Interactive Family Music Therapy: Untangling the

Interactive Family Music Therapy: Untangling the System Joanne Mclntyre Redbank House,Westmeod.Austra/io

Interactive Family Music Therapy can have a unique role to play when v^/orking as part of a multidisciplinary team by demonstrating a capacity to 'surprise' a client/patient when they least expect it. It provides a positive shared experience that can add to multidisciplinary assessment and treatment planning.This article will illustrate the role Interactive Family Music Therapy has at Redbank House and includes case material. Keywords: music therapy, interactivefamilymusic therapy

In July 2006 a registered music therapist (RMT) was employed as part of the multidisciplinary team at Redbank House, Westmead. Since then Music Therapy (MT) has been conducted with groups, individuals and families. Families admitted to the programme, receive an average of two to three MT sessions for the duration of their one to two week admission. When utilised within the multidisciplinary team, MT may assist the team with gathering information for initial diagnosis and for future treatment. This article focuses on the application of Interactive Family Music Therapy (IFMT) by defming and reviewing its benefits and by presenting two case studies to support its use within the multidisciplinary team. The definition of music therapy, with regard to its ideals, approaches and philosophies, can differ greatly across the world (Bruscia, 1998; Wigram, Pedersen, & Bonde, 2002). The Australian Music Therapy Association (AMTA) defmes MT as: ... an allied health profession practised throughout Australia and in more than 40 countries around the world. It is the planned and creative use of music to attain and maintain health and wellbeing, and may address physical, psychological, emotional, cognitive and social needs of individuals within a therapeutic relationship. Music therapy focuses on meeting therapeutic aims, which distinguishes it from musical entertainment or music education. People of any age or ability may benefit from a music therapy program, regardless of musical skill or background. (AMTA, 2006).

Address for correspondence-. Joanne Mclntyre, Redbank House, Adolescent, Child and Family Unit, Westmead NSW 2145, Australia. E-mail: [email protected] 260

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Interactive Family Music Therapy

MT has a variety of potential therapeutic benefits for families. First, it provides opportunities for a family to engage in intergenerational music making where each individuals developmental stage is respected (Malchiodi & Perry, 2008). From a babe in arms to a grandmother, each family member can participate at their own level when given an appropriate instrument. For example, bells can be fastened around a baby's wrist or ankle, an electric guitar is suitable for an adolescent, a floor drum and drumstick for a dad, a tambourine for a mum. A MT session can often be the first time a family has participated in an activity together for quite some time. That outcome itself may act as a catalyst for further discussion later in die session or within future family therapy sessions. Second, the collective process of making music may provide more immediate access to family processes than words. The issues surrounding some family systems are often complex and, at times, words may fail to express the depth of a family member's emotions. Music — that is, melody, harmony and rhythm — can, however, provide a more immediate route, both to connection and to the processing of these issues (Hilliard, 2003). Music is revealing, where words are obscuring, because it can have not only a content but a transient play of contents. It can articulate feelings without becoming wedded to them ... The assignment of meanings is a shifting, kaleidoscopic play, probably below the threshold of consciousness, certainly outside the pale of discursive thinking. The last effect is ... to make things conceivable rather than store up propositions. Not communication but insight is the gift of music; in a very naive phrase, a knowledge of'how feelings go'. (Langer, 1976, pp. 243-244) Little research has been conducted on music therapy with families but the potential benefits are supported by studies of cbildren and adolescents in individual and group therapy. Recently, music therapy has been applied to children who have severe emotional disturbances, bigh degrees of impulsivity and limited ability to self-regulate (Layman, Hussey, & Laing, 2002). Research has found that early trauma affects the developing nervous system, causing chronic states of over-arousal in traumatised children. Music is an ideal way to assist these children to self-regulate and soothe as it creates a middle ground between over-arousal and numbness. It tberefore helps the child to experience a state of stability. The immediate success that children experience in the music therapy setting can provide a boost to selfesteem and create a successful, nonthreatening environment in which the therapist can help the child to decrease symptoms of arousal or disinhibition. A study by Montello and Coons (1998) supports this theory. They found that students who were experiencing severe obstacles in forming relationships with peers and family members because of early trauma began to achieve self-worth and self-esteem as a result of playing music together in a group. Group Music Therapy can also facilitate the process of self expression and provide a channel for transforming frustration, anger, and aggression in the experience of creativity and self mastery. (Montello & Coons, 1998, p. 56)

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Some studies have also been conducted with mothers and their children. In 1996, Lenz worked with babies who were experiencing feeding and sleeping problems. She believed that these problems were due to difficulties in the interactions between the mum and her newborn. They participated in MT sessions to assist in repairing and building the relationships so as to alleviate the babies' difficulties. The MT was found to assist the mothers in relating to their child and as a result the feeding and sleeping problems improved. Levinge (1993) describes a project with three mothers and their young children who were experiencing great difficulty in interacting, communicating and engaging with each other. At the end of the project Levinge observed, 'music therapy had been able to provide a nurturing facilitating environment in which each couple could be nurtured'. These examples and other work by Warwick (1995) indicate that both children and parents benefit from joint MT sessions and the musical interactions that occur can give parents new insights into their relationships with their children (Oldfield, 2006). These observations and studies are the foundations of IFMT. Interactive Family Music Therapy

The IFMT approach arose from clinical practice and research conducted by Amelia Oldfield. While working with parents and preschool children with autistic spectrum disorder at a children's unit in England, Oldfield found that musical interactions between family members gave an indication of what was happening in the family system. This approach was different to the way music therapists had worked previously. Traditionally, music therapists emphasised the importance of the relationship between the therapist and the client, and indicated that the focus for therapeutic change lay in that relationship (Bunt & Pavlicevic, 2001 ; Nordoff & Robbins, 1977). MT and the Multidisciplinary Team

MT is a dynamic, and potent therapy w^hen used alone or as part of a multidisciplinary team. Because music is used as a means to connect with families, it is often perceived as a ftin time and a relaxing part of a family admission to Redbank House. This perception may allow the family to play and speak freely about what is happening in day-to-day family living, and at times issues are disclosed in MT that have not been spoken about in other therapy sessions. This feeling of being free to play and to be themselves within MT may lead to further discussion by the multidisciplinary team on how MT could be beneficial in ftiture treatment. The role of a RMT within a multidisciplinary team is quite unique. The reason for its uniqueness is that a RMT is not utilised for any specific issue like a speech therapist, physiotherapist or psychologist is. The RMT provides treatment to the family to assist and support the team in a nonspecific area of difficulty so clearer diagnosis and treatment can be put in place.

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Interactive Fannily Music Therapy

The Aims of IFMT at Redbank House

By playing music together family members ate exposing themselves to the possibility of identifying key issues that ate affecting theit system. If thete is hostility between siblings or other relationships, then the ability to play together as a group is comptomised. As a family learns to listen to the music that is being played, and to participate in the music making, skills such as social interaction, self-expression and acquisition of music skills occut. The nonverbal aspect of the sessions and the focus on the music, has also been observed in assisting with increasing on-task behaviour and reducing stress and anxiety. A good example of this is when a pattern on the drum is taught to the family and each individual has to play the pattern while they are being timed. This type of playing assists with concentration and focus as well as promoting interaction with each other These outcomes have links with Winnicott's theory of 'transitional phenomena' and particularly the 'transitional object' (Winnicott, 1951, p. 19). In his theory, the transitional object is an item 'created' ot favoured by the infant as a substitute fot the mother in her absence. A good example of this is the teddy bear. In a MT session, the music is 'self-made' and not already existing befóte it is played. Once the music is recorded and transferred to CD it becomes a concrete object. The similarity between the teddy bear and the CD is that they may serve a transitional purpose (Schaverien, 1999). The purpose of this transitional object of music, is to help to progress the participant through their issues in an expressive and nonverbal way and to ideally assist in achieving resolution ovet time. What Happens in an IFMT Session?

The structure and content of the IFMT session varies from family to family according to the needs of the individuals and the family as a whole. The following outline is a template of what is typically experienced in an IFMT session at Redbank House. Verbal Introduction

The family arrives at the MT room often looking anxious and uncomfortable. After they are seated, the normal introductions occur and the family is given the MT room guidelines regarding safety and being careful with the instruments. This verbal introduction assists in settling the family and debunks the mystery of what is going to occur in the MT session. Music Introduction

Once the verbal introduction has concluded, the music introduction begins. Each family member is asked to choose a djembe (African drum) and to play together with the therapist. The therapist gives a very simple beat to play and each person copies it. As the family begins to play in time with each other, the therapist changes the rhythm. This simple change in rhythm can reveal who is listening, who is watching, who is rhythmical and what family members are able to play together.

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Family members are then paired together to play different rhythms to explore interactively the relationships within the family. Structured Music Making

The therapist asks the family memhers what music they like to listen to and if there is any particular song they would like to play as a family. If the song is known to the therapist, the therapist arranges the song in a simple way for the family to play. If they don't have any particular song or piece of music they like, then the therapist chooses one that is easily playable for the family. Songs may include 'We Will Rock You', 'Smoke on the Water', 'T.N.T', 'Sweet Child of Mine', 'Somewhere Over the Rainbow', 'Lean On Me' or 'Stand By Me'. All these songs have a simple beat and harmony. With the support of the therapist, the drum kit and electric guitars can be played with simplified chords to produce music that sounds pleasing to the family. A recording is made of the piece and at the end of the admission the family is given a CD with their music on it. As explained earlier, this CD can serve as a transitional object. Improvised Music Making (Family)

Depending on the nature and receptiveness of the family, the therapist utilises family improvisation. For some families it is a natural move from structured music making into free improvisation. For other families, the nature of the issues surrounding the admission may cause a block in free creativity and improvisation. When this occurs, the therapist has to be sensitive to the family's difficulties in improvising, and move on to other music making that is less confronting. Improvised Music Making (Individual)

Near the end of the MT session, the therapist invites individual family members to play the keyboard in a duet style improvisation. Not all family members or families are comfortable with this close proximity playing with the therapist. This improvisation may assist in revealing more information about the family's issues through the music. In individual improvisation participants tend to play music that is a direct reflection of what they are feeling without them knowing it. For example, a child who has ADHD will often play loud, chaotic music without patterns or connection to what the therapist is playing. Verbal Debriefing

After the individual improvisation occurs, a brief verbal debriefing occurs. Direct questions are asked to the parent/s regarding the music their children played and to the children about the music their parent/s played. At this point the therapist may intervene by adding positive comments to assist the parents and children in finding encouraging and positive words to speak. Some parents and children find positive reinforcement difficult to give and receive. Two Case Studies

The family names and circumstances have been altered and or changed for confidentiality reasons.

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The Escada Family

The Escada family was admitted to the Child and Family Unit for two weeks to assess Thomas [10], to assist in family relationships and to recommend future treatment. Thomas was the youngest of six children ranging in age from 10 to 19. The eldest sibling was a female with the other five being boys. They were born to parents of Middle Eastern origin who had been living in Australia for 22 years. The father was a tradesman and the mother performed home duties and did not speak fluent English. Thomas had a long history of school refusal and noncompliance at school when he did attend. Over a number of years Thomas had also developed encopresis (I.e., involuntary soiling]. No treatment had been successful and his family were disconnected and angry. The Escada family had two MT sessions that were markedly different, both in attitude and in musical content. The first session was chaotic, loud, and from a therapist's perspective, difficult to manage. They were highly anxious about coming to MT and as a result they all talked nonstop in ever increasing crescendos. Family members also laughed at each other when they played music and were unable to concentrate on tasks given to them by the music therapist. After trying to contain the family by playing 'We Will Rock You', one of the adolescent boys began playing a rhythm on the darabooka [a middle eastern hand drum]. Instantly everyone was quiet. They then spontaneously began to either tap the rhythm on their lap or on the instrument they were holding. This playing went on for a few minutes and eventually each family member was playing in unison. The father indicated to finish after a short time of this playing and everyone finished together All were smiling and laughing appropriately and appeared to be pleasantly surprised with the outcome. The father announced that if he had known that this was how MT was going to be, he would have brought all their drums from home. He said goodbye stating that they would all have drums for next week. The nurse commented at the end of the session that that was the first time she had witnessed the children and mother listening to and following the instructions of the father The next week came, and so did the family with all their drums. The music was loud and full of energy when they played together. No one laughed at anybody and each individual had the opportunity to solo and play as a group. Once again the father appeared to lead the drumming and once again the family followed him. Thomas became more relaxed and compliant in the session. He was able to play as a member of the family and not stand out or demand attention while he was drumming. He also was able to concentrate and stay on task for a longer time.

The therapist recorded the drumming and the structured music making from both sessions and made a CD for the family to take away with them. During debriefmg at the end of the second session, one of the older boys made a comment that this was the First time the family had done anything together for at least 12 months. When asked whether it was a good experience and something they would like to explore when discharged, there was an overwhelming yes' from each person.

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When speaking to the team about the contrasting sessions, it became clear that what was being exhibited in the second session, that is, the family being respectful and co-operative, was an outcome of the work the other members of the team had done in the week previous to MT. The music served as a vehicle to bring the family together in something they were all connected with — their culture — , and gave them a practical opportunity to practice the behaviour the other members of the team had talked to them about. With this family, the outcomes in MT were indications of their ability to modify their behaviour in a short time period. It was also evidence that what had been occurring in the 'talking' therapies, was having an effect on the way the family related to each other in a group setting. Music Therapy gave the Escada family the opportunity to take charge of their own therapy within the MT session. This was a clear indicator that they had the ability to change things at home when they left Redbank House. On discharge Thomas was booked into a clinic for further treatment and the family appeared to be more understanding and supportive of his issues. The Benjamin Family

Billy was a 14-year-old boy admitted to Redbank House Adolescent Family Unit CAFU] with severe depression. After about 6 weeks, the family was referred for a family admission for one week to assist in developing a plan that would see Billy back at school and managing his depression. Billy had been having individual MT sessions since the beginning of his admission. He was responding positively in the sessions by playing extended improvisations on the piano with the therapist. He was identified as being particularly receptive to music by the music therapist He played the piano with confidence and was able to play songs by ear very easily. His confidence at the piano was in direct contrast to his persona when not playing music. Billy was withdrawn and sat hunched over when he wasn't playing an instrument. He gave very little eye contact and grunted or shrugged his shoulders when the music therapist spoke with him. When his family, comprising an older sister C15], a younger brother [7), and mother were admitted for a family admission, they were motivated to participate in MT. When they arrived for MT, Billy was particularly animated. This was different to his usual appearance on arrival to MT. With his family he appeared relaxed and pleased that his family was attending. After the initial verbal introduction, the family members were asked to each choose a hand drum. At this point the therapist's assumption was that the drumming would be loud and chaotic and that there would not be much connection or co-operation between the family members. As they started following the therapist's musical cues, it became evident that chaos and disconnection were not going to be a part of this family's playing. They played in time with each other and they gave each other visual contact. As the therapist began to direct two individuals to play together at a time, the drumming became more co-ordinated and rhythmical. The therapist then changed the dynamics by changing the pairing around and still the drumming was connected and rhythmical. There were slight differences between the siblings, however, the most significant drumming was between Billy and his mother. The

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engagement and connection was strong and it sounded as if it was one person drumming. The therapist began to explore this family connection further by inviting each family member to improvise at the piano. One by one they came and improvised with the therapist. At the end of each improvisation, they clapped and made positive comments about the playing. This was a family who in everyday life was experiencing aggression, fear, anxiety, trauma and no connection, yet, in the music their playing was opposite to this. Each individual's piano improvisation was quite different, however, through each one there was a common rhythm and style. The mother, after playing the piano, commented on the similarity of each child's playing. This greatly moved her and she had a tear in her eye as she spoke.

This was the right time to stop playing music and to verbally debrief with the family. The sister and mother appeared to grasp the meaning of what had just happened in the music. The therapist asked them to put in their own words for Billy and his younger brother what they had experienced and observed. Both the mother and sister stated that they were surprised at how good the music sounded. They also spoke about how no one in the family had learnt a musical instrument. At the end of the debriefing the mother mentioned how good it was that they could all do something together without fighting. When the therapist reported back to the team on how the family had presented as connected, engaged and co-operative in MT, the team were surprised. In an attempt to explain why this may have occurred, the music therapist stated that perhaps underneath the difficulties in everyday life, there was still a strong connection to each other that became evident when they played music together. It was concluded that the musical connection may be an indicator that this family had the ability to change how they related to each other over time. In Conclusion

The case studies raise several issues that may be significant considerations when working with families affected by mental health issues. The choice of instruments and repertoire is an important consideration when working with different cultures and may have a significant impact on how the family responds. When families play music together a re-establishment of parental roles may occur in a passive yet significant way, one that brings the hierarchy of the family back into order. Within a family system, gender issues may be detected through the way they play music together and the music they choose to play together. For some families, playing music together assists them in their quest for communication and connectedness. Listening to their recorded music on CD once discharged may help them to recall how they worked and played together as a family. It may also prompt family members to continue developing the relationships within the family system through the expressive therapy of music. For the multidisciplinary team, it often adds to the diagnostic picture needed when recommending future treatment options. Interactive Family Music Therapy offers the opportunity for the music therapist to observe the family system in an environment that is different and perhaps unwit-


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tingly more exposing than more traditional therapies. It has the potential to be a useful addition diagnostically and may provide a less confronting option for families seeking further treatment. Its future development would benefit from both qualitative and quantitative research within a multidisciplinary team approach. References Btuscia, K.E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas. Bunt, L., & Pavlicevic, M. (2001). Music and emotion: Perspectives from music therapy in music and emotion. In P. Juslin, & J. Sloboda (Eds.), Oxford: Oxford University Ptess. Hilliatd, R.E. (2003). Music therapy in paediatric palliative care: A complimentary zpprozch. Journal ofPalliative Care, 19{1), 127-132. Langer, S.K., (1976). Philosophy in a new key, a study in the symbolism of reason, rite and art (3rd ed.). Cambridge: Harvard University Press. Layman, D., Hussey, D., & Laing, S., (2002). Fostet care ttends in the United States: Ramifications for music therapists. Music Therapy Perspectives 20(1), 38-46. Lenz, G. (1996). Music therapy and early interractional disorders: Example of the cry babies. Paper presented at the 8th World Congress of Music Therapy, 'Sound and Psyche', Hamburg, Germany. Levinge, A. (1993). The nursing couple. Paper presented at the 7th World Congress of Music Therapy, Vbtoria, Spain. Malchiodi, C.A., & Perry, B.D., (2008). Creative interventions with traumatized children. Guilford Press. Montello, L.M., & Coons, E.E. (1998). Effects of active versus passive group music therapy on préadolescents with emotional, learning and behavioral disorders. Journal of Music Therapy, 55, 49-67. NordofF, P., & Robbins, C. (1971). Therapy in music for handicapped children. London: Gollancz. Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day. Oldfield, A. (2006). Interactive music therapy: A positive approach. London and Philadelphia: Jessica Kingsley Publishers. Oldfield, A. (2006). Interactive music therapy in child and family psychiatry: Clinical practice, research and teaching. London and Philadelphia: Jessica Kingsley Publishers. Schaverien, J. (1999). Art within analysis: Scapegoat, transference and transformation. Journal of Analytical Psychology, 44{A), 479-510. Warwick, A. (1995). Music therapy in the education service: Research with autistic childten. In T. Wigram, B. Saperston & R. West (Eds.), The art and science of music therapy: A handbook, (pp. 209—225). Chur, Switzerland: Harwood Academic Publishers. Wigram, T , Pedersen, I. & Bonde, L. (2002). A comprehensive guide to music therapy: theory, clinical practice, research and training. London: Jessica Kingsley Publishers. Winnicott, D.W. (1951). Transitional objects and transitional phenomena. Playing and reality. London: Penguin. Winnicott, D.W. (1960). Playing and reality. UK: Pelican Publications. Winnicott, D.W. (1971). Holding and interpretation. NewYork: Grove Press. Wi 268


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