Therapeutic methods of experienced music therapists as a function of the kind of clients and the goals of therapy

Transcription

1 Music Therapy Today October 2002 Therapeutic methods of experienced music therapists as a function of the kind of clients and the goals of therapy Klaus Drieschner and Almut Pioch Abstract This article centers on the variety of therapeutic approaches and questions the idea that a certain music therapy tradition and training is based on the practice of teaching and trading their methods. Moreover, it shows that the methods of a certain approach were developed from the l kind of clients and specific situated goals and actions of therapy. This geopsychology-like approach reminds us, that we should not only look at the founders and persons, who developed a certain approach and practice, but to regard their ecological situation and performance during the time of development. The authors focused on questions of receptive and active methods, problem-focussed and music-focussed approaches and scheduling levels of structuring for the therapeutic practice of 30 experienced therapists were elaborated and researched. Their conclusion: This study has shown that these dimensions are not merely theoretical constructs but also exist in the clinical reality.... The results suggest that the egostrength of clients can explain a lot of the methodological variation. However, there is definitely no general agreement about the choice of methods. The statistical analysis showed that the goal of therapy and the target group together account for % of the differences between therapeutic methods on the three dimensions. This means that factors such as the theoretical frames of reference of the therapist, differences in 1

2 Introduction professional socialisation, personal preferences etcetera, may be at least as important for the choice of method. Having presented this for the first time at the 2001 EMTC conference in Naples, we would like to share with you the emergence of this important empirical study into the real world of applied music therapy. (JF) Introduction An international conference like this reminds us that music therapy is a collective term for a huge variety of therapeutic methods. The situation is sometimes confusing, even for us, let alone for outsiders, such as other health care professionals, clients, health care managers, or the general public. A definition of music therapy (and there are many) only sets the common ground of our profession. It does not guarantee a strong professional identity, as little, for example, as definition of the European border automatically leads to a European integrationprocess. Let me stick to this metaphor for a moment. Today, it has generally been accepted that the integration of Europe requires the recognition of regional identities. The idea is that acceptance of the differences between the parts will lead to an integrated whole. This seemingly contradictory idea may also be true for music therapy: In order to get a strong professional identity, we have to find out in which way the methods of music therapy differ. This is our first researchquestion. It may seem paradox, but as you will see, a systematic look at the differences between methods automatically opens the eyes for what they have in common. Once we know in which way methods of music therapy differ, we should ask whether the methodological pluralism makes sense from the point of view of the client. Of course, different problems of clients require differ- and the goals of therapy 2

3 Method ent methods of treatment. However, it makes less sense if clients with very similar problems and goals of therapy are treated very differently, because of different theoretical backgrounds, professional socialisations or methodological preferences of their therapists. From the clients point of view, these are irrelevant and coincidental factors. Clients are interested in the best possible treatment for their problems, given the state of the art. Therefore, the second question of our study was whether and to what extent the kind of client and the goals of therapy determine the therapeutic methods used by music therapists. Method How did we try to answer the two research questions? We conducted intensive standardized interviews with 30 registered music therapists working in adult psychiatry, geriatrics, child psychiatry, or the care for the mentally handicapped. They had an average experience of 14,5 years. The focus of the interview was on the therapeutic methods, the respondents implemented during their workweek. In this study, the term method refers to the actual in-session behaviour of the therapist as it is experienced by the client and not to background variables such as the theoretical assumptions, goals, and the like. Together the 30 therapists used 140 methods. 13 methods had a purely diagnostic purpose and are left out of the analysis presented in the following. There were about as many methods for individual music therapy as for group therapy. The interview contained 20 questions with which the position of each method on the three dimensions was assessed. and the goals of therapy 3

4 Method The conceptually most simple dimension was the well-known distinction between receptive and active music therapy. That means, listening to music or actively making music as core element of the method. Methods with both, active and receptive elements lay in between. The second dimension, "focus of attention", has to do with the function of music in the method. In some methods the relevance of the music or activity for the client s problem is discussed explicitly. We call these methods problem-focused because the client s attention is drawn to the impact of the music activities on his problem. In other methods, the therapeutic process is presumed to take place within the music or activity itself, without explicitly focusing on the relevance for the problem of the client. Such methods we call music-focused. This dimension is similar to the well-known distinction between music as therapy and music in therapy. The third dimension we called "level of structuring". The term structuring refers to all activities with which the therapist limits the behavioural freedom of the client. Structuring includes things such as determining the kind of activity, or giving specific instructions, choosing the music or the instruments, etcetera. The dimension level of structuring includes the concept of directivity but is a broader concept. We believe that most differences between methods, defined in terms of actual, observable therapeutic behaviour, can be located in one of these three dimensions. Now, we can conceptualise methods of music therapy within a three-dimensional space (see Figure 1 on page 5). and the goals of therapy 4

5 Method FIGURE 1. Three dimensional space of music therapy methods A few examples: In the corner at the front bottom left, you would find music therapy with free improvisations as core element, which are explicitly discussed in terms of relevance for the client s problem. At the rear top left, you find a method like Guided Imagery and Music (GIM): a receptive method, highly structured by the therapist, and with an explicit focus on the client s problem. At the front right top, you would find a method like making pop-music with delinquents with the aim of enhancing empathy, endurance, and self-esteem. The clients attention is on the musical process, the intended therapeutic effects are assumed to result directly from the activity itself. At the vertical edge in and the goals of therapy 5

6 Method the rear right, you find music therapy for Alzheimer patients, in which listening to familiar music is used to enhance the sense of identity or to reduce agitation. Depending on whether the client chooses the music by himself, the method receives its position on the dimension level of structuring. If listening is combined with singing, the method shifts towards the front. Apart from three dimensions, we inquired about the presumed importance of four different therapeutic mechanisms in each method: The effect of the music by itself. This factor includes the potential of music to enhance relaxation, to activate emotions, to evoke memories or to induce physiological changes. Secondly, effects resulting from the music-activities, that is the interaction of the client with the music material. This mechanism may be linked to effects such as increasing expressiveness, enhancing selfcontrol, etc. Thirdly, the therapeutic relationship, which is generally regarded as an important therapeutic factor. And finally, the factor insight, that is effects resulting from a better understanding one s own personal or social functioning. If music therapy is conceptualised as an interaction between client, therapist, and the music or music material (see Figure 2 on page 7), the four factors emphasise different aspects of this interaction. and the goals of therapy 6

7 Method FIGURE 2. Four therapeutic mechanisms as interactions between therapist, client and music Mechanism A is located at the music-corner as the effects are presumed to result directly from the music itself. Mechanism B is an interaction of the client with the music or material, which, of course may be facilitated by the therapist. Mechanism C is an interaction between client and therapist, mediated by the music. Mechanism D refers to cognitive-emotional processes within the client, facilitated by the therapist and the music or material. and the goals of therapy 7

8 3. Results 3. Results 3.1 RESULTS CONCERNING THE FIRST RESEARCH QUESTION The results of the statistical analysis provided evidence that the three dimensions are a valid concept for the conceptualisation of differences between methods of music therapy. First, a principal component analysis with orthogonal rotation perfectly supported the dimensions active versus receptive and focus of attention. The factor level of structuring might consist of two sub-dimensions. Secondly, the three dimensions were found to be more or less independent from each other. Only the dimensions focus of attention and level of structuring correlate moderately (.35). Methods with more music focus tend to be more structured than methods with problem focus. Thirdly, the scales for the three dimensions have a very satisfactory reliability (Cronbach s alphas between.84 and.89). 3.2 RESULTS CONCERNING THE SECOND RESEARCH QUESTION Does the kind of method depend on the category of patients and the goals of therapy? For the statistical analysis we distinguished between six categories of patients: geriatric patients, most of whom suffering from a form of dementia; children with various kinds of psychopathology; mentally handicapped patients with various problems; adults with neurotic or personality problems; adults with depression of anxiety; and psychotic patients. Unfortunately, we could only distinguish different adult categories, because splitting the other groups would have resulted in too small numbers of methods for the statistical analysis. and the goals of therapy 8

9 3. Results FIGURE 3. The three dimensions as function of the category of patients As Figure 3 on page 9 shows, methods for each target-group have a specific pattern on the three dimensions. This means that on average the therapeutic methods with different kinds of patients are positioned at different locations within the cube shown in Figure 1 on page 5. If we look specifically at the dimension receptive active (the rhombuses), we see that receptive methods are most common with the elderly and the goals of therapy 9

10 3. Results and with depressive adults. They are rare in therapies with neurotic adults and with children. On the dimension focus of attention (the triangles), we see a strong music focus in the therapies with the mentally handicapped. In contrast, in therapies with neurotic or personality disordered adults it seems far more common to draw the clients attention explicitly to the therapeutic meaning of the music activities. The level of structuring (the rectangles) is lower in music therapy with non-psychotic adults than with any other target-group. This dimension seems to bee a function of the ego-strength of clients. It seems as if the structure provided by the therapist compensates for the lack of structuring capacities of the clients. Are there also systematic differences between methods for different goals of therapy? For this analysis, we used five categories of goal, which had been used in earlier research in the Netherlands: SUPPORTIVE GOALS Structuring, which includes limiting the negative impact of the problem Focal behaviour-change or symptom-reduction Enhancing problem-related insight Enhancing general insight and personality change Notice that the five categories form one dimension from more superficial goals, to goals with a more profound impact on the patient. and the goals of therapy 10

11 3. Results FIGURE 4. The three dimensions as function of the goal of therapy Figure 4 on page 11 shows that, like in Figure 3 on page 9, the methods for each kind of goals have their own pattern, which again corresponds to different positions in the cube. Only the methods which aim at the two different kinds of insight have a similar pattern, which is more pronounced if a deeper and more general insight is intended. If we look at the three dimensions separately, we see that in general, with more far-reaching goals, methods become more active and less receptive (see the rhombuses), they become more problem-focused and less musicfocussed (see the triangles) and they become less structured (see the rectangles). and the goals of therapy 11

12 3. Results These results can again partly be interpreted in terms of ego-strength. Goals with a profound impact of the patients are more common for patients with considerable ego strength. Therefore less structure and a more explicit focus on the therapeutic relevance of the activities may be possible in therapies with these kinds of goals. Two MANOVA showed that the category of patients and the goal of therapy both make a statistically significant difference for the three dimensions (p<.01). Univariate ANOVA s for each of the three dimensions were all significant at the.05 level except one. There was only a trend for the influence of the goals of therapy on the dimension focus of attention (p=.69). What about the presumed therapeutic mechanisms? Figure 5 on page 13 shows differences in therapeutic mechanisms in therapies with different categories of patients. (A higher position of the symbol means that the mechanism is on average considered more important in the methods for the respective category of patients). and the goals of therapy 12

13 3. Results FIGURE 5. Presumed therapeutic mechanisms as function of the category of patients The factor insight (the white triangle) is considered most important in therapies with neurotic or personality disordered adults. In contrast, it is considered especially unimportant with the elderly or with mentally handicapped clients. The opposite is true for the therapeutic impact of the music by itself (the black rectangle). This factor is regarded as important for elderly or mentally handicapped clients but as unimportant for neurotic and personality disordered adults. Interesting is also the important role of the therapeutic relationship in therapies with psychotic adults (black rectangle). and the goals of therapy 13

14 3. Results The importance of the four therapeutic factors also clearly varies with the kind of therapy goals, as the next figure shows. FIGURE 6. Presumed therapeutic mechanisms as function of the goals of therapy The importance of the music by itself (see the black rectangles) seems to decrease, while the importance of the factor insight (white triangles) increases when goals of therapy become more far-reaching. Of course, it is not surprising that insight is considered more important, when insight is the general goal of therapy. More remarkable is the importance of the interaction with the music material (white rectangles) in therapies aimed at general insight. This suggests that insight does not primarily result from verbal interventions but also from musical experiences. It is also interesting that the presumed importance of the therapeutic relationship seems not to depend much on the kind of therapy goal. and the goals of therapy 14

15 Conclusion Again two MANOVA s showed that both, the category of clients and the goal of therapy, made a difference for the presumed therapeutic mechanism of methods (p <.01). Furthermore, univariate ANOVA s were significant for the music itself and insight, for the influence of the category of clients on the importance of the therapeutic relationship and for the influence of the goal of therapy on the importance of the interaction patient music/material (all p<.05). Conclusion What can be concluded regarding the second research question? In general, there seems to be some consensus among experienced music therapists, which general type of methods have to be used for certain categories of clients and goals of therapy. The results suggest that the ego-strength of clients can explain a lot of the methodological variation. However, there is definitely no general agreement about the choice of methods. The statistical analysis showed that the goal of therapy and the target group together account for % of the differences between therapeutic methods on the three dimensions. This means that factors such as the theoretical frames of reference of the therapist, differences in professional socialisation, personal preferences etcetera, may be at least as important for the choice of method. As these are certainly irrelevant factors from the point of view of the client, we would like to see their influence reduced. What can be the impact of this study? As mentioned earlier, we believe that a systematic look at the differences between methods of music therapy opens the eyes for what methods have in common. For example, a Chinese choir of eighty psychiatric patients, a Nordoff-Robbins therapy, and the goals of therapy 15

16 Conclusion and a vibro-acoustic treatment are so different that it is hard to perceive them as products of the same profession. However, they can conceptually be linked together with the three dimensions receptive-active, focus of attention and level of structuring. Furthermore, this study has shown that these dimensions are not merely theoretical constructs but also exist in the clinical reality. Therefore, we believe that they can support the development of a strong and international professional identity of music therapy. In addition, the study can be used for a completely different purpose. If experienced music therapists with very different theoretical and educational backgrounds, independent from each other, make similar choices regarding therapeutic methods, this can be seen as representing a kind of implicit methodological knowledge. This implicit knowledge is probably based on a common experience of which methods are most effective in certain situations. If what methods of experienced therapists have in common is not only common practice, but also good practice, the results of this study are not only a description of the reality, but can also be used prescriptively, as a standard. For example, if music therapists implicitly agree that receptive methods of music therapy are useful for the treatment of depressed adults, this implicit knowledge could be used for the development of specific methods for this category of patients or for the training of music therapists. At the very least, it can serve as a worthwhile hypothesis for outcome research. From an international point of view, it would be interesting to find out whether the results from this study hold for other countries as well. This and the goals of therapy 16

17 Conclusion would be evidence that our conclusions represent a kind of universal methodological knowledge and not only the Dutch reality. ADDRESS: Klaus Drieschner music therapist and research psychologist Almut Pioch musictherapist K.drieschner@wolmail.nl Reiderlandlaan DR Groningen The Netherlands This article can be cited as: Drieschner, K. & Pioch, A. (2002) Therapeutic methods of experienced music therapists as a function of the kind of clients and the goals of therapy Music Therapy Today, October, available at and the goals of therapy 17