Notes on notes: A critical reflection on clinical writing in music therapy practice

Biases in perception

For a phenomenologist, every account of a music therapy session in our clinical writing is an act of interpretation. What crosses the threshold of perception into memory is fraught with complexity. Spinelli (2005) suggests that ‘our experience of reality is always made up of an interaction between the raw matter of the world, whatever that may be, and what might be broadly called “our mental faculties”’ (p. 12). Our experience of what we call reality ‘emerges from the interaction or inter-relatedness of the two’ (Spinelli, 2005: 12).

Husserl’s concept of intentionality sheds light on the significance of interpretation in perception. What we are conscious of is always something: The nature of consciousness is that it is directed (Spinelli, 2005: 16). The sheer amount of sensory information at any one moment is such that the vast majority of it does not even reach our conscious awareness; some form of unconscious attentional editing is occurring at every instant. Within a therapeutic context, the intentionality of both client and therapist is likely to differ, and what they both feel are the most important aspects of the process can differ widely (c.f. Yalom and Elkin, 1991).

Furthermore, our perception is dependent on ‘a variety of inferences derived from the neural signals . . . [these] may be more or less adequate, but never complete, or completely true’ (Spinelli, 2005: 37). Gestalt psychologists in the early 20th century discovered the tendency to see things as whole, rather than as their separate constituent elements. They claimed that we group things together according to their similarity, proximity, continuity and closure – the tendency to close or complete an incomplete pattern (Spinelli, 2005: 42–43). In addition, our motivational and attitudinal state, the perceptual set – our expectation of what we will perceive due to our past experiences – and perceptual context – what is happening at the same time as or around the act of perception – also act as a bias to our perception (Spinelli, 2005: 46). For music therapists, and clients of music therapy, our understanding of the music and our unconscious expectations of what might occur in and constitute a music therapy session can both shape our perception.

Our perception of others is also compromised along similar lines. Despite ‘the limitations of human experience, [through which] our perception of others undergoes continuous (if at times unaccepted or unnoticed) flux and alteration’ (Spinelli, 2005: 71), we nevertheless attempt to form a unified and consistent impression of others. This seems to trump accuracy and truthfulness: Spinelli (2005) writes, ‘we combine speculation and inference with direct data’ (p. 60). There are hidden biases present within perception dependent on many factors. These factors might stem from our motivations and biases around culture, gender, race, sexuality, religion, disability and so on. Perceptually, the truism of Anaïs Nin (1961) holds: ‘we see things not as they are, but as we are’ (p. 124). Therefore, intersubjectively we cannot escape an unconscious editing and interpreting of everything that happens in the music therapy encounter, and it is especially important for inclusive practice that we unceasingly try to uncover and work on our own biases and assumptions.

Phenomenologically ‘we can never know the real world, only the interpreted world – the world that emerges through our reflections upon it’ (Spinelli, 2005: 202). However, this is not a point of despair for our clinical writing. It merely nudges us to acknowledge the inescapable role of interpretation in making sense of the world and our work as music therapists.

Theoretical seepage

If we cannot help but interpret and create meaning from our experiences, then our theoretical orientation, established during and after training, probably influences our clinical writing. This influence may not be as obvious as assigning a specific theoretical label to a client’s behaviour. It may show up in the way we place the client in a web of implied discourse and by favouring certain interpretations over others when making sense of the therapeutic encounter.

We should consider whether our training and theoretical orientation essentially changes who we are, including how we perceive, comprehend and interpret our intersubjective encounters. This certainly seems to be suggested in a study by Hoskyns where the responses and observations of students, both at the beginning and ending of their training, to a video of vignettes of music therapy clinical work are compared to the response of an experienced therapist. Hoskyns found that the beginner students were more focused on single events and the individual behaviours of the client, whereas the more experienced students and the therapist moved ‘from a preoccupation with discrete events and a variety of assumptions to a more objective and balanced view of the whole interaction observed’ (Bunt and Hoskyns, 2004 [2002]: 187–188). Hoskyns asserts that ‘the overall effect of therapy training changes the quality and approach of therapists’ observation and listening’ (Bunt and Hoskyns, 2004 [2002]: 187). Apart from demonstrating that therapy training is a perceptually transformative process, this study also assumes that certain types of seeing, experiencing and understanding are, to use Hoskyns’ words, more objective, balanced and of higher quality. Rather than claiming objectivity and balance, it would be more reasonable to assert that our training teaches us to privilege particular types of meanings and observations over others – those embedded within a particular music therapy theory, experience of the client group and clinical experience.

In addition, we might wonder if our theoretical orientation, conceptions of music therapy and sense of meaning conveyed in our clinical writing seep into our clients’ manner of making sense of their own lives. For Jung (1963), the therapist’s job is ‘to kindle a light of meaning in the darkness of mere being’ (p. 326). This might lead us to ponder whether clients feel that their music therapy is a success to the extent that they find their own lives meaningful through their own experience and understanding of what is conveyed, consciously or not, in music therapy.

Referrals, reports and existential unease

Regardless of how descriptive and filled with relevant information a referral might be, it is still an inadequate preparation for the first encounter with a client. May (1983) writes that ‘the grasping of the being of the other person occurs on a different level from our knowledge of specific things about him’ (p. 92). As the existential psychotherapist Cohn (1997) states, ‘there is no ‘history’ to be taken for there is no history as such. A client’s history is disclosed in the process of interaction between therapist and client’ (p. 33). This encounter is about the intersubjective moment when two whole beings meet: ‘if you pluck a violin string, the corresponding strings in another violin in the room will resonate with corresponding movement of their own’ (May, 1983: 22). Cohn (1997) goes even further and asserts, ‘the client you meet as the therapist is the client who meets you. There is no client as such. If two therapists meet the same client, it is not the same client’ (p. 33). This might be vividly and audibly illustrated in music therapy, where the music improvised between a client and a music therapist would certainly be unique to them and different to the music produced by the same client with another music therapist.

The first encounter with a client reveals more than any referral might show. Conversely, when writing reports at the end of the therapy, a kind of simplification of the client may occur that misses something vital. This vital element could be the extreme specificity of the intersubjective encounter generated by two people at a certain time and place. This is captured so tangibly in a music therapy coimprovisation but less easily in formal clinical writing created solely by the therapist.

The theoretical frame used to understand and describe what has happened during the course of therapy, however consciously or unconsciously used, also seems to exert a subtle influence. May (1983) questions, ‘and does not this patient, or any person for that matter, evade our investigations, slip through our scientific fingers like sea foam, precisely to the extent that we rely on the logical consistency of our own system?’ (p. 38). Perhaps not to the extent of us just ‘seeing merely a projection of our own theories about him’ (May, 1983: 37), but they can be ‘based on a set of assumptions that cannot be easily challenged, debated or disagreed with’ (Deurzen, 1997: 2).

Writing about music

The challenges around writing about music are well-known and are even greater in music therapy where an additional layer of complexity and metaphor is overlaid. Pavlicevic (1997) comments that

we seem to feel that unless we can talk about the musical experience, then [1] the non-verbal experience is incomplete; [2] professional colleagues will think that we do not know what we are doing; and [3] our clinical grasp of the work will be questioned – we might be seen to be doing ‘just music’ (p. 11).

The importance of finding a way to communicate about all aspects of music therapy is noted by Mette Ridder (2007): ‘It is essential for our profession that we develop methods that document our clinical work; a documentation that can be applied to evidence-based practice’ (p. 64). For both clinicians and researchers, finding a way to describe and write about what happens in a music therapy session is challenging (see Ansdell, 1999), and many different research approaches have been created (Wosch and Wigram, 2007).

The music therapist’s own relationship to and understanding of the role of music within sessions also play a part in how meaning might be constructed and written about. Pavlicevic (1997) highlights two positions which she refers to as the absolutist, where ‘the meaning of the music is simply itself’ (p. 138), and referentialist, where ‘there may be too much meaning and not [enough] musical substance’ (p. 138). Pavlicevic (1997) asserts that music therapists generally draw on aspects of both these positions to appraise what happened in sessions, where ‘the music is being read as something “other” than itself’ and a ‘clinical-interactive’ meaning is construed (p. 26). She suggests that the music therapist listens to the music in a uniquely therapeutic way ‘not quite to music as music . . . but to the person portrayed in the spontaneous music-making’ (Pavlicevic, 1997: 25).

Music without words

Music therapists often use music, video clips or audio recordings to reveal the meaning of their work more vividly than written descriptions. Mette Ridder (2007) notes that video clips can quickly convey the music therapy approach and its various aspects to professionals unfamiliar with the field. A complete musical transcription could also represent what happened in the music, with advantages such as exactitude and portrayal of many dimensions of musical elements (Wosch and Wigram, 2007). However, there are difficulties in sharing this material with colleagues who do not read music and capturing fundamental expressive aspects of the experience. Like making verbatim transcripts of any spoken parts of sessions, there are several associated challenges: the time required to create the transcript, the overwhelming amount of generated material and the inappropriateness of audio recording for many clinical situations. To maintain client confidentiality, make the material accessible and useful and provide a comprehensible record of treatment, a degree of editing, selecting, sorting, categorising and explaining is essential.

Analysing a music therapy session or therapy process without words, entirely through the creation and performance of a piece of music, seems like an alluring idea. The music critic Keller (2001) created a method of musical analysis called ‘Wordless Functional Analysis’, where he composed a score that elucidated the structure and expressive elements of a piece of music without the accompanying text. In music therapy, this method would need to be adapted to reveal the relationships between the music as a representation of the client’s difficulties or reason for referral and how closely the music adheres or departs from its own grammar and cultural context. However, Pavlicevic (1997) notes that while ‘music generates and portrays the therapeutic relationship’ (p. 56), it cannot capture the essence and significance of the therapeutic relationship alone.

The actual meaning of the music itself within the therapeutic relationship might vary, compounding the challenges around finding ways to represent it. Ruud proposes that music might function in four ways: as a sound phenomenon, where the sensory aspects of the music and sound are important; a structural phenomenon, where the music refers to meanings implicit within the musical patterns and structures themselves; a semantic phenomenon, where the music refers to meanings beyond itself, and a pragmatic phenomenon, where the music mirrors the processes of interpersonal communication (in Bonde, 2007: 255). Depending on the client and context, any one of these properties might assume greater importance and influence in how we think about the musical aspects of the session. The question remains of how we might capture and honour the richness and often multiple meanings of the music in writing.

Music, metaphor and poetry

Inselmann (2007) writes ‘the main problem of evaluating music therapy is the translation of what the music is symbolising into verbal symbols’ (p. 164). Inevitably, something gets changed, or lost, in translation. For some researchers, embracing metaphorical and poetic language is a better fit when writing about music therapy. Leite (2003) suggests that to integrate the different aspects of music therapy, ‘the use of music-related metaphors to describe the psychological processes and interpersonal dynamics that may occur in therapeutic music making’ is preferable. Rykov (2011) advocates writing poetically about the musical encounter as she wants ‘the reader to really “get it”, to truly understand what music therapy means for the client’. She continues, ‘Poetry is a superior form for writing about nonverbal, embodied music therapy essence because poetry is so inherently musical’ (Rykov, 2011). However, she concedes that ‘nondiscursive writing in an evidence-based milieu is a questionable pursuit’ (Rykov, 2011).

Music therapists need to guard against relying on metaphor too greatly to describe the music. For Abrams (2007), ‘loosely descriptive, anecdotal and/or speculative reflections are insufficient, as they cannot properly ground meanings and new understandings’ (p. 92). Trondalen (2007) advocates a contrapuntal understanding of the music incorporating phenomenological and hermeneutic perspectives: ‘The researcher may describe the musical improvisation rooted in the client’s perception but add her own understanding of the musical processes, i.e. construct reality based on knowledge, language and historical situated-ness’ (p. 199). In effect, Trondalen is calling for a synthesis that might incorporate context, Ruud’s categories and multiple other perspectives, contrapuntally informing each other to produce a richer sense of holistic meaning.

The power of patterns on music and words

For the understanding of the music in the session, and our writing about the session afterward, patterns of musical and linguistic grammar determine certain aspects of both discourses. These might subtly shift their meaning. Phenomenologically, we tend to perceive, or even impose, patterns on sensory information (Spinelli, 2005), but these same gestalts are also at work in language and the language-like aspects of music (Pavlicevic, 1997). Pavlicevic (1997) writes, ‘Language may explain the event, describe it; language may construct the way that we see the event, and it may begin to operate independently of the event, becoming a discourse that is self-perpetuating’ (p. 8). For De Backer and Wigram (2007), ‘music searches for a structure . . . The music goes its own direction, and as a therapist one has to support that’ (p. 132). This independence of the music may be part of its function within the therapy session and might cultivate a client’s ‘symbolizing capacity’ (p. 132). They note that, ‘The music anticipates something which is not yet there, a type of structure, within which the patient possibly can enter’ (De Backer and Wigram, 2007: 132).

Pavlicevic (1997) notes that ‘writing about music therapy is always a compromise in colour and focus’ (p. 185) because in music therapy, ‘we remove ourselves from our more familiar mode, and immerse ourselves in the illusory, the immaterial, the intangible’ (p. 184). To communicate with other professionals about the work, the music therapist starts a dialogue where a ‘negotiation of meaning needs to take place at the descriptive level, as well as at the level of inference and interpretation’ (Pavlicevic, 1997: 15). For Priestley (1975), ‘the therapist must find the music in words and words in music and search all his [sic] working life for the meaning in both’ (p. 250).

The language speaks, not the subject

As therapists, our own relationship to language itself impacts what we choose to write. The French psychoanalyst Lacan suggested that language itself has its own form of agency and that the subject is irredeemably split from the language in which it talks and thinks. For Lacan, what is thought of as the ego – the talker of our internal monologue – is not the subject: ‘the ego is what a person says of him/herself; the Subject is the unrecognised self that is speaking’ (Bailly, 2009: 35). McAfee (2004) writes, ‘we become who we are as a result of taking part in signifying processes. There is no self-aware self prior to our use of language’ (p. 29). Homer (2005) concurs: ‘We are born into language – the language through which the desires of others are articulated and through which we are forced to articulate our own desire’ (p. 44).

Therefore, for Lacan, it is futile to suppose that the subject has control over his or her own language. Language is merely something into which the subject is born. Meaning in a person’s discourse comes through the relationship between signifiers, rather than an objective signification of an action or object (Bailly, 2009: 50). Both therapists and clients cannot avoid the emotional and associational resonances (the relationship between signifiers or signifying chains) of particular words and what they might trigger. For example, to understand a client who says they just want to be ‘happy’ would involve investigating the unconscious associational chain of what ‘happy’ means for the client. ‘Happy’ might be linked to feeling ‘in control’, ‘feeling like I did when I was a child without responsibilities’ and ‘away from the current situation’ or something completely different. Consequently, for Lacan, for both the client and therapist using language in the therapy process is both more ambiguous and also richer in association; finding a clear way to represent and record what happened in a therapy session is harder and more complex.

Kristeva’s semiotic and symbolic

Kristeva, a French psychoanalyst and student of Lacan, developed a theory of language that emphasised the body’s role in the creation of meaning. Her theory seems to capture an important aspect of why a written transcription of words or music may not be a completely adequate way to record sessions. What seems to be lacking is what Kristeva describes as the semiotic mode of the signification of language. For Kristeva, the semiotic is not just a study of signs but ‘the extra-verbal way in which bodily energy and affects make their way into language’ (McAfee, 2004: 17). She pairs this with the symbolic mode of signification that attempts to use language purely to express meaning unambiguously.

These two modes of signification are not mutually exclusive. Kristeva asserts that the semiotic mode is always discharged into the symbolic, indeed ‘signification is meaningful because of the way the semiotic energizes it’ (McAfee, 2004: 18). The semiotic precedes the symbolic. It is the mobile interplay of the biological and psychological drives, expressed through rhythm, sound and sensory articulations. In literature, the semiotic corresponds most closely to poetry, but there is a direct corollary in music, dance and other art forms. A baby’s babbling and cooing are examples of the semiotic:

Discrete quantities of energy move through the body of the subject who is not yet constituted as such and, in the course of his development, they are arranged according to the various constraints imposed on this body – always already involved in a semiotic process – by family and social structures (Kristeva in McAfee, 2004: 18).

However, the semiotic is always present as the substratum of all speech: ‘Because the subject is always both semiotic and symbolic, no signifying system that he produces can be either “exclusively” semiotic or “exclusively” symbolic and is instead necessarily marked by an indebtedness to both’ (Kristeva, 1986: 93). It would be impossible to record within a transcript the subtle, motile interplay of emphases, accents and articulations generated within speech – the semiotic leakage into the signifying act – just as it would be in the musical act, even though as musicians and therapists, we are perhaps very attuned to these aspects. This is one of the very elements that can impart such rich and important meaning to therapeutic work.

The notes speak, not the therapist

When rewriting my lost notes due to the faulty laptop, I found that I could not reconstruct them exactly as before. This led me to wonder whether using different words or grammar to describe the same events was important. It felt as though I was simply accessing some sort of underlying memory of an experience that many different forms of language might describe. However, it also felt likely that different word choices would represent subtle shifts in emotional tone or emphasis. Then, I pondered whether reconstructing the text word-for-word later, even if it were possible, could also alter its meaning somehow. It seemed important to explore the autonomy of the text itself and how far meaning was dependent on the reader, wider context and even its position in time.

From a literary, rather than therapeutic, context, some of these ideas are explored in the meta-fictional short story ‘Pierre Menard, Author of the Quixote’, by the Argentinian writer Borges (2000). The character, Pierre Menard, sets out to write an exact word-for-word version of Cervante’s Don Quixote and completes two and a half chapters of it before his death. The story provocatively suggests many interesting ideas about the relationship between a reader, writer and text:

One particularly interesting insight is that with the irrevocable severing of the link between signifier and signified . . . the door becomes open for a kind of writing where identical texts can mean different things since they are, even if literally the same word for word, never the same or identical to themselves (de Toro, in Giskin, 2005: 105).

In the story, the literary critic protagonist believes that Pierre Menard’s version of Don Quixote is more profound than the original because it was written in a later time period. Following this reasoning, even if I were able to reconstruct my notes completely, using exactly the same words, their meaning would have changed as the link between the signifier, the text and the signified, the described therapy session activities, would be different.

The clinical relevance of this can be highlighted with an imaginary example. It is easy to conceive of a situation where the same text might hold different meanings and implications if coincidentally written about two different clients. For example, the note, ‘the client spent the first few minutes of the session smiling and talking animatedly’ would likely hold different connotations for a client who had recently suffered a bereavement, than one who had just received some good news. Borges’ story demonstrates the inseparability of the meaning of a piece of writing from its context. The meaning of our clinical writing even if we use the exact same words, similarly, may be altered by context.

Another way in which the same text might assume multiple meanings is when it is read by different people. Post-modernists in France in the 1960s declared the absolute independence of texts from their writers. Barthes (1977 [1967]) in his famous essay, The Death of the Author, ascribes this tendency first to Mallarmé: ‘for Mallarmé . . . it is language which speaks, not the author’ (p. 3). And this language speaks to the reader; the reader being the locus of understanding: ‘the unity of a text is not in its origin, it is in its destination; . . . the reader is . . . only that someone who holds gathered into a single field all the paths of which the text is constituted’ (Barthes, 1977 [1967]: 6). The music therapy clients who read our reports about their sessions will likely have a quite different understanding of the text than a neutral third party.

Contextualising the writing in clinical practice

Ideally, the ultimate beneficiary of all clinical writing in music therapy should be the client. However, it is more realistic to assert that it is produced for the therapist, to help process and account for the work; the institution, to assess the effectiveness of the intervention, and even the wider regulatory context, to monitor the efficacy and safety of both. It is noteworthy that, except in very rare circumstances, clients do not choose to access what is written about them. In the National Health Service (NHS; 2019), patients have the legal right to access their treatment notes, but very few actually do. The writing often seems to be about, but not for, the client.

In terms of wider social and institutional contexts, one of the functions or consequences of writing may be to exercise power or control over an individual. Foucault (1977), when describing the history of the modern penal system in Discipline and Punish, referred to the intention of producing docile bodies, locating the prisoner in the nexus between power, control and knowledge. Foucault (1977) wrote that ‘a body is docile that may be subjected, used, transformed and improved’ (p. 136). For Foucault, the ways in which modern power produces docile bodies are hierarchical observation, where the mere act of observing another can alter their behaviour; normalising judgement, where a person’s behaviour is ranked in relation to others, and the examination, which ‘combines hierarchical observation with normative judgement’ (Gutting, 2005: 85–86). All these locate the subject in a ‘network of writing’ (Foucault, 1977: 189), meaning that the most challenging or problematic subjects have the most written about them. This constitutes what Foucault (1977) refers to as power-knowledge: ‘There is no power relation without the correlative constitution of a field of knowledge, nor any knowledge that does not presuppose and constitute at the same time power relations’ (p. 27). The obvious resonances with our own therapeutic protocols of observation, referral, assessment, evaluation and report writing should alert us to the fact that we are, in a sense, subjecting our clients to an exercise of power-knowledge, whether we are aware of it or not.

The medium of music therapy itself produces a whole matrix of behaviours, in clients, therapists and institutions, that convey messages about power, control and normalising judgement (c.f. Myerscough, 2023; Pickard, 2022; Vencatasamy, 2023). McLuhan (1964) writes in the famous opening chapter of Understanding Media that ‘the personal and social consequences of any medium – that is, of any extension of ourselves – result from the new scale that is introduced into our affairs by each extension of ourselves, or by any new technology’ (p. 7), ergo: the medium is the message. Even if our intention in therapy is to help and support clients, the ‘medium’ of therapy – the way that we organise things in terms of the time, place, space and writing – may have an unwitting influence on what it actually conveys.