Trends of differentiation and integration in UK music therapy and the spectrum of music-centredness

Abstract

A long-standing trend to differentiate and even oppose psychodynamic and ecological approaches to practice can be identified in the UK music therapy literature. This is complicated by the way in which ecologically oriented thinking is associated with practice identified to be music-centred. While the trend to differentiate and separate approaches is most apparent in the literature, it is also evident that in practice, therapists have long integrated different perspectives and ways of working, this integral trend having its roots in the work of the UK music therapy pioneers. This article explores how the ecologically oriented thinking associated with the Community Music Therapy movement, and introduced soon after the turn of the 21st century, served in part to broaden the scope of UK practice in a progressive, integrally oriented way. However, the article also discusses the rejection of psychotherapeutically oriented thinking made by some ecologically oriented authors to make space for the new way of thinking. It is suggested that this rejection has been less helpful for the development of the profession as a whole, as the different ways of working in music therapy can be understood to address different types and levels of need. This means that psychodynamic, developmental, ecological, neurological and other perspectives are all potentially important. Case vignettes are used to illustrate this and an integral approach to working, with music-centredness discussed in a way that embraces the full spectrum of UK practice.

Keywords

Ecological/Community Music Therapy Guided Imagery and Music integral practice music-centred Psychodynamic Music Therapy United Kingdom

Introduction

In UK music therapy, there has been a long-standing trend to differentiate and even oppose psychotherapeutically oriented and ecologically oriented practice; the former associated with Psychodynamic, or Psychoanalytically-Informed Music Therapy, and the latter with Community Music Therapy (CoMT) and music-centred practice. It has been suggested that the polarized thinking which is a symptom of this trend continues to be evident (Annesley, 2019; Sutton, 2019; Wetherick, 2019). Indeed, Wetherick suggests there are increasingly separated discourses in the literature with a ‘lack of integrated meta-theoretical discussion or examples of shared practice’ (p. 67). This separation of approaches, he believes, inhibits the coherent development of the profession and the effective training of future practitioners.

This article attempts to contribute to the discussion, exploring different types and levels of practice, illustrated with case examples. The overarching theme is integral practice. This is where, along with the trend to differentiate, a trend to integrate approaches has also long been evident in UK music therapy, with roots in the flexible working practice of pioneers such as Nordoff and Robbins, Alvin, and Priestley (Ansdell, 2002, 2014). From these early days onwards, and in fact throughout the history of the discipline in the United Kingdom, practitioners from diverse training backgrounds have advocated an integral approach to both theory and practice (Brown, 1999; Davies and Richards, 2002; Odell-Miller, 2001, 2014; Pavlicevic, 1997; Robarts, 2009, 2014, 2018).

These trends to differentiate and to integrate need not necessarily be considered mutually exclusive. Indeed, I would argue it important to be clear how approaches differ, so as to understand when it may and may not be helpful to integrate the different perspectives and ways of working. Potentially useful in clarifying the difference between approaches is Ansdell’s (2002, 2014) discussion of the contrasting identities and roles, sites and boundaries, aims and means, assumptions and attitudes adopted in psychotherapeutically oriented music therapy and in CoMT. Also helpful is Bruscia’s (2011) discussion of the way in which the roles of client, therapist and music differ depending on the type of work being undertaken.¹ Of note here, while Ansdell appears to believe psychodynamic and ecologically oriented practice to be incompatible, Bruscia does not, making a strong case for working in an integral way.

In understanding the origins of the division between ‘schools of practice’ in UK music therapy, Darnley-Smith’s (2013) research is useful, where she contrasts psychodynamic and music-centred approaches to improvisation, examining the background, history and development of each tradition. However, while she differentiates the approaches for the purposes of her research, she also suggests that the work of many therapists is in reality likely to move between approaches according to client need, her own work included. Annesley (2019) is a therapist who gives examples of this, describing the ‘integrative client-centred approach’ (p. 74) which he has developed. In this, he incorporates both psychodynamic and music-centred thinking dependent on client need. I work in such an integrative way myself as I believe many other Music Therapists may do in practice. The apparent divide between ways of working may thus be something that is more evident in the literature than in the actual practice of therapists.

To explore further the trends to differentiate and integrate approaches in UK music therapy, I consider next how the post-modern emphasis on context has played out in the evolution of the profession. Context in this sense can be associated both with the intersubjectivity of the client–therapist relationship and with the wider social, cultural and political context of the client’s music experience.

Music therapy and the post-modern emphasis on context

Intersubjectivity became increasingly important in both the verbal therapies and in music therapy towards the end of the twentieth century. There was a shift in emphasis that can be understood to result from the influence of post-modernism where context is important (Thomas, 2016; Wilber, 2000). Thus, verbal psychotherapy became less exclusively focused on the inner subjective world of the client and on symbolic content. Rather, the relational context of the client’s inner experience and the associated intersubjective processes came to the fore. In other words, the therapy relationship became the focus. This shift in emphasis in psychotherapy was reflected in the application of psychoanalytic and related thinking to music therapy (Bruscia, 1998b; Davies et al., 2015; Davies and Richards, 2002; De Backer and Sutton, 2014a; Lawes, 2013, 2020; Odell-Miller, 2001; Pederson, 2006; Priestley, 1975, 1994; Streeter, 1999a, 1999b; Tyler, 1998).

One of the most important and well-established ways to understand and work with intersubjectivity in music therapy involves theories of transference and countertransference. Here the focus is on the unconscious dynamics of the relationship between client(s) and therapist, both within and around the music. Such intersubjective content is understood most fundamentally in terms of the infant–mother relationship. Dependent on the client, and on the therapist’s way of working, the therapist may make verbal interpretations that relate to this type of unconscious content. This might be in improvisation-based Psychodynamic Music Therapy or, for example, in Guided Imagery and Music (GIM).

Case example 1

Francesca, a psychologist who attended a series of GIM sessions, described her needs as having not been well met by her mother. I knew it was likely that her internalized experience of this primary relationship may become manifest in some way in the therapy. While GIM was originally developed with a humanistic and transpersonal theoretical orientation, many GIM therapists also find it useful to be aware of and be able to work with transference and countertransference. Incorporated into an integral way of working, psychodynamic thinking may be more or less important depending on the client’s way of engaging in the process. There can potentially be quite complex, multi-faceted positive and negative transferences to both music and therapist (Bruscia, 1998a).

As I began working with Francesca, I noted that she quite often commented that the music I chose for her was either too short or too long for her process. It was important for me to acknowledge my perceived ‘failure’ in the transference and helpful for us to think together about Francesca’s experience of me at this level so that it could begin to be worked through. If I had taken her ‘criticism’ at face value, an opportunity would have been missed. However hard I might have tried to find music that seemed the right length for her, the problem may have persisted if not addressed in a psychodynamically informed way. Once acknowledged and contained through her experience being discussed and its psychodynamic meaning explored, the problem evaporated in that form. Francesca’s internalized experience of an unattuned mother continued to be worked on and transformed within the music and imagery experience itself. Gradually, she discovered the resources she had within to mother herself. Paralleling this inner process, Francesca’s everyday relationship with her mother eventually began to improve. For the first time, Francesca experienced gratitude towards her mother, while remaining aware of what she felt had been missing in her childhood.

No absolute truth

In the episode of work with Francesca described, my focus was on the unconscious dynamics of intersubjectivity, this content understood in terms of the transference relationship. However, this was not the only way I might have understood the reality co-experienced by Francesca and myself. There could have been other ways. There is no final, absolute truth about what occurs in music therapy. It is more a question of what may or may not be helpful in understanding and addressing client need in any particular circumstance:

Labelling something as a transference reaction is not a truth statement; it is merely a proposition for considering the possibility of seeing it that way . . . This may seem unnecessary to say, but in many circles, transferences are discussed as if they are clinical realities – true entities in themselves, characterised by definite and characteristic structures and dynamics. I do not believe this . . .

In my own experience, analysing transferences in GIM is helpful most – but not all – of the time. Thus, if as a construct, transference muddies rather than clarifies what is taking place in therapy, then by all means abandon it and find something else to use as a guide. (Bruscia, 1998a: 430)

In the episode of work described with Francesca, psychodynamic thinking gave me a productive way to understand and work with a ‘negative’ aspect of Francesca’s experience of both the music and myself. However, this was only at the beginning of our work together which lasted several years. Later in the process, direct work with the transference did not feature. Rather psychodynamic thinking informed the integral, broadly humanistic approach which I adopted. Thus, it often seemed to me that there were transferences within Francesca’s imagery experience itself. For instance, imagery related to feeding difficulties which could easily have been thought about in relation to the internalized mother–infant relationship. However, it was not necessary to interpret the imagery in a psychodynamic way for the process to be worked through. Where many kinds of interpretation could have been possible in any case, my focus was more on helping Francesca explore the meaning of her experience in her own way. This is what is most usual in GIM, where the lived experience of the music and imagery process itself is more important than insights derived from the experience, though these too have their place.

Non-conscious and unconscious dynamics of intersubjectivity

Theories of transference and countertransference remain important in UK music therapy. In other theories of intersubjectivity utilized, there is less emphasis on unconscious content. UK Music Therapists have long been attracted to Winnicott’s work (Levinge, 2015; Pavlicevic, 1997; Tyler, 1998; Winnicott, 1971). Winnicott’s understanding of play in psychotherapy is especially useful, where he discusses how change can take place without it being necessary to interpret or even understand unconscious content. It is the activity of playing itself that counts, the therapist needing to help the client play who is unable to do so. Simply ‘playing together’ may be what most matters, not symbolic meaning.

Music Therapist’s understanding of interactive music-based play has been further enriched by research in mother–infant interaction. Associated with the latter are theories of communicative musicality, intersubjectivity, affect attunement and forms of vitality (Malloch and Trevarthen, 2009; Stern, 2000, 2010). Smeijsters (2005), for instance, uses Stern’s work to develop his theory of the client’s music being a direct manifestation of their way of being-in-the-world, meaning that issues can potentially be addressed musically. For example, if the client’s music is rigidly repetitive, this is likely to reflect the client’s way of being generally. This makes it potentially possible to help the client become less rigid as a person through working musically with them. Related to this is Nordoff and Robbins’ (1977) concept of the ‘music child’ (pp. 1–2). As the therapist works to support the development of the client’s music, the process for the client is one of self-realization. Musical outcomes are the focus, with music and musical experience understood to be ‘the stuff of life’ (Swann and Procter, 2016).

Stern’s (2004) later work on implicit relational knowing and on change in psychotherapy has also been influential (Trondalen, 2016). Here Stern, as a psychoanalyst, differentiates the non-conscious dimensions of intersubjectivity associated with implicit relational knowing, from the dimensions of intersubjectivity which are psychodynamically repressed and thus unconscious. Stern explores the importance of spontaneous, unplanned for moments of authentic meeting between the client and therapist. These moments of meeting occur in the domain of implicit relational knowing and effect psychotherapeutic change without the need for transference interpretation.

In my own work, I find it helpful to think about the non-conscious and unconscious dimensions of intersubjectivity operating in interplay in music therapy improvisation (Grotstein, 2007; Lawes, 2013, 2020). Within this interplay, I believe it important to appreciate that not all unconscious content and processes are psychodynamically repressed as Stern describes. Rather unconscious creativity and the associated ‘dreaming in music’, which I consider to be central in music therapy improvisation, are structurally unconscious (Lawes, 2020).

Psychodynamic work in music therapy is not always about making the unconscious conscious and about the music symbolically representing something else as music-centred practitioners sometimes tend to assume (Ansdell, 1995, 2002, 2014; Procter, 2015, 2016). There is not necessarily a concern with symbolic content or with unconscious dynamic content understood in terms of transference and countertransference, though there can be. The work may as much be about the non-conscious dimensions of interaction and change as Stern (2004) describes, as it may also involve working collaboratively with unconscious creativity which never becomes fully conscious when ‘playing together’ in music (Lawes, 2020).

Case example 2

In individual improvisation-based music therapy sessions which take place in a pre-school special needs play group, James, who is 3 years old and diagnosed with autism, becomes increasingly engaged in interactive spontaneous music-making over the course of two-term’s work. I participate in James’ evolving musical process, facilitating its evolution informed by developmental and psychoanalytic perspectives. The approach I adopt appears accessible to James, allowing him to go at his own pace. He alternates episodes of engagement and withdrawal, but increasingly initiates interaction in the sessions. James begins to develop, repeat and vary a repertoire of different musical ideas, as he plays the piano standing beside me. Using affect attunement, I focus on matching the dynamic qualities of James’ music-making in my music (Wigram, 2004). This approach supports the evolution of the process in the domain of implicit relational knowing (Stern, 2004) with James playing progressively more extended sequences of music. I also at times allow myself to ‘dream’ something new. When timed well and James is ready, this ‘dreaming in music’ seems to support him to develop further his own musical ideas and expression. The use of this unconsciously oriented technique also appears to support the evolution of the shared music which seems to create us as much as we create it (Lawes, 2020).

Broader contexts of meaning in music therapy

The work with James located his music-making within an intersubjective context of meaning and engagement (the therapy relationship) so as to support his development. Ecologically oriented perspectives are important in locating the client’s music experience in wider contexts of meaning. CoMT, which is associated with ecologically oriented work, was originally proposed by Ansdell (2002) as a new paradigm for UK practice. In one sense, the thinking associated with CoMT simply extended and broadened the existing post-modern emphasis on intersubjectivity and context in music therapy. The client’s music experience was understood to be located and worked with not simply within the context of personal (therapeutic) relationships but also within the wider social, cultural and political context.

While I continue to work principally in a psychotherapeutically oriented way myself, my thinking and practice has been enriched by the CoMT/ecological literature. As a result, I have been able to broaden the integral scope of what I have to offer as a Music Therapist, with psychotherapeutic and ecological thinking not incompatible in my experience. Indeed, Bruscia (2011) suggests that the efficacy of ecologically oriented practice may depend on the reflexivity of the therapist, this reflexivity potentially involving an extension of the use of countertransference in psychotherapeutically oriented work.

Case example 3

As well as receiving individual music therapy, James (described in case example 2 above), also attends a singing group. He attends this along with all the other children and staff at the play group. This ecologically oriented work I co-facilitate with one of the nursery nurses. Where the individual work is based on free improvisation, the group work is based on a repertoire of nursery rhymes and involves everyone in an experience of community.

Initially, James screams all the way through the sessions, so the decision is made to allow him to play freely in the large play space we use. For many weeks, James appears not to be interested in the singing session, absorbed in other things. Then one day, while accompanying a nursery rhyme at the piano, I notice James in the distance looking at himself in a mirror. He is mouthing the words to the song. Soon after this, he begins to tolerate sitting with the group during the sessions and to join in with some of the actions. He also vocalizes, at first with short high-pitched screams. These are nevertheless precisely timed with certain key words in the songs. A few weeks later, the screaming has becoming singing, with James confidently singing the lyrics of some of the songs. He has become a full active participant in the sessions.

Discussion of case example

I believe that both types of work were important for James. While the individual work was more accessible for him to begin with, because it did not put any pressure or expectation on him, the group singing sessions offered a different kind of opportunity and met a different type of need once he was ready to engage (Bruscia, 2011).

The different aspects of my work with James were part of my integral approach to practice in the setting. Importantly, James’ experience of me in the singing group appeared not to affect his engagement and progress in the individual work, where I was more personally attentive to him and the type of music was quite different. In fact, following James becoming an active participant in the singing group, I sometimes suggested that he sung nursery rhymes during the individual sessions which he readily accepted. We negotiated which songs to sing, sometimes his choice and sometimes mine. We were able to ‘play’ with the songs in a more creative way than was possible in the group sessions, taking turns to sing, sometimes performing the songs faster and sometimes slower.

My introducing the nursery rhymes in the individual work represented something of an amalgamation of approaches. For much of the time, I continued to attune with James and to follow his lead, adopting a child-centred, non-directive approach involving free improvisation. However, when I suggested we sing a nursery rhyme, I became more directive. I adopted what might be described as an educationally oriented approach. The intention was to help foster the development of James’ capacity to negotiate and compromise while continuing to be listened to and understood.

The ever-broadening spectrum of practice and application in UK music therapy

Case example 3 illustrates how different types of work provide different musical and therapeutic opportunities and meet different, if sometimes overlapping, areas of need, where the different approaches may also be able to be integrated. I have developed this integral way of working gradually, paralleling developments in the profession. When I trained as a Music Therapist at the end of the 1990s, the emphasis was on improvisation. Since then, song-writing (Baker and Wigram, 2005) and the use of technology (Hahna et al., 2012) have also become important, as has community-oriented work sometimes involving performance (Ansdell, 2002, 2014; Ansdell and Pavlicevic, 2004). GIM is gradually becoming established in the United Kingdom. Skills-sharing and joint working have also become important (Colbert and Bent, 2018; Maclean and Tillotson, 2019; Oldfield and Carr, 2018; Strange et al., 2017; Tomlinson, 2020; Twyford and Watson, 2008). Some therapists are undertaking further training in Neurologic Music Therapy (Thaut and Hoemberg, 2014), reflecting the contemporary importance of perspectives from neuroscience in the field (Fachner et al., 2019; Hsu et al., 2015; Odell-Miller et al., 2018; O’Kelly, 2016). The range of client groups and settings in which music therapists work has also broadened over the years, with online working developed in response to the COVID-19 pandemic. It is evident that there is a rich and ever-evolving diversity of practice in the United Kingdom.

Case example 4

My own work in special needs education has evolved to include not only direct but also indirect work with students as well as work with staff. ‘Song-based music interaction’ sessions are delivered by staff up to three times a week and involve me in skills sharing. I train staff to attune and support students in a flexible, mutually negotiated way in singing familiar songs. Staff learn how to begin and then develop the work, drawing on the principles of communicative musicality (Malloch and Trevarthen, 2009). This type of work enables staff to incorporate a musical dimension in their relationship with students. This supports student well-being, development and engagement generally, an additional advantage being that sessions can be delivered several times a week.

‘Music listening programmes’ involve students listening to recorded music to support settling into school, transitioning, managing frustration, calming and so on. In developing the music programmes, I draw on my specialist experience in GIM. I work closely with other therapy colleagues and with parents, the students helping choose the music where possible drawing on their existing music preferences.

In ‘student-focused reflective team-work sessions’, staff are supported to engage in short GIM (visualization-based) experiences. They gain new insights about students and their needs in this way which are shared and discussed. The reflective process helps the staff to be more in touch with their creative imagination and intuition, as together they develop and sometimes re-orient their work with students.

These three types of work are beyond anything I anticipated would be part of my practice when I first qualified, and considerably extend the scope of what the music therapy service has to offer with integral working involved in various ways. The influence of additional specialist training has been important, as has ecologically oriented thinking in reflecting on what I may be able to provide beyond the therapy room, whether directly or indirectly.

‘One-way’ and integral thinking in music therapy

Bruscia (2011) explores how the different approaches in music therapy address different types of need, with the client, therapist and music having different roles to play in each way of working. Clients may have their psychotherapeutic needs as much as they may have a need for community-based participation, for instance. Bruscia (2011) implores the profession (in the United States) to move beyond ‘one-way’ thinking. Indeed, he suggests it unethical to claim that clients can benefit from the full potential of what music therapy has to offer if one approach only is adopted to the exclusion of others. One type of work cannot replace another as different types of need are met.

I suggest that the ‘polarised either/or meta-theoretical argument’ (Sutton, 2019: 4) sometimes apparent in the UK literature among practitioners of different approaches may result partly from a tendency towards ‘one way’ thinking. To understand this, Wilber’s (2001) exploration of the different contexts of meaning in the creative arts is useful. With music, these contexts include the creator’s conscious intention; unconscious content or meaning; the social, cultural, historical and political context; listener’s responses; and the formal elements of the music. Wilber highlights how any single context of meaning always exists within others. For instance, in music therapy, perspectives which focus on the music therapy relationship exist within the broader cultural and social contexts of meaning highlighted by ecologically oriented thinking. Similarly, non-conscious interaction can be thought of as existing within the context of the unconscious dynamics of interaction that can be identified through the application of psychoanalytic and related thinking.

While each context of meaning in music therapy and the associated theoretical perspective may be whole and complete in its own terms, each whole is at the same time also a part – there are always contexts within contexts within contexts of meaning. However complete and true a perspective may seem in its own right, according to Wilber (2001), it starts to become false when the reality and importance of other perspectives is denied. This is ‘one-way’ thinking as Bruscia (2011) discusses, drawing on Wilber’s work. The problem with such thinking from an integral perspective is that each context of meaning highlights a different dimension of need making the full spectrum of approaches potentially important (Bruscia, 2011). The therapeutic significance and meaning of the music as this relates to one context of meaning (e.g. a psychodynamic one), may not be obvious and may not be able to be discovered through exclusive immersion in another context of meaning (e.g. an ecological one) (Wilber, 2001).

I imagine that many UK Music Therapists have drawn on and been enriched by the ecologically oriented literature first introduced just after the turn of the 21st century (Ansdell, 2002; Ansdell and Pavlicevic, 2004). There is certainly an integral aspect to the thinking in the way that CoMT embraces a continuum of practice ranging from individual work in the therapy room to more community-oriented work. What I believe may be more problematical for the profession as a whole to assimilate, is the rejection of psychotherapeutically oriented thinking in discussing ecologically oriented practice in contrast. Psychodynamic work is critiqued as being too narrow in scope in terms of meeting what people and contemporary society need, the imported theory considered alien to music-centred working (Ansdell, 1995, 2002, 2014; Procter, 2015, 2016).

In such arguments, I believe there to be an element of ‘one-way’ thinking which itself is too narrow. What is missed, I suggest, is a realization of the potentially important role that Psychodynamic Music Therapy can have in identifying and addressing dimensions of need that may not otherwise even be recognized. Psychotherapeutically oriented and ecologically oriented thinking are both important and can potentially complement one another.

Experts and integral thinking

Ansdell (2014) promotes the ongoing importance of CoMT in bringing to ‘an increasingly reductionist, individualized and medicalized culture of care a more flexible ecological understanding of the complex relationships between music, people, health, illness and well-being – understood at physical, psychological, social, cultural and political levels simultaneously’ (p. 44). Ansdell’s integral thinking here links to his critique of the pursuit of statutory legitimacy and professionalization in UK music therapy, a topic that has previously been explored in this journal from different perspectives (Ansdell and Pavlicevic, 2008; Barrington, 2008; Procter, 2008).

More recently, Pickard (2020), writing from a critical disability studies perspective, reflects on what she believes may be an outdated expert model of music therapy in the United Kingdom. She discusses this in terms of therapists being required to adhere to the Health and Care Professions (HCPC) Standards of Proficiency which Pickard believes to be aligned with deficit-based interpretations of difference, diversity and disability. In this type of affiliation with the medical model, the implication is that therapists are experts whose role is to help normalize their disabled clients.

Ecological perspectives are important in music therapy, in balancing the type of ‘one-way’ thinking that can be associated with an over exclusive adherence to the expert model. Awareness of critical disability, neurodiversity and social justice–oriented perspectives is surely vital, where there may otherwise be the potential for expert ‘normal’ therapists to disable, disempower and demoralize clients through trying to ‘fix’ them (Pickard, 2020). Issues such as this are, however, complex, where Bruscia (2011) suggests that in integral thinking, it may be necessary and appropriate for the music therapist at times to inhabit an expert stance as much as there may be a need at other times to inhabit the role of simply being a musician or human being, working with clients similarly perceived, the relationship one of human-to-human. While therapists may need the capacity to adopt a non-hierarchical, non-pathologizing approach, ‘one way’ thinking associated with this can potentially result in a difficulty being an expert when this is authentically called for and when it may be helpful for the client (Bruscia, 2011).

The need to be a music therapy expert when formulating detailed therapy plans or reports does not conflict with the ability to work collaboratively and in a client-centred way in therapy sessions. The different aspects of the role are complementary. Identifying as a Music Psychotherapist or psychological therapist when engaging with the multi-disciplinary team (to clarify the type of work and expertise that Music Therapists have) need not conflict with identifying as a musician working alongside others similarly perceived (potentially both service users and staff) in ecologically oriented work.

The reality of what happens in music therapy

Wilber (2000) identifies a tendency to deny the reality of inner subjective and intersubjective depth in both modernism and post-modernism. Such depth is that of unconscious experience, potentially embracing the entire spectrum of the psychodynamic, collective/Archetypal and transpersonal unconscious (Lawes, 2013; Wilber, 2000). While ecologically orientated thinking may be important in contemporary music therapy, a post-modern alignment with psycho-social principles appears sometimes to lead practitioners to tend to deny or marginalize depth and its reality – or at least depth as can be associated with the psychodynamic dimensions of the music experience. I believe that this may be the case when Procter (2016), for example, asserts how we ‘need a rigorous focus on what actually happens in music therapy sessions, rather than being seduced into well-meaning emotional fantasy’ (p. 65). Associated with this, Procter critiques transference and countertransference oriented (psychodynamic) working, and the links made with psychoanalytic ‘free association’ where improvised music is understood to provide access to the unconscious (Darnley-Smith and Patey, 2003; Odell-Miller, 2001; Procter, 2015). He regards ‘slavish adherence to non-musical precepts imported from other disciplines (e.g. behaviourism or psychoanalysis) with suspicion as they are likely to distract from acute awareness of what it is to be musically with another person’ (Procter, 2016: 56).

In contrast, I would suggest ‘emotional fantasy’ to be real in its own way and potentially an important dimension of ‘what actually happens’ in sessions at the level of transference and countertransference. Indeed, the potential of music therapy in meeting client need may depend on working with the reality of ‘emotional fantasy’ and the associated unconscious dimensions of communication, perception and meaning at times, not only within but also around the music experience. If not, the scope of the work may be restricted (Bruscia, 2011). My work with Francesca provides one example of working with the reality experienced ‘below the surface’, drawing on psychodynamic thinking (case example 1). Another example from work in special needs education illustrates the importance of boundaries and containment in psychodynamic working. The purpose is to allow unconscious psychic reality to become manifest as the principal reality being co-experienced by client and therapist (Parsons, 1999). Working in this way makes it possible to identify and work with dimensions of need that may otherwise be missed.

Case example 5

Simon, an adolescent with complex needs, attended music therapy for a term, but seemed quite ambivalent about it, sometimes declining to attend. After the first holiday separation, Simon refused to attend altogether but appeared to continue to be engaged with me in a meaningful way. For example, one day I was sitting in the staff room when the door was open and Simon walked past. He pointed at me saying ‘I’m not going to your stupid music therapy’. Thinking about this in supervision, it seemed that there may be a hidden, unconscious meaning to Simon’s declining to attend, so that I should not immediately give up on him and accept his request at surface value. Rather I went to collect him at the beginning of his sessions, clarifying that it was always his choice whether to attend and requesting his teacher put no pressure on him to do so. When he told me he did not wish to go and found this difficult to talk about, I explained that I would return to the music therapy room and be there for the next 45 minutes should he wish to attend the session. At the end, I returned to class to inform him his session had finished which he always acknowledged. In this way, I continued to provide a contained space for him, both physically (in the external world) and at the level of psychic reality (in his and my minds).

I negotiated with the head teacher that I could continue to provide sessions like this for up to 6 weeks. I informed Simon after 4 weeks that there would only be two more sessions of this type, thus providing a boundary. After these two sessions, should he continue not to wish to attend we would finish. My sense was that he was still engaged in the process meaningfully with me at the level of psychic reality. Even though he had not yet made it to the therapy room, he had begun to talk with me more in the classroom at the beginning of sessions. Then on the day of the final ‘classroom’ session, after which we would potentially finish for good, Simon said he would like to come with me to the therapy room. Once there, he explained how he had got to know many staff at the school who had become important to him, but they had all left. The hidden, unconscious reason that he did not want to attend sessions had emerged and turned out to be related to his fear that I would also leave him. This I had already done during the holiday separation, of course, which seemed to precipitate his declining to attend sessions all together. Simon explained that he would like to continue and was able to ask if I would tell the head teacher that I was not to leave for 2 years. It turned out that our work continued for that amount of time with Simon attending every session.

Without a psychodynamic understanding of boundaries, containment and unconscious communication as my model of working with Simon, the therapy would have ended prematurely. An opportunity to help Simon with a core issue affecting his well-being and engagement with others would have been missed.

Music as inherently psychotherapeutic

In the episode of work with Simon described, the process did not have a musical dimension at all, as is occasionally the case in my work. More usually, the music is central, with my practice psychotherapeutically oriented in what I consider to be a music-centred way. I understand this partly in terms of music and musicking (Small, 1998) potentially having a psychotherapeutic function not only in therapy but also in everyday life. This function of music I associate with the way it (and the arts generally) opens consciousness to dream awake (Campbell, 1968; Lawes, 2013, 2016, 2020).

In describing musicking to potentially have a psychotherapeutic function, my intension is to highlight what I consider to be the unconscious processes involved, which can be understood psychoanalytically to involve the container-contained relationship (experienced in relation to the music) and waking unconscious dreaming (Grotstein, 2007; Lawes, 2020; Ogden, 2005). These unconscious processes feature not only in creative music experiences (improvisation and composition) but also in performance-based and receptive (listening-based) experiences, where music effectively functions intersubjectively as transformative container (Lawes, 2016, 2017).

There are, of course, many other ways to understand music’s psychotherapeutic function, where different terms and concepts might be used, without the necessity for a theory of the unconscious. Procter (2015), for example, discusses an ecologically oriented way to think about improvisation in music therapy that can be held alongside or overlap with the psychoanalytically oriented idea of ‘dreaming in music’ (Lawes, 2020).

While in general terms, musicking may have an inherent potential to open consciousness to depth (as I conceive of it) in a life enriching way, it is not necessarily the case that people can access the psychotherapeutic benefits of musicking as may support their well-being. Music therapists might be considered specialists who help with this in one way or another, whatever theories they draw on.

Case example 6

Aysha, a middle-aged bereaved lady, attended a series of GIM sessions. The first few and last sessions were resource-oriented Supportive Music and Imagery (SMI) sessions (Paik-Maier, 2010). During these sessions, Aysha created images on paper with art materials while listening to recorded music mostly from her own collection including Arabic pop music. In the remaining GIM sessions, she listened to programmes of recorded music in a deeply relaxed state (in an altered or non-ordinary state of consciousness) while imaging (visualizing spontaneously), my role being to provide non-directive verbal support.

Aysha told me how she had become estranged from her son who had died a year before we met. She needed help to grieve and say goodbye. Aysha explained that while she loved music deeply, she had stopped listening to it because it made her too emotional. She had also given up singing in the choir which had previously been so important to her. My sense was that Aysha knew of music’s inherent capacity to open her to dream, this being one reason why music was so meaningful for her. Her problem was that music now opened her to depths of unprocessed emotional pain and turmoil within that were unmanageable. Music was overwhelming rather than emotionally containing and transformative. At this time of emotional challenge, Aysha needed help to engage with the psychotherapeutic potential music had to support her grieving process.

In GIM, listening to music with another was never overwhelming. After her initial SMI sessions and several preparatory GIM sessions, Aysha felt ready to say goodbye to her son. In a powerful and transformative GIM session, she visualized him in front of her as they said goodbye before he receded into the distance. The music helped shape and contain the emotionality of the experience, allowing Aysha to fully live and work through the pain of her loss without needing to disengage. The following week, she reported that something had shifted at a deep level: she had been able to ‘let go’ and felt ready to begin to move on in her life.

Complementing her GIM sessions, Aysha’s SMI sessions were also important, especially the final few sessions. During one of these sessions, while creating an image listening to an Arabic pop song that has especial personal meaning for her, Aysha found herself identifying deeply with the bass line in the music. This was something that she believed could help her hold onto a sense of herself which she easily lost when caught up with the needs of others in her family. I encouraged her to open to, even to ‘become’ the bass line in the music while she drew, to help her internalize the music and what it could be for her, experientially. Aysha began to use the music to support her in daily living, this being one of the aims and potentials of SMI.

Broadly considered, the integral efficacy of the work related to the way in which different dimensions and levels of need were addressed directly or indirectly. This involved the therapy having both a resource-oriented dimension (i.e. the SMI sessions), and a problem or issue-oriented dimension (i.e. the GIM sessions) focused on Aysha’s grief process. By the conclusion of our work, Aysha had begun attending her choir again, where the socially oriented dimension of the musicking involved so nurtured her well-being. From an integral perspective, this was an important indirect outcome of the process. In her life journey, music had always been important and would likely continue to be, personally, socially and culturally. GIM had been a part of this journey when specific help was needed to access music’s psychotherapeutic potential.

The spectrum of music-centredness in music therapy

Sutton (2019) proposes it possible to be ‘music-centred’ across the spectrum of approaches in music therapy, including in Psychodynamic Music Therapy. Procter (2015, 2016), who identifies himself to be a music-centred practitioner, believes the application of psychoanalytic thinking to be more problematic. His concern is that it may distract the Music Therapist’s awareness away from what it is like to be with clients musically and from what ‘actually happens’ (Procter, 2016: 65) in sessions. Similarly, Ansdell proposes that ‘the problem with modelling music therapy on psychotherapy has been that it has led it down the wrong street – it has led it away from a detailed thinking about music as a phenomenon’ (Annesley and Ansdell, 2018). I would suggest the opposite to be the case, which I understand in terms of their being different levels of listening to and working with the music.

As discussed above, at a non-conscious level of consciousness, the client’s music in improvisation-based work can be understood to be a direct manifestation of the client’s way of being-in-the-world (Smeijsters, 2005). Musical problems or limitations, including in the interaction with the therapist, are personal and interpersonal problems or limitations sounded musically, and so can be addressed musically at this level of non-conscious interaction. I suggest something similar to occur in Psychodynamic Music Therapy, where the client’s sounds and music generated within the intersubjective context are worked with as sounding difficulties at the deeper level of psychic or unconscious reality.

Streeter (1999a), De Backer and Sutton (De Backer, 2004; De Backer and Sutton, 2014b), for example, provide detailed music-centred accounts of clinical work including notated transcriptions of the music. Here, psychoanalytic theory and the associated model of working are used to help the therapist inhabit a particular way of being, listening, thinking and responding to the client both within and around the musical process, open to unconscious depth. This allows the client’s unconscious difficulties to emerge and become manifest as their musical difficulties in which the therapist participates closely. The value of music as a psychotherapeutic modality at this level lies in the way it may be able to be used to gain access to otherwise hidden and inaccessible areas of experience and trauma before and beyond the reach of words. Core aspects of need may be able to be identified and addressed as not otherwise possible. The very basis of this way of working is the therapist’s awareness of the immediacy of what it is like to be with the client musically (and in other ways) at the level of psychic or unconscious reality.

Levels of listening and musical perception

De Backer (2004) describes the music of some clients with autism, psychosis and severe trauma to be formless, more sensory than musical in nature as experienced at the level of psychic reality in sessions. However, in studying recordings of the music for the purposes of his research, he sometimes found himself beginning to hear phrasing, themes, motifs, musical accents, variation and development. These were elements of musical form that he did not originally perceive, nor consider to be present. In subsequently hearing the music differently, De Backer believes he made an illusory interpretation of the music, where he had become disconnected from the formless reality of the experience in the session at the level of transference and countertransference.

Related to this, the pre-recorded music used in GIM can be experienced by clients as responding to their needs in the most intimate, attuned and personal way at the level of psychic reality. The music functions as intersubjective participant in the client’s process at this level. The client’s experience of this can be very real and therapeutically significant, while at another level – objectively considered – the music does not respond actively to client need (Lawes, 2016).

These examples help illuminate how the music in music therapy can be heard differently at different levels of listening. What appears to be real about the immediacy of the music experience at one level of listening may be illusory at another level. Thus, there are different ways of paying detailed attention to music as phenomena (Annesley and Ansdell, 2018), with each potentially important. There are different levels of awareness when it comes to apprehending what ‘actually happens’ (Procter, 2015: 65) in sessions. Interpretation, fantasy and illusion are perhaps always in some way involved whatever approach is adopted, reflecting the complex, multi-dimensional nature of reality and consequently of music-centredness in music therapy.

Conclusion: development as transcend and include

Music therapy is an ever-evolving profession, where from an integral perspective, different ways of working can be understood to meet different aspects and levels of need (Bruscia, 2011). Soon after the turn of the 21st century, ecologically oriented perspectives begun to be introduced and assimilated by the procession. It was perhaps inevitable that those leading these developments in the United Kingdom needed to disidentify with the existing perceived dominant ‘one-way’ model of practice, to create space for new ways of thinking. Wilber (2000) discusses development in these terms. However, he also suggests no stage of development to be complete when the previous stage is simply disidentified with so as to transcend it. To conclude the process, the previous stage with everything it represents needs to be integrated and included within the new developmental stage. The process is always to ‘(first) transcend and (then) include’.

In terms of Wilber’s understanding of development, there appears to be lingering difficulty in fully completing a stage in the evolution of UK music therapy, in as much as there is the continuing sense of a conflictual divide and associated separation between approaches (Annesley, 2019; Sutton, 2019; Wetherick, 2019). The difficulty is most obvious when an approach is presented (or perceived to be presented) as the ‘one-way’ of thinking and practicing in music therapy, with other ways of working critiqued as inadequate for us all. It is then, I suggest, that the critiques made start to become problematical for the profession as a whole, inhibiting the full working through of the developmental process as Wilber (2000) describes. No single approach is suited to identifying and addressing all areas and levels of need. Indeed, this is what the critiques tend to highlight in their most useful aspect, so that in integral thinking, different approaches are needed, with music therapy itself limited otherwise in terms of what it has to offer (Bruscia, 2011).

Of course, it is not realistic nor necessary for every therapist to work in every possible way. Neither can the qualifying Masters training programmes in the United Kingdom cover everything (Bruscia, 2011). Many therapists specialize in one or more ways of working and in working with particular client groups, myself included. Therapists publish about their specialisms without necessarily referring to other approaches. Such acknowledgement is not always necessary in my view, while it may also be the case that there is not as much ‘integrated meta-theoretical discussion’ (Wetherick, 2019: 67) as there might be in the UK literature generally.

Within the rich diversity of practice within the profession, I suspect there may be an integral dimension to many therapist’s work. The nature of such integral working is likely to be different for each person depending on training, experience and other factors. In adopting an integral approach, I believe it perfectly feasible to hold different orientations and perspectives in mind simultaneously. It is possible to work in a psychoanalytically or developmentally informed way in the music, where the therapist is at one level ‘the mother’ and the client ‘the infant’, and simultaneously have an ecologically informed understanding of the client being another musician allied with critical disability studies and similar perspectives. Every therapist can be an expert at times aligned with the status quo in the settings and cultures in which they work, and a ‘contrarian’ (Annesley and Procter, 2019) at other times, challenging perspectives and assumptions that may be too limiting. Working with psychodynamic boundaries and containment is not about rigidly adhering to an expert mentality aligned with the medical model so as to feel legitimate as a therapist (Ansdell, 2002, 2014). Rather, it is a way of working that may be able to be used to identify and meet need as is not otherwise possible, the music-centredness of psychodynamic working complementing that of other approaches.

There is both breadth and depth in the rich diversity of music therapy thinking and practice in the United Kingdom. This is apparent both in our clinical practice and in our training courses. Individually we may be more drawn to some ways of thinking and working than others. As a profession, our diversity is to be valued and celebrated.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Martin Lawes

Notes

Author biography

Martin Lawes qualified as a Music Therapist in 1999. His clinical experience has been in special needs education, mental health and palliative care. He is published in four peer-reviewed journals, is a BAMT registered supervisor and has taught as visiting lecturer on three of the music therapy MA training programmes. Martin is additionally trained in Guided Imagery and Music (GIM). He is a Fellow of the Association for Music and Imagery (AMI), registered as a Primary Trainer with AMI and founder of the London based Integrative GIM Training Programme. He is former chair of the board and former chair of the education and training committee of the European Association of Music and Imagery (EAMI).

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