Noreen Kirwin Donnell

Transcription

1 Messages through the Music: Musical Dialogue as a Means of Communicative Contact Noreen Kirwin Donnell Wilfrid Laurier University Faculty of Music Music Therapy Department Supervisor Dr. Heidi Ahonen-Eerikainen Methodological key words Phenomenological, naturalistic and collective case study; adapted grounded theory, narrative Content key words Communication, autism, developmental delay, communication-accentuated music therapy, mother-baby interaction, musical dialogue Biography Noreen (Kirwin) Donnell holds both undergraduate (1988) and graduate (2003) degrees from the music therapy programme at Wilfrid Laurier University. She is accredited by the Canadian Association for Music Therapy. Noreen is owner of Halton Music Therapy Services, a music therapy private practice in Burlington, ON, and co-owner of Music Express, an innovative group programme for children with communication difficulties, which combines the disciplines of music therapy and speech-language pathology. Noreen has worked with various clienteles since She began her professional career at Southwestern Regional Centre in Blenheim Ontario, a residential center for adults with developmental disabilities. Noreen initiated a pilot study at Prism Centre, a rehabilitation center for children with physical disabilities in Chatham, Ontario. A move to Oakville in 1996 led to a position at Hamilton Psychiatric Hospital with adults with psychiatric challenges. Since 1998, Noreen Donnell has worked with children with communication challenges. In her research thesis, Messages through the Music, Noreen examined

2 musical dialogue within clinical music therapy, musical interventions/methods utilized to elicit and sustain contact with children, and the inner dialogue of the music therapist. In 2004, Noreen was appointed director of a research cluster, communication-accentuated music therapy, within the Laurier Centre for Music Therapy Research. She is a part-time instructor at Wilfrid Laurier University in Waterloo, ON.

3 i Abstract Musical dialogue plays a significant role in communicating effectively with children with autism. Through an examination of episodic dialogue within the treatment session, this study offers readers various methods used to elicit communicative contact, as well as insight into the inner dialogue of the music therapist. Reciprocity, empowerment, acceptance, discovery, and acknowledgement are the non-verbal musical messages conveyed to the child. Relevant theoretical links to music therapy, symbiotic, and psychodynamic literature accompany each clinical example of episodic dialogue.

4 ii I wish to gratefully acknowledge: Acknowledgements My academic supervisor Dr. Heidi Ahonen-Eerikainen for her optimism, intellect, and encouragement, Dr. Colin Lee, Dr. Rosemary Fischer, and Dr. Carolyn Arnason for their scholarly guidance and expertise, My fellow classmates, the fabulous group of seven, Ruth Roberts, Laurel Young, Adrienne Pringle, Susan LeMessurier Quinn, Melissa Jessop, and Caryl Ann Browning for their strength, camaraderie and generosity of spirit, The children and parents with whom I have the honour of working this project would not have happened without your cooperation. My parents, Jim and Maureen Kirwin for their continued support and love, and for having the wisdom and foresight many years ago to enroll me in piano lessons! My husband Steve, for sustaining me on my academic and personal journey, for his unbiased feedback, technical expertise, and for taking on double duty at home, And lastly, to my sons, Kyle and Benjamin, for believing in their Mom.

5 iii Table of Contents Abstract... i Acknowledgements... ii Table of Contents...iii List of Figures... iv 1. Preface Introduction Method Results Episodic Dialogue The Dialogue of Reciprocity The Dialogue of Acceptance The Dialogue of Discovery The Dialogue of Acknowledgement The Dialogue of Empowerment Establishing Communicative Contact through Musical Dialogue Musicality Motherhood Theoretical Influences Philosophical Definition Episodic Dialogue Additional Findings Free Association Body Sensations Images/Metaphors Moments of musical dialogue: Interventions of Therapist Emotional Response/Feelings Role of Music Atmosphere Discussion References... 71

6 iv List of Figures Figure 1: Play the Drum Figure 2: Symbolic Representation of Communicative Contact... 57

7 1 1. Preface A boy with autism Anxiously paces the room His eyes betray a raw and naked fear At first, the music is only an extra sound it has not been filtered out or in He touches the door, the wall, and the desk, in rapid succession Door, wall, desk Door, wall, desk They become a touchstone trio that helps him arrive safely to the next moment Jonathan, it s okay, sings the therapist Jonathan, it s okay He pauses what s that sound? Is she singing to me? His pace slows and the ritual changes Wall, desk, door Wall, desk, door Jonathan offers a sly glance to the therapist He walks to the center of the room and stops pacing He moves forward and backward, alternating heel to toe In perfect rhythm to his song And in that brief moment, a dialogue begins (CD Extract 1)

8 2 2. Introduction A common thread weaves throughout clinical music therapy: Communication through music establishes a vital bond not easily replicated through other means. Music not only engages the listener to respond, it compels the listener to interact. Dialogue may be defined as encompassing all the different ways we give and receive messages. Musical dialogue is further defined as a moment of authentic reciprocity within music. Upon entering into a musical dialogue, an implied and potent message is I hear you. You are important to me. The music therapy session is an invitation to dialogue with one another. In the space that is created through musical dialogue, the diagnosis slips away and individuality emerges. Although these moments of musical interchange may range in time from ephemeral to extended, both therapist and client become equally invested in the relationship. I entered the world of qualitative research with a watchful eye and guarded anticipation, poised to embark on a research journey. It is therefore useful to consider the path that leads one to research a specific topic. Initially, my interests were externally motivated. My current clinical work is in close collaboration with a speech pathologist, so the two worlds of music therapy and speech pathology and their interconnection greatly interested me. The link between the clinical and theoretical aspects of speech and music therapy and a demonstration about how involvement in music therapy improved communication skills was a defined interest. It was also my intention to use this research study as a basis for a curriculum or resource book a tangible and marketable product.

9 3 A secondary point of interest was spirituality and music therapy. A case with a palliative child had a significant personal and professional impact I felt I needed to write about this, too. Dividing my initial interests into two sections, the tangible and the intangible, I struggled to choose between them. The challenge was in the choosing, defining, and narrowing down the scope of my research. Once content to watch and wait, I became impatient to explore the world of qualitative research. Information was absorbed and I prepared to use this knowledge and put it into practise; groundwork for a comprehensive research project began in earnest. It was necessary to read and collect articles on the various subjects of interest: communication, speech processing, speech physiology, mother-baby interaction, developmental music therapy, pre-verbal communication through music, communicationaccentuated music therapy, and intermusical versus intramusical relationships. A conscious decision to follow the first path was taken I needed the luxury and benefit of space and time before I was ready to write about my palliative care experience. In class discussion, the word dialogue was used in an unrelated context. I jotted down the word and knew instinctively I had found my focus. It was a relief: Dialogue that s the word I need! How do autistic children learn to be in dialogue? How is musical dialogue defined? This interests me more than speech therapy, yet it is still connected. (Research seminar notes, October, 2002)

10 4 The more I considered the term, dialogue, the more it appealed to me. Something had become very evident: one needs to have passion about their research topic. One of the most exciting things to me in clinical music therapy is when the client and I are in an active musical exchange, where the boundaries between client and therapist are not distinctly polarized. In individual supervision with Dr. Ahonen-Eerikainen, I was introduced to the works of Daniel Stern, D.W. Winnicott, Amelia Oldfield, Mercedes Pavlicevic, and Dorit Amir, and to perspectives from the symbiotic, humanistic, and psychodynamic fields. This was a new world for me, and one that appeared to connect directly to my interests. For example, in Amir s article, Experiencing Music Therapy: Meaningful Moments in the Music Therapy Process (1996), she examined the phenomena of significant experiences between the client and therapist. Although difficult to describe verbally, Amir listed these moments as occurring on multiple levels: interpersonal/intrapersonal, and external/ interpersonal levels, and within four realms: physical, cognitive, emotional, and spiritual. Pavlicevic (1988) writes in a similar vein about critical moments improvisational moments that appear to have a striking significance. These moments inevitably led to discovery about the client, the therapist, the musical interaction between client and therapist, and the musical improvisation itself. Listening in a session for musical and interpersonal moments of significance between the client and the therapist is another important aspect of clinical music therapy (Arnason, 2003).

11 5 In my research, I attempt to identify and categorize moments of active dialogue between client and therapist, also examining sessions for critical and meaningful moments. My predominant thoughts at this time in the research process were: 1. It is good to know I am not alone in my pursuit of knowledge in this area. 2. I hope I have something new to offer that has not been done or said before. (Supervision notes, November, 2002) Upon learning that these were my experiences with my clients, and it would be new information from a new perspective, ensured that I could add to the existing literature. The word dialogue may also be used in the context of research itself: preknowledge is in constant dialogue with the data, i.e., the knowledge informs the data, and the data informs the knowledge. Termed abductive reasoning, this infers that the writer s previous knowledge of a topic provides a way to describe and interpret. The data or material is allowed to speak and dialogue with different theoretical units. (Pierce as cited in Ahonen-Eerikainen, 1999). In descriptive research, it is necessary to look for patterns as the theory emerges. My research questions began to emerge and take form: 1. How can musical dialogue be defined and described? 2. Why is dialogue essential to an effective therapeutic process? 3. How do musical and verbal dialogues differ? 4. What are the tools for creating and fostering a musical dialogue?

12 6 5. What are the implications for musical dialogue in the development of the therapeutic relationship? Information, knowledge, and experience linked to make tentative connections, and permanent circuits were created. My clinical work with a boy with Childhood Disintegrative Disorder became a direct link to my research. Jonathan (pseudonym) was a child who had lost many abilities in a short amount of time, and who developed normally until age five. He engaged in self-stimulation, repetitive movements, twirling, jumping, and climbing. He no longer spoke. He cried frequently it is possible he remembered an earlier and healthier time in his life. Verbal dialogue was unnecessary and ineffective. I discussed my work with Jonathan with my supervisor, and it was extremely enlightening to hear another perspective: Sender and receiver are reciprocal. An intimacy and richness is created through dialogue, and a musical awakening may occur. What does the music mean in the relationship? (Supervision notes, November, 2002) Types of musical dialogue began to emerge naturally. I noted in my supervision that the music I was using with Jonathan appeared to contain an essence of waiting, embracing, expectation, humour, play, and invitation. For a child who was a mystery to many, I was searching musically for the key. As Dr. Ahonen-Eerkainen astutely asked, What if some children have no door? (supervision notes, November, 2003).

13 7 Our discussions began to encompass a broader context, namely the use of music as a transitional object. Similar to a child s blanket (Ahonen-Eerikainen, 2000), the music provides safety, security, and a familiar sense of comfort. Transitional play (Winnicott, 1988) is the play and interaction that occurs between client and therapist. Self-object is using the music as an expansion of the self, when it is used to externalize negative feelings. Dr. Ahonen-Eerikainen observed that I frequently employed minor keys and modes in my improvisations with Jonathan. She questioned whether my sadness for Jonathan s condition was a projection evident in my choice of music. The word research no longer had an intimidating connotation the intimidation had been replaced by excitement and a sense of emerging confidence. Bruscia (1995) defines the essence of research as: The researcher seeks to identify those properties of the phenomenon which give it its basic meaning, character, identity, or to discover which of its elements must be present for the phenomenon to exist and be defined as such. (p.322) An inquiry into the essence of musical dialogue was deemed interesting and worthy of research. From my epistemological perspective, I believed it was possible to define musical dialogue and demonstrate how to generate it. This brings me to the present in my writing process. In qualitative research, one must not only examine the research process, but also the researcher. I am a music

14 8 therapist; I am also a mother, a daughter, and a wife. I believe it is in this primary role as a mother of two young boys, that I am drawn to working with children. Children should grow up happy. They should laugh and run and play, and be free of the worries and stresses that accompany adult life. They should not have to struggle to communicate or make sense of the world. When I meet a child with a communication challenge, whether it is from physical, neurological, or cognitive causes, I have a passionate need to help them. It is necessary to clarify this point: this is not a need borne out of pity or sympathy, it is a need to ease their isolation and bring them joy, and in some small way, restore their wonder and innocence. As Paul Nordoff said: You won t be able to bring more to a child than what you have in your heart, in your mind, in your fingers, in your whole body as a living music (Nordoff as cited in Bruscia, 1987, p. 62) I am also a communicator. I like to talk about my feelings and thoughts and I like to listen to other people talk about the same things. It has always been a skill of mine making people feel at ease through conversation. This quality undoubtedly has led me to my work with children with communication needs. Music-making is a natural extension of verbal discourse. There are many times I feel fortunate to have such a powerful medium with which to communicate, especially for those individuals with little to no verbal skills. My philosophy of music therapy has evolved steadily over the past decade. The first facility in which I worked, ascribed to and operated under a strictly behavioural

15 9 model. Although I did not fully embrace this philosophy, I found a way to inject my own beliefs into the constraints of a behaviouristic model. One way to do this was to link up and network with like-minded people. I forged several relationships with psychologists, social workers, augmentative communication instructors, and developmental service workers who believed in a humanistic and client-centred philosophy. After six years, I knew I needed to be in a wholly client-centred work environment, one that did not solely view external behaviour as indicative of a person s capabilities. My subsequent employment at a psychiatric facility afforded me the chance to work within a model that resonated more with my philosophy. Psychosocial rehabilitation focuses on the inner person and looks at the less tangible qualities of self-esteem, personal growth, and building on an individual s inherent strengths. Upon opening my practise, I finally had the opportunity to define what it meant to me to be a music therapist. The time had come to solidify my philosophy and articulate my beliefs and learning in concrete terms. Supervising interns in a private practise forced me to develop that philosophy as a model within which to work. The Halton Music Therapy Services model (2000) was developed with the input and assistance of Adrienne Pringle during her internship, and in preparation for the CAMT national conference. It begins with three fundamental beliefs: 1. Music is an effective catalyst to change. 2. The change must be meaningful to the person we are treating 3. A positive client-therapist relationship must be present before any change can occur.

16 10 Circling these three fundamental and constant beliefs are seven constants depicted in a fluid motion to infer a dynamic energy: 1. Quality the music used in a session must be of a high quality, as one must never compromise musicianship or musicality. The quality of the relationship must also be of a high standard, as should be the quality of the care and treatment of the client. 2. Respect there must be mutual respect between the client and the therapist. If necessary, limits may be implemented to assist the therapeutic process. 3. Freedom one must be free to follow a client s response, even if that means abandoning a planned agenda. This is a potent method of establishing and maintaining a positive client-therapist relationship. Musical flexibility is paramount. 4. Preparedness one should prepare well for sessions, and possess a sense of session readiness and not session rigidity. 5. Awareness one needs to exhibit vigilant sensitivity to changes in the client and the process, and be prepared to make changes in the session to better the relationship. 6. Accessibility one should strive for open communication with clients, parents, and other professionals in order to alleviate the mystery of what we do, and in order to work towards a common goal. 7. Advocacy one has the responsibility to advocate on behalf of our clients with the information we derive from sessions, especially for those clients who cannot advocate for themselves.

17 11 The client, of course, is central to the model. These three elements combine to characterize clinical interventions and are manifested in many different ways and variations (Donnell & Pringle, 2000).In fact, my clients define my definition of music therapy. Opening a private practise after 10 years spent in music therapy positions within facilities and hospitals was a welcome and calculated risk. My clinical door is wide open to whoever seeks out the benefits of music therapy. Although the clients arrive with diagnoses that vary in both scope and severity, they have one primary thing in common they are changed by their musical interactions. And I am changed by their willingness to share their musical self with me. My philosophy has been significantly altered in the last few years, especially with the input from Dr. Colin Lee. His aesthetic music therapy model (AeMT) considers music as the basis and crux of therapy (Lee, 2003). It is an improvisational approach that embraces musical dialogue as its core. To be music-centered, one needs to understand musical structure and how that structure balances within the client-therapist relationship. In this study, I aim to not only view the effect the interaction has on the client-therapist relationship, but also to take an in-depth look at the musical responses of both parties. Through my studies with Dr. Lee, I concur that we need to look more closely and astutely at the music of our clients, rather than relying on theories based in other disciplines. This past year of study also gave me opportunities to define my working style as a process-oriented music therapist. Ahonen-Eerikainen (2000) explored the various methods music therapists use to approach the therapy session and divided working styles

18 12 into directive and non-directive. Music therapists may be method-accentuated, goalaccentuated, development theory-accentuated, or process-accentuated. To further define these terms, it is useful to view method-accentuated therapists as using the same method for all children. If one is a goal and result accentuated therapist, one is free to vary their methods and goals to achieve results. A development theory accentuated therapist adapts their methods according the developmental stage of the child. Lastly, a processaccentuated therapist allows themself to float (Ahonen-Eerikainen, 2000, p.162) in a situation, genuinely mirroring and reflecting a child s actions and molding the therapy session on the child s terms. Further to this, I am not only interested in the longitudinal gains in therapy - the singular music therapy session is a process in and of itself. The focus of this research project is not how a client traveled from point A to point B over a period of several sessions, but the process itself within each session, i.e. which techniques and interventions were utilized to dialogue with each child in the moment. Although the majority of links to relevant literature will be included in the Results section, it is necessary to include some preliminary information here. There are several terms related to communication. They include: speech, language, signs, pictures, print, gestures, and facial expressions. To define these terms further, language refers to a system of words and how words are put together to become meaningful. Expressive language is how we use words and sentences, while receptive language is how we understand words and sentences. Speech or articulation refers to how speech sounds are made physically,

19 13 and how they sound. This is commonly known as pronunciation. Pragmatics refers to the use of speech, language, or any other communication system to interact with others. It includes eye contact, turn-taking, greeting, asking questions, answering, protesting, etc. (Halton Preschool Speech and Language, 1999.) There are several reasons why we communicate: 1. To provide information 2. To receive information 3. To describe events 4. To influence listeners to believe/do/feel something 5. To express ones own intentions, beliefs, feelings 6. To indicate a desire fore further communication/ human contact 7. To acquire new behaviours 8. To entertain 9. For social interaction 10. For personal gratification To communicate, we employ both expressive and receptive language. Our output or expressive communication includes motor responses such as pointing, touching and manipulating objects, vocal responses such as vocal sounds and nonlinguistic utterances, and verbal responses, i.e. uttering sounds classified as belonging to the linguistic code of our community. Receptive communication, or the input, includes awareness observable responses such as turning to look at the sound source,

20 14 discrimination, i.e. the observable response such as responding differentially to the sound presented, and understanding where the observable responses are related to a sound stimulus, e.g. following directions. We also communicate using a combination of both expressive and receptive modes by imitating behaviours (repeating motor or speech patterns), initiating behaviours without a previous verbal event, and responding behaviours, such as utterances (sung, verbal, vocal, motor) that are in response to previous verbal/vocal/musical events (Halton Preschool Speech and Language, 1999). There are various developmental levels of communication. At a gestural level, individuals utilize visual cues (pointing), body language, touch, and movement. Next, at pre-verbal level, responses may be categorized as oral-motor, crying and comfort sounds, vocalizations (singing, intonation patterns) babbling, lalling, inflected vocal play, and word approximations. At a verbal level, individuals begin at single and double word utterances, followed by two-four words phrases, followed by complete sentences and comprehension of and response to questions. Throughout each communicative developmental level are the non-verbal social cues: eye contact, initiating contact, play, and joint attention (Loewy, 1995). Communication is important within a music therapy environment because it addresses both verbal and non-verbal modes of expression. Music and speech are bound by the common elements that they share: pitch, melody, rhythm, dynamics, and timbre. Music therapists use rhythmic patterns to reinforce word patterns, and use melody to meet, extend, and enhance vocalization. By drawing upon a child s repertoire of sounds,

21 15 speech patterns and movements within a multisensory approach, music therapists aim to facilitate and develop communication. The early stages of language development are inherently musical, and since language is acquired through dynamic interactions with people and objects in the environment, musical interaction is a perfect fit for enhancing communication (Donnell & Pringle, 2002). In examining the specific use of music to enhance speech in children, language and articulation skills are the two main areas of focus. Intonation, beat, and rhythm may be utilized as cues for word retrieval, sequencing, and memory. Songs provide children with the motivation for repeated practise of actions and words and develop oral motor skills, articulation, and vocabulary. Music also acts as a strong cue for developing routines and signaling transitions. The use of music assists children to attend to auditory stimuli in a pleasant and intrinsically motivating way (Donnell & Pace, 2000). Several researchers have examined the phenomenon of communicationaccentuated music therapy with pre-verbal or non-verbal children. Two of the most influential individuals in the world of music therapy are Paul Nordoff and Clive Robbins. Their Creative Music Therapy model is an improvisational approach to individual and group therapy that champions the use of active music-making to engage attention, promote active involvement, and propel inner experiences outward (Nordoff & Robbins, 1977). It is called creative because it involves three relational aspects of creative work. The therapist creates the musical resources that are utilized within each therapeutic experience, the experiences and techniques that are used in each clinical situation, and the

22 16 process in which these techniques and experiences are sequenced (Robbins as cited in Bruscia, 1987). Musical improvisation is the primary method of interaction between the therapist and client, and it serves as the main force for therapy: the therapist will find the essence of music as therapy to lie in his improvisational creation of music as a language of communication between him and an individual child. The words of this language are the components of music at his disposal; its expressive content is carried by his use of them. In the clinical situation he becomes the center of musical responsiveness himself; the music his fingers draw from the instrument arises from his impressions of the child: facial expression, glance, posture, behaviour, condition - all express that presence his music will reflect and go out to meet. (Nordoff and Robbins, 1971, p ) It is important to note that in creative music therapy, clinical goals are encased within musical goals. Nordoff and Robbins (1971) viewed musical interresponsiveness as interpersonal communicativeness, musical freedom as personal freedom, and independent musical creativity as a measure of self-confidence, all manifestations of therapeutic growth. Based on Nordoff and Robbins belief that there are two main change processes, the child-therapist relationship and the child-music relationship, Bruscia (1987) identified five stages of therapeutic growth in creative music therapy:

23 17 1. Musical Awakening while establishing a relationship 2. Musical Responsiveness within an activity relationship 3. Musical Involvement within a working relationship 4. Musical and Interpersonal independence 5. Assimilation and closure (Nordoff & Robbins as cited in Bruscia, 1987, p. 65) By attaining musical expression and communicativeness, a child s life is profoundly and irrevocably impacted. Oldfield (1995) explores some of the possible reasons why music is effective with people with communication difficulties: What is it about music or sound that motivates and interests people who are experiencing communication difficulties, and why music rather than another medium? (p.227) Motherese - the speech that mothers use with their infants - is more musical than verbal, with the intonation of words highly exaggerated and specific syllabic accents accentuated (Papousek and Papousek, 1981). The infant responds to the quality of the voice, the variances in intonation, and the familiar sounds. Sounds that are used in early babbling exchanges, and similarly, in musical dialogue, are non-specific and can be interpreted in many different ways. A child with a communication delay who is uncertain of what response is required from a verbal sentence, and is unclear about the meaning of

24 18 words, may be more comfortable communicating in a simpler and less specific form of communication, such as music (Oldfield, 1995). It is also emphasized in this article that music, unlike speech, may be intended for the player only. In a clinical setting, the child may choose to respond to the music as if it was being played for him, or may choose to believe the player is only playing for himself. Children who are isolated or persistent in rejecting any form of communication may take their time in responding to the therapist, while the therapist simply pretends to play music for herself. Oldfield (1995) bases her opinions on two main beliefs: 1. The ability to respond and participate in musical activities precedes the acquisition and use of speech 2. Music may be more enticing than speech and appeal to children who have isolated themselves and rejected all usual forms of communication. In The Musical Stages of Speech: A Developmental Model of Pre-Verbal Sound Making, Loewy (1995) argues that language is viewed historically within a cognitive context, while the musical elements of speech symbolize the most personal and expressive part of the human condition. She clearly delineates several techniques for each musical stage of speech from infancy to childhood. For example, in Stage 1, the crying sound at birth marks a child s first vocal expression in a new environment (Loewy, 1995, p.51). Within the first month, it acts a signal to indicate hunger, discomfort, loneliness, or distress. It is the first audible expression of affective need. To address the

25 19 cry in a clinical setting, the music therapist must treat this as a primal release or expression, and use a tonal/vocal holding technique. Holding or blanketing the sound response by matching the child s cry with a long steady tone, established within the key of the child s tones is recommended. This gives the child a sense of acoustical resonance (Loewy, 1995, p 53), invites further vocal exploration, and provides comfort and stimulation. Ahonen-Eerikainen (1999) relates the process of communication-accentuated music therapy to mother-infant symbiotic contact, with the mother s presence acting as the creator of safety. She cites the role of music as a way to contact the child, ensure a safe environment, motivate the child to interact, build basic communication skills, be a language and a channel to communication, and a tool for expressing emotion. Four relationships are essential to the process: 1. Child and therapist 2. Child s music and therapist s music 3. Child and child s music 4. Therapist and child s music She incorporates Stern s theory of the The Four Senses of Self (1985) with the six stages of communication-accentuated music therapy, leading to both the emergence of active communication and the emergence of the self. They are:

26 20 1. Meeting and creating the contact in music: The Sense of an Emergent Self 2. Music as a language, as a form of self-expression: The Sense of a Core Self 3. Experiencing the leadership in music: The Sense of a Subjective Self 4. Music as a means of reciprocal dialogue: The Sense of a Subjective Self 5. Stimulation of verbal language: The Sense of a Verbal Self 6. Symbolic play: The Sense of a Verbal Self: The Capacity of Symbolic Play (Ahonen-Eerikainen, 1999) In his article, A World of Sound and Music, Klaus Bang (1998) says that music therapy is one of the most important means of developing an acoustic-visual-motor unity, and provides challenged individuals with an optimal means of communication. For the contact-impaired person, music may become the communicative channel in which they may converse. Bang advocates using music to access speech and language skills, because both processes involve auditory production and perception of sound. Musical activity and active listening to music may support the acquisition of language, of attention and perception, the transfer of movement to sound and of sound to movement, and unifies language, music, and movement. The goals of music therapy, therefore, are to establish contact and communication, to develop sensory, physical, and motor development, to promote social development, to access social-communicative skills, to develop speech and language skills, to activate emotional processes, and finally, to promote relaxation (Bang, 1998).

27 21 Grinnell (as cited in Bruscia, 1987) advocates a developmental therapeutic process combining techniques of music therapy, play therapy, and verbal psychotherapy while working with noncommunicative and emotionally challenged children. In Stage 1, the therapist focuses on establishing a relationship though various musical activities, mainly instrumental improvisation. During the second stage, the child is encouraged to express his/her feelings through symbolic means. Techniques in this stage involve using song improvisations, projective musical stories, doll play and puppetry. Stage 3 engages the child in verbal processing of emotional conflicts. Grinnell also incorporates the idea of an optimal mismatch in her work with children. Developed by cognitive theorists, this phenomenon is the use of tasks that are developmentally challenging yet within the integrative capacities of the child. For example, in the first stage of therapy, the most difficult incongruity occurs between therapist and child, namely their different modes of communication. Noncommunicative children cannot assimilate or accommodate verbal language and may react by blocking out the therapist, distorting the receptive language, engaging in echolalia, or use other forms of superficial interaction. In order to combat this discrepancy, Grinnell replaces it with an optimal mismatch music:

28 22 The child can discover the safety in letting another human being, at a distance, share his world; a new safety in expressing himself and being heard and responded to. He does not have to enter the frightening world of communicative speech in order to make this human contact. It provides an optimal mismatch between his level of communicative functioning and a similar modality that is primitive and nonverbal yet involves mutual communication, one step beyond the child s present social withdrawal. (Grinnell as cited in Bruscia, 1987, p. 381) The qualitative research presented here is based on detailed narratives of my clinical work with children with communication disorders. I will conduct in-depth analyses of how dialogue is created within music therapy sessions with children with PDD, CDD, and Autism Spectrum Disorders. I will examine, define, analyze, and categorize the various dimensions of dialogue. It is also my intention to investigate and link some of the theoretical parallels between mother-infant interaction and therapistclient communication. This study will further delve into the implications for the relationship between client and therapist once musical dialogue occurs. Ultimately, I desire to offer music therapists innovative musical intervention strategies for promoting dialogue. Stimulating discussion and dialogue about an inherent phenomenon within the music therapy session has a myriad of implications for the therapeutic relationship. It is my intention to verify the importance and significance of musical dialogue within the clinical setting.

29 23 3. Method Once committed to doing research, it is essential to be well versed in the methods of conducting research, and how to generate a detailed study. There are several different methodological perspectives. Single-case research design (Aldridge, 1994), action research (Reasons, 1988), grounded theory (Corbin & Strauss, 1998), phenomenology (Forinash, 1995), narrative writing (Kenny, 1996, Smeisters, 1997), phenomenography (Marton, 1988), and data collection techniques such as observation (Silverman, 1993) and text/interview methods (Denzin and Lincoln, 1994) were all considered as part of my research process. The following paragraphs outline the steps taken to arrive at my research method for this study. Although there were aspects from each methodology that could be applied to my research, certain ones applied directly and appealed to my style of writing and inquiry. In an observational inquiry, one can be a complete observer, a participant observer, or have an active member role (Stake, 1998). The focus is on what is observable; motivations and attitudes can be analysed after the recording is complete. In my inquiry, I have an active role as both the researcher and the therapist. Sessions were videotaped or audiotaped in order to categorize complex, observable behaviour and analyse the data. Grounded theory has a pragmatic and symbolic philosophy. This research method includes the perspective of the participant and the interpretive view of the researcher. Sessions are audio or video taped and systematically gathered and analysed. Note taking, coding, sampling, memoing, sorting, and writing are all components of grounded theory

30 24 methodology (Corbin & Strauss, 1988). I utilized and adapted the various methods outlined in grounded theory. Session videotapes comprised my source of data for intense observation and analysis. A narrative style of writing appeals to me on both a personal and professional level; texts that are vital and convey meaning are important to the reader. In any academic reading, the eye usually searches for an example or a story to illustrate a theoretical viewpoint. Poetic transcription is defined as the creation of poem-like compositions from the words of interviewees, and representing or re-framing a story in a creative form of writing (Glesne, 1997). Initially dismissed as too nebulous and perhaps not scientific enough, I changed my view and now am aware of the value of presenting data using this unique perspective. The case study is another research design that applies to this research query. It has the advantage of being flexible, gives the reader an understanding of a client s experience, allows for a close analysis of the therapist-client interaction, and is an appropriate method for practitioners wishing to incorporate research into their own practise (Bruscia, 1991). The single-case research design was discarded in favour of the collective case study, i.e. the study of a number of cases jointly in order to inquire into a phenomenon, population, or general condition. In order to examine the phenomenon of musical dialogue, I selected four children with a diagnosis of autism spectrum disorder (ASD) from my clinical practise and analysed my interactions with them.

31 25 Phenomenology is a both a philosophy and a methodology. It proposes that we search not for truth, but for meaning and relevance. As a research approach, it allows the researcher to examine an experience as it is lived. These experiences exist and it is not necessary to categorize them as valid or invalid, true or false (Forinash, 1995). In other words, it should not be reduced to quantifiable data or as a hypothesis to prove or disprove. As an investigative tool in music therapy, phenomenological research strives to define the essence of music therapy from the perspectives of the therapists and the client. In learning about this method, it was evident that my inquiry would be phenomenological in nature, using empirical methods such as describing, gathering, and observing experiences. To summarize, my research includes five methodological perspectives. It is a phenomenological, naturalistic and collective case study using adapted grounded theory and a narrative writing style. Another important aspect of the research process is to ensure validity and reliability. It is necessary to consider the facet of credibility in extensive detail. To ensure a significant level of trustworthiness, I triangulated my findings and data analysis in supervision and during research seminars with classmates and faculty. Throughout my research study preparation, I continued to examine my clinical work with Jonathan. Dr. Ahonen-Eerikainen and I viewed a videotape of Jonathan s session together, and she posed many questions for me to ponder:

32 26 How do I invite him back when he runs away? What is inviting music? What is he saying to me when he improvises on the piano? Does he have a reason to dialogue? Why does he both laugh and cry within the session? Is sitting on my lap a sign of trust? Why does he appear to feel insecure so easily? (Analytic memo, January, 2003) After obtaining consent from participants, I began to design my data collection forms to be used when videotaping was complete. My original categories of dialogue were initially named expectational, humouristic, invitational, and anticipatory. Employing a narrative style, I re-named them to more descriptive titles, such as I m Here, What did you Say?, Come and Play, I m Waiting, and Just Listen, that s Enough as a way to parallel and equate musical dialogue with an implicit message. I searched for a way to depict graphically or symbolically the various realms of musical dialogue spheres, circles, and bubbles presented themselves as distinct possibilities. In order to conduct my study, I initially chose four children with autism spectrum disorder from my current caseload. Autism Spectrum Disorder is the term used to describe and classify children who have difficulties in three main areas: social interaction, behaviour, and communication. There are currently five disorders under the ASD umbrella. They are: Autism Disorder, Asperger s Disorder, Childhood Disintegrative Disorder, Rett s Syndrome, and Pervasive Developmental Disorder - Not Otherwise Specified. Each of these disorders has specific diagnostic criteria as outlined by the American Psychiatric Association in its Diagnostic & Statistical Manual of Mental

33 27 Disorders (DSM-IV, TR). All of the children had an impaired ability to express themselves verbally, or non-verbally, and/or to comprehend information. There are many possible causes of communication disorders. They may be caused by developmental lags, maturational lags, organic deficits and abnormalities, severe restriction of sensory input, sensory impairment, sensory deprivation, perceptual-motor disturbance, maladaptive behaviour, emotional disorder/trauma, functional retardation/developmental delay, inadequate vocal development, impairment of interpersonal relations (Geneva Centre, 1999). For this study, I audiotaped 1 or videotaped 2-3 sessions per child. Each audiotape and videotape was reviewed meticulously by transcribing and noting any interactive moments between the child and me. In my notes, I described what I saw and what I heard, e.g. eye contact, physical space, body movement, any vocal or verbal output, facial expressions, affect responses, and harmonic, melodic or rhythmical responses, as well as the time of each occurrence. The next phase of my research was to categorize data and identify theoretical constructs related to the data. Each episode of dialogue was labeled with a quoted phrase and three columns were created. Here are two examples: 1 Although session videotaping was the intended method for data documentation, a parent of one of my clients consented to audiotaped sessions only.

34 28 I Can Help You INTERVENTION QUALITIES THEORETICAL CONSTRUCT Instrumental glissando Dependency Kohut Vocalization Intimacy Extended self Kinesthetic Trust Translator of Action Come and Play INTERVENTION QUALITIES THEORETICAL CONSTRUCT Vocal beckoning Persistence Mother baby interaction Rhythmic repetition Invitation Nordoff-Robbins Musical tension Expectation Winnicott In the column entitled Intervention, I listed the technique used to dialogue with the child. The second column noted those qualities I believed were present when the episode occurred, while the third column included theorist s names and concepts that I could use to substantiate my data. By using a chart such as that above, I was able to organize the data in a clear and concise format. I chose to use simple quoted phrases instead of complex clinical terminology in order to make the data accessible and as way of relating easily to the reader. Although the phrases themselves are simple, the messages are not. They are the expressions that immediately came to mind as I watched the video or listened to the audiotapes. After completing a comprehensive review of all the episodes, I began to look for similarities between each one. I condensed the data to ensure that there were not repeated episodes with similar messages, and integrated any related occurrences. I examined the various quoted expressions for themes. For example, Take your time, I can wait and

35 29 Just listen that s enough are categorized as messages of acceptance. By doing this, several themes became apparent, and I was able to create sub-categories for each theme. To validate my data, I consulted weekly with my advisor, Dr. Heidi Ahonen-Eerikainen, and conferred with my peers and other faculty members. My entry into the world of qualitative research may be characterized as a coming of age. I feel a freedom that I never thought possible my knowledge of research was antiquated and out-dated, rooted firmly in empirical and quantitative methods. There are a myriad of possibilities to disseminate the results of qualitative inquiries and the nuances between the various methods are subtle and infinite. The results based on the methodology outlined here are summarized in the next section. To fully experience each example, I have included an accompanying CD with a sample of clinical extracts.

36 30 4. Results 4.1 Episodic Dialogue The following vignettes are descriptions of episodes of dialogue that occurred with my individual clients. They feature the children named Jonathan, Katy, and Matthew (all pseudonyms). In coding and categorizing these episodes of communicative contact, several themes of dialogue became apparent. They are: the dialogues of reciprocity, acceptance, discovery, acknowledgement, and empowerment. Within each branch of dialogue, the episodes are entitled with a caption. The caption is an expressive translation of my thoughts and intentions as a music therapist while in dialogue with my client. Essentially, it is what I am saying clinically and musically when I intervene with each child. Each vignette is accompanied with an explanation of the intervention, the inherent qualities of each episode, and the intersecting theoretical constructs from the worlds of music therapy, psychodynamics, symbiotic, and psychobiology related directly to each episode The Dialogue of Reciprocity (a) Come and play (CD Extract 2) The child enters the music room and immediately sits beside the music therapist at the piano. His slight frame moves quickly and purposely there is intention to his movements. The therapist hands him a small ocean drum and mallet. She begins to play the piano. The song is in a minor key (D) with a pulsating rhythm. The lyrics are simple and repetitive: Play the drum, Jonathan. Play the drum, Jonathan. One more time, Jonathan.

37 31 She pauses to wait for him. If he plays, she plays. She alters the rhythm to encompass his beat. The dialogue continues for a significant amount of time. Throughout this episode, the child alternately sits on his chair and on the therapist s lap. When he does the latter, the therapist reaches her arms around him in order that they may play the drum together. In this example, I employ several forms of intervention. I vocalize to clearly explain my need for Jonathan to participate and shape it into a song. I improvise the chords and melody, although I have chosen the key for this song before the session. Rhythm is also an important element in this example. The initial rhythm is a strict 4/4 to engage Jonathan quickly and suggests a percussive sound. The rhythm is stretched and pulled as Jonathan begins to beat the drum. We use the drum sound to substitute for a word in our song. For example, I sing, Play the, Jonathan. Play the Jonathan. Kinesthetic elements are incorporated through physical contact, tactile exploration of the instruments, and the active playing of the instruments. Unlike many children with autism, Jonathan appears to crave physical contact. Although it is momentary, it is frequent throughout the session. He repeatedly sits on my lap, and, although his size prevents him from doing so, he tries to cuddle and hug me. Instruments are touched, smelled, and tasted. Jonathan plays the drum independently as well as together with me. Several qualities are evident in this moment of dialogue. There is an element of persistence on both of our parts. I continue the song as long as Jonathan continues to be

38 32 interested and present by my side. I persist in getting his attention and keeping it. I feel successful the longer he stays with me. I persist in making the music interesting, by varying some of the lyrics, or the tempo of the song. Jonathan demonstrates persistence by staying focused and alternating his seating between my lap and his chair. There is an essence of expectation. I purposely suspend the music and the lyrics, so Jonathan can sense a release when the resolution occurs with his playing. For example: Figure 1: Play the Drum In Healing Heritage, Nordoff (1988) discusses the importance of melodic and harmonic tension to lend a sense of urgency to the music. He urges music therapists to cease thinking in terms of dissonance and consonance, and commence thinking in terms of tension and relaxation. There is also the element of invitation in my music with Jonathan: I want him to play and participate. I repeatedly invite him to play with both the music and the lyrics. When that playing occurs, the tension is released, and the element of reciprocity becomes strikingly apparent. In Steen Moller s (1996) article Music as a Means of Contact and Communication with the Physically and Mentally Handicapped, five levels of contact through music are outlined based on a client s response level. They are:

39 33 1. I feel contact between us. 2. I see/hear contact. 3. You control the contact. 4. Our contact takes the form of dialogue. 5. We contact each other through free, improvised music. The above example could be classified as a Level 4. Both the client and therapist take turns at producing sound and listening (Steen Moller, 1996, p.152). (b) We re a team (CD Extract 3) The client and therapist sit on the floor by the gathering drum. After playing it in the predictable way, the therapist flips it over and invites the client to sit inside. He hesitates at first this is a new experience. But his uncertainty gives way to curiousity, and he deftly climbs in, sweeping his hands across the smooth inner side of the drum. The therapist asks, Do you want to go around in the drum? making a circular movement with her hand. She begins to spin the drum slowly on the floor, singing, Jonathan goes round in the drum to the melody of Sally Go Round The Sun. She continues this song, changing direction several times. Jonathan smiles as he hangs on tightly to the sides of the drum. When the song stops, she asks him, Do you want to go around again? This time, she takes his hand and they make the circular motion together. Eventually he is able to sign for more turns in the drum. The pattern is repeated until Jonathan jumps out of the drum, indicating an abrupt end to the activity. The intervention in the above example includes kinesthetic and vocal elements. The unconventional use of the drum appears to appeal to Jonathan s physical nature, and the vestibular motion in an enclosed space provides him with a pleasurable experience.

40 34 The drum is transformed temporarily into a playful ride, and to make the ride go, Jonathan has to communicate non-verbally with the therapist. Through repeated trials, he is given the opportunity to practise communicating with another person, without the pressure of the spoken word. I accompany this vocally to give momentum and form to my actions within the activity. We must work in tandem in order for the game to occur. In what Heimlich (as cited in Bruscia, 1987) terms as rhythmic motor maneuvers, rocking, creeping, swaying, stretching, skipping, jumping, ball-bouncing, ball-rolling, pushing, pulling, or any other repetitive gross motor movements, can all be used to meet a variety of needs and goal areas. Music is used to accompany, reflect, stimulate, and guide the client s experience (Heimlich as cited in Bruscia, 1987, p. 293). Several techniques are fundamental to these rhythmic motor maneuvers including synchrony (moving together in time), variation (adjusting the intensity or speed of the actions through musical accompaniment), and reciprocal interaction (each person is dependent on the other s movements/music). In a related view, Winnicott (1971) states that playing games is a creative experience, one that implies trust, and mimics the first interaction experienced by mother and infant. Stern (1996) agrees, and believes that play is a most unusual activity, especially in the pre-verbal stage. Learning is a desirable by-product of free play, but it is not the goal. Just as a baby cannot talk and cannot understand the words being spoken, the child with a communication challenge faces a similar dilemma. This limits the play to the sounds the parent or the therapist can make, the facial expressions exchanges, the

41 35 gestures, and the sharing of emotions and excitement. As Stern says, Play is limited to the very essentials of human interaction. It is a simple, pure, and unreflected activity. It is improvisation, unencumbered. (Stern, 1996, p. 9). (c) You call, I ll answer (CD Extract 4) The child tentatively makes a sound. The therapist taps the child s vocal rhythm back. The child tries out another sound. It is repeated back to her with a slight twist. The child looks up. The therapist rolls her fingers on the drum and repeats the last rhythm. Next, a low-pitched aaah yaah emerges from the child. The therapist does that too, repeating rhythmically every sound the child offers. The child mimics the therapist this time, repeating the tonic note. They vocalize together, moving to the subdominant, and back to the tonic, accompanied by the therapist s drum playing. The therapist borrows the child s aah yah sound and transforms it into a vocal phrase - all done as the session comes to a close a natural ending to the rhythmical flow of musical conversation. The interventions used here are rhythmic reciprocity, improvisation, imitation, and vocalization techniques. The immediacy of the therapist s response to the client s rhythmical offerings is crucial to the establishment of communicative contact. To dialogue is to send and receive messages. Katy and I are establishing our rules of dialogue, i.e. how we communicate. My message to her is clear: I will respond to your offering whenever and however it is made. Sometimes the imitation is exact and sometimes it is given back with a variation. I make a conscious effort to use Katy s vocalizations as a basis for lyrics to an improvised song. Although, she is non-verbal, it is important for her sounds to be meaningful and utilized for a communicative purpose.

42 36 In Improvisational Models of Music Therapy, Bruscia (1987) delineates several paraverbal techniques that employ rhythm as the communicative basis. They include: imitation, repetition, variation, exaggeration, and modeling. The therapist may echo a client s rhythm or play the rhythm in unison. He states that by repeating a musical phrase or a musical element, music therapists may offer a sense of predictability, demonstrate cause and effect, encourage awareness of others, and convey acceptance. Oldfield (1999) believes that these types of musical exchanges allow a non-verbal and/or noncommunicating older child to communicate within a pre-verbal stage, by re-creating basic sound responses and interactions. In her article, Communicating Through Music, Oldfield was reminded of her own dialogues with her infant daughters while working with a child named Timothy, with Asperger Syndrome. Her daughter, at 13 months, enjoyed passing an object back and forth, and, although, Timothy was too old to engage in the same activity, he delighted in a paralleled musical improvisation. Timothy was thrilled in hearing his sounds imitated vocally or rhythmically by Oldfield. These building blocks eventually led to Timothy spontaneously vocalizing and beginning to use some simple phrases to communicate (Oldfield, 1999). I believe there are elements of mutual investment and equality in any call and response activity. I am invested in Katy s sounds and dependent on them for my response, and she needs me to respond to her sounds. The equality becomes tangibly apparent as we take turns responding: we are allies within collaborative music making.

43 The Dialogue of Acceptance (a) Just listen, that s enough (CD Extract 5) The child and the therapist share the piano bench. The music is quiet and sustained. The child bows his head and steals glances at the therapist. Occasionally, he ventures a note on the upper register of the piano, and then quickly withdraws his hand, as if overwhelmed by his own sound. Both therapist and child are very still. The therapist vocalizes his name repeatedly. She sings about the piano and how they are sitting at it together and how beautiful the notes are that he offers to their composition. They remain beside each other for a long time. In this example, the interventions include vocal, kinesthetic, and improvisational elements. The vocal line is significant here, as it sets the mood and provides Matthew with a concrete explanation of their purpose at the piano. I sing softly and slowly to suspend the moment and in an effort to keep him with me. His furtive playing adds a subtlety that quietly announces his presence. Improvised music is played on the black keys in the pentatonic mode. This ensures that Matthew s efforts are rewarded with resonance not dissonance. There is an overall quality of tenderness and intimacy to this episode. The mood was sustained long enough for both of us to relax into the music. Matthew did not bolt after a few moments of active engagement, unlike other times. He appeared to be enthralled by the sustained sounds of the piano as indicated by his intense listening. It is ironic that in a song where listening is the only expectation, he independently offered his own musical ideas to the dialogue. Ahonen-Eerikainen (1999) compared communication-

44 38 accentuated music therapy to Stern s theory of the Four Senses of Self (1985). In Stage 1, the music meets and creates contact with the child to convey a safe and secure atmosphere for communication. The music therapist s role is to create a space for the child in which they are tempted to communicate. This intimacy and meeting in the world of music may be related to Stern s emerging of emotions which leads to the development of the self. I accepted Matthew s presence at the piano as an indication of his readiness to communicate, and did not attempt to transform his passive response into an active response. (b) I can wait for you The child barricades himself in a corner with three small chairs and a gathering drum. It is impossible for the therapist to access him physically. He does not appear unhappy, but repeatedly touches the wall behind him. The therapist gets her guitar and approaches the child. She sits on the floor and faces him his brown eyes are barely visible behind his makeshift fortress. As the therapist begins to play soft, arpeggiated chords (Amin7, Dmin, Emaj) his repetitive movements slow. Occasionally the therapist sings his name, but mostly she just plays. After a few minutes, he stands, reaches out, and touches the guitar. This clinical example highlights the use of an instrumental accompaniment as an effective intervention. The tempo of the music is slow, the mood is gentle, and the chord structure is simple. Guitar music creates an intimate feel it is a resonant and vibrating instrument. Most importantly, the guitar is portable and can be brought to the child virtually anywhere in the room. I do not request that Jonathan abandon his safe place, the

45 39 one he has methodically created. By bringing the music to him without any implicit expectation, Jonathan is given a powerful message of acceptance and patience. Children have their own agendas and it is necessary to honour their sense of individuality. It is more difficult to predict the agenda of a child with autism because it is not as conventional. Nordoff and Robbins (1977) believed these natural impulses should be used as dynamic forces instead of being labeled as undesirable behaviour. Removing the chairs or attempting to persuade Jonathan to leave the corner, would have been essentially disrespectful to Jonathan and his need for isolation. Wigram (1999) employs waiting as a technique for assessing communication disorders in children. In the beginning of Wigram s assessment, the child is given time to explore the room, relate to the therapist, or choose an instrument. The child may choose to do none of the above, and this is valuable information in itself for the assessor. Wigram advocates the use of unobtrusive piano music to reflect a feeling of empathy for the child s physical and/or emotional state while they explore the room. He equates waiting time as revealing time when, later in the assessment, he pauses his interactions with the child to see if they initiate a new idea or returns to a favourite instrument (Wigram, 1999). If I had not waited for Jonathan, I doubt he would have stood up and reached over his barrier to touch the guitar.

46 40 (c) Take as much time as you need (CD Extract 6) Both therapist and child are seated on the floor, an array of instruments and materials are in a large box between them. The child reaches into the box and chooses a plastic orange. Taking her cue, the therapist places another piece of plastic fruit in front of the child, and launches into Oranges and Bananas (Arseneault, 2000), with several verses. The child looks around, not appearing overly interested. She still holds the orange, and occasionally smells and tastes it. The song ends. The therapist chooses a drum for the child, and prepares to begin another song. Suddenly, the child quietly vocalizes a phrase from Oranges and Bananas, as if to say, Wait! I still want to hear that song you played before. The therapist pauses and quickly adapts the current song to incorporate the previous melody. The child laughs there is an implicit understanding about what just happened. Similar to the previous example, demonstrating patience towards my client was imperative here. To intervene, I utilize two pre-composed songs, adapted lyrics, and repetition. It is crucial that I hear and respond to Katy s vocalizations. In reflection on this episode, I questioned whether Katy s delayed response was a way to extend the previous activity, or did it take a substantial amount of time for her to process what she heard? In either case, it was Katy s way of communicating and dialoguing with me. It impressed on me the importance and value of repetition for a child such as Katy, repetition of material is a necessity, not a courtesy, for processing. A delayed response should not be viewed as a negative phenomenon. Rather, it demonstrates to me that a learning process occurred, and perhaps is evidence of an underlying neurological process. Trevarthen (1999) writes that music, like language, can be perceived, stored, and studied as a timeless structure (p.161). Therefore, it is not presumptuous to say that Trevarthen

47 41 would interpret Katy s delayed response as proof of unconscious material being present in the architecture of the music. In other words, the music I played reminded her of a previous and pleasant association, one that she wanted repeated The Dialogue of Discovery (a) What s this? The child sits in the corner, playing with a loose thread from the carpet. He is not looking at the therapist. The therapist crosses the room and opens her instrument cupboard. She takes out an African gourd cabasa. The beads that surround the instrument are bright green and orange. With a shake of it, she asks, What s this? with a mixture of curiousity and excitement in her voice. The child looks up immediately upon hearing the new sound and seeing the new object. He runs to the therapist, takes the gourd from her, and begins to eagerly explore it himself. Although this is essentially a verbal intervention, the outcome is a brief but important moment of dialogue. I introduce a novel stimulus to gain Matthew s attention. I choose a brightly coloured object to appeal to his visual sense and one with beads to appeal to his tactile sense. From previous sessions, I know he likes percussion instruments, so the gourd offers a new sound experience. The qualities inherent in this interaction are excitement, novelty, surprise, and anticipation. By using an excited tone of voice, Matthew cannot resist looking up at me. Not only is my voice showing excitement, I am holding an unfamiliar object to inject an element of surprise. He anticipates a new sensory experience and quickly accesses me in order to obtain the instrument. Wigram (1999) also uses a similar technique to re-establish the attention or interest of the child once it begins to wane. In his assessment process, he specifically

48 42 chooses metallic instruments (metallophone, windchimes, gong) to give the child a new sound experience. In his work with infants, Stern (1996) advises parents that the presentation of stimuli, i.e. sounds or facial expressions, must constantly be varied to maintain the same level of interest, excitement and delight in the baby. (Stern, 1996, p.8). This is termed as habituation and is defined as a rapid loss of interest if the same thing is done two or three times in succession. I offered Matthew a new instrument to keep his interest and attention, which led to an opportunity for exploration. Hoelzley (1993, 1994) writes that novel and unusual auditory stimuli arouse attention and communicative responses. By utilizing specific wind instruments, which have a wide tonal sound spectrum, Hoelzely was able to evoke significant and positive cognitive, affective, and psycho-motoric responses in children with autism. (b) Let s explore together (CD Extract 7) The child glances at the large cymbal that sits by the piano. The therapist immediately pulls it closer to the child. She outlines the outer circle of the cymbal slowly and methodically, as she spins it. Its ridged texture is attractive to the boy. He reaches out and tentatively touches it, too. The therapist begins to vocalize with an unaccompanied voice: It is shiny It is shiny and gold And it goes round and round. He spins it as she sings. During this moment, the cymbal is never sounded - rather, each feature is explored and described in detail. The clinical intervention in this example is both musical and kinesthetic. The a capella vocal line appears to sustain Jonathan s attention, by creating a suspended

49 43 intimacy. I chose a minor key (D) and a simple melodic line that suited repetition. I purposely do not direct Jonathan to play the cymbal. I want him to choose how to explore the cymbal and I want to label and call attention to its visual qualities and capabilities. The cymbal has kinesthetic appeal. It is cool to the touch, has different textures, reflects light, and spins. This shared activity provided both of us with a quiet space to dialogue and was a way for him to acquire new information. Bruscia (1987) states: Unlike rhythmic dialogues, the focus of this maneuver is physical interaction with the instrument itself rather than the production of musical material. (Heimlich as cited in Bruscia, 1987, p. 291). Exploration is an essential element of dialoguing with a child with autism. Wigram (1999) has found that children with autism have specific physical and tactile behaviours when encountering instruments. They may flick, spin, fiddle with parts, or play instruments in a tactile manner but without musical intention, e.g. plucking each string of a guitar and watching the vibration, and may choose instruments based on their material quality. Jonathan was interested in the cymbal, and was focused on exploring it. I ensure that clients are free to explore all the contents of the therapy room, and have no difficulty with a child using an instrument in an unconventional way, as long as they are not damaging them.

50 The Dialogue of Acknowledgement (a) That s funny! (CD Extracts 8, 9) 1. The therapist hands a multi-coloured lollipop drum to the child. He immediately sticks out his tongue and licks it. With a laugh, the therapist begins a short, improvised melody in C major, on the piano that incorporates and directs this behaviour: My lollipop drum My lollipop drum Oh please don t lick My lollipop drum! Upon hearing these words, the child grins, licks the drum one more time, and hands it back to the therapist. Both client and therapist laugh at their private joke. 2. Therapist and child sit together on the floor. It is the middle of the session. The therapist begins a song to help the child focus on strengthening the muscles of her mouth. It is a fun song, called the Tongue Pokey (Pringle, 2002). It becomes a delightful musical game and by the end of it, both therapist and child are laughing: You put your tongue out You put your tongue in You put your tongue out You put it in your mouth And you say, ta-ta-ta That s what it s all about!

51 45 The intervention used in both these clinical examples is an improvised song. I chose to acknowledge both behaviours, (which might be interpreted as maladaptive or inappropriate), as logical responses to a stimulus. In the first example, the drum looks like a real lollipop- anyone might be tempted to respond as he did! In the second example, the song utilized is visually comical. Children with autism frequently experience stimuli in amodal and unconventional ways. By vocalizing about what Jonathan was doing, I made him aware of his own behaviour while gently and simultaneously correcting the behaviour. In both examples, we saw the humour in the situation and were able to engage in a collective dialogue about it. Nordoff and Robbins (as cited in Bruscia, 1987) use a transitional activityexperience to establish reciprocity and ease the tension that may accompany a period of resistiveness. New songs, musical teasing games, or playful activities are a way to transition the child into a new stage in the relationship and resolve any conflict that arises. Although both Jonathan and Katy exhibited their behaviour later in the therapy process, and it was not necessarily a defined period of resistiveness, it was important to acknowledge the moment, incorporate the response, and find collective humour in the situation. It was also a welcome indicator of both children s increased comfort in the music therapy environment: they were relaxed enough to laugh. Oldfield (1991) observed that as her client s abilities to communicate improved, new naughty behaviours (p. 173) developed. At this stage in their relationship, she was able to exert more pressure on her client, and be more directive within the session. It is

52 46 noteworthy that in an examination of present literature there is not an abundance of articles regarding humour and children with autism. (b) I hear you (CD Extract 10) The child is frightened. It is his first session in the music therapy room. It is an unfamiliar place new smells, new sights, new sounds, and, most significantly, a new person with whom he is alone. His agitation is apparent in his vocal sounds and sudden movements. As his anxiety increases, the therapist chooses to play her violin, in an effort to match the sound -she is a strong believer that the violin is the closest instrument to the human voice. He is huddled under the piano clutching a drum. The therapist does not come too close, but is near enough to make eye contact. His vocalizations are rapid and chaotic, and she joins him with frenetic instrumental playing. His resolve to shut her out is waning, and he moves quickly to grab the guitar. His whine changes in pitch and tone. It is more breathy and lower in pitch, and the therapist matches that, too. Although he leaves his secluded space only briefly, there is a look of absolute recognition and relief in his eyes, as if to say, You hear me. This is an example of a purely musical intervention. No words were necessary here, but the presence of acute listening and the right music to reflect Jonathan s fear was paramount to making contact and initiating a dialogue. An instantaneous duet with voice and violin occurred, one that incorporated and shaped his sounds into an essential part of a shared and aesthetic musical experience. A sense of intimacy and contact was created through musical reflection. Stern (1996) describes affect attunement as an intimate dance, whereby mother and infant initiate, complement, and respond to one another. The mother adjusts her expression to match that of her infant and the infant changes his response to see if there is a corresponding change in the mother. They engage in a form of

53 47 protoconversation (Bateson as cited in Trevarthen, 1999, p.197). In a similar way, I am trying to tune in to Jonathan s internal state and first and foremost match his anxiety. I change and shift my musical reflection only if he changes and shifts his response to me. This is one of the most powerful messages conveyed through music. (c) I notice and respond to everything you do (CD Extract 11, 12) 1. The child and therapist are playing the guitar together. After placing his hand on the strings, he slides it quickly up and down the fret board. The therapist sings about his actions. He puts his hand in the sound hole of the guitar. The therapist reflects this back to him, too. He looks up at the therapist and smiles. He strums the guitar, and, again, is treated to some new lyrics to incorporate his exploration. Improvisation, vocal and instrumental interventions are evident in this example. Every action Matthew offers is acknowledged and incorporated into the activity. Reflective lyrics translate his internal response to the external world, and make them integral parts of the song. The immediacy of my response is important as soon as Matthew presents a new response, I react through clinical music. It is my clinical responsibility, to decode a client s responses, capture the quality of the act, and share the information with the client, all in a comprehendible musical language. Stern (1985) stated that everyone is born with an intrinsic motivation to connect in an intimate and emotional relationship from birth. By engaging in what Winnicott (1971) terms empathic mirroring, Matthew gains a stronger sense of self. Through musical reflection and decoding, there is an implicit emotional impact. Inherent in these reactions are the qualities of unconditional acceptance and acknowledgement. These are strong messages we all have the need to be noticed.

54 48 2. The therapist sings to the child: Who s got hair that s curly and red? Katy has hair that s curly and red! Who s got freckles on her nose? Katy has freckles on her nose? Must be Katy Must be Katy Who has a mouth that likes to smile? Katy has a mouth that likes to smile! Who has hands that like to clap? Katy has hands that like to clap Must be Katy Must be Katy Must be Katy, Katy The child sits alert and smiles as the therapist touches her hair, her eyes, and her mouth. She giggles especially at the touching of the freckles on her nose. The therapist continues with the song the possibilities for verses are endless. They sing about her shoes, her shirt, and her jacket. The therapist sings as long as the child smiles and watches. In this intervention, I employ a songwriting technique to compose a contact song. Katy is required only to listen and enjoy the moment. As I sing this, I gently touch her hair, her eyes, and her nose to give her a tactile sense of what I am singing about. The

55 49 repetition of her name is also important to her gaining self-awareness. This song is truly for her: I describe her physical presence, and I let her know what makes her special. I make a conscious decision not to sing or adapt it for any of my other clients. The contact song is: the first reciprocal musical expression, the first two-way musical communication, the first overt musical indication initiated by the client of an awareness of the existence of another (Boxhill, 1981, p.80) I chose this melody because of its structural elements, not on any specific melodic or rhythmical motif she had offered, and based the lyrics on her essence. She is a beautiful child, inside and out, and has a way of interacting with people that makes them smile. The structure of the song allows me to add several verses spontaneously and involve her presence as an integral part of the song. Boxhill (as cited in Bruscia, 1987) states that the contact song forms a unique bond between therapist and client, which can be used throughout the course of therapy as a greeting, a place to return for safety, a reminder of the relationship, an affirmation of trust, and a means of reaching out to one another (p. 386). As music therapists, we give our gift of individualized songs freely and without expectation.

56 The Dialogue of Empowerment (a) I can help you Child and therapist sit together on the floor. The ocean drum lies between them. The therapist offers it to the child, but he pushes it away. As the therapist begins to tip it back and forth and side to side, the sound of waves fills the room. The child reaches out to grasp and move the therapist s forearm. He directs the sound by himself. This connection becomes a living circuit and continues for several minutes. To empower is to enable or give authority to someone (Random House College Dictionary, 1982). In this example, I have to demonstrate how the instrument is played and help Jonathan to play it. Instead of viewing his initial resistance as a definitive negative response to my request, I choose to assume Jonathan wants to play the ocean drum, but simply needs an introduction to the new sound and instrument, and some assistance from me. I base my assumption on his body language and facial expression. Although he pushes the instrument away, he remains seated with me. There are elements of dependency, intimacy, and trust in this example. Jonathan is dependent on me to make contact with the drum. I am dependent on him to move my arm in order to make a sound. This dependency creates a palpable sense of intimacy between client and therapist. The trust is implicit: we must trust each other to make this connection work. This example differs from sharing an instrument and playing it together. I acted as the conduit for his actions. It was his instrument to play and I was the translator for his actions. Heinz Kohut (1977) described a similar phenomenon, termed the extended self. In his book, The Restoration of the Self Kohut states that healthy narcissism (self

57 51 love) will lead individuals to seek out others as an extension of themselves, i.e. their interior self. Jonathan appeared frozen; he had the impulse to play the instrument and express himself, but his condition may have stopped him from carrying out his desire. He simply needed some assistance. If viewing this incident through a psychodynamic lens, it is useful to consider Walsh and Stewart s (1999) essay on the necessity for clear and consistent boundaries. To demonstrate a consistency of attitude, the therapist must not have a pre-set agenda and should commit to being with the client for the sole purpose of receiving the client s communications, i.e. to respond and give meaning to them. By doing so, the therapist conveys that the room can cope (Walsh & Stewart, 1999, p.5) with any communications from the client. Jonathan needed to know his initial response of resistance was accepted and acknowledged, and that I could help him overcome it. (b) We can t do this without you (CD Extract 13) It is the end of the session. The therapist plays the opening chords of a goodbye song. The child knows this song and what it means. However, he remains in the corner sitting on a large drum. The chair reserved for him is empty. The therapist beckons him with a gesture to come and sit down beside her. She continues to play, but alters the lyrics. She pats the chair again and suspends the music on the V chord. The child eventually abandons his post and takes his place beside the therapist. She sings: Goodbye to Jonathan Goodbye to you. We ll see you next week Goodbye, Goodbye

58 52 The session does not end with this exchange. Jonathan goes to the door. He waits. The therapist waits, too. He fiddles with the doorknob. The therapist waits, although she knows what he wants. Jonathan looks her in the eye. What do you want, Jonathan? she says quietly, Do you want to go? He echoes, Go? They open the door together and Jonathon runs down the hall to greet his mother. The interventions utilized in this example include instrumental music, vocalization, a closing song, and visual and verbal cueing. Although I know and accept Jonathan s frequent need for an isolated space, I also want him to realize I need his physical presence and attention to close the session. By suspending the music, withholding the tonic chord, and changing the lyrics, I hope to convey a sense of waiting. The empty chair serves as a strong visual cue no one but Jonathan can sit there. The quality most dominant here is one of empowerment. Jonathan is expected to be an equal and integral part of the dyad. His presence is a signal of his acceptance and of his significance to the process. My message to him is straightforward, You hold the power to direct the session, and I will wait until you use it. I want Jonathan to develop a selfpresence, and an awareness of his importance within our session together. Robbins and Robbins (1991) describe their work with a disabled child, Lyndal, whom, in their words, was fearful, self-protective, and behaviourally unpredictable (p.60). By discovering the music child within, the Robbins team was able to musically uncover and transform an old self into a new self. They believe that music therapy is the force that aids in achieving the core of humanistic psychology: self-actualization. A child

59 53 lacking the cognitive infrastructure to articulate their inner life verbally expresses it through musical responses and the music therapist must work directly with the inner life to bring basic, fundamental changes (Robbins and Robbins, 1991, p.70). (c) It s good to be the boss (CD Extracts 14, 15) 1. The child approaches the piano and steadies herself by placing both her hands on the keys. The therapist plays their Hello song, one that was composed using small snippets of the child s favourite melodies. Today, however, the child vocalizes and moves to the music. She nods her head in perfect time to the pulse of the song. The song ends and she continues to pulse a steady beat now with her whole body. The therapist mirrors this rhythm in a descending pattern, improvising a new melody to slow and speed the tempo in response to the child. They continue their animated dialogue. Musical space is given to pulse the beat together. The child is in soundless synchronicity with the therapist. She is the silent partner. 2. Child and therapist sit at the piano. The instrument of choice today is the harmonica. He takes it eagerly from the box, runs his tongue along the grooves, and taps it on his teeth. Using a I vi V-IV pattern, the therapist begins to play. The child s playing is energetic and intense. He has an innate sense of timing and musicality his music soars in response to the piano music. They meet often on the same chord, and freely take turns leading and following each other. The therapist adds words, and moves into an adapted familiar song. She leaves space in the music for him to answer her musical question. Both child and therapist return to their musical point of departure, and the duet ends simultaneously. In the first example, I intervene with an improvisatory instrumental technique. Taking my tempo cues from Katy, I attempt to ensure that the music she hears is

60 54 synchronized and rhythmical. It is not my intent to prompt Katy to vocalize or accompany me in any other way than the way she is doing. Her intense listening to the music is evident by her mirroring, shifting, leading and controlling the pulse. In a sense, she is sending a distinct signal to dialogue with me. Not only is she my silent partner, her active response makes her an equal partner. Trevarthen, in his formidable study of musicality, human psychobiology, and infant communication introduces the reader to the concept of the Intrinsic Motive Pulse (1999). The IMP is defined as the body-moving rhythmic and emotionally modulated system. (Trevarthen, 1999, p.160). The musical impulse has the capacity to move the body and triggers neurochemical responses of elated or sad feelings, or of vitality and rest. Developmental research brings evidence that human beings are intrinsically motivated from infancy to perceive and demonstrate preference for the sounds of speech, singing, and music songs and music make us move rhythmically and cause us to register interest and happiness. Katy and I experienced a sympathetic awareness of each other, termed mimesis (Donald as cited in Trevarthen, 1999, p.171). We were simultaneously aware of rhythmic posture, gestures, and bodily movements in the other person. Trevarthen (personal communications, July 22, 2003) theorized two possibilities for her response: 1) that Katy has difficulties with volition and simply could not stop moving to the beat or 2) derives pleasure from the rhythm and is motivated to make it continue.

61 55 In the second example, I base my harmonic choices on the instrument chosen by the child. Once we begin to improvise, we move in and out of the leadership position, with my role primarily defined as the supporter of the child s music. Matthew, the child in the second example has verbal skills that are primarily echolalic and modeled by others. He takes very little initiative to communicate verbally, and is generally a passive individual. It is interesting that his music is in distinct contrast to his general passivity. It is passionate, intense, energetic, and dynamically explosive. Clearly, musical improvisation allows him to be the boss and express an inner self. Pavlicevic (1997) tells of a similar event in her book, Music Therapy in Context. While working with a woman with a complicated mental illness, whose posture and manner conveyed an introverted and quiet personality, Pavlicevic was surprised to encounter her intense and passionate music. Musical improvisation appeared to channel, capture, and display a hidden expressiveness. Oldfield (1995) differentiates between following and initiating while communicating through music. She likens both phenomena to integral components of a verbal dialogue between two people. Persons involved in a conversation focus on the verbal messages, although other processes are present, namely, following and initiating. All aspects of communication must be considered when working with individuals with communication disorders. Not only must the therapist be aware of the exact cause of the communication challenge, but must also adapt his or her way of communicating to attune to the needs of the child. Especially when using the medium of music, the non-verbal features of communication are significantly important. There are an absence of words and

62 56 complex sentences to interpret, i.e. no verbal content upon which to focus. The therapist is therefore faced with several questions: Does the music therapist initiate a sound herself? Does she wait until the child contributes a sound? Does the music therapist encourage a child to play with her or does she follow the playing of the child? (Oldfield, 1995, p.226) How one chooses to communicate musically is crucial to the communication process. These aforementioned clinical examples of episodic dialogue are a cross-section of my clinical work with communicatively challenged children. Themes of reciprocity, empowerment, acceptance, acknowledgement, and discovery emerged from moments of dialogue. It was important to my process as a researcher to find a way to graphically depict my model of establishing communicative contact through musical dialogue. The symbol of a tree (Figure 2), with its associative imagery of strength and power, serves to encapsulate and condense my theory.

63 Establishing Communicative Contact through Musical Dialogue Figure 2: Symbolic Representation of Communicative Contact