Case Examples of Music Therapy for Multiple Disabilities [1 ed.] 9781937440329

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Case Examples of Music Therapy for Multiple Disabilities Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Multiple Disabilities 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: 978-1-937440-32-9 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 Discovering Meaning in Kelly’s Nonverbal Expressions Suzanne Nowikas CASE TWO Self-Communications in Creative Music Therapy Carol M. Robbins Clive Robbins CASE THREE Creative Music Therapy in Bringing Order, Change and Communicativeness to the Life of a Brain-Injured Adolescent Clive E. Robbins Carol M. Robbins CASE FOUR Like Singing with a Bird: Improvisational Music Therapy with a Blind Four-Year-Old Jo Salas David Gonzalez CASE FIVE Roni: Music—An Eye for the Blind Chava Sekeles CASE SIX The Use of Piano Improvisation in Developing Interaction and Participation in a Blind Boy with Behavioral Disturbances Helen Shoemark CASE SEVEN Lisa: The Experience of a Child with Multiple Disabilities Barbara L. Wheeler

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 multiple disabilities. 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 multiple disabilities about the potential benefits of music therapy. About Multiple Disabilities A person with multiple disabilities is one who has more than one significant disability in the areas of motor function, vision or hearing, behavior or emotional functioning, and/or intellectual abilities. Each disability may vary in severity, and one disability may induce or exacerbate another thereby creating very significant challenges for the child. In some definitions, the diagnosis of multiple disability always includes subaverage intellectual functioning; in others, the diagnosis may refer to any combination of disabilities. The case examples in this book provide myriad perspectives not only on how various disabilities are manifested differently by each individual, both within and outside of a musical context, but also how these problems can be addressed through carefully designed music experiences that capitalize on the individual’s strengths and resources. 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 multiple disabilities, 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 multiple disabilities, 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 multiple disabilities are as interested in this question as scientists and researchers. Their interest is in whether individuals with multiple disabilities 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 Multiple Disabilities 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 multiple disabilities. Additional case examples have been written, which further elaborate how individuals with multiple disabilities can derive therapeutic benefits from music. Here is a list of other published case examples along with other writings on the topic. Agrotou, A. (1994). Isolation and the Multi-Handicapped Patient: An Analysis of the Music Therapist-Patient Affects and Processes. The Arts in Psychotherapy, 21(5), 359-365. Arnason, C. (2006). Woman to Woman: A Music Therapist’s Experience of Working with a Physically Challenged and Non-Verbal Woman. British Journal of Music Therapy, 20(1), 13-21. Bertolami, M. D., & Martino, L. M. (2002). Music therapy in a Private School for Visually Impaired and Multiply Handicapped Children. Voices: A World Forum for Music Therapy, 2(1). Retrieved June 30, 2011 from: https://normt.uib.no/index.php/voices/article/viewArticle/69/59 Crowe, B. (1999). The Special Place of Music for a Multiply Disabled Girl. In J. Hibben (Ed.), Inside Music Therapy: Client Experiences (pp. 199-202). Gilsum, NH: Barcelona Publishers. Ghetti, C. M. (2002). Comparison of the Effectiveness of Three Music Therapy Conditions to Modulate Behavior States in Students with Profound Disabilities: A Pilot Study. Music Therapy Perspectives, 20(1), 20-30. Kennedy, R., & Kua-Walker, Y. (2006). Movement, Singing, and Instrument Playing Strategies for a Child with Myotonic Dystrophy. Music Therapy Perspectives, 24 (1), 390–51. Krout, R. (1987). Music Therapy with Multi-Handicapped Students: Individualizing Treatment within a Group Setting. Journal of Music Therapy, 24(1), 2-13. Meadows, A. (2002). Approaches to Music and Movement for Children with Severe and Profound Multiple Disabilities. Australian Journal of Music Therapy, 13, 17-27. Meadows, T. (1997). Music Therapy for Children with Severe and Profound Multiple Disabilities: A Review of Literature. Australian Journal of Music Therapy, 8, 3-17. Nordoff, P., & Robbins, C. (2004). Therapy in Music for Handicapped Children. Gilsum, NH: Barcelona Publishers. Perry, M. M. R. (2003). Relating Improvisational Music Therapy with Severely and Multiply Disabled Children to Communication Development. Journal of Music Therapy, 40(3), 227-246 Perry, M. R. (1998). How Improvisation-Based Music Therapy Can Regulate Arousal to Facilitate Communication Development of Children with Multiple Disabilities. In R. R. Pratt, & D. E.

Grocke (Eds.), MusicMedicine 3: MusicMedicine and Music Therapy: Expanding Horizons (pp. 212-218). Saint Louis, MO: MMB Music, Inc. Pfeifer, M. (1989). A Step in the Right Direction: Suggested Strategies for Implementing Music Therapy with the Multihandicapped Child. Music Therapy Perspectives, 6, 57-60. Retrieved from EBSCOhost. Rainey Perry, M. (2003). Relating Improvisational Music Therapy with Severely and Multiply Disabled Children to Communication Development. Journal of Music Therapy, 40(3), 227-246. Roberts, D. (1986). A Review of Two Case Studies Using Music Therapy with Multihandicapped Children. Twelfth National Conference of the Australian Music Therapy Association Inc. “Perspectives on Progress”, pp. 40–48. Stephenson, J. (2006). Music Therapy and the Education of Students with Severe Disabilities. Education and Training in Developmental Disabilities, 41(3), 290-299. Voigt, M. (1999). Orff Music Therapy with Multi-Handicapped Children. In T. Wigram, & J. De Backer (Eds.), Clinical Applications of Music Therapy in Developmental Disability, Paediatrics and Neurology (pp. 166-182). London: Jessica Kingsley Publishers, Ltd. Watson, T. (2007). Working with People with Profound and Multiple Learning Disabilities in Music Therapy. In T. Watson (Ed.), Music Therapy with Adults with Learning Disabilities (pp. 98-111). New York, NY US: Routledge/Taylor & Francis Group. Wheeler, B. L. (1999). Experiencing Pleasure in Working with Severely Disabled Children. Journal of Music Therapy, 36(1), 56-80. Wheeler, B. L. (1999). Lisa: The Experience of a Child with Multiple Disabilities. In J. Hibben (Ed.), Inside Music Therapy: Client Experiences (pp. 237-246). Gilsum, NH: Barcelona Publishers. Wheeler, B. L., & Stultz, S. (2008). Using Typical Infant Development to Inform Music Therapy with Children with Disabilities. Early Childhood Education Journal, 35(6), 585-591. Wigram, T. (1997). The Effect of Vibroacoustic Therapy Compared with Music and Movement Based Physiotherapy on Multiply Handicapped Patients with High Muscle Tone and Spasticity. In T. Wigram, & C. Dileo (Eds.), Music Vibration and Health (pp. 69-86). Cherry Hill, NJ: Jeffrey Books. Reference for Introduction Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Multiple Disabilities

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

CASE ONE Discovering Meaning in Kelly’s Nonverbal Expressions Suzanne Nowikas Introduction Kelly can be an affectionate and interactive child, yet also withdrawn and in her own world—all in the same session. She shows her many sides in the session I describe—her 36th session of music therapy. In order to compose the most complete picture of what Kelly’s experience may be like in music therapy, I have interviewed two people who I feel are key in understanding her: Antoinette Lubrano, Kelly’s co-therapist, and Barbara, Kelly’s mother. Antoinette and Barbara watched a videotape of session 36 with me in separate interviews. To get as close to Kelly’s own voice as possible, I have created an inferred soliloquy (in italics) that is my interpretation of what Kelly’s verbal expressions might be like if she were able to speak; these are based on my observations of her over several years of therapy. Her voice will be a thread throughout the chapter in a further attempt to relate my experiences of her as closely as I can to what a nine-year-old’s perspective might be. The entire narrative is based on conjecture, impressions, assertions, and interpretations. I do not assume to be able fully to understand any person’s experience in therapy. I do feel, however, that through piecing together others’ experiences of Kelly, we may somehow be able to develop a fuller picture about who she might be. We bring our own personal expectations of her to this setting, but it is not the purpose of this account to identify one truism about Kelly. In Session 36, as in all our sessions with Kelly, the co-therapist and I work as a team; I create the musical themes at the piano to support, reflect, enliven, move, encourage, and motivate Kelly. Antoinette vocally, physically, and gesturally facilitates and supports Kelly’s participation on the floor. We use improvised music in a variety of different styles and idioms, on the piano, with our voices, and on the guitar, to reach Kelly. Some of the musical ideas become themes that are brought back from week to week. The music is developed solely for Kelly and the hope is that she will begin to recognize and identify with the themes and know that they are “hers.” Excerpts of the music from Session 36 are included here. Kelly Barbara had a normal pregnancy and delivery. At six months of age, Kelly had her first seizure. She then underwent MRI (magnetic resonance imaging), which revealed that she was missing a portion of her corpus callosum. This is the portion of the brain that connects the right

and left cerebral hemispheres. Her seizures continued, but it was not clear that she was physically or language delayed until she was one year old. At one year, she was not babbling and her seizures had increased. She began crawling at two and a half years old and worked with her mother and baby-sitter on developing walking skills for at least one hour a day (in addition to physical therapy sessions). Seven months later, she began walking. She was still not babbling at this time. Barbara commented in regard to controlling her seizures, “We have tried everything,” referring to special diets and an assortment of medications and dosages. Kelly continues to have seizures one or two times a day. They are each less than 10 minutes long and they usually occur when she is waking up. Her head dips and shakes a bit. Barbara said, “They take their toll when they are that frequent.” Early Moments

Session 36

I am always struck each time I see her. She is angelic-looking, beautiful curly blond hair to her shoulders and a peaches-and-cream complexion. As she enters, I hear her hum. Yes! She wants to be here. She looks tired today and a little pale. I watch her sit down in a chair that is approximately 6 feet away from the piano. To see her, I must crane my neck and turn around while continuing to play. A little smile comes over her face, a cue for me to begin singing our greeting song [Figure 1]. She seems to be anticipating something. I’m happy to be back in music. Everything looks the same. Where is my chair? Hmmmmm. That song—when I hear that song, it makes me feel nice. Hmmmmm. Hello

Figure 1. Hello music. I decide to hold out each tone of the hello song (emphasizing each note with my voice). I know she is warming up to the situation, but I feel she needs a little more energy from the music. I play in a livelier way, adding harmonic changes, and wait for little humming responses after I play very short phrases. She turns toward Antoinette as if noticing her for the first time; she is really listening. Barbara* commented about these first few moments of the session: She is very aware that you both are there to give her pleasure. And that makes her feel happy. There is a moment [when] she is going to turn to Antoinette and seek her own sort of stimulation. But the music overtakes that [feeling] and it is so rich and enjoyable that the self-stimulation isn’t necessary. She [is thinking,] “Oooh, I’m going to miss this. This is beautiful.” She looks tired. The music is peaceful to her. It’s peaceful and it’s soothing. Antoinette related her experience bringing Kelly into the therapy room: For a moment there, I felt she was on the border; she wanted to come in, but she didn’t know how. She wanted to be a part of that welcoming, a part of the music. For instance, when she first walked in, she was slow; she went right to her chair. Then you played a faster tempo and she responded immediately. I think she was really absorbing it. And the way she was looking at me and looking at you. I really felt that she wanted to be part of it, part of your music. She was happy; she was in a really good mood. She was familiar with [the chair] and was comfortable. She was sitting up and she was ready for something, ready to be involved and engaged. Where is Antoinette? She has beautiful thick curly hair like Mommy’s. I want to touch it. It feels soft and warm. She doesn’t pull away from me. I think she likes me. Kelly develops unique and separate relationships with each of us on the therapy team. Antoinette and I have cultivated strong and different relationships with her. Our differing roles, perspectives, and impressions afford us the opportunity to understand her better and to appreciate more fully the complexity of her world and relationships with others. To the Drum I sing, “You want to play,” and she signs, “Play.” It is always a great feeling of assurance when I know she understands what I’m saying. Antoinette brings the drum closer to her and hands her the mallets. I encourage her to play, which she does in short bursts. The sleepiness is more apparent. Her eyes look glazed over and she puts the mallets down on the drum and turns to Antoinette to withdraw from activity. Don’t they understand that I’m busy listening? Sometimes I hear so many sounds together and it doesn’t make sense. I’m so tired. Antoinette? Hmmmm. I’m so tired. I

can’t hold the stick anymore. I’ll put it on the drum. Okay, now can I go to sleep, Antoinette? Antoinette discussed this moment: When she came to me [this time, it was as if] she was coming to me for encouragement to participate in active music-making. When she backed up [away from the drum], I felt that she was ambivalent or not sure what she wanted to do. Each time she approached me (through the course of therapy), I tried to understand why she decided to come to me. Is it a way of avoiding music-making or does she really want physical contact from me? Or is it both at the same time? Barbara had a slightly different perspective of what she believed to be Kelly’s experience: I don’t think she is going to Antoinette for help. She is tired. She rises above [her sleepiness when she hears] certain tones. It takes her away from [her tiredness, sleepiness], just like the self-stimulation [does], because it is so pleasurable and she is drawn by it. And in general, more active music seems to get her going. It was an active moment, an active sound, and she connected to that sound. She is listening very carefully. There are moments when she wants you [Suzanne] to restart, just by glancing. [These are] very passive indications, but definitely [her communicating that] “I want more of this.” Throughout our review of the video, Barbara clearly distinguished between Kelly’s responses and interactions that were elicited by a relationship during a musical experience and her responses based directly on aspects of the music. Barbara said, “I think there is a pull between Kelly being connected and unconnected. Music can be both a personal and a shared (relationship thing) experience. I think she can be both active and passive when she is connected and enjoys experiencing music in both of these modes.” I like to bounce when I’m happy. Sometimes when I think of something happy, I begin to bounce. I think about Mommy and Daddy. It’s fun to go up and down. Suzanne is looking at me. She is bouncing in the music, too. We are all having fun together. Maybe we can all dance together someday. Antoinette and I agree with Barbara’s statement that “Kelly is a complicated child. On the face of it, she is probably very simple to people, but I think she’s complex and hard to understand.” We have learned that she communicates choices clearly and definitively at times yet can also be ambivalent. How many of these changes are due to the medication she takes each day? We are not sure. Sometimes, making a connection with her feels like a battle—a battle between the power of the music, the strength of our commitment to her, and the potency of her medication. Antoinette discussed her relationship with Kelly in reference to the drum work in Session 36:

I’m sitting behind her and though she’s not leaning on me, I sense that she wants and feels my support. I sometimes think that we are communicating on another level — maybe a sixth sense. I’m thinking, “Come on, play that drum,” and I believe she is definitely sensing this even when I wasn’t touching her. And the music you’re playing is also saying, “Try.” I think she was asking herself, “Do I want to do this? Maybe I don’t want to do this.” She feels our strength and motivation. Here, I think she is trying to tell me, “No, I don’t want to.” She just wants to be held and loved. Maybe she doesn’t want to work. She doesn’t want to play the drum. I sometimes wonder if this is another wave of medication. Antoinette, help me. I don’t want to work on the drum. Let me hug you. Suzanne wants me to play; can you take care of me? You like it when I hug you, right? Oh no! You want me to play more, too? I’m seeing different colors; everything looks blurry. I feel air on my face. I hear voices and music. I like it, but I want to go somewhere. I feel far away. Where’s Mommy? I feel sleepy. Everything is so soft, warm, and syrupy slow. In her discussion of Kelly’s musical life outside of music therapy, Barbara described her own use of music to enhance speech goals: In the past couple of years, I made cassettes [about different objects] that we [would place] on a table. One was a ball, one was a can of blocks, one was a telephone. I [created] a song to go with each object. These were objects that she knows. I won’t tell you what the speech objectives were because it’s irrelevant. She experiences the objects in a different way with the song. She is more focused. There’s more life to these objects. The music enriches the object. That’s how I feel and she feels that. Kelly withdrew from playing the drum in Session 36. I asked Barbara what she thought Kelly was feeling. Was there something that we were doing that was making her want to cuddle? Barbara answered: I think she is not connected to the music. And the music is not big enough to draw her out. I think generally that she is very tired at this point. It’s completely obvious to me that she is not drawn into the musical experience at that moment, and so she is doing what she would when she is tired. There are periods in Kelly’s sessions in which she seems almost transfixed, intently listening and absorbing the sounds that she is hearing. Her responses to the music are sometimes manifested outwardly with flapping arms and jumping, but often it is more subtle. We hear little humming sounds and see half-smiles or notice more directed glances. This is the strongest indication we have that she is experiencing something that is moving to her. Barbara refers to the drum work when she begins to explain Kelly’s responses and how they are demonstrated in this session:

The moments that she is really into the musical experience, she doesn’t [necessarily] want to [play] in a real active way. That doesn’t mean that she isn’t really getting a lot out of it at those moments. There are other times that I see her more active, but it’s irrelevant. She’s definitely into it at those times [when no activity is taking place]. I think you can participate passively. I wouldn’t underemphasize the impact of what that does for her, even though it doesn’t appear that she’s really leading you directly. She’s quite aware of the differences in the music, and some of it is more striking than others. To the Cymbal Sensing that she was no longer interested in the drum, I leave the piano bench and move the cymbal closer to her. She has been attracted to the cymbal in prior sessions. I’m hoping her interest in the sound will overtake her sleepiness and desire to withdraw. I tap it once after bringing it closer. She seems interested, leaves Antoinette’s lap, begins to spin the cymbal with one hand. She hums and stands as I bring it over. I play a pentatonic theme lightly in treble register of the piano [Figure 2]. The music has an almost mysterious quality to it; I leave spaces after each phrase, hoping she’ll fill them with the cymbal. I occasionally return to thematic music for the drum, which is composed of pentatonic octaves [Figure 3]. Interlude with cymbal

Figure 2. Interlude with cymbal. Pentatonic Theme Drum music

Figure 3. Pentatonic theme. Bright, shiny! I see me. It’s cold and golden. Around and around, look what I can do! New colors each time it goes round and round again. Barbara commented: I think it became clear to you that she did not want to play the cymbal, but when she was spinning, it was enjoyable for her. [Pause] It was sensory for her when she was touching it, the movement was sensory. She was experiencing [the cymbal] with the sound. How she takes that all in, I don’t know. Somehow it was very pleasurable, that sort of feeling, as opposed to banging the drum, sensory and pleasurable and seemed to match the [music]. Her movement was in agreement with the sound. I ask Barbara if she thought Kelly’s experience might also have been visual. I thought perhaps the lights were reflecting off of the cymbal and she could possibly see herself. Barbara said she could not tell from this excerpt, but that it might very well be the case. She said that some sort of shine or refection might be attractive to her. She also thought that the cymbal was cold and the texture of it might be pleasurable. Antoinette pointed out something to me that I had missed during previous viewings of the videotape: She turns the mallet around so that the wooden part was striking the cymbal. Kelly reaches back and takes Antoinette’s hand and moves it in a downward motion on the cymbal while she continues to spin it. This continues as Antoinette taps the cymbal repeatedly. Antoinette commented: She doesn’t do this often. She took my hand because I was holding the mallet. Maybe she recognizes [the music] you’re playing. I don’t know. Her relationship with the cymbal is a familiar experience from a past session.

Antoinette then offers Kelly the mallet in the same position, with the wooden side of the mallet within striking distance of the cymbal. Kelly bounces several times, accepts the mallet, hums, and smiles. She then strikes the cymbal a few times, looking over to the piano between beating. I reflect what she is doing by holding chords in the middle register of the piano. Kelly seems happy. She hums and smiles, turning the mallet around so that the soft side is striking the cymbal. I play with her on each beat that she plays. She stands with Antoinette supporting her back. Then she begins to bounce and I enliven the music by changing my articulation, returning to mostly the upper register of the piano. Bouncing up and down [Flaps hands, flaps hands]. Keep going. It’s fun, pretty. I hear that! More—more music! I play short phrases, leaving silences before repeating the phrase. I am asking her a question in the music and am waiting for a response from her. She seems awake and ready for action. Will she answer me? She has turned the mallet over and the wood end is facing the cymbal. When I leave a space in the music, she fills it, and a dialogue ensues, back and forth. I play a chord; she answers. She looks away in the distance. I begin to play a tremolo in order to refocus her. She begins the dialogue again. This continues consistently for several minutes. I begin to play with her, not only waiting for her to fill in the silences. I sense that she is tiring. She subsequently puts the mallet down on the drum and moves toward Antoinette. Antoinette tries to characterize Kelly’s experience: I heard the joy in her music. I wonder if she felt and experienced it as significant and meaningful. It seemed that way from her bouncing and playfulness. I wonder if she felt our joy that she was playing. She was bouncing and jumping. The music was in a higher register; it was light and playful. She was there! From her own perspective, Antoinette described the nature of Kelly’s interaction with me: There is a sense of awareness on her part when she plays and you follow her on the piano. She seems to know that you are with her.... Does she understand or is she aware of the dialogue/musical interaction? I think so. Antoinette has a unique role as co-therapist, constantly deciding whether to actively assist Kelly. She stated: I want to say something about sitting so closely by her [as opposed to moving away]. I really think that with Kelly, it is important to be that physically close to her. And even if I’m not holding her or doing hand-over-hand prompting in that moment, I know what I’m feeling. It’s almost as if I’m saying in my mind, “I’m here.” [I’m] passing my strength on to her. I think it comes across but yet it’s not forced.... The feeling elicited when you’re working and someone is behind you is “You can do it.”

Barbara commented about Kelly’s interactions with Antoinette and the difference between the drum and cymbal work: That [drum work], was an example of [a time] when a lot of the leading by Antoinette was unsuccessful, and Kelly didn’t like it. And maybe it caused her to retreat all the more into something perseverative. But here with the cymbal, there was the moment that this was successful direction. There were moments when Antoinette tried to keep her going and was successful in keeping her connected to it. The time with the drum was so long that it was unsuccessful and the continuation of it was so long that it made her retreat and really get disconnected from the musical experience, whereas this time, there was some persistence in trying to direct her and she fairly quickly responded and it was successful. Had Kelly stopped with the drums sooner, she might not have retreated as much. I was surprised by Barbara’s next observation about the cymbal playing. It was quite contrary to my perception of the cymbal work: She does not like the sound of the cymbal with the [wooden part] of the mallet. She likes the sound of the [soft] mallet side. She was hitting it, but she wasn’t really into it. She might have started to get into the music, then she turned it around and got the [soft] mallet sound. The first time she heard it, she was really listening and she liked it and then she hit it a few more times. She liked the sound and it enhanced the music. [Pause] She was experiencing the instrument in a number of ways that were comfortable and pleasurable for her. One was with the mallet side and one was by touching [the cymbal]. [When] she hit it with the [wooden side], she didn’t like it and even though she continued playing, she didn’t like it; it disturbed her. Maybe I’ll change my mind if I keep watching, but I felt that [hesitation] she’s hitting [the cymbal] to restart [you]. She wants the music, but I don’t think she likes that sound. Why did she [move her hands in a flapping motion]? Yes, she wants you [to play], but I don’t think she likes the sound of the wooden side of the mallet. We continued to watch the videotape and Barbara remarked as the dialogue between Kelly and I ensued: I think she is tolerating it now. She was not tolerating it before. Is she so into responding and playing with you or is it the community feeling [she derives from] playing together? Is it that she’s not focused on the sound? Is she tolerating it now that she’s done it a number of times? When she first played, she hated the sound. Maybe the success, the noise of it, makes her more comfortable. I don’t know. Now it’s okay. At this point in the session, I present a small communication board containing three laminated pictures of instruments attached with Velcro on a board. There is an additional “I want” symbol that Kelly’s speech therapist has provided. Kelly consistently uses the chart that we have brought into the sessions. She usually makes a choice but sometimes does not follow through with the particular corresponding instrument that she chooses. This week, she chooses

the tambourine. We usually ask her to choose two times to see if she will be consistent in her selection. She follows through this time with choosing and playing the tambourine. They have a board for me where I choose what I want to play. The pictures are pretty. I have different boards wherever I go. I know how to choose. I want [she hesitates] the piano? The tambourine? I’ll pick the tambourine. Here comes Suzanne with the tambourine; she is moving so fast! Sometimes I don’t know what I want to play, but it is fun to touch the pictures. To the Tambourine Kelly hums before we start playing. She taps the tambourine with the back of her hand. I begin a rhythmic improvisation in E-flat major. She alternates playing with Antoinette. A melody develops in the music [Figure 4]. Tambourine

Figure 4. Improvisation in E-flat major. She seems to be listening and bounces in my direction. I begin to sing nonverbally with the new melody. I add dissonance to give the music a little more energy and spice. I again wait for her responses in the music. She yawns and smiles at the same time. I increase the tempo and intensity of the music. She smiles contentedly, although she does not seem to have the energy to continue to play without stopping. She hums and moves her head to the music. Antoinette plays the tambourine for several beats, then gently touches Kelly’s elbow. It seems as if Kelly is finished with what she will do. She moves to the piano bench and sits beside me. Sometimes Antoinette and Suzanne play so fast on the instruments. I can’t do that. I wait till they are finished. Oh, maybe I’ll show them I can play fast too. [Tap,

tap,tap, tap] Yes, see? Oh, they like that; the music sounds louder. Enough! I’m tired. Haven’t I done enough? Can’t I listen now? Barbara provided an example of how her 17-month-old son response to music differs from Kelly’s experience: He likes music a lot. He continually sways to the music. When he sways, though, he is swaying to show somebody. When Kelly jumps and flaps her hands, she is effervescent with joy. She is not necessarily moving to show someone else, like my baby. Kelly’s flapping reflects personal joy and she would do it regardless of whether or not someone was present.... It’s very personal for her. That was what she was doing with Antoinette at that moment. She doesn’t sway; she cuddles. Even though it looks all the same, I don’t think it is. We discussed how Kelly uses instruments in order to get a musical response from me. Barbara stated: She goes between [playing for herself] and using instruments to get you to play. It’s merely cause and effect. [At those times,] she really doesn’t want to play. She wants you to play. She’s so focused on processing that sound that to be able to process that sound and play (this is sometimes, I’m saying) is difficult and not rewarding for her. There are other times when she does use the instrument for expression. And she’s gone between [both experiences here] with the [tambourine playing]. I don’t know why there are moments when she is real passive but clearly processing the sound and there are other times when she is enjoying [listening to] the sound versus [being] active in the sound. Is it too complicated for her to process? Is it too beautiful or is she just not inspired? When I watch ballet (I danced for 14 years), it doesn’t inspire me necessarily to want to go up and do a pirouette. I added that I thought there might be a delay in Kelly’s processing, even with her smiles. It doesn’t always occur at the exact moment that the sound is happening. I questioned whether when there is silence she is still hearing music. Barbara replied: The route for all auditory messages is very slow. So we would almost have forgotten the music by the time she is getting the message. Is she still getting the message? I don’t know physiologically what the answer to that really is. Maybe the message has gotten up there. When Kelly leaves her music therapy sessions, she often is happy and excited, jumping up and down, humming, seemingly very active. This is often contrary to the mood that she presents in the therapy room, especially on days that she appears very tired because of the effects of the medication. I questioned Barbara about this in relation to our discussion of how Kelly processes sound. I wondered out loud whether she is happy and relieved to be out of music therapy. Barbara responded:

I don’t really know [what that’s about]. I don’t think that it’s that she is so happy to see me and I don’t think it’s that she is so happy to get out of the session. I don’t know if I can answer. I want to tell Mommy what we did; let me show her. I’ll dance and move around the room. She tells me that she knows I’m happy. Yes! Antoinette and Suzanne are saying good-bye to Mommy. They are talking. I hear the good-bye music in my head. Mommy is putting on my jacket. We’re going to school now. Barbara was careful throughout our interview not to go further than she felt comfortable in trying to interpret Kelly’s experience. There were some topics that she addressed with a great deal of assuredness and certainty but other areas in which she did not even attempt to venture an answer or an explanation. This again reinforced the idea to me that Kelly could be mysterious and in some ways “unknowable” even to those closest to her. This conversation about processing of information led us into a discussion about Kelly’s overall experience in music therapy from Barbara’s perspective: This is presumptuous, too, but the motor planning [needed to play instruments] requires such effort for her. When I think that the goal of music therapy is to get her to participate ... [She hesitates.] There are reasons to want her to participate. It’s good to be able to motor-plan and do things, but that to me, to some extent, [may] take away from some of the pleasure she gets from it. It would take away from some of the experience itself. I then asked Barbara how, from her perspective, music therapy helps Kelly. I think it’s a happy experience for her. I just have to be honest that when I drive down here (I tell my husband and my caregiver this all the time), it feels so good that I’m taking her here. I feel like I’m expanding her life a little bit. I feel like I’m giving her pleasure.... I could get technical about it. Just getting her to use her senses more is great, developing a relationship to sound and differences in sound is great. I could get technical about it, but I [won’t]. I’m giving her something enriching and it’s a lovely experience. It’s just a lovely experience. Antoinette compared session 36 to the other sessions in Kelly’s course of therapy: [Her responses] are subtle. There have been times when maybe she played more and we saw some of that. It’s more subtle, but it is indicative of who she is. In this session, I think we are able to redirect her more. She is gently pulled out of the low energy, inactivity, spaciness, and wave of medications into active listening. I think I’ve seen her potential and what she can do [in earlier sessions] and even if the next session is different, it helps me say, “Wait, she can play that.” And it can be that she does want to be here but doesn’t want to work, or she just wants to listen. That’s how I link the

sessions together. Here’s this child coming every week or every few weeks, and she’s had these experiences. I think she holds on to them. I really do. I have to believe that. Barbara questioned what a music therapy experience might be like for her other children: I have two other children, and I think, “Would this be nice for them?” They wouldn’t experience it in quite the same way as Kelly does. It is uniquely beautiful to her and enriching to her in a way that it couldn’t be for the other children. So many other people might say, “Well, those two kids could get more out of it.” I disagree. Who are we in our world to say that it is more enriching for us? I would argue that it’s probably more enriching for her. Compared to everything else in this world that we “normal people” take input from, other than a unique, select few like you [a musician], the input from a half-hour music session is likely to be quite small. But if you look at the odds, it’s probably a much greater impact for [Kelly] than for most other people in this world. Her intake from the world is probably smaller than most people, but I argue, therefore, [that] her intake from music is probably greater proportionately. To the piano I see her interest in the tambourine is waning. Antoinette continues to present the instrument to her and taps it several times herself. Kelly moves away and sits next to me on the piano bench. I point to the picture of the piano on her board as she sits and wait to see what she will do. She gently touches a few notes. I reflect her touch very gently with light chords in a minor key. She plays clusters and some single notes. Barbara commented: I think she wanted more of you at that moment. And she didn’t get it, and then she felt, “Oh well, that’s it.” I tried to clarify Barbara’s statement by saying that Kelly seemed to “check out.” Barbara went on: You do have to be a mastermind to take all these messages from her because it’s pretty difficult, but I suspect that she wanted you to [play for her]. I begin to play a melody [Figure 5] that I have played in past sessions in a livelier manner: Piano Theme

Figure 5. Piano theme in C. Kelly occasionally reaches out and plays a note that is related to the melody. Since her early sessions, she has always had an uncanny ability to play the notes that corresponded to the key that I was playing in improvisations with the piano. Sometimes this occurs when she is not even looking directly at the keyboard. Antoinette and I do not have an explanation for this. We have tried to get philosophical about it. Perhaps she feels the music in a different way, without needing to think about it. This openness to the experience may enable her to connect in a way that we trained musicians find challenging to relate to. Her mother said, “I feel that it’s beyond me to be able to comment on whether she can do that.” Kelly’s interest in actually playing the piano wanes, yet she begins to hum along with the music. I vocalize with her and in response to her. It is a very special moment of connection in the session. She seems to be enjoying the vocal interaction and revels in her own ability to create musical sounds. I asked Barbara what she thought about the quality of Kelly’s vocalizations at this point in the session: I think it’s lovely. Her speech therapist would [say], “Wow, is this possible?” It’s far superior to anything we can get — to anything we do. I’m sure the speech therapist would just say, “Wow!” because I know this therapist so well and yes, Kelly’s so happy. It just makes me beam. For me [what is so important] is that she’s so happy, and it’s coming out. It’s outward expression, which we don’t get [to see] as much.

Good-bye Kelly moves back to her chair after this vocal interplay. I begin to play the music to the good-bye song [Figure 6]. She listens intently, occasionally smiling and humming, but mostly, just listening. She waves good-bye in the air, not addressing anyone in particular, but letting us know she understands what is happening. In past sessions, she might begin to tug at the doorknob in anticipation of her exit, but in this session and other recent sessions, she waits patiently. Suzanne knows I want to leave when I wave my hand. Sometimes we sing goodbye. I like good-bye. I know we’ll be leaving soon when we sing good-bye. I like to hear this song, lots of times. I like to sit and listen; sometimes I move up and down when I hear this song. Barbara compared the good-bye time to the beginning of the session: When she came in and now [during the] ending, it was so distinctly different from the rest of the session. It’s almost as if you’re saying: ‘We’re singing this good-bye song to you. We are singing this song to you.” And like it was in the beginning, she sits there and is taking it in. It’s almost as if she is saying, “I know you’re singing this to me. I know it’s not quite a shared musical experience, but I’m participating; I’m listening to the sound.” It’s like, “I know you’re singing this to me and I like this and I like that you’re doing this for me.” It’s the way she’s sitting. She’s very alert; she’s very erect. Good-Bye

Figure 6. Good-bye music.

I explained that Kelly put herself in that position in the beginning and ending of the session. Barbara responded: Did she? It just seemed like it was the exact same thing as the beginning. “You two do this to me!” So it was really nice, just really nice. During the good-bye song, we sing to Kelly repeatedly and incorporate our own names. We continue with some embellishments and I play some harmonic variations. I am always curious, when she is away from the door at this ending point in the session, how long she will actually feel relaxed about continuing this song before wanting to leave. I eventually bring it to a close. The music stops. She gets up out of her seat and approaches the door. She tries to open it. Antoinette is right behind her and assists her in opening it, and she leaves first, heading in the direction of her mother in the waiting room, with Antoinette right behind her. _______________ * Throughout, both Barbara’s and Antoinette’s comments are indented (but not italicized).

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

CASE TWO Self-Communications in Creative Music Therapy Carol M. Robbins Clive Robbins, D.M.M. Abstract This case describes Creative Music Therapy with Lyndal, a nine-year old Australian girl with multiple handicaps. Through individual and group work aimed at developing her musical expressivity and interresponsiveness, Lyndal was able to find and set free the “music child” within her. The effects of this release of potential on various aspects of self are described. Introduction In answering a question, one communicates one’s self. This simple aphorism of Sufi thought (Corbin, 1969) captures the very essence of creative music therapy. Every time the therapist creates a musical idea, or offers a musical phrase, it is an invitation for the child to respond—a question for the child to answer; in repeating the child’s motif, or extending the child’s phrase, or complementing the child’s timbre, or in leading the child into another tempo or dynamic range, the therapist is in effect posing musical questions; and the child—in responding spontaneously to the music, the therapist, and the situation—is continuously communicating his or her self, and the state of the self. In doing this the child also communicates the individuality of that self—the inner directive will, its capability to assert or express itself or communicate its potentials as they manifest, and its inherent proclivities. So that in the child’s response we experience together with the self, the being-within-the-self. And it is in the being-within-the-self that the potential for creative development lies. In creative music therapy, the child’s self is developed from within—using inner resources—the most important of which is the “music child.” The “music child” is that part of the inner self in every child “which responds to musical experience, finds it meaningful and engaging, remembers music, and enjoys some form of musical experience” (Nordoff & Robbins, 1977, p. 1). This individualized musicality is inborn in every child, regardless of handicap, and reflects a universal sensitivity to music and its various elements. In order for the “music child” to function, the child must be open to experiencing himself, others and the world around him; for it is through these experiences that receptive, cognitive and expressive capabilities are

developed. Thus, it is the “music child” that answers the questions posed by music, and in so doing, communicates the self. When the child is disabled or handicapped in some way, the music child is encased within what we call the “condition child.” The condition child denotes the child as it has come to be, through the number of years it has been living with a neurological deficiency or a physiological condition, with some form of handicapping condition. A child’s personality develops in response to the life experience he or she can assimilate. Very often this development is limited, partialized, deformed, and incomplete—the child’s potential for development has not been released—a state represented symbolically in Figure 1 by an uneven, irregular form.

Figure 1. The Condition Child The condition child is obviously a self, the self that the child has been able to develop, or the present state of the child’s self. Then we find that in music therapy we can reach the inherent, inborn musicality, which is so fundamental to human nature. We begin to reach the music child, Figure 2.

Figure 2. The Music Child

First, the therapist becomes aware of an inner growth of awareness. Perceptibly, if all goes well in the early sessions, the child’s personality develops a new nucleus of selfhood which is formed in (or by) musical experience, through musical communication, through the beginnings of musical activity. This musical-personal nucleus then is nurtured, encouraged, challenged, supported, answered by the therapist and begins to take the individuality beyond the previous limits of its function, beyond the behavior barrier of the condition child.

Figure 3. The Old Self and New Self In the growing child-therapist inter-activity and inter-relationship the personality expands, a “new self is formed, and the former condition child becomes the “old self.” (See Figure 3 for symbolic representations). If a therapist is working with a child who is deeply neurotic, emotionally disturbed, or with what might be called a strong emotional overlay, you find that the old self remains, to some extent. Therapy then can lie in resolving the conflicts between the old and the new selves. The child is still going to be self-protective–an old mode of conduct–until it outgrows this need and old modes of life, reactions, habits or other limiting behaviors are replaced by new perceptions, a new sense of self, a new confidence in living. Method We would like to illustrate this process with excerpts from a course of creative music therapy with Lyndal, an Australian child. We worked with Lyndal over a period of four and a half years, in both individual and group sessions. The individual sessions centered on interactive improvisation, and the group sessions involved Lyndal in a musical drama. Creative music therapy involves two therapists working as a team, one at the piano and the other directly with the child or group. In individual work, musical improvisation is the predominant means of interaction with the child—it is the way that contact is established with the “music child:” ...the therapist will find the essence of music as therapy to lie in his improvisational creation of music as a language of communication between him and an individual child.

The “words” of this language are the components of music at his disposal, its expressive content is carried by his use of them. In the clinical situation he becomes the centre of musical responsiveness himself; the music his fingers draw from the instrument arises from his impressions of the child: facial expression, glance, posture, behaviour, condition—all express that presence his music will reflect and go out to meet. The flexibility of his playing searches out the region of contact for that child, creates the emotional substances of the contact and sets the musical ground for interactivity. The timing of his playing—its tempo, its rhythms and pauses—attentively follows, leads and follows the child’s activity (Nordoff & Robbins, 1971, pp. 143-144). In group work, the predominant means of accessing the “music child” is through learning, performing, and responding to specially composed songs, instrumental pieces, and musical dramas, and to the developmental content of such compositions. Background Information We first met Lyndal in September, 1984; she was then nine years old, and had just become resident at “Warrah,” a Rudolf Steiner special school in Australia where we were working and living. She was brain injured, mildly micro cephalic, hypertonic, and with some unsteadiness of gait. She was moderately mentally handicapped and emotionally unstable. Her behavior was fearful, stereotypic and, possibly because of frustration and confusion, selfinjurious. She reacted adversely to loud or unexpected sounds: dogs barking, sirens, car horns, doors slamming, and so forth. Even radio and television at normal listening levels provoked screaming tantrums and a self-injurious reaction in which she would repeatedly strike her forehead against a wall or other firm object. Beneath her bangs there was often a large contusion. She was a much loved child, but life at home for her parents and two brothers was constrained and muted. She had quite a bit of usable speech and could make her wishes known; she often repeated phrases continuously and inappropriately, apparently in the wish to make conversation. Lyndal had attended a state school for some years and had made some progress, although she remained on the sidelines in many school activities because she was so fearful, self-protective and behaviorally unpredictable. Treatment Process Don’t Play the Piano! Lyndal began weekly individual music therapy sessions shortly after being admitted to “Warrah”. Very quickly her responses revealed a dichotomy, a split. She always came eagerly to the music room, she possessed considerable inherent sensitivity to music and enjoyed it immensely. She liked to sing—preferably something she could imitate—and had a good sense of pitch. She was also sensitive to rhythmic patterns and the melodic rhythms. But in beating

the drum to piano and vocal improvisation she showed an instability that was linked to a disabling lack of self-control and confidence. At the drum she was over-vulnerable to musical stimulation and to the excitation of her own physical activity—and her beating always tended to break away into disorder. There was evidence that a drive to beat freely and strongly lived within her, but her reactions suggested that she was frightened of the power of her own impulsive energy and was repressing it. Whenever the music or her beating seemed on the verge of becoming too vigorous she would call out “Don’t play the piano!” or interject “See you later!”, her way of escaping the situation. She also developed a real anxiety about the large 16inch cymbal, and it had to go out of sight behind the piano. Gradually, in these sessions her responses took on some stability and it was apparent that—within limits she determined—she was beginning to place some trust in us and in herself, active in music. Lyndal Takes a Role After four sessions we temporarily suspended her individual therapy as rehearsals for a school play required schedule changes. We began working with the 35 children in the school on The Children’s Christmas Play (Nordoff & Robbins, 1970). The girl who was to have played Mary became ill and we asked Lyndal to take the part. When her parents were told they were pessimistic: “We hope Lyndal doesn’t spoil your play” was their concern. I assured them that this play was for the children, and that if it was necessary for Clive to be beside her throughout the entire performance it would be perfectly fine. In the rehearsals she was initially scattered and giggly; she behaved well but did not seem to have any idea what it was all about. When the Angel brought Mary the doll that was the Christ Child, Lyndal took it carelessly with a complete lack of feeling, sometimes holding it upside down. The turning point came in one rehearsal when, as the Angel approached Lyndal, seated in the stable, to present the baby, Clive made a big stretch upward with both hands, “Lyndal,” he said, “reach up to Heaven where it’s coming from!” The drama of the moment caught her, she imitated him—immediately attentive to the gesture—took the baby with much more awareness and held it as one would hold a child. We practiced this several times. Later that day, while Clive was walking outside, his and Lyndal’s paths happened to cross and she came toward him raising her arms high in the same receiving gesture, smiling with pleasure and satisfaction. After this she became serious about the play and seemed to feel her role in it. The play was performed to an applauding audience. Lyndal played her role securely, joined in singing the chorus parts, and sat attentively and quietly while other children acted out their roles. As the play approaches its ending, there is a rhythmic-speech chorus that builds to a climax on the words, “Hail King! Blessed is He! Joy! Joy! Joy!” These words are supported by strong chords on the piano, and as everyone bursts into the final chorus of “Christmas Bells,” the hand cymbals enter with repeating dramatic crashes. We did not realize at the time the impression the experience must have made on Lyndal; the mood of this Handelian finale was one of celebration: bells were given out and more and more children rang them to build up the crescendo—through all of this loud, vigorous music, the hand cymbals and the large cymbal on the stand added to the jubilation. Bells and both cymbals finished with a sustained fortissimo

tremolo. Lyndal showed no distress whatsoever at the very high dynamic level the music reached. Lyndal’s parents were deeply happy with their daughter’s achievements. We received a Christmas card from them with the simple message: “Thank you for having faith in Lyndal.” Am I Going To Play The Cymbal? Quite early in the New Year, before school began and her individual therapy resumed, she would ask us whenever we met: “Am I going to play the cymbal today?” If we asked her in return: “Well, are you?” She would reply, softly but firmly, and perhaps a little wistfully: “No.” It was obvious that the cymbal attracted her, obsessed her to a degree: to have had the freedom to let go and strike it forcefully with strength to produce a glorious crash, full of overtones and shimmer, would have been very important to this constrained child. The attainment of this freedom became one of the goals in our work with her. Lyndal resumed individual therapy, and had one session weekly, lasting on an average 15-20 minutes. Her fifth session begins in a way that typifies her response at this time: she comes running in with a bright eagerness, happily sings her greeting song, loses control the moment she starts beating the drum, then, as the therapist accompanies her disorder, calls out “Stop!” and becomes anxious. In this and the following session, Clive and I take our cue directly from her; we work to engage her perception of structure in music to stabilize her activity, develop her vocal and rhythmic skills, and build her confidence. Concurrently, we also gently lead her further into the area of freer beating where she becomes disordered; we want to explore her ability to acquire control over her reactions—and, at the same time, we work to familiarize her with this up surging of emotional and physical energy in herself in the hope that she can come to enjoy using it self-expressively. We intuitively sense that in this deeper, eruptive region of reaction and disorder lies the source of Lyndal’s self-injurious behavior, and that it could be therapeutic to engage this energy through improvisation and bring it into musical expression. Lyndal’s ambivalence continues, she is both drawn to the instrumental work and apprehensive of it. Carefully, she is led into using a very small cymbal (less than 6 inches in diameter) mounted on the cymbal stand. The trusting relationship develops as she requests activities and is secure in alternate moments in which we lead her into widening her areas of experience. She is always eager to show what she knows she can do—and at the same time very directly lets us know when she has had enough of a challenging activity. Gradually, a repertoire of shared music builds up and progressive connections are established, for example, the phrase she originally used as a means of self-protection, “See you later,” becomes transformed into a much enjoyed song in tango rhythm (Figure 4). In tapping the melodic rhythm to this song on the drum, Lyndal spontaneously uses the small cymbal to punctuate the phrases. This results in warm approval from us and cheers of self-congratulation from Lyndal. As a contrast in instrumental timbre, Lyndal plays resonator bells and is sensitive to the gentleness and lyric tonal quality of the music that is made with them: “Can You Sing To The Sun?” (Nordoff & Robbins, 1962). It is clear that in music her emotional life is being reached and

engaged with an immediacy not possible in other areas of experience. Her powers of concentration are also being exercised by the clearly structured objectives of much of the work.

Figure 4. Musical Excerpt 1 As the sessions proceed, her overall sphere of experience steadily deepens and widens, her attentiveness to rhythmic structure becomes more precise, and her ability to sustain focused work improves. In the eighth session a medium-sized cymbal replaces the small one and through a quiet improvisation, she is eased into playing it. Later, she is intrigued by the Phrygian mode and is able to sustain a short but controlled crescendo on timpani. When she does need to step aside from such a challenging activity she does it adroitly: using a beguiling tone of voice she diverts the therapists into a less threatening alternative, “Now! Carol, Clive, can we beat on the resonator bells?”–showing a more accomplished, healthier form of self-protection.

Although ambivalence shadowed her advances and each step forward was usually followed by nervous uncertainty, progress continued. Her confidence was steadily increasing, and this was fundamentally due to the nourishment her musicality was absorbing from the sessions. Her inborn musicality was such an important part of her personality that it was at the root of her personality development. By the tenth session, Lyndal is smiling and confident playing the medium-sized cymbal. She plays it carefully yet in a relaxed manner. She is responding with trust, as we encourage her to sing freely as she beats to dramatic music. In the fifteenth session, it is clear that much more was coming out by way of freedom and assertiveness. The work in this session sometimes sounds like a child making lots of noise, but it is Lyndal—a nine-year-old who always felt apprehensive, kept herself in, always suppressed, and always constrained, except when she banged her head on a wall in utter fear and frustration—now releasing this energy openly through the joy of music. How she needs a situation in which her feelings are accepted, enhanced and made communicative and selfexpressive! In this session, Lyndal beats to forceful, serious music over a range of tempo. As she beats she raises her voice, and holds high tones. Then, to music in a Spanish idiom, she uses the cymbal with the same strength with which she is singing. Although she beats strongly, she moderates the cymbal’s power by using it rather slowly, such as by beating on the first beats of measures (Figure 5). At no time in the session does she shrink from the intense coactivity.

Figure 5. Musical Excerpt 2 Free At Last We had visitors observing the sixteenth session, and Lyndal seemed to have decided from the very first moment and maybe because they were there, that this was the day to really let go. The session quickly built up to a high level of intensity and the dramatic discharge of energy overwhelmed the visitors. They were taken totally by surprise and sat in stunned immobility. Later they admitted that they were actually frightened by the power of the music and by Lyndal’s unrestrained singing and use of the drum and cymbal-so much so that they failed to see her rapturous beam of joy as she achieved the catharsis she had been seeking. The excerpt below shows the very vigorous compelling fortissimo music that was called for by

Lyndal’s forceful beating. I attempt to sing in a way that totally projects my energy into the room. Lyndal sings out freely as she is borne along by the drive of the penetrating rhythms and dissonances of the piano. At 160 beats per minute she can hardly control her beating. Our music-making together has an intensity that borders on the maniacal, yet it has purpose and direction. When I sing short dramatic phrases, Lyndal begins to use the cymbal—first to punctuate them, then accent them (Figure 6).

Figure 6. Musical Excerpt 3 As the improvisation rises to a climax, Lyndal’s cymbal beating becomes continuous. She sustains a crescendo for over a minute, much of the time beating as hard and as fast as she can. Her tempo attains 260 beats per minute. The room rings with cymbal crashes, overtones, piano, and voices. Who would not love to do that, to be that free, that unrestrained, that unconventional, that unlimited by the norms of behavior! And add to this dynamic of experience what it must mean for Lyndal! Of course, our visitors were in a state of shock; they had no way of knowing what was going on. They knew nothing about Lyndal or where she was coming from, and this was unlike any experience they had had. Where would they have heard music like this unless in a very dramatic or adventurous film, or possibly an opera? As the vigorous improvisation comes to a close, Lyndal calls out: “Now sing!” She sits beside me at the piano and joins in singing phrases antiphonally. I lead her into a world of music in total contrast to the preceding rhythmic percussion: the improvisation is in a moderately slow 3/4 and the experience is lyric and thoughtful; melody and harmony predominate (Figure 7).

Figure 7. Musical Excerpt 4 Lyndal is utterly attentive, she sings the melodic phrases accurately while responding to their rhythms on a drum with her hands. She anticipates repetitions of rhythmic structure and sensitively follows a ritardando and diminuendo. Then she asks for a reed horn and blows rhythmic patterns antiphonally with me. The session closes with Lyndal singing her good-bye song very freely, and bidding goodbye to the stunned, perplexed visitors. After this session, Lyndal’s parents reported that there was an immediate effect on her tolerance of “family” sound levels; she was no longer upset by louder or unexpected noises—all sounds at home could go up to normal levels. Reports from the school and residents at “Warrah” also indicated that the head-banging was diminishing and that the contusion on her forehead was healing. It was absolutely necessary to generate this dramatic intensity of music-making to enable Lyndal to achieve her “break through.” If one considers all of the great dramas, whether in theater or opera, they are essentially concerned with emotional disturbance and the conflict and pain this brings about—and perhaps the struggle toward resolution. So it can be in music therapy with emotionally disturbed children—they too can be in highly dramatic situations and making what for them are enormous steps. Such happenings are not little events! An

achievement like this is a world-changing event! And it is wonderful that the power of music can support such developments—it nourishes the inner growth of these children. Stage Two After a transitional period in which Lyndal consolidated her new gains and confidence, we entered what was in effect “stage two” of music therapy with her. By this time, she sings and uses a variety of drums; the cymbal work now includes the two large cymbals in use in the regular group work. In the 30th session, Lyndal’s wish to use a large cymbal freely is well illustrated when she raises both mallets high above her head in time for the last note of a melodic phrase— apparently about to beat with great strength. Instead, she brings her arms down slowly with utter caution, makes contact with the cymbal gently and leaves the mallets resting on it to damp the sound. Despite her caution, her use of the instruments develops steadily: her tempo range is widening, her control is improving, and her movements are larger and smoother. She has acquired some poise and is becoming noticeably more graceful. Clive and I work directly for greater physical freedom—for with Lyndal, physical freedom promotes emotional freedom. There is a noticeable air of confidence about her that sustains a positive level of working relationship with us. She participates, willingly, in music and songs developed to widen her circle of experience. During these sessions, Clive begins to raise both cymbals high to extend her reachingbeating movements. Her technique of cymbal playing, in which the beater simultaneously strikes and damps the instrument, is defeated by Clive playfully withdrawing the cymbal as she strikes it, so leaving its tone sounding freely. She sees the humor in what he is doing and goes along with it. Impulses to beat the large cymbal firmly progressively break through. In her 40th session, seated at the piano beside me, Lyndal participates in a creatively free vocal exploration that takes her up to the G above the staff. As she sings she often plays the piano freely, with an appropriate musical style. She is relaxed, smiling, confident, obviously enjoying the vocal competence she is discovering and the mutuality she shares in singing with us. In these last weeks of our work with her she uses the cymbal proficiently, with decision, and no hesitancy whatsoever. She successfully masters a challenging part on a metallophone in the Shaker Waltz, (Pinson, 1988), and works hard to sing The Prayer of the Little Ducks (Nordoff, 1983), which she then performs as a solo before the whole school—a new and important achievement for her. Discussion and Conclusion Lyndal’s general development showed a rounded maturation: she had become quite a self-confident adolescent; she could hold conversations, could function better at home, and had become the leader of her class at school. She had released and realized much of her potential. We experienced this at first hand on a visit to Australia in 1990, when we were asked to make a television videotape with her. After not seeing her for fourteen months, we found in

our warm-up session that all her music was still alive within her. As she was filmed the following day in a twenty-five minute demonstration, she was radiant! It was so moving! She is such a self-possessed young lady now, and greets people with confidence. We have truly seen her changing in her personality, in herself, the self that she presents to other people, the self that she lives with. She now verbalizes her concerns and frustrations, and the self-injurious behavior has completely disappeared. All through this work she has lived in a very supportive environment at “Warrah.” This study of Lyndal shows well the effect of central focused therapy, supported by several peripheral contributing therapies. What growth occurred in music would be taken up and developed in the environment; conversely, the security and courage she gained from the environment would play over into the music sessions—a very beneficial cycle of events. In conclusion, let us look again at this concept of the “music child” present, not only in Lyndal, but in all children. If the “music child” is capable of changing the personality and changing it permanently—and of releasing developmental potentials to give the unfolding personality such a positive sense of identity—from where does it get the power to do this, to be a self-creating force within the self? In answer, we reintroduce a concept we considered earlier, one that will complete this working model: the “being within the self.” We can term this the “being child,” and find that it is contained within the music child (Figure 8).

Figure 8. The “Being Child” Within The “Music Child” As the child develops, the “old self disappears or dissolves, its remnants transformed and absorbed into the “new self.” This process can be described in terms of the four major psychological orientations: behavioral, psychodynamic, humanistic, and transpersonal. Quite often, as was evident in the work with the outer expressions of Lyndal, we are, to quite an extent, working behaviorally—we all must, of necessity, work with behavior. As you work to resolve, within developing children, the tensions that lie between the old self and the new self, you are also working psychodynamically, either on a practical level, where children’s musical activities themselves symbolize inner needs or drives, or with clients who can articulate their inner lives verbally, in more traditional ways. In the centre of the diagram, in the region of

being, music therapy is directly involved in self-actualization—which is the core of the humanistic force in psychology. Self-actualization in this context is also transpersonal insofar as we are, through creative music therapy, calling beings into existence that have not existed before. There has been the potential but it has not been actualized into existence before. This may appear to be over-reaching, or presumptuous, but we are all working with the inner lives of children—and we are working for their futures, for every year of their lives to come. We are working to bring basic, fundamental changes to human beings. We are working at considerable depth, much greater depths than often we understand. This viewpoint is part of the humility we should have in taking this art of music into therapy—because of all that’s there in the music itself: music as it has been handed on to us through the whole of human evolution, through all that the great composers have evolved in their explorations of form, melody, harmony, rhythm and expression, through all that lives in the music we have inherited from all the folk of the earth.

Figure 9. Orientations of the Self As music therapists we have this glorious task, involving two glorious arts: the art of evolving a human personality out of itself through another art which enables us to communicate with all the dynamics that are potential there. One runs out of concepts and words eventually, in trying to put what music therapy is into words.

Glossary Hypertonic: Having excessive muscular tension. Micro-cephalic: Having an abnormally small skull. Moderately Mentally Handicapped: Generally denoting a person testing in an IQ range of 35-49. Stereotypic: Having fixed, repetitive patterns of speech and behavior. Acknowledgement The authors would like to thank the New Zealand Society for Music Therapy for its permission to revise and reprint this case study, which was originally published in the Society’s Annual Journal (1990). References Corbin, H. (1969). Creative Imagination in the Sufism of Ibn Arabi. Translated by R. Manheim. London: Routledge and Kegan Paul. Nordoff P. (1983). Some Prayers from the Ark. Bryn Mawr, PA: Theodore Presser. Nordoff, P. & Robbins, C. (1962). The First Book of Children’s Play songs. Bryn Mawr, PA: Theodore Presser. Nordoff P., & Robbins C. (1970). The Children’s Christmas Play. Bryn Mawr, PA: Theodore Presser. Nordoff, P., & Robbins, C. (1971). Therapy in Music for Handicapped Children. New York: St. Martin’s Press. Nordoff P., & Robbins C. (1977). Creative Music Therapy. New York: John Day Co. Pinson, J. (1988). Mallet Magic. Denton, TX: Home Church School Resources.

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

CASE THREE Creative Music Therapy in Bringing Order, Change and Communicativeness to the Life of a Brain-Injured Adolescent Clive E. Robbins Carol M. Robbins Abstract Two therapists work as a team, using improvised music to engage Hilary, an acting-out adolescent girl with brain injury. Through the creative process, Hilary learns to channel her natural impulses into musical expression and interaction. As this occurs, she is able to bring order, change, and communicativeness into other aspects of her life. Introduction Music is, above all, a means for bringing about changes: changes of mood, changes in relationship, changes of attitude, changes in attentiveness. One has only to consider how, in a lively, enthusiastic group sing-along, songs in various moods directly influence the participation of the singers. As an agent for the transmission of energy, stimulation, joy, warmth—and order—music is unique. In contrast to the melodic-conceptual experience of singing, consider moving to music, as, for example, responding to the compelling impact of tribal African drumming. How physically animating the beat and polyrhythm’s are! How the timbres of the drums speak the rhythms directly into our bodies! And yet how directional such drumming is, what purpose it has! How it communicates the power of the body’s need to move rhythmically! In considering the kinds of changes that we work to bring about in a client in therapy, it is important to realize that sometimes our wish to bring about a particular change can be misplaced. We can only change what is inherent in the functional possibilities of the organism— to the extent that these make changes possible. Should the damage or the disturbance be extensive, such changes as may be achievable must lie within these possibilities. However, we must not underestimate what changes could become possible through a creative approach, especially when the explorative nature of music therapy based on improvisation discloses areas of ability and sensitivity which would otherwise remain undiscovered. The all-important area, in which we can bring about change, is personality development. Here we can, through music, often bypass some of the organically-based dysfunctions that hinder competent functioning in life. This is where improvised music can play such a vital role in treatment. In working interactively with a client, a therapist can improvise ways around the

barriers, around the difficulties, to reach the living sensitivities, and then work into the problem areas, where creative work has the possibility of releasing potentials for resolution and development. Let us consider the act of creation, or creativity, which is so intrinsic to the level of clinical musicianship we are considering. Those who consume music passively tend to think of creativity as something ephemeral, arbitrary, perhaps haphazard and undependable, and lacking in substantial reality. But a glance at the world of music will quickly demonstrate that the products of creativity are anything but insubstantial. Every piece of music that is important to us—that we are swept along by, enjoy in a particular personal way—has been created. Before it existed, it was inconceivable. But some musician, or group of musicians, has a musical idea, and then begins the process of creation. It might last three minutes, it might last three years, but through this process an experience is realized that becomes part of the very fabric of life. Recognize that once all the music we respond to did not exist, and then through countless acts of musical creation, came into existence. And from being nothing before, now it exists. Realize how firmly it stands in our consciousness: how we carry it around with us, what a vehicle it is for us to share in, what strength it has in our emotional lives, our mental lives, our spiritual lives. It is extraordinary! The rich musical furniture of our lives, everything from folk music to film music, Scott Joplin to Bartok, all has come into being through this process of creation. The potential impact of musical creativity transfers directly into the processes of music therapy. When a therapist works individually with a client through improvisation, he or she will be called upon to create, or adapt, in response to clinical situations, themes with which that individual comes to identify positively. These themes then become sources of nourishment for individuation, express much of the content of the client-therapist relationship, and provide significant opportunities for interaction and intercommunication. Such music, generated spontaneously in response to clinical events and needs, becomes uniquely substantial to the person in therapy. Method This clinical narrative provides an illustration of “Creative Music Therapy,” an approach originally developed for handicapped children in 1959 by Paul Nordoff and Clive Robbins (1977). In its individual application, the approach involves two therapists working as a team with a single child, with improvisation as the focus of the creative therapy process. One therapist improvises at the piano, creating music to engage the child in a therapeutic experience, while the other works directly with the child, helping him or her to respond, either instrumentally or vocally, to the improvised music and to the clinical intentions of the therapist at the piano. The therapists work as partners with clearly defined and equal roles and responsibilities. Each session involves creating an individualized musical repertoire for the child—one that capitalizes on the child’s innate musicality and reflects the child’s unique personality. This musical repertoire is created by the therapist cumulatively, session by session, motif by motif, line by line. Several basic concepts are involved.

First and foremost, the therapist improvises music which accepts and meets the child’s emotional state, while also matching, accompanying, and enhancing how the child is expressing it. It is important for the therapist to respond to the child from moment to moment, often supporting every musical response the child makes, no matter how fleeting or incipient, and musically seizing upon every opportunity to explore its expressive possibilities. The therapist works to evoke either a vocal or instrumental response, depending on the natural propensities of the child. As the child formulates each response, the therapist creates musical situations and activities that encourage the child to further develop the response—to gain some measure of mastery over the music. In doing so, the therapist motivates the child to acquire musical skills needed to participate more fully. Through improvisation, the therapist is constantly “sounding out” the character and extent of the child’s responsiveness, and stimulating, answering, or stabilizing the child’s activities as clinically appropriate. With the acquisition of each skill, the child is musically guided to discover new expressive options and choices that the skill has made possible. In the process of discovering musical possibilities and gaining musical skills, the therapist also engages the child in communicative dialogues, thereby showing the many ways that the child can relate his/her musical expression to that of another person. The child, increasingly confident in personal musical expression, learns how to be inter-responsive. It is essential to the practice of this approach that each session be fully documented with the aid of an audio or video recording, thus ensuring continuity of clinical technique and a clear perception of all phenomena pertinent to the child’s response process. This gives essential clinical guidance for subsequent sessions. Any improvised music that has been important is transcribed so that it can return as an ongoing theme in therapy. We would like to illustrate creative music therapy by describing our work with a 16year-old girl at Inala, a Rudolf Steiner special school in Sydney, Australia. (“Inala” is an Aboriginal word for “peace”). To know this young lady, and the severity of her disabilities, is to realize that the only way you can do anything for her—apart from entertain her and perhaps lighten her mood—the only way you might bring about a significant change is through improvisation. This means a leap into the unknown from the first moment of the first session, to find out what responses music can stimulate—and then support to foster and advance communication. How will a therapist achieve musical interaction with her? She is a multihandicapped person—it quickly became evident that how she manifested in music was symptomatic of her condition. Background Information We want to introduce Hilary not as a “case study” but as a human being who is following a path. And we, as her therapists, are about to find and take a new path with her. We cannot know where the bends will be, where that path will lead us. When working with improvisation, working creatively, there is no recipe—as that would remove the spontaneity, the livingness, the creativity, and the wonderful unexpected moments of unfolding and discovery. When we first began working with her, we did ask for case material, but inquired only about relevant medical problems, such as severe epilepsy. We wanted to meet her as she

would be in music with us—to form and work freely from our own uninfluenced perceptions. Once our independent clinical assessment was made, that would be the time to study her case material. Hilary was born in 1966. She was very much a wanted child as a long series of miscarriages and misfortunes preceded her birth. Pregnancy was difficult, birth was induced, and delivery was instrumental. Though difficult to diagnose with any certainty in infancy, it was later to be evident that Hilary had sustained brain damage. There were early breathing problems. Abnormality was noted at 15 months, and all the developmental milestones were late. She did not develop speech. There were some physical disabilities: she had poor balance and was unsteady on her feet, walking in little shuffling steps a good deal of the time. She was frightened of heights and stairs. Generally, she was placid but overreacted to loud noises. When she was three, she began to react adversely toward other children and became withdrawn for long periods. She first attended Inala School as a day student. As she got older, her behavior problems worsened with tantrums and the pulling of other children’s hair. At six her parents requested that she become resident at the school. Her behavior problems continued. When Hilary was 16, her future became uncertain. She was uncooperative, stubborn, and disruptive in the classroom. Her behavior was threatening to prevent her admittance to the Activity Therapy Centre (a sheltered workshop for moderately to profoundly disabled adolescents and adults) and she faced the real possibility of institutionalization. At this time we were asked to take her in the hope that music therapy could effect a positive change. Once weekly sessions were scheduled. We will describe the first four sessions in some detail, because this is where the major changes began to take place. Treatment Process First Session Hilary comes willingly to her first session, but is very tense; Carol repeats a “Good Morning Hilary” phrase to her, trying to put her more at ease. I notice her fingers trembling, and when I give her drumsticks, there are short bursts of fast, tense beating, most of it around 260 beats per minute (bpm). On the cymbal she beats forcefully at 190-220 bpm, drowning out the music that Carol is improvising to meet her. As part of the exploration, I sit Hilary on the piano bench. She touches the piano keys twice then attacks Carol, grabbing her hair, pulling her head down. Carol goes with the pull, singing gently while undoing Hilary’s grip. Hilary then grabs at Carol’s skirt and knees. She is strong. She yells once as we try to calm her. I return her to her chair, near the piano but not close to it. She listens quietly as music is played and sung to her. Her agitation diminishes over the next several minutes and she is calm when taken back to her classroom. We noted in detail all aspects of Hilary’s reaction and response. Most of the music had been improvised to meet her disturbed state, but because this did not recur (she never attacked Carol again) and the music was not appropriate to the coactivity that subsequently developed, it was not used again. However, the melodic phrase with which Carol greeted her at

the beginning of the session did become part of her repertoire, becoming extended in later sessions. It was in a Mixolydian mode (Figure 1):

Figure 1. Musical Excerpt 1 Second Session Hilary is noticeably happy to come to the session with me. She still shows much tension, but I also see a spark of anticipation. I bring her to the drum as in the first session and again she beats in a fast, driven tempo, 200-260 beats per minute (bpm). She is aware of Carol’s improvising, and her beating becomes responsive to the music at times, as when she stops beating at the ends of phrases. It appears that Hilary gains support from the music, she beats more confidently when the music is stronger-and often stops when the music is soft. She is obviously intent on having Carol make music for and with her. She makes a sound of pleasure when Carol begins to sing. We perceive her sensitivity. Experimentally, I place a large timpani before her. At first, to encourage her listening, Carol plays gently using arrieggiated chords. Hilary impresses us with her self-restraint as she holds back her beating to this soft music. After a minute or so Carol introduces vigorous, forceful music to release Hilary into free strong beating. She needs to do this and seizes the opportunity immediately, beating the timpani energetically in the tempo of Carol’s bass octaves at 200 bpm. (See middle of Figure 2). As Carol brings the vigorous music to a close and returns to softer music, Hilary finishes her beating with a flourish which contains a clear, rapid triplet. It seems to originate unconsciously, but it tells us that rhythmic ability is latent within her. She is keen to continue and chuckles as she beats.

Late in the session she spontaneously beats to soft music at 200 bpm and follows a ritardando to 170 bpm. In an improvised “Goodbye song” her beating shows her sensitivity to dynamics. She smiles a number of times. After the session ends, I escort her to the girl’s toilet and, while waiting outside, I hear her screaming. Questions leap into my mind: Why, after such a promising session? Was she

Figure 2. Musical Excerpt 2

angry that she had to leave the music room? Could it be that in the improvised music and in beating with it, Hilary had experienced a special kind of release and freedom that carried over into this letting go of some of her feelings? The kind of liveliness of contact that she felt in the music was definitely unattainable in her daily life—where else in the normal circle of her life could she be this activated-even though she was in a fine school? She must have found the session stimulating and satisfying; perhaps then, the screaming arose as a way of readjusting to the norm. It occurred to me that there was something quite positive about Hilary finding a private place to scream! In a little while she returned quietly to the classroom. Further insight can be gained from studying Hilary’s way of making music against the background of a comprehensive examination of the clinical and experiential significance of tempo and dynamics. Figure 3 presents a “Tempo-Dynamics Schema” derived from studying the responses of over 200 variously handicapped children in improvisational individual music therapy (Nordoff & Robbins, 1977, p. 158-159). When a fast tempo is determined pathologically by the present condition of the child, one finds that it originates in nervousness, tenseness, hyperactivity, over excitation, obsessiveness, or in resistiveness, in which the child is “running away” to avoid contact through the music with the therapist. For the improvisational therapist, these reactions are much more vividly real than the words can convey: there is a directness and clarity of emotional communication when the therapist is creating music with the child. There is an immediacy of understanding if one follows and lives in the child’s sounds moment to moment. In contrast to the pathology driven fastness is a fast tempo which originates in normal musical experience. The normal range of fast tempos can bring activation and alertness, buoyancy, and a host of qualities that can open up musical enjoyments such as joyfulness, gaiety, playfulness, happy excitement, and fervor. It is interesting to note how all of the pathological states associated with fast tempos are self-isolating, whereas the normal musical experiences of fast tempos bring sharing and uniting with others. When seen in this way, the schema provides a map of musical terrains that can guide the therapist in bringing about change. Through the give-and-take of improvisation, changes in tempo can bring the condition that is on the pathological side over, as this is possible, into the area of normal musical experience: to take what the child is driven to do, and through putting music to it, make it a shared experience in which new, more satisfying emotional experiences can be generated. The dynamics of music can be used in the same way. When a drum or any instrument is beaten loudly, and when this originates in a pathological state of being, one hears aggression, frustration or anger; or as so often observed in emotionally disturbed children, adolescents, and adults, the sounds reflect a lack of impulse control, emotional-motor discharge, nonresponsive assertiveness, and the resistiveness of “shutting the other person out.” In contrast, the loud dynamic in normal musical experience conveys animation and eagerness, exuberance, assertive freedom-all very positive qualities-confidence, and climactic fulfillment. The universal significance of musical tempo and dynamic is nicely illustrated by the true story of an African drummer from Zambia. Whenever he became burdened with a certain emotional disturbance, he would get up in the night, awaken his two wives (both of whom were competent drummers), and then work through his disturbance rhythmically. The drumming allowed him to discharge his emotional tensions with the empathic support of his

musicianly wives, who alternately followed and led him through various modes of rhythmic experience: from fast to slow and back, and from loud to soft and back. In terms of the schema, the man needed an emotional-motor discharge, in which he could assert himself and determine his own course of action, while still being supported by others beating with him. This shared release helped his drumming to become expressive and communicative. He could somehow “objectify” his feelings and their transformations—and therein be healed. TEMPO AND DYNAMIC SCHEMA IN CREATIVE MUSIC THERAPY Pathologically Determined Normal Musical Experience FAST TEMPOS

SLOW TEMPOS

LOUD TEMPOS

SOFT DYNAMICS

Figure 3. Tempo-Dynamics Schema In Hilary’s first session, her loud cymbal beating had the character of aggression, even anger. In the second session, she moved into loud drum beating, which seemed to come more from frustration. But as Carol took it up with minor, purposeful music, you could hear animation and eagerness coming to expression in her beating. Already a change was beginning.

Third Session Hilary is eager and excited as she enters, but inhibited at first, unable to respond freely. When I give her the drumsticks, they tremble rapidly in the air. Her initial beating comes about as she tentatively brings the trembling drumsticks into contact with the drum—it is soft and fast, 360 bpm. It suggests tenseness possibly compounded with fear. Carol plays to match and meet her mood, and when she begins to sing, Hilary makes a sound of pleasure—in the same key. After much encouragement, Hilary begins to beat with a little more intention at 285 bpm. Carol carefully improvises to support her, and Hilary’s beating becomes sustained. Her face relaxes. A lightness and delicacy emerge in the shared music. Hilary’s tempo comes down to 250 bpm. When Hilary has found her confidence and Carol feels she is in secure contact with her, she improvises a song to bring in the experience of a slower beat (Figure 4). The song is in waltz time and begins at 90 bpm: “Let’s play a song, Hilary’s song, Let’s play a song, together. Hilary can play a slow song, together, together, together.”

Figure 4. Musical Excerpt 3

As the song is repeated Hilary beats the cymbal rapidly several times. Her beating impulses seem to begin in double tempo, two beats to Carol’s one, but then quicken into cymbal tremolos. To give her an experience of beating in a slower tempo, Carol asks me to guide her, and adapts the song to include my name. I take Hilary’s left hand and beat with it to the song, now at 75 bpm; she makes an exclamation of pleasure. When I release her hand she accelerates until she is beating at 300 bpm—subdividing the beat exactly by four. Hilary feels the pulse of the music, and is drawn to unite with it. Yet within her is tenseness that she can only discharge in fast tempi. But also within her are musical sensitivity and a sense of rhythm which, in a way we do not yet fully understand, somehow take over and order her “discharge” beating by bringing it into a 4:1 relationship with the slow tempo. She does not do this consciously by deciding: “Now I will beat four beats to one.” Something much more primal takes place: as the internal pressure accelerates her beating toward the rapidity it needs for discharge, her hearing, musical feeling, and sense of rhythm bring about this concurrence, in this example through beating sixteenth notes. This ordering must happen at a subconscious level, but once it has happened she is able to hear and feel the concurrence, and so feel the release of the discharge within the secure pulse of the music. Carol’s earlier improvising in the tempo of her fast beating must have given her a personal feeling of being accepted-while, at the same time, “making musical sense” of her need to beat fast. This imparting of musical meaning to the fast beating would have already contributed to the awakening of her musicality and so, to some extent, have prepared the ground for the beating of multiples of the basic beat. This now becomes part of her way of responding, it is just beginning; she will go on to do more of it. As the session continues, I take her left arm again and beat to the song at 80 bpm; Hilary joins in with her right arm, beating in the same tempo. Clearly this is her beating impulse. I am only guiding. Again she enjoys the movement together and laughs. I let her arm go free and very steadily she accelerates to exactly two to the beat, stays with this for some moments, and then accelerates further. At the piano, Carol goes with the accelerated beating until a ritardando seems musically inevitable: as if it is the right segue into a repeat of the song. Hilary stops immediately—the ritardando heightens her awareness of the music. She waits as Carol’s momentum unwinds to a natural conclusion, then recommences “a tempo,” beating with the song at 85 bpm. She stays in the tempo to the end. Hilary’s control in the accelerando was remarkable! She was not letting herself simply “run away.” When the music paused she stopped and waited until it continued. An inner control is beginning to show. The session draws to a close with the “Goodbye Song,” after which I experimentally invite Hilary to sing—something we have never heard her do. As I sing freely, Hilary laughs in a musical voice. Fourth Session Hilary is very keen to come to music, and enters the room stamping her feet in excitement and humming with pleasure. Carol sings “Good morning” to her–this time

introducing considerable rubato-Hilary watches and listens with total attention; the rubato brings the element of suspense into the song and she smiles as she receives the greeting. It is so important in therapy to get out of a metronomic beat whenever it no longer serves its purpose—that of keeping the music or the music-makers together. Certainly a metronomic or fixed beat is absolutely necessary whenever rhythmic regularity is required or, for example, in group singing, when everyone has to know where they are in the music in order to stay together, similarly in movement to music. But the moment an improviser or performer brings in a pause, a fermata, or a ritardando, an expressive element is introduced. This arouses keener listening—one listens not because the music takes place on a predictable beat, but because a melodic statement is being made in its own time. The melody or musical statement does not have to move for any other reason than that the musician wants it that way. It is not driven by a beat, and this makes one much more attentive to it. This can add a living sense of immediacy to a song, especially when you are singing 1Q a child. Thus, there are times in therapy when you need the predictability of the beat, and times when it is important to get away from it. As the session continues, Hilary starts to beat confidently in tempo with the song, 120 bpm, and then accelerates with impressive and steady control to 265 bpm. Carol accelerates all the way with her. Hilary seems to be bridging something in her. She made this measured accelerando from the tempo of Carol’s music, in which she began because she is musically sensitive to the fast beating which she still needs to do. What inner process is involved in this? This is the second time Hilary has presented this kind of response: she did not jump from one tempo to the other, but accelerated gradually across a range of tempos. She was linking her response to the music we were presenting with what she needed to do out of her state of self. She was connecting and integrating. There was something moderating at work—she was filling in a gap between sense impression and the tenseness and energy that comes to expression in fast beating. Often, in this kind of work, it happens that a therapist has an intuition. At this moment, Carol decided not to go with Hilary’s fast beating, but to hold a constant tempo and see what would happen. As Carol sets a tempo of 75 bpm, Hilary immediately beats multiples of the beat: 3:1 (225 bpm); a sequence follows in which she changes quickly from 3:1 to 2:1 and back to 3:1. When Carol sings and the tension of the music increases, Hilary’s beating goes up to 4:1 (300 bpm):

Figure 5. Musical Excerpt 4 She stops, waits, recommences at 4:1, then drops to 3:1. She pauses again when Carol makes a diminuendo; as the dynamic is increased she beats again at 3:1. Carol now plays with her fast beating. This happens over a fifty-second period. Carol decides to go further into structure by introducing an eight measure phrase in 3/4, in G minor, ending with a clear cadence (Figure 5). We had heard Hilary stop beating many times at the ends of phrases—can we now use this perception deliberately in a short piece of rhythmic structure as a basis for work together? Carol plays this phrase, stopping on the tonic and raising her hands off the keyboard in a clear visual signal to stimulate Hilary’s control; Hilary beats in the tempo, 165 bpm, and stops five beats after Carol. To a repeat, she stops three beats after Carol. The third time she beats faster than the tempo and stops about two beats early-she looks cheekily at Carol as if to say “I made you stop this time!” We all laugh. The fourth time she again beats fast and deliberately continues long after the therapist has stopped, laughing in a spirit of devilment. The fifth time, she “overheats” by about six beats. Later in the session when we come back to this activity, Hilary picks up the tempo more surely and responds attentively. This time Carol plays the phrase, and Hilary beats in tempo, 160 bpm, adding only two beats beyond the phrase. To a repetition, she beats three beats beyond the stop. The therapist takes this principle of coactivity into “Hilary’s Song.” Hilary beats at 3:1 to the slow tempo. She stops one beat after the end of each of the first two phrases. She stops before the end of the next phrase, out of her keenness to participate, for she is watching Carol closely.

Figure 6. Musical Excerpt 5 As the song leads into a climax Hilary beats vigorously; Carol accompanies her fast beating with the accompaniment while singing the song. Although she is animated, Hilary stops precisely at the end of the next phrase. Carol then begins the next phrase in a soft dynamic, Hilary beats quietly. The phrase is short but she is concentrating and stops exactly again. She laughs with recognition at the musical humor in what they are doing. She sustains her attentiveness. I then stand behind Hilary and, holding her arms, guide her in beating at 55 bpm. She enjoys the assertiveness of the slow tempo and the accompanying music. As she beats, I move my hands up her arm until she is beating alone but can feel the support of my hands resting on her shoulders. She begins an extremely well controlled accelerando that reaches 125 bpm and holds it for eight measures. Her tempo then gradually rises to 210 bpm, where it stays for over 30 seconds. Throughout the accelerando she watches Carol keenly, obviously aware that they are making this musical adventure together–and enjoying the freedom of being a co-creator. The accelerando is led to its climax at 300 bpm, then Carol and I take her back to slow beating at 70 bpm. As Carol begins the “Goodbye Song” Hilary joins in the singing. She does not have the language or the vocal control but the quality of her commitment is unmistakable. She sings through the first two phrases; her voice is soft and breathy but she sustains her tones and some are on pitch. It was in this session that Hilary began to consolidate her involvement and abilities in music: she brought more control to bear on her urge to accelerate into faster beating; the compulsion to beat fast was becoming increasingly ordered by the rhythmic responsiveness of

her multiple beating; she was gaining the control required to beat in a soft dynamic; slow and moderate tempos were coming into her tempo range; and she could participate closely with the therapist in a recognized goal in rhythmic structure. As music was now such a uniquely important area of activity, experience and relationship for her, consolidation in musical participation would mean, in an intimately real sense, consolidation of self. It is not surprising that with this positive feeling of her own self, and her living pleasure in the music, Hilary should spontaneously attempt to sing–and sing a song to which she felt attached. Subsequent Sessions This brief singing apparently brought Hilary to the limit of her abilities. She did not sing again in music therapy until her 30th session, and then not until two years later, although vocal expressions of pleasure were numerous. Her individual sessions, averaging about 17 minutes in length, continued on a weekly basis. On the afternoons of the days she had her individual sessions, she, together with several older girls, sat in on a group activity with a class of eight to 10-year-olds. These sessions brought her much enjoyment. She was included in greeting songs, and sometimes taken round to greet the children. She was gentle with them, and they were unafraid of her. While watching and listening to the singing games she could be seen hugging herself with pleasure.

Figure 7. Musical Excerpt 6 She was an ebullient “dancer” but, being unsteady on her feet, needed support. Even so, she could overwhelm her partner with the vigor of her movements. At this time, she also became an enthusiastic member of an adolescent music group. Most of the effects of music therapy became evident in her school and hostel life by the twelfth session. She was lighter in mood, happier, more amenable and receptive. She seemed fulfilled, more complete as a person. It was noticed that she walked more purposefully. The aggressive behavior almost completely stopped, and only reappeared when she was unusually stressed or upset. Later it ceased entirely. Her teacher, an older woman with considerable experience with the handicapped, was outspoken about the positive changes in Hilary since beginning music therapy. Her individual work continued to be essentially rhythmic. Her slowest tempo came down to 75 bpm, which made a wider range of musical experience possible. She spent about half her sessions at the piano, playing single tones in each hand with Carol’s supportive, responsive improvisations. She reached a stage of freedom in her playing which, to anyone who knew her line of progress in music, would be recognized as being creative. We continued taking her over the next two years as the staff of the school felt that her individual sessions were especially important to her. A year later, when she moved to the Activity Therapy Center, her sessions were reinstated for some months to support her during the transition. Altogether she had 55 sessions of individual therapy. She went on to join a music group of adults from the Activity Therapy Centre. Acknowledgement The authors would like to thank the Australian Music Therapy Association for its permission to revise and reprint this case study, which was originally published in its proceedings of Thirteenth National Conference of the AMTA (1988). Reference Nordoff, P & Robbins, C. (1977). Creative Music Therapy. New York: John Day.

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

CASE FOUR Like Singing with a Bird: Improvisational Music Therapy with a Blind Four-Year-Old Jo Salas David Gonzalez Abstract This case describes a 10-month period of music therapy with Gabriela, a four-year-old girl with osteopetrosis, bilateral optic atrophy, and resultant developmental delays. The dramatic changes in Gabriela’s functioning while in music therapy sessions are discussed, along with musical, interpersonal, and archetypal elements which contributed to the effectiveness of the therapy. Background Information At the time of this study, Gabriela was a four year-old girl attending a full-time program at a child development center for visually and neurologically impaired children. She was diagnosed as having osteopetrosis—excessive calcification of the bones—which had caused bilateral optic atrophy. She was completely blind. Her head was disproportionately large, measuring above the 95th percentile for her age, while her height and weight were in the fifth percentile. Gabriela showed mild to moderate deficits in physical, cognitive, and language areas, generally functioning as a 12- to 18-month-old child. She was able to walk with assistance, but seemed to experience disequilibrium, anxiety, and possibly physical discomfort with movement, in part due to her over-large head and decreased muscle tone. She preferred to be carried. Fine motor coordination was also delayed. Gabriela had little spontaneous or purposeful speech. Her most frequent verbalizations were echolalic repetitions of phrases she had heard during the day. In a similar repetitive way, she often sang lines or whole verses of children’s songs. She cried and screamed frequently in a high-pitched, penetrating voice. Occasionally she would say “No” or “Leave me alone” in an appropriate context. Gabriela’s receptive language ability was difficult to assess since her apparent comprehension varied widely, probably according to emotional and behavioral variables. The Vineland Adaptive Behavior Scales placed her communication skills at about the one-year fourmonth age level.

Overall, Gabriela was a seriously impaired child, unable to interact effectively with peers and staff, almost immobilized by her blindness and other physical abnormalities, insecure in her world. At home, she was reported to be somewhat more relaxed and responsive. She lived with her parents, grandmother, older brother, and twin brother, who was born without abnormalities. Italian was spoken in the home. Gabriela’s family was very caring, and supportive of her treatment at the center. Method Gabriela was seen in individual music therapy from October 1988 to July 1989. This case study focuses on the period from February to May, when David Gonzalez (who was already working with Gabriela) was joined by Jo Salas. Weekly half-hour sessions took place in a comfortable, medium-sized room equipped with a piano, percussion instruments, and guitar. Child-sized furniture was stored along one wall, leaving the floor space open. A floor-to-ceiling window gave a view of the busy central hallway with its constant flow of children, toys, and helpers. The noise of children playing and crying was often loud in the music therapy room, accentuating, by contrast, the subtlety of Gabriela’s music. We turned off the lights for these sessions, creating a restful, intimate semidarkness, further setting off this space from the larger environment. Our approach in this work, established by David in the initial phase of therapy, was based on clinical improvisation, client-centeredness, and an in-the-moment responsiveness to all musical, affective, and behavioral phenomena, to the degree that we were aware of them. This open-ended approach reflected a shared theoretical orientation, and was also particularly appropriate with this child, whose inner world was a mystery to us and her other helpers. Treatment Process Phase One: October to January with David During this time, Gabriela developed a familiarity with David, with the instruments— drum, cymbal, tambourine, piano and guitar—and with some of the forms and possibilities of music-making. Her musical affinity began to emerge in her readiness to participate and in her ability to play with rhythmic accuracy. Consistent with her characteristic remoteness in other contexts, her playing tended to be self-referential and self-stimulating rather than related or communicative. Vocalizing was minimal, although she did sometimes sing fragments of children’s repertoire familiar from her classroom. A strong rapport and affection developed between Gabriela and David, along with some ritual elements which were to remain significant throughout her therapy. Among these was the “name cadence theme,” her name set to a minor 7th interval resolving down to a major 6th or up to the octave. Phase Two: February to May with David and Jo

2/8/89. In my first meeting with Gabriela, David carries her into the darkened room. I notice her over-sized head, the fluffy red hair, the huge eyes, and blank expression. Standing near me, Gabriela nestling in his arms, David tells her who I am. He begins singing her name, playfully, quite assertively, reflecting the guttural sounds she makes in response. I join in and we improvise on her name in harmony, our voices spanning the range from bass to soprano. David moves to the piano, placing Gabriela in my lap. I sense her surprise, her caution, her absorption of tactile information about me. Her congested breathing is noisy. David plays the name cadence theme, then develops the music into a rhythmic improvisation. I sing with the piano. Gabriela taps the rhythm into the palm of my hand, audibly and accurately. This threeway collaboration continues for some time, with Gabriela responding readily to changes in tempo, occasionally falling silent, then resuming her tapping. Eventually David segues into a “goodbye” song. Pausing, he invites her to supply the missing word: “It’s time to say...” She is silent. David and I sing goodbye in unison, very softly. 2/22/89. This time, I am playing the violin as David brings Gabriela into the room. She responds to this new sound with small birdlike calls. When I play her familiar name cadence theme, she immediately sings a sustained note in the chord. Her voice has an astonishing purity and sweetness. She continues to sing, weaving her voice with the violin. Her sense of pitch is as precise as her sense of rhythm. David sings too, mirroring and supporting her sounds. She initiates some rhythmic articulation. We follow her lead. She becomes increasingly animated and playful, clapping the rhythms as well as singing. The music develops in intensity, the themes changing and evolving. I switch to singing. Now our three voices move together in harmony, David singing in falsetto to stay close to her pitch range. He sings her name. She echoes it. Then she echoes his name, and mine. I feel she is acknowledging our presence with her, and at the same time, her awareness of our separate identities. Gabriela listens to pizzicato on the violin, then sings again and claps in rhythm when, with the bow, I play her name cadence. I am struck with a sense of privilege. It is like singing with a bird, so delicate, elusive, and beautiful is her music. In the goodbye song, she is silent. 3/8/89. Gabriela comes in to the sound of the violin playing contemplatively. She sings immediately, effortlessly finding a related pitch, then introduces a playful rhythmic motif. In the space of the next few minutes, she initiates a series of new melodic and rhythmic themes, which David and I embrace with an answering musical playfulness. One of these new themes is “Skip to my Lou.” She stops to listen to us singing the song, then sings it again when she hears me play it on the violin. We launch into a musical exploration of this song. We try different tempi, timbres, dynamics, tonalities. Gabriela sings, she plays the tambourine and cymbal, she makes musical invitations and accepts ours. Her musical expression becomes ever more varied, confident, and full. David praises her in Italian: “Che cosa bella, Gabriela!” (How beautiful!). 3/22/89. In spite of the two-week gap since the last session, Gabriela has no difficulty establishing continuity. Hearing the violin playing her name cadence theme as she comes in, she begins vocalizing with explorative, explosive sounds. I reflect and interact with her on the violin. Then she sings “Skip to my Lou.” Her voice is as full and strong as it was at the climax of the last session. It is an extraordinary voice for a tiny child; exquisitely focused and rich, confident and accurate in pitch. This time she articulates more of the lyrics: “Lost my partner,

what’ll I do?” Accompanying on the guitar, David amplifies the boisterous mood she has created. We improvise together, trying variations and new themes. At one point, David inserts our names: “Skip to my Lou, Gabriela,” “Skip to my Lou, David,” “Skip to my Lou, Jo.” She echoes his name and her own, but not mine. David plays suspended guitar chords, the pace slower now. I sing “Skip to my Lou, my baby.” She echoes my phrase precisely, matching its tenderness and intimacy. We keep singing in a lyrical, rubato call and response. Her phrases answer mine, not mimicking, but musically and affectively related. I feel our music’s pathos and beauty and the connection we have cocreated. David, listening and supporting on the guitar, begins to sing softly in a bossa nova style: “The music makes me feel so good; it makes me want to dance.” But Gabriela is quiet for a long time. David and I keep playing, searching for her. Eventually she joins in with drum and cymbal. When David begins the Goodbye song, she sings very clearly: “It’s time to say goodbye,” then falls silent again. 4/5/89. David carries Gabriela into the room. She is bubbling with merriment. Soon we are all caught up in wordless laughing. What’s the joke? Somehow it’s just hilarious to be together, to be laughing for no reason. Gabriela’s laugh is the most joyful sound I have ever heard. She starts making percussive mouth sounds in a rhythm which she emphasizes by clapping. She stops when we join her, coming in again a moment later when she hears the violin. We are now singing in three-part harmony. Gabriela sings half-notes while clapping perfectly coordinated eighth-notes. She sings with the violin when I play the name cadence, then she introduces “Skip to my Lou.” The energy builds until she is laughing again. I play a sustained D on the violin. Gabriela quickly comes in with an F#. Still playing, I sing lyrical phrases based on “Skip to my Lou,” similar to last time. She echoes and intertwines her own phrases in response. Our music moves through different moods, different styles. There is a strong sense of excitement, musically embodied in the volume and syncopated rhythms. With David’s help, Gabriela dances on her fragile little legs, amid more peals of laughter. As we approach the end of the session, I play more contemplatively. The mood changes. In Gabriela’s silence we feel her reluctance to leave this joyful space. We praise her and hug her and try to help her look forward to lunchtime. 4/12/89. Gabriela is rather subdued when she comes in for her session. David mentions that she has been upset this morning. Her participation is at first sporadic and quiet, becoming gradually more adventurous. She sings in unison with the violin, she brings in melodic and rhythmic motifs, she responds without hesitation to changes in style, tonality, and tempo. The session culminates in a piece with a rhythmic modal theme to which we chant her name. Gabriela plays the cymbal forcefully. In the goodbye song, she plays the drum but does not sing. 5/3/89. David plays the guitar while I sing. He introduces the name cadence theme. Gabriela is silent until I play it on the violin—instantly, she sings with us. Then she shows us a new theme, a half-sung, half-chanted phrase which we cannot quite master. For a while we all stumble around in search of a place to meet. Then, over a sustained D on the violin, Gabriela breaks into “Mockingbird,” her voice stronger than ever. She even has a little vibrato, perhaps in imitation of the violin. We all sing, in a spontaneous four-part arrangement. As usual, it seems effortless for this four year-old to maintain a harmony part.

David changes the words of “Mockingbird” to “Everybody loves Gabriela.” She picks this up, singing the words triumphantly. The improvisation continues in a collective composition with several related themes, articulated, interwoven, and restated with artistic intent and effect. As in any inspired improvisation, the leadership shifts imperceptibly between all three of us. It is Gabriela who concludes our piece with a full-blown reprise of “Everybody loves Gabriela.” 5/10/89. This is to be my second to last session with Gabriela. David plays a meditative ostinato in a IV-I progression with a suspended bass in the key of A, while I sing quietly on the note E. In this setting we begin to improvise on her name. Gabriela in her very silence calls us deeper and deeper into the music. Staying with the same chords, David begins to emphasize the rhythm. Gabriela claps loudly, then vocalizes playfully as I start to add violin. I hint at “Mockingbird,” and she immediately begins to sing it, soon changing the words to “Everybody loves Gabriela.” The ostinato continues uninterrupted, with the suspended IVth chord modifying to become a Vllth chord. David plays arpeggiated chords while I sing a harmony line a third above her melody. There is a deep, gentle holding in the harmonic integrity and repetition of our music. The music becomes louder, more rhythmic. David and Gabriela sing playful sounds on the off beats. So far this session the harmonic foundation has been the IV-I or VII-I progression. Now David makes a change, introducing minor, dissonant chords in a swelling rhythm. Eventually he establishes a slow descending progression: C-Bb-Ab-G. I play, amplifying the solemnity of the music. Gabriela sings in chest tones, her voice somber and passionate. She finds an F to sing and holds it against the descending line, creating a cycle of harmony and dissonance. David places her on his lap, tucking her between the guitar and his body. We all sing her name. She introduces the words “Everybody loves Gabriela,” finding a new melody for this tonal setting. The music flows on. Sometimes Gabriela sings alone, sometimes our voices blend in harmony. Finally we end with an all-out reprise of the theme, loud, harmonically rich, and passionate. She does not sing in the goodbye song in spite of an extended pause on an unresolved chord. I am struggling with my own resistance to saying goodbye. Eventually I sing that I will see her one more time. 5/24/89. This session, my last, begins with a vigorous improvisation around a 7th chord, reminiscent of last week’s theme, this time with a rock beat. Eventually Gabriela introduces more lyrical singing. The music evolves exploratively through varied themes and moods. I sing about leaving. She joins in, her voice dancing with the violin. The music keeps changing. David plays her name cadence theme. For the first time, she sings it herself without waiting for the violin or our voices. Our music becomes rather slow and mournful. Now she is making half-vocalized sounds, blowing through her tongue and teeth. I play a farewell improvisation for her. She continues with her mouth sounds. To the melody of “Skip to my Lou, my baby” I sing about our time together. She is silent. Third Phase: July with David

In the first session after Jo left, Gabriela was confused, anxious, and even frightened by her absence. It was as if without the violin and Jo’s voice she were in a different and unknown space. This time together was devoted to re-establishing our one-to-one relationship, to moving through the feelings of fear and loss, and to finding new musical surfaces for contact. Her initial expressions were crying, screeching, and bizarre rote counting in a pressed, high-pitched voice. Playing the songs that had been established with Jo seemed to make the situation worse. She became mute. After a long silence, she began to tap the guitar with her hands. This became the first area of contact for us in the session—a pulse—simple and primary. I sang a bright pentatonic melody over it, but she did not respond with her voice. She played the basic beat over and over again. After a long while, I changed the music to a more introspective chord progression with a flamenco feel. Still no vocal response came but her tapping increased in tempo. This was the first sign of musical responsiveness. It gave me hope. The music moved through a short, halting improvisation and then stopped. At the end of the session, I was stunned as Gabriela spoke in an unusually appropriate fashion and asked for several songs that had been part of her repertoire with Jo and me. It was surprising to hear her speak with such clarity and directiveness. Though she was grieving for Jo, and still getting used to being alone with me again, she knew that this was her music place. She did not want to leave, she needed more. The following session proved her need. She came into the room saying “Tickle, tickle, tickle” in a delightful bouncy voice. This became a word/tone improvisation in which we echoed and reflected each other’s phrases and pitches. Her astute musicality was back and as playful as ever. After this she requested “Happy Birthday” which we blended with the “tickle” theme in a long improvisation. Then she introduced a poignant new melody. I accompanied it with a slow descending bass over a D major chord, leading to a G minor 6th chord in the first inversion. There was immediacy in it, an urgency and momentum like that of the earlier sessions, yet somehow different. Because it was just the two of us again the music felt very intimate, very precious. Once again we had opened again into new musical territory. The significance of this renewed musical expressiveness was great. It indicated the depth from which her inspiration emerged. She had made the adjustment to Jo’s leaving. Clearly this had been a loss for her. But the willingness to reach out and play remained. The capacity to connect through the music was as strong as ever. Discussion and Conclusions Gabriela entered music therapy as a very disabled child, handicapped physically, poorly connected to the world around her, almost completely helpless, powerless, and vulnerable. In the context of a rich musical environment and our loving, consistent presence, she experienced herself very differently. Strengths were revealed that had been hidden by her disabilities. In place of impairment, she encountered her giftedness; in place of isolation, she experienced intimacy and interaction; in place of powerlessness, she found herself able to shape the events and circumstances around her. Nordoff and Robbins (1977) speak of the “Music Child,” a well-functioning and healthy aspect, realized in music, of an otherwise poorly developed or disturbed personality (p. 1).

Gabriela embodied the Music Child. Her outstanding musical ability was the vehicle for her connection and interaction with us, for her unconstrained self-expression. Far from being simply a random talent without broader significance, Gabriela’s gifts were superbly integrative and communicative. Music was the catalyst for the potential that lay within this child. Our interventions were mostly in service to the creation of a safe, aesthetically rich world whose operating principles were acceptance, spontaneity, and creative freedom. In this world, Gabriela was able to actualize far more of her being than was usually possible for her. She was called by the music she heard. It awoke her musicality. She found that her every initiative or response met with an immediate acceptance and an answering creativity. An ecological process developed, with each experience of creativity and interaction encouraging her to become yet more adventurous and assertive. Her singing grew increasingly strong, extraordinarily so for a four year-old child. She clearly felt quite free to introduce new musical elements and themes, as well as readily responding to the highly varied and often sophisticated offers made to her. Initially, our playing provided a context, a connective tissue for her fragments of expression. But as she grew in confidence, she was able to establish coherence herself, quite masterfully shaping our improvisations with the introduction, development and recapitulation of themes. The musical coherence, artistry, and integrity of our collective music was rewarding not only to Gabriela but also to us. The kind of musical high point that we might experience from time to time with other clients was, with Gabriela, the domain of our musical contact. We often found ourselves surrendering to the music, following its calls and suggestions, leaping hand-inhand into musical adventure. This was at first rather disconcerting. Could this be therapy if it was so pleasurable? Were we irresponsible to let the therapist/client polarity fade, to be replaced by a sense of being fellow musicians? Our doubts were soon eased. Gabriela’s flowering in these sessions made it very clear that whatever was happening was healing for her. We realized that indeed what we were experiencing was a rare fusion of the aesthetic and the therapeutic. Each musical step that suggested itself was also the right therapeutic step. Fluctuations and increments of expansiveness, intimacy, autonomy, and emotional expression were synchronous with the changing elements of the music. To address the issues of the therapy was to address the issues of the music, and the beauty belonged to both. Gabriela, the epitome of musical expressiveness, paradoxically, also embodied isolation and helplessness. Part of our response to her came from the presence of these feelings within ourselves, primal emotions perhaps from our own mute early life. Just as our shared music allowed Gabriela to open to a place inside her where transformation was possible, so we also allowed ourselves to be deeply touched and changed. We felt vulnerable and exposed in these sessions, moved sometimes to tears—or to laughter. In the presence of such weakness and such strength as hers, there was an imperative to be as honest and as giving as we were capable of being. Our encounter with Gabriela was an important and memorable experience for both of us, in part because of the uniqueness of this little girl, and of our musical experience with her. We have come to feel that that there was a further aspect of the therapy and the three-way interaction that was unusual and notable. This had to do with the presence of masculine and feminine archetypes embodied in our personalities and in the music itself. The masculine

principle was inherent in David’s physical presence, his voice, his interventions and general style, the instruments he used and the ways he used them. David generally supplied the musical elements of rhythm, increased tempo and volume, and vertical harmonies. He often initiated change and risk-taking. Jo’s music was characteristically fluid, effecting changes through incremental modifications. She contributed linear rather than chordal harmonies. The timbre and register of her voice and violin communicated a feminine quality, reflected also in her style of interaction. (We realized after these sessions were over that Gabriela, blind as she was, would not have been able to picture Jo playing the violin. To her, this instrument was another animated presence in the room, to which she related with a particular affinity). We consider that it was significantly the fulfillment of this dimension that allowed Gabriela to flourish as she did during the middle phase of her music therapy. Her musical expression, her whole mode of being, was qualitatively different in this archetypally complete context. And, in the third phase, although she was shaken to find that Jo—and the violin—were gone, she was able to re-establish her strength and expressiveness. The time with all of us had been an opening to which there would be no closing. We were recently told by her mother that, almost two years later, Gabriela continues to reach out triumphantly to her world through her music. Gabriela was the quintessential Music Child. Music allowed her to access the magnificently functioning expressive and creative aspects of her personality. Perhaps we can see the Music Child as another archetype, when, as in this situation, the Child finds its Music Parents. Glossary Bilateral Optic Atrophy: Irreversible damage to the optic nerves. Client-centeredness: Therapeutic approach developed by Carl Rogers based on the belief that growth and healing will take place in the context of a loving, authentic, and nonjudgmental therapeutic relationship (Roger, 1951). Osteopetrosis: Excessive calcification of the bones, making them brittle and subject to spontaneous fractures. References Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New York: John Day. Rogers, C. (1951). Client-centered Therapy. Boston: Houghton Mifflin.

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

CASE FIVE Ron: Music—An Eye for the Blind Chava Skeles Patient Profile Ron, the firstborn son of a large family, was referred for music therapy when he was 12 years old. A few months after a normal birth he began to display disturbing symptoms. When he was examined it became clear that he was almost totally blind, able to distinguish only between light and darkness, and he also suffered from both grand mal and petit mal epilepsy. Soon afterward he was diagnosed as suffering from right hemiplegia (Cerebral Palsy), spastic type. Ron had undergone physiotherapy from the age of ten months, and later special treatment for the blind. At the age of nine he entered a program for blind multi-handicapped children. During the intake process I discerned limping on the right leg, a clenched right fist, flexion and pronation of the forearm, retraction of the shoulder and contracture of the elbow. His gait appeared unsteady, probably as a result of his blindness and spasticity. He was ignoring the disabled right side of his body, avoiding contact with it, and preferring not to make use of either his right arm or leg. Movemental activity with music revealed that he did not even know the various parts of his body. Though he displayed an obvious tendency for music, his singing and playing on even the simplest of musical instruments lacked both rhythmic continuity and expressive ability, despite the fact that he was making use only of the left (unaffected) side of his body. Verbal communication was extremely limited, and on hearing even the simplest of questions Ron would go into a state of extreme anxiety, expressed by increased spasticity, arm flapping, confusion, and a lack of concentration. He seemed to be unaware of his disabilities and had probably not achieved a sufficient degree of body-awareness or self-awareness, thus the majority of his comments and declarations were divorced from reality, such as, “Next time I’ll come by myself, on my motorbike.” Therapeutic Considerations The complex combination of Ron’s problems led to great difficulties in planning priorities for effective treatment. In addition there was a combination of primary retardation

(which can accompany brain damage), secondary retardation (as a result of his blindness and spasticity), as well as the emotional liability which characterizes C.P. spastic children. It was apparent that initial therapy must be concerned with a reduction of spasm and hypertonia in the right half of the body, in order to permit him to experience sensations in those denied areas and create a precondition for relaxation and trust. It should be recalled that at this time Ron was still undergoing group music therapy at an educational institution; individual music therapy was an extracurricular program. Due to his blindness and epileptic seizures, Ron often found himself in a state of alarm and confusion. As a result, loss of muscle tone increased and his body (which in any case lacked balance) would lose control. Such loss of control would lead to anxiety and other reactions of the autonomic nervous system. Feldenkrais describes this as “an instinctive reaction to the state of falling” (1949, Ch. 10). Ron also tended to enter into a state of anxiety in those situations which he perceived as being “under examination.” Whenever being questioned (as was customary in his traditional upbringing) his spasticity would increase and he would complain of pains. Because of his retardation and limited awareness he was unable to describe his feelings in words, or to cope with them in any other way. Since C.P. consists of irreversible brain damage, the question arises as to whether spasticity can in any way be decreased. If so, in what way can this be achieved by music therapy? Schneider mentions that among the various positive effects of music on the C.P. patient, music can in fact influence spasticity and bring about a certain degree of relaxation (in Gaston, 1968, Ch.10). This may be only temporary, and the basic brain damage cannot be cured, but there are however some advantages in this: 1. Relaxation can lead to a corrective experience for the spastic child. 2. It might also reduce anxiety and improve function. 3. It might help to prevent the subsequent development of abnormal patterns of movement. In the light of all this, the short-term aims of therapy were defined as follows: Each weekly session would begin with musical movement-stimulation aimed at maximum release and relaxation, as a basis for further activity. The patient would be encouraged to reach a greater awareness of his body. Should such awareness be achieved through sensory-motor activity, there would be the chance of a corrective experience for the Body-Scheme. In addition Ron had to be taught how to breathe properly; something which could also lead to an improvement of his vocality and the possible opening up of a vocal channel through which he might express his emotions. In music therapy, as already mentioned, the cognitive abilities can improve as a by product of the groundwork invested in both body and mind. It seemed there was a chance that if Ron’s physical and mental tensions could be reduced, leading to an improvement of his breathing, vocality and body-scheme, he would eventually find it easier to express himself verbally, and perhaps even to enrich his creative abilities.

Music Therapy (Over a Three-Year Period) Before going into details regarding Ron’s therapy, I would like to refer back to the hypnotic model of traditional healing rituals. The traditional Indian healer in hypnotic ritual employs methods aimed at creating an atmosphere of relaxation and maximum concentration. To this end he establishes a soothing atmosphere devoid of excessive stimuli, speaks and sings quietly, and makes use of rattles or drums in a repetitive and moderate tempo. His patient remains passive, either lying on his back, or seated in a crouching position facing the healer. We had seen one impressive example of hypnotic ritual in eastern Ecuador which was both filmed and recorded in its entirety and enabled us to scrutinize the therapeutic process and reach our own conclusions regarding present-day music therapy. There the patient lies on her back while the healer sings and plays for her during a full 10 hours with the aim of discovering, contacting, and banishing the evil spirits responsible for her malady. All this time the healer maintains a repetitive unity of rhythm, dynamic and melody. The range of voice he employs in his singing is limited, reaching only a sixth in moments of climax; the singing moves from high to low and is always relaxed, the words or syllables are evenly paced and accompanied by the soft rustling of palm fronds. These principles of repetition which characterize such rituals, in music, movement, the healer’s actions and speech, are shared by today’s music therapist, however, the therapeutic rationale is different. The Indian healer’s efforts are aimed at seeking out the evil spirit responsible for his patient’s suffering. In doing so he leads his patient into a prolonged state of utter relaxation, but this is not the healer’s avowed aim, it is more of a side issue. As opposed to this, the music therapist regards the inducement of such relaxation as an interim stage which enables the continuation of therapy. The music therapist’s “Ritual” is brief, but is repeated over a lengthy series of sessions, whereas that of the traditional healer is a prolonged, onetime event. Indeed it is recommended that in a case such as Ron’s the music therapist recreate such a relaxing atmosphere at the start of each and every therapeutic session. The basis for any relaxation exercise is a permanent and repetitive beat. The Japanese gynecologist Dr. Murooka (1976) conducted a series of experiments with a thousand month-old infants, using the sound of the heartbeat as it is heard in the womb. His report conclusively shows that a continuation of the in utero auditory environment serves as a relaxing influence. Four-hundred-three infants ceased their crying, 161 fell asleep after an average of 41 seconds, while the rest responded more slowly. In an attempt to further realize Murooka’s conclusions, as well as similar results obtained by Salk (1973) and others, Vogel (1984) designed an ovoidlike structure similar to the womb within which the patient would lie on a water bed and listen to recordings representing womb sound while being given a massage according to the Shantala approach (Leboyer 1976). In Vogel’s technique, designed for brain damaged and retarded patients, special attention is paid to repetition and continuity. The “Walking to the Womb”; temperature, lighting, sound and vibrations; the division of therapy into well-defined stages; the massage and the deliberate fading out of such stimuli towards the end of treatment—all these constitute a relaxing and therapeutic environment. Recent reports from this German clinic show a significant improvement in the condition of patients who were previously in need of a high degree of medication in order to reduce their aggressive tendencies; in fact the changes were

so radical that some of the patients were released from medication altogether. It should be stressed that there are very few institutions in today’s world devoted to a therapeutic approach which closely follows the results of such research into the auditory womb sensation, which is aimed at regression in order to stimulate development. My own clinical experience has taught me that the simulation of a womb-like heartbeat in order to achieve relaxation can be extremely effective, either by use of a metronome, or by soft rattling or drumming. In practice it is done as follows: The spastic patient lies supine on a carpeted floor in a quiet room, exposed to the minimum of stimuli. The therapist is at his side, but remains silent. A recorded tape reproduces heartbeats whose tempo is dictated by the patient’s condition (ranging between largo—56, and andante—76). After a while the therapist assists the patient to start moving his limbs, according to the natural stages of infant development: head movement, shoulder to fingertips, hips to legs and feet. This includes rotations in order to decrease spasticity. Stage by stage the therapist inserts suggestions based on the characteristic elements of the lullaby which is being sung to the patient. In Ron’s case, this singing succeeded in transferring to him certain information regarding his physical actions, how this might help him, as well as a mirroring of his own physical and emotional condition. It should perhaps be stressed here that lying on the floor eliminates the effort to overcome the force of gravity and thus leads to greater muscular relaxation. From lying supine we turn to lying prone, and from there stage by stage, progress through all the processes of motor development up to and including standing and walking. During this, the patient becomes more and more independent and in control of his functions, while the therapist provides him with musical support. In other words, just as the patient progresses through various developmental stages (from simple to complex activity) so the music develops from basic beat-units to possibly complex textures. However, the repetitive beat-unit and tempo remain steady, the dynamics moderate, the melodic line is based on tonal or modal structures, and the harmony is traditional (although not necessarily primitive or dull). This kind of music must be improvised and cannot be prerecorded. The therapist follows the patient’s activity and improvises music and lyrics according to whatever develops, while at the same time preserving the above-mentioned musical framework. This process of matching music to patient while responding to his needs resembles, in a way, the early development of object relation as viewed by Winnicott (1965). The infant experiences its mother as its primary environment, in which both of them progress stage by stage from dependence to independence. Since at birth the ego exists only as an unopened bud, the mother serves, in the initial stages of infant life, as an auxiliary ego and must adapt herself to the ever-changing needs of her infant. She must emphasize the joy of living and what Freud defined as “the pleasure principle”; or as Winnicott puts it she is supposed to act as “a good enough mother” in order that her infant will develop emotionally stage by stage and experience the continuum of existence. Generally, a mother looking at her infant mirrors its own sensations (in movement or mimicry, in speech or in song), and in so doing facilitates holding and contact with the infant’s feelings. In other words, the infant needs motherly response to his actions and emotions in order to experience their significance. Winnicott also stresses the importance of psychological .

and physical holding as factors in the infant’s natural development. Such holding gives the infant a clearly defined framework, and serves to develop its sense of physical boundaries as well as those of the ego. According to D.I.M.T., musical improvisation matched to the patient’s own passing experiences can symbolize the dynamics of such object relation. This can be crucial in the case of a blind child who has no visual experience. Music which is suited to his needs will be perceived by way of a healthy sensory channel and can therefore serve to protect, contain, reflect and support a sense of pleasure, and at the same time to facilitate the continuity of motor and emotional activity. During his first year of therapy Ron underwent a weekly one-hour session as described in Figure 1. The various stages were repetitive, but they gradually changed their time proportions. Relaxation soon took only ten to fifteen minutes and the remainder of the session could be devoted to physiological and psychological problems as they emerged during therapy. I have deliberately not gone into details about the exact duration of the various stages within each session. The timing would change according to the child’s development. It should be emphasized here that Ron was at the same time undergoing physiotherapy and group music therapy, but not psychotherapy. It therefore seemed logical that individual music therapy could gradually be oriented away from his physical handicaps toward his psychological problems. After about a year-and-a-half Ron was more and more inclined to talk about his paralyzed hand, his blindness, his anger, frustration and helplessness. Some of these conversations were conducted by means of improvised song, some by direct speech. It took a full year until song could be replaced by normal conversation. It was clear that direct speech, without the soothing element of music, still aroused his basic anxieties, which were typified by increased spasm in the right side of his body, hand flapping, loss of balance and overall helplessness. Gradually, however, normal conversation took the place of song, with no external signs of anxiety. Step by step with his increasing awareness and acceptance of his severely handicapped condition, Ron stopped clipping off his syllables, both song and speech became more fluent, and his vocal dynamics began to match the emotions he tried to express. A therapeutic approach based on the constant recording of all sessions and the consequent results of studying these playbacks can be extremely advantageous when it comes to internalizing the process and progress of therapy. This was indeed the case with Ron. In his third year he began to compose songs on his own initiative, most of them simply described the atmosphere of the neighborhood in which he lived, some of them were devoted to his own personal experiences, while others served to sum up his emotions.

Figure 1. Sample Hour of Therapy (Sequence Chart, First year)

From this period I would like to present an example of Ron’s verbal ability, and his capability for internalizing emotional matter. A child is born and his eyes don’t see Because those eyes are blind A child is born and his right hand’s no good And that can drive you wild. But still you can feel And touch things But still you can hear All those voices if only You lend them an ear. (From the Hebrew)

Conclusion In detailing this case of a multihandicapped child I have attempted to demonstrate the importance of the developmental process through music. Over a three-year period of weekly sessions the patient passed through the various stages of the developmental process, expressed on a variety of levels: sensory and motor activity, the expression of emotion, independence and initiative, comprehension and cognition. The long-term goals of this therapy were to furnish Ron with strategies by which he could protect himself in a state of anxiety, to increase his self-confidence, both physical and mental, and to teach him to confront his disabilities both in actions and in words. The improvement was more apparent within the therapeutic space than within the educational institution which he attended, or within his own home. It was therefore recommended that the approach and some of the techniques employed in music therapy be adopted by other therapists and educators, and that both group and individual therapy be continued. References Feldenkrais, M. Body and Mature Behaviour. Tel Aviv: Aleph, Ltd., 1949.

Gaston, E.T., ed. Music in Therapy. New York: Macmillan, 1968. Leboyer, F. Shantala. Un Art Traditionel Pour le Massage des Enfants. Paris: Seuil, 1976. Murooka, H. “Analysis of Intra-Uterine Sounds on Journal de Gynecologic Obstetrique et Biologie de la Reproduction 5 (1976): 367-376.the Newborn Infant.” Salk, L. “The role of the Hearbeat in the Relation Between Mother and Infant.” Scientific American (May 1973). Vogel, B. “Prenatal Stimuli Through Music-Therapy.” British Journal of Music Therapy 15, no. 3 (1984). Winnicott, D.W. “Ego Distortion in Terms of True and False Self.” The Maturation Process and the Facilitating Environment. London: Hogarth Press and The Institute of Psychoanalysis, 1965. Winnicott, D.W. Playing and Reality. Harmondsworth: Penguin Books, 1971.

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

CASE SIX The Use of Piano Improvisation in Developing Interaction and Participation in a Blind Boy with Behavioral Disturbances Helen Shoemark Abstract This case describes music therapy in a school setting with Brian, an eight-year-old boy who was referred to music therapy because of an excellent sense of rhythm and the need to develop relationships which encouraged interaction and participation. The goal in his Individual Education Program (IEP) was to develop piano skills and the interactive behaviors necessary to do so. The method used was piano improvisation, based on the principles of “Creative Music Therapy” (Nordoff & Robbins, 1977) and the classroom philosophy of “Gentle Teaching” (McGee, et al., 1987). Through music therapy, Brian developed several basic music skills, learned to spontaneously interact and participate with the therapist in making music, and increased his participation in classroom activities. Introduction This case study took place in a residential education facility for children with multiple disabilities. The philosophy of the school embraces Individualized Education Programs (IEPs) for each student. Music therapy is well established, employing two part-time music therapists at the time of this study to serve 54 students. The music therapists work to accomplish aims of the IEP within a team approach. The main areas addressed in music therapy are communication and self-awareness. Background Information Brian comes from a family of three children, two girls and Brian (the youngest). Upon admission to the school, Brian was 6 years old, and during the course of this study, he turned eight. The family lived in a country town, while Brian was in residential care at the school. He returned home during school vacation periods. Brian had attended the school for approximately 18 months at the commencement of this program. Brian was born by normal birth at 27 weeks gestation. During the first few weeks after birth, he had persistent and severe bouts of apnoea (cessation or suspension of breathing) and brachycardia (slowness of the heartbeat), and was treated for prolonged periods with ventilation. The large doses of oxygen induced retrolental fibroplasia, which in Brian’s case,

manifested as detached retinas. As a result, Brian had no useful vision or light perception. His hearing tested as normal. Brian also evidenced seizures from the time of birth and has been taking Tegratol to control them. At six years of age Brian’s pediatrician noted head-banging, no speech, apart from clicking of tongue, rubbing of eyes with fists and continual crying at home. Upon admission to the school that year (and for many months thereafter), Brian presented as a developmentally delayed child, with the same characteristics observed when he was six years old. His behavior also included vocal chanting which was often wailing in nature. The phrase was usually four to six notes, with certain phrases being used often and others occurring only occasionally. He would persist with this wailing for periods of up to 45-minutes, and it was usually intensified if a caregiver tried to redirect him. Thus, it was used as a form of communication to remove caregivers and to avoid engagement in activity (Donnellan, et al., 1985). The only positive interaction in which he would engage was cuddling with staff during lunch times. This was deemed inappropriate for a boy of seven, and was halted. During the first 18 months at school, Brian participated in group music sessions with his class (four other students). He showed obvious enthusiasm for musical instruments, playing any that he could find. He displayed a sense of rhythm, beating in a regulated fashion for as long as allowed. He enjoyed songs and was able to accurately produce the melody and lyrics of several lines and/or line endings from songs in his repertoire. He would not tolerate playing or singing with anyone else. He used no verbal communication. He was unable to cope with turn-taking, withdrawing into eye-poking and tongue-clicking for much of the session when not engaged. Rationale for Method At the beginning of the school year, Brian had been placed with a new teacher and new class. The teacher advocated that a “gentle teaching” approach be taken, as outlined by McGee et al (1987). Its basic goal is to teach bonding through three interactional stances: (1) That the care-giver’s presence signals safety and security; (2) That the caregiver’s words and contacts (e.g. looks, smiles, embraces, touch etc.) are inherently rewarding; and (3) That participation yields reward. This shift in philosophical orientation required agreement from all those working with Brian’s class, along with additional training. Brian’s behavior showed that he had little trust for those around him, and yet he desperately needed positive input, as demonstrated by the acceptance of hugging in the playground. The classroom teacher encouraged all those working with Brian to adhere to the central concept of gentle teaching: that bonding is the center of all future complex human development, and punishment results in submission, “the antithesis of bonding” (McGee, et al., 1987, p. 19). Staff were to create an environment of proactive rather than reactive teaching; using activities which would offer reward for participation and interaction. To this effect, music was considered to be a primary tool. Brian did not use speech and language to communicate, whereas rhythm and melody (as evidenced in his chanting) already existed as avenues for self-expression and communication. In the classroom, Brian had produced on a drum the commonly known rhythm pattern: “ta...ti-ti..ta–ta.......ta–ta!” He expressed great delight (jumping and laughing) when the pattern was correctly completed by the teacher, and subsequently, the music therapist. His

enjoyment of this participation with another person, and his sense of rhythm indicated that music may be a starting point for developing an equitable and rewarding relationship, in line with the “gentle teaching” approach. Given his need for involvement in positive relationships, and his interest in rhythm, it was agreed that the music therapy program could focus on interaction and participation through his already established uses of rhythm and melody. The long-term goal specified for the IEP was to employ a range of basic piano techniques in musical improvisation with the music therapist. Specific short term objectives were designed to move Brian through a gradual sequence from passive acceptance of the music therapist’s participation to more active initiation of musical interaction with her. They were: (1) To accept the music therapist’s touch and manipulation of his hands when teaching Brian playing techniques; (2) To co-actively work with the music therapist to develop techniques, using some effort to move responsively with the therapist; (3) To co-operatively work with the music therapist to develop techniques, by anticipating movements and using equal efforts; (4)To independently achieve techniques after modeling without the need for physical contact; (5) To initiate techniques without being presented a model (i.e., without mention or example); (6) To respond to the music therapist’s techniques with reflective techniques, by mirroring, extending, and contrasting what is presented by the therapist. Treatment Process Brian’s music therapy program can be divided into three main periods: the initial period (February through April); the exploration period (May through August); and the control period (September through November). Initial Period In the initial period, Brian received two sessions per week in the classroom, with another child participating. The sessions were scheduled for 30 minutes early in the day to maximize energy levels; however, sometimes the sessions were shortened due to the short concentration span of the two children. These classroom sessions provided a period of observation and rapport development. Each session was devoted to introducing songs that would be used later as formats for teaching communication and social skills as well as rhythmic improvization skills on the drum. In the improvisation work during the initial period, Brian and the therapist both played the same small, tunable drum. This was done to give Brian equal opportunities for creativity and participation. The therapist responded to any patterns initiated by Brian with imitation or playing the patterns simultaneously. Brian’s patterns usually consisted of straight quarter/eighth note patterns or combinations of dotted and straight notes. They were generally of four quarter beats’ duration. The therapist would also initiate patterns, and Brian would immediately try to copy them. He was usually successful with straight, dotted and triplet rhythms. During these improvisation exercises, Brian was relaxed (smiling, at-ease posture) and attended the activity for periods of approximately 10 minutes. He used open-handed and closed-handed beating, scratching with finger-nails and rubbing with open-hand. He accepted

the therapist’s presence, and participation in turn-taking, but he did not enjoy playing simultaneously. It became obvious in the period from February through March that Brian would benefit more from individual work in a place other than the classroom. His rhythmic interplay with the therapist was beginning to be an important part of each session, and this needed to be extended and explored; however, Brian was often distracted by other activity in the classroom. It was, therefore, decided to remove Brian to the music room for individual sessions. This allowed the entire session to focus on his music-making, and provided the isolation to encourage full concentration. Exploration Period As sessions were transferred to the music room, the possibility of using the piano was introduced. Since Brian had enjoyed playing the piano with the therapist while in the classroom, it was hoped that the piano could be utilized within the individual setting to extend the scope of his improvizations beyond rhythm to include melody, and greater texture and dynamics. Sessions were held twice weekly? Beginning with this period of therapy, improvisation was used as the primary modality, based in principle on the Creative Music Therapy model of Nordoff and Robbins (1977). As described in Bruscia (1987), each session involves three phases which occur spontaneously as the client’s responses dictate. They are: (1) Meeting the child musically, (2) Evoking musical responses, and (3) Developing musical skills, expressive freedom and interresponsiveness. The author had successfully used this model with similar children on earlier occasions. The main approach taken in relating to Brian during this period consisted of: introducing new techniques for him to learn through modeling and co-operative practice; and playing in an alternating rather than simultaneous fashion. When placed at the piano, Brian demonstrated enthusiasm in creating sounds, and craved to discover new ways to approach the keyboard. Several piano techniques were introduced, along with variations of them in speed, volume, and register. The techniques were: Tone Clusters: Brian would produce these either with closed fist or open hand or full arm placed at a right angle to the keyboard. He would also slide from black to white keys. Fingers: Brian would play two or three fingers together, or isolated fingers on black and white notes. Glissandi: Brian would slide his fingers or hands across the keys in ascending or descending motions. Trills: Brian would alternate quickly between the two index fingers or between wholehand clusters. Brian listened closely as each new technique was introduced, and immediately made attempts to copy the sound. Generally, he was unable to learn new techniques simply by listening, but required demonstration or physical intervention by the therapist. Since Brian was reluctant to accept physical intervention at the beginning, the learning of techniques had to be approached in stages, as described earlier. Each technique was introduced to offer a new type of sound, while also offering a new hand shape and tactile sensation. Brian had spontaneously offered the closed-hand cluster, and

this remained his “home-base” sound. When he felt insecure with a new sound or technique offered by the therapist, he would return to the cluster. Similarly, when he was angry, upset, or frustrated, he would play the closed-hand cluster continually, until the intensity of the emotion was dissipated. It most often appeared at the beginning of a session, when he was coming straight from the play-ground to the music room. Brian was still overwhelmed by the playground because he did not have the skills of orientation and communication he needed to play with the other children. He was often frustrated, and sometimes upset. The therapist would offer Brian the piano, and he would “attack” it with the clusters. The second technique which Brian thoroughly internalized was the glissando. The therapist introduced this to Brian as a contrast to the clusters. It took him several sessions (over a period of approximately six weeks) to master the glissando. As the therapist moved her contact finger over the keys, she held Brian’s hand behind her’s with her thumb, thus exposing him to the action without the responsibility for producing the actual sound. For approximately four sessions, he needed modeling first and then co-operative work before he would achieve it independently. After this he would use the glissando to express happiness. He would often play a series of glissandi after the clusters, almost to indicate a finale to the expression of frustration. Rather than developing new or more advanced hand actions, the next technique was aimed at further delineation of the keyboard. Brian was exposed to the black notes as distinct from the white notes, using open hand and arm clusters. The arm clusters often brought giggles and smiles. Brian discovered sliding down from black to white notes, and thereby demonstrated his understanding of their spatial relationship. The use of isolated fingers to play isolated notes originated with the use of the children’s nursery song “Hey-Di-Ho.” It had been sung in the playground when the music therapist was pushing Brian on the swing. In the session it was used as a familiar activity to close the session. Brian would sing, while the therapist played it on the piano. As the second period of therapy progressed, and Brian would sometimes arrive happy, he would request “Hey-Di-Ho” to open the session. He made the request by singing the first line. Then as the therapist played, Brian began to search out the notes, an octave above. The therapist put Brian’s hand over her’s, grasping his index finger with her thumb and third finger, directing it to the notes of the melody. This offered Brian the contact with the correct keys and the spatial interval between the keys in sequence, while receiving total support for the rhythm and continuity of the melody. Brian was thrilled, smiling and requesting it verbally with “More?”. Brian did not achieve independence in playing “Hey-Di-Ho,” but this was not a priority. After playing the song a few times, Brian would sometimes initiate independent exploration of other notes on the keyboard. If the therapist played a single note he would seek out the note an octave higher, and match it, then move by tone or semitone either side to hear the contrast. He could sometimes happily settle on a note one tone apart. The final technique to be introduced was the trill. This was introduced incidentally, as ornamentation of “Hey-Di-Ho.” Brian’s excited response encouraged the therapist to introduce it to him as a technique. The fine manipulation of two fingers on one hand to produce a trill was overcome by using the index fingers from each hand. This was introduced in the same way as use of isolated fingers, with the therapist holding the index fingers within her own fingers. Brian

learned this within two sessions, initiating extensions of it independently. He used random intervals for the index finger trills, and then incorporated them into his cluster playing. At this point, playing clusters became part of his happy repertoire too. He began to utilize speed in the trills. He began slowly, building speed as he continued. The control of this aspect gave him immense pleasure. The therapist also demonstrated the use of decreasing speed, and he incorporated this to produce lengthy passages of accelerating and decelerating cluster glissandi. In the latter part of the exploration period, Brian began to arrive in a happy state on a consistent basis. This was due to increased communication and play skills for the playground. His increase in confidence was attributed to the “gentle teaching” approach and the acknowledged role of music within it. His exploration of the piano took on an independent nature, not requiring modeling, and initiating techniques he had learned. Brian accepted the therapist playing piano with him for periods of about our quarter-note beats at a time. The therapist’s improvisation during these brief periods was usually restricted to a rhythmic underlay to support Brian’s material, occasionally extended to reflect Brian’s material such as the clusters. This step into simultaneous playing saw the shift into the third period of the program. Control Period This was a period when Brian worked to bring all of his piano techniques under greater control—so that he could produce them as he wanted, and in any combination. He accepted the therapist’s participation, often halting to listen and then rejoining her with the same sound or a contrast. Brian had the tendency to increase volume as he became more engrossed in his playing. The therapist had until this point controlled that by offering a different technique, thus evoking a halt in Brian’s playing, and then often matching the reduced volume and playing style. During the control period, Brian would still increase volume but would also respond to a diminished volume in the same playing style by the therapist, displaying greater cognitive control over his playing. The therapist controlled the volume of his playing only when it was considered that the forceful playing was withdrawing Brian into a self-stimulating situation. Brian enjoyed the contrast of high and low notes. He played clusters in the bass region, using his whole body weight in an almost jumping style, and would glissandi up and down the length of the keyboard allowing the therapist to complete the glissando where his reach ended. Late in this period, Brian enjoyed the simultaneous participation of the therapist. He was able to sustain his playing and listen to the shifts in the therapist’s playing; responding sometimes with an answer, and at other times choosing to sustain his own material. He would initiate a “theme,” and then either return to it for security, or insist on the therapist’s recognition of his leadership capacity. His signature themes were the clusters and the glissandi (which never ceased to make him giggle). Brian arrived upset for only one session in this period. He furiously bashed clusters and glissandi for ten minutes, and as the intensity of the anger subsided, the closed-hand clusters opened into flat-hand clusters. The fingers finally began to search out the notes of “Hey-Di-Ho,” as Brian sang the lyrics. The therapist supported this with an approximate bass line (Brian’s

melody was not accurate) until Brian moved away to more general improvising, and the relationship became an equal one. Evaluation Evaluation was conducted through observation by the therapist. Notes were taken with regard to aims being addressed, and the therapist’s participation. By the end of his music therapy program, Brian had achieved all of the IEP aims and maintained all of the skills he had developed. Brian accepted the therapist’s manipulation of his hands in late July. He skipped working co-actively, moving directly to a co-operative mode for late-July and August. In early September (just before the school vacation), he began producing techniques after modeling and initiating techniques without any modeling. In late October, Brian began to respond to the therapist’s techniques with reflective techniques. The development of a relationship involving interaction and participation through rhythm and melody (the underlying ‘gentle teaching’ aim) was established when Brian first accepted the therapist’s manipulation of his hands to achieve a technique. From this point, it was strengthened and deepened by the participation in the music. Discussion and Conclusions The three core phases of a Nordoff-Robbins session: meeting the child musically, evoking musical response, and developing musical skills, formed the ideal basis for Brian’s therapy. The musical interaction this approach fosters, echoes the bonding that the ‘gentle teaching’ method so explicitly details for working with children with special needs. The emphasis was modified to meet the educational constraints of IEPs, with much time being spent on actually developing musical skills. Nonetheless, the philosophical stance of meeting the child musically and evoking responses was ever present in the therapist’s manner. The music therapy program provided Brian with an intensive period of success on a biweekly basis. This success in interaction and participation served to help raise his self-esteem. Evidence of the carry-over in self-esteem came from his classroom teacher’s reports that his mood was consistently happy on returning from music therapy (singing to himself, moving through space confidently), and he had become quite co-operative in following instructions. The music therapy sessions helped him to work more efficiently and comfortably within the more difficult environment of the classroom. After this program, the therapist left the facility. The ensuing music therapist continued the individual music therapy program with Brian. After a another school year, his musical accomplishments culminated in a high-powered and complex drum improvisation with the therapist, which he performed at the school Christmas concert to a rapturous audience of nearly 200 people! References Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield: Charles C. Thomas.

Donnellan, A., Mirenda, P., Mesaros, R., & Fassbender, L. (1985). Analyzing the communicative functions of aberrant behavior. Journal of the Association of Persons with Severe Handicaps, 9(3), 201-212. McGee, J., Menolascino, F., Hobbs, D., Menousek, P. (1987). A non-aversive approach to helping persons with mental retardation. New York: Human Sciences Press Inc. Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New York: The John Day Company.

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

CASE SEVEN Lisa: The Experience of a Child with Multiple Disabilities Barbara L. Wheeler Introduction Lisa is an attractive girl with long dark hair. She is a child with multiple severe disabilities, classified as being multiply handicapped. She is nonverbal, although she occasionally makes some sounds. Although she walks with no problems, she tends to lean to one side because of scoliosis. She occasionally drools. I met Lisa in 1992 when she was nine years old. She had been referred by her school district at her mother’s urging for initial evaluation and then for music therapy which was written into Lisa’s individualized education program (IEP). Lisa’s mother brought her to each session, generally accompanied by Lisa’s two younger sisters. Lisa’s mother sat in on the first few sessions. Later, when we tried to have her mother go to a different room, Lisa became so upset that we decided that she should stay in the room. These sessions, in which we used familiar songs, movement, and percussion instruments, were continued for two years, after which I began working one day a week with Lisa at her school. I continued seeing Lisa there with a small group for one and a half years. In an effort to communicate what might have been Lisa’s experience of her four years of therapy with me, I report an interview with her mother, and then I describe her behavior in sessions over the period. Since Lisa does not speak or communicate in a manner that allows me to know exactly how she experienced the music therapy, I write what I think she would say if she could speak her thoughts. I have put Lisa’s thoughts in italics. Because of the large amount of speculation involved, I ground my statements about her experience in the behaviors that I observed and in my own reactions to her experience. Lisa’s Mother’s Perspective I interviewed Lisa’s mother to get her perception of Lisa’s experience. Her mother is a teacher, doing only occasional substitute teaching during the time of the individual sessions, and homemaker. During the interview, we reviewed the chronology of the work with Lisa, including some significant sessions. We also listened to audio-taped portions of several sessions and looked at videotaped portions of sessions. With each, I asked her mother what she thought Lisa was experiencing and questioned her to develop her responses as fully as possible. What is presented here is a summary of what Lisa’s mother said during that interview. She has also reviewed what I have written to be sure that it reflects her sense of Lisa’s experience.

Lisa’s mother first remembered Lisa’s jumping with the recorded music and felt that she was reacting to the rhythm of the music. She felt, though, that Lisa generally responded to all aspects of music, not just the rhythm. She spoke of the variety of situations in which she had seen Lisa respond to all types of music; she described as an example Lisa’s humming with a singer in church. Because of this general enjoyment of music, she felt that any response that Lisa made to music indicated some kind of pleasure. She felt that Lisa was probably more responsive in music therapy than she had been in most other areas of her life during that time. She felt that music and tones appealed to Lisa and that I offered her an avenue of communication through my singing that appealed to her. Lisa’s mother was very aware of Lisa’s enjoyment of the attention that she received from us and felt that this was an influence on Lisa’s pleasure. She also felt that because the work with me was done individually, there were fewer distractions than there were at school and that this increased her responsiveness and pleasure. She said that when she would say, “It’s time to go to Barbara’s,” Lisa would walk toward the car, although she would not do that in response to saying it was time to go somewhere else. She felt that this indicated pleasure as well as understanding. In response to my question about the times that Lisa simply did not respond, Lisa’s mother said: I think Lisa just “zones out” for some reason. I think something in her brain is just not clicking at certain times. I think that when she is tuned in, she always enjoys music. I think if she’s not responding, it’s just because she’s not tuned in, not that she doesn’t like music or doesn’t want to participate in some way with the music. We spoke of some of the differences in the way that Lisa responded to music therapy when she had the individual sessions in my home compared to the later ones at the school. Her mother felt that she was more distracted at school and that this is consistent with Lisa’s general behavior. Many things make her lose her attention, and those things were more plentiful at school. She said that Lisa has continued vocalizing at a high level on the bus and at home. She feels that her vocalizing was and is generally a way of attempting to communicate and that now vocalizing may at times be a way of getting attention (such as when she vocalizes when she is supposed to be going to sleep at night). She spoke also of Lisa’s enjoyment of other children, particularly those of approximately her age. She said that Lisa, who is now 14 years six months, will at times hug a visiting child or lie on top of one of her sisters in order to hug her. I kept Lisa’s mother’s perceptions in mind as I tried to understand Lisa’s experience of the music therapy. In some instances, they changed my sense of Lisa’s experience, as expressed in the remainder of the chapter. Lisa’s Music Therapy Individual Music Therapy The First Session. When Lisa first came to my house for music therapy, her mother helped her out of the car and held her hand as they walked to the house. In the assessment

session, Lisa danced spontaneously and clapped, jumped, and swayed to recorded fifties music, with the latter responses being prompted. She used rhythm instruments appropriately, possibly because they were placed in her hands. As she was leaving at the end, she jumped up and down and made some sounds. As I watched Lisa walk to my house before the first session, I was struck by the fragility of this child who did not speak and responded only minimally. I wondered what she might be feeling and what would evolve in our relationship. As she participated in the assessment session, showing apparent pleasure at some aspects and possibly doing some things mechanically (such as moving a tambourine that was placed into her hand), I wondered what was in this child’s mind and how she experienced the session. Here I am in this new situation. I wonder what it is about. There are instruments here and a piano. I like those things. And the lady is friendly. I am not sure. The instruments are okay, but I really like the recorded music, especially this fifties music. I love to dance to the music. I could do this for a long time. Now that we’re finished, I’m excited to be seeing the rest of my family and be leaving, but this was an interesting new thing to do. Early Sessions, 2–14. For the next sessions, Lisa’s responses were somewhat inconsistent. This proved to be a pattern that would continue throughout her music therapy. As her mother said at one point, “If there’s one thing we know about Lisa, it’s that she’s inconsistent.” This seems to be primarily a neurologically based problem; something in Lisa’s system does not seem to allow her to consistently process and respond to information. Her mother calls this “zoning out,” and it was very much a part of working with her at times. At other times her responses, particularly vocal responses and following directions, were consistent and exciting. She said something that sounded like “music” and at times sang it where there was a space in a song (“Lisa can make some music”) or would say it when she wanted to use the recorded music. After some of these sessions, I felt optimistic about Lisa’s responses. After other sessions, when she responded very little, I felt very pessimistic. I believe it was later that I realized that these variations in response were part of what Lisa went through and I accepted them as part of working with her. I like these music times. It is fun to come with my mother and my sisters and have all this attention. I especially like to dance with the tapes. Sometimes Barbara wants me to do things when I can’t. Sometimes I don’t even know what she’s talking about. I just sit and don’t really know what is happening. But other times, it is really fun to say “music” and dance to the music. And Barbara gives me lots of attention and helps make the music and gets very excited when I do things. I like that. Vocal Sessions, 15–65. During the next period of time, extending over the next year and five months, Lisa’s vocal development was very exciting and was emphasized in our work. In the early months of this period, many of the vocalizations were around a song that had originally

been improvised, “Me dance to the music,” with which Lisa used hand signing as well as singing or filling in words when given a space in the song. I wrote the following session note after session 52 in November 1993: Near the end of the session, Lisa walked to the tape recorder and appeared to want to play the tape so she could dance. I asked her what she wanted, and she seemed to respond “music.” We played the music a bit, then I turned the tape off and, in response to her look, said, “What do you want now?” She said (or appeared to say), “More music.” I said, “Are you sure?” She said, “Yes.” We repeated this routine or a similar one when she said “Dance” in response to my question as to what she wanted, approximately eight times. Her inflections were so clear and so consistent that, although the words themselves were not clear, there was no doubt in either my mind or her mother’s that Lisa and I were having the conversation reported. It seemed so clear that it made me wonder how many other times Lisa is saying words but we simply cannot understand her. During this same period, Lisa played instruments and continued to respond to commands. For a while, I encouraged her through a song to ask me for the rhythm sticks, then I would drop them on the floor when she said “yeah,” indicating that she wanted me to do this. Unfortunately, throwing things on the floor generalized beyond this setting and became a problem in school; although it had led to good use of her voice to ask for things, the strategy could not be continued. Near the end of this portion of Lisa’s music therapy, she used her voice for extended singing and humming for approximately three sessions. I thought that this indicated increasing enjoyment of her voice and was very excited about it; however, shortly after that, her vocalizations to approximate words or to indicate her wishes decreased sharply, although she did continue the humming and singing. They never resumed at the level that they had been, and I never knew exactly why. It is possible that with increasing demands for them, her vocalizations became less enjoyable to Lisa, or perhaps they were simply something that changed for her or no longer provided an enjoyable outlet for her. These have been really fun times in music. It has been so much fun coming to Barbara’s and dancing. We’ve been doing all these fun songs where we dance and sing together and then Barbara gives me spaces and I get to put in my own words. Barbara gets so excited and I get excited and then we do some more! And we always get to dance. I love to dance! Then we got to throw the sticks on the floor. I loved that! I would just say “yeah” and Barbara would give me the stick, then I could throw it on the floor and we would laugh and sometimes I would pick it up. Sometimes Barbara would pick it up for me. I did the same thing in school, too. That was fun. But we don’t do that anymore. I miss it. I really liked all that singing also. I just let my voice go wherever it wanted to. I did that in school also. People like it when I do that. I like it.

There are still times when I just need to sit, though. But there haven’t been so many of them lately. The music has been lots of fun. I love coming here! Final Sessions, 66-82. In the final individual music therapy sessions, Lisa’s vocalizations that approximated words or showed her wishes decreased, although her humming and singing continued. She had more periods of not responding. During this time, I dealt again with feeling discouraged when Lisa did so little, particularly since it was such a change from earlier sessions when her responses had been increasing and I had been so excited. The decrease of responses might have been due to its being summer, when although she was involved in a summer program, the expectations placed on her were much lower than during the regular school year. My knowledge, beginning in July, that as of September I would be seeing her in a different setting might have led me to respond to her differently. At any rate, there was less energy to the sessions and Lisa was less responsive. Things are changing a little. I’m not sure why, but I don’t like to do the same songs as much. And we don’t get to throw the sticks down. I still like to sing and Barbara plays the guitar while I do that. We’re doing other things that are fun, but it’s not really the same as it was before. I miss those other times. Sometimes I just sit now and don’t do anything. I just need to do that. Music Therapy Sessions in School I was looking forward to Lisa’s music therapy as part of her school program and hoped that some of the responses that she had made in the private music therapy sessions would carry over to her school environment. I also hoped that the new setting might help to bring back some of the energy that had been lacking in recent sessions. I especially wanted to see if her interest in music could help to develop her social skills, so I planned her music therapy sessions to be held with another child. I also wondered if she would be confused to see me away from my home and wished that I could help her to understand the change. The First Year. There were many changes. First, Lisa was seeing me in a place where she spent much of her time, rather than in my home office. Second, she saw me with another child. Third, the move of her music therapy to her school coincided with her movement into a class of older children, where she had many more demands placed on her. Lisa was 11 years 9 months when the music therapy sessions at her school began. The first part of the first year until after Christmas was a time of major adjustment for Lisa. Even small changes had always been difficult for Lisa and would generally lead to her being less responsive, so it was not surprising that the school changes were difficult. Not only was she adjusting to the change in her music therapy setting and having to share me and the music with another child, but she was adjusting to many more demands being placed on her. Her response was to withdraw. Lisa’s responses in all areas decreased during this time and she nearly stopped vocalizing. In addition, the room where the music therapy was held served other needs for teachers and students and there were frequent interruptions. These interruptions led to Lisa

being much less attentive; once her attention was diverted, she often remained distracted and unresponsive for the entire session. I don’t know what is going on here. There are a lot of changes and I feel very confused. Barbara is here, but I don’t know why she’s here instead of the old place. I don’t understand. And we’re not alone like we used to be; this other girl is always here getting some of the attention. I’m in a different classroom with different kids and a different teacher and they want me to do so many things differently. Then all these people come into the room while we’re having music and I’d like to know what they’re doing. I’m interested in them but don’t know what to do, so I just look at them and don’t do anything. I don’t like this music like I used to when it was just Barbara and me and we were in the special room in her house. That used to be so fun. I really miss those times. Later in the year, it seemed as though Lisa had adjusted to the changes and was ready to continue her development. She began vocalizing again and frequently made requests vocally, generally after being prompted. She seemed to enjoy the activities and the other child who was in the group as well as several adults who assisted with the group at times. She continued to be distracted by people coming into the room, although less so. Some very nice emotional engagement occurred during this time. In one session in the middle of a song Lisa put her head down on my leg and hugged my leg. I thought it was a caring gesture; she may also have been wishing for my undivided attention, since it was being shared. This was just one of a number of emotional reactions during this time. These music times have been fun. I got used to all the changes and to having someone else be in music therapy with us. Sometimes it’s even fun having her there to do things with. Sometimes I still don’t like it, though. One day I put my head on Barbara’s knee just to sort of remember that we have a special friendship. I’ve known her a lot longer than anyone else has. The songs where we do things like stand and sit and move around are fun. I’m not always so speedy on these, but I get around to doing what they tell me to. It’s kind of fun to move around like that, and everyone is always happy when I do what the song says. I like the instruments, too, and have been playing them the way they want me to. And we still get to dance. I always love to dance. Second Year. During this year, we could see the results of the previous year’s efforts to treat Lisa with the expectation that she would respond more consistently. She showed progress in all areas and responded more consistently than ever. She appeared very connected with me and the other child and seemed to respond in order to get attention. She would laugh engagingly, particularly when someone dropped something or otherwise made a mistake. Her sense of humor seemed to be more developed than many of her other responses and made working with her very special. One thing that seemed particularly significant emotionally was Lisa’s attachment to a student teacher who assisted with the sessions. This young woman shared many of Lisa’s physical features, and Lisa quickly seemed drawn to her. Lisa would stare at her and smile and

even reach out to her. On the student teacher’s last day when we spoke of the fact that she would be leaving, tears welled up in Lisa’s eyes and she appeared quite upset. This attachment seemed to reflect her ability to experience deep emotions. This has been fun lately. All of us have had so much fun together. Playing the instruments and then letting someone else play them is lots of fun. It’s nice not to play alone all the time, even though I used to enjoy it. Now sometimes we go back and forth with the instruments and we laugh and move and it’s so much fun. And we’ve been doing some new songs that have been fun. I like doing these new things, especially when I catch on to them. I don’t always do everything as fast as everyone else, but I usually do it. It’s fun to do these things. I really liked that teacher’s helper. She looks like me. We have the same hair and are about the same size. I felt like she was my friend. When she would smile at me and hold my hand to help me, I just felt so wonderful that she was doing that. When they said she was leaving, I couldn’t believe it! I felt so sad. I wish she would have stayed. I wonder why she had to go. I’ll really miss her. When I left the school in April of the school year, I told Lisa that I would be leaving and would miss her; it was never clear to me if she understood that I would not be back. My fouryear relationship with Lisa touched me in many ways. I have tried to reflect in this chapter ways that I hope it touched her as well as her other impressions of it. I hope that I have been true to her experience of the music therapy sessions, so that if she could read this, she would say, “Yes, that’s exactly what I felt.”

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)