Music therapy techniques as predictors of change in mental health care

The Arts in Psychotherapy 39 (2012) 333–341

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The Arts in Psychotherapy

Music therapy techniques as predictors of change in mental health care夽 Karin Mössler, Dr. sc. mus. a,∗ , Jörg Assmus, PhD b , Tor Olav Heldal, MA c , Katharina Fuchs, Mag. art. d , Christian Gold, PhD b a

GAMUT, University of Bergen, Lars Hilles Gate 3, 5015 Bergen, Norway GAMUT, Uni Health, Uni Research, Postboks 7810, 5020 Bergen, Norway Nordfjord Psychiatric Centre, Førde Health Trust, Sjukehusvei 14, 6770 Nordfjordeid, Norway d State Psychiatric Clinic Wagner-Jauregg, Wagner Jauregg Weg 15, 4020 Linz, Austria b c

a r t i c l e

i n f o

Keywords: Music therapy techniques Reproducing music Outcome predictors Therapy motivation Process-orientation

a b s t r a c t The application of music in therapy is realised through different working modalities which can be categorised into three types of techniques: production, reception, and reproduction. These techniques are commonly used in mental health settings in music therapy practice and previous research suggests that specific working modalities might be important predictors of change in music therapy. However, little is known about which ingredients specifically contribute to the outcomes of music therapy. This study aimed to investigate the application of music therapy techniques and whether they predict changes in clinical outcomes in mental health settings with individuals displaying a low therapy motivation. Participants (N = 31) were assessed before, during, and after participating in individual music therapy. Music therapy techniques were assessed for three selected therapy sessions per participant. Associations between music therapy techniques and outcomes were calculated using linear models with repeated measures. Results showed that reproduction techniques were used most intensely. In addition, relational competencies (interpersonal and social skills) amongst the participants improved when focusing on reproducing music (e.g. singing or playing familiar songs, learning musical skills). Results indicated that reproduction music therapy techniques may foster the development of relational competencies in individuals with low motivation. © 2012 Elsevier Inc. All rights reserved.

Individuals afflicted with a mental illness may often display difficulty in the areas of emotional responsiveness and social interaction, verbally and non-verbally. Challenges in interpersonal and intrapersonal skills can result in individuals experiencing low motivation for verbal therapies such as psychotherapy or psychological counselling. To that end, mental health care clients with low motivation are frequently referred to music therapy, as the primary medium of interaction is music rather than verbal language (Hannibal, 2005). Although, music therapy has been indicated as an effective intervention with regard to fostering motivation, emotional expression, and relatedness (Gold, Mössler, et al., submitted for publication) additional process-outcome research is needed to identify the most effective music therapy techniques with this particular client group.

夽 [ClinicalTrials.gov Identifier: NCT00137189]. ∗ Corresponding author. Present address: GAMUT, Uni Health, Uni Research, Postboks 7810, 5020 Bergen, Norway. Tel.: +47 97479289. E-mail addresses: [email protected] (K. Mössler), [email protected] (J. Assmus), [email protected] (T.O. Heldal), [email protected] (K. Fuchs), [email protected] (C. Gold). 0197-4556/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.aip.2012.05.002

In music therapy, musical experiences and the therapeutic relationship developing through them are used as dynamic forces producing therapeutic change (Bruscia, 1998). Relational musical experiences that deepen the therapeutic relationship are fostered by the use of music therapy techniques which are applied within a systematic process between the client and therapist. Music therapy techniques can be understood as working modes offering different musical and relational experiences. These techniques work in tandem with psychotherapeutic techniques (e.g. mirroring, holding, confronting) within specific use of musical parameters (e.g. rhythm, sound, tonality) (Storz, 2000a; Wigram, 2004). Music therapy techniques can be assigned to the following categories: Production techniques focus on emotional expression and the creation of the relationship through musical improvisation (e.g. structured, thematic, communicative, trying out, free improvisation) in which the client and therapist create something musically new. Reproduction techniques involve the client and therapist playing or singing precomposed pieces of music as well as learning or practicing musical skills (e.g. guitar chords, melodies on the piano). They may provide a holding structure and framework in which the actualisation of memories can be supported and explored within the context of relationship. Reception techniques involve the client listening to live (e.g. music played by the therapist) or recorded music. These

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musical experiences may be used to focus on conscious awareness of the client’s current mental state, emerging associations, as well as to facilitate relaxation or pain management (Storz, 2000a, 2011). In each of the three categories of music therapy techniques, both the therapist and client contribute mutually and are engaged in a therapeutic process within the context of relating and communicating. Thus, the choice of techniques will also be the result of this mutual process. Previous research in mental health care has provided supporting evidence that specific factors in music therapy are of importance. According to these findings, techniques focusing on musical communication, expression, and transformation may be of relevance (Danner & Oberegelsbacher, 2001) when working with clients with psychosomatic problems in mental health care. Another study found that music therapy-specific techniques (e.g. free improvisation, songs) were associated with bigger improvement compared to less specific techniques not unique to music therapy (e.g. free play, puppet play) in children and adolescents (Gold, Wigram, & Voracek, 2007). Although psychotherapy research has demonstrated that specific factors are of little importance to produce psychotherapeutic change (Cooper, 2008; Lambert & Ogles, 2004; Wampold, 2001), music therapy research is sparse in this area and more research is needed in order to support or challenge this notion. Outcome studies in adult mental health care have mainly investigated music therapy techniques in one of the two ways: (a) either several techniques were applied within individual or group music therapy but were not statistically tested in terms of their particular impact on outcomes (De l’Etoile, 2002; Tang, Yao, & Zheng, 1994; Yang, Li, Weng, Zhang, & Ma, 1998), or (b) one main technique applied within a session was investigated for various outcomes (Grocke, Bloch, & Castle, 2009; Silverman & Marcionetti, 2004; Talwar et al., 2006). In terms of external validity, focusing on only one technique when investigating music therapy may not appropriately reflect effective common clinical practice in mental health care. In this setting it is more common to implement production, reproduction as well as reception techniques as they are related to differing therapeutic topics and goals which may all be vital within the same therapeutic process (Storz, 2004). In the present study we aimed to examine whether different types of music therapy techniques can explain some of the variance in outcomes of clients in mental health care with low therapy motivation. In this context, it was important to first understand which music therapy techniques are being used within this client population. Examining music therapy techniques in this field is of clinical interest as it may contribute to a better understanding of how clients can improve their engagement into therapeutic processes. Specifically, the main objectives of this study were to explore: • which music therapy techniques are applied within music therapy in clients with mental illness presenting with a low therapy motivation, and • whether music therapy techniques predict changes in clinical outcomes related to the development of ego-strength, relational competencies, and quality of life. Method This was an exploratory study using a naturalistic, observational design with pre, post and intermediate tests of clients who began music therapy. It used data from an international multicentre randomised controlled trial (Gold, Mössler, et al., submitted for publication; Gold et al., 2005) that had shown positive effects as well as additional material concerning the use of music therapy techniques in the same clients. It should be emphasised that the

present study only used data from the experimental group of that trial. Furthermore, it only used data from those sites where the additional data were available. Music therapy in this study was guided by a manual of resourceoriented principles (Rolvsjord, Gold, & Stige, 2005). That manual describes desirable attitudes of the therapist but does not impose any restrictions on particular techniques. The use of techniques was allowed to vary from client to client, similar to clinical practice outside the study, and therefore it was possible to examine their application and potential impact. Data collection was carried out at one decentralised psychiatric centre in Nordfjordeid (Norway) and one psychiatric clinic in Linz (Austria). Data were collected from a range of different outcome measures used within the overall multicentre study as well as therapy journals. Therapy journals were used as source for assessing music therapy techniques quantitatively. Participants We included clients with any non-organic mental disorder according to ICD-10 criteria (F1–F6). Within this population, we included only those who met one or more types of low motivation (Gold, Mössler, et al., submitted for publication; Gold et al., 2005) because having difficulties to engage in verbal therapy is typical reason for referral to music therapy (Hannibal, 2005). Specifically, participants had to meet at least one of the following criteria: • The client is lacking or has insufficient insight into illness. • The client has difficulties talking about feelings or problems. • The client wants a “medication cure”, s/he does not believe in talking. • The client has not achieved sufficient improvement in previous psychotherapy. This was based on the judgement of the interdisciplinary team, i.e. of all professionals directly involved in the client’s treatment. The final decision to refer a client to the study was made and signed by the ward clinician, i.e. the person with primary responsibility of the client’s treatment plan. Clients suffering from severe mental retardation or a life-threatening illness were excluded from the study (Gold et al., 2005). We initially included 40 participants for the present study (Austria: 23; Norway: 17). However, due to drop out and resulting missing values in outcome assessments, the usable sample size was reduced to N = 31 (Austria: n = 22; Norway: n = 9). The most frequent diagnoses were schizophrenia, schizotypal or delusional disorder (ICD-10: F2, n = 14), affective disorder (F3, n = 8), and personality disorder (F6, n = 6). The remaining three participants presented either a neurotic/somatoform disorder (F4, n = 2) or a mental and behavioural disorder due to psychoactive substance abuse (F1, n = 1). The sample thus included similar numbers of participants with psychotic (n = 14) and non-psychotic (n = 17) disorders. The most frequent types of low motivation were not having achieved sufficient improvement in previous psychotherapy (n = 21) and difficulties in talking about feelings or problems (n = 20; overlaps possible). There were 19 male and 12 female participants. The mean age was 37 with a range from 18 to 59. Most of the participants (n = 29) received music therapy as inpatients; two were out-patients and one attended a day-clinical setting. Participants were offered up to 26 sessions of individual music therapy over a course of three months in addition to standard care. The sessions were offered twice a week, lasting 45 min each (Gold et al., 2005). The average number of music therapy sessions received was 19, ranging from 12 to 25. Music therapy was conducted by three therapists trained at master’s level in music

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therapy. One had graduated from the Sogn og Fjordane University College, Sandane, Norway, which is a training focused on interaction theory and resource-orientation and based on humanistic perspectives. The two others had graduated from the University of Music and Performing Arts Vienna, Austria, a training with a focus on humanistic and psychodynamic theory construction. In both institutions music therapists were trained in the conscious use of music as a therapeutic medium in relation to various music therapy techniques. Ethical approval was granted by the Regional Committee for Medical Research Ethics in Western Norway (REK VEST) as well as the Ethics Committee of Upper Austria. All participants gave written informed consent. Outcome measures When selecting outcome measures it is of importance to consider the client population, the therapeutic approach and the goals that should be achieved within therapy (Gold, in press; Kazdin, 1999, 2001). Therefore, we aimed at selecting a maximum of five outcome measures – from a larger pool of measures available (Gold et al., 2005) – that we felt were most relevant to our particular population and the goals of music therapy. According to our clinical experience these clients rarely have concrete ideas about what should improve or change in their lives when starting therapy. They typically do not come with an urgent need to talk about problems or conflicts, but are interested in “doing something with music”. Their needs and wishes may initially be connected to: (a) a joint activity such as playing something together; (b) experiencing joy; (c) experiencing mastery; or (d) experiencing a safe place through playing or singing familiar songs. Interpreting these wishes, therapeutic goals may be formulated as follows: (a) nurturing social and relational abilities; (b) improving quality of life; (c) supporting selfesteem and self-efficacy; and (d) gaining self-confidence (Mössler, 2011; Mössler et al., 2011). Furthermore, working with music may be a goal in itself for clients attending music therapy. Considering these goals, we were most interested in outcomes related to the development of ego-strengths, relational competences and quality of life, rather than symptoms or functioning. Therefore, we chose the following outcomes: • Self-esteem was measured using the Rosenberg Self-Esteem Scale, a self-report measure containing 10 items with demonstrated reliability (Rosenberg, 1989). • Self-efficacy was assessed using the General Perceived SelfEfficacy Scale. This self-report scale includes 10 items. The scale has demonstrated reliability in clinical as well as in non-clinical samples (Schwarzer & Jerusalem, 1995). • Interpersonal problems, as a proxy measure for (lack of) relational competence, were measured with the Inventory of Interpersonal Problems (short version), a self-report measure with 32 items. The scale has shown reliability and validity (Barkham, Hardy, & Startup, 1996). • Actual social relationships were assessed using the 11-item Quality of Life Enjoyment and Satisfaction Questionnaire. Reliability and validity have been demonstrated for this scale (Endicott, Nee, Harrison, & Blumenthal, 1993). • Interest in music measured by the Interest in Music Scale, subscale Musical Activity and Emotional Engagement with Music. This 10-item scale was especially established for assessing the client’s access to music and how s/he is making use of it for either being in contact with oneself and others through music, or express oneself through music. Reliability has been confirmed for this scale (Gold, Rolvsjord, Mössler, & Stige, 2012). In all scales except the Inventory of Interpersonal Problems, a high score represents a favourable outcome. Measures were taken

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before inclusion into the study as well as after one month (intermediate test, early during music therapy) and three months (post-test, end of music therapy). Music therapy techniques After each music therapy session, the music therapist wrote a detailed report of the session using a semi-structured format. Guidance was given for what type of information the journals should contain, but without restricting them in any way. Because of this format, the journals contained all the relevant information from which data about the use of music therapy techniques could be extracted. Under the journal headings “therapy process” and “techniques” information were provided about which techniques had been used and how much the client had been engaged in the particular working mode. From the available pool of data for all sessions, we selected those sessions that were closest to the time points of outcome measurement. For each participant, the first session, the session prior to intermediate test (Mdn = 8th session, range: 2–15) and prior to post-test (Mdn = 18th session, range: 11–25) were analysed. To categorise and rate therapy techniques we used the Questionnaire for the Assessment of Music Therapeutic Working Modes (Mössler, 2008a; Mössler & Oberegelsbacher, 2004). This scale was originally developed for evaluating music therapeutic working modes in psychiatry, psychosomatic, and children with special needs based on the music therapy practice in Austria. It represents the use of each technique on a five-point Likert scale and was chosen because it reflects the broad spectrum of production, reproduction and reception techniques. After discussing the usefulness of the scale with all music therapists collaborating on this study, the scale was slightly revised for improved applicability in the context of this study. One technique that was more relevant to the work with children (situation songs) was removed from the scale. We added one technique (learning or practicing musical skills), which was important reflecting our clinical practice with this population. Furthermore, the original scale suggested a separation of vocal improvisation techniques and improvisation techniques in general. This separation was viewed as redundant and we therefore merged the vocal improvisation techniques into the improvisation techniques. The final scale included 11 items with a five point intensity each (0 = not at all, 4 = very much). Intensity was defined primarily by the amount of time spent on each technique, but also taking into account the degree of engagement with it. We also included an additional question about “other techniques”. This category was never used and therefore not relevant for the analysis. The following techniques were represented in the final scale. The production subscale included five techniques: structured, thematic, communicative, “trying-out,” and free improvisation. Singing or playing pre-composed songs, and learning or practicing musical skills, were the two items of the reproduction subscale. The four items of the reception subscale were listening to live music, listening to recorded music, listening in combination with body perception, or with movement and dance. Although the techniques included in this scale do not claim completeness, they were considered as comprehensive and valuable according to the study population as well as the cross-cultural implementation of the study. More detailed information on the scale is provided in Appendix 1. The music therapists who had conducted the sessions rated the items of the scale on the basis of their reflexive therapy journals. For gaining consistency, the music therapists were trained in developing a common understanding of the items and their definitions (Appendix 1). A shared understanding was established by working on concrete examples. Raters were asked to assess the intensity with which each technique was applied within a session.

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We relied on therapist self-ratings because we expected the music therapists who had conducted the sessions to be able to provide a more accurate account of the techniques used than independent observers who would read and interpret the journal entries without any personal recollection of the session. Therefore, we refrained from adding independent observer ratings or assessing inter-rater reliability for any such ratings. Data analysis – music therapy techniques The first aim of the statistical analysis was to describe the application of the different music therapy techniques and the three subscales (production, reproduction, reception), respectively. Techniques and subscales were analysed in terms of their frequency of appearance and their effective intensity which were defined as follows. We defined the frequency of a music therapy technique as the number of sessions (of the three selected) where the technique was used. Correspondingly, the frequency of a subscale was defined as the number of sessions where at least one of the techniques in that category was used. That is, any session was only counted once, so that it did not matter how many of the techniques belonging to the subscale were used in the session. In contrast, we defined the effective intensity of a music therapy technique as the mean of the intensities of those sessions where the technique was used. (Recall from above that intensity was the score from 0 to 4 in a given session.) This is, for a single technique, the sum of all intensities divided by the frequency of the technique. Correspondingly, for a subscale it is the sum of the intensities divided by the frequency and the number of techniques belonging to the subscale. In other words, effective intensity always ranged from 0 to 4, just like the original items, but represented how much a technique was used if and when it was used. We used nonparametric statistical tests, Chi-squared for frequencies and Wilcoxon for effective intensities, to test whether there was a different use of the techniques between clients with a psychotic versus a non-psychotic disorder. Because the three subscales were of equal importance to us, we used Bonferroni adjustment to correct for multiple testing (i.e. we regarded effects as significant when p ≤ .05/3 = .0167). Data analysis – outcome predictors We used a linear model with repeated measures (Generalised Equations Estimation, GEE) (Verbeke & Molenberghs, 2009) to account for the time dependence of the measures (i.e. measures for the same participant at more than one time points) and to control for important confounding variables. The change scores in outcomes were the dependent variables. The intensities of the three subscales (i.e. the mean intensities of the techniques belonging to the subscales production, reception, reproduction) were used as predictors. Age, sex, diagnosis (psychotic/non-psychotic), therapist, and time point were entered as potential confounders. We calculated two types of models: a fully adjusted model, containing all predictors and confounders, and an unadjusted model, containing only one of the predictors (i.e. we calculated one unadjusted model for each predictor). While the association between predictors and outcomes is adjusted for confounding in the fully adjusted models, the unadjusted models show the crude association. Formulas of the models are shown in Appendix 2. Here, multiple testing was accounted for as follows: each combination of approaches (Appendix 2) was implemented for each outcome both in the fully adjusted and the unadjusted model, thus there were four combinations of approaches and a total of eight coefficient estimates for each variable and each outcome. Bonferroni adjustment therefore led to a highly conservative significance level of p ≤ .0063

Table 1 Frequency and effective intensity of music therapy techniques. Technique

Frequency N (%)

Effective intensity Rate

Production techniques Structured improvisation Thematic improvisation Communicative improvisation “Trying out” improvisation Free improvisation Reproduction techniques Singing or playing pre-composed songs Learning or practicing musical skills Reception techniques Listening to live music (therapist plays) Listening to recorded music Listening to music and body perception Listening to music and dance/movement

49 (52.7) 29 (31.2) 11 (11.8) 24 (25.8) 1 (1.1) 29 (31.2) 58 (62.4) 49 (52.7) 35 (37.6) 26 (28.0) 12 (12.9) 19 (20.4) 3 (3.2) 0 (0.0)

0.76 1.97 2.00 1.88 1.00 2.07 1.92 2.86 2.37 0.67 1.67 2.26 2.33 0.00

(=.05/8). In all linear models, positive coefficients indicated that an increasing intensity of a music therapeutic technique was associated with an increasing value for the outcome variable. Therefore, for all outcomes except interpersonal problems a positive coefficient implied that greater use of the technique was associated with greater improvement, whereas for interpersonal problems this was reversed. All computations were done in R (version 2.12.1, www.rproject.org). Results Music therapy techniques Both frequency and effective intensity were highest for the reproduction techniques and subscale, respectively (Table 1). In other words, the techniques singing or playing pre-composed songs and learning musical skills were used most frequently per client, and if they were used in a session, they were also used most intensely. The frequency of the production subscale was slightly lower, and reception techniques were applied least frequently. The effective intensities were fairly similar between the reception and production subscale. Within the production subscale emphasis was given to structured, communicative and free improvisation, while the therapist’s play and recorded music were prominent on the reception subscale. Some techniques were not or hardly ever used. One reception technique (listening to music in combination with dance/movement) was not used at all and another reception technique (listening to music in combination with body perception) was only used three times. This is similar for one production technique (“trying-out” improvisation) which was only used once. All frequencies and effective intensities are listed in Table 1. No significant differences were found between participants with psychotic and non-psychotic disorders. Outcome predictors Linear models with repeated measures were calculated for the Baseline model (changes from baseline) and the Intercept model (changes between time points; Appendix 2). No significant effects of music therapy techniques were found for the Intercept model. The results of the GEE calculations for the Baseline model are presented in Table 2, excluding the outcome variable for self-efficacy as no effects could be identified for this variable. Music therapy techniques as predictor variables are highlighted with grey background. From this table it can be seen that many significant effects were found when applying the strict Bonferroni-corrected significance level (p < .0063; highlighted in bold font), but most

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Table 2 Music therapy techniques as outcome predictors: coefficients and p-values of the Baseline model. Point approach

Interval approach

Adjusted model b (SE) Self-esteem Time Production techniques Reproduction techniques Reception techniques Age Sex: male Diagnosis Therapist Interest in music Time Production techniques Reproduction techniques Reception techniques Age Sex: male Diagnosis Therapist Interpersonal problems Time Production techniques Reproduction techniques Reception techniques Age Sex: male Diagnosis Therapist Social relationship Time Production techniques Reproduction techniques Reception techniques Age Sex: male Diagnosis Therapist

Unadjusted model p

−3.61 (1.24) 2.96 (0.94)

– – – – .0117 – .0037 .0015

3.24 (0.78)

– – – – – – – .0000

0.11 (0.04)

7.85 (3.57)

– – – .0280 – – – – – – – – – – – –

Adjusted model

b (SE)

p

−5.91 (2.47) 0.13 (0.06) −3.85 (1.70) 2.75 (0.77)

– – – .0165 .0360 – .0232 .0004

2.43 (0.73)

– – – – – – – .0009

8.46 (3.16)

−2.10 (0.98) 1.13 (0.45) −3.34 (1.55) 0.092 (0.045)

b (SE)

Unadjusted model p

−3.70 (1.28) 2.62 (0.95)

– – – – .0217 – .0037 .0057

2.91 (0.81)

– – – – – – – .0003

0.12 (0.05)

– – – .0075 – – – –

– – – – – – – –

– .0280 .0120 .0310 .0400 – – –

– – – – – – – –

b (SE)

p

−3.85 (1.70) 2.75 (0.77)

– – – – .0360 – .0232 .0004

2.43 (0.73)

– – – – – – – .0009

0.13 (0.06)

−2.58 (1.23) 12.4 (4.3)

−2.16 (0.98) 1.25 (0.48) 0.092 (0.045)

– – .0360 .0041 – – – – – .0286 .0097 – .0400 – – –

Note: The music therapy techniques (predictors) are marked by grey background. All non-significant predictors (p > .05) are removed. Coefficients and p-values are significant after the Bonferroni-adjustment (p < .0063). The models are defined in Eqs. (1) and (2).

of them concerned confounding variables (age, diagnosis, and therapist) that were not of substantial interest for this study. There was one exception: Reception techniques showed a significant negative effect on interpersonal problems (b = 2.75, p = .0004), suggesting that greater intensity in the use of reception techniques was associated with less improvement in interpersonal problems. Additionally, we found a number of predictor variables with p-values between the Bonferroni-corrected level and the conventional significance level (p < .05), marked by plain numbers in Table 2. These cannot strictly be interpreted as significant effects but can be seen as tendencies that might indicate useful hypotheses for future research. While changes in self-efficacy, self-esteem, and interest in music were largely unrelated to the use of any particular techniques, some tendencies were found for interpersonal problems and particularly social relationships. Tendencies of positive effects of reproduction techniques on interpersonal problems and social relationships could be seen. The unadjusted models of the Interval approach indicated that social relationships tended to increase when reproduction techniques were used more intensely (b = 1.25, p = .0097). Concurrently, interpersonal problems tended to decrease more when focusing on reproduction techniques more intensely (b = −2.58, p = .0360). In contrast, both reception techniques and production techniques

might be associated negatively with improvements in social relationships (Table 2). Discussion The main finding of this study is that reproduction techniques such as singing or playing pre-composed songs and learning musical skills (e.g. practicing a melody on the piano) might play an important role in music therapy when interacting with clients in mental health care with low therapy motivation. Reproduction techniques were used more frequently than production and reception techniques, and if they were used, the amount of time, interest and motivation spent on this working mode was higher in comparison to other techniques. Reproduction techniques might also play an important role in predicting outcomes related to relational aspects. In contrast to production and reception techniques, reproduction techniques tend to decrease interpersonal problems and increase social relationships. Getting in contact with others, to feel comfortable in the presence of other people, to open up and show feelings to another person, but also to disagree with others when a situation calls for it are examples of abilities that might increase more when working actively with familiar and known musical pieces. Reproducing music might help people in mental health care

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to build up a stronger relationship with themselves as well as with others. Clinical implications Previous qualitative and quantitative research on music therapy techniques in mental health care has concentrated on the investigation of production techniques (improvising, also composing) (Albornoz, 2011; De Backer, 2008; Erkkilä et al., 2011; Grocke, Bloch, & Castle, 2009; Solli, 2008), which might underline the importance of these types of techniques in this specific field. Our findings concerning the application of music therapy techniques have shown that production techniques are of certain relevance. However, the use of reproduction techniques appeared even more relevant. Our sample was representative for typical music therapy practice in that it consisted of clients who were hard to reach verbally, who had difficulties articulating their problems or feelings, and who showed a lack of motivation to participate in verbal psychotherapy. When working with this client population, our experiences were that participants especially struggled to “connect to themselves” (i.e. to their inner world) and hence showed difficulties in perceiving and articulating needs, feelings or problems. Their main interest was at first to do something with music without having more psychologically minded ideas about therapy goals or what to change related to their current life situation (see case examples in Mössler et al., 2011). Our findings suggest that the involvement and engagement with therapy for this client population could be supported by the experience of reproducing music embedded in a therapeutic relationship. This activity might provide a holding structure, a secure musical space in which the client dares to get involved with her/his musical and personal topics (Rolvsjord, 2001). It can be assumed that the structure, provided by a pre-composed piece, offers those holding and containing qualities clients are seeking when the creation of own (musical) ideas, wishes or needs are not accessible or perceivable, and therefore cannot yet be expressed. As an illustrative example, a participant in this study sang and practiced the Harry Belafonte song “Island in the Sun” on instruments many times and eventually was able to describe that this island represented her husband who had died recently. On the safe basis of the familiar and repeating song structure, she recognised all her feelings of sadness, longings and despair which were represented through the song almost long before she was able to talk about them (the full case history was presented in Mössler, 2008b). Another participant redefined her self-image by practicing pieces on the recorder, which had been a hobby in her youth. She found access to hidden resources and started to build up new representations of herself, rather than focusing on deficits and failures determining her self-image at that time. For a third participant, it was important to master the first line of Beethoven’s “Für Elise” on the piano, and she discovered herself as being self-efficient by being able to reproduce this piece. Her self-confidence improved, and this enabled her to solve difficulties also outside the therapeutic room (the full case history was presented in Mössler, 2011). These short glimpses into cases may help to elucidate potential meanings of reproduction techniques. These techniques may be understood as music experiences promoting the building up of a client’s self-concept on the basis of musical resources. Through reproducing music, clients may be able to better connect to their own ideas and feelings as well as to better understand and adapt to the ideas and feelings of others while still retaining their own identity (Bruscia, 1998). It therefore has a resource-activating (Decker-Voigt, Oberegelsbacher, & Timmermann, 2008) as well as a reassuring function. The pre-composed music might act as a representation into which own feelings can be transferred. Due to the known or even famous musical piece that has already found social

recognition, clients may feel confirmed in their emotions which are being reinforced or doubled (Bolterauer, 2006) when reproducing the musical piece. Own emotions may be validated by the pre-composed “substitute” which might also act as a transitional object (Wiesmüller, 2005). Furthermore, the achievement and mastering of musical goals can serve as a basis for building up images about other goals that could be achieved in life. One last but important aspect concerns the meaning of reproduction techniques in terms of a protection function. Holding on to the reproduction of a musical piece might also indicate a resistance to get in contact with oneself and potential threatening emotions as well as in contact with the therapist, but still guarantees to keep the therapeutic framework. In this sense, reproducing something familiar musically might help the client with low motivation to continue attending the therapy. We believe that the process of reproducing does not only support the actualisation of memories, but may also help to build up inner representations which were not accessible before. These may support the client’s ability to relate to oneself as well as to others with respect to their own feelings and personal boundaries. In this sense, reproducing music might also strengthen the ability to mentalise (Fonagy, Gergely, Jurist, & Target, 2002). In the music therapy literature, mainly improvisation techniques have so far been investigated in relation to mentalisation and object theories (De Backer, 2008; Metzner, 2010; Strehlow, 2009). Even though improvisation techniques take an important place in music therapy in general and mental health care in particular, the meaning of reproducing music in this field embedded in this particular theoretical framework needs to be explored qualitatively. This has long been underrepresented in the literature but recently there seems to be an upcoming interest in this working mode (Smetana, 2012). Limitations and directions for future research This study was based on previous research suggesting that specific ingredients can be of importance in music therapy (Danner & Oberegelsbacher, 2001) and that music therapy may be more successful when these are emphasised (Gold et al., 2007). The present study showed tendencies in the same direction to support this body of literature, even though most of these were not statistically significant in this study due to limited sample size and power (Gold, 2004). Therefore, the meaning of reproduction techniques and their potential importance as outcome predictors in individual music therapy as outlined in the first part of the discussion need to be investigated more in depth. One might ask if reproduction techniques were preferred by the therapists conducting the sessions in this study. As all therapists were trained in the application of all techniques, and two of them were especially educated in a music therapy tradition emphasising improvisation techniques (Mössler, 2010), our findings do not seem to reflect a one-sided use of techniques steered by the therapists. Music therapy techniques were rated retrospectively on the basis of therapy journals. Future research would benefit from more objective assessments of techniques, for example using video recordings and independent raters. However, there is no reason to believe that this could have led to any systematic bias in the study results. Importantly, the outcomes were rated by clients and were thus independent of the ratings of techniques. The lack of significant effects in this study might be caused by the absence of an impact of music therapy techniques on outcome variables, but it could also be due to a lack of power in the tests. The sample of this study was relatively small (about half as many participants as in Gold et al., 2007); furthermore, we used Bonferroni adjustment which is extremely conservative and allows only very strong predictors to become significant. It is also reasonable to assume that the client’s presentation, represented by the

K. Mössler et al. / The Arts in Psychotherapy 39 (2012) 333–341

outcomes, is a result of the entire therapy up to the time point when it is measured. As our data collection only included three sessions per participant (of an average total of 19 sessions), one may question whether the whole therapy was adequately represented. Taking into account the occurrence of differences in the use of techniques and assuming that outcomes are influenced by several sessions that have taken place before measurement, a larger sample of sessions may be worthwhile to include. To summarise, increased sample size, more objective data concerning techniques, as well as extracting data from more sessions may all lead to a more conclusive answer of the potential impact of techniques on outcomes. The individual therapist, as well as the client’s diagnosis, also seemed to play an important role. This may be related to common factors theory (Wampold, 2001) especially emphasising factors in therapy that are connected to the therapist’s being rather than doing as well as the variables inherent to the client. Future research should also take these factors into account. The examination of mechanisms of change in music therapy is still in its infancy, currently raising more questions than providing satisfying answers. Further process-outcome research is needed to explore in greater depth what it is that makes music therapy work. It is especially important to find working modes for those people in mental health care who are hard to reach verbally and hard to engage in psychotherapeutic treatment. Motivation for therapy may be a crucial point for the process and success of therapy as it may not work if clients are not motivated (Schneider, Klauer, Janssen, & Tetzlaff, 1999; Wampold, 2001). Findings of this study suggest that reproduction techniques might be of particular importance when working with clients with low motivation. Relational competences tend to increase more when focusing on reproducing music. Consequently, this working mode might help to get in contact with these clients and engage them in therapy. Furthermore, it seems to be relevant that clients are actively involved in a musical activity rather than focusing on working modalities operating with music listening. Working actively with a familiar song, concurrently representing something of the client’s inner world, may help people in mental health care more sufficiently to express themselves in a time of speechlessness and find ways to reconnect to this inner world as well as to their social environment.

Acknowledgements We would like to thank our colleagues at the Grieg Academy Music Therapy Research Centre and Monika Smetana for their feedback on a previous version of the article. This study was conducted with institutional support from the State Psychiatric Clinic Wagner-Jauregg Linz, Austria and the Nordfjord Psychiatric Centre, Nordfjordeid, Norway. This study was supported by a grant from the Research Council of Norway (project no. 186025, program Mental Health).

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Technique

Explanation

Thematic improvisation

Musical performance and expression of a certain topic (e.g. images, memories, emotions) Musical dialogue and interaction (e.g. partner play, call-response) between client and therapist resulting out of a psychodynamic context Important situations of the future or from the past are visualised by the client and tried to be performed, expressed, and transformed musically Musical play without rules in the sense of the free association; can include aspects of composing

Communicative improvisation

“Trying out” improvisation

Free improvisation

Reproduction techniques Singing or playing pre-composed songs

Singing or playing known and familiar songs to build up trust, to support the client’s personal musical resources and preferences, and to promote the actualisation of memories Learning or practicing musical skills is used in the sense of “practice without practicing” (Schmölz, 1974). It does not aim at perfectionism through repetition by using a behavioural oriented training method. Moreover, the opportunity to practice on a self-motivated basis is given where failed performances are recognised as valuable as the successful ones. The focus is on the client’s conscious awareness of her/his behaviour while practicing

Learning or practicing musical skills (e.g. guitar chords, playing melodies on the piano)

Reception techniques Listening to live music (therapist plays for the client)

The therapist’s play intents to support the client’s sensual awareness for creating a willingness to listen and perceive. Furthermore, it is used in moments of containment, where live music can create an immediate respond to the client’s needs Listening to recorded music can be used similarly to the use of live music but lacking the possibility to react musical spontaneously on the client’s upcoming needs. Relaxation as well as free association can be supported while listening to music Relaxation as well as free association can be supported while listening to music Exercises to support the client’s bodyand self-perception while listening to music (e.g. sound journey through the body, muscle relaxation, yoga exercises)

Listening to recorded music

Listening to music in combination with body perception Listening to music in combination with dance/movement

Others (specify) Note: The amount of time spent on a particular technique; additionally considering how much the client was interested to engage with the particular technique should influence the rating decision. Categories are partly based on Oberegelsbacher (1997) and Storz (2000b). Response categories: very much (4), much (3), somewhat (2), little (1), not at all (0).

Appendix 2. Appendix 1.

Statistical methods

Rating scale music therapy techniques Technique Production techniques Structured improvisation

Explanation Structured musical games based on musical parameters such as rhythm or melody (e.g. rhythmic games like imitating a rhythm or a melody, playing contrasts)

The adjusted model for the change scores of each outcome Y and the session i at the time point t was specified as



Yit = b0 + b1 t +

techniques





bi Xijt +



predictors

bk Cik + eit ,

confounding

 



control



(1)

K. Mössler et al. / The Arts in Psychotherapy 39 (2012) 333–341

Intercept approach

Outcomes

Dependent variables

340

ΔY

ΔY

1

ΔY

Baseline approach

Months

2

ΔY

1

0

2

Outcome: Y0

1

Outcome: Y1

3

Outcome: Y2

Time axis

Intercept Baseline

Therapeutic techniques

Predictors

Session: S0 Point approach

Session: S2

X =S 1

Interval approach

Session: S1 X =S

1

2

X =(S + S )/2 1

0

X =S

1

2

Point approach

X =S

X =S 1

2

1

Interval approach 0

2

2

X =(S + S + S )/3

X =(S + S )/2 1

2

2

1

0

1

2

Fig. 1. Time line and approaches used in the linear model with repeated measures. Above time line: approaches for outcomes. Below time line: approaches for predictors. Notation: Yi , outcome variables at time point i; Yi , change of the outcome variables at time point i; Xi , predictor variable in the model at time point i; Si , intensity of the use of therapy techniques in session i. Arrows show the covered time interval of the outcome change score in the different approaches.

where X denotes the music therapy techniques (these vary over time), C, the confounding variables (these are time independent) and e, the error term. The coefficients b describe the association between each variable and the outcome. The indices j and k denote the techniques or confounders that are included in the model. The unadjusted model was Yit = b0 + b1 t + eit

(time)

or

Yit = b0 + bj Xijt + eit

(predictors)

or

Yit = b0 + bk Cik + eit

(confounders)

(2)

specified as using the same notation as in the fully adjusted model. Fig. 1 shows further how Y and X were defined in the different models. The change scores Y were conceptualised in two ways: change from baseline to each time point (“Baseline approach”), and change between two neighbouring time points (“Intercept approach”). For the technique variables X, we also conceptualised the predictor in two different (though related) ways: first, we simply used the intensity in the session at the corresponding time point (“Point approach”). Second, because the first two selected sessions both occurred before the one-month assessment and may therefore both influence the change of the outcomes within this time interval, we also used the mean intensity of both sessions during the time interval the change in outcome covered (“Interval approach”). Having defined the models, we estimated the coefficients b with the corresponding confidence interval. Additionally, we tested for each variable if it was associated with the outcome (i.e., if the coefficient for the predictor was significantly different from zero). References Albornoz, Y. (2011). The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse: A randomized controlled trial. Nordic Journal of Music Therapy, 20(3), 208–224. Barkham, M., Hardy, G. E., & Startup, M. (1996). The IIP-32: A short version of the Inventory of Interpersonal Problems. British Journal of Clinical Psychology, 35, 21–35. Bolterauer, J. (2006). Die Macht der Musik. Psychoanalytische Überlegungen zur Wirkungsweise von Musik und ihren Wurzeln in der frühkindlichen Entwicklung [Power of music. Psychoanalytical reflections on the effects of music and its roots in early childhood development]. Psyche, 60, 1173–1204. Bruscia, K. E. (1998). Defining music therapy (2nd ed.). Gilsum: Barcelona Publishers.

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