Developing identities using music technology in therapeutic settings

Aims

The study focused on music therapists’ uses of electronic musical technologies using specialist assistive devices (electronic music technologies [EMTs]) in recognition of the fact that there is little published research examining the scope or application of such methods. The study had three main aims overall:

Participants

Participants were six music therapists (four female, two male) who were currently using or had used music technology as part of their work. The understanding of music technology for this project was in line with the aforementioned definition of EMTs, and did not include amplified technologies or those that did not require specialist input devices, such as electric pianos, microphones and similar. The range of the post-qualifying experience of the participants ranged from 1.5–22 years. Participants were recruited through their response to a survey distributed to the Association of Professional Music Therapists (APMT) ¹ and to a later call for research participants posted to all members of the same association.

The contexts in which participants worked varied across special schools, children’s and adult hospices, and adult rehabilitation settings with a range of clinical populations. All of the participants used EMTs in work with children and most used them with adolescents. Only two of the participants used EMTs in work with adults. Participants were given full details about the project and once they had agreed to participate they were provided with a summary of the research proposal for their information and for submission to local research advisory and ethics committees. Consent forms were provided for themselves and their clients whose video clinical records were to be used in the interviews (see later for more information). Ethical approval had been granted by the National Research Ethics Service prior to the study commencing.

The participant music therapists discussed cases relating to 16 clients (three female, 13 male) who had a range of diagnoses which were mostly congenital in nature. Eight of the clients were children aged 12 and under; five were adolescent and aged 13–17 years, and three were adults. The female clients were either children or adolescents and all other clients were male. Six clients had acquired conditions, three had conditions which were degenerative in nature, and 14 of the clients had learning difficulties or acquired cognitive impairments and were heavily dependent. Only two of the clients had no known cognitive impairments and only two had means for communicating verbally. Overall, the clients tended to be heavily dependent with complex cognitive, physical, communication and sensory needs. Physical difficulties were notable across the client population, as were sensory impairments. Importantly for this paper, however, all of the clients were observed to have conscious awareness and were responsive to their environments such that they have a sense of self in the world and an awareness of the effect of oneself in the surrounding environment.

Materials

Data were collected during two individual interviews with each participant which gathered background information about the music therapy participants and their experiences working with EMTs. The interviews also used video clinical records as a secondary source of data which provided the basis for the discussions. Semi-structured interviews were used to elicit the participants’ views on their general use and evaluation of EMTs in their work as well as their decisions to use technology in the specific cases discussed in conjunction with the video clinical records. Preliminary analysis of the first interviews provided structure for the second interview with each participant; the main purpose of the second interviews was to member check the analyses undertaken and to collect additional data to add further credibility to the analyses. The second interview schedule was a modified version of the first, incorporating the themes that emerged across all participants. During the second interview, new unseen video clinical records were observed against which the themes emergent from the initial interview analyses were checked with participants to determine a ‘fit’.

Procedure

Following successful recruitment, local ethics clearance and consent gained, participants were asked to identify up to three clients with whom they had used EMTs and where video clinical records of the work existed. During the first interview participants selected three extracts of up to 15 minutes each from their own work representing their clinical practice with at least two different clients illustrating their application of EMTs in a therapeutic session. Typically, participants engaged the client in individual or group sessions through active music making in which the client used an EMT to create their musical sounds. The musical creations were either clinically improvised music making which emphasized the dialogical nature between therapist and client (Wigram, 2004), improvised songs, or song activities (e.g., welcome songs; turn-taking) in which the client used music technology to ‘voice’ their participation. Participants played the extracts to the primary investigator, stopping when they wanted to describe or explain the particular technique being applied (cf. Davidson & Good, 2002). The semi-structured interview format allowed for additional general discussion of participants’ perceptions and uses of EMTs with various client populations so that a broad understanding of the benefits, disadvantages and applications of technology in therapeutic settings could be achieved. The interviews were transcribed verbatim by a professional transcription service and checked against the recording by the primary investigator.

Preliminary analysis of the initial interviews was undertaken independently by both investigators using open coding procedures from grounded theory (Strauss & Corbin, 1990). Once the independent analyses were complete, comparisons were made and consensus about the emergent concepts, themes and proposed categories was reached. This process involved considerable refinement, relabeling and reorganization until all concepts and themes were categorized.

The initial analyses were used to shape the second interview which served a dual purpose: first, participants revisited one of the video extracts used in the first interview in order to confirm the analysis; second, participants were given an opportunity to discuss how the emergent themes fitted their practice, drawing on additional clinical video records to determine a fit between the emergent analyses, the observable use of technology in sessions, and the clinician’s perceptions of this practice. Interviews were again transcribed verbatim and the preliminary concepts and categories were used to guide the subsequent analysis of the second interviews, whilst allowing the emergence of new concepts and themes. In instances where the data did not fit the existing analysis, data were reorganized accordingly. Both investigators’ analyses were triangulated and finalized once they had reached consensus. Member checking through the second interviews also served to assist with processes to ensure trustworthiness.

Identity construction

Many individuals with congenital or acquired disabilities rely heavily on the support provided by others and traditional therapies often represent a continuation of those kinds of dependence relationships. Music therapy with those with a narrative sense of self (Gallagher, 2000) aims to challenge negative self-constructs stemming from dependency by offering opportunities to learn and develop new skills. EMTs represent one way in which this becomes more possible: they can be tailored to suit the available movements of clients no matter how minimal or weak (from a small hand movement to a blink of an eyelid) and therefore do not require constant therapist facilitation as can be the case when using acoustic instruments:

. . . it gives them that control they’re able to place the sounds where they want them to go when we’re playing together . . . sometimes that doesn’t happen if you’re . . . helping them in some way to play physically, giving them some support, it’s very hard not to know that you haven’t made that extra move and so moved the switch or done something that’s . . . made that happen rather than them doing it totally independently. And I have a big thing about children with physical difficulties really being given . . . that chance to do it all for themselves. Not having anyone else interfering really. (Participant 5 B7)

Providing clients with a sense of control over their environments offers feelings of empowerment, especially if they are aware of the sense of cause and effect which so often gets lost when using traditional instruments (see Magee & Burland, 2008a, 2008b). For individuals who are living with a long-standing disability or who are adapting to a more recently acquired disability, EMTs offer an opportunity to overcome some of their frustrations associated with physical disability:

I think it’s . . . vital really, because it’s their only way . . . to make a change . . . and to . . . choose to do something for themselves and control somebody else. It gives them that little bit of control which they don’t get otherwise. (P5B8)

Individuals with disabilities are often ‘locked into a body they can’t control’ (P3B23) and the quote above demonstrates how music therapy involving EMTs empowers them to explore sound and offers a way to communicate with others. One advantage of EMTs relates to notions of ‘small input/big output’ (P4B15) and can offer clients access to alternative identities that reach far beyond feelings of dependency on others. For example, many of the cases discussed in this research refer to non-verbal clients with a limited amount of movement: it is easy to see how EMTs used in such contexts provide opportunities for clients to connect with a different sense of self which contradicts the ‘dependent self’ experienced by those with disability. This is illustrated in the following extract by one of the therapists who highlighted the impact of using EMTs for young people with complex needs stemming from congenital disabilities:

. . . that perhaps is . . . the main reason that I use it, or one of the main reasons that I use music technology, is to just empower and enable the children . . . to be a part of things, because it doesn’t require so much effort and it opens up so many more possibilities for them, instrument wise specifically. (P1B4)

EMTs facilitate a sense of belonging and participation and allow clients to access therapy sessions from which they might otherwise be excluded if they used solely traditional instruments. The technology provides a way for clients to participate in group therapy in addition to interacting with the therapist:

. . . as a group, trying to work on group skills, I think that it’s enabling . . . because everybody . . . is creating exactly the same sound so nobody is doing anything more than anybody else . . . so they’re all . . . enabled in the group, and I think that’s valuable. (P1B22)

The opportunity to feel equal, have an equal voice in group exchanges and feel the same as others is important for individuals’ identities: they are provided with an empowered sense of self – with feelings of agency over their environments and an opportunity to communicate with others. Since identity formation is influenced by social contexts (MacDonald et al., 2002), the opportunity to be a member of a group is crucial. Similarly, using EMTS provides opportunities for clients to be creative and work in equal partnership with others. In the following, the therapist describes the normalizing experience of using technology for the creative act of song-writing:

This is something that people do . . . you know, writing songs together. I think it brings him an amazing amount of self-esteem and confidence. (P4B24)

Such feelings of being able are important motivators for individuals to engage in therapy and accessing associations with different musical identities (e.g., as a performer or composer) may provide an opportunity to begin to adapt to disability. Therefore offering clients opportunities to optimize their skills and feel a sense of achievement are clearly important aspects for the music therapist to consider. For example, one participant described how using EMTs with one client helped to reinforce movements that would be useful in his rehabilitation because he was so pleased (and ‘giggling’) when he realized that he was controlling the sound.

Numerous data extracts detailed these kinds of visibly positive responses to therapy which has incorporated EMTs, reinforcing the notion that music therapy using these tools is effective and necessary because of technology’s capacity to connect individuals with their self-identities:

That experience for her was a very, very powerful experience . . . which I think for her . . . was very rewarding. It made her feel very good about herself and that isn’t functional, that’s her realizing . . . that she’s been empowered, she’s been enabled, that she has independence and that . . . she’s making music with someone, which she’s aware of because she’s making that eye contact and she’s sharing that. She was sharing those moments with me . . . for her to generate that sort of response is quite incredible. (P1B15)

This quote aptly summarizes the potential of music therapy using EMTs for helping individuals to construct identities – by offering them a sense of independence and control, both in their music making and in their opportunities to create with others. Such feelings of independence and control are not commonplace for these clients in their everyday lives and therefore EMTs provide empowerment and a temporary release from their disabilities and awareness of all that they cannot do. As EMTs can be specifically tailored to each individual, clients are able to participate actively in music making, no matter how limited their movements. Perhaps more importantly, clients are also ‘given a voice’ (P2B18) and are therefore able to communicate musically with others and express themselves.

The relationship between EMTs and identity construction described in this section motivates clients to become engaged because these tools provide a way for them to think of themselves differently, challenging the negative self-constructs that often lead to a ‘salvaged self’ (Charmaz, 1987). The sense of achievement derived from understanding the cause and effect relationship between movement and sound motivates and enables clients to acquire or optimize skills, such that a wide range of therapeutic gains may be achieved.

Accessing alternative identities

One further benefit of EMTs is that they enable individuals to connect with different identities, such as those associated more generally with the contexts and applications of technology. Access to alternative identities is an important part of the process of identity construction, and can play a vital role in helping clients with a range of complex needs.

As discussed, one of the advantages of using EMTs in music therapy is that music becomes accessible to everyone because it can be tailored to even the most restricted movements. For clients who are adapting to disability, music can be a constant amidst overwhelming change because EMTs allow them to continue to be active music makers, particularly in cases where playing acoustic instruments becomes impossible due to a degenerative condition. As one participant states: ‘. . . everything else in their lives stops but the music can still carry on’ (P5B9). Music can therefore be seen as providing a connection with a previous healthy or positive identity which may serve a vital role in helping the process of adapting to disability:

There’s one that I feel is very obvious and this is with younger people, and people who have a previous history of using music technology, so they were using software programs to write music ‘pre’ their brain injury and for teenagers with long term illness, it allows you to work with the healthy part of the individual, so it takes the focus from the medical model to the more social model, and you’re looking at . . . somebody’s ability . . . at what they can do . . . maintained and healthy, as opposed to the disability, and I think as a way of reaffirming identity, music technology has a large part to play. (P2B5)

There are two identities at work in this example. First, it is suggested that music technology provides access to age-related identities: EMTs allow clients to choose from a wider palette of sounds than traditional instruments, and as such they are able to express individual musical preferences by selecting preferred musical timbres and beats (those associated with rock or pop idioms, for example). This provides young clients access to social identities such as ‘rock star’, ‘DJ’ or ‘music fan’ and by default offers a connection with other music fans (see the work of Tarrant, North, & Hargreaves, 2002, for example). It also enables adolescent and young adult clients access to culturally relevant musical identities associated with youth culture. For example, hip hop, as a genre is ‘born out of struggle, and it is because these patients struggle that they can so thoroughly relate’ (Steele, 2011, p. 317). Using music technology enables young clients to create music which speaks how they are. This reflects how young clients develop musical identities (MacDonald et al., 2002), which are described as being socially defined. Second, working with aspects of individual identities that existed prior to disability (such as an interest in music) can provide useful connections with healthy identities and the sense that they are able. For some individuals this may be particularly difficult if they are unable to create music as once they did, but for others the connection with previous selves is powerful and motivating:

I actually decided to give it a try . . . with a patient . . . who is a young man who, because he has a brain tumour and because of his . . . current self-esteem, his own body image at the moment, his anger at his illness, he’s a very musical person, but not engaging with me at all and with my predecessor he didn’t either . . . there’s just no way he’s going to come and do music with me. So, on a very lovely sunny morning I put the Soundbeam up in the garden and I turned the speakers up really loud and I just played in the beam, and I knew that this chap . . . had a real interest in technology. His background was in computers . . . and so he came out . . . and started: ‘Well come on then, what’s this?’. And I just started to talk to him about it and showed him how it worked . . . and he started to explore . . . later on [I] looked across the garden to find him in there where he was making these beautiful movements and playing music on the Soundbeam. ² (P6B3)

In this example, EMTs provide direct contact with the client’s unspoiled identity before his diagnosis and was the motivation he needed to engage with therapy. Despite the fact that he is described as ‘a very musical person’, it was the connection with his previous professional identity that allowed him to remember himself as a healthy person, in control of his life. This is exemplified further by his need to understand how the music technology available, the Soundbeam, worked. This opportunity provided by the therapist allowed him to access a more positive identity such that he engaged with the technology and therapy, an achievement that previously seemed unobtainable for his current and previous therapists. This is reminiscent of the feelings of empowerment described previously, in relation to more profoundly disabled clients, and emphasizes the importance for clients to feel like an individual with a distinct identity reflecting their own musical preferences and which allows them to communicate something of themselves to others.

In the same way, EMTs also provide opportunities for clients to access other cultural identities in relation to particular roles, offering positive associations:

For example . . . a DJ set-up . . . that’s something Alex has seen before on the . . . TV . . . heard on the radio and CDs, of DJs. And he identifies with himself as this, this DJ in that moment and . . . he is somebody who is actually quite isolated in his situation and he actually spends most of his time at home . . . so you know, this sense of doing something that is a normal part of the world but is actually something . . . that’s normal but it’s something that is actually quite special because not everybody can be DJs. And he is able to identify himself with that and make that connection to the world. A DJ is somebody who plays to lots of people and he was able to engage with that, or be that, person . . . DJs are . . . I suppose it’s a bit like a rock musician, guitar, you know. When you take the guitar you assume that position. For lots of teenagers that’s what they do and in a way it’s the same thing with a DJ . . . they assume some sense of superiority in a way, some sense of, of mastery, I suppose, of skill, of being cool . . . of being important, of being valued, of being special, of being loved. (P4B2)

Music technology provides a means by which clients can access identities that emphasize belonging and similarity to peers: they access the role of DJ, entertaining and connecting with others, and they can access the role of ‘composer’, creating a style of modern music with which young people typically identify (P4B2), thereby reinforcing age-appropriate cultural and social roles. Such roles, or musical identities (Hargreaves et al., 2002), offer individuals a way to communicate with others and to project an image of themselves that is different from their ‘spoiled’ identities (Charmaz, 1991).

It is also possible for individuals to explore expressions of ethnicity or national identity (Folkestad, 2002) by using EMTs:

Initially when I first started working with him he didn’t have enough movement to access acoustic instruments at all . . . it was his choice to continue using Soundbeam, and I think part of that was to do with the fact that in the past he’d been a bodhrán player and had taken part in lots of Irish music and the frustration that he would have felt at accessing instruments, acoustic instruments that were perhaps more familiar, but not being able to play them to the same standard or to achieve the sounds that he would have pre-morbidly . . . it was something that he was comfortable with, something that he felt very free with and something he was able to control more perhaps. (P2A8)

This quote refers to a client with a particular cultural heritage (Irish) who was no longer able to access traditional acoustic instruments, but could create these sounds using EMTs. The music therefore provided a way for him to express aspects of previous identities and to explore and communicate different identities during his therapy sessions. Along with these benefits, the flexibility and scope of EMTs is particularly important in that they are perceived as modern, relevant, and easily accessible:

There are so many lovely colours in this palette [associated with EMTs] and so many different things that the teenagers, or whoever we’re working with, can access very, very quickly. The palette doesn’t actually require a huge amount of skill to get into and yet it can bring such quick results musically . . . with the touch of a . . . finger on a mouse pad you can hear back a little drum loop . . . or a bass guitar sound . . . it really acts as quite a lot of music very, very quickly in a culturally relevant form . . . they have the sense that they’ve made this and they’ve played it without having to actually touch . . . pick a guitar up. (P4B18)

It is the breadth and accessibility that make EMTs an appealing choice for the study’s participants, particularly because there are so many ways in which they enable clients to express themselves, communicate and connect with others, and construct and develop alternate identities as they ‘repair the self’ (Charmaz, 1991). Therefore using EMTs in therapy has benefits for the client as well as the range of available opportunities for the therapist (Magee & Burland, 2008b). It would be misleading to claim that using EMTs is superior to using acoustic instruments, as a number of limitations have been identified, including aesthetic drawbacks and risks for both the therapist and the client (Magee & Burland, 2008b; Whitehead-Pleaux, Clark, & Spall, 2011). It is clear, however, that EMTs are powerful in their ability to enable and empower a variety of clients and, more importantly, they are a vital means for individuals to construct, develop and repair identities.