The therapeutic relationship in music therapy in a Flexible Assertive Community Treatment team: A joint interview study of service users and their Music Therapist

Abstract

Flexible Assertive Community Treatment provides integrated and community-based support to clients with mental illness and challenges in social functioning. Music therapy has been incorporated into several Norwegian Flexible Assertive Community Treatment teams, but there is limited published research on its outcomes. The Flexible Assertive Community Treatment model is recovery oriented, and the significance of robust relationships with staff members is emphasised. To understand the processes and critical factors in the relationships between service users and their Music Therapist in Flexible Assertive Community Treatment, we addressed the following research question: What characterises the relationship and interaction between the Music Therapist and the service user in the context of Flexible Assertive Community Treatment? Six joint interviews with service users and their Music Therapist were conducted using a dyadic approach. Using reflexive thematic analysis, the characteristics of the music therapy relationship were categorised in three themes; (1) the humanistic, therapeutic relationship, (2) the friendship-like relationship and (3) the musical relationship. The relationship between the service user and the Music Therapist is essential to therapeutic outcome, and links to common factors in therapy. Building relationships with the Music Therapist and the Flexible Assertive Community Treatment team may be a vital step towards social participation for the service user and may be understood as a critical factor towards recovery.

Keywords

common factors community treatment co-occurring disorders helpful relationships mental disorders recovery

Introduction

This article explores the therapeutic relationship between service users and their Music Therapist in the context of Flexible Assertive Community Treatment (FACT) in a Norwegian mental health service. FACT is a multidisciplinary model that provides integrated, recovery-oriented and community-based support to clients with severe mental illness and challenges in social functioning (Van Veldhuizen and Bähler, 2015). The model has been implemented in the Netherlands, the United Kingdom, Denmark, Sweden and Norway (Trane et al., 2021). Since 2013, approximately 70 FACT teams have been established in Norway and operate in Norwegian districts as an outreach service; the care is offered at the residence of the service users.¹ FACT teams provide long-term, coordinated care from teams comprised of, at a minimum, a psychiatrist, a nurse, a social worker, a psychologist, an Individual Placement and Support worker and a peer support worker.² Music therapy has been incorporated into several Norwegian FACT teams, and music therapy is explicitly mentioned in a 2023 revised Norwegian FACT model description (NKROP and NAPHA, 2023). However, this treatment approach is novel, and there is currently limited published research on its outcome.

FACT service users frequently experience addiction, psychotic-, affective-, personality-, developmental-, or attention-deficit/hyperactivity disorder, or a combination of these conditions. In addition, the client group in FACT have significant challenges in social functioning (Van Veldhuizen and Bähler, 2015). Although family and friends can be vital sources of support, many users are isolated and lack social relationships and networks (Ingram et al., 2020; Linz and Sturm, 2013).

The FACT model prioritises personal growth and emphasises recovery-oriented practices, focusing on connectedness, hope, identity, meaning and empowerment (Leamy et al., 2011). The social and relational aspects of recovery are crucial, especially for individuals who struggle with social relationships, which is common in the FACT user group. Therefore, an orientation towards relational recovery (Price-Robertson et al., 2017) is expedient.³ Relational recovery focuses on the (micro)processes necessary to establish and maintain relationships (Karlsson and Borg, 2017). Recovery must be understood to develop through social relationships, as confirmed by qualitative research (Mezzina et al., 2006; Schön et al., 2009 Topor et al., 2011). As Brekke et al. (2020) concluded, ‘recovery in co-occurring conditions may be understood as a relational process that happens in and through relationships with others’ (p. 97).

The effectiveness of FACT in enhancing social functioning is subject to mixed results (Brekke et al., 2021; Clausen et al., 2020; Landheim and Odden, 2020). Service users, however, have emphasised the significance of establishing positive and enduring relationships with staff members and the team (Landheim and Odden, 2020). These findings suggest the need to prioritise social recovery efforts and explore the characteristics and qualities of relationships between service users and professional helpers in the FACT team.

The therapeutic relationship

‘Significant positive personality change does not occur except in a relationship’ (p. 96), Rogers (1957) hypothesised. Indeed, the quality of the client–therapist relationship, defined by Norcross (2010) as ‘the feelings and attitudes that therapist and client have toward one another and how these are expressed’ (p. 114), appears to be a reliable predictor of positive therapeutic outcome (Ardito and Rabellino, 2011; Budge and Wampold, 2015). Particularly for people who have challenges in social functioning, a human connection with an individual (i.e. the therapist) who is empathetic and caring is likely to be health-promoting (Nissen-Lie et al., 2021; Wampold and Imel, 2015). This resonates with Rogers’ 1957 theory, which posits that the critical processes in the client–therapist relationship depend on empathy. Rogers (1957) emphasised three factors essential to positive change in the client: that the therapist (1) experiences unconditional positive regard for the client, (2) experiences an empathetic understanding for the client and (3) strives to communicate this experience to the client. More recently, Norcross (2010) highlighted empathy, alliance, goal consensus and collaboration, positive regard and therapist congruence as key aspects for positive therapeutic outcome. These are known as ‘common factors’, and are predictors of positive outcomes across various types of psychotherapy regardless of specific techniques used (Wampold and Imel, 2015).

A challenge in research on therapeutic relationships is the differing perceptions of the relationship between clients and therapists (Bachelor, 2013; Hartmann et al., 2015). It is, therefore, essential to involve both parties in studies investigating client–therapist relationships to explore different perspectives effectively (Norcross and Wampold, 2011; Stange Bernhardt et al., 2021).

Service users’ experiences of professional helpful relationships

Service users in mental health care have described helping relationships with professionals as resembling friendships (Lindvig et al., 2019; Topor and Denhov, 2015), where the professional and service user take part in a mutually created and collaborative dyad (Borg and Kristiansen, 2004). Building trust appears vital to the relationships, involving (1) hopefulness and loving concern, (2) commitment, (3) honesty and expectation and (4) action and courage (Brekke et al., 2018). Chemistry, that is, a good ‘match’ between the service user and the helping professional, is mentioned by service users in several studies as an essential ingredient in the relationship (Borg and Kristiansen, 2004; Brekke et al., 2018; Lindvig et al., 2019).

Furthermore, service users value helping professionals’ concrete acts of recognition or help. These actions can be understood as so-called micro-affirmations (Topor et al., 2018) and range from seemingly small doings such as greeting ‘good morning’ (Lindvig et al., 2019) to accompanying the user to activities or ‘bending the rules’ by, for example, lending money to the service user (Borg and Kristiansen, 2004). The high value given to helpers who go beyond what is expected in their professional role is a prevalent finding in several studies (Borg and Kristiansen, 2004; Brekke et al., 2018; Topor and Denhov, 2015; Lindvig et al., 2019). These actions are linked to building a friendship-like relationship between the service user and the helping professional, where the service user experiences being treated like an equal human being, that is, as opposed to a ‘doer and done to’ relationship (Benjamin, 2004).

Foster (2007) discussed the concept of friendship in the context of music therapy and touched upon paradoxes that Music Therapists may face in their relationships with service users. Like other micro-affirmations and methods of transcending traditional roles, music fosters mutuality and intimacy beyond the conventional roles of expert and recipient. Importantly, service users are aware of their distinct roles and acknowledge that the relationship with their therapists is not a ‘real’ friendship. However, it is worth noting that this particular aspect of the therapeutic relationship holds significant value for the service users, emphasising its importance in therapy (Lindvig et al., 2019; Topor and Denhov, 2015).

Relational music therapy

Relational recovery emphasises the dialogic, intersubjective and responsive relationship, a focus that is mirrored by relational music therapy (Trondalen, 2016), which builds on the relational turn (Mitchell and Aron, 1999) and interpersonal theory (Sullivan, 2013). As a form of collaborative activity, music therapy has been highlighted as intersubjective and relational (Ansdell, 2015; Trondalen, 2016). Music can facilitate a situation where the partners are equally dependent on each other musically and can lay the ground for mutual appreciative recognition (Trolldalen, 1997; Wilhelmsen and Fuhr, 2018). For service users who find social relationships difficult, the relationship with a Music Therapist can help to develop their confidence with reciprocal interactions and build increased trust with other people (Solli and Rolvsjord, 2015).

Ansdell (2015) critiqued Music Therapist researchers borrowing the model of ‘the therapeutic relationship’ from the psychotherapeutic tradition, as it can turn the relationship into ‘a rather “fixed thing”’ (p. 166). We appreciate Ansdell’s argument but at the same time, we would like to clarify that Norcross and Wampold (2019) underlined that ‘the goal is for an empathic therapist to collaboratively create an optimal relationship with an active client on the basis of the client’s personality, culture, and preferences’ (p. 3). However, we fully support Ansdell (2015) in that it is ‘helpful to think of how the specifically musical relationship between client and therapist offers something different or unique’ (p. 166).

To understand the processes and critical factors in establishing and maintaining the relationships that make music therapy work, the present study aimed to explore the characteristics of the relationship between the service user and Music Therapist in FACT services in Norway. Hence, we sought to address the following research question: What characterises the relationship and interaction between the Music Therapist and the service user in the context of FACT?

Design and methods

Context

The research was carried out by the first author (Skånland), a music and health post-doctoral researcher,⁴ in line with discussions on methodological approaches, theoretical foundation and philosophical perspectives with the second author (Trondalen) and the team at the Centre for Research in Music and Health (CREMAH) at the Norwegian Academy of Music.

The study was conducted as a sub-study within a national research project at Hospital Inn that evaluated the implementation of the FACT model in five regions across Norway. The present study focused specifically on exploring music therapy offered within the FACT model and connects to the primary research study’s aim of investigating service user experiences and recovery within FACT teams in Norway.⁵

The FACT teams selected for the main study operate in areas with varying population densities and geography. All had a team of case managers, peer specialists, an occupational specialist, a psychologist, and a psychiatrist. Of the five teams, two had employed Music Therapists. Using purposeful sampling, one of these teams was recruited for the present research. The FACT model fidelity of this team was assessed as strong.⁶ For more information on the context of the FACT teams and the leading project, please refer to Brekke et al. (2021) and Trane et al. (2021, 2022a, 2022b).

Design

This study has a qualitative design. Implementing a dyadic approach, the study explores the interaction between service users and their Music Therapist in joint interviews. The chosen research method allowed for an ecological understanding of the participants’ lived experiences (DeNora, 2013; Kvale and Brinkmann, 2015), and, importantly, it allowed the participants to speak on their own behalf as experts by experience (McCaffrey et al., 2018; Mezzina et al., 2006).

A challenge in exploring therapeutic relationships is that service users and therapists tend to experience their relationship differently (Bachelor, 2013). Research on the therapeutic alliance shows that the service user’s experiences of empathy and collaboration best predicts the therapy’s success (Norcross, 2010). The voice of the service user is thus essential (Brekke et al., 2018; Norcross and Wampold, 2011). To cover both perspectives, it appears necessary to include both service user and therapist when exploring their relationship (Fuhr, 2022; Stange Bernhardt et al., 2021). Therefore, a dyadic approach was chosen, involving joint interviews with service users and their Music Therapist (Polak and Green, 2016). While the dyadic design involves risks related to power dynamics (Caldwell, 2014), the partners’ willingness to speak freely about topics raised in the conversation and possible tension between the interviewees (Zarhin, 2018), we found it to be a fruitful approach. The joint form allowed for construction of shared narratives between the service user and therapist and offered a space to explore and challenge shared or contrasting experiences within the dyad. It also added rich and observable moments of interaction between the participants. In addition, the joint form allowed the service users to lean on the Music Therapist and offered a form of safety for the service users. A more thorough discussion of potentials and pitfalls of joint interviews in exploring client–therapist relationships in music therapy can be found in Fuhr and Skånland (under review).

Recruitment and participants

When we began recruitment, the FACT team leader referred us to the Music Therapist who informed potential service users about the study and enquired about their participation. Six adult service users – two women and four men – agreed to participate in the research interviews with their Music Therapist. The same Music Therapist worked with all six service users. He was experienced as a Music Therapist and had been employed as part of the FACT team for the last 1–2 years. Five service users lived at home, while one was in hospital at the time of the interview. The service users had moderate or severe mental illness and/or substance use disorders combined with challenges in social function. All participants had worked with the Music Therapist for more than a year at the time of the interview. The Music Therapist and service users lived in the same rural area in Norway. The Music Therapist met the service users for individual sessions. He would typically come to the service users’ homes but could also meet on the FACT premises for their music therapy sessions.

Data collection

Six joint interviews were performed in 2021. Due to the coronavirus disease (COVID)-19 lockdown, the interviews were conducted via a digital hospital platform. In five interviews, the Music Therapist and service user sat together, while the interviewer participated from a different location. In the case of the hospitalised client, the three participated from separate locations. All interviews lasted about 1 hour and were recorded on an external recorder. Prior to the interviews, the participants were asked to prepare a song to play or listen to at the beginning of the interview. This offered a glimpse into their practice and set the tone for the following conversation.

The interviews explored the user–therapist relationship and social factors in music therapy. The interview guide (Appendix 1) included questions relating to the Working Alliance Inventory (Hatcher and Gillaspy, 2006), and questions such as ‘can you describe your relationship?’, ‘do you feel understood by the Music Therapist?’, ‘do you ever disagree, and how do you solve that?’ and ‘what is the role of music in your relationship?’. The flexible, semi-structured approach allowed for explorations and dialogues between the participants within the interview conversation.

Analysis

The interview data were transcribed verbatim and analysed using a theoretical, reflexive thematic analysis approach (Braun et al., 2019). The analysis was performed deductively; the theoretical framework of the therapeutic relationship served as a lens for coding and interpreting the data. The analysis began with a thorough reading of the transcripts, taking notes in the margin to become familiar with the material and gain a holistic understanding of each conversation. These notes served as the basis for initial codes. From there, codes were grouped into themes, focusing on identifying prominent topics. The themes were then further categorised into potential main and sub-themes.

Writing was an integral part of the analysis, with the formulation of themes occurring in parallel with the writing. Some themes were refined, merged or deleted as the analysis progressed. The entire analysis and reporting process was recursive, with movement back and forth between the phases, and the six phases described by Braun and Clarke (2006, 2021) blending. The full interview transcripts were consulted several times before the final formulation of the themes. Quotes that were selected for the article were translated to English by the authors.

Ethical considerations

The study was ethically approved by the local data protection officer at Hospital Inn (ID 137850) in accordance with the Regional Committee for Medical and Health Research Ethics. Participants were given verbal and written information about the study, and all participants signed a written consent form before the interviews. They were informed that participation was voluntary and that they could withdraw at any time without consequences. The interview conversations were recorded on an external recorder and stored securely. All interviews were transcribed shortly after the interview and were anonymised successively. Participants have been given fictitious names, and all identifiable information has been removed. For confidentiality reasons, we have not offered individual information about the participants.

During the interviews, the participants were reminded that they could end the interview anytime. The Music Therapist offered explicit support to the service users by directly complimenting or helping them when they expressed difficulties in verbalising their experiences. The study design of the joint interview further allowed the Music Therapist and service users to debrief immediately after the interview conversation and/or in their continuing therapy.

In-person follow-up interviews were planned but were not conducted due to ongoing COVID-19 lockdowns. These interviews may have provided insights into how the study impacted future collaborations among the participants. Joint interviews can be sensitive to existing power dynamics and conflicts within the dyad (Caldwell, 2014; Zarhin, 2018). The interviewer had several discussions with the Music Therapist, both before and after the interviews, to determine who should be included and how to conduct the study ethically. For a more comprehensive discussion on ethics in joint client–therapist interviews, please refer to Fuhr and Skånland (under review).

Results

The interviews explored the overarching question: What characterises the relationship and interaction between the Music Therapist and the service user in the context of FACT?

Below, we will present the three main themes emerging from the analysis: The humanistic, therapeutic relationship, the friendship-like relationship, and the musical relationship. The three main themes are presented separately underpinned by sub-themes, illustrated through quotes from the participants. We present the Music Therapist as Oscar, and the six service users as Adam, Jan, Juni, Mari, Mats and Robert.

The humanistic, therapeutic relationship

Empathy

The service users described Oscar as an empathetic and understanding Music Therapist, explaining how he would carefully tune into their current state, showing how he cared by calling them to ask how they were doing or leaving them alone when it was ‘too much’. Adam explained:

But you never say that things aren’t going well, Oscar; you don’t do that. You don’t say much when you see that I’m struggling. Then you just leave me alone. This is something you’re professional at, right? You’re really good at this.

While the service users could describe how they felt that the Music Therapist understood them, his empathy towards them was also observable in how he addressed them during our conversations:

I’ve been concerned that it’s okay to take care of yourself along the way, that it’s important. And to do it at a pace that suits you, the fear must be confronted, but you must do it so that you can endure it yourself (Oscar).

Oscar’s empathetic approach was further evident in how he would adjust their activities and focus according to the service users’ current life situation:

Mats:

Sometimes I feel really down, especially around Christmas time and such, because it’s so dark outside (laughs) and my grandfather was diagnosed with cancer before Christmas and things like that, so he knew that I’ve been struggling a bit more. And then we’ve focused on other things.

Interviewer:

Yeah, right. You’ve adapted a bit when things got a little extra difficult for you?

Mats:

Yes.

Oscar:

And then you started working, right, and that’s also something that takes energy and strength.

Mats:

Yes!

Oscar:

So, it’s good to have a slightly different approach to what we’re working on.

Mats:

Um-hum.

Unconditional regard

The Music Therapist praised each service user several times and in various ways during the interview conversations. One example is when he directed Mats with a question:

Oscar:

Do you think it has been nice to discover that you have a good voice?

Mats:

Yes, he says I have a good voice (laughs).

Interviewer:

Do you believe him when he says that?

Mats:

I’m not convinced yet (laughs).

The six service users differed in personality, character, challenges, and personal goals. Yet, Oscar demonstrated positive regard for each of them in the ways he acknowledged their resources, efforts and developments, as in conversation with Mats: ‘You have been very motivated to work on this, and you are very courageous to dare to tackle it’.

A resource-oriented focus

It became apparent that Oscar consistently drew on the service users’ resources. Through his descriptions of their work together, it was obvious that Oscar recognised the service users’ potential and valued their contributions:

Interviewer:

How is it when you play with Oscar? Does it become like Oscar is helping you, or do you also feel that you contribute to the relationship?

Mari:

No, I feel that it’s very giving both ways. Yes. He’s so good at kind of jumping in if I present an idea or a sentence. No one else would care. My friend or mom or dad wouldn’t react. But he! He grasps it like that! I mean, he suddenly starts to hum or present an idea or something. You are competent, for real, Oscar; oh my god, I’ll tell you that. I don’t get how; it can just be something I scribbled down or something like that. ‘Oh, this, this!’ Then he brings out the guitar and adds a song or something.

Here, Mari described how Oscar offers a specific affirmation of her contributions, however small or seemingly insignificant, which is different from what other people in her life would do. He builds on her resources to create something more. In the creative musical process, they are both adding value and being valued. Furthermore, Oscar demonstrated that he valued the service users’ thoughts and opinions by asking for their input during the interview. In these ways they developed shared narratives by exploring and negotiating topics together. This was observable in how they could talk about disagreements and navigate through them:

Oscar:

Part of the challenge that we have worked quite a lot with is to repeat and do the same time after time. That’s not easy. (. . .) To start with, it’s about me managing to play along. But in the next phase, it’s to do with us including more musicians, then it must be a clear structure.

Jan:

Structure is kind of a key word for most of the things I’m dealing with, to manage to keep it up, keep it going. It’s kind of a part of the challenges I’m dealing with.

(. . .)

Interviewer:

But what would happen, Oscar? What’s the reason you want to structure it and get it into these musical structures?

Oscar:

Well, it’s to get to where you have talked about that you want, to play with others and for others, to record. To record something in a studio, then you need to have a quite clear structure on what you want to record.

(. . .)

Oscar:

What I want to ask you is, do you think I should take more control, less control, or is it ok as it is now?

Jan:

Yes, well perhaps, a little more control if there should be a collaboration with others.

(. . .)

Interviewer:

Do you think it’s ok that Oscar asks you like he does now? Asks you in a way how you want to . . .

Jan:

Well, it’s important if we want to move on. If we are going to have a plan on how to develop it.

The friendship-like relationship

Mutual appreciative recognition

When the interviewer asked the service users to describe Oscar and their relationship, several pointed to their chemistry. The experience of having chemistry appears to be key in their relationship and allows the service users to let their guard down:

At first, I started with a girl. And then she was going to quit. Then I met Oscar, and I think it clicked a bit more. I feel like we’ve found the chemistry, making it easier to let go and dare a little more. So, there’s a bit more energy to things (laughs). (. . .) There are some people you click with better than others, of course (Juni).

Their mutual appreciation became evident in how Oscar and the service users complimented each other during the interview. The service users turned to Oscar several times during the conversations to praise him:

He’s himself. He’s so calm and peaceful, but you manage to bring me back when I ramble. And he’s so knowledgeable. Yes. Musically, I mean. He can hear that it’s a D and it’s a G, and I’m just sitting there like ‘huh?’ not understanding anything (laughs). So, you’re reliable, I can call you; or come for a coffee, you know (Mari).

Throughout the interviews, Oscar frequently directed his attention to the service users and acknowledged that he was learning from them, as well. In this way, he emphasised that he was not the only expert in the room:

Oscar:

It’s exciting for me, Robert, because you know many things that I don’t, and I try to learn as much as possible from you. [R: Yes.] Not to mention, we’ve had some great conversations about how things fit together, how we do things, and how we think. [R: Yes.] And it’s just as exciting for me, really. [R: Yes.] So, I can try to learn a bit more. [R: Yes.] Um-hum.

Robert:

(indistinct). It’s equally rewarding both ways.

Oscar:

Yes. And then there’s the technical side of guitars, amplifiers, and stuff, where you are light years ahead of me, so I just have to listen (laughs.). Listen devoutly. That’s how it is, I’ll have to work a little harder if I want to catch up (laughs). (. . .)

Robert:

So, it always comes down to what you can or can’t do. So, what I can’t do, you can. The more of us, the more knowledge we have.

Micro-affirmations – going beyond

The friendship-like aspects of the relationships between Oscar and the service users were apparent in how they could begin a session with a cup of coffee or tea and a smoke, as noted by Adam:

I’m afraid of being stuck in the hospital, right. I would like to, but it’s simply a consequence of life, you know, and if you’ve lived a little rough. But it’s also attractive to just sit at home with me, Oscar, and have a cup of tea or coffee together and make something together.

The fact that the Music Therapist meets the service users where they live perhaps adds to their friendship-like relationship, as he is invited into their home and personal sphere. This creates a dynamic shift in the therapeutic relationship because the therapist becomes the guest.

When the interviewer asked Mats how Oscar supports him to make him feel safe, he said, ‘he sings with me’. This is a small and concrete, yet essential way for Oscar to support Mats when he performs. This support extends to Oscar joining Mats in activities outside of music therapy, including walks with an ‘activity network’, joining him in team sports, and being by his side at choir rehearsals:

Interviewer:

Can you say a little about how Oscar is?

Mats:

Yes. He’s thoughtful and caring. He follows my tempo and backs me where I need it. And it’s not just music therapy; we talk about other things as well. If I struggle. And then he’s come along on walks with [a network]. He helped me join there, but then he also joins. So, he supports me outside of music therapy, so I feel safer.

Interviewer:

So, you appreciate that he also joins you outside of music therapy?

Mats:

Yes. It helps me a little extra with going outdoors and such.

Oscar:

And then we had the team sports tournament together. And then I came with you to start training, but then it was corona-shut unfortunately.

In these concrete ways, Oscar goes beyond his primary role as therapist and thus offers extended support in several of Mats’ life arenas.

The musical relationship

Music as communication

Playing music together allows the partners to build a relationship while not having to share all aspects of their personal history in words. Robert stated that ‘music is a good way to communicate’ and said that ‘playing means more than all the conversations in the world’. The service users seemed to experience a form of weariness regarding verbal communication and expressed appreciation for music therapy because it is expressive, collaborative, fun and nonverbal. They noted that it is ‘easier to sing than to talk’, or easier to express oneself through music, as Juni said:

Interviewer:

You mentioned earlier that there’s a difference between talking to a psychologist and getting more benefits from playing music. Could you say more about that? What is it that makes music therapy different?

Juni:

It’s about the guitar, yeah, no (laughs). It’s difficult to answer, but one can express oneself in a way. It becomes something positive; you’re not just sitting there. I mean, now I know myself well enough, beginning to at least, that there’s no point in just ‘blah blah’ if you know what I mean? And maybe I can express myself better, or at least in a different way, with the guitar, I think. It gives me a lot more. I don’t know why.

Oscar noted how they build a trusting relationship through the music which leads to trust also in other life arenas:

Oscar:

I find something about the frame around it, with FACT and all that, that’s exciting. When we meet for music therapy, we are also concerned with the rest of our lives and talk about it. I care about it, and we have some nice conversations. I think this combination is essential, as it gives what we do in music therapy even greater value.

Robert:

Yes, that’s what it does. It gives it greater value.

Oscar:

I think that the strong relationship we build through music can withstand difficult topics that may be harder to deal with and discuss.

Robert:

Yes, absolutely.

Oscar:

Like when we had that conversation last week, you know.

Robert:

Yes, so it brings more good things with it.

Collaborative interplay

In doing music together, the therapist and service user appear more equal in their relationship, as both offer something to the musical teamwork. While being valued by the other, they both also add value, and this can be seen concretely in how they were both described as necessary partners in the musical interplay:

Interviewer:

What does music do in the relationship between you and Oscar?

Jan:

Well, it’s that we gather around something, right? And that we, without the one, the other doesn’t function. (. . .) But it’s kind of what music is about, to be a team, right?

To not simply be on the receiving end but also to take responsibility and contribute was expressed as significant by the service users:

Giving back; that is probably the most essential thing for self-confidence and self-esteem. That you are not just someone who takes and asks for things, but someone who can primarily give. That feeling is greater than anything else (Mari).

The service users actively contribute to the musical interplay through creative input, such as music-making, song writing, and performance. Their contributions are explicitly recognised and valued, and reflected in the concrete feedback they receive. According to the service users, the musical relationship with Oscar is ‘very rewarding both ways’.

The shared, aesthetic experience

Oscar often referred to the joint music-making as ‘something beautiful’, as in conversation with Juni. They described the experience of playing music together as being together in time and emotion, sometimes leading to a state of flow and transcendence:

Oscar:

My experience is that we have many and sound experiences of starting to improvise, and then we kind of play ourselves into something that becomes beautiful, that becomes nice.

Juni:

Yes, right. Yes, you say it correctly.

Oscar:

And that we are pleased about and kind of . . .

Juni:

Um-hum.

Oscar:

And can experience that, what? Has one hour passed already?

Juni:

Yes, right.

Oscar:

Right, so we get that feeling. And I think that’s precisely because it’s a sound . . .

Juni:

Sound interplay.

Oscar:

Yes, sound interplay.

Juni:

Yes, quite simply.

Oscar:

And that it’s something that becomes nice and beautiful and pleasant to dwell within.

The musical interplay is unique in that the partners contribute to the musical communication simultaneously and create harmonies that can be experienced as something more than the combined individual contributions. This aesthetic experience has value as an embodied, phenomenological experience that is profoundly different from verbal communication.

Discussion

Whereas FACT service users commonly struggle with challenges in social functioning, they emphasise the importance of stable and long-lasting relationships with staff members and the FACT team (Brekke et al., 2018; Landheim and Odden, 2020). To understand the factors that make one such type of relationship work, we addressed the following research question: What characterises the relationship and interaction between the Music Therapist and the service user in the context of FACT?

Through thematic analysis of the joint interviews, the main themes of the music therapy relationship were, (1) the humanistic, therapeutic relationship, (2) the friendship-like relationship, and (3) the musical relationship. Sub-themes were, respectively, (1) empathy, unconditional regard, and a resource-oriented focus, (2) mutual appreciative recognition and micro-affirmations – going beyond and (3) music as communication, collaborative interplay, and the shared, aesthetic experience.

The study’s participants appear to represent well-functioning relationships between service users and their Music Therapist, indicating that they represent a case of ‘good practice’. The interview guide featured specific questions about challenges and potential disagreements among the participants. The Music Therapist and individual service users did have disagreements but managed to navigate them in a constructive manner, and there was no observed tension between them during the interviews. It should be noted that the research design, which involved joint interviews, could have limited the participation of therapeutic dyads experiencing challenges in their relationship. For a more detailed discussion of this issue, see Fuhr and Skånland (under review). The therapeutic relationships explored in the present study relate to the humanistic approach to music therapy (Ruud, 2010). It is clear how the Music Therapist relates to the service users in an empathetic, resource-oriented way, mirroring Rogers’ (1957) humanistic approach to therapy. Empathy and positive regard relate to common factors in psychotherapy research that account for the efficacy of therapeutic interventions, regardless of the specific technique used. For an elaboration of common factors, please refer to Wampold and Imel (2015).

The music-therapeutic relationships are further presented as friendship-like and are built on trust. In their study on experiences of professional helping relations, Brekke et al. (2018) highlighted how ‘trust is a basic prerequisite for a therapeutic alliance through which other interventions may be delivered’ (p. 61). It appears in the current study that trust between the service users and the Music Therapist is built on a compound of factors, including positive regard and empathy, chemistry, micro-affirmations, and the Music Therapist’s willingness to support the service users in activities outside of their individual music therapy sessions, mirroring Brekke et al.’s (2018) findings.

The interview conversations paint a picture of therapeutic relationships beginning with a trusting relationship between the service user and the Music Therapist and extending outside their individual therapy sessions. Oscar’s explicit recognition of the service users and the more implicit forms of acknowledgement, such as having coffee together, can be understood as micro-affirmations (Topor et al., 2018). Brekke et al. (2021) accentuate the significance of such micro-affirmations for FACT service users, linking it to the importance of feeling like a citizen. While the willingness of helpful professionals to ‘go beyond’ what is expected has been highlighted by service users (Lindvig et al., 2019; Topor and Denhov, 2015) and is also emphasised in the current study, the music therapy setting itself can be seen as ‘going beyond’. Music therapy is presented as significantly distinct from verbal therapy and is valued as something enjoyable. Several of the participants associated playing music with dreams of playing in a band, and they acknowledged Oscar’s musical proficiency. Therefore, music therapy is perhaps perceived as surpassing traditional therapy, and Oscar is not only regarded as a therapist but also as a musician and a music teacher.

The friendship-like relationship between the service users and the Music Therapist seems essential, yet it is important to note that the therapeutic relationship is distinct from a genuine friendship. Philosophically, the partners may be viewed as equals, but this equality does not necessarily translate to the nature of their relationship itself. The Music Therapist has the clear role and responsibility of the helper, and the service users are dependent on the help offered. All the service users have been working with Oscar over a year, but they still rely on his support in activities outside of their individual sessions.

The therapeutic relationship between service users and their Music Therapist is a musical relationship, and music provides unique content and context to the relationship. According to Ansdell (2015), collaborative musical interplay offers a context for building intimate but not necessarily personal relationships. This is particularly valuable for individuals who struggle to connect and communicate verbally. As some service users expressed, music provides a means of self-expression that is sometimes easier than words. For example, one service user stated, ‘I can express myself better, or at least in a different way, with the guitar’. The phenomenology of the musical relationship is unique in its aesthetic and embodied character and appears to include a different form of vitality and emotion than non-musical relationships (Ansdell, 2015; Stensæth, 2015). The music facilitates a form of ‘thirdness’ in which the relationship is enhanced beyond what each person brings individually (Benjamin, 2017; Wilhelmsen, 2012).

The participants further described the collaborative musicking (c.f. Pavlicevic and Ansdell, 2009) as an enjoyable and mutually beneficial activity where both partners are equally necessary. To make contributions, to feel valued and add value is the foundation of mattering, which is understood to be a basic human need (Prilleltensky, 2020). According to Oscar, music provides a platform for building robust relationships between the participants that can endure difficult topics in other life arenas. By providing a unique context for building healthy relationships, music can afford new relational experiences for service users and contribute to their journey towards relational recovery.

The context of FACT, where a collaborative team provides help to the service users on their own premises, promotes greater mutual engagement and a more flexible approach to expert roles. This is evident in the way the Music Therapist joins service users in activities such as hiking, team sports, choirs, and performances. In addition, other members of the FACT team occasionally participate in music therapy sessions, and service users have even performed music with Oscar during team members’ lunch breaks. While the service users are defined as patients in treatment at the hospital, the professional help they receive from the FACT team is community oriented. Consequently, the FACT model blurs the boundaries between psychotherapeutic practices and community music therapy, emphasising the aspect of recovery.

The relationship between client and therapist – or service user and Music Therapist – can be understood as essential to the therapeutic outcome in and of itself (Nissen-Lie et al., 2021; Wampold and Imel, 2015). As Wampold and Imel (2015) point out, a human connection with an empathetic and caring individual ought to be health-promoting, particularly for individuals who can experience challenges with social relationships. This links to relational recovery, which pinpoints relationships as the foundation for recovery (Price-Robertson et al., 2017). For service users in FACT, building relationships with the professional helpers in the team may become an essential first step towards social participation (Skånland, 2022). It may therefore be understood as a critical factor towards recovery.

Research limitations and strengths

The research design does not permit immediate generalisation of the results; instead, it contributes to our understanding of helpful relationships that can be transferred to other contexts. The study only involved participants from one FACT team and represents a case of ‘good practice’, potentially reinforced by the FACT team’s high fidelity. The joint interview may have limited the inclusion of less successful therapeutic dyads. However, this methodological choice provided access to observable moments in the interaction between service users and their Music Therapist and allowed them to construct shared narratives so that we could understand more about what did go well. This enriched the data material and may have provided a useful basis for further development in the music-therapeutic process. Including both service users and Music Therapist was essential to access both partners’ understanding of their relationship. Due to ongoing COVID-19 lockdowns, we could not conduct an ethnographic research design (Pang, 2019). However, an ethnographic follow-up study would be valuable in further developing our understanding of the music-therapeutic relationship in real-life settings.

Footnotes

Appendix 1 Acknowledgements

A warm and humble thank you to the participants in the study. Thank you, Anne Landheim and the team at Hospital Inn for accommodating the research and the team at the Centre for Research in Music and Health, particularly Karette Stensæth and Hans Petter Solli, for collaboration and reflexive research dialogues.

Author contributions

Skånland performed the interviews, analysed the data and wrote the article in line with discussions on music therapy approaches, theoretical foundations and overall elaborations with Trondalen. Both authors actively participated in revising the article and provided their approval for the final text.

ORCID iD

Marie Strand Skånland

Notes

Author biographies

Marie Strand Skånland, PhD, is Head of Research, Associate Professor and a Post Doc. researcher at Ansgar University College in Norway, where she also contributes to the bachelor programme in Music and Health. Her current Post Doc. research explores relationships and social belonging in and through music therapy in the context of Flexible Assertive Community Treatment.

Gro Trondalen, PhD, Fellow of AMI, is a Professor in Music Therapy and Senior Researcher at the Centre for Research in Music and Health (CREMAH), Norwegian Academy of Music, Norway.

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