4.1 Referral Criteria and Clinical Practice in Music Therapy - An Introduction

4.
1 Referral Criteria and Clinical Practice

in Music Therapy – An Introduction
Tony Wigram, Anne Mette Rasmussen
and Stine Lindahl Jacobsen
Clients with language disorders or delays are often referred to speech therapy. If
they have cerebral palsy or other physical disabilities, physiotherapy is indicated.
For serious emotional trauma, psychological counselling or psychotherapy can be
prescribed, and for mental illness such as schizophrenia or bipolar disorder, clients
are referred to psychiatric treatment, often including medication. But when and why
are clients referred to music therapy?
Music therapy is useful for people who find it difficult to communicate with
others, due to physical or mental limitations or emotional problems. Music therapy
is also relevant in counteracting the isolation of the client, establishing a sense of
community and promoting interaction, and in regulating emotional tension in order to
facilitate growth. Of course, music therapy can also be useful in physical rehabilitation
or cognitive stimulation. Criteria for referral to music therapy are often defined
precisely according to the clinical area involved, and are created in discussions within
interdisciplinary teams or with staff in the specific institution within the clinical field
(Smeijsters 1999; Waldon and Gattino 2018). For example, for disorders on the autism
spectrum, referral criteria will be directly related to the disorder. The defined criteria
will be clearly associated with pathological indicators and include all of the aspects of
autism that can be working objectives for the music therapy.
Conditions for music therapy vary greatly from country to country, but there is
an international effort to establish formal frameworks for referral to music therapy,
for example through recommendations of music therapy in national treatment
guidelines, authorisation of music therapists in national laws, and subsidy schemes
Copyright © 2019. Jessica Kingsley Publishers. All rights reserved.
similar to those of other health-care professions.
Referral criteria and needs met by music therapy

For clients within the autism spectrum, referral criteria could, for example, be defined
using the following list of difficulties that music therapy can address:
• difficulties with social interaction, verbal as well as non-verbal
• lack of understanding of or motivation for communication
• rigid and repetitive patterns of activity and play
233
A Comprehensive Guide to Music Therapy, 2nd Edition : Theory, Clinical Practice, Research and Training, edited by Stine Lindahl Jacobsen, et al.,
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234 A COMPREHENSIVE GUIDE TO MUSIC THERAPY
• poor or lacking relationships with others

• hypersensitivity to sounds
• lack of ability or interest in sharing experiences with others
• serious difficulties in coping with change
• apparent lack of ability to learn from experiences
• lack of emotional reciprocity and empathy
• low self-esteem.
Expected length of intervention

Another important aspect is the expected length of the music therapy intervention.
As in all treatment, it can be difficult to predict how many sessions will be necessary
to achieve progress and development – and to meet the needs described above with
a long-term effect. In recent years, there has been a growing political focus on cost-
benefit analysis and evidence-based treatment – in other words, how effective a
treatment is compared to its cost. This means that the music therapist must provide
a clearly defined framework for assessment, treatment and continuing evaluation
before the therapy is started and possibly continued. This can be supported by
references to results documented in scientific literature on assessment, as well as
short-term and long-term therapy with the specific client population. Indication for
music therapy is thus closely associated with clearly formulated expectations for the
outcome of the therapy. These expectations should be formulated from the same
professional basis (see also Chapter 5.2).
Suggested plan of treatment and assessment

periods in music therapy referral
1. Initial assessment – approximately three sessions.

2. First treatment period – approximately ten sessions.
3. Mid-term evaluation.
4. Second treatment period – approximately ten sessions, depending on need
and with the possibility of extension.
5. Final evaluation of the therapy.
An initial baseline assessment of two to three sessions is a critical phase, where both
the client’s potential and the relevance of music therapy can be assessed. The need
Music Therapy in Clinical Practice 235
for this baseline assessment is clearly described by experienced clinicians such as

Wigram and Wosch (2007) and Oldfield (2006a, 2006b) in England, Di Franco (1999)
in Italy, and Schumacher and Calvet-Kruppa (2007) in Germany. Furthermore,
the International Music Therapy Assessment Consortium in a recent publication
on music therapy assessment offers general guidance on how to perform initial
assessment and what to consider (Gattino, Jacobsen and Storm 2018).
Criteria for referral

There should be a mid-term evaluation of the process and interim results of the
therapy, and this should document the need for a longer treatment period, if
necessary. We know that it can take months to identify significant and substantial
results. The length of the next treatment period is determined by the mid-term
evaluation. Many case studies in different clinical areas have documented effect over
time. Lastly, there should be a final evaluation with detailed documentation of the
process and the achieved results.
It is very important to specify the duration of the therapy, for example four to six
months, and then report the results, which should refer directly to the referral criteria,
the needs of the client and the formulated expectations. If this is done thoroughly, it
can reinforce the music therapist’s credibility and support recommendations for the
continuation of therapy. The most effective and ethical way to do this is to use well-
documented assessment methods or other methods of measurement to ensure quality
and integrity of treatment intervention (Waldon and Gattino 2018). In Chapter 5.2, a
selection of music therapy assessment tools will be presented.
In this part of the book, clinicians and researchers will introduce music therapy
treatment in selected clinical areas, including evidence for the treatment. The selection
of clinical areas is based on Danish experience, and therefore also in most cases
according to specific Danish conditions. However, these clinical areas correspond
well with those covered in the international literature.
4.2 Music Therapy for Psychiatric Clients
The term ‘music therapy in psychiatry’ in this book refers to music therapy in two
main areas: hospital psychiatry and social/community psychiatry. The music therapy
approach used is different for these two areas and types of institutions, as the primary
aims of hospital psychiatry are to assess, diagnose and initiate treatment. In social/
community psychiatry, the primary aim is to provide help and give support for self-
help and recovery (a process towards complete or partial recovery and quality of life,
despite psychological problems), so the individual can manage social as well as work
situations in a better way. Music therapists are most often trained to fulfil both of
these functions, which will be shown in the next two chapters.
4.2.1 Music Therapy for Adults in Hospital Psychiatry

Inge Nygaard Pedersen, Niels Hannibal and Lars Ole Bonde
Introduction
Music therapy has been used in hospital psychiatry in Denmark and many other
countries for several decades. This includes musical activities with a therapeutic
aim, as well as more long-term, insight-oriented individual and group music
therapy. These approaches are all part of the services offered at hospitals, and
music therapy can be chosen as part of the individual’s comprehensive treatment
plan at psychiatric hospitals where music therapists are employed. There are two
main approaches in music therapy:
• Active or expressive music therapy, including musical improvisation, musical
performance, singing, songwriting and movement to music.
• Receptive music therapy, which can be listening to recorded music selected

by the music therapist or the patient, listening to recorded music created by
the patient, or listening to selected classical music to induce inner imagery
(see Part 3).
In hospital psychiatry, music therapists work as part of a treatment team. Patients are
often referred to music therapy by psychiatrists, psychologists or other professionals,
and group or individual music therapy often starts with a short trial period
(assessment). If the patient is to benefit from music therapy, they must be able to:
• attend therapy regularly
• reflect verbally or musically
236
4.2 Music Therapy for Psychiatric Clients
The term ‘music therapy in psychiatry’ in this book refers to music therapy in two
main areas: hospital psychiatry and social/community psychiatry. The music therapy
approach used is different for these two areas and types of institutions, as the primary
aims of hospital psychiatry are to assess, diagnose and initiate treatment. In social/
community psychiatry, the primary aim is to provide help and give support for self-
help and recovery (a process towards complete or partial recovery and quality of life,
despite psychological problems), so the individual can manage social as well as work
situations in a better way. Music therapists are most often trained to fulfil both of
these functions, which will be shown in the next two chapters.
4.2.1 Music Therapy for Adults in Hospital Psychiatry

Inge Nygaard Pedersen, Niels Hannibal and Lars Ole Bonde
Introduction
Music therapy has been used in hospital psychiatry in Denmark and many other
countries for several decades. This includes musical activities with a therapeutic
aim, as well as more long-term, insight-oriented individual and group music
therapy. These approaches are all part of the services offered at hospitals, and
music therapy can be chosen as part of the individual’s comprehensive treatment
plan at psychiatric hospitals where music therapists are employed. There are two
main approaches in music therapy:
• Active or expressive music therapy, including musical improvisation, musical
performance, singing, songwriting and movement to music.
• Receptive music therapy, which can be listening to recorded music selected

by the music therapist or the patient, listening to recorded music created by
the patient, or listening to selected classical music to induce inner imagery
(see Part 3).
In hospital psychiatry, music therapists work as part of a treatment team. Patients are
often referred to music therapy by psychiatrists, psychologists or other professionals,
and group or individual music therapy often starts with a short trial period
(assessment). If the patient is to benefit from music therapy, they must be able to:
• attend therapy regularly
• reflect verbally or musically
236
• (eventually) define goals for the therapy or have an opinion regarding the
therapist’s suggested goals
• enter into a therapeutic alliance or wish to work with their difficulties in
entering into such an alliance
• be deemed not at risk of psychotic relapse or worsening of symptoms.
It is not necessary to be able to play an instrument or sing well to participate in
music therapy. It is sufficient that patients find it meaningful to express themselves
personally and symbolically through sound and music.
Pioneers in psychiatric music therapy

In Europe, music therapy as a psychoanalytically based psychiatric treatment (see
Chapter 2.3.1) started in England at the beginning of the 1970s, when music therapist
and musician Mary Priestley was employed in several hospitals in London.
Priestley built on elements of Juliette Alvin’s improvisational methods, working
from a psychoanalytical perspective and understanding of psychological symptoms.
She believed that these symptoms were rooted in traumatic experiences from
early childhood. She developed her music therapy techniques through work with
adult psychiatric patients, by trying different techniques in collaboration with two
colleagues; she called these trials ‘intertherapy’. Her group of colleagues alternated
trying out the roles of patient, therapist and supervisor, before they used the
techniques in therapy with patients. Priestley was the first music therapist to describe
the influence of psychoanalysis and psychodynamic theory on music therapy practice
in the 1970s (see Chapter 2.3.1).
Priestley called her approach analytical music therapy (in the 1970s and 80s), but
considered whether exploratory music therapy would be a more fitting term. In several
countries, the term analytical music therapy was initially replaced by analytically
oriented music therapy (see Chapter 3.3). Today most treatment using music, in
psychiatry as well as in other areas, is simply called music therapy. Music therapy in
Europe has a theoretical psychodynamic understanding that forms a solid basis for
many other applied theories used with other groups of clients (see Chapters 2.3.1 and
3.3). There are, however, variations in the terms used with specific client groups in
hospital psychiatry, where supplemental descriptions such as mentalisation-based
(Hannibal and Schwantes 2017), cognitive (Lund 2012) and modified GIM music
therapy (Bonde and Pedersen 2015; Brink-Jensen 2015; Moe 2001) are used in daily
practice (see also Chapter 3.2).
A characteristic method used by Priestley that is still applied today is the use of
playing rules/titles or ‘givens’ to structure the improvisation. These are established
by the therapist or by both therapist and client before the improvisation starts.
Priestley considered uncovering and re-experiencing traumatic experiences from
early childhood to be the healing factors in the process, where music plays a major
role by facilitating memory and inducing emotions and imagination in the present
moment. In this way, music can actualise and make audible previous traumas, in
actual relationships and in the transference relationship between the patient and
therapist. Thus, Priestley developed the use of musical improvisation as a specific
psychotherapy method that creates an arena for re-enactment of early relationship
experiences.
Priestley also developed (inspired by Racker 1968) a differentiated definition
of the terms empathy and countertransference as central clinical concepts; seen
as empathic countertransference (E-countertransference) and complementary
countertransference (C-countertransference). She was aware that confrontative
C-countertransference was not helpful without a concurrent deep empathy from
the therapist (E-countertransference) (Priestley 1975, 1994; see also Chapters 2.3.1
and 3.3).
Another characteristic of Priestley’s model is alternating between improvisation
and verbal reflection. The therapist uses disciplined subjectivity as a way of relating
in musical improvisation (see Chapter 2.3.1).
Newer developments in music therapy in hospital psychiatry

In hospital psychiatry today, the primary focus is on relationship experiences in a
here-and-now perspective through the therapist–patient relationship, and only the
early memories that emerge through this process are actively incorporated into the
therapy. Traditional transference interpretation is not used today. The concept of
transference instead is seen in a relational perspective, where both partners contribute
to the circular transference relationship that develops.
In musical improvisation, an attitude of disciplined subjectivity replaces classical
technical analytical rules such as neutrality and abstinence (see Chapter 2.3.1).
Clarification, mentalisation and confrontation are used in the verbal reflection, rather
than interpretation, as in classical psychoanalysis. The basic attitudes of professional
empathy and the therapist’s involvement in the patient’s situation have been carried
over from analytical music therapy, but the patient’s experience of continuity,
mentalisation and possible insight is seen as the primary aim of music therapy. The
therapy process is not aiming at identifying early traumas but is following whatever
comes up in the here-and-now relationship between the therapist and the patient;
and whatever comes up is examined together in the right timing for a possible new
understanding. Thus, the therapy process is floating with the here-and-now process
of the therapist–patient relationship. (In Denmark, this is called process-oriented
music therapy – PROM.) See also Odell-Miller (2014) and De Backer and Sutton
(2014). Another approach developed in mental health is resource-oriented music
therapy (Rolvsjord 2010).
The music therapist’s qualifications

To practise music therapy in hospital psychiatry, the therapist should have a master’s
degree in music therapy. A master’s programme where psychotherapy training is an
integrated element, in addition to academic and musical subjects, is very valuable in
this context. The practical psychotherapy training that is part of the Danish university
music therapy programme is based on theories from newer relational psychoanalysis,
with roots in ego psychology, object relations theories, attachment theory and
self-psychology, mentalisation-based treatment theory, as well as transpersonal
psychology (see Chapters 2.2, 2.3 and 2.4).
This training heightens the music therapist’s awareness of their way of being
present in the therapist–patient relationship as well as their influence on the
continuous relationship process. With schizophrenic and psychotic patients, it is
especially important that the music therapist is able to use ‘professional empathy’
when working with symptoms and personal resources. This is important because the
focus is on helping the patient develop and strengthen the self, by continuously being
seen and heard through the therapist’s empathic validation, and through the therapist’s
awareness of the patient’s need for both closeness and distance in the musical duets
(see Chapter 2.3.1). If working with individuals with personality disorders or
borderline disorders, the music therapist should be trained in mentalisation. Here
the music therapist must be able to follow the patient’s development process while
focusing on whether the patient is able to recognise (sensorily and emotionally)
aspects of their inner life and distinguish this from others’ inner lives, and whether
the patient is able to cognitively reflect on their relationship with the therapist.
Regulating the patient’s arousal is an important part of this process. When working
with patients with pronounced anxiety disorders, the music therapist must be able
to use professional empathy and challenge or confront when the timing is right, in
this way containing the patient’s ambivalence regarding resignation and motivation.
Music therapy treatment

As an example, the following music therapy treatment options are available

in hospital psychiatry in Denmark. Most of these options will also be available in
hospital psychiatry in other European countries:
• Music listening groups (open, partially open or closed) – primarily for
patients on closed or secure units. The structure of the group is adapted
to the patients’ emotional and mental states. The music therapist and the
patients bring music for the group to listen to, and there is a conversation
about what the music means to the person who brought it, as well as to the
other members of the group. The music therapist is responsible for creating
a safe atmosphere, also in cases where some members do not like the music,
which may make the patient who brought the music feel that his/her identity
is being devalued (Lund and Fønsbo 2011).
• Therapeutic song workshop for mixed groups on the psychosis and
schizophrenia spectrum. The group works with body image, breathing,
voice awareness and voice expression. Songs are created using the personal
resources of the group. There are therapeutic conversations about the song
workshop’s significance for the members’ life situations.
• Therapeutic music-making in a group, where the group plays easy
arrangements of songs and musical pieces that everyone can be a part of.
The music is chosen according to the composition, wishes and strengths of
the particular group. Between musical performances, there are conversations
about the group’s experiences.
• Music listening in a group: music listening and inner imagery. This is offered
to outpatients with a higher functional level, who have anxiety disorders and
a Global Assessment of Functioning score higher than 40 (see later in this
chapter).
• Individual music therapy for all diagnoses (see more detailed descriptions
later on in this chapter).
Research and practice in music therapy

with different client populations
Music therapy for patients with schizophrenia
Music therapy for people with schizophrenia has existed for more than 20 years in
several countries in Europe. This includes individual as well as group music therapy,
and active as well as receptive music therapy. This treatment is based on international
evidence: three Cochrane reviews (Geretsegger et al. 2017; Gold et al. 2005; Mössler
et al. 2011) have shown significantly beneficial results from the use of music therapy
combined with standard treatment, when compared with standard treatment alone.
Music therapy has been shown to be particularly effective in reducing negative
symptoms such as emotional and social withdrawal, reduced ability to establish
contact, and limited expressiveness. These results were achieved with inpatients with
schizophrenia diagnoses, where both group and individual music therapy were used.
A systematic review with similar results has been carried out concerning acute adult
psychiatric inpatients, also including patients suffering from schizophrenia (Carr,
Odell-Miller and Priebe 2013).
A significant effect of group music therapy on negative symptoms was also shown
through patient self-evaluations regarding subjective experiences of psychosocial
orientation and increased motivation for contact and communication with others
(Ulrich, Houtmans and Gold 2007). As these results correspond to earlier findings,
the research group concludes that as music therapy reduces negative symptoms,
thus improving abilities for social interaction, these results may make people with
schizophrenia better equipped to adapt to society after discharge from the hospital.
They also point out that these are important results, as the medical profession has not
yet found medicine that has a satisfactory influence on negative symptoms (Pedersen
2012; Simonsen et al. 2001).
An international study of 144 adult patients with diagnosed schizophrenia,
depression and substance abuse showed improvement of negative symptoms and
higher functioning after three months of bi-weekly music therapy based on the
resource-oriented music therapy model (Gold et al. 2013).
This finding corresponds with every attempt to register attendance for treatment
and level of drop-out. Attendance for treatment is high (90%) and drop out is
low (11–17%) (Hannibal 2005; Hannibal et al. 2011, 2012b). In a recent study
validating a tool to test the level of therapeutic alliance in music therapy (Helping
Alliance questionnaire-II), 45 people were offered the HAq-II; 31 answered, and
high alliance was found in 60 per cent. The findings also showed that there was no
difference between patients with psychotic or non-psychotic diagnoses or between
gender, and only one patient out of 45 dropped out (Hannibal et al. 2017). A more
rigorous study of alliance building is needed to further investigate the level and
quality of alliance in music therapy within this field.
A beneficial effect, however, is dependent on the length of treatment. Gold et al.
(2009) have shown that there are greater and more long-term improvements for
individuals with severe mental illness, including schizophrenia, when the therapy
lasts 16–51 sessions, whereas 3–10 sessions show fewer and more short-term pos-
itive changes.
The influence of group music therapy on the negative symptoms of persons with
schizophrenia has been described by several music therapists who use therapeutic
music-making and songwriting (Carr 2014; Jensen 2011) or music listening groups
(Lund and Fønsbo 2011). In listening groups, music is selected by the music therapist or
by the patients themselves, and after music listening, there is a conversation about what
the music means to the person who selected it, as well as its meaning for and influence
on the rest of the group. This gives the patients the opportunity to communicate
and introduce themselves through their choice of music instead of through their life
histories. The latter can be difficult for those with schizophrenia (Pedersen 2012).
Patient responses in questionnaires regarding the benefits of group music therapy
using therapeutic music-making and songwriting indicate clearly that both methods
promote social engagement and a sense of being present in the here-and-now, as patients
see the group as a safe place, where they can experience community and connectedness.
In the questionnaires, patients are quoted saying that ‘I could forget about myself ’, ‘I can
concentrate better’, ‘the music makes my suicidal thoughts go away’ or ‘the best thing is
when the music swings and it all comes together’ (Jensen 2011).
The positive influence of music on impaired attention and ability to communicate

is documented in a doctoral dissertation, where Moe (2001) shows that individuals
with schizophrenia can improve their ability to maintain attention and to access inner
imagery by participating in music listening in groups where the focus is on inner
imagery and experiences during listening. These experiences were subsequently
shown to have a restorative effect (Moe 2001).
In another doctoral dissertation on individual music therapy with persons with
schizophrenia, De Backer (2005) showed that these patients could overcome their
tendency to withdraw, as well as their lack of communication skills. Specifically,
this was seen in their movement from playing automatically and monotonously
with the music therapist with no obvious connection to the music, towards playing
intentionally and contributing to the development of melodic and rhythmic musical
forms. In the early sessions of therapy, the music therapist matched the automatic
way the patient played and then he gradually varied his way of playing, in a tempo
that allowed the patient to follow the changes.
Another music therapy approach to counteracting the schizophrenic patient’s
social isolation and reducing negative symptoms is documented by Jensen (1999),
Lindvang (1998, 2005) and John (1995). They work specifically with the music
therapist’s timing regarding closeness and distance in shared music-making in
individual music therapy. The music therapist moves through four phases: from
imitation, to variation, to creating a background for the patient’s music, to more
autonomous playing. For example, the music therapist can consciously mirror
and imitate the playing of the patient in the first sessions of music therapy. This
creates a safe environment for the patient, who can stay in their isolated world, while
playing with another (the music therapist). The music therapist can then gradually,
through the music, complement the patient’s playing by introducing a more varied
structure in the music, for example a distinct rhythmic or harmonic background for
the patient’s music, while the shared music is still defined by the patient’s musical
expression. In this way, the patient can be supported to start varying their own
musical expression. In a third phase, the music therapist can play music that is more
challenging or provoking, create contrasts, and separate their own music from the
patient’s music, without demanding that the patient follow. This makes a fourth phase
possible, where both contribute to creating something new together, developing more
flexibility in their interaction. It is important that these four phases are unfolded with
a timing that is adapted to the individual patient, as this will make possible shared
musical creation that is autonomous and creative.
In individual music therapy, simple rhythm training repeated over time
can improve concentration and memory, and can counteract depersonalisation
(Pedersen 1999). An objective of the music therapy is that the patient becomes able
to sustain simple rhythmic patterns by performing body movements to the rhythmic
pattern, while at the same time accenting the rhythm with their voice. In a detailed
description of music therapy with a person with schizophrenia (Pedersen 1999), the
patient experiences moving away from unrealistic fantasies of being a professional

drummer to realising that he can sustain and express himself here and now, through
a simple rhythmic pattern that can be performed together with the music therapist,
as well as alone (Pedersen 1999). This gives the patient an anchor and an emerging
awareness of an inner mental space. At the same time, it creates a growing experience
of ‘I exist – I can sustain, repeat and hear myself in a recognisable rhythmic pattern’,
which counteracts depersonalisation, a common, general symptom for people with
schizophrenia (Pedersen 2012, pp.53–54).
Individual music therapy methods work because of the music therapist’s ability to
consciously use countertransference – the sensations and emotions a music therapist
experiences in their encounter with persons with schizophrenia – in combination
with the music’s qualities, because sensations and emotions consciously experienced
can be played out and transformed through musical improvisation (De Backer 2005;
Jensen 1999; Lindvang 1998, 2005; Odell-Miller 2007; Pedersen 2007a).
Music therapy for patients with depression

Depression affects many people. An estimated 15–25 per cent of all women and 7–12
per cent of all men will suffer from depression for a period of 6–12 months, depending
on the degree of severity. The majority of those suffering from depression experience
relapse. Fifty per cent of patients with depression have other disorders, such as anxiety,
compulsive disorders or substance abuse (Poulsen, Munk-Jørgensen and Bolwig 2007).
As is the case with schizophrenia, there is also evidence for music therapy for
people with depression. There are positive findings in Maratos and colleagues’
Cochrane review from 2008, which were confirmed in the Cochrane review from
2017 (Aalbers et al. 2017). Gold and colleagues’ meta-analysis from 2009 shows that
there is a clear dose-response relationship for depressive symptoms and functioning,
that is, an increased number of sessions gives greater benefits. Finally, Erkkilä and
colleagues’ randomised controlled trial study from 2011 documents that depressive
symptoms can be reduced and patients’ functioning improved as a result of music
therapy. It is important to achieve reduction of depressive symptoms, and in Erkkilä

and colleagues’ study, effects were seen after three months. Patients receiving music
therapy had significantly less anxiety and fewer depressive symptoms and their level
of functioning was significantly better, compared with the control group not receiving
music therapy. Participants in the study were 79 patients with light, moderate and
severe depression without psychotic symptoms. Music therapy appeared to be
effective for all levels of depression. Patients with depression are very vulnerable, and
it is therefore important that treatment takes into account their emotional tolerance
and does not cause them undue stress. Music therapy can be applied to patient groups
that are traditionally seen as difficult to treat, a fact that is supported by a low drop-
out rate from music therapy for patients with schizophrenia or personality disorders
(Hannibal et al. 2012b).
Treatment of a patient with depression can be aimed in part at reducing the

patient’s depressive symptoms, in part at preventing relapse, and, finally, at developing
coping skills, that is, new and better strategies to handle stress. As patients with
depression have a tendency to withdraw socially and to have low levels of activity,
an important aim is to improve the patient’s ability to interact with others, as well as
reducing social isolation and emotional discomfort. The main goal for the patient
is to be able to manage and reduce the vulnerability that can lead to depression.
Music therapy works towards this goal by focusing on three dimensions: alleviation
of symptoms, prevention and change.
Research shows that listening to music activates us neurologically and
hormonally. In 2013, Alluri and colleagues showed that music listening activates the
auditory and motor areas of the brain, as well as higher and lower cognitive functions.
McKinney and colleagues showed in their study from 1995 that music listening can
also be seen on the neurohormonal level. They found that it was possible, after eight
weeks of intervention using the receptive music therapy method guided imagery
and music (GIM), to measure qualitative changes in the mood of the clients, as well
as measurable changes in plasma level of the neurohormone ß-endorphin, when
compared with the control group. Thus, music listening in a therapeutic context can
affect the level of specific neurohormones, as well as promoting mood changes. Music
can activate emotions and induce inner imagery and sensations, and this leads to
experienced as well as measurable changes (Bonde 2009). On the psychological level,
a patient with depression is often unable to reach out to the world because of their
condition. Receptive methods can reach the patient and help to initiate a therapeutic
process. These patients may also need help regulating emotions, for example feelings
of sadness. Music listening can be a comforting factor. In this way, receptive music
therapy methods can be used to increase as well as reduce the individual’s cognitive
and psychomotor level of activity.
As individuals with depression have a tendency to withdraw socially, the
communicative potential of music is essential. Communication through music can
happen when people are playing and ‘swinging’ together, but it is also always present
as a dimension in active improvisational music therapy. For patients with depression,

direct and verbal communication with others about their inner state is often not possible
(Gabbard 2000). They often do not trust in or expect that others can understand or
want them to share their personal thoughts and emotions. The patients withdraw from
others. Their inner world is generally ruled by negative thoughts, resignation, sadness
and so on. A person with depression loses the ability to reach out, and to talk about their
situation is often experienced as shameful, negative and overwhelming. Openness and
verbalisation are in this sense the greatest enemies of depression (ibid.). The ability to
express oneself and communicate is an unavoidable condition for therapeutic progress,
and this is precisely possible in active music therapy.
Music is also an action. Music and musical expression require a greater or
smaller degree of activity. For people with depression, who have problems expressing
themselves verbally, music can be a channel for communication. By actively playing,

the person can access emotions, moods and sensations that then can be channelled
into the music. In the first sessions of therapy, making even the smallest sound
can seem to be insurmountable, but it can also be the beginning of a psychological
opening. New research has been carried out showing that music therapy with a focus
on voice work can be beneficial for individuals with depression. This is because
activation of the voice also activates other bodily functions associated with creating
vocal sounds (Storm 2013).
In summary, music therapy can help patients with depression by reducing
depressive symptoms and anxiety, and by improving the level of functioning. This
can be done through active as well as receptive music therapy methods, combined
with individual or group conversations. According to the above-mentioned studies,
there is a low level of drop-out from music therapy, the level of tolerance is high, and
benefits are significant.
Music therapy for patients with personality disorders

More than 10 per cent of the adult population in Denmark (as an example) are estimated
to meet the diagnostic criteria for a personality disorder (Simonsen and Møhl 2010).
The percentage of the population with a borderline diagnosis is between 0.7 and 2.7
per cent (prevalence). Genetics and environmental influences both play a part in the
development of personality disorders. Psychosocial conditions and the quality of close
relationships play a particularly important role. The term personality disorder describes
many different mental conditions that have certain characteristics in common. The
patient has personality traits that deviate from the culturally accepted or expected in at
least two of the following areas: perception and attitude, affectivity, impulse control and
interpersonal relationships. Behaviour is rigid and inappropriate, and often harmful
for oneself and/or others. Ten different types of personality disorders are described in
the ICD-10 diagnostic system (World Health Organization 1992). The clinical picture
is therefore often very diverse. However, there are certain common mechanisms for
most patients with personality disorders: they experience a feeling of emptiness; they
are easily overwhelmed by their own emotions; it is hard for them to trust others and
their attachment style is ambivalent or totally lacking; it is difficult for them to mentalise
when they are emotionally aroused (in other words, their perception of themselves and
their surroundings is to an extreme degree ruled by automatic and generalised schemes,
rather than by what is actually happening); their relationships are weak and vulnerable
to misunderstanding and misinterpretation of others’ intentions and behaviour. This
is also true in a therapeutic setting.
Since the mid-90s, 40 per cent of the patients who receive music therapy in
Denmark have been those with personality disorders (Hannibal et al. 2012b), in
hospitals as well as social psychiatry facilities. There are many well-described
examples of how music therapy with this client population has contributed to better
quality of life, and fewer negative symptoms. The case description later in this
chapter shows the great benefits achieved by a patient through music therapy. In a
doctoral dissertation (Hannibal 2001), there are two additional case examples where
patients document their benefits from therapy. From 2003 to 2010, group music
therapy was part of the treatment plan for outpatients with personality disorders
at Aalborg Psychiatric Hospital (now Aalborg University Hospital, Psychiatry); 104
patients received music therapy in addition to intensive psychotherapy, and, for many
of these patients, music therapy was an important, beneficial and special treatment
(Hannibal 2008; Hannibal et al. 2011). In contrast to music therapy for patients with
depression or schizophrenia, there is still a need for research that can document the
effect of music therapy with this client population. However, it has been seen that the
drop-out rate for music therapy is relatively low for this group as well (Hannibal et al.
2012b), and this could be an indication of a positive therapeutic alliance. As building
a relationship through the therapeutic alliance is a central issue for this group of
clients, regular, stable attendance is a positive result. A small pilot study with only
four participants, each receiving 40 hours of music therapy, showed positive results
(Hannibal et al. 2018).
Views on treatment and prognosis for patients with personality disorders have
changed radically in the last decade, from seeing the group as almost resistant to
treatment, to seeing treatment as a realistic possibility. This new attitude can be
illustrated by the existence of outpatient treatment in Denmark that includes music
therapy (Petersen et al. 2008). The change in attitude towards treatment is specifically
due to the emergence of mentalisation-based treatment (MBT), which was developed
in England by, among others, Fonagy and Bateman (Bateman and Fonagy 2006, 2010;
see Chapter 2.3.2).
In short, an approach to treatment was developed that builds on a broad
theoretical basis. Psychodynamic theory, attachment theory and neuropsychology are
all integrated into the approach. The focus of the therapy is changed to the ‘here-and-
now’, and understanding (implicit knowledge) as well as actions (explicit knowledge)
is given prominence. Attention is given to helping patients improve their ability to
see and perceive others from inside and themselves from the outside (mentalisation).
Finally, the role of the therapist is changed, to focusing on helping patients form and
create their own understanding, rather than the therapist analysing and interpreting
the patients’ thoughts and emotions.
Research shows that clinical improvisation is an intervention that addresses implicit
relational patterns (see Chapter 2.3.3 on Daniel Stern). These patterns are the way in
which we as humans relate to others, and they are often automatic and not consciously
enacted. The implicit relational patterns also are related to a person’s attachment style.
This means that if a person is very avoidant in attachment to others, this will also be
apparent in musical interaction. Here the person will also avoid closeness and intimacy.
If a person has a dependent attachment style, they will try to follow and adapt their
music to the other’s music. In this perspective, music can make visible patterns that
are difficult to observe, and the therapist and patient can start building a relationship
without having to challenge the attachment style of the patient (Pedersen 2014).
There is theoretical and research evidence that individuals with personality
disorders have insecure attachment in the form of either avoidant or ambivalent
(Jørgensen 2006). Through music therapy, they are able to work with ‘how’ they
relate to others, but there are also other challenges. First of all, musical activities can
activate anxiety and insecurity – for the same reasons music can activate emotions that
can be addressed therapeutically, it can activate anxiety at a high arousal level when
implicit attachment patterns are triggered. Different interaction patterns in musical
improvisation are described by Strehlow and Lindner (2016). High arousal reduces the
ability to mentalise, and this is a problem. These patients have experienced such massive
neglect or abuse that their basic ability to be trusting and secure around others is very
fragile or lacking. In order to protect themselves from feeling these uncomfortable
emotions, they often avoid entering into close relationships. It is a constant challenge,
especially in the early phases of psychotherapy with these patients, to keep the intense
emotional reactions at a tolerable level. If the stress is too great, there is a risk that these
patients will discontinue therapy, harm themselves or attempt suicide.
Another challenge is that patients with personality disorders often suffer from what
is called teleological thinking (Bateman and Fonagy 2007). Thinking teleologically
means only perceiving purposeful actions as real. There is no awareness of the
intentions behind the action. If one experiences mental discomfort, an action such
as self-harm will seem to relieve the discomfort, and only very concrete actions from
others are perceived as attempts to help. Nurturing attention from another person is
not in itself seen as helpful. Just meeting understanding from another person doesn’t
make the patient feel better. In this perspective, music therapy can seem very far from
concrete help, something like: ‘I’m anxious and depressed, and you want me to play the
drums?’ Because music therapy is still a relatively new treatment method, it is also new
and unfamiliar to many patients. Everything that is new and therefore also potentially
uncontrollable can easily be perceived as a threat, because it causes anxiety. So the music
therapy method must be adapted to the style of the individual patient.
Clinical experience shows that all music therapy methods can be used with this
client group if the above-mentioned conditions are met, and if there is a continuous
focus on maintaining and strengthening the patient’s ability to mentalise, both
explicitly and implicitly.
For more information on treatment and research regarding music therapy with
personality disorders, see Hannibal et al. (2012a), Hannibal (2013) and Hannibal
and Schwantes (2017).
Group music therapy for patients with anxiety disorders

In group music therapy with patients with anxiety disorders (general psychiatry),
the music therapy clinic has developed a treatment that focuses on facilitating inner
imagery through music listening as a curative factor. The music therapy offered is a
GIM method (see Chapter 3.2) called group music therapy: music listening and inner
imagery. The therapy takes place in a closed group of up to six patients, who meet
10–12 times with the option of continuing in the next group. The group starts with
a conversation that can result in a common focus (working theme) for the session.
The music therapist(s) then choose a piece of music (5–12 minutes in duration) that
matches and challenges this focus. After a relaxation induction (sitting or lying down),
the group members listen to the music with their eyes closed, and after listening, they
draw a picture that reflects the inner experiences they had during listening, before
they again express themselves verbally. The group then meets in the circle again
and relates their experiences; each group member presents their picture and tells
the others what it means to them. The other group members give feedback to each
member’s picture. The music therapist(s) summarises the dialogue, relates it to earlier
statements and material from earlier sessions – and assumes an open and curious
attitude to the process each individual patient is going through and the direction
this process might take. Results of a number of group therapies are documented in
research reports that also analyse the role the quite challenging music plays in the
patient’s process (Bonde 2011b; Bonde and Pedersen 2015).
Earlier experiences suggest that in many cases it is possible to build a fruitful
working alliance with patients with non-productive psychosis, social intellectualising,
compulsion and difficulties expressing emotions – an alliance concerning the
patient’s motivation to cooperate with regards to the music therapy setting and goals.
After this, it is usually possible to identify relevant psychological issues that can be
addressed in therapy. The effect of the treatment can, among other things, be a higher
degree of reflectivity and authenticity.
Among patients with productive psychosis, it is especially beneficial to use
music therapy to establish a working alliance with those whose autistic traits are very
pronounced, or patients with megalomania (delusions of grandeur) or self-devaluation.
In these cases, themes such as establishing an alliance or moving in and out of interaction
can be the focus of therapy. In quite a few cases, this has helped to motivate the patient
to further continue in their treatment plan, with or without music therapy.
Music therapy in child and adolescent psychiatry

In the last 20 years, there have been several initiatives to implement music therapy
in child and adolescent psychiatry in Denmark, for example. In the Adolescent
Psychiatric Unit at Odense University Hospital, Denmark, for example, Holck and
Østergaard were granted state funding for a music therapy project.
The project showed that the adolescents, regardless of the level of severity of
their mental condition, attended therapy regularly, were interested in expressing
themselves, and increased their social interaction with each other and close staff
through the project (Nissen et al. 1995).
At the Child and Adolescent Psychiatric Hospital (now the Centre for Child
and Adolescent Psychiatry) in Aarhus, Denmark, Irgens-Møller worked as a music
therapist in a two-year project funded by private grants. In this project, the
music therapist worked with music therapy assessment and individual sessions
with preschool children (Irgens-Møller 1998a, 1998b). Goals for the individual
sessions varied, from working through emotional issues, to development of
communication and social skills, to impulse regulation and increasing self-esteem.
For half of the children, a visible positive development in relation to the child’s
important problems was seen, and in half of the cases, observations from music
therapy sessions contributed to new information about the child.
At the Child and Adolescent Psychiatric Centre in Slagelse, Denmark, music
therapist Karin Thambour Mariegaard was employed for a number of years (2005–
2011) and adapted an assessment method in her music therapy practice that was
inspired by cognitive therapy.
Finally, the Music Therapy Clinic at Aalborg Psychiatric Hospital (now
Aalborg University Hospital, Psychiatry) cooperated for five years with the Child
and Adolescent Psychiatry Unit. Here Holck conducted music therapy assessment
and short-term therapy with a number of 9–13-year-old inpatients with pervasive
developmental disorders, anorexia, obsessive-compulsive disorder or depression.
The main goal of music therapy was to identify and develop the children’s socio-
communicative abilities as well as their imaginative and emotional empathic
competencies at the time of admission to the hospital. For this purpose, Holck
described and created a series of music therapy ‘playing rules’ (Holck 2008a, 2009)
that focused on the musical interaction related to the defined goals.
The playing rules used can be categorised as:
• musical playing rules
• referential playing rules
• playing rules that support verbalisation during musical interaction
• playing rules that support verbalisation and reflection after musical

interaction.
For each category, Holck (2008a) presented examples of different playing rules and
how they were used, illustrated with case vignettes.
In all of these different projects and positions, music therapy was deemed very
positive by other staff members. In the internal evaluation report on music therapy
at Aalborg Psychiatric Hospital, the chief physician, department head, deputy head
and psychologist all assessed:
that music therapy contributes with useful information to the total picture of the
child. Observations from music therapy can, thus, support or supplement the
working diagnosis. Furthermore, music therapy often gives nuances to the total
picture, and shows what the child is able to do in situations that are less verbal and
more musical and playful. This is the case regarding social and emotional skills, as
well as the ability to reflect on these. (Holck 2008a, p.21)
Closing remarks
Besides music therapy treatment, music therapists regularly attend referral meetings
and treatment team meetings when relevant, and they have an ongoing dialogue with
the individual patient’s physician and contact person. Music therapists also teach other
psychiatric colleagues about music therapy and how it is applied, and they participate
in courses, project days and lectures arranged by the hospital. An important part of a
music therapist’s work in psychiatry is presentation and documentation of their work.
In Denmark, an integrated clinic at Aalborg University and Aalborg University
Hospital, Psychiatry has existed since 1995, and this clinic – the Music Therapy
Clinic, Centre for Treatment and Research – produced, from 1998 to 2011, the annual
publication Music Therapy in Psychiatry, with case presentations and theoretical
articles on different aspects of music therapy practice, written by music therapists
in psychiatry in Denmark and later in Scandinavia. The publication, first in book
form, was converted to the e-magazine Music Therapy in Psychiatry Online (MIPO)
in Danish between 2012 and 2017.1
CASE EXAMPLE AND PATIENT NARRATIVE

A male patient (41 years old) was referred to psychotherapy at a psychiatric hospital.
During the referral meeting, it was decided that he should be offered psychotherapy in
the form of music therapy. He was referred with the diagnosis ‘personality disorder/
disturbance of personality structure’, which was the conclusion after an evaluation
using the following tests: WAIS, Luria’s 10-word test and the Rorschach test.
Characteristic traits were intellectualising, obsessive-compulsive behaviour, and
very little contact with his emotions. The patient attended one-hour music therapy
sessions as an outpatient once a week for two years. The aim of the therapy was to
work towards the patient establishing better contact with himself and with others –
primarily women. Partial aims were working with boundaries and autonomy, and
supporting the patient in clarifying future employment possibilities. The following are
excerpts from the case, illustrated through music examples 3 to 8 that can be heard
on the link www.jkp.com/voucher using the code GAUREXY (examples 1 and 2 are
also available via this link).
1 Available at http://journals.aau.dk/index.php/MIPO
Example 3: The therapist and patient both

improvise on the piano (separate pianos)
The excerpt is from the first music therapy session. The patient has been asked to
choose an instrument (he chooses one of two pianos in the music therapy room).
He is asked to play a note, listen to it carefully and let the note lead him to the next
note. In other words, he is asked to try to direct his attention to the sound of the
note, instead of focusing on his preconceived idea of how it is supposed to sound
(becoming present in the sound). The patient alternates playing in the high and deep
registers (avoiding the middle register), and it looks and sounds as if he is gradually
becoming more absorbed in listening (that he is immersing himself in the sound). The
music therapist plays a simple repeated note as an accompaniment during the whole
improvisation (one note in the middle register of the piano). The notes of the therapist
and patient join together and create harmonies that invite them to focus inwards
and listen, and the body language of the patient shows intense concentration in the
improvisation. The music therapist hears quite a lot of intentional contact between the
patient and the therapist in the music. In the conversation following the improvisation,
and after hearing the recording of the music, the patient expresses that he barely
heard the therapist’s music. However, he had a sense of a musical centre somewhere
that he felt drawn to. He knew he needed this centre to allow himself to be aware and
present in his own music.
In this case, the patient gave permission that the examples be used for further
analysis and research. When he was invited to the clinic four years later and listened
to this example, he was asked to focus on the contact between patient and therapist.
He was asked to score his interpretation of the contact on a scale of 1 to 10, where
1 meant no contact and 10 meant very close contact. The music in this example was
scored at 9. This shows that the patient’s perception had changed significantly through
the therapy, and that it was a longer-lasting change.
Example 4: The therapist plays a drum; the patient plays the piano
This example is from session 14. The patient plays out his restlessness in the music
and asks the therapist to act as a focus point or lifeline, while the patient challenges
boundaries, allows himself to take up more space and allows more aggressive energy
in the music.
Example 5: Both the therapist and patient improvise vocally

This example is from session 32. The patient has started to dream very intensely,
having not had dream activity for many years. The patient often starts music therapy
sessions by relating a recent dream. He also paints watercolours between sessions.

He brings these with him and says a few words about them in the sessions. Finally, he
writes a journal, which he wishes to give to the music therapist, who reads it between
sessions. The watercolours and journal notes are primarily commented on by the
patient himself. In this session, the patient relates a dream. In the dream, he is running
around, looking for something. He comes to a barbed-wire fence and climbs over
it. On the other side, there is a frozen lake, and in the middle of the lake there is a
patch of ice so thin that he can see a petrified sea urchin through it. He says that
the sea urchin is a part of him that needs to come alive. The music therapist and the
patient agree to use their voices to express the qualities of the sea urchin. This is the
first time the patient tries to improvise with his voice. The therapist attempts to match
the patient’s pitch and expressiveness. There is a movement from very little vibrato
to much more vibrato in the vocal sounds towards the end of the improvisation. This
can be understood as ‘something that is frozen starts to thaw’. The therapist matches
empathically and supports the patient in his expression.
Example 6: Both the therapist and the patient improvise vocally

This example is from session 42. The patient is now much more familiar with vocal
improvisation. The night before the session, he had a dream about a black panther,
and this is the symbol that he and the therapist attempt to express with their voices. This
makes the patient use a much deeper voice, and he experiences this as an expression
of something masculine. He also finds that it is much easier for him to make himself
heard and ‘stand alone’ with his voice when using a deeper pitch. This gives him
confidence to express himself as intensely and ‘primitively’ as he does in this case.
The therapist matches his expression, and, through her sounds, she encourages the
patient to explore his own boundaries in the vocal improvisation.
Example 7: The patient improvises alone vocally

This example is from session 44. Here the patient uses an integrated vocal sound
that contains both ‘light’ and ‘dark’ (high and deep) sounds. The patient feels more
confident in expressing himself, and can do so independently. He feels that his feminine
and masculine sides are more alive and present, and that they are more integrated.
Example 8: The therapist and patient

both improvise with voice and piano
This example is from the last session, number 57. The therapist and the patient play
freely in the flow of the music. Both of them contribute to the music with new ideas, and
let themselves be immersed in the music of the moment. There are no defined roles.
The therapist feels free to express herself and play her own ideas, inspired by the joint
improvisation and without thinking about supporting, amplifying or accompanying the

patient. The music sums up many of the elements that have been expressed in earlier
sessions. This is the first time that the therapist and patient have improvised vocally
while playing the piano at the same time.
The patient made his own decision about when to terminate therapy. He felt he
was now ready to go out into the world and try out his strength, using his experiences
from music therapy. The same patient wrote, by request, the following patient narrative,
three years after music therapy ended. As seen in the narrative, the music helped the
patient to achieve a broader sense of self and greater personal freedom. Regarding
the aims defined at the start of the therapy, the patient developed more flexible,
yet clear, boundaries, and a greater degree of autonomy, in this way improving his
contact with himself and others, including women. The patient was fully rehabilitated
shortly after termination of the music therapy.
To illustrate some of the inner processes the patient experienced in music therapy,
we have, with his permission, included seven of his watercolours. The seven paintings
are selected from a collection of 63 watercolours that the patient brought with him to
music therapy (see paintings on the following pages).
Patient narrative
The background for my participation in music therapy (September 1994 to May
1996) was a very long period of illness and absence from my job as a preschool
teacher; a job that got on my nerves more and more, where I became more and more
stressed, nervous and confused from having to relate to so many people and new
impressions. Finally, I completely lost perspective, and as a result I constantly forgot
what I was in the process of doing. A thorough psychological test confirmed that this
job wasn’t the right one for me. Based on this, it was suggested (and I accepted) that
I start psychotherapy in the form of individual music therapy once a week.
I was a little nervous when I arrived at my first session. I wasn’t sure of what music
therapy was, had never heard of it before. I had also grown up in a very unmusical
family, and my experiences in school were limited to getting hit on the head for not
singing or for singing out of tune. It took some time, about a half year, before I started
feeling like I could find my own space in the music. Early on, it was the piano that I
was drawn to; the piano with its many keys ranging from the very deep to the very
high. In the beginning, I was most drawn to the dark, sorrowful, melancholy sounds;
later lighter, higher notes appeared. At first, they were opposed to each other; later
they began to relate to each other, to play together and dance in and out and around
each other. I experienced more and more that there was a space in the music; at the
same time my daily life seemed more and more sad and full of anxiety.
After a good while in therapy, I started using my voice as an instrument; this I
especially felt was a breakthrough – something that was difficult but that also gave
me direct contact with and access to my deepest feelings.
Figure 4.2.1.1: A little boy reaches

out to a mother figure, who is
distant. The man in the middle,
who is an observer of reality, is
the most important figure here
Figure 4.2.1.2: The petrified sea urchin,

which appeared under the ice in a
dream, has become a face here. It is
still under the surface of the water
Figure 4.2.1.3: The face has now

moved above the surface of the
water – this creates insecurity
in relation to other people
Figure 4.2.1.4: An indescribable

anxiety has broken loose and
is manifested in dreams and
fantasies of devils and snakes
Figure 4.2.1.5: The devil is growing.

It can be experienced both as
dangerous and as an important, not
acknowledged source of energy
Figure 4.2.1.6: Now there seems

to be a better balance between
feminine and masculine sides
Figure 4.2.1.7: I feel much younger

now, but much more integrated
Shortly after this, dreams poured forth, long dream sequences that I wrote down as
they came – dreams from the time I was on LSD, dreams of being pursued, dreams
where there were strange creatures and animals like crocodiles, panthers, snakes…
A lot happened during this period; I felt like a child again, like being a boy all alone
in the world in a good, new and exciting way. I started being more aware of where I
was and what I wanted. Three or four months later I made the decision to end therapy,
felt that it was finished; now the time had come to go out into the world again and
test my strength.
A little more than three years have now passed since the music stopped. Quite
a lot has happened since then. I feel that I have changed quite a bit. In some ways
I’m still the same person, but at the same time I have a feeling of being able to ‘fill
myself out’ much more today. Earlier I felt like I was a sad, lonely and misunderstood
‘Steppenwolf’, sitting in a waiting room, and when I was with other people, I often
felt like the spy who came in from the cold. I’m still a ‘Steppenwolf’, but now a much
freer, more spontaneous, active and cheerful one – instead of a silent and speculating
wolf, I’m now a wolf who joins in, barking with pleasure. I’ve become much better
at being aware of my own needs, and the fear of hurting others has moved into the
background. The morning crises I used to have – crises that could last all day, and
where I felt that catastrophe was lurking right around the corner – have more or less
disappeared. Although music therapy officially has ended, I feel that it is still going
on. All the experiments, notes and themes that I played out in the music, I now use in
different encounters with other people, and it gives me a great feeling of freedom;
freedom understood in the way that I have many different keys to play in, many
different ways to tackle situations. I still do voice exercises to become aware of how
I feel right now, deep inside. This is a good tool for me to relax knots and tensions
that are forming.
4.2.2 Music Therapy in Social Psychiatry

Niels Hannibal, Inge Nygaard Pedersen and Trine Hestbæk
Music therapy in social psychiatry has existed in several countries in Europe since
the beginning of this century. The client population consists of people who (for the
time being) are not hospitalised, and who live in their own homes or in residential
facilities. In the social psychiatry approach the aim is ‘psychosocial rehabilitation’,
which includes professional support for mentally vulnerable people and those with
psychosocial disabilities to help in recovery and make independent living possible
(according to the Danish Social Agency 2014).
‘Support’ is a broad term that covers areas such as: gaining control of one’s life,
establishing relationships to others, finding employment or getting an education.
Social psychiatry in Denmark and many other countries is based on recovery, which
means that the goal is not to be completely cured in a psychiatric sense, but to receive
support for a process where the individual can have good quality of life despite their
mental problems, and can gain control, completely or in part, of their life situation.
Therefore, the support must be individually adapted and must contribute to increased
coping in everyday life. Said simply, the individual must receive help for self-help,
so that they can manage life as independently as possible. The main difference
between social psychiatry and hospital psychiatry is that social psychiatry focuses
on resources, rehabilitation and empowerment, while hospital psychiatry focuses on
assessment, diagnosis and treatment. In addition, in social psychiatry, individuals
are not often referred for treatment by external professionals, whereas treatment in
hospital psychiatry is usually prescribed by psychiatrists. This means that self-referral
is to a certain degree possible in social psychiatry.
In social psychiatry, music therapists can use a psychodynamic approach (see
Chapter 3.3) and a community music therapy approach (see Chapter 3.7). With
a traditional psychodynamic music therapy approach, both individual and group
therapy are offered, using a wide variety of active and receptive music therapy
methods, for example improvisation, songwriting and musical life history (see
Chapter 3.9). Through relational therapy, the therapist seeks to prevent relapse,
develop resources and help the individual to live a more independent life. Gold et al.
(2005) and Gold et al. (2013) showed, in a study of resource-oriented individual
music therapy for clients with low motivation for treatment, that negative symptoms
were reduced and the level of function was significantly improved after three months
of music therapy. These research results are in accordance with those of a meta-
analysis conducted by Gold and colleagues regarding people with schizophrenia and
people with affective disorders. The meta-analysis documented a clear relationship
between length of treatment and its effect (‘dose-response relationship’) (Gold et al.
2009). The more sessions offered, the greater the effect of therapy. This is especially
important in social psychiatry, where music therapy is often considered long term.
The community music therapy approach (see Chapter 3.7) is different from
traditional dynamic music therapy in several important ways. Here the therapist is not
in the same way defined as someone who is treating a patient, but rather as a facilitator
for growth and development. The focus is on using music as a means to include, activate
and motivate vulnerable people to become social, interactive, expressive and creative –
as participating and ‘performing’ individuals. Here the resource aspect is important, and
roles, participation, direction and so on are actively addressed, so that the individual
becomes more engaged and active and can experience being an equal member of
the group. Community music therapy is usually conducted in groups. Methods are,
for example, choral singing, client bands, theatre projects or similar activities, where
there is often a performance for an audience at the end of the project. Rydahl (2011)
formulates it in this way: community music therapy can counteract the marginalisation
and exclusion that many of the participants in social psychiatry experience. ‘Community
music therapy is about social inclusion, identity and resources brought about through
the group gaining mastery together’ (ibid., p.132). The participant in community music
therapy is not defined as a patient or client, but rather as a participant, contributor or
creative, expressive individual. The processes in the different musical media create a
good framework for fostering participation, community, interaction, coping and trying
out new ways of acting and expressing oneself.
In a small user survey regarding music therapy in social psychiatry in the
municipality of Aarhus, conducted in 2009–10 with 19 participants, there was a
positive response in regard to the individual as well as group music therapy that
was offered (Jensen 2011). For the participants, music therapy was a supportive,
growth-oriented and preventative intervention. They reported in the survey

that their symptoms were less stressful and their cognitive functions, such as
concentration, were improved. They also found that their self-esteem and social
competencies were improved.
The study also illustrates the importance of alternating between two parallel
approaches in social psychiatry, analytically oriented music therapy and community
music therapy. This requires an awareness of one’s role as music therapist and an
active focus on the relationships in the different contexts. Alternating between the two
approaches also affects the relationship between user and therapist, and it involves
practical as well, and so on. Community music therapy is offered in a broader context.
Awareness of roles is seen as a prerequisite for being able to manage these shifts in
roles and functions, which is a fundamental part of the music therapist’s training.
The breadth of music therapy’s field of activities can be seen in Table 4.2.2.1, an
overview of Jensen’s music therapy services during the time of the study.
Table 4.2.2.1: Services offered by a music therapist in social

psychiatry in the course of a year (Jensen 2011, p.118)
Music therapy services No. of participants
Individual music therapy: 412 sessions 27
Open music group in collaboration with social worker: 48 sessions of 15
two hours each
Youth group in network: two sessions of three hours 6
Group at the Centre for Adult Special Education: 15 sessions of three 5
hours each
Community music therapy: 21 different cultural events >100
To sum up this chapter, a user testimonial from the same report follows below (Jensen
2011, p.125).
CASE EXAMPLE
The participant is a woman, aged 42, with the diagnoses anxiety, depression and
social phobia. She describes her situation in this way:
My despair was so intense that it tore apart my train of thought. Medicine helped
somewhat, but I needed to come out of the situation that I was trapped in. My social
worker brought me to music therapy. Only the first time, after that I went there myself.
People as well as loud noises were threatening to me, and, at the same time, it was like
I was sleepwalking, even though I could hear and see everything that was happening
around me. I had a hard time concentrating and felt helpless, even in an ordinary
conversation, so I was very nervous when I arrived. (ibid., p.125)
In talking about the first sessions of music therapy, she says that it was good that she
played, even though she couldn’t keep the beat, but it didn’t do anything for her. The
music therapist interacted with her musically. ‘It was free improvisation, and always
communicative. It felt friendly and accommodating, and gave me a sense of being
very present’ (ibid., p.125).
The woman accepted the invitation to play different percussion instruments, and
this changed from being frightening to becoming a playful game, where the music
moved from one instrument to another. The music therapist made it clear that ‘here,
there is nothing that is wrong’. The woman took this to heart, and experienced profound
joy at being completely present and feeling more real. These experiences were
strengthened when the woman started using her earlier musical experiences. She had
played music when she was young, and in music therapy they could now alternate
improvising freely with playing from sheet music. This gave her more self-esteem
and affected her encounters with other people. She describes that these encounters
became easier for her to handle. In conclusion, she says:
Often, when I am anxious or sad, I can now comfort myself by singing. Earlier, I went
around talking gibberish when I was frustrated. Now I can make it into a song, which
makes the situation much better. Music transforms a worried, frightened feeling to a
trusting feeling. And then my thoughts often go the same way, which makes everything
easier to handle. (ibid., p.125)
This example illustrates how this woman gains access to new or forgotten sides of her
personality, which gives her better quality of life, while also helping her to improve
her situation socially as well as personally. How music therapy in social psychiatry
can help the individual to rediscover inner resources is illustrated in this final statement
from another music therapy participant:
When I’m there (in music therapy), I can put the psychiatric ward, the municipality
and the psychiatrist aside and just be present. I can find myself again. When I have
anxiety and hear voices, I go to music therapy and use the abilities and qualities that
are inside me, which gives meaning to my life. My experience from earlier becomes
clearer – I can draw on that experience. I have abilities that I wasn’t aware of and
didn’t expect to find. (Jacobsen and Hannibal 2012, pp.41–2)

4.1 Referral Criteria and Clinical Practice in Music Therapy - An Introduction

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4.1 Referral Criteria and Clinical Practice in Music Therapy - An Introduction

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4.

1 Referral Criteria and Clinical Practice

similar to those of other health-care professions.

Referral criteria and needs met by music therapy

• poor or lacking relationships with others

Expected length of intervention

Suggested plan of treatment and assessment

1. Initial assessment – approximately three sessions.

for this baseline assessment is clearly described by experienced clinicians such as

Criteria for referral

4.2.1 Music Therapy for Adults in Hospital Psychiatry

• Receptive music therapy, which can be listening to recorded music selected

4.2.1 Music Therapy for Adults in Hospital Psychiatry

• Receptive music therapy, which can be listening to recorded music selected

Pioneers in psychiatric music therapy

Newer developments in music therapy in hospital psychiatry

The music therapist’s qualifications

Music therapy treatment

As an example, the following music therapy treatment options are available

Research and practice in music therapy

The positive influence of music on impaired attention and ability to communicate

patient experiences moving away from unrealistic fantasies of being a professional

Music therapy for patients with depression

therapy. It is important to achieve reduction of depressive symptoms, and in Erkkilä

Treatment of a patient with depression can be aimed in part at reducing the

as a dimension in active improvisational music therapy. For patients with depression,

themselves verbally, music can be a channel for communication. By actively playing,

Music therapy for patients with personality disorders

Group music therapy for patients with anxiety disorders

to further continue in their treatment plan, with or without music therapy.

Music therapy in child and adolescent psychiatry

• playing rules that support verbalisation and reflection after musical

CASE EXAMPLE AND PATIENT NARRATIVE

Example 3: The therapist and patient both

Example 5: Both the therapist and patient improvise vocally

sessions by relating a recent dream. He also paints watercolours between sessions.

Example 6: Both the therapist and the patient improvise vocally

Example 7: The patient improvises alone vocally

Example 8: The therapist and patient

improvisation and without thinking about supporting, amplifying or accompanying the

Figure 4.2.1.1: A little boy reaches

Figure 4.2.1.2: The petrified sea urchin,

Figure 4.2.1.3: The face has now

Figure 4.2.1.4: An indescribable

Figure 4.2.1.5: The devil is growing.

Figure 4.2.1.6: Now there seems

Figure 4.2.1.7: I feel much younger

4.2.2 Music Therapy in Social Psychiatry

growth-oriented and preventative intervention. They reported in the survey

Table 4.2.2.1: Services offered by a music therapist in social

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