Research Rigour and Therapeutic Flexibility: Appendix

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1 Research Rigour and Therapeutic Flexibility: Appendix Randi Rolvsjord, Christian Gold & Brynjulf Stige Appendix to the article Research Rigour and Therapeutic Flexibility by Randi Rolvsjord, Christian Gold & Brynjulf Stige, published in NJMT 14(1) Therapeutic Principles for Resourceoriented Music Therapy: A Contextual Approach to the Field of Mental Health Introduction This text was developed for the purpose of training therapists to become competent in the application of the therapeutic principles for resource-oriented music therapy in the field of mental health.[1] The concept of resources includes personal, social, cultural, and economic aspects. The principles are developed for clinical work in the field of mental health and are informed by literature that stresses a) the importance of contextual factors in the healing process, b) collaboration and equality between client and therapist, and c) the role of music as a health resource. We will briefly introduce these three basic points before presenting the principles, giving explanatory comments and examples, and clarifying the importance of adherence and competence when applying these principles. A contextual approach to music psychotherapy embraces the whole therapeutic context as a potential source (or resource) for change and development in terms of the client s health. Thus, the outcome is primarily related to the client s capacity to use the therapeutic context for making important changes in her or his life. The client uses the space provided in therapy to activate or mobilize resources for change, which makes the processes that people engage in within therapy similar to other healing processes that people engage in outside of therapy. Thus, this perspective influences how we understand the relationship between the therapist and the client. The main source of change in such a model cannot be attributed to the therapist s interventions, but must be attributed in large part to the process of collaboration. This necessitates a reconsideration of the powerrelations in therapy, since the main source of change in therapy is connected to the client s efforts in mobilizing her/his resources. In this approach, music may be understood as a health resource through the twofold process of affordance and appropriation. Affordance is the range of resources that music and its materials may provide. Appropriation is how this affordance is used. Music, then, can be understood in terms of being materials and events that afford embodiment, feeling and modes of action. Thus, music provides a ground for selfperception of body, regulation of emotions, and development of social relationships. In other words, music is not reduced to a means or a medium of communication only, but is understood as a contextual and multifaceted process. To take a resource-oriented approach is not a way of ignoring pathology or avoiding problems that reveal themselves during the therapy process. To work with resources and problems can be very relevant in some therapeutic situations. Deciding how, when, and how much to focus on resources versus problems requires clinical judgement. This decision should be informed by the guidelines of this manual. 1

2 The Principles, An Overview We are adopting a structure suggested by Waltz et al.[2] which lists four categories of principles: (1) Unique and essential (2) essential but not unique (3) acceptable but not necessary (4) not acceptable (proscribed). Waltz et al. illuminate how the unique and essential principles of one approach (e.g., psychodynamic therapy) may be proscribed in another (e.g., behavioural therapy) and vice versa whereas principles in the middle categories, (2) and (3), may be shared by both. We find this helpful and have therefore chosen to organize our principles in relation to how they are unique, essential, acceptable or proscribed. Otherwise, one could see differences between approaches where there are none, or no differences where there are some. One could also be misled in terms of the degree to which a treatment effect is specific to its stated principles, for example, when unique principles are present, but acceptable ones prevail. The formulation of these therapeutic principles is based upon clinical experience and theoretical studies. What we present here as resource-oriented music therapy is a contextual approach informed by literature on contextual factors and collaboration in therapy with clients with mental health problems, and is not defined as a specific music therapy model. For the sake of comparison, however, the principles are related to more established models of music therapy in psychiatry. Taken together the principles illuminate contextual and collaborative features associated with resourceoriented music therapy in a psychiatric setting. The sequence given does not reveal priority (the first principle under each heading is not necessarily more important than the second). Since the manual will be used by the therapist, not by the client, the guidelines are given from the viewpoint of the therapist. We want to reiterate, however, that a central value when formulating these principles has been that the therapeutic process should be characterized by equality and collaboration. 1. Unique and Essential Therapeutic Principles We understand the therapeutic principles in this section to be unique and essential to resource-oriented music therapy. These principles are understood as central and defining for this approach/perspective, and have only been articulated to a very limited degree as central and defining in existing music therapy models Focusing on the client s strengths and potentials Recognizing the client s competence related to her/his therapeutic process Collaborating with the client concerning goals of therapy and methods of working Acknowledging the client s musical identity Being emotionally involved in music Fostering positive emotions. 2. Essential but not Unique Therapeutic Principles The principles in this category are essential to a resource-oriented music therapy perspective, but are also essential to existing music therapy models. These principles are as important as the previous Engaging the client in music interplay (such as musical improvisation, creating songs, playing pre-composed music or listening to music) Acknowledging and encouraging musical skills and potentials Reflecting verbally on music and musical interplay Listening and interacting empathically Tuning into the client s musical expressions Collaborating with the client concerning the length and termination of the therapy process. 2

3 3. Acceptable but not Necessary Therapeutic Principles In this category we describe therapeutic actions that might be relevant in some cases, but that are not considered essential and defining to resource-oriented music therapy Teaching instruments/music Sharing one s own experiences Presenting/performing music with the client outside the therapy setting Providing therapeutic rationale Having music as the primary goal of therapy 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 Neglecting the client s strengths and potentials Having a strong focus on pathology Avoiding emerging problems and negative emotions Directing in a non-collaborative 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 not the only function of therapy, and not the only way of promoting health. To nurture and develop 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/his skills, ways of coping, achievements, personality, competencies, social relationships, etc. To focus on the client s strengths and potentials or to focus on problems and pathology are not seen as mutually exclusive alternatives, but might be interacting processes. It is important to keep 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: To focus 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 Recognizing the client s competence related to her/his therapeutic process To focus on the client s strengths, potentials, and resources in order to nurture and develop her/his ability for coping, thereby promoting health, easily turns out to be paradoxical. Helping the other in order to empower him- or her-self might actually decrease her/his autonomy and empowerment. To avoid this paradoxical situation, the therapist must continuously focus on the client s strengths and potentials and 3

4 show her/his belief in these through the recognition of the client s competence related to her/his therapeutic process. The therapist must not take the position of the expert, but must connect with the client and create a mutual and collaborative relationship. What this is not: To recognize the client s competence related to her/his therapeutic process is not to reduce 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. As the creation of a relationship between therapist and client based upon equality and mutuality is desired, collaboration is necessary. Collaboration implies a shared responsibility of the process of therapy in which both the therapist and the client are using their competences towards their common goal/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 related to her/his own life. Obviously, when a client makes the decision to work in music therapy, she/he usually has an interest in music, and some previous experiences of what music means to her/him in her/his life. However, at the same time, she/he usually does not know what music therapy is, and she/he has limited knowledge of the possibilities inherent in different methods of music therapy. Therefore, this collaboration in terms of establishing goals and methods of working is essential. For the therapist to show determination, have authority, and to set and keep boundaries is not incompatible with this principle. 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/his problems. 1.4 Acknowledging the client s musical identity The client s musical resources are related to her/his musical identity. The client s musical identity is related to the culture of the community she/he belongs to, as well as being related to one s personal and collective history. To recognize and acknowledge her/his musical identity is a way of focusing and nurturing these resources. This might be a way of developing the client s individual musical competencies, as well as nurturing her/his 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 only playing music that the client is familiar with. 1.5 Being emotionally involved in music The musical interaction is the foundation of resource-oriented music therapy. To be emotionally involved in music is to supply energy and vitality to the musical interplay. This makes experiences of mutuality, authenticity, and beauty possible. This means that 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: To be authentic and involved in the music is not to play out your emotions in ways that are interfering negatively with the therapist role by reducing 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, flow, and relational emotions such as feelings of belonging. The music therapist 4

5 should foster such emotions by recognizing these aspects of music making, by being authentic and 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 pre-composed music or listening to music) It is essential to a resource-oriented music therapy approach that the therapist engage the client in some kind of musical activity. To enter such a musical space and gain new experiences through musicing 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/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 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 is not paying attention only to the musical product. 2.3 Reflecting verbally on music and musical interplay To talk about the music and to talk about the musical interplay are very important aspects of resourceoriented music therapy in psychiatry. It is essential that the therapist is open to verbal reflections and creates a space for verbal reflections in the sessions. The time spent for verbal reflections can vary greatly, both within a single client s therapeutic process, and from client to client. Verbal reflections might lead into the musical activities in some cases. In other cases, verbal reflections might follow the musical activity. Verbal reflections can be discussions of the lyrics, on how the music sounded, on the emotions related to the musical expressions, or on music in everyday life. 5

6 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 to do verbal therapy. To include and emphasize the importance of verbal reflections on musical interplay (and music) is not to do 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 expressions, for example, her/his body-language. Empathy implies a sensitivity and willingness to understand the client s thoughts, feelings and struggles from the client s point of view. What this is not: Empathetic listening is not agreeing with everything the client says. 2.5 Tuning into the client s musical expressions The therapist should tune into the vitality or energy level of the client s music. In any musical interplay between the therapist and the client, there is an expression of vitality and emotions. To tune into the client s musical expression of such vitality affects is the consequence of empathetic listening. What this is not: Tuning into the client s musical expressions is not never challenging or stimulating the client s music. 2.6 Collaborating with the client concerning the length and termination of the therapy process The 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 there will be time spent in preparing for termination and dealing with issues related to closure and parting. This implies that client and therapist collaborate on making a contract that indicates a projected timeframe 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 timeframe. 3 Acceptable but not Necessary Therapeutic Principles The principles in this category might be of importance in some but not in other cases. They are not essential to resource-oriented music therapy, but might be included in a constructive way. 3.1 Teaching instruments/music To teach a client an instrument can be an acceptable therapeutic action if the client wants to learn to play an instrument. To learn to play an instrument is to develop and nurture musical skills. These musical skills are 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. What this is not: Teaching instruments or music is not to leave the therapeutic process in favour of a pedagogical one. 3.2 Sharing own experiences 6

7 To share one s own experiences might be important when creating an equal relationship, and when being empathetic. It can also be an important way of confronting the client with what her/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 own experience is not to transgress the responsibilities and constraints of the therapeutic relationship. 3.3 Presenting/performing music with the client outside therapy setting Performing music outside of 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: Presenting/performing music with the client outside therapy session is not to leave behind the work inside therapy setting or to exploit performance for the benefit of the therapist or the profession. 3.4 Providing therapeutic rationale Occasionally a client will ask for an explanation about how music therapy works. Providing a rationale for the therapy is a way of recognizing the client s interest as well as her/his competence. Furthermore, it takes her/his wish for more knowledge seriously. 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 therapeutic rationale is not to explain everything the music therapist does, or to give lectures that distract from the focus upon the collaborative therapeutic process. 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 participation in a choir possible, and improving musical skills. In a resource-oriented perspective, musical goals are always directly or indirectly related to health needs. What this is not: Having music as the primary goal of therapy is not to ignore the client s health needs. 3.6 Reflecting verbally and musically on problems To reflect and explore 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. 7

8 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. 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/his therapeutic process. 4.4 Directing in a non-collaborative style If the therapist adopts a non-collaborative style and then begins to direct the therapeutic work, this conflicts with the principle of engaging in an equal relationship and significantly reduces the possibility for genuine collaboration. For example, implementation of standardized procedures would be proscribed if this is not a collaboratively chosen way of working. Application of the Principles We want to emphasize that an effective application of the therapeutic principles for resource-oriented music therapy involves adherence as well as competence. Adherence is related to whether a principle or a procedure in a manual is used and how much it is used. However, it is not always the case that more is better it would be inappropriate for a therapist to use a certain principle as often or as long as possible. Therefore, the competent application of the principle is essential. Competence is related to whether the delivery of the principle is implemented in a good (adequate) way. Most psychotherapeutic interventions will only work if they are implemented in an appropriate way and at the right time. We would like to emphasize that the competent application of the therapeutic principles for resourceoriented music therapy requires an understanding of the underlying theory. Therefore, for the most effective application of the therapeutic principles, we recommend actively utilizing the relevant literature. Following this text you will find a list of the recommended literature that has been important for the development of these principles. Qualitative and quantitative research which further examines the principles of this approach is still ongoing and may change some of our perceptions of this. It is for example possible that the relative importance of certain principles or the relationship between certain principles and phase of the therapy process could be clarified. Dialogue concerning the principles is welcomed and may be directed to randi.rolvsjord@grieg.uib.no. Notes [1] The manual is an appendix to the article Research Rigour and Therapeutic Flexibility: Rationale for a Therapy Manual Developed for a Randomized Controlled Trial published in June 2005 in Nordic Journal of Music Therapy, 14(1), pp

9 [2] Waltz, J., Addis, M E., Koerner, K., & Jacobson, N.S (1993). Testing the Integrity of a Psychotherapy Protocol: Assessment of Adherence and Competence. Journal of Consulting and Clinical Psychology, 61(4), pp Recommended Literature On Resource-oriented Music Therapy Procter, S. (2002). Empowering and Enabling Music Therapy in Non-medical Mental Health Provision. In: Kenny, C.B., & Stige, B. (Eds.). Contemporary Voices in Music Therapy. Oslo: Unipub Forlag. Rolvsjord, R (2004). Therapy as Empowerment. Clinical and Political Implications of Empowerment Philosophy in Mental Health Practises of Music Therapy. Nordic Journal of Music Therapy, 13(2), pp Rolvsjord, R (2001). Sophie Learns to Play her Songs of Tears. Nordic Journal of Music Therapy 10(1), p Ruud, E. (1998). Music Therapy. Improvisation, Communication and Culture. Gilsum, NH: Barcelona Publishers. Schwabe, C. (2000/2005). Resource-Oriented Music Therapy: The Developement of a Concept. [Original title: Wachstumsförderung versus musikalische Psychospekulation. Ressourcenorientierte Musiktherapie]. Nordic Journal of Music Therapy, 14(1), pp Solli, H.P. (2003). Twist and Shout improvisasjon som gruppemusikkterapi på psykiatrisk sykehus ["Twist and Shout" - on improvisation as group music therapy in a psychiatric hospital]. Musikkterapi, No. 2, 2003, pp Stige, B. (2002). Culture-Centered Music Therapy. Gilsum, NH: Barcelona Publishers. On the Contextual Approach to Psychotherapy Bohart, A.C., & Tallman, K. (1999). How Clients Make Therapy Work. The Process of Active Self-Healing. Washington, DC: American Psychological Association. Bohart, A.C. (2000). The Client Is the Most Important Common Factor: Clients Self-Healing Capacities and Psychotherapy. Journal of Psychotherapy Integration, Vol.10(2), Frank, J.D., & Frank, J.B. (1991). Persuasion & Healing. A Comparative Study of Psychotherapy. Baltimore: The Johns Hopkins University Press. Hubble, M. A., Duncan, B. L & Miller S.D (eds) (1999). The Heart and Soul of Change. What Works in Psychotherapy. Washington, DC: Americal Psychological association. Wampold, B.E. (2001). The Great Psychotherapy Debate: Models, Methods and Findings. New Jersey: Lawrence Erlbaum Associates. 9

10 On Health Promotion, Empowerment, and Positive Psychology Antonovsky, A. (1987). Unravelling the Mystery of Health. How People Manage Stress and Stay Well. London: Jossey-Bass Publishers. Dalton, J.H., Elias, M.J., & Wandersman, A. (2001). Community Psychology. Linking Individuals and Communities. London: Wadsworth (Thomson Learning). Fitzsimons, S., & Fuller, R. (2002). Empowerment and It s Implications for Clinical Practise in Mental Health: A Review. Journal of Mental Health, 11(5), Fredrickson, B L. (2002). Positive emotions. In Snyder C.R., & Lopez, S.J. (Eds.), Handbook of Positive Psychology (pp ). Oxford: Oxford University Press. Jordan, J., & Hartling, L.M. (2002). New Developments in Relational Cultural Theory. In: Ballou, M., & Brown, L.S. (Eds.). Rethinking Mental Health & Disorder. Feminist Perspectives. London: The Guilford Press. Seligman, M E.P., & Csikszentmihaly, M. (2000). Positive Psychology. American Psychologist, 55(1), pp On Music as Health Resource DeNora, T. (2000). Music in Everyday Life. Cambridge: University Press. Ruud, E. (1998). Music Therapy. Improvisation, Communication and Culture. Gilsum, NH: Barcelona Publishers. Ruud, E. (2001). Varme øyeblikk. Om musikk, helse og livskvalitet [Hot Moments. On Music, Health and Quality of Life]. Oslo: Unipub forlag. Sloboda, J & O Neill, S. (2001). Emotion in Everyday Listening to Music. In: P. Juslin & J. Sloboda (Eds). Music and Emotion: Theory and Research. Oxford: Oxford University Press. Stige, B. (2002). Culture-Centered Music Therapy. Gilsum, NH: Barcelona Publishers Tyson, E.H., & Baffour, T.D. (2004). Art-based strengths: a solution-focused intervention with adolescents in an acute-care psychiatric setting. The Arts in Psychotherapy, 31, pp