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Assignment Two

Timothy M. Johnson

Faculty of Fine Arts and Music, University of Melbourne

M04AA: Master of Music Therapy

MUSI90041: Applications of Music in Therapy A

Dr. Grace Thompson

Due Date: 17/06/2021

Word Count: 2954

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Question One

Approach to Assessment

My assessment approach towards Nadifa would largely be informed by the “RIOT”

framework posed by Jacobsen et al. (2019). The regimented documentation protocols within

the hospital system would render her medical records a valuable source of physiological and

psychological information. Informal interviews would form a significant component of my

assessment focus. I would seek to informally interview interdisciplinary team members,

particularly nursing staff, to gather information regarding Nadifa’s response to the stress of

the hospital environment (McFerran & Heiderscheit, 2016). I would interview Nadifa’s

parents to gain an insight into her behavioural and psychological needs, and her musical

history and identity. Through interviewing and observing Nadifa throughout the initial few

sessions I would aim to get a sense of Nadifa’s perspective of her condition, and insight into

her emotional state and needs. I would focus on asking Nadifa about her relationship to

music, and keenly observe her musical engagement. I would eschew formal testing with

Nadifa, privileging the need to foster an effective therapeutic relationship (Hilliard, 2001),

although I would be influenced somewhat by Saarikallio et al.’s (2015) Healthy/Unhealthy

Uses of Music Scale (HUMS) in informally assessing Nadifa’s music listening habits. I

would pay special attention where possible to observing Nadifa’s family dynamic, as family

theorists have posed that eating disorders are symptomatic of underlying family issues

(Hilliard, 2001).

Hypothetical Assessment

Nadifa’s medical records indicate that this is her first time in an inpatient program,

and that she has attended two outpatient treatment facilities prior to being admitted (Justice,

1994). She is severely underweight at 39kg, has an electrolyte imbalance and is at significant

risk of internal organ damage (Justice, 1994). She has been suffering from amenorrhea for
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roughly six months (McFerran & Heiderscheit, 2016). Nadifa’s psychological assessment

states that she has received a diagnosis of anorexia nervosa and is suffering from severe

cognitive distortions and body dysmorphia (Hilliard, 2001). Nadifa is assessed as having a

possible comorbidity of oppositional defiant disorder (Eating Disorders in Australia, n.d.;

McFerran & Heiderscheit, 2016) and a possible significant early childhood trauma or abuse

(Justice, 1994). She has also been noted to have tendencies towards perfectionism.

Nursing staff have revealed that Nadifa has exhibited difficult and aggressive

behaviour towards them, especially regarding eating. Nadifa has been observed to have high

levels of anxiety associated with mealtime (Bibb et al., 2015). Nadifa has been socially

withdrawn from fellow patients, avoiding interacting with them as much as possible. Nadifa’s

favourite nurse Tracy has stated that Nadifa has disclosed that Nicky Minaj is her favourite

artist and has observed Nadifa singing under her breath with her eyes closed while listening

to music on headphones. Nadifa’s parents have detailed that Nadifa has been socially

withdrawn from a young age. Nadifa has a history of issues throughout her schooling,

demonstrating a propensity to argue with teachers and authority figures. Nadifa has a strong

tendency to refuse to comply with parent requests, especially related to eating, and has

become very defensive and emotional when confronted by her parents about her eating and

weight. Nadifa has become obsessed with tracking the kilojoule content of her food. Nadifa

has no history of playing a musical instrument, though listens to music on headphones

frequently.

Nadifa exhibited significant resistance to verbal communication (Lejonclou &

Trondalen, 2009) and facially referenced me minimally during our introductory session.

Nadifa was initially reluctant to engage when invited to share her favourite music. When I

offered to sing and play a Nicky Minaj song, however, she tentatively agreed and appeared

somewhat engaged, as evidenced by her non-verbal communication. Nadifa refused an egg

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shaker when offered in this session. In my second and third individual sessions with Nadifa,

she became somewhat more forthcoming in disclosing her preferred musical artists and

genres. Nadifa accepted, somewhat reluctantly, when offered the opportunity to play me

some of her favourite songs on my Bluetooth speaker via Spotify. During this listening

process she appeared to be engaged and to strongly identify with the music. When prompted

following this listening session, Nadifa stated words to the effect of “music is a special,

private place that I can go to” and “music helps me escape difficult thoughts”. Nadifa, when

asked, also stated that she “could never be good enough to play a musical instrument”. When

gently probed about her feelings towards her condition and being in hospital Nadifa stated “I

hate it, I want to go home” and “there’s nothing wrong with me”.

Nadifa has significant and urgent needs related to her physical health. Nadifa’s

psychological needs regarding her eating disorder are directly linked to these physical health

needs. Nadifa’s most pressing needs in this area are related to her cognitive distortions

surrounding her condition, and her severe anxiety related to eating and mealtimes. Nadifa

also has significant needs in the domain of social connection given her withdrawn tendency

and underdeveloped social interaction skills. Nadifa seems to have needs in the domain of

self-confidence and self-efficacy, and needs relating to creative expression.

Question Two

I have chosen behaviourism as my preferred theoretical framework in working with

Nadifa. Behaviourism is predicated on the basis that behavioural outcomes can be achieved

via operant conditioning (Hanser, 2015). Cognitive-behavioural therapy (CBT) represents a

synthesis of behavioural and cognitive approaches and recognises that thoughts, concepts,

and emotions are indissolubly connected with behaviour (Hanser, 2015). Music therapy

informed by a CBT approach seeks to gradually change maladaptive behaviours through a

process of identifying and working with cognitive distortions and dysfunctional emotions
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(McFerran & Heiderscheit, 2016). Although the reliability of which has been somewhat

challenged, empirical evidence most strongly favours a CBT influenced music therapy

approach in the treatment of eating disorders (McFerran & Heiderscheit, 2016).

Given the severity and urgency of her medical condition (Justice, 1994), addressing

Nadifa’s cognitive distortions related to her eating disorder and her severe anxiety associated

with mealtimes are identified as her most pressing needs in the domain of music therapy

(Bibb et al., 2015). There is strong evidence to suggest that a cognitive behavioural approach

is effective at addressing anxiety associated with mealtimes (Hilliard, 2001; Justice, 1994)

and that using music therapy can be utilised as a means of cognitive diversion (Hilliard,

2001). Behaviourally informed approaches are most frequently adopted within the hospital

setting, and are recognised as being the most consonant with the highly medicalised models

present within (McFerran & Heiderscheit, 2016). Patients are at significant risk of stress and

being emotionally overwhelmed during initial exposure to the hospital environment (Hilliard,

2001) and CBT informed music therapy has been demonstrated as having potential as a

motivating agent in the difficult recovery process associated with eating disorders (Hilliard,

2001). Given Nadifa’s referral to group music therapy, a behaviourally informed approach is

judged as the most suitable framework in terms of therapeutic scope allowed by the group

setting.

Question Three

Goals/Objectives

Goal:

For Nadifa to have reduced levels of stress and anxiety via musical experiences.

Objectives:

For Nadifa to have reduced levels of anxiety associated with mealtimes.

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For Nadifa to have increased awareness of her body through guided music relaxation

experiences.

Goal:

For Nadifa to have reduced levels of cognitive distortions related to her eating disorder.

Objectives:

For Nadifa to have reduced levels of guilt and shame associated with eating via musical

activities.

For Nadifa to participate in lyrical analysis.

Methods/Session Plan

In addressing Nadifa’s goal of achieving reduced levels of stress and anxiety via

musical experiences, I would employ various methods. I would work with Nadifa to devise a

calming music playlist for her to listen to individually during mealtime, as described by

Hilliard (2001). In alignment with typical music therapy programs addressing eating

disorders in a hospital setting, group sessions would be scheduled immediately following

mealtime (Bibb et al., 2015; Hilliard, 2001; Justice, 1994). Group sessions would commence

with a series of guided relaxation techniques reinforced by music. The intent of these

methods would be to facilitate experiences of self-regulation for coping with the stress

associated with both adapting engrained behaviours and the felt bodily sensations of weight

gain (Justice, 1994). In a seated group setting, I would guide a variety of stretching and

breathing exercises as described by Justice (1994). Accompanied by the solo piano

instrumental album “Pianoscapes” (Jones, 1985) I would guide a series of non-strenuous

muscle stretch and relaxation poses, synchronising these to the gentle and consistent musical

phrasing of the music. Accompanied by Cannon in D (Pachelbel et al., 1991) I would

verbally instruct the group in yoga influenced breathing techniques, targeting in turn the

lower, middle, and upper lung (Justice, 1994).

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In addressing Nadifa’s goal of having reduced levels of cognitive distortions related to

her eating disorder I would use various methods within a group setting. These function on

one level as a cognitive diversion, mentally engaging and distracting the patients from the felt

stress and shame associated with eating (Hilliard, 2001). I would facilitate a group singing

and lyrical analysis as described by Hilliard (2001). I would prepare a list of songs with

appropriate lyrical themes, such as “Recover” (Beddingfield & White, 2010), “Gravity”

(Bareilles, 2007), and “The Middle” (Adkins et al., 2001), and after leading group singing

each song would invite group members to discuss how the song resonated with them

emotionally. As the therapeutic relationship continued to develop, I would invite group

members to prepare and bring their music selections for this activity.

Following on from the group singing and lyrical analysis, I would facilitate group

song-writing activity, as described by McFerran and Heiderscheit (2016). The specific style

of song-writing technique that I would utilise would in large measure be dictated by the level

of engagement, and degree of musical experience and confidence evident in the group. I

would have to retain a degree of flexibility therapeutically in determining the most

appropriate song-writing method to utilise. In the case of a particularly unengaged group, I

may opt for a lyrical collage technique as described by Baker (2015), instructing the group

members to look for discrete lyrical phrases within existing songs that are emotionally

resonant. I would have preprepared song-lists to serve as prompts to help facilitate this

process. In the case of a more engaged group, it may be more appropriate to instruct the

group members to offer up original words or phrases. In terms of the musical component, I

may opt for a song-parody style technique as outlined by Baker (2015) or guide an original

composition to one or another degree. To ensure an egalitarian and collaborative process I

would use a dry erase board visible to all group members.

Documentation
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The documentation format that I would use would be significantly determined by

facility protocols of the hospital that I was working at (Wheeler et al., 2005). Supplementary

to my initial assessment of each client, I would document the goals and objectives devised for

each client. The music therapy methods used would be documented with the view of making

them easily replicable by an unfamiliar reader of the document. Detailed progress notes

would be recorded after each individual and group session with the aim of documenting any

information relevant to the client’s progress or otherwise towards their goals and objectives.

As described by Wheeler et al. (2005), as part of my documentation strategy it may be

prudent for me to devise or utilise existing operational definitions to minimise the level of

ambiguity in my progress notes. This may relate to behaviour designated as oppositional or

behaviour indicative of anxiety, or an otherwise maladaptive nature. The utmost care would

be taken to comply with facility policy and legal requirements regarding storage of all

documentation.

Evaluation

Evaluation of Nadifa would be achieved via review of her progress notes and

consultation with interdisciplinary team members. In reference to her goal of having reduced

levels of stress and anxiety via musical experiences, aspects of her behaviour will have to be

examined. Discrete behaviours indicative of stress and anxiety, such as jaw clenching and

nail-biting, could be tallied in progress notes, though this may be operationally unfeasible.

Formal, longitudinal psychological assessments could be conducted to measure Nadifa’s

anxiety and stress levels during and following mealtimes, though a qualitative assessment

conducted via professional observation and self-report would be a far more viable option. In

reference to Nadifa’s goal of having reduced levels of cognitive distortions related to her

eating disorder the most appropriate evaluation tool will be via self-report. Behaviours and
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associated with guilt and shame may be identified and tallied in her progress notes though

these would not be considered as reliable as a qualitative analysis.

Question Four

Psychodynamic

Adopting a psychodynamic framework in working with Nadifa would significantly

alter my music therapy practice processes. Psychodynamic approaches are founded on the

premise that therapeutic progress can be achieved via examining past events and uncovering

elements in the unconscious mind (Isenberg, 2015; McFerran & Heiderscheit, 2016). In

accordance with these precepts, Nadifa’s goals would be less related to specific behavioural

outcomes and be more purposed towards increasing her level of self-insight regarding her

eating disorder, possibly her being able to identify some of her own personality traits or

identify life experiences that have significantly shaped her.

In accordance with this shift in goals for Nadifa, the methods employed would need to

also be adapted. Typical of music therapy work done in this space within this theoretical

framework I would seek to use improvisation (McFerran & Heiderscheit, 2016). Lejonclou

and Trondalen (2009) recognised that the creative process of improvisation may disrupt

engrained behavioural patterns. In Nadifa’s case, challenging her self-belief that she is

incapable of playing an instrument may precipitate a dismantling of other self-beliefs that are

relevant to her eating disorder. As noted by Justice (1994), improvisation techniques may aid

sufferers of eating disorders in overcoming traits of perfectionism, which is also relevant to

my assessment of Nadifa.

Documentation, while still needing to comply with the strict format protocols of the

hospital, would be comprised predominantly of self-reported insights from Nadifa.

Behavioural outcomes, while not entirely irrelevant, are not a standard of measurement

within the psychodynamic framework. The evaluation process would involve reviewing
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progress notes and analysing Nadifa’s shift in perspective. I view the psychodynamic

framework as somewhat viable in Nadifa’s case, however not the most optimised approach

given the time sensitivity of Nadifa’s condition.

Humanistic

Adopting a humanistic theoretical framework would drastically alter my professional

practices. Humanistic approaches are predicated on the notion that the individual has the

innate potential and drive to achieve self-actualisation (McFerran & Heiderscheit, 2016).

Given the view of self-actualisation within a humanistic lens as an inherently relational goal

(Abrams, 2015), the goals adopted for Nadifa within this framework would be purposed

towards promoting her sense of self-efficacy and her identified needs for social connection.

Similarly to a psychodynamic approach, improvisation presents itself as a valid

methodology within a humanistic framework (McFerran & Heiderscheit, 2016). The process

of becoming an essential part of something greater than oneself via the process of group

improvisation is consonant with foundational humanistic philosophy (Abrams, 2015). As

noted by Justice (1994), group improvisation can foster a degree of self-worth within

individuals suffering from eating disorders that isn’t contingent on their bodily weight. The

method Justice (1994) elucidates of facilitating aesthetically rich musical experiences via

structured improvisations seems valuable in the case of Nadifa who has no experience

playing a musical instrument. Justice’s (1994) method of utilising choir chimes seems a

viable method of facilitating social connection in the case of Nadifa who has underdeveloped

social interaction skills.

The documentation and evaluation processes would closely mirror those within a

psychodynamic framework. Whilst acknowledging that there would be some value in

adopting a humanistic approach in working Nadifa, I don’t see it as a viable framework

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considering the hierarchy of Nadifa’s needs and the medicalised model present within the

hospital system.

Ecological

Adopting an ecological theoretical framework would somewhat reform my

professional practices in working with Nadifa. Ecological theory is founded on the

recognition that there are a multitude of dynamic systemic influences at various scales

impinging on the individual at all times (McFerran & Heiderscheit, 2016). In the case of

Nadifa, this would entail a move of focus from her biological, psychological, and immediate

environmental influences and a move towards considering her external systems, including but

not limited to her immediate family, her school environment, and various societal pressures.

In accordance with this perspective shift, I would adapt Nadifa’s goals to be purposed

towards empowering her to confront one or more of these macro level systems. Exploring

Nadifa’s family system would seem to be an important avenue of consideration as eating

disorders have been linked to dysfunctional family dynamics (Hilliard, 2001). Exploring the

influence of societal norms and pressures on Nadifa may also be a fertile ground for

therapeutic progress given the observed causal relationship with eating disorders (Justice,

1994; McFerran & Heiderscheit, 2016).

I view an ecological approach as being somewhat mutually compatible with

behavioural, psychodynamic, and humanistic frameworks. These other frameworks can be

viewed as being nested within the more overarching and global concerns of an ecological

framework. Consequently, similar music therapy methods may be utilised. I may utilise

improvisation with the similar aims of promoting self-insight within Nadifa. An ecological

framework would entail pursuing this process further and prompting Nadifa to consider the

implications for her social interactions within the school environment, likely via verbal

processing. Song-writing and lyrical analysis techniques may also be applicable from an
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ecological perspective, with the added process of encouraging Nadifa to share these changes

in cognition with her immediate family.

While this macro, systemic view of causality holds immense personal interest and

doubtless value in Nadifa’s context, it may be difficult to implement within the time,

resource, and model constraints present within a hospital setting.

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References

Abrams, B. (2015). Humanistic Approaches. In B. L. Wheeler, Music Therapy Handbook.

Guilford Publications.

http://ebookcentral.proquest.com/lib/unimelb/detail.action?docID=1760730

Adkins, J., Burch, R., Linton, T., & Haden, R. (2001). The Middle. DreamWorks.

Baker, F. (2015). Therapeutic songwriting: Developments in theory, methods and practice

(UniM INTERNET resource). Palgrave Macmillan.

https://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=cat00006a

&AN=melb.b6568952&site=eds-live&scope=site&custid=s2775460

Bareilles, S. (2007). Gravity. Epic.

Beddingfield, N., & White, E. (2010). Recover. Epic.

Bibb, J., Castle, D., & Newton, R. (2015). The role of music therapy in reducing post meal

related anxiety for patients with anorexia nervosa. Journal of Eating Disorders, 3(1),

50. https://doi.org/10.1186/s40337-015-0088-5

Eating Disorders in Australia. (n.d.). Retrieved 17 June 2021, from

https://nedc.com.au/eating-disorders/eating-disorders-explained/the-facts/eating-

disorders-in-australia/

Hanser, S. (2015). Cognitive Behavioural Approaches. In B. L. Wheeler, Music Therapy

Handbook. Guilford Publications.

http://ebookcentral.proquest.com/lib/unimelb/detail.action?docID=1760730

Hilliard, R. E. (2001). The Use of Cognitive-Behavioral Music Therapy in the Treatment of

Women with Eating Disorders. Music Therapy Perspectives, 19(2), 109–113.

https://doi.org/10.1093/mtp/19.2.109
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Isenberg, C. (2015). Psychodynamic Approaches. In B. L. Wheeler, Music Therapy

Handbook. Guilford Publications.

http://ebookcentral.proquest.com/lib/unimelb/detail.action?docID=1760730

Jones, M. (1985). Pianoscapes. Narada Lotus.

Justice, R. W. (1994). Music Therapy Interventions for People with Eating Disorders in an

Inpatient Setting. Music Therapy Perspectives, 12(2), 104–110.

https://doi.org/10.1093/mtp/12.2.104

Lejonclou, A., & Trondalen, G. (2009). ‘I’ve started to move into my own body’: Music

therapy with women suffering from eating disorders. Nordic Journal of Music

Therapy, 18(1), 79–92. https://doi.org/10.1080/08098130802610924

McFerran, K., & Heiderscheit, A. (2016). A multi-theoretical approach for music therapy in

eating disorder treatment. In Creative Arts Therapies and Clients with Eating

Disorders (Vol. 1). Jessica Kingsley Publishers. http://minerva-

access.unimelb.edu.au/handle/11343/57012

Pachelbel, J., Baumgartner, R., Galway, J., Spreen, G., & Laine, C. (1991). Pachelbel’s

greatest hit: Canon in D.

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Unhealthy Music Scale. Child and Adolescent Mental Health, 20(4), 210.

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music therapist (UniM INTERNET resource). Barcelona Publishers.

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&AN=melb.b6352897&site=eds-live&scope=site&custid=s2775460