that emerges in the actual setting. In other words, the cognitive evaluation of music therapy in action is not cognitive in itself. Intuition is understood as an immediate awareness emerging from the music therapist’s consciousness. Such an intuitive approach to methods and procedures is what Eide and Eide (1996, p. 55) call an “old hand,” from a theoretical point of view. An “old hand” (as opposed to a “beginner’s hand”) is a result of being able to be present musically, therapeutically, and personally. This means being able to be present as an active listener and participant at the same time. Eide and Eide point out that this present awareness consists of two components: “attending” and “listening” (p. 139). “Attending” means to be aware and present by the client, while “listening” is connected to observation and interpretation of the other person’s experience of himself. Hence, music therapeutic intuition can be understood as a lived performance of an immediate and creative mobilization of the total and unified experience the music therapist possesses. In clinical practice, the music therapist’s choices of methodology and procedures in the session are informed by the immediate affectively attuned awareness (Trondalen & Skårderud, 2007), with its inherent tacit knowledge (empathy, professional skills, experience, and intuition), which is perceived and performed in the here-and-now.

WORKING WITH CAREGIVERS Individual Supervision Some music therapists seek individual supervision through expressive or receptive music therapy (GIM). It is the author’s experience that the supervisee uses the musical experiences to promote her personal growth by investigating personal and professional issues that hinder—or promote—her job performance. The issues at stake are most often related to unstable working conditions, relationships with bosses or peers, very sick patients, lack of self-confidence, burnout, or unresolved personal issues that influence performance at work. Through the unfolding of music expression and/or images, the supervisee explores her feelings, actions, and new ways of relating. The music evidently functions both as a frame and as an agent in itself. A supervisee called her supervision process nourishment, as she was using her own medium—the music, to explore a variety of issues, while at the same time nurturing herself through the music.

Pastoral Counseling Some music therapists seek pastoral counseling through music, as they are longing for deeper insight about themselves as a need in their daily life or in a palliative end-of-life setting. In other words, they are working toward integration of the physical, mental, and existential aspects of life (Sigurdson, 2008).

Group Work Music therapists can also join a music therapy group for supervision and self-experience. In this case, music therapists can be termed caregivers (as therapists). In this case, they are not attending such a group as clients with some mental, physical, or existential problems, but instead they are attending the group for nurturing and self-care. In such a group, the Song Sensitation approach is based upon the premise that song, as a symbol, holds unique inherent qualities as it is linking emotion and cognition (Loewy, 2002/2007). The lyrics and thoughts expressed therein can inspire both the individual and the

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community-at-large. Songs are used to unite and bring people together, integrating groups through a variety of themes and issues. In this process, every music therapist brings a favorite song to the group. The music therapist running the group receives the song prior to the group meeting. The session begins with a relaxation and listening phase. With lights off or dimmed, the group listens to the song twice. Instructions are given so that the listeners’ eyes are closed and the body is in a relaxed state of mind. After listening to the song in this state, the lights are put on and the music therapists get the lyrics and pencils to write and draw thoughts or feelings related to the lead musician, the song, or self. The feedback and reflection process includes processing about the music, lyrics, and how and why the music therapist feels that this song is important to other music therapists in the group and to himself. The last phase is called actualizing the song, as the group re-creates the song in their own way; the group member who selected the song provides preferences of the song’s arrangement by assigning instruments and deciding on the tempo, dynamics, and harmonies. When the song is brought into a therapeutic context, the group domain, it becomes flexible. The music therapists in the group may interpret the song in terms of their own process. The music therapist who brought the song may hear others’ interpretations and feeling about his song, which may elucidate parts of self that he did not know beforehand. In other words, such rich opportunities for interpretation can provide insights about feelings and different interpretations of meaning. This process can strengthen personal identity (self in relation to others) as well as deepen the group process. There are many ways of preventing illness and promoting well-being for music therapists as caregivers, ranging from attending music therapy oneself to participating in music activities for joy and recreation. The project Caring for the Caregiver training as part of the New York City Music Therapy Relief Project offers useful ideas on how to take care of oneself as a caregiver (Loewy & Hara, 2002/2007). The author would like to draw attention to this text as an inspiration for the music therapist to dance, paint, sing, play, express, feel, listen, and imagine—to nurture herself to be able to nurture others—and not least as a necessary and wonderful part of life itself.

RESEARCH EVIDENCE Music therapy strives to be an evidence-based practice (EBP) to ensure that procedures used in music therapy are safe, effective, and cost-effective. This includes levels of evidence-based practice from expert opinion to meta-analyses. In addition, researchers aim at publishing clients’ personal voices, elucidated through everything from research case studies to bigger qualitative or mixed method studies. Research evidence and publications referring to music therapy with musicians and performing artists are of limited quantity. This may be due to many reasons. First, music therapy is a new treatment modality including a variety of practices dependent on different referral systems and (often lack of) governmental authorisation. Second, many music therapists treating musicians are not trained in research methodology or have a stronger passion for working clinically than doing research. Third, musicians being offered or seeking music therapy very seldom have one diagnosis. Hence, musicians are included in general research studies investigating music treatment in relation to their medical condition. Two examples of such studies are the Cochrane Reviews Music interventions for improving psychological and physical outcomes in cancer patients (Bradt, Dileo, Grocke, & Magill, 2011) and Music for stress and anxiety reduction in coronary heart disease patients (Bradt & Dileo, 2009). The reviews show positive results of music therapy and music medicine; however, these results are inconsistent due to different variables. Both reviews conclude that more research is needed on the effects of music offered by a trained music therapist.

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This general way of treating musicians (included in studies above) may explain the results from a national survey saying that aside from no treatment, seeing a General Practitioner (GP or PCP in the USA) is often the least effective in treating, such as performance anxiety (Fishbein & Middelstadt, 1988). In other words, treatment of musicians is often a “hidden” practice, as musicians are included in bigger studies and therefore do not report themselves as receiving treatment adapted for their special needs. In addition, very often the GPs do not have experience in treating performance anxiety and other musicianrelated problems, and therefore they are not able to offer adequate treatment when the musician visits his medical doctor. A fourth reason may be related to the author’s experience as a music therapist and a researcher, which is similar to Ralph Spintge’s observation when treating musicians: “… artists are extremely sensitive re privacy” (Spintge, personal communication, 2012). Very often musicians do not want anyone to know they are having problems or participate in research which might lead to possible identification. Many music therapists, who have published in different settings, also confirm verbally that some published literature does not say explicitly that the clients attending music therapy are musicians. The author assumes that this is due to the fact that recognition may not only influence the musician at a personal level, but also have an effect on a professional career as a performing musician. Consequently, literature on music therapy with musicians may be implicit in the publications, but not presented as such. In addition, according to Brodsky, Sloboda, and Waterman (1994), personality characteristics such as being introverted and unsocial were found to be common in musicians who had experienced maladaptive musical performance, which might prevent musicians from seeking treatment. Sometimes it is also difficult to use evidence-based research methodology on music therapy with musicians, as a session very often includes a variety of treatment modalities (e.g., songwriting, improvisation, music listening), depending on the client’s needs in the here-and-now. Limiting treatment to specific protocols in the session for clean research results may raise ethical questions (Dileo, 2000), e.g., when there is a conflict between remaining true to the randomized controlled study (RCT) or to the client’s needs. For example, when designing an RCT, there might be clinical challenges if the client wants to do something that the trial does not take into account, in addition to difficulties in separating the different modalities from each other in a stringent way. Nevertheless, there are successful examples of how various interventions have been used to approach performance anxiety (Chungwon, 2004; Rider, 1987), such as guided imagery showing a significant method of managing performance anxiety (Esplen & Hodnett, 1999). Also, McKinney et al. (1997) studied the effect of receptive music therapy, i.e., GIM on mood and cortisol in healthy adults. Such changes in hormonal regulation may have health implications for chronic stress, from which musicians suffer a great deal. A clinical trial of a music-generated vibrotactile environment for musicians (i.e., music medicine) indicated that music-enhanced therapies were just as effective as traditional counseling (Brodsky & Sloboda, 1997). Martin (2007) studied the effect of a series of Guided Music Imagery (GMI) sessions on music performance anxiety (MPA). The results showed a trend toward reduction in MPA and indicated that GMI may be useful in reducing MPA (in tertiary musicians). A qualitative study explored short-term GIM with 10 musicians. The study, based on a hermeneuticphenomenological approach, points out that the musicians used the music as nurturing in a way that supported personal strength and promoted well-being (Trondalen, 2011b). A case study with a male musician shows how GIM can promote a hero’s journey and affect personal life and work performance (Trondalen, 2010). Some studies include both expressive and receptive modalities of music. Youngshin (2008) trialed (a) an improvisation-assisted desensitization and (b) music-assisted progressive muscle relaxation with six female pianists with MPA. The goals were to help the musicians to discover the sources of their performance anxiety and acquire appropriate coping skills. Youngshin concluded that there was a significant reduction in anxiety and a nonsignificant reduction in MPA. Another study treating performance anxiety examined the effects of improvisational group music therapy, muscle relaxation, and

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focusing on performance anxiety in two studies. The interventions significantly reduced anxiety, increased confidence, and had a significantly positive effect on MPA. In the second part of the study, the musicians reported less stress, less self-involved (narcissistic) behavior than the control group, and an increase in feelings of confidence. The researchers suggest that music therapy interventions might be employed as a preventive means in institutions that train musicians (Montello et al., 1990, p. 56). In a case study from individual music psychotherapy with a percussionist with dysthymic disorder, the music therapist found that redirecting musical playing into new areas decreased negative self-appraisal and improved self-esteem (Nolan, 2003). In another case study, a female jazz pianist plagued with a false-self personality constellation and symptoms of posttraumatic stress disorder used instrumental and vocal improvisation to deal with her struggles and discover her purpose in life (Montello, 2003). Other case studies confirm positive development, while providing useful ideas and theoretical interpretations of music therapy with musicians, whether in private or institutional settings (Austin, 2006; Decker-Vogt, 2012; Timmermann, 1983), and providing useful insights from clients (Miller, 1999). There is an increased tendency to burn out among music educators, and this is influenced by environmental and demographic variables (Check, Bradley, Parr, & Lan, 2003). Music therapy techniques (e.g., re-creational) seem to provide useful intervention for music teachers’ burnout. The researchers (2003) found that experimental group subjects who received instruction regarding the use of music listening for stress reduction and were required to select and listen to music recordings that were meaningful to them, reported significantly lower levels of burnout symptoms than control group subjects. Noteworthy is also the PhD study Exploring Burnout and Renewal Among Music Therapy Faculty (Richardson-Delgado, 2006), which indicates that music therapy educators experience significantly less burnout than the normative sample on the Maslach Burnout Inventory (MBI), and that the music therapy educators use music as a way to combat stress and help with the renewal process. This is similar to the findings from Batt-Rawden’s (2007) study of the role and significance of music and musicking in everyday life for the long-term ill.

SUMMARY AND CONCLUSIONS This chapter addresses music therapy offered to musicians. The rationale has been to present research and examples of music therapy to inspire a variety of music therapy approaches within a diversity of contexts. Every music therapy approach has to be context-sensitive in regard to both musical preferences and the systemic setting. According to Maranto (1994), the Bio-Psycho-Social perspective is the most viable to date, with its inherent reliance on system theories. Accordingly, when treating musicians, biology (i.e., physical aspects), psychological issues (mental state, existential being), and context are to be connected and taken into consideration. The author would like to support the growing interest in a departure from a key focus on diagnosis, in favour of a wellness model for illness prevention for musicians, focusing on resources and strengths, while emphasizing health promotion and preventive actions (Cockey, 2000; Rolvsjord, 2010; Roskam & Reuer, 1999; Ruud, 2008; Spahn, 2009, 2012). The author is not saying that music therapists should avoid or not take psychological or medical treatments into consideration. However, it is, e.g., interesting to note whether performance anxiety is termed “occupational stresses or pathology” (Martin, 2007, p. 31). The flutist J. Buller (2002) describes what it is like to be an injured musician: “It’s painful; it’s as if my familiar self and world has died” (p. 22). When musicians tend to lose their connections to familiar events and experiences in their lives, illness and trauma basically pose a threat to “their existential being” (Schei, 2009, p. 10). It is, however, the author’s basic assumption that it is worthwhile to promote positive musical experiences to support positive emotions and an improved quality of life,

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which in turn can also influence medical conditions. Not unlike this, Maranto (1994, p. 271) suggests that the word medicine in the term performing arts medicine should be changed perhaps to health, as in performing arts health, not in the least so as to elicit more appropriate associations with prevention as opposed to pathology. Health, including physical, mental, and existential dimensions, can be understood as a resource that everybody has and administrates in different ways within different contexts. Maranto suggests a rationale for the use of music to treat performance anxiety in musicians. This is due to the fact that music is a safe, noninvasive, accessible, stigma-free treatment for stress and performance anxiety in musicians, and it is an approach that may positively contribute to their lifestyles (Maranto, 1989, p. 280). In her suggested rationale, she also draws attention to the musician’s belief system, as she points out that musicians are aware of music’s influence on them personally and on their lives (p. 279). Music may support the musician’s inner life and strengthen personal development. Providing the musician with an integrative Bio-Psycho-Musical model for supporting musicians provides cutting-edge health care to musicians and performing artists using music as part of promoting health (Loewy, 2000; Quentzel & Loewy, 2012a, 2012b). Musical experiences, which include relating to others through music, can afford some possibilities of personal action that the musician himself can appropriate into his everyday life (DeNora, 2000; Trondalen, 2004). The fact that the music therapist is a musician herself and relates to music, music performance, and music listening in similar ways and terms as a professional musician (Wolfe, O’Connell, & Epps, 1998) can indicate that music therapists should be well suited to work with musicians in therapy. Institutions that train musicians should offer health promotion and wellness courses to music students (Ginsborg, Kreutz, Thomas, & Williamon, 2009; Manchester, 2007) and professional musicians. These courses should include advice on healthy nutrition (Spahn, 2009), physical training for the living body (Merleau-Ponty, 1945/89), e.g., slow movement techniques and methods such as Alexander or Pilates, and music. To strengthen identity and nurture personal and professional development, the author suggests music-making and music listening, individually and/or in group. At a metatheoretical level, a reinforcement of the musician’s personal sense of well-being and existential coherence (Antonovsky, 1987) connects personal, transpersonal, and social spaces (Ruud, 1997). These spaces arise from and support one’s personal and professional identity as a musician. A closing reflection presents itself: whether it is possible to grasp the processes of a context sensitive and flexible music therapy treatment (as an art form) within a research paradigm basically rooted in medical and naturalistic thinking based on a mechanistic, cause-effect model—or not (Trondalen, 2011a). The author does, however, believe that there is a need for a wide range of research to be performed side by side. In other words, it is essential to make use of a variety of designs when exploring philosophical, theoretical, and empirical facets of the relating experience through music, aiming at providing the musician his very best sounding relationship in music therapy.

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ENDNOTES iJuliette

Alvin developed a comprehensive approach to music therapy, “Free Improvisational Music Therapy” (Bruscia, 1987). She was an accomplished cellist. Her theoretical orientations are implemented within the framework of various psychological theories, including both behavioral and analytical stems. Her own work “reflects an orientation toward psychoanalytic theory” (1987, p. 83).

Chapter 25

Spiritual Practices Annie Heiderscheit _____________________________________________ DEFINITION Spirituality stems from the Hebrew word ruah, which means breath, air, wind, that which gives life, or breath of God (Holliday, 1988). The definition of spirituality has evolved from its Hebrew origins over the past several decades. Frankl (1963) described spirituality as the essence of one’s humanity. Mische (1982) defines spirituality as a process or sacred journey. Murray and Zenter (1989) describe spirituality as quality that fosters inspiration, reverence, awe, meaning, and purpose. Cohen (1993) also writes that spirituality includes finding deep meaning in everything, even in the face of illness. Frankl (1963) wrote that the importance of finding meaning in one’s life was the most important task in life. Wilber (1996), in his writings on spirituality, developed a model of four quadrants that provides a representation of an individual’s experience of the world. This model illustrates the breadth and depth of connections that we experience as human beings. His model includes the following quadrants: individual interior (I), which represents one’s thoughts, feelings, intentions, and perceptions; collective interior (We), which represents relationships with others, being part of a culture; individual exterior (It), which recognizes the physical body; and collective exterior (Its), which represents the environment, nature, family, and community. Wilber, Patten, Leonard, and Morelli (2008) describe that as one engages in life (connected and aware of all four quadrants) in a more balanced manner, this allows an individual to experience their “wholeness, singleness, and integralness” (p. 29). Pargament (1997) lists the following characteristics as those commonly associated with spirituality: connectedness in relationships with self, others, nature, or a Higher Power, meaning and purpose in life, transcendence, love and compassion, wholeness and energy. Chiu, Emblen, van Hofwegen, Sawatsky, and Meyerhoff (2004) describe spirituality as a power or energy that stimulates motivation, inspiration, and creativity. Brown (2010) writes, “spirituality brings a sense of perspective, meaning and purpose in our lives” (p. 64). Puchalski, Ferrell and Borneman (2010) describe spirituality as the way individuals find and attach meaning to life, the purpose they find for life, and how they experience connectedness to others, self, nature, the significant or sacred. Kreitzer and Dose (2009) identify the following characteristics commonly associated with spirituality: • • • • • •

Connectedness and relationship (self, others, Higher Power, and nature) Finding meaning and purpose in life Experiencing transcendence Wholeness Love and compassion Energy (motivates, inspires, and fosters creativity)

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Alcoholics Anonymous (AA) has utilized spirituality as an integral part of its program since its inception. In The Big Book (2002), spirituality is defined as a concept of how we relate to others, ourselves, and to our own understanding of God. Some of the changes that are entailed in this spiritual process include moving from fear to trust, self-pity to gratitude, resentment to acceptance, and dishonesty to honesty. While the concept of spirituality has evolved more recently, it also continues to encompass an individual’s religious beliefs and practices. This can include their belief in God, a Higher Power or deity. These include spiritual traditions including Christianity, Buddhism, Taoism, Islam, Judaism, Shamanism, and other world religions (Wilber, Patten, Leonard, & Morelli, 2008). Belief in a God, Great Creator, or Divine Spirit involves a practice or ritual of reaching out or striving to connect with a Divine Spirit (Freeman, 2001). In the process of striving to connect with their Higher Power, God, self, or others, individuals may utilize various methods or practices to foster this connection. The next section will identify various practices that are commonly used to develop or foster the many characteristics and aspects of spirituality.

SPIRITUAL PRACTICES Spiritual practices are ways in which individuals foster a connection with self, others, nature, or with their Higher Power or God through an experience of focusing inward or a directed focus outside one’s self. As this connection is experienced, it can foster a sense of love and compassion for self, others, and the world at large. These practices also help individuals develop insights and understanding and assist in meaning in the events and circumstances of life. Spiritual practices allow opportunities to transcend the challenges and struggles that arise and help one to discover a sense of wholeness. These practices also instill inspiration and motivation and enhance creativity, which can create a shift in energy. There are many spiritual practices that individuals may use, and some may be very personal and unique to their spiritual or religious beliefs. The spiritual practices included in this section and listed below are not a comprehensive list, but include those practices that are more commonly utilized. It is important to note that individuals may have their own unique and personal practice. • • • • • • • • •

Prayer Meditation Music, singing, and chanting Art Journaling or writing Spending time in nature Labyrinth walking Guided imagery Yoga

Prayer is a way to reach out and connect (Kreitzer & Dose, 2009) with self, others, or a Higher Power. Prayer can be expressed in a variety of forms and can be offered through words, poetry, song, chant, silence, and movement. Prayer can be offered and experienced individually or as a part of a community, therefore allowing it to be a very private or group experience. Prayers can serve as a means of offering thanks or gratitude, or asking for healing, insight, strength, support, courage, or whatever else they may need.

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Meditation is a practice utilized in many cultures around the world and has been used for centuries as a spiritual and healing practice (Kreitzer & Dose, 2009). Kabat-Zinn (2005) describes meditation as a way of being rather than an implementation of technique. Meditation is a practice of calming the mind, by quieting thoughts and relaxing the body. It can be a self-directed practice or also experienced in a group or community setting. This meditative state allows one to step out of thought patterns, emotions, behaviors, and routines to experience a different way of being. This mindfulnessbased practice can allow for an individual to explore how to be more effective, less reactive, and more authentic (Kreitzer & Dose, 2009). Making music, singing, and chanting are also methods of achieving a relaxing and meditative state, expressing gratitude, offering a prayer, and connecting with self, others, and a Higher Power. In many religious and spiritual traditions, singing and chanting serve as form of prayer (Gass & Brehony, 1999). They are also a means of expressing feelings and gaining insight, awareness, and perspective. Listening to music can also foster these experiences. The process of creating music facilitates connecting to one’s creative energy also. Music can be combined with and enhance other spiritual practices as well. Creating art is another method of expressing feelings and gaining insights and perspective. It can also serve as a means to entering into a meditative or relaxed state and connecting with one’s creative energy. Fostering and connecting to one’s creative energy can also provide a way to connect to a Higher Power. These experiences can be completed individually or in a group to foster connecting with others as well. Journaling or writing can serve as a tool to express feelings (Pennebaker, 1997) or to process and record experiences (Kreitzer & Dose, 2009). This written expression can be done in creative forms such as story and poetry, or may include a daily or regular practice of journaling. The experience of writing can provide the opportunity to connect with self, and sharing one’s writings can foster connections with others. For some, the process of writing may foster a connection with their Higher Power. Nature can serve as a connection to a Higher Power or creation. For some, being in the beauty of nature is a spiritual and healing experience and a reminder that as a human being, they are part of a larger world or something greater than one’s self. Being in nature can provide a sense of peace and calm and can also be a place to relax, meditate, or journal. In nature, we can feel our connection and interdependence to the world around us. The term “biophilia” means a love for life and living systems (Wilson, 1984). It refers to the innate attraction and positive emotions that human beings feel toward other living beings and natural surroundings. A labyrinth is a nonbranching, circular path that leads to a center, having one way in and one way out (Kreitzer & Dose, 2009). A labyrinth is often seen as a form of meditation and prayer. The labyrinth can also serve as a metaphor of life experiences or life’s journey and as a way to experience and achieve enlightenment. The process of walking the labyrinth can facilitate gaining awareness and insight. Guided imagery is a means of experiencing images and sensations that can be healing and also of a spiritual nature. These images can foster a connection to self and a Higher Power. The combined use of music and imagery can facilitate a trancelike and deeply relaxed state (Achterberg, 1985). The guided imagery experience may include images that connect to significant periods in life that help to foster a sense of meaning and purpose (Bush, 1995). It may include images of nature or images that foster healing or a deeper spiritual connection to self, others, or a Higher Power. Yoga is described as a physical, mental, and spiritual practice. Yoga is derived from the Sanskrit word yuj, which means to unite or join (Chopra & Simon, 2004). The purpose of yoga is to unite the body, mind, and spirit in order to achieve a sense of balance. The elements of yoga include poses and breathing, which then prepare the body for meditation. This process allows for experiencing a sense of wholeness and greater connection to self. Many spiritual practices allow one to experience an aesthetic response, which is a human response to that which is beautiful in nature or in the arts (Crowe, 2004). Gaston (1968) and Maslow

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(1970) suggest that the aesthetic reaction is fundamental and innate to the human experience. The aesthetic experience can be transcendent or transpersonal, in which one is completely focused in the moment and “overpowered with strong positive emotions” (Crowe, 2004, p. 274). The experience of beauty or the aesthetic can create a sense of peace and calm and of being connected to or an integrative part of the world as a whole. Aigen (1995) suggests that one can experience this sense of a unified whole through the inherent qualities in music (melody, harmony, and rhythm). Spiritual practices are based in creating, facilitating, and allowing an experience for an individual or a group. These experiences are utilized to foster connection in many different ways. These practices allow one to connect with self and one’s own spirit and energy. They also foster a connection to others, community, nature, the world, the universe, and a Higher Power or God. Spiritual practices foster experiencing love, compassion, and a sense of wholeness, inspiration, and creativity. Through the experience of engaging in spiritual practices, a sense of meaning and purpose can also be achieved. While music in and of itself can be a spiritual practice, music is easily woven into a variety of spiritual practices. The elements and qualities innate in music ensure its role and function in life and in spirituality. Dissanayake (2001) describes the social and personal uses of music as universal features, since in many cultures music is an integral part of ritual used to alter one’s consciousness. She illustrates this with the example of mother-infant interactions and music. The vocalizations of mothers, which include soft, breathy tones accompanied by rhythmic patting, foster an emotional connection between mother and infant. This example of music-based behavior and interaction illustrates the nature of how music fosters connection with others.

NEEDS AND RESOURCES Clients struggling to manage a chronic mental illness, experiencing a relapse, or coping with a traumatic experience may be wrestling with issues related to spirituality. For example, a client struggling with an addiction or a relapse may be in search of a deeper personal relationship with self and others in order to foster meaning and purpose for recovery. A client with an eating disorder may be searching for strength and hope, in order to engage in treatment and be motivated for recovery. A client managing chronic depression or anxiety may be seeking personal growth in order gain a sense of empowerment over their illness. A client processing through a traumatic experience may be questioning why they became the victim and expressing anger at their Higher Power. When working to address the spiritual needs and issues in the therapy process, it is helpful to understand the client’s connection and experiences to spirituality. Their connection and experiences may serve as resources to draw upon in the therapeutic process. Understanding the role spirituality has played in their life is vital to addressing these issues. For example, has spirituality helped them discover meaning in life? If so, it may well serve that role again. If the client has a history of using spiritual practices in their life, this can be an indication to incorporate them into their current process. Addressing spiritual needs and issues can be approached and addressed in music therapy. In order to address these needs for a client, it is necessary to understand how music and musical elements lend themselves to connecting with spirituality and spiritual practices for the client. Music can serve as a valuable resource in exploring the spiritual needs of clients in individual and group therapy sessions. Musical characteristics that are utilized with spiritual practices vary greatly, depending on the age, cultural background, and the music preferences of the individual or group. Important considerations regarding musical characteristics include utilizing music that is meaningful to the individual or group. Discovering what music is meaningful to an individual or group can be completed by an assessment or asking the client to bring into the session(s) music that is important or significant to him. Music that is meaningful to the client(s) allows for greater exploration into one’s purpose and meaning in life.

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It is helpful to focus on musical elements that are related to characteristics associated with spirituality. Connection and support are experienced through the musical elements of harmony and rhythm, as harmony is a tonal representation of relationship and connection is experienced as rhythms that intersect and work together. The level of consonance in music can be indicative of a sense of peace and calm, which can allow a client to experience a sense of wholeness. The peace and calm within music and musical elements can also be representative of being in nature and fostering a connection with nature, Divine Spirit, or God. The consonance and open and expansive feeling that can be created musically through slower rhythms and tempos, instrumentation, harmony, and structure in the music allows clients to transcend their own experiences by being in the music. This can allow the client(s) to rise above or transcend their own experiences or struggles.

REFERRAL AND ASSESSMENT PROCEDURES The therapist may notice comments or questions that arise in sessions that indicate the client may be exploring or struggling with spiritual issues. This is an opportunity to further assess their spiritual needs. Assessing spiritual needs begins with understanding what issues or areas are encompassed. Many spiritual assessment tools include the following: hope, strength, meaning, comfort, peace, love, connection, sense of well-being, involvement in organized religion, and personal spirituality. These areas can be assessed by asking questions such as: Are you active in a faith/spiritual community? How and when do you connect with your spirit? When have you felt a sense of peace in your life? What helps you find meaning in your life? What gives you meaning? What gives you hope? When do you feel a sense of love for self and others? When do you feel a sense of inner strength? There are also formalized spiritual assessments that can be utilized to further assess spiritual issues. These assessments can help to identify spiritual issues and needs to be addressed in order to better develop goals and objectives for the client’s treatment plan. A listing of spirituality assessments is included at the end of the chapter. Many health care organizations may have chaplains or spiritual directors on staff who assess and address the spiritual needs of clients. While spiritual care departments exist, it is important to know when to refer a client for spiritual care services. If a client is involved with a spiritual or faith community, it may be appropriate to encourage or refer him to meet with a pastor or priest in order to best meet his spiritual needs. Spirituality is a personal experience, in that what it means to one person may vary greatly to the next. Spirituality is an individual as well as a community experience as it relates to connectedness and relationships. Due to the individual nature of one’s spirituality and religious and collective experiences, it is important to be respectful of a client’s spiritual and religious views and beliefs. Lo et al. (2002) provide the following guidelines when addressing spiritual practices and issues: The therapist should not impose her own beliefs and must respect the client’s beliefs and follow the client’s lead. It is also important to recognize when additional resources might be warranted for a client and when a referral may be appropriate for a chaplain or spiritual care provider.

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OVERVIEW OF METHODS AND PROCEDURES Receptive Music Therapy • •

Song Analysis and Discussion: Clients listen to a song and explore and discuss its personal meaning with the therapist. Directed Imagery and Music: involves using music while guiding the client through an imagery experience using a script based on the client’s needs.

Improvisational Music Therapy • •

Empowerment Drumming: Individuals in the group take on leadership roles in the course of a drum circle to foster a sense of empowerment. Group Toning: Clients breathe deeply and tone on various vowels and tones in a free manner.

Re-creative Music Therapy • •

Group Singing: Clients choose and sing songs together with accompaniment provided by the therapist. Group Drumming: Clients interact musically by re-creating specified African rhythms in a drum circle.

Compositional Music Therapy • •

Songwriting: The client and therapist compose a song to support the client’s spiritual needs. Group Music Composition for Meditation: Clients compose meditative music together as a group, then notate, re-create, and record it.

GUIDELINES FOR RECEPTIVE MUSIC THERAPY Song Analysis and Discussion Overview. This method involves listening to a song and discussing its personal meaning with the client. Song analysis is a tool that can be utilized for group or individual music therapy sessions. For group purposes, song analysis can help foster connections among group members as well as explore a particular topic or focus that is common among them as a group. Within the group process, each member may discover new meaning as the topic is explored and discussed as a group. The intervention may be utilized when helping a group to connect or develop a sense of awareness or understanding of one another. It may also be utilized to explore a particular topic that the group needs to process through in greater depth. Songs serve as a means of communication and can express what a client may wish he could say or may express something he would like to hear. Each element in the song helps to convey this message. Therefore, understanding the elements of the song and how they work together and how clients may relate to these is important in the process of song analysis. Song analysis may not be appropriate if the therapist has a group that is not ready or able to discuss feelings or issues in depth. Given the nature of

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spiritual practices and issues, it may be contraindicated to utilize music with religious references for a group with very diverse spiritual beliefs. Song analysis and discussion is a form of music psychotherapy (Gardstrom & Hiller, 2010) and is used at the intensive and primary level. Preparation. A song or songs can be selected (by the therapist) based on the focus of the group or a topic that relates to the group members. It is important for the therapist to listen to the song prior to the session to understand the elements of the song and how those elements work together and impact the listener. This includes the vocalist, harmonies, consonance and dissonance, tempo, rhythm, dynamics, instrumentation, and the lyrics. While the group members may not be able to identify or discuss the elements of the music by which they feel impacted, it is helpful for the therapist to understand the relationship of the musical elements and how they are an integral component of the song and what it is communicating. Gardstrom and Hiller (2010) encourage music therapists to consider the following when choosing a song: a client’s perception of how they may identify with the song, how the client may empathize with characters in the song, the client(s) projection of themselves or their experiences onto those described in the song, the client’s cognitive capacity, a client’s stage in treatment, gender, song familiarity and preferences, theme or focus of the lyrics, mood or emotion of the song, singer’s perspective or the point of view of the song, various elements and attributes in the accompaniment, and the presentation of the song, whether live or recorded. There is no one right answer but several points to consider when selecting a song for a session. Keeping the client or group in mind while considering these different areas will help determine songs most appropriate for their therapeutic process. The therapist may or may not decide to bring the lyrics of the song to the session. If lyrics are provided, be sure the lyrics are consistent with the recording. Inaccuracies can become a distraction for the listener. Also be sure to provide enough copies for each member of the group to have their own lyrics. If there is any significance to the particular artist or group that recorded this song, obtaining this information can be helpful, if it pertains to the focus for the group or discussion of the song. It is also helpful to gather significant information about the song itself, if it pertains to the group or the discussion of the song. This may include the intention of the songwriter or the story of how the song was written. It is helpful to have the room set up with comfortable seating and have the chairs in a circle. Sitting in a circle allows each member of the group have a connection in this configuration, so they are able to see and hear one another. It also ensures that the facilitator can see and hear each group member. The sound source should be close enough to the circle that it can be operated with ease and from a seated position within the circle. This allows the process to be fluid and uninterrupted by the therapist having to get up from the circle to start, stop, or adjust the music. If the sound source cannot be moved close to the circle, a remote control can be a helpful tool to allow the facilitator to remain in the circle.

What to observe. Observe the group as they listen to the song, noticing body language and facial expressions as the group listens. They may have reactions to certain lyrics or musical moments within the song. Songs can connect to our emotions, and this may stir an emotional reaction. Observe how the group listens as a whole. Do they make eye contact with each other or do they listen and focus inward? When the song is done, notice how the group returns from the listening experience to the group discussion of the song. Procedures. To begin the intervention, tell the group that you have selected a song to share with the group. For example the song “Little Butterfly” by Jana Stanfield describes feeling closed off and isolated from others and being afraid to reach out and connect. “Beauty from Pain” by Superchick is a song that describes finding a sense of hope, strength, and meaning in the midst of life’s struggles. In the process described above, the therapist selected the song; one adaptation is to use songs selected by the clients. The therapist may choose to provide a focus or theme for the song selection process. This could include a song that describes the client’s experience of his struggle or a song that

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describes or expresses what gives him meaning in this process. Whatever focus or theme is selected, allow it to be broad enough that the client can personalize it and bring his perspective to it. It will be important for the therapist to discern whether the group members are ready to share a song within the session. It may be helpful to begin the process with a therapist-selected song to allow the group to experience the process of listening to and discussing their own experiences of a song with the group. This can allow them to acclimate to the process and begin to feel a greater sense of ease in sharing with each other on a more personal level. Begin by describing the procedure for the group, explaining that this will include listening to the song and having some time after the listening portion to share their thoughts, feelings, and experience of the song. If printed lyrics are used in the session, have the group listen to the song initially without lyrics, as this allows the listening experience to be an emotional experience rather than a more cognitive experience in which they read the lyrics as they hear the song. Listening without lyrics not only allows for a greater emotional connection, but also has the clients rely on the lyrics they perceive as opposed to the actual lyrics. This again permits them to project their own experiences onto the music, as they rely on what they are hearing and how they connect with it. After the group has listened to the song (without the lyrics), ask them to share any thoughts they may have about it. This may include feelings, any part of the song that captured their attention, any lyrics that stood out to them, or any other part of the song to which they connected. The comments that group members share may connect their life experience to the song. Clients may project their experiences into the song, as if the song is about their own experiences. Therefore, comments, thoughts, feelings, and experiences that are shared in the discussion allow the facilitator the opportunity to ask questions that give depth to the processing and help the clients connect to their own experiences and to shared or common experiences of fellow group members. When the discussion reaches a point where it feels appropriate to introduce the lyric sheets, distribute them to each group member and play the song again for the group. After listening to the song with the lyric sheets, ask the group if they have any other thoughts, feelings, or reactions to share. Follow up with any questions to allow for additional discussion as time allows. In closing the session, you may wish to ask the group to end with a question connecting back to the song. For example, what is one thing from the song you would like to take with you today? Allow each member of the group to respond to the question as a closing. This gives an opportunity for each member to share their own experience of connecting within as well as connecting with each other as they share this information. Adaptations. Song or music communication (Bruscia, 1998a) can also be utilized in an individual or group session. This process includes the therapist asking the client(s) to bring in a song or piece of music that expresses or describes something about the client that is relevant to their therapeutic process; it can also include the therapist selecting a song or piece of music that relates to the client’s process. Song dedication is another adaptation that can be utilized in a group session. This entails having each client select a song to dedicate to someone in the group and bring the song to the session to share. The client will choose in the song what he feels his peer may need to hear in it. A song or piece of music may be sung and played live. The music therapist needs to discern whether a live or prerecorded version would be best for the group or individual session. Each is a viable option but brings differences to the overall listening experience. In a live experience, the listening has a greater connection to the vocalist and can bring a greater level of compassion and being cared for, in that the therapist is singing to the group. Utilizing a prerecorded version may be warranted if there are aspects of the recording that are unique and cannot be done live. For example, there may be instrumentation in the recording that adds to the expressiveness of the song that cannot be completed live. Also, if the gender of the vocalist is significant to the song and differs from the gender of the therapist, this may warrant using the prerecorded song.

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Directed Imagery and Music Overview. Directed imagery and music involves using music while guiding the client through an imagery experience using a script based on the client’s needs. Directed imagery and music can be utilized to facilitate relaxation and connecting to one’s own energy. For a group or individual who may be stressed, overwhelmed, anxious, or feeling disconnected from his own spirit, energy, or compassion for self, directed imagery and music can foster this connection within. While this method can be utilized for a wide array of goals in therapy, in this area of spirituality and spiritual practices, the focus is on connecting within. In order to do this, it also requires achieving a relaxed state. While the goal of the intervention is connecting within, relaxation is a by-product of the experience, since a relaxed state is necessary to help quiet the mind to reach a meditative state to connect inward. This experience is often and typically contraindicated for clients who are psychotic or who may dissociate or hallucinate or have a history of trauma. This can be especially difficult to manage in a group directed imagery and music experience. Therefore, it is important to know if the members of the group are appropriate for this type of intervention. Directed imagery and music is a basic method of music therapy that the music therapist can facilitate at the augmentative level. However, with practice and experience, skilled music therapists are able to guide more freely and without the aid of written scripts. Continued practice and skill development further enhance guiding and selecting music appropriate for the experience. Preparation. Begin by finding or creating the script for the directed imagery experience. (Scripts are included in the Resources section). The overall experience is focused on connecting within to one’s own energy or spirit. One may choose imagery that focuses on being present at a relaxing place, on letting go of something they no longer want to hold on to, on receiving a gift they may need in their life, or on following a path that helps them discover what they want or need. Next, select the music that supports the imagery experience. Consider the script and the intention of the experience, as well as the movement or lack of movement. For example, if the imagery includes walking on a path, gentle movement in the music will support this. If the imagery is focused on being in a relaxing place, music that has little movement will help support holding them there. Determine which musical elements will support the imagery you have selected. Overall, look for music at a slower tempo to help slow down the rhythms of the body; this will allow the participants to begin to breathe to this tempo and begin to slow the breath and help facilitate the relaxation response. Also consider music that provides an open and expansive feeling, as it facilitates connection with one’s own energy or spirit and taking in the energy one needs. Whenever possible, it can be helpful to let the clients know to dress comfortably for the session to further facilitate their ability to relax. It is important to have a space large enough for members of the group to be comfortable and not feel crowded. It is helpful to have space to accommodate the different needs that people may have in being able to get comfortable. Yoga mats and headrests may be utilized to allow group members to get comfortable on the floor. It is helpful to have some yoga props such as bolsters to help provide any back support for those who might want or need it. Reclining chairs can allow individuals to get into a comfortable position without being on the floor. It is also helpful to have blankets to allow participants not only to feel a sense of security, but also to be warm enough in the process of relaxing. Take time to find out how to dim the lighting in the space to further facilitate the clients’ relaxation. This may be accomplished with a dimmer switch on the room lights or, if that is not possible, with battery-operated candles to soften the light in the space. Getting this determined ahead of time reduces the amount of time it takes to accomplish this within the session. Determine the best location in the room to guide the experience. Ensure that everyone will be able to hear the verbal guiding and also be able to hear the music as well. Having the layout of the space

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determined in advance will allow the group members to find their own space according to what feels comfortable for each of them. What to observe. In the process of the directed imagery experience, it is important to observe the body language, facial expression, and movements of the participants. This will indicate when they are relaxed enough to move from the relaxation portion of the guided imagery experience into the imagery portion. If clients are moving or fidgeting, it may mean they are physically uncomfortable or distracted. The therapist can offer encouragement or directions while guiding; for example, if members are struggling with distractions, guide them to notice the distracting thoughts and let them go, bringing the focus back to the imagery, the music, or their breathing. Procedures. Begin by introducing the plan for the session today. Give a brief description of what the session will entail and answer any questions the group may have. Then allow a few minutes for participants to get what they need to get comfortable for the session. Ensure that when they are settled into place they can adequately hear the music and the guiding and that everyone is also comfortable with the dim level of lighting. When everyone is comfortably in place, start the music and begin the relaxation component of the experience. The directed imagery experience must begin with a brief relaxation in order to help the group transition into the imagery portion experience. This can include focusing on the breath and doing diaphragmatic breathing. Determine which experience will best match the needs of the particular individual or group. This might include a body scan (Kabat-Zinn, 2005), imaging a warm light bringing energy to the body, feeling their heart beating and sending energy throughout the body, or creating your own way of sensing energy and spirit in the body. Be sure at the end of the directed imagery experience that participants are guided back to the space around them, helping them transition from the imagery back into reality. Scripts as well as guided imagery script resources are included in the resources section at the end of the chapter. Following the directed relaxation experience, move directly into the directed imagery experience. Scripts should help clients to experience a sense of peace and discover a place that is calming or comforting for them or help them to explore what they need at this time in their therapeutic process by evoking imagery that focuses on connecting within. When the experience is complete, guide the participants back to the room. This can be accomplished by guiding the client(s) to bring their image to a close, begin to become aware of the space around them, take in the sounds around them, feel the mat or cushion that supports them, bring their awareness back to their breathing, breathing in deep and letting that air out, and, when they feel ready, beginning to wiggle their fingers and toes. Finally, the clients are directed to slowly open their eyes and come back to this space when they feel ready. When everyone is focused back in the space, it is important to take time to allow each person to share his experience with the group. While this is a group experience, it is also an individual experience of going inward. Participants may or may not choose to share their experiences, but it is nevertheless important to ascertain that they are in a calm and alert state of mind before leaving the session. Adaptations. There are many adaptations that can be utilized within the directed imagery and music experience. The therapist may choose to utilize live music as a part of the experience. When doing so, ensure that the music supports the intention of the imagery experience and that the therapist can guide the clients smoothly while playing the music. The directed imagery itself can be adapted as well. The therapist may choose to use images of nature to foster a connection with the outside world or a Higher Power. The directed imagery could include images of significant people in the client’s life to foster a connection to others. The imagery could also include receiving what they need to feel a sense of wholeness. With any adaptation, it is important to select the music that supports the imagery. Closing experiences might include drawing, creating a mandala, moving to the music, or journaling, in addition to verbal discussion.

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GUIDELINES FOR IMPROVISATIONAL MUSIC THERAPY Empowerment Drumming Overview. This experience involves facilitating individuals in the group to take on leadership roles in the course of a drum circle to foster a sense of empowerment. Empowerment drumming in a group can be a helpful intervention for persons who may have a tendency to intellectualize or stay more in their thoughts; the process of drumming helps them shift to being in their body and to discover this part of themselves. For persons who struggle to engage in the verbal process, utilizing a nonverbal means of interacting can help to facilitate an intense level of engagement that can lead to verbal processing about the experience. Empowerment drumming allows clients to explore and discover their connection within the music. They discover how they relate to each other as well as their own sense of self. In the process of actively engaging in music-making, individuals can experience a sense of transcendence, as they become fully present in the moment and are able to step out of their thoughts or struggles. The active drumming process can also shift and move energy in the body, allowing participants to feel more energized or inspired or helping them connect to their own creativity. However, individuals with auditory processing or sensory issues may find the process overwhelming and become more anxious due to all the auditory information that is processed in the drumming experience. Clients who have experienced trauma may feel overwhelmed by the sound, and it may trigger a traumatic memory, depending on the nature of their trauma. This process can also be contraindicated in a group setting for clients who dissociate or hallucinate or are psychotic, as the sound may be overwhelming. While group drumming is a common practice in music therapy and an entry-level music therapist may be able to facilitate a drum circle, empowerment drumming is moving into the realm of exploring the relationship and connections to self and others in the experience. This requires additional facilitation experience or training to bring the group process to this therapeutic level in the drumming. The level of practice is intensive. Preparation. The space for the session will need to be large enough for the group to be comfortably seated in a circle with instruments in the center. Again, since drumming can be a louder experience, it is important to have space for the session that will not disturb any individual or group that may be taking place at the same time. Depending on the group, it can be helpful to have the instruments already in the center of the circle when the group arrives. If this may be distracting for the group, the instruments can be moved to the center of the circle at the beginning of the drumming experience. Be sure to have a wide variety of instruments available for group members to allow participants to change or explore using different instruments throughout the session. In addition to the drums, include rhythm instruments, such as those described for the drum circle, which will provide variety of texture and timbre. These options for instrumentation allow group members the power and freedom of choice within the session. The variety of instruments also allows group members to explore different sounds they may like and how sounds work together. What to observe. Notice how members of the group approach the instruments, whether or not they are eager or hesitant or need support and encouragement to engage. They may need time to explore the instruments to discover what they want to play. Observe if there are instruments from which they shy away. For example, someone may choose only small rhythm instruments and avoid playing a drum or avoid the larger drums. Listen to the overall sound to hear if they are playing as a group or if they are playing as individuals. Are they responding to each other in the music? Also notice if someone has a tendency to play in a way that overpowers others or if they are playing rhythms that do not seem to

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integrate into the rhythms of the group. The group may struggle to stay together musically if they feel pulled by a conflicting rhythm. In the process of drumming, notice when the group becomes more comfortable and confident playing the instruments. Observe what happens to the music when this occurs. Listen for the moments when the group is in their “groove,” when all the rhythms are working together. Be sure to make note of these moments and process them with the group. Procedures. Begin by seating the group in the circle and then introduce members to each other and do a brief check-in. Follow the opening with a discussion of what the word empowerment means to each person. Let the group know they will be exploring the experience and feeling of empowerment in the drumming and that their experience of empowerment will be discussed at the end of the session. Be sure to refer to the definition or words the group used to define empowerment so these personal feelings and ideas can be incorporated into the discussion again at the end of the session. If there are members of the group who have not been involved in drumming before, they may need a brief introduction to the various instruments and how each one is played. The group may also need brief instruction on how to play hand drums. Keep this instruction brief and encourage participants to explore and discover the sounds the instruments are able to produce. When the group is ready to begin, the therapist, in the role of facilitator, plays a basic and consistent rhythm (calling rhythm); this rhythm serves as the structure for the group. Encourage the group to begin playing when they are ready and to play a rhythm that matches what the therapist is playing or a rhythm that complements what she is playing. Keep the rhythm consistent and allow the members of the group to play within the structure of this basic rhythm. Keep playing until the group feels established and solid in the experience and then slowly bring the volume down and fade out the drumming. Take time to process the experience with the group, asking them to share what they noticed and experienced. Next, ask a member of the group to play the calling rhythm using a gathering drum or one of the larger drums. Allow the individual who is playing the calling rhythm to introduce his rhythm and instruct the other group members to begin playing a rhythm that matches or complements the calling rhythm when they are ready. The individual playing the calling rhythm will determine and then communicate the change by beginning to bring the volume down and slowing the rhythm and eventually fading out the drumming. Take time to process the experience with the group, asking them to share what they noticed and experienced. Ask the individual who played the calling rhythm how they felt and what they noticed during the experience. For the final experience, ask each member of the group to select the instrument he would like to play and come back to his seat in the circle. Let the group know that during this next experience there will not be a calling rhythm, but that the playing will begin when someone in the group feels ready to play, and that each person can join in when ready. Instruct the group members to be present in the silence and let the rhythms and music emerge from within. The therapist continues to play until the group feels established and solid in the rhythm and then slowly brings the volume down and fades out the drumming. Take time to process the experience with the group, asking them to share what they noticed and experienced, for example, asking them what felt different from one experience to the next. After processing the experience, return to the word empowerment that the group discussed at the start of the session. Share again how the group described or defined empowerment and ask if they experienced that within the drumming. Ask them to share specific moments and how that felt. Help the group identify and discuss how these empowering experiences apply to their lives. Some clients may express not feeling empowered by the experience, but feeling lost at times in the music experience. It may be helpful to identify if such a client experiences that sense of “being lost” in life. This insight may provide an opening to further address and discover how he can begin to find his way rather than feel lost. Finally,

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to close the session, ask each member of the group to share one thing he is going to take with him from the experience today. This may be a one-word description or a brief phrase. Adaptations. This can be adapted by drumming in nature, allowing the group to experience sending the sound they create out into the world. This can also foster feeling a connection not only with self and others, but also with the energy of the universe. This could also serve the function of a meditative experience for some, especially when the group sets the intention of creating a meditative experience. To facilitate this, the group might discuss what they need to hear in the music to render it meditative and then create those sounds for themselves. Afterward, the group can explore how it felt empowering to create what they wanted or needed in the experience. This can also be utilized within family-based work to explore dynamics within the family system. However, working with families does require additional family therapy training or collaboration with a family therapist.

Group Toning Overview. This involves breathing deeply and toning on various vowels and tones in a free manner. It is appropriate for a group that has a good level of group cohesion and is receptive to exploring the use of the voice in this open manner. The goal in this experience is to facilitate connecting to one’s inner self through one’s breath, voice, and energy, while also connecting to others through the collective creation of tone and sound. This experience can also be relaxing and meditative. Using the voice in this manner is intimate and individuals can feel more vulnerable. Clients with any trauma in their background may feel too exposed in this type of process. This would not be suitable in a group setting for clients who are psychotic, delusional, or actively hallucinating. The level of therapy is augmentative. Preparation. Vocal toning is very simple to do. However, it is helpful to experience or practice toning before facilitating a toning session. The following steps are suggested: (1) Get into a comfortable position. (2) Begin to take slow deep breaths. Make each inhalation long, slow, and as deep as possible. With each inhalation, try to breathe a little deeper. (3) Exhale as slowly as possible, allowing the tones to come out for as long as possible. (4) Tone on a pitch or on pitches that feel most comfortable. Use any of the vowel sounds: a, e, i, o, u (oo). (5) Keep repeating this for approximately five to ten minutes. It is important to determine which configuration may feel most comfortable for the group. It is best to have the group in a circle to ensure that they can hear each other. For example, yoga mats can be laid out in a circle format for members to lie on with everyone’s head at the center of the circle; alternatively, meditation mats or cushions can be placed in a circle for members to sit on. It is ideal to have a space that allows the sound to fully resonate (wood and stone allow for the greatest resonance), if that option exists. It is also helpful to have lighting that can be dimmed, as this is a meditative and relaxing practice. A singing bowl, drum, or rhythm instruments may be made available to use during the toning experience. What to observe. When everyone has taken his or her place in the circle, notice whether everyone is comfortable. Be sure to have headrests, blankets, or yoga bolsters available to helpful ensure that everyone is physically at ease. When everyone is comfortably in place, continue to listen throughout the experience to notice if everyone is engaged and provide any needed support or encouragement. When the toning is completed, and as the group begins to sit up and face each other, notice body language and facial expressions. Observe if the group appears more relaxed compared to start of the session. Notice interactions in the processing portion of the session, to see if their connection with self or others has shifted as well. Procedures. Ask each group member to get a mat or cushion and to gather in a circle. When everyone is settled, check in with each participant and ask how he is feeling today and if there is anything

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anyone wants or needs from the experience today. Next, ask everyone to move into a comfortable position in the circle on his mat or cushion. Begin by guiding the group through a deep breathing exercise. This can be accompanied with live or prerecorded music to help entrain the breath. Following the deep breathing exercise, remind the group that they can tone on any of the vowels and explore tones and sounds, using various vowel sounds and pitches. Harmonies may emerge as well as experiencing consonant and dissonant sounds. Suggest that they may feel more comfortable with their eyes closed. It is important to note that some clients may be self-conscious about singing and may not want to sing very loudly. It can be helpful to give participants permission to sing at a volume that feels best for them. You may find at times that a client may sing loudly and overpower the experience. If this occurs, it can be helpful to let clients know they should be able to hear others at all times. As the facilitator, the therapist may choose to begin the experience by leading with a tone for the group to use as their starting point. Provide support and allow the group time to experiment and become attuned to the experience. As voices naturally begin to quiet and the toning fades, guide the group to take some slow deep breaths and encourage them to notice how they feel. Guide the group back to the space and ask them to open their eyes and to sit up when they are ready if they have been lying down. Take time to ease the group from the experience into the processing portion of the session. Ask the group members to share any observations or experiences from the toning exercise. Encourage them to notice how they felt during the experience and how they feel afterward. Remind them that toning is something they can do on their own as well. Adaptations. For groups that have never toned before and that may feel some apprehension, playing a drone sound in the background will give them a constant tone to build upon. A shruti box or a singing bowl may be helpful for this. This can also help those who are new to the experience to feel that their voice is less exposed. A gentle rhythm on a drum could be utilized as well. A word or phrase can be introduced into the toning experience so the group can tone or chant the word or phrase. The word can be toned in an elongated fashion, or group members may explore different ways of toning or chanting it. The word or phrase could serve as the intention of the group or something the group wants or needs from the session that day.

GUIDELINES FOR RE-CREATIVE MUSIC THERAPY Group Singing Overview. This involves the group choosing and singing songs together with accompaniment provided by the therapist. Singing in a group provides a sense of connectedness. Voices joining in unison and in harmony create a feeling and experience of togetherness. This can be helpful for a group that has developed a connection and may need to experience a feeling of support or deeper connection with others. Group singing can also allow an individual to experience one’s sense of self and others simultaneously within the music. The goals for this experience include understanding the connection between members as they sing together, the significance of that connection, the sense of vulnerability experienced through one’s own singing voice, and the sense of community that can be fostered in the experience. These skills are developed more profoundly with additional experience. It is important to have good group cohesion before introducing a group singing experience. The singing voice is more intimate and personal than the speaking voice, so if good group cohesion is not present, asking group members to sing with each other may make them feel uncomfortable or too vulnerable. Facilitating group singing is a skill that an entry-level therapist possesses. This experience is at the augmentative level of therapy.

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Preparation. It is helpful to have a collection of songs that will be utilized with the group. Songs should be selected based on the preferences and expressed interests of the group members. This will ensure that the songs included in the session are the songs they are interested in singing. The songs may focus on a particular theme or topic such as support, friendship, and connection. The theme can be the message inherent in the song, but also within the experience itself. It is helpful to have lyric sheets or music (if possible) for each member of the group. This will increase their level of participation, as they may not know all the words to each song. The room should be large enough for group members to sit comfortably in a circle. This allows the group members to face each other, to feel a connection within the circle and to hear each other’s voices. The therapist should sit in the circle with the group and have the accompanying instrument situated so that she can see each member of the group. What to observe. It is important in the group process to observe everyone’s participation and that participation feels balanced within the group. Notice when the group sings if the voices are balanced or if a voice is overpowering the group. Any overpowering dynamic in the group can impact one’s sense of support or connection within the group. Notice if there is enough support being provided by the accompanying instrument. Participants may need to hear a stronger sense of rhythm to feel supported within the music. This may also shift and change the more a group sings together or depending on their familiarity with any given song. Be sure to notice how the level of support needed from the accompaniment may change at time throughout the session and be responsive to those needs. Procedures. When everyone is seated and the introductions and check-in have been completed, distribute the lyrics or music sheets to the group members. Invite them to take a few moments to look at the songs included. Ask them to decide as a group what they might like to sing first. After singing the song, ask the group how it felt to sing together and encourage them to share their thoughts, feelings, or observations about the song or the experience. Clients may comment on how it felt to sing together, what the song meant to them, if their mood changed, or what they noticed about others. Allow for time to share and discuss these experiences following each song the group sings together. Continue to sing the songs requested by the group, providing discussion time following each song. When it is time to close the session, allow enough time for one more song. This song can serve as the closing for the session. Let the group discuss and decide what song they would like to use to close the session. After the final song is completed, the therapist can end the session by giving the group a moment of silence and holding the musical moment. Another way to close the group is to ask each group member to share a word that describes their experience of singing in the group. Adaptations. This might include changing the theme or topic for the songs based on the needs of the group, or asking each member of the group to bring the lyrics and chords to a song that fits a particular focus or theme. Another option is for the therapist to choose the theme or song. An example of this could include selecting the song “Lean on Me” by Bill Withers for clients who have a difficult time allowing themselves to accept support from others or who have a tendency to isolate. In a similar manner, the song “Life Uncommon” by Jewel explores finding your strength, hope, and courage in the midst of the struggle. Having rhythm instruments available will allow group members to play along as they sing.

Group Drumming Overview. This method involves interacting through re-creating specified African rhythms in a drum circle. Learning basic African rhythms can be helpful in the group process to foster the development of group cohesion. This intervention can be appropriate for a group that needs to practice listening to one another. It is important for the group to be able to practice listening to the rhythms provided by the facilitator and then work together to re-create these rhythms. If the group is not yet able to work within

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this type of call-and-response structure and tolerate working cooperatively to learn some complex rhythms, they are likely not ready for this intervention. Group drumming is a practice that many beginning music therapists may feel comfortable facilitating; additional training may be required to learn some basic African rhythms and facilitate this type of experience. This practice is at the augmentative level of therapy. Preparation. The room will need to be large enough for the group to be seated in a circle with instruments in the center with space for participants to be able to change instruments throughout the experience. Since drumming can be a louder group experience, it is important to have space for the session that will not disturb any individual or group activity that may be taking place at the same time. If keeping a low volume is necessary for the space or facility, this can be addressed with the group prior to the session by reminding them to be mindful of the volume of their playing or by utilizing Not So LoudTM drums manufactured by Remo, Inc. These drums provide a softer resonance and are designed for use in settings where sound needs to be minimized. Be sure to have a wide variety of instruments available for group members; this will allow participants to change or explore different instruments throughout the session. In addition to the drums, include rhythm instruments that will provide a variety of textures and timbres, for example, various sizes of djembes, tubanos, and frame drums; bongos; maracas; egg shakers; cabasa; tambourine; triangle; claves; frog rasp; and shekeres. These options for instrumentation allow group members greater power and freedom of choice within the session. The variety of instruments also allows them to explore different sounds they may like and to discover how sounds blend together. What to observe. It is important in the group process to observe everyone’s participation, which should feel balanced within the group. Notice if anyone is overpowering the group with their playing. Any dynamic of overpowering within the group can impact one’s sense of comfort, safety, support, and connection in the group. Notice whether there is enough instruction or support being provided. Participants may need to hear a rhythm broken down or played in a simplified way to be able to play it back. This may also shift and change as the group becomes more acclimated to the experience, as their confidence in playing builds, and as they develop group cohesion within this experience. Notice how group members listen and respond to each other rhythmically and musically. Observe any shift of affect during the experience. Notice if postures or body language change or if there is a change in any individual’s level of comfort or confidence during the drumming experience. Procedures. If there are members of the group who have not been involved in drumming before, they may need a brief introduction to the various instruments and how they are played. It can also be helpful to provide some cultural background to the role of drumming within the African culture, sharing briefly the function of the different drums and of drumming in the community life. Begin by introducing a basic African rhythm to the group. When the rhythm feels set in the group and the group is playing the rhythm cohesively, remind the participants that they can change instruments throughout the experience. As the group feels more and more solid in the rhythm, begin to add different rhythmic motif, to the extent the group is able to do so. Ask the group to hold the rhythm at a steady and consistent pulse, and then demonstrate another rhythmic motif and identify two group members to play this new rhythm as the remainder of the group holds the original rhythm. Continue to add motifs as long as the group is able to imitate them. As the facilitator, ensure that each rhythmic motif can be heard. It may be necessary to direct the dynamics through the use of hand signals. When it feels appropriate, direct the drumming to a close through the use of head gestures or hand signals. Take time to talk with the group to process the experience. Ask them to share what they noticed, felt, heard, or experienced during the drumming. Ask the group to consider if there are any similarities between what happened in the music as they drummed together and how that might be

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similar to what happens in life. Highlight and validate any connections they are able to make about their experiences drumming and their relationship to self and others. Adaptations. Singing or chanting an African song can be added to the drumming. This could also be adapted by using rhythms and songs from another culture. You can choose a culture(s) that may have a connection to the focus or goal for the therapy session. For example, you could discuss how in the African culture and with those persons forced into slavery, spirituals were sung as a way of expressing and coping with struggle and feeling a sense of community in the midst of the struggle. This process could include rhythms, songs, or chants that are utilized to express cultural struggles, allowing communities to join rhythmically and musically to support one another through the struggle.

GUIDELINES FOR COMPOSITIONAL MUSIC THERAPY Songwriting Overview. The therapist composes a song with an individual client or group to support their spiritual needs. When a client needs help connecting within or deepening his spiritual practice, songwriting can serve as a message to one’s self or as a prayer or meditation. When a client is looking for a way to connect within or to his Higher Power and to develop a practice of doing this on his own, creating a song to support this practice can be helpful. The song can then be recorded and the client can use his own song as a meditation or as a part of his meditation practice. The goals for this process include helping the client determine what he wishes to say or hear in his song to support his meditative practice and to connect with himself or his Higher Power, and to foster a sense of power within (empowerment). Clients who do not have some idea about what they wish to say within their song may not be ready to engage in this method. It is important that the words are those of the client in order to help him foster a connection that is authentic. While songwriting can be a simple or complex process, in the realm of spiritual practices, this emerges as a music psychotherapy practice and would be practiced at the intensive or primary level. Helping the client find his own words that foster a connection with self or the Divine establishes a deep, intimate, and personal relationship. Because of the deeply personal focus of this experience, this method is practiced in an individual session. Preparation. To prepare for the session, it can be helpful to ask the client to begin to gather and bring in his own journaling, quotes, scripture, readings, and poems that he is drawn to or already uses in his meditative practice. Be sure that paper and writing utensils are available, or a computer to type the words directly into a document. Ensure that instruments that the client would like to include as a part of the song are available so the lyrics can be played and heard with the specific instrumentation in the songwriting process. The space should be comfortable enough to allow working with the client without feeling too crowded, but also not so large a space that it feels too open, creating a feeling of vulnerability for the client. What to observe. Be sure to observe whether the language in the lyrics is that of the client, taking care to ensure that words or phrases do not get imposed on him. Notice if the client is struggling with the language or what he is trying to communicate. If so, ask questions and work to clarify to help him find his language or words. The client may also need input regarding musical elements, but again, ensure that the client is creating what he wants and needs, so he will still have ownership of the creation. Procedures. Begin by brainstorming words, concepts, and ideas that come to mind with a focus on writing the song for the client’s meditative practice. These words and ideas can be grouped or prioritized to help pull concepts together. They can be written on paper and laid out in front of the client and therapist so that the words and ideas can be drawn, upon in the midst of the writing process. Begin to formulate the lyrics utilizing words and ideas from this list. Sometimes a verse will emerge first or

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sometimes the chorus. It is helpful to begin the process and be open to what emerges without setting constraints on what needs to happen first. If an intended verse feels like it may actually work as a chorus, work with the client to determine what he or she would like to do. Continue writing until the song reaches a desired state of completion for the client. When the lyrics are complete, take time to help the client discern the music that would best accompany them. This may include exploring different instrumental sounds and harmonic sequences to allow the client to hear what he wants musically. When the instrumentation and harmonic sequence have been determined, begin to create the melody for the song. This involves trying out different melody lines and helping the client determine the melody that helps to communicate what he wants to say with his song. Once the composition is completed, the therapist can record the song with the client. It may take more than one session to complete the entire process. When the song has been recorded, create a CD of the recording to give to the client. Discuss with the client how he might use the song at home as a part of his meditative practice. After the client has had an opportunity to utilize his recording as a part of his meditative practice, talk with him about the experience. Adaptations. There are several ways to adapt this process. If the client enjoys writing his own poetry, he may have a poem he has created that he would like to utilize. He may wish to write the song in the form of a poem, prayer, or chant. A mandala could be created to use alongside the song or as a focusing or starting point of the meditation. In this process, have the client get into a comfortable position, with the paper and drawing materials at the ready. Ask the client to close his eyes and to begin to take some slow, deep breaths. When their breathing is slowed and deep, introduce the song into the meditative process. As the song begins, direct the client(s) to begin to create his mandala when he feels ready. If the client needs more time to complete his mandala, either replay the song or choose some instrumental music to play as he completes the mandala. Clients who practice yoga may choose to incorporate yoga poses into their meditative practice with their song as well.

Group Music Composition for Meditation Overview. This intervention involves composing meditative music together as a group and then notating, re-creating, and recording it. It is designed for a group that has a good level of cohesion, has the ability to work together cooperatively, and can form connections with each other. The goals in this process include connecting with others in a sense of community and creating a tool to foster and support their own self-care or meditative practice. Following the completion of the music composition, the goal will be for group members to continue to use their creation to accompany their self-care practice; this composition will serve as a reminder of their experience in connecting to others. This process does require skill on the part of the therapist to draw on music abilities of varying levels from within the group. Some group members may have strong music skills, while others may have limited music abilities. It is the responsibility of the music therapist to help the group determine how each member can best play an integral part in this composition. It is important that the music therapist possess the ability to engage all clients in the process, without allowing any one individual to overpower the group or the process. A group that does not have a strong level of cohesion or struggles to work cooperatively would not be appropriate for this intervention. If participants are not willing to engage in actively creating a composition, this intervention would be contraindicated. This is practiced at an augmentative or intensive level of therapy. Preparation. Be sure to have a wide variety of instruments available to allow the group to explore and determine the instrumentation they want included as a part of the composition. These may include tuned instruments such as guitar, piano, keyboard, xylophones, and bass bars, as well as various

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nontuned instruments including a gathering drum, djembes, tubanos, large frame drum, egg shakers, and chime tree or Tibetan cymbals. It will be helpful to know in advance if there are members of the group who play an instrument(s); if so, they can bring their instrument to the session. Also needed are instruments that those participants with little or no music training or experience can play. The large drums and bass bars produce a deep sound that can create a sense of relaxation and calm; the ocean drum provides a soothing sound connection to the environment; frame drums, djembes, tubanos, and egg shakers provide a consistent rhythm that fosters a meditative state; and the chime tree or Tibetan chimes provide a celestial or ethereal quality. It is also helpful to have a dry-erase board or a large pad of paper on an easel on which to write down ideas, concepts, and chord progressions during the creative and composition process. The room will need to be large enough for the group to be seated in a semicircle with instruments in the center with space for participants to move freely between the instruments. The board or easel with the large pad of paper should be placed at the front of the group. The therapist should be situated near the board or easel to have easy access to write down the ideas or information provided by the group. What to observe. It is important to observe that all group members are actively engaged in the process. Some group members may need prompting and encouragement to actively engage, especially if some possess more music training or experience than others. Remind the group that this is a collaboration of all members and that contributing ideas and creating the pulse and different timbres or sound colors is as important as having skills on a traditional instrument. Procedures. Begin by having the group determine the intention of their meditation. Ideas can be introduced to the group, and the group as a whole can decide on the focus or intention the composition will support. Once the intention is set, discuss with the group what they need to hear and experience in the music that supports the intention. This may include describing qualities of the intention and then describing how these qualities may sound in musical terms. For example, if the intention is to experience inner peace, this may include qualities such as quiet, calm, and stillness. These may translate to musical qualities like slow rhythms, subtle movement, soft dynamics, major tonality, long and drawn out tones, and lower pitches. Once the musical qualities have been determined, begin to explore which instrumentation matches these qualities based on the available instruments and the musical abilities of the group members and the music therapist. This can require listening to various instruments to allow the group to determine the sound qualities they prefer. Once the instruments have been determined, begin to play around or improvise with rhythm, tonality, and melody to determine these elements of the composition. During this part of the process, there may be rhythms or chord progressions that the group decides they would like to use. Continue creating and making notations until the composition is complete. Notations can be written on the dry-erase board in order to hold on to those elements for the composition. The notation of the composition will need to be such that members of the group can read and follow it, regardless of their musical training. Once the composition is complete and the notation is finished, the group will need time to practice their composition before they record it. It is helpful to have the clients listen during the practice session with their intention in mind to ensure that they have achieved what they had hoped with the composition. Changes can always be made if the group determines they are necessary for the composition. Allow the group to decide when they feel ready to record the composition. When the recording of the composition is completed, discuss with the group what their experience of creating the composition was like and how it felt to work together and make these decisions regarding their composition collectively. Copies of the recording should then be provided to each member of the group. The group may decide whether they would like to experience a group meditation utilizing their recording or if they would prefer to meditate individually and come back to the group to share their

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experiences. Allowing the group to decide on these options gives them the opportunity to work together in making decisions as a community. Adaptations. The composition could be adapted to include chanting a mantra using key words or phrases that connect to the intention of the meditation. The composition could be a vocal composition, or be composed of chanting and toning, or be a combination of the two. These adaptations can be made based on the preferences, music skills, and level of comfort for the group members. The composition could also be used in a group experience in which the individuals walk a labyrinth. If the labyrinth is outdoors, this can also allow individuals to combine various spiritual practices by bringing nature into the experience. Group members may find other ways to combine the composition with other spiritual practices. They may find that sharing these discoveries with each other is another way to connect and support one another.

CLOSING REMARKS ON METHODOLOGY Spirituality can be addressed in both group and individual sessions. It is important to determine when it is appropriate to address this in a group session and when it may be more appropriate to address these issues with a client individually. Groups may be helpful when clients are facing common issues or engaged in treatment that incorporates a focus on spirituality, such as some chemical dependency treatment programs that use The Big Book from Alcoholics Anonymous. For group sessions, it is best to keep group size at around 8 to 10 clients, as this supports and fosters sharing and disclosure. If the size of a group gets too large, clients are less likely to engage in discussion or to disclose. In many programs or facilities, music therapy group sessions may be offered one or two times per week. It will be important to gauge and determine with the group if addressing these spiritual issues is warranted on a weekly or periodic basis. Individual sessions to address spiritual issues may be warranted when a more in-depth process or more time is required. To address and process spiritual issues in individual sessions, it is helpful to have frequent consistency in these sessions; meeting a minimum of one hour weekly is advised. This helps to keep the client engaged in processing these issues, whereas less frequent sessions create a rather disjointed process. Determining the format and structure of sessions is dependent on various factors. When working with groups, it is important to understand the level of group cohesion or the level of connectedness between members of the group. If a group is just developing, it may be beneficial to begin with more receptive approaches. For example, the therapist may introduce a song for lyric discussion and foster group members’ connections through the song. Developing group cohesion helps to foster engagement, which will allow the group to engage in re-creative, creative, and improvisational interventions. Deep breathing or brief meditative experiences can serve as tools to begin a session by providing time to focus and connect within and then transition into a guided imagery experience, group drumming, or improvisation. They also can serve as a means of bringing focus and allowing clients to connect within, as well as serve as a means of closing a session. These deep breathing and brief meditative experiences can help clients connect within, which can be helpful when the group moves into a creative or improvisation experience. When a client is connected within, he may find he is able to connect more deeply and authentically with others or his Higher Power.

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RESEARCH EVIDENCE Music Therapy to Address Spiritual Needs Over the past few decades, spirituality has emerged as a concept that moves beyond religious affiliation (Kreitzer & Dose, 2009) and into the realm of impacting health outcomes. Research has demonstrated that a sense of spiritual well-being has a positive impact on emotions and a patient’s ability to adjust to their illness (McClain, Rosenfeld, & Breitbart, 2003; McClain-Jacobson et al., 2004). This research has further demonstrated that interventions directed toward addressing a patient’s spiritual needs will in turn impact his physical, emotional, and social well-being (Meraviglia, Sutter, Gaskamp, Adams, & Titler, 2008). Recent research has also shown that patients encountering spiritual distress tend to have poor health outcomes (Meraviglia et al., 2008). The North American Nursing Diagnosis Association International (NANDA) (2012) recognizes the need to address this issue and has helped by defining spiritual distress as “impaired ability to experience and integrate meaning and purpose in life through … connectedness with self, others, art, music, literature, nature, or a power greater than oneself” (p. 175). Spiritual distress in terminally ill patients has been associated with depression, emotional despair, suicidal thoughts, and substance abuse (Larson & Larson, 2003; Pargament, Koenig, Tarakeshwar, & Hahn, 2001). It can manifest as hopelessness or a false sense of hope, increased somatic issues or complaints, or thoughts of harming self or suicide (Villagomeza, 2005). The majority of the research examining how spirituality impacts health can be found in the medical literature, particularly with cancer patients. It is important to note that the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) has included spiritual care to the accreditation criteria (JCAHO, 2012). This requires hospitals to establish guidelines for documentation and assessment of patient’s spiritual beliefs and practices (Kreitzer & Dose, 2009). It also requires that hospitals provide spiritual care for those patients who request it. The growing interest in the relationship between spirituality and health has also prompted music therapy clinicians and researchers to further explore this concept. Broucek (1987) explored the potential of music therapy to move beyond the boundary of healing and into “whole-ing” (p. 50), to nurture the life spirit of not only patients, but also the community at large, and the music therapists as well. She theorized that because music therapy fosters a sense of wholeness in patients by giving them a sense of belonging and connection with others as well as experiences of self-discovery, self-expression, and self-exploration. Aldridge (1995) wrote of spirituality, that the spiritual elements of our experience, such as patience, prayer, hope, grace, meditation, forgiveness, and fellowship, are what help us as human beings to “rise above the matters at hand so that in the face of suffering we can find purpose, meaning, and hope” (p. 104). He also writes that spirituality and religion serve as “mediating factors for coping with an impending loss of life and are positive factors for maintaining well-being” (p. 105). Aldridge (1995) suggests that music therapy is a viable approach to meeting the spiritual needs of patients. In music therapy sessions, patients have the opportunity to connect with another human being, be creative, be present in the moment, and restore hope. Amir (1996) proposed a holistic model of music therapy that emphasizes the innate uniqueness of music in the therapeutic process. The proposed model is holistic in that it refers to the well-being of the whole person (mind, body, spirit). The spiritual area of this model suggests that this occurs when the client “feels his or her soul, with a sense of being connected to a higher power and to the universe” (p. 49). In the process of connecting to self and others, the client experiences a sense of being alive. Amir (1992) also suggests that clients find meaning in these moments of connection. Lipe (2002) completed a review of health care–related literature from 1973 to 2000 and found 52 published articles or book chapters on the topic of music, music therapy, spirituality, and health. She

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found that the majority of the articles focused on supporting patients’ healing and growth in the face of physical, emotional, and psychological struggle, end-of-life care, and personal/spiritual growth. She identified seven patterns that emerged in her review of the literature. These included the observations that as an individual engages with music, concepts of hope, meaning, and purpose are experienced; creativity is experienced or accessed; a sense of openness is felt within a safe environment; feelings, beliefs, and unconscious processes are accessed; altered states of consciousness are experienced, allowing for new insights; new avenues of communication are explored; and a sense of peace, comfort, and reassurance is felt and a release may occur. There are several empirical studies that report the effectiveness of music therapy in addressing the following areas related to spiritual support: anxiety (Gallagher, 2001; Longfield, 1995), relaxation and comfort from pain (Krout, 2001; Longfield, 1995; Magill, 2001; Salmon, 2001), quality of life (Hilliard, 2003), expanded consciousness and feeling of aliveness (O’Callaghan & McDermott, 2004), and hope, and forgiveness of self and others (Dileo & Dneaster, 2005; Pawuk & Schumacher, 2010). Walker (1995) described the use of music therapy to address spiritual issues of chemically dependent clients. He suggested that because spirituality involves thoughts, feelings, and behaviors, these need to be addressed for an individual to achieve recovery. The spiritual functions of music therapy included fostering creativity, developing a positive attitude, connecting with self and others, expressing feelings, and altering states of consciousness. Music therapy sessions incorporated songwriting, music relaxation, lyric analysis, music and movement, and active music-making to address spiritual issues. Wlodarczyk (2007) found in her research with 10 patients in an inpatient palliative care unit that when they received music therapy sessions that included music for life review, music listening for relaxation, singing with the therapist and family members, using music for prayer, or receiving a gift song dedicated by a loved one, these sessions stimulated a greater level of patient-initiated discussion of spiritual issues. Patients in the music therapy group initiated discussion of spiritual issues in 35% of these visits, while in the control group, which received no music and only dialogue and conversation, patients initiated discussion of spiritual issues 15% of the time. Magill (2009) interviewed caregivers who were present in music therapy sessions with their loved one prior to death. She found that caregivers mentioned one or more of the following spiritual issues in the music therapy sessions: God or a Higher Power, meaning and purpose in life, faith, hope, transcendence, nature, and beauty. There were also themes that emerged from the interviews; these included experiencing the following in the music therapy sessions: joy; being present in the moment; empowerment; connectedness to self, others, and God; and feeling hope. The body of research surrounding music therapy in hospice and palliative care demonstrates the impact of music not only on evoking a discussion of spiritual issues by patients in the sessions, but also in addressing their spiritual needs. Furthermore, it is evident that addressing the spiritual needs of patients can impact their well-being and health outcomes. While the greatest evidence supporting the use of music therapy to address spiritual needs is with cancer patients, the spiritual needs that arise in the course of a cancer diagnosis are not dissimilar from those encountered by patients struggling with other physical disorders or even those struggling with mental illness. In an overview of music therapy clinical interventions in adult psychiatry, Hougthon et al. (2002) state that music therapy can be used to express feelings; facilitate relaxation; foster social interactions and engagement with others; stimulate motivation, self-awareness, and insight; build self-esteem and selfconfidence; and shift physical energy and affect. Crowe (2004) also identified the following areas where music therapy can meet the spiritual needs of clients: to provide a sense of belonging with family and community, experience pleasure and joy through music-making, foster creativity and creative expression, enhance quality of life through satisfaction in socialization, deepen interpersonal relationships, discover a sense of purpose or meaning, and connect to the spirit or sacred.

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Music and music therapy possess the potential to connect to patients and to address and meet their deep and complex spiritual needs. The innate flexibility of music as a therapeutic agent paired with a music therapist’s knowledge and ability to employ a variety of methods ensures that a wide range of deep spiritual needs of patients can be addressed. The next section will explore the research literature surrounding the four music therapy methods outlined earlier in the chapter and how they address spirituality.

Receptive Music Therapy Music listening is often utilized to address a variety of patient needs. Listening to music that is relaxing or sedative facilitates the process of entrainment, where the rhythms of the body synchronize with the rhythm in music (Flatischler, 1992; Fried, 1990; Rider, 1985). Entering into a relaxed, calm, or meditative state fosters a connection to self and helps one to experience wholeness (Goldman, 1988), because music, with its structure and form, brings order to chaos (Beck, 1996–1997). Lingham and Theorell (2009) found that listening to sedative music induced increased feelings of energy and joy as well as feelings of calmness and relaxation. Music is also utilized to achieve altered states of consciousness, which provide opportunities to address spiritual issues around connection to self, others, one’s Higher Power, the therapist, and/or the music. Bonny (1975) discovered that listening to select pieces of classical music, combined with imagery, allowed clients to reach various levels of consciousness and achieve peak or transcendental experiences. Toomey (1996–1997) concluded from her analysis that the BMGIM offers substantive evidence of facilitating spiritual growth for clients. Grocke (1999) described the key or significant moments in BMGIM sessions as pivotal moments, peak experiences, or transpersonal experiences. Marr (2001) illustrated spiritual experiences as a part of GIM sessions in two case studies in which participants experienced being in the presence of God or Jesus and a love for self and others, and in which one found a renewed sense of energy and passion. Abrams (2001) concluded that transpersonal experiences in the BMGIM hold a strong sense of unity. Heiderscheit (2005) found in her research utilizing the BMGIM with adults in chemical dependency treatment that subjects in the experimental group also experienced a significant change in their interpersonal problems and that while subjects were not necessarily motivated for chemical dependency treatment, they demonstrated a motivation to engage in the BMGIM sessions. Blom (2011) suggests that transpersonal and spiritual experiences in BMGIM sessions are connected to how the imager makes connections and makes meaning of these events in relationship to the self, to the music, and to the therapist. Listening to songs and discussing and analyzing lyrics is another receptive method that fosters the development of connection. Bruscia (1998b) wrote, “songs are the ways that human beings explore emotions. They express who we are and how we feel; they bring us closer to others, and they keep us company when we are alone” (pp. 9–10). Duey (1991) found in his group work with women diagnosed with multiple personality disorders that through the process of sharing and discussing songs, the group was able to develop a sense of trust, explore their feelings, and support and comfort each other. Gilboa et al. (2009) discovered that through the process of sharing music that was meaningful in their life, students developed a more accepting attitude toward others, made self-discoveries, connected with others, and better understood their connection in the world. McFerran (2010) found that utilizing song communication allowed a 16-year-old girl in residential psychiatric treatment to connect to a specific memory; she was able to use the song as a way of connecting to her own experiences, and communicating them to the therapist, which helped to foster her connection with the therapist.

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Receptive methods are utilized to address a variety of spiritual needs. Listening to soothing or sedative music facilitates reaching a relaxed and meditative state, which helps the listener to be in the moment and to connect with self, others, their Higher Power, and the therapist. Some suggest that the aesthetic experience in music is a connective force (Aigen, 2008). While listening to music fosters connection, it can also foster positive emotions such as joy, inspire hope, and reenergize the listener. The combined use of music and imagery, as in the BMGIM, assists clients in finding meaning in life, fostering spiritual growth, transcending a struggle or situation, finding a renewed passion or energy, and connecting with self or a Higher Power. Additionally, songs also provide an avenue for meeting a client’s spiritual needs. While songs are a representation of ourselves and our lives, in exploring our relationship with a song and its meaning in our life, we can not only connect with self and others, but also engage in self-discovery.

Improvisational Music Therapy Improvisational methods are flexible and easily adapted to a variety of clinical settings. Improvisational methods can also be utilized to address various client needs and therapeutic goals. Bruscia (1987) identifies that improvisational music therapy addresses several goals. The following are most applicable to addressing spiritual issues: awareness of self and others, self-expression, integration of self, connection to others, and insight about self, others, and the environment. Music improvisation embodies the concept of creatively being in the present moment with self, others, and the environment. Bruscia (2004) writes, “improvisation is the process of continually creating life anew” (p. 18). Priestley (1994) suggests that the process of improvising in Analytical Music Therapy opens oneself to a deeper level of sharing through the “musical duet” (p. 6) created with the therapist. She describes through clinical examples how clients experience a sense of wholeness, discover meaning in the music, connect with self, and connect with the therapist in the process of improvisation. Wigram (2004) writes, “the foundation for meaning in improvised music is usually specific to the person who is creating it, and the empathic level of sharing what goes on is not precise but is nevertheless truthful in reflecting moods, emotions, and attitudes” (p. 35). It is in these moments of creating and being present that meaning, awareness, and insights are discovered. Stige (1999) described the use of improvisation with a client diagnosed with anxiety and borderline personality disorder; the client was able to decrease his anxiety and discover a sense feeling of being alive. Austin (1999) described working a client struggling with intimacy issues. Through vocal improvisations, the client developed an awareness and acceptance of her feelings and herself and discovered her inner strength and her authentic self. In both cases, clients developed insights that provided them with new ways of being in their life, which in turn provided a greater sense of meaning. Sekeles (1999) detailed music therapy sessions with a 39-year-old divorced woman whose 19year-old son was killed in the course of his military service. As a result of her grief, she became depressed and began isolating herself, suffered from insomnia, and stopped eating. Breathing was introduced initially in the music therapy sessions, and this developed into improvising melodies, which progressed to improvising a verbal dialogue. This process allowed the client to develop the awareness and insight that “part of the cork blocking her spiritual throat had been removed” (p. 192). This insight further allowed the patient turn to biblical texts of lament to further process her grief through musical and vocal improvisations. The improvisational process is designed to foster sharing inner feelings. During the improvisation, the therapist is not imitating what the client plays, but giving focus to the movement of the music in the elements. The connection fostered between the therapist and client in the improvisation allows for more in-depth exploration of feelings that leads to the discovery of meaning.

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Improvisational methods hold countless opportunities and potentials to address the spiritual needs of clients by connecting to self and others within the music and feeling a sense of connectedness to the music itself and the therapist. These connections help to foster the development of awareness, insight, and meaning. In the midst of spontaneously creating music there can be an experience of transcendence, a rising above the struggle and finding new meaning. Through the process of being in the moment and cocreating musically, a new sense of self can emerge, as well as a feeling of wholeness. Additionally, this active engagement with music can motivate, inspire and shift energy.

Re-creative Music Therapy Re-creating music provides an immediate experience of connection. Ansdell (2002) and Stige (2004) describe the practice of Community Music Therapy and how the use of making music in the context of community fosters connections on many different levels. Singing or playing music places an individual in the music itself. Austin (1999) writes, “the voice is a powerful source of connection to oneself” (p. 143). Singing is a direct and intimate connection to breath, body, and emotions. It is an intimate experience since when singing, the instrument is the body. It is “a way to transcend everyday reality and contact the transpersonal, spiritual dimensions of life” (Austin, 1999, p. 143). This transcendent experience allows a client to feel a sense of wholeness and shift in energy. Anshel and Kipper (1988) describe that in the process of group singing, breathing and movement become synchronized, while shared emotional expression occurs. In this creative process, the human spirit feels the sense of connection to others through sound. Crowe (2004) writes, “participating in a goaloriented, pleasurable, social interaction like playing music together positively affects the quality of life as an expressive human spirit” (p. 301). Fostering the connection between mind, body, and spirit in these creative and expressive moments provides the opportunity for a client to experience their entire being in harmony. Gass and Brehony (1999) suggest that chant and toning opens the heart, lifts the spirit, and shifts consciousness. Through the process of chanting, feelings and energy are released; then, due to the repetitive nature of chant, entrainment of body rhythms and mood occurs. The process of chanting alters breath, allowing for slower, deeper breaths. This process fosters a sense of being present, instilling a sense of peace and transcending the day-to-day struggles. Rio (2005) found in her qualitative investigation with adults who resided at a church-based shelter and struggled with mental health issues that the emotional expression they experienced in singing in a gospel choir allowed for the expression grief, loss, and, joy, and helped them achieve a state of being in which they felt beauty and a deeper sense of spirituality. Myskja and Nord (2008) discovered that nursing home residents diagnosed with dementia demonstrated a significant decrease in levels of depression when they engaged in singing familiar and preferred songs. Rolvsjord (2010) undertook music therapy collaborative work with two young women in their 20s who were struggling with mental health issues. Both young women came to music therapy with a desire to sing and engaged in singing with the music therapist in their sessions. Through singing, they experienced joy, a sense of accomplishment (selfefficacy), positive shifts in mood and self-esteem, motivation, inspiration, and an increased sense of hope and greater meaning in life. Key elements of spiritual practice include the experience of transcendence and a sense of wholeness. Engaging in experiences of music-making such as singing or playing music is important in connecting to one’s whole self—body, mind, and spirit. While singing offers the opportunity of connecting with others, clinicians and researchers have discovered the many ways that singing, chanting, toning, or playing music together also allow an individual or group to be in the music and transcend the struggles of the moment. In this transcendence is the experience of wholeness and renewed energy that comes from outside oneself.

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Compositional Music Therapy Creating a song or music composition serves as a psychotherapeutic technique that can help foster insights and explore issues relevant to the client’s therapeutic process (Crowe, 2004). Bruscia (1998b) described songs and musical compositions as “the sounds of our personal development” (p. 9). Creating musical compositions provide opportunities for clients to develop self-awareness, express their emotions, develop new ways of coping, and foster creativity, self-esteem, and self-confidence (Crowe, 2004). Finding these new ways of coping, along with self-confidence, fosters feelings of being empowered. Pavlicevic (1997) suggests that the act of creating and composing music actually “offers a new synthesis of the self” (p. 156). Ficken (2010) describes music composition as a “potent tool in therapy” (p. 111). The process of creating the elements and then recording the composition gives it a lasting effect as the client can revisit the creative process and be reminded of and relive the experience. Songwriting methods are utilized widely with a variety of patients in psychiatry, including those being treated for addictions (Baker, Gleadhill, & Dingle, 2007; Freed, 1987; Gallagher & Steele, 2002; Ghetti, 2004; Jones, 2005; Walker, 1995), depression (Cordobes, 1997; Ficken, 1976; Goldstein, 1990; Rolvsjord, 2005), eating disorders (McFerran, Baker, Patton, & Sawyer, 2006), and schizophrenia (Silverman, 2003). Baker, Wigram, Stott and McFerran (2008) surveyed 477 practicing professional music therapists from 29 countries about their use of songwriting as a therapeutic intervention. They found that songwriting was used to address the following therapeutic goals: develop self-confidence, enhance selfesteem, experience a sense of mastery, develop a sense of self, express and clarify thoughts and feelings, enhance social skills, increase motivation, manage stress and anxiety, gain insight, communicate with loved ones, tell their own story, and enhance spirituality. In the area of psychiatry, songwriting was most frequently utilized to address emotional and psychological issues, many of which interface with areas of spirituality. Perilli (1991) and Boone (1991) found in their use of songwriting with clients diagnosed with schizophrenia that they were able to explore beliefs and fears, express emotions, connect with self and others, and discover self-acceptance. Smith (1991) worked with a client struggling with a major depressive disorder, borderline personality disorder, and thoughts of suicide. Through the use of songwriting, the client found a creative way to share and express her thoughts and feelings, develop and gain insight about herself, and develop a positive sense of self-regard. Heiderscheit (2008) discovered through the process of creating songs in group sessions with clients with eating disorders and in addictions treatment (2009) that clients gained a sense of selfefficacy, discovered renewed sense of energy, and felt more empowered in their recovery and life. Rolvsjord (2010) found, in working with a client diagnosed with posttraumatic stress disorder and depression and who engaged in self-harm, that songwriting allowed her to connect with her authentic self, accessing her inner strength and creating a feeling of empowerment. McFerran (2010) discovered in working with adolescents with chronic illness that songwriting allowed them to engage in meaningful, even existential discussions related to their illness. Creating music, whether through writing songs or creating musical compositions, is an effective way to address various spiritual issues or needs. These creative processes foster opportunities for clients to engage in self-discovery, connect with self and others on deeper levels, explore meaning and purpose in their life, and foster and utilize their creativity. Clients can also develop a greater sense of self-efficacy or empowerment in creating and accomplishing something they were not sure they could accomplish.

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SUMMARY AND CONCLUSIONS Spirituality has grown from an idea of a belief in God or a Higher Power to a concept deeply connected to health and well-being. While the focus on meeting the spiritual needs of clients stemmed from the field of palliative care, it has emerged into many other areas of health care. This new understanding of how spirituality impacts not only health, but also health outcomes, has prompted accreditation organizations, professional associations, and treatment programs to make assessing and addressing spiritual needs an integral and necessary component of patient care. Spiritual needs are individual and personal and can be complex. The characteristics associated with spirituality help to define how to engage or experience spirituality: • • • • • 

Connectedness and relationship (self, others, Higher Power, and nature) Finding meaning and purpose in life Experiencing transcendence Wholeness Love and compassion Energy (motivates, inspires, and fosters creativity)

What is also evident when reviewing these characteristics is that all of these characteristics relating to spirituality can be achieved in and through music. Through the therapeutic application of music, clients are provided opportunities to experience and explore their spirituality. Through the use of any of the four methods in music therapy, the therapist can work to facilitate opportunities and moments for clients to engage their spirituality. Consider the following quote from Henri Nouwen (Nepo, 2005, p. x): We cannot change the world by a new plan, project, or idea. We cannot even change other people by our convictions, stories, advice, or proposals, but we can offer a space where people are encouraged to disarm themselves, lay aside their occupations and preoccupations, and listen with attention and care to the voices speaking in their own center. Music therapy methods provide the space for these experiences. Whether through receptive, improvisation, re-creative, or creative experiences, a music therapist utilizes the power of music to create the space where clients can be vulnerable, be in the moment, and connect deep within the self. Entering this space then allows meaning to emerge, hope to be discovered, creativity to be engaged; it fosters connections to a Higher Power and facilitates the occurrence of transcendent and transpersonal moments and feeling a sense of wholeness and peace. While much of the music therapy literature suggests a connection to spirituality, it does not focus on spirituality as a central concept in the therapeutic process. Additionally, most of what is in the literature includes narrative cases. While these help to detail the level of depth and experiences in sessions, they do not provide empirical evidence. Additionally, with the emergence of spirituality as a focus in health care and its connection to health outcomes, music therapy literature must begin to reflect this impact. The research literature must move beyond inferential references to spirituality and begin to explore it as a central focus.

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Puchalski, C., & Romer, A. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3, 129–137. Puchalski, C., Ferrell, B., & Borneman, T. (2010). Evaluation of the FICA tool for spiritual assessment. Journal of Pain and Symptom Management, 40(2), 163–173. Reed, P. (1992). An emerging paradigm for the investigation of spirituality in nursing. Research in Nursing and Health, 15, 349–357. Rider, M. (1985). Entrainment mechanisms are involved in pain reduction, muscle relaxation, and musicmediated imagery. Journal of Music Therapy, 22(4), 183–192. Rio, R. (2005). Adults in recovery: A year with members of the Choirhouse. Nordic Journal of Music Therapy, 14(2), 107–119. Rolvsjord, R. (2005). Collaborations on songwriting with clients with mental health problems. In F. Baker & T. Wigram (Eds.), Songwriting: Methods, techniques and clinical applications for music therapy clinicians, educators and students (pp. 97–115). Philadelphia, PA: Jessica Kingsley. Rolvsjord, R. (2010). Resource-oriented music therapy in mental health care. Gilsum, NH: Barcelona Publishers. Salmon, D. (2001). Music therapy as a psycho-spiritual process in palliative care. Journal of Palliative Care, 17, 142–146. Sekeles, C. (1999). Working through loss and mourning in music therapy. In T. Wigram & J. De Backer (Eds.), Clinical applications of music therapy in psychiatry (pp. 176–196). Philadelphia, PA: Jessica Kingsley. Silverman, M. (2003). Contingency songwriting to reduce combativeness and non-cooperation in a client with schizophrenia: A case study. The Arts in Psychotherapy, 30, 25–33. Short, A., Gibb, H., & Holmes, C. (2011). Integrating words, images, and text in BMGIM: Finding connections through semiotic intertextuality. Nordic Journal of Music Therapy, 20(1), 3–21. Smith, G. (1991). The song-writing process: A woman’s struggle against depression and suicide. In K. Bruscia (Ed.), Case Studies in Music Therapy (pp. 479–496). Gilsum, NH: Barcelona Publishers. Stige, B. (1999). The meaning of music-from the client’s perspective. In T. Wigram & J. De Backer (Eds.), Clinical applications of music therapy in psychiatry (pp. 61–83). Philadelphia, PA: Jessica Kingsley. Stige, B. (2004). Community music therapy: Culture, care and welfare. In M. Pavlicevic & G. Andsell (Eds.), Community music therapy. Philadelphia, PA: Jessica Kingsley. Tanyi, R. (2002). Towards clarification of the meaning of spirituality. Journal of Advanced Nursing, 39, 500–509. Villagomeza, T. (2005). Spiritual distress in adult cancer patients: Toward conceptual clarity. Holistic Nursing Practice, 83, 285–294. Walker, J. (1995). Music therapy, spirituality and chemically dependent clients. Journal of Chemical Dependency Treatment, 5(2), 145–166. Wigram, T. (2004). Improvisation: Methods and techniques for music therapy clinicians, educators and students. Philadelphia, PA: Jessica Kingsley. Wilber, K. (1996). A brief history of everything. Boston: Shambhala Publications, Inc. Wilber, K., Patten, T., Leonard, A., & Morelli, M. (2008). Integral life practice. Boston: Shambhala Publications Inc. Wilson, Edward O. (1984). Biophilia. Cambridge: Harvard University Press. Wlodarczyk, N. (2007). The effect of music therapy on spirituality of persons in an inpatient hospice unit as measured by self-report. Journal of Music Therapy, 64(2), 113–122.

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RESOURCES Relaxation Resources The Relaxation and Stress Reduction Workbook (2008) by Martha Davis, Elizabeth Eshelman, & Matthew McKay. Published by New Harbinger Publications, Inc., in Oakland, California. This book includes information, relaxation exercises, and guided imagery scripts. Remo, Inc. www.remo.com - Visit the website to get information on drums and drum products. You can also find information on their Not So LoudTM line of drums and mallets.

Spiritual Assessment A spiritual assessment can be included as a component of a comprehensive music therapy assessment, which may include asking about cultural considerations, religious background, and religious or spiritual practices. This can also include questions such as: What are your sources of strength, comfort, peace, and hope? Where do you find or get support? Many facilities employ chaplains to help clients address religious or spiritual needs. They may conduct a spiritual assessment as a part of their work. It is important to be aware of whether this is a part of their regular practice, in order to respect professional boundaries and not require a client to answer the same set of questions. If this information is obtained by a chaplain, it may be in the client’s chart and accessible to treatment team members. There are also tools such as: • HOPE (H is sources of hope, strength, meaning, comfort, peace, love, and connection; O is organized religion; P is personal spirituality; E is the effects of being ill) (Anadarajah, Long, & Smith, 2001). • Spiritual Well-Being Scale (Paloutzian & Ellison, 1982). The Spiritual Well-Being Scale is composed of 20 items, 10 of which assess religious well-being specifically and 10 of which assess existential well-being.

Spiritual Support Services Collaborating with chaplains, clergy, and spiritual directors can help provide support in addressing spirituality and spiritual issues.

Guided Imagery Scripts Guided Imagery for Groups: Fifty Visualizations that promote relaxation, problem solving, creativity, and well-being (1995) by Andrew Schwartz. Published by Whole Person Associates, in Duluth, Minnesota. This book includes scripts that focus on well-being, spiritual centering, healing, self-esteem, and a variety of other areas. Four scripts are also included that were created by the author and utilized in individual and group music therapy sessions.

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Your Relaxing Place: A Directed Imagery Script Copyright © 2011 by Annie Heiderscheit Take a moment and allow yourself to get into a comfortable position. You may want to lie down or be in a reclined position. You can close your eyes if you like or focus on a spot on the wall or ceiling. As you settle into that comfortable space, begin to take some slow, deep breaths … breathing in deep through your nose and letting the air out through your mouth. For a few moments, just allow your awareness to focus on your breathing … as you breathe in deep through your nose and let the air out through your mouth. Notice the movement of your breath. Feel how the air moves into your lungs and moves out. As you continue to breathe, each time you exhale, allow yourself to breathe away anything you want to let go of right now. Let go of any stress … tension … anxiety … let go of any busy or hurried thoughts. With each breath, feel yourself releasing them. Now, as you continue to breathe, begin to bring your focus to an image of a place that is relaxing to you. This can be a place that is indoors or outdoors. Maybe a room that is special to you or a place you have been to before. Wherever this place may be, just give yourself time to be there. Let yourself notice the things about this place that make you want to be there. Notice how it feels to be at this place. As you take time at this place, continue to take some slow, deep breaths, breathing in deep through your nose and letting the air out through your mouth. Notice the colors at this place. Let yourself take in the beauty of those colors. If at any time you notice any distracting thoughts, allow yourself to acknowledge the thought and let it go. Just bring your image to your breathing, breathing in deep through your nose, letting the air out through your mouth. As you continue to take time to be at this place, notice all those things that draw you to this place and make you want to be here. Give yourself time to explore this place. Experience this place through all of your senses. Notice what sounds you hear … notice what fragrances you smell … be mindful of what you see that draws you here. As you take in all the things about this place that make you want to be here, know that this is a place you can come back to whenever you want or need to. This place is only a thought away. Take a moment to look around this place one more time … take some slow, deep breaths. Then, when you feel ready, slowly begin to bring your image to a close, knowing you can return at any time. Bring your awareness back to your breathing, breathing in deep through your nose, letting the air out through your mouth. With each breath, slowly become aware of the space around you. Begin to notice the sounds around you. Now slowly begin to wiggle your fingers and wiggle your toes … and when you feel ready, you can slowly open your eyes and come back to this space.

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Letting Go: A Directed Imagery Script Copyright © 2011 by Annie Heiderscheit Take a moment and allow yourself to get into a comfortable position. You may want to lie down or be in a reclined position. You can close your eyes if you like or focus on a spot on the wall or ceiling. As you settle into that comfortable space, begin to take some slow deep breaths… breathing in deep through your nose and letting the air out through your mouth. For a few moments just allow your awareness to focus on your breathing… as you breathe in deep through your nose and let the air out through your mouth. Notice the movement of your breath. Feel how the air moves into your lungs and moves out. As you continue to breathe, each time you exhale allow yourself to breathe away anything you want to let go of right now. Let go of any stress… tension… anxiety… Let go of any busy or hurried thoughts. With each breath, feel yourself releasing them. Now, as you continue to breathe, begin to bring your focus to an image a gentle stream is flowing just in front of you. As you look down, you see the water move gently downstream. You hear the gentle ripple as the water moves. As you stand at the stream, become aware of something you have been holding onto that you want to let go of. Notice that what you are holding in your hands is the very thing you want to let go of. Take moment and notice it… Notice how you feel as you see it… If at any time you notice any distracting thoughts, allow yourself to acknowledge the thought and let it go. Just bringing your image or to your breathing, breathing in deep through your nose, letting the air out through your mouth. As you acknowledge what you have been holding onto, know that you can set this down on the stream and allow it to float down the stream… letting it go. Give yourself a few moments and when you feel ready, set it on the water in the stream and allow it to float away. Continue to take slow deep breaths as you take the time to do this. (Allow time here). After you have released this on the water, notice how you feel as you watch it float away. Continue to take some slow deep breaths, breathing in as deep as you can and letting that air out. Continue to notice how letting this go feels. Know that you need only hold on to those things that are helpful or useful to you. You can let go of those things that are no longer helpful for you. You can always return to this place and let go of anything you need to let go of. Now, bring your awareness back to your breathing, breathing in deep through your nose, letting the air out through your mouth. With each breath, slowly become aware of the space around you. Begin to notice the sounds around you. Now slowly begin to wiggle your fingers and wiggle your toes … and when you feel ready, you can slowly open your eyes and come back to this space.

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A Gift: A Directed Imagery Script Copyright © 2011 by Annie Heiderscheit Take a moment and allow yourself to get into a comfortable position. You may want to lie down or be in a reclined position. You can close your eyes if you like or focus on a spot on the wall or ceiling. As you settle into that comfortable space, begin to take some slow, deep breaths … breathing in deep through your nose and letting the air out through your mouth. For a few moments, just allow your awareness to focus on your breathing … as you breathe in deep through your nose and let the air out through your mouth. Notice the movement of your breath. Feel how the air moves into your lungs and moves out. As you continue to breathe, each time you exhale, allow yourself to breathe away anything you want to let go of right now. Let go of any stress … tension … anxiety … let go of any busy or hurried thoughts. With each breath, feel yourself releasing them. Now, as you continue to breathe, begin to bring your focus to an image of a box. You are holding this box in your hands, and in this box is a gift for you. This gift is something you want or need. With each breath, notice what you see about the box … feel the box in your hands. As the image becomes clearer, become aware of how you feel as you hold this gift. As you continue to breathe, breathing in deep and letting the air out … you take a moment and open the box and discover the gift inside. With each breath, give yourself time to take in and receive this gift … remembering that this gift is for you. (Allow time here.) If at any time you notice any distracting thoughts, allow yourself to acknowledge the thought and let it go. Just bring your image to your breathing, breathing in deep through your nose, letting the air out through your mouth. As you discover and receive this gift, notice how you feel as you hold the gift now. Know that this gift is just for you. This gift is something you can always come back to. This image is only a thought away. Take another look at this gift … take in what is important to you about this gift, and hold on to that. As you continue to take slow, deep breaths, breathing in deep and letting the air out, it is time to slowly bring your image to a close. Know that this gift is always with you in whatever way you want it to be. Slowly bring your image to a close, and with each breath, notice the image fading, remembering that you can return to this image at any time. Now, bring your awareness back to your breathing, breathing in deep through your nose, letting the air out through your mouth. With each breath, slowly become aware of the space around you. Begin to notice the sounds around you. Now slowly begin to wiggle your fingers and wiggle your toes … and when you feel ready, you can slowly open your eyes and come back to this space.

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The Path: A Directed Imagery Script Copyright © 2011 by Annie Heiderscheit Take a moment and allow yourself to get into a comfortable position. You may want to lie down or be in a reclined position. You can close your eyes if you like or focus on a spot on the wall or ceiling. As you settle into that comfortable space, begin to take some slow, deep breaths … breathing in deep through your nose and letting the air out through your mouth. For a few moments, just allow your awareness to focus on your breathing … as you breathe in deep through your nose and let the air out through your mouth. Notice the movement of your breath. Feel how the air moves into your lungs and moves out. As you continue to breathe, each time you exhale, allow yourself to breathe away anything you want to let go of right now. Let go of any stress … tension … anxiety … let go of any busy or hurried thoughts. With each breath, feel yourself releasing them. Now, as you continue to breathe, begin to bring your focus to an image of a path. Notice a path just in front of you. See how it winds around. Notice what surrounds the path … grass … trees. Give yourself time to walk along this path, taking in the beauty of this place. As you walk, breathe in the fresh air … take in the fragrances of nature and let yourself relax and enjoy this journey. (Allow time here.) Notice how you feel as you walk along this path. Notice the colors you see along the way … take in the sounds you hear … notice where your path leads you … give yourself time to enjoy this experience. If at any time you notice any distracting thoughts, allow yourself to acknowledge the thought and let it go. Just bring your image to your breathing, breathing in deep through your nose, letting the air out through your mouth. As you continue on this path, take in the beauty that is all around you. Notice all the things about this journey that you enjoyed. With each breath you take, feel yourself breathing in the calm and peacefulness of this place. Know that this is a path you can always return to as it is only a thought away. Let yourself take with you with anything you have enjoyed about this journey. Now as begin to return from this place, slowly bring your awareness back to your breathing, breathing in deep through your nose, letting the air out through your mouth. With each breath, slowly become aware of the space around you. Begin to notice the sounds around you. Now slowly begin to wiggle your fingers and wiggle your toes … and when you feel ready, you can slowly open your eyes and come back to this space.

Guidelines for Music Therapy Practice A Four Volume Series GUIDELINES FOR MUSIC THERAPY PRACTICE IN DEVELOPMENTAL HEALTH Edited by Michelle R. Hintz 1) Introduction: Michelle R. Hintz 2) Early Intervention: Elizabeth K. Schwartz 3) Autism: Michelle R. Hintz 4) Rett Syndrome: Jennifer M. Sokira 5) Developmental Speech and Language Disorders: Kathleen M. Howland 6) Attentional Deficits in School Children: Michelle R. Hintz 7) Learning Disabilities in School Children: Michelle R. Hintz 8) Behavioral and Interpersonal Problems in School Children: Patricia McCarrick 9) Children with Hearing Loss: Christine Barton 10) Visually Impaired School Children: Paige A. Robbins Elwafi 11) Mild to Moderate Intellectual Disability: Douglas R. Keith 12) Severe to Profound Intellectual and Developmental Disabilities: Donna W. Polen 13) Physical Disabilities in School Children: Jennifer M. Sokira 14) Individuals with Severe and Multiple Disabilities: Barbara Wheeler GUIDELINES FOR MUSIC THERAPY PRACTICE IN MENTAL HEALTH Edited by Lillian Eyre 1) Introduction: Lillian Eyre 2) Adults with Schizophrenia and Psychotic Disorders: Andrea McGraw Hunt 3) Adult Groups in the Inpatient Setting: Lillian Eyre 4) Adults in a Recovery Model Setting: Lillian Eyre 5) Children and Adolescents in an Inpatient Psychiatric Setting: Bridget Doak 6) Foster Care Youth: Michael L. Zanders 7) Survivors of Catastrophic Event Trauma: Ronald M. Borczon 8) Women Survivors of Abuse and Developmental Trauma: Sandra Lynn Curtis 9) Adult Male Survivors of Abuse and Developmental Trauma: Jeffrey H. Hatcher 10) Children and Adolescents with PTSD and Survivors of Abuse and Neglect: Penny Rogers 11) Adults with Depression and/or Anxiety: Nancy A. Jackson 12) Adults and Adolescents with Borderline Personality Disorder: J. M. Dvorkin 13) Adults and Adolescents with Eating Disorders: Peggy Tileston 14) Adults with Substance Use Disorders: Kathleen M. Murphy 15) Adolescents with Substance Use Disorders: Katrina Skewes McFerran 16) Adult Males in Forensic Settings: Vaughn Kaser 17) Adult Females in Correctional Facilities: Karen Anne Litecky Melendez 18) Adjudicated Adolescents: Susan Gardstrom 19) Juvenile Male Sexl Offenders: Lori L. De Rea-Kolb 20) Elderly Residents in Nursing Facilities: Elaine A. Abbott

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Persons with Alzheimer’s and Other Dementias: Laurel Young Professional Burnout: Darlene M. Brooks Stress Reduction and Wellness: Seung-A Kim Musicians: Gro Trondalen Spiritual Practices: Annie Heiderscheit GUIDELINES FOR MUSIC THERAPY PRACTICE IN PEDIATRIC CARE Edited by Joke Bradt 1) Introduction: Joke Bradt 2) Pain Management with Children: Joke Bradt 3) Premature Infants: Monika Nöcker-Ribaupierre 4) Full-Term Hospitalized Newborns: Helen Shoemark 5) Pediatric Intensive Care: Claire Ghetti 6) Surgical and Procedural Support for Children: John Mondanaro 7) Burn Care for Children: Annette Whitehead-Pleaux 8) Children with Cancer: Beth Dun 9) Palliative and End-of-Life Care for Children: Kathryn Lindenfelser 10) Brain Injuries and Rehabilitation in Children: Jeanette Kennelly 11) Respiratory Care for Children: Joanne Loewy 12) Medically Fragile Children in Low Awareness States: Jennifer Townsend 13) Children in General Inpatient Care: Christine Neugebauer GUIDELINES FOR MUSIC THERAPY PRACTICE IN ADULT MEDICAL CARE Edited by Joy Allen 1) Introduction: Joy Allen 2) Surgical and Procedural support: Annie Heiderscheit 3) Pain Management with Adults: Joy Allen 4) Adults in Critical Care: Jeanette Tamplin 5) Adults in Cardiac Care: Christine Pollard Leist 6) Adults with Stroke: Simon Gilbertson 7) Adults with Traumatic Brain Injury: Victoria Policastro Vega 8) Adults with Neurogenic Communication Disorders: Nicki Cohen 9) Adults with Neurogenerative Diseases: Wendy Magee 10) Adults with HIV/AIDS: Douglas Keith 11) Adults with Cancer: Joy Allen 12) Adults in Palliative/Hospice Care: Amy Clement-Cortes 13) Caring for Caregivers: Barbara Daveson

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THE BARCELONA COLLECTION OF PRINT AND E-BOOKS 2013 ANALYTIC MUSIC THERAPY • Essays on Analytical Music Therapy (Priestley) • Music Therapy in Action (2nd Edition) (Priestley) • The Dynamics of Music Psychotherapy (Bruscia) • Group Analytic Music Therapy (Ahonen-Eerikäinen) CASE STUDIES • Case Examples of Guided Imagery and Music (Bruscia) • Case Examples of Improvisational Music Therapy (Bruscia) • Case Examples of Music Therapy for___ (Bruscia): o Alzheimer’s Disease o Autism and Rett Syndrome o Children and Adolescents with Emotional or Behavioral Problems o Developmental Problems in Learning and Communication o End of Life o Event Trauma o Medical Conditions o Mood Disorders o Multiple Disabilities o Musicians o Personality Disorders o Schizophrenia and other Psychoses o Self-Development o Substance Use Disorders o Survivors of Abuse • Case Examples of the Use of Songs in Psychotherapy (Bruscia) • Studies in Music Therapy (Bruscia) • Inside Music Therapy: Client Experiences (Hibben) • Psychodynamic Music Therapy: Case Studies (Hadley) CHILDREN WITH SPECIAL NEEDS • Alike and Different: The Clinical and Educational Uses of Orff-Schulwerk – Second Edition (Bitcon) • The Miracle of Music Therapy (Boxill) • Music for Fun, Music for Learning (Birkenshaw-Fleming) • Music: Motion and Emotion: The Developmental-Integrative Model in Music Therapy (Sekeles) • Music, Therapy, and Early Childhood (Schwartz) • Music Therapy in Special Education (Nordoff & Robbins)

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Therapy in Music for Handicapped Children (Nordoff & Robbins) COMMUNITY MUSIC THERAPY • Elaborations Toward a Notion of Community Music Therapy (Stige) • Culture-Centered Music Therapy (Stige) INFANCY AND EARLY CHILDHOOD • Music, Therapy, and Early Childhood (Schwartz) • Music Therapy for Premature and Newborn Infants (Nöcker-Ribaupierre) END OF LIFE • Music Therapy: Death and Grief (Sekeles) FEMINISM • Feminist Perspectives in Music Therapy (Hadley) FIELDWORK AND INTERNSHIP TRAINING • Clinical Training Guide for the Student Music Therapist (Wheeler, Shultis & Polen) • Music Therapy: A Fieldwork Primer (Borczon) • Music Therapy Supervision (Forinash) GROUP WORK • Music Therapy: Group Vignettes (Borczon) • Music Therapy Improvisation for Groups: Essential Leadership Competencies (Gardstrom) GUIDED IMAGERY AND MUSIC (BONNY METHOD) • Guided Imagery and Music: The Bonny Method and Beyond (Bruscia & Grocke) • Music and Consciousness: The Evolution of Guided Imagery and Music (Bonny) • Music and Your Mind: Listening with a New Consciousness (Bonny & Savary) • Music for the Imagination (Bruscia) GUITAR • Guitar Skills for Music Therapists and Music Educators (Meyer, De Villers, Ebnet) • Use of the Guitar in Music Therapy (Oden) IMPROVISATIONAL MUSIC THERAPY • The Architecture of Aesthetic Music Therapy (Lee) • Essays on Analytical Music Therapy (Priestley) • Creative Music Therapy: A Guide to Fostering Clinical Musicianship – Second Edition with Four CDs (Nordoff & Robbins) • Group Analytic Music Therapy (Ahonen-Eerikäinen) • Healing Heritage: Paul Nordoff Exploring the Tonal Language of Music (Robbins & Robbins) • Improvising in Styles: A Workbook for Music Therapists, Educators, and Musicians (Lee & Houde) • Music as Therapy: A Dialogal Perspective (Garred) • Music-Centered Music Therapy (Aigen) • Music Therapy: Improvisation, Communication, and Culture (Ruud) • Music Therapy Improvisation for Groups: Essential Leadership Competencies (Gardstrom) • Paths of Development in Nordoff-Robbins Music Therapy (Aigen)

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Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters) MUSIC FOR CHILDREN TO SING AND PLAY • Distant Bells (Levin & Levin) • Learning Songs (Levin & Levin) • Learning Through Music (Levin & Levin) • Learning Through Songs (Levin & Levin) • Let’s Make Music (Levin & Levin) • Music for Fun, Music for Learning (Birkenshaw-Fleming) • Snow White: A Guide to Child-Centered Musical Theatre (Lauri, Groeschel, Robbins, Ritholz & Turry) • Symphonics R Us (Levin & Levin) NORDOFF-ROBBINS MUSIC THERAPY (CREATIVE MUSIC THERAPY) • The Architecture of Aesthetic Music Therapy (Lee) • Being in Music: Foundations of Nordoff-Robbins Music Therapy (Aigen) • Conversations on Nordoff-Robbins Music Therapy (Verney & Ansdell) • Creative Music Therapy: A Guide to Fostering Clinical Musicianship – Second Edition with Four CDs (Nordoff & Robbins) • Healing Heritage: Paul Nordoff Exploring the Tonal Language of Music (Robbins & Robbins) • Here We Are in Music: One Year with an Adolescent Creative Music Therapy Group (Aigen) • A Journey into Creative Music Therapy (Robbins) • Music Therapy in Special Education (Nordoff & Robbins) • Paths of Development in Nordoff-Robbins Music Therapy (Aigen) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Therapy in Music for Handicapped Children (Nordoff & Robbins) MUSIC THERAPY PRACTICE • Guidelines for Music Therapy Practice in Mental Health (Eyre) • Guidelines for Music Therapy Practice in Developmental Health (Hintz) • Guidelines for Music Therapy Practice in Pediatric Care (Bradt) • Guidelines for Music Therapy Practice in Adult Medical Care (Allen) MUSIC PSYCHOTHERAPY • The Dynamics of Music Psychotherapy (Bruscia) • Essays on Analytical Music Therapy (Priestley) • Emotional Processes in Music Therapy (Pellitteri) • Group Analytic Music Therapy (Ahonen-Eerikäinen) • Guided Imagery and Music: The Bonny Method and Beyond (Bruscia & Grocke) • Music and Consciousness: The Evolution of Guided Imagery and Music (Bonny) • Music and Your Mind: Listening with a New Consciousness (Bonny & Savary)

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Music Therapy: Group Vignettes (Borczon) Psychodynamic Music Therapy: Case Studies (Hadley)

ORFF-SCHULWERK • Alike and Different: The Clinical and Educational Uses of Orff-Schulwerk – Second Edition (Bitcon) PIANO • Functional Piano for Music Therapists and Music Educators (Massicot) • Improvising in Styles: A Workbook for Music Therapists, Educators, and Musicians (Lee & Houde) PROFOUND MENTAL RETARDATION • Age-Appropriate Activities for Adults with Profound Mental Retardation – Second Edition (Galerstein, Martin & Powe) PSYCHODRAMA • Acting Your Inner Music (Moreno) PSYCHIATRY – MENTAL HEALTH • Music Therapy in the Treatment of Adults with Mental Disorders: Theoretical Bases and Clinical Interventions (Unkefer & Thaut) • Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire) • Psychodynamic Music Therapy: Case Studies (Hadley) • Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord) RACE • Experience Race as a Music Therapist: Personal Narratives (Hadley) RESEARCH • A Guide to Writing and Presenting in Music Therapy (Aigen) • Multiple Perspectives: A Guide to Qualitative Research in Music Therapy (Smeijsters) • Music Therapy Research: Quantitative and Qualitative Perspectives – First Edition (1995) (Wheeler) • Music Therapy Research – Second Edition (2005) (Wheeler) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Qualitative Inquiries in Music Therapy: A Monograph Series (Free Downloads Available Here) • Qualitative Music Therapy Research: Beginning Dialogues (Langenberg, Frömmer & Aigen) SUPERVISION • Music Therapy Supervision (Forinash) THEORY • Culture-Centered Music Therapy (Stige) • Defining Music Therapy – Second Edition (Bruscia) • Emotional Processes in Music Therapy (Pellitteri) • Music and Life in the Field of Play: An Anthology (Kenny)

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Music as Therapy: A Dialogal Perspective (Garred) Music-Centered Music Therapy (Aigen) Music Therapy and its Relationship to Current Treatment Theories (Ruud) Music Therapy: A Perspective from the Humanities (Ruud) Music Therapy: Improvisation, Communication, and Culture (Ruud) Music—The Therapeutic Edge: Readings from William W. Sears (Sears) The Music Within You (Katsh & Fishman) Readings on Music Therapy Theory (Bruscia) Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord) The Rhythmic Language of Health and Disease (Rider) Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters)

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Authentic Voices, Authentic Singing (Uhlig) Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire)