Resource-Oriented Music Therapy in Mental Health Care [1 ed.] 9781891278952, 9781891278556

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Resource-Oriented Music Therapy In Mental Health Care Copyright © 2010 by Barcelona Publishers All rights reserved. No part of this book may be reproduced in any form whatsoever, including by photocopying, on audio- or videotape, by any electronic means, or in information storage and retrieval systems. For permission to reproduce, contact Barcelona Publishers.

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Dedication

To my clients

Blackbird singing in the dead of night, Take these broken wings and learn to fly

From: “Blackbird” by John Lennon and Paul McCartney

ACKNOWLEDGMENTS Several people have contributed to this book in various ways and in different stages of the process of writing. Clients with whom I have collaborated over the years have inspired my thinking and been my most important teachers. Colleagues have listened to my ideas, inspired me, and encouraged me to write. First of all, I want thank the people who have contributed to the research project on which this book is based and those who have provided help and feedback in the process of writing this book. I want to thank the informants “Emma” and “Maria,” for their participation in the research project presented in this book. Without your participation, this book would not have been possible. The work you did in music therapy moved me a lot. It was lovely to take part in the work you did and all the music we shared. I feel both proud and humble that I have had the opportunity to learn from you throughout this research and for being allowed to share this within the academia of music therapy. For this, I am very thankful. A special thank-you to the chief psychiatrist in the hospital for allowing me to collect the empirical material there. Thanks to the Aalborg group, Tony Wigram, and other members of the Ph.D. research school at Aalborg University for including me in the doctoral program. Thanks to Even Ruud, my steadfast supervisor, who has been generously sharing his knowledge and inspired my work for many years. Thanks also to the members of the international research group NISE (situated at Sogn og Fjordane University College), Cochavit Elefant, Christian Gold, Leif Edvard Aarø, Brynjulf Stige, Mercédès Pavlicevic, and Gary Ansdell. It was of great value when developing the research project to have such an experienced group of researchers with whom to discuss it. Thank you for your support, your challenges, and your critical questions. Thanks to all members of GAMUT — the Grieg Academy Music Therapy Research Unit. The research community we share means a lot to me. I learn so much from all of you and from being part of a research group which comprises such differing research perspectives. A special thanks to the leader of GAMUT, Brynjulf Stige. Thanks to Simon Procter for helping with the language, and Rebecka Ahvenniemi for typing the musical notations. Thanks to my husband, Rune Rolvsjord, for lots of support, patience, and practical assistance.

PREFACE This book is about a resource-oriented approach to music therapy. It offers a theoretical and empirical exploration of the idea that therapy is as much about stimulating clients’ strengths as it is about fixing problems or curing pathology. This may sound simple and even self-evident, and the reader might ask if there is a need to write a book about it. Yet, if it is self-evident, is it less important? If it is simple, is it less valuable? For me, the work with this book has been a journey in exploring the importance and the meaning of such a simple idea as resource-oriented music therapy. Throughout this work, I have tried to put the resource-oriented aspects in the foreground and explored the meaning of the conceptualization, the meaning in terms of practice, the meaning of clients’ experiences. My journey has gone through landscapes of practice, of theory, of critique, and of politics. The resource-oriented approach presented in this book is contextual and relational. Thus, more than simply implying that the therapist is supposed to nurture and develop the client’s recourses, it involves getting into a mutual and equal collaboration where less weight is put on the therapist’s techniques. The relationships between therapist and client as well as between individuals and society are emphasized, building onto values of democratic participation and equality. The resource-oriented approach presented in this book relates to a broad, interdisciplinary landscape of theory including empowerment philosophy, positive psychology, and current musicology. The context for the explorations offered in this book is mental health care and in particular psychotherapeutic work in individual settings. My intentions with this book have not been to explore the idea of resourceoriented music therapy in terms of the development of general theory for music therapy. I hope, however, that readers working within other fields of practice, in music therapy or related disciplines, will find it interesting and will be able to transfer some of the ideas to their work. Randi Rolvsjord Bergen, Norway February 2010

CONTENTS ACKNOWLEDGMENTS...................................................................................VII PREFACE ....................................................................................................... VIII CONTENTS........................................................................................................ IX

INTRODUCTION............................................................................................... 1 RELATED APPROACHES IN MUSIC THERAPY .............................................. 6 APPROACH OR PARADIGM? ................................................................... 10 RESEARCHING RESOURCE-ORIENTED MUSIC THERAPY ............... 11 HOW TO READ THIS BOOK ..................................................................... 15

PART ONE FRAMES AND DESCRIPTIONS.................................................................... 17 Chapter 1 MUSIC THERAPY AND THE POLITICS OF MENTAL HEALTH CARE ........ 18 THE POLITICS OF AN ILLNESS IDEOLOGY ......................................... 20 THE PRESENCE OF A MEDICAL MODEL IN MUSIC THERAPY........ 25 WHAT IS MENTAL HEALTH? .................................................................. 28 STRATEGIES FOR MENTAL HEALTH CARE ........................................ 31 MUSIC POLITICS AND MUSIC THERAPY IN MENTAL HEALTH CARE ............................................................................................................ 33 THE POWER OF DISCOURSE................................................................... 36 Chapter 2 PATHS TOWARD A CONCEPTUALIZATION OF THERAPY ......................... 38 THE CONCEPT AND THE PHILOSOPHY OF EMPOWERMENT.......... 39 EMPOWERMENT IN PRACTICE .............................................................. 42 THE COMMON FACTORS APPROACH AND THE ARTICULATION OF A CONTEXTUAL MODEL................................................................... 46

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Randi Rolvsjord COMMON FACTORS ................................................................................. 49 PERSPECTIVES FROM THE POSITIVE PSYCHOLOGY MOVEMENT 53 TOWARD A POSITIVE THERAPY ........................................................... 55

Chapter 3 PATHS TOWARD A CONCEPT OF MUSIC..................................................... 59 MUSIC “ITSELF”?....................................................................................... 60 CONTEXTUALITY ..................................................................................... 64 THE CONCEPT OF AFFORDANCES: BRIDGING THE GAP AND POSITIONING THE INDIVIDUAL ............................................................ 67 PLURALITIES OF EXPERIENCES AND MULTIPLE MEANINGS........ 69 Chapter 4 TOWARD A CONCEPT OF RESOURCE-ORIENTED MUSIC THERAPY ...... 73 RESOURCE-ORIENTED MUSIC THERAPY INVOLVES NURTURING OF STRENGTHS, RESOURCES, AND POTENTIALS ............................. 74 RESOURCE-ORIENTED MUSIC THERAPY INVOLVES (EQUAL) COLLABORATION RATHER THAN INTERVENTION.......................... 77 RESOURCE-ORIENTED MUSIC THERAPY VIEWS THE INDIVIDUAL WITHIN THEIR CONTEXT ............................................... 80 IN RESOURCE-ORIENTED MUSIC THERAPY, MUSIC IS SEEN AS A HEALTH RESOURCE ................................................................................. 83

PART TWO CASE STUDIES ............................................................................................... 86 Chapter 5 COLLABORATIONS WITH MARIA: MUSIC THERAPIST’S STORY............... 89 WHAT CAN MARIA USE MUSIC THERAPY FOR (SESSIONS 1-3)..... 89 ESTABLISHING A MUTUAL FOCUS FOR THE THERAPEUTIC WORK (SESSIONS 4–8).............................................................................. 92 NEGOTIATING AIMS AND GOALS (SESSIONS 5–23).......................... 94 FACING NEW CHALLENGES (SESSIONS 24–34).................................. 96

Contents XI ENDING THE THERAPY (SESSIONS 35–36) .......................................... 99 Chapter 6 MARIA’S EXPERIENCES: .............................................................................. 101 “BECAUSE IT’S MUSIC, AND MUSIC IS A BIG PART OF MY LIFE”101 “IT GIVES SO MUCH JOY TO SING”..................................................... 102 “IT HELPS TO SING”................................................................................ 104 “FINALLY IT IS SOMETHING I CAN DO” ............................................ 105 “SOMETHING I’D NEVER DARED TO DO BEFORE” ......................... 109 Chapter 7 REFLECTIONS: MASTERY AND JOY IN THE THERAPEUTIC PROCESS . 113 MUSIC FOR MUSIC.................................................................................. 115 THE EXPERIENCE OF MASTERY AND DEVELOPMENT OF SELF-ESTEEM AND SELF-EFFICACY ............................................ 117 THE EXPERIENCE OF MASTERY AND THE FOSTERING OF ENABLEMENT AND SOCIAL CAPITAL ............................................... 120 EXPERIENCES OF MASTERY PROVIDING JOY ................................. 122 THE THERAPEUTIC VALUE OF POSITIVE EMOTIONS .................... 124 IN CONCLUSION...................................................................................... 126 Chapter 8 COLLABORATIONS WITH EMMA: MUSIC THERAPIST’S STORY ............. 127 WORK PHASE ONE (SESSIONS 1–8)..................................................... 127 WORK PHASE TWO (SESSIONS 9–22) .................................................. 130 WORK PHASE THREE (SESSIONS 23–43) ............................................ 135 WORK PHASE FOUR (SESSIONS 43–66) .............................................. 138 WORK PHASE FIVE (SESSIONS 67–98) ................................................ 140 LAST YEAR OF THERAPY (SESSIONS 99–113)................................... 143 TERMINATING THE THERAPY (SESSIONS 114–117) ........................ 146 Chapter 9 EMMA’S EXPERIENCES:............................................................................... 150 “IT’S NICE TO BE ABLE TO USE MUSIC AGAIN”.............................. 150

XII Randi Rolvsjord SINGING HER LIFE AND TRAUMA ...................................................... 154 “PERHAPS I HAD A LITTLE BIT OF IT INSIDE ME” .......................... 157 “SOMETHING TO HOLD ON TO” .......................................................... 159 THE MOST DIFFICULT MOMENTS IN THERAPY .............................. 162 “I HAVE FOUND A WAY THAT WORKS”............................................ 164 Chapter 10 REFLECTIONS: NEGOTIATIONS OF RESOURCES AND PROBLEMS ...... 166 THE PROBLEMS OF PROBLEMS........................................................... 169 THE PROBLEMS OF STRENGTHS......................................................... 171 THE DIALECTIC OF STRENGTHS AND PROBLEMS IN THERAPY. 174 SOME GENERAL IMPLICATIONS ......................................................... 177

PART THREE WORKING RESOURCE-ORIENTED .......................................................... 181 Chapter 11 THE CLIENT’S CRAFT ................................................................................... 182 THE CLIENT IN A CONTEXTUAL MODEL .......................................... 184 CLIENT’S ACTIVE ROLE IN THERAPY................................................ 187 CLIENT’S COMPETENCE IN USE OF MUSIC IN EVERYDAY LIFE. 190 CLIENT’S USE OF ARTIFACTS AND SKILLS FROM MUSIC THERAPY OUTSIDE OF THERAPY ............................. 194 Chapter 12 THE THERAPIST’S CRAFT ............................................................................ 197 THE THERAPIST IN A CONTEXTUAL MODEL................................... 198 THERAPIST’S BEING .............................................................................. 200 THERAPIST’S DOING.............................................................................. 202 Chapter 13 THE THERAPEUTIC RELATIONSHIP .......................................................... 214 DOING TOGETHER.................................................................................. 217 EQUALITY AS PERFORMANCE OF RESPECT .................................... 218

Contents XIII NEGOTIATIONS AS PERFORMANCE OF DEMOCRATIC PARTICIPATION ..................................................... 221 MUTUAL EMPOWERMENT ................................................................... 224 AUTHENTICITY AND SELF-DISCLOSURE.......................................... 228 FINAL THOUGHTS ...................................................................................... 231 REFERENCES ............................................................................................... 233 INDEX............................................................................................................. 258 APPENDIX ..................................................................................................... 262

INTRODUCTION

1. Thou shalt not believe thou art something. 2. Thou shalt not believe thou art as good as we. 3. Thou shalt not believe thou art more wise than we. 4. Thou shalt not fancy thyself better than we. 5. Thou shalt not believe thou knowest more than we. 6. Thou shalt not believe thou are greater than we. 7. Thou shalt not believe thou amountest to anything 8. Thou shalt not laugh at us. 9. Thou shalt not believe that anyone is concerned with thee. 10. Thou shalt not believe thou canst teach us anything (Aksel Sandemose, 1936, pp. 77–78)

Aksel Sandemose, a Norwegian author born in Denmark, articulated a mentality in the Scandinavian countries called the Law of Jante in his famous novel A Fugitive Crosses His Tracks, which is about a young man, Espen Arnakke, and his confessions about his life in the village called Jante. The Law of Jante represents a mentality that restrains people from exploring their strengths and potentials. It is an informal, oppressive law that forbids anyone from standing out from the crowd. It is a mentality that takes many forms and restrains people in very different ways. I come from Jante. For me, it represents a deep need for recognition related to a freedom to be myself with my strengths and my weaknesses. Janteism is a form of oppression experienced so strongly by the main character in Sandemose’s novel, as well as by many Scandinavians through generations. Interestingly, the Law of Jante seems to have a strong foothold in the egalitarian Scandinavian societies. The Law of Jante can be seen as a popular ideology or icon, a social code of modesty, or a culture of minimalist equality (Hedetoft, 2000; Nelson & Shavitt, 2002). The Law of Jante encourages not pushing oneself above community. On the positive side, this might be connected to the value of the doctrine of solidarity and the principle of universal and free medical

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care (Cable, 19951). On the other hand, it strongly encourages people to put the community before the individual, to the possible detriment of involving a strong pressure toward conformity that might stifle creativity and incentive (Silvera & Seger, 2004). In this way, this informal law may even mask oppression as social democracy and equality. I can only speculate as to whether Janteism should imply that a resource-oriented perspective related to mental health care should be especially important in Scandinavian societies, but I have recently become aware that my own activism for a resource-oriented perspective is connected to my own experiences in Jante. I have come to see this as an important experience on my way toward this resource-oriented approach to music therapy. Janteism, in my experience, holds people back from using their strengths and resources, often even imputing feelings of shame if they do. Through my interest in feminist theory and research, I also came to be interested in struggles against oppression in a more academic way. Feminist theory, feminist research, and feminist critique of research contribute knowledge about the mechanisms of oppression. Above all, these served as an entrance to postmodern and poststructuralist ideas of language. Through feminist and poststructuralist thinking, I became interested in the part language plays in the construction of meaning as well as in its functions in stabilizing, conserving, or destabilizing the status quo (Rolvsjord, 2004b; 2006b). Our understanding of our reality is very much influenced by the words we use to describe it. This also implicates language in the conservation and even constitution of power structures. After becoming a music therapist and practicing music therapy with people with mental health problems, my concern to oppose oppression and inequality also encompasses the rights and “treatment” of this group of people in general. This is still strongly rooted in feminism, as violence toward and sexual abuse of women and children are sadly frequently associated with mental health problems. More generally, mental health problems are (and have historically been) connected with various aspects of oppression, for example social stigmatization, as with the current focus in the media on people with mental health problems as “dangerous.” Even more than this, it is connected to the demoralizing aspects of illness and hospitalization, to the individualization of illness, to inequality in the 1

Cable (1995) makes an interesting comparison between the Norwegian Jante mentality and the American “pursuit of happiness” in relation to health in the two countries.

Introduction 3 therapeutic relationship, to the heavy focus on problems and pathology rather than on strengths, resources, and potentials. These last injustices might also be connected to Janteism. Janteism is a good (but bad) example of how equality has been interchanged with indifference, in a way that severely limits what is considered normal. Equality is not relevant as a concept unless there is difference and diversity (Becker, 2005). Equality is instead built upon respect in spite of differences, and this includes an acknowledgment of both strengths and weaknesses (Sennett, 2003). Music therapy is not part of standard care in psychiatric institutions or mental health services in the municipalities of Norway, the rest of Europe, or Western societies in general, but there are increasing numbers of music therapists working in this field of practice. These music therapists, however, have widely differing roles and positions in their institutions, and they work in a diversity of ways. In Norway, music therapists working in the field of mental health are not usually employed to deliver treatment within the institutions (as psychologists and medical doctors are), but rather they have a “freer” role connected to the wards or occupational therapy units. Such a position may be regarded as politically problematic for the profession of music therapy, since it often weakens the acceptance and status of music therapy as an important part of the treatment offered in the institutions and of the music therapist’s competence. On the other hand, it also affords possibilities and potentials for unfolding practice in a variety of ways and within various settings and frameworks, as highlighted in the recent growth of literature about community music therapy. Thus, music therapy has not been limited strictly to treatment or psychotherapy but has played an important role in a broader treatment context, offering clients opportunities for musical engagement in their leisure time in the hospital, nurturing their musical interests, developing musical skills, and enjoying music together with others. In my practice of music therapy in a psychiatric institution, I have met men and women with mental health problems in life crises, and time after time I have felt deeply impressed by how they use music therapy. Often, I have seen that clients grasp the possibilities in music therapy and start using the musical interplay in very constructive ways, as I also emphasized in a case report published a few years ago that described a young girl’s use of songs as communication (Rolvsjord, 2001a). I have seen that clients play a very important role in forming the therapeutic interaction and finding ways of working in music therapy. This has made

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me feel very privileged and humble as I have been in a position to witness, support, and take part in their work with music. These experiences form an important background for my working toward a resource-oriented approach to music therapy. These experiences made me feel something of a foreigner when reading the music therapy literature related to the field of mental health. First, most of the music therapy literature and research in the field of mental health care has treated music therapy as treatment and/or psychotherapy and, in line with most of the psychological and medical literature about psychiatry, this music therapy literature is very much oriented toward the client’s problems and pathology, with aspects related to the nurturing and development of strengths and resources playing a less important role. This contrasts with my experiences in practice, where such aspects have been essential to those parts of my work that might be characterized as psychotherapeutic, not just to other types of work I engage in as a music therapist. Second, the literature is to a large degree focused on the therapist-expert’s interventions. Later in this book, this will be related to a medical model of psychotherapy. Responding to the demand for evidence-based treatment, music therapy literature and research in psychiatry have been preoccupied with exploring and documenting the outcomes of music therapy, i.e., the effects of various interventions in relation to various mental health problems, symptoms, and diseases. This constitutes an important contribution to research into music therapy, 2 but it seems to obscure equally important aspects of music therapy concerned with the development of strengths, experiences of positive emotions, and social participation, as well as the client’s contribution to the outcome of music therapy. There seems to be a discrepancy, or gap, between, on the one hand, music therapy literature and research that conceives of music therapy as treatment (of problems and pathology) and, on the other hand, the broad and often resource-oriented practice of music therapy in this field. This gap is perhaps partly due to the implicit oppositional conceptualizations being offered: When referring to music therapy as psychotherapy and treatment, we tend to think of work with the client’s problems and ways of reducing the problems and symptoms, whereas all the other things a music therapist does tend to be exclusively associated with strengths and 2

In a recent Cochrane review (Gold, Heldal, Dahle, & Wigram, 2005) of music therapy for schizophrenic spectrum illnesses, the positive effects of music therapy are particularly related to the reduction of negative symptoms.

Introduction 5 resources and to the entertainment and joy of musicking. My concern in this book, however, has been not so much to document the value of “the other things music therapists do” as to explore psychotherapeutic music therapy practice within a framework that I hope might go some way toward breaking down the perceived oppositional relationship between problem-oriented treatment and resource-oriented entertainment (to slightly overstate the case), thus also making it easier to detect the therapeutic value of the “nonpsychotherapeutic” work in this field. I wish to emphasize, however, that resource-oriented music therapy is not only concerned with entertainment or recreational areas according to Bruscia’s (1998) terminology, but also can be an essential part of individual psychotherapy. Therapy can be as much about nurturing resources and strengths as it is about fixing pathology and solving problems. This is the basic tenet of this book. Musical interaction in music therapy offers opportunities not only to explore problems, trauma, and difficult emotions, but also to explore strengths; to experience pleasure, joy, and mastery; and to try out ways of using music as a resource in everyday life. The exploration of these “positive” aspects of therapy, in individual psychotherapeutic settings, provides the main focus for the explorations presented in this book. In this book, I draw on literature and research that in various ways integrate academic and political critique: the philosophy of empowerment, which has been connected with human rights movements; the common factors approach, involving critique of the “medical model” and its focus on the therapist’s interventions in relation to the outcomes of psychotherapy; positive psychology, critiquing the illness focus in mainstream psychology and psychiatry; and, finally, feminist theory, highlighting inequalities and the oppression of women and other minority groups. I have been concerned to use a language and a discourse that emphasizes and makes visible the strengths and resources of the clients. I have aimed to write about music therapy in a way that acknowledges and demonstrates the craft, the resources, and the competence used by the clients in the process of music therapy. My intentions have been to apply theory and to write about music therapy in a way that accords with a resource-oriented practice. This, of course, has political implications, requiring levels of critique of traditional music therapy perspectives and models as well as of mental health care practice and theory in general.

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RELATED APPROACHES IN MUSIC THERAPY

There are numerous references within the music therapy literature to concepts that are in accord with a resource-oriented approach, such as mastery, strengths, achievement, or the development of skills. Among early authors in the field of music therapy who made explicit such aspects of the music therapeutic process was William W. Sears (19963). In the classic article “Processes in Music Therapy,” he proposed a classification of experiences offered to the individual in a music situation in music therapy: “Experience within structure,” “Experience in self-organization,” and “Experiences in relating to others” (Sears, 1996, p. 34). Each classification consists of a set of constructs that define an explicit relationship between music and the individual’s behavior — that is, the ways of engaging with music that the client is involved with. The “Experiences within structure” are mostly concerned with processes that are inherent and required by the music itself. The “Experiences in self-organization” and the “Experiences in relating to others” are perhaps more interesting from a resource-oriented point of view because to a large degree they are concerned with processes that relate to what I would call the client’s enablement and possibilities for participation. I cannot go into the whole set of Sears’s classifications here but rather will mention some of them: “Music provides compensatory endeavors for the handicapped individual,” “Music provides opportunities for socially acceptable reward and nonreward,” “Music provides for the enhancement of pride in self,” “Music provides for enhancement of esteem by others.” And, in relation to others: “Music provides opportunities for individual choice of response in groups,” “Music provides opportunities for acceptance of responsibility to self and others,” “Music provides for learning realistic social skills and personal behavior patterns acceptable in institutional and community peer groups” (Sears, 1996). Today, Sears’s list of categorizations resembles a manifesto for resource-oriented music therapy, and this might to taken to imply that to search out evidence of resource-oriented thinking in the music therapy literature is like looking for trees in the forest. Such an assumption might be seen as particularly pertinent in relation to the Norwegian tradition of 3

This article was first published in E. T. Gaston’s (1968) book Music in Therapy.

Introduction 7 music therapy that provides the context for my work. This tradition evolved from the Nordoff-Robbins approach and in the early days was very much situated in special education (Ruud, 1990). It has been a central focus in this tradition of music therapy practice to facilitate musical mastery and to provide for musical interplay with possibilities for anyone to participate despite handicap or illness. From the NordoffRobbins approach, concepts like “the music child” and aims concerned with self-actualization point to an orientation toward resources rather than a focus upon pathology and problems. Despite this, there is not much literature that explicitly discusses resource-oriented or strength-oriented perspectives. One explanation for this could be that such perspectives have become peripheral rather than central to the literature either because they have been considered of lesser importance or because they have been understood as self-evident and thus not requiring attention within the literature. Another important perspective that has influenced the discourse of music therapy in resource-oriented directions is Antonovsky’s salutogenic orientation, which has been introduced in to music therapy literature by Ruud (1998) and Bruscia (1998). Bruscia’s famous definition of music therapy explicitly builds on a salutogenic approach with the notion of health promotion given emphasis in the second edition (Bruscia, 1998). Bruscia’s and Ruud’s (Ruud, 1998) applications of Antonovsky’s ideas particularly highlight two important areas that Antonovsky’s model can contribute to an understanding of a resource-oriented approach to music therapy in mental health care: the continuum model of health and illness and the focus on health resources. Explicit references and elaborations of the concept of resourceoriented music therapy have nevertheless previously been discussed by Schwabe (20054) and previously elaborated on by this author (Rolvsjord, 2004a; 2006a; 2007; Rolvsjord, Gold, & Stige, 2005). To be mentioned is also Solli (2003; 2006; 2008), who describes a resource-oriented practice in individual settings as well as group work. Schwabe (2005) argues that 4

Schwabe’s article Wachstumsförderung versus musikalische Psychospekulation. Ressourcenorientierte Musiktherapie from 2000 was available in an English translation (2005). Because of the language barriers, I was not aware of this article before 2004, by which time I had already been exploring the resourceoriented approach to music therapy for a while. Therefore, it would be accurate to say that my work has not been particularly influenced by Schwabe’s elaboration of the concept of resource-oriented music therapy, but at the same time it is very interesting to note that similar perspectives have been elaborated.

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music therapy is implicitly resource-oriented due to the specific characteristics of music, even though explicitly considering it resourceoriented is relatively new. Schwabe argues that this aspect of music therapy could be an integrative element of the different traditions and schools in music therapy (Schwabe, 2005, p. 49). In his conceptualization, resource-oriented music therapy involves (1) releasing self-healing forces; (2) enabling the patient to establish a direct, constructive, and active contact with their surrounding reality (this involves a focus on dealing with external reality); and (3) focus on potentials rather than disorders. Schwabe’s resource-oriented approach is highly contextually situated, as he explains, and it is very critical toward what he calls a “regimentation culture” in the field of psychosocial care (Schwabe, 2005, p. 51). Clearly, Schwabe is distancing himself from the medical-oriented practice (or, as he terms it, “pharmacological music therapy”), the “effectance-motivated” music therapy, by emphasizing the active role of the patients (Schwabe, 2005, p. 52). Finally, Schwabe emphasizes that, on an implicit level, all psychotherapy in general and, therefore, music therapy too, consists of resource-oriented aspects as well as aspects concerning the immediate treatment of pathological processes. The resource-oriented aspects are of existential importance because of the limitations of the curative approaches: Only if you realize that there are damages that cannot be treated, which however can lead to other permanent damages if no treatment occurs, you realize that discovery and support of healthy personality aspects is of existential importance. (Schwabe, 2005, p. 55) Schwabe’s resource-oriented approach is certainly similar to the resource-oriented approach that will be outlined in this book, but it differs in relation to the understanding of resource orientation as an implicit and common factor of music therapy. The idea of a resource-oriented aspect being implicitly part of musical interaction is also central to other authors. In Daveson’s (2001) article, she argues that processes of empowerment are implicit in music therapy; Garred (2006) uses the term “resource-oriented,” but in his text this is related exclusively to music-based therapy, with explicit reference to the Nordoff-Robbins tradition. Although the Nordoff-Robbins approach must be said to involve emphasis on resource-oriented processes such as mastery or self-actualization, the term “resource-oriented” has

Introduction 9 also been used in descriptions of Analytical Music Therapy (Bonde, Pedersen, & Wigram, 2001). Less oriented toward a specific approach to music therapy is the use of the term by Trondalen (2004), emphasizing the salutogenic orientation toward health and a focus on coping, connection, and meaning (Trondalen, 2004, p. 132). The apparent disagreements here are, however, implicitly yet clearly connected to different ways of defining and understanding the concept of being resource-oriented and are thus demonstrating the need for a more articulated conceptualization and theoretical foundation of music therapy, which is the scope of this book. The resource-oriented approach that will be elaborated on throughout this book can be seen in context with a broader academic and social movement that has proposed a contextual- and strength-focused alternative to traditional problem- or pathology-oriented perspectives on psychiatry and mental health practices. There are examples of research as well as practice-oriented music therapy literature from the field of mental health that link with such alternative perspectives such as feminist therapy (Amir, 2006; Curtis, 1996; Curtis, 2006; Purdon, 2006; York, 2006); music therapy in the context of social psychiatry and nonmedical contexts (Hadsell, 1974; Hviid, 2005; Normann, 2005; Procter, 2002); and solution-focused interventions (Tyson & Baffour, 2004). Finally, several authors, such as Aasgaard (2002; 2004), Aigen (2005), Ansdell (2003), Kenny (1982; 1989), Procter (2002; 2004), Ruud (1990; 1998), and Stige (2002; 2006a; 2006b), have presented theoretical perspectives that illuminate aspects connected to or in support of a resource-oriented discourse about music therapy, even though the explicitness connected to such a discourse remains somewhat unexplored and less accentuated in terms of the generation of a theoretical foundation for a resource-oriented approach. The reader will recognize that many of the texts referenced are connected to presentations of culture-oriented perspectives and community music therapy. In the discourse of community music therapy, these authors have in various ways emphasized the cultural context of the client and pointed to therapeutic endeavors in relation to resources, such as cultural competences, cultural participation, social networks, and musical and personal strengths. These are aspects that the reader will find emphasized throughout this book. The resource-oriented approach that will be presented in this book is indeed related to theoretical perspectives explored in relation to community music therapy but differs by its focus on music therapy as a psychotherapeutic practice.

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APPROACH OR PARADIGM? In this book, I will present a theoretical exploration of the concept of resource-oriented music therapy that links to related discourses in an interdisciplinary academic landscape. Thus, the theoretical foundation of resource-oriented music therapy that will be presented here aligns with forces counteracting what has been called the strong illness ideology or a medical model in mental health care and psychotherapy (see chapter 1). The shift from a medical model of psychotherapy to a contextual model can in many ways be understood as paradigmatic. Thus, we might understand the resource-oriented approach explored in this book as connected to a particular paradigm. Paradigms are often regarded as incommensurable perspectives, with limited possibilities for “communicating” with each other: According to this view, one conceptual scheme cannot be expressed or comprehended in terms of another (Kuhn, 1970). They have fundamentally distinct languages, and even where they may share some conceptualizations, these are imbued with radically different meanings (Jackson & Carter, 1991). It seems important to acknowledge the difficulties inherent in understanding texts that originate within another paradigm, as this serves to protect plurality and guard against imperialist aspirations (Jackson & Carter, 1991, p. 111). By the same token, a total neglect of other paradigms might result in a lack of exposure to critical engagement. A quandary inherent in this is how, or rather if, it is possible to critique and discuss concepts that arise within a different paradigm. Thus, in the same way as it would be considered ignorant to critique hermeneutics on the grounds of a supposed lack of objectivity, so it could similarly be considered ignorant to evaluate (for example) analytically informed music therapy from the standpoint of a resource-oriented approach, because it is unclear even whether similarly named concepts convey the same meaning. I am aware that the term “resource-oriented” may have very different connotations within different models and traditions of music therapy. For example, there is a widespread perception that analytical music therapy is fundamentally resource-oriented (Bonde, Pedersen, & Wigram, 2001, p. 97). I would argue, however, that the term “resource-oriented” is here being imbued with a rather different meaning than what is put forward in this book, and that the term cannot therefore be used as a putative

Introduction 11 common factor between all music therapy traditions. It seems to me crucial that in any attempt to transcend paradigmatic incommensurability, there is sufficient acknowledgment of the diverse understandings of this term and, more generally, of discursive integrity. Only in this manner may the different models, traditions, or paradigms be fruitfully harnessed as a source for professional learning and development within the broader field of music therapy. When this is said, I want to emphasize that resource-oriented music therapy can also be seen as an approach inclusive of perspectives necessary to understand better the role of the “positive” aspects of a therapeutic process. I am convinced that there are aspects of resource activation in the practice of many different psychotherapeutic and music therapeutic models. A resource-oriented perspective can nevertheless probably add something to these perspectives and models by helping to make those aspects more central, or by providing more awareness and rationale as to why such resource-oriented aspects are important. As an approach, resource-oriented music therapy, however, is also involving a particular stance of attitudes toward the clients and the therapeutic process. In this way, a resource-oriented approach to music therapy might imply more than adding some positive or friendly element to existing models.

RESEARCHING RESOURCE-ORIENTED MUSIC THERAPY From 2004–2008, I was engaged in an international collaborative research project titled “Music Therapy in Late Modernity: Community Music Therapy and Resource-oriented Music Therapy.” The project was situated at Sogn og Fjordane University College5 and funded by the Norwegian Research Council. The collaborative research project aimed at integrating qualitative and quantitative research methodologies related both to community music therapy as well as to music therapy in mental health. The research collaboration involved regular meetings with an

5

The music therapy education in Sandane moved to the Grieg Academy, University of Bergen, in 2006. At the same time GAMUT, The Grieg Academy Music Therapy Research Centre, was established.

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international research group discussing and developing the research projects involved.6 The portfolio of the collaborative research project included two empirical research projects about resource-oriented music therapy in mental health care: (1) a randomized controlled trial (RCT) of the effects of resource-oriented music therapy (Gold, Rolvsjord, & Stige, 2005) and (2) a qualitative explorative study aimed toward theory building. The latter project forms the base for the elaborations presented in this book. I have, however, also been involved with the planning and feasibility of the RCT. The RCT project has been expanded in time and space and developed into an ongoing project: “Resource-oriented Music Therapy for Psychiatric Patients with Low Therapy Motivation: Randomized Controlled Trial (2008–2010).”7 At the starting point for my engagements with these research projects, a resource-oriented approach to music therapy was not clearly described, and this posed challenges to both of the studies. With these projects, we sought at the same time to develop a conceptualization of a resourceoriented approach to music therapy, to explore the clients’ experiences as well as to study the effects of the therapy. This may not seem feasible, but this complexity also afforded possibilities that enriched the research process. It necessitated a continuous alternation of focus and implied levels of interaction between theory and practice. Furthermore, a resource-oriented approach to music therapy, as explored throughout this research period, was based on a contextual model of psychotherapy, a model that encompasses the whole therapeutic situation as promoter of change, with a specific emphasis on the client’s own effort and competence related to the therapeutic process. These aspects of the therapeutic process are not readily addressed in the frames of a rigorous research design, such as an RCT (Rolvsjord, Gold, & Stige, 2005). Therefore, with the qualitative research, we have sought to support as well as to challenge the RCT by addressing the contextual aspects. In the qualitative study, two main research questions were addressed: 6

Participants in the research collaboration: Brynjulf Stige (project leader), Gary Ansdell, Cochavit Elefant, Christian Gold, Randi Rolvsjord, and Leif Edvard Aaroe 7 This project is conducted in collaboration with three hospitals in Norway (Nordfjord Psychiatry Centre, Stavanger University Hospital, and Jæren District Psychiatric Centre) and three sites abroad (Centre University of Melbourne, Australia; Oregon State Hospital, USA; and Wagner-Jauregg University Hospital, Linz, Austria).

Introduction 13 (1) What defines and describes a resource-oriented approach to music therapy? (2) What are the client’s experiences in resource-oriented music therapy? There is a certain tension between these two main research questions. While the second is concerned with the client’s perspectives, the first aims toward definitions that are more closely related to the therapist’s perspectives. There are also tensions related to the power relations that such questions actualize. Within a single study, I was asking very open questions, wanting the client’s voice to come to the fore but simultaneously working toward definitions and descriptions that are associated with the researcher’s knowledge and power to create definitions. It was also a challenge to work with the two research questions at the same time, because in many ways the second research question presupposes an answer to the first research question, but at the same time I also wanted to let the empirical explorations of the clients’ experiences inform my responses to the questions concerned with the notion of a resource-oriented approach to music therapy. Because of these implications and tensions, the second research question became the main focus for the empirical explorations, whereas the first research question was primarily explored through studies of literature. This was also a decision that facilitated more in-depth analysis and more layers of description in the empirical explorations. The empirical explorations took the form of an ethnographically informed qualitative case study. Two cases, processes of music therapy, from my own practice of music therapy were studied. The cases were selected from the population of clients receiving music therapy at the psychiatric hospital where I had my practice, through purposeful sampling (Creswell, 1998, p. 118; Ryen, 2002, p. 88): That is, potentially interesting and information-rich cases were selected. The case studies may be described as instrumental (Stake, 1995) as they become a vehicle to better understand the issue and contribute to a general understanding. The empirical material for each case study was collected through multiple sources of information, such as participant observation, interviews, and interpretation of artifacts (Creswell, 1998; Ryen, 2002). Combining different types of techniques for collecting empirical material is advised in the ethnographic tradition of fieldwork (Ryen, 2002; Stige, 2005), and it is also sometimes seen as a means of triangulation (Fangen, 2004). Triangulation is in some traditions of qualitative research used as a way of validating the data. Another function of such triangulation of methods is to see the different ways of collecting empirical material as deepening

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the understanding of different aspects of the case, rather than as confirming the data (Ryen, 2002, p. 195). Studying cases from my own music therapy practice meant that I was engaging myself and the clients in dual roles, as client/informant and therapist/researcher. These dual roles are challenging and necessitate reflection and ethical responsibility. The researcher’s role when doing participant observations can vary considerably according to the degree to which the researcher is taking an active part in the group, activity, or culture that is being studied. In this study, I had the role of a therapist, and as such my role as a researcher can be understood to be that of a full participant (Fangen, 2004, p. 104). In the sessions, my main responsibility and concern were to be as good a therapist as possible and to locate my full attention and awareness in the present situation shared with the client. This position also brings the potential for closeness and insider views that are valuable because they offer important perspectives and positions for understanding from a hermeneutic and constructivist perspective (Naples, 2003). The semistructured interviews (Kvale, 1996) focused upon the clients’ experiences in music therapy. The principal aim of interviewing is to come closer to the client’s perspectives on the process and the meanings of music therapy in relation to their health and life challenges. Interviewing is not, however, considered to be a technique used to reveal the truth of the other’s life world. Kvale describes the qualitative interview as a construction site for knowledge, an interchange of views between two persons conversing about a theme of mutual interest (Kvale, 1996, p. 14). This mutuality in the process implies first of all that interviewing should be viewed as a mutual process of meaning construction, in which both parties contribute to the construction of meaning. The stories that clients tell about their lives are inevitably colored by the context and by the person listening to the story. Interviewing is, in other words, not a one-way process in which I as the researcher gather the informant’s perspectives on the case studied, but a mutual exchange of ideas that produces knowledge. In some of the interviews, songs introduced in different periods of the therapy were used to help the informant to recall experiences (McLeod, 2000, p. 197). Both the interviews and the analysis involved procedures of member checking. The analysis of the empirical material involved a combination of a thematic analysis (Bruscia, 2005; Miles & Huberman, 1994) and narrative techniques (Kenny, 2005; Lawrence-Lightfoot & Davis, 1997). The thematic analysis involved open coding of the transcriptions of the

Introduction 15 interviews to identify categories and main themes. In this part of the analysis, I used the computer software Atlas/ti as an aid. In accordance with an ethnographic tradition, writing is understood as an important part of the construction of meaning and hence the process of analysis (Stige, 2005). The process of writing is concerned with narrativity, with voice, and with structure and form, as well as with power relations and politics. The analysis of the empirical material can also be described as an abductive process (Alvesson & Skjöldberg, 2000), in which the empirical material was brought into contact with theory throughout the analysis (Willis, 2000).

HOW TO READ THIS BOOK

This book is organized into three parts: frames and descriptions, case studies, and working resource-oriented. Part One, “Frames and Descriptions,” will outline the theoretical perspectives informing a resource-oriented approach to music therapy and intends to contextualize the approach. Chapter 1 will seek to provide a context for the book with regard to important current discussions in mental health politics and its role in relation to music therapy. The starting point for the discussion is the critique of the illness ideology and medical model that has been dominating the provision of mental health care for decades. The chapter does not intend to give a comprehensive overview of the politics of music therapy in mental health, but rather to posit the resource-oriented approach in a political and discursive landscape. Chapter 2 will provide a theoretical context for the conceptualization of therapy within mental health care. Three informing perspectives will be illuminated: the philosophy of empowerment and its focus on the interplay between individuals and society; a contextual model of psychotherapy with a specific emphasis on relational factors and the client’s own efforts; and positive psychology, emphasizing the importance of positive emotions and strengths as part of the therapeutic process. Chapter 3 will provide the theoretical context for the understanding of the conceptualization of music. The focus will be on perspectives from musicology and music sociology. The various theoretical perspectives presented in Chapters 2 and 3 are in many ways representative of different paths to the resource-oriented perspective explored throughout this book. In different ways, they point toward an

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approach to music therapy that emphasizes the development of strengths and resources as part of therapeutic encounter, that strive toward equal relationship, that emphasize cultural awareness and societal engagement, and that emphasize the possibilities of the use of music as a health resource. The last chapter in this part will sum up the most essential characteristics and include elaborations toward a conceptualization of a resource-oriented approach to music therapy. In the second part of the book, two case studies will be presented. Both clients, Emma and Maria, are young, resourceful, music-loving women who suffer considerable mental health problems. In both of the case studies, I had a double role as a therapist and a researcher. The chapters presenting the case studies are intending to demonstrate and explore a resource-oriented practice of music therapy in terms of the focus, musical and verbal interaction, relationship, and process. The outcome of therapy was not the focus in the research and is only illuminated through the client’s own comments. The chapters are organized through the voices and perspectives of the therapist, the client, and the researcher. Chapters 5 and 8 provide a chronological account of the therapeutic process voiced by the therapist. In Chapters 6 and 9, the focus is the client’s story and her experiences in music therapy. Finally, Chapters 7 and 10 are focused on the researcher’s reflections and theoretical elaborations of the cases. Part Three, “Working Resource-Oriented,” will go more in depth into the implications for practice. The resource-oriented approach to music therapy that is outlined in this book is contextual. The concept of resources comprises not only an individual’s strengths and potentials but also their access to resources in the social community. The whole therapeutic context, and in particular the client’s use of the therapeutic situation, rather than the therapist’s interventions and techniques, is understood as the dynamic force in therapy. With this as a background, the last part of this book is intended to explore the implications for practice from within a contextual model, where the therapist is not in charge of and the hero of therapeutic encounter. Thus, in Chapter 11, I discuss the client’s craft in therapy and ask: What do clients do to make therapy work? In Chapter 12, the therapist’s craft will be discussed through the presentation of therapeutic principles for a resource-oriented approach to music therapy. Finally, the therapeutic relationship will be explored in Chapter 13.

PART ONE FRAMES AND DESCRIPTIONS

Chapter 1

MUSIC THERAPY AND THE POLITICS OF MENTAL HEALTH CARE The practice, discourse, and research of music therapy are performed in a cultural, social, and political context. The politics of music therapy are interwoven with politics of science, politics of health, and cultural politics. Even if therapy as such is commonly considered an apolitical activity, it is inevitably connected to a web of politics. Any practice of music therapy is linked with political conditions and decisions on various levels of the institutional and cultural contexts, whether the music therapists are involved with social activism or they comply with the ideological and economical systems in which they are posited. Thus, on both practical and theoretical levels, music therapy is performed in contexts that are molded by various political conditions and ideologies regarding health, illness, and therapy, as well as ideologies of music and science. In this book, a strong emphasis will be put on a philosophy of empowerment that also embraces the idea of therapy as being political per se and even encourages political activism as part of therapeutic endeavors. In this chapter, I will outline some recent discussions regarding mental health care with strong political undertones that form an important premise for the discourse in this book. The starting point for this will be the implications of an “illness ideology” for mental health and mental health care. Thus, the resource-oriented approach presented in this book links with theoretical perspectives that to various degrees contain levels of critique and political engagement. This level of critique involves:    

skepticism toward diagnostic systems; skepticism toward the belief in interventions as the exclusive effective factor, and therefore critique of the evidence-based medicine movement; critique of excessive focus on problems and pathology; critique of individualistic focus on health concerns; and

MT and the Politics of Mental Health Care 19 

critique of the power structures in psychiatric health services.

I will argue that the medical model at the core of the illness ideology has been and is a very strong model that has influenced and dominated the discourse and understanding of mental health, of illness and disease, of mental health care and psychotherapy, as well as of research in this field. There have, however, in recent decades, been political and social movements counteracting the illness ideology related to health care in general and mental health care in specific that have yielded influences over political levels of decisions. An important political signal that broadens up the conceptualizations of health and health care is the World Health Organization’s (WHO) constitutional definition of health, which states that “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1946). With this constitution, mental health concerns are related to political, social, and cultural levels rather than merely biological and medical ones. This broadened scope has in Norway contributed to political decisions of a conceptual change from psychiatry to mental health care, this implying a change of direction in mental health care politics that involves more interest in social and cultural aspects, as well as in positive health. Similarly, since the 1970s, patient activists in the USA and Europe have aggressively asserted their claims to be regarded as experts on their own illnesses, with the rights to play an active role in health care decision-making. Today, this has become an important principle in mental health care policy (Tomes, 2007). This emphasis on user participation has been connected to a broader focus in society on the rights and possibilities connected to democracy and citizenship (Braye, 2000). Terms such as “user participation” have, however, been used in ways with regard to mental health care that carry meanings varying from compliance to medical treatment to user-led services. Therefore, in practice, user participation in health care may often involve consumerism rather than democratic possibilities. Thus we may ask if the language of patient empowerment when used to justify positions in political debates has become essentially bankrupt (Becker, 2005; Tomes, 2007, p. 698).

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Randi Rolvsjord THE POLITICS OF AN ILLNESS IDEOLOGY

Over the past decades, there has been an ever-widening definition of psychological distress. The increasing numbers of diagnostic labels available in the diagnostic manuals DSM-IV (American Psychiatric Association, 2007) and ICD-10 (World Health Organization, 1999) serve as a manifestation of this development. We may in some ways relate this development to the evolving competence of the investigation of mental health disorders, a development that makes possible more nuanced categories of mental health problems and might at the best provide some better indications for available treatments. As Maddux emphasizes in the following quote, however, this development also has wider implications related to the politics of mental health care as well as to the wider understanding of mental health problems in our society: We are fast approaching the point at which everything that human beings think, feel, do, and desire that is not perfectly logical, adaptive, or effective will be labeled a mental disorder. Not only does each new category of mental disorder trivialize the sufferings of people with severe psychological difficulties, but each new category becomes an opportunity for individuals to evade moral and legal responsibility for their behavior (Resnek, 1997). It is time to stop the “madness.” (Maddux, 2002a, p. 18) With reference to the field of psychology, Maddux claims the existence of an illness ideology,8 an underlying model of thinking that has become dominant in mainstream psychology. This ideology “narrows our focus on what is weak and defective about people, to the exclusion of what is strong and healthy” (Maddux, 2002a, p. 322). According to Maddux, the illness ideology is consistent with certain assumptions concerning the field of psychology and the practice of psychotherapy. Within such a model or ideology, the practice of psychotherapy and the field of psychology in general are primarily concerned with psychopathology. Second, the illness ideology links with a discrete model 8

Other researchers use similar conceptualizations, such as “medical model” (Wampold, 2001), “disease model” (Mechanic, 1999), or “pathogenic orientation” (Antonovsky, 1979; 1987), to describe a similar set of underlying assumptions.

MT and the Politics of Mental Health Care 21 of mental health problems, describing clinical problems and clinical populations as differing in kind, not just in degree of removal from normality. Third, mental health problems and psychopathology are identified as something that resides in the individual. Finally, it follows from these assumptions that the therapist’s task is to identify (diagnose) and prescribe an intervention (treatment) that will eliminate or cure the disorder (Maddux, 2002a, p. 14). I wish to emphasize that the notion of therapeutic practice in the field of mental health promulgated by the medical model is a highly dominating discourse, as has been pointed out by several critical voices for decades (Engel, 1977; Furedi, 2005; Illich, 1975; Maddux, 2002a; Seligman & Csikszentmihalyi, 2000; Szasz, 1979; Wampold, 2001). However, it is important to emphasize that in psychotherapy (and also in music therapy), the medical model does not imply a model that is physiochemically based, but one that takes the same form as the medical model in medicine (Wampold, 2001): To summarize, the medical model presented herein takes the same form as the medical model in medicine, but differs in that (a) disorders, problems, or complaints and rationale for change are held to have psychological rather than physiochemical etiology; (b) explanations for disorders, problems, or complaints and rationale for change are psychologically rather than physiochemically based; and (c) specific ingredients are psychotherapeutic rather than medical. Because the medical model of psychotherapy requires neither physiochemical nor mentalistic constructs, strict behavioral interventions would fit into this model. (Wampold, 2001, p. 16) In this way, the critique of a medical model in mental health care and psychotherapy is not primarily a critique of the biomedical model and its relevance to psychiatry, as is the focus in some critical contributions (Engel, 1977; Szasz, 1979). The critique of the medical model by Wampold, Maddux, and others does not imply a total rejection of biological factors related to mental health, nor does it imply a nonapproval of pharmacological treatments. The main point of this critique of the medical model is related, rather, to a structural metalevel of the model as explained by Wampold in the previous quote and similarly identified by authors in favor of a medical model (Oates, 1995; Shah & Mountain, 2007). However, it is difficult to conceive of an alternative

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approach without approval of the need for an understanding of mental health and mental health problems involving biological, psychological, social, and cultural perspectives. With a constructivist perspective, Maddux identifies the illness ideology as a strong discourse or a grand narrative (Alvesson, 2002) — that is, a dominant and often inexplicit underlying theory. From the point of the social constructivist, mental health, mental health problems, and diseases are social constructions based in a set of values that form our conceptions of mental health and of diseases. Terms that are commonly used when talking about therapy, such as “illness,” “treatment,” “patient,” “clinic,” “clinical,” “intervention,” and “symptom,” are all consistent with the illness ideology. By using this language, he claims, we enter into the discourse of the illness ideology: The terms emphasize abnormality over normality, maladjustment over adjustment, and sickness over health. They promote the dichotomy between normal and abnormal behaviors, clinical and nonclinical problems, and clinical and nonclinical populations. They situate the locus of human adjustment and maladjustment inside the person rather than in the person’s interactions with the environment or in sociocultural values and sociocultural forces such as prejudice and oppression. Finally, these terms portray the people who are seeking help as passive victims of intrapsychic and biological forces beyond their direct control, who therefore should be the passive recipients of an expert’s “care” and “cure.” (Maddux, 2002a, p. 14) One pertinent example is the use of the term “intervention” (Bohart & Tallman, 1999, p. 13; Maddux, 2002a), a term that has been used rather unreflectively in music therapy literature as a seemingly “neutral term” describing the therapist’s goal-directed use of techniques. Even in Bruscia’s definition, music therapy is a “systematic process of interventions” (Bruscia, 1998, p. 20). This term, which is also associated with military language, implies that someone from the outside is taking action. This someone, who is dedicated to the intervention, is usually the therapist, although I will argue in this book that the client takes similar actions in the mutual interplay in music therapy. In music therapy discourse, I consider the use of the term “intervention” to be connected to a medical model because it is a term that is exclusively used to describe

MT and the Politics of Mental Health Care 23 the therapist’s actions, usually indicating the choice and subsequent use of a technique in order to achieve a certain effect. This implies a discourse in which the therapist’s actions are regarded as more important in relation to the outcome of therapy than the client’s, thus preserving the traditional patriarchal power relation. This is not at all to argue that the therapist’s actions are unimportant, nor that the therapist is “not doing anything.” The term “intervention” is, however, problematic in a discourse emphasizing equality and mutuality, and I therefore prefer to talk about collaborations, negotiations, and interactions when describing the process of resource-oriented music therapy. It is exactly such exaggeration of the professional expertise to which medical sociologist Furedi points when discussing the societal and personal implications of the illness ideology. Furedi holds that we (in Western societies) are developing a therapy culture, a culture that involves a cultivation of vulnerability among people because we increasingly tend to perceive people’s life problems as pathology in need of professional expertise. Furedi points to a paradox related to the therapeutic practice. Most psychotherapeutic traditions, he argues, hold up a therapeutic ideal related to self-determination and autonomy. This ideal is, however, in sharp conflict with the message that a person once labeled with a mental health diagnoses is in need of experts. Thus, the helplessness, powerlessness, and vulnerability are emphasized, along with the “promised” effect related to self-determination and autonomy: With such high rates of prevalence of illness and damaged emotions, the ideals of therapeutic self-determination are negated by a powerful cultural narrative of human helplessness. (Furedi, 2004, p. 114) Receiving this double message, people become disempowered and socially and culturally dependent upon medical expertise to solve their problems. Following Furedi’s argument, the development of such a therapy culture makes it more likely that people will perceive themselves as ill9: In practice, therapeutic culture helps individuals reconcile themselves to a more “realistic” and more “vulnerable” version of the self. The self is presented as constantly subject to grave 9

See also Illich’s famous arguments about medical nemesis (Illich, 1975).

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Randi Rolvsjord injury and illness. The insistence that such risks are part of everyday life has the effect of heightening the individual’s sense of vulnerability and disposition to illness. (Furedi, 2004, p. 107)

It has to be added here that the power of expertise that to an increasing degree is merged with professionalism is also a social construction that is connected not only to governmental recognition, license, and legitimization (Johnson, 2001), but also to the interactions between professionals and lay persons accepting the professionals’ rights to authority (Purdy & Banks, 2001). One of the most prominent aspects of mental health politics over past decades has been the evidence-based medicine movement and its sister movement, evidence-based practice in related disciplines. Wampold (2001) outlines two current examples of adherence to the medical model in psychotherapy discourse — psychotherapy treatment manuals and empirically supported treatments — that we might relate to the EBM (evidence-based medicine) movement. The EBM movement adheres to the medical model in directing treatment toward a disorder, problem, or complaint; in the use of therapy manuals; and in requiring evidence related to specificity — for example, via the use of placebos. In this way, the EBM movement can be understood as one manifestation of the illness ideology. I have to emphasize here, however, that it need not necessarily be so. I am not trying to argue against effect studies per se; rather, my concern is that these demands for evidence-based research easily force us into medical-model thinking, by the fundamental question, “What works?” So even if the proposed hierarchy of evidence (Ansdell, Pavlicevic, & Procter, 2004; Goodman, 2003) does not necessitate a link between diagnosis and interventions, the medical model is very often taken for granted in the EBM movement.10 As outlined here, one of the main problems with the illness ideology is connected to the underlying power relation involving the person seeking help and the therapist, as well as to more systemic levels in the organization of mental health care. There are dilemmas related to the policy of the EBM movement on the one hand and the call for user participation on the other hand. The EBM movement on one hand enhances the possibilities for user participation as consumerism, but at the same time, it is conserving the unequal power relation between experts 10

I have previously discussed this along with colleagues (Rolvsjord, Gold, & Stige, 2005a).

MT and the Politics of Mental Health Care 25 and clients and in this way limits possibilities for (democratic) user participation.

THE PRESENCE OF A MEDICAL MODEL IN MUSIC THERAPY

At this point, the reader might ask if there is such a thing as an illness ideology or a medical model in music therapy. To this, I will say “yes.” The medical model in psychotherapy is more than a “straw man,” a fictive model created simply in order to present the resource-oriented approach as an original contribution, i.e., one that offers new knowledge and ideas about music therapy. Where I have already in the introduction claimed that resource orientation is not a factor common to all traditions and practices of theory, this is first of all because I see the medical model alive and well in music therapy discourse.11 As the medical model also in music therapy might be a so-called grand narrative that is taken for granted and not discussed explicitly, adherence to this model is often not made explicit in texts. Although a physiochemically based approach is not the core of a medical model, as explained previously, a medical (physiochemically based) music therapy would be likely to adhere with such a model. The clearest example of this in music therapy literature pertaining to the field of mental health is perhaps Unkefehr and Thaut’s (2005) book, which combines behavioristic psychological theory with neurological perspectives. Thaut (2005) describes his theoretical model in the following way, pointing out the specificity of the therapeutic interventions as the main source of change: Renewed efforts are under way to develop a theoretical paradigm of music therapy in psychiatry, in which the uniqueness, efficiency, and specificity of the therapeutic music interventions can be conceptualized and researched with an emphasis on a cognitive neuropsychiatric framework (Halligan & David, 2001). Such a paradigm must be able to integrate musical response models in music perception and music cognition with concepts of 11

See also Ansdell’s description of a consensus model in music therapy discourse (Ansdell, 2002; 2003), with many similarities to the medical model.

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Randi Rolvsjord music’s influence on nonmusical human behavior, psychologically and neurobiologically, and with concepts of behavioral learning and therapeutic change. (Thaut, 2005, p. 86)

More analogous to a physiochemically based medical model, from a behavioristic approach, are music activities and musical interactions intended to provide positive reinforcement for appropriate behavior (Silverman, 2003). The success of the music therapeutic interventions is measured in terms of the frequency of inappropriate behavior, as defined by the music therapist. The result is a rather mechanical and linear understanding of the therapeutic process in accordance with the medical model. Music therapy interventions are decided by the therapist, who makes the decisions based upon her or his expertise. Specific clinical interventions are suggested in the last chapter of Unkefer and Thaut’s (2005) book in the form of a manual (Houghton, Scovel, Smeltkop, Thaut, Unkefer, & Wilson, 2005). In accordance with the medical model, this guide describes the symptomology of schizophrenia, bipolar disorder, and General Anxiety Disorder, and links music therapy programs as well as specific techniques to the pathological symptoms via an identification of the needs of a patient displaying a specific symptom or behavior characteristic. A similar example is the multimodal psychiatric music therapy manual by Cassity and Cassity (2006), in which they describe the therapeutic process in terms of an accountability procedure that is in accord with the General Standards of the AMTA, focusing on referral and acceptance, assessment, program planning, implementation, documentation, and termination of services. Several other articles suggest interventions or techniques related specifically to a particular deficit or problem (Silverman, 2005; Smeijsters & Cleven, 2006). Odell-Miller (2007) suggests that music therapists select their interventions (i.e., choose ways of working) on the basis of the client’s diagnosis. Indeed, in her literature review, she identifies only one article (Stige, 1999) that very clearly states that the intervention was not based on the client’s diagnosis (Odell-Miller, 2007, p. 109). This may indicate a more widespread adherence to the medical model. Odell-Miller considers “that the presence of diagnostic criteria serves to provide an understanding of what someone might need in terms of an intervention” (2007, p. 84). Finally, literature linking to psychoanalytic and psychodynamic psychology and psychotherapeutic traditions represents a major part of the music therapy literature in the field of adult mental health and is in

MT and the Politics of Mental Health Care 27 many ways the dominant position in this field of practice. However, it is not self-evident what we include in this “big box” of tradition. Psychoanalytically informed music therapy is rather heterogeneous, and music therapists making use of psychoanalytically informed theory may also belong to different traditions of music therapy such as those founded by Priestley, Nordoff and Robbins, or Benenzon. Furthermore, music therapists using psychoanalytically oriented perspectives in the field of psychiatry relate to a large spectrum of traditions and theories within the psychoanalytic landscape, such as Freud and Klein (Priestley, 1994; Streeter, 1999), Jung (Austin, 1999; Priestley, 1994), Lacan and Bion (De Backer, 2004; De Backer & Van Camp, 2003), Winnicott (De Backer & Van Camp, 1999; Jensen, 1999; Stige, 1999), or Stern (Hannibal, 2003; Rolvsjord, 2001; Stewart, 1996), to mention just a few (see also Hadley, 2003). The differences within these theories are considerable with regard to perspectives on the causality of psychopathology, with regard to understandings of the therapeutic process, and not least with regard to the therapeutic relationship. The origins of psychoanalysis, however, lie in the medical model (Pilgrim, 1998, p. 537; Wampold, 2001, p. 10), pointing to the practice of Freud as a physician developing treatment for hysterics. There are indeed also several aspects related to the tradition of Analytical Music Therapy (AMT, the Priestley model) that are analogous to a medical model. The focus in AMT is intrapsychic conflict (Priestley, 1994, p. 155ff.), and the main aim is described in terms of regulation the patient’s defense mechanisms (Priestley, 1994, p. 170). Such aspects relate to a primary focus on conflicts and resides the problems in the intrapsychic. The therapist’s role is also considerably analogous to the expert’s role in the medical model, as AMT emphasizes therapist expertise and skilled and parental or even patriarchal 12 interventions as defined through several specified techniques (Priestley, 1994, p. 37ff.) and involving possibilities for the therapist to directly access and understand the inner conflicts of the client through the symbolic music and processes of transference and countertransference. Thus, the traditional version of psychoanalysis and analytical music therapy can be seen to align well with a medical model. Psychoanalysis in general, as well as analytically oriented music therapy, has developed considerably since Freud. Indeed, a paradigmatic 12

Priestley (1994) consequently named the therapist “he” and the client “she,” which implies a discourse accepting a very patriarchal tradition. The patriarchal tendency of psychoanalysis is also emphasized by De Backer (2004, p. 78).

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shift within psychoanalytic theories in music therapy from monadic to dyadic forms has been described (Wigram, Bonde, & Pedersen, 2002, p. 83). Very important in this concern are the perspectives furnished by research into early infant development (by researchers such as Trevarthen, Mead, Stern, and Bråthen, among others) that transformed developmental theory in the 1990s. This development comprised a rejection of central aspects related to Freud’s libido theory, Mahler’s concept of symbiosis, etc., and resulted in greater focus upon the present moment (Stern, 2004), relationship (Alvarez, 1992; Stern, 2004; Stern et al., 1998), resource activation (Wöller & Kruse, 2001), and acting as well as talking (Johnsen, Sundet, & Torsteinsson, 2000). These developments obviously also introduce more “positive” or strengths-oriented aspects to the therapeutic interaction in music therapy. Pedersen’s ego-supportive therapeutic approach, “a reorganizing and holding method” (Pedersen, 1998; 1999) or Metzner’s focus on interactions and scenic understanding (Metzner, 1999; 2004) can be seen as representative in this regard. There are also case studies that clearly describe the results of an analytically oriented therapy process in terms of the development of strengths and resources (Hannibal, 2003; Nolan, 2003; Pedersen, 2003) and a few contributions moving toward a more contextually oriented use of psychoanalytic theory (Maratos, 2004; Metzner, 2007). In this literature, however, focusing on a client’s strengths and potentials is still seen as a tool for coming into contact with basic inner conflicts (Hannibal, 2003), rather than a primary concern of the therapy. Further, the primary function of music seems predetermined as a symbolic display of the unconscious (De Backer & Van Camp, 2003), contributing to maintain an expert-knower positioning of the therapist. So even with the relational turn in psychoanalysis, psychoanalytic approaches in several ways adhere to and stabilize the discourse of the illness ideology.

WHAT IS MENTAL HEALTH? How we conceive psychological illness and wellness has wideranging implications for individuals, medical and mental health professionals, government agencies and programs, and society at large. (Maddux, Snyder, & Lopez, 2004, p. 321)

MT and the Politics of Mental Health Care 29 The illness ideology, as outlined previously, implies that health and disease are understood according to a discrete model. In such a discrete or dichotomous model, health is seen as the usual state of being and disease, the unusual state. Thus, health is understood as an either-or state. Alternatively, in a continuum model, health and illness are seen as opposite poles of a continuum. According to such a model, mental illness is not a distinctly different category from mental health, and there are instead varying degrees of sickness and normality (Horwitz & Scheid, 1999, p. 1). With regard to mental health and illness, the continuous model is disputed. Over recent decades, biomedical research has increased its emphasis on a discrete model. We can also observe a similar emphasis of a discrete model in research related to mental health with the EBM movement. In most cases, however, the causes and conditions of mental illness are disputed and the treatments uncertain (Mechanics, 1999, p. 15). Among those who adhere to a discrete model, this problem is usually seen as a weakness in the diagnostic system rather than an argument for a continuous model. The psychiatric diagnostic manuals (DSM-IV and ICD-10) are, however, clearly based on conventions rather than on any objective reality of discrete diseases. Thus, adherence to a continuous model will usually lead to less emphasis being put on making definite diagnoses, since treatment approaches are unlikely to differ on the basis of meeting diagnostic criteria (Mechanics, 1999, p. 16). Horwitz and Scheid (1999) argue, however, that we might not need to have an absolute answer to this problem if we also allow the research questions being addressed to direct our view of mental health and disorders (Horwitz & Scheid, 1999, p. 2). Understanding health as a continuum is in many ways similar to the dialectic approach to health described by Jensen (1994). This approach might help us disentangle another pertinent aspect of health. A dialectic approach implies that understanding is generated through the transgressing of oppositions. The dialectic view of health embraces oppositions such as life and death, pain and well-being, illness and health (Jensen, 1994, pp. 19–20), and involves and interest in the positive-health end of the continuum with regard to research as well as strategies for care. Aspects of positive health and well-being are also emphasized as an important part of health — for instance, in health psychology (Blaxter, 2004; Marks, Murray, Evans, & Willig, 2000), and by the positive psychology movement (Carr, 2004; Snyder & Lopez, 2002). A basic assumption in the dialectic concept of health concerns the relationship between well-being and pain and that between life and death. It is argued

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that well-being cannot be experienced without the feeling of pain or illness. It is not so much the absence of illness that matters for a person to be able to experience good health, as it is how illness affects the person’s life. Health then becomes a quality of human life, permitting a variety of ways in which the tensions between pleasant and painful aspects of life can be managed. With such a dialectic concept of health, different strategies for promoting health can be acknowledged. Thus, it seems important to understand health in ways that may comprise both physical and psychological aspects of negative health (that is, disease) and positive health (which would include nonphysiological aspects of well-being). Finally, it is also important, as Stige (2002; 2003a) emphasizes with his definition of health that relates to “qualification for participation,” to see health in general as well as mental health in relation to the social, cultural, and economic/material context. Stige emphasizes that health, as well as health problems, are “due to complex interactions between biological, cultural, social, and cultural factors” (Stige, 2003a, p. 203). Thus, Stige argues for a position that allows for biological as well as social and cultural causes of illness as well as health being imputed through the relationship between individual and community. This implies an emphasis on the societal and community concerns for health. Although bad health as well as good health are always experienced and situated in the individual person, health, as well as health problems, are always experienced and constructed in context, in relation to social, cultural, and political aspects. With such a position, which we also might associate with the social disability model (Donoghue, 2003; Freund, 2001; Simenski, 2003), mental health problems are at least to some extent a function of the society involving cultural, societal, and political norms and constraints for participation. With regard to mental health, authors have pointed toward aspects of our postmodern society that can be regarded as constructive of mental health and mental health problems (Cushman, 1995; Whitely, 2008). Whitely (2008) argues that society in its postmodern condition of rapid sociocultural change is associated with some psychosocial costs, or links between this society’s influence and mental health. Whitely argues that tendencies in postmodern time such as individualization, social roles and self-identity, the culture of expertise, the transformation of intimacy, and future orientation are related to a person’s experience of mental health as well as to ideas of mental health care and psychotherapy.

MT and the Politics of Mental Health Care 31 STRATEGIES FOR MENTAL HEALTH CARE Contemporary Western medicine is likened to a well-organized, heroic, and technologically sophisticated effort to pull drowning people out of a raging river. Devotedly engaged in this task, often quite well rewarded, the establishment members never raise their ease or minds to inquire upstream, around the bend in the river, about who or what is pushing all these people in. (Antonovsky, 1987, p. 89) This metaphor, known as “the bias of the downstream focus,”13 is used by the Israeli medical sociologist Aaron Antonovsky to position his salutogenic orientation in the landscape of health-work traditions. To explain his salutogenic orientation, he continues the metaphor: To continue the metaphor, my fundamental philosophical assumption is that the river is the stream of life. None walks the shore safely. Moreover, it is clear to me that much of the river is polluted, literally and figuratively. There are forks in the river that lead to gentle streams or to dangerous rapids and whirlpools. My work has been devoted to confronting the question: Wherever one is in the stream — whose nature is determined by historical, social-cultural, and physical environmental conditions — what shapes one’s ability to swim well? (Antonovsky, 1987, p. 90) Antonovsky holds that in attempting to approach an understanding of health work, including health promotion, prevention of disease, and therapy, two fundamentally different strategies are possible. The first is the traditional medical strategy that aims to explain why people become ill and how to cure the illness. The other strategy, as a contrast, aims toward explanations of why people maintain good health. To cope with illness, and to move toward health through the strengthening and development of resources that promote capabilities of assimilation and coping, is the main therapeutic strategy. Antonovsky’s perspectives lead 13

The metaphor was originally presented in “moderately antimedical establishment literature.” A more exact reference is not given in Antonovsky’s text.

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us toward a direction that involves a mental health care practice that is engaged with coping and positive health as well as health problems and illness. A problem, however, is that Antonovsky’s strategy might be too much involved with the individual’s ability to adapt to a stressful environment and is not taking into account the collective levels of human existence (Stige, 2002, p. 189), and thus conforms to an individualization of health concerns. 14 In the continuation of this, we should also ask whether the emphasis on adaptation in Antonovsky’s model leads to an approach in which the mentally ill person must him- or herself be blamed for a lack of ability or effort to adapt. I have already argued that one of the problems with the medical model is the individualization of health concerns. It is to be emphasized that focusing on positive health does not exclude the risk of individualization of mental health problems. Similar critiques are also raised about the positive psychology and resilience research by Maracek (2002). From a postmodern feminist perspective, Maracek argues that resilience is a description of the individual’s capabilities to assimilate to the environment, mainly the capabilities to cope with stressors. The slide from there to blaming the victim is all but inevitable. Furnishing examples from research into women’s ability to cope with and recover from gender-linked violations, she says that “the Resilient Woman stifles social critique; her image replaces a focus on social and economic injustices with a focus on individual triumph through personal will” (Maracek, 2002, p. 11). So by too little focus on the contextual aspects, the risk of ending up with a “re-silent” woman rather than “resilient” woman is obvious. Hence, we are in need of strategies for mental health work that take into consideration aspects of coping and positive health but with a mindfulness to contextual aspects. The challenge is perhaps to devise theories that can be called “both/and” theories, theories that see people both as constrained by their circumstances and as casual agents, as Suyemoto (2002) suggests. She emphasizes that people are actively involved in the construction of their reality as well as co-constructing this with others. Suyemoto proposes that identity is “actively self-constructed and reconstructed by an individual situated in a sociohistorical and cultural context” (Suyemoto, 2002, p. 72). In contrast to traditional psychological theories concerning personality and personality formation, the interplay and interdependence between the 14

It must be emphasized that Antonovsky in many articles discussed his theory on aggregated levels (Antonovsky, 1987, p. 174; 1991a; 1991b; 1993).

MT and the Politics of Mental Health Care 33 individual and their sociocultural context are taken into account. Diagnostic manuals (ICD-10 and DSM-IV) locate mental health problems within the individual, although sometimes, as with the PTSD (posttraumatic stress disorder) diagnoses, something outside the person is acknowledged as the main cause of the illness. From a feminist perspective, the diagnosis and treatment of PTSD, particularly where it is related to sexual and domestic violence, is still problematic because the focus of the problem is nevertheless transferred from violence as a societal, cultural, and political problem, to the individual (Maracek, 2002; Worell & Remer, 1996/2003). Sexual violation is more than a cause of illness — it is also a crime. Strengthening an individual’s ability to cope with life in the aftermath of such devastating violence is of course a legitimate objective for mental health services, but this must never lead to neglect of the contextual and political aspects of the person’s life situation (Becker, 2005).

MUSIC POLITICS AND MUSIC THERAPY IN MENTAL HEALTH CARE

Where does music fit into this picture? So far in this chapter we have been discussing mental health politics with the focus on the discourses and political debates connected to mental health and mental health care. Obviously, music therapy also interacts with another political arena, that of music politics. Music is (like therapy) sometimes considered apolitical in nature, but such an understanding is based on paradigms from traditional musicology that are nowadays much disputed, as I will argue in a following chapter. In his potent critique of musicology, Bohlman (1993) points out the efforts that have been made to keep music “pure” and “value-free” as part of a clearly political act of depoliticizing music. The failure within musicology to see music as embedded in cultural contexts has led to an ignorance of those political actions related to the colonization and Westernization of music, as well as an essentialization of music by means of its separation from the body, language, dance, etc. In fact, some very interesting power relations have been revealed within music politics (Bohlman, 1993). Music is connected to sexual politics (McClary, 1991, p. 27; Whitely, 1997) as well as to social movements (Eyerman & Jamison, 1998). Music plays a role in the constitution of social class and social and

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cultural capital (Bourdieu, 1998/2001; Green, 2003). Thus, music is not uninflected by politics but is, as Small suggests, always a political act: Any performance, in fact, that the hearer has no choice but to hear affirms a relationship of unequal power that leaves the hearer diminished as a human being; for whatever else it might be, all musicking is ultimately a political act. (Small, 1998, p. 211) Here, however, I would like to focus on one pertinent aspect of music politics that arguably interacts with mental health politics with regard to music therapy, namely the elitist tendency of music culture and music politics. Small (1998) points out that the music industry, whether in Western art music or popular music, has tended to celebrate the musical genius and is structured around a few musical stars, composers, performers, and “works.” The music industry seems to have developed into a very elitist and competitive social field, with television programs such as Pop Idol and American Idol or performing competitions as obvious examples. There are, in other words, strong elitist tendencies in Western societies with regard to music’s cultural politics. For most of us, music is very much related to musical achievements. Small (1998) voices a clear critique of this tendency in society, which sends out a false message to people about their possibilities in music and their rights to use music at their own level. He points to the culpability of music education, and in particular music teachers, in having killed off in so many children the drive to learn to play an instrument or to sing by telling them that they are not musical. The elitist tendencies in society have led people to believe erroneously that music is only for the especially talented few. Similarly, Sloboda (2005) suggests that our society (and especially our system of formal education) is very concerned with musical achievement, but much less so with the emotional and sensual enjoyment of music. This renders musical experience for many people a matter of anxiety and humiliation, leaving them “musically wounded” (Sloboda, 2005, p. 271). As a musical practice, music therapy is inevitably participating in the arena of music politics. It must be stated that in this arena, music therapy has been on the forefront regarding important cultural values. Music therapy involves a possibility for people to engage with music and have few or no requirements as to their musical skills. As Bruscia (1998) emphasizes, the nonjudgmental perspective of music is at the core of music therapy practice. Music therapy is not limited to those clients who

MT and the Politics of Mental Health Care 35 have an extensive musical background or those who can demonstrate specific abilities or skills. Rather, as emphasized by Bruscia, music therapists strive to accept the client’s music at whatever level it is performed and seek to help the client to use her or his musical potentials. In this way, music therapy may serve as one important counterpoint to the elitist music culture. In a Norwegian context, Ruud (1996) has described music therapy as being on the forefront of a cultural and political movement aiming toward possibilities for all people (regardless of disabilities or illness) to participate in music. The role of music therapy in this “Music for All” movement has included personal engagement and political activism from music therapists. Even more important, music therapy has demonstrated the potentials and possibilities of engagement with music in spite of disability or illness. In this way, Ruud (1996) considers music therapy in terms of reformative politics. Even if music therapy has, and still is, counteracting the elitist culture by providing people with access to music, the elitist tendency of music culture and music politics is still very present in Western society. When coupled with the illness ideology in mental health care contexts, new problems arise. The elitist culture, when interacting with illness ideology, is forcing the music therapist into a double position of expertise. Not only are we as therapists experts on the client’s disease and illness, but as music therapists we also are experts on music. This imposes a particular challenge with regard to power relations. If not solved and counteracted, this might contribute to put our clients in specific and people with mental health problems in general in a position creating more vulnerability. There is yet another side to this: When we engage in a music therapy practice, we bring music into a health-related context, which would be to some extent colored by the illness ideology. As a health resource, music is related to positive health rather than to ill health or pathology, and I think that it is important to let music continue to have that role. There could be a danger that music, initially connected with healthy and joyful dimensions of people’s lives, could in a therapeutic practice focused on pathology and problems be transformed into something associated with illness, problems, and pathology. There is a risk of inflicting problems and even pathology on an otherwise healthy and sound relationship to music by bringing music into therapy. The political and ethical concern of music therapy must be to bring something “normal” and free from illness into the illness-dominated environment of a hospital (Aasgaard, 2002;

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2004), while still not neglecting (indeed, acknowledging) the pain and problems that the client is experiencing in her or his life.

THE POWER OF DISCOURSE As a discourse, music therapy is not something discovered “outside” language and subsequently described “inside” language, but something actively constructed in and through language. (Ansdell, 2003, p. 154) How we perceive and understand music therapy is related to the larger body of academic and political discourses. Music therapy is part of the co-construction of our culture and hence our reality. The languages we use not only are ways of representing objective truths, but also play an important part in the construction of our reality. A practical implication of such a notion of what is often called the centrality of discourse (Alvesson, 2002) is that a differing discourse of therapeutic work does not necessarily represent a fundamentally different reality, but it does influence the way we understand it, and thus influences our actions. Furthermore, the ways in which we conceptualize music therapy processes influence not only our practice but also the broader political discourse on organizational as well as community levels. Thus, our practice, theories, and philosophies are not neutral. The discourse we use either contributes to the stabilization and conservation of certain values in the community or else contributes to the destabilization of values and politics by transgressing or challenging others (Ansdell, 2003; Rolvsjord, 2006b). The discourse of music therapy — how we talk and write about music therapy — above all influences both the depiction and perception of the client and the music therapy process. The stories that clients tell about their lives are inevitably colored by the context and by the person listening to the story. The stories of our lives are always “works in progress,” and our stories also influence how we live our lives (Barker & Buchanan-Barker, 2004). It is the same with the stories of therapy. The stories that therapists, clients, and researchers tell about therapy can be about victors or about victims, emphasizing on the one hand weaknesses and pathology or, on the other, coping and resources (Duncan & Miller, 2000; Goldstein, 1997). The client’s story and the therapist’s listening, as

MT and the Politics of Mental Health Care 37 well as the therapist’s stories about the client and the therapy, must be seen as co-constructive of the reality, always situated in a cultural and political context. Striving to facilitate empowerment thus implies acknowledging the client’s own resources and efforts in the music therapy process as well as in the discourses of music therapy. The therapist will have to listen for stories about strengths and coping and tell stories that give credit to the client and make her or his resources become visible and audible. From my point of view, this has the potential to transform music therapy into an empowering political discourse. However, it must be emphasized that words do not automatically lead into action. Sadly, the use of words such as “user participation” and “collaboration” does not always lead into a practice in mental health care that is empowering. Rhetoric (whether professional, governmental, or medical/psychological) is not the same as experienced reality (Tomes, 2007).

Chapter 2

PATHS TOWARD A CONCEPTUALIZATION OF THERAPY In this chapter, I will present perspectives that have informed and thus represent a theoretical frame for the conceptualization of a resourceoriented approach illuminated throughout this book. These informing perspectives come from a variety of academic fields. They include literature on a range of research methodologies and thus offer a range of argument and documentation in relation to resource-oriented therapeutic work in the area of mental health. Still, the approach presented in this book is deeply rooted in a humanistic tradition and in humanistic values related to humanity as well as to research. Further, I have intended to align myself with forces counteracting the strong illness ideology of the field of mental health discussed in the previous chapter and consequently have drawn on literature and research that in various ways integrate academic and political critique. It needs to be emphasized that there exist alternative possibilities for a theoretical foundation of a resource-oriented approach to therapy other than the one explored in this book. Antonovsky’s salutogenic orientation (Antonovsky, 1979; 1987) is one example that is already well known to many music therapists. Other perspectives that are potentially relevant are the resilience research, as well as perspectives in the tradition of humanistic psychology, including client-centered and person-centered approaches. When exploring theoretical frameworks or foundations for a resource-oriented approach, it is important to reflect on what such a theoretical frame has to offer in terms of its implications for the practice of music therapy. The relationships between philosophy, theory, and practice are complex and interconnected, and a linear causal model suggesting that a philosophy will articulate a theory that will guide our practice would be at best an oversimplification. Rather, philosophy, theory, and practice must be seen as interdependent aspects coconstructing the discourse of music therapy (see Stige, 2003a). In this way, the theoretical frameworks offered in this and the following chapter

Paths Toward a Conceptualization … 39 must not be seen as a recipe on how to work, but rather as a resource for understanding and perspectives providing possible focus that influence practical work. Empowerment philosophy, the common factors approach, and positive psychology point in three different ways to some of the aspects that I have come to understand as essential to a resource-oriented approach to music therapy. They point first to the therapeutic value of the development of strengths and resources; second, to the importance of the client’s role in relation to the outcome of therapy; third, to collaborative relationships and the need for self-determination and participation in decision-making in the therapeutic process; and finally, to the importance of understanding health as well as illness in interaction with social, cultural, and political contexts. These themes, however, are illuminated in various ways through these perspectives, so that they together bring important nuances to the understanding and conceptualization of a resource-oriented approach to music therapy in mental health care.

THE CONCEPT AND THE PHILOSOPHY OF EMPOWERMENT Empowerment as a concept is related to community psychology and the preventive model. Born out of the civil rights movement in the 1960s and ‘70s, it has been linked with the antimedical and antipsychiatric movements as well as with feminism and feminist approaches to therapy. Moreover, it represents a philosophy connected to political, democratic, and humanistic values (Renblad, 2003; Sørensen, Graff-Iversen, Haugstvedt, Enger-Karlsen, Narum, & Nybø, 2002). As a paradigm, it has been deployed within a variety of academic fields such as community studies, business and management, sociology, psychology, and pedagogy (Renblad, 2003). Empowerment is a concept that is always situated in a context, a fact that renders its definition dependent on the specific context within which it occurs (Dalton, Elias, & Wandersman, 2001). Empowerment always happens and unfolds in culture and differs from situation to situation. Thus, multiple definitions are possible, each tending to emphasize different aspects of empowerment. Finally, empowerment is a multilevel construct, corresponding to individual, organizational, and community levels of analyses and practices. These levels are interdependent and

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interactive in the empowerment process (Cowger, 1997; Dalton, Elias, & Wandersman, 2001; Perkins & Zimmerman, 1995; Schulz, Israel, Zimmerman, & Checkoway, 1995). It seems, however, that there is no clear delineation between the various levels and dimensions of the concept of empowerment. To describe the individual level, the concept of psychological empowerment is used (Dalton, Elias, & Wandersman, 2001; Zimmerman, 2000). Psychological empowerment involves changes in behavior, cognitions, and emotions. We might suggest that a person who is becoming more skeptical toward traditional authority, more willing to oppose injustice, and more involved in citizen participation is psychologically empowered (Dalton, Elias, & Wandersman, 2001, p. 347). Psychological empowerment includes belief about one’s competence, efforts to exert control, and an understanding of the sociopolitical environment (Zimmerman, 2000). Thus, the ability to act and participate, as well as the feeling that one has the right to do so, is central to empowerment (Renblad, 2003, p. 28). Different dimensions of psychological empowerment could be identified as intrapersonal, interactional, and behavioral. Aspects such as self-esteem, self-efficacy, and locus of control might be seen as intrapersonal aspects of psychological empowerment. The interactional dimension describes people’s use of their analytical skills to influence their environment, while the behavioral dimension describes how the individual takes control by participating in the community (Zimmerman, 2000). Empowerment can also establish meaning on aggregated levels. The organizational level of empowerment includes the opportunities organizations provide for people to gain control and power in their lives. Empowerment is connected to how organizations develop, how they influence politics, and how they offer alternative modes of service provision. We may therefore talk about empowering organizations and empowered organizations. Organizations characterized by shared responsibilities, a supportive atmosphere, and social activities are regarded as empowering organizations. Empowered organizations are those that have an influence upon the larger community. Usually, empowered organizations mobilize economic resources and achieve their goals successfully (Zimmerman, 2000). The community level of empowerment is described as one that “initiates efforts to improve the community, responds to threats of quality of life, and provides opportunities for citizen participation” (Zimmerman, 2000, p. 54). An empowering community, then, is usually connected with democracy, and

Paths Toward a Conceptualization … 41 also with the provision of resources such as health care, schools, information distribution, etc., to its residents. Dalton, Elias, and Wandersman (2001) underline that empowerment is a social as well as individual process. Empowerment therefore involves individual change as well as changes in the community. Although the levels are described as interacting and interdependent, this does not necessarily mean that empowerment on one level leads to empowerment on other levels. For example, empowering an organization does not mean that all members of that organization are empowered (Dalton, Elias, & Wandersman, 2001, p. 347). This is important to bear in mind when therapeutic practices are related to processes of empowerment. The philosophy of empowerment implies possibilities for therapeutic work at various levels but also points to the importance of awareness of the interaction between different levels of empowerment. Another multidimensional aspect of the concept is well presented by Renblad (2003), who draws on an analysis of the concept by Dunst, Trivette, and LaPointe (Renblad, 2003, p. 31). Here, empowerment is understood in terms of perspective, process, performance, and indicators of outcome. Empowerment is a perspective and a philosophy supporting the idea that people are competent and have equal value. Second, empowerment is a process connected to participatory activities and collaborations. As a performance, empowerment is highly related to a person’s self-perception and to the skills and knowledge that are developed through enabling opportunities and relational experiences. Finally, empowerment could refer to the outcome indicators of the process — knowledge, skills, personal strengths, etc. However, other authors point out a need for outcome measures of empowerment that are related to the person in context (Finfgeld, 2004; Fitzsimons & Fuller, 2002). It must be emphasized that empowerment is a politically loaded concept referring to power and power-relations. Critiques of empowerment are often related to these power aspects, arguing that if one individual or group gains more power, there is always somebody else who suffers a loss of power. It is important, therefore, to differentiate between two types of power, “power to” and “power over” (Sprague & Hayes, 2000; Stang, 2003). “Power over” refers to traditional patriarchal 15 15

Patriarchal power is not necessarily connected to the biological male sex but is representative of a type of power that has been and is connected with the oppression of women.

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patterns of power and is easily (or perhaps inevitably) connected with oppression. This type of power is not compatible with empowerment. Power as “power to” is described as a form based upon values connected with collaboration, mutuality, and respect. Thus, empowerment practices involve a distribution and promotion of power that do not imply the oppression or powerlessness of other individuals and groups. Empowerment of one marginalized group does not lead to reduction of power (in the meaning of “power to”) for other groups. To empower women does not necessarily lead to an oppression of men. Second, it is crucial not to see power as a possession of the individual, removed from the relationships that foster and accumulate resources and control. This, it is argued, leads to a displacement of the responsibility for people’s health from the public/governmental level to the individual level, ultimately contributing to an individualization of community problems (Dalton, Elias, & Wandersman, 2001; Sørensen et al., 2002; Sprague & Hayes, 2000; Stang, 2003).

EMPOWERMENT IN PRACTICE The concept of empowerment is discussed in two different articles related to music therapy (Daveson, 2001; Procter, 2002). Daveson (2001) suggests that empowerment is intrinsic to, and a consequence of, music therapy practice in general. She argues that this is primarily due to the “empowering action dimensions” in music therapy practices (Daveson, 2001, p. 30). She also suggests that music therapy in general shares some common features with empowerment, such as a participatory process and client ownership. In this way, Daveson argues, music therapy is empowering to clients per se, and thus allowing the philosophy of empowerment to guide therapy would not result in any need for change in music therapy practice. Although I agree that the musical interaction in music therapy is potentially empowering, I think that her argument is based on a vague and perhaps overly comprehensive understanding of the concept of empowerment. Mutuality and active participation in musicking may be important constituents of empowerment in music therapy, but this does not necessarily mean that music therapy is always empowering. A much more radical application of the empowerment concept in music therapy is to be found in an article by Procter (2002). In this article, empowerment is understood as an ideology that challenges existing

Paths Toward a Conceptualization … 43 practices and reframes alternatives outside traditional medical institutions. In contrast to a medical model of therapy, Procter describes music therapeutic work with the users of a nonmedical health center as an enabling and empowering process in which the music-making is “building on people’s experiences of who they are and what they can do” (Procter, 2002, p. 96). In Procter’s article, empowerment is thus understood as a philosophy guiding the practical work of music therapy, having political as well as relational dimensions. In this way, empowerment can be understood as a metaphor for therapy, offering ways of conceptualizing and representing music therapeutic practices. However, viewing therapy as empowerment results in a conceptualization of music therapy very different from that derived from medical or psychoanalytical discourse. Empowerment philosophy brings with it differing — perhaps even conflicting — ways of representing health, illness, problems, therapy, and even music, and I will argue that such discursive distinctions are related to political power. Empowerment philosophy challenges some very basic assumptions concerning the process of music therapy. Music therapy is usually defined as a process in which one person offers help to another person with some kind of need for this help (Bruscia, 1998). Empowerment philosophy, however, challenges the very idea of professional helpers and, as Townsend argues in the following quote, moves us toward interdependent processes and egalitarian relationships: Processes that enable participation can be described by adapting an old proverb: You can care for people for a day. But if you educate people to become involved, you have helped them to care for themselves and others for a lifetime. Participation engages people as activists in shaping their own lives. In contrast to the one-way dependence underlying caregiving, participation is enabled in two-way, interdependent processes that generate empowerment for us all. (Townsend, 1998, p. 1) To clarify the practical implications of empowerment philosophy, there are several different models describing attitudes, techniques, and interventions (Barker, Stevenson, & Leamy, 2000; Fitzsimons & Fuller, 2002; Stewart, 1994; Townsend, 1998; Worell & Remer, 1996/2003). Focusing on the strengths and resources of the client, however, seems to be agreed upon as an important implication of empowerment philosophy (Zimmerman, 2000). Therapy as empowerment has to do with

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collaborating with the client in the development of her or his ability to act and to participate in community. This ability has to do with individual strengths as well as with the social, cultural, and economical resources available and the use of such resources. Being able to keep your house clean could, for instance, mean that you can afford to pay somebody to clean it. Ability and participation are also connected to what is available for the client — such as support, close relationships, meaningful activities in which to participate, etc. (Stewart, 1994). Thus, empowerment includes access to valued resources (Nelson, Lord, & Ochocka, 2001), and this is why empowerment is so much concerned with politics. This recognition of the client’s competences in relation to the therapeutic process compels us to put the client “in the driver’s seat,” to withdraw from every top-down aspect of the therapeutic process (Saleebey, 1997; Stewart, 1994; Worell & Remer, 1996/2003). The process of enablement and empowerment therefore involves a transfer of definitional power from the expert therapist to a client with the ability to empower oneself. Thus, in several empowerment models, equal relationships and collaboratory interactions are emphasized (Barker, Stevenson, & Leamy, 2000; Dalton, Elias, & Wandersman, 2001; Finfgeld, 2004; Fitzsimons & Fuller, 2002; Sprague & Hayes, 2000; Stang, 2003; Townsend, 1998; Worell & Remer, 1996/2003). Therapeutic effort within a philosophy of empowerment implies focus on the client’s resources and potentials rather than on their weakness or pathology. It involves the recognition and acknowledgment of resources and potentials as well as development and learning of skills and competences that will promote self-determination and participation. Although this focus upon the nurturing and development of strengths is very important within the philosophy of empowerment, it does not necessarily lead to empowerment. We might explain this by referring to Foucault’s notion of discursive power. According to Foucault, power is connected to the distinctions and divisions in language that define people and values (Foucault, 2001). A focus on the client’s existing resources and the development of new resources could be considered to lead simply to yet another expert opinion, demonstrating power to define the other according to normality and pathology, strengths and weaknesses. Thus, it is emphasized that the processes of nurturing and recognizing the client’s strengths as well as developing new skills and resources must be concerned with helping the client to achieve what is important for that person: a process of enablement (Procter, 2002; Stewart, 1994). Taking the client’s strengths seriously compels us to recognize the

Paths Toward a Conceptualization … 45 knowledge and competences in relation to the process of therapy that the client already possesses as well as those that he or she may yet develop. From my point of view, this impels us to recognize the client’s goals and to acknowledge the ways in which they are using music and music therapy to improve their quality of life. A resource-oriented approach therefore not only implies recognition and development of the client’s musical skills and resources, but also elicits an attitude toward the client as a resourced person who might otherwise be considered to “interfere” with the performance of music therapy. There is an ongoing debate within music therapy academia concerning the role of music therapy in institutions and communities (Erkillä, 2003; Kenny & Stige, 2002; Pavlicevic & Ansdell, 2004; Stige, 2003a).16 The notions of community music therapy and practices situated in culture are contrasted with traditional “clinical” music therapy situated in institutions and in the music therapy room. Practices that are presented as community music therapy accord with a philosophy of empowerment in the sense that they emphasize participation in community and the processes of enablement described. To infer from this that the relevance of empowerment philosophy is limited to community music therapy might be erroneous. (A degree of uncertainty is perhaps inevitable here, given community music therapy’s apparent determination to evade definition.) Empowerment philosophy is a culture-centered17 perspective (Stige, 2002), but it does not exclude traditional individual practice settings. In fact, it has been emphasized that empowerment usually begins at the individual level with the person acquiring the knowledge, skills, and competence required to address personal concerns (Fitzsimons & Fuller, 2002, p. 491). Moreover, while it is incompatible with the traditional model that situates problems in the individual and considers the role of therapy to be the solution of problems through the use of appropriate techniques, it nevertheless does not compromise the individual’s use of psychotherapy or music therapy. It would be contradictory to the empowerment perspective to disregard the individual’s right to choose a specific type of therapy and her or his ability to make use of it. In my view, this is not a philosophy that excludes individual music (psycho)therapy as a possibility for developing empowering interactions. 16

See also discussions on community music therapy in www.voices.no.

17

The term “culture-centered” (Stige, 2002) denotes a perspective on music therapy more than a specific type of practice.

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A culture-centered perspective involves cultural reflexivity and an awareness of cultural aspects related to humanity, health, and music (Stige, 2002a). How such a perspective can influence the therapeutic process is explored in feminist empowerment therapy. In feminist empowerment therapy, the political dimensions of the therapeutic process are outlined by the focus on the interdependent relationship between personal and social identities and the slogan, “The personal is political” (Sprague & Hayes, 2000, p. 675; Worell & Remer, 1996/2003, pp. 66ff.). Traditional gender-role socialization and discrimination against people based upon gender, disabilities, race, physical characteristics, sexual orientation, class, religion, etc., is seen as crucial to the development of social as well as personal identities. Feminist therapy therefore empowers people by reframing pathology and problems in the cultural and political context, by separating the individual sense of powerlessness from the external aspects of discrimination and oppression, and by initiating social change. 18 The therapeutic relationship is seen as a model of equal relationships, thus implying a potential for changing other relationships in the direction of mutuality and equality (Worell & Remer, 1996/2003).

THE COMMON FACTORS APPROACH AND THE ARTICULATION OF A CONTEXTUAL MODEL A second important theoretical framework for the resource-oriented approach presented in this book is the so-called “common factors approach.” What is called a common factors approach has grown up as a result of interpretations of meta-analyses of psychotherapy outcome research that have revealed nonsignificant results of comparisons of different psychotherapies. The common factors approach implies a change of interest and focus from the specific ingredients of psychotherapy to the extratherapeutic factors and to the factors that are common to all psychotherapeutic models. Thus, similarly to empowerment philosophy, the common factors approach challenges the

18

See Curtis (1996) for an implementation of this within clinical music therapy practice.

Paths Toward a Conceptualization … 47 medical model. As an alternative, a contextual 19 model has been articulated. In the story of Alice in Wonderland, the dodo bird judging the race proclaimed that “everybody has won and all must have prizes.” This saying was introduced into the discourse of psychotherapy by Saul Rosenzweig in 1936, in an article in which he hypothesizes that all psychotherapies produce some benefits for the patients, due to some common factors of the different psychotherapies (Luborsky, Singer, & Luborsky, 1976). Since then, the dodo bird verdict has been confirmed by several studies, comparative studies, and meta-analyses of comparative studies (Lambert & Ogles, 2004; Luborsky et al., 1976; Luborsky et al., 2002; Wampold, 2001). These meta-analyses show first of all that most patients benefit from psychotherapy, i.e., that psychotherapy is efficacious (Lambert & Ogles, 2004). Not only is psychotherapy superior to no treatment, but the benefits of psychotherapy exceed the benefits accrued through placebo treatment. It is also worth noting that the effects of the placebo treatment comparisons are smaller when the placebo treatments themselves emphasize the common factors (Lambert & Ogles, 2004). Second, metaanalyses and comparison studies show little or no significant differences between the effectiveness of different bona fide psychotherapies (Lambert & Ogles, 2004; Luborgsky et al., 2002; Wampold, 2001). Earlier results of meta-analyses of comparative studies seemed to show significantly better results for some types of psychotherapies as treatment for some specific conditions, such as CBT (Cognitive Behavioral Therapy) for phobic disorders (Lambert & Ogles, 2004). It has been argued, however, that such differences in outcome may be related to the effects of researchers’ allegiances and the inclusion of studies that compare one type of psychotherapy with non–bona fide psychotherapy. When these factors are controlled for, the studies provide additional evidence for the equivalence of bona fide treatments, i.e., treatments delivered by a trained therapist applying a viable treatment model (Lambert & Ogles, 2004; Messer & Wampold, 2002; Wampold, 2001).

19

It must be emphasized that the concept of “context” within the common factors literature seems slightly different from the meaning of context in empowerment literature. There is a clear tendency that empowerment philosophy highlights political, cultural, and social aspects with regard to contextual aspects more than what is the case within the common factors approach.

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Several authors have discussed alternative explanations for the nonsignificant results of comparisons of the effects of different psychotherapies. Either the dodo bird verdict is to be supported, and explained by means of the characteristics of psychotherapeutic practice, or the dodo verdict is regarded as a methodological question, suggesting that the apparent equivalence of treatment is a result of limitations in the research methodology (Chwalisz, 2001; Lambert & Ogles, 2004; Luborsky et al., 2002). Depending on which argument the authors believe is the more credible, differing recommendations for research strategies are outlined, such as improved reliability and larger samples of clinical trials to better study the effects of the specific ingredients (Chwalisz, 2001; Drisko, 2004). Alternatively, more research into common factors, and research that is not tied to specific diagnoses, is recommended (Lambert & Ogles, 2004; Messer & Wampold, 2002). The implications of the dodo bird verdict for our therapeutic practice and our understanding thereof are of course also related to the explanations of the results of the meta-analyses of comparative studies. If the equivalence of the outcomes of different psychotherapies is seen to be related to the limitations in research methodology, there seems to be no reason to change practice. If the dodo bird verdict is accepted, it should inevitably lead to changes in how psychotherapies are both conceptualized and practiced. If the dodo bird verdict is to be regarded as more than a problem of methodological reliability, then it poses a serious challenge to some of the basic assumptions of the Evidence-Based Medicine (EBM) movement, not only in relation to research methodology, but also in relation to the intimate ties between the medical model and the EBM movement as it is applied to psychotherapy (and music therapy). A medical model in psychotherapy is conceived as analogous to the medical model in medicine but is distinguished by the nature of the explanations it offers. The medical model in medicine is physiochemically based, whereas the explanations in a medical model of psychotherapy are primarily psychological (Wampold, 2001). As explained previously, what Wampold as well as Bohart and Tallman (1999) refer to as the medical model of psychotherapy is a metaperspective referring to a basis in causal relationships between problems, explanations of the problem, specific interventions, and outcomes. Thus, according to this model, the therapist, as an expert, identifies the problem and knows what the best procedure is to use in order to change or mend that particular problem or deficit; whereas the client’s importance is limited to the provision of information, motivation, and compliance with the treatment (Bohart & Tallman, 1999;

Paths Toward a Conceptualization … 49 Nerheim, 1996). The evidence-supported treatment movement within mental health care is rooted in this kind of medical model, emphasizing the specificity of interventions in relation to particular diagnoses (Wampold, 2001, p. 19). If the medical model of psychotherapy holds, one should expect that the dodo bird verdict is the exception to the rule, and that a multitude of differences related to the outcome of different psychotherapeutic approaches would have been found. In contrast, Wampold (2001) and Bohart and Tallman (1999) argue that the findings from psychotherapy research, the dodo bird verdict, are incompatible with the medical model. Wampold argues for a contextual model of psychotherapy (Wampold, 2001, p. 2). Such a contextual model, in accordance with the approach of Frank (1989) and Frank and Frank (1991), emphasizes a holistic common factors approach and encompasses the whole therapeutic context or situation as providing potentials for change and development related to the client’s health. In such a contextual model, the specific ingredients are not seen as the main source of change in the therapeutic process but are necessary in order to construct a coherent treatment in which the therapist has faith and that provides a rationale for the client to believe in. Similarly, Bohart and Talman (1999) argue for a model with a contextual and holistic framework, but one that puts the client at its center. In their model of the client as active self-healer, therapy is essentially seen as the provision of a supportive context within which the individual’s naturally occurring self-righting and self-healing capacities can operate (Bohart, 2000, p. 130; Bohart & Tallman, 1999, p. 18). In sharp contrast with the mechanical (fundamentalistic) medical understanding, they argue that the client her- or himself is the main factor that promotes changes in therapy, by her or his use of the relationship and the procedures that the therapist and the client are co-constructing. The client uses the space provided by the help of the therapist to activate or mobilize her or his resources for change.

COMMON FACTORS The concept of common factors can appear confusing when reading the literature. Sometimes the concept is used widely, referring to anything that could have some influence upon the therapeutic process and its outcome, except for the specific ingredients that are seen as specific to

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one particular psychotherapy approach. This would include extratherapeutic factors such as the social context and client’s factors. In other instances, it is used more specifically and comprises only the factors that will be actively involved inside therapy but are not regarded as specific to any particular psychotherapy approach. In general, the common factors include variables that are found in a variety of therapies regardless of the therapist’s orientation (Lambert, 1992). Different sets of common factors are presented by different authors (Grencavage & Norcross, 1990; Jørgensen, 2004; Lambert, 1992; Lambert & Ogles, 2004; Tracey, Lichtenberg, Goodyear, Clairborn, & Wampold, 2003). A contextual model outlines various factors that can be related to the effect of psychotherapy. These factors have been accounted for in the literature in several ways. Lambert’s well-known estimation of the comparative impact of different factors contributing to the outcome of psychotherapy (Asay & Lambert, 1999; Lambert, 1992; Lambert & Barley, 2002) holds that as much as 40% of psychotherapy outcome is due to factors outside therapy, mainly to the client and to the client’s environment. Expectancy effects (placebo) and specific therapeutic factors each account for 15% of the therapeutic outcome. And, finally, Lambert attributes 30% of the therapeutic outcome to the common factors. Wampold (2001) makes a different calculation based upon the results of meta-analyses. As a starting point for his calculations, he considers that 13% of the effects of the variables in outcomes are actually related to psychotherapy. From these percentages, he attributes as much as 70% to common factors, including hope and expectancy effects, and 8% to specific factors. The other 22% remains unexplained, but Wampold suggests that client differences play an important role (Wampold, 2001). The extratherapeutic factors are discarded before he calculates the outcome variability percentages, a move that partially explains the differences between the two sets of calculations. It seems likely that the different factors are unequally important when it comes to individual cases. According to both sets of calculations, the extratherapeutic factors are very important and make even more significant contributions to the client’s health than psychotherapy or other treatments. Such extratherapeutic factors are factors that aid in recovery regardless of participation in psychotherapy. These factors can be attributed to the client as well as to the environment. The severity of the disturbance, problem or disorder; economy; social network; and cultural participation are aspects that are important for health and recovery from mental illness

Paths Toward a Conceptualization … 51 (Asay & Lambert, 1999; Lambert & Barley, 2002). Drisko (2004) also emphasizes the contextual importance of health policy and agency in terms of the accessibility of health services. A considerable part of the treatment effects are also attributed to the client’s expectancy and hopes related to the treatment. Hope is connected to the ability to envision a pathway toward health or improved quality of life. Hopes and expectancy are also connected to agency: the ability to move toward such a pathway or goal (Snyder, Rand, & Sigmon, 2002; Snyder, Scott, & Cheavens, 1999). Further, Wampold (2001) argues that therapist allegiance, i.e., the therapist’s belief in the treatment, is also a critical component for the outcome. The role of specific factors is primarily ascribed importance in relation to presumed specific effects, but also in connection with expectancy and hope. The specific ingredients and their theoretical rationale are seen as very important both in order for the treatment to be convincing for the client and in terms of therapist allegiance, which is considered to be a very important common factor (Wampold, 2001). Lambert and Ogles (2004) focus on the factors inside the psychotherapeutic setting as they structure the common factors in three categories: support factors, learning factors, and action factors. Grencavage and Norcross (1990), on the other hand, categorize the common factors into five subgroups: client characteristics, therapist qualities, change processes, treatment structures, and relationship elements. Building on the work of Grencavage and Norcross, Tracey et al. (2003) present cluster analysis resulting in three categories or clusters: bonding, information, and structure. The first cluster of common factors is connected to the bonding between therapist and client and comprises such factors as motivation, positive relationship, empathy and warmth, and therapeutic alliance. The second cluster is information or explanation and is connected to such aspects as therapist allegiance, feedback, information, and the provision of treatment rationale. The third cluster is related to the latent and implicit structuring of therapy, such as the use of techniques and rituals, the interaction between participants, or therapist and client roles. They also place these clusters of common factors in relation to two dimensions that describe emotional experiences (hot processing versus cold processing) and activity (the external vs. internal basis of therapy). This model becomes very complex, but it serves to depict some of the interrelatedness that gets lost in more simplistic lists of categories. It is likely that several of the same common factors that are important for the outcome of psychotherapy also play an important role in music therapy. Music, on the other hand, might be understood as a

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specific ingredient if music therapy were to be compared with verbal psychotherapy, but could alternatively be considered a common factor of all music therapy perspectives. My suggestion would be that musicking as the basic form of interaction in music therapy is interdependently related to both common factors and the specific ingredients in music therapy. Hallan (2004) suggests that music plays an important role that is also related to different common factors of psychotherapy. Drawing on qualitative interviews with music therapists from three countries and with different orientations, she concludes that music seems to be very significant in connection with Lambert’s support factors that promote a good working alliance and bonding. She argues further that music complements and amplifies the verbal communication related to processes of learning, and that the musical interaction alone seems to involve important learning processes. She also emphasizes the aspects of action involved in music therapy, relating these to Lambert’s action factors and arguing that the active action-oriented interactions in music therapy stimulate such common factors. In terms of the practice of music therapy, the common factors approach impels us to increase our awareness of the total situation of the therapy, not limiting our interests to the therapist’s use of techniques and interventions. This has implications in relation to both research and therapeutic practice. The common factors illuminate some of the general aspects of the therapeutic situation that are potentially fruitful to nurture also in the practice of music therapy. From my point of view, the shift away from a medical model toward a contextual model of psychotherapy that the common factors approach supports is also very important when considering music therapy. Analogously to the critique of the medical model outlined in the literature on common factors, it is reasonable to assume that music therapeutic techniques and the power of music itself have been given too much attention in relation to the therapeutic process (Rolvsjord, 2006a). The contextual model impels us to refocus our attention away from the therapist and the music’s capabilities and toward how clients make use of music and music therapy in their strivings toward health and quality of life, and even toward music and musical experiences and activities. This need not imply that we should stop considering music as a powerful source that can be used therapeutically, but it emphasizes the importance of considering also the client’s craft in terms of how they use music in therapy and in everyday life.

Paths Toward a Conceptualization … 53 PERSPECTIVES FROM THE POSITIVE PSYCHOLOGY MOVEMENT “Positive psychology” started as a critique of mainstream psychology that had largely become a science of healing, of repairing damage within a disease model of human functioning (Maddux, 2002a; Seligman, 2002). In contrast, more interest in what makes people’s lives worth living has been called for. Theory and research in the field of positive psychology have naturally been directed toward such positive aspects of human life in general and in relation to psychotherapy in specific. This has resulted in a rapidly growing amount of research related to themes such as happiness, human well-being and life satisfactions, resilience, positive emotions, and positive individual traits and strengths (Seligman & Csikszentmihalyi, 2000). The field of positive psychology includes research into and theory development of the positive subjective levels of experience, such as wellbeing, happiness, and hope; of individual levels, including personal traits and capacities; as well as of group levels, for example, regarding institutions moving individuals toward better citizenship (Seligman, 2002). It is my impression, though, that the aggregated levels are the least explored in the field of positive psychology, although there are strong political arguments regarding the implications of the mainstream understanding of psychopathology as something residing in the individual (Maddux, 2002). The aim of positive psychology is related to the importance of development of human strengths and resources in relation to well-being in general as well as in illness prevention and therapy: The aim of positive psychology is to catalyze a change in psychology from a preoccupation only with repairing the worst things in life to also building the best qualities in life. To redress the previous imbalance, we must bring the building of strengths to the forefront in the treatment and prevention of mental illness. (Seligman, 2002, p. 3) It is important to note that the movement of positive psychology and the research engagements it offers is regarded as a supplement, and a corrective, to mainstream psychology more than as an alternative. It attempts not to continue to marginalize or exclude but to bring in again and revitalize the positive aspects of human experience and nature (Jørgensen & Nafstad, 2004; Seligman, Steen, Park, & Peterson, 2005).

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Thus, a balance between the orientation toward strengths and resources and that toward problems and weakness is emphasized (Lopez, Snyder, & Rasmussen, 2003). Positive prevention has been described as the foreground of the positive psychology approach (Seligman, 2002). Seligman describes the engagement in prevention as a discovery of the buffering effects of human strengths, such as courage, hope, optimism, capacity for flow, or interpersonal skills, in relation to mental health. A strategy for positive psychology in relation to prevention is to contribute to more knowledge about how to foster such preventive strengths in children and youth (Seligman, 2002). Of specific interest in relation to the agenda of this book, to conceptualize a resource-oriented approach to music therapy, is the research and theory related to the fostering of positive emotions and the building of strengths related to human growth. The role of positive emotions has been explored in relation to general well-being in daily life as well as in prevention and therapy (Fredrickson, 2000; Fredrickson & Losada, 2005; Seligman, Steen, Park, & Peterson, 2005). Ultimately, happy people live longer (Delamonthe, 2005; Seligman, 2003). This is of special interest because we all know from experiences in music therapy as well as in daily life that music is very often connected to positive emotions, to experiences of pleasure, joy, contentment, or interest. The “Broaden and Build” theory that is presented by Barbara Fredrickson (Fredrickson, 2000; 2002) provides us with an understanding of the functions that positive emotions can have in daily life as well as in therapy. In addition to the commonly recognized function of stimulating us to continue with whatever is providing a pleasurable feel, Fredrickson’s theory holds that positive emotions broaden the thoughtaction repertoire and lead to a buildup of enduring resources. For instance, joy urges playfulness and creativity; interest creates the urge to explore, learn, and experience new things; and contentment urges seeing the wide perspectives and the savoring of current life circumstances. In contrast, negative emotions are found to narrow one’s momentary thought-action repertoire by preparing us to act in a particular way (for example, to attack when angry or to escape when afraid). In addition to the broadening effect of positive emotions, Fredrickson’s research has demonstrated that positive emotions can correct or “undo” the lingering aftereffects of negative emotions (Fredrickson, 2002; Fredrickson, Mancuso, Branigan, & Tugade, 2000). Positive emotions contribute to efficient emotion regulation, to enhance the ability to bounce back from negative emotional experiences, and to

Paths Toward a Conceptualization … 55 flexibly adapt to stressful experiences. To be able to experience positive emotions amid stress and negative emotions has advantages in processes of coping. Positive emotions and broadened thinking influence one another reciprocally and over time produce an upward spiral in which people become better able to cope and find positive meaning in life. Therefore, this theory is a strong argument for stimulation of positive emotions also in a therapeutic setting. It is suggested that stimulation of positive emotions in therapy will enhance the therapeutic learning processes (Fredrickson & Joiner, 2002). Also of interest is the relationship between the use of strengths and the experiences of mastery that is related to positive emotions and experiences of meaningfulness, which is related to the so-called eudemonic view of happiness (Ryan & Deci, 2001; Selnes, Martinsen, & Vittersø, 2004). Seligman (2003) emphasizes the importance of the use of strengths related to happiness, arguing that “[i]t is not just positive feelings we want; we want to be entitled to our positive feelings” (Seligman, 2003, p. 8). The type of strengths he discussed is most characteristically descriptive of the person. These types of strengths he calls “signature strengths.” Through the use of our signature strengths, we find energy and enjoyment. A positive effect related to happiness is documented (Seligman, Seligman, Steen, Park, & Peterson, 2005). Similarly, in Csikszentmihalyi’s theory of flow, enjoyment is also related to the experiences of achievements, mastery, and self-actualization. The best moments are happening when we work hard to accomplish something difficult and worthwhile. Such experiences of achievement, enjoyment, and flow are not to be seen as unimportant happy moments, but deeply interwoven with well-being, happiness, and health issues (Csikszentmihalyi, 2002).

TOWARD A POSITIVE THERAPY Treatment is not just fixing what is broken; it is nurturing what is best. (Seligman & Csikszentmihalyi, 2000, p. 7) Although prevention has been in the foreground for positive psychology so far, implications for a positive therapy has been more and more clearly articulated over recent years. Seligman and Csikszentmihalyi emphasize in this quote the importance of a strengths-building strategy in

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psychotherapy. Obviously, as emphasized by Seligman and Csikszentmihalyi, building on to people’s strengths is to some degree part of what a competent psychotherapist does no matter what his therapeutic views are and no matter what techniques he uses. Positive psychology, however, suggests that this should be in the foreground of therapeutic endeavors. It must also be said that research in positive psychology has been directed toward factors of great relevance for research in the common factors approach, such as hope and expectancy, empathy and motivation. Seligman (2002) emphasizes that the use of positive psychology in psychotherapy has been a blind spot in outcome research due to the focus on validating specific techniques that repair damage and not on those therapies that nurture strengths. The building of strengths as an essential part of the therapeutic process has been invisible in outcome researches that focus on the reduction of symptoms. There is, however, a growing amount of research studying specific positive interventions (Seligman et al., 2005). Indeed, the use of strengths as part of psychotherapeutic interventions shows promising effects (Seligman, Steen, Park, & Peterson, 2005). In this way, positive psychology and the conceptualization of a positive therapy offer perhaps first of all a completion of the field of psychology, in terms of being a discipline involved with the studies of human beings and their behaviors, thoughts, emotions, and interactions. In relation to mental health care provisions, this is crucial, not least because the picture of the client and her or his situation is incomplete if we omit half of the human repertoire, that which entails people’s strengths (Snyder et al., 2003, p. 25). However, specifically in relation to mental health and psychotherapy within mental health care provisions, positive psychology offers a critique of the extensive focus on psychopathology and psychotherapy as a cure for pathology, including sharp critiques of the diagnostic manuals (DSMIV and ICD-10). Wright and Lopez (2002) argue in favor of a diagnostic focus on mental health problems that includes evaluations of human strengths as well as environmental resources. The current diagnostic manuals suffer from a fundamental negative bias that involves “basic propositions regarding the concept of saliency, value, and context” (Wright & Lopez, 2002, p. 29). Several other aspirations toward strengths-inclusive assessments have been presented in order to contribute to more balanced evaluations of mental health and mental health problems (Lopez & Snyder, 2003).

Paths Toward a Conceptualization … 57 Even more radically, Maddux (2002a) emphasize the problems of the focus on pathology in mainstream clinical psychology, emphasizing the tendency of the diagnostic manuals to construct mental health problems as disorders residing in the individuals. He argues that positive psychology offers a new way of thinking about human behavior, where ineffective behaviors are seen as problems of living, not disorders or diseases. He emphasizes: “These problems of living are located not inside individuals but in the interactions between the individual and other people, including society at large” (Maddux, 2002a, p. 15). The diagnostic manuals represent the core, as well as the political power, of the illness ideology that constructs human life problems as pathologies and contribute to a discourse that emphasizes abnormality over normality and that leads to a portrayal of people with mental health problems that focuses one-sidedly on their weaknesses and failures as human beings (Maddux, 2002a; Maddux, Snyder, & Lopez, 2004). What would be characteristic of positive therapy? Positive psychology implies that the interest is moved from pathology and problems to well-being, health, and full functioning, according to Joseph and Linley (2004; 2006). They clarify that positive psychology has revitalized Roger’s proposals of the human self-actualizing tendency and organismic valuing process. They argue, however, that positive therapy does not equal person-centered theory (Roger’s view). A renewed belief in the person’s ability to know what is important to them and what is essential to fulfill their lives is at the core of the implications for therapeutic practice. Central to the developments of this ideological base is also the self-determination theory (Ryan & Deci, 2000). Selfdetermination theory posits three basic psychological needs: autonomy, competence and relatedness. It is emphasized that the social environment must provide nutrients to allow for such a fulfillment. The defining features of positive therapy, according to Joseph and Linley, are first, the focus on the client as the expert, and second, that therapy is about the relationship rather than techniques: Our stance, therefore, is that it is not what the therapist does (i.e., their technique) that determines whether a therapy is a good candidate as positive therapy. Rather, it is what the therapist thinks (i.e., his or her fundamental assumptions) that is important: The crux of being a positive therapist is that the therapist adopts the way of thinking that fully embraces the notion that his or her task is to facilitate the client’s actualizing

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Randi Rolvsjord tendency. It is our ideas about human nature that make us the psychotherapists we are. (Joseph & Linley, 2004, p. 362)

Following Joseph and Linley’s (2004; 2006) argument, we understand that positive therapy is not so much about doing particular things, using particular positive techniques, as much as it is about attitudes and values. By outlining how things are done, they point to positive therapy as a relational approach based on some fundamental positive assumptions of human beings’ capacity for change. Thus, at the crux of being a positive therapist is a way of thinking that fully embraces the idea of clients as competent and able to develop their strengths. Indeed, as emphasized by Joseph and Linley, this would imply a real change in health care systems if it were based on the view that it is the client and not the therapist who knows best (Joseph & Linley, 2004, p. 365).

Chapter 3

PATHS TOWARD A CONCEPT OF MUSIC So far in this book, the frames for a resource-oriented approach to music therapy have been rooted in psychological and sociological approaches to health and therapy. The fields of theory that I have explored so far are, however, essentially related to verbal therapy and do not take into consideration the specific aspects related to music therapy as a therapy in which musical interactions are a central element. A call for more indigenous and music-centered theories of music therapy that relate our understanding of music more to the studies of music and to music therapy itself has been proposed in recent discourses of music therapy (Aigen, 1991; 2005; Ansdell, 1995; Kenny, 1989; 1996). In his book Music for Life (1995), Ansdell argues that we need to look toward the music to understand how music therapy works, stating that: “Creative Music Therapy works in the way music itself works, and its ‘results’ are essentially of the same kind as music achieves for all of us” (Ansdell, 1995, p. 5). With reference to this quote, Aigen 10 years later attributes the whole dynamic or mechanism of music therapy to the music, identified as musical forces, musical experiences, musical processes, and structures of music (Aigen, 2005, p. 51). Ansdell’s quote is interesting also because it can be understood very differently according to what our ontological understanding of music is. This accentuates the necessity of exploring literature from the field of musicology and to reflect on ontological questions of the concept of music in relation to the role of music in resource-oriented music therapy. The current, culturally informed, or so-called “new musicology” represents a paradigmatic shift in the discipline of musicology that has led to the recognition of subjective as well as contextual dimensions of music. No longer is it common simply to equate music with musical works or to regard meaning as embedded in musical structures. Instead, interest has been directed toward contextualized processes of interpretation and performance. This shift has its origins in feminist critique, as well as in more interdisciplinary perspectives on music, in particular from sociology and anthropology (Bohlman, 1993; Cook & Everist, 1999; Ruud, 2000;

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Williams, 2001). This paradigm shift involves several aspects that are of immediate relevance to music therapy and in particular to how we understand the role of music in music therapy, as recently emphasized by several music therapy researchers (Ansdell, 1997; 2003; 2004; Ruud, 2000; Stige, 2002; 2003a). According to Ansdell (2003), however, this development has failed to impact significantly on music therapy research or practice, possibly because new musicology can almost be read “as a manifesto for music therapy” (Ansdell, 2003, p. 156). So perhaps more than changing our practices radically, this development in musicology has provided music therapists with theoretical arguments and a discourse to which we can relate our thinking. It is, however, tempting to connect the increasing interest in and awareness of the cultural and social implications of music therapy practices to the foothold these theoretical perspectives have gained within the discourse of music therapy. In the following, I will use some discussions from current musicology in order to explore in greater depth questions concerning the ontology of music. My intention is not to offer a comprehensive review of current musicology but rather to explore some perspectives that can inform the role and concept of music within a resource-oriented approach to music therapy. The role of music in music therapy, and specifically in resource-oriented approaches, is inevitably related to our understanding of music. Our understanding of the role of music — its functions, potentials, or power — cannot be clarified and understood without an understanding of what music “itself” is. But, as I will argue throughout this chapter, there are very blurred distinctions between any possible features of music as an autonomous object and how music is used in a certain practice. This is apparently because music is always performed, perceived, and experienced by humans.

MUSIC “ITSELF”? Music “itself” is a formulation that tends to indicate the existence of music as an autonomous object. The idea of music as an autonomous object is often related to formalism as well as to the positivist traditions of musicology and has been the focus of numerous texts in the field of musicology. The cultural turn in musicology has introduced scope for immense critical reflection. A vigorous critique, which can be said to have led to a paradigmatic shift in the field of musicology, was made of

Paths Toward a Concept of Music 61 the tendency to perceive music as synonymous with a musical work. The idea of music as works is often related to the Western music tradition and to the masterpieces or canons. In musicology, there has been a tradition of studying the structures and meanings as embodied in the musical work (or even in the score) itself. This analytical methodology, most commonly represented by Heinrich Schenker, was coupled with a formalist philosophy and the idea of absolute music. As several music therapists have emphasized, conceiving of music as autonomous works can be highly problematic in music therapy because it easily leads to a mechanical understanding of music therapy processes, implying that the effectiveness of music therapy is related purely to the properties of the specific music rather than also being linked to the ways in which music is part of larger interactive encounters (Ruud, 1990; 1998; 2000). It might also be felt to conflict with the nonjudgmental perspective that is fundamental to the practice of music therapy (Bruscia, 1998), because of the implied concentration on achievements related to music’s aesthetic qualities. The cultural turn in musicology is clearly a strong argument against essentialism in music therapy (Ansdell, 2003; Ruud, 1998). At the same time, the concept of musical work is related to an object character of music to which we also relate in music therapy (Schwabe, 2005, p. 52) or at least act “as if” it existed (Ansdell, 1997). This (pretended) object character of music, which may be our focus of attention in music therapy, is related to aesthetic qualities of music and can be considered useful in therapeutic work (Aigen, 2005; Ansdell, 1997; Schwabe, 2005). At the beginning of his very influential book, Musicking, Small paraphrases the ensuing discussions concerning the meaning of music and the function of music in human life by stating: “There is no such thing as music” (Small, 1998, p. 2). In this assertion, he challenges the assumption within traditional musicology that music is synonymous with musical works and in particular with the works of the Western classical tradition. Small, on the other hand, argues that music is not a thing or a work at all, but an activity. He introduces the verb form “musicking” and proposes the following definition of it: To music is to take part, in any capacity in a musical performance, whether by performing, by listening, by rehearsing or practicing, by providing material for performance (what is called composing), or by dancing. (Small, 1998, p. 9)

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“Musicking,” then, is a descriptive term that covers all kinds of participation, active and passive, in all kinds of musical performances, whether they are live or recorded. By this very wide, nonjudgmental, and anti-elitist definition, Small’s concept of musicking differs from the very similar concept of “musicing” introduced by Elliot (1995). Elliot’s concept is restricted to active music-making, although this still involves listening. Small, on the other hand, even includes the actions of the ticketseller at the concert hall door as musicking. By means of this wide concept, he highlights the contextual, relational, political, and technological aspects of musicking. Arguing that music is an activity and not an object implies a turn away from interest in musical structures and toward interest in performance and in the perception of music. This turn can be exemplified by Keil’s much-cited article, “Motion and Feeling Through Music” (Keil, 1994). Keil argues that in any kind of music, meaning is related not only to syntax and structures but to what he calls “engendered feelings.” Meanings are not just embodied in musical structures but are created in the performance, in the way the musicians attack the tones and in the drive created through the participatory discrepancies. Keil’s perspectives in this article are primarily connected to popular music and jazz, but the importance of such performative aspects is not to be restricted to popular music. Performance is also frequently discussed in relation to the questions of the autonomous musical work (Bowen, 1999; Cook, 1999). The emphasis on performance contradicts the assumptions of a linear connection between the composer’s ideas of a composition and the listener’s perceptions (Cook, 1999, p. 241). The concept of performance inevitably demonstrates the action aspect of music and thereby positions the musicians (including the listeners) within the explanations of music’s ontology. The notion of musicking, with its emphasis on performance and interpretation, needs not imply a total denial of musical works or objects. To overlook these aspects of music would be to neglect some important aspects of meaningful musical experience. Treitler, one of the musicologists credited for the turn in musicology, argues that we are in danger of reducing music to a signification of some extramusical meaning and, in so doing, contributing to the disappearance of the aesthetic object. Treitler argues that we have to accept a provisional autonomous status for the musical work, a status that demands that it be experienced aesthetically without consideration of the practical purposes and context (Treitler, 1999, p. 358). Acknowledgment of the social and contextual

Paths Toward a Concept of Music 63 aspects of musical meaning need not exclude the significance of the aesthetic: And the concepts of autonomy and of the aesthetic are not hostile, but are, rather, necessary to interpretations of any depth beyond that of superficial impression. They do not stand as obstacles to the development of the social and cultural meanings of music, but as the means to assure interpretations that are rich and have depth. That is, present needs call for realignment: the re-aestheticization as well as the re-historicization of music. No dogma, old or new, should be allowed to oppose their union. (Treitler, 1999, p. 377) What could such a provisional autonomous object be? In Treitler’s article, the provisional autonomous object is related to something in music itself that demands to be experienced aesthetically without any extramusical references — that is, an experience that need not be related emotionally or intellectually to something outside itself. Aksnes (2002) draws on Husserl and Heidegger when she explores a similar provisional existence of music as an object, but she very clearly posits it in the experience of the subject. Thus, for her, the object character would be the temporal flux, the lived experience of the music, the meeting point of the music and the individual: First of all, Husserl’s analyses of constitution have made it clear that it is futile to seek music as it is “in itself.” Music simply does not exist independent of experience — thus, the musicologist studies not compositions in themselves, but compositions as experiences by the musicologist himself (cf. Kant’s Erscheinungswelt). This, again, leads to an internalization of musical meaning: Meaning is not something in the music itself, as many musicologists and music philosophers seem to believe, but something that arises through individual subjects’ encounters with musical works. This implies that one can neither make complete analyses nor grasp the meaning of a musical work, in the sense of one final, allembracing entity. Musical meaning is episodic and emerges from the totality of perspectives that the listener/musicologist takes at any given time. This is not to deny, however, that there

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The lived experience of music, the meeting point of the music and the individual, seems to be the closest we can get to the autonomous “object” of music. The lived experience demands a mode of consciousness that can be characterized by conflation rather than by objectifying the distance between the music and the individual (Aksnes, 2002, p. 35). Aksnes emphasizes the primacy of interpretation, and thus she posits the individual in a primary role in the process of the creation of musical meaning. This implies that primary interpretations are those relating to contextual aspects of tradition, culture, politics, and social interaction.

CONTEXTUALITY In his now classic article “The Web of Culture,” Tomlinson (1984) describes contextuality as a web of culture in which meaning arises. He outlines a strong argument for the necessity of knowledge about context in relation to the interpretation of music. Tomlinson emphasizes that culture must not be seen as the cause of human actions but as a context of which they form a part. Human actions such as their music and musicking are not determined by culture but are a part of it and thus always part of the process that creates it. It is only in a cultural context, however, that music can have meaning. If we try to understand music without understanding the context in which it occurs, ours will inevitably be an ethnocentric interpretation that bases the meaning in our own cultural context (Tomlinson, 1984). We must ask about the status of music in this web of culture. Clearly, there are different possible perspectives that seem to be connected to how much of the focus is on music as works (or, to use a more constructivist term, “texts”) and how much we focus upon music as a social/cultural practice. The web of culture is itself a construction, as emphasized by Tomlinson himself (Tomlinson, 1984, p. 357): It is a metaphor that links texts, musical works, performances, and human interactions together in the construction we call culture. This is important because it clarifies that culture is not a stable thing that molds people and music. Culture is, rather,

Paths Toward a Concept of Music 65 the result of continuous social interactions, a process of co-creations and continuous development in which music plays a part. McClary (1991; 2000) has also very clearly highlighted music’s situatedness in a cultural context. Her writings are a strong argument against the autonomous music object, the “pure music.” She elegantly undermines any possibility of autonomous, or “pure,” music, pointing out that the contextually situated conventions that provide significant meanings not only are understandable in a cultural context but also actually co-construct the very context, the world or reality. Through analyses of music, of works as well as performances from Western classical music as well as from popular music, she explores how music not only maintains but also actively constructs narratives of gender and sexuality in particularly engendered power relations. Her main interest lies in the relationship between music and other discourses in social and historical contexts. Music is always dependent on the conferring social meaning — as ethnomusicologists have long recognized, the study of signification in music cannot be undertaken in isolation from the human contexts that create, transmit, and respond to it. However, this is not to suggest that music is nothing but an epiphenomenon that can be explained by way of social determinism. Music and other discourses do not simply reflect a social reality that exists immutably on the outside; rather, social reality itself is constituted within such discursive practices. (McClary, 1991, p. 21) McClary clarifies the intertextuality between different cultural discourses, which is one important part of the meaning of music, but her writings focus to a much lesser degree on the interaction between the subject, the musicking person, and the music. She seems to fail to take into consideration the lived experience of the music, as Treitler points out (Treitler, 1999). Another problem with her argument is that her human subjects are either the composers and performers of music that intentionally or unintentionally say something through music or the more passive listener who is affected by their music. As DeNora points out in her critique of new musicology, it is probably too tightly committed to the interpretation and critique of musical texts and so fails to explain how this construction of reality can take place: that is, how we are affected by it (DeNora, 2000, p. 30; 2003, p. 36).

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Obviously, contextuality is not only about intertextuality. 20 The concept seems to hide the human interaction involved. This must be the most important aspect when we apply the concept to music therapy. Musicking is always a culturally situated practice, and music therapy will always be one specific form of situated practice. In this context, the individuals interact with one another as well as with the music. Small’s concept of musicking is, as we have already seen, related to a social and political context. In his book, he explores in particular the event of performance in a traditional concert hall but uses this as an example of what musicking is about. He claims that social relationships are at the center of the meaning of music: The act of musicking establishes in the place where it is happening a set of relationships, and it is in those relationships that the meaning of the act lies. They are to be found not only between those organized sounds which are conventionally thought of as being the stuff of musical meaning but also between people who are taking part, in whatever capacity, in the performance; and they model, or stand as a metaphor for, ideal relationships as the participants in the performance imagine them to be: relationships between person and person, between individual and society, between humanity and the natural world and even perhaps the supernatural world. (Small, 1998, p. 13) Small emphasizes three aspects connected to relationships and social and cultural politics: exploration, affirmation, and celebration. These aspects might exemplify some of the social and political powers related to the contextuality of music. That is, music as a culturally situated practice implies some health related potentials that may be used in the context of music therapy.

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There are uses of the concept of “text” that include human beings, but the concept of “intertextuality” often focuses on musical works and written texts (Korsyn, 1999).

Paths Toward a Concept of Music 67 THE CONCEPT OF AFFORDANCES: BRIDGING THE GAP AND POSITIONING THE INDIVIDUAL

DeNora (2000; 2003) explains the important role music can play in people’s lives through the description of a twofold process of musical “affordances” and musical “appropriations.” Musical affordances are the resources music and its materials provide in situations of use. Appropriations are how the affordances are used — the “takings” and “usings” of music (Ansdell, 2004, p. 73). DeNora emphasizes that understanding music as an affordance structure differs from understanding music as a “cause” or “stimulus” that leads to action or emotional response, because what music affords emerges when it is handled by its recipients. The concept of affordance emphasizes music’s effects as dependent upon the ways in which it is used: It posits music as something to be acted with and acted upon. It is through this appropriation that music comes to “afford” things, which is to say that music’s affordances, while they might be anticipated, cannot be pre-determined but rather depend upon how music’s “users” connect music to other things; how they interact with and in turn act upon music as they have activated it. (DeNora, 2003, p. 48) When talking about the ontology of music and musical meaning, we are, as this text might be considered to demonstrate, easily caught up in the binary either/or of nature/culture, context/individuality, extra- or intramusical meaning. The concept of affordances, which originates from J.J. Gibson, is currently used by several authors in musicology (Clarke, 2003), sociology (DeNora, 2000), and music therapy (Stige, 2002a; 2003a; Ansdell, 2004). It is a concept that seems to bridge the gaps between such binary oppositions, as the music psychologist Clarke suggests. By considering music in terms of its affordances, discussions of musical meaning (which have often been excessively abstract, or diverted into a consideration of emotional responses to music, or caught up in a discussion of music’s relationship with language) can combine with a consideration of its social uses and functions in a manner that recognizes the pluralities of

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In a similar way, Stige (2003a) also sees the concept of affordance as bridging the gaps between, on the one hand, the meaning potentials in music that are related to both human biology and culture and, on the other, the situated event of musicking, as when he refers to: … the notion of affordance, which suggests that it is possible to treat music as a situated event and activity without overlooking the meaning potential of the musical material as based in human biology and developed in cultural history. (Stige, 2003a, p. 180) The connections between what music affords and how this musical affordance is appropriated offer us an important perspective on our understanding of music therapy processes. It is clear that such an understanding of music cannot be compatible with a linear understanding of music as a means that acts upon the individual and of the therapist as the expert knowing which music would be most suitable to induce the warranted change in the client. Rather, it emphasizes the client’s own role in constituting the use of music. As with the perspectives presented in previous chapters, this, albeit from a very different angle, positions the client’s use of the music in the foreground of the music therapeutic process. The cultural turn in musicology implies recognition of what might be termed a “fundamental attribution error” — the failure to see one’s own meaning as contextually situated, thus neglecting other possibilities for the construction of meaning (Ruud, 2000). If the power of music is not so much related to the music itself but to the subjective and contextualized use of music, then we must ask questions concerning the equality of access to music, within society in general as well as within music therapy. Could it be that we have not only attributed too much of the mechanisms of music therapy to an uncontextualized and autonomous “music object,” but also erroneously attributed the power of music to the therapist rather than to the client? I think that it is time that we acknowledged the centrality of the client to the musical interaction in music therapy. Music is not simply an autonomous object with which interventions can be made: it has to be appropriated by the client for her to experience it as meaningful. And, further, it seems to make possible a plurality of

Paths Toward a Concept of Music 69 experiences and functions that the musical interaction in music therapy can afford.

PLURALITIES OF EXPERIENCES AND MULTIPLE MEANINGS When music has “lost” its autonomy, when its meanings are situated in contexts and dependent upon appropriation by a person, we have to live with pluralities and multiple meanings. Thus, the emphasis on contextuality, performance, and subjectivity in new musicology does not simply imply a straightforward switch of view from music as object to music as process, but rather it has expanded and pluralized our conceptualizations of music (Williams, 2001). Similarly, McClary writes: “We don’t really know what music is anymore” (McClary, 1991, p. 19). This extends directly into the practice of music therapy, where we find ourselves encountering not only a variety of means of understanding what music is but also a plurality of different kinds and genres of music, and multiple ways of making use of these. The plurality of music is very clearly argued for in Bohlman’s article “Ontologies of Music” (Bohlman, 1999). Bohlman starts from the traditional dualism between music as an “object” and music as a “process”, but expands these two common conditions of music with two more: the “embeddedness” of music in relation to other activities, and its “adumbration” — that is, the recognition of music when music is not present. Such pluralities of music are exemplified musical practices in everyday life (Bohlman, 1999, p. 19). Pluralities of music are related not only to different cultures on a global level but also to local and individual experiences and practices. Music is experienced as a process when shared in a group or a community but more recognized as an object when my music is separated from your music. It is more an object when it becomes a work and when it is notated or recorded. It is a process when it becomes a language and communicates something. It is embedded in language when it becomes songs, or when language sounds like music. It is embedded in movies and dance. It is part of our experience of religion or nature when our memories of music make us experience meaningfulness (Bohlman, 1999). Pluralities and multiple meanings are also related to different levels of experience and to the use of music. Grasping these pluralities of music,

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Stige (2002; 2003a) outlines three main concepts to describe music in relation to humankind: the human capacity called “protomusicality,” the historical plurality of “musics,” and the social activity of “musicking” (Stige, 2003a, p. 150). The term “musicking” points to the pluralities of musical practices and activities that people engage in within and beyond music therapy. Throughout this text, I have argued that active involvement with music is the most central aspect related to music, musical meaning, and musical experience. The ontology of music is not separable from the practice of music but is related to multiple ways of engaging with music. The different ways of relating to and acting with music afford different experiences and meanings. With Small (1998), we see that musicking is a concept that comprises a multiplicity of ways of involvement with music. We listen, dance, compose, improvise, perform; we sing or play or act as ticketsellers. There are also numerous differing ways of listening, such as listening alone or together with others, having the music in the background, dancing or walking to music, or taking part in a GIM session. The same goes for playing and singing. We can rehearse scales in a room alone, play in a band at a rock concert, play in a symphony orchestra, improvise, or play precomposed music. Musicking is also sometimes apparently separated from the activities of daily life, as when we go to a concert or perhaps a music therapy session, but more often it is embedded in everyday life activities, as demonstrated so clearly by DeNora (2000) and Sloboda and O’Neill (2001). We might listen to music while traveling to work, sing while cleaning the house, use music while working out, be exposed to music when shopping or going to a pub. Second, the different practices of “musics” are always situated in cultural contexts and imply different traditions for musicking constitutive of different genres of music and different styles of performance. “Musics” is a concept that represents the cultural traditions of music-making (Stige, 2003a, p. 157). As culturally situated, music always involves understandings of music, roles of music, and ways of musicking that are representative of a cultural and historical tradition. This involves different ways of understanding what music is, such as the different ontologies that Bohlman (1999) presents, as well as the differing traditions of performance, including those of composing, listening and social interaction. These traditions are, however, also articulated and manifested as different musical genres of musical works. So this is perhaps the closest we come to a musical object, as it is related to different properties of musical works that can be said to offer affordances. It must be

Paths Toward a Concept of Music 71 emphasized that these are never unrelated to — indeed, they are always embedded in — a culturally situated way of listening to or performing music. The human capacity of protomusicality is connected to phylogenesis, and represents a very basic inherited human capacity: If protomusicality is music as human capacity, evolved in phylogeny, it will represent a potential for development in every human being. The potential will be more or less developed, and it will be shaped in different directions, depending upon the ontogeny of the individual, which again depends upon the cultural history of the groups and persons the individual gets in contact with. This then, I suggest, contextualizes the momentto-moment lived experience of the musicking of a therapy process. (Stige, 2003a, p. 151) Protomusicality, or communicative musicality,21 is described as an inherent, and therefore universal, capacity that permits human communication and that is understood as a basis for the development of languages as well as musical interaction. This capacity is further developed in ontogeny and thus connected to aspects of musicality that are related to musics and musicking. The individual’s appropriation of music involves some type of musicality that does not simply make musical appropriations possible but also actually regulates or conducts the ways in which we use music. Small (1998) argues that everyone is born capable of musicking, yet it seems that many people in Western societies believe themselves to be incapable of the simplest musical acts. Small suggests that they might have been taught to be unmusical. So this is not so much a problem related to lack of musical ability as it is a process of demusicalization (Small, 1998, p. 212). In some cultures, there is a greater tendency to think that everyone is capable of high levels of musical expertise (Davidson, Howe, & Sloboda, 1997). However, this is not only a matter of viewing people’s capabilities and possibilities differently, but also is as much a question of musical values and the structural organization of music in culture, as I have already argued.

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The concept of communicative musicality was introduced by Trevarthen and Malloch (2000).

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When music is about affordances and appropriations, its resources are both connected to what it affords and to how it is appropriated. The appropriations are connected to both culture and society, but also involve a capacity for musicking. Obviously, there are different types of qualifications and skills connected to musical appropriations. The culturally mediated aspects of musicking are, for example, concretized by Ruud as a process of learning musical codes that belong to a certain tradition of music (Ruud, 1990; 1998). Musicianship (Elliot, 1995; Pavlicevic & Ansdell, 2009) involves formal and informal musical (and social) skills and knowledge that we use when participating in musicmaking or when going to a concert. I wish to point out yet another type of musicality as musical experience skills. This is linked to the use of music in everyday life, as well as to the use of music in a therapeutic context. These musical experience skills are representative of the competencies that people draw on when they use music to regulate their emotions, as motivation for working, as a device for social ordering, or as a means of communication in a music therapy session. Appropriations of music in daily life as well as in music therapy require some skills or knowledge that seem to be based on musical experience more than on formal musical training.

Chapter 4

TOWARD A CONCEPT OF RESOURCE-ORIENTED MUSIC THERAPY So far in this book, I have offered a theoretical framework for a resourceoriented approach to music therapy that draws on literature related to theories from empowerment philosophy, the common factors approach, positive psychology, and current musicology. These perspectives have, except for the musicological perspectives, each in turn offered a strong critique of traditional psychiatry and its understanding of mental health and treatment of mental health problems. In this chapter, we will take one further step toward a conceptualization of a resource-oriented approach to music therapy. This task comprises of levels of generalization, description, and definition. We encounter several dilemmas when approaching this. First, the agenda of defining and describing is inevitably connected to an expert position, which is rather contradictory to the resource-oriented and participatory perspectives illuminated. Besides this, the resource-oriented approach to music therapy that I present in this book is oriented toward the varying resources and strengths of the clients, the varying resources in individuals’ contexts, the varying resources of the music therapists, and the multiple affordances of music. Thus, it would in many ways be futile to make generalizations or definitions about an approach that comprises such vast variations. Blumer argued that concepts of social theory in general allow only for rough identifications, proposing the notion of sensitizing concepts. A sensitizing concept lacks the specifications of attributes, but instead provides a general sense of reference and guidance in approaching the empirical instances. According to Blumer, sensitizing concepts on the one hand hinder us in coming to grips with the social world, but on the other hand mirror the complexity of the object of study, the social world. “Since the immediate data of observation in the form of the distinctive expressions in the separate instances of study are different, in approaching the empirical instances one cannot rely on benchmarks or fixed, objective traits of expressions” (Blumer, 1954, p. 5).

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These generalizations that I offer as I approach the question of what characterizes a resource-oriented approach to music therapy are indeed sensitizing in nature. The hope is that the idea of a resource-oriented approach, even if exact definitions cannot be offered, will evoke a process of further generalization in the reader and thus be useful for music therapy researchers and music therapists in their practice. This is precisely the point emphasized by Rappaport when he somewhat informally acknowledges the problems inherent in defining empowerment but argues that the idea is what stimulates us to promote it. This is perhaps the function that sensitizing concepts and conceptual generalizations can have: The idea is more important than the thing itself. We do not know what empowerment is, but, like obscenity, we know it when we see it. The idea stimulates attempts to create the thing itself. (Rappaport, 1984, p. 2) Therefore, despite the aforementioned objections, I offer in this chapter four statements characterizing a resource-oriented approach to music therapy: (1) resource-oriented music therapy involves the nurturing of strengths, resources, and potentials; (2) resource-oriented music therapy involves collaboration rather than intervention; (3) resourceoriented music therapy views the individual within their context; and (4) in resource-oriented music therapy, music is seen as a resource. This will hopefully give the reader a general sense of reference and a suggestion of a direction of where to look in terms of understanding the approach presented.

RESOURCE-ORIENTED MUSIC THERAPY INVOLVES NURTURING OF STRENGTHS, RESOURCES, AND POTENTIALS

It is perhaps self-evident to state that resource-oriented music therapy is concerned with the acknowledgment, stimulation, and development of resources. Nevertheless, it is not self-evident that therapeutic work should be about strengths and resources. In a resource-oriented approach to music therapy, the client’s resources are the center of attention, involving more than an additional element of resource activation in an otherwise problem-oriented interaction. Resources are seen as an essential part of

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the focus of therapy at every stage of the therapy: in other words, they should be a significant part of the assessments, of the therapeutic collaborations, and of the evaluation of the therapy. “Resource” is a concept borrowed from economics but is also frequently used in sociology in a much broader sense, and often related to health. This link to economics may, however, serve to highlight the relationship between access and possibilities for appropriation, in the process inevitably reminding us of the political implications of such a relationship. Access to resources involves possibilities and potentials and can be realized in diverse ways. It is something that individuals can gain from, and it is connected both with a political and economic system that distributes resources, as well as with the individual’s varying abilities and possibilities for enablement: What we understand by resources is more than personal strengths and musical skills; it must be connected to cultural and political contexts. Resources are always related to negotiations between individuals and situations; they are “objects” of access, use, and possibility. The concept of resources that we apply must therefore be understood as a sensitizing concept that includes social, cultural, and economical aspects, such as social network and possibilities for participation in cultural activities. (Rolvsjord et al., 2005a, p. 18) I want to emphasize that this concept of resources involves the person’s musical resources, including musical competence and potentials such as instrumental skills, knowledge of a repertoire of songs, and singing ability. Musical competence can also be connected to the use of music in everyday life. Further, it also involves the possibilities for access to music such as a choir, a music café, technology for music listening, etc. This in turn enables social participation and fosters social relationship. Social relationships are emphasized as important health resources in relation to both social support (Morrison & Bennett, 2006; Turner, 1999) and social capital (Procter, 2006; Putnam, 2000; Turner, 2004). It is, however, important not to limit our focus to musical skills and competence, as music therapy can also be an arena in which other strengths and resources are acknowledged and developed. Using strengths and developing resources could be therapeutically valuable in several ways, particularly in the context of the dialectic

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relationship between health and illness. Both the salutogenic model (Antonovsky, 1987) and research into resilience suggest that resources can be connected to the prevention of mental health problems and illness in a diversity of ways, as well as to the ability to cope with stressors and illness. “Resilience” is a concept that refers to the individual’s ability to tolerate stress and comprises such aspects as hardiness and power of resistance. In the sociology of health, resources have been perceived as moderators of the negative impact of stressors (Pearlin, 1999, p. 169). Resources can have a moderating or buffering function, which reduces the negative effects of life stress. These buffering effects have significance only in stressful circumstances. What is called a “main effect,” on the other hand, is relevant in all circumstances. A main effect is related to the function of the resources directly in relation to health and quality of life (Morrison & Bennett, 2006; Pearlin, 1999; Turner, 1999). Frank and Frank (1991) also describe the functions of therapy in terms of reducing the demoralization that follows illness. When illness strikes, it is not only the effects of the illness itself that threaten our health, but also the implications of the illness on our total life situation. When mental illness leads to hospitalization, this is often related to stigmatization, and it also disturbs or hinders our participation in social activities that usually contribute to our sense of health and quality of life. Engagement with something that is not related to illness or treatment can thus play an important role in the total health situation. From a resourceoriented perspective, though, it is problematic, and perhaps even paradoxical, if resources are valued exclusively in terms of the impact they have upon problems and pathology. Resources are clearly important not only in relation to the negative and illness-related aspects of health, but also more directly in relation to well-being and quality of life (Ryan & Deci, 2001; Seligman, 2003). The concept of empowerment can also be related to the process and outcome of therapy without interpolating problems, weaknesses, and pathologies onto the agenda. The development of resources, strengths, and enablement is an important part of empowerment. In the positive psychology perspective, using strengths is emphasized related to experience of positive emotions and of happiness. As Seligman (2003) emphasizes, the use of strengths is often tied up with positive emotions, and in this way it is perhaps inevitable that positive emotions will be an important part of experiences in resource-oriented music therapy.

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RESOURCE-ORIENTED MUSIC THERAPY INVOLVES (EQUAL) COLLABORATION RATHER THAN INTERVENTION Focusing on nurturing the client’s strengths but at the same time not taking into account the client’s strengths related to the therapeutic process (i.e., her or his competence and knowledge about her- or himself, about ways of working, about how to use music, about problems and solutions) would be paradoxical. The neglect of these competences would be a demonstration of the client’s lack of ability and resources, or at least a demonstration of the therapist’s failure to see these resources. Its functions would be that of a double bind communication (Bateson, 1972). The focus upon the client’s use of whatever the therapeutic setting can offer also leads, I think, to a conception of therapeutic actions more as collaborations than interventions. It is not only the therapist’s expertise that makes therapy work. This understanding necessitates shared responsibilities throughout the process of music therapy and collaborations related to goals for the therapy, ways of working, and evaluation of the outcomes of therapy. With the contextual model of psychotherapy as a basis for understanding the process of therapy, it is relevant to seek greater understanding both of how clients make therapy work and of how client and therapist relate to each other. Through the research into common factors in psychotherapy, the therapeutic value of the relationship is emphasized. The therapeutic alliance, composed of collaboration, emotional aspects, motivation, and agreements about the goals and tasks of therapy, is one of the most frequently mentioned common factors and is found in several studies as a critical factor related to the outcome of psychotherapy (Horvath & Bedi, 2002; Wampold, 2001). In their review of research, Tryon and Winograd (2002) found that goal consensus and collaborative involvement are important in relation to initial engagement as well as to the outcome of psychotherapy. Thus, a good collaborative relationship seems to be directly related to change, growth, and developmental processes. As I have emphasized previously, empowerment philosophy underlines the importance of equal relationships, self-determination, and participation in decision-making processes in general. The importance for the individual, as well as for groups, of having a voice in society and of participating in the community is strongly emphasized. This is understood

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as an important health issue. The degree of participation in decisionmaking and social support is related to a reduction in psychological and somatic symptoms and a reduction in perceived stress levels, whereas powerlessness and lack of social support are seen as a health risk factor (Fitzsimons & Fuller, 2002). Participation in decision-making processes is seen as a valuable goal or outcome as well as part of the process of empowerment. We may say that in this way empowerment philosophy embodies a critique of the traditional expert-patient relationship, because it takes aspects of self-determination directly into the core of therapy, the therapeutic relationship. Dreier (1994) points out the paradoxical consequences of interventions that aim to promote self-determination and the empowerment of another person, arguing that such interventions are doomed to failure. If I am an autonomous person, able to take care of myself and to make important decisions in my life, this is confirmed by you not interfering. If you try to help me to be able to make my own decisions, you will limit my ways of influencing my own life (Dreier, 1994, p. 193). In this way, helping someone toward self-help could easily become helping them toward helplessness. Dreier’s solution for this dilemma is to regard the patient as actively involved in promoting his own health, which necessitates a genuine collaboration. Such collaborations might also reduce the potential shame of dependency constituted by the modern ideal of the autonomous individual (Sennett, 2003). Collaborations are unlikely to eliminate this problem, but may reduce its effects by exchanging dependency for interdependency. It may not be possible to empower the other, but it is possible to develop empowering interactions with them. This involves a transfer of power from the expert-therapist to the client with regard to the identification of problems, goals, and solutions. In the following section, I will outline three interacting and interdependent aspects that I consider to characterize this collaboration in therapy: equality, mutuality, and participation. Collaboration is primarily connected with aspects of equality. Stige (2002) defines music therapy as a professional practice as “situated health musicking in a planned process of collaboration between client and therapist” (Stige, 2002, p. 200). According to Stige, music therapy as a process of collaboration underlines both the equality and the differences between the two agents involved, as there is shared responsibility but different roles. The concept of equality thus need not be opposed with difference. Rather, an equal relationship requires awareness, “a conscious

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inattention to designated differences” (Becker, 2005, p. 104). Equality in the relationship then must involve an active and conscious striving toward ideals of equal rights, counteracting oppressive power relations. In many respects, negotiations imply the performance of equality, since the precondition for negotiations is that both parties participate in the decision-making process. The concept of mutuality also describes a central aspect of collaboration. Mutuality is concerned with engagement, with equality, with shared responsibility, with affective responsiveness. Research into early interaction between babies and their primary caregiver has contributed to our understanding of mutuality and demonstrated that mutuality does not necessitate similar roles and similar capacities (Stern, 1985; Trevarthen, 1988; Trevarthen, Kokkinaki, & Fiamenenghi, 1999). In a therapeutic relationship, the emotional commitment and the desire for a continuous relationship are for obvious reasons different than they are between a primary caretaker and her or his child, but the protocommunication, with its turn-taking and affect attunement, offers a clear-cut model of mutuality. Even in a therapeutic relationship, mutuality has to involve more than a one-way emphatic response from the therapist to the client. Mutuality involves a person-to-person responsive relationship in which both client and therapist are directly and personally involved. Thus, mutuality and interdependency seem to be relational qualities that are compatible with empowerment and probably even promote empowerment. In order to be empowered in the relationship, people need to contribute to as well as benefit from relationships (Jordan & Hartling, 2002; Sprague & Hayes, 2000, p. 683). In music therapy, this also has a musical component that involves musical engagement and perhaps even a musical desire in the direction of making the music meaningful, aesthetic, and expressive. Sennett also describes mutuality in connection with the recognition and awareness of mutual needs required for respect (Sennett, 2003, p. 55). The third aspect that I will mention is participation. Participation in music therapy is perhaps a very obvious aspect of collaboration. Both therapist and client are active participants in the process of music therapy, as they are musicking together. Stige (2006a) describes two basic notions of participation: participation as an individual activity (which requires simply that the client comes to therapy and does something active) and participation as a collaborative activity (which involves communal or/and political activity). In empowerment philosophy, the latter form of participation is highlighted and connected to a political dimension related

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to the redistribution of power. Participation in decision-making processes is emphasized, so that this kind of participation is concerned with selfdetermination (Ryan & Deci, 2000) or citizen participation (Dalton, Elias, & Wandersman, 2001). I want to emphasize that it is crucial that both therapist and client take part in the decision-making process in therapy. Neither the role as an intervening therapist, nor the role of “absent” analytical therapist, nor the therapist role that leaves all decisions to the client can stimulate collaboration on its own. This aspect of participation can also be clarified by emphasizing the therapist as a role model. The therapist has to be visible and to have a clear voice as a person, in order to give space for the client to do the same (Worell & Remer, 1996/2003). Thus, taking part in decision-making processes does not necessarily mean holding the power to control all decisions, but rather having the opportunity to exert influence and make one’s voice heard.

RESOURCE-ORIENTED MUSIC THERAPY VIEWS THE INDIVIDUAL WITHIN THEIR CONTEXT As argued previously traditional (medical model) psychology and psychiatry are founded on a concept of pathology as something that resides solely in the individual. Consequently, these approaches tend to obscure the interpersonal, structural, societal, and cultural aspects of the problems. Diagnosis constitutes an individualization of the problem, defining it as a disease and the individual as that which needs “fixing” (Furedi, 2004; Maddux, 2002a; Suyemoto, 2002). The growing gamut of psychiatric diseases such as posttraumatic stress disorder, gambling addictions, and sexual disorders masks social and structural problems as pathology. As soon as problems are defined as pathology, their solutions are no longer political but therapeutic and medical. The problem of individualization can be seen as a problem related not only to the understanding of pathology, but also to positive concepts of health such as well-being and quality of life. In late modern society, well-being, happiness, and even health are part of individual “image building” or “shopping for identity.” Similarly to illness, the individual’s responsibility for well-being has to be seen in connection with structural aspects. Research in positive psychology has shown that happiness is related not so much to economy and material welfare as to aspects of

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social relationship and possibilities to use our strengths (Carr, 2004; Csikszentmihalyi, 2002; Keyes & Haidt, 2003; Seligmann, 2003). Health is intimately linked with resources as well as with power, which is ultimately about having access to and control over resources. The social capital discourse has connected health differences to inequality in resources, not only in terms of material and economic resources, but also in terms of social and cultural participation and networks. From a sociological point of view, health can be seen as “a function of our location within the system of social stratification” (Turner, 2004, p. 5). As Turner (2004) emphasizes, this links the restoration of health of both groups and individuals with empowerment. This understanding links with the notion of “power to” rather than “power over” as the basic idea of empowerment. Thus, empowerment philosophy somehow bridges the gap, or at least aspires to bridge the gap, between therapy and society, pointing very clearly to the contextual aspects related to health and linking the therapeutic process to the interaction between individual and community. Empowerment always unfolds in context, and cannot be seen in isolation from the interaction between individual and society. This again renders the notion of empowerment through individual psychotherapy something of a dilemma. Becker (2005) points out this dilemma in relation to the use of the concept of empowerment in feminist therapy. She argues that psychotherapy promises empowerment but offers only a type of compensatory power that supports and reproduces the existing power arrangements because it neglects the need for social action to promote change. The need for structural change has been masked by the individualistic discourse of therapy. The options for making changes in life have been reduced to that of individual growth toward better adaptation. A concept of “purely” personal empowerment is, as Becker sees it, one of the problems and paradoxes of therapeutic culture (Becker, 2005, p. 59). A problem we may encounter is that our good intentions of empowerment may be overruled by the organizational constraints of the medical health care system at large as described by Townsend (1998). This also compels us to ask whether individual psychotherapy, including resource-oriented music therapy, can really be empowering for the client. We have to ask if the idea of empowerment is compatible only with therapeutic practices that aim directly at change at structural levels, such as community music therapy. I feel tempted to answer, paradoxically, “yes” and “no” to this question. In feminist therapy, in individual as well as group formats, the

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slogan “the personal is political” has been used to model an indirect way of relating empowerment to social and political aspects of change, not just to a “purely” personal brand of empowerment. Worell and Remer (1996/2003) identify practical implications of the feminist slogan “the personal is political,” including the separation of external from internal, the reframing of pathology as coping strategies, and the acquisition of skills for initiating environmental change (Worell & Remer, 1996/2003, pp. 68ff.). The practical implications of this slogan or principle would involve talking and reflecting upon the contextual aspects of problems with clients — for example, talking about how society at large deals with sexual violence. Becker argues, however, that in practice feminist therapy has been “an often unintended translation of the political into the purely personal” (Becker, 2005, p. 136). She argues that through the focus on emotional and relational competence, psychotherapy adds to the sum of women’s responsibility for the contexts in which they live, thereby simply constraining them to tolerate better an oppressive environment: Psychotherapists’ attempts to “empower” their clients may well be assisting women to experience an increased sense of control, while those women remain firmly situated within an oppressive social context. Without a corresponding increase in her actual ability to make changes in that context, a woman may gain from therapy only an illusory sense of agency in the world. (Becker, 2005, p. 139) Becker’s critiques are, however, important as a reminder that any therapy aiming toward empowerment has at the very least to involve an active and conscious awareness of structural, social, and political aspects. Contextual aspects may be brought into the verbal exchange — for example, related to traumas and life situation. From a musical perspective, an interest in the client’s use of music outside therapy also contextualizes the therapy, providing possibilities for making use of the musical experiences gained inside music therapy in everyday life.

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IN RESOURCE-ORIENTED MUSIC THERAPY, MUSIC IS SEEN AS A HEALTH RESOURCE

The concept of resources is in this book used as descriptive not only of the individual’s personal strengths, but also of those resources to which a person has access. Thus, music as a health resource must be understood both on an individual level and on social and structural levels. In other words, music as a health resource comprises the individual’s musical competences as well as being something that can be accessed through some kind of engagement with music. The concepts of affordance and appropriation may, as explained in the previous chapter, help us to disentangle this complexity. With DeNora’s (2000; 2003) descriptions of a twofold process of affordance and appropriation, musical meaning becomes intimately tied with the use of music. DeNora argues that this leads to a dynamic conceptualization of music as a resource for “doing, thinking, and feeling ‘other things’” (DeNora, 2003, p. 57). Similarly, Ruud also states that “involvement in music is a potential resource for obtaining a better quality of life” (Ruud, 1998, p. 57). Thus, music has certain qualities that represent potentials that can only be actualized through human engagement with music. As a resource, music can be used in multiple ways that actualize various different meanings that we again relate to aspects of health in differing ways. From research into people’s use of music in daily life, it is, clearly demonstrated that people engage with music in ways that are related to health and quality of life. They use music to regulate their emotions, to regulate their corporal activity. They use music to construct their identities, to assist feelings of embodiment, or as an aid for social ordering and social relationships (Butterton, 2004; DeNora, 2000; Frith, 2003; Ruud, 1997; 2005; Sloboda, 2005; Sloboda & O’Neill, 2001). We can say that this research has demonstrated that a “therapeutic repertoire” of ways of using music is not only used by music therapists in music therapy settings, but also used extensively by people in their everyday lives. The fact that clients use music in similar ways outside music therapy need not be seen as an argument against music therapy, but rather as a contribution to our understanding of how music therapy works (see Chapter 11). Through this type of research, we learn that clients are likely to have considerable competence as to how they can use music so as to benefit their health in various ways. An important concern for music

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therapy in a resource-oriented perspective must be to acknowledge and nurture such resources. Understanding music as a resource does not mean only that we have to consider its plurality of meanings and the multiple possibilities relating to the use of music in therapy. It also implies that we have to consider access and “rights” to music as a concern for music therapy. Thus, when we understand music as resources, this obviously connects music, as well as the practice of music therapy, to politics. Once music is considered to be a health resource, access to music must be a concern for music therapy — one that cannot be limited to the individual’s musical capabilities but is related to culture and politics. Access to music must be understood in terms of social, economical, political, cultural, and individual factors. One important goal for music therapy, then, must be to provide an opportunity for people to have access to music, as suggested by Aigen: Music therapy consists of providing opportunities for musicing to people for whom special adaptations are necessary. The functions of music for disabled individuals or for those in need of therapy are the same as for other people. (Aigen, 2005, p. 93) At this point, I must emphasize that, as far as music therapy is concerned, we are obviously talking about not only professional engagement with music, but also the possibilities for appropriations of music in everyday life. Several authors have emphasized that we all have musicality as a birthright (Davidson, Howe, & Sloboda, 1997; Small, 1998). This does not, however, imply that we are all equal in talent or skills. Differences exist, but they should not restrain the music-loving amateur from developing and using her musical skills. Music therapy is concerned not with possibilities to use music at a professional level, but rather with opportunities to use music in everyday life. This is indeed a political concern. Viewed from this perspective, music therapy is quite often a process of regaining rights to music. As Small (1998) has pointed out, there are structural constraints in society that keep people away from musicking. Such constraints may be economic, social, or cultural. A poor economy might on an individual level limit such forms of access to music as buying CDs, owning a CD player, paying for concerts or music lessons, or studying music. On a community level, a poor economy might limit opportunities for there to be professional orchestras, venues for musical performance, or instruments and music technology within schools. Even music therapeutic

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practices are to a certain degree economically restricted. Social and cultural constraints might be connected to class, gender, or religion. When access to music and the relationship to music are matters of concern for music therapy, a political and societal dimension is brought into therapy. We cannot engage in people’s access to music without having a concern for the structural aspects of their possibilities for musicking. There are also personal constraints that limit people’s possibilities for engagement with music. Personal constraints could be related to a lack of musical skills or of musical and social competence that makes it difficult to participate in the arenas for music that exist in a community. There could also be other problems, such as physical disability, performance anxiety, social anxiety, lack of self-esteem, or depression, which might make participation in music difficult. However, individual constraints never exist in a vacuum: They are always connected to the structural or societal/community levels. Obviously, there are also capacious aspects of this, which are related to the roles and arenas of music — i.e., what music can be used for in different places (Persen, 2005, p. 87). There are arenas for participation in music-making that are at least more open to anyone who wants to participate. As these musical arenas are embedded in social contexts, there are always unwritten rules that restrict participation. You have to know how to play an instrument to play in a marching-band; you have to be able to sing in tune to sing in a choir; and you have to know when and how to applaud in a concert. Rights to music are also about equal possibilities to define how to music, why to music, when to music, and what music. For music therapy, this question relates to the cultural context of which both client and therapist are part. Where access and enablement are concerns for music therapy, these concerns do not only apply to musicking in society (i.e., outside music therapy or in community music therapy), although this is certainly of importance. I wish to emphasize that music therapy, even in individual psychotherapeutic settings, works because the client has access to and an ability to use the musicking on offer in this setting in ways that promote growth, development, and change. Thus, in individual music therapy the concerns of access and the power of music are related to selfdetermination of music within the therapy just as empowerment is related to the use of music in everyday life. The therapist cannot make all the decisions about the music and musical activities in music therapy while at the same time encouraging the client to use music in the way she or he wants outside of music therapy.

PART TWO CASE STUDIES The two case studies that will be presented in the forthcoming chapters are the music therapeutic collaborations with two young women in their twenties, Maria and Emma. In both cases, I was the therapist as well as the researcher. Both clients were inpatients in the hospital when our collaborations began. They had individual sessions in music therapy, in addition to standard care, including verbal psychotherapy and treatment with psychopharmacologicals. The sessions in music therapy were usually scheduled once a week, but in some periods we would also meet more frequently. The music therapy sessions usually lasted 45 to 60 minutes. The client in the first case study is Maria. She grew up in a village together with her parents and three siblings. She had completed the compulsory 10 years of school. Maria was referred to the hospital after severe self-harm and suicide attempts that escalated after an experience of a suspicious death (possibly suicide) of a school friend. She had also experienced other traumas that were connected to sexual abuse and the sudden and dramatic deaths of people close to her. Her self-mutilation continued during her hospitalization. Due to this, she frequently visited the local doctor to have her arms stitched, and she was also on some occasions transferred to the physical hospital after having taken an overdose. She was diagnosed with Borderline Personality Disorder, impulsive type (F.10.1, ICD-10). Maria came to music therapy because of her interest in music. She had a natural talent for singing and spent lots of time listening to music, but she had no formal training in music. In the last months of her 9-month stay in the hospital, she was moved to an apartment in the hospital grounds to ensure a gradual transition to life outside the institution. She was not satisfied with this arrangement, however, and left the hospital. The client in the second case study, Emma, grew up in a small town, living with her mother and father. Her mother had a severe mental illness, and her father was violent, beating her mother as well as Emma. She came into foster care at the age of 17 but left a year later for a different part of the country to study as well as to be more distant from her parents.

Part Two: Case Studies 87 Despite her hard life, she had managed to finish high school22 and had started higher education by the time I first met her. She had also been actively involved in organizations and in church. Music was one of her main interests, and she had studied music in high school. She was diagnosed with Posttraumatic Stress Disorder, PTSD (F43.1, ICD 10). She experienced periods of depression and self-harm. At the beginning of her 3-year period of music therapy she was an inpatient in the psychiatric hospital. At that point, she was about to finish her first year at the university college. After about 6 months, as she took up her studies again, she stayed half of each week in the hospital and the other half in her own place. After one year, her contact with the hospital was mainly as an outpatient but with some short periods of hospitalization. She finished her education 2 years after her initial admission and moved to another town to work. However, she continued to come back every second week for music therapy and meetings with the psychiatrist. Unfortunately, the decrease of support did not work out very well, and she came more irregularly and less frequently to the hospital and to our sessions. When she needed more intensive support in a very difficult phase, she was transferred to another hospital closer to her and our collaborations ended. There are some similarities as well as differences between the two cases, as the reader will notice. As mentioned, both clients are young women. They both have experienced trauma, and they both have difficulties with depressions and self-mutilations. As for their musical experiences, they both loved to sing and brought with them songs for the music therapy sessions. Both therapeutic processes are rather long-term, especially the collaborations with Emma that lasted for 3 years, 133 sessions. Maria’s therapy, on the other hand, lasted for a period of 9 months, 35 sessions. One other similarity the reader will notice is that in both cases work with songs formed an important part of the collaborations. Both Emma and Maria came to music therapy with a wish to sing, and we spent much time together singing songs. In both cases, we also created songs together, and this formed an essential part of the collaborations with Emma. The work with songs was not, however, a predetermined way of working but something in which both clients wanted to be engaged. The empirical material in the case studies was collected using participant observations and research interviews. A log was written after each of the sessions. The interviews were conducted at different stages of the therapeutic process, all together three interviews with Maria and five 22

In the Norwegian school system, “Videregående skole,” for ages 16 to 19.

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interviews with Emma. The final interview with both clients was conducted approximately one month after therapy was ended. In addition to this, artifacts like musical notations of songs and some audio recordings of songs were collected. The following chapters are focused and organized around the therapist’s, client’s, and researcher’s story and voice. All parts of the empirical material are used in all of the chapters, but, given the change of voice, some parts of the empirical material are give more weight in some of the chapters. Thus, the research interviews are most central in the chapters organized around the client’s voice so as to get as close as possible to their experience. Similarly, in the chapters presenting the therapist’s account of the therapeutic process, more weight is given to the log and the artifacts.

Chapter 5

COLLABORATIONS WITH MARIA: MUSIC THERAPIST’S STORY WHAT CAN MARIA USE MUSIC THERAPY FOR? (SESSIONS 1–3) “I like this girl,” I thought immediately when Maria came for her first session in music therapy. She appeared smiling and friendly, and it was easy to talk with her. Immediately, I found myself infected by her cheerful mood and enjoying being together with her. During our first conversation, which focused on the possibilities of using music in relation to her health and quality of life, there were not many traces of her major difficulties in life — the pains that had caused her to do harm to herself so many times. I shared with her some of my professional experiences with music therapy and told her how clients that I had worked with in my practice had experience music as valuable to their health and quality of life. She in turn shared with me her emotional experiences with music — music had sometimes made her sad and sometimes made her glad. “I always listen to music on the bus,” she said. She told me that she would like to learn to play a keyboard, and that she loved singing. Maria was eager to start making music, and we started to sing some songs together. She had a beautiful voice and was singing perfectly in tune while also putting on a second voice on one of the songs. I told her it was nice to sing with her. Typically, after we finished a song, she was rather critically commenting upon her own voice. After a few songs, however, she said: “This is very nice — I want to do more of this!” During the first sessions, I gave examples of and engaged her in different musical activities that we could do in music therapy, such as singing, improvising, and trying different instruments, so as to show her some of the possibilities she had. Thus, during these first sessions, we tried different ways of making music together, with varying degrees of success. “This is weird,” she said when we were improvising together on xylophone, chimes, and piano — “this is funny” — “this is terrible” —

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“the xylophone does not fit well with the piano.” After an improvisation on metalophone and piano, her imagination brought us to a magic scene in a cave with dripping ice, a scenery that she connected with sadness. In the second session, Maria started to amplify her voice with a microphone, and she suggested several songs to sing. One of the songs she brought was Sarah McLachlan’s “Angel,” which later proved its significance at many different occasions. Spend all your time waiting for that second chance, For the break that would make it okay. There’s always some reason to feel not good enough, And it’s hard at the end of the day. […] In the arms of the angel, Fly away from here, From this dark, cold, hotel room And the endlessness that you fear. You are pulled from the wreckage Of your silent reverie; You’re in the arms of the angel, May you find some comfort here. (Sarah McLachlan) I immediately got the impression that the lyrics in this song meant something special to her. When I asked why she liked that particular song so much, she told me that many of the songs she liked were about birds and angels. She liked that type of lyrics so much more than the silly typical pop music love-lyrics. Although I thought that perhaps this angel/bird theme was important to her, I was concerned not to push her into something potentially emotionally challenging, but instead tried to communicate openness to go into this at her own pace in order to regulate the emotional intensity. I did not have to wait long. When Maria came for our third session together, she looked exhausted and in pain. She was escorted by her contact person at the ward, who explained to me that Maria did not feel up to music therapy that day. The contact person had, however, encouraged her to go and told her that perhaps she could use the session with me to deal with some of the difficult things. I invited her in “just for a little while,” “to talk or just listen to some music,” emphasizing that she did not have to sing or play if she did not feel up to it. Maria agreed to come in and talk for a while. I

Maria’s Experience… 91 tried to be emotional available for her if she wanted to talk about her difficult morning, but careful not to push her into talk about her problems: Randi: I understand that your morning has been very difficult … Maria: Do you know why I was admitted to the hospital? Randi: Yes, I know … did you hurt yourself today? Maria: Yes … there is a song I want to listen to, but it’s too sad, it reminds me about someone who died. Then Maria continued talking and shared with me bits of her traumas. She told me that some years ago she had been baby-sitting next door and had a good relationship with her neighbors. This was destroyed when the man had raped her friend and cousin. This incident was brought to court, but the man was not sentenced. However, his wife had committed suicide that same day when Maria was going to testify, and Maria was left with very ambivalent feelings that made it hard for her to grieve over the loss of a woman whom she had felt close to. “Such stories of sexual abuse make me furious!” I said, and I ranted a bit about the political questions concerning how such cases are treated in our law system as well as in media, so often ending up with blaming the victims of this crime. Maria then told me that she too had been sexually abused by another man in the local community before she started school. This man had also abused several girls in the community, but likewise with the other man, he was not sentenced in court. Maria had been forced to touch his penis. Her story made me wonder about her angel and bird songs, and I asked her if her songs about angels and birds had anything to do with all of this. She explained that they represented for her a wish to find some peace, and that this was connected to her thoughts about death. During this conversation, Maria gradually livened up, and while I gradually became aware of this vitality change, I altered the focus of our talk toward her coping: Randi: When I listen to your story, it strikes me that you must also be very strong. You have faced so many problems in your life. Maria: Yes, I think I am strong. Randi: Yes, you must be, but I know that doesn’t make it less painful.

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After this verbal exchange, we started to sing together, and when this session came close to its end, she did not want to stop. I asked her if she wanted another session the next day. She did, but it turned out difficult to schedule the session. As a consequence, we decided to meet early in the morning on the next day, even if she was struggling very hard to get up in the morning, as the same morning had proven. I asked her if she wanted me to talk to the staff in her ward and ask them to push her a bit to help her get up in the morning, but then she replied: “No, then it will be like today [when she ended up cutting herself]. I will manage myself!”

ESTABLISHING A MUTUAL FOCUS FOR THE THERAPEUTIC WORK (SESSIONS 4–8) Maria did manage to get up to our fourth session. She was obviously a bit tired when she arrived, but told me that she had slept well and almost jumped out of bed in the morning. She asked if we could start to listen to some CDs that she had brought “so that I can wake up a bit.” This seemed like a very good idea. After listening and talking a bit about the music we listened to, we started singing a song from the end of last session. I played the piano and she sang, amplified with a microphone. We sang the song twice, and then she wanted to try again a third time, but I suggested instead that I could teach her to accompany herself at the piano, reminding her about and acknowledging her wish to learn to play the piano as part of her aims with the sessions. She agreed to try. She learned quickly, and after I had showed her the chords, she easily managed to play a simple accompaniment of chords with her right hand and a bass line with her left hand. We both sang. I played the electric bass and after a while also added a second voice to vary the musical arrangement. She was very eager to learn more and was reluctant to end the session. Before she left, she commented: “Actually, I am quite lucky because I easily hear how the music is going.” I replied by confirming that she indeed had a good musical ear and that she also had a very nice voice. With this session, a way of working together that turned out to be typical for our collaborations was established. The focus was on singing songs together and learning to play the piano. Maria maintained goals with her engagements in music therapy that were purely “musical.” She wanted to sing because she liked to sing, and she wanted to learn to play

Maria’s Experience… 93 the piano because it would be great to play. I agreed with her that singing and playing were indeed valuable and seemed important for her. On the other hand, I was concerned that the focus on achievement and musical skills could also build up more performance anxiety that could have impeded her ability to use music. Finding a balance between, on the one hand, approval of her musical skills and acknowledgment of her wish to develop these skills further and, on the other hand, the fostering of a less achievement-focused relationship to music became a central concern for me. In this way, the goals were continuously negotiated. I also hoped and assumed that our musical interplay would imply possibilities to develop a good relation, and that this would be empowering to her. In the following sessions, she learned to play more songs and to play simple accompaniments in various ways, using various rhythmical patterns and different chord arrangements. She also continued singing songs with me accompanying her on the piano, and we made arrangements of the songs we sang together. In Sessions 6 and 7, she seemed increasingly playful in our sessions, and we sang and laughed and she tried the drums. Maria was 5 minutes late for her eighth session; she looked exhausted and sad. “You look sad,” I said, and she said, “I just want to cry and cry, but it will not happen.” She was sad and also angry, she continued: “No one understands me; I feel very lonely.” She told me that was thinking about death a lot; she knew several people who had died. She told me that when she was born, her parents were told that she was going to die. “I wish I died back then,” she said. “Perhaps the fact that you’re still alive means that you have this little bit of will to live deep inside you?” I replied. “Doctors saved me” she said, but I insisted that even doctors cannot save people if they don’t have a little bit of life-will and some strengths. “Well,” she said, “perhaps I have just a tiny little ‘pin’ of will to live and strength to live.” After this, we continued talking for a while, but then suddenly she claimed she wanted to sing. “But I don’t want to sing those songs,” she said, and pointed to some of the songs that we had sometimes been singing together: “Angel” (Sarah McLachlan) and “A Place Nearby” (Lene Marlin). “They make me all too sad.” She had brought with her a songbook and chose songs from the book: “That’s What Friends Are For” (Sager & Bacharach), “Yesterday” (Lennon & McCartney), “Your Song” (Elton John), “Can You Feel the Love Tonight?” (from Disney’s The Lion King). No “silly love songs.” No songs about death and despair either, but songs with an optimistic tone. I was deeply impressed.

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In the rest of the session, we started to write a song. She suggested words and sentences that could be included: “I feel broken,” “I need some time to heal,” “I feel like a bird with a broken wing,” “when I am ready to fly,” “then I can start to live again,” “pain,” “darkness,” “sorrow,” “hope.” “I do want a song with some hope,” she said. “I want to get on with my life, you know.” At the end of the session, we started to sing another precomposed song, a Norwegian song by Rolf Løvland, “Danse Mot Vår” (“Dancing Toward Spring”). She asked me to show her the chords on the piano, as she wanted to learn to accompany herself. As we were about to close the session, the following mutually recognizing verbal exchange took place: Maria: It was good that I came here today. Randi: Was it? Maria: I feel a bit better now. Randi: It seemed that you knew for yourself what you needed to feel better — that you shouldn’t sing those sad songs. Maria: “Danse Mot Vår” is also a sad song, but even so, there’s hope in it, too. Randi: Perhaps that’s the sort of song you want to create: sad, but with hope? Maria: That would have been nice.

NEGOTIATING AIMS AND GOALS (SESSIONS 5–23) Although Maria on some occasions shared with me some of her difficult life experiences and used some of the sessions to talk about them, her aims with music therapy were still primarily musical — she wanted to sing and to learn to play the piano — and in the following sessions she was eagerly gripping any opportunity to sing and to play the piano. Maria’s interest in music and her motivation toward music were also characteristic of her engagement in music therapy sessions. From the beginning, she suggested many songs that she wanted to sing: She was eager to learn new songs to sing and to play on the piano. Often she was reluctant to end the sessions and, as in the following example from Session 11, she cajoled me into doing “just another song” even when we had agreed to have our next session on the following day. It must be said that I was clearly easy to cajole in this way, because I too very much

Maria’s Experience… 95 enjoyed playing and singing with her. Even so, she was not just motivating herself for singing — she was also motivating me. “Just one more song?” she asked, and suggested Whitney Houston’s “I Will Always Love You.” “Yes, that’s okay,” I said, “but we have to close the session after that.” After we had finished the song, she said: “Can we sing ‘Angel’ once more? I don’t want to stop!” I said: “We can meet again tomorrow,” but “Okay, let’s do ‘Angel’ once more.” Maria laughed and replied: “I knew you would say yes to that song — you like it so much!” I laughed and said that she obviously knew how to persuade me, then added: “You are right indeed.” “And tomorrow,” she said, “I want to sing ‘The Rose’ and ‘Imagine’ in two voices.” The progress with the song we started to write in Session 8 slowed down. Maria wanted to sing and to learn more on the piano, but hesitated to work more with the songwriting because, as she said, it led her into thinking some destructive thoughts. In spite of this, I made a proposal for one verse and a chorus on the basis of the sentences and words she had suggested in Session 8. In her 12th session, I presented this to her. She started immediately to work with a second verse because she thought the song was too short, and by the end of the session we had finished the song.23 At the end of the session, Maria was not completely happy with this song. “It’s too sad,” she said. “Why is that?” I asked, and she explained that everybody said that she should think more positively. Wanting to recognize her difficult as well as positive feelings, I said that I thought that it was okay to create a sad song. She replied, “I feel just like that,” but added: “The song makes me feel sick — I should have written something more jolly.” “But you too have the right to be sad,” I argued, “and you are having a hard time, even if you also can be strong and clever and are sometimes also glad. I have met you many times when you have a cheerful mood, and you often make people around you smile.” In the following sessions, she did, however, repeatedly want to sing the song. Together we created a second voice to the song, and I taught her to play an accompaniment on the piano. In Session 15, I reminded her about the ambivalent feelings she had had with the song when we first created it, and I asked her: “How do you feel about the song now?” “I feel the song is mine,” she said. Then she continued telling me that some people find it hard to understand that she can be sad because “she is like 23

The song is not presented here due to the client’s wish to have the possibility of using the song in public without compromising her anonymity.

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always cheerful, they think.” I said that music is sometimes connected with happy feelings and sometimes connected with sad feelings. She replied that she often uses music that fits with her emotions, and mentioned several happy songs and some sad songs. Reflecting on the verbal exchange after the session, I thought that to recognize her own feelings, both the good and the bad, seemed so crucial for her. It seemed that the music therapy sessions provided opportunities for me to be emotionally available and empathic to her both when she was joyful and when she was in emotional distress. Although she obviously had many problems that probably would have to be addressed at some point, it seemed also utterly important to acknowledge the value of the precious moments of pleasure and joy that she often seemed to find when singing. In the period before Christmas, she engaged me in singing lots of Christmas songs. I was slightly surprised by her love of these traditional songs but impressed by her way of using the Christmas songs to feel moments of joy and pleasure, in spite of rather ambivalent expectations and previous experiences of Christmas celebrations. In the last session before our Christmas break, she asked me if I could try to give her some homework on the piano when we started our sessions again after Christmas, as she thought that this would help her to practice a bit more on the piano. I agreed to that but also emphasized that I think it’s important not only to focus on the achievements but also to sing and just enjoy the music. She dropped in later the same day with a present — a homemade, golden, flute-playing angel. I did not ask what the angel represented, but it made me hope that the moments of pleasure and joy she experienced in our sessions provided her with some of the peacefulness she was longing for and made her think not so much about death. Certainly, it meant something to me! It felt like a warm appreciation of me and of the music we had together, which was empowering for me.

FACING NEW CHALLENGES (SESSIONS 24–34)

Maria’s treatment in the hospital was getting into a new phase. To enhance the transition to life outside of hospital, it was arranged for her to move out of the ward and into an apartment in the hospital area. Maria was not happy with this idea and was not coping well with the transition

Maria’s Experience… 97 plan; her self-mutilation increased and she became gradually more depressed. As a consequence, her planned move to the apartment was preliminary postponed. After a Christmas break, we started up again with music therapy, and as we had agreed in the last session before Christmas, I started giving her some homework for her to practice on the piano. Maria was increasingly depressed. She was eating very little and having difficulties in getting out of bed, and when she came to Session 25, she hadn’t done her homework. She was not feeling up to piano-playing at all. She told me she was feeling very tired, and that she was thinking about death a lot. I asked her about these thoughts, and she told me she had thoughts about walking into the ice-cold fjord — to swim out and then let herself drown. She didn’t dare to, she said, and explained that she didn’t want to be laid in a coffin, buried with soil. “If you could choose,” I asked, “would you rather live if things were going to be better?” She answered that she did want to live if things were to be better, but “I am not sure if they will ever be better.” After this, we started to sing together and spent the rest of the session singing. As she sang, I was astounded by the intensity and beauty of her singing. She was singing with so much intensity in her voice and was using more of her dynamic register, in terms of both volume and timbre, than I had ever heard before in her singing. I was feeling that she was singing for her life! Coming to the next session (25), her face was pale and without vitality, her voice was flat, and she seemed to have problems in articulating when she spoke. She tried to sing and tried to improvise a bit on the piano, but both her voice and her play at the piano were barely audible. At the end of the session, she seemed even sadder. The following day, I got a phone call from her ward: The staff told me that they were not able to get Maria out of bed, and they asked me to come to her room and try to motivate her. Ten minutes later, I was on my way, wondering what could possibly engage her, feeling taken aback by the challenge from the ward. In the session the day before, I had felt unable to engage her with music in ways that were good for her. Nobody answered when I knocked on her door. I knocked again and entered the room. She was lying in bed. I explained to her that I had been told that she could not manage to get to our session, but that I hoped that it would be okay that I came to see her. “You seemed a bit sad after our last session,” I said, “and I wonder if you were sad because you didn’t sing as well as you do when you are in better shape.” I then told her I know how well she can sing, and if she sometimes doesn’t sing so well, that doesn’t

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change my impression. I suggested that she come with me to the music therapy room just to listen to a song on CD, “The Prayer” (with Celine Dion and Andrea Bocelli), a song that she previously had told me that she wanted to learn to sing. And, I said to her: “I’d like to show you another song that I found the other day, which I think you might like. And then after that you can go back to your bed if you like.” To my surprise, Maria agreed to this suggestion and came with me. I felt moved by her engagement with music that helped her to get out of bed and out of her inactive and destructive mood, and somehow a bit proud to be a music therapist. A while after, in the music therapy room, we listened to the song together. She smiled a bit but was otherwise showing no facial expressions. After we had listened to the song, I started singing the other song for her, “End of the World” (by Kent/Dee). When I came to part two of the song, I made a mistake, and she started to sing. When I had finished the song, she suggested singing the song together with me. By the end of the session, we had arranged the song in two voices and she was planning to learn to play it on the piano in the next session. After this, Maria was away for 3 weeks on a leave from hospital, but on the morning of the subsequent session, the same thing happened. I got a phone call from the ward, one of the staff telling me that she had harmed herself every day during the last week, and that they could not get Maria out of bed for the music therapy session. This time, I brought with me some new songs that I had found. Again, she was in bed. I showed her the new songs, and she asked me if she could have some copies. I went to make some right away. When I came back, she had put herself into a sitting position but was still in bed. I asked her if I could sit down. We talked for a while, and then she said: “It’s such a long time since I managed to sing.” I told her that music is not only about achievements, and that I thought that perhaps it’s important to sing also when you are not able to have the very best achievement. I also maintained that I remembered very well how good she was able to sing when she was not that depressed. We ended up looking at the new songs I had brought and decided which songs we wanted to try to do together. For the following sessions, she came without any support but was continuously depressed and expressed anger and despair about the level of support she received at the hospital. In this part of the therapeutic process, she was less interested in piano-playing. However, she was still interested in singing, and I was not putting any pressure upon her to engage in musical activities other than singing.

Maria’s Experience… 99 In our 33rd session, she told me that one of her acquaintances, a young woman, had died. Maria thought that she might have committed suicide, but she didn’t know for sure. She had only met the girl once, but told me that they had had good contact, so her death was a shock to her. Therefore, she wanted me to sing the McLachlan song “Angel” for her. She then sang the song beautifully, and I commented that I had never heard her singing this particular song so beautifully before. At this stage in the therapeutic process, she was eager to let me make some recordings while she was singing. In Session 34, she asked me if I could put together a CD for her with some of the recordings. I agreed to do so, and this seemed to nurture her motivation for our next sessions.

ENDING THE THERAPY (SESSIONS 35–36) Maria had finally moved into the transitional apartment, but as a consequence of her dissatisfaction with this arrangement, she had also told her medical doctor that she wanted to leave the hospital. When she came to music therapy, she seemed determined in wanting to leave the hospital. The medical doctor had tried to persuade her to stay, and as part of the efforts to make her stay, he had arranged for her a 2-week leave in case she made up her mind differently. As she was leaving hospital this abruptly, there was no time for a good and planned termination of the therapeutic process. She came for a session with me the day she was leaving and agreed to come back for a final session after her 2-week leave. She said that she would have liked to continue with doing music together with me, but there was too long a travel from her home to the hospital. We talked about different possibilities for her to continue with some music activities, and in connection with this, I told her about a music therapist in her local village and volunteered to make contact if she wanted me to. When she came back for the final session, she did ask me to contact the local music therapist. We spent most of the session singing together and also listening to the CD that I had compiled for her with the song we had created together and some of the other songs she had been singing with me. Some days later, she sent me a text message telling me that she missed the opportunity to sing with me. She also told me that she had played the CD to some friends and that they all had asked to have a copy.

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Some weeks later, she was admitted to another psychiatric institution. Again, she texted my mobile phone: “There is no music room here ….”

Maria’s Experience… 101

Chapter 6

MARIA’S EXPERIENCES: “BECAUSE IT’S MUSIC, AND MUSIC IS A BIG PART OF MY LIFE” When Maria first came to music therapy, she came because of her already established interest in music. In our first sessions, she emphasized that she wanted to learn to play the piano or a keyboard, and perhaps to some extent also the guitar. When I asked her about why she would like to learn to play an instrument, she said that it would be nice to be able to play an instrument in order to accompany herself while singing: Maria: It would be an advantage to be able to play an instrument. Randi: In order for you to accompany yourself? Maria: Yes — and it’s nice just to be able to play an instrument. Randi: How do you mean “nice”? Maria: That I can learn something new — it’s like a hobby to play an instrument. She was interested in learning something and imagined that it would be a good thing to be able to play an instrument on various occasions: Maria: Perhaps you could teach me a bit on the guitar? But most of all, I would like to play the piano or a keyboard. Randi: You want to learn more music? Maria: Just to be able to play a song — then I could at least do that. Randi: Yes, that is important. Maria: I’m not sure how I will make use of it later, but one will make use of it later. Randi: How do you think you might make use of it?

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Randi Rolvsjord Maria: If you are at a party, for example, then you could grab your guitar and play. Or if you want to have a career, it would be good to play an instrument. … You can accompany others if they want to sing. … All in all, playing is fun, and if you are bored, you can play the guitar, and I like both singing and playing. I would have something to do to help pass the time.

There is another important dimension to this: She needs something to do in her leisure time. Even if she sometimes spends time on doing music because she cannot come up with other things to do, she feels that usually it is meaningful to spend time doing music. She also used the music room in the afternoon: Maria: I have used it many times, to have something to do in my leisure time, and to try to cope with things … Randi: Could you tell me a bit more about that? You were talking about … Maria: Pastime … it’s about having something to do, instead of like decomposing in a chair — which is not good. So in a way, it’s something positive, yes … When Maria started in music therapy, she was motivated to learn more about music and to develop her musical skills. Essentially, she just enjoyed singing, and as she said in Session 13: “Usually, I look forward very much to coming here because it’s music, and music is a part of my life.” Music was something she liked to do, and this motivated her to continue coming to music therapy. She said that even if she had not been able to listen to music as much as she usually did when she was in the hospital, she likes singing and music is her hobby. In the hospital environment where she found fewer opportunities to listen to music, it became even more important to nurture this interest in music that was such an important part of her life.

“IT GIVES SO MUCH JOY TO SING” “I think it is really enjoyable to sing, so I always gain something when singing,” Maria said in her last session of music therapy. “Well, what do

Maria’s Experience… 103 you gain?” I asked, and she continued: “I think it gives so much joy to sing.” The enjoyable experience of singing had, for Maria, a bodily dimension, a feeling of pleasure. She emphasized how good it felt to use the full volume of her voice, to sing out loud. Maria described how she sometimes longed for opportunities to use the full volume of her voice, to roar, to “let rip,” to sing without restraining herself as she often did when she sang together with other people. When she did sing out loud, she felt that she was using herself, and her body, her energy and strengths, and this gave her a good feeling: Maria: It is incredibly good to use your voice. Randi: It’s good? Maria: Yes. Randi: In what ways? Maria: I don’t know. It is just to let it out, to sing out loud. It’s hard to explain. Randi: What is “it”? Maria: I’m not sure. It’s just to let your voice out, to sing out loud, to roar a bit. When I am together with lots of people, I sing very quietly. And then it’s like: “Oh, I’m looking forward to being on my own, so that I can just roar it out.” It’s lovely to sing out loud. In this quote, we sense also that the aspect of the bodily pleasure of “letting rip” is also perhaps connected to freedom from performance anxiety. When alone, or together with me in the music therapy room, she felt free to let go of her restraints and to sing the way she liked. To be able to use the full volume of her voice when singing is, on the other hand, also an achievement that makes it more enjoyable for her to sing and that provides possibilities for more aesthetic nuances in the music. Thus, the enjoyment related to the aesthetics of her own singing is interwoven with her satisfaction in her own achievements. Randi: Is it possible to describe how you feel when you sing and you think it sounds good? Maria: It’s hard to explain … it is very good to finally succeed with something. Randi: Does it have a bodily feel?

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Randi Rolvsjord Maria: No, I don’t think so … but at the moment you sing, then you can feel a bit more energetic. I guess you need that, to be able to sing, to sing out loud … then you need to have some energy; if not, you won’t manage.

The music is beautiful when she sings well. It was important for her that the music sounded good. More specifically, she described how the aesthetic quality of the sound of her voice made her enjoy singing. In particular, she mentioned that she found pleasure in the echo effect that she could produce when singing into a microphone.

“IT HELPS TO SING” Maria: It helps to sing if I have a bad day. Randi: Yes? Maria: If not always, at least very often. Maria explained that there were days when she did not feel up to our sessions at all, but that if she came, then it often happened that she felt glad that she had, that it actually helped her. When she listened to music or sang when she felt depressed, then her “mood was lifted up.” Obviously, as Maria had observed, there were situations when music did not make her feel better. Sometimes nothing seemed interesting. She said that there were also times when it was important to stay with the negative emotions and to feel the intensity of her sorrow. On those occasions, she could use music to help her cry. Mostly, she used music to make herself feel better. Maria explained that the positive change of emotional state that she experienced would vary in length: Sometimes it lasted just for the session; at other times, it lasted for the rest of the day: Maria: It has happened many times that I’m feeling a bit depressed when I come, and then I sing, and everything is just fine. [laugh] At least I feel it’s getting better. That is actually true. It sounds a bit “too simple” in a way. […] Take today, for example. I didn’t feel very good, but then … I felt a bit better, and now I feel good. […] Yes — it seems I have “seen the light.” [laugh] Well, I have. Randi: How long does it last?

Maria’s Experience… 105 Maria: It can vary from the rest of the session, to throughout the day, or a few hours … Randi. Is it possible to describe … you said you’ve “seen the light”? Maria: Perhaps it is because I’m doing something I like doing, and perhaps it is because I achieve something. Again, it’s a bit of “yes, at least I managed something today.” Randi: Yes. Maria: It’s mostly about that, I think, and I enjoy singing very much. It also has to do with what songs you are singing. Some songs make you sad and some songs make you happy. I usually try to choose songs that are positive. So even when Maria felt bad and had to struggle to motivate herself to come to the sessions, she felt that singing did her good. One important aspect of this is the sense of achievement that she experienced when singing.

“FINALLY IT IS SOMETHING I CAN DO” Maria: I like to sing Randi: Yes, you do! Maria: I do …. Randi: It’s my impression that it is very important to you, to sing. Maria: To use something that I can do … finally, it’s something I can do. Randi: Yes, you sing well. Maria: A little bit. Randi: Yes, you do!!! Music was obviously an area of strengths and resources for Maria. She had a nice voice and good voice control. She knew a large repertoire of songs, mostly pop music but also more traditional songs. When singing, she had intuitively good phrasing. When playing the piano, she could hear very well when the harmonies were changing. She also had considerable knowledge about how different kinds of music affected her emotionally, and she knew how to use this as an aid for emotional regulation. She

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came to most sessions, especially in the first months of therapy, with many suggestions for songs that she wanted to try to sing. I taught her the chords to some of these songs, and she tried to accompany herself on the piano while singing. In these musical interactions, she explored her musical capabilities, and experienced confirmation that she was capable of something, that she had some strength. Maria emphasized that when coming to the music therapy sessions, she had expectations of achievement: Maria: Yes, because then I was going to something I liked: I like going to conversations, too, because then you can talk about things that are difficult, but it’s very different when it is something you like to do. When I was coming to see you, I had expectations in a way — I don’t have that when I see a doctor. Randi: You had expectations? About what? Maria: That I should be able to do things, that it should be like this and that — that sort of thing. Randi: You expected that you should manage to do something? Maria: Yes … that I should be able to do it properly. Randi: And did you? Maria: Yes. As we see in this quote, her expectations of mastery and achievement were often fulfilled through experiences of success. In other words, her musical abilities were confirmed through musical interaction. Maria was eager to learn something in music therapy, and during the first months of our sessions together, she started to sing more loudly in the sessions. In our second interview, she accounted for this by suggesting that it was because she was singing much more than before. She told me, however, that she was more conscious than before about using her diaphragm effectively when singing. She had learned to use her diaphragm and her breathing to greater effect when singing. Maria emphasized that this made it more fun to sing, that she felt able to make more variations in her singing. This was important for her to be satisfied with the aesthetic quality of her performance. She had heard others talking about the importance of this and had been exploring it when singing in music therapy. She had experienced that it had helped her to gain volume when singing. Rightly, she emphasized that she had learned this all by herself!

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Maria: I’ve learned to sing out louder, I think, but maybe it’s because I sing more often. But I’ve learned to use my stomach instead of my lungs, in a way. I’m more aware of using my stomach [diaphragm] when I sing than I was before. Randi: Yes … Maria: I do kind of think while I’m singing that I should be using my stomach. Randi: Did you learn that somewhere before? Maria: I don’t know. I read some interviews, and heard people say that you’re not supposed to do anything with your breathing, but do it with your stomach instead — and it actually helps. Randi: In what ways does it help? Maria: I feel that I sing better, that I get more out of my voice when I do it with my stomach, that I can sustain the notes and maybe get higher — so it’s nice. Randi: So you think that you have learned more about singing? Maria: Actually, I think I’ve taught myself. Randi: Yes, indeed you have [both laugh] — absolutely. Sometimes however, persistent work was required in order to attain achievement. For example, to create a song together with me was a difficult task for Maria. In the interviews, she emphasized that creating the lyrics was very difficult indeed, but nevertheless the song was finished, and as a finished product it served as evidence of her success. So although Maria found the songwriting process very difficult, the song served as concrete evidence of her mastery in the end: “It’s okay as a first song: After all, it’s not going to be released, and there might be more songs ….” Maria generally set high standards for herself as well as for me when we were making music together. This perfectionism also caused frustration and despair when she sometimes failed to achieve at the level she would have liked. Randi: How was it in the times when you didn’t manage? Maria: That wasn’t fun. I was usually depressed, and then everything was negative, and I wasn’t satisfied with myself.

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The following quote from her second interview illustrates how, at other times, Maria experienced that mastery in music therapy sessions neutralized her feelings of shortcomings in other areas: Maria: It’s a bit like, “You’ve done something, you’re capable” — it’s always like … “good” … if you’ve had a lousy day, and you’ve not been able to do things, and then you manage something. Then it’s not so bad after all. When I asked her what she thought about the role of music therapy in relation to her health situation, she expressed hope that music therapy could remind her that she had “got something”: “It does something for you when you sing, ‘Oh, YES!’ You are capable! If not for others, then for yourself, and that is the most important thing … definitely.” When Maria experienced the breadth of her musical abilities, and in particular her ability to sing, she connected this experience with a more general sense of capability, or at least it provided a buffer against her negative feelings of being a failure: Randi: Can you think of anything else you want to tell me about music therapy? Maria: No … it’s a bit like … I’ve sung in choirs, but I’ve always been very shy about being the center of attention, and I was just pretending to sing. But I feel that I’ve been building myself up a bit here, that I have become stronger. I feel I’m mastering this, singing, and that’s very nice. Randi: It’s important to feel that you can do something. Maria: I’m not that much of a failure after all.

Maria’s Experience… 109 “SOMETHING I’D NEVER DARED TO DO BEFORE” As already emphasized, Maria wanted to be able to use her music in her daily life, and this involved being able to sing together with others and to perform when other people were present. In the interviews, she emphasized such social aspects of her experience. For Maria, even singing in front of me was a victory at first, as she described in her first interview. Maria: I think it [music therapy] has been quite interesting because I like to sing, and I think it has been fun that I have dared to sing in front of a person that I don’t know very well. Randi: Yes! Maria: It was sort of victory for me. Usually I can be quite shy, but I just jumped into it and did it. Randi: So you felt rather nervous the first times? Maria: Yes, I was … I thought, What will this person think? But now I am hooked [laugh] — me and my mice … no [laugh] … it’s very nice to learn a bit on the piano, and just to do the things I like to do …. Sometimes the audience was present, if only in her imagination: Maria: Yes, I will miss it … I will miss having someone to play with me, so that I can sing along, because I like singing a lot. I will have to put on a CD to sing along with, and that’s nothing like a microphone and a piano. … I feel like a star when I am here. [laugh] Randi: Like a star? [laugh] Maria: Yes, the Pop Idol feeling — I imagine that I have an audience. I have a vivid imagination! [laugh] During the course of her therapy, she also started to use music more in other arenas. In the hospital, one of the ward staff, who also happened to be a good guitarist, encouraged her to sing together with her in the ward. Sometimes they would sit down and sing in her room or in a corner of the living room, but at other times their singing was more “visible” in the social space of the ward. Maria talked about one of these

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performances, which took the form of a little concert in the ward. She emphasized how important this was for her self-esteem: Maria: Yes, I had a mini concert, me and Anne … we sang “The Rose” as a duet, and I sang “A Place Nearby,” and she played. We performed for the other patients. And when I went to bed that evening, I felt good about myself. Randi: Yes. Maria: I was proud because I had achieved something, something I’d never dared to do before — not that it was a big audience — it was no bigger than for karaoke — and then I was really nervous. Yes, I did it before, but I did it better this time. I was calmer. Randi: You were proud of yourself? Maria: Yes, that I was able to do it — that I dared to. I have a bit of performance anxiety, you know. The aspect of performance in this case goes way beyond music therapy sessions, and even beyond music therapy. I was never directly involved in the performances she did outside of music therapy. Maria would bring some of the songs that she had sung on such occasions into music therapy, to rehearse or just to sing them. On other occasions, she would take songs we had been singing in music therapy to play or sing with other staff members. These performances were arranged on her initiative, or else were initiated by staff in her ward, as with the example above. So it seems that Maria had been using the experiences that she had had with me in music therapy in conjunction with the opportunities that had arisen to make music with staff or other patients in the ward, in order to explore and try out musical performance in different arenas, and to challenge herself to dare to perform in front of others. In our last interview, a few months after our collaborations had come to an end, she also talked about how she had been able to dare to use her music in several new arenas. She talked about her experiences with a new music therapist and her experiences of singing alone in the ward in another psychiatric hospital. She felt more confident doing such things, even if it was still challenging and scary: Maria: Yes, I get a bit shy if there are lots of people around — then I don’t quite dare. But I have noticed that if I’m in

Maria’s Experience… 111 the living room with, say, two, three, four, or five people [in her new institution], then it’s okay for me to sing even if they are in the room. But then I have to be very focused, like “don’t think about it, don’t think about it, don’t think about it” — like, just sing and don’t take any notice of them.. Randi: Yes … this is something new? Maria: Yes. Randi: Yes? Maria: Yes, I know, I realize, it’s a bit like “wow!” And when I went to see the new music therapist for the first time, it was a bit like, “Oh, I’m dreading this,” but I just launched myself into it anyway. Randi: Yes ... Maria: But I kind of think that it’s because I don’t know these people so well … Randi: Yes? Maria: Then, in a way, it doesn’t matter that much. Randi: But at the same time, you dared to give away that CD [to people she knew] … Maria: Yes [laugh] … it was a bit like, “Wow! What do they think?” I don’t always feel sure that the CD is any good. How I think about it depends upon my mood: “Oh, my God, what a crap CD,” or “I’m no good at all,” or then suddenly more like, “Yes, I’m actually quite good.” Randi: [laugh] Maria: ... like ups and downs … Randi: But at least there are some moments when you feel that you are capable? Maria: Yes [laugh] … I am bit of a bighead. .

During the period when we were drawing our collaboration in music therapy to a close, I had compiled for her (at her request) a CD comprising a selection of recordings of songs that we had been singing in music therapy. In subsequent meetings with her sister, friends, and acquaintances, she talked about the CD and about the song that she had created and recorded during her stay in the hospital — “I told them that I had a CD with myself singing” — and then she gave copies of the CD to her sister and her friends. One of her sister’s friends told her that they had heard the song and asked her if she could make a copy of it. In this way,

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the CD was distributed among her family, friends, and acquaintances. It seems clear that this CD nurtured the interest in music that Maria shares with her sister and her friends. One of Maria’s neighbors had a studio in his house. She had previously told me that he had invited her to come and record a song in the studio. The experience of success with the CD that we had made encouraged her to go the studio and do a new, more professional, recording of the song.

Chapter 7

REFLECTIONS: MASTERY AND JOY IN THE THERAPEUTIC PROCESS In the previous chapter, I presented Maria’s experience related to her process of music therapy. In Maria’s account of the therapeutic process, she was emphasizing music therapy in relation to some “positive” dimensions rather than to “negative” dimensions such as music as a possibility to work with problems or the expression of difficult emotions. To be honest, when exploring Maria’s experiences in music therapy as a researcher, I was both surprised and challenged. I had clearly anticipated her to forefront mastery and joy as important aspects of her experience, but I was taken aback by the degree to which this was the sole focus in her story. Her insistence on the value of music therapy in terms of musical achievement and moments of happiness were an important lesson for me with regard to acknowledgment of the client’s frame of reference and is indeed a powerful documentation of the significance of these levels of experience in terms of a therapeutic process. It seems to me worth noting that whereas the lay concept of therapy relates very much to experiences of positive emotions, professional therapeutic practice has been preoccupied with negative emotions. In music therapy discourse, distinctions are frequently made between the therapeutic use of music and the use of music as “mere” recreation, entertainment, or activation. Maria’s story compels us to ask if we, by these distinctions, have sacrificed one of the most powerful dimensions of music therapy on the altar of serious therapeutic professionalization. Can we regard a music therapeutic process as successful even if all it does is to bring moments of joy and a sense of mastery in music? Maria’s story points toward such an understanding, and this will be the focus for this chapter. The analysis of the interviews with Maria identified two main themes characteristic of Maria’s experience: (1) experiences of positive emotions and (2) experiences of musical mastery and enablement. Experiences of musical mastery and enablement were central to Maria’s experiences in music therapy. The experiences related to this

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theme had several nuances and levels connected to experiences of self, relationship, and social participation. First of all, Maria experienced time after time in her music therapy sessions that she was capable of singing. Singing songs as I accompanied her on the piano provided her with a repeated confirmation of musical skills and capability, reminding her that there was at least one thing that she was able to do: sing. Second, her experiences of musical achievements had also a relational dimension involved with a sense of performing better together. This is descriptive of a mutual experience where the musical interplay afforded possibilities for us to achieve our very best, feeling that the musical interplay with the other person implied a better performance than we could possibly achieve on our own. Finally, Maria’s experiences in music therapy included levels of musical enablement and social participation. Her engagement with music in music therapy provided her with some opportunities related to the use of music in her social life inside and outside of the hospital. The experiences of positive emotions were emphasized as a very important part of the experiences in music therapy. First, Maria’s experiences connected to this theme were involving the pleasure and joy in singing. For Maria, singing was something that she really enjoyed doing. Her account of the emotions connected to singing involves aspects of pleasure related to both aesthetic and bodily experience. Moreover, her experiences of joy were connected to her musical achievements — generally, she felt happy when she felt able to sing well. Second, Maria’s experiences with music were related to a strong interest in and motivation for music. Thus, her experience of positive emotions involved finding motivation and interest. She emphasized the importance of having a hobby, of having something meaningful to do in her leisure time. This was connected to her life in general as well as to her particular life situation in the hospital. Finally, Maria emphasized the importance of moments of joy and interest in relation to her struggles to cope with her days. Generally, she was feeling better after music therapy. Singing, in particular, was lightening up her (depressed) mood and thus gave her some sense of hope, motivation, and meaning in life. It is important to note the interrelatedness of these themes. Mastery was on one hand an important aspect of Maria’s joy in singing. On the other hand, obviously her motivation, interest in, and enjoyment of music were indeed connected to her achievement and enablement. In the following, I want to explore the positive experiences of joy and mastery in terms of their role in the therapeutic process.

Master and Joy in the Therapeutic Process 115 MUSIC FOR MUSIC In a Norwegian article, Stige asks whether it might sometimes be appropriate to replace the slogan “music for health” with “better health for more music” (Stige, 2003b, p. 21). He argues that the value of music for people is so important that it might sometimes become rather paradoxical to think of music as a means toward something else. The use of music can be an important end in itself, as music can provide value and meaning in life. To neglect this insight within music therapy might be to run the risk of resituating music in the realm of illness and problems as discussed in Chapter 1. It is important, though, to conceive of the connection between health and music as two-way: the two may be able to stimulate each other reciprocally, resulting in an upward spiral. Good health might enable possibilities for engagement with music, and engagement with music might provide health-enhancing experiences. It would perhaps be even more precise to describe Maria’s approach to music therapy more as “music for music.” In Maria’s frame of reference, music was the means as well as the end. Singing achievements and the development of musical skills had a direct meaning for Maria. She wanted to be a better singer because she wanted to sing! She wanted to learn to play the piano so that she could accompany herself when singing. Her main goal was related to her enablement to use music in her life inside and outside of music therapy. For Maria, the ability to music, as manifested in musical achievement, was the central aim of music therapy. Indeed her story also includes several experiences that also relate to health, such as self-esteem, social participation, and relief of depressive symptoms (feeling better). In spite of this, her main focus related to goals and the evaluation of the music therapeutic process seems musical rather than health-related. This was so even if the music therapist’s, as well the other staff’s, frame of reference for music therapy was more concerned with “music for health.” Maria, however, maintained her own frame of reference and consequently valued music for the sake of music. Maria’s interest in music was her primary motivation for coming to music therapy. In general, when in the hospital, she was not very motivated to do things. She struggled to get up in the morning, and the staff in the hospital had a hard time motivating her to participate in the activities on offer. Later in the course of therapy, her motivation to learn to play a new instrument decreased as she was increasingly depressed, but

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she still managed to come to music therapy, and she still wanted to sing. Moreover, music seemed to be one of very few things in which she was interested and with which she was motivated to actively engage. This was typical for Maria’s experience. A study of the population attending music therapy in a psychiatric clinic (Hannibal, 2005) indicated that this may well be a more common aspect of music therapy experience. Hannibal’s study showed that interest in music is one of the main reasons bringing people to music therapy (Hannibal, 2005), but the importance of interest in music seems not to be mirrored in the music therapy literature. Maria’s interest in music obviously also enhanced her motivation for therapy and made possible the continuity and regularity of our encounters. From the very starting point of music therapy, Maria’s goals were related to musical achievement. She wanted to sing and to learn to play on the keyboard. Clearly, Maria was expecting to develop her musical skills through her music therapy sessions. At the beginning, she expected music therapy to be similar to lessons in music school, but she discovered that it was also very different from that: “I expected it to be more like in music school, but it was not like that.” Even if she discovered that music therapy was not exactly the same as having lessons in music school, she continued expecting to achieve something musically in our sessions, and she encouraged me to try to give her some homework to enhance her progress on the piano. It is tempting to speculate as to whether her comparison to music school and her emphasis on the music therapy as differing from music school had something to do with the health-relatedness of music therapy. It is also possible to suggest that the inevitable health-related focus in a therapeutic setting can decrease perceived demands for achievements, so that her motivation to achieve in music is coming from her rather than controlled by someone else. It is common to differentiate between internal or intrinsic motivation, which is authentic and self-authored, and extrinsic motivation that is externally controlled. Intrinsic motivation is the inherent tendency to seek out novelty and challenges, to extend and to exercise one’s capacities, to explore and to learn (Ryan & Deci, 2000). Intrinsic motivation to engage with music develops from pleasurable and enjoyable experiences with music (Sloboda, 2005). It is usually connected more to interest, excitement, and confidence, as well as to general well-being (Nix, Ryan, Manly, & Deci, 1999; Ryan & Deci, 2000, p. 69). In this way, Maria’s experiences of joy and mastery not only derived from her motivation, but also maintained or increased her motivation for music.

Master and Joy in the Therapeutic Process 117 THE EXPERIENCE OF MASTERY AND DEVELOPMENT OF SELF-ESTEEM AND SELF-EFFICACY Experiences of mastery of music and the development of musical skills can be important for people in various ways. They can be important for their own sake as they enable musical activity and participation. They can also be important because the development of musical skills can be related to the aesthetic quality of performances. So far in this chapter, the focus has been on music as a therapeutic end in itself. Even if Maria in the interviews emphasized music as her main goal, she was also outlining implications that her engagement with music went beyond the purely musical. By her expression “Yes, I’m capable!,” she is giving an account of her musical achievements that we might relate to a growing awareness of capability and the germ of self-esteem. This impels us to ask if experiences connected to mastery of music can influence more general aspects of self- and life experience and contribute to mastery and coping in other areas of life. When Maria explains that her achievements in music give her a feeling of “being not that much of a failure after all,” we sense the importance, if not existential meaning, of such experiences. From the perspective of self-determination theory, Ryan and Deci (2000) identify competence as a basic psychological need along with relatedness and autonomy. These basic needs appear to be essential for facilitating optimal functioning of naturally inherent growth tendencies as well as for social development and personal well-being (Ryan & Deci, 2000, p. 68). It would follow from such a theory that any experience of mastery and development of skills and competencies would stimulate the natural capacity for growth and self-healing. In the following section, I will explore experiences of musical mastery related to perceived selfefficacy and self-esteem. These aspects are deeply interwoven and arguably inseparable, as will be clear in the following. Self-efficacy, defined by Bandura as the “beliefs in one’s capabilities to organize and execute the courses of action required to produce given attainments” (Bandura, 1997, p. 3), has much to do with attributing success to one’s own efforts. This is a very important aspect that is often emphasized in relation to personal levels of empowerment and selfdetermination. This attribution to one’s own efforts is important in relation to self-efficacy, because self-efficacy is closely related to an understanding of causality. That people can exercise influence over what they do and over changes in their lives is a basic premise of efficacy

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theory. It is also of central importance that one’s own efforts are acknowledged in relation to the experience of mastery. This attribution of mastery to one’s own efforts is very important for agency and control. In general, people with good self-efficacy attribute mastery to their own efforts and failure to their own lack of effort. Bandura, however, emphasizes that human behavior is determined by many interacting factors concerning not only self but also society, including internal, personal, cognitive, behavioral, and emotional factors. People are contributors to rather than sole determiners of what happens to them (Bandura, 1997, p. 3). It is important to note the relational aspects of the experience of mastery. In the music therapy sessions with Maria, it was not only her achieving musically but the two of us. Maria challenged me to use my musical skills optimally, to play and sing well. In a paper about the role of performances in music therapy practices, Ansdell (2005) writes about the paradoxes and potentials related to performance in music therapy. One of the aspects he outlines is the possibility of performing better or “a head taller” than you can. Together with others, it is possible to reach into the zone of proximal development and to develop and achieve better than you thought you could. I might speculate that it is to such experiences of mutual achievement that Maria refers in the interviews when she says that she feels “like a star” in music therapy, or when she talks about the “Pop Idol feeling.” In this way, argues Ansdell with reference to Fred Newman and Vygotsky, performance might be a possibility of “being who you aren’t, doing what you can’t.” He claims that such experiences can be important therapeutically because they paradoxically permit us to know better who we are. So rather than understanding Maria’s imaginative Idol performance as a trace of narcissism or hypomania, we might see it as part of her striving toward her own identity and self-worth. The paradoxical thing is that even if the mutual performance enables her to do better together and to go beyond herself in the performance, she is still the one singing! This is what she is capable of. She might simply feel like a star because she feels respected and treated like a star and because she actually performed like one. She performed as well as she could. Interestingly, when in the closing period of Maria’s music therapy I was compiling the CD of some of the songs we had been singing in the sessions, my technical assistant remarked, “This sounds better than a lot of what we hear on Pop Idol!” The point, however, is neither the aesthetic quality of her performance nor the subjective evaluation of her

Master and Joy in the Therapeutic Process 119 achievements. The point is that she, and I, experienced that together we could create a better performance than on our own and that she felt good about being able to perform so well. It is emphasized that the development of perceived self-efficacy is also informed by feedback from others and by comparisons with others. The relational experience with the therapist might contribute to this but can never substitute for the possibilities of feedback from within a larger social network. The recording of our compilation CD, and in particular the recording of her self-created song, provided Maria with opportunities to receive feedback from others (both persons in her ward and outside the hospital) and to make comparisons with others. In the fourth interview, she told me that she had given the CD to several people — family, friends, and acquaintances — and that they had given her lots of positive feedback, especially about the song we had created together. She evidently invested automatic trust neither in their judgment nor in their trustworthiness in giving honest feedback. Her ironic comments reveal her doubts and ambivalence but, as she says, she started to believe in it as time goes by: “I am starting to believe not that I am so amazingly good, but that I am capable of singing.” Self-esteem differs from self-efficacy, according to Bandura, in that perceived self-efficacy is concerned with judgments of personal capability, whereas self-esteem is concerned with judgments of selfworth. There is no fixed relationship between how people perceive their capabilities and how much they like themselves, but people tend to cultivate their capabilities in activities that give them a sense of self-worth (Bandura, 1997, p. 11). Both Bandura (1997) and Wormnes and Manger (2005) regard experiences of mastery as important building blocks contributing to the development of self-esteem. Experiences of mastery and the development of self-efficacy related to specific areas will gradually enhance general efficacy and self-esteem. This understanding, which can be called a hierarchical model (Wormnes & Manger, 2005, p. 30), implies that repeated experiences on lower or more specific levels will have consequences related to more general levels of self-efficacy and self-esteem. Such a hierarchical model is, however, limited in its application to understanding frequent shifts of perceived self-esteem because it represents self-esteem as a fairly stable trait of the personality. Mruk (1999) outlines competence and worthiness as the core characteristics of self-esteem, defining self-esteem as “the lived status of one’s competence in dealing with the challenges of living in a worthy way over time” (Mruk, 1999, p. 26). Competence is reflected in and

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through our individual actions and is related to aspects such as success, mastery, and authenticity according to Mruk. Worthiness, on the other hand, is related to the values of our actions and thus links self-esteem with the social and cultural construction of values. Success (mastery) is important for self-esteem and is connected to the basic component of competence, but we need also to understand self-esteem in relation to social and emotional aspects. Thus, Mruk offers a more dynamic understanding of this source of self-esteem that includes the following aspects: acceptance versus rejection, virtue versus guilt, influence versus powerlessness, and achievement versus failure. Success does not necessarily lead to the development of self-esteem, but it is more likely to do so if we are being valued or accepted, if we are morally approving our behavior, if we experience influence over our environment, and if we achieve things that also have personal significance (Mruk, 1999, pp. 82ff.). For Maria, it seems that music was able to be that type of activity. This is at least one of the reasons why it was useful for her to engage therapeutically in music. When Maria talked about her friends and relatives, it was about a social network in which musical interest, musical skills, and musical ability were regarded and highly valued. Furthermore, her hospital ward provided a very affirming environment in relation to music. Several of the staff in this ward were not only interested in music but also actually capable musicians themselves, and they provided recognition of her use of musical skills and encouraged her engagement with music. So we can say that engagement with music and musical achievements were highly valued both by Maria herself and in her community. In this way, it seems that experiencing mastery of music could also be related to the development of a more general sense of selfesteem for Maria.

THE EXPERIENCE OF MASTERY AND THE FOSTERING OF ENABLEMENT AND SOCIAL CAPITAL When mastery and achievement are related to a sense of self-worth, this is, as argued in the previous section, connected to the valuation of such skills and achievements within society and culture at large. On the one hand, this implies an opportunity to use music to build up a sense of social belonging, social networks, or social capital (Procter, 2006). On the

Master and Joy in the Therapeutic Process 121 other hand, social validation of musical achievements can also deter people from engagement with music, from asserting their rights to music. Here we encounter a cultural paradox related to the value of achievement in music as well as more generally in life. Our culture claims that a person’s worth is independent of their achievements but at the same time celebrates individual achievements. The cultivation of the musical genius exemplifies the valuation of musical expertise in our culture, and the problems that this brings, together with our focus upon musical achievement rather than the enjoyment of music, have provoked substantial critique (Sloboda, 2005; Small, 1998). In sociology, the concepts of cultural capital and social capital describe the value of cultural competence and participation as generating social participation and social networks that empower the individual. Within Bourdieu’s concept of cultural capital, musical competence is understood as a possible means for distinction. Bourdieu in particular emphasizes the habitus, the cultural (and musical) competence connected to social status and, above all, a particular sort of musical competence associated with the powerful social class. Social capital is a broader concept that comprises the generation of social relationships and social networks that empower people, with trust and reciprocity as features closely associated (Field, 2003). People connect to social networks that tend to share values. Musical identity, musical taste, and competence confirm such social groups (Ruud, 1997; 1998). Putnam (2000) promotes artistic participation as important as it creates social networks even if this is not the goal of the musical participation. Procter (2006) sees musical interplay in music therapy as emerging social or musical capital. The musical interplay in music therapy does not automatically build up social capital, he argues, but can be understood as a kind of “pre-social” capital. The musical interaction in music therapy affords possibilities for aspects of musical reciprocity and thus involves possibilities for people with mental health problems that “impede their ability to build and maintain links with others” (Procter, 2006, p. 158). In this way, Procter emphasizes the possibilities of musical interactions in music therapy to generate social capital, first of all related to the development of social capability. The apparent limitation that we may relate to the social arena of music therapy (in most cases) in an institutional setting is to a large extent separate from the client’s social arena in everyday life. The Norwegian psychologist Arnhild Lauveng, who has suffered from and recovered from schizophrenia, has written about her own

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experiences as a patient (Lauveng, 2005). One of the things she experienced was that, after having been hospitalized for several months, her life had been emptied of “normal” activities, and she had nothing to talk about with her friends. She had been watching no movies, nor listening to music, nor going to school. I think that her experience points toward a very devastating consequence of hospitalization, which we at the best can only seek to reduce, and this might be what happened to Maria. During her time in the hospital, she had been engaged with music, she had produced a song and a CD, and this actually helped her to keep in touch with friends who shared her musical interests, thus enhancing her social participation. Going back to the concept of social capital, we might with Procter (2006) understand this enhanced possibility for social participation as the fruit of pre-social capital generated in music therapy. In the case of Maria, however, it seems that her musical engagement is also involving more than a pre-social capital. Although her social network is fragile, her engagement with, and competence in, music is clearly facilitating her social interaction with friends and family, providing a sense of belonging and reciprocity. In the social and cultural context of which Maria is part, musical competence and skills are highly valued. With regard to Maria’s story about her musically skilled cousins, we might suggest that musical competence and skills provide status in this social context, although not in the sense of political and economic distinction. Music seems to be a shared interest: By participating in the music (by singing, playing instruments, talking about music, and creating her own CDs), she confirms her membership in the social group.

EXPERIENCES OF MASTERY PROVIDING JOY Maria’s experiences of joy are very much connected to the experience of achievement. The enjoyment related to the aesthetics of her own musical engagement is interwoven with her satisfaction with her own achievements. The music is beautiful when she sings well. It was important for her that the music sounded good. More specifically, she described how the aesthetic quality of the sound of her voice made her enjoy singing. To be able to use the full volume of her voice when singing is a concrete achievement that she mentions makes it more enjoyable for her to sing and that provides possibilities for more aesthetic nuances in

Master and Joy in the Therapeutic Process 123 the music. In particular, she mentioned that she found pleasure in the echo effect that she could produce when singing into a microphone. It this way, we may relate Maria’s experience connected to mastery and achievement with the eudemonic dimensions of happiness and wellbeing previously discussed in chapter 2. This dimension connects happiness and well-being to self-actualization and the deployment of strengths and virtues. According to Csikszentmihalyi, the best moments happen when we work hard to accomplish something difficult and worthwhile. Flow experience also typically involves a sense of control and a loss of sense of self as separate from the environment: It is often experienced as a feeling of union with the environment. Finally, it involves a transformation of time: Time sometimes goes very quickly, and sometimes just a minute seems to last a very long time. Music is mentioned as one of the activities that might provide experiences of flow, and Csikszentmihalyi emphasizes investment in the activity as the key factor related to flow experiences (Csikszentmihalyi, 2002). Perhaps the concept of flow is a bit over the top as descriptive of Maria’s experiences in general, but there were moments when she “let rip” when she felt good and capable and perfectly engaged in the activity. When the music sounded good, Maria felt she was achieving. For Maria, music, and in particular singing, was one of her strengths. When singing, she experienced that it was something that she could do and even that she was successful in doing it. What Seligman proposes is that we all have some strength that he calls signature strengths, strengths that are most characteristically descriptive of “me.” Our signature strengths not only represent something that we are good at, but one of the characteristics of signature strengths is that we find energy and enjoyment in using them. Using those strengths more often and in new ways increases happiness and decreases symptoms of depression (Seligman et al., 2005). Seligman differentiates between talents and strengths, arguing that strengths are moral traits, whereas talents are nonmoral. Further, he emphasizes that talents do not generally build personal resources and happiness to the same extent as strengths, and also that the lines are fuzzy (Seligman, 2002, p. 134). Although musicality might be understood as a talent, we might perhaps also relate musicking to some of the signature strengths mentioned in an indirect way: We might think of musicking as a setting in which different types of strengths can be used, such as “love of learning,” “appreciation of beauty and excellence,” or “playfulness and humor,” to mention some of the signature strengths defined by Seligman

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(Seligman, 2003, pp. 134ff.). The main point made by Seligman, however, is that to do things that we feel we manage well provides experiences of joy.

THE THERAPEUTIC VALUE OF POSITIVE EMOTIONS Positive emotions are commonly part of experiences with music. For many people, music is associated with positive emotions such as joy, contentment, or interest and with experiences of pleasure. Music has a central role in celebrations and activities connected with positive emotions. We go to concerts to have an enjoyable evening, we sing when celebrating, we dance at parties, and we listen to music to relax or to find a pause from our daily hassles. But even if pleasure and joy are quite characteristic of the experience of music in general, they are experiences often treated with ambivalence in the music therapy literature (Stige, 2006b). Further, the role of pleasure and joy in the music therapy literature is perhaps more frequently related to other types of client populations and has been much more a topic of interest in relation to work with children than with adults. Accounts of experiences of positive emotions related to musical interaction in music therapy in texts related to adult mental health care are rare (Stige, 2006b). Stige (2006b) emphasizes that there seem to be assumptions in the music therapy literature that pleasure motivates, and thereby has an effect as a motivating factor, rather than the experiences of pleasure and joy being understood as important aspects of “real” therapy. Stige proposes that music therapists should be interested in the individual client’s experiences of pleasure, mood, and positive emotions in therapy, and suggests that this will lead to more interest in aesthetic and sensuous aspects of music (Stige, 2006b). Similarly, Siri Næss (2001) emphasizes that positive emotions and pleasure not only have a function, such as making us more resilient or decreasing our blood pressure, but also are essential components of the subjective experience of quality of life. Thus, when music brings joy to our life, it is valuable per se. Joy is not only a means toward something else but also is important to us as it makes us feel that life is worth living. This chapter could have ended here, because this is the most essential lesson that Maria is teaching us: “I think it gives so much joy to sing.” For her, joy in music is a good enough reason to be engaged with music therapy.

Master and Joy in the Therapeutic Process 125 Evaluating the therapeutic value of positive emotions is in this sense paradoxical. Despite this paradox, I will now delve more deeply into the experiences of positive emotions, of interest and motivation, and of pleasure and joy, and what the role of such positive emotions can be in relation to music therapy. As outlined in chapter 2, in positive psychology, happiness has been an area of interest for research related to aspects of health. For people with severe mental health problems, however, happiness often seems far away. Perhaps even moments of experiencing joy or other positive emotions are worth striving for? To have something interesting to take part in, to feel some moments of joy and pleasure and engagement: These are perhaps some of the things that could make life more manageable? As Maria expresses it, “It helps to sing if I have a bad day.” Such moments with positive emotions may not be enough in themselves to make the patient well, to cure the illness, to solve any problem. Yet if music therapy can do nothing else but add some moments of joy and a tiny germ of motivation that makes it possible to live through the day, this is a big step toward making life worth living. It is important also to consider the risks of suicide related to mental health problems. Survival is an essential aspect of mental health, and it should be worth striving for. Experience of positive emotions might also be connected to empowerment, even if the only thing it does is to motivate us to repeat the active engagement with music in order to have further experiences of joy. What the research about positive emotions suggests is that experiences of joy and interest are important, as they build up resources that can be used to create a richer life and that can act as a buffer against negative experiences. With Fredrickson’s Broaden and Build Theory that was previously outlined in chapter 2, positive emotions have a function related to a broadening of the thought-action repertoire. Fredrickson states that: “Positive emotions appear to broaden people’s momentary thought-action repertoire and build their enduring personal resources” (Fredrickson, 2002, p. 122). First, the urges to be active and outdoors, playful, and social increase when in a positive emotional state (Fredrickson & Branigan, 2005). Second, the Broaden and Build Theory holds that this broadened mind-set in turn builds an individual’s physical, intellectual, and social resources. These new resources might again contribute to new positive emotions. Fredrickson argues that the broadened thought-actions that positive emotions create involve the development or building of personal resources that can initiate growth and resilience. A positive

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spiral is indicated because the building of resilience will enhance new positive emotions (Fredrickson, 2002). Maria’s story on the other hand also exemplifies the “undo effect” of positive emotions (see chapter 2), the contribution of positive emotions to efficient emotion regulation, enhancing the ability to bounce back from negative emotional experiences and to adapt flexibly to stressful experiences (Tugade & Fredrickson, 2004). Even when Maria felt bad and had to struggle to motivate herself to come to the sessions and to sing, she felt that singing did her good and reported that she was “feeling better.” Finally, it is emphasized that the experience of positive emotions is seldom something that just happens to us: We have a role in creating our own joy (Carr, 2004; Seligman, 2003). Yet, it is important not to use this type of theory as just another way of blaming the victim, of blaming people for not being able to provide themselves with happiness. Mental illnesses often limit people’s opportunities to engage in activities that could potentially bring joy. This is, however, not a problem restricted to the lack of motivation that constitutes part of the symptoms of several mental illnesses: it is also related to the demoralizing aspects of diagnoses and hospitalization (Frank & Frank, 1991; Furedi, 2004). In this way Maria’s story is a strong documentation of a person’s capacity for, and striving toward, the enjoyment of musical engagement. Even in a difficult life situation, in the hospital, suffering from depression, Maria used music to hold on to and to nurture some feelings of joy.

IN CONCLUSION For Maria, enjoying music was a good enough reason for music therapy. She found a way of using music to make herself feel better and to experience some moments of pleasure and joy, as well as to develop her musical skills. For Maria, this was what music therapy was about, and as we have seen, this was important and valuable for her. In this way, this case study exemplifies how music therapy may sometimes solely be focused on positive aspects of health.

Chapter 8

COLLABORATIONS WITH EMMA: MUSIC THERAPIST’S STORY WORK PHASE ONE (SESSIONS 1–8) When Emma first came to music therapy, she told me that she wanted to sing, but she was afraid that her voice was ugly. I asked why she thought her voice was ugly, and she said that someone had told her, and that it was also proven by her grades at school. I said that to me singing is not so much about having a beautiful voice or being able to use the right techniques, but something valuable just for the sake of singing. She told me that she had previously been singing a lot, and loved singing, but had found that in recent years she had gradually stopped. Since leaving her hometown to study (a year before being admitted to the hospital), she had not sung at all. Later in that first session, I invited her to sing together with me. I gave her a songbook, and she chose a couple of songs. I started to sing, and after a while she joined in. Her voice was barely audible, but she sang, and I enjoyed singing with her. I was moved by her wish to sing and her courage to start singing in that first session. After the session, I wrote the following note in my log as a reflection on her wish to sing: I think that it must be essential for her to make herself heard, and I would like to work toward that. During the first weeks of music therapy, she gradually sang with greater volume. Her voice was a very light and clear soprano voice. It felt easy for me to fit my own voice in with her singing. In the coming weeks and months, it became clear that having a voice was indeed going to be an important theme for our collaborative work, both literally and metaphorically. Emma brought songs with her to our sessions. The songs she chose were quite often songs that were familiar to me and also songs that I too enjoyed singing. Her musical identity was connected to her

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participation in church and choir, a background that I also shared with her. Thus I knew the musical genres well. One of the songs she brought with her in one of the first sessions, a song new to me, was a lovely song called “Eg Tenne Tusen Lys” (“I Will Light a Thousand Candles”). The song lyrics were about lighting candles for more justice for poor and weak and oppressed people. She had previously sung the song in a choir, and now she taught it to me; we rehearsed the female voices of the choir arrangement. This song seemed to give her some hope and to soothe her pains a little bit, and during the following months and years we came back to the song again and again. In these beginning sessions in particular, the song provided me with an opportunity to connect to her situation. I made it clear to her that I metaphorically lit a candle for her while singing it. I was moved by her deep engagement with disadvantaged people and the strengths that she put into her engagement, at the same time feeling that it was essential to see her own story of oppression. Singing songs together was the type of musical interaction that worked the best for us in the beginning sessions. During the first sessions, she also tried to play a little bit on the piano, and I tried to engage her in improvisations. Piano-playing, however, seemed very much to trigger her performance anxiety. With regard to improvisation, she told me that she had hated the improvisation they did at school. I had emphasized that there are many ways of improvising. On one occasion, she agreed to try. I handed her an ocean drum and started to improvise on the piano, but this caused her to hyperventilate and blink her eyes rapidly. I stopped playing and sat down in front of her, I said: “Oh, I can see that this was difficult for you.” I then quite firmly asked her to stop blinking. On this direct request, she took control over her breathing and blinking and was able to sing together with me again. In our fifth session, I suggested to Emma that we could also try to create our own songs. I had the impression that she chose songs very deliberately to communicate and to work with different life themes. Emma seized on this idea, and for the session after, she brought her first poem to music therapy. We decided to try to make it into a song. During the week before the next session, I could not resist starting to work with the song, because I thought that the poem was so beautiful and that it conjured up ideas for a melody in me that encouraged me to start composing the song (appendix p. 282).

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Walking Alone Walking all the streets alone Streets in the dark Streets to get lost Walking alone Praying “angels come and get me home” Angels with wings Angels to fly Fly me away Walking every step alone Steps so hard Steps so cold Walking alone Praying “angels come and take me” Heaven with happiness Heaven with joy Take me home Walking all the streets alone Walking in fear Walking to walk Walking alone In the following session (Session 7), I presented Emma with my suggestion for a melody. I told her, “Your poem has almost been crying out for a melody, so I couldn’t resist working on it.” We discussed some details in the song, and at the end of the session, Emma said: “It is strange to hear that my poem — that the words that I have written — has become such a nice, beautiful song.” The work with this song initiated a very productive process of work. It appeared that Emma had been writing poems for years. In the following sessions, she started to bring with her poems that she wrote during the week, and we started to create songs together. The work with songwriting, however, continuously alternated with singing precomposed songs together. This song-singing was a very significant part of what we did in the sessions. To me, it felt so important and meaningful just to sing

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together with her. Most of these songs we would sing as duets, with me at the piano. The songs were in various genres, but most often pop music, songs from musicals and some gospel/Christian pop songs. Later, I learned that for Emma, singing duets (in two lines) was something new. For both of us, singing together in this way was very much connected to feelings of joy and a sense of mastery. Clearly, I started to look forward to the sessions.

WORK PHASE TWO (SESSIONS 9–22) In this period, Emma was in the hospital all the time, and we had sessions once or more often twice a week. After the idea of songwriting had been introduced to her, she brought with her new poems for almost every session, sometimes several poems a week. It was not possible for us to create songs out of all of her poems, so usually I would ask her what poems she thought needed the most to become a song. Sometimes, however, I would have an idea for a melody to one of her poems and start working on that idea between the sessions. Other times, we selected a poem in the sessions and started to collaborate on the song. Usually, I started to improvise some chords on the piano while singing bits or pieces of a melody, and she would guide me toward a melody by her responses and suggestions: sometimes just nodding, smiling, or shaking her head; other times giving me clear messages like “no, nothing like that” or “yes, this is more like it — can you repeat that?” Several of the poems Emma wrote and brought with her to the sessions dealt with traumatic episodes from her childhood. One of the first songs of this kind (from Session 9) tells the story of a little scared girl and an abusive father (appendix p. 269): Father’s Crime Little and scared Always filled with fear Because of a father’s hand Who’s touching so often it can … Struggling and fighting Against the world of pain, which is biting

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Father’s lips touch And the pain is just too much Living or dying What to choose or maybe crying? Father’s hand stole your soul And made the world around you so cold I remember doubting whether it would be possible to create a song out of a poem telling such a brutal story. Over the following week, however, I sat down and wrote a suggestion for a melody. After I had presented my idea for a melody, she said: “This is very strange — you have made such an angry song out of my sad poem.” “Well, this is probably because the poem made me feel very angry,” I replied. “I feel really furious about men and fathers doing such things to their children.” I emphasized, however, that we could change the song if she wanted it to be more of a sad type of song. Then she said: “No, I like it that way too — can you make it angrier?” Our conversation then turned to the political aspects of sexual abuse and domestic violence. We talked about how practices in law and media tend to view girls and women accusing someone of sexual abuse with suspicion. I emphasized that sexual abuse is a criminal act and thus a political and societal concern. We then ended up discussing how we could make the song sound angrier. “Perhaps we should add some drums,” I suggested. “I can show you a simple rock rhythm that will work.” Emma, however, did not like that idea. In the end, we decided to add only some accentuations based on syncopation and some blues notes. In the following session (Session 11), Emma gave the song the title “Father’s Crime.” This signified to me that she, at least intellectually, had realized that she had “rights” to feel angry about her father’s violence. In the same session (11), we had collaborated on composing the music to another poem, “Cry Out and Shout.” Emma had been actively involved in the creation of the melody for the poem, suggesting melodic phrases, and the melody had gotten a strong gospel feel (appendix, p. 265). Cry Out and Shout Cry out and shout, let your voice be heard! Cry out and shout, let your voice be heard!

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We might say that this song reflects the goal that Emma had defined for her music therapy: to start singing again. Through the lyrics, we may also sense the immense importance to her of having a voice that could be heard. To sing and to let one’s voice be heard is a central and integral aspect of life. To have a voice and to be heard are of vital concern for the little girl in the song. “You know, when I started to create a melody for this poem,” I told her, “I was a bit surprised about that jolly gospel feel that came up. But I think that this came to my mind because I felt happy when reading this poem — because I agree so much that this girl’s voice must be heard, and I think the little girl is you!” I observed a distinct change in her voice in this session (13), and I wrote in my log: “In this session, she sang with a strong voice!” In the session before (12), we had also created another song, “Give It On,” that in a different and beautiful way also expressed some little germ

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of self-acknowledgment. In this simple song, composed in the style of a worship-song, she acknowledged that in spite of her problems, she might have something to give to others. The song was written to one of her friends (appendix p. 271). Give It On I give you my peace So you can give it on Let the swords fall down And live in peace … from now on I give you my joy So you can give it on Bring laugh and smiles So anybody can do the same … from now on I give you my tears So you can give it on Learn that tears are like diamonds And give tears … from no one I give you the whole of me So you can give it on Use me as you need me And bring our friendship out … from now on For our 14th session, she invited, for the first time, one of the staff from her ward to listen to the songs that we had created, and in the subsequent session, she invited the chief psychiatrist for the same purpose. The chief psychiatrist acknowledged the importance of the songs by asking for a copy to put in her medical files. This was important for me personally because of my somewhat peripheral role in her overall treatment up to that point. It was also important for her that other staff understood how important music therapy was to her. The psychiatrist further asked her about what it meant for her that the poems were created into songs. She replied that “they become something” and explained to him that with the song “Father’s Crime,” it was good to have an angry melody — because “it is allowed to be angry in music.”

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The summer approached, and I had 3 weeks off for a vacation. While I was away, she had spent time in the music room alone as well as with staff from her ward. She had practiced playing the piano and started to create two new songs, demonstrating strengths such as musical capacity, engagement, and motivation. Despite her apparent motivation for music, Emma was going into a very difficult time. A preliminary discharge from the hospital was planned for over the summer, and she planned to go to her hometown as well as on a holiday abroad with a friend. As these events came closer, she was increasingly frequently harming herself — and due to these circumstances, her leave was postponed and her holiday abroad canceled. During these weeks (Sessions 19–21), we composed a song about her mom. The song is telling the story of one of the psychotic episodes of her mother, in which Emma was dragged into her psychotic world with no possibilities for escaping the situation. This song was originally written in Norwegian (appendix p. 274): Psyk Mamma

Mummy’s eyes

Når mamma ikke er I øynene sine Vet jeg at hun heller ikke kan se mine For hun krangler med usynlige menn Som hun kjefter på om og igjen

When I can’t find mummy in her eyes I know that she cannot see me She quarrels with invisible men Scolding to them over and over again

En egen verden full av sorg Hun har bygget seg en beskyttelsesborg Der ingen andre slipper inn. Hun sier: Nei den er min!

Her own world full of grief She has built around herself a protecting castle, where nobody else is allowed to come. She says: No, this is mine!

Byen brenner røm i vei Hun vet ikke hvor hun skal gjøre av seg Ingen andre kan lukte Flammene som Mars-boerne slukte

The town is on fire, get out! She doesn’t know where to go Nobody else can sense the smell Of the flames that the spacemen put out

I din egen lille verden

In your own little world

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Legger du ut på den lange ferden Du sloss mot usynlige troll Og kjemper med usynlige skjold

You go so far away You fight against invisible trolls And fight with invisible shields

Når mamma ikke er i øynene sine Vet jeg at hun heller ikke kan se mine Lite barn rekker likevel handa mot Men det er ingen mamma der til å ta imot.

When I can’t find mummy in her eyes I know she cannot see me The little child stretches out for her anyway. But there is no mummy there to take her hand.

The song moved me deeply. As a mother, I have experienced the unconditional love of a child and from a child. The loneliness of the little girl in the song, of Emma, seemed almost unbearable. I wanted to try to nurture the lovely little girl, and asked Emma to tell me more about her: Did she have any picture of herself as a child? Did she have some good memories at all from her childhood? I wanted her to see that she had indeed been a lovely little girl, worthy of love and recognition. Did anyone see that? Her grandparents did, she told me. She remembered doing nice things with them — like going to a café. I was so sorry to hear that they had died early. After Session 22, Emma went away for a 4-week leave from hospital.

WORK PHASE THREE (SESSIONS 23–43) It was very nice to see Emma again after her leave. I very much looked forward to starting work with her again. The first half a year of collaborations had moved me. I liked her very much. She had such a strong story, and I enjoyed very much the music we shared. Coming for Session 23, she said that she had been looking forward to starting with music therapy again because, as she said, “music gives me a little break from all the difficult and hard things.” Although she obviously had had a hard time on her own, she impressed me by bringing lots of new songs with her as well as a brand-new choir arrangement for the song “Cry Out and Shout.” In order to try out her arrangement, we needed some more voices. We discussed whom we could ask to come and try out the

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arrangements, and, after a while, I made a few phone calls. A few minutes later, we had gathered a few staff and therapists for a short, 10-minute choir exercise. A new term of her studies was about to start, and it was arranged for her to stay half of the week in the hospital and the rest of the week in the town of her university college. In that way, she could follow her courses, but without having to stay all week on her own. Starting her studies again and staying on her own half of the week were a big challenge for her. Her stay at the hospital had weakened her social network. Her study progression had been delayed, with the consequence that she had to start in a new group of students. Gradually, she became more depressed. In the music therapy sessions, we continued with the songwriting as well as with singing precomposed songs together. The poems and songs she brought with her to our sessions revealed her despair, her loneliness, and her vulnerability. For Session 30, she brought three poems, all about death and suicidal thoughts. Again, I thought: Is it possible to create a song out of this? I was concerned that creating a song out of a poem with a suicidal theme would somehow contribute to a glorification of death. I consulted my supervisor as well as talked over the poem with Emma, and felt assured that the most important thing would be to recognize these very difficult feelings by creating a song out of her poem. Working with the poem was indeed challenging. We ended up composing this song by improvising the melody based upon a simple chord scheme24 (appendix p. 267). Engleliv

Angel life

De kom og hentet meg i natt Og gav meg deres fineste skatt Englevinger, så jeg kunne fly mot himmelen Og endelig få være med i stjernevrimmelen

They came and picked me up tonight, and gave me a treasure Angel wings, so that I could fly into the sky. And finally, mingling with the stars

Jeg sitter på en stjerne og har endelig fred

I’m sitting on a star and have finally peace

24

A technique inspired by Diane Austin’s vocal holding (Austin, 1999).

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Her kan jeg slippe og tenke på alt det jeg led Slippe og tenke på, helvete som satte sine spor Nå lar jeg bare englene synge i kor

I don’t need to think about all I’ve suffered I don’t need to think about the hell that marked me I just let the angels’ choir sing

La dem synge i kor om freden som fyller døden sammen med gleden Gleden av å endelig få komme bort Fra livet, og alt det stygge som ble gjort

Let their choir sing about peace The peace of death as well as joy The joy of getting away from life And all the evil things that were done

Det var en uutholdelig smerte Som rev og slet i mitt knuste hjerte Døden var det eneste, som kunne redde meg ifra alt det som skjedde

It was a pain too heavy to bear It destroyed and broke my heart Death was the only thing that could save me Save me from all the things that happened

De kom og hentet meg i natt Og gav meg deres fineste skatt Sitter på en stjerne og har endelig fred Jeg tenker ikke lenger på alt det jeg led

They came and picked me up tonight, and gave me a treasure I’m sitting on a star and finally I’ve found peace I don’t need to think about all I’ve suffered

Emma was really worn out at the time, and her sadness threatened to be overwhelming. Therefore, we spent only a little part of each session for the work with this song so as to regulate the emotional intensity. The song was finished eight sessions later. Quite often in this period, she was shivering and freezing as she arrived for the sessions. Singing songs together, however, made her relax a bit, and it seemed that she was feeling somewhat better. We would alternate in suggesting songs to sing. I had different reasons for my choices of songs. Sometimes I would choose songs that I thought would perhaps soothe her pains for a little while; other times, I would choose songs that somehow commented on her situation. Other times, I would select songs that I enjoyed singing together with her.

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At this time, a music therapy student came to have her practice placement with me. On the student’s first day in the hospital, Emma told me that she had always wanted to learn to play the flute (Session 32). By coincidence, the music therapy student played the flute, and she offered to lend Emma a flute for some weeks so that she could find out if she enjoyed playing it. We also decided that for the duration of her placement, the student would join in Emma’s sessions and use some of the time in each session as a flute lesson. This chance to play the flute was of great importance. Learning to play the flute seemed enjoyable for Emma and provided her with good experiences of mastery in a period when she was really struggling for life. At this time, Emma’s aunt also contacted her for the first time in several years, and when Emma told her about her fluteplaying, the aunt offered to buy her a flute. Emma was ambivalent to this offer due to their previous lack of contact, but eventually decided to accept it and became the proud owner of a brand-new flute. As Christmastime approached, she seemed a bit more confident, and I sensed a little trace or germ of hope. In Session 42, we sang “Bridge Over Troubled Water” (Simon & Garfunkel). When I suggested that she had been metaphorically swimming in troubled water for a while, she said that she felt she was beginning to have a bridge to stand on. “What is the bridge built of?” I asked, and she answered: “from good moments.” Just after this, she learned that she had passed an exam in her studies with a good grade.

WORK PHASE FOUR (SESSIONS 43–66) A new semester of studies started for Emma. Our collaborations in music therapy had lasted for a year. The arrangements with staying half a week in the hospital and the rest of the week on her own continued. A change in Emma’s other treatment took place when Emma suddenly denied that her father had sexually abused her. This happened after hospital staff had challenged her to go to court with the abuse. As a response to this, she revealed that she had invented the story of sexual abuse as a way of maximizing her problems enough to get help. A story about a father that had been hitting mother and child had apparently not been effective enough for her to get the help she needed. Because of this, the approach of her verbal psychotherapists had changed. In music therapy, however, it seemed right to go on in the same way. After this, I was never sure if the

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sexual abuse had happened or not, but I found the emotional content of the songs about the violent and abusive father as true as ever. The point for me was not to reveal the absolute “truth” of her life, but to help to give voice to narratives that were helpful to her. A song, as a narrative, also always has the potential of being biographically true or not. Among the songs created in this semester was a song about her experiences with child welfare. In the song “Svik” (“Betrayal”), she told the story of how her schoolteachers and school nurses, as well as the social services’ child welfare department, failed to understand the severity of her situation at home and hence took no action. We also created a song formed as a letter to her mom revealing her love as well as her need for distance. Another important song was a song about self-mutilation, “Røde Tårer” (“Red Tears”), based on a poem that Emma had brought into therapy in Session 46. With this song, Emma revealed that she had a “project” involving all of her songs: She was going to tell the story of her life. She explained that “I have stopped doing this, but I need a song about it, because it has been a big part of me for a long time.” One particularly important song has to be mentioned among those we created during this semester. When spring arrived (Session 60), we composed a song that she called “The Spring Is Gone.” The song, perhaps the most beautiful of all the songs we made together, was the first out of several songs that voiced her fear of getting better, her ambivalent feelings about being able to “walk on her own” (appendix p. 278): The Spring Is Gone The spring is gone and I’m no longer there My life has really changed, and I am really scared Somebody told me: I have to walk on my own And I know, I have to do it But it’s really, really hard The leaves have all turned brown And here I’m standing all alone The steps are hard to walk, and I’m afraid to do it wrong I know they told me: I have to try it on my own And I’m trying, I really do But I’m tired, and it’s hard So take, take the spring — and take the brown leaves

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WORK PHASE FIVE (SESSIONS 67–98) Emma started the last year of her study program. She had finished all of her exams so far with good results. She had moved out from hospital and come to her sessions only as an outpatient. When she came, she stayed for the day at the hospital to meet with me, the psychiatrist, and other staff that followed up on her. When the semester started, she seemed optimistic. She had been working most of the summer and looked forward to her last year of studies. She had also made arrangements for flute lessons, and seemed excited about that. Staying on her own was indeed difficult; she was tired and struggled hard with her life. One precomposed song had particular significance for her at this time. “Streets of London” (Ralph McTell) resembled her loneliness and despair and voiced her silent cries. Her pain and despair were almost overwhelming. In spite of this, in Session 84, we started to work with a new poem that very explicitly expressed her ambivalent feeling about getting better and stronger (appendix p. 263): Be With Me Now All alone in a world cold as stone Trying to carry it all alone My life is nothing else than pain Wish it could be washed away with the rain But I know it’s here to stay And I fall on my knees and pray: Be with me now Please, show me when I don’t know how I’m all tired and scared All my body is filled with fear Please, don’t let me go Be with me now!

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I’m struggling to survive every day But it’s hard to find the right way The edge is very near me now I want to fall down but I don’t know how If I fall there’s no more pain But I’m too scared to let it rain Be with me now Please, show me when I don’t know how I’m all tired and scared All my body is filled with fear Please, don’t let me go Be with me now! By the end of the session, she seemed a bit reluctant to go, and I got the impression that it was something she wanted to tell me, so I looked at her and waited, and she said, “Recently, I have understood.” She stopped and said: “Forget it.” I looked at her and said: “I think this is important — I want to hear.” She was searching for the right words: “I don’t dare to use my strengths, because that might mean that I lose the help.” She explained that she was so terrified of losing the help and support that she received from the hospital. She was very scared that she would be thrown out of the hospital immediately if she was able to manage anything on her own. “I have found a bit of peace in music therapy, and I am scared of losing that, too.” In many of our sessions and through her songs, she had shown me how weak she could feel, but she also had made me see the germ of strength that was growing inside her. I had shared with her my experience of her as a person with strengths and resources as well as with problems and weaknesses. Emma wrote many songs that expressed her ambivalence about having strengths. As she was about to try to trust her strengths more, and to try to live outside the hospital again, she was terrified by the thought of being left alone. Just after this (in Session 84), I brought Paul McCartney and John Lennon’s song “Blackbird” into the sessions as a symbol of her struggles. “I think that perhaps you too, like the blackbird, are about to learn to fly with broken wings,” I said. We talked a bit about the blackbird flying with broken wings, with regard to her struggles to cope with her life in spite of her difficult childhood. “Blackbird” was a song that she liked

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very much and that she had been singing in choirs, but the song acquired a new symbolic meaning for her when it was introduced in music therapy: to acknowledge her strengths and resources — her ability to fly despite her weaknesses and problems. This was indeed very scary for her. A new song about her childhood traumas was also created during this period. The poem “Min Barndom” (“My Childhood”) was brought into music therapy in Session 95. It was in late spring, during her preparations for exams, and she was planning to go to her hometown to work there for the summer. Although she had arranged to live in a friend’s house, she was afraid of contact with her parents. The poem expressed in a very concrete way a very traumatic episode from her childhood, her father’s violence and how terrified she had felt. In the following session, we started making a song out of the poem. We both sat down at the piano, and I suggested some ideas for a melody. The melody started quietly, but there was a sudden dramatic shift in the music at the start of the third verse. At this point, she started crying. When I asked her about this, she nevertheless confirmed that this was how she wanted the song to be. We discussed some details and then put the song away for the rest of the session. In this song, we find the little scared girl hiding in a wardrobe, witnessing her father hitting her mother (appendix p. 272): Min Barndom

My Childhood

Så liten og redd Og skjønner ikke hva som har skjedd Mor ligger nede og blør Skrikene forteller hva far gjør Blod over alt Da mor ned trappa falt

So little and scared Don’t know what happened Mum lies downstairs, bleeding Her screams tell me what Dad is doing Blood is everywhere When mum fell down the stairs

Så redd og så liten Og uendelig sliten Av å gjemme seg inni et skap For resten av huset er fylt med hat Gjemme seg bort

So scared and so little And extremely exhausted From hiding in a wardrobe When the rest of the house is filled with hatred — hiding

For hvis far får tak i deg da er det gjort

If Daddy gets you, then it’s done

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Da ligger du nede, mens fars knyttneve over deg truer, alt som han utad skjuler Du hadde sagt noe galt, og nå, nå får du betalt

You will lie down with his threatening fist above you, seeing all his hidden self You said something wrong, and now you’ll have to pay the price

Men du er skyld i det selv For du gjorde visst noe galt i kveld Du vet ikke hva Men du tror på det far sa Du fortjener hvert slag Du får prøve å glemme det til neste dag

But it is your own fault ‘Cause you did something wrong Don’t know what But you believe your Dad’s words You deserve every hit You’d better try to forget before another day comes

A few weeks later, she demonstrated her strengths and resources when finishing her education in the university college. After that, she moved to another town nearby and started working.

LAST YEAR OF THERAPY (SESSIONS 99–113) When Emma finished her study program at the university college, she moved to another part of the county to work. It was arranged that she could come for sessions every second week and stay in the hospital from Friday to Monday. In the beginning, Emma seemed quite happy with her new job and was talking warmly about her new colleagues. She made friends with another newly employed young woman in particular, and they sometimes engaged in musical interplay together. Although her work was going well, it seemed difficult for Emma at this point in her life to have therapy sessions only every second week and to not have more support in her daily life. After a few weeks, Emma was struggling very hard with her life. Her move to another town made it difficult for the hospital to support her adequately in this new and challenging life situation. On days when Emma was really struggling with her life, she was sometimes unable to sing. On those occasions, I would sometimes offer to sing for her. Although she was not able to sing or to play along with me,

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she was able to be there and to listen to the music. One such session was Session 105: Emma was tired and quiet when she arrived for the session. She said that she was too tired to sing, but that she might play the piano. I was hesitant about her playing the piano, because this had often upset her before. Instead, I told her that I had been working with the bridge on one of our song, and suggested singing it for her. As I sang, she started crying quietly but confirmed that she liked the song — that the song was “right.” I then suggested that I could sing some other songs to her. I started to sing, and after a couple of songs I asked her if she wanted to join in. “No, it’s good just to listen,” she said. I continued singing songs from our repertoire. While I sang for her, she put her legs on the chair, looked calm, and smiled. After the last songs, we had this exchange: Emma: It was a bit weird today. Randi: But it looks like music did something good to you? Emma: Yes, it just came — and embraced me and did everything around me good. Randi: Oh, just keep it there, keep it like a good, warm quilt — you deserve it. In other sessions, she was active and continuously developed her musical skills. In the last semester of music therapy, she took another huge step toward letting her voice be heard when she wanted to try to amplify her voice. In one of the last sessions (106), she suggested trying to sing through a microphone. I was taken aback by her suggestion because so many times before she had been really negative to the idea. I probably looked like I had “fallen from Moon,” as she started to laugh: “Yes, you didn’t think you would hear that from me ….” She explained that she was going to sing for a mass at church and wanted to practice using a microphone in a safe space. For Emma, singing through a microphone was very scary — but she dared to try, and to her and my surprise, she actually she enjoyed doing it. A few sessions later (Session 111), she suggested that we tape-record our singing, because she wanted to hear her own voice. This again had two purposes, the second being that she wanted to get used to hearing her own voice in order to be more prepared for singing through a microphone in church or elsewhere. She had already done this on some occasions previously, as with the mass, and she had received positive feedback. She also wanted to listen and decide for herself how her voice sounded.

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This is perhaps risky in some ways. What if she decided that her singing voice was not good enough to be used outside music therapy? This might well have happened, but there is another important aspect here: that of self-determination. It was no longer her father, nor her teacher, nor me who had the right to define what a nice voice sounded like. It was not up to any of us to decide about her voice and how she was going to use it. I was impressed. This was an important aspect of being able to use music in the way she wanted. In the penultimate song we wrote together, she brought up the image of the bird with broken wings from “Blackbird.” This song, “The Eagle,” was written in a very turbulent period (Sessions 111–112), when the responsibility for her support was about to be transferred from our hospital to another, with lack of support as the unfortunate result. In this song, she questions the range of her strengths (appendix p. 276): The Eagle I’m an eagle with two broken wings And every time I try to fly, I fly down I’m an eagle with blinded eyes and now I realize: I will never learn to see So could you reach out a hand, or am I just too forgone to be saved, Just too far gone to be saved? So could you reach out a hand, or am I just too forgone to be saved, Just too far gone to be saved? I’m an eagle with nowhere to fly I am a broken bird with a broken heart … I’m an eagle with blinded eyes and now I realize: I will never learn to see So could you reach out a hand, or am I just too forgone to be saved, Just too far gone to be saved? So could you reach out a hand, or am I just too forgone to be saved, Just too far gone to be saved?

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I reach out I reach in But there’s no way to reach I fly up I fly down But there’s just a broken wing So could you reach out a hand, or am I just too forgone to be saved, Just too far gone to be saved? So could you reach out a hand, or am I just too forgone to be saved, Just too far gone to be saved? She tried to fly, tried to cope on her own, but it was too hard. Even if the wings could hold her in the air, they were not yet strong enough to for flying all alone. The damage is done, the bird is wounded. She could still fly, even with broken wings and blinded eyes, if flying in a safe environment: if there were good places to rest, if there were enough support and affirmation, if the air were not too cold.

TERMINATING THE THERAPY (SESSIONS 114–117) When Emma came to her 114th session, the continuation of the treatment in the hospital was unclear. A few days before, she had taken an overdose of medication, but after taking the pills she had called for help and gotten to the intensive care unit of the hospital in time. She had started to see a psychologist at a hospital nearer to her house and work, and she did not know what arrangements she was going to have at my hospital. I ensured her that whatever happened, we would at least find a time and place for a few sessions to end our collaborations. It was, however, planned for her to come for a new session 2 weeks later. By this time, we had created 32 songs together. For this session, Emma had written a poem about religious faith and doubt. It was a prayer to God, in which she begs for His peace and questions why He is so distant, not providing her with the help she needs (appendix p. 280).

Emma: Music Therapist’s Story Untitled I’m longing for your everlasting peace, oh God But I can’t find it here Still, those questions running in my mind Are you near? Are you here? Are you near? Are you here? I can’t find your grace, oh Lord I can’t see your face, oh God Are you there to save me? Are you there to save me? Have you got the answers to my questions, Lord? Why did you let me live in pain Were all my tears shed in vain? Are you near? Are you here? Are you near? Are you here? I can’t find your grace, oh Lord I can’t see your face, oh God Are you there to save me? Are you there to save me? Oh, Father, I am tired of this life I’ve got Will you show me The way to your precious house? Are you near? Are you here? Are you near? Are you here? I can’t find your grace, oh Lord I can’t see your face, oh God Are you there to save me? Are you there to save me?

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The poem expressed her despair and feelings of hopelessness. She seemed determined not to come back to the hospital. She was not talking much but said that she was sad her attempt on suicide had not been successful. Her monotone voice when talking about this worried me. I told her that I had hopes for her, that I did believe her life to be better, but I was feeling the poverty of my words. In spite of her despair, she sang with me. This final song created in therapy was also very important because it dealt with an aspect of her and of her life that she wanted and needed to confirm. She later told me that during her stay in the hospital, she had felt somehow distanced from her faith. During our years of work together, I always knew about her religious identity, through the songs she brought and because she talked about her participation in the church. Her faith and participation in the church were obviously an important resource in her life, providing her with hope as well as a social network. Occasionally, we had sung religious songs together, but with this song she acknowledged how important her faith was to her, and she provided me with an opportunity to confirm and acknowledge this resource. After this session, she did not come back to the hospital. I had only telephone contact with her because she could not manage to come to the hospital. I had made a suggestion for a melody for the song, and as she was unable to come to our session, I actually performed the song for her over the telephone. For me, this was a way of showing her that I thought this song was very important to her and a possibility for me to give something to her, to show her I cared. Although it did feel a bit weird to sing it through the phone, she was eager to listen to it. A few days later, she did make another suicide attempt and was admitted to a hospital closer to her house and work. After her transfer to another hospital, the music therapy had to be terminated. I asked her how many sessions she thought we should have in order to end the therapy and to say our good-byes. As we both had foreseen her transfer to another hospital for a while, and both of us felt very sad about ending the music therapy, we agreed to have two sessions together to terminate our collaborative work. “It’s better to do it quick than to go through a long-lasting torment,” she said. The closing sessions were arranged in her new hospital. For the first session, we decided to go through the songs we had created together. She invited her new medical doctor to listen to some of our songs, and she took part in half of the session. In this way, Emma was able to communicate some important things to her doctor without having to tell

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her everything and managed to build some sort of a bridge from music therapy to her new psychotherapy. So in this session (116), we sang a selection of the songs together. I also had made an audio recording of the songs for her. We talked about the whole collection of the songs, ranging across such broad life themes and telling the story of her difficult life. I asked her if she felt that there were more songs that should have been written, but she replied: “No, I feel that the collection is complete — there are no more songs to be written.” In total, we had composed 32 songs together. We spent the final session singing together the precomposed songs that had been important to her, and me, during the years we had worked together. It was lovely to sing through many of the songs that we had been singing so many times together. I felt very sad to say good-bye to her but very proud of her and very glad that she had trusted me to be part of her life and songs.

Chapter 9

EMMA’S EXPERIENCES: “IT’S NICE TO BE ABLE TO USE MUSIC AGAIN” Emma: Ever since I was a little girl, I have always wanted to sing, but my father always told me that I couldn’t sing, that I should keep my mouth shut because it was so horrible to listen to. That robbed me of the guts to try and sing, but it has never taken away my desire to try and do it. Emma had come to music therapy with a wish to sing, at a point in her life when she had stopped singing completely. Through the interviews, she talked more in detail about the background of her silenced voice. It turned out, her previous experiences with music had been very mixed. Although her first experiences of singing were not appreciated by her parents, and although her father counteracted her engagement with music by telling her that her voice was ugly, she retained sufficient determination to go on singing and had good experiences in being in a choir in her early youth. Singing in this choir was a joyful experience for her, providing a space free from conflicts and problems: “It was a space of freedom, something I liked to do.” But in the competitive environment at school, her joy in music got lost: Emma: Music has always meant … when I used to live at home, it meant a lot to me. I used to sing in a choir then, and it was a kind of freedom, but later … when I started to have music exams at high school, it was just a burden … it turned into something horrible and all about performance. Then, in a way, I lost a part of me. The only thing that seemed to matter was getting the best grades and having a good technique with the instruments (or voice). Music, which had previously been a source of joy and freedom, became a heavy burden.

Emma’s Experience 151 Then she felt that she was just not up to it anymore; it was just awful and wrong. She managed, however, to finish school. After that, she stopped musical activities entirely and did not sing again at all until she came to music therapy. The intensity of this loss was immense, as she felt that she had lost a part of herself. In music therapy, however, she started to explore new ways of using music. She realized how important music was to her, and she managed to free herself from the focus on achievement, so that she could again engage with music. In music therapy, she felt that she could use her musical skills, but at the same time that it didn’t matter so much if she made a mistake. Emma described her first experience in music therapy in the following: Emma: First, it was to be respected for what I am, what I can do and what I can’t. Nothing was required of me, and I was very surprised how important music was to me. I think I must have been repressing how much I’d missed it, to have been so unaware of it. When I started in music therapy, I got the impression that it was indeed very important, and I don’t think I’d realized that before I started here. … I think I was a bit scared that it would be about achievement again. I had that very strongly inside me — that I can’t do this, I can’t do that … I’m not able to, not clever enough, blah blah blah. I didn’t think about all the things I can do, but when I started here, I was able to start very carefully and I felt, “Okay, I can actually use music even if I am not going to be a professional.” And to be met with — to be allowed to use music just for yourself in a way … and not to be pressured to do something or say something I couldn’t, or didn’t dare to — that kind of thing. Emma emphasized the importance of a nonjudgmental environment that helped her start engaging with music again. It was safer to explore her musical abilities in music therapy because she did not feel that she had to achieve at a particular level. Even if it was difficult for her at first to start singing again, she experienced joy in singing and freedom from expectations about achievement. “It was a bit painful … but it turned into something good after a while because I was not going to perform so well — it was like, ‘Okay then, I can just relax and have some fun.’” Even if

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music therapy sessions also aroused difficult emotions and memories for her, she nevertheless experienced joy in singing In the safe and nonjudgmental space of music therapy, she was able to explore and develop her ability to sing, and to sing in duets in particular: Emma: It feels very good — I very much enjoy singing duets. It is nice to be able to do it. It is only here that I have started to dare to try to do that because I’ve always been so scared of making mistakes, of not managing. But now I dare to, and even if I make some mistakes, that doesn’t matter. The ability to use music for herself, without feeling pressure to perform well all the time, was of central importance to Emma. This does not imply, however, that she did not achieve anything, nor that her achievements did not matter at all. As the previous quote suggests, it was important to her that I acknowledged her musical abilities, both the resources and the limitations. Emma had lots of musical skills before starting in music therapy, and in music therapy she had opportunities to start using those skills again. This led first of all to an acknowledgment of the skills she already had, but also to her developing some new skills related to singing, playing the flute and composing songs. This achievement was not restricted to the music therapy sessions. Somewhat “surprised,” she confirmed that she could also do this outside of music therapy: Randi: No, hadn’t you sung duets before at all? In the choir? Emma: Yes, in the choir together with others, but not like this. Randi: Can you sing duets in other places too now, like with only two people together? Emma: Yes … actually. Again, the important point here is that she was able to use music on her own level, and that this made it possible for her to “unfold” in music and to develop and grow as a musician. Increasing confidence in own abilities together with the development of new musical skills also led to opportunities for participation in musicmaking outside of music therapy. Early on, she started to sing and play together with other patients or staff in the ward. During the course of

Emma’s Experience 153 therapy, she also started to use music more outside the hospital, leading sing-alongs and using music in her work. Learning to play the flute was one of the things that provided Emma with opportunities to participate in music outside the hospital. For example, she was contacted by the local marching band and invited to start playing with them. One year after she started playing the flute, she told me, in an interview, about a performance she had done in the church, playing the flute: Emma: The people at work know that I very much enjoy doing musical things, and I and one of my colleagues have been using the music room at work a lot. And then someone asked me to play with them. I said like “Aargh,” but it was very nice to have a chance to play along. I told them that I’m not very good at it, but that I can play a bit. I haven’t played anything for such a long time, but I really enjoy it. It is very nice to be able to take part even if I haven’t played for 10 years and even if I’m not amazingly good at it. It’s nice that I can use music on my own level, that it can be fun, that I dare to use music more than before. And our rehearsal went well …. Her shy and reserved agreement to take part in this performance revealed a residual uncertainty, and perhaps surprise, at her ability to perform. Simultaneously, she demonstrated an acknowledgment of her capacity and skills as well as of her limitations. Sharing this with the people asking her to take part in the performance created the space for her own participation on her own level. In music therapy, Emma experienced a way of engagement with music that was valued for qualities other than musical skills and “amazingly good” performance. Music was for her to engage with, not only for professional musicians. Through her experiences in music therapy, she felt that she had a right to music in her own ways, on her own level, as she wanted to. Summing up what music therapy had meant to her in our last interview, Emma used the following words: Emma: It doesn’t matter so much anymore … I don’t need to perform so well all the time with music anymore. I can use music exactly the way I want. And I don’t need to be so amazingly good to use it. I’m much more daring

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Randi Rolvsjord now than I used to be. Now I can use music in my work, and I can sing at church. Last time I was in the hospital, I even sang for all the others in the ward. I’m much more daring like that now than before. Randi: Yes … Emma: It’s nice to be able to use music again, to dare to use music.

SINGING HER LIFE AND TRAUMA When talking about her music therapy, and the songwriting in particular, Emma emphasized the importance of being able to get into contact with her emotions, to express and communicate her experiences: Emma: Through music, I have dared to feel my loneliness, I have dared to feel that I want to move on, but that I don’t really dare to. I have dared to feel what happened when I was little, and I have dared to feel when I want my life to end — and at the same time, I have been able to tell it to you people that have been around. Randi: To us? Emma: Yes, to you, and to my contact person in the ward, to the psychiatrist. Randi: Those that you have shared the songs with? Emma: Hmm … Randi: I think that’s an important part of the story. But you say that the music has made you dare — that you dared to in music — how can that be? Emma: I don’t know … it becomes less scary … music is music in a way. It becomes less scary to express things through music than to talk about it. Randi: Yes. Emma: At the same time, music makes things feel very strong and painful, but it’s still less scary, I feel. Emma explained these aspects of her experience in relation to some of the songs we created in therapy. One song in particular that she put forward was “Father’s Crime.” Emma talked about “Father’s Crime” in

Emma’s Experience 155 two of the interviews, and she described how the work with this song helped her to come into contact with her feelings of anger: Emma: When I wrote “Father’s Crime” (a song that describes something that did not happen, but rather how it was, my fear of Daddy and how scared I was of him) … when I wrote that poem, I was very sad. And when I came up here and the song was finished and it was very angry … that was weird … it was a big contrast, because when I wrote that poem I was indeed very sad, but when the song was finished, it had become a very angry and aggressive song. I was a bit like “Oh?” It was very strange to see how I interpreted it and how you interpreted it. And it became right as well, the song expressed how it was, and it was expressing me, but not the way I thought about it at first. Emma explained that the music, or rather I, was catching hold of something that she did not dare to feel — her anger. She explained that music was angry on her behalf, when she could not allow herself that feeling. This helped her to find her way toward a more differentiated experience of the affects involved. In a later interview, she talked about how she had used this song after we finished it, and she acknowledged her feelings of anger related to what her father had done to her. Although she still thought it was scary to have these emotions, she seemed better able to tolerate them: Randi: Yes, but he did many things to you that give you very good reasons to be angry, and sad. Emma: Yes, and then the music was angry for me, and that felt good. When I don’t dare to be angry, then music can be angry on my behalf. Randi: Are there any ways you have used this, used this song later? Emma: Yes, I have used it like … that it is allowed to be angry in a way, and after we wrote it, I actually became angry with Dad. Randi: So the emotion became yours eventually? Emma: Hmm … yes, it did. [almost crying]

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So our collaborative songwriting provided Emma with opportunities to come into contact with her emotions and to work with her traumas. In contrast to the previously mentioned song (“Father’s Crime”), with the song “My Childhood,” the melody seemed to fit very well with her emotions related to the event: “I could almost hear how angry Dad was in that melody.” The song made it more real, because she recognized her feelings from the actual situation in the music. The song mirrored the threatening behavior of a strong and aggressive father, how he slammed doors, made noises, and stomped his feet. This song clearly brought Emma into contact with strong emotions that were directly related to her childhood traumas. This was obviously painful but also important because it provided a means of enabling these emotions to be heard and understood. Emma said that I had created music to the song that seemed not only to fit her experience but also to express accurately how she felt in that situation, and that this indicated to her that I had understood how she felt. Thus she felt acknowledged by me: Emma: It’s good to have this song. I feel that I’ve been able to explain how it was in a very concrete and direct way through the lyrics and the music. And when the music turned out the way it did, then it sort of confirmed the things I’d been thinking about. It confirmed how it was … see? Randi: Yes? But what I’m wondering about is when you say you’d explained, then who had you explained it to? Emma: To you … Randi: To me — not for yourself, but to me? Emma: Yes, and when the music became as it did, then it confirmed that you looked at it the same way as I felt it. Randi: That I’d understood how it was? Emma: Yes, and that feels good. As Emma explained, she experiences me taking part in what she felt: Emma: I think it’s helped me a lot that it has been expressed through music, because that way it is not only me expressing it, but you, too: You have sung the songs for me and together with me. Randi: The fact that we’ve been singing together, and that I’ve been singing the songs for you?

Emma’s Experience 157 Emma: Hmm … Randi: What’s that about? Emma: It’s like I have felt very, very lonely many times, but when we sing the songs together, then I’m not so much alone — then there’s also somebody else taking part in it. You take part in what I feel. Through music, Emma found a way of establishing contact with her emotions. Through songs, she found a way of tolerating her emotions more effectively and communicating with people around her. During our therapeutic collaborations, the meanings of the songs had gradually developed into a project of telling the story of her life. Through her process, she became more and more conscious that she had a bigger narrative project related to the collection of songs as a whole. It was evidencing her life, confirming the things that she had been through. In the following quote, we can also see that the process of writing songs, manifested in the collection of songs, had become part of her identity. Emma: The songs are a part of my history — they are a part of me. And if you take away some of them, you take away a part of me. They have been so important, and it has become my way of feeling things, my way of daring to face the painful and difficult things, as well as the good things in my life, a way to express all the ambivalent feelings and thoughts I have inside my mind …. Music has become my way of doing that, and if you take away some of it, you take away a part of me.

“PERHAPS I HAD A LITTLE BIT OF IT INSIDE ME” A third song Emma talked about in the interviews was the song “Give It On,” one of the first songs (from Session 12) that dealt with her ambivalent feelings of being strong but also weak. In this song, she was acknowledging that she had something to give to others. In the interviews, she explained that she wrote this song to a friend. At the time she wrote it, she wished that she could have given her friend all of the things in the song. At the time, she did not feel that she had much or anything to give. It was nevertheless a little fragile part of her deep inside, even if she did

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not dare to admit to having it. Yet in the music she could. “Perhaps I had a little bit of it inside me,” she said, “but I did not dare to feel that I had it.” It was scary for Emma to acknowledge that she too had some strength — that she had something to give to others, something that could be valuable for them. In the song, however, she dared to acknowledge this. A few weeks later (in Session 15), we sang for her psychiatrist this song and other songs that we had composed together. After listening to this song, he commented that it was different from the other songs, more positive. In an interview, she explained how his reaction and his comment on this song made her scared and worried: Emma: I was terrified when we sang it for the psychiatrist, and when he said: “Look, that was something else.” Then I was scared to death. Randi: And that was when you became scared? Emma: Then I realized what we had done. I didn’t really think that way when we wrote it. Randi: You are still talking about “Give It On”? Emma: Yes, and when he said that, then I thought, “Oh, NO, it’s not like that.” Randi: So suddenly the song could be dangerous? Emma: Yes, I was terrified because the psychiatrist might have thought: “Well, good, now she has changed her thoughts; it’s going well, she can go back home.” In spite of this reaction, for Emma, expressing things through songs was less threatening than doing so verbally. On the one hand, she explained, music clarifies and intensifies emotions; on the other hand, it renders them less dangerous, less threatening. Thus, for Emma it was safer to communicate things through music than through words: Emma: Music makes it less scary. Randi: Less scary? Emma: Yes, it feels safer to say things through music than to talk about them. Randi: How can that be? Emma: I don’t know … perhaps because I sort of think that a song is a song.

Emma’s Experience 159 Randi: You don’t have to take a song very literally — not all songs mean that much: I’m thinking of songs like “Baby, It’s Cold Outside.” Emma: All the songs that we have written mean something in particular, but I might think that they don’t have to mean anything, even if they do. It is something I want to tell, and it is something that is described in the songs, but the song can still be just a song. In such a frame of play, a song may have meaning beyond itself, but equally it may not. Some of the songs Emma and I sang together did not have any particular personal meaning: They were just songs. But a song may also have a very deep personal meaning and be used to communicate emotions and traumas in a nuanced way. This made it possible for Emma to dare to communicate through songs. A song is just a song, yet it is not.

“SOMETHING TO HOLD ON TO” Talking about her use of songs after they had been created, Emma emphasized the possibilities both for using the songs as a means of communication and for using the songs as an aid for coping in moments of distress and challenging life situations. The communication of emotions and experiences with the songs also goes beyond the therapeutic relationship and the music therapy sessions. On several occasions, she invited her psychiatrist and her contact persons in the ward to music therapy to listen to some of the songs that we had created. In this way, she was able to communicate things that she felt were too difficult to talk about verbally. In the early stages of her therapy, she invited the psychiatrist and other staff to our sessions “just” to listen to some of the songs and to see what we were doing in music therapy. Later, she used this opportunity more deliberately to communicate something in particular. Emma also explained that she could use the songs in various difficult life situations: Randi: Where do you keep the songs? Emma: I have them in a folder. Randi: Yes … do you sometimes take them out?

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Randi Rolvsjord Emma: Hmm … [nodding] Randi: Yes, you do … do you sing them or …? Emma: No, hmm, I haven’t … I have played them … not recently, but I have played them — things like that. Randi: Yes … so it’s more like you hear them in your head when you get them out? Emma: Yes. Randi: Could you tell me something about what makes you get the songs out? Do you know? Emma: Often, it’s if I’m feeling like I was when I first wrote the song. Then it’s good to get the song out — when I feel the same way. Randi: Okay … how come that’s good? Emma: It’s good to see that I’ve felt this way before — and gotten over it, that things have gotten better. So maybe I can make myself remember that even if I feel like this right now, it might get better. Otherwise, it just loads of chaos into my head when I feel this way. Randi: So, it’s a bit like you are more able to control it? Emma: Sort of.

When she had experienced distress or life challenges that brought her into a particular emotional state similar to those expressed in one of her songs, she would recall the song, often by actually and literally finding the song (either the sheet music or the recording). Then she would either recall the song in her mind or listen to the recording. In doing so, she reminded herself that she had felt this way before and that it was possible to overcome it. Thus, the songs became something she could hold on to when things were difficult. One specific example she put forward was related to a song titled “Jeg Skulle Ønske” (“I Wish”), a song about her relationship with her parents. The song describes how she was still affected by her parents’ ways of appealing to her and threatening her. At the time she wrote this song, they were phoning her on a daily basis, often several times every night, and she was struggling to assert control in relation to this communication. Time and again, they made her feel responsible and made her take responsibility for them. In an interview, Emma talked about how this song helped her to hold on to her own emotions in encounters with her parents. This was important for her when she was challenged by their demands for her help.

Emma’s Experience 161 She was living in her hometown for the summer, working a lot and staying with a friend. Even though she was not staying with them, they phoned her frequently and asked her to visit them. On one visit, she found that her mother was ill and that her father had been hitting her. This led her to assume responsibility by arranging for her mother to stay at a “women’s refuge.” In this situation, highly challenging both emotionally and practically, she used the song as an aid in keeping herself together and as a means of acknowledging her wish to protect herself from the feelings evoked by her parents: Emma: My parents cried, it was a real mess, and I felt that I had to be my mummy’s mummy, that I had to take responsibility for her — and drive her to the “women’s refuge.” This song went on and on inside my head. I felt that I didn’t want this, I didn’t want to feel like I did. I just wanted to get away. If I hadn’t had to work, I would have just left. Daddy cried, and he was angry — it was all the same as ever. … It was very hard to cope with this, very painful, and then this song went on and on in my head. It was a bit weird, but it made it easier to hold on and to cope — because somehow it was already expressed — and that gave me something to hold on to. Randi: Something to hold on to? Emma: A desire. That it is not supposed to be like this — the song made me hold on to the knowledge that I didn’t want it to be like that, and it helped me to avoid becoming completely passive, like it was when I used to live at home. I didn’t dare to feel that I didn’t want this then. But this time, I felt that this was something I didn’t want to be part of. Facing the same situation at home that she had already survived, the same emotional threats by her parents, she used this song as a way of holding on to her current situation as an adult, reminding herself of her “right” to make her own decisions. This helped her to acknowledge and tolerate her own feelings in the situation and helped her to keep herself integrated and in control of the situation.

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On days when Emma was really struggling with her life, she was sometimes unable to sing. On those occasions, I would sometimes offer to sing for her. In Interview 4, I asked her about those sessions, and she explained that sometimes music became part of the chaos that she felt inside. When music was part of that chaos, she felt unable to play or to sing along, even if she wanted to take part. Emma: There have been several sessions lately when I just wasn’t up to doing anything. I don’t think that happened so much before, but it has been like that a few times lately. Randi: How was that? Emma: It has been very difficult, because I would like to very much, but I just can’t, I’m just not capable. But at the same time, it has been very good to be here in spite of this, when you have been singing or playing. Just to listen, to receive instead — if you can understand. Randi: But at the same time, you wanted to join in? Emma: Yes, deep inside — but it was too difficult. It has been so chaotic around me lately that sometimes I just simply cannot do anything at all. Even just to sing a note or strike a key on the piano would be too much. Then even the music becomes part of the chaos inside me. Randi: Music too becomes a part of the chaos? So what happens when I sing to you then? Emma: Then you weave things together a bit. Randi: Weave it together? Emma: Yes, then it’s not that chaotic anymore. You grab a part of it and put it aside and then put it back on the right spot. Randi: Through music? Emma: Hmm … Randi: How can that happen? Emma: Music doesn’t need to be part of that huge chaos. It is a part of me, but it’s tidied up in a way. So in the next session, I might be able to join in even if things are still chaotic.

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Still, it appears from what Emma said that she was able on these occasions to regulate the intensity of these chaotic feelings enough to stay with the music and, as she said, “to receive” and “to listen.” Although she was not able to sing or to play along with me, she was able to be there and to listen to the music. When I sang and she listened, she got the impression that music did not need to be part of the chaos, and this made it possible for her to join in with me in the following session. With one particular song — “Streets of London” — the connection between the song and her difficult emotions was especially overwhelming. The lyrics of this song fit all too well with her traumatic life story. By singing this song in our sessions, she was brought into contact with some very difficult emotions, and she started crying every time we sang the song. She explained this in an interview: “I recognized myself too well in some of it. When we started to sing it, the music became too strong, a little too close. The music expressed something that I could not bear the emotions of: It all became very difficult.” She also emphasized the difference between songs that she had written herself or together with me and songs that somebody else had written. She experienced it to be more intrusive when somebody else had written a song that fitted so well with her feelings. “Streets of London” evoked emotions so overwhelming that she felt that this song had been “taken away from her,” that she had lost the ability to enjoy and sing this song that she liked so very much. In several sessions, she tried to sing it but just burst into tears. Regaining a possibility of using this song again without feeling overwhelmed became a goal for our last sessions in music therapy. This effort was not directed toward elimination or neglect of her strong emotions and traumatic life story, but rather toward her being able to regulate and tolerate the intensity of her emotions so that she could again sing this song that she loved very much. In the last session, she did sing the song together with me, and in the interview some weeks later, she expressed surprise at her successful attempt to sing the song. Although she was still moved by the song, she was able to sing it again: Emma: It went much better than I thought it would. Randi: Yes … Emma: I think it’s a really beautiful song, but it has been so hard to sing it because I recognize myself in it so much. I have always wanted to sing it because I think it’s such

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“I HAVE FOUND A WAY THAT WORKS” Many of the poems that Emma wrote and brought with her into music therapy were connected with her traumatic experiences and described different facets of her life problems and difficult emotions. Through the process of songwriting, Emma found a way of giving voice to her experience. She grasped the possibilities of this way of working to the full. “I have found a way that works,” Emma said when I asked her about her experiences in music therapy in our first interview. “I dare much more here … to show all the ambivalent feelings and the chaos inside me,” Emma explained in the fourth interview. She dared to do this more in music therapy than within other therapy sessions. It seemed less dangerous in music therapy to show that she could have a good day. She could do that without fearing that she would have to stop coming to music therapy as a consequence. The result was, she emphasized, that she could use a bit more of all her sides in music therapy, more than she could do elsewhere. I asked her what this meant for her … Emma: It is good that someone can see … that I dare to let someone see all sides of me. And gradually as time went by and I dared to do more of that in music therapy, then I also dared to do a little bit of the same in sessions with, for example, the psychiatrist. Randi: How come? Emma: Because then I had tried it out already. When I had tried it here and nothing happened, perhaps I might dare to show the psychiatrist or my contact person at the ward as well. I have tried it out in a place where I feel safe. Randi: Yes … Emma And if nothing dramatic happens there, okay, then perhaps it might not happen in other places? Randi: So your calculation is that the psychiatrist is a bit like me?

Emma’s Experience 165 Emma: No, he is far more scary than you, he is the boss … [both laugh] … but yes, I do. Emma is taking the risk in music therapy of showing her strengths as well as her weaknesses. There is more: What we learn from this quote is that she gradually started to do the same with other therapists and staff in the hospital. In music therapy, Emma alternated between the hard emotional work connected to the songwriting and the joy of singing and engaging with music. This possibility created for Emma a therapeutic arena where she could dare to use her strengths without feeling that her weaknesses and pains were neglected: Randi: Do you have any thoughts about what the alternation between doing something enjoyable and doing something difficult does as far as the therapy is concerned? Emma: I think it has been very good for me in a way. When I have sessions with you, I dare to make use of them irrespective of whether I’m having a hard day or a good day. I dare to show all of me. I don’t think I dared to do that when I saw a psychologist and the focus was always on the difficult and the painful things. That makes me feel that I have to go into the painful things to go there. But now I feel that I have used both sides of me, what is painful and what is good. It has been good to use not only the part of me that is in pain. I feel I have a different relationship with you. Randi: A different relationship with me? Could you say a bit more about that? Emma: It doesn’t need to be so grave all the time. It’s hard to tell, but it’s very different.

Chapter 10

REFLECTIONS: NEGOTIATIONS OF RESOURCES AND PROBLEMS Emma: I don’t think about music therapy as a method of “treatment.” That’s what I do when I go to see the psychiatrist, thinking I am going for a session of treatment. I don’t think that I am going for a session of treatment when I come to you — I think that’s part of it. Randi: What are you coming for, then? Emma: For music therapy. Randi: But what do you mean by a “session of treatment”? Emma: Something that deals with the grave, big, terrible things; it is something very professional. It has to be something all the time — you have to bring something forward, some sort of a problem. I can’t go there and not have something to talk about, but I can do that here. Randi: What happens when you don’t bring something here? Emma: Then we just sing or just do something. Randi: But isn’t that bringing something, too? Emma: Yes, but not in the same way, I can’t go to the psychiatrist and tell fairy tales, can I? Randi: Have you tried? [both laugh] But I think this is important, that it is a bit different, that it is not treatment in that way? Emma: But then again, it is — I notice that when I look back at all the songs we have written. I just didn’t think of that when I was in the middle of it. Randi: So now you think that it has been treatment? [laughter] Emma: Yes, but not like — I can see that it has been treatment, as I have been able to talk very much and to work with and express things in music, and that is treatment, but I just don’t think about it as treatment. Randi: Perhaps the word doesn’t really fit? Emma: No, I don’t think it does. Randi: Me neither.

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I have chosen to start this chapter by quoting a section from a dialogue between Emma and me because I think that, by rather paradoxically describing music therapy as “not treatment, but treatment,” she grasps and articulates a central aspect of the problems related to a conceptualization of resource-oriented music therapy. The concept of treatment is inherently bound up with medically and pathologically oriented practice related to the curing of diseases. Even if the term “therapy,” whose association with the medical term “treatment” is somewhat looser, is etymologically more closely related to “care” than to “cure” (Stige, 2003a), it is nevertheless in professional clinical practices frequently used to denote the fixing of pathology or problems. Throughout this book, I am arguing that it is as important to nurture and develop resources and potentials as it is to work with problems in therapy. Emma’s experiences with the therapeutic process, as explicated in the previous chapter, were indeed connected both to positive experiences and to experiences of contact and work with negative emotions and problems. Moreover, this case study pointed toward the dialectic between the focus on problems and the focus on resources as essential to the therapeutic process and afforded possibilities for empowerment. Through the analysis of the research interviews with Emma, three main themes characteristic of her experience in music therapy were identified: (1) regaining right to music; (2) voicing trauma and negative emotions; and (3) negotiations of resources and problems. First, regaining rights to music were a central theme in Emma’s music therapy. Emma had experienced that her relationship to music had been destroyed by too great a focus on performance. Even if she previously had experienced joy and freedom when singing and been an active choir singer, she had completely stopped singing more than a year before coming to music therapy. In music therapy, she experienced being able to start singing again after this long and total break. To be able to sing was for her as important as to feel entitled to have a voice and to be able to enjoy music. In music therapy, she explored and developed her musical skills, and this also enabled her to start using music more outside music therapy. With this, she also regained the possibility of experiencing freedom and joy in music. This, along with her recognition that she had “rights” to and possibilities of using music at her own level, was very important for her because music constituted a source of joy, mastery, and experiences of freedom in her life. She realized that she did not need to be

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“amazingly good” in order to be able to engage with music, and she started to explore appropriate arenas for her musical engagement. Second, music therapy also provided opportunities for voicing trauma and negative emotions. Working with problems, trauma, and difficult emotions was a central part of Emma’s music therapy. Through the process of singing songs and writing songs, she found a way of working with her difficult life experiences. Some of her songs dealt with traumas in her past, but the majority of songs were focused on current life challenges. The work with the songs enabled contact with and differentiation of emotions. The expressions of her difficult emotions and traumas through her songs and the collaboration of composing a melody to her poems also provided her with confirmation and recognition of emotions. When the songs fitted with the emotional meaning of the songs, she felt understood and recognized. Being able to express herself through songs also contributed to a better toleration of emotions. In the form of a song, she could allow herself emotions otherwise difficult to tolerate. The songs also provided possibilities for her to communicate with the therapist and other important persons. Thus, she used the songs as communication of emotions. Finally, the process of songwriting evolved into a narrative project of telling her life story, a project of singing her life. The third theme, negotiations of problems and resources, focuses on the relationship between resources and problems, strengths and weaknesses. Emma experienced that through music therapy she came into contact with and worked with both her strengths and her problems. The interaction in music therapy allowed her to be strong and weak. Thus, she experienced music therapy as a possibility to acknowledge both resources and problems. In music therapy, she came into contact with some of her strengths, but also with her ambivalence and fear connected to the acknowledgment of strengths. Thus, there were several problems with strengths. Too great a focus on strengths and resources was connected to fear of losing support and help. This therefore points to the confrontational aspects of a resource-oriented approach. However, in the therapeutic collaborations there was a constant dialectic of problems and strengths. This continuous shift of focus from problems to resources implied possibilities of emotional regulation. In this chapter, I will focus my reflections on the last theme — that is, Emma’s process in music therapy in terms of a negotiation of problems and resources. It must be emphasized, though, that in some ways this latter theme is a consequence of the first two. The first theme, regaining rights to music, is first of all connected to experiences in exploring

Reflections 169 resources and of using and developing her musical strengths. The second theme, in contrast, is first of all descriptive of her experiences with writing songs about her difficulties in life.

THE PROBLEMS OF PROBLEMS Emma’s music therapy had, as we have seen, provided her with opportunities to work with problems, such as current life challenges, emotional distress, and childhood traumas, as well as to develop her musical abilities. As we can understand from her songs and her story about this therapy, Emma also came in contact with her resources. Through musical and verbal interaction, she explored and developed her musical skills and her skills in creating poems, as well as more general resources related to her possibilities for coping. This said, Emma clearly also valued the recognition of her pains and the possibilities to work with her problems. She emphasized several times the possibility to express, have contact with, and communicate her difficulties in music. Emma emphasized that it had been very important to her that she had been able to show me, and to use, all sides of herself in the therapy. When talking about her music therapy, Emma emphasized music therapy as a possibility to use both her strengths and her problems, “to show all of me” as she put it. As we saw in the quote at the beginning of this chapter, she contrasts this experience with the problem-focused therapies that she had experienced requiring her to always come forward with a problem and even invent problems. In music therapy, however, she did not feel obligated to go into the difficult things — it was possible “just to sing.” Interwoven in Emma’s reflections concerning her experience with music therapy is a critique of the graveness of other therapies, always demanding her to “deal with the big terrible things.” Much similar criticism has been leveled in the literature at the fields of psychology and psychiatry and the professional practices related to these disciplines, because of the exclusive orientation toward problems and pathology that has come to dominate (see Chapter 1). It is argued that this field is based on an illness ideology observable also in society, and that this has led to a widespread idea that connects problems and emotional pain to illness and a need for expert help (Furedi, 2004). The traditional stance within psychology and psychiatry toward dealing with problems, trauma, and negative emotions is problematic, first, because it locates these within the

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individual, and second, because it tends to equate the person with their illness or problem. On a structural level, the practices of therapy are established to help people with problems or illness, and the tools that are provided for assessment and treatment are to a large degree oriented toward problems and pathology, as Wright and Lopez argue in their discussion about the inclusion of strengths and resources in the process of assessment and diagnosis: Clinical settings are established to help solve problems — physical, mental, or emotional. And that is part of the problem. Being problem-oriented, the clinician easily concentrates on pathology, dysfunction, and troubles, to the neglect of discovering those important assets in the person and resources in the environment that must be drawn upon in the problemsolving efforts. (Wright & Lopez, 2002, p. 36) This might be an important aspect also of Emma’s experience, at least when going to verbal therapy, as she felt that it was anticipated and even required of her that she come up with a problem. Interestingly, her music therapy was not inflicted by such requirements related to “treatment.” If we follow her argument in the quote at the beginning of this chapter, her account of this situation does not explain fully why music therapy for her implies less anticipation of focus on the “grave and difficult.” Nevertheless, she is explaining that in music therapy there is a possibility of “just singing songs.” Her description of the possibility of “just singing songs” is imbued with two different levels of meaning. First, it points toward an aspect of doing music that affords possibilities of various modes of interaction with the therapist and that implies various possibilities of showing something of oneself. Second, it points toward the ambiguity of music as expression and symbol. The songs might on the one hand be representations of her emotions or difficulties, but each is at the same time always just a song. In this way, it seems that this possibility of “just singing songs” is implying a transgression of the problemoriented constitution of therapy in medical settings. When describing her experiences in music therapy, Emma is emphasizing the possibility of using both sides of herself (Chapter 9). She felt acknowledged for being both strong and weak: “I have used both sides of me, what is painful and what is good.” She continues this sentence by stating, “I feel I have a different relationship with you,” and

Reflections 171 thereby emphasizing the relational dimension of her experience. It is really interesting to notice the relational consequences that Emma put forward in connection with the possibility of using both sides of herself in music therapy. Her experience of showing and using both her weaknesses and strengths in music therapy is on one hand related to an existential experience related to her being, but at the same time this is experienced in connection, in relationship. There are again two aspects of this. First, she is experiencing her strengths in a relationship. Second, she feels that being able to use her strengths is contributing to the relationship. In relation to the philosophy of empowerment this is crucial, related to the emphasis on mutuality and equality of the relationship. A relationship in which the one part is only “visible” in terms of her problems and weaknesses is hardly possible to conceive of as empowering, as this creates a power relationship in which one person’s strengths are devaluated (see also Chapter 13).

THE PROBLEMS OF STRENGTHS Clearly, Emma is a woman with many resources. She always had good grades in school, and even when she was in the hospital because of her mental health problems, she was able to keep up with her studies at the university college. She is a socially competent woman, socially engaged and with an impressive capacity for caring. In spite of her problems, she had a good social network; obviously, I would say that this was because she is such a nice person to be with. Her social engagement is significant, as she had held office in organizations, published articles in newspapers, and given lectures. She also had musical experience, skills, and competence that she explored and developed throughout the music therapy process; she knew a large repertoire of songs; she had skills in singing, in arranging, in composing, in writing poems, and in playing the flute. Even so, she had survived a long-lasting childhood trauma and she was suffering from severe mental health problems. In this section, I will focus on Emma’s negative experiences and ambivalent feelings related to the acknowledgments of her strengths in music therapy. Throughout her childhood and youth, Emma had always been one of the “clever and silent girls”: Her need for help was not acknowledged, even though her mother’s psychotic illness was well known among people in the health care system and even though teachers and nurses at

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school were alarmed by her situation. Thus, Emma had experienced that she had to “scream” loudly and for a long time in order to get help. First, when she needed a new family as a teenager, and later, when she needed help with her mental health problems. She had experienced the need to invent a story about sexual abuse, because her story of violence and neglect was not enough to make anyone take action and provide help. In some ways, this too is a story about her strengths: It takes quite a lot of systemic understanding to finally get through to a health care system that was not able to see her problems for all her strengths. Sadly, it sometimes takes a lot of strengths to get the help you need, and with the consumer mentality in health care provision, demands for user competence are increasing (Tomes, 2007). There is also another side to this, with regard to how help is distributed. Thus, we must ask what qualifies as help. Unsurprisingly, I would say that it seems that help is provided when someone is having problems or an illness or is in some kind of crisis situation. But do strengths disqualify people from health care services? Does the existence of strengths preclude the existence of severe problems? A book about child welfare points out the problems of linking resources to the evaluation of the need for help. Being clever in school might reduce the chances that the child’s or adolescent’s problems are considered severe enough to take action and provide help (Follesø, 2006). The essential problem is how the relationship between strengths and problems, resources and pathology, is perceived and understood in the health care system. It is also a question of how we understand the relationship between resources and problems. If a person has lots of resources, does that mean that the problems are less severe? Research on posttraumatic growth has demonstrated that the experience of growth and experiences of distress may be essentially separated dimensions, implying that the experience of growth will not necessarily imply a commensurate reduction of distress (Tedeschi & Calhoun, 2004). Thus, it would be essential to emphasize the need to provide information about the potency of strengths relative to the powerful effects of the weakness or pathology as suggested by Lopez, Snyder, and Rasmussen, (2003). It is similarly argued that there is a need for a four-front approach to assessment in which serious attention is given to the deficiencies and undermining characteristics of the person, the strengths and assets of the person, the lacks and destructive factors in the environment, and the resources and opportunities in the environment (Wright & Lopez, 2002).

Reflections 173 The image of the “Blackbird” that was brought into Emma’s therapy is an image that contains both weakness and strengths. It points to the possibility of using one’s strengths to go on despite one’s problems, weaknesses, or pathology. However, the problems are still there. Her childhood traumas had wounded her, resulting in severe mental health problems. For Emma, in the hospital it was safe to be weak and very scary explore and use her strengths and resources. Indeed, images like the “Blackbird” bring with them a risk of romanticizing. It is important not to idealize the world, not to trivialize the problems, pains, and pathology. The individual’s strengths are not always enough (Pearlin, 1999), and if we don’t acknowledge that, we are at great risk of blaming the victim. Emma was carrying a heavy burden of traumatic experiences, but she had also lots of resources. Her resources are important, as they have helped her to cope as impressively as she has in her life. Yet in some ways, they had also been a threat to her. I can only speculate as to whether her strengths had also been her enemy by reducing her chances of getting help with her problems, because strengths and problems have been seen as dimensions of human beings, each of which ruled out the other. Emma had experienced during her life that people did not provide her with the help and support that she needed. So when therapists or staff acknowledged her strengths and noticed the positive emotions, it is not surprising that she got scared that she would lose her support. We have to realize that ultimately the health care system does work this way. Starting to use resources and strengths will ultimately lead to discharge from the hospital and a reduction in the support on offer. Contracts and regulations of treatment both in the hospital and in outpatient psychotherapy are intended to make sure that clients are offered help for as long as they need help, but at the same time, the requirement for economic efficiency has led to shorter periods of treatment. So it seems that it is quite common and natural that patients in the hospital are afraid of losing the help and support that is offered if they get better. To Emma, as we have seen, this potential threat became almost paralyzing. With the songs “The Spring Is Gone” and “Be With Me Now,” she managed to acknowledge how this fear was hindering her, almost paralyzing her and making her unable to cope. I have already pointed toward some relational aspects connected to Emma’s experience of using her strengths in therapy. On one hand, it seemed essential for her that I recognized her strengths and resources as discussed in the previous section, but on the other hand, this was potentially threatening for her if not balanced with recognition of her problems. Thus, somehow her

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strengths and problems had to be negotiated for her to be able to use her strengths, first in the therapeutic relationship and later between her and other therapists and staff, and for her to start using her strengths in her daily life. In this way, her story is also pointing to the necessity of understanding even individual strengths in relation to a social context. It seems that using her strengths in music therapy only had limited consequences for her life. Perhaps paradoxically, this allowed for music therapy to be a safe place for her to explore some of her resources (that is, without risking being thrown out of the hospital). But it was first when she dared to use her strength in her everyday life that it was actually helping her to cope.

THE DIALECTIC OF STRENGTHS AND PROBLEMS IN THERAPY As I have already made clear, Emma used music therapy both to work with her problems and traumas (and in particular all the difficult emotions related to these) and to develop and nurture her musical strengths and abilities. These two parts of the therapeutic experience were, however, integrated and interrelated parts of the therapeutic process. When I started working with the empirical material from this case, I hypothesized that the work with problems and traumas was initiated by the development of musical ability and the focus upon strengths and resources. I thought that the strengths-oriented parts of the therapy made possible the work with traumas, because they helped to regulate the intensity of emotions and also strengthened the sense of self. Indeed, this was one important aspect that we might relate to this dialectic. Yet Emma’s experiences clearly exemplify that the relationship also worked the other way around — that the opportunity of using music to work with problems helped her to get away from a performance-oriented relationship to music. Before going more closely into these perspectives, I will illuminate some of the characteristics of this dialectic of strengths and problems in the therapeutic process. First of all, the sessions as well as the overall process of therapy were characterized by a constant shift of focus. In most of the sessions, there was a continuous alternation between the work with songwriting, which to a large extent was focused on her life problems, and that with song-singing, which to a large extent was focused on her strengths and her enjoyment of music. This is very simplified, because

Reflections 175 there were similar possibilities of alternation of foci also within one single activity. When writing songs, it is possible to alternate between a focus on the lyrics and meaning signified with the song and a focus on the musical activity of songwriting, such as the skills in composition or the technical aspects of musical arrangements and notation. When singing precomposed songs, there were possibilities for similar alternations of focus related to the selections of songs and their relative personal meaning, as well as between focus on musical achievements and the song’s various levels of meaning. Thus, being together with music as our engagement provided a set of possibilities and afforded different ways of experiencing the musical activities sometimes concerned with problems, sometimes only for joy. This is connected to the second characteristic of this dialectic, which namely is representative of a constant awareness of the always ambiguous levels of meaning in music, or, as Emma explained it, “a song is just a song.” This dialectic possibility had less to do with shifts of type of activity and more to do with Emma’s capacity for emotional regulation. A third dimension of this shift of focus is the verbal dialogues, which obviously also interact with the various foci of musical experience mentioned. We have seen that Emma’s music therapy and the process of writing songs in particular involved contact with and work with very difficult life experiences and evoked emotions difficult for Emma to tolerate. To have contact with emotions is seen as an essential aspect of therapeutic work in many different psychotherapeutic traditions and has been regarded as one common factor in psychotherapy (Tracey et al., 2003). This also for Emma provided possibilities for emotional growth related to emotional awareness, recognition, toleration, and communication of emotions. Emma emphasized, however, that the work with some of the songs was indeed challenging and potentially overwhelming. Reflecting on such occasions in the interviews, Emma emphasized the importance of other musical activities, such a flute-playing and song-singing, in regulating the intensity, or to use her words, “in order not to be eaten up by it.” In this way, she was able to work with songs and the life experiences the songs represented and still feel able to feel in control of the situation. Emma repeatedly talked about how she “dared” when describing her experiences in music therapy (dared to feel, dared to communicate, dared to show her strengths, dared to show her feelings). This aspect of control is perhaps also related to Emma’s experience of “daring” in music therapy. She could gain a sense of control in such emotionally challenging situations by engaging in a new activity or by preserving the ambiguity of the songs.

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As mentioned, the dialectic also afforded possibilities the other way around, as the work with problems also enhanced the experience of her strengths. This may sound paradoxical, but in some ways the work with her problems opened new possibilities for her to use music in ways that were not tied with achievements and musical performance. The use of music to work with her traumas involved the possibility of a less achievement-oriented focus on music. Using music in these ways also toned down the elements of achievement by focusing on the emotional experience of music. In several instances, with the songs we had written together as well as with other songs that turned out to be emotionally important to her, new meanings and ways of using the songs were acquired, and this actively eroded any lingering concept of requirements connected to skill or achievement levels. Focusing on the emotional aspects of the music took focus away from performance and skills. It was not only the striving toward achievement and perfect performances that had made it difficult for Emma to use music in the way she wanted. In her story, she also emphasizes that music was sometimes overwhelming, as with the song “Streets of London.” Thus, enjoyment of music and freedom to use music are sometimes rendered difficult by the strong emotions music can stimulate. Indeed, the overwhelming emotions connected to “Streets of London” were also to some extent induced in therapy. In this way, her experience with this particular song is, in other words, a negative example where a focus on difficult emotions had (for a while) limited her possibility to engage with music (or at least with this particular song). In some ways, this can be perceived as a negative side effect of music therapy. Emma’s experiences points to a possible risk factor of music therapy when using music to work with trauma. We might risk tying some songs or some types of music to the patient’s problems, trauma, or symptoms, thereby inflicting problems on an otherwise healthy and sound relationship with music. Emma pointed to the shifting focus that was characteristic of the sessions when she reflected on what had made it possible for her both to use her strengths and to show her weaknesses in music therapy. This made her experience of music therapy very different from her experience of verbal psychotherapy. In music therapy, a musical interaction involves using musical and creative strengths, and for most clients this implies doing something that they are interested in and that they see as a hobby. In this way, using their strengths becomes intimately tied with the engagement in music therapy. In music therapy, it was always possible “just to sing,” whereas the idea of “telling fairy tales” in her therapy with

Reflections 177 the psychiatrist was ridiculous. The exploration of strengths, however, not only was connected to positive, emotionally loaded experiences of mastery, pleasure, and joy, but also was very challenging and sometimes terrifying. Although challenging and terrifying, using her strengths was a natural and central part of the interaction in music therapy, and the dialectic between the focus on problems and focus on strengths was important. Thus, the focus on strengths and her use of her strengths in therapy did not “disturb” the “real” therapy (Lauveng, 2005), but was essential to the therapeutic process.

SOME GENERAL IMPLICATIONS Finally in this chapter, I will focus on resources and problems in terms of a resource-oriented approach to music therapy in general. To think that a resource-oriented approach would necessarily be less challenging and an “easy way” of working within music therapy would be at the very least an oversimplification. Focusing on strengths and resources invokes opportunities for positive emotions and positive experiences of joy, pleasure, mastery, and communion. These experiences are related to selfefficacy and the ability to cope, as documented in the reflections of Maria’s case. Emma’s case, however, demonstrated that a focus upon strengths and resources can be as confronting as pointing to problems or pathology. Focusing on strengths is not an “easy” way of doing therapy that is only connected to positive experiences and positive emotions. It is not simply a happy alternative. This is not a “therapy without tears” or a “Had enough of tears? Try resource-oriented music therapy!”–style alternative to traditional psychotherapy. Neither is it a therapy that nurtures and develops strengths and resources unrelated to problems and weakness, even to pathology. So, clearly, strengths and problems both have a place in therapy. Problems as wells as resources have a natural part in any therapeutic process, because people have strengths as well as weaknesses, and problems as well as resources. These need not be treated as separate parts of the therapeutic process, but might rather be seen as interacting aspects. Resources and strengths (both personally and environmentally located), hope, social networks, family interests, ability to cope, cognitive resources, etc., play important roles in people’s lives in relation to health, as positive psychology demonstrates (Carr, 2004; Snyder & Lopez, 2002),

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and they should be pursued in therapy for their own value. At the same time, strengths and resources are also interesting in relation to work with problems and weakness, as Emma’s case clearly demonstrated. A balance between the orientation toward strengths and resources and that toward problems and weakness is called for (Lopez, Snyder, & Rasmussen, 2003), not least because the picture of the client and her or his situation is incomplete if we omit half of the human repertoire, that which entails people’s strengths (Snyder et al., 2003, p. 25), or perhaps alternatively that which entails their weaknesses and problems (even if this alternative seems quite unlikely in mental health care systems). Snyder et al. (2003) argue that the interest in the client’s strengths is important in several ways. First, the client understands that the clinician is interested in the whole person. Second, the client is shown that she or he is not equated with the problem. Third, the client’s problem is not reinforced, and they are encouraged to consider their assets. Fourth, the client can recall or reclaim worth, and thus buffer against the demoralizing effect of the illness. Fifth, it can facilitate an alliance of trust and mutuality (Snyder et al., 2003, p. 36). Thus, when strengths and resources, as well as weaknesses and problems, are part of a therapeutic collaboration, this may contribute to enhanced possibilities for coping as well as foster a good therapeutic relationship. I would suggest that both of these highly interacting aspects of a therapeutic process may be important in terms of empowerment. The cases of Emma and Maria clearly demonstrate that we cannot think about music therapy as an arena in which either to explore problems or to develop strengths and resources. Emma’s case (Chapter 12) demonstrates that working with resources can also be highly selfconfronting and difficult. The extent to which music therapy was experienced and used as an opportunity to work with problems varied considerably between the cases included in this research. I can only speculate about the reasons for this, but three areas of possibly significant factors suggest themselves: first, the client’s problems and their strengths (including their pathology, their musical ability, and their relationship to music, as well their ability to engage in self-exploration); second, the client’s expectations, frame of reference, motivation, and goals related to music therapy; and third, contextual factors such as other treatment, the frequency and number of sessions, the relationship between therapist and client, and so on. Somewhat simplistically, we can view the difference

Reflections 179 between Emma’s music therapy and Maria’s music therapy in terms of the quadrants of this figure25: Figure 1: Resource orientation and problem orientation as independent variables.

A

B

Problem orientation C

D

Resource orientation

This figure illustrates resource orientation and problem orientation as independent variables of the therapeutic process (Rolvsjord et al., 2005a). According to such a figure, we could imagine four different constellations of problem orientation versus resource orientation. Quadrant A would exemplify music therapy that is considerably oriented toward resources and less oriented toward problems. In quadrant B, we would have a therapy that was considerably oriented toward problems and also considerably oriented toward resources. Quadrant C would be less oriented toward both problems and resources, and it is difficult to conceive of such a therapy as meaningful. Finally, quadrant D would be a therapy that was considerably concerned with problems and less concerned with resources, which would also be difficult to conceive of as 25

This figure was previously published in the article “Research Rigour and Therapeutic Flexibility” (Rolvsjord, Gold, & Stige, 2005a).

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resource-oriented. With regard to the two cases that have been studied in this research, I would place Emma’s music therapy in quadrant B and Maria’s music therapy in quadrant A. The case of Emma’s music therapy also offered insights into the dialectics of resources and problems in therapy (Chapter 12). Resources and problems need not constitute conflicting areas of focus in therapy but can instead represent useful and important shifts that enhance the therapeutic work.

PART THREE WORKING RESOURCE-ORIENTED Throughout this book, I have argued that the resource-oriented approach presented here is linked to a contextual model. Thus, when asking for implications for a therapeutic practice, we need to take into consideration that when therapy works, it is not due to a single factor, such as the therapist’s skilled use of techniques. What I am proposing is that we need look more in the direction of what clients do in therapy. Thus, working within a resource-oriented approach must imply that we take the client’s resources seriously and do whatever we can to nurture the use of those resources so as to foster empowerment. However, this is not to turn a mechanical model upside down: The main implication of a contextual model is relational. A contextual approach to resource-oriented music therapy aims to stimulate resources and potentials through an equal collaboration between client and therapist. We may, with DeNora (2006), think of music therapy in terms of social action, and thereby emphasize the relational and contextual aspects. DeNora argues that a focus on the music therapist’s craft leads to a concern with what the client does in therapy. Thus, she argues for a symmetrical focus on both the therapist’s and the client’s craft: If we are to understand the mechanisms of music’s effects, then it is important to develop a symmetrical focus on both the music therapist’s and the client’s craft in health promotion/healing activity, and this focus on process is a vital component of valuing music therapy’s role as an effective modality in health care. (DeNora, 2006, p. 90) This section, therefore, is not going to be a recipe for how to work. Instead, its focus is on the two people involved in the therapeutic encounter, their contributions to the therapeutic work, their use of competence, their actions, their collaborations.

Chapter 11

THE CLIENT’S CRAFT In a book chapter discussing music therapy in terms of a redistribution of social capital, Procter (2004) introduces us to the music therapeutic work with Josie. Josie was a woman coming to music therapy in a nonmedical center for people with mental health problems. In this short description of their music therapeutic collaborations, we are introduced to a client who has plenty of music experience but who seems very dismissive of her own playing as well as the music she makes together with the music therapist. The therapist feels, it seems, dragged into a dilemma because of this — feeling tempted to engage verbally with her instead of in music but simultaneously opposed to her “trashing” of their music. As a way of providing for a possibility to experience that music is not only a bad thing, a mutual valuation of their music, the therapist suggested instead that for the next ten sessions, they would just play and not talk. We learn in the continuation of the story that Josie reluctantly agreed to this. This agreement seemed to lead to a process of change, providing the client with new positive experiences of engagement with music and later possibilities for participation in community activities. Now, let’s turn to another example from practice found in music therapy literature. In an article by Solli (2008), we find a description of a music therapy process with a man suffering from schizophrenia. The man, called Paul, has a passionate interest in music. He has previously been playing in a rock band and frequently engages himself in playing the guitar to CDs of rock music. Paul and the music therapist meet and play together, Paul on guitar and the music therapist on drum set. “I tried not to follow all of Paul’s figures and ideas — just focusing on providing a straight beat in a steady pulse. This way, we now made our first fragile and uneven kind of groove together,” the author and therapist explains (Solli, 2008, p. 69). In order to provide for some structure in the sessions, the music therapist would usually try to end the music after about 15 to 20 minutes and to ask the client about their musical interplay. Paul would sometimes just nod and continue, other times responding with short utterings about the music. The client’s verbal responses seemed generally

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limited, but in one period of their therapeutic work, the verbal conversations seemed more increasingly confusing for him. On one of those days, when the therapist persistently induced a verbal dialogue between the improvisations, Paul at first continued to play even more intensively so as to avoid the verbal conversation, but then in one session, he suddenly stopped playing and replied: “Shut up and play!” The therapist respected this request for musical focus, and they continued their work together with a musical focus that seemed to afford important structure and relational possibilities. In both of these examples, we find two people, a client and a music therapist, collaborating. In both examples, two people were taking initiatives as well as responding to each other, in ways that led the therapeutic work into constructive dialogues and musical engagement that seemed to afford possibilities of change of importance to the clients’ mental health — a successful therapeutic outcome. My mission here by putting the two cases together, however, is to point out that what therapists do and what clients do in therapy is sometimes quite similar. In the first example, we find a therapist who convinces the client to play instead of talk; in the second example, we find a client convincing his therapist of the same. Nevertheless, therapeutic progress is usually attributed to the rightness of the actions and insight of the music therapist, whereas the client’s actions remain invisible, insignificant, or pathological. When the therapist “acts” in therapy, we tend to call it “intervention” and thus emphasize the conscious aspects and skillful use of professional techniques and expertise. Thus, we describe the therapist’s action in ways that emphasize and constitute power. In contrast, when the client acts in therapy, we often describe it in terms of a “response” or “initiative”, or even “resistance” or “noncompliance”, and thereby devaluate the power of the action. My claim is that even if both of these suggestions to stop talking had led to important developments in the therapeutic process, we would be more likely to think about the therapist’s initiative in terms of a therapeutic intervention, whereas we would think about the client’s initiative in terms of a response (even an inappropriate one) to the therapist’s verbal intervention. Of course, the therapist’s suggestion is based upon his competence and his experience in communication, but the same could be said about the client’s suggestion as well. In both cases, however, we find a collaborative partner who does more than comply with the suggestion, a partner who tries out the new possibilities the new “rule” implies for their interaction, and as we see from the continuations

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of both stories, who takes part in decision-making processes in the following sessions. Such relational implications will be the focus for the final chapter (chapter 13). In this chapter, however, I would like to ask: What is the client’s role in therapy? What do clients do to make music therapy work? In this chapter, the explorations of clients’ craft, understood as their competent contributions in therapy, will mainly be theoretical, but with the use of examples from the case study. It must be emphasized that the case study presented in this book was not designed specifically with the intentions of exploring such aspects of the therapeutic work. For example, the study did not include microlevels of analysis of interactions in the sessions, which would be the type of data that allows for the best explorations of the client’s actions in therapy. Further, the interviews were not particularly focused toward exploration of the clients’ use of music either outside of therapy or of their own generative thinking and efforts during the therapy sessions. However, from the research interviews and the participatory observations, some ways in which the clients took actions in the sessions have been put forward. So here I want to use the cases presented in this book in order to exemplify anecdotally some possible crafts of which clients may make use in therapy.

THE CLIENT IN A CONTEXTUAL MODEL I started this book by pointing to the risk of music therapy adhering with and even contributing to a therapy culture that leans itself toward an illness ideology (see Chapter 1) that by its focus on people’s problems and illnesses depicts the clients in terms of their vulnerabilities and their needs for our expertise. In a medical model of psychotherapy, the client’s role in relation to the outcome and change processes of therapy seems to be of little importance, although it must be said that there seems to be agreement (at least in theory) about placebo effects and about natural recovery from mental illness. Even within the common factors approach, however, the client’s role in therapy remains invisible and less significant than that of the therapist in much of the literature. Client variables are often concerned with pathology and related to specific diagnoses, to their severity and comorbidity, to personality characteristics, and to social and interpersonal factors, as well as to age, gender, or socioeconomic status (Clarkin & Levi, 2004). It is worth noting that the client has also received

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less attention than other common factors in the literature and often remains quite invisible in the large box of the extratherapeutic, although the client’s hope and expectations and the client’s active seeking of help are emphasized by most authors (Bohart, 2000). Different calculations exist concerning the relative size of various factors in psychotherapy in relation to therapeutic outcome. A wellknown and much-used calculation by Lambert (1992) estimates that extratherapeutic factors, consisting of aspects such as the client’s strengths and the resources and support in the client’s environment, account for as much as 40% of the outcome variance (see Chapter 2). With the meta-analyses presented by Wampold (2001), the total portion of the outcome variance attributable to specific factors attenuated, lending even more significance to general factors and common factors such as client factors, extratherapeutic factors, and therapist variables. This indicates that therapeutic progress is even more dependent on the client than what previous calculations accounted for (Hubble & Miller, 2004). Still, there are uncertainties, for example, as to how many of the common factors should be attributed to the client’s efforts in therapy. Bohart and Tallman argue, for example, that although the common factors in psychotherapy are presented from the perspective of the therapist, most of them could be and should be attributed to the client, thus claiming that the client is the most potent common factor (Bohart, 2000; Bohart & Tallman, 1999; Tallman & Bohart, 1999). As emphasized by Hubble and Miller (2004), the overwhelming importance of the client and the extratherapeutic factors seems a good argument for a strengths-based treatment aiming ”to help clients to do more of what they already do that works” (Hubble & Miller, 2004, p. 343). Such assumptions might just lead to a redirecting of our expertise to the developments of people’s strengths rather than people’s weaknesses. My claim is that we have to stop believing so much in the power of our interventions and expertise and start to see more of the power of our clients. I will quote psychologists Hubble and Miller, who have pointed this out very clearly: … clients are anything but mere repositories of resilience waiting to be tapped by strengths-based therapists. Such a view, as already noted, maintains the focus of professional discourse and practice on therapeutic process — specifically, one in which clients are dependent on the expert machination of therapists to unleash their potential. The data makes abundantly

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It is not only due to the estimations of the client’s important role in relation to the outcome of therapy that we need to put light on the client’s craft in therapy. As previously argued, the philosophy of empowerment necessitates a radical alternation of power distribution for providing possibilities for empowerment. The client’s contributions to the therapeutic process have been less explored in music therapy research than the therapist’s contributions, and I propose that we should look further in the direction of clients’ competent contributions and clients’ craft in therapy, both in practice and in research. The client’s contributions, however, must be understood with regard to a contextual model, which is at its core relational. Therefore, considering the client’s contributions need not imply that the therapist’s craft is superfluous. I will argue that the therapist’s competence and craft is needed as much when working within a resource-oriented approach as it is when the therapeutic work is oriented around conflict or pathology. But without paying attention to what the clients do to make music therapy work, we remain stuck in a very one-sided story about music therapy, a story that not only shows just half of the picture but also is oppressive to the people whom we are intending to empower, the clients. Therefore, in this chapter I will be putting in an argument for the competent and active client. This is, however, not to say that clients are always active in therapy. Obviously, there are clients demonstrating a more passive attitude, clients who come to therapy thinking that the therapist will fix their problems, wanting a “pill cure.” Does this necessarily imply a lack of competence? Ellis (2004) argues that therapists often miss the opportunity to cultivate the client’s active involvement in the first contact, if this is organized as a strictly evaluative meeting. This is, he argues, planting the idea that the therapist, when finished with her or his assessments, will prescribe the right treatment. I think that it is relevant to ask how much this image of a “passive” client is a result of therapist’s effective ways of “preventing” the client’s activity, combined with the client’s expectations of an expert therapist informed by the illness ideology as elaborated in Chapter 1.

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CLIENT’S ACTIVE ROLE IN THERAPY Clients’ ability to self-right and self-heal is demonstrated by natural recovery from mental illness and by the use people make of self-help literature and materials. Self-righting is understood as the tendency to bounce back from adversity, to take proactive action in order to find a functional way of accommodating the challenges of life. Self-healing is understood as a developmental tendency to integrate information and to develop more differentiated knowledge structures (Bohart & Tallman, 1999, p. 58). The processes of self-righting and self-healing are connected with both the achievement of individual identity, dignity, and actualization and fitting in with others in society (Bohart & Tallman, 1999, p. 64). Thus, natural healing processes occur in everyday life when individuals confront their problems, and involve both proactivity and actions, emotions and generative thinking. Such processes might involve acceptance of self and of events, shifts of attention, cessation of selfblame, patience, toleration of uncertainty and ambiguity, creative perseverance, not trying too hard, looking for other paths, goal evaluation, talking with others, building up one’s skills, modeling, exposure, doing something different, adopting metacognitive perspectives, creativity, reframing, taking advantages of changes in environment, and trusting intuition (Bohart & Tallman, 1999, pp. 57ff.). Lampropoulos (2001) describes similarities between psychotherapy and other change-inducing social relationships, such as those between parent and child, teacher and pupil, or coach and athlete. He argues that the common factors in psychotherapy also seem to be common to a broader range of change-inducing social relationships. He has found very similar factors in these relationships, and his argument thus supports Bohart and Tallman’s case that it is the client’s active use of the therapeutic situation that is of central importance in psychotherapy. As I will come back to soon, from the perspective of music therapy, it is equally interesting to observe that research into the use of music in everyday life has similarly provided us with knowledge about the broad range of potentially health-promoting and quality of life–enhancing uses of music in which people naturally engage (Rolvsjord, 2006a). Bohart and Tallman (Bohart, 2000; Bohart & Tallman, 1999; Tallman & Bohart, 1999) argue that the processes of change that occur in therapy are the same as those that occur outside of therapy. What

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therapists do, they argue, is simply to use naturally occurring client change processes. The therapist’s primary task is to provide a workspace for the client and also, by her or his expertise, to provide some tools or methods of which the client can make use. In therapy, the client is offered opportunities to engage in generative thinking, to have new experiences, and to explore alternative pathways: These are comparable to a “normal” way of progressing toward change outside the therapeutic setting. In therapy, as in everyday life, clients think about their problems, explore, develop new perspectives, try out their new perspectives in action, and receive feedback from the environment. Similar ideas about the client’s generative thinking are implicit in Duncan and Miller’s presentations of the heroic client (Duncan & Miller, 2000). Duncan and Miller are emphasizing the need for the therapist to accord with and honor the client’s theory of change. The notion of “client’s theory of change” basically implies that clients have knowledge of what would be best for them. Clients come to therapy with beliefs and values concerned with the nature of their problems as well as with what therapy is and how therapy might help them. In psychotherapy process research, Rennie (2000) explored clients’ active roles with the use of IPR (interpersonal recall) interviews related to their reflexivity during sessions as well as between sessions. Clients’ reflexivity in the context of a therapy session involved reflecting on themselves (including self in the world and self with others other than the therapist), reflecting on the therapist and the relationship with the therapist, and reflecting on the therapist’s techniques (Rennie, 2000, p. 153). Rennie exemplifies with a case study demonstrating how the client actively takes control and responsibility in the therapeutic encounter by consciously encouraging the therapist by overestimating the effect of their therapy, by controlling the impact of the therapist on her relationship with herself, and by taking control over the therapist’s use of techniques by making shifts of focus. Summing up the implications of the findings, Rennie states: The findings contribute to the understanding of the dynamic relationship between the client as both agent and patient and the therapist as agent and even, conceivably (as when the therapist is actually contributing to difficulties in the relationship in ways that are nontherapeutic), the therapist as patient. It is suggested that, in any given moment, the client may be the sole agent dealing with his or her experience, an agent collaborating with

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the therapist as agent, an agent combating the therapist’s agency (or, possibly patienthood), or a patient acquiescing to therapist’s agency. In all but one of these forms of activity, the client is exerting control. (Rennie, 2000, p. 165) Similarly (although based only in his own experience of the therapeutic situation), Gold (2000) describes active episodes of a client’s engagement in discussions with the therapist and argues that this exemplifies that clients are actively engaged with generative thinking during the sessions. In both of the case studies presented in this book, there are examples of the clients’ active control of the sessions, both with regard to control of the musical activities and also in terms of more emotional and relational control. Emma’s song choices and shift of focus in sessions can be described as a way she actively took control over the level of emotional intensity in the sessions. By selecting songs, she could not only regulate her own emotions but also to some extent control the emotional intensity of the therapist’s verbal and musical responses. In this way, she indicated to me whether she could tolerate any emotional confrontations. As with Maria, we have seen that she actively and consciously used her choice of songs in order to motivate the therapist and sometimes even to prolong the sessions. Her suggestions of songs included songs she knew I liked and enjoyed singing with her, and she used this knowledge actively. Both Emma and Maria were active in terms of leading our interactions in music therapy into types of musical interactions that they felt comfortable with and could make use of therapeutically. They both took a great deal of responsibility in this matter by bringing with them or suggesting songs that they wanted us to sing in the sessions. With the suggestion of songs, they also both actively “opened up” themes that were important for them to discuss. In a similar way, Emma also took responsibility for the way of working by bringing with her poems. Indeed, this also involved an active and prolonged work in between the sessions. It was also Emma who developed and articulated her therapeutic project of creating her life story in songs. The client’s active efforts during the therapeutic process also involve the time in between the sessions. The therapist has very limited control and influence over the rest of the week, which is the main arena for life and the place where health-enhancing change should be localized. With reference to psychodynamic therapy, Gold (2000) also questions the lack of descriptions of psychotherapy where the client’s efforts to apply and

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expand what is learned in the therapy sessions into everyday life is accounted for: Descriptions of psychodynamic therapy rarely if ever make references to the patient’s/client’s active use of the treatment, of his or her efforts to apply and expand what is learned in the sessions to life in the other 167 hours of the week. Therapeutic progress is almost always attributed to the rightness of the actions and insights of the therapist. (Gold, 2000, p. 211) It must be mentioned, however, that there is an increasing tendency to assign homework as part of the psychotherapy process. Assigning homework may be regarded as a way of attributing the outcome of therapy to the client’s efforts and may be understood as a strategy for enhancing the client’s active participation (Ellis, 2004). There might, however, also be a risk linked with this, the risk of the therapist asserting control over the rest of the week. Here we also encounter a need for more research in music therapy. In music therapy, the client’s involvement during the rest of the week would additionally involve an interest in how clients use music in everyday life in general, how they implement their musical learning from therapy in everyday life, and also, more specifically, in how they bring musical artifacts from therapy into their life.

CLIENT’S COMPETENCE IN USE OF MUSIC IN EVERYDAY LIFE Most clients have previous experiences with music before they come to music therapy. They have been engaged with music in everyday life in some way or another, by listening to music, singing while listening, singing in public arrangements, singing in choir, playing an instrument, going to concerts, dancing, etc. Working within mental health care services, we meet people with different backgrounds, different levels of education, different jobs, and indeed also with various levels of musical competence (and expertise). Such previous experiences with music and the use of music in everyday life are to be considered part of a competence valuable regarding the goals of therapy and ways of working in music therapy. Research into people’s use of music in everyday life

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points also to various uses of music that are to some extent health-related, supporting the idea of clients’ “craft” in terms of their knowledge about possibilities to use music to promote their health. Sloboda (2005) reports a study of the use of music in everyday life that focused on the activities accompanying self-chosen music listening, as well as functions of music associated with that use. The findings from the study demonstrate clearly how music listening is embedded in various everyday life activities, such as listening to music when waking up, taking a bath, doing housework, doing deskwork, reading, traveling, and socializing. Some of the functions of the use of music in those situations reported frequently were: as a reminder of valued past event, to put in a good mood, to move to tears, enhancement of mood, evoking tingles/goose bumps, calming, or pleasure. Most people mentioned between one and four different situations with the use of music and between one and two functions associated with that use (Sloboda, 2005). Thus, it is likely to assume from this that people, including our clients, normally have experiences of the use of music and that they are likely to know something about the functions of this use of music in their everyday lives. Also, several of the functions people reported are obviously related to aspects of well-being and health. North, Hargreaves, and Hargreaves (2004) did a study of the use of music in everyday life that had a broader focus and included experiences both when the subjects had chosen to listen to music and when they had not chosen to be able to listen to music. One interesting finding from this study is that most listening episodes occurred together with people, although the study also indicated that people had more liking for the music heard in isolation, probably because they could control the music better on their own. North et al. demonstrate in this study the context dependency related to the use of music as well as the experience related to the use of it. With regard to why people listened to music, which is perhaps most interesting related to our discussion, North et al. concluded that an overall assessment reflected a rather passive attitude toward music (North, Hargreaves, & Hargreaves, 2004, p. 74). That is, in many of the situations in everyday life in which people listened to music, by choice or not, they did not report a specific purpose, but it served as a background taken for granted. Interestingly, in a replication of this study with Pakistani participants and context, the findings indicated more engaged, purposeful listening (Rana & North, 2007). In spite of this finding, the study by North et al. demonstrated that people often consciously have a purpose with their listening, thus demonstrating the capability for the

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purposeful use of music. Further, the study documented that people do actively use music as a resource in everyday life with regard to social, emotional, and cognitive functions: In summary, our results show very clearly that people do indeed consciously and actively use music in different interpersonal and social contexts in order to produce different psychological states, that the resulting musical experience occurs on a variety of different levels of engagement, and that the value placed upon the music is dependent upon these contexts. (North, Hargreaves, & Hargreaves, 2004, p. 75) These quantitative studies clearly show that people do actively use music in their everyday life with different purposes that can be considered health-related. Such active uses of music in everyday life are also explored in qualitative studies that give us more nuances into people’s competence in the use of music in various life situations and life events (Bull, 2005; Butterton, 2004; DeNora, 2000; Ruud, 1997). DeNora’s (2000) research of women’s use of music in everyday life is a wonderful documentation of people’s competence regarding the use of music. Not only do the women included in this study use music in ways that are connected to aspects that we might think of as health-related in a broad sense, but their level of reflections documents their active, intentional, and competent engagement with music: In none of these examples, however, does music simply act upon individuals, like a stimulus. Rather, music’s ‘effects’ come from the ways in which individuals orient to it, how they interpret it and how they place it within their personal musical maps, within the semiotic web of music and extra-musical associations. (DeNora, 2000, p. 61) DeNora is underlining the transformative powers of music as something common between the interviews. People stress experience with and use of music in terms of its power to change things and make things happen (DeNora, 2000, p. 18). The informant’s active use of music were connected to a sense of self, agency, and identity; music as having a role in constituting body experiences; and music as a device for social ordering. The informants in De Nora’s research are telling stories about how they use music to enhance intimate relationships, to get into a

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particular mood, to relax, as an aid when exercising, to get ready for a party, as a container for memories, etc. It can be emphasized that this active and reflexive use of music is observed both in situations involving togetherness with other persons and also in solitary situations. Bull (2005) also describes the use of mobile music devices, such as iPods, in the creation of a private space within a crowded and noisy public sphere. Similar to DeNora’s study, Bull’s study is demonstrating the knowledge and competence in people’s use of music in everyday life. From these studies, we get a sense of a competent and reflexive use of music that has many similarities to the way music therapists also engage with music. Considering also the idea of clients having a theory of change, it is likely that for clients coming to music therapy their previous experiences with such use of music would have contributed to the formation of such a theory. At this point, I will have to point out one thing regarding this type of music experience competence. The reader might argue that the literature on the use of music in everyday life reports studies concerning people with good health and that we don’t know if this is applicable to people with mental health problems. First, I must say that I don’t see any reason not to believe that people with mental health problems would have the same type of experience. Also, there are examples in the literature showing that people do indeed use music in ways that can be seen as promoting their health outside of therapy settings and also when confronting specific life challenges. Batt-Rawden, DeNora, and Ruud (2005) describe active involvement with music as a self-healing practice, based on an ethnographic study of music listening with people who had long-term illness. The study demonstrated how a participatory study design inviting the informants to compile CDs together with their favorite pieces of music enhanced already established patterns of the health-promoting use of music, such as using music in mood regulation, self-awareness, relaxation, and focus on the healthy parts. In a qualitative master thesis, Skarpeid (2008) has interviewed adolescence girls with mental health problems about their music-listening habits and use of iPods or other mobile technological devices for music listening. The results from the study demonstrate similar active involvement in their music listening, related to relationship, regulation and control of emotions, and construction of identity. So the ability to be actively involved with the use of music in everyday life seems to be common, even among a group of clients who often are considered passive and unengaged in verbal therapy.

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As emphasized in Chapter 3, the appropriation (use of) of music that makes music become meaningful is related to different levels of musical competence, such as communicative musicality, musicianship, and musical experience skills. Communicative musicality as a basic human capacity is perhaps not likely to vary too much among clients with mental health problems. Musicianship, however, implies cultural processes of learning as described as a “cultivated facility of musicality in action within sociocultural contexts” (Pavlicevic & Ansdell, 2009, p. 362). Thus, the clients (as well as the therapists) bring with them musical competence related to their previous engagement with music, involving aspects such as competence in various musical genres, skills on various instruments, and musical identity. This obviously also interact with their experiences with the use of music in everyday life. With the clients who are presented in this book, it is clear that both Maria and Emma had previous experiences with music. Both Emma and Maria had previous competence in music, involving, for example, a large repertoire of songs and singing skills. Emma also had some formal music competence and had been an active choir singer. More importantly related to their “craft” in therapy, they had also had previous experiences with and knowledge as to how they could use music in everyday life, that is, music experience skills (see Chapter 3). Maria, for example, had previous experiences regarding the possibility of regulating her emotions to “cheer her up” or to “help her cry.” She had also had experiences of using music to pass the time, as well as experiences with music as a shared interest with relatives and peers.

CLIENT’S USE OF ARTIFACTS AND SKILLS FROM MUSIC THERAPY OUTSIDE OF THERAPY We also need to look more into clients’ use of the actual music therapy sessions. From psychotherapy research mentioned previously in this chapter, I have pointed to the clients’ efforts in making use of their experiences in therapy outside of therapy — that is, how clients make use of what they have learned in therapy in between sessions as well as after the therapeutic process is terminated. With regard to music therapy, this also has quite concrete implications for how clients make use of artifacts produced in therapy or make use of musical skills acquired in music

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therapy to enhance their quality of life or as a provider of social participation. In relation to this, the research literature in music therapy so far is limited, and there is obviously need for more research. One exception, however, is Aasgaard’s (2002) study of song creations by children with cancer. Although this study is exploring experiences with a very different population and is situated in a different institutional context, it might well give us some indications with regard to the question of competence. Aasgaard was studying the life stories of songs. One of the themes that he put forward in his discussion was that the songs’ “history” did not develop solely through the interaction between music therapist and child. Parents, other relatives, and people from the hospital milieu and beyond had roles connected to the history of the songs. In this way, the songs’ histories “challenge any belief that the important things (in music therapy) go on solely within music therapy sessions and within predetermined, enclosed areas of music therapy activities” (Aasgaard, 2002, p. 217). From the presentations of these song histories, it is clear that neither the therapist nor the child (client) is the director of the use of the songs. The song histories reveal that several agents take actions regarding the use of the songs, so we cannot attribute this solely to the children’s (clients’) efforts and competence. A survey about songwriting with different client populations (Baker, Wigram, Stott, & McFerran, 2009) included questions about the life of the songs after their completion. The results indicated that within a psychiatric setting, clients will often keep a recording of a song written in therapy; it is also frequently reported that the client distributes the song to a wider audience through performance and/or through sharing of recordings. However, according to this study, the therapist seems to be responsible for the involvement of other therapists regarding the song (Baker et al., 2009, p. 50). A very significant initiative in Emma’s therapy was her invitations to the psychiatrist, psychologist, and staff at her ward to come to a session and listen to some of the songs. Indeed, this is a powerful “intervention.” In contrast to the findings from the aforementioned survey, she was solely responsible. Emma’s intentions were also clearly articulated regarding this choice: She wanted to use the songs as a means of communicating things to the psychiatrist that were else too difficult for her to express verbally, and she wanted them to experience music therapy since this felt so important to her. By doing this, Emma also showed creativity in

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relation to how her sessions in music therapy could transfer more to other areas of her life. It seems that for both Maria and Emma, music therapy opened some doors regarding their possibility to use music outside of music therapy. This involved both recognition of their skills and capability (Maria) and awareness of possible arenas for the use of music (Emma). There is, however, nothing automatic about the transfer of such experiences to everyday life. At least regarding such individual session formats, the transfer to everyday life is dependent on efforts from the clients. With Maria, although I was the one who created our compilation CD, she was the one who in the first place suggested compiling it. She took the initiative to share it with friends and family, and in this way she used the CD as one step toward a more active engagement with music. Emma, in turn, started to sing duets with a colleague at work, started to have flute lessons, and started to use music more at work.

Chapter 12

THE THERAPIST’S CRAFT We must ask, based on the theory and conceptualizations offered in this book, what the implications for practical work are. Or, indeed, are there any at all? Does a resource-oriented approach imply any directions for how the music therapist should act in therapy? Would a resource-oriented approach imply any changes in ways of working, or is it just another theory designed to support “work as usual”? The notion of client’s craft implies that the therapy is organized around the client’s resources, perceptions, experiences, and ideas, as emphasized by Duncan and Miller (2000, p. 11). They argue that the shift of focus of interest from therapeutic intervention (what the therapist does) to how the client uses the therapy inevitably leads to a more resource-oriented perspective: As suggested, therapists can begin to cast their clients in the role as the primary agents of change by listening for and being curious about their competencies (in other words, their part in bringing about and maintaining positive change). This requires a balance between listening emphatically to their difficulties with a mindfulness to their strengths and resources. (Duncan & Miller, 2000, p. 70) I have in the previous chapter emphasized the need for us to explore and acknowledge in our practices the client’s craft in relation to the process of resource-oriented music therapy. This need not imply that the therapist’s craft is superfluous or unneeded. It is not less difficult to foster resources than to treat pathology, as Schwabe points out: I would also like to point out that it would be a dangerous simplification to understand resource-oriented action merely as bringing some friendly impulses to therapy. In contrast to this simplifying thinking, I would like to emphasize that it is not less difficult to activate self-healing forces in the patient than to treat

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The focus in this chapter will be on the therapist’s craft and the implementation of a resource-oriented approach. I think first of all that resource-oriented music therapy necessitates a conscious awareness and attitude. The therapist has to learn to look for resources as much as she or he looks for problems and pathology. Moreover, the therapist must learn to trust the client’s knowledge of and competence in relation to her or his needs, goals, and ways of working. This means being flexible as to which types of musical interaction and ways of working to use. When carrying out a resource-oriented approach to music therapy, one has to counteract the strong problem-oriented theories of the therapeutic culture. Problemand individual-focused understandings of therapy are deeply woven into the way we talk and think about therapy and also into the way many clients think about therapy. In many ways, this hinders us from noticing the client’s resources. Further, in the field of music therapy, we often tend to conceive of music therapy as inevitably resource-oriented. Such an assumption may inhibit our ability to reflect on what we actually do and thus has to be counteracted through the conscious choice of a resourceoriented approach.

THE THERAPIST IN A CONTEXTUAL MODEL From research into common factors and the contextual model, we know that what the therapists do counts for only a small part of the outcome of therapy. Further, when considering the therapist’s “craft” in relation to a contextual model, it is important not to equate the therapist’s role with the effects of her or his use of specific therapeutic techniques and models. In research on therapist variables, aspects such as the her or his personality, her or his style of communicating, culture and values, and her or his belief in the therapeutic model are considered relevant in relation to the outcome of therapy (Beutler, Malik, Alimohamed, Harwood, Telebi, & Wong, 2004; Wampold, 2001). In a meta-analysis of therapist variables, Beutler et al. (2004) compared current studies related to four categories relevant to therapists’ contributions to the therapeutic process. The categories were based on a division of extratherapeutic traits and therapy-specific states on one hand

The Therapist’s Craft 199 and divided into observable and inferred variables on the other hand. Beutler et al. were, however, emphasizing that the focus on discrete therapist variables “may detract us from the more important influences of therapist, intervention, and patient fit with one another” (Beutler et al., 2004, p. 228). Thus, it is important to consider the therapist’s contributions in relation to what the client is doing and with regard to relational aspects as well as other important contextual aspects. However, the focus on distinctive qualities or therapist variables may on the other hand help us to retain a wide focus, where the therapist’s contributions are more than her or his use of specific techniques. Summing up their results, Beutler et al. (2004) referred to the observable traits, such as the therapist’s sex, age, and race, as poor predictors of outcome. They also called for further research addressing such traits in terms of cultural concepts rather than biological, such as gender, ethnicity, and age. The results also indicate that observable states, such as the therapist’s training, skill, and clinical experience, are weak contributors to the outcome of therapy. The authors emphasized the need to compare such variables to the compatibility of the client’s qualities. It is emphasized that whereas there might be effects of therapists’ adherence to manual-guided treatment, allowing therapist flexibility seems equally important. As for the inferred traits, there are promising effects related to therapists’ well-being and to cultural values and attitudes. Also related to therapists’ culture and attitudes, the relative differences and similarities between therapists’ and clients’ beliefs seems crucial. Some clients experience a good alliance with the therapist if values are shared, as is indicated in Hersoug et al. (2003), but for other clients, experiencing differences in values and opinions can be motivating (Beutler et al., 2004). Finally, with regard to the inferred states, the therapist’s contributions to the relationship were regarded as promising, along with a therapist’s model of treatment. With regard to this latter category, Wampold (2001) emphasized the importance of the therapist’s allegiance — that is, the therapist’s belief in what she or he is doing. The analysis by Beutler et al. (2004) of therapist variables does not point toward some singular states or traits proven to be of crucial importance. The need for more research is emphasized, with specific attention to compatibility with the clients. With this analysis, however, it is clear that we must not equate the therapist contributions with specific techniques, but also take into consideration other aspects of therapist factors. Thus, therapist’s craft must be related to aspects of being as well as doing. Therapists’ “doings” are connected to their use of methods and

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techniques, and will in the following be related to therapeutic principles for resource-oriented music therapy. Therapists’ “beings” are related to how the therapist as a person is contributing to the collaboration. The therapist as a person contributes to the relationship in music therapy in terms of both her or his personhood and her or his musicianship. Obviously, in practice, divisions between the therapist’s doing and being are often blurred, as our actions and attitudes and personal styles of doing are always connected. In the review discussed above (Beutler et al., 2004), flexibility as much as specific techniques were emphasized. Such a call for flexibility inevitably leads to more emphasis on therapists’ “ways of doing” and “ways of being” rather than on what they do. In their discussion of positive therapy, Joseph and Linley address some of the same when claiming: “Positive therapy is not so much about what you do, as it is about how you do it” (2006, p. 15). The “what” component here can be related to the techniques of the therapist, but the “how” component seems even more important, and must also be related to aspects of the therapist as a person providing some sense of personal style, cultural attitudes, or relational quality to the actions. This does not, however, disqualify attempts to provide more expertise and professional qualifications among music therapists. Rather, it outlines the need for flexibility of therapeutic techniques and ways of working and the importance of a solid and thus trustworthy theoretical perspective.

THERAPIST’S BEING The therapist’s contributions to the therapeutic process are, as emphasized in the previous section, more than the use of specific techniques. Further, it is difficult to disentangle the research literature that discusses aspects related to the “being” dimension of the therapist’s contributions. Much of the literature, as referred to in the previous section, is focused on specific variables in relation to the outcome of therapy; this often blurs the relational aspects, as the relationship becomes mixed up with the outcome. This might lead us to think of relationship in terms of a technique, as something the therapist creates as a means in the therapy process (see Chapter 13). So rather than pointing to specific therapist variables as potentially significant for therapeutic outcome, I will put forward some reflections and implications of the therapist’s “being” related to the

The Therapist’s Craft 201 conceptualization of resource-oriented music therapy presented in this book. Throughout this book, I have been emphasizing the relational aspects related to resource-oriented music therapy, with emphasis on equality and mutuality. Thus, I have pointed toward the therapy as a collaboration in which the therapist contributes as a “real person,” genuine and authentic, a person with personality, a person with strengths and weaknesses, a person with professional competence and experience, a person with musical skills and musical identity, a person participating in a community, a person with cultural values and political opinions. Similarly, I have emphasized the importance of seeing and treating the client, in therapy and in the discourse of music therapy, as a person in the same way. “Respect” is the key word here. With this perspective, the therapist’s personhood and musicianship are important features of the relationship that inevitably influence the therapeutic process. Further, aspects of therapist’s being could be seen as strengths that may enhance the therapeutic process rather than as aspects that are regarded inappropriate to a therapeutic encounter.26 The therapist is, as is the client, a person with strengths and weaknesses, with resources and problems. This is all part of the therapist’s being, and even the parts of us that we might think of in terms of weakness or vulnerability might enhance the therapeutic process (Austin, 2002; Pavlicevic, 1997). In terms of the development of an equal and mutual relationship, it would be relevant to suggest that a relationship in which both parts use their strengths would be empowering. It is reasonable to believe that when the therapist also uses her or his strengths in therapy, this influences the relationship and contributes to the music. Using our strengths gives us energy and joy (Seligman, 2003), and in this way we stay engaged, which is likely to positively strengthen the relationship with the client. Further, by using her or his strengths, the therapist is a role model for the client, and this might enable the client to use her or his own strengths. With regard to music therapy, the therapist’s being also involves her or his musicianship as well as professional musical qualifications. Being a music therapist requires some levels of formal musical qualifications, involving musical breadth and flexibility and several instrumental skills (see Bruscia, 1998). Also here, there is obviously a more personal 26

See Lee (2008) for reflections on being a music therapist and a homosexual person.

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dimension to this involving the therapist’s musicianship — that is, with regard to the therapist’s musical and cultural background, involving musical identity and cultural belonging, as well as various musical competences with regard to musical genres and styles. What this means in a therapeutic process will of course always relate to compatibility with the client’s musicianship. With the cases presented in this book, both clients brought music into the therapy that was in a genre that was familiar to me. In both cases, the music therapist and the client also brought songs into the sessions that were new to the other person. Knowing the same music might create a sense of belonging to the same or similar subcultural group. On the other hand, when therapist and client have a very different musical background, this can also produce wonderful music and new, rich experiences. When discussing the client’s craft in music therapy, I emphasized the client’s competence and referred to the concept of client’s theory of change (Duncan & Miller, 2000). In a similar way, the therapist enters the therapeutic collaborations with ideas and theories and a tool kit of techniques and methods. The therapist’s belief in her or his model and in what she or he is doing is referred to as therapist’s allegiance, and it is emphasized as one very important factor (Wampold, 2001). Therapist’s allegiance has often been connected with the therapist believing in what she or he is doing: techniques and interventions. With the resourceoriented approach as it is put forward in this book, the emphasis is instead on the collaboration, with a mindfulness of the client’s competence, efforts, and theory of change. Thus, the therapist needs to believe in the client even more than in her or his techniques. This might involve, however, that the therapist share the underlying values related to theoretical frames of the approach.

THERAPIST’S DOING Together with colleagues, I have developed some principles for resourceoriented music therapy (Rolvsjord et al., 2005a27; Rolvsjord et al., 2005b). 27

The therapeutic principles were previously published in the Nordic Journal of Music Therapy article “Research Rigour and Therapeutic Flexibility” (Rolvsjord et al., 2005a).

The Therapist’s Craft 203 These principles were originally formulated as a flexible “manual” or guidelines for an RCT on resource-oriented music therapy. However, they were built up from the literature study, as well as my experience as a practitioner in the field of mental health. In these principles, I have tried to specify what a resource-oriented approach should imply in the practical work that is the doing dimension of therapist’s contributions. Since these principles are meant to guide the therapist, they are formulated from the therapist’s perspective and focus upon the therapist’s attitudes and actions. The very formulation of such principles is in itself paradoxical. In a resource-oriented approach, the essential idea is that the therapy must be oriented around the client’s resources, which are very likely to differ very much from case to case. The principles are therefore flexible and open and focused upon attitudes as much as actions. Second, I have throughout this book emphasized the importance of the client’s ways of using whatever the therapeutic setting affords and the client’s contributions to the therapeutic relationship. The principles must therefore be seen in connection with the contextual model of therapy. A structure suggested by Waltz, Addis, Koerner, and Jacobson (1993) was adopted for the purpose of formulating the principles. This structure lists four categories of principles: (1) unique and essential; (2) essential but not unique; (3) acceptable but not necessary; and (4) not acceptable (proscribed). An approach to music therapy does not exist in a vacuum: It is surrounded by other perspectives and approaches that may be more or less similar. In order to make similarities as well as differences transparent, it might be useful to outline not only what a therapy comprises, but also what it does not comprise. Waltz et al. illuminate how the unique and essential principles of one approach (e.g., psychodynamic therapy) may be proscribed in another (e.g., behavioral therapy) and vice versa — whereas principles in the middle categories, (2) and (3), may be shared by both. Taken together, the principles should illuminate contextual and collaborative aspects when working as a music therapist within a resource-oriented approach in a mental health care setting. The sequence given does not imply priority (the first principle under each heading is not necessarily more important than the second). I also want to emphasize that it is not necessarily a case of “the more, the better.” How much each of the principles is used will vary according to the client’s resources and problems; the therapist’s qualifications, personality, and personal style; and the phase of the therapy.

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1. Unique and Essential Therapeutic Principles The therapeutic principles in this section are understood to be unique and essential to resource-oriented music therapy. These principles are understood as central and defining for this approach, and have only been articulated to a very limited degree as central and defining in existing music therapy models. 1.1 Focusing on the client’s strengths and potentials. 1.2 Recognizing the client’s competence related to her or his therapeutic process. 1.3 Collaborating with the client concerning goals of therapy and methods of working. 1.4 Acknowledging the client’s musical identity. 1.5 Being emotionally involved in music. 1.6 Fostering positive emotions. 2. Essential but Not Unique Therapeutic Principles The principles in this category are essential to a resourceoriented music therapy perspective but are also essential to existing music therapy models. I want to remind the reader that these principles are as important as the previous. 2.1 Engaging the client in musical interplay (such as musical improvisation, creating songs, playing precomposed music, or listening to music). 2.2 Acknowledging and encouraging musical skills and potentials. 2.3 Reflecting verbally on music and musical interplay. 2.4 Listening and interacting empathically. 2.5 Tuning in to the client’s musical expressions. 2.6 Collaborating with the client concerning the length and termination of the therapy process. 3. Acceptable but Not Necessary Therapeutic Principles This category describes therapeutic actions that might be relevant in some cases and that can be very important in some cases, but that are not considered essential and defining to resource-oriented music therapy. 3.1 Teaching instruments/music.

The Therapist’s Craft 205 3.2 Sharing one’s own experiences. 3.3 Performing music with the client outside the therapy setting. 3.4 Providing therapeutic rationale. 3.5 Having music as the primary goal of therapy. 3.6 Reflecting verbally and musically on problems. 4. Not Acceptable (Proscribed) Therapeutic Principles Proscribed principles are therapeutic actions that are seen as strongly contradictory to a resource-oriented perspective. 4.1 4.2 4.3 4.4

Neglecting the client’s strengths and potentials. Having a strong focus on pathology. Avoiding emerging problems and negative emotions. Directing in a noncollaborative style.

1. Unique and Essential Therapeutic Principles 1.1 Focus on the Client’s Strengths and Potentials In traditional medical or pathogenic models, therapy is concerned with the cure of pathology and the relief or reduction of symptoms. However, this is neither the only function of therapy nor the only way of promoting health. Nurturing and developing the client’s strengths, resources, and potentials is an essential part of a resource-oriented therapy. The client’s strengths and potentials may be related to her or his skills, ways of coping, achievements, personality, competencies, social relationships, etc. Focusing on the client’s strengths and potentials and focusing on problems and pathology are not seen as mutually exclusive alternatives, but might be interacting processes. It is important to bear in mind that focusing upon the client’s strengths and potentials may be experienced as a form of confrontation. Hence, the therapist will need to make necessary adjustments when interacting with the client. What this is not: Focusing on the client’s strengths and potentials does not mean that the music therapist should continuously praise the client or that problems and pathology should be ignored. 1.2 Recognizing the Client’s Competence Related to Her or His Therapeutic Process

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Focusing on the client’s strengths, potentials, and resources in order to nurture and develop her or his ability for coping, thereby promoting health, can easily turn out to be paradoxical. Helping the other in order to empower her or him might actually decrease her or his autonomy and empowerment. To avoid this paradoxical situation, the therapist must continuously focus on the client‘s strengths and potentials and show her or his belief in these through the recognition of the client’s competence related to her or his therapeutic process. The therapist must not take the position of an expert but must connect with the client and create a mutual and collaborative relationship. What this is not: Recognizing the client’s competence in relation to her or his therapeutic process is not a way of neglecting the therapist’s competence. 1.3 Collaborating with the Client Concerning Goals of Therapy and Methods of Working This principle is a consequence of the previous one. As the creation of a relationship between therapist and client based upon equality and mutuality is desired, collaboration is necessary. Collaboration implies shared responsibility for the process of therapy in which both the therapist and the client use their competences in pursuit of their common goal or agreement to help the client. This principle, like the previous one, is concerned with the importance of equality in the relationship between therapist and client and the necessity of acknowledging the client’s competence in relation to her or his own life. Obviously, when a client makes the decision to work in music therapy, she or he usually has an interest in music and some previous experiences of what music means to her or him in her or his life. However, at the same time, she or he usually does not know what music therapy is, and she or he has limited knowledge of the possibilities inherent in different methods of music therapy. Therefore, this collaboration is essential in terms of establishing goals and methods of working. This does not mean, however, that the therapist cannot show determination, have authority, or establish and maintain boundaries. What this is not: Collaborating with the client is not rejecting the asymmetric relationship in such a way that the client feels the responsibility to help the therapist with her or his problems.

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1.4 Acknowledging the Client’s Musical Identity The client’s musical resources are related to her or his musical identity. The client’s musical identity is related to the culture of the community she or he belongs to, as well as to their personal and collective history. Recognizing and acknowledging her or his musical identity is a way of focusing on and nurturing these resources. This might be a way of developing the client’s individual musical competencies, as well as nurturing her or his sense of social and cultural belonging in a community. It must be noted, however, that musical identity is not always connected with positive emotions and resources in the community. In several cultures, for example, music-making is very much connected to elitist activities, and active music-making is reserved for those with good musical skills. In such cases, taking back the rights to music might be an important goal within a resource-oriented music therapy approach. What this is not: Acknowledging the client’s musical identity is not simply playing music with which the client is familiar.

1.5 Being Emotionally Involved in Music Musical interaction is the foundation of resource-oriented music therapy. Emotional involvement in music means supplying energy and vitality to the musical interplay. This makes experiences of mutuality, authenticity, and beauty possible. Hence the therapist should not only match and mirror the client’s musical expressions but should actively co-create the music as well, taking musical initiatives and enjoying the music and musical interplay. What this is not: Being authentic and involved in the music does not mean playing out your emotions in ways that interfere negatively with the therapist role by reducing your awareness of the client’s expressions.

1.6 Fostering Positive Emotions Positive emotions are seen as a resource. Positive emotions are important for health and well-being. Active music-making inside and outside of music therapy evokes positive emotions such as joy, pleasure, relaxation, excitement, and flow, and relational emotions such as feelings of belonging. The music therapist should foster such emotions by recognizing these aspects of music-making, by being authentic and

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involved in the music, by creating good music, and by using a musical genre that the client and the therapist both enjoy. What this is not: Fostering positive emotions is not avoiding negative emotions.

2. Essential but Not Unique Therapeutic Principles The reader is reminded that these principles are as important as the previous.

2.1 Engaging the Client in Music Interplay (such as musical improvisation, creating songs, playing precomposed music, or listening to music) It is essential to a resource-oriented music therapy approach that the therapist should engage the client in some kind of musical activity. To enter such a musical space and gain new experiences through musicking is the basic foundation of the music therapy process. Musical experiences might be connected to the musical interplay in therapy, to interpretations of musical meaning, or to the expression of emotions. In resourceoriented music therapy, the therapist will collaborate with the client in order to decide in which type of musical interaction and experience she or he will participate. Therefore, it is useful to try different forms of musical activities, especially in the first sessions of therapy, in order to explore the potentials related to these different forms of musical interplay. What this is not: Engaging the client in musical interplay is not coercing the client to play an instrument.

2.2 Acknowledging and Encouraging Musical Skills and Potentials An interest in music, if not a necessary condition, may be an important starting point for a client engaging in music therapy. This interest can be seen as a therapeutic potential, which implies a motivation for the therapy as well as a motivation for participation in other music activities. In addition, the music therapy client will often have acquired certain music skills prior to engaging in music therapy, such as instrumental skills, knowledge of music theory, singing skills, knowing a repertoire of songs, etc. Other musical skills that may have been acquired are related to ways

The Therapist’s Craft 209 of using and experiencing music, such as the regulation of emotions through music or the use of music to communicate. It is essential that the music therapist acknowledges such skills and stimulates further development of musical skills and potentials. What this is not: Acknowledging and stimulating musical skills and potentials does not mean paying attention only to the musical product.

2.3 Reflecting Verbally on Music and Musical Interplay Talking about the music and about the musical interplay is a very important aspect of resource-oriented music therapy in mental health care. It is essential that the therapist is open to verbal reflection and creates a space for such reflection in the sessions. The time devoted to verbal reflection can vary greatly, both within a single client’s therapeutic process and from client to client. Verbal reflections might lead into musical activities in some cases. In other cases, verbal reflections might follow the musical activity. Verbal reflections can be discussions of the lyrics, of how the music sounded, of the emotions related to the musical expressions, or of music in everyday life. What this is not: Verbal reflection on musical interplay does not imply that the verbal interaction is seen as more important than the musical interaction. It is not the same as doing verbal therapy. Including and emphasizing the importance of verbal reflection on musical interplay (and music) does not necessarily mean doing a lot of talking in every session.

2.4 Listening and Interacting Empathically To be an empathetic listener, the therapist must recognize the emotional expression presented by the client when talking or playing or through other means of expression — for example, her or his body language. Empathy implies sensitivity to and a willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. What this is not: Empathetic listening does not mean agreeing with everything the client says.

2.5 Tuning In to the Client’s Musical Expression The therapist should tune in to the vitality or energy level of the client’s music. In any musical interplay between the therapist and the client, there

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is an expression of vitality and emotions. Tuning in to the client’s musical expression of such vitality affects is the consequence of empathetic listening What this is not: Tuning in to the client’s musical expression does not mean that the therapist never challenges or stimulates the client’s music.

2.6 Collaborating with the Client Concerning the Length and Termination of the Therapy Process Any professional therapeutic process by necessity has an end. Planning for termination means that the client knows that this relationship will not end abruptly and that time will be spent preparing for termination and dealing with issues related to closure and parting. This implies that client and therapist collaborate in making a contract that indicates a projected time frame for the therapy. Furthermore, if either the therapist or the client decides to end therapy earlier for some reason, they will agree on and plan for an ending period. Planning for termination is an important component in building trust. What this is not: Collaborating with the client concerning the length and termination of the therapy process does not preclude the possibility of having a fixed time frame.

3. Acceptable but Not Necessary Therapeutic Principles The principles in this category might be of importance in some cases but not in others. They are not essential to resource-oriented music therapy but might be included in a constructive way.

3.1 Teaching Instruments/Music Teaching a client to play an instrument can be an acceptable therapeutic action if the client wants to learn to play that instrument. Learning to play an instrument is a way of developing and nurturing musical skills that are themselves considered to be resources in several ways. They can contribute to a sense of mastery and self-efficacy and can contribute to self-esteem. They may potentially lead to inclusion in some kind of social group. Learning an instrument might also be a way of stimulating positive emotions.

The Therapist’s Craft 211 What this is not: Teaching instruments or music does not mean abandoning the therapeutic process in favor of a pedagogical one.

3.2 Sharing One’s Own Experiences Sharing one’s own experiences might be important in creating an equal relationship and when being empathetic. It can also be an important way of confronting the client with what her or his actions do to a relationship, positively or negatively. However, it is very important that such sharing does not turn into the kind of self-disclosure that makes the client feel obliged to help the therapist. What this is not: Sharing one’s own experiences does not mean transgressing the responsibilities and constraints of the therapeutic relationship.

3.3 Performing Music with the Client Outside the Therapy Setting Performing music outside the therapy setting can be important for empowering the client in some cases but would at other times be very problematic and even unethical. It is therefore essential that performances are prepared and processed carefully, and that their value and relevance for the therapy process are evaluated thoroughly. What this is not: Performing music with the client outside the therapy session does not mean leaving the work behind in the therapy setting or exploiting performance for the benefit of the therapist or the profession.

3.4 Providing a Therapeutic Rationale Occasionally, a client will ask for an explanation of how music therapy works. Providing a rationale for the therapy is a way of recognizing the client’s interest as well as her or his competence. Furthermore, it takes seriously her or his wish for more knowledge. It may be that providing a treatment rationale contributes to the hope, expectation, and motivation of the client in that it is a way of showing that the therapist believes in this approach to therapy. What this is not: Providing a therapeutic rationale does not mean explaining everything the music therapist does or giving “lectures” that distract from the focus upon the collaborative therapeutic process.

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3.5 Having Music as the Primary Goal of Therapy The goal for music therapy need not always be directly related to health needs: It may be related to musical needs as well. Examples of musical goals include restoring the ability to enjoy music, making possible participation in a choir, and improving musical skills. In a resourceoriented perspective, musical goals are always directly or indirectly related to health needs. What this is not: Having music as the primary goal of therapy does not mean ignoring the client’s health needs.

3.6 Reflecting Verbally and Musically on Problems Reflecting on and exploring problems, conflicts, and traumas verbally or in music is accepted in resource-oriented music therapy. In some music therapy processes, verbal/musical reflection on problems, conflicts, and traumas will play a very important role in the treatment. What this is not: Reflecting verbally and musically on problems does not imply that the focus on strengths and potentials is neglected.

4. Not Acceptable (Proscribed) Therapeutic Principles These are seen as strongly contradictory to a resource-oriented perspective.

4.1 Neglecting the Client’s Strengths and Potentials Neglecting the client’s strengths and potentials is proscribed in a resource-oriented approach. The focus on strengths and potentials should not be limited to musical skills.

4.2 Having a Strong Focus on Pathology In resource-oriented music therapy, it is essential to focus on the client’s resources, strengths, and potentials. As a consequence, a strong focus on pathology is proscribed.

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4.3 Avoiding Emerging Problems and Negative Emotions When a client brings up a problem or negative emotion in a session, it is proscribed not to meet the client’s wish to deal with this verbally or musically. To avoid an emerging problem or negative emotion is contradictory to the essential principle of acknowledging the client’s competence in terms of shaping her or his therapeutic process.

4.4 Directing in a Noncollaborative Style If the therapist adopts a noncollaborative style and then begins to direct the therapeutic work, this conflicts with the principle of engaging the client in an equal relationship and significantly reduces the possibility of genuine collaboration. For example, the implementation of standardized procedures would be proscribed unless this were a collaboratively chosen way of working.

Chapter 13

THE THERAPEUTIC RELATIONSHIP In the previous chapters, I have outlined aspects of client’s craft in therapy as well as the therapist’s craft as important to the therapeutic process and outcome. But neither the client nor the therapist is acting on their own; their craft is performed in the therapeutic relationship and in the specific context of the therapeutic arena. As the importance of the client, therapist, and relationships is outlined, it is important to underline that these three different “factors” are to a very high degree interdependent (Lambert & Barley, 2002). A change in the client’s role will inevitably influence the therapist’s role as well as the relationship between them. If we start to think differently about the client, we will start to think differently about the relationship as well as about ourselves as therapists. At least two points have to be clarified here. First, the implications of acknowledging the importance of the client’s efforts in therapy inevitably lead to and necessitate a more collaborative relationship. Second, the therapeutic relationship is not just a means of enabling the specific ingredients to work, but is directly related to change, growth, learning, and developmental processes. What is suggested throughout this book is that both client and therapist should be active participants in the collaboration (Chapter 4). Collaboration implies that both participants are actively involved in the process of assessment, in deciding the goal for the therapy, and in finding a way to work toward problem-solving, development, or other goals. This implies taking on a “collaborative mind-set” as suggested by Bohart and Tallman (1999). Such a collaborative mind-set will also imply some flexibility in relation to the roles and responsibilities in therapy as well as how the therapist and client will collaborate. The task of the therapist is not to decide what the right therapeutic intervention is, and to execute that intervention, but to help the client become involved and motivated and to help her or him to actively use the therapy (Bohart, 2000, p. 137). There are obviously different types of collaboration and different role sets that the client and therapist can adopt in a therapeutic relationship. Different types of collaboration offer different roles and

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distributions of power and control. Even in drug-based medical treatments, some collaboration in the form of compliance with the treatment will be necessary. In other therapies — for example, CBT (Cognitive Behavioral Therapy) — the client collaboration is likely to be more active and participatory, but still the therapist’s interventions and the client’s compliance with them are seen as the main promoter of change. On the other side of the continuum, we can suggest client-centered therapy in which the client has the leading role or the quasi-therapeutic situation of a person using a self-help book. With the conceptualization of common factors in psychotherapy, the therapeutic relationship has been a focus for psychotherapy research. In the comprehensive review of research presented in the book Psychotherapy Relationships That Work (Norcross, 2002), we learn that it is found to be empirically supported that various relationship factors have been effective in relation to the outcome of therapy. Summing up their review of goal consensus and collaborative involvement, Tryan and Winograd (2002) emphasize that collaborative involvement that includes “friendly, cooperative, affiliative behavior on the part of both participants” is associated with better outcomes (p. 121). Likewise, this is also true for the effects of a good therapeutic alliance, as the quality and strengths of the collaborative relationship inclusive of positive affective bonds, sense of partnership, and agreements of goals are an important ingredient of successful therapies (Horvath & Bedi, 2002). A third element to be mentioned is empathy. Empathy has been related to the outcome of therapy as a relationship condition enhancing feelings of safety and increases compliance; as a corrective emotional experience, so that they see themselves as worthy of respect; as involving a cognitiveaffective processing that promotes meaning creation; and as a support of the client’s active self-healing capacities (Bohart, Elliot, Greenberg, & Watson, 2002). Such evidence on the effectiveness of various common factors in therapy, however, may perhaps unintentionally lead into the idea of relationship being an intervention — that is, something that the therapist creates as a means of fixing the client’s problems. A collaborative relationship, however, is something more than a means to achieve a warranted therapeutic outcome. To conceive of the relationship as an intervention would be paradoxical to the equal relationship, as articulated so eloquently by Bohart and Tallman:

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Randi Rolvsjord Because therapy is a meeting of minds, the relationship between ourselves and our clients is the most important part of therapy. We relate to our clients as people, and let them relate to us in the same way. This may seem obvious, but we believe that the relationship in therapy is a real one between two human beings, not primarily an intervention. (Bohart & Tallman, 1999, p. 235)

This quote illuminates one of the basic underlying assumptions regarding a mutual and egalitarian relationship. The authors point to the need to focus on the therapeutic relationship as genuine and authentic. The therapeutic relationship should be a model of egalitarian relationships in general, as emphasized so clearly in empowerment philosophy. As a model of egalitarian relationships, we should strive not to reproduce the societal power imbalances that are experienced by women, people with learning disabilities or mental health problems, or people from minority groups (Worell & Remer, 1996/2003). Therefore, the aspect of mutuality is crucial. To enter into such a mutually and authentic relationship with the client is, however, not to disclose anything and everything. It does not mean abandoning the legal, economic, and professional asymmetry of the therapeutic relationship. Neither does it imply that the client is going to take care of the therapist (Surrey, 1997). Nor does such mutuality represent a withdrawal from professional competency or professional skills. Mutuality and equality do not imply that we are alike or that we have identical roles (Sprague & Hayes, 2000). Thus, this kind of relationship can also be constructed between people with very different abilities (Sprague & Hayes, 2000, p. 684; Surrey, 1997, p. 43). Previously in this book, I have argued for a therapeutic approach where the qualities of the therapeutic relationship are described in terms of mutuality, equality, and participation (Chapter 4). In this chapter, I will go more thoroughly into the qualities of such a relationship in practice. I will try to outline how the qualities of therapeutic relationships are performed by both parties and involve as much of the client’s as well as the therapist’s contributions. I will use examples from the case studies presented in this book to exemplify this mutual performance of equal therapeutic relationship. It must be emphasized, though, that the therapeutic relationship as such was not a primary focus for the case studies. The examples are therefore anecdotal rather than based on systematic analyses.

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DOING TOGETHER I start the elaborations on the therapeutic relationship in this chapter by putting forward one aspect of the therapeutic collaboration in resourceoriented music therapy that perhaps to some extent must be seen as a general characteristic of the therapeutic relationship in music therapy. In music therapy, much of the sessions are centered on an active involvement in music by both client and therapist; thus a characteristic and specific feature of music therapy is that client and therapist are doing something together, and more specifically, they are doing music together. This mutual and active engagement with music, as we have previously discussed in this book (Chapter 3), affords a plurality of meanings and possibilities in a therapeutic collaboration. Music affords possibilities that can enhance therapeutic work through various ways of use and involvement. With the cases presented in this book, we have, for example, seen music be used as a means of communication, as a way of regulating emotions, or as an arena for experience of mastery and development of musical skills. Musical interaction has in music therapy literature been related to a type of basic communication, characterized by mutuality (Pavlicevic, 1997) and related to aspects of communicative musicality (Trevarthen & Malloch, 2000). Here, I will point to the action aspect of this interaction. In music therapy, the mutual engagement with music is more than having another channel or media for communication. Making music together in music therapy is inevitably also putting a dimension of “doing together” into the therapeutic relationship. In research interviews, Emma emphasized the possibility of “just doing things” in relation to the possibility of exploring both her resources and her problems. As we have seen (Chapters 9 and 10), this opportunity of doing things involved a possibility of shift of focus that helped Emma dare to use music therapy. Moreover, doing together also contributed to the relationship. Doing together may provide a sense of equality and community in which formal roles become less important. Ruud (1998) is making a comparison between the musical interaction in music therapy and that of experiencing a liminal state together, a rite the passage. With reference to anthropologist Victor Turner, he uses the term “communitas” to describe this social experience. What characterizes communitas is a sense of equality and intense togetherness or closeness. Ruud refers to communitas as potential experiences in musical

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improvisation, more than some characteristic of the relationship in music therapy in general: “Instead of ‘aesthetic refinement,’ improvisation in music therapy seeks to build a community (‘communitas’) through a temporary leveling out of all social roles” (Ruud, 1998, p. 131). Thus, we might think about the aspect of doing together in music therapy as related to a transgression of the social (unequal) roles of therapist and expert — and thus contributing to mutuality and equality. The concept of communitas is perhaps a bit over the top, characteristic of peak experiences and particular moments in the musical interactions rather than descriptive of the togetherness of doing together when making music with another person. Rather, when playing music, we go into a mood of doing together than affords possibilities of communitas. Through the establishment of this small community of practice (Wenger, 1998), in which we share a desire, joy, and competence of music, we move toward a sense of togetherness in which the inequality established by the constitution of the professional relationship is overruled.

EQUALITY AS PERFORMANCE OF RESPECT In social life as in art, mutuality requires expressive work. It must be enacted, performed. (Sennett, 2003, p. 9) It has been pointed out by several authors that musical interplay in music therapy provides experiences of mutuality (Pavlicevic, 1997; Rolvsjord, 2002; Ruud, 1998). Such aspects of mutuality in musical interactions are connected to inborn social capacities, such as communicative musicality, and to the musical features of basic communicative interactions (Trevarthen & Malloch, 2000). Thus, we might suggest that musical interactions represent an arena in which egalitarian and empowering relationships might be fostered. However, this does not mean that all kinds of musicking and all kinds of music therapy are inevitably egalitarian. Musical interactions might also provide experiences of subordination and domination. There are numerous examples of hierarchical structures in the organization of music (see, e.g., Small, 1998) describing power relations between performers and listeners, and conductors and musicians). Good teamwork may be characterized as a group in which the individuals perform better together than alone. Sennett, in his highly

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recommended book Respect in the World of Inequality, relates such an optimizing of mutual performance to the concept of respect, understanding musical performances as a collaborative expressive practice of mutual respect. He exemplifies this (2003, pp. 50–52) with the story of a performance of Schubert’s famous song “Die Erlkönig” by the singer Dietrich Fischer-Dieskau and the pianist Gerald Moore. This specific piece of music makes high achievement demands on both singer and pianist. At one point in the song, the pianist is supposed to play staccato notes illustrating the effect of a machine gun — something that is extremely difficult to do at a high volume. Sennett writes that in several performances of this song, the singer uses the volume in his voice to convey the effect of the child’s terror and the father’s attempts to comfort him, which causes the machine-gun effect of the piano part to get lost. In this particular performance, however, Fischer-Dieskau instead lifts the sound to the top of his throat, speaking harshly rather than singing at exactly the moment when the clanging effect of the piano could have gotten lost. In this way, the singer reinforces the effect of the staccato piano chords. Singer and pianist, by respecting each other’s strengths as well as limitations, optimize their mutual achievement. Sennett’s example may help us to illuminate the meaning of an egalitarian therapeutic relationship in terms of performed respect. Equality needs to be performed in relationship, and the concept of respect may help us to disentangle some of the complexities related to the performance of equality and mutuality in a relationship that is in some ways characterized by asymmetry due to the different roles ascribed to the contributors through the institutional and legal constitutions of the professional practice. Mutual respect involves acknowledging the other’s strengths and skills, as well as the limitations of their capabilities. The concept of respect is, in other words, embedded with an acknowledgment of difference. Thus, equality does not rule out difference. On the contrary, it is argued, difference can be seen as a prerequisite for equality: To place equality and difference in opposition to each other fails to capture their interdependence, when in fact equality takes for granted a social pact to consider very different individuals as similar for a particular reason. Thus, the idea of equality implies a dependence on difference, and implicit in demands for equality are the differences among the individuals and groups that are making such demands; indeed, if we were

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Sennett’s example beautifully illustrates the recognition of difference as the base for mutual respect. Collaborations between people who respect each other are characterized by opportunities for the use and development of strengths as well as adjustment and compensation for weaknesses. Again, it is important to note that what we are talking about as performed respect is mutual. Both parts contribute to the creation of an equal relationship. I have in a previous chapter discussed the aspects of mastery related to my collaborations with Maria. For Maria, it was very important that the music “sounded right.” She challenged me musically and encouraged me to play and sing my best in every session. In her first interview, Maria talked about a situation from one of her earliest sessions in which she had felt that her voice was being drowned by my piano-playing and that she could not control her intonation. In our musical interplay, both of us were being challenged by some of our limitations. I had problems playing softly enough on the piano, due to my limited piano skills as well as the state of the instrument. In later sessions, Maria amplified her voice using a microphone, and this probably enabled each of us to support each other better in the music. There were times when we were able to “do better together,” to help each other to do our very best, and to respect each other’s limitations to make the best out of the music. Maria explained that on those occasions she “felt like a star,” and indeed I too enjoyed very much making music with her and shared my enjoyment with her. In turn, Maria also verbally acknowledged my musical skills, telling me, “really … you are a fine troubadour.” The mutual acknowledgment of strengths and limitations and the recognition of differences are central aspects of respect. Although the examples here are connected to the achievement of optimal musical performance, they may serve to illuminate an aspect of respect that is also part of social life in general as well as the therapeutic practice. According to Sennett, there are three modern codes of respect: make something of yourself, take care of yourself, and help others (Sennett, 2003, p. 260). These are, as Sennett explores in his book, connected to a conceptualization of autonomy that implies “accepting in others what one does not understand about them” (Sennett, 2003, p. 262). Based on the acknowledgment of people’s needs to achieve respect, both in terms of self-respect and to feel socially respected, we have to negotiate a helping

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relation that doesn’t compromise with people’s possibility to achieve respect. Mutual recognition seems of crucial importance, as well as the possibility to participate more actively in the conditions of their own care.

NEGOTIATIONS AS PERFORMANCE OF DEMOCRATIC PARTICIPATION I have in previous chapters of this book emphasized aspects of selfdetermination and participation in the therapeutic process. When less weight of the outcome potential is put on the therapist’s intervention and more weight is put on the client’s ways of using the whole therapeutic situation, the expert role of the therapist has to be exchanged for equality and mutuality. Following from this, decisions about how to work in therapy should concern not exclusively the expertise of the therapist, but also that of the client. Thus, to find a good way of working together in therapy is a collaborative task. Fitzsimons and Fuller describe this collaboration in terms of a democratic participation: Empowerment requires the democratic participation of those who are affected by the intervention. Regardless of their level of disability, individuals need to have as much to say as possible in the development of their goals. (Fitzsimons & Fuller, 2002, p. 490) Democratic participation is characterized by equal rights to influence decisions. As a principle for decision-making processes in the frames of a psychotherapeutic relationship, democratic participation means that both the therapist and the client are engaged. It might be fruitful to think about collaborations in terms of negotiations. Negotiations as involving compromises as well as arguments are in everyday life as well as in political arenas representative of decision-making processes between equals. To engage yourself in negotiations implies at least some degree of respect. Negotiating involves listening to the other person’s argument and acknowledging the difference of perspectives and needs. Aiming toward compromises, we search to recognize the other person’s needs without losing our own integrity. In Emma’s music therapy, our collaboration concerning ways to work within music therapy turned out to be one that implied a negotiation

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of strengths and problems/lack of skills related to both therapist and client. It is not only the therapist’s strengths and expertise that are supposed to be used, but also the client’s strengths and resources. When I in the beginning of our work together suggested to Emma that we could perhaps write our own songs, I had the impression that she chose songs very deliberately to communicate and to work with different themes. Simultaneously, I also suggested it to her because I had had previous good experiences with this way of working, and I felt that I used my strengths in a good way when working with songs. I am not so good at playing songs by heart, I am not so good at playing in rock bands, but I am quite good at writing songs, and I love doing it. Similarly, when Emma seized on this idea, it was also because this was a way of working in which she felt able to use her strengths. It provided acknowledgment of her competence as well as of mine. Even if this way working suited both of us, we also had continuous negotiations about working with improvisations as well. I was concerned about her performance anxiety and argued that improvisation could be a chance to use music that was “free” from the requirements of performing well. In the first semester of our work, I suggested several times that we might try improvising together. Emma reluctantly agreed to try, but she told me that her previous experience with improvisation (in school) had been terrible. In one of the first sessions (see chapter 8), the following episode that might exemplify this took part: I handed her the ocean drum so that she could try an instrument that I thought would not provoke so much performance anxiety. For Emma, this too was absolutely terrifying. It caused her to start blinking her eyes and shivering. In later sessions, I sometimes engaged her in some very structured vocal improvisational techniques as a way of composing a melody to some of the poems. She managed this very well, but still she obviously did not feel comfortable with improvisation, although she seemed less frightened when the act of improvisation was embedded in the act of composition. She realized that she was indeed not incapable of musical improvising. However, looking back at this now, I must admit that the main reason for suggesting improvising music was perhaps my own professional insecurity. Throughout my studies in music therapy, I had developed some kind of understanding of improvisation as the most “therapeutic,” the “real” music therapy. I had failed to acknowledge the possibilities of working with songs — because it seemed so simple. In this way, also my expertise was negotiated in the therapeutic process, resulting in better possibilities for both of us to use our strengths in the therapeutic work.

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Such collaborations about goals and ways of working in therapy are often described as an important element of therapeutic alliance along with sense of partnership and emotional bonding. In their discussions of therapeutic alliance, Safran and Muran (2006) use the term “negotiations” when they point to the therapeutic alliance as an ongoing process. They describe the alliance as a constantly shifting, emergent property of the therapeutic relationship (Safran & Muran, 2006, p. 288). One important aspect of this therapeutic alliance, according to Safran and Muran, is the negotiation of needs. This involves an experience of needs being negotiated without compromising the one’s integrity, but also without treating the other as an object. In one of our last sessions before Emma was moved to the other hospital, the following incident happened. At this time, Emma was experiencing a situation of conflict in the ward that made her feel both rejected and deeply unvalued. On this particular day, we had had a long music therapy session, and when the session was supposed to be finished, she curled herself into a corner in the music therapy room and announced that she was going to stay. I felt on the one hand moved because she was telling me in such a strong way that she valued the safe space with me, but on the other hand I was concerned that I had other patients to take care of, and also that this behavior could possibly make it difficult for me and traumatic for her, e.g., if I had to get the ward people to come and carry her out of my room before the next client was due to come. At the time of the day that this happened, I was supposed to have my lunch break before seeing the next patient for music therapy, and this was the “clutching at straws” that I grasped toward as a solution. I announced quite firmly to her that I had more patients coming to me for music therapy after lunch, and that I was quite hungry and in need of a lunch break. Then I suggested to her that I could eat my lunch in the music therapy room, and that she could stay with me for half an hour more if she came and sat with me at the table and had a cup of tea and a chat with me. She agreed to these conditions. We went to the kitchen next to my office and made some tea. Then she sat down and drank tea and talked with me about this-and-that while I had my lunch. She left after half an hour for her ward with a “Thank you for letting me stay.” In contrast to the other situations that I have already discussed in this chapter, this is a situation characterized by negative emotions and problems. In this situation, I have to say, I felt both mean and egocentric in fighting for my own right to have lunch and a break. Still, this situation can illustrate aspects of the negotiation of needs and recognition. For me,

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it was important to state my limits and my rights as well as my capability of taking care of myself in this situation. Simultaneously, she expressed very clearly her need for a shelter, and she communicated clearly, although perhaps in a rather odd way, that she valued me. I was aware and moved by that. By insisting on having my lunch break, I clearly demonstrated that I took responsibility for myself and that I did not compromise with either my own needs for a break or her fellow patients’ needs for their sessions. By giving her the possibility of being there during my lunch break, provided that she could sit down with me at the table and talk, a situation was avoided that could have left her feeling deeply humiliated. In this situation, we both claimed our right to be treated with respect while simultaneously recognizing the other’s needs. This example intends to illuminate a negotiation of needs involving mutual recognition. Mutual recognition seems perhaps basic to a therapeutic encounter, but as Sennett emphasizes, it is not something that happens automatically but involves complexities of personal character as well as social structure: “Treating others with respect cannot occur simply by commanding that it should happen. Mutual recognition has to be negotiated; this negotiation engages the complexities of personal character as much as social structure” (Sennett, 2003, p. 260). In terms of mutual recognition, the therapeutic relation challenges us by its inherently unequal constitution.

MUTUAL EMPOWERMENT Therapeutic relationship is indeed challenging in terms of power relations. Inequalities exist in the very constitution of the helping relation. Sennett points also to a “shame of dependence” that is related to the high value of autonomy in Western cultures and that renders the professional helping relations particularly challenging: “Even a freely given gift can injure the self-respect of the person to whom it is given” (Sennett, 2003, p. 149). However, in private life (outside therapy), dependency and interdependency are characteristic of good relationships — for example, between children and their parents as well as between lovers. In talking about her own experiences as a patient, Norwegian psychologist Lauveng emphasizes the importance of having the possibility of giving something to her helpers. In situations when she could contribute with something that would be useful for another person, doing so helped her to regain her

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self-respect: “It’s hard always to be the one who receives and not to have opportunities to give”28 (Lauveng, 2005, p. 102). The importance of mutuality is also emphasized in feminist therapy. In accordance with the philosophy of empowerment, feminist therapy articulates focus on power relations and the expert-therapist role is devaluated. But this might be problematic if it implied a failure to accept credit from the client. Such a denial of the therapist’s powerful role in the client’s life would represent a false equality according to Becker (2005, p. 166). Recognizing the client’s craft need not imply a neglect of the therapist’s craft. A devaluation of the therapist’s expertise, in relation to the therapeutic outcome, must not imply that the therapist does not recognize what she or he has meant for the client. Worell and Remer (1996/2003) emphasize the important function of the therapist as a role model. Acknowledging such gifts or “payback” is a way of acknowledging that the therapist too is worthy of respect, as well as respecting the client’s valuing of the therapy and her or his wish to share this with the therapist. Both Maria and Emma gave me gifts, small tokens whose value was less economic than symbolic: a homemade Christmas card, some homemade soaps, a CD with a new recording of a song we had composed together. After the last session before Christmas, I found a Christmas present waiting for me in the music therapy room (see chapter 5). Maria had been there during my lunch break and put it there for me. She had made me a plaster figure to decorate my wall. It was a golden, fluteplaying angel. Angels had been a theme in several songs that we had been singing, and one of the songs that I always very much enjoyed singing with her was the song “Angel”. For my part, I also dared to think of it as a symbol of the meaning that music, music therapy, and I might have for her. In feminist relational cultural theory, Jordan and Hartling (2002) argue that growth-fostering relationships are characterized by mutual empathy and mutual empowerment. They explain this mutuality by stating that: Healthy development occurs when both people are growing and changing in the relationship. When individuals are engaged in mutually empathic and mutually empowering relationships, both people are becoming more responsive in fostering the well28

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Moreover, they argue that the outcome of such a mutual relationship is also a desire for relationships that goes beyond that particular relationship. Growth, then, implies not only a development toward separation, independency, and individual autonomy, but also simultaneously a development toward greater mutuality and empathic possibilities. Mutuality and interdependency seem to be relational qualities that are compatible with empowerment and probably even promote it. In order to be empowered in relationships, people need to contribute to as well as to benefit from such relationships (Sprague & Hayes, 2000, p. 683). There is no reason why this should not also be true of the therapeutic relationship. In principle, I would think of any good or successful music therapy process as having an empowering function for the therapist as well as for the client. This is because inevitably a good therapeutic process will nurture, develop, and confirm the therapist’s professional and personal, capabilities. Surrey attributes the empowerment related to the therapist’s role first of all to their capability as a therapist, to the capacity to be emotionally present and authentic: For the therapist, mutuality refers to this way of being in relationship: emphatically attuned, emotionally responsive, authentically present, and open to change. The therapist’s growth in the relationship involves enhanced emphatic possibilities, capacities to stay present with a range of difficult feelings in herself and others, and greater freedom to “stay in” the process and bring more and more of herself into the relationship. (Surrey, 1997, p. 43) This, I believe, will in most cases in the long run also provide the therapist with recognition from other professionals in the institution where she or he works. Of course, when asking about how the therapist has been empowered, it must be emphasized that just as questions about the outcome of therapy for the client have to be understood within a contextual model, so this applies also to the therapist’s empowerment. Thus, the experiences I will refer to as empowering for the therapist in this process must be understood in a contextual frame of understanding.

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The cases of Emma’s and Maria’s music therapy have illustrated a process of empowerment, a process in which they developed their strengths and resources, enhanced their capabilities for coping, and developed new possibilities for participation in music activities outside music therapy. It is striking that these music therapy processes have also affected me very much. These are collaborations and therapeutic processes in which I feel that I have used myself in a diversity of ways, in which I have been challenged personally and professionally, but in which I have also felt that each session has been important not only for the clients, but for me as well. This work, especially with Emma and Maria but also with some other “singers” in the hospital, provided for me a very good opportunity to develop my voice and my confidence in singing. Together with these “singers,” I have had the opportunity to learn lots of new songs and to develop my ability to sing duets. They have challenged me to sing for other people in the hospital, to use a microphone, to make recordings. For all of these opportunities, I am really thankful! The songs that we had written together, and my research on these cases, equipped me with opportunities to sing outside music therapy: I have performed some of these songs that I wrote together with Maria and Emma in conferences and research seminars. Over the course of these years, I have gradually felt more able to sing in other people’s presences outside of music therapy, too. I have had the opportunity to research these music therapeutic processes, and presenting my research has provided me with some lovely and deeply needed “excuses” for singing. Having some songs to present to others has allowed me to sing without having too much focus upon my own performance, which has made me able to dare to sing more out loud in front of an audience. Another important dimension of this work for me is related to my role as a professional music therapist and scholar. Emma and Maria have been ambassadors for music therapy and for me as a professional music therapist in the hospital. They have raised their voices and emphasized the importance of music therapy to nurses and psychiatrists, and suggested music therapy to fellow patients. They have invited nurses and psychiatrists to music therapy to see what we have been working on and in this way contributed to knowledge about music therapy among other professions. This enhanced my professional participation in the hospital, increasing my opportunities to take part in the decision-making processes in the hospital. Moreover, having agreed to be my informants in the study reported in this book, they have facilitated for me greater professional

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acknowledgment and respect in my position in the hospital as well as in the university and in the wider world of music therapy academia.

AUTHENTICITY AND SELF-DISCLOSURE I have in this final chapter emphasized the therapeutic relation in terms of mutuality. In this section, I will consider aspects related to authenticity and propose self-disclosure as a type of performance of authenticity in the therapeutic relation. Self-disclosure appears quite self-evident as part of a mutual relationship, although the concept in the psychotherapy literature refers solely to the therapist’s acts of telling something about her- or himself. Sharing experiences is fundamental to a therapeutic relationship, but is sometimes solely attributed to the client’s efforts in therapy. Thus, the need for a conceptualization of the therapist’s sharing must be seen in juxtaposition to the idea of distance as a necessary condition for a healthy therapeutic relationship. The therapeutic relationship should never include an attitude of superiority; both members of the interaction must be open to influence by the other. Both must risk change and the uncertainty which accompanies growth. This does not imply that both grow in the same way, or that there is no difference between therapist and client. But mutuality in therapy does rest on the assumption that real growth of an individual can occur only in the context of a real, mutually responsive relationship. (Jordan, 1997, p. 143) Self-disclosure can be defined as “therapist statements that reveal something personal about the therapist” (Hill & Knox, 2002, p. 255). Verbal self-disclosure can involve disclosure of facts (“I have four children”), disclosure of feelings (“I feel angry when I hear about that”), insights, or strategies. Self-disclosure is used in several psychotherapeutic approaches (e.g., humanistic therapy, feminist therapy, and multicultural theory) and avoided in others. Self-disclosure can be seen as a prerequisite for the client’s openness, serving to build trust and openness, mutuality and intimacy. It is understood as a way in which the client can learn about their impact on others (Jordan & Hartling, 2002, p. 51), and it is often viewed as equalizing power in the therapeutic relationship (Hill &

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Knox, 2002; Worell & Remer, 1996/2003). Hill and Knox’s definition of self-disclosure excludes disclosures that are not verbal, and in music therapy we inevitably also disclose personal things in our music, such as musical identity, musical competence, or emotions. Previously in this chapter aspects of mutual empowerment were illuminated. I argued that within the feminist approach, the mutual experience of empowerment has been emphasized and almost understood as part of empowerment by definition (Jordan, 1997; Sprague & Hayes, 2000; Worell & Remer, 1996/2003). Similarly, Sennett’s concept of respect is anchored in the experience of mutuality. Following this we have to ask: How does the client know that the therapy or the therapeutic relationship is also empowering for the therapist? Does she or he have to know about it? To what degree must, or should, the therapist share her or his experience of empowerment with the client? With both Maria and Emma, I shared on various occasions my own gains from the therapeutic collaborations. On one of these occasions, in one of the last sessions with Emma, I wrote about this in the log: I tell her that I think it feels strange and sad to end our collaborations. I tell her I have also gained lots from the contact that we have had, both professionally and personally. Professionally, that I have learned a great deal about trusting the client’s resources and knowledge about how they can use music. I have learned much from the interviews, and lots of new songs. But it has also been important to me personally to sing and to create so many gorgeous songs. I think, however, that the most explicit sharing of my experiences of mutual empowerment typically happened in the sessions in which we evaluated the music therapy. In other sessions, it took the form of comments like, “Oh, I am glad you taught me this song,” or, “It was really nice to sing together with you today.” Maria on some occasions also explicitly shared with me the fact that she knew that I liked to sing a specific song. Thus, perhaps even some knowledge of mutual empowerment is shared even before any verbal statement of it is mooted. What my empirical material does not show is how this sort of sharing contributed to the therapeutic process. Generally, I would think that knowing that the therapist also values the collaborations must be something good for the client.

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The therapist’s sharing of the meaning of therapy as it has contributed to empowerment implies disclosing something personal that is not only related to the positive gains, but also involves sharing something of the therapist’s vulnerability. Let me just emphasize also that when disclosure is warranted in therapy, this is not without caution. It is important not to disrupt the client’s flow in therapy, not to become a burden to the client, not to be intrusive. Disclosing something is not about disclosing everything (Surrey, 1997). Yet, it is tempting also to reverse this question: Why are we so afraid of mutuality and closeness in the therapeutic relationship? Why are we not skeptical of the ethic implications of “distance” in the therapeutic relationship? If we accept to acknowledge the genuineness of the therapeutic relationship, we must also open up the possibilities for a variety of collaborative styles and qualities of the relationship. Client and therapist are different just as other people, and their relationship would vary considerably in relation to how intimate they would be (Joseph & Linley, 2006). This is crucial to acknowledge, because if we try to develop the same degree of intimacy and the same type of relationship with every client, we seem to overlook the core of a relationship: that it unfolds between people. There is a danger that we conceive of ourselves as “super-therapists” (Tweed & Salter, 2000), omnipotent experts who are able to help any client.

FINAL THOUGHTS Looking back on the journey of my research and the process of writing this book, there is one single lesson that stands out: that at the core of a resource-oriented approach is the fostering of egalitarian relationships. Empowerment is not something the therapist can do for the client with the use of sophisticated techniques and expertise. The clients may lead us on the way, as they are the key to their own empowerment. A resourceoriented approach to music therapy is about noticing, acknowledging, and making use of the client’s resources through the fostering of a collaborative relationship. Music therapists have a wonderful opportunity to be in the forefront in recognizing and making clients’ resources visible, (and not the least, audible). In music therapy, we have so many possibilities to see and to make use of the client’s resources, as the musical interaction allows clients to unfold and show us their musical and relational strengths. Thus, music may help us to move toward more egalitarian relationships, as we let ourselves be engaged with the music together with our clients. There is a discursive side to this as well: We cannot foster the client’s resources, foster empowerment, without talking about the client and talking about therapy in ways that acknowledge their resources and more equally distribute the power of change. This is a real challenge because the discourse of therapy is preoccupied with the weakness of the client. Our aim must be to talk about clients in ways that don’t diminish their resources but that still acknowledge their pains and their struggles. I wish to emphasize, as I have argued throughout this book, that discourse matters! The way we talk about music therapy influences the way we perform music therapy. The discursive practice of music therapy involves how we talk about music therapy and about the client in the sessions of therapy, how we talk about therapy and about the client in meetings with other therapists and staff, and how we represent music therapy in academic discourse, in writing and public presentations. With this discursive implication, the question of equal power relations that I identified as at the core of empowerment and the core of the resourceoriented approach also has a political dimension. In this book, the efforts toward a more egalitarian discourse of music therapy has involved connecting the resource-oriented approach to a broad landscape of academic discourse, such as empowerment philosophy,

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positive psychology, the common factors approach, and current musicology. Hence I have been aligning with forces counteracting the extensive focus on problems and pathology that has dominated the professional discourse of therapy. As mentioned in the first chapter, however, mental health care politics is changing. For several years, there have been political movements toward more user participation, toward more focus on health promotion, and toward more interest in cultural activities as part of health concerns. I think it is crucial that music therapy is part of this development in mental health care, and my hope is that this book will inspire such developments in music therapy practice.

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INDEX

A access to music;35; 68; 84 affordances;67; 68; 70; 72; 73; 83 Aigen;9; 59; 61; 84 Amir;9 Ansdell;IV; 9; 12; 24; 25; 36; 45; 59; 60; 61; 67; 72; 118; 194 Antonovsky;7; 20; 31; 32; 38; 76 Austin;27; 136; 201 autonomous music;60; 61; 62; 63; 64; 65; 68; 78 autonomy;23; 57; 69; 117; 220; 224; 226

B Baker;195 Bandura;117; 119 Becker;3; 19; 33; 79; 81; 82; 220; 225 Beutler;198; 199; 200 Blackbird;141; 145; 173 blaming the victim;32; 126; 173 Bohart;22; 48; 49; 185; 187; 214; 215; 216 Bohlman;33; 59; 69; 70 Bonde;9; 10; 28 Broaden and Build;54; 125 Bruscia;5; 7; 14; 22; 34; 43; 61; 201

C Cassity;26 client’s theory of change;188; 202 client-centered;38; 215 collaboration; 37; 42; 74; 77ff; 178; 181; 201;206; 213; 217; 221 common factors; 47; 49ff; 50; 51; 52; 184; 185; 187; 198; 215

communicative musicality;71; 194; 217; 218 communitas;217; 218 community music therapy;3; 9; 11; 45; 81; 85 competence;40; 57; 75; 117; 119; 121; 218 client's competence; 5; 77; 83; 85; 172; 181; 183ff; 190ff therapist's competence; 3; 45; 181; 201ff consumerism;19; 24 contextual; 9; 10; 12; 32; 33; 47; 49; 50; 51; 52; 59; 62; 64; 77; 81; 82; 178; 181; 184; 186; 198; 199; 203; 226 continuum model;7; 29 control; 40; 42; 80; 81; 82; 118; 188; 189; 190; 191; 193; 215; 220 coping;9; 31; 32; 36; 37; 55; 117; 169; 205; 206; Csikszentmihalyi;21; 53; 55; 81; 123 cultural capital;34; 121 cultural context;9; 32; 64; 65; 85; 122 cultural politics;18; 34; 66 Curtis;9; 46

D Dalton;39; 40; 41; 42; 44; 80 Daveson;8; 42 De Backer;27; 28 decision-making;19; 39; 77; 79; 80; 184; 221; 227 demoralization;76 DeNora;65; 67; 70; 83; 181; 192; 193; 234; 237 diagnostic manuals;20; 29; 56; 57 dialectic approach;29 dichotomous model;29

Index discourse;18; 19; 21; 22; 25; 28; 36; 43; 57; 81; 185; 201; 231 discrete model;20; 29 dodo bird verdict;47; 48; 49 Duncan;36; 188; 197; 202

E egalitarian;1; 43; 216; 218; 219; 231 elitist tendency;34; 35 emotional regulation;106; 168; 175 empathy;51; 56; 215; 225 empowerment; 8; 15; 18; 19; 37ff; 73ff; 85; 117; 125; 167; 171; 178; 181; 186; 216;229; 230; 231 Empowerment;VII; X; 39; 40; 41; 42; 43; 45; 81; 221; 224; 231; 234; 235; 236; 237; 238; 245; 247; 248; 250; 252; 253; 254; 257 enablement; 44; 45; 75; 76; 85; 120 equality; 1; 3; 23; 46; 68; 78; 79; 171; 201; 206; 216; 217; 219; 221; 225 essentialism;61 ethnographic;13; 15; 193 eudemonic;55; 123 evidence-based;4; 18; 24; 48; 240 Expectancy effects;50 extratherapeutic factors;46; 50; 185

F feminist therapy;9; 46; 81; 225; 228 flow;54; 55; 123; 207; 230 Frank;49; 76; 126 Fredrickson;54; 125 Furedi;21; 23; 24; 80; 126; 169

259

health promotion;7; 31; 181 heroic client;188 Houghton;26 Hubble;185; 186 humanistic;38; 39; 228 Hviid;9

I illness ideology; 10; 15; 18; 19; 20; 22; 23; 24; 25; 28; 29; 35; 38; 57; 169; 184; 186 individualization;2; 30; 32; 42; 80 interdependency;78; 79; 224; 226 intertextuality;65; 66 interventions;4; 5; 18; 21ff; 24ff; 43; 48; 52; 56; 68; 77ff; 185; 202; 215

J Jante;1; 2 Jensen;27; 29 Joseph;57; 58; 200; 230 joy; 54; 113; 114; 116; 122; 124ff 167; 175; 177; 201; 207; 218

K Kenny;9; 14; 45; 59 Kuhn;10; 243 Kvale;14; 243

L Lambert;47; 48; 50; 51; 52; 185; 214 Lee;201 Luborsky;47; 48

G Garred;8 Gold; 4; 7; 12; 24; 179; 189; 190

H Hadley;27 Hannibal;27; 28; 116 happiness;2; 53; 55; 76; 80; 113; 123; 125; 126; 129

M Maddux;20; 21; 22; 28; 53; 57; 80 Maratos;28 mastery;, 6; 7; 8; 55; 113ff; 167; 177; 210; 217; 220 McClary;33; 65; 69 McLeod;14 Mechanic;20

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medical model;4; 5; 10; 15; 19; 20ff; 25ff; 43; 47; 48; 49; 52; 80; 184 Metzner;28 Miller;26; 36; 185; 186; 188; 197; 202 motivation;51; 56; 72; 77; 114ff; 125; 126; 134; 178; 208; 211 music politics;33; 34; 35 musicianship;72; 194; 200; 201 musicking;34; 42; 52; 61; 62; 65; 66; 68; 70ff; 75; 84; 85; 123; 208; 218 musics;70; 71 mutuality; 23; 42; 46; 78; 79; 171; 178; 201; 206; 207; 216; 217; 218; 219; 221; 225; 226; 228; 229; 230

N negative emotions;54; 113; 167; 168; 169; 205; 208; 223 negotiations;23; 75; 79; 167; 168; 221; 222; 223 new musicology;59; 65; 69 Nordoff-Robbins;7; 8 Normann;9 North;191; 192

O

person-centered;38; 57 placebo;47; 50; 184 pleasure;5; 54; 96; 103; 104; 114; 123; 124; 125; 126; 177; 191; 207 political;18; 19; 30; 33; 34; 35; 36ff; 43; 46; 47; 53; 57; 62; 66; 75; 79; 80; 82; 84; 85; 91; 122; 131; 201; 221; 231 positive emotions; 4; 53; 54; 55; 76; 113; 114; 124; 125; 126; 173; 177; 204; 207; 208; 210 positive health;19; 29; 32; 35 positive psychology; 15; 29; 32; 39; 53; 55; 56; 57; 73; 76; 80; 125; 177; 232 positive therapy;55; 56; 57; 58; 200 power over;41; 81 power relation;23; 24 power relations;13; 15; 23; 24; 33; 35; 65; 79; 218; 224; 225; 231 power to;13; 41; 44; 80; 81; 192 prevention;31; 53; 54; 55; 76 Priestley;27 Procter; 9; 24; 42; 44; 75; 120; 121; 122; 182 protomusicality;70; 71 psychoanalysis;27; 28 purposeful sampling;13 Putnam;75; 121

R

Odell-Miller;26

P paradigm;10; 25; 39; 60 participant observation;13 participation;4; 6; 9; 30; 39ff; 50; 62; 75ff; 85; 114; 115; 117; 121; 122; 182; 190; 195; 208; 212; 216; 221; 227 pathology; 3; 4; 5; 7; 9; 18; 23; 35; 36; 44; 46; 56; 57; 76; 80; 82; 167; 169; 170; 172; 173; 177; 178; 184; 186; 197; 198; 205; 212 Pavlicevic;24; 45; 72; 194; 201; 217; 218 Pedersen;9; 10; 28 performance;34; 41; 45; 59; 61; 62; 66; 69; 70; 79; 84; 85; 93; 114; 118; 167; 174; 176; 195; 211; 216; 219; 220; 222; 227; 228

recovery;50; 184; 187 Renblad;39; 40; 41 resilience;32; 38; 53; 76; 125; 185 respect;3; 42; 79; 215; 219; 220; 221; 224; 225; 228; 229 Rolvsjord; 2; 3; 7; 12; 24; 27; 36; 52; 75; 179; 187; 202; 218 Ruud;7; 9; 35; 59; 61; 68; 72; 83; 121; 192; 193; 217; 218 Ryan;55; 57; 76; 80; 116; 117

S salutogenic;7; 9; 31; 38; 76 Schwabe;7; 8; 61; 197; 198; 250 Sears;6; 250 self-actualization;7; 8; 55; 123 self-determination;23; 39; 44; 57; 77; 78; 80; 85; 117; 145; 221

Index self-efficacy;40; 117; 119; 177; 210 self-esteem; 40; 85; 110; 115; 117; 119; 120; 210 self-heal;187 self-right;187 self-worth;118; 119; 120 Seligman;21; 53; 54; 55; 56; 76; 123; 126; 201 Sennett;3; 78; 79; 218; 219; 220; 224; 229 sensitizing concepts;73; 74 sexual abuse;2; 86; 91; 131; 138; 172 sexual violence;82 signature strengths;55; 123 Silverman;26 Skarpeid;193 Sloboda;34; 70; 71; 83; 84; 116; 121; 191 Small;34; 61; 62; 66; 70; 71; 84; 121; 218 Smeijsters;26 Snyder;28; 29; 51; 54; 56; 57; 172; 177; 178; social activism;18 social capital;75; 81; 120; 121; 122; 182 social disability model;30 social movements;19; 33 social participation;114; 121 Solli;7; 182 songwriting; 95; 107; 129; 130; 136; 154; 156; 164; 165; 168; 174; 195 specific techniques;26; 56; 199; 200 Sprague;41; 44; 46; 79; 216; 226; 229 Stige;7; 9; 12; 13; 15; 24; 26; 27; 30; 32; 38; 45; 46; 60; 67; 68; 70; 71; 78; 79; 115; 124; 167; 179 Streeter;27 strengths-inclusive assessments;56 symptoms;4; 26; 56; 78; 115; 123; 126; 176; 205

T Tallman;22; 48; 49; 185; 187; 214; 215; 216 termination;26; 99; 204; 210 Thaut;25; 26 therapeutic alliance;51; 77; 215; 223 therapeutic principles;16; 200; 202; 204

261

therapeutic relationship 3; 16; 27; 46; 78; 79; 159; 174; 178; 203; 211; 214ff; 223; 226; 228ff therapist allegiance;51 Tomlinson;64 Townsend;43; 44; 81 trauma;5; 87; 154; 167ff; 171; 176 Treitler;62; 63; 65; 255 triangulation;13 Trondalen;9 Tyson;9

U Unkefer;26 user participation;19; 24; 37

W Wampold;20; 21; 24; 27; 47; 48; 49; 50; 51; 77; 185; 198; 199; 202 well-being;19; 29; 53; 54; 55; 57; 76; 80; 116; 117; 123; 191; 199; 207; 226 Wigram;4; 9; 10; 28; 195 Worell;33; 43; 44; 46; 80; 82; 216; 225; 229 worthiness;119

Y York;9

Å Aasgaard;9; 35; 195

APPENDIX

Appendix 263

264 Randi Rolvsjord

Appendix 265

266 Randi Rolvsjord

Appendix 267

268 Randi Rolvsjord

Appendix 269

270 Randi Rolvsjord

Appendix 271

272 Randi Rolvsjord

Appendix 273

274 Randi Rolvsjord

Appendix 275

276 Randi Rolvsjord

Appendix 277

278 Randi Rolvsjord

Appendix 279

280 Randi Rolvsjord

Appendix 281

282 Randi Rolvsjord