Case Examples of Music Therapy for Developmental Problems in Learning and Communication [1 ed.] 9781937440275

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Case Examples of Music Therapy for Developmental Problems in Learning and Communication Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Developmental Problems in Learning and Communication Copyright © 2012 by Barcelona Publishers All rights reserved. No part of this e-book may be reproduced and/or distributed in any form whatsoever. E-ISBN: 978-1-937440-27-5 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: © 2012 Frank McShane

Table of Contents CASE ONE

Developing Speech with Music: A Neurodevelopmental Approach A. Blythe LaGasse

CASE TWO

Singing a Special Song Christina Rago Julie Hibben

CASE THREE

Speaking Without Talking: Fifty Analytical Music Therapy Sessions with a Boy with Selective Mutism Wolfgang Mahns

CASE FOUR

Preverbal Communication through Music to Overcome a Child’s Language Disorder Amelia Oldfield

CASE FIVE

Growing Up in Music: A Journey through Early Childhood Music Development in Music Therapy Elizabeth K. Schwartz

CASE SIX

Anat: A Body Aware—A Soul Alerted: Developmental Integrative Music Therapy with a Hypotonic Down’s Syndrome Child Chava Sekeles

CASE SEVEN

Alon: From the Jungle To the King’s Palace Chava Sekeles

CASE EIGHT

From Violent Rap to Lovely Blues: The Transformation of Aggressive Behavior through Vocal Music Therapy Sylka Uhlig

Introduction Kenneth E. Bruscia Case examples provide very unique and valuable insights into how different forms of therapy are practiced, as well as how clients respond to those therapies. This e-book describes various ways that music therapy has been used to help individuals with developmental problems. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform all those affected by developmental problems about the potential benefits of music therapy. About Developmental Problems Terminology for the various developmental problems observed in infants, children, and adolescents has varied extensively over the last few decades, so it is important for the reader to pay particular attention to how the author defined and used diagnostic terms at the time the case example was written. According to current diagnostic classification by the American Psychiatric Association (APA, 2000), developmental disorders are those that are first diagnosed during infancy, childhood, or adolescence. These disorders include: • Mental Retardation (significantly sub-average intellectual functioning accompanied by deficits in adaptive behavior). • Learning Disorders (e.g., reading, mathematics, writing disorders) • Communication Disorders (expressive and/or receptive disorders in speech and language) • Pervasive Developmental Disorders (e.g., autism, Rett’s, Asperger’s) • Attention-Deficit and Disruptive Behavior Disorders (formerly called MBD or minimal brain defect or dysfunction) • Feeding and Eating Disorders • Tic Disorders • Elimination Disorders, and • Other Disorders (e.g., separation anxiety, attachment disorder, selective mutism, stereotypic movement disorders) Additional developmental disorders found in this set of cases (but not mentioned above) include Down’s syndrome, cerebral palsy, and hypotonia. Down’s Syndrome is a congenital chromosomal abnormality that leads to mental retardation and other developmental delays. Cerebral palsy is a disorder of movement, muscle tone, or posture caused by brain injury most often before birth. Hypotonia is a symptom of cerebral palsy characterized by a lack of muscle tone. About Music Therapy (Based on Bruscia, 1993) Definition and Applications

In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants. Music therapy is used with individuals of all ages and with a variety of conditions, including psychiatric disorders, medical problems, physical handicaps, sensory impairments, developmental disabilities, substance abuse, communication disorders, interpersonal problems, and aging. It is also used for self-development purposes, such as improving learning, building self-esteem, reducing stress, supporting physical exercise, and facilitating a host of other health-related activities. Given its wide applications, music therapists may be found in general hospitals, psychiatric facilities, schools, prisons, community centers, training institutes, private practices, and universities. Basic Premises The thing that makes music therapy different from every other form of therapy is its reliance on music as the primary medium for promoting the client’s health. Every session involves the client in a music experience of some kind. The main ones are listening to, recreating, improvising, and composing music. These will be described in more detail in the next few paragraphs; however, it is important to explain immediately that clients do not have to be musicians to participate in or benefit from music therapy. In fact, because most clients have not had previous musical training, the music activities and experiences used in therapy sessions are always designed to take advantage of the innate tendencies of all human beings to make and appreciate music at their own developmental levels. Of course, in clinical situations, music therapists may encounter clients who have physical or mental impairments that interfere with one or more of these basic musical potentials. Therefore, care is always taken to adapt music therapy experiences to the unique musical capabilities and preferences of each client. Music therapists also screen clients who may have adverse psychological or psychophysiological reactions to participation in music. Four Basic Music Experiences Used in Therapy To understand how music therapy works, it is necessary to examine the unique nature of each of the four types of music experience—listening to, recreating, improvising, and composing. In those therapy sessions that involve listening, the client takes in and reacts to live or recorded music in the style preferred by the client. The client may respond through activities such as relaxation or meditation, structured or free movement, perceptual tasks, freeassociation, story-telling, imaging, reminiscing, drawing, and so forth. Music listening experiences are used with clients who need to be activated, soothed, or further developed— either physically, emotionally, intellectually, and/or spiritually—as these are the kinds of responses that music listening elicits.

In those therapy sessions that involve re-creating music, the client sings or plays precomposed music. This may include learning how to produce sounds, imitating musical phrases, learning how to sing, learning to read notation, participating in group sing-along’s, performing a song or piece, participating in a musical show or drama, and so forth. Re-creative experiences are most appropriate for clients who need to develop sensorimotor skills, learn adaptive behaviors, maintain reality orientation, master different role behaviors, identify with the feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, 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 aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for individuals with developmental problems, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them. This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples

For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made to present an accurate and unbiased account of the therapy process to the extent possible, and theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with an individual with developmental problems, the truth value of the case is of vital interest. That leads to the second scientific question: Can the information learned in this case be applied to other cases? Or even more rigorously, can the findings of this case be generalized to similar or matched cases? Here too, readers who are directly affected by developmental problems are as interested in this question as scientists and researchers. Their interest is in whether individuals with developmental problems in their own lives can derive the same benefits of music therapy as the client in this case did. Scientists or researchers can also glean other very important information from case studies. Because clinical cases provide rich descriptions of the therapy process, they usually provide myriad ideas for what needs to be studied scientifically. By describing what seemed to work and or not work for a particular client, a clinical case reveals to the researcher which clinical protocols and therapeutic outcomes warrant further research, while also suggesting specific hypotheses that might be tested. Moreover, because events unfold naturally in a clinical case as they do in real life, and because variables cannot be controlled as in laboratory research, the clinical case gives very important information on what specific variables must be

considered when doing research, not only the most likely independent and dependent variables that are likely to be related, but also what extraneous variables need to be controlled. Of course, a research case can provide the same insights, to some degree, as a clinical case; they too offer valuable information on potential independent, dependent, and extraneous variables to consider. The greatest advantage of the research case is not only that it provides objective evidence of what works or doesn’t work in therapy, but also because it can reveal the “effect size” of the therapeutic change. That is, a single-case research study can show how big an effect the independent variable had on the dependent variable, or the extent to which the treatment protocol was effective in inducing therapeutic change in the client. Though this effect and its size cannot be generalized, careful replication of research cases and meta-analysis can begin to build a case for the establishment of clinical cause-effect relationships. Reading from a Personal Perspective By their very nature, case examples invite the reader to identify with one or more characters involved in the case, and then move from identifying with one character to identifying with another. The characters may include the client, the therapist, other clients, loved ones, and so forth. Identifying with people involved in the case not only helps the reader to understand first-hand what each character is experiencing, but also gives the reader an opportunity to compare how the character reacted with how the reader would react. Here are some examples: 1) Identifying with the client: What must the client be thinking or feeling about the therapist, music, other clients, or loved one? If I were the client, would I think or feel the same? What does this client need and want from those involved in the therapy process, and would I need or want the same? These same questions can be posed for every client involved in the case. 2) Identifying with the therapist: What must the therapist be thinking or feeling about the client, the music, the other clients, or the client’s loved one? Would I think or feel the same? What kind of person would I be if I were working with this client? What is the therapist trying to do, and would I try to do the same? 3) Identifying with loved ones: What must the loved one be thinking or feeling about the client, the therapist, the music, and other clients? If I were a loved one, would I think or feel the same? What does this person need or want, and would I need or want the same? Does this person believe that music therapy will help, and would I? How does the loved one feel about the therapist, and how he or she is relating to the client? Does the therapist know what he or she is doing? The fascinating thing about taking an empathic position is that once one successfully steps into one character’s shoes, and becomes sensitive to who he or she is, an endless number of additional empathic positions arise, and one’s entire personal reaction to the case becomes enlivened. Reading from a Clinical Perspective

A clinical perspective is concerned primarily with methodological questions that are most often posed by other clinicians. Clinicians want to know what does and does not work when working with a client in music therapy. Practically speaking then, they are most interested in the following kinds of questions: 1) Based on this case, what should I be looking for in clients? What client needs and resources do I have to address more in my own work? How can I assess these facets of the client in music therapy? 2) Based on this case, what kind of therapist-client relationship is best for this kind of client, and what is the best way of forming such a relationship? 3) What is the role of music in working with this clientele? What types of music experiences are most therapeutically relevant and effective? What styles of music are most appropriate? 4) Based on this case, what are the best ways of responding to the client when he or she is acting out, abreacting, resisting, or not progressing? 5) Based on this case, what clinical criteria should be used in evaluating the client’s therapeutic progress? Other Writings on Music Therapy For Developmental Problems The case examples in this e-book were taken exclusively from various books published by Barcelona Publishers. Thus, these cases, though typical, may not comprise a representative sample of all clinical practices in music therapy for individuals with developmental problems. Additional case examples have been written, which further elaborate how individuals with developmental problems can derive therapeutic benefits from music. Here is a list of other published case examples along with other writings on the topic. Barber, E. (1973). Music Therapy with Retarded Children. Australian Journal of Mental Retardation, 2(7), 210-213. Beathard, B., & Krout, R. E. (2008). A Music Therapy Clinical Case Study of a Girl with Childhood Apraxia of Speech: Finding Lily’s Voice. The Arts in Psychotherapy, 35(2), 107–116. Bixler, J. (1968). Musical Aptitude in the Educable Mentally Retarded Child. Journal of Music Therapy, 5(2), 41-43. Braithwaite, M., & Sigafoos, J. (1998). Effects of Social versus Musical Antecedents on Communication Responsiveness in Five Children with Developmental Disabilities. Journal of Music Therapy, 35(2), 88-104. Caron, J. R., Donnell, N. E., & Friedman, M. (1996). The Reduction of Bruxism Using Passive Music Listening with Persons Having Developmental Disabilities. Canadian Journal of Music Therapy, 4(1), 35-69. Cassity, M. D. (1977). Nontraditional Guitar Techniques for the Educable and Trainable Mentally Retarded Residents in Music Therapy Activities. Journal of Music Therapy, 14(1), 39-42. Chase, K. M. (2004). Music Therapy Assessment for Children with Developmental Disabilities: A Survey Study. Journal of Music Therapy, 41(1), 28-54.

Chase, K. M. (2004). Music Therapy Assessment for Children with Developmental Disabilities: A Survey Study. Journal of Music Therapy, 41(1), 28-54. Cohen, N. S. (1988). The Use of Superimposed Rhythm to Decrease the Rate of Speech in a BrainDamaged Adolescent. Journal of Music Therapy, 25(2), 85-93. Conn, J. (1984). Music for the Older Mildly Intellectually Handicapped Student: A Functional Life Skills Approach. Tenth National Conference of the Australian Music Therapy Association, Inc. 22-26. Crowe, B. J. (1987). Stimulating Creativity in the Mentally Retarded through Music Experiences. The Arts in Psychotherapy, 14(3), 237-241 Curtis, S., & Mercado, C. S. (2004). Community Music Therapy for Citizens with Developmental Disabilities. Voices: A World Forum for Music Therapy, 4(3). Retrieved June 29, 2011 from https://normt.uib.no/index.php/voices/article/viewArticle/185/144 DeBedout, J. K., & Worden, M. C. (2006). Motivators for Children with Severe Intellectual Disabilities in the Self-Contained Classroom: A Movement Analysis. Journal of Music Therapy, 43(2), 123–135. DiGiammarino, M. (1990). Functional Music Skills of Persons with Mental Retardation. Journal of Music Therapy, 27(4), 209-220. DiGiammarino, M. (1994). Functional Music Leisure Skills for Individuals with Mental Retardation. Music Therapy Perspectives, 12(1), 15-19. Dileo, C. L. (1976). The Relationship of Diagnostic and Social Factors to the Singing Ranges of Institutionalized Mentally Retarded Persons. Journal of Music Therapy, 13(1), 17-28. Duffy, B., & Fuller, R. (2000). Role of Music Therapy in Social Skills Development in Children with Moderate Intellectual Disability. Journal of Applied Research in Intellectual Disabilities, 13(2), 7789. Elefant, C. (2009). Unmasking Hidden Resources: Communication in Children with Severe Developmental Disabilities in Music Therapy. In V. Karkou (Ed.), Arts therapies in schools: Research and practice (pp. 243-258) London, UK: Jessica Kingsley Publishers, Inc. Elefant, C. (2009). Unmasking Hidden Resources: Communication in Children with Severe Developmental Disabilities in Music Therapy. In V. Karkou (Ed.), Arts therapies in schools: Research and practice (pp. 243-258). London, UK: Jessica Kingsley Publishers, Inc. Ely, E., & Scott, K. (1994). Integrating Clients with an Intellectual Disability into the Community through Music Therapy. Australian Journal of Music Therapy, 5, 7-18. Farnan, L. (2003). Music Therapy at Central Wisconsin Center for the Developmentally Disabled. Voices: A World Forum for Music Therapy, 3(2). Farnan, L. A. (2007). Music Therapy and Developmental Disabilities: A Glance Back and a Look Forward. Music Therapy Perspectives, 25(2), 80–85. Force, B. (1983). The Effects of Mainstreaming on the Learning of Nonretarded Children in an Elementary Music Classroom. Journal of Music Therapy, 20(1), 2-13. Ford, S. E. (1999). The Effect of Music on the Self-Injurious Behavior of an Adult Female with Severe Developmental Disabilities. Journal of Music Therapy, 36(4), 293-313 Furman, C. E., & Furman, A. G. (1996). Uses of Music Therapy with People Having Mental Retardation: An Update of a Previous Analysis. In C. E. Furman (Ed.), Effectiveness of Music Therapy Procedures: Documentation of Research and Clinical Practice (pp. 279-296). Silver Spring, MD: National Association for Music Therapy, Inc. Galerstein, N., Martin, K., & Powe, D. (1998). Age Appropriate Activities for Adults with Profound Mental Retardation: A Collaborative Design by Music Therapy, Occupational Therapy and Speech Pathology. Saint Louis, MO: MMB Books, Inc. Garwood, E. C. (1988). The Effect of Contingent Music in Combination with a Bell Pad on Enuresis of a Mentally Retarded Adult. Journal of Music Therapy, 25(2), 103-109

Geist, K., McCarthy, J., Rodgers-Smith, A., & Porter, J. (2008). Integrating Music Therapy Services and Speech-Language Therapy Services for Children with Severe Communication Impairments: A CoTreatment Model. Journal of Instructional Psychology, 35(4), 311-316. Gfeller, K. (1987). Songwriting as a Tool for Reading and Language Remediation. Music Therapy, 6(2), 2838. Goodman, K. D. (2007). Music Therapy Groupwork with Special Needs Children: The Evolving Process. Springfield, IL: Charles C. Thomas. Graham, J. (2004). Communicating with the Uncommunicative: Music Therapy with Pre-Verbal Adults. British Journal of Learning Disabilities, 32(1), 24-29 Grant, R. E., & LeCroy, S. (1986). Effects of Sensory Mode Input on the Performance of Rhythmic Perception Tasks by Mentally Retarded Subjects. Journal of Music Therapy, 23(1), 2-9. Grocke, D., & Wigram, T. (2006). Perceptual Listening in Intellectual Disability and Music Appreciation in Adults. In Receptive Methods in Music Therapy: Techniques and Clinical Applications for Music Therapy Clinicians, Educators and Students (xxxx). London: Jessica Kingsley Publishers. Gross, W., Linden, U., & Ostermann, T. (2010). Effects of Music Therapy in the Treatment of Children with Delayed Speech Development - Results of a Pilot Study. BMC Complementary and Alternative Medicine, 10, 39. Hobson, M. (2006). The Collaboration of Music Therapy and Speech-Language Pathology in the Treatment of Neurogenic Communication Disorders: Part I--Diagnosis, Therapist Roles, and Rationale for Music. Music Therapy Perspectives, 24(2), 58-65. Hooper, J., Wigram, T., Carson, D., & Lindsay, B. (2008). A Review of the Music and Intellectual Disability Literature (1943-2006): Part two: Experimental writing. Music Therapy Perspectives, 26(2), 8096. Humphrey, T. (1981). Selection of Music Therapy Activities by Mentally Retarded Young Adults of Low, Moderate, and High Activity. Perceptual and Motor Skills, 53(3), 905-906. Jones, R. E. (1986). Assessing Developmental Levels of Mentally Retarded Students with the MusicalPerception Assessment of Cognitive Development. Journal of Music Therapy, 23(3), 166-173. Kennelly, J., Hamilton, L., & Cros, J. (2001). The Interface of Music Therapy and Speech Pathology in the Rehabilitation of Children with Acquired Brain Injury. Australian Journal of Music Therapy, 12, 13-20. King, B. (2007). Language and Speech: Distinguishing between Aphasia, Apraxia, and Dysarthria in Music Therapy Research and Practice. Music Therapy Perspectives, 25(1), 13–18 Krauss, T., & Galloway, H. (1982). Melodic Intonation Therapy with Language Delayed Apraxic Children. Journal of Music Therapy, 19(2), 102-113. Loewy, J. V. (1995). The Musical Stages of Speech: A Developmental Model of Pre-Verbal Sound Making. Music Therapy, 13(1), 47-73. Luck, G., Riikilä, K., Lartillot, O., Erkkilä, J., Toiviainen, P., Mäkelä, A., & Värri, J. (2006). Exploring Relationships between Level of Mental Retardation and Features of Music Therapy Improvisations: A Computational Approach. Nordic Journal of Music Therapy, 15(1), 30-48. Madsen, C. K. (1981). Music therapy: A Behavioral Guide for the Mentally Retarded. Lawrence, Kansas: National Association for Music Therapy, Inc. May, N., & Michel, D. E. (1974). The Development of Music Therapy Procedures with Speech and Language Disorders. Journal of Music Therapy, 11(2), 74-80. McCarthy, J., Geist, K., Zojwala, R., & Schock, M. Z. (2008). A Survey of Music Therapists’ Work with Speech-Language Pathologists and Experiences with Augmentative and Alternative Communication. Journal of Music Therapy, 45(4), 405-426. McNamara, J. (1981). The Use of Music in Group Therapy to Eliminate Self-Injurious Behavior in the Profoundly Retarded. The Australian Music Therapy Association Bulletin, 4(4), 3-7.

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References for Introduction American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Developmental Problems in Learning and Communication

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE ONE Developing Speech with Music: A Neurodevelopmental Approach A. Blythe LaGasse Introduction This chapter illustrates the use of Neurologic Music Therapy (NMT) with a child who has a neurodevelopment disorder. Daniel was a six-year-old boy with Down syndrome whose parents sought music therapy in order to improve his speech communication abilities. He received services from a music therapy private practice that was housed within a SpeechLanguage Pathology center. Individualized treatment goals were speech specific and focused on speech intelligibility and a multimodal approach to functional communication. Based upon Neurological Music Therapy (Thaut, 2005), the treatment approach was determined by examining evidence utilizing the Rational-Scientific Mediating Model (R-SMM) and developing client-specific interventions using the steps set forth by the Transformational Design Model (Thaut, 2005). Foundational Concepts Neurologic Music Therapy Neurologic Music Therapy (NMT) is defined as “the therapeutic application of music to cognitive, sensory, and motor dysfunctions due to neurologic disease of the human nervous system” (Thaut, 2005, p. 126). NMT is an evidence-based approach that is based on scientific evidence supporting the use of specific music therapy interventions (Thaut, 2005). Neurologic Music Therapists utilize standardized techniques for functional rehabilitation training in sensorimotor, cognitive, and speech and language domains. NMT is guided by the Rational-Scientific Mediating Model (R-SMM), a neuroscience model of music perception and production. This model is utilized to systematically examine the influence of music on changes in nonmusical function (Thaut, 2000). The R-SMM guides the development of evidence-based therapeutic interventions that are adaptable to each individual’s needs and functional therapeutic goals. These treatment techniques have standardized terminology and application, based on functional therapeutic goals and the mechanism within the music that is facilitating change (Thaut, 2005). The design of the therapeutic interventions is not limited, but is rationally guided by technique standardization. The NMT practitioner is encouraged to use creativity in the construction of logical therapeutic music interventions.

The carefully crafted musical stimulus promotes physiologic change. NMT is heavily based on the role of rhythm in therapeutic intervention; however, the NMT practitioner must also consider all elements of music that promote change. Melody, harmony, musical structure, lyrics, range, dynamics and tempo are all elements that should be carefully considered (Thaut, 2005). Guided by research, the NMT practitioner is the creator of the therapeutic music experience and facilitates the use of music in therapy. Treatment in NMT is subdivided into three areas of functioning: 1) cognitive rehabilitation, 2) sensorimotor rehabilitation, and 3) speech and language rehabilitation. Treatment interventions are based on evidence of musical responses within each of these domains, and how such evidence can be meaningfully translated into cognitive, affective and sensorimotor therapeutic responses. To help guide treatment in these areas, Thaut (2000) developed a five-step model called the Transformational Design Model (TDM), which aids the music therapist in translating the R-SMM into functional therapeutic music interventions. The TDM aids the NMT practitioner in developing creative therapeutic interventions while logically maintaining treatment focus. Although NMT has been developed from research and evidence in neurological rehabilitation, NMT techniques can be utilized to address functional goals in children with neurodevelopment disabilities. There is a growing body of research demonstrating the effectiveness of NMT techniques with children (e.g., Claussen & Thaut, 1997; Krauss & Galloway, 1982; Kwak, 2000; Lim, 2010; Pasiali, 2008). According to Thaut, Mertel and Leins (2008), the major areas of focus with children who have disabilities include education, rehabilitation, and development. Educational goals focus on academic, social, emotional, and physical skills. Rehabilitative goals focus on remedial or compensatory therapy for physical and speech deficits. Developmental goals enhance the course of normal development by providing social, emotional, and sensorimotor experiences. In order to properly utilize NMT techniques with children, it is essential to understand neurological development, as children with neurodevelopmental disorders will be learning skills for the first time and will not, in most cases, be re-learning skills. For instance, the development of motor synchronization abilities must be carefully considered when implementing techniques heavily based on rhythmic cueing. Research from the biomedical sciences provides support for the use of rhythmic cueing with children; however, the motor synchronization abilities of children differ from abilities of adults (e.g., Hurt-Thaut & Johnson, 2003; Mastrokalou & Hatziharistos, 2007; Smoll, 1974a, 1974b, 1975; Thomas & Moon, 1976; Volman & Geuze, 2000). This is just one example of why the NMT practitioner must carefully consider many aspects of child development (neurological, social, motor, linguistic, etc.) when implementing NMT techniques. The Client Daniel, a boy with Down syndrome, was six years old at the time of his initial music therapy assessment. He had been reported as non-compliant and demonstrated negative behaviors during speech interventions at school. At the time of his evaluation, he was not receiving any private services for physical, cognitive, or speech needs. Daniel attended a private preschool and received 30 minutes of speech therapy once a week at school. According to his

mother, he was becoming increasingly frustrated with his inability to communicate with others. His frustration resulted in tantrums and inappropriate behaviors such as yelling “no” or biting. At the time of his assessment, Daniel’s primary needs were in the area of functional communication. He exhibited severely delayed speech articulation, vocabulary use, sentence use and ability to use speech in communication. Daniel’s speech was rapid, cluttered and accompanied by a series of fast gestures. His primary method of communication was a Picture Exchange Communication System (PECS) that was being implemented in school and at home. He was also learning sign language to express his wants and needs at school and home. Daniel was warm and open to others and was reported to, quickly, make friends with children in his class and in his community. His desire to interact was demonstrated through his ability to initiate conversation and attempt age-appropriate reciprocal communication. Daniel demonstrated excellent receptive language skills, as evidenced by his ability to follow directions and to respond to questions with signs or PECS. The primary factor that was limiting his social abilities was his verbal communication. When he attempted to communicate with others (including same-age peers), and his ideas were not understood, he would either shut down and cease communication attempts, or become visibly frustrated. Daniel’s mother had heard about music therapy for children with Down syndrome and decided to seek services since Daniel loved listening to music. Assessment The assessment process within NMT practice involves an in-depth look at a person’s non-musical functioning, including any available non-musical testing measures, functional assessments, or gold standards (accepted measurements in the field). When available, nonmusical measures are obtained from other professionals including speech-language pathologists, physical therapists, and occupational therapists. In addition to functional measures of ability, the Neurological Music Therapist will engage in non-musical observation of the client’s behavior within the typical or targeted setting (i.e., school, speech-language pathology session, etc.). During the non-musical assessment, baseline data are collected in the identified areas of need. After compilation of information about the client’s non-musical functioning is completed, the Neurological Music Therapist will consult the R-SMM to determine what evidence-based techniques are appropriate for the client’s needs. The final phase of the assessment is the application of NMT techniques to determine if there is a change in behaviors when musical stimuli are present. Changes in behavior are often immediately recognizable within this method and are documented in terms of possible treatment outcomes. The treatment plan is constructed from the baseline data, observed change in behavior with application of NMT techniques and the recommended course of NMT treatment. Daniel’s Assessment Documentation about Daniel’s current and past treatment was supplied by his mother and was reviewed during the assessment phase. His speech-language goals were of specific concern to his parents and therefore were the focus of the assessment. Daniel’s other skills

were also assessed (i.e., cognitive, motor, emotional, etc.); for the purposes of this chapter, however, I will focus on the speech assessment. Daniel demonstrated the ability to produce four initial phonemes in words including /b, m, w, d/ (age-matched norms are able to produce most phonemes within words), and he had mastered signs including name signs for his family and different foods. He did not have the ability to produce want or need phrases, middle or ending consonants, or to verbally communicate thoughts. He attempted to pair verbalizations with mastered signs, although verbal intelligibility was very low. Daniel’s receptive language was delayed in comparison with age-matched peers; however, he demonstrated stronger receptive than expressive language. When undergoing the non-musical assessment, he exhibited inattentiveness and frustration when not understood. The music assessment was constructed to determine if Daniel’s observed non-musical behaviors changed when musical stimulus was present. Observed changes included the ability to sequence speech and sign with rhythmic cueing. He was also able to produce two-word phrases with rhythmic prompting, although intelligibility was still low. Daniel’s attention improved and his frustration when misunderstood decreased while engaged in music. Based on this information, Daniel’s treatment plan included the recommendation to begin music therapy services once a week for 40-minutes per session, inclusive of a home treatment program to be carried out by the parents. The Therapeutic Process Although NMT is a scientific approach, there is no lack of age-appropriate elements within sessions. The intention is to reach the targeted goals and objectives while implementing exercises that are motivating, exploratory, aesthetically pleasing and success-oriented. From the “welcome” song to the therapeutic music experiences, every exercise implemented within the session is a direct translation of the equivalent non-musical task, as facilitated by the steps of the TDM. The therapist is the researcher, the creator, and the facilitator in this model--the researcher of the non-musical exercises that would be utilized within other disciplines to reach the target goal/objective; the creator of the isomorphic music experience that embodies the non-musical exercise while adding age-appropriate musical aesthetics; and, the facilitator who can modify and adapt to accommodate the client’s needs and to promote success. The therapeutic process in NMT also incorporates constant examination of research in the fields of neuroscience, neurodevelopment, learning, and music in therapy. This constant inquiry into evidence-based practice aids the therapist in continually expanding his/her therapeutic repertoire, which ensures excellence in services provided to clients. The following description not only illustrates NMT techniques for verbal communication in a child with a developmental disorder, but also how research provided insight into techniques that were current and success-oriented. Typical Session Sessions began with an assessment of Daniel’s arousal level (with observation of his activity, energy, and attentiveness). After observation, a tempo that matched his arousal level

was set on the metronome and played at that tempo for the entire duration of the session (at a comfortable volume). The metronome was utilized as a pacing device for priming motor movements. If the metronome tempo was too fast/slow for production of speech utterances, then the tempo was adjusted to promote success. Often during speech exercises, the tempo was twice that of the speech of the utterance/target syllable. Since Daniel’s speech (when engaged in speech exercises) was often very slow, the extra metronome click provided an anticipatory cue for the words/syllables. After assessment of his arousal level, Daniel was immediately engaged in a welcome song that emphasized utilizing common greeting phrases (e.g., “Hello, how are you?”). We would then explore different aspects of functional communication with age-appropriate musical experiences. This would typically begin with articulation practice using instruments to reinforce production (i.e., Therapist: I can say ba, ba, ba, ball, I can say [Client response: ba, ba, ba, ball]). Articulation practice was also paired with a large body movement such as playing a drum, bouncing on a therapy ball or moving his hands with the rhythm of the song. Articulation exercises were then embedded in other functional communication exercises. The focus of the remainder of the session was on functional communication. A multifaceted communication approach was utilized in order to provide the client with as many tools as possible for success. This approach involved the use of pictorial communication, signed communication, or gestural communication, along with verbal communication in order to promote success. The idea is that if the child’s verbal utterances are not enough to express his thoughts, then the second mode of communication helps to complete the communicative gesture. These concepts were presented using the technique Developmental Speech and Language Training through Music (Thaut, 2005), which emphasizes age-appropriate speech and language experiences that are motivating. For Daniel, different musical experiences were presented on a picture board and would include activities such as “frog song,” “instrument playing,” “singing,” “dancing” and “drumming.” Each picture card represented a functional communication exercise that could be completed. For example, the “instrument playing” application may utilize instruments to work on want/need phrases (i.e., I want the _____), whereas the “frog song” may work on describing the placement of an object (i.e., Fred the frog is on/in/behind/under the table). Other exercises worked on vocabulary. For instance, with “singing” we might pair word cards with actual items (“Apple” was paired with an apple/apple shaker, “ball” with an actual ball, etc.) and a song would be created to reinforce the vocabulary, including a description of the item (i.e., I bounce the ball, the red ball, the red ball) while Daniel was manipulating or attending to the object. When engaged in these exercises, Daniel would be exposed to rhythmic cues from the metronome and the rhythmic structure of the songs created for the experience. He would often hear an example provided by myself and then would be cued by the rhythm and structure of the music to provide his own response (i.e., Blythe likes the purple ball, purple ball, purple ball. I like the [client response]). I would follow Daniel’s lead in order to promote further exploration of language and vocabulary. If Daniel rolled the ball, our song would adapt to include language reflecting the new action. Therefore, the experiences were part therapist-directed and part client-driven. Providing an experience in which the client would need to use his communication to change the experience was used to encourage spontaneous communication. For example, with

instrument playing the client would choose an instrument to play and after time for exploration of the instrument, I would bring out two new instruments and play them. Daniel would see the new instruments and would need to communicate that he was “finished” with his instrument and initiate a phrase for acquiring a new instrument (i.e., “I want _____ please”). This allowed Daniel to practice learned phrases without adult prompting, in an effort to encourage spontaneous communication that he could use outside music therapy sessions. After each experience, the targeted speech or language goal was reinforced nonmusically, or if possible, in another location. For example, if we were engaging in an experience about “stop” and “go,” we would look outside at the traffic light and carry-on our experience non-musically waiting for the red light to turn to green by verbalizing “Let’s stop” and “Let’s go!” Transfer to outside objects/situations wasn’t immediate, so a gradual transfer was often necessary. We would pair outside or new objects with the items we were just using, and then fade over time. Rhythm was still present when practicing speech without the melodic and structural cues, and Daniel was encouraged to self-cue by tapping on his leg with the rhythm when he had difficulty verbalizing. Daniel responded more favorably to experiences that were more “play” oriented than the experiences that were more focused on “work,” such as articulation applications. Although every effort was made to make all experiences engaging for Daniel, there was a difference in the more clinician-directed vs. child-directed experiences. However, a balance between the two allowed Daniel to practice all of the skills that were targeted, with maximal interest and participation. This also decreased the occurrence of tantrums and frustration. First Three Months Daniel’s initial treatment period was three months, enough time to ascertain if NMT treatment was beneficial in reaching his non-musical goals and objectives. This period in NMT, as in other approaches, is a time in which a relationship is established. Daniel was immediately friendly, and for the first few weeks displayed developmentally appropriate behaviors of environmental exploration. This exploration of the environment was incorporated into the first few weeks of treatment, encouraging as much communication as possible while allowing for exploration. The relationship in NMT is built on success-oriented and aesthetically pleasing experiences. The therapeutic music experiences target goals and objectives while building a client-therapist relationship. According to Kumin (2006), the typical child is 100% intelligible by four years of age. However, it is unusual for a person with Down syndrome to be 100% intelligible at any age. Furthermore, delays in speech production in children with Down syndrome have been documented to continue into adulthood, with significant delays in consonant acquisition (Kumin, Council, & Goodman, 1994). At six years of age, Daniel had extremely low intelligibility, with few acquired phonemes. During the first three months of services, the focus of treatment was on producing isolated phonemes, producing those phonemes in the initial position of words and producing simple two-word phrases. Interventions were also designed to increase prosodic elements of vocalizations. Each of the exercises implemented were developed utilizing the TDM. The non-musical exercise, as would be implemented in speech therapy, was first outlined. In order to achieve appropriate non-musical applications, speech-language

pathologists, research and current texts on speech interventions were consulted. Music was then created to transform this nonmusical exercise into a therapeutic music application. Developmental Speech and Language Training through Music (DSLM) experiences utilized aspects of play and natural interaction, in combination with specific (directive) cues for responses within the play experience. Once the child produced the word when prompted, the prompts were faded in order to allow for spontaneous production within DSLM experiences. The typical structure of the music was a simple composition with instructions or prompts imbedded within the lyrics or musical structure that were utilized to elicit a response. This was in place of the verbal prompts given in speech therapy and provided a temporal cue for responses. An ongoing rhythmic stimulus (metronome) continued during the client’s response time in order to promote the motor speech response. The songs composed were ageappropriate for a six-year-old child and combined elements of active engagement in speech production and “speech breaks,” where participation in musical play was encouraged. It was soon evident that Daniel was able to synchronize his speech to the stimulus provided by the metronome and harmonic instrument. An example of motor synchronization was his ability to repeat a learned phoneme, such as /ba/. When asked to repeat the phoneme without musical stimuli, he would exhibit a three-second pause between productions (if he were to produce the syllable a second time at all). With musical stimulus present at a functional tempo, he would produce three to six successive repetitions of the phoneme. This ability soon allowed for more oral motor practice of unlearned syllables within each exercise. Synchronization was also evident in the sequencing of phrases. Without rhythmic stimulus, he would require several verbal prompts and an extended pause for execution of the phrase. With rhythmic stimulus, the phrase was produced in time, or slightly after, the stimulus. This production was even more successful when the response followed a structured musical cue. Daniel’s treatment was supplemented at home, with weekly assignments that were given to his parents to complete throughout the week. These assignments focused on utilizing rhythmic cues for when his speech was unintelligible and redirections to use his augmentative communication methods (sign language and PECS). Any musical exercises that were to be carried out at home were demonstrated to Daniel’s mother at the end of each session. The family was provided with a written explanation of each exercise to be implemented, when possible. These exercises were designed to take very little time or to be completed while engaged in play. The family was successful in implementing most of the prescribed exercises over the weeks and often asked for additional tools that would be useful. The implementation of such exercises not only provided added opportunities for Daniel to practice skills that he was learning, but also encouraged him to use those skills in his typical environment. This incorporated the family into the treatment process, rather than relying solely on the therapistclient interaction to facilitate change. A non-musical re-evaluation was completed at the end of three months to determine if music therapy was an effective treatment method. By the end of three months, Daniel was consistently producing four new phonemes within the initial position of words. He had increased spoken vocabulary to include eight additional (intelligible) words, increased sign vocabulary by nine signs, and was able to speak and sign the two-word phrase “I want” with minimal assistance. By this time in the treatment process, it was apparent that he had the ability and showed the desire to learn effective communication. Language learning in persons

with Down syndrome has been suggested to continue into adolescence (Rondal, 2003), and therefore, this was seen as an important period for growth. In order to provide the best treatment outcomes possible, Daniel’s parents were referred to a local speech therapist. Next Six Months The next six months were filled with changes for Daniel. He was integrated into a new class, began receiving music therapy twice a week, and underwent a full speech-language pathology assessment. Following the speech assessment, he also began speech therapy sessions once a week. The speech therapy assessment was in agreement with the three-month music therapy re-evaluation. During the next six months of Daniel’s treatment, objectives for phoneme production continued, with emphasis on placing phonemes in the initial position and middle position of words. Increasing vocabulary was targeted, as well as production of two- to three-word phrases. By this time, he was back in school and his communication methods (speech, sign and PECS) were being utilized at home, in school, in speech therapy, and in music therapy. The implementation of therapeutic music experiences for functional phrases began with phrases targeted by his parents and school. He continued to work on “I want” phrases, adding verbalizations for the desired object or action word (i.e., “I want more” or “I want ball”). Additionally, he began working on a phrase for introducing himself to his peers at his new school. As in other experiences, a song was created in order to allow him to practice the targeted phrase in response to the question “What’s your name?” Utilizing the rhythm and sign cues to sequence the speech of the phrase, Daniel graduated from imitative responses to an initiated response. In order to prepare him for school, the musical cues were faded and spoken cues were utilized. As in the first three months, rhythm was integral to all therapeutic music experiences for speech production and the DSLM was the primary technique utilized. During this treatment period, attempts were made to decrease Daniel’s dependence on someone else cueing him for speech. Therefore, he was encouraged to provide his own motor tapping cues on his leg, matching one tap to one syllable in order to learn a functional way to self-cue when he wished to speak. Although research regarding rhythm for speech production in children is in its infancy, there have been promising results for using rhythmic cues for speech communication in children (e.g., Carroll, 1996). He was also encouraged to sign (another type of motor movement pairing) while speaking a word in order to better facilitate functional communication. Rhythmic tapping/signing was encouraged whenever he was producing twosyllable words or phrases. Daniel was very successful with pairing sign language with speech. Rhythmic tapping was less natural, but he gradually became adept at cuing himself without prompts from an adult. The progression to self-cue speech was completed by first practicing the pairing of syllabic speech with instrument playing (i.e., three instruments are placed on a white board under a written phrase with three syllables), then pairing syllabic speech with touching the actual syllables of the written word, and then cueing by tapping on his knee. The environment in which he cued himself was also changed periodically, as we would take “field trips” and meet other therapists or office workers that were unfamiliar to Daniel so that he could practice his speech and speech cueing with an unfamiliar listener. This was completed to reinforce step five

of the TDM, which focuses on fading the musical cues and transitioning into the typical environment. During this treatment period, Daniel was integrated into public school and was increasingly showing signs of frustration when he was not understood. When this occurred during the music therapy session, he would “shut down” verbally and physically. This shutdown involved a closed (often hunched over) position and refusal to talk. This often occurred when he was attempting to spontaneously tell a story about his new friends at school. Methods for preventing meltdowns were implemented, including adding his classmates to his PECS book, reminding him to slow down his speech and aiding him in cuing his speech. When meltdowns occurred, a short musical improvisation was often implemented, since exploratory behavior on an instrument usually redirected the client back to the music experience. Final Three Months Over the last three months of services, Daniel continued to learn sign language very quickly, as evidenced by his ability to spontaneously use new signs just a few weeks after learning the sign(s). A consultation with then current research supported the use of written words for language learning in children with Down syndrome (Buckley, 2000) and this became an integral element in his music therapy sessions. It was soon apparent that he had the ability to sound out a written word. The combination of visual language (sign & written), spoken language, and rhythmic cuing was observed to be the most beneficial for him. He had the ability to learn new words by sounding-out the written word (requiring some help) and practicing the sounds within the word. Words were always paired with the visual representation of the word (i.e., if the word was “ball” then he would find the ball or the picture of a ball). He also practiced writing the words that he would verbalize. After 12 months of music therapy, sessions were terminated due to the occupational relocation of Daniel’s family. It was recommended that he continue receiving speech-language and music therapy services with an emphasis on communication. The final report and progress note showed that Daniel made a number of improvements. Developmental Speech and Language Training through Music aided him in learning functional phrases that were generalized into his typical environments including “I want ______,” “more please,” “my name is Daniel,” “shoes on/off” and “no thank you.” In total, he improved from overall low intelligibility to more than ten consistently intelligible target phrases (up to four words). His success with new phrases (or self-generated phrases) was often dependent on the consonantvowel combinations of the attempted phrase and his acquired phoneme repertoire. Focused attention on phoneme production increased his success with intelligible speech due to improvements on targeted phonemes in initial, middle and ending positions. He was able to consistently utilize targeted phonemes in the initial and middle position of words (91% success) and started placing phonemes in the final position of words. He was also more successful at initiating intelligible phrases utilizing self-cueing techniques, with 84% intelligibility for twoword phrases (identified by an unfamiliar listener). When not understood verbally, Daniel was more consistent in initiating the use of signs or PECS to communicate. Furthermore, DSLM aided him in vocabulary learning through the use of motivating musical experiences, literature and music, and age-appropriate language incorporated into musical play. Vocabulary gains were demonstrated in increased expressive

vocabulary use (signs and spoken) and the increased ability to demonstrate receptive understanding (i.e., following more complex directives). In the final months of treatment, he had independently demonstrated the use of 19 unprompted signs. Furthermore, instances of frustration decreased, with only two instances of visible frustration in the last two months of treatment. Summary Daniel made several important improvements in his expressive language through the use of DSLM and rhythmic cueing. Although there were some immediate improvements (such as sequencing oral motor movements with rhythm), the production of intelligible speech was a gradual process that involved practice in different environments. The use of Neurologic Music Therapy for practice with children with developmental disabilities involves consideration of current literature in development, neuroscience, and music. The R-SMM and TDM helped to guide the Neurologic Music Therapist in developing treatment-specific applications that facilitate the functional goals of the client. Although NMT has been primarily researched with adults in neurological rehabilitation, using current research to guide practice in music therapy for children with developmental disabilities will aid music therapists in developing protocols that promote success in music therapy treatment. References Buckley, S.J. (2000). Speech, language and communication for individuals with Down Syndrome-An overview. Down Syndrome Issues and Information. Retrieved from http://www.downsyndrome.org/information/language/overview/. Carroll, D. (1996). A study of the effectiveness of an adaptation of melodic intonation therapy in increasing the communicative speech of children with Down syndrome. (Unpublished doctoral dissertation). McGill University, Canada. Claussen, D.W. & Thaut, M.H. (1997). Music as a mnemonic device for children with learning disabilities. Canadian Journal of Music Therapy, 5, 55–66. Hurt-Thaut, C. & Johnson, S. (2003). Neurologic music therapy with children: Scientific foundations and clinical application. In S. Robb (Ed.), Music Therapy in Pediatric Heathcare: Research and Evidence-based Practice (p. 81-100). Silver Spring, MD: American Music Therapy Association. Krauss, T. & Galloway, H. (1982). Melodic Intonation Therapy with language delayed apraxic children. Journal of Music Therapy, 19(2), 102-113. Kumin L. (2006). Speech intelligibility and childhood verbal apraxia in children with Down syndrome. Down Syndrome Research and Practice, 10(1), 10-22. Kumin, L., Council, C. & Goodman, M. (1994). A longitudinal study of the emergence of phonemes in children with Down Syndrome. Journal of Communication Disorders, 27, 293-303. Kwak, E.E. (2000). Effect of rhythmic auditory stimulation on gait performance in children with spastic cerebral palsy. (Unpublished master’s thesis). University of Kansas, Lawrence.

Lim, H.A. (2010). Effects of “Developmental Speech and Language Training through Music” on speech production in children with autism spectrum disorders. Journal of Music Therapy, 47(1), 226. Mastrokalou, N. & Hatziharistos, D. (2007). Rhythmic ability in children and the effects of age, sex, and tempo. Perceptual and Motor Skills, 104(3, Pt 1), 901-912. Pasiali, V. (2008). Music therapy and resiliency: A pilot project. Unpublished manuscript. Michigan State University. Rondal, J.A. (2003). Maintenance training in older ages. In J.A. Rondal & S. Buckley (Eds.), Speech and language intervention in Down syndrome (pp. 166-183). London: Whurr Publishers Ltd. Smoll, F.L. (1974a). Development of rhythmic ability in response to selected tempos. Perceptual and Motor Skills, 39, 767-772. Smoll, F.L. (1974b). Development of spatial and temporal elements of rhythmic ability. Journal of Motor Behavior, 6, 53-58. Smoll, F.L. (1975). Preferred tempo in performance of repetitive movements. Perceptual and Motor Skills, 40, 439-442. Thaut, M.H. (2000). A Scientific Model of Music in Therapy and Medicine. San Antonio, TX: IMR Press. Thaut, M.H. (2005). Rhythm, Music, and the Brain. London, England: Taylor & Francis. Thaut, M.H., Mertel, K. & Leins, A.K. (2008). Music for children with physical disabilities. In W.B. Davis, K.E. Gfeller, & M.H. Thaut (Eds.), An Introduction to Music Therapy: Theory and Practice (3rd ed.) (pp. 143-180). Silver Spring, MD: American Music Therapy Association. Thomas, J. R. & Moon, D. (1976). Measuring motor rhythmic ability in children. Research Quarterly, 47, 20-32. Volman, M. J. M. & Geuze, R. H. (2000). Temporal stability of rhythmic tapping “on” and “off the beat”: A developmental study. Psychological Research, 63, 62-69.

Taken from: Hibben, J. (Ed.) (1999). Inside Music Therapy: Client Experiences. Gilsum NH: Barcelona Publishers.

CASE TWO Singing a Special Song Christina Rago Julie Hibben Julie’s Introduction I am grateful to Christina, Franny’s mother, for writing about Franny’s life with music. Christina has always been perceptive about the value of Franny’s music and a strong advocate for her needs. Franny and I worked together (in sessions they called music lessons) for three and a half years, from third grade until sixth. Franny, who has developmental delays and mild cerebral palsy, used her sessions to sing and record familiar songs and to role play. Franny is now 15. Christina has chosen to use their real names. Christina Tells of Franny’s Music Music and Franny have been together from the beginning. Before she had language, she loved to sing and be sung to. She loved to rock and be held and watched my lips carefully as they moved. She’d copy my movements and I’d move her fingers and hands in finger play or in rhythms. Her sister, Maria, was learning Suzuki violin, and “Twinkle, Twinkle, Little Star” was played often in our house. Maria’s Suzuki teacher encouraged us to rub or tap the children in the same bow movement as the song to reinforce the rhythm of the music. I used this technique with Franny as well, to practice songs and integrate the music into her mind and body. Franny’s disabilities are traced to agenesis of the corpus collosum (the nerve bundle that connects the right and left hemispheres of the brain never formed) and mild cerebral palsy. She also has overall developmental delay. She walks now in her own style, which can be viewed as awkward at times, but it gets her where she needs to go, and she has made enormous progress. She is 15 years old, and her condition was diagnosed when she was nine months old. The prognosis at that time was that she would not walk, but she has gone from a walker to a wheelchair, to a walker again, then crutches, and finally, at seven years old, she was able to walk without help. Music, in the meantime, was a rhythmic link to the perambulations and movements of the outside world. She learned sign language before she was able to vocalize

speech. She began to talk in kindergarten and now speaks quite intelligibly. She still receives language and speech therapy. Throughout Franny’s life, music has served as a way to order aspects of her life. For example, we would sing together: “Clean up, clean up, everybody clean up” or “Hungry, hungry, I am hungry.” Music was a soothing influence during her morning wake-up period and for her evening lullaby. Music remains a form of socialization in group chorus at school and when she sings hymns at church. Music deepens feelings of comfort and security at home and with her family and friends. This summer, she attended an overnight camp deep in the northern woods for a week. While [she was] there, I know, music and her repertoire of many songs made it easy for her to make friends quickly and share experiences. In preschool, Franny sang a number of her songs during circle time. The songs were familiar and were a way of being together as a group, of enjoying friendships, of combining song with sign language, and of demonstrating a sense of community. As the songs were introduced into our household, the familiar world of home became integrated into the new patterns and structures of the preschool. In third grade, Franny began private lessons with Julie Hibben. The work she did with Ms. Hibben supported and supplemented the public school’s music program. The songs from the public school were the springboard for improvisation and were expanded in the sessions. The public school music teacher had said that she felt ill equipped to deal with Franny and that Franny’s classroom aide needed to bear the responsibility for her music instruction. In one of my arguments for the public school to continue support for Franny’s outside instruction--when she was in fifth grade--I explained how her one-on-one instruction was crucial to the success of her “integration plan.” This individualized program allowed Franny to work in depth and without pressure so that she could take part more fully in all aspects, including performance, of the public school program. Music is Franny’s most integral subject--it is as critical and reinforcing as language. It is another language for her. Since Franny doesn’t participate in the school foreign language program, she should at least have music. Franny remembers the music she hears and responds to it vocally. Music helps her memory, her language, and her counting skills. The music program reinforces and supports everything the special-education teachers are working on as outlined in the individualized education program (IEP) and the goals we periodically set for her to meet in her daily life. Franny needs reinforcement to learn to use her voice appropriately--with the right amount of loudness, intensity, and expression. Music does this and more for Franny. The sessions with Ms. Hibben included singing the songs she was learning in her music class at school, listening to the sound of her own voice in recordings where she heard herself through speakers while using a microphone, making new recordings, and doing imaginative play. Ms. Hibben gave Franny the freedom during these sessions to make choices and order their “play.” I saw a tremendous release in Franny’s face after her sessions. She would enter the room appearing tight and walk out unburdened. Ms. Hibben used the sessions to help Franny explore her feelings in the course of their play together. The play would include setting up the space (a trip, restaurant, a party, putting a baby to bed) and getting dressed (using scarves). “Several weeks ago,” Ms. Hibben wrote in her first report, “Franny said we were not going to play doctor anymore, perhaps a sign that she is letting go of some of those fears.” I know that

the operations Franny experienced in first and second grades to enable her to walk had a terrible downside. The trauma of the experience was healed through music. Franny used tapes from her public school music class and learned the songs for that class with Ms. Hibben. This process built her confidence about singing. She was no longer too shy to take part in the music class with the other kids. Franny’s interactive playing on pianos and drums was uninhibited and she used expressive gestures. Using language with the playing helped Franny organize herself: “My turn, your turn.” She would often initiate words or sing to herself while playing. The structure of the sessions with Ms. Hibben was very much a participatory construct. Ms. Hibben used a typed list of things they did together during the lesson, and Franny chose the order of things. Being in charge was a critical part of Franny’s learning. Sessions always began with a long duo-piano improvisation. Franny was always reluctant to try something new, so Ms. Hibben was careful about what to introduce. For example, early in their work together, Franny would ask to hold the mike but would make no sound. After about two tothree weeks, she began to sing into the mike and record her songs. She always enjoyed pretend play: “You be the wolf and I’ll be the gramma,” she’d say, and the play would evolve into acting out going to the doctor and having Ms. Hibben’s (not Franny’s!) foot examined for new foot braces. They would listen to a tape of songs prepared for Franny to learn by her public school music teacher and Franny would sit down with the printed version and sing them. By the fifth grade, Franny had made considerable progress. At home, at this time, she was singing Ella Fitzgerald songs and liked sophisticated melodies and words. The rhythms and syncopation of the music from the thirties and forties intrigued her. During Franny’s sessions with Ms. Hibben in fifth and sixth grades, she began to experience herself as an artist. Because of her music skills, she began to have a sense of competence and control. She used about 15 songs regularly, exploring her own ideas and practicing skills. The songs she used linked her to her social milieu and her family. She created a series of mini performances during their sessions. Franny was developing her innate sense of musical idioms. Ms. Hibben wrote that she would repeat the last phrase of a song to signify the ending or she would add a two-beat cadence on the piano at the end of her song. She would also alternate phrases with Ms. Hibben, spontaneously making up words to a familiar tune. They created many variations in a callresponse style. Franny filled a 90-minute tape with her recordings. Franny could now sing many songs from memory (multiple verses) and stand confidently in front of the mike and read song sheets. Her finger work on the keyboard was in synchrony with the rhythm of the words of her song. Ms. Hibben wrote, “She is never at a loss for an appropriate song; when I sing ‘Hush Little Baby’ to put her to sleep, she will sing ‘All the Pretty Little Horses’ and ‘Consider Yourself to put me to sleep!” One of Franny’s favorite songs was “So Long, Farewell.” She did this with hand movements and performed it at school. Music has a special emotional charge for Franny. She uses music to induce moods, to relax, and to self-entertain. Her repertoire of songs continues to expand, and these songs are friends or emotional contexts and have meanings associated with the words. She likes to end a song with a bang on the piano; by doing this, she feels and shares the tension and release. Ms. Hibben feels that the songs Franny sings and the music she hears represent emotional peaks

and valleys and provide her with a broader spectrum of emotion than she normally experiences. Franny’s responses to music are spontaneous. By that, I mean that in all other aspects of her life, she has to think hard. Her movements need to be thought through because of her cerebral palsy. Walking is something she must do with great concentration, as she makes sure that her voluntary movements are made with precision. She doesn’t want to step too high or too far; she needs to coordinate where she goes with what she sees. Eating, playing with toys, and talking all require motor planning and forethought. Music reaches her ears and she responds with delight, enthusiasm, and direct participation. Music was used in the early grades as a way to formalize or structure transitions through the use of a “hello song” and a “goodbye song,” and at home, we used lullabies for nap time and a song for washing up: “Now it’s time to wash your hands, wash your hands, wash your hands; now it’s time to wash your hands so early in the morning.” By contrast, her present program in a new school consists of “ensemble” playing. She learns songs with eight other special-needs students who use a guitar, a harmonica, drums, an electric piano with sound effects, a small harp called a music maker, and a voice amplified by a mike. They sing a range of simple songs--from Native American to Irish folk songs--characterized by a simple melody and repeated phrases. Franny enjoys being with others and sharing the joy of music. Music is a key part of Franny’s preparation for enjoyment of an independent life. She likes to sit at the piano and play an accompaniment to her own voice. She sings songs we have collected in a three-ring binder over the years from her music classes. She likes to return to old favorites and add to her repertoire. She enjoys singing along with tapes at home in her room and she listens to music from the radio on the AM station, like any teenager. At 15, she likes to read aloud to herself and is learning to modulate her voice. She is learning to recognize within herself the range of her vocal abilities and is trying to carry tunes on pitch and maintain her breath control throughout a song. There seem to be great possibilities open to Franny as she grows with music in her surroundings. Music has opened different avenues for expression and understanding. It will always be a part of her life.

Taken from: Hadley, S. (Ed.) (2003). Psychodynamic Music Therapy: Case Studies. Gilsum NH: Barcelona Publishers.

CASE THREE Speaking Without Talking: Fifty Analytical Music Therapy Sessions with a Boy with Selective Mutism* Wolfgang Mahns Abstract In this case study, analytical music therapy with an eight-year-old Turkish boy with selective mutism is described. Within fifty individual sessions, and regular discussions with parents and teachers, he was gradually able to rediscover his vocal expression. In this child therapy it is shown that the whole spectrum of symbolic interactions (music, drawing, playing) is needed. Institutional aspects (special school) are discussed, as well as cultural aspects, and reflections on the function of music, musical instruments, and improvisation in a child therapy approach. Introduction In recent years, therapeutic treatment has been introduced into various schools (comprehensive schools, special schools, and regular primary schools) in Hamburg, Germany, to enhance traditional approaches with special programs for dealing with learning and behavioral disorders. The methods employed include play-, client-centered, and music therapy and can be viewed as a balanced combination of pedagogy and therapy in order to both prevent having to send students to special-needs schools and to provide full-time therapeutic treatment for psychological needs. One thing is common in all cases: the knowledge that educational institutions in the future need to be more demanding not only in terms of improving the quality of methodological and didactic practices, but also in terms of possibilities for improving the quality of diagnosis and treatment of children with emotional/behavioral disturbances and meeting the psychosocial needs of these students. The justification for therapeutic treatment within schools can be shown simply by the fact that referral for therapy through medical insurance or regional educational consulting centers for those in lower socioeconomic groups is rare or given far too late. Consulting or preventive teachers and therapists within schools can respond much more quickly, because they are available as a starting place right “in the field.” Furthermore, an interaction with their teaching colleagues is possible without any of the misunderstandings that so often arise between the different service providers of psychosocial care for disturbed children and adolescents in educational settings.

For a number of years now, I have been working as a music therapist in a school in Hamburg for children with learning difficulties. In addition to providing music education, I spend a few hours per week providing individual sessions in music therapy. In arrangement with my colleagues, selected children that are applicable for these sessions are treated in a separate therapy room. This room offers the needed protection/privacy as well as the possibility to make lots of noise. The acceptance and understanding for my work has grown over time in this school. From my point of view, music therapy is a psychoanalytically oriented treatment for children and adolescents who experience disturbances in perception, behavior, school attendance, or physical activities. I try to give them the opportunity to express their concerns and needs through therapeutic play and discussion. Furthermore, I try to help them to increase their expressive ability and to understand their unconscious motivations. Music offers a way to this understanding. Using instrumental as well as vocal and movement improvisation with the children, music provides a variety of rich experiences and layers of emotional expression. In such improvisations, the work with the spontaneous, unplanned, and the unforeseen is where the special value of music therapy lies. Even before the expression can be verbalized, the reaction is already being expressed through a different medium, which also means that it allows the client to express feelings that have usually been impossible to verbalize. Other forms of symbolic expression that I incorporate into sessions include painting, puppet play, and other similar activities. When working with children, one needs to particularly consider the following. A child’s disturbed interaction, often seen in various neurotic symptoms, is accompanied by the problem of differentiating between inner and outer worlds (fantasy and reality). Often these children are able to express their emotions, anxieties, and needs, despite the most extreme troubles faced within their family environments. This expression acts as a “transitional object” to facilitate the pain (Winnicott, 1971, p. 13ff). This can become symbolized and overcome through art, music or play. A child that faces the loss of a relationship and is not able to express this pain, for instance, is in a terrible situation and has only one option: to flee into a psychological manifestation; a neurotic symptom, so to speak. By using music, play, and art, and by relearning the ability to claim objects, these symptoms can be transmitted into symbolic expression. These therapeutic treatments have great success in healing. The use of music therapy with children is not about using set music for a set purpose. Such an understanding of music and of therapy suggests it be used as a substitute for medication or surgery. Rather, it is more like preparing a field for symbolic actions, allowing rigid boundaries to flow freely again. Using only one form of symbolic expression, i.e., musical improvisation, is not very effective from my experience. For specific emotional layers it seems to be more effective to use concrete therapeutic forms of play or art therapy, to build a tower with woodblocks or to paint a fantasy picture. The child feels the resistance of the material which needs to be overcome or has the pleasure of a finished relatively imperishable product. The musical improvisation, on the other hand, offers the opportunity to intensify a feeling or produce a sense of achievement without making mistakes. Unconscious feelings are thus sounding in the flow of time. The created musical shape can be explored in terms of inner states and ambivalences. These connections are further intensified through exploration and then the extensive clinical material is documented.

“Osman”

Background Material

This case study examines the music-therapy work I conducted with a Turkish boy named Osman.1 I worked with him for nearly two years, while he was visiting our special school. He did not speak at all. An examination in the audiology department of the university hospital found no organic cause. Selective mutism was the diagnosis. It was suggested that Osman’s parents should bring him to an educational consulting center, where in the safe, anxiety-free environment of play therapy, he may speak. The parents refused to follow this advice, but Osman’s social worker suggested trying music therapy. Before I discuss the process of the sessions in detail, the symptomatology, history and diagnostic picture of selective mutism will be explained. I will also outline my plan for the therapy. Finally, after describing the music therapy treatment, I will illuminate the progress Osman made in music therapy and discuss possible reasons for this. Symptomatology Osman did not speak. The eight-year-old Turkish boy could speak, his parents knew, but in school he did not speak. The first time I met him was in his first grade music class. He participated as long as he did not need to produce any loud sounds. He did not sing or play any brass instrument, as this would be very close to singing. Whenever the class was singing a song, it did not seem to reach him at all, although his eyes and mouth would twist. When children in the class were laughing, it was very hard for him not to do so, and when he cried, it happened without any noise at all. It looked as though he wanted to punish himself or his environment. Osman was the main topic in staff meetings. He was making people feel insecure, sad, and even aggressive. The question was, should he really be in this school at all, or should he visit another school for speech disturbances or even for children with developmental delays? It was absolutely unclear what he was able to do or was not and whether he could follow the lessons or not. Also his classmates had ambivalent feelings toward him — partly aggressive, partly indifferent. It even seemed as if Osman’s silence weakened the rules of interaction. All that was important in terms of communication in school lost its significance (questions and answers, encouragement and admonishment, praise and punishment). This symptom of not speaking was not only examined in relation to his social context at school; it had consequences both socially and for Osman’s educational development. Anamnesis (Case History) I gathered information about Osman’s life from various resources: reports from his preschool and the special school, an opinion from the audiology department of the university hospital in Hamburg, as well as discussions with his social worker and a visit with his family. The usual first interview (a personal history) was not feasible, as Osman would not express himself verbally. When Osman began individual music therapy sessions he was about eight years old. He had two sisters, three and four years older than he. His father was fifty, his mother thirty-five

years old. Both parents had moved to Germany to work and save money to enable their siblings to have a better life when they returned to Turkey in the future. Mr. G. was quite disappointed that he had produced only girls at first, but his son finally arrived three years after his second daughter, and he was very proud. Immediately after Osman’s birth, the family moved to Germany. Osman learned to speak quite late, when he was four years old. He realized that most other children around him were speaking in a different language. He tried to communicate with them, but this was very difficult, as even his sisters could not assist him at all, because they did not leave the house except to go to school. It was during this period of his speech development that a traumatic event occurred. He was hospitalized for six weeks due to dizzy spells and sudden fevers. Because the hospital was far away from their home, Osman did not have many visitors. His mother reported that each time they had to leave it was very difficult for him. She recalled that after the stay in the hospital he acted very differently. Incidentally, the results of the medical examination remained unclear. Both parents were working, but they arranged their shifts so that one of them would always be at home. Mr. G. can be described as warmhearted and very close to his children, especially to Osman. However, he was not often at home, doing shift-work and a lot of overtime. His wife, in complete contrast to him, showed very little emotion. Her face had hard features; she looked as if she had worked her entire life. The housework was done completely by the two sisters, while the mother took care of Osman. Osman enjoyed the advantages of the typical gender-specific conditions of his Turkish upbringing. However, what deviated from the typical model was that Osman was exposed to physical and sadistic punishment when he pushed the limits. Even more unusual was that the punishment was received from his mother, and the comfort from his father. The family of five lived in a two and a half room flat. The larger room was used as a kitchen, the smaller one as a living room. This was where the two girls slept. Beside it was the half room, which served as the parents’ bedroom, and in which Osman also had a mattress. The living conditions were extremely poor. No luxury goods could be afforded, as the majority of the money was supposed to go back to Turkey. Even toys, dolls, cars, etc. were hardly found anywhere. Admittedly, they did purchase a large color television, a video camera, and a variety of electrical devices as status symbols of great worth that would be taken with them when they returned to Turkey to live. The onset of Osman’s silence was a visit to a public school. Before regular primary school, children should go to a preschool. He reacted with panic at the thought of another separation. His whole body trembled as his mother left him at the preschool. He responded to this completely strange world by being shy and hiding. He even attempted to go back home with his mother when she left. As soon as he recognized his hopelessness, he gave up. His mother always accompanied him to school, but as soon they entered the building, he refused to talk at all. He did not speak to anyone; not to the teachers or the children. Various attempts to integrate him into the group, verbal and nonverbal, were totally unsuccessful. He had to repeat the preschool class, but when no progress was seen at all, he was transferred to the special school. In a small group setting of ten children with a very warm and caring social pedagogue2 he began to feel more comfortable.

His nonverbal communication skills developed well in this new learning environment. He enjoyed playing and enjoyed listening to stories. His drawings were very expressive. This talent was nurtured by the social worker. From that point on, whenever he drew a picture, he expressed his moods, feelings, and fears in an imaginative manner. In place of getting a personal history from Osman, I asked him to draw me a picture with a definite theme, the theme being “My Friend” (picture 1). The drawing depicts a young boy with his hand held high, in his right hand a knife, which is pointing toward a cloud directly overhead. In the cloud is his name. There are various possible interpretations of this picture. It could be that Osman was representing himself, a cloud over him, to equally protect him and to stand between him and others. The knife as phallus symbol is expressive of wishes, aggression: pushing through the silence, or being in conflict with others. Another detail would allow for a different interpretation: The cloud at his mouth could be seen as a “call” in comic-style technique, so that we could assume that he indeed has a friend, whom Osman wants to call, to get in contact with him. Most likely both definitions are realistic. “I am my best friend,” and “A friend is out there calling my name.” More likely, the ambivalence of his silence seems to be saying: I would like to talk, but that is impossible as I have to show my teeth for that. And that is dangerous.

Picture 1 Diagnostic Picture In the biographies of mute children, there is almost always an occurrence of an early separation, or a deprivation, that leaves them destabilized. In addition to the initial loneliness, there is wider environmental damage. The development of a personal vocabulary is blocked, due to a lack of encouragement; a younger or older sibling may have grown up with preferable treatment. Additional demands, such as achieving at school, inhibit language for formulating thoughts, thus leading to repression, because at the basis is a self that is not fully developed and has not been assimilated (Dührssen, 1982, p. 184ff). “The starting point lies in the Epoche,

in the affective meaningful sound, and not the articulated word making a connection between the infant and his environment” (Ibid, p. 189). The deprivation experience, or rather the demands generally placed on children with particularly sensitive personality structures, can lead to a reaction of mutism, sometimes acute and dramatic, sometimes gradual and insidious. Only seldom will a person be faced with complete silence (“totally mute”). “In the majority of cases, verbal communication is refused in significant groups, while generally, in the context of the family, at least a certain amount of speech contact is maintained” (Ibid, p. 184). I speak here of “selective mutism” or “partial mutism.” Mutism is in no way, as is often misconstrued in lay circles, a defiant reaction of the child. That is why the earlier term of “chosen silence” is misleading. Innate adverse factors rarely play a role. Rather, the mute child experiences a number of unfavorable factors, which together prevent him/her from communicating with others. These general statements about the disorder of mutism are pertinent to Osman’s case. Several unfavorable factors were interacting with each other. His mother was unable to give him the love and warmth he needed. One can assume that she could not understand the extent of his fear of loneliness and separation. Furthermore, she had taken over the role traditionally inhabited by the father in a Turkish family. So, as the only male child, contradictory expectations were requested from him. On the one hand he was the “prince,” whom everyone served, yet on the other hand he was a disappointment to his family because he did not behave appropriately for his age. It is important not to forget the difficult conditions facing a Turkish family living in Germany. The parents saw their roots in Turkey. They come from there and would return there to live. In the meantime — for more than ten years — they continued to maintain their traditions and cultural practices in the midst of an atmosphere of hatred toward foreigners. The Turkish children attending school, however, were able to understand the difference between them and their schoolmates. They usually had no chance to compare the differences to their parents. They had to adjust their behavior, educational practices, and language in some ways in order to survive their German school experience. Often they felt as though they could not understand and fulfill expectations in the school situation. Because their parents usually could not help them to understand, this failure to learn could result in psychosomatic or neurotic disorders. When Mrs. G. reported that the reason Osman did not speak at school was because he was ashamed, this indicated a fear of appearing inadequate. However, the underlying problem lay more deeply. When he “punished” his teachers and schoolmates with silence, he was actually meaning to punish his mother. However, his anger over his mother’s aggression toward him, over his failure to fulfill his wishes, could not be pointed directly toward her. This was forbidden by the taboo of the “good mother.” So, Osman redirected his aggression toward the hostile school and anyone who gave him an obvious reason to do so, by speaking another language. Admittedly this anger was not expressed as outward aggression, rather it appeared at first as a mute reaction. Therapy Plan

The ability of music therapy to include nonverbal expression seems to offer alternative healing prospects to those who are mute. This is not just because the mute person is provided with an alternative language. This would not produce a lasting result, just as when one gets a stutterer to sing. Other forms of symbolic expression (art, dance, music, play, etc.) are much more suitable in order to create a bridge between inner and outer worlds, between experience and action, between fantasy and reality. Winnicott speaks about these transitory phenomena, which take on great significance in overcoming the separation experience (Winnicott, 1971, p. 12). Therefore, music therapy with Osman must include the following guidelines: He must have individual music therapy. Only in a one-to-one situation would Osman be able to overcome his fears, and to abandon parts of himself with the added value of being able to take it back if it caused him undue anxiety or felt too premature. Along with musical expression, children frequently benefit from playing with toys, and above all Osman’s passion for drawing should be involved. In this way one can engage the transitional phenomena through various modes. At least two to three years of therapy are essential, because such a deeply embedded disturbance as mutism can only be resolved gradually. The school environment, more specifically the special school, even with its clearly defined boundaries, is not always favorable. In Osman’s case, however, it is exactly what is indicated, because the silence occurred at school. This had consequences for his educational progress. Furthermore, it allowed for the possibility of support by his teacher. The supportive therapy room, particularly important in providing the entitled anonymity, is especially necessary in the therapy with Osman. In this way he would be able to make important progress within therapy while still not reconciling with the public. I planned on having individual therapy sessions for forty minutes per week for a period of at least two years. Discussions with his teachers and parents would also take place on a regular basis. Osman would be informed of this involvement of those around him. In addition to the usual variety of musical instruments available in the music therapy room, cloth puppets, building blocks, and a small oven were also provided to meet additional needs a child may have. In Osman’s particular case, a variety of diverse drawing and painting materials were also always available. After speaking with Osman’s teacher, it seemed important, at least in the beginning, that he be picked up from his classroom and brought to the therapy sessions. In this way, the adjustment to the new environment would not be so drastic, as compared with him walking over by himself. I had never had a client who was mute, let me make myself clear, so I had great expectations on all sides: When will he start to talk? I have to clarify the expectations I had at that stage, even though they were unconscious. I also must say that I did not feel that using the “ISO-principle” (Altschuler, 1948; Benenzon, 1983, p. 165) would be appropriate in this case. That would entail beginning in the same state of the absolute speechlessness. That would reduce opportunities for experiencing the normal external world as it is. Treatment I worked with Osman in music therapy for almost two years, for a total of fifty sessions, one session per week. The beginning of the treatment focused on exploring the therapy room

and its possibilities. Osman remained rather passive, especially when it came to the musical instruments. His main focus was still on drawing, which I accompanied with piano music. I saw my main function as accompanying Osman in his activities inside and outside of the music therapy room. Now and then, I reassured Osman that in music therapy he would not be forced to do anything he did not want to do. I knew that he would not speak, but was sure that he had his reasons. Sometimes it was a bit confusing to have a silent individual in front of me: to suggest, to inform, to show feelings, but at the same time realizing the intense feelings inside of him: the anger, the sadness, and the rage. I tried to understand his actual needs and wishes without language. But then I had the idea of using gestures for yes/no, with thumb up for yes and thumb down for no. Thankfully, Osman utilized this new option imaginatively. Through a combination of both symbols he even created a gesture for “I don’t know.” During the third session Osman discovered a candle and matches that I kept in the cupboard for festive events. He lit one match after another and let them fly through the room like rockets. Because of this, I moved the following session outside, where we lit a small bonfire. With this significant action he showed me how much fire he had inside, the desire for a warm center, for a mother that would understand his feelings. Playing with fire can also refer to the unresolved Oedipus complex: a desire for his mother that could not be satisfied because she could only show her hard side. The music therapy room has the theme “beat and be beaten.” The following occurred during the fourth session: Osman found the animals and puppets and started to throw them around, pull them, and finally beat them up. “Osman, shall we make some music?” I asked, as the puppets lay scattered and he was taking a rest. He nodded, and walked in the direction of the bass drum and the bongos. I accompanied him on the piano, and expressed the pain I experienced during his outbreak of rage. When we finished I said: “That sounded like you beat someone up.” Osman did not react; instead he took a pencil and a piece of paper and started drawing. The drawing showed a person crying (picture 2). He drew with a lot of pressure, which nearly forced the pencil to break. By using the agreed upon gestures, I found out that it was about his mother.

Picture 2 Viewing the three scenes in combination (beating puppets, beating drums, and drawing his mother crying), one could conclude that this was a representation of a real experience. I had discovered through conversations with his parents that he had received physical punishment by his mother due to his aggressive actions and because of his temporary mutism. The tears of his mother are therefore ambivalent. In one way it could show her helplessness in terms of his not fulfilling her expectations. Alternatively, he probably projected himself into the picture: as the person who was beaten. In the seventeenth session, after about half a year, Osman decided to build a cave in the therapy room. He had done this several times before, most often with the piano at the center of his cave. Tables, chairs, and a climbing board, with hung blankets, functioned as walls. He chose not to build a door. On the piano he placed some flowers, so the whole cave was very comfortable. I was to make music in the cave, but he did not want to enter the “living room.” Instead he painted a series of pictures: either at the table, or on drawing paper on the floor. While I played the piano, I sang and explained to him what I saw in his pictures. He drew dragons, snakes, and sometimes a little child in the middle of all these beasts (picture 3). In this session, the cave was built with more tables and was darker inside. A few bongos, the portable cassette recorder, paper, and markers were inside. I carefully asked him: “Osman, what do you think about allowing me to enter the cave with you?” He thought about it for a little while, then raised his hand with pleasure to symbolize the yes sign. Inside the cave he painted more pictures that provided additional information about his inner conflicts. On the bongos, we played at times mysteriously, at other times wild music. I continued to comment on his pictures and he would agree or disagree with it.

Picture 3 This first picture (picture 3) shows an ill person in a bed, surrounded by dragons, snakes, a ghost, and a spider. It looks ominous in regards to how the snakes spread their poison. The two dragons seem to come to help him out, by grabbing the snakes with their claws. In the next picture (picture 4) a giant snake surrounds both a child and a dragon, attacks the child with its poison, but is hit by the dragon and is dripping with blood.

Picture 4 The third picture (picture 5) finally shows the snake lying in its own blood, the child walking on it celebrating in triumph.

Picture 5 After this picture, Osman left the “cave,” took a cymbal out of the cabinet, and started playing a rhythm. I took a rattle and joined him, singing, “We are celebrating, because the snake is beaten.” He finished by throwing the cymbal on the floor and kicking it. It was apparent that by overcoming his inner conflicts through his art he experienced an obvious release, the snake symbolizing his mother. In my conversations with Osman’s parents, his mother never seemed to understand, although the teachers stressed it again and again, the importance of not forcing him to speak. Osman’s mother, however, suggested draconic actions, through an operation, like tongue correction, or in an educational way, through beating. I tried to be understanding of her feelings of helplessness, but also asked her to please be patient with her son. In the following weeks, Osman experienced very extreme feelings. In one session, he left the therapy room in total chaos, flooding the floor with a container of water. This manifested punishment fantasies in me; these probably mirrored the expectations that Osman directed toward me. In the very next session (19), for the first time, I experienced Osman tenderly embrace his favorite animal, a big monkey. Right after that he threw him straight across the room again. I tried to support this action with a matching phrase on the piano. I also loudly cried: “Ouch, ouch, you hurt me,” whenever he beat or threw the monkey. Some of what Osman did to the monkey had been done to him. In this musical-scenic play I was a kind of “substitute-I” that expressed the pain that Osman was not able to express. At the end of this session, Osman climbed up onto the instrument cabinet and gave me signals to come over and catch him. Osman enjoyed this game so much that he wanted it to be repeated over and over again. I was pleased by the fact that Osman obviously developed more and more trust in me catching him — and symbolically, too. Some major changes occurred in his pictures at this time. Superman replaced the dragon to protect the child from the bad snake. The child was now lying in bed or in a kind of prison. The musical part of this experience now involved vocal sounds by Osman. He placed microphones and bongos on a table, and from this elevated place he produced electrically supported sounds. He stretched himself to appear bigger, and, lost in the protection of the microphone, he had no fear of his own voice.

The twentieth session, after eight months of working with Osman, marks a significant turning point. It was hard to understand his suggestions and demands that day. “Osman, sometimes it is not easy to understand what you want me to do. Don’t you think it would be easier to tell me what you mean?” Osman did not react at first. We improvised, beginning with a calm mood and becoming disturbed by wild drum rolls once in a while. After we finished, I asked him if he wanted to draw a picture. He nodded.

Picture 6 His picture (picture 6) showed two people in the center, a small and a big superman fighting a snake, a dragon, and a ghost. One object was puzzling to me. Through questioning, I found out that it was a bomb. I asked: “Osman, do you think that something dangerous will happen, like a bomb blowing up, if you start talking?” He reacted very impulsively. He scrunched up his picture, and held it in his hand undecidedly. “What would you like to do with that picture?” He found an empty coffee can in the cabinet and put the picture inside of it. I named it the “secret can” from then on. That seemed to please him. From then on all his pictures went in that can. Everything that held value for him had a safe place. The following session (21) began somewhat unusually. Outside there was some bulky refuge lying out. Osman discovered this large amount of trash that was waiting to be taken away by the maintenance staff. He literally dragged me outside and indicated that he wanted to examine the trash. He examined the different heaps and quietly whispered what he discovered. He took some things like markers, chalk, and a comic with him. On the way back, I recognized that his whispering got quieter. The closer he got to the school, the less intense his talking became. Back in the therapy room I asked him if his treasure should stay here or go home with him. He signified that it should remain here. In the following sessions, Osman redefined his activities. The drawing activities decreased and the musical activities increased in the therapy room. Except for some clearly understandable whispered statements he was still not talking. I did not pressure him at all about the big event of him talking for the first time. In the twenty-fourth session, on the way from the classroom to the therapy room, Osman went into the secretary’s office and wanted to make a phone call. So we talked to each other on the phone, Osman using the secretary’s

phone, and I from phone in the principal’s office. A small conversation took place; a little question and answer game or, rather, an amusing vocal improvisation. More important than anything was the hanging up and calling again procedure. In this play, was I the friend from Osman’s first picture who is calling him? In any case, Osman had rediscovered and dared to show his voice “publicly.” This event spread through the school like wildfire. Everybody took an interest in it as if it were a miracle. It was very important that he did not get too much attention now, because that would completely destroy all of the hard work. Also, the relationship between Osman and his mother seemed to improve. One day he proudly presented his warm, colorful, handmade sweater from his mother. She had given him something that would keep him warm and wrapped up during the cold winter. Osman drew the last picture during the twenty-seventh session (picture 7). It depicted a house with a straw roof and smoke coming out of the chimney. Outside of the house Osman was raising the Turkish flag. For the first time there were no animals, dragons, snakes, or supermen. Maybe this was a sign that his fears had diminished and his ego-strength had developed. Through the connection with his country he may also have been saying: I am at home. I am a Turk in a German school, in an environment that at first was full of danger, threat, and discomfort, but here I can also have the feeling of being “at home.” Following that picture I put on a cassette of Turkish pop music for him, which I had in my cupboard for working with foreign children. At first he was surprised, but then he smiled, gave the bongos to me, and grabbed himself a guitar. We were now a Turkish band. All we needed was an audience and a few belly dancers.

Picture 7 From then on, Osman often asked if his friend Olaf could join the session. Such a desire often plays a significant role in therapy with children. It sometimes functions as a defense in response to the intensity of the relationship between therapist and child — someone should come between the two. Maybe this was the case for Osman. But it soon became apparent that the addition of Olaf to the therapy helped in achieving the next therapeutic step. Olaf was proof for all the things that Osman and I experienced. Besides, Olaf was an object for Osman to dominate and to rule. He was also someone who, spontaneously and without questioning,

followed my directions and suggestions and, therefore, motivated Osman to do the same. In particular, the music activities took longer. When Osman was sad, we played sad music. When words like “Gypsy,” “dried flower,” “watered flower” or “travel” were mentioned, we played music using the therapeutic technique of “associative improvisation” (Eschen, 1983, p.41 ff). Then, a sudden end to music therapy with Osman occurred because the family decided to leave Germany and return to Turkey. The last session was a long prepared for celebration for three — Osman invited Olaf. The final piece of music was a lengthy improvisation based on a melody made by Osman with the words “bella, bella, bella.” Osman imagined that he was a Gypsy and traveled throughout the world. Once in a while, the Gypsies celebrated a fest and sung their “bella, bella, bella.” Osman and I sang out as loudly as possible. I played the piano and Osman played the drum. Olaf preferred to stay in the background with his rattles. I was very impressed with how Osman was using his voice during the improvisation. I was not sure what the meaning of the words bella, bella were. I was not aware until I looked them up in a Turkish dictionary that they meant “misfortune, evil.” Of course, separation is always a bit sad, however the music did not sound sad at all. The music therapy treatment with Osman ended with a last visit with the family. Everybody was there, between cartons and suitcases. It was very surprising for me that the evening ended in a three-hour festive dinner. Mr. and Mrs. G. were very grateful of my efforts, and even invited me, and my family, to visit them in one of their apartment houses in Izmir, Turkey. Discussion and Conclusions In the fifty sessions, Osman was given the chance to play through and experience various forms of symbolic expression of situations that until now he had missed out on in his development. I will take the opportunity to talk once again about my first visit with the family. This visit was a little difficult. First of all, there was the language barrier. Second, I got the feeling that Mrs. G. did not understand much of it and could not relate to it emotionally. She strongly believed that Osman was bad and that the teachers should just be tougher, like they are in Turkey. The atmosphere relaxed somewhat when Mrs. G. brought out the photo album. This provided an opportunity to talk about a lot of other things. She indicated that she felt that the basis of Osman’s silence was because he was embarrassed at school. Other photos were of his hospital stay and of Turkey. Osman was in the room the entire time. He was mostly silent, without even reacting to what was said. His mother and sisters continuously encouraged him to talk, without any success. He was stuck in an inner conflict. This was usually a place where he talked. To him, I was part of the “enemy” world. After a while, he tried to get some attention. He threw some cars through the air, turned the television on and off, turned the volume completely up, and filled his mother’s tea with spoonfuls of sugar until the cup overflowed. Mrs. G. set no limits. It was easy to see her anger in her facial expressions and her gestures, but she simply ignored her son. From this, I came to understand the reason for his silence: a deep-rooted wish to express his enormous anger and his strong desire to be acknowledged and to be given clear limits. I tried to explain again to Mrs. G. that Osman would not be forced by us to speak. She seemed to feel that Osman had made a positive connection with me. The very last comment I heard from

her was the following: “Take him with you; take him home with you. You can keep him!” What does it take for a mother to say that she wants to give her son away! Osman had to struggle with several separation experiences: his stay in the hospital, the fact that his mother was working most of the time, as well as the move to the German school. In addition, a sensitive child like Osman had greater difficulties dealing with living in two worlds: Turkey at home and German at school. Furthermore, it is important to realize that he was not given the chance at home to resolve this difficulty he had with these transitions. His mother did not have a sense of a child’s need for toys as vehicles for understanding. Playing, according to her, was just a stage before becoming an adult. And this stage should be squashed quickly, even if it hurts. Thus, Osman’s relationship to his toys at home and to the things in the therapy room made sense: erratic and destructive, without respect. It was probably a lifesaver that he discovered drawing as a way to express himself. Other transitions in the process from fantasy to reality were also seen: making a fire, using a microphone, using the telephone, playing hide and seek, and building a cave. His progress in individual music therapy was predictably difficult. The trust given to me increased when given the possibility to play and express things symbolically. In this way, it was possible for him to trust his voice again. I would now like to comment about the function of music therapy in Osman’s case. In the beginning, the idea of making music seemed to be dangerous for him. The first improvisations were simply to indicate the beginning and the end of a session. In addition, the musical accompaniment that I offered him as background music for his activities was significant. This gave a kind of “musical foundation” which made my presence known, holding him in the activities without any pressure or expectations of him. For Osman, drawing was a more concrete way to explore his fantasies. Through an improvisation, music can certainly intensify an emotional state, and the picture completed this for him. Through improvisation, things were expressed in the outer world that he was not ready to express verbally. In one improvisation, which I later named “beating up,” the sound was dramatic, and this was also reflected in his drawing. Perhaps the music here had the effect of encouraging, stimulating, and allowing him to “talk” about his experiences and feelings; in his case, through pictures. Through this multimodal approach to music therapy (music-speechmusic; playmusic-drawing, etc) it is possible to examine similarities and differences in the transformation process. One example of this was when wild music followed a “nice” story. Another function of the music was the specific appeal of the different musical instruments. Of course, it took Osman a long time before he chose brass instruments. Relatively early on, he discovered the rattles and the bongos and bass drums. The rattles fit with his desire to walk around, so of course he chose them first. They were his companions. The bongos and the bass drum allowed him to be wild and to show his impulses and the real fire inside him. These sound pictures were usually very short. They had more of a cathartic function. To perform longer lasting music with piano accompaniment was not appropriate for him. In music therapy with children instruments are often used as toys. This was true for Osman. Tone bars were used as construction blocks; sticks as knifes, swords or guns. His growth process went hand in hand with the act of rising up on the table and extending the microphone stand. But more than anything, Osman had a preference for the toylike character of the bongos; perhaps for him it was like the puppet. He carried it through the room, beat it up, threw it on the floor, picked it up, and touched it gently. Furthermore, the bongos were the

only instruments he allowed into his cave. This important role of the instruments was further captured when he expressed his first vocal sounds through the microphone. Just as one can identify and connect with a musical instrument, naturally one can also feel threatened by an opponent while fighting against it. In one situation, in Osman’s fantasy, the cymbal was dressed up as a snake and was therefore seen as an enemy that needed to be beaten. Therefore, in addition to their traditional functions, instruments can be objects of play. They can be filled with life because of their outer appearance and what they are made of. When this is the case, the sound experience may be subordinate. In the whole spectrum of symbolic interaction (music, drawing, and play), sound was the very last form that was recovered and was only important later on when a third party was involved. I was particularly touched by the gradual development of the voice: from the sound over the microphone, to the childlike whispering on the telephone, to the loudly given orders to his friend Olaf. Finally, Osman’s singing voice was an incredible discovery. He was able to understand and reproduce melismatic Turkish quarter-tone music, as well as to build bright sounds from the piano into his melodies. During the course of the therapy with Osman the music-making became more and more central. To summarize, I will list the different functions of music in Osman’s treatment. It is very interesting to see that music found its place in the final phase, when Osman was already using language: • • • • • •

Structuring the sessions Wrapped in a sound (musical nourishment) Intensifying emotions being experienced in the moment Adding sounds to certain impulses Identification and argument with the musical instruments (toylike qualities) Contact and dialogue

I would like to end this case study with some statements about the end of Osman’s therapy: Osman’s contact with his same aged peers is considered to be normal. He is not bothering anyone with silence or aggression. On the other hand, he is not yet able to understand the limits of his power, so he sometimes gets into trouble with stronger classmates. Had it not been for the sudden end to therapy, due to the return to Turkey, the sessions would have been continued for a while. The goal would have been to stabilize his condition and include him into a group setting, where he would have learned group processes having to do with confrontation and agreement. How the new environment, the different treatment of students in Turkey, and the lack of understanding will influence his further development is difficult to predict. Maybe he will resort to selective mutism in stressful situations. However, I hope that he became stable enough through the treatment he received in the special school, the individual music therapy sessions, and his understanding teachers to handle other problems better. His rapid development through music therapy lead me to believe that his chances are good. In addition, his parents now have a far more positive attitude toward him. They bought him a bicycle right before they left. Osman showed it to me on one of my home visits and, for the first time, I saw

a glimpse of being proud of her son in Mrs. G.’s eyes, as he was circling around, waving and smiling at us. References Altschuler, I. M. (1948). “A Psychiatrist’s Experience with Music as a Therapeutic Agent.” In O. Sullivan & M. Schoen (eds.), Music and Medicine. New York: Schumann. Benenzon, R. O. (1983). Einführung in die Musiktherapie. München: Kösel. Dührssen, A. (1982). Psychogene Erkrankungen bei Kindern und Jugendlichen. Göttingen, Zürich: Verlag für Medizinische Psychologie im Verlag Vandenboeck & Ruprecht. Eschen, J. Th. (2002). “Analytical Music Therapy — Introduction.” In Johannes Th. Eschen (ed.), Analytical Music Therapy. London and Philadelphia: Jessica Kingsley Publisher. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock Publications Ltd. ________________ * This article was first published in Isabelle Frohne (ed.) (1999): Musik und Gestalt — Klinische Musiktherapie als Integrative Psychoherapie. Göttingen: Wandenhoeck & Ruprecht. The German title is: “Die musiktherapeutische Behandlung eines achtjährigen mutischen Kindes.” 1 His name has been changed for purposes of confidentiality. 2 In Germany, a social pedagogue, unlike a social worker who is involved with more administrative duties, is involved in different practical activities like working with emotionally disturbed children in homes, schools, or in consulting centers.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE FOUR Preverbal Communication through Music to Overcome a Child’s Language Disorder Amelia Oldfield Abstract his case describes two years of group and individual music therapy for a five-year old boy with a language disorder. A wide variety of music therapy techniques are used, all aimed at motivating Jamie to communicate, either nonverbally or verbally. Background Information Jamie is the only child of very caring and capable parents. As a young child, he appeared somewhat smaller and slower than other children in his age group, and eye contact was often difficult. His mother reports that, as a baby, he did not babble at all, and used very few other non verbal means of communication, such as pointing. He was always a very quiet child, and only occasionally and inconsistently used words. At two and a half, Jamie found mixing with other children very difficult, and would often appear to be in a world of his own. However, he did not present any major behaviour problems and was able to play by himself. At this stage, the pediatrician reassured his parents that Jamie’s development was not necessarily abnormal. Nevertheless, both his parents and other professionals involved continued to be concerned. Jamie’s health visitor wrote a report at this time describing him as: “rather worrying in a not altogether definable way.” When Jamie was three, he was assessed by a clinical psychologist who suggested that, although his overall intelligence was within the normal range, there were great discrepancies in his skills. He had high scores for manipulative skills, such as putting puzzles together, and marked problems with both comprehension and expressive language. Jamie’s hearing was also tested at this stage as he seemed both oversensitive to some sounds and oblivious to others. It was found to be within the normal range. Jamie was then referred to the Child Development Centre where he began having regular sessions with the speech therapist. He also started attending a small play therapy group of four children. This is a structured group run by a clinical psychologist where the emphasis is on encouraging social integration. She reports that, over a period of a year, Jamie took part in more group activities and managed to overcome some of his fears and obsessions. He became more able to tolerate the screaming of another child in the group, for example, which he had been terrified of at first.

When Jamie was four, he was assessed by the local specialist consultant in child psychiatry. He suggested that, although Jamie’s language was very restricted, he was showing signs of imagination. In spite of his difficulties, Jamie seemed to be developing an understanding of the meaning of words; therefore, there seemed to be potential for the development of abstract thought. The psychiatrist felt that Jamie’s social problems and occasional disturbed behaviour were the result of his great difficulties in understanding social practices. Thus, he diagnosed Jamie as having a specific language disorder. In his opinion, there was no evidence of autism or an autistic like disorder. The term “language disorder” generally describes an atypical pattern of language acquisition and development. Unlike children whose language may be delayed but nevertheless following a normal pattern of acquisition, children with language disorders have both a delayed and deviant pattern of development (Webster & McConnell, 1987). Deviancy or disruption may occur in any or all aspects of speech and language: context, form or use; or as a result of a distorted interaction between them (Bloom & Lahey, 1978). Jamie had difficulties in all these aspects of language development, and particularly in the area of language use. This affected his ability to establish social relationships and to relate to the world around him. A speech therapy report written a couple of months later agreed with this diagnosis. The speech therapist explained that Jamie had difficulties processing sentences in order to comply with a task. Although he responded to everyday instructions, he was reacting more to the context and the routine than to the actual meaning of the instruction. Jamie could say quite long sentences, but had difficulties learning when to use these sentences appropriately. He was mainly silent and only made occasional, spontaneous, self-generated comments. From the age of four to the present, Jamie has been attending a small language unit for eight children with language disorders. The children in this class receive very specialised schooling, and the main focus of the work is on improving their language difficulties. The class is based in an ordinary school, and the children are integrated into other “normal” classes at times, as well as working together as a group at other times. Both the teacher from the unit and Jamie’s parents are still unsure about Jamie’s diagnosis, and suspect that he might have some autistic tendencies. At five, Jamie was referred to me at the Child Development Centre by his language unit teacher. She had noticed that Jamie seemed to respond to words in songs more easily than spoken words. She hoped that I might devise some exercises for both her and Jamie’s parents to use with him to improve his speech. Music Therapy Assessment I saw Jamie for three consecutive weekly, half hour music therapy assessment sessions. The purpose of these sessions was: (1) to determine whether music therapy would be a useful way of helping Jamie, and if so to roughly outline what kind of direction this treatment might take; (2) to see whether he responded to me in a different way through music and thus to shed new light on some of his difficulties; and (3) to suggest ways in which both his teacher and his parents could use music with him. Jamie presented as a small, attractive looking boy with a serious and often puzzled expression. He had no difficulties separating from his mother, and showed no anxiety about

coming into the music therapy room with me. He seemed to understand simple requests or comments such as: “Here is a chair for you, Jamie” or “Shall we finish this now?” He was able to point to me and to choose an instrument for me on request. He could listen to my playing and also play himself and was good at taking turns with me. He made very few verbal contributions or vocalisations, but at one point suddenly and surprisingly, made an appropriate comment about an instrument, saying in a very clear voice, “There’s a ball inside.” Jamie particularly enjoyed activities where we teased one another, or where he could “control” me by, for example, making me jump when he played the drum. At these times, he would look straight at me and have a beautiful mischievous smile. Jamie seemed pleased to listen to the music and the songs I improvised on the piano and the clarinet. He anticipated the ends of harmonic phrases by looking up at the appropriate moment, and showed that he knew and recognised a number of songs by occasionally filling in words when I left a gap. For example, I would sing: “London bridge is falling....,” and Jamie would say: “Down!” Sometimes he would sing the words at the correct pitch to fit in with the song. Jamie enjoyed playing the instruments, and would spontaneously explore various ways of playing them in a creative way. For example: he seemed to experiment with the different sounds the drumstick made on various parts of the drum, and played the cabasa in a number of ways, stroking and rattling the beads as well as shaking the whole instrument. Jamie generally seemed to prefer the quieter instruments. He did not appear particularly frightened of loud sounds, but would blink slightly anxiously when they occurred. With a little encouragement, he could join in and enjoy both quiet and loud improvisations. He was able to follow dynamic changes when we improvised together, but had more difficulty following rhythmic changes. He appeared to be able to play in a regular pulse for short periods, but the pulse was hesitant and gave his playing a slightly tentative feeling. Jamie found it difficult to move freely or spontaneously to music. His physical reactions were slow, and he needed encouragement to do things such as march or jump to the music. Jamie seemed to be developing a positive relationship with me. He was at ease playing the musical instruments, and was able to both listen to and contribute musical ideas during our improvisations. I felt he would benefit from a situation where he could communicate with an adult without having either to understand spoken language or use words himself. The areas I thought we could work on were: increasing his motivation to communicate with another person; providing an opportunity for Jamie to vocalise freely and spontaneously; increasing Jamie’s confidence and enabling him to speed up his reactions so they were more spontaneous. I therefore recommended that he should have weekly individual music therapy treatment for at least six months. Jamie appeared to be more spontaneous in his communication with me during our sessions than he was with other adults. This was probably because far less speech was necessary in my sessions than in other situations. The fact that he was more at ease in this non verbal situation seemed to confirm the diagnosis of language disorder. After reading Jamie’s notes, I had expected him to be more sensitive to loud sounds and was surprised when he did not seem to mind hitting the drum very loudly. On reflection, however, it became clear that it was unexpected and unexplained loud noises that particularly troubled Jamie, and not loud sounds that he knew were about to occur or sounds which he himself produced or controlled.

I did not think that it would be beneficial to give Jamie’s parents or his teacher structured musical exercises to improve his speech. I felt the priority was to help Jamie feel at ease with a non verbal means of communication, so that he would eventually become more spontaneous in his efforts to communicate. I also thought that Jamie should be encouraged to enjoy making sounds and vocalising without the pressure of using the correct word or structure. Jamie had never babbled or experimented with sounds as a baby, and I thought that he needed to discover the fun of producing sounds. I therefore suggested that both his parents and his teacher should encourage Jamie to vocalise in any way, and that they should try to engage him in playful vocal dialogues. I also suggested they do “toddler” like rhymes such as “Incy Wincy Spider” or “Round and Round the Garden” with him, so that Jamie could laugh at them with an adult, and learn to enjoy communicating in a simple way. Treatment Process Phase One: Introductory Group Work Unfortunately, I did not have any spaces available to see Jamie for individual music therapy sessions immediately, and he was therefore put on a waiting list. As it happened, however, I had already arranged to see the group of children in the language unit that Jamie attended for a a twelve week period, starting four weeks after I had finished the assessment on Jamie. I was, therefore, able to observe and work with Jamie in a group setting before I started to work with him individually. The group sessions occurred once a week, lasted approximately forty minutes and went on for one school term (twelve weeks). Both the teacher and the welfare assistant took part, and I reviewed our work with the teacher every week, directly after the session. All eight children in the group were diagnosed as having language disorders. Jamie, however, was shyer and more withdrawn than the other children. The group sessions had two or three specific aims for each child. These were determined jointly by the teaching staff and myself after a couple of “exploratory” sessions. Generally, the goals were: to provide a different setting for the teaching staff to observe the children’s strengths and difficulties, and to give the teaching staff ideas of musical activities to use in the classroom. Given my large case load, this is one of the only ways I can provide some input to a large number of children. The musical material and the activities used in the group would vary from week to week, and was largely determined by the aims for individual children. Although suggestions for activities for the following week’s session might be made when we reviewed our sessions, I would always remain flexible and would usually choose activities on the spur of the moment, based on the children’s reactions and moods on any particular day. Nevertheless, I would always start off with a familiar greeting song and end with a “good bye” activity. Throughout the group I would often alternate between activities which involved the group as a whole and activities which involved one or two children playing on their own. An example of a general group activity would be: the whole group plays together on various percussion instruments led by improvised music I play on the piano. When the piano stops the children all move around and exchange instruments. Playing starts again when the piano begins. An example of an activity involving two children would be: two children sit back to back in the middle of the

circle, each with a different instrument, and are asked to have a musical conversation. The rest of the group is encouraged to listen. I would also try to alternate between activities where the children were actively involved in playing instruments, singing or dancing, and activities which required concentrated listening without so much active involvement. After observing Jamie within the group for two sessions it became clear that he was much more withdrawn in this setting than he had been with me on a one to one basis. We therefore decided that individual aims for Jamie would be: to help him concentrate and listen to instructions; to encourage him to communicate in any way with either adults or children; and to encourage him to make eye contact and to make any vocal sounds. During the first five sessions, Jamie seemed to understand some but by no means all the instructions, and was able to take part in a few activities only. He seemed to enjoy choosing and playing instruments, but was unable to pass an instrument to another child. He did not understand the games involving drama where we pretended to put a tambourine to sleep, for example, and he needed help whenever any of the activities involved moving around the room. He made little eye contact, and only used a few sporadic single words. He often appeared to be in a world of his own, and made no efforts to communicate with either the children or the adults in the group. During the sixth session, there was a marked change in Jamie. He suddenly appeared more at ease, smiling happily and looking straight at me when I played the clarinet. He was able to contribute some vocal noises to a song where all the children were suggesting different sounds, and even gave his instrument to another child when this was suggested to him. From this session onwards, Jamie continued to progress well. He learned how to “conduct” by pointing to other children and adults. He would listen to instructions better, and he began to take part in even quite complicated activities. He started using more words, both on request and spontaneously. Both Jamie’s teacher and I were pleased with Jamie’s progress within the group, however we felt that he would benefit even more from individual sessions. Phase Two: Individual Sessions Two weeks after the group finished, a space became available, and I started to see Jamie for regular weekly individual music therapy sessions. Although he had made some progress during the group sessions, the aims remained the same: to increase communication, eye contact, vocalization, and spontaneity. As Jamie’s use of words had improved, I continued to keep a record of both spontaneous speech and the speech he used to answer direct questions. Nevertheless, I still did not want Jamie to feel that this was the focus of our sessions, or that I was putting pressure on him to talk. The individual sessions lasted half an hour, and were held at the same time and in the same room every week. After each session, I would briefly discuss with Jamie’s mother how he was progressing. Like the group sessions I would start and end each session with familiar “hello” and “good bye” activities. In between, sessions would vary from week to week depending on Jamie’s mood, on what had happened the previous week, and in what particular areas I felt I should be helping Jamie. In general, I would spend some time encouraging him to choose instruments or activities, and then attempt to follow and support his playing; at other times, I

would make suggestions myself. For example, I might suggest that we take turns playing the glockenspiel, and pass each other the stick when our turn was finished; or I might encourage Jamie to play three different instruments that would make me jump, wave my arms or shake my head depending on which instrument he played; or I might suggest that we have a “noise” dialogue on the kazoos. I would always try to give each of our activities a structure with a clear ending. I would prepare Jamie for each ending by saying “One more turn each,” or “Try to find a way to finish this off.” Jamie was at ease with me straight away, and was delighted with the familiar “hello” song on the guitar. This led to a sung “noise” dialogue accompanied by shared guitar strumming. Jamie initiated vocal sounds such as “Hey” with great delight, and would then laugh happily. He gradually added “funny” faces to these noises, particularly when I encouraged him by mirroring and extending his contributions. Jamie was clearly excited and pleased with these humorous exchanges, and I was able to keep them mischievous and creative rather than just silly. These vocal dialogues immediately followed my greeting to him, and became a regular part of our sessions. Sometimes Jamie would respond immediately, and at other times it seemed to take him a little time to relax and allow himself to enjoy this basic form of communication. Over the first six months of treatment, Jamie continued to become more spontaneous in any familiar activities that we shared. However, he would revert to a blank, puzzled expression whenever I introduced anything new. I, therefore, made a conscious effort not to allow the sessions to become too stereotyped and, while always keeping some familiarity, tried to vary the way we played together, always introducing at least one new idea every week, As Jamie became more able to make his own choices and contributions, he started to use more single words or two word phrases, both spontaneously and in answer to direct questions. In a conducting game, Jamie gradually managed to give me more and more complicated instructions, such as “Play the drum and the cymbal loudly.” Nevertheless, his speech was still far from normal, and at times he would be unable to say something as simple as “Goodbye, Amelia” or tell me which day of the week he came for music therapy. Jamie still found it difficult to move quickly or spontaneously. However, he started to enjoy and understand imaginative games where I pretended to fall asleep on the piano, or I hid from him in the room. At these times he could react quite fast to “Wake me up!” or “Find me!” Jamie continued to enjoy experimenting with various ways of playing the instruments, and seemed to become more sensitive to various tone colours. He began to listen much more carefully to the sounds he produced. His sense of rhythm also improved. He would enjoy improvising on the piano and quickly became able to pick out tunes such as “Ba-Ba Black Sheep,” “Happy Birthday To You” and “Puff the Magic Dragon.” As he apparently wanted to learn more tunes, and enjoyed playing the piano, I arranged for him to start piano lessons with a teacher who had an interest in children with special needs. This also meant that there could be a clear separation between my work and more formal piano teaching. As Jamie gradually became more spontaneous in his contributions, he also developed some slightly obsessive behaviours, such as repeating a tune fragment again and again, or insisting on holding the drumstick in a certain way. Nevertheless, he could be distracted from these obsessions relatively easily. As time went on, these rituals seemed to die away, and were replaced by ordinary “toddler like” naughtiness and rebelliousness. The only slightly strange

behaviour that did occasionally creep back was that of Jamie “telling off” his right hand for misbehaving. By the end of six months of individual music therapy sessions, Jamie had made great progress, and the aims set out at the beginning of our work together had been achieved. Progress had also been noticed at school, and at home Jamie’s parents were delighted with his greater willingness and ability to communicate. However, they were also finding him a great deal naughtier and less easy to manage. I therefore decided that, as I had developed such a good rapport with Jamie, I would continue to see him for another four months with a view to helping both Jamie and his parents to cope with these new “naughty” behaviours. I also thought that his communication skills could be further improved. Phase Three: A Slightly New Direction Aims for the last four months of treatment were: to diminish silly behaviours such as screaming or deliberately throwing objects; to encourage longer spontaneous and creative dialogues with me (nonverbal and verbal); and to help Jamie to answer questions appropriately (and not let him divert me from this). When dealing with Jamie’s “naughty” behaviours, I felt it was important to explain what I thought about these behaviours, and why I was responding in a particular way. I told him that we would work out ways of stopping his naughty behaviours together. At times, I would smile at him, and tell him in a “teasing” way that I thought he was trying to be naughty. At other times, I would suggest to him that it was easier to opt out of an activity and be naughty, than to continue our work. When he threw an object, I would take his hand and physically help him to pick it up again, saying that it was important for us both to make the naughty behaviour “better.” Occasionally he would get “stuck” when asked to do something and say “I can’t.” In this case I would either help him physically (and comment that I was giving him a “helping hand”), or I would say that perhaps what I had asked Jamie to do was too difficult. This approach seemed to work well. He remained mischievous but became more accepting of direction, and would allow himself to be diverted from whatever was causing a problem more easily. During the last few sessions, Jamie sometimes became “moody,” and on one occasion, he cried when he did not have time to play an instrument he had wanted to play. He seemed relieved to be told that there was nothing wrong with being sad and crying. During the last four months, Jamie continued to make progress in his communication skills. By the end of my time with him he was able to hold ordinary conversations with me. He would initiate a conversation and ask appropriate questions. However, he would still sometimes need encouragement to answer questions. Overall, the progress he made during that year was remarkable. From a quiet often mouse-like child, he had become a vocal, boisterous child, often full of mischief and fun. Discussion and Conclusions

In the first instance, the musical instruments and our music-making interested Jamie, and motivated him to be actively involved with me. This enabled me to start building up a relationship with him which was initially based on shared enjoyment of the music and the musical activities. Jamie was able to maintain this positive relationship with me because I used very little speech in our assessment sessions. He could, therefore, relax and simply enjoy being with me. We were playing music together and communicating through sound, but very few specific words needed to be said or understood. It was the use of music as a means of communication which was essential at this point, and this could only have been achieved through music therapy. For the first few group sessions, Jamie again became very shy and withdrawn. This was probably because far more speech was necessary in this situation to understand what was going on and what was expected of him. However, he was able to maintain an interest in the group because of his fascination for music. The familiar structure of the sessions gradually reassured him, and gave him the confidence he needed to take part with the other children and make his own contributions. When I started working with Jamie individually, the familiar framework of a “hello” and “good bye” activity reassured him, and allowed him to start work with me straight away. In fact, it became clear that Jamie relied too heavily on familiar and predictable activities, and I had to start introducing “surprises” so that he did not become entirely dependent on this familiarity. One of the most important things that we worked on throughout Jamie’s individual sessions was vocalisation. As Jamie had never babbled as a baby, I felt that he needed to discover what fun it could be producing sounds and experimenting with different vocal noises. It is interesting to note that it was during these vocal exchanges that Jamie first started using his face in an expressive way, wrinkling his nose and making “funny” faces. This ability to encourage a child to have vocal sung dialogues which can be varied and made interesting through musical improvisation is unique to the music therapist. Another important aspect of our work was the fact that I was able to put Jamie “in control” by encouraging him, for example, to conduct my playing. I think this was helpful in building up Jamie’s confidence, as his language difficulties often made him feel confused and “out of control.” Slowly, and almost in spite of himself, Jamie discovered that it was not only easy to communicate with an adult, but that it could be fun and therefore worth the effort. This was my main aim with Jamie but it happened so gradually that I only realised how much progress he had made when I looked back at how little he had initially contributed. Finally, it is interesting to note that as Jamie’s abilities to communicate improved, he developed new “naughty” behaviours. The approach that I used to help him with these behaviours was based on explaining my actions very carefully, and making use of his new found language and comprehension skills. At this stage, I was also able to put more pressure on Jamie and be more demanding, something I would have avoided doing in the earlier stages. I think it was my relationship with Jamie which was crucial at this point, rather than the special skills that I have as a music therapist. Nevertheless, I had developed this relationship through our musicmaking, so it was important for me to continue and complete our work together. When I recently telephoned Jamie’s family one evening to find out whether they would be happy for me to write this case study, I heard a familiar voice in the background: “I don’t

want to go to bed!” Certainly, this is a well-known and unwelcome communication for any parent to receive from a child, but in this instance, I could not help feeling moved. I was reminded of the amount of progress Jamie had made since I first saw him two years previously, when he had hardly been able to use speech to communicate in any way at all. Although I generally enjoy my work as a music therapist, I do sometimes wonder whether I am really achieving results, and whether the children could equally well be helped through means such as special teaching or play therapy. Cases like Jamie make up for the times when progress seems to be very slow or nonexistent, and help to maintain my belief that music therapy is a truly unique and invaluable form of treatment. References Bloom, L., & Lahey, M. (1978). Language Development and Language Disorders. New York: John Wiley and Sons. Webster, A., &McConnell. C. (1987). Children with Speech and Language Disorders. London: Cassel.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE FIVE Growing Up in Music: A Journey through Early Childhood Music Development in Music Therapy Elizabeth K. Schwartz Introduction Growing up happens so naturally for most children that parents, siblings, family and friends take for granted the complex experiences and responses necessary for growth. The first few years are crucial to this developmental process. Children embrace language, early friendships, physical coordination and control, and a fundamental sense of themselves in the world. The amount of change during these critical first years is commonly viewed as being greater than at any other time in their lives (Bredekamp & Copple, 2009). Sometimes, though, development does not occur as expected, or when expected. Parents or others close to the child notice that s/he is not speaking or making sounds; s/he does not move as other children her/his age move; or that s/he does not smile or play. For these parents and children, the journey to adulthood will be challenging and frequently filled with uncertainty, fear and sadness. In 1986, Early Intervention (EI) was formally instituted in the United States through the passage of Public Law 99-457, now known as the Individuals with Disabilities Education Act (Humpal & Colwell, 2006). As such, it formalized a process of support for children with special developmental or learning needs and their families. This chapter describes one such program, called My Grownup and Me, in which music therapy experiences provided support to several young children and their families. Music became a core experience through which these little ones, all under three years old, had the opportunity to develop and grow. In the cases presented, children were able to access music therapy through the Early Intervention system. The therapist’s task was to empower the family as they sought to give their child experiences that ameliorated disabling conditions and allowed for developmental growth. This was accomplished through the modeling of interventions, information sharing and supportive relationships. As part of the emphasis on family, the Early Intervention System, as regulated through the Individual with Disabilities Act, requires that any services be provided in ‘naturalistic’ or ‘community’ environments to the greatest extent possible (Schwartz, 2009). In the cases to follow, music therapy sessions were held as a group experience at the children’s’ room of a local library. The name of the program--My Grownup and Me--spells out the importance of family as a focal point of the therapy. Foundational Concepts

Music and Child Development Young children have a simple trajectory--to grow up. Expectations that they will grow in a certain way are commonly referred to as normal development (Kegan, 1982). This growth occurs simultaneously across cognitive, motor, language, social and behavioral domains, and is usually understood to occur in stages or levels. For example, Kegan (1982) and Piaget (Ginsberg & Opper, 1969) developed models of cognitive development using a stage-like framework, while Mahler, Pine and Bergman (1975), Erikson (1963) and Stern (1985) focused on identity development within a broader developmental framework during the first six years of life. Music develops in young children just as movement, language, and thoughts and feelings develop (Briggs, 1991; Gordon, 2003; McDonald & Simons, 1989). From coo to cry, the musical sounds made by young children are one of the foundations of communication that form a child’s sense of self and connection to others (De L’Etoile, 2006). The elements of music, such as pitch, melody, rhythm and musical form are naturally absorbed, integrated and engaged by all children (Gordon, 2003). Furthermore, the way in which children begin to sing, move or play an instrument happens in a developmental sequence that parallels speech, cognition or physical development (Briggs, 1991). Schwartz (2008) built upon these frameworks to articulate a five-level continuum of development central to her music therapy practice: Awareness, Trust, Independence, Control and Responsibility. Awareness is “an awakening of the senses, of physical and sensual being. It is the beginning of thoughts and feelings. Awareness is reflexive and instinctual” (Schwartz, 2008 p.49). Within the level of Trust, “the young child reaches out and finds a response that helps to form a perception of the world as a place that has meaning, reliability and safety. Trust also means looking inward and finding constancy and stability” (Schwartz, 2008 p. 59). The child gaining Independence “can have experiences separate from another person. He or she can create the opportunity for experience in response to his or her own internal motivation” (Schwartz, 2008 p. 69). As children move into the level of Control, “They can use their cognitive abilities and communication skill to make choices. These choices become integrated into the ‘self’ “(Schwartz, 2008 p. 79). Responsibility “implies the recognition of the interdependency of the self with the external world while preserving the ability to maintain the “self” (Schwartz, 2008 p. 91). Movement from one level to the next is dependent on mastery of the prior level. Components of each level include all the areas that humans are made up of--physical, cognitive, emotional, social, sensory, and of course, musical dimensions. In the three cases presented, the children are in the first three developmental levels: Awareness, Trust and Independence. Music Therapy within a Developmental Framework Music therapy within this early childhood framework seeks to promote and expand development in as healthy a manner as possible. This therapy focuses on dynamic growth from Awareness to Trust; from Trust to Independence to Control; and from Control to Responsibility. In partnership with the parent or caregiver, the therapist crafts interventions and experiences that allow the child the opportunity to fully explore and integrate one’s self within each level. The therapeutic work described supports both expansion of self within a level, as well as

movement toward the next level. Language in these levels is still rudimentary, and cognition is just beginning to emerge. Insight and self-awareness, or meta-cognition, are a long way off. What is left is music and relationships. The therapeutic process, by necessity in very early childhood, is all about the music and the music makers. The music interventions used in the My Grownup and Me follow this developmental design. Pitch and rhythm are the earliest elements used, as they are the earliest elements developed (Schwartz, 2008). The unaccompanied voice is the primary tool in the beginning. The immediacy and spontaneity afforded by singing is modeled after the ‘motherese’ and ‘singsong’ vocal quality used in early parent/child dyads (De L’Etoile, 2006). The singing voice also provides a musical format that can be adopted by any adult and emphasizes the shared nature of music experienced by children in these early years. Singing simple songs, vocalizing freely, and moving to rhythms are all musical experiences in which any child can learn to participate. The role of the music therapist in this type of program is to create interventions that the parent1 can learn, remember and recreate within and outside the music therapy session. In this way, the therapist gives the music to the child and parent so that the activity/experience can be owned by the duo. This kind of giving/letting go imitates, in many ways, the process of parent/child individuation that is necessary for growth. In My Grownup and Me, the child becomes part of a larger community represented by the other children and parents who join the group. Again, the emphasis is on supporting the child as he or she connects with other children and to their caregivers. This web of relationships becomes a social community though the shared experience of music making. Rather than the commonly used therapeutic triangle of therapist, client and music, early childhood music therapy can be pictured as a circle of music surrounding, encouraging, supporting and fostering all of these complex relationships. The early childhood music therapist, then, engages the child and family in music that promotes healthy, normal development. Therapy is considered from a strength-based point of view intended to reposition the child away from particular deficits and toward increasing positive, functional and dynamic growth. The therapy happens at the moment in which the child’s drive to develop and the barrier of the disability collide. The music therapist uses music interventions to propel the child toward healthy development and away from this restraint of the disability. The Clients Concern for their child’s development is only one challenge faced by parents who access Early Intervention. Emotional upheaval swings from hope to despair, frustration to longing and love. These myriad, complex and contradictory emotions surface as the family comes to terms with the idea that their child may be disabled. Many families are uninformed about child development. And for many, the true nature of their child’s difficulties are only unveiled over time. Early Intervention regulations speak of challenges and needs rather than diagnosis; hence the majority of young children only receive a formal diagnosis much later. Michael2 was 21 months when he began My Grownup and Me. He was a substantial little fellow who still had his chubby “baby cheeks.” He wore glasses, even at his young age.

Michael was initially referred to Early Intervention with concerns of developmental delay. He was slow to sit up and turn over. At 21 months he had only a few word approximations. He was just beginning to stand and was not yet walking. Michael came to group most often with his mother, but was frequently joined by his extended family. Peter had just turned two when he started in My Grownup and Me. He was an active boy whose handsome face and compact frame looked like the epitome of the word “toddler.” Peter had begun to receive speech therapy as part of Early Intervention, and his family was most concerned about his developing language. Peter came to group with his mother, who struggled to keep up with him as he darted about the room. She also shared that he had difficulties in other structured activities such as parent/child groups or library programs. Peter had two older siblings who shared in the responsibility of looking after Peter. Emma was 26-months old and one of the few girls receiving services in My Grownup and Me. She was slight and quick to show intense determination in everything she did. Emma’s family had her evaluated through Early Intervention primarily because of difficulty understanding her speech. As there was a history of special needs in the family, they were concerned that her language difficulties might speak to more significant developmental problems. Emma’s mother was committed to bringing Emma to the group even though she was extremely busy juggling family responsibilities. Assessment Children within Early Intervention receive a professional, comprehensive assessment in order to determine eligibility, necessary services, and outcomes expected from interventions. The parent/child group does not have a separate assessment process for eligibility, but it is generally provided when the treatment team feels that the child and caregiver would benefit from greater exposure to the experiences that come from participating in a community group. Since My Grownup and Me is centered in music therapy interventions, the recommending team recognizes that the child responds well to music and thereby suggests placement in the program. Assessing the child’s needs through musical play happens naturally within the first few group sessions, and is accomplished through observation. Musical responses are used, in addition to non-musical information, as an indication of developmental maturity. My Grownup and Me also makes use of a more formal assessment tool, the MIECD--Music Indicators of Early Childhood Development (Schwartz, 2008). During his first session, Michael maintained a pleasant affect as he sat in his mother’s lap. He did not focus his gaze, but scanned from side to side, most often turning towards his mother’s face. He briefly grasped toys placed in his hands but did not hold them for long. He needed support to sit independently. When greeted by the music therapist with a vocalized ascending octave followed by a descending minor third (Good Morning!), Michael swung his head to search for the source of the sound. As the group began to join in the gathering song, Michael moved his entire body in a steady rhythmic bounce. The end of each song phrase was followed by a defined silence. Michael filled in with a non-specific short vocalization each time, combined with a gestural approximation of the sign for ‘more.’ With these responses as the basis, Michael was assessed to be in the developmental level of Awareness.

Peter’s first session was distressing and chaotic. He resisted coming into the room and had to be carried by his mother. The greeting music, based on pitch and melody, did nothing to soothe or attract him. It wasn’t until movement and rhythm became prominent that Peter lessened his crying and looked toward the face of the therapist. The music had a very clear structure with a sixteen bar format, 2/4 meter and consistent tempo sung by the therapist with accompanying drum beat. Peter let his mother put him down, and he began to move around the room in a rhythmic march. When the music stopped, Peter stopped and glanced at the therapist. Although it first appeared that Peter was unaware of his surroundings, his subsequent musical responses made it clear that he was hyper aware of the musical environment but was not able to accept and integrate these experiences. Peter was assessed to be in the developmental level of Trust. Emma immediately moved close to the music therapist as she began to sing a melody built around notes of the triad. Emma repeated back the simple intervals with pitch accuracy but had difficulty pronouncing the words of the lyrics. She would dance up to the therapist, bring her face close, but as soon as the melody ended, would take off. When presented with a maraca, Emma’s shaking was fast and active. While she gazed intently at the music therapist, Emma did not look at either her mother or the other children in the group for any length of time. Emma was assessed to be beginning the developmental level of Independence. The Therapeutic Process Michael: Becoming Aware In Michael’s first two sessions of My Grownup and Me, he was literally and figuratively surrounded by the love of his family. He had great difficulty maintaining an erect posture and needed his mother’s support to remain upright. Michael’s hands would flex open and closed, and he would sporadically bring them together in a clap. His legs and lower body needed positioning in order to move. Despite this obvious physical weakness, Michael had a bright affect and an animated face. He would swivel to put his face up against his mother’s chest and tip his head back to focus on her. He would smile, and his pudgy cheeks would crinkle up delightfully. Sometimes, however, this look of adoration would morph into an open-mouthed bite. Equally unexpectedly, Michael would roughly bang his head on mom’s chest or knee. Mom appeared to be confused and dismayed by these behaviors. As the pair sat on the floor, I moved closer and sang a “Good Morning” greeting utilizing an octave leap followed by a descending minor third (sol, Sol, Mi). Michael shifted his upper body toward me and the source of the sound. His eyes opened wide. I moved to his other side and repeated the musical phrase. Michael followed me with his eyes, face and upper body. The improvised song continued as I changed my position throughout all the planes surrounding Michael - up, down, in and out. Each time he made attempts to find me in space. Mom watched the musical game intently. The last time, I landed in the space that signaled the beginning of the gathering song - calling all the children and adults to join in the music circle. Michael and Mom were now positioned facing into the group, and Michael and I had a direct line of sight and

hearing. Despite all the other children and grownups in the group, Michael’s posture and facial gaze remained firmly focused on me as the source of the music. Gathering songs (Schwartz, 2009) are a technique used in early childhood music therapy to bring everyone together in the music space. They have strong, steady rhythm along with musical gestures and are clearly structured. Michael began bouncing in response to this new song, and his delight in the sound and movement was shared by his mother, whose body relaxed as she released her tight hold on him. It was almost as if she could begin to let go, since the music would hold her child safe. By session three and four, our greeting song had become routine, and Michael would begin looking for me even before I had time to sing. I would purposefully move toward the other children in the group and shake their hands as I sang Michael’s “Good Morning” song. As Michael searched for his music, I would in essence transfer my greeting to his peers through my singing to them. In the music circle, I asked Michael’s mom to sit in a different spot each time so that Michael would have the opportunity to experience the sounds from all different locations--something he could not do for himself due to his movement limitations. As the gathering song began, Michael had the experience of the music all around him, and was afforded the opportunity to gain awareness of the people and objects in his immediate environment. The lyrics and melodic rhythm of the gathering song supported this awareness of self and others. Adapted from the tune of an American folk song “Go In and Out My Window,” the exciting rhythmic movement of ‘clap hands in the circle’ was followed by an accented, sung exclamation--“Here”--with two beats of silence afterwards. Then, suddenly, “There!” pointing outward across the circle, “Friends are everywhere.” Michael’s mother joined in singing and helped Michael to point out toward the others in the music circle. The duo engaged happily in the musical awareness of themselves and all the others within the music group. Both Michael and Mom shared in the joy of becoming aware. Instead of the inward focus that limited Michael’s awareness of anything other than his family and could have been the cause of his frustration (seen in the biting and banging), Michael and his mother joined together in opening up to the world through the joy of a shared musical experience. Peter: Learning to Trust Peter’s initial sessions in My Grownup and Me were marked by moments of calm and attention followed by screams and running away. When he was finally able to enter the room, he would walk straight through the others and sometimes over children and toys to get what he wanted. Once he found the object, he would intimately examine it to the exclusion of all else and tantrum if it were taken away. When the toys were cleaned up and the music began, Peter would throw himself on the floor, kicking or hitting his mother. Peter’s mother would become visibly upset and appeared to be embarrassed by her son’s behavior. She would chase after him or try to restrain him, but with little success. The fleeting nature of the music experience in early childhood is matched by a technique called embedded music (Schwartz, 2009). In embedded music, very short musical phrases or simple intervals are sung or played that match the activity in which the child is engaged. The duration and the timing of musical fragments are sporadic and in the moment themselves. As Peter lay on the floor manipulating his chosen toy, I would lay down next to him

with my face close to his. I chanted very insistently “A toy on my knee, a toy on my toe, a toy on my belly, now time to go.” The meter of the chant was very deliberate, falling on every other beat. On the word ‘go,’ my voice would glissando down two octaves as I rolled away from Peter. Each time, his eyes would flicker and meet mine directly for a brief second. I came back again and again and again, each time repeating the same silly musical game. The flicker of attention grew longer and there was a hint of a smile. Peter’s mom watched the game with a relaxed look on her face, perhaps glad to see such moments of happiness. I invited her to join me in the chant. She learned it quickly and took over this musical play with Peter. All this ended as the session moved into the gathering song. It was apparent that the intimacy of the music circle and the joint music making was more than Peter could handle at that time. I encouraged Mom to stay in the group and allow Peter to watch from afar. I suspect she felt foolish participating in the songs and instrument play without a child on her lap, but she had given me her trust and was willing to try this new kind of interaction. Peter wandered but kept turning back to watch us both. My Grownup and Me, provides for a great number of music therapy interventions within the session, a strategy that matches the attending abilities of young children. After the closeness of the gathering and mutual play songs, the group changes to a less cohesive activity and everyone stands to move around the room using marching, running and jumping. The musical material keeps the group together through strong rhythm, consistent tempo, defined meter and clear structure. As the group swept past Peter (Mom included), all marching to the beat, he began to move his body in synchrony with the drum. His whole body started to respond and then he picked up his feet and joined us. The strong finish of the song was followed by several long moments of silence. Peter and the other children stood absolutely still. When the silence hung heavy in the room, I sang “Uh, Oh” on a descending fourth followed by a very deliberate perfect fifth from sol to do. “Listen!” Peter did not move. “Run,” I shouted, and Peter ran. “Uh, oh. Listen!” “Jump,” I shouted, and Peter jumped. Now it was Mom’s turn to stand still as she admired the wonder of her son listening and doing. At session five, Mom entered the room complaining. “All he wants to do at home is march,” she explained with a twinkle in her eye. “What do you do?” I asked. “We march,” she said with determination. Peter was now able to walk by himself into the room. He most often made his way to me and molded his whole body into mine for a few seconds as a way of saying hello. Sometimes he would actually say “hi.” On week six, Peter entered independently, looked me in the eye and sang “Good morning!” using a pitched interval that approximated the downward fifth heard later as “listen.” He would now sit on my lap for the “Toy Song” and at the final glissando would send his toy car careening across the room to his mother. Mom would then send it back to him, imitating “Goooooooo!” Sometimes I would make the car go, and it would veer off course toward another child. While Peter was able to trust his mother with the car, the game and with himself, he was not yet ready to let go with his peers. Mom saw the new aspect to the game, and I could see she understood how the music could engage other children with Peter. Peter’s greatest musical participation was still during the active music and movement part of the session. He sang along now with pitched intervals on “Uh, Oh. Listen.” He also took command of his actions and that of the group by shouting “march.” He could now pick up his

feet and place them firmly on the ground in rhythm, and his marching had become deliberate and sure. For an active boy who thrived on rhythm, meter and structure, the music gave him an auditory and physical space in which to be organized and whole, instead of scattered and disconnected. His mother also had a predictable place in which to meet Peter at his best, and her delight was evident. Many children like Peter find it difficult to be held, to be confined, or to be immersed in environments that provide too much unanticipated sensory information. Being a parent to a childlike Peter means that the traditionally accepted physical closeness marking the mother/child relationship, such as holding or rocking, is rebuffed by the child. The parent most often misunderstands the child’s aversion and interprets it as a form of rejection. This sense of rejection causes the parent to mistrust his/her instincts and pull away from the child, making the situation even more difficult. Feelings of failure as a parent often follow. The closure of My Grownup and Me begins the only planned harmonic intervention of the session. Resonator bells tuned to the pentatonic are set out in the middle of the circle, and the children are motioned to leave the movement play and come once again into the center. Each child takes a bell and a mallet. Some give a bell to their caregiver, and some give a bell to a peer. None of them play the two handed instruments very effectively at this age, so the grownups must each become an active part of the group, providing the musical accompaniment to our “Good bye.” Peter, as with many children with similar musical sensibilities, is drawn into the delicate, warm timbre of the instrument. The melody makes use of the minor third that is prevalent in the pentatonic, and the rhythmic flow is reminiscent of a mother rocking her baby. Peter plops down on the floor, wedged between his mother and me. The melody and rhythm do not stop. Peter lays his head on Mom’s lap and she scoops him up in her arms. He stares intently into her face and calmly lets her rock him to the music. Emma: Feeling Free Emma had no difficulty entering the music room, and in making herself comfortable amid the toys and the other children. She carefully selected the toy that she wanted and sat very contentedly playing with it. Although she allowed her mother to take off her jacket and hat, she wasted no time in getting down to solitary play. If another child approached her, she simply stood up, took her things and went to play in another area of the room. She was able to use single words to comment on things, but she did not use this skill to communicate with her peers, her mom, or me. Since she accomplished most actions on her own, it was as if she had no need for spoken language. To someone viewing from the outside, she might look like a very independent child. It was a whole different Emma, though, once the music of the gathering song began. Emma sat primly in her mother’s lap and did not take her eyes off me for a second. Within the first few measures, she began to clap or pat or stamp as the words of the song directed. She began, very quietly, to sing along with precise use of pitch and simple intervals in imitation of the melody. Although the consonants and vowels of the words were unclear, the music was accurate. Mom looked very proud, but did not sing along. As soon as the song ended, Emma

bolted out of the circle and toward the other side of the room. Mom quickly chased after her and brought her back without a word. Emma never looked at her. But then, the maracas! Emma came hurrying back to the circle and took hold of two Chiquita or mini-size maracas. She shook them fiercely with a clenched intensity. It was in direct contrast to the Latin flavored swing of the maracas song that I chose. “I like this song,” I sang calmly, swaying from side to side with a syncopated pattern. Emma shook the maracas furiously. Early childhood music at this level relies on contrast and change, offering the child the opportunity to experience and make musical choices. The B section of this maracas song abruptly moves into a strong 2/4 meter, with very straight, even rhythmic patterns. The lyrics include the words “Yes, I can!” This section of the music fit Emma’s intensity and tempo perfectly, and she joined in singing “Yes, I Can.” The song ends just as abruptly, with a vocal crescendo leading to the word “Stop.” Emma stopped and then bolted again! Mom got up and chased Emma. I sat, planted firmly in the middle of the circle, picked up the maracas and began to calmly sing the lilting A section. Emma moved with Mom back to the circle and took up her maracas. Again, her shaking was matched by the B section of the song. The crescendo toward “stop” was long and drawn out. Emma shook and waited and waited and then joined in the word “Stop.” As before, she left the circle, but I indicated to Mom to stay seated and calm in the circle. Emma ran a short distance and then looked back toward us. I once again began the maracas song. Emma stood and watched. Mom sat and played. Emma independently moved closer, picked up maracas from the middle of the circle, and happily joined in. By week four of the sessions, Emma was able to remain in the ‘music circle’ as long as the music was familiar to her. Instead of moving through rigid response patterns of fleeing and then being chased, Emma was making a choice to be a music maker, finally independent of the rigidity that had controlled her, preventing her from being truly independent. During week five and six Emma showed, through her actions and behavior, that she was anticipating the maracas song. She would position herself close to me, allow me to take her hands, shake together while moving rhythmically to the gentle sway of the song. The furious shaking seen in the first sessions had been replaced by a true musical reaction to the choices provided by the tempo, meter and dynamic changes of the song. The next week, Emma came to me with a toy and proceeded to ‘tell’ me a very long and involved story using vocal inflection, intonation and scattered consonants that let me know these were words. The details of the story were lost in her poor articulation, but the impact of relating her thoughts to another person vocally was very clear. I looked over at Mom and then back at Emma, “and what happened next?” I asked. Mom moved closer and Emma continued to ‘tell her story’ to both of us in a lovely spoken song. Summary Michael, Peter and Emma all have a long developmental journey ahead. Some will go farther than others. The caregivers of these little ones might not fully understand all that happened during these sessions. However, over the many years that this program has been provided, the impact of the music lingers, as evidenced by the number of parents who have

come back to me years later remembering in vivid detail the songs, chants and musical fun that they shared with their child. For Michael, his alertness to the timbre and pitch of my voice provided the encouragement to attend outside of himself and become aware first of the music, his mother and me, and then to the other children. Rhythm and musical structure gave Peter the repeated, predictable comfort he seemed to require to allow him to trust in his mother, in me and in his environment. Emma’s musical responsiveness allowed her to experience choices in melody, rhythm and movement and gave her the opportunity to be supported by her mother and me as she moved away from rigid patterns toward greater freedom and independence. Becoming aware, learning to trust, being independent and free from the confines of a disability happened through the music shared among the child, caregiver, therapist and group. My Grownup and Me, relies on music experiences to promote healthy development and assist the family in helping the child to ‘grow up.’ While the children described above had the benefits of other supportive services, music was where their strength and potential was given a place to shine. Music was the common ground where the grownup and child could meet in mutually understood play. It was in music that the necessary movement toward growth was experienced. References Briggs, C. A. (1991). A model for understanding musical development. Music Therapy, 10(1), 1– 21. Bredekamp, S & Copple, C. (Eds.) (2009). Developmentally Appropriate Practices in Early Childhood Programs Serving Children from Birth through Age 8, Washington D.C.: National Association for the Education of Young Children. De L’Etoile, S. K. (2006). Infant-directed singing: A theory for clinical intervention. Music Therapy Perspectives, 24(2), 22–29. Erickson, E. H. (1963). Childhood and Society. New York: Norton. Ginsberg, H. & Opper, S. (1969). Piaget’s Theory of Intellectual Development: An Introduction. New Jersey: Prentice-Hall. Gordon, E. E. (2003). A Music Learning Theory for Newborn and Young Children. Chicago: GIA Publications, Inc. (Originally published 1990). Humpal, M. E. & Colwell, C. C. (2006). Effective Clinical Practices in Music Therapy: Early Childhood and School Age Educational Settings. Silver Spring, MD: American Music Therapy Association, Inc. Kegan, R. (1982). The Evolving Self. Cambridge, MA: Harvard University Press. Mahler, M., Pine, F. & Bergman, A. (1975). The Psychological Birth of the Human Infant. London: H. Karnac Ltd. McDonald, D. T. & Simons, G. M. (1989). Musical Growth and Development: Birth Through Six. New York: Schirmer Books. Schwartz, E. K. (2008). Music, Therapy, and Early Childhood: A Developmental Approach. Gilsum, NH: Barcelona Publishers. Schwartz, E. K. (2009). In the Beginning: Music therapy in early intervention Groups. Imagine Early Childhood Newsletter, Volume 15, 13-14. Stern, D. (1985). The Interpersonal World of the Infant. New York: Basic Books.

Wilson, F. R. & Roehmann, F. L. (1990). Music and Child Development. St. Louis, MO: MMB Music, Inc. .

____________________________________ or caregiver 2 The children whose stories are told below have been created from real life events, but are not specific, actual children. Unlike therapy with many adults, children are unable to consent to their own therapy. While parents must agree to therapy, the fragile nature of this time of life makes it extremely difficult to expose parents to the possible pain an examination of their child might pose through publication. However, the details of the music, the therapy and the responses in these case studies reflect children I have encountered in my many years of clinical experience. 1

Taken from: Sekeles, C. (1996). Music: Motion and Emotion—The Developmental Integrative Model in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SIX Anat: A Body Aware—A Soul Alerted: Developmental Integrative Music Therapy with a Hypotonic Down’s Syndrome Child Chava Sekeles Introduction This case deals with a child suffering from Hypotonia1 and, in order to improve this, was treated with music of a stimulative character.2 As a result, whether this be a spontaneous reaction without any extramusical encouragement, or with the addition of verbal guidance, the patient is liable to start moving in a manner which will increase muscle tone and enhance overall alertness.3 The observations, test methods and therapeutic programs of various developmental schools (Kephart, 1960; Kohen-Raz, 1970; Ayres, 1972; Piaget, 1974; Prechtl, 1978), display an identity of views on a matter which is crucial to our main subject consideration. The earliest stages of life serve as a sensory-motor basis upon which the vital and complex processes of learning, emotionality, and socialization can develop. The greater the maturity of intersensory, intrasensory and sensory-motor integration, the greater the ability of the child to develop those complex systems so essential to healthy functioning.4 Infants born with Down syndrome display many symptoms connected with primary retardation. Before going into therapeutic details, I should like to focus on this particular group in order to demonstrate the stimulative influence of music, and the physiopsychological changes it can bring about as a predisposition for continued therapy. The reason for choosing Down syndrome children as an example is based on the following statistics: 1. 77% are born with muscular hypotonia 2. 84% have weak initial reflexes 3. 82% lack the Moro reflex 4. 77% suffer from hyper-flexibility and hyper-extensibility. Such birth symptoms undoubtedly serve as handicaps for infant development. To this day we do not know the basic causes of the Down syndrome child’s retardation, but one can assume that the above mentioned factors contribute to primary mental retardation, and secondary developmental retardation. For these and other reasons it is essential to intervene

and alter these factors as soon as is feasibly possible. In order to further understand this we shall first discuss the Down syndrome child’s potential for secondary retardation, and the stimulation programs available today in various institutions throughout the world. The Development of Down syndrome Children During his lifetime the human being expends a great deal of his energy in countering the natural force of gravity: this is an ongoing dynamic process which commences at birth. An infant who for whatever reason maintains a prone position and finds difficulty in countering the force of gravity is liable to be handicapped in his or her overall development, adversely affecting the potential for independence and limiting the concept of the surrounding world. As already stated, the sequence of movement and posture is partially hereditary and partially the result of practice in gaining control. In this respect we should perhaps recall the initial reflexes which serve as a model for potential voluntary movement. For example the Moro reflex, which is lacking in a high percentage of Down syndrome infants, is regarded as a vestige of Man’s apelike past when grasping the branch of a tree was essential for survival. It is this reflex which serves as a basis for developing extension movements and overcoming the force of gravity. Another example is the weak Tonic Neck Reflex whose function is to teach the infant how to make use of each half of the body by itself, or the weak grasping reflex which serves as the basis for voluntary holding movements. Such cycles of learning extend beyond mere movement and, as previously stated, determine the infant’s concept of the world around him as well as influencing his emotional state. Between the ages of two to five or six months the infant generally lies facedown on its stomach, raising its head when it hears its mother’s voice and turning in that direction. This simple action, which is generally taken for granted, has in fact great psychophysiological significance. The infant extends the neck muscles in order to overcome the force of gravity and expand his field of vision. This is the first step in controlling his world by means of integrating and combining auditory stimulation, motor reaction, and visual and proprioceptive information. Proprioceptive information leads to a vestibular reaction in order to deal with a new state of balance, and at the same time the infant’s concept of his surroundings is enhanced and enlarged. By this process the infant gradually learns the sound of the mother’s voice with her visual appearance, thus reinforcing confidence in her actual existence. As opposed to the healthy infant just described, the Down syndrome infant moves little and lethargically, apparently devoid of energy. Despite the fact that he is capable of hearing his mother’s voice, hypotonia leads to clumsiness, and the lack of, or weakness in, initial reflexes hampers the development of basic motor patterns. In addition, the mother is liable to interpret his lethargic reactions as if he were “fragile.” Thus she may be liable to treat him too delicately and so deny him the very tactile and movemental stimulation which enhances sensory-motor integration, defines the body’s boundaries and makes motor planning efficient. Such an example demonstrates just how hypotonia and a lack of, or weakness in, initial reflexes can lead to a chain reaction of disabilities from birth. The achievements of a normal infant, exposed to normal stimuli, will never be equaled by the Down syndrome infant unless he is encouraged and guided in the right direction. The following sketches serve as examples of normal and abnormal infant posture:

Figure 1. Normal and abnormal infant posture.

Figure 2. Normal postural response when riding wheel board in prone position (4-year-old boy)

Figure 3. Poor postural response (the Tonic Labyrinthine Reflex is poorly integrated) (4-year-old boy)

For these reasons, in various institutions around the world, programs have been developed whose purpose is to provide the earliest possible stimulation in order to achieve the greatest narrowing of the gap between the normal and the Down syndrome infant. These programs focus on physical development (Zausmer & Peuschell, 1972; Brinkworth, 1975), as well as on the development of speech and language (Buckley, et al., 1968; Weistuch & Lewis, 1985). This consists of joint instruction of both parents and child from birth until the age of four to five years. Parents and children benefit from this in equal measure. A consistent and continuous series of encounters with professional advisors helps the frustrated and often resentful parent to channel his or her feelings toward more productive and practical aims. Above and beyond the exercising of the child’s senses, movement, speech and intelligence, it is the constant parent-child contact which creates that essential interaction which aids emotional development. Eye contact can serve as a good example. Cunningham & Berger (1981) showed that the eye contact of a Down syndrome infant is different and slower than that of a normal child. Thus a special sort of encouragement is needed in order to develop a swifter, more normal eye contact between infant and parent. The different categories of Down syndrome which affect the child’s development potential must also be taken into account. Certain stimulatory programs have revealed that Down syndrome children in various categories who were given early and controlled treatment made good (albeit relative) progress according to Gesell (1974) in four areas of examination: motor coordination, development of speech, adaptability, and personal and societal behavior (Fishier, et al., 1964). Among the achievements of such controlled stimulatory programs, one must stress the lessening of the stigma attached to a Down syndrome infant and his chances for progress. In the past he was generally looked upon as severely retarded and destined to spend his whole life in institutions. Today most Down syndrome children are able to learn and develop if given adequate treatment both at home and in school. It is only a minority who are in fact severely handicapped and dependent (Peushell, 1984). Scientific research into Down syndrome is still unable to define the exact source of retardation5 or to indicate treatment. Similarly, research into the results of stimulation with laboratory animals, while demonstrating improvement, is as yet unable to prove the relevance of such experimentation as far as human beings are concerned. For example, examination of the results of controlled experiments in sensory stimulation of rats over a thirty-day period (Rozenzweig, et al., 1972) revealed that in addition to an improvement in their motor function, there were also morphological changes in the brain, an increase in brain weight, a thickening of the cerebral cortex, and an increase in the level of acetylcholinesterase.6 Whatever the case, basic maladjustment of the cerebral cortex in Down syndrome children can serve only as an indirect explanation of the existence of mental retardation. Rahmani (1981) voices criticism about the capability of any sensory-motor integration program’s capability to advance learning potential, particularly in cases of learning disability. It should be emphasized, however, that no claims are made by the advocates of stimulation programs that they are directly capable of advancing academic skills, but that they serve to

improve the patient’s day-to-day functional ability, enable him to experience positive sensations, bolster his self-image, and thus reinforce the basis for learning. Rahmani also warns against any rigid or arbitrary interpretation of the hierarchy of developmental continuity, since many of these stages overlap one another. The young brain is still flexible and capable of developing alternative skills which can assist the process of learning (ibid.). Music Therapy and Down Syndrome Early stages of stimulatory programs for Down syndrome children include musical activity, especially rhythmic. Peushell (1987) stresses the need to encourage and develop verbal communication and improved motor skills, to facilitate emotional expression, teach socialization and encourage overall motivation. When one considers the multifaceted difficulties of the Down syndrome child, Peushell does in fact, propose a variety of therapeutic possibilities. Even though the actual causes of retardation, hypotonia, speech impediment, etc. are still unclear, clinical experience shows us that consistent and controlled therapy can lead to positive results. Such a program can, as already stressed, involve music due to its inherent links with, and influence on, sensation, movement, vocality, emotion and cognition. A review of professional music therapy literature reveals that the general attitude toward Down syndrome children is similar to that adopted toward other categories of retardation. Until the 1950s or thereabouts, music was employed in the treatment of the retarded mainly as an instrument for the improvement of learning abilities, due to the fact that music can be absorbed in a concrete manner which does not demand any great intellectual ability (Howery in Gaston, 1968, Ch. 3). From the 1950s the aims of music therapy expanded and became directed toward observation and diagnosis, the establishment of contact, adjustment to extra-institutional surroundings, the acquisition of day-to-day skills and abilities (A.D.L.),7 development of speech and language (Somerville, 1958), the learning of body concepts by means of Activating Song (Lathom in Schneider, 1963, pp. 115-121), and more. Since there does not exist any specific approach to this syndrome, I should like to describe the role music can play in the treatment of the basic developmental problems it presents: movement, posture, sensory-motor integration, vocalization, and the child’s emotional world. Such an approach can become a part of developmental therapy from a tender age, and can continue through schooling, at which stage the child is usually compelled to mainly concentrate on academic studies. From the various Down syndrome children I have treated, I have chosen Anat as an illuminating example. Anat: Patient Profile Anat was born retarded in 1974, the first daughter in a family of three; her mother was then 29 years old. Both parents are academics and have undergone professional instruction and guidance since Anat was born. At the age of 18-months Anat began to attend a kindergarten within the Institute for Child Development, and underwent treatment by a multidisciplinary

team of therapists. From the age of three to six she was in a special kindergarten for the retarded, although for a certain period there was a time-sharing arrangement with a kindergarten for normal children. During compulsory kindergarten attendance she was integrated into a regular study program, with the acquiescence of a kindergarten teacher who was totally devoted to the child’s development. From the age of seven to 13 she studied at a special school for those with learning disabilities, and recently completed her studies in its high school. She benefited from three years of individual music therapy, an additional two years of group music therapy, cognitive enrichment, and psychological support during those years. She has also undergone plastic surgery in order to improve the chin and the eyes, and to shorten her lolling tongue.8 Clearly, Anat has, since birth, been given the best possible treatment from every point of view. I have followed Anat’s development since birth, and first began individual music therapy with her when she was five years old. The first two months of observation revealed the following: 1. Low muscle tone despite her active participation in earlier stimulation programs. Basic movement existed but its quality was poor due to still extant hypotonia. The hips and pelvis were unstable, and could not sufficiently resist the force of gravity. The muscles of the face and tongue were hypotonic, arms dangled, and walking was clumsy. There could be no doubt that such physical postures betrayed a state of retardation and demanded continued treatment. 2. Trying to listen to music or a vocal narrative while lying down in a relaxed position, Anat would soon enter into a state of physical restlessness. Passive listening seemed to be impossible; later she was unable to recall the content of what she had heard. It seemed that intellectual perception in such a pose was ineffective. 3. Once given the choice, Anat supplemented her listening with energetic movement, a spontaneous acting out of what she was hearing. Later she would be able to recall such content more lucidly and with greater ease. 4. As a result of predetermined movement exercises dictated by music of an ecstatic nature, a number of features could be noted: a. Increase in muscle tone b. Improved anti-gravitational posture c. Overall alertness and improved perceptive abilities d. A better ability to recall and repeat verbal content.9 In the course of time it became clear that after an initial exercise devoted to movement and posture, not only her overall input and output improved, but also her willingness to confront emotional problems. Such observations have no scientific foundation. Furthermore, despite the fact that hypotonia is mentioned as an integral part of Down’s Syndrome, I have yet to find any research which can explain its origins, or even its connection with difficulties of attention. The assumption was that despite the fact that the majority of Down syndrome children are able to control basic motor function from kindergarten age (Peushell 1987, pp. 15-52),

hypotonia, nevertheless, continues to sabotage any complex movemental development (Sekeles & Cohen, 1988).10 It would seem that the infant lying on the rug and simply listening, while reducing his muscular tone to the minimum, for some reason is limiting his powers of concentration. In such a state he indulges in “self-therapy” by means of excess movement which might indeed increase muscle tone. A further example of such self-help can be seen in the video documentation of Piano Lesson for Hypotonic Down syndrome Child under the guidance of Yael Barnet. Whenever the pupil had to play normally with flexed fingers he encountered difficulty due to the fact that the flexed posture decreases muscle tone, or a worsening of the basic condition. The spontaneous solution discovered by the pupil’s instincts was to stretch the fingers while playing. In this way muscle tone was increased and he was able to play in rhythm and with a quality which was comparatively quite good. This shows us how a change of movement and posture can, as a side effect, contribute to change and improvement in learning ability. However, the music therapist’s prime consideration is not to improve the patient’s learning skills, but rather to help change basic disabilities, particularly physical, vocal, and emotional, with the aim of creating a situation for the improvement of learning ability and societal adjustment. With this in mind I devised (in 1982) a program of auditory stimulation for Anat and for other Down syndrome children. For the first three months this occupied the entire therapy hour, but eventually became half of that, leaving more time to deal with any aroused emotional content (Sekeles 1988). During the years 1985-87 I joined forces with movement specialist Einya Cohen, and the emphasis shifted from spontaneous movemental reaction to music, to guided and predetermined actions designed to enrich and expand the movemental repertoire, to reinforce physical awareness and to promote integration between emotion and cognition by means of the unique contribution afforded by the combination of these two art forms. Figure 4 details the program developed for music therapy with Down syndrome children. The Program Musical Element 1. The most direct way to increase muscle tone is by stimulating the vestibular system. The influence of the vestibular system on muscle tone is mediated by way of the lateral and medial vestibular nuclei in the brain stem, through efferent transmissions down the spinal cord. Kampinsky & Ward (1950) found that individuals with insufficient afferent flow, or integration from the vestibular system, must work harder in order to perform certain movements. This is also true with slow hypotonic children. The vestibular system enables the organism to follow a movement, in particular regarding a change toward gravitation. It helps the organism to distinguish between sensory stimulation connected with the external world or in body motion (e.g. do you go around on a roundabout, or does the roundabout go around you?) The vestibular system transmits stimuli to the cerebellum and to the pons, thus causing excitation, or inhibition and relaxation. This depends upon the character of the stimulation: slow rhythmic stimulation while moving the limbs of a passive patient leads to inhibition and relaxation; fast rhythmic stimulation accompanied by fast energetic stimulation leads to excitation (Ayres 1972).

Figure 4. The Therapeutic Approach As opposed to the well-recognized links between the vestibular system and the visual system, it remains unclear whether the auditory system has any similar connection with the vestibular system, apart from the fact that both are located within the inner ear. The linkage is probably indirect. Music of a stimulative nature leads the patient into spontaneous motor reaction in the same way it affects the participants in ecstatic healing rituals—rapid motion, whirling, spinning, leaping, etc. Depending upon the functioning of the vestibular system, changes of head posture influence the sense of balance; hence it is the vestibular system, once activated, which influences muscle tone, and muscle tone in turn increases and changes body posture. Ayres suggests that there appears to be a two-way connection between the auditory and vestibular systems at the brain stem level. She emphasizes, as a result of clinical observation, the links between vestibular stimulation and the hearing process, particularly the

improvement of those vocal skills connected with hearing ability (Ayres 1972, 27). It should, however, be stressed that Ayres’ programs for sensory-motor treatment do not refer to auditory stimuli unless these are relevant to the development of language. At this stage I would propose the use of ecstatic musical styles which have over the millennia served as stimuli for movement and postural change: since their influence is on a subcortical level and demand a simple spontaneous response which can be easily achieved, the patient has no need of a cognitive effort in order to react. The music assists him to maintain a motor continuity; the activity is pleasant, releases negative energies if such exist, and this can be effective in both individual and group therapy. In addition, such activity can easily be transferred to the home or to any educational institution.11 In this context the means at our disposal assume great significance. We can use recordings of traditional ecstatic healing rituals in which drums (occasionally oboes) play a central role. On other occasions we can improvise the music ourselves, and when necessary add instruments which might suit the therapeutic situation and are an integral part of Western culture (piano, cymbals, electric guitar, etc.). Apart from authentic recordings of healing rituals, we might also make use of rock, break dance, and so forth. It should also be pointed out that style is less important than the musical elements involved and the accumulation processes which typify them. This stage of free movement with excitatory musical stimulation will usually last some five to ten minutes. In the case of Anat (and others) all these stages of music-movement activity became shorter after about three months of therapy, thus allowing more time for psychological treatment. Musical Element 2: Flow and control. Movement and arrest is another way of increasing muscle tone and the patient’s body control. Over the years I have been observing both patients and nonpatients from the ages of three to sixty, and have discovered spontaneous reactions which are common to all. Without any verbal guidance each and every patient (depending on his own motor ability and freedom of movement) would respond by moving or stopping according to the following musical elements: repetitive beat units, acceleration or deceleration, excessive changes in volume, the expansion of vocal range, and the continuation or cessation of the music.12 Here it is worthwhile stressing that since it is important for movement to be arrested in a balanced posture (without decreasing muscle tone), it is the role of the therapist to guide the actions by his music. This means before the break there should be no deceleration, diminishment of vocal range or decrescendo—quite the opposite, the music breaks off at a climax. There is an advantage here in that it is the therapist who creates the music, since this enables him to observe the patient or patients and to dictate and balance their movement and posture as required. In Anat’s case, although she responded spontaneously to rhythm, intensity, continuation and cessation, she had difficulty in combating the force of gravity and thus retaining her balance. This condition improved during the course of therapy, particularly after the movement specialist joined the program and made her own contribution. This improvement of swifter reaction to such musical components as tempo and intensity came as a direct result of an increase of muscle tone (as described previously). After about two years of therapy her ability to move and arrest movement was almost identical to that of any normal child with no motor problems, but with no special training in movement. This also found expression in her interactions with her companions, thus aiding the development of societal relationships and overall self-confidence.

Musical Element 3. The employment of the usual activities of physical rehabilitation, such as sitting and bouncing on a Physio-Ball led to increased muscle tone and an improvement of posture. Music therapy’s additional contribution to this process consisted of activation by means of song. The melody and the manner in which it was performed dictated rhythmic movement, while the lyric clarified and reinforced the message. The song itself was composed of movement and arrest and through a play situation suited to the child’s world supported the activities defined above (1. & 2.). It should also be noted that when the aim is to reduce muscle tone, the patient lies prone across the ball and propels it very slowly. In this case the song components and the verbal instructions were obviously variable. Anat reacted to such singing extremely well, and after a few weeks began to control movement and arrest and even to supplement these with complex movemental variations as she exercised on the ball. In other words, there was not only an improvement in muscle tone, in movement, and in posture, but Anat was also gaining self-confidence in order to independently develop more complex patterns of movement. We should now consider the fact that in all stages the child is enabled to be creative and to develop his own movemental repertoire through his own experience and functional improvement. Musical Element 4. Such activity is aimed at improving the fine motor skills by means of both playing music and/or by reacting to it in movement. In both cases the principal factor is the increase and acceleration of all musical components, and their cessation at a climax. At the start it is preferable to make use of a full drum set and to activate global arm movement. This is transferred by degrees to smaller percussion instruments, drums and xylophones for example, and eventually to plucked instruments, such as an autoharp, and thence to keyboard instruments, piano, organ or synthesizer. Such graduated activity allows the hypotonic child to exploit finger flexion (or semi-flexion) for maximum efficiency without resorting to hyperextension in order to increase muscle tone. It is important to bear in mind that, as opposed to other forms of physical exercise, music activity creates an immediate auditory feedback which can be linked to emotional matters aroused during therapy. These are a few examples which reveal Anat’s concerns, “When I’m scared when Dad goes out to work,” or “I got all het-up today on the bus on the way to school.” These were themes she raised on her own initiative while playing on the full drum set in the accumulative manner already described. There would appear to be a natural analogy between accumulative playing toward a climax and the accumulation of anxiety, excitement, anger and so forth. The physical sensation of emotion, experienced through music and movement, is transmitted by the patient (in this case as well as in others) and merges with his own feelings. This is something which opens up the possibility of working on these emotions, and expressing them through music in order to achieve release, moderation, and sublimation. An example of such a link between musical action and emotion is a poem which Anat composed at age 10: The drum gets angry when I am cross The drum is a thunder beating at my ears When you are angry and at a loss It’s best to beat the biggest drums.

Musical Element 5. Down syndrome children generally speak unclearly, in low, hoarse voices and their speech tends to accelerate. This can be partially explained by the hypotonia of the tongue, lips and muscles employed in voice production. By making use of a combination of vocality and movement, or of vocality and instrumental playing, it is possible to treat problems of articulation, rhythmic exactitude, and the control of the duration and acceleration of voice production. Voice production exercises are preceded by guided self-massage of the mouth and lips and other facial features. Later on the enunciation of various syllables is combined with contracting and relaxing the facial muscles in accordance with the therapeutic approach of Paula Garbourg (1982). From here we progress to the elocution of complete words and sentences, accompanied and reinforced by individual movement on the part of the patient and music played by the therapist. It should be noted that although Anat’s diction improved in regard to certain syllables with which she had previous difficulty, not only in speech but also in song, her singing showed no marked improvement as hoarseness and limited vocal range remained unchanged. In general, as with other patients, this is an aspect which does not make satisfactory progress and is worthy of further study and a new approach. Musical Element 6. At this stage of therapy, which links sensory, movemental, and vocal treatment with the emotional aspects, the therapist composes a story with dramatic emphasis, reinforced by playing and singing. The themes of such a story derive from the patient’s own personal world, either directly or by inference. The patient acts out the story by means of movement, voice, instruments, or the use of any other property available in the therapy room. In this way, depending upon personal ability and willingness, he or she confronts all of the above mentioned aspects. Themes raised and elaborated upon by Anat during therapy included such subjects as: “Why do they call me retarded?” “Grandma fell ill and died.” “Mummy bore me a sister,” and so on. As we shall see, such themes were without doubt extremely significant in Anat’s private world, just as they are central to life in general. During the process of adapting such themes, Anat composed a number of little poems, two of which (also written at the age of ten) I would like to quote here: 1. I’m sad today In my neighborhood they called me retarded Mommy said that I shouldn’t be hurt What do you think—that I haven’t any feelings?* 2. I visited Mommy in the hospital Mommy was lying on a white sheet with blue stripes She explained to me that she’s not sick She explained to me that a new baby isn’t a disease. I saw the baby and they told me that it’s my sister What do you mean sister? They didn’t even ask me! I felt angry and my tummy hurt

I don’t want a baby and I don’t want presents I just want to be sad and to cry.** These poems reflect Anat’s ability for self-expression and the manner in which she was capable of confronting and discussing her feelings. This serves as a confirmation of the potential for psychotherapy with children suffering from moderate mental retardation, of the level of verbal expression which can be achieved, and of the value of integrated therapy between body and mind. Conclusion In this chapter I have presented a program of developmental therapy which employs music as an intermediate agent. In this program sensory-movemental exercises and games are aimed at improving the patient’s physical ability to function as well as encouraging her to expand her awareness of her psychological and societal situation. We still lack definitive scientific research concerning the links between physical posture and mental receptivity, or the influences of improved physical stability as an encouragement to learning ability. However, clinical observation in all spheres concerned with developmentalintegrative therapy demonstrate that in practice, there does exist a positive connection between both of these. In this context the acknowledged contribution of music to the various fields of developmental therapy (occupational therapy, physiotherapy, speech therapy, psychotherapy, etc.) emerges from the following aspects: 1. The inherent potential of music to evoke movemental reaction, and the ability to direct such movement by means of specific musical components, mainly tempo, dynamics, tonal range, continuation and cessation. 2. The natural combination of vocality with instruments, and/or movement, which permits both creative and playful treatment of vocal problems. 3. The natural links between music and emotions which enable the patient to make contact with repressed feelings and subjects. 4. The possibilities presented by playing on a variety of instruments for the development of fine motor skills in an enjoyable and satisfying manner. 5. The sensory-motor integration which optimal musical activity facilitates. As an example of a music therapy process, first aimed at the creation of awareness and the overcoming of hypotonia, we took the case of Anat, born with Down syndrome (Trisomy 21), who also suffered from pronounced hypotonia. Despite the fact that she underwent an impressive series of treatments, her hypotonia continued to sabotage her movemental abilities, above and beyond the basic movements demanded by day-to-day existence. According to observation by others, as well as by me, there seemed to be some connection between her physical alertness, concentration and intellectual responsivity. Based on many months of observing Anat as well as other Down syndrome children, I drew up a plan for a therapy session which would include various stages and aspects of motorintegration by means of music.

Over a three-month period the sensory-movemental phase was reduced to about half an hour, thus allowing more time to deal with the emotional matters which Anat would raise. As her skills developed, she was more and more capable of increasing muscle tone and improving her overall Body Alertness in a very short space of time. It is worthwhile mentioning here that despite differences of category, natural potential, and therapeutic and family history, clinical records show a relative degree of progress in all those Down syndrome children who for at least a whole year were subjected to continuous music therapy, as described above. I should like to stress that a combination of movement and music therapy administered by two specialists is to be highly recommended as it enables a higher level of awareness of the body and its repertoire of movement. There can be no doubt that as long as the child continues his development and is capable of a more conscious confrontation with the various aspects of body and mind, he can better confront his own congenital problems. And so, Anat became a member of a local dance group composed of normal boys and girls of her own age. She excels in her spinal posture and head holding. We believe that this contributes to better perception and reception of her surroundings, and at the same time to a lessening of the external impression of her being retarded. References See end of Case Seven

Taken from: Sekeles, C. (1996). Music: Motion and Emotion—The Developmental Integrative Model in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SEVEN Alon—From the Jungle To the King’s Palace: Developmental Integrative Music Therapy with a Child Suffering from MBD and Elective Mutism Chava Sekeles Introduction This case history presents the problems facing the music therapist when confronted with a combination of both psychological and physiological handicaps. For these reasons I have chosen to relate the case of Alon, who was born at term, probably with a minimal neurological defect which was only detected when he first entered primary school. In his early years Alon suffered from various physical complaints and also developed elective mutism. At the outset of music therapy the strategy was that of “holding” with an emphasis on stability and calm. Despite the importance of this for Alon’s emotional condition, it should be stressed that as long as his psychological problems were dealt with in the above mentioned atmosphere no positive changes were accomplished. On the other hand, once the therapeutic approach was modified and the neurophysiological ailments were treated by stimulative music, there began a dramatic change in his psychological state. This example indicates the need, from time to time, for a balance between the use of relaxing and stimulating music during therapy, and demonstrates music’s potential for awakening emotional processes through the physical being, and thus creating a breakthrough to verbal expression and to hitherto repressed content. Alon: Patient Profile Alon, the youngest of six children, had a normal birth. His mother was an art teacher and his father was an office worker. Alon was bottle fed for his first four months and then preferred semiliquid foods up to the age of six. His parents were extremely concerned by his recurrent upper respiratory infections, which hampered his ability to perform essential functions such as breathing, sucking and eating. Perhaps due to this, they paid less attention to the delay in Alon’s motor skills, and to his limited ability for verbal communication which emerged during pre-kindergarten child care. In fact Alon would speak only at home. When he was three and a half years old Alon underwent tonsillectomy and adenoidectomy. While these operations succeeded from a physical point of view, the psychological symptoms of disturbed communication became more severe. As a result Alon was referred to a psychological clinic and was diagnosed as suffering from elective mutism.1

E.E.G. examination revealed no pathology, and due to Alon’s noncooperation it was impossible at this stage to carry out an accurate neurodevelopmental examination. The difficulties encountered in psychotherapy raised the question of alternative approaches, and so his family, together with the consultant psychologist, referred Alon to music therapy, with the indication that music could serve as a preverbal medium capable of circumventing speech.2 Since Alon never spoke outside of the family circle, I decided to conduct the first intake and observation in his own home before starting in the music therapy clinic. In this way I was able to observe his behavior and how he would make contact within an environment in which he would make use of speech, as opposed to the outside world. Before going into details about the psychological aspects of the case and the elective mutism syndrome, I would like to present a brief outline of the dominant features observed during the intake process which describe Alon’s sensory, motor and vocal development. Vocal Development 1. Able to pronounce all syllables and to speak within the family circle, and to a limited extent during music therapy. 2. While speaking, emphasizes the musical characteristics of speech, rather than its verbal meaning. 3. No emotional correspondence between speech content and its musical components. 4. Strong tendency to alliteration. 5. Stops speaking when sensing even a minor threat. 6. Vocal intensity in the music room limited, from pp to p. 7. Tendency to swallow syllables and accelerate toward the end of sentences. 8. Is, however, able to pronounce all syllables. Sensory-Motor Development 1. General hypotonia. 2. Inadequate ability to hop or jump according to chronological age. 3. Cannot skip. 4. Crawling normal, but slow for his age. 5. Left-right drum beating unskilled, often drops the drumsticks. 6. Does not maintain consistent beat-unit; has difficulty in repeating a rhythm pattern. 7. Plays xylophone at random, and has difficulty maintaining visualmotor contact. 8. Inability to cross midline in play. 9. Inadequate pincher grasp and finger separation. 10. Poor graphic skills. 11. General dependence on Activities of Daily Living (A.D.L.). 12. Avoids physical contact. 13. Needs and enjoys vestibular stimulation. 14. Other sensory channels appear normal.

According to this data Alon would seem to be a hypotonic child with immature motor development, as well as apraxia of both gross and fine motor skills. Speech was orderly, but its musical aspects, which in my view are linked with emotion, were impaired. It is quite possible that it was his hypotonia which caused poor dynamics, babbling and acceleration. So far so good regarding Alon’s vocal and sensory-movemental development. In order to fill in the picture we must now consider his psychological development. Elective mutism has been defined as “persistent refusal to talk in one or more major social situations, including school, despite ability to comprehend spoken language and to speak” (DSM-III-R 1987, 88). Differential diagnosis includes speech defects emanating from mental retardation, autism, hearing problems, depression, etc. Elective mutist children, however, can talk and understand even though there can occasionally occur a delay in the development of speech and difficulties of articulation, particularly after emigration and a conflict of languages. The mutism is accompanied by additional symptoms: social isolation, physical repulsion, negativism, compulsive traits, passive aggression, fear of change and dependence on key figures, shyness, temper tantrums, school refusal, etc. (ibid.). This begins after the acquisition of speech, but is often only fully revealed within an educational framework. It can last for a few weeks, occasionally even for a few years. The average is about one percent of those referred to psychological treatment, slightly more girls than boys. Families are often typified by overprotectiveness and by a prolongation of the child’s infancy. Psychiatric literature describes the causes of elective mutism as being liable to emerge from early oral trauma, early hospitalization, as well as already mentioned, bilingual conflicts resulting from emigration (Harold et al. 1981, 904). The negative trends and the mutism are generally directed at the parents, even though the silence is expressed away from home. More than once this dynamic of nonspeech has been observed between parents themselves (Browne et al. 1963). Regarding Alon, his own mutism, as observed in educational and therapeutic setting, was expressed in a total lack of verbal communication outside the family circle, as well as in a syndrome of isolation, physical repulsion and shyness, in compulsive behavior and in passive aggression. Therapeutic Analysis and Consideration Alon suffered from a wide variety of developmental problems: 1. Neurological defects which included hypotonia and apraxia whose treatment had been postponed due to the greater urgency of other medical disorders. Rejection of touch could have been either the result of neurological immaturity, or an emotional side effect of surgery. The desire for vestibular stimulation might indicate movemental deprivation, but perhaps also a lack of initial experience at an early age. In other words Alon showed an attempt to improve his low muscle tone, which had been hampering development. As already mentioned, motor deprivation may harm body scheme development and thus undermine the child’s overall sense of confidence. Functions such as following the mother

while crawling on the floor and comprehending “object permanency” may be impaired. This is also the case at a later stage, when connecting with and playing with other children. And indeed during Alon’s treatment the assumptions based on observation were in fact verified: it emerged that his neurological damage, worsened by his physical condition, had served as a significant factor in his emotional development. 2. Medical problems at an early age, such as the upper respiratory infections, in an area considered to be from a developmental point of view essential to the infant’s oral gratification. Melany Klein (1955 in Mitchell 1986) stresses that oral frustration may well increase sadistic oral impulses aimed at the mother. In other words, along with the internalization of pleasurable substances, the infant also internalizes pain and dissatisfaction and so links these with the source of nourishment. At an early stage breast or bottle, which serve as part-objects, are conceived by the infant as total and a total part of itself. This connection is reinforced by the mother who regards food as representing herself. Normal feeding symbolizes acceptance of motherhood, but food refusal signifies rejection. The more the infant develops negative experiences the greater its sadistic fantasies, and hence guilt feelings and anxieties. One of the most primitive infantile defense mechanisms is “splitting,” the ego divides between “good” and “bad,” thus enabling it to destroy the “bad” object. “Splitting, provided it is not excessive and does not lead to rigidity, is an extremely important mechanism of defense which not only lays the foundation for later and less primitive mechanisms, like repression, but continues to function in a modified form throughout life” (Klein in Segal 1974, 36). Indeed during Alon’s treatment “splitting” emerged as a central theme. Anna Freud emphasizes the links between normal functioning of the oral area and normal psychological development. According to her, while eating in itself is a biological function (a response to the visceroceptive stimulus of hunger and of salivating), eating problems, even though organic in origin, can serve as the basis for development of neurotic anxieties. When the mother has to feed her infant against his will he is liable to develop feelings of hostility and frustration toward her; similarly the gradual variations of diet define his future preferences and rejections. “Organic feeding disorders become the basis for the nonorganic types. Neurotic disturbances arise more easily where loss of pleasure in the function of eating has prepared the ground for them” (A. Freud 1946, 131). As we shall see, this was proven during therapy when there began to emerge elements of oral-sadism. Indeed, it seemed to me that the combination of basic neurological immaturity, and frequent illnesses in U.R.T. during infancy had affected Alon’s oral area which serves as the focus of contact and pleasure in the first stages of life. This problem became more crucial as the result of surgery on already sensitive and painful organs. According to Erikson (1950), normal development of the oral area is central to the creation of basic trust and primary objectrelation.3 Roberston and Bowlby (1952) and Bowl by (1960), researched the effects of hospitalization on children under the age of four. Observation revealed that even those who were hospitalized for short periods underwent the following stages: protest (due to anxiety at being separated from the parent), despair, and then denial (these latter two serving as defense mechanisms). It appears that even after the 1950s, when parents were permitted to remain in hospital at the child’s bedside, the same stages could be observed. The very experience of being cut off from home, and the traumas of hospitalization, surgery and treatment, sufficed to

create such reactions. Jessner and Kaplan (1949) stress that mouth and throat operations, despite the fact that these generally demand only brief hospitalization, are liable to be very psychologically injurious. It can be assumed that Alon, who in any case underwent a difficult period of oral development, became fixated at the protest stage and expressed this by elective mutism and isolation. Roth et al. (1967), suggests that the more complex the child’s progress from one developmental stage to the next, the greater the imprints of the preceding stage. On the assumption that his mutism was a symptom of deep anxiety and that stressing it might be of no help, I told Alon that “in the music room it’s forbidden to talk, here we just play, and converse, through music.” In this paradoxical approach I saw a chance of diminishing his mutism by means of extremely exaggerating it. It seemed that at this stage Alon should be accepted as is, and that the role of the therapist was to create a supportive atmosphere for expression. Similarly he should be given, in a symbolic manner, the chance to experience a sense of holding, with the therapist assuming the role of “the good enough mother,” a term coined by Winnicott (1971).4 My assumption was that it would be best to deal first and foremost with Alon’s passive aggression and to let it find expression in an atmosphere of trust, both through diverting aggressive emotions to the primary agent (music) and then by transmitting those same emotions to the secondary agent (therapist). Similarly, due to both physical and psychological considerations, it would be preferable to deal with oral and respiratory problems by means of wind instruments, flutes, trumpets, whistles, etc., thus circumventing the need for speech.5 His posture problem seemed to be less urgent, his psychological condition seemed to demand more immediate attention. In retrospect this might have been an error of judgment since effective therapy should include body-mind integration from the outset. Nevertheless, during the first fourteen months of therapy Alon made slow but steady progress; he was gaining confidence and basic trust. At home he would talk as usual, but in the music room extremely briefly (something he started doing the moment that “paradoxical rule” was proposed). He still had no verbal contact with children or adults within any other framework. During music therapy sessions his voice remained introverted and subdued; despite any encouragement he remained incapable of shouting, or of expressing anger. It was as if he had a hidden lump in his throat. All this time he was being treated by modal and tonal music with a permanent continuity, rhythmic repetition, mid-range pitch, simple melodies and traditional harmony. Most themes were adopted from his own fragmentary efforts, and were repeated as they were, or when necessary arranged by the therapist: sometimes by playing, as an unaccompanied song, or in a combination of both. This kind of music, which developed during observation, gave him room for creativity without being pressured, and freedom to game-play without educational and other demands. In other words, the musical organization described below actually served as a clearly supportive framework within which he was able to act freely. This supportive framework was created within the therapeutic space: vacant in its centre, but with instruments readily available next to, and hanging on, the walls.

In this way Alon could choose movement, instrumental playing, or listening, according to his needs. The role of the therapist was to reassure the self-confidence derived from the music and the space in which it took place, and at the same time to encourage significant expression with no anxieties. This was done both by music and words. Despite the fact that Alon’s self-confidence increased, it should be emphasized that his posture remained slack and defeatist and he had difficulties in expressing his emotions. Since music therapy cannot be defined as one of the exact sciences, it was hard to predict whether another form of music, ecstatic for example, would automatically provoke a different response. It is possible that these fourteen months were essential for the establishment of basic trust. Whatever the case, at the end of this period there occurred a number of changes both at home and within the educational framework which led to a severe regression in Alon’s condition. There were a change in kindergarten teachers and the loss of a father figure for a number of months. It appeared that anxiety in the face of loss influenced him to such an extent that his mutism became total even at home, his movements came to resemble the stereotype of an autistic child, and he would mouth into the microphone sighs, gurgles and the sound of vomiting. I interpreted these as a sign of despair and almost passive protest, which demanded a reassessment of the therapeutic approach.* The Jungle The sudden worsening of Alon’s condition seemed to indicate that supportiveness, constancy, musical and verbal mirroring, even relaxing conditions, were still not enough to enable him to stand against the anxiety-ridden changes with which he was confronted at this stage. In kindergarten he began to undergo developmental-occupational therapy, but the results were not evident, either at home or in the music room. Quite the opposite, it seemed as if muscular hypotonia and “mental hypotonia” were being more and more closely linked. Despite grave doubts about a drastic change in the manner of therapy, I nevertheless decided on such a step, knowing that certain boundaries would still be retained: the therapeutic space, the therapist, the content, and the familiar musical instruments. This new approach was aimed at creating something similar to the dynamics of ecstatic healing rituals in which movemental, sometimes vocal, and other expressive elements are taken to the extreme. In these the shaman drums and dances, serves as a model for the patient and thus legitimizes freedom of movement, and dramatic role playing. As a consequence, at our next session Alon was confronted with some ten minutes of music: drums recorded at a voodoo ceremony in Haiti. I had also set up in the music room something resembling a tent and explained to Alon that this was the “lair of the beast.” There were several considerations involved: 1. There was a chance that such music might stimulate the child into spontaneous movement leading to increased muscle tone, swifter movement and hence to an outlet for aggressive energy. 2. Within Alon’s magical thinking, animals might be employed as metaphorical sources for strength and brutality.

3. The tent might represent a limited intermediate area6 as a place of refuge. On the other hand, the more expansive intermediate area (the room itself) could be the space into which he would emerge, expand, and try out new experiences. At this stage of assessment and interpretation there was no guarantee that Alon would in fact react to such musical stimulation, to the offer of the “lair,” or indeed to the vocalmovemental example he was due to get from the therapist. In retrospect it can be said that the new (ecstatic) music and the borrowed metaphor of the beast’s lair had a dramatic impact on Alon from the very first moment. He began to run around the room as if in a trance, leaping, somersaulting, roaring, hurling cushions, beating on drums and cymbals—all this, it should be noted, according to the tempo and intensity dictated by the recording with no need for intervention or modeling on the part of the therapist. Once this was all over, he crept into the lair and started speaking through the tent wall, acting out the role of a vicious man-eating tiger. At this stage I supported his aggressiveness with drum beats and verbal mirroring.* By role playing within the beast’s lair, Alon split the world into “goodies” and “baddies.” He placed himself among the “baddies” while counting me (and the piano) among the “goodies.” His role was to devour; my role was that of the victim. In a similar manner he divided up the musical instruments: drums, cymbals and the flute were bad, while guitar, piano and fiddle were good. This revealed the stage of fixation in which he was at present situated and the need to deal with splitting. An example of the content he expressed verbally from within the tent: The snake will bite you, strike you—like all the other beasts you’ll be caught. Your face will be devoured, your tent collapse—the stinking drum be banished. They’ll hate it, be angry and tear the jungle apart. You’ll be dead, they’ll give you a dangerous drink—poison. Retarded beasts will beat the mother of this sweet child—will strike the sweet sun and the blue heavens,…. The above is only a small example of what Alon came out with during that same session, but it serves to show just how much built-up fury he had inside, and how much energy had been required to repress it. It was the stimulus of ecstatic music and its consequent physical freedom which led to his ability to express his aggressions through music-play, and hence communicate them to his therapist. My task at this stage was to contain, support through music and words, and give the child the feeling that his aggression was not necessarily destructive of the object.7 About halfway through this therapy session Alon emerged from his lair and continued to speak in a kind of incantation,8 accompanying himself on a drum with an accurate rhythm composed of repetitive structures:

It should be noted that after such intense movemental activity Alon’s muscle tone undoubtedly increased, something which found expression in his stable rhythm on the drums. Whereas previously he would often lose hold of the drum sticks he now played with great strength and confidence. There was a certain paradox between his drumming and his

incantation. I saw his drumming as the expression of his aggression, and his quiet intoning as that of his introversion and anxiety. Gradually the drumming, which by its nature is a physical activity, led to an increase of vocal dynamic and a closing of the gap between physical and verbal expression. In his book Human Aggression, Anthony Storr (1968) emphasizes that aggression is not a reflex which vanishes when the stimulation which triggers it ceases, but rather a complex of physiological reactions which remain long after the original stimulus has been removed. Storr stresses the importance of finding a physical outlet for aggression which can enable the physiological symptoms to be gradually moderated. During aggressive reaction, the adrenaline secretion into the bloodstream increases, thus creating a condition similar to the activity of the sympathetic system.9 This can explain why Alon’s frenzied musical activity (drums, movement and voice) was effective on two levels: the organization of movement and posture, and the release and hence moderation of aggressive energies. In his case the kind of calm, melodic music employed during the first months of therapy would have been of no avail. Nevertheless it should be noted that D.I.M.T. does not limit treatment to the cathartic level of ecstatic healing ritual, but goes on to verbal elaboration and development by various techniques used in psychotherapy. It appeared that the tempestuous music employed touched upon a sensitive spot in Alon’s inner life which needed to be exposed and had not been reached by the verbal mirroring and nonmusical games activities usually practiced in child therapy. The music served to unlock a gate behind which lay a dense jungle. Following the dramatic outburst of speech described above, the therapeutic space became Alon’s jungle (as he saw it) in which he was free to act out the wild beast and transmit to the therapist his aggressive feelings to his full satisfaction. Only later was it possible to develop them verbally. Clear awareness of a make believe situation enabled him to be aggressive with no risk of guilt feelings. At this stage, whenever I tried to start a session without an ecstatic musical opening, Alon would have difficulty entering into the role and would revert to his previous introverted dynamic. The music served not only as an opening, but also as a support for aggressive content when expressed in words, and as a summation and closing of the session. Gradually, over a period of about sixteen months, the gap began to close between the introverted, mute and hypotonic child, and the impulsive, screeching wild animal.* During the jungle stage the therapy session took on a kind of loosely built sonata format whose parts varied in duration and content according to the patient’s needs and the therapeutic aims. As his skills increased, less time could be devoted to the technical stages of the opening and closing, and more to tackling psychological problems.** Structure of the Therapeutic Session

During the jungle period it was impossible to ignore obvious oral elements, in particular fantasies of oral sadism: “I am an animal which eats you up; I bite, I poison, I swallow; I’ll eat you, and Mom, and Dad.” There was also a clear splitting between good and bad figures; and at the same time between music and between instruments. Such observation on the part of the therapist, relying on the psychodynamic definitions of psychosexual development as well as on the Kleinian concept of splitting were of great help in clarifying therapeutic goals and their realization. In addition to the use of musical means and equipment, the lair, puppets and other properties to be found in the therapy room, Alon would also ask to hear recorded music, in particular such as would express evil. Out of a wide selection of works which were at his disposal and which he could try out on the tape recorder, at this stage he showed an overwhelming preference for two in particular: John Cage’s Solo No. 1, and parts of Luciano Berio’s Sinfonía, both of which employ unconventional vocality. Alon’s choice, it seemed, was directly connected with his own psychological syndrome, and the free style of these works gave him the legitimacy he sought in order to make use of his own voice in a variety of ways within a wide dynamic. The end of this stage of therapy was reached when he began to express his aggressions not as a tiger or other wild animal but as Alon himself. Likewise he began to realize that good and bad can coexist, and that it was permissible to speak about fearful fantasies and even direct them toward his parents or other family members without being hurt and without destroying or losing them. The Recording Studio After some sixteen months during which the therapeutic space was the jungle, Alon now transformed it into “the recording studio.” This was made possible by his emerging strengths which enabled him to more closely approach the realities of the music room, and with the lessening of his need for aggressive expression. Alon now turned himself into a singer/musician and cast me in the role of recording engineer and/or musician when necessary. The structure of the therapy session remained similar but the opening and closing were reduced to a few minutes. The jungle had clearly turned into the studio when Alon started a session by chanting the following composition: This studio is new and strong—a very beautiful studio—the other studio was a little bit very old. We’d come into the studio, and what a stink it had! Until we started the music, skunks

kept coming in through the door. Then we strengthened that studio. We lit lights when it was dark. We had to light two spotlights on the drums. Leaving is forbidden—we even locked the door. Leaving is forbidden: out there are the skunks who fart everything up—and after the skunks will come a bear and a monkey. Q: Do you feel safe in this studio? A: It’s all O.K. We have to be in a studio. This is our home.* This was his way of metaphorically describing the process he had undergone in building up a sense of trust in the therapy room (it used to be old and stank, now it is new, strong and handsome) and in music (the brightly lit drums which later banished the skunks with their music). By speaking in the first person plural (“We’d come in—we started to play—we lit lights,” etc.) he was acknowledging a joint effort and his faith in the therapist. On the other hand he still demonstrated anxiety about the outside world (skunks, bears, monkeys, figures from the previous jungle period), hence the locking of the door and “leaving forbidden.” The studio was “our home,” a haven in which he could act out his fantasies without any risk. There was no doubt that the jungle images were a projection, or aggressive and dangerous representation, of inner content. I was still uncertain about Alon’s ability at this stage to organize himself within the confines of the studio, and to gather enough strength to be able to function in a wider perspective than that of the existing therapeutic space. This studio period lasted for some three months, during which Alon played the singer, accompanied himself on a variety of instruments of his own choosing, and emphasized the pure musical result no less than the emotional content.10 Whereas during the previous stage he had preferred works by Cage and Berio, he now chose, from time to time, a wide range of pieces including Paul Winter’s Callings, short excerpts from Mozart, classical jazz, songs by Israeli folk composer Sascha Argov, local children’s songs, Jewish liturgy (mainly in the Sephardic style), and more. It seemed as if this expansion of choice served as the symbol for a similar expansion of his own potential for emotions and experiences. This was most evident in the variations within the dynamic and content of his verbal expression. During this period Alon would speak quite freely within the music room, but not at the kindergarten. Nevertheless it was decided, on the basis of music therapy recordings which revealed his verbal and mental abilities, as well as on the opinion of a psychologist, to transfer him to a special class in a regular school.11 At the outset of the school term he still did not employ speech as a means of communication, but this situation gradually improved, as did his overall organizational abilities. As already noted, in music therapy Alon had begun to lay stress more and more on aesthetics, on rhythmic and melodic organization, and had begun to be extremely free in expressing his emotions both in music and in words. The stimulative stage was now a mere two to three minutes of jumping on a trampoline with break dance music. Music drama was often within a framework of his own devising which recalled the Balinese gamelan ensemble. Alon would seat himself in the middle, surrounded by various percussion instruments, and would sing and accompany himself on whatever he fancied. Shifting from instrument to instrument and the need for coordination developed his

movement skills and enabled him to achieve rich and variegated expression. Indeed the balance between tension and relaxation, retention and release, planning and improvisation (typical elements of musical creativity) were at their most evident during this studio period. In general, this was a period typified by organization and control, by the ability to repel or delay sudden impulse, by greater freedom of expression of sensations and emotions, by an accumulation of knowledge and experience, by the ability to express dissatisfaction, and by the forming of selfwill. All these are characteristics of normal development during the psychosexual anal stage, and indeed this was a consideration which helped in determining therapeutic strategy. Despite a certain similarity between the tent or lair and the gamelan circle, moving in and out of the circle displayed flexibility and ease. The lair was for hiding, whereas the circle was a symbol of the entire therapeutic space. Both Alon’s movements and posture revealed a greater openness to his surroundings, as opposed to the curling-up introversion or the extravagant reactions to ecstatic music which typified the jungle period. Such openness could be discerned by a balance between contraction and extension: in other words stability opposing the force of gravity, and by inference, confidence in confronting the outside world. After about three months there were new subjects for discussion. Alon would raise them partially in his role as singer/musician, partially in verbal conversation: Disasters: “The old lady upstairs died and they took her away to hospital in an ambulance.” Existential threats: “The skunks came back and got into the studio and the animals won’t let the singer appear,” etc. Despite the fact that such content tended to renew his anxieties, Alon was by now able to face them without resource to his previous aggression and also without regression. He now had new and more varied strategies: relaxing by means of calming music, or performing a kind of musical dialogue in which he would play a variety of roles. Skunks: “Mister singer, we’ve come to spoil your song.” Singer: “You’re nothing more than a load of stinking skunks and I can scare you off. Scram! I’ve got drums and xylophones which can finish you off just like that!” During one session he was seeking ways to resuscitate a woman who had died. He chose a doll which symbolized her and tried to revive her by breathing through a flute resting on her bosom. Convinced that this would not work he said, “Impossible. The dead are dead and it’s all nonsense. She’s got to be buried.” And he did so—he discovered a “grave” beneath the mattress, laid the doll to rest and covered her with a blanket and then said, “That’s it. We’re finished for today. We’ve got to tidy up the room.”* Here we can see how Alon employed rational thought when magical thoughts and deeds could not help him solve problems. I assumed that such subjects were linked with past disasters and could now be ventilated and elaborated. This marked the end of the studio stage. Alon was now ready for further development. The Royal Palace

Gradually the recording studio became transformed into the “royal palace,” a “wizard’s tower” or a “knight’s fortress.” The fantasies were concentrated around a royal family generally composed of king, queen and prince. At the outset of this stage Alon would arrange festivities, pageants and concerts within the palace. He would alternate as master of ceremonies, musician, actor, king and prince. I was cast as either queen or musician. After about three months there began to emerge themes of sexual fantasy, envy and aggression. On one occasion the fantasy of the prince’s marriage seemed to arouse great anxiety in Alon and he began to curse himself harshly with a soft percussion accompaniment. Since this episode seemed to signify some kind of exorcism, I should like to describe it in detail. Alon arrived for therapy, and after a brief opening initiated a royal wedding for the prince which soon turned into the wedding of “The evil king and queen. He doesn’t care if the Jews will die, won’t be able to move, will be weak, will be sick, drink poison, won’t go to the doctor, will die and won’t be able to move.” At this point, having linked his fantasies of the royal family to his own, Alon paused for a moment and continued to direct his curses at himself, employing a soft drumming accompaniment with a constant relaxing rhythm: “You’re a dumbo, you’re a son-of-a-bitch. You’re stupid. You’re an ‘Ostimuck.’ You’re nothing. You should be hit. Weak, don’t exercise. Don’t go to the doctor. Drop dead! You’ll never move.” Then he suddenly stopped, looked at me and yelled, “And don’t you dare sing that stupid song. You hear? I can’t stand this song. It’s stuck to me. Yeah! Get rid of this song!” I tried, by mirroring, to demonstrate that by singing it he had brought this song out, but he insisted that only music could banish it. And so I sang him a “Song of Exorcism” in which the piano accompaniment used chromatics to stress dramatic elements with a low range and a tense harmony. At the same time voice and words were repetitive with a calm and objective dynamic. Alon eventually relaxed, and requested a short repeat just in case some of the curses had remained within him. I added a few incantatory phrases using a few of his own words here and there as if it were a magic formula: The song has gone, has gone from you The song has gone - and vanished The song was gone when you sang it And now it pesters you less. Alon seemed to be satisfied, and said, “Enough, enough. Let’s do one more song and then finish.”* The Song of Exorcism It would seem that during his entire therapy Alon had placed his trust in music as a means of relaxation, or self-defense, or a means of clarifying difficult situations. Even when he would shut himself off in the beast’s lair he would sing and play, and even permit me to invade

his privacy by means of singing or playing. Similarly, on occasions he would block the entrance to his lair with musical instruments but would still make use of singing and playing to transmit emotional messages. Some of these came across loud and clear even without the use of words. However, when he felt sufficiently confident he would add meaningful words to his instrumental playing. It should be mentioned here that above and beyond the significance that the music therapist attaches to the choice of instrument, most patients regard the instrument as capable of sounding threats while not being threatening in themselves, as opposed to verbalvocality whose content is considered to be comparatively unequivocal. During the first stage of therapy (before his regression) Alon had become acquainted with various musical instruments and had experienced the modeling of various ways of self expression through music and song, with the aid of careful and limited interpretation on the part of the therapist. With his jungle outburst of speech he had begun to bestow emotional qualities on certain instruments, to express this verbally and to utilize his playing as a metaphor and an externalization of his emotions. During the organizational studio stage he played for its own sake, emphasizing control, aesthetics and harmony, and paying attention to the end product. During the king’s palace stage, whose content was without doubt of an oedipal character, his use of instruments became more sophisticated. For example while accusing himself he accompanied his harsh words with a gentle rhythm on drums and rattles, thus creating an ambivalence which enabled him to express his feelings without risk. However, once the curses became too strong for him, he applied to me for musical support. In that instance I supported him by singing a soft repetitive incantation of key words while at the same time describing on the piano the tensions and anxieties they portrayed. This is significant because in fact this was the first time that Alon had directly appealed to me for assistance: not for the tiger, not for the singer but for him, himself. He was not satisfied with the words offered in response: the devil within which expressed itself in song had to be exorcised by the same means, by song. Only after administering such first-aid could Alon be prepared to verbally describe what had happened. This was a process in which music’s preverbal role was dominant, and in which one could convey without words the musical message: “It seems that you fear the feelings which the curses arouse,” as well as by incantation and repetition to ease the anxiety. The cursing occurred only twice, one week after another, and then Alon seemed to regain a certain emotional stability, and some five months before the conclusion of music therapy he began to talk at school and to become involved in social activity to a remarkable degree. During his last five months of music therapy he continued to raise oedipal themes, particularly in variations on the tale he had created. There was a king, a queen and a prince. They lived in a palace. At night cruel knights kidnapped the prince and turned him into a weak dumbo-boy. Then they regretted it and brought him back to his bed. Instead they killed the king, his father. The queen and the prince disappeared to another place, to another country. All of these variations were based on the same motif which he had improvised (possibly from part of a well-known Israeli song he had once heard):

In the development of this story there was a systematic plot line which symbolically described Alon’s growth and development. At the outset he improvised a song with no instrumental accompaniment. Next he chose certain instruments and accompanied his own singing with a dynamic identity between voice and instrument. Later he requested piano accompaniment which he received in carefully moderated doses. At the sixth session Alon sang his story with a slight alteration of content: When the king, queen and prince heard the knights storming the palace, they fought them. The prince was his father’s staunchest supporter and the king said to him, “You are brave and strong.” And in the end everyone celebrated, and the prince married Snow White, and the king married the queen, and this, this was the end. Musically, Alon’s singing here is clear and rich in dynamic expression. The piano accompaniment is mainly contrapuntal, both musically and emotionally. Voice and instrument interact smoothly. The keen listener will be able to distinguish that here the music therapist is not simply following the patient, but that there exists a blend between two partners.* From a psychological point of view Alon had found a reasonable solution by identifying with a father figure, reconciliation with reality, and a building of self-confidence. The following table can serve to analyze and compare the various stages of the therapeutic process:

Conclusion I deliberately selected Alon’s case as a suitable summary of this presentation of the Developmental-Integrative Model in Music Therapy. His case demanded a holistic approach which could perceive both neurological and psychological problems at one and the same time. Music played a variable role according to the demands and stages of therapy in progress, on the assumption that both physical and psychological needs can respond to music’s intrinsic qualities and its stimulating and relaxing features: Alon was initially treated with protective, relaxing music without taking into account his need for excitation and stimulation. (Maybe this is why the first stage of his therapy took so long). The change of therapeutic strategy led to significant, even dramatic changes in all behavioral levels, and to a balance between tension and relaxation, stimulation and soothing. Flow and control, movement and arrest, these are the basics both of the art of music and the development of the human infant. Deliberate use of basic musical elements and of music as a part of more complex artistic forms allows us to channel that same flow and control in order to re-create preliminary states of relaxation, excitation and alertness. Furthermore, as a result of clinical practice we know that sounds which serve to moderate physical and mental blocking are also capable of penetrating intellectual control, thus enabling the patient’s threatening contents and fantasies to be brought to the surface (Sekeles 1989).

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CASE EIGHT From Violent Rap to Lovely Blues: The Transformation of Aggressive Behavior through Vocal Music Therapy Sylka Uhlig Introduction The voice as a primary therapeutic instrument will be addressed in this chapter. Through vocal expression, chaos can be transformed into order--crying into singing, aggressive shouting into the structure of a rap song. This transformation of emotions demonstrates the ability to change behavior and to stimulate neurological development (Uhlig, 2006; Cramer, 1998). This remarkable learning capacity will be evidenced by children with special needs in a public school setting in New York City. Children ‘at-risk’ demonstrate honesty in expressing their most personal desires and fears through vocal music therapy. Through this process, they discover their pure musicality. Cursing, shouting, singing, rapping, chanting, and songwriting help them to survive their personal and familiar environments and increase their learning potential. Foundational Concepts The idea of transforming emotions through music is rooted in the origins of spontaneous vocalizations in a speech-like (recitative) style (Uhlig, 2006; Clayton & Sager, 2005; Karolyi, 1998). Since the voice is our first instrument, we always use it as a primary form of expression: sighing, babbling, laughing, crying, shouting, screaming, and groaning. More sophisticated forms of vocalization include humming, calling, talking, and singing (Uhlig, 2006). I interpret these primary forms as ancient forms of rap because they include a recitative structure and melodic phrasing (see appendix A for an introduction to rap). This primary form of vocal expression has been used for centuries to help transform emotions (Clayton, et al., 2005; Austin, 2009; Uhlig, 2006; Bossinger, 2005; Karolyi, 1998; Cramer, 1998). We cope with myriad issues through vocalization: working through sadness and pain, grief and loss, hard labor, along with happiness and pleasure. In the recitative songs of the slaves, for example, working men were able to express their frustrations with extremely hard labor, and directly transform these emotions into a spontaneous vocalization by putting shouts or strident words into a regular rhythm (Uhlig, 2006). In so doing, the Negro song was created. These simple, rhythmical songs helped to structure emotions in order to ease their hours, days, and years of hard labor and oppression (Allen, Ware & Garrison, 1867). The same transformational process is common for other emotions. By putting words of grief in a rhythm, weeping rituals were created by women all over the world to mourn death

(Holst-Warhaft, 1992). By putting words of happiness and pleasure in a rhythm, like those used in sporting competitions, songs of encouragement and strength are spontaneously created (Uhlig, 2006). The lullaby is another example of placing vocal sounds in a simple rhythm: softly singing soothing sounds and words that are calming to a child (Austin, 2009; Aldridge, 2008; Bossinger, 2005; Cramer, 1998). These are all natural, culturally derived forms of human vocalization used as authentic tools for coping, healing and well-being (Austin, 2009; Uhlig, 2006). Clayton, et. al. (2005) described these various vocal utterances as attempts for rhythmic coordination and entrainment, a natural search for homeostasis. Throughout the world people have created these forms without musical training or instruction (Clayton, et. al., 2005; Uhlig, 2006). But the effect can be even stronger and more directed through musical instruction and repetition within the context of a helping relationship. In the section that follows, I link behavioral adaptation and academic learning with deeper neurological processes. My premise is that singing activates deeper brain structures, and in so doing, stimulates neurological development, healing emotional trauma and activating the child’s learning potential. Behavioral Adaptation Research has shown that music therapy has the potential to transform aggressive behavior, resulting in a form of aggression regulation (Hakvoort, 2008; Turry & Marcus, 2004). For example. Choi, Lee and Lee (2008) demonstrated the effects of a group music intervention on aggression regulation and improved self-esteem in children with highly aggressive behavior. Similarly, Fouche and Torrance (2005) described how rap and hip-hop music brought local gangs and group members together, enabling them to address aggressiveness and social differences within the gangs. Academic Achievement A growing body of literature suggests that music leaning promotes skill development in other areas. For example, Rauscher (2003) found that ‘at risk’ children who received two years of individual keyboard instruction scored higher on a standardized arithmetic test than children in control groups. Similarly, Douglas and Willatts (1994) found that eight to 11 year-old children with reading problems who received music instruction showed a significant improvement in overall reading performance when compared to children who did not receive instruction. Speech and Language Development Music experiences that focus on singing, including aural skills development, appear to remediate deficits in both reading and language development. Overy (2003) examined the connection between dyslexia and music perception, demonstrating how dyslectic children experience difficulties with musical timing, but not with musical pitch. Through careful intervention, she showed how focusing music instruction on pitch and tonal skills improved both phonological and spelling skills. Overy (2003) hypothesized that “singing might lead

directly to phonologic development, while learning to read music might help with learning to read text” (p. 503). Further, Kennedy and Scott (2005) examined the effect of music therapy interventions on the development of English as a second language for children of Hispanic ethnicity (ages 1012). They developed an intervention that included storytelling, singing, chanting, playing instruments and engaging in musical games (like fill-in songs--providing answers in rhythm to therapist-chanted questions). Through listening to and singing songs while viewing the lyrics on a white board, children improved their speaking and writing skills after each month of intervention. Importantly, even after the intervention finished, children were able to continue using the vocal techniques in order to maintain and improve their language skills, particularly fluency, diction and rate of speech. Finally, the emotional potential natural to the singing experience also seems important for the development of language. Singing can transform aggression into a personal experience of being heard, understood, and accepted (Uhlig, 2006; Bossinger, 2005; Turry & Marcus, 2004). Singing can extend communication from inside into the world outside. Being heard and understood in the world outside improves self-identity and self esteem (Uhlig, 2006). Thus, for children who live in stressful environments, transforming difficult feelings into music underlies the learning process. Feelings need to be released, and in so doing they are transformed into healthy expression. Neurological Development Underlying the child’s ability to learn music, and the implications this has for learning in other areas, is the specific effect this learning has on neurological processes. Schellenberg (2004) found that children with music instruction in keyboard and voice groups showed significant improvement in general intelligence compared to children in control groups who received drama or no lessons. In particular, singing activates sophisticated neurological processing within the brain (Cramer, 1998), bringing about the potential to heal trauma, change behavior and stimulate brain development at a neurological level (Schneck & Berger, 2006). This potential is particularly significant for children who are “at risk” because it suggests that musical experiences, and singing in particular, facilitate both primary emotional expression and behavioral adaptation necessary for learning and development. Rohmert (1994, cited in Cramer, 1998) suggested that through singing, specific neurological areas are stimulated by vocal vibrations, spreading impulses to the cerebral cortex and transporting vital energy in the form of stimuli. These stimuli arouse the capacity for concentration, balance in the body, and sensorial movement. Vocal activity stimulates concentration and cognition through articulating and memorizing words, and coordinates speech and movement through simultaneously singing, playing and dancing (Cramer, 1998; Schneck & Berger, 2006; Uhlig, 2006) . When vocalizing, the relaxing elements of this vibration, and the rhythmical pattern of breath control, carry the potential to decrease anxiety and develop entrainment (Clayton, et. al., 2005; Schneck & Berger, 2006; Uhlig, 2006; Loewy, 2004). Rhythmic engagement used in vocalizations--like rap--structures emotional expression and appears to decrease tension, worry and nervousness through a repeated and relaxed pattern. If the relaxation effect is felt by the rapper, this person is carried to a different level of

perception, wherein the violent mood (as I will describe later in this chapter) is changed into a pleasurable state of fulfillment and developed entrainment. This transformation of affect, observed in the music-making process, can be understood as a “fight-or-flight” response (Schneck & Berger, 2006). When children live in destructive situations, like those at the school I worked in, they learn to protect themselves at an early age. This protection strategy often manifests itself in aggressive behavior, or “acting out.” If the frightening home situation continues, then this fight or flight response is reinforced. These children act as if they need to fight (violence) or flee (escape) the unsafe environment. Neglected and deprived of comfort, attention and understanding, they overcompensate against this enormous anxiety, and unhealthy behavior ensues. Schneck and Berger (2006) explain that during these moments of high anxiety or fear, the homeostatic control mechanisms of the body are activated, and stress hormones are produced when homeostasis cannot be maintained. The central nervous system receives these alarm signals and perceives the stressor as a threat to its survival, shifting to an emergency mode. These stressors can influence the child’s physiology enormously: heart rate, blood flow, respiration, pupil dilation, blood sugar level, etc. can all be effected in response to the stressor (Schneck & Berger, 2006). Such stress responses are quite normal, and when activated, the child (or adult) responds to the environment in order to reduce their stress. However, if the stressor continues, or the child is unable to cope with or diminish the stress, his/her body can become flooded with excess hormones, leading to unhealthy or even pathological behavior. Importantly, cognitive function can also become seriously affected, further impeding the child’s ability to adapt and respond to the stressor. Over time, exposure to such stressors may lead to a generalized impairment in cognitive functioning, which has significant implications for learning (Schneck & Berger, 2006). Any therapeutic response to children who live in these kinds of stressful environments must address the underlying stress response at a physiological, emotional and cognitive level. When stress is ongoing, the child’s ability to learn is blocked because of his/her anxiety: the brain is simply too busy protecting the body from danger (i.e., the amygdala shuts down during emergency) to analyze and respond. It is only after relief from anxiety, when relaxation and comfort are experienced during homeostasis, that cognition can begin again (Schneck & Berger, 2006). Singing and composing songs about feelings and ideas directly addresses the child’s emotional world, while simultaneously opening the child to learning and adaptation. Working on personal vocal expression, a song addresses speech development through the combination of rhythm, melodic line and lyrics. A song has the ability to structure time by establishing a rhythm. Through rhythm, the impulses of the child can be organized into an expressive form. Melody organizes the patterns of high or low tones and flows with the child’s mood changes. Space for emotional expression can thereby be created and developed, activating the brain beyond “fight or flight.” The child can therein experience emotional satisfaction when expressing pleasure, sadness, or even aggression. Lyrics give meaning to the song and stimulate cognitive processes of concentration, memorization, pronunciation, phonology, and spelling skills, as well as symbolic play. These musical elements can create a container in which the child can feel a sense of safety and decreased anxiety that are fundamental to exploration and development (Uhlig, 2006).

In the case of Richard, that follows, singing, and rap in particular, was used to express his isolation and profound anger. Here, the music stirred and exposed qualities and capacities that had not been developed, resulting in behavioral change. Richard shows us the potential of these abilities in every child: an emotional and neurological potential waiting for somebody to awaken. The Client The public school I worked in served children with special needs (aged five to 12) in an underprivileged part of New York City. In addition to developmental delays, these children were also ‘at risk’ because of the environments they live in. They were often physically neglected, receiving a minimum of support at home. As a result, many of these children were extremely emotionally disturbed. Because of a lack of positive attention, they unconsciously altered their behavior to receive negative attention--apparently better than no attention at all. Consequently, their need for attention and personal expression was so profound they had difficulty developing the ability to constructively listen, cooperate and work together in the classroom. To overcome these serious difficulties required a sensitive and attuned collaboration between teachers and therapists. During my years of work I have been fortunate enough to build strong collaborations with staff members, essential to any integrated learning experience. Together with classroom teachers and the speech pathologist, we found ways of combining our methods, wherein we experienced the power of music to hold the positive and negative emotions of the children in a structured, acceptable and enjoyable therapeutic experience--all centered on the form of the improvised song. Richard Richard was an underweight 11-year-old African American boy with developmental delays, average speech skills, erratic concentration, and poor academic skills. He was often extremely violent, acted out and, paradoxically, also showed ‘grown-up’ behavior. Apparently, he had been masking his fears with misbehavior from a young age. Richard’s constant severe mood changes, street-smart behavior, and bad language, episodic irritability and wild tantrums, created regular conflicts at school. Once or twice a week, a simple conflict would suddenly escalate into a tantrum of extreme aggression. Richard would yell, scream, and curse, hitting everything and everybody around him. During these tantrums, three or four staff members were called to help the teacher in the classroom. These helpers were trained to safely hold Richard’s body close to the floor, preventing his classmates from being attacked, and then calming him down afterward. These incidents took between 20 and 30 minutes, and afterwards, everyone involved--classmates, teachers and Richard himself--needed a “time-out” to reorient and reorganize for the tasks at school. Richard’s outbursts exhausted and annoyed everybody around him. Not only was his behavior disagreeable, it also limited his academic performance. These interruptions, combined with his lack of interest in school, blocked his cognitive progress: neurologically, his amygdale had shut down. A big change was needed.

The people in Richard’s home environment were neither interested nor involved in his education. He lived with his mother in a shared home situation with additional adults and children. There was no structure or guidance in his life. In the morning, Richard would wear the clothes he found around the house. This could be a sweater of an adult or an unwashed t-shirt from the day before. He took care of himself--as much as this was possible for an 11-year-old. Although Richard’s teacher had reached out to his mother, she had never visited the school, and everyone assumed she had no interest in his educational development. Richard’s teacher referred him to music therapy because of his extreme aggressive behavior. She hoped that the music could offer him a tool for relaxation to calm his temper. She also welcomed support and cooperation of another sort: all the children relaxed when Richard was out of the classroom during music therapy. The Therapeutic Process I started working with Richard in a dyad during his first year in music therapy, but soon separated him from the other boy so that I could focus more specifically on his needs. In so doing, I discovered his tremendous musicality. For example, Richard intuitively acknowledged ‘unusual’ musical scales and their moods. After hearing a pentatonic scale at the piano, he described it as ‘Chinese’ sounding, sensing perfectly subtle differences in tonal center. When we played instruments together with untamed rhythmic patterns on drums and rich melodic variations on harmonica, his mood and facial expression changed visibly and his body moved to the rhythm of the music. He became intensely involved in music making, playing instruments with remarkable coordination, and exhibiting significant auditory-motor and sensory-motor skills. However, he was most engaged when he vocally transformed parts of his aggression into rap, spontaneously experimenting with shouting sounds and screaming words. He vocalized more and more, and his speech-like articulations seemed gradually to release his tension. I supported his vocalizations with a simple repetitive chord progression on the piano or just the rhythm button of the keyboard, matching his rhythm. I also used a vocal rhythm pattern myself to offer a structured model to contain his sounds. I had to be sensitive in the ways I used my voice, not connecting too closely to him yet. Richard finally became the music himself--he was in the flow--rapping about his deep frustration and anger, putting screaming sounds and words into a rhythm. Typically, his hard and violent vocalizations were like the aggressive outbursts I saw in the classroom. He expressed himself for weeks and months as follows: (Shouting sounds) Yeah, wow … Asshole, bitch, I am a nigger, I hate you, Be careful, Nobody can touch me, Yeah, yeah, Stay away, f…ing asshole, Don’t f… with me,

I am strong, Yeah, yeah, yeah Don’t mess with me, Be careful, You don’t know me, Wow, yeah, yeah… (Shouting sounds) During our second year together, Richard went to a higher level, not only shouting, screaming, and playing hard, but also creating beautiful and significant improvised songs. He started vocally to compose music that was touching in its purity. He expressed himself most verbally in a rhythmical pattern--still similar to rap--while I supported him with a simple chord progression on the piano, matching his characteristic rhythm. His need for personal expression would let him utter whole sentences such as ‘I am a nigger from Jamaica,’ ‘don’t mess with me,’ ‘nobody knows who I am’ and ‘I punch you right in your face.’ He would also rap and sing freely about his teachers and people in his life, expressing shocking or very emotional truths. Musically and vocally supportive, I always contained his aggressive expression and sang and rapped to him, mirroring, provoking, or inviting more articulations about his inner world. In the beginning, he primarily expressed himself without answering my sounds. Later, he developed a sense of vocal dialogue with me. He surprised me with his responsiveness to special subjects during a rap like ‘Twin-towers were knocked down September 11,’ or suddenly ‘Mr. B., I miss you,’ about a teacher who left the school. Continuing the musical pattern on piano, I first wove vocal sounds like ‘yeah’ and ‘wow’ in a rhythmic pattern, and later added words into his meaningful messages. I also provoked his moods, for example when I sang “sometimes we don’t know what we feel or what we do,” addressing his aggressive behavior. Unexpectedly, he picked up on my words and often integrated them in the ongoing song. He sang back “…yeah, we don’t know what we feel, yeah, yeah…” creating his own version of it. We never talked about the meaning of the words, but we improvised intensely together using non-verbal and verbal sounds, creating solos and refrains, and singing call and response patterns. At every moment our improvised songs carried different but very meaningful content. Rhythmically shouting and expressing what he needed to say seemed to be a release for his aggression. After these vocal outbursts, he appeared more relaxed. I did not judge or stop this primary expression when he musically--in rap form--cursed or expressed his feelings vocally. Richard behaved like an adult who had learned to protect himself in a world of danger (fight-or-flight response). He was actually in a ‘flow’ while rapping and he had learned to relax by searching for sounds and rhymes in his words. In between his aggressive shouts, he started to weave in soft words that sometimes included me. I was never sure if he really meant me, saw me or heard me--except when he answered my words. I never felt personally attacked and I never made an interpretation of his cursing words. I accepted them as his primary expression of hate and anxiety. Through playing piano rhythmically and repeating the vocalizations through rapping and countering his words, I offered a structure of safety where he could feel held. My positive musical and personal presence demonstrated that I accepted him, even when I was far from understanding him. Through these experiences, he could develop a sense of comfort and safety.

We worked this way for a further six months into his second year of music therapy. Gradually, little by little, Richard began to relax. In experiencing safety, and feeling understood, he could begin to develop a sense of others. He started to sing about people, especially about the children in his class. He demonstrated an unexpected softness, often surprising me with tender lyrics. We often sang together now, exchanging vocal sounds, improvising lyrics, and answering each other’s words. We musically played together and created fill-in song constructions, improvising in a vocal dialogue. In these experiences I realized that Richard had noticed me as a person, present with him in the same room. This kind of awareness extended into dialogues with others. He started with recitative forms of word construction, calling the names of teachers, and singing about his class as a whole group, he communicated with them in song. In this way, he was tremendously involved in putting these words into a fitting rhythm. One very touching song he created during this time was about love, especially for his own classmates. Instead of hate and anger, he sang about love. We took his original poem, written alone before he entered the music room, and thoughtfully worked to fit the text into a Blues form. Searching for a suitable accompaniment, Richard chose a slow ‘bluesy’ rhythm for his words, while I offered him a fitting pattern at the piano: We are happy Love is happiness from the bottom of my heart God loves us from his heart We know we are a happy family The kids run around with me. Love is happy[ness] with my heart From class […] love is happy[ness] with my heart To the kids from my heart I love when the kids play with each other When I am home the kids play with me The kids like to be happy Richard was now engaged and relaxed in a way that showed me his homeostatic state had been modulated. A transformation had happened so that his soft rapping and singing lyrically, smiling and dancing, had exposed a totally different side of his personality. I had never before seen this kind of transformation in him and noticed how his behavior was also changing. In Richard grew a perception of the change he had made, but there was not yet full awareness. Fulfilled and proud of his personal song and musical experiences, combined with a feeling of being supported and understood, Richard planned to go on with ‘making songs’ and creating more lyrics. By working on various lyrics about his personal experiences, he became enthusiastically involved in learning to find the “correct” words. But more important was his wish to perform this song at his graduation party. He needed to satisfy his desire to perform, even “show off,” so that he could be seen and noticed in a positive way. He was very well known at school--but sadly only through his negative behavior. Determined, he practiced the song in front of the video camera, controlling his movements and experimenting with his vocal and acting skills. His need for positive attention and recognition as a rapper, particularly within

the culture of his African American school, showed how much his priorities and behavior had changed. Not only was he seeking recognition for his artistic abilities, he was seeking recognition from his community, one he now felt he belonged to. Richard had performed once before during a holiday show, watched by his mother, who had visited her son’s school for the first time. Preparing for the next performance, and her second visit, his excitement and awareness made him adopt the attitude of a ‘star.’ He imitated movements he had seen on video clips and infused his music and dance with great talent, transforming his art into his own personal context. The appreciation of his race and culture was acknowledged by his teachers, classmates and school in general. And I, a white European woman, supported, engaged and accepted his cultural progression. In so doing, his negative role vanished. His personal transformation from violent rap into lovely blues shifted not only on a musical level, but also on a cultural level into a positive identification. During this time, whenever he saw me at school, he enthusiastically told me that he had made a new song--which we later practiced in the music therapy session. He was curious to learn how to read and write with more accuracy. Asking me for help with spelling and expression, he carried over his curiosity for learning into the classroom. His teacher, who personally supported his development and carefully noticed any changes, told me that his cognitive potential had been engaged. His reading and writing skills improved significantly and his motivation for learning increased. But most importantly, there was a big decrease in his tantrums--there had now been months without any aggressive outbursts. On the day of the concert, Richard performed his rap-blues with enormous success. He was proud of his performance and received lots of acknowledgement from his schoolmates. He had illustrated perfectly his love and attention for his peers--and he was rewarded with their powerful appreciation after the show. His intensive musical interactions and positive experiences appeared to greatly strengthen his self-esteem. Above all, the teachers were pleased to have the opportunity to meet his mother again when she came for his second performance. Using time for a cooperative conversation with her about Richard’s development, everybody shared their appreciation for his touching performance. Summary Richard had made an emotional and cognitive transformation. He had become more conscious of himself, and in so doing, was able to acknowledge others and their feelings. His voice offered him a primary form of expression: shouting, screaming and rapping, supported by musical accompaniment. The significant effect of vocalization integrated his personal need to release emotional and physical tension. He experienced relaxation and comfort, developed a sense of safety, and opened his cognitive potential. His emotional expression strengthened subtle transformations of behavior, freeing up energy and relaxing tension, creating safety and comfort, and finding homeostatic balance. Above all, this process helped his brain to develop significantly, as he started to sing more words and to make up various lyrics himself, concentrating on fitting or rhyming words. In Richard’s case, the vocal activity of shouts, supported by music, was met with positive encouragement. This stimulation developed into relaxation, activating concentration and then

cognition. His emotional involvement set larger neurological processes in motion and finally influenced his cognitive development, as well as his emotional and social well-being. References Allen, W. F., Ware, C. P. & Garrison, L. M. (1867). Slave Songs of the United States. Bedford, Massachusetts: Applewood Books. Aldridge, G. (2008). Melody in Music Therapy, A Therapeutic Narrative Analysis. Philadelphia PA: Jessica Kingsley Publishers. Austin, D. (2009) The Theory and Practice of Vocal Psychotherapy: Songs of the Self. Philadelphia, PA: Jessica Kingsley Publishers. Bossinger, W. (2005). Die Heilende Kraft des Singens. Germany: Norderstedt, Books on Demand GmbH. Choi, A., Lee, M. & Lee, J. (2010). Group music intervention reduces aggression and improves self-esteem in children with highly aggressive behavior: A pilot controlled trial. Evidencebased Complementary and Alternate Medicine, 7(2), 213-217. Clayton, M. & Sager, R. (2005). In time with the music: The concept of entrainment and its significance for ethnomusicology. In S. Hal-lam, I. Cross and M. Thaut (Eds.), The Oxford Handbook of Music Psychology. New York: Oxford University Press Inc. Cramer, A. (1998). Das Buch von der Stimme, Ihre Formende und Heilende Kraft Verstehen und Erfahren. Zurich/Dusseldorf, Germany: Walter Verlag. Douglas, S. & Willatts, P. (2003). Can music instruction affect children’s cognitive development? ERIC Digest. ED480540. Retrieved from www.eric.ed.gov. Elligan, D. E. (2004). A Practical Guide for Communicating with Youth and Young Adults Through Rap Music. New York: Kensington Publishing Corp. Fouche, S. & Torrance, K. (2005). Lose yourself in the music, the moment, yo! Music therapy with an adolescent group involved in gangsterism. VOICES: A World Forum of Music Therapy, 5(3). Hackvoort, L. (2008). Rapmuziektherapie, een muzikale methodiek. Tijdschrift Voor Vaktherapie, 4, 15-21. Holst-Warhaft, G. (1992). Dangerous Voices, Women’s Laments and Greek literature. London and New York: Routledge. Karolyi, O. (1998). Traditional African and Oriental music. Middlesex, England: Penguin books. Kennedy, R. & Scott, A. (2005). A pilot study: The effects of music therapy interventions on middle school students’ ESL skills. Journal of Music Therapy, 42(4), 244-261. Loewy, J. V. (2004). Integrating music, language and voice in music therapy. VOICES: A World Forum of Music Therapy, 4(1). Overy, K. (2003) Dyslexia and Music, From Timing Deficits to Musical Intervention. New York Academy of Sciences, 999, 497-505. Rainey Perry, M. & Ri, C. J. (2005). Developing intentional communication: A combined music and speech therapy approach. Paper presented at 11th World Congress of Music Therapy, July, Brisbane Australia. Rauscher, F. H. (2003). Can music instruction affect children’s cognitive development? ERIC Digest ED480540. Retrieved from www.eric.ed.gov.

Schneck, D. J. & Berger, D. (2006) The Music Effect: Music Physiology and Clinical Applications. Philadelphia, PA: Jessica Kingsley Publishers. Schellenberg, E. G. (2004) Music lessons enhance IQ. Psychological Science, 15(8), 511-514. Tyson, E. H. (2002). Hip hop therapy: An exploratory study of a rap music intervention with atrisk and delinquent youth. Journal of Poetry Therapy, 15(3), 131-144. Turry, A. & Marcus, D. (2004) Musical Community: Music Therapy at Northeast Center for Special Care. Retrieved from www.nordeastcnter.com. Uhlig, S. (2006) Authentic Voices--Authentic Singing: A Multicultural Approach to Vocal Music Therapy. Gilsum, NH: Barcelona Publishers. Appendix A Rap music has various forms, and as Elligan (2004) describes when discussing rap as therapy, is different from hip-hop. Rap is the music, the beats and the rhyme of a culture known as hip-hop. Elligan (2004) differentiates several forms of rap: Gangsta rap, Materialistic rap, Political/Protest rap, Positive rap, Spiritual rap, and rap forms not otherwise specified. Rap songs critically analyze society. Rap songs create culture shock, exposing different cultural norms unfamiliar to others. The culture of rap provides the foundation for the development of a community, and like all communities, focuses on sharing the same interests and identities. Rap has primarily grown out of the interaction of poverty, music, dance, graffiti and fun (Elligan, 2004). For example, the aspects of anger, abuse, misery and inhuman circumstances of many people living in urban poor ghetto communities are expressed through Gangsta rap. Poor academic choices and a minimum of social and emotional care created a collective need to report about them through Political rap. Herein rap demonstrates its value as an educational tool, to bring into awareness issues important to the listener. Finally, rap has developed from an idiosyncratic form of expression in the ghettos of large cities into an important form of communication for communities of interest. Elligan (2004) calls for the use of rap therapy as a means of promoting positive behavioral change and improved insight into the lives of the clients through five steps: 1. Assessing the person’s interest in rap music and hip-hop (clothing, videos, concerts, etc.) and developing a plan for using rap music with a person. 2. Building a relationship and alliance with the person through discussing the different types of rap songs to which he or she enjoys listening. 3. Challenging the person with the lyrics of his or her rap icons in order to reevaluate his or her thoughts and behaviors. 4. Asking the person to write raps about the desired changes they have set for themselves. 5. Monitoring and maintaining the progress made through continued discussion and feedback (p. 65).

Other E-books in this Series Available from: www.barcelonapublishers.com

Case Examples of Music Therapy— For Alzheimer’s Disease For Autism and Rett Syndrome In Bereavement For Children and Adolescents with Emotional or Behavioral Problems For Developmental Problems in Learning and Communication At the End of Life For Event Trauma For Medical Conditions For Mood Disorders For Multiple Disabilities For Musicians For Personality Disorders For Schizophrenia and Other Psychoses For Self-Development For Substance Use Disorders For Survivors of Abuse

Barcelona Titles by Topic Available at www.barcelonapublishers.com Analytical Music Therapy • Essays on Analytical Music Therapy (Priestley) • Music Therapy in Action (Priestley) • The Dynamics of Music Psychotherapy (Bruscia) • Group Analytic Music Therapy (Ahonen-Eerikäinen) Case Studies • Case Studies in Music Therapy (Bruscia) • Inside Music Therapy: Client Experiences (Hibben) • Psychodynamic Music Therapy: Case Studies (Hadley) • Developments in Music Therapy Practice: Case Study Perspectives • Case Examples of Music Therapy: A Series of 16 e-books 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) • Therapy in Music for Handicapped Children (Nordoff & Robbins) 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 Skills

• Guitar Skills for Music Therapists and Music Educators (Meyer, De Villers, Ebnet) 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) • 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 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) • 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) Periodicals (Free Downloads Available) • International Journal of Arts Medicine • Qualitative Inquiries in Music Therapy: A Monograph Series 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) 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) • 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)

Voice

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The Music Within You (Katsh & Fishman) 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)