Abstract
This book’s many merits make it a delight to read but quite a challenge to review. The back cover intriguingly describes its focus as ‘practice-based evidence’; not until the final chapter is this inversion of a more familiar formulation seen to have been deliberate rather than serendipitous. Auriel Warwick’s eloquent prelude reflects on her development as a therapist in the early days of the profession, including her discovery of ‘latent learning’ and the realisation that the contrasting approaches required to meet individual autistic children’s unique needs cannot be reconciled into a single all-purpose blueprint. Thus, the reader is warned not to expect a recipe for working with people with autistic spectrum conditions, nor be surprised by the wide-ranging diversity of the ensuing chapters, which chart evolving processes more often than presenting fully fledged approaches. The authors explore the dilemmas encountered in real-life therapy situations, and the reflective, creative and always professional ways in which they have sought to resolve them. This window into the ups and downs of the real work of music therapists is paradoxically more encouraging than a collection of ‘success stories’.
Some chapters draw on previous writing by their authors but all have been commissioned and written expressly for the present book, which cannot therefore be described as a ‘reader’ in the sense of an anthology of seminal existing texts on a topic. Nor is it a ‘handbook’ in the sense of a systematic survey of the field, though it performs many of the same functions, covering as it does so many areas of practice, contexts and theories, often with the support of extensive reviews of relevant literature. The many case studies and shorter vignettes are a strong feature, bringing theory to life. I propose to comment on each chapter in order, apart from Chapter 1 on the challenge of carrying out positivist research in music therapy, which I shall discuss last.
Joy Gravestock describes psychoanalytically informed relational music therapy for children with high functioning autism. The breadth and depth of her further training in the psychodynamic understanding of therapy is deployed in ‘meaning making’ in confusing clinical situations, rather than in imposing a theoretical framework. Three small vignettes illustrate how for desperate families a diagnosis of autism can become a bargaining chip, trumping alternative diagnoses in a bid to access support. The evolution of her approach, focusing on the lived experience of clients rather than their diagnoses, is then so vividly and convincingly described that it was only on looking back that I noticed she had achieved this without presenting actual case material.
Robin Bates discusses a thorny ethical question pertinent to all forms of therapy: can one justify a directive intervention, even one made the client’s best interests, and how can one know what those best interests are? He describes a client eager to touch and play instruments but so conflicted he was unable to take the plunge. A momentary physical prompt broke the ice and allowed him in subsequent sessions to make full therapeutic use of the instruments. Did this outcome justify an instinctive intervention which could be said to have infringed the client’s autonomy? Bates’ exploration of this ethical dilemma fills a surprising gap in the autism literature since, as he notes, there is no entry on autism in four major texts on health ethics including one on ethics in music therapy. His account of the evolution of an ‘ethics of encouragement’ is subtle and insightful, and a summary here could not do it justice.
I was initially surprised to find a chapter on Musical Interaction Therapy (MIT), since early accounts of this approach speak of the contribution of a musician, not (as in the present chapter) a music therapist. Dawn Wimpory, MIT’s principal originator, expounds the detailed evidence that a major impairment in the autistic child is a deficit in the micro-timing of interpersonal interaction. She then advocates music, not to remediate this primary deficit directly, but as a way of scaffolding and encouraging later developments in interaction and play which, in the normal infant, develop spontaneously on the foundation of this micro-timing capacity. Music therapist Elise Gwilym situates her MIT practice in relation to the familiar concepts of Creative Music Therapy, Vitality Affects and Dynamic Form and then brings theory to life in her descriptions of what can actually happen in MIT sessions. In a 2-minute video clip of interaction, available online from the publishers, the revealing micro-analytic commentary in the text might have been easier to follow in the form of on screen subtitles and/or a musical transcription. Gwilym’s survey of research into MIT outlines some of the reasons it has yet to be established that the musical component of MIT is essential rather than incidental to the observed effects. This admission makes her adverse comparison with the inconclusive TIME-A study (see Chapter 1 below) seem somewhat churlish.
Becky White describes work with groups of adolescents with autistic spectrum conditions, drawing inspiration eclectically from psychoanalytical, developmental and music-centred theory. Her account of a typical session will be familiar to many who have worked with such groups. White develops a nuanced understanding of the concept of ritual as a valued experience the teenagers share with their non-autistic adolescent peers, rather than a euphemism for the rigid behaviour patterns which frequently separate them from their peers. Her empathy with the clients springs from recollections of her own social and emotional needs and musical tastes as a normal teenager, supported by a succinct survey of current research into adolescent development. White provides practical tips on how the therapist’s own music can provide a secure framework and a springboard into flexible creativity, within a contemporary sound world with which the teenagers identify.
Alastair Robertson follows the twists and turns of therapy with a middle-aged man, first one-to-one and subsequently in a group. ‘Donald’ presented as isolated and anxious, but Robertson’s alertness to ‘the many subtle languages which can unfold in the therapy room’ revealed Donald’s hitherto hidden desire to belong and participate, gradually manifest through receptive as well as expressive music-making, body movements and use of space (in ways typically studied by dance movement therapists) and eventually use of art materials. Robertson reflects on the questions he asked himself during the therapy, thus encouraging the reader also to consider what Donald might have been trying to communicate. He shows how a rigid adherence to music as the therapeutic medium would have deprived Donald of the chances for development and change afforded by elements of other arts modalities, and stresses the value of open communication with the team, including the support workers, in increasing understanding.
Josie Nugent thoroughly reviews recent writing on music therapy for children with autistic spectrum conditions and their families. Her two contrasting case studies do not so much break new ground as exemplify the flexible adaptation of a consistent approach to meet the contrasting needs of two children and their families. ‘Ewan’, aged 5, was intellectually only mildly delayed. His autistic condition manifested most clearly in a tendency to sensory overload, necessitating regular time out. Novel, imaginative activities, with clear structures and often a strong visual element, drew him gradually into relationship with Josie. Unusually, in order to first develop this relationship, family members were included only towards the end of each session. For ‘Peter’, also aged 5, by contrast, his mother was present throughout all sessions. Once again, imaginative playful activities were key to building relationships. Despite initial difficulty in relinquishing control, Nugent was able to allow mother an increasing share in running the session, thus equipping her to continue musical play with her son at home independently of the therapist.
Emma Maclean and Claire Tillotson explore collaborative approaches in educational settings, considering how music therapists ‘share aims, progress and outcomes with their teams, other staff and parents/carers’. Collaborating with all these, especially in settings where the ‘team around the child’ is not firmly established, is a balancing act between maintaining the distinction between the therapeutic and the educational understanding of aims, progress and outcomes, and seeking ways of supporting and learning from each other’s work. Some readers may share Tillotson’s experience of weekly MDT meetings in a single institution, but more will identify with Maclean’s more peripatetic existence, in which liaison is harder to establish and maintain.
The use of formal music therapy rating scales, in response to requests for greater objectivity and multidisciplinary information-sharing, is illustrated with reference to three such scales plus Ockelford’s (2008) Sounds of Intent Framework. The authors concede, however, that therapist-led experiential sessions or actual participation in clinical sessions both lead to greater understanding than abstract formal evidence of outcomes. They then describe collaboration with educational staff, speech and language therapists and parents/carers and cite the Scottish Government’s (2010) threefold vision of the educational contribution of specialised services, whereby music therapists are seen first as delivering an unique resource for children with autistic conditions, second as trainers equipping others to incorporate insights from music therapy into their work, and third as contributors to an integrated health promotion and prevention culture.
Kate Fawcett describes work in a transitional centre for children currently without permanent educational provision, who often have secondary diagnoses such as ADHD or attachment disorder. This is a setting where physical and organisational uncertainty and unpredictability could easily rule out productive work by destroying the security provided by reliable boundaries of place and time. Her main title, ‘finding a place’, reflects not only the centre’s brief of preparing clients for a permanent placement, but also the steps she took to construct a safe, boundaried ‘conceptual space’ to act as ‘the playground that the client and I could create and occupy through improvisation’. She succinctly explains the role of co-created musical improvisation in building relationship, broadening the discussion to include cross modal communication whereby visual, spatial and occasionally tactile signals often enhance and occasionally predominate over the purely musical. The three extended case studies, synthesised from elements of real cases, illustrate the need for flexibility in response both to the wide variety in clients’ language development and use and also to their contrasting internal models of self and associated defensive structures. It would be hard to find a more convincing exposition and justification of the concepts of therapeutic space and the field of play.
Cindy-Jo Morison tells of work in a secure ward for adults with the most severe challenging behaviour. The carefully planned and structured regime, which might be considered unduly restricting, paradoxically offered the only safe route, for both patient and staff, out of the narrow world into which the patient’s condition and earlier life experiences had confined him. The story of ‘Mark’ progresses cautiously stage by stage, from choosing between two CDs by gesturing through a small window in a locked door, to freely roaming the hospital ward and even (with supervision) the grounds, and enjoying outings with his family. The team’s collaborative approach originated in an Australian model. Fresh risk assessments preceded each small change to Mark’s therapeutic regime. By closely cooperating with the team in a way of working for which her previous work had probably not prepared her, Morison was able to establish music as a viable communication channel for Mark, which other members of the team were eventually able to use with him independently. It should be noted that this approach is not an application of neurologic music therapy, in which the author biography tells us Morison is trained.
Tina Warnock discusses the value of non-verbal voice work in developing intersubjective relatedness in children with autistic spectrum conditions, drawing parallels between the developmental trajectory of the child’s use of voice and Daniel Stern’s (1985) four stages in the development of a sense of self, understood as ‘not stages to be passed through but rather layers to be built upon’. As one of the earliest modes of communication to emerge, the voice, so intimately connected to a person’s physical and emotional state, is the ideal medium through which to establish and develop relatedness with a child whose autistic condition often interferes with the integration of external and internal sensory information. Two case studies are supported by online video examples, with subtitles interpreting the behaviour of child and therapist in terms of the aforementioned developmental stages in both the use of voice and the sense of self. Here, Warnock is not describing her conscious thought processes at the time, so much as illustrating how the fluctuations in vocal and other behaviour of both parties may be understood in developmental terms.
Beth Pickard explores the ‘social model of disability’ which locates disability in society’s failure to adapt to the individual with an impairment, rather than in the individual’s inability to adapt to society’s norms. The expression ‘valuing neuro-diversity’ in the title acknowledges autistic spectrum functioning as a variant deserving of respect, rather than an impairment to be overcome. Two therapeutic approaches congruent with the social model are a non-directive attitude and person-centred therapy, of which only the former has previously received much explicit attention in the music therapy literature. Pickard also introduces the concept of pre-therapy, whereby ‘psychological contact’ must be established before therapy proper can begin. Her examples of pre-therapy techniques, however, while appropriate and effective, are not unusual in music therapy practice, and would not normally be seen as separate from music therapy proper. Two case studies concern 16-year-old males in a unit aiming to develop functional, vocational and social skills to encourage independence in the transition to adult life. A generally behaviourist approach was followed but music therapy was offered, primarily to those with little or no verbal communication, to give them an expressive outlet. A microanalysis (reported but not presented in the chapter) of video extracts of each client’s music therapy, using Bruscia’s Improvisational Assessment Profile for Autonomy, revealed that both young men adopted mainly the ‘Dependent’ and ‘Follower’ roles and would thus have the greatest opportunity for growth through a non-directive therapeutic relationship. In fact, their autonomy did increase both within and outside therapy. Pickard points out that young people with profound intellectual disability, in addition to an autistic spectrum condition, are an under-researched group, including in the music therapy literature.
Peter Whelan, with 20 years experience in a school with a regional reputation for the education of children with autistic spectrum conditions, presents one extended case study informed by psychosynthesis. I was not familiar with this discipline, and on this my first encounter, I was left with more questions than answers. How, for example, does this more complex, essentially metaphysical, representation of the elements which require integrating to achieve a full realisation of the self add materially to the simpler model developed by Jung (1947)? For me, the most engaging part of the chapter was the description of the stages by which the client discovered, accepted and integrated parts of himself, as manifest in the joint music-making. It would have been fascinating to have audio recordings of the interactions between therapist and ‘Fan’, ‘Rock Star’, ‘Quiet Mouse’ and ‘Roaring Lion’, which must have involved sophisticated and flexible improvisation by the therapist.
Turning to Chapter 1, perhaps this informative and balanced account of Amelia Oldfield and colleagues’ wrestling with the notorious difficulty of positivistic outcome research in music therapy would have been better placed last in the book. It describes their experience as one of two UK research teams participating in the TIME-A study (Crawford et al., 2017), a large international RCT of music therapy for children on the autistic spectrum. The primary outcome measure, the Autism Diagnostic Observation Schedule, failed to confirm the positive outcomes revealed by the secondary measure and witnessed to by clinical observation and parental feedback. As the team had feared from the outset, the study designers’ choice of a measurement instrument originally intended to give a diagnostic snapshot was not suited to detecting and tracking progress over time. The remedy suggested is not to abandon the quest for objective, measurable outcomes, but rather to give all forms of data due weight, since reliance on one-dimensional standardised instruments may miss real benefits and thus undermine faith in an intervention. This is an important chapter, of which all would-be positivist researchers should take heed, but to avoid dampening the reader’s enthusiasm at the outset it could have been placed after the encouraging picture painted by the qualitative approach of the other chapters.
The editors’ final chapter revisits all that has gone before in order to illustrate some overarching themes. I was struck by the demonstration of how the Health and Care Professions Council (HCPC) standards of proficiency specific to music therapy, sometimes criticised as prescriptive, actually accommodate and give legitimacy to the wide range of therapeutic practice presented in this book without constraining it, except in ways which are essentially ethical. A helpful table summarises each chapter in terms of the client group, therapeutic approach, suggested benefits and requisite therapist skills. Despite the considerable variety in the first two categories, it is no surprise to find much overlap in the benefits and skills categories.
Having recently been an editor of a comparable multi-chapter themed volume with an international authorship, I was impressed to find just as great a range of approaches in a book confined to UK music therapy. This witnesses to the healthy state of the profession in Britain, though I should have welcomed a statement of the rationale for not including any contributions from the profession in Europe, where the picture often broadly mirrors ours. It would be unfortunate if any reader were to gain the impression of an insular British music therapy identity, when this is so far from the truth. That said, the editorial team is to be commended for commissioning such a rich wealth of talent and for supporting each author through to completion.
I was puzzled by the grouping of the chapters under three umbrella headings which suggest fundamental differences which simply do not exist. All the approaches described use predominantly improvised music making and respect autistic identity and culture, and many describe collaborative approaches. The impression given by this artificial division, albeit belied by the individual chapters, is of three contrasting or even competing theories and ideologies. If the intention was simply to help readers navigate the text, perhaps a summary table like that in the final chapter could have been offered in the introduction.
Many chapters include an extensive range of up-to-date citations of relevant and interesting writing, tempting the reader both to verify what is being said and also to explore the topic further, but the practice of repeating the same citation in the body of the text every single time an idea or concept associated with it is mentioned sometimes disrupts the flow. This may be required in certain types of academic writing, but not in a book, except perhaps a handbook. Furthermore, because many citations appear in several chapters, much space could have been saved by collecting references at the end of the book, where they would be just as easy to consult as at the end of individual chapters.
My three decades working as a music therapist with many children and adults with autistic spectrum conditions do not make me an expert. I have, therefore, approached this book from the perspective of a generalist music therapist, without specialised post-qualification training, wishing to work with clients with autistic spectrum conditions. As such, I found it constantly illuminating and absorbing. If I were still a practising clinician, my work with this client group would certainly be challenged and enhanced. I am not, however, sure the book will always be so helpful, or indeed comprehensible, to persons on the autistic spectrum or their families, as suggested at the end of the introduction. Readers from other professions might welcome more explanation of music therapy specific jargon, perhaps in the form of a glossary. The standard of writing is generally very high, which makes it most regrettable that the same cannot be said of the proof reading. Cost-effectiveness cannot justify skimping on proofreading time or expertise. Shoddy presentation can easily suggest careless thinking. Despite these reservations, I can, without hesitation, recommend this book to clinicians and urge them to read it from cover to cover, marvel at the diversity of current practice and adopt the spirit of openness to new ideas espoused by the writers and editors.
The book deserves an international readership. Perhaps the biggest market will be the many professional training programmes, here and abroad, where its diversity of content should guard against the natural tendency of the trainee and newly fledged professional to seek cut and dried answers to the question, ‘How should I work with people with autistic spectrum conditions?’
