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

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).

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.

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.

‘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.

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.

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.