Are you my 'client'?

I have been challenged recently to think more deeply about my rejection of the word 'client'. I’ve been trying not to use the word for a number of years, and frankly, it’s been a hard habit to break.  But I had made a very conscious decision in opposition to what I perceived as the institutionalised power imbalance invoked when the ‘client’ was framed as a recipient of my expert treatment.  The use of the word 'institutionalised' refers to the unconscious use of the word; the fact it was just accepted that people who participate in music therapy in all places and various ways should simply be considered to be one amalgamated whole, rather than the unique, context bound beings that they are.  'Power imbalance' referred to my belief that music therapy, as I practice it, is more of collaborative act than one directed by my superior understanding of a vulnerable person's needs. I use 'recipient' as suggestive of passivity on the part of the people who participate in music therapy, in contrast to the well-documented need for active commitment as fundamental to the success of therapy. 'Expert treatment' refers to the assumed use of a treatment model, which in my opinion is a very specific model involving formal stages of referral, assessment, goal setting, implementation of the planned activity, followed by evaluation of efficacy.

So, I had my issues with the relevance of the word client to the way I practice music therapy and perhaps even the way music therapy is practiced in many contexts informed by contemporary social policy.

Client is a convenient word however, and it is pragmatic to argue that replacing one word with what would potentially be four - person / people participating in music therapy - is both inefficient and confusing. However, I do recall the movement in the 1990s from language where people were described as 'autistic child' to 'child with autism', and at the time the change felt problematic for the same reason.  The importance of putting the person before the diagnosis seemed to make it worthwhile however, and it no longer feels cumbersome at all.

A problem with removing all connotations of power imbalance in music therapy was suggested by a colleague of mine, Jason Kenner, who pointed out that avoiding the reality that we have power in the relationship with our client is irresponsible. We are responsible for the music therapy context and committed to striving for therapeutic outcomes in relationship with our clients.  He suggests that by removing the recognition of this power, we may actually be disempowering ourselves and inadvertently relieving ourselves of responsibility within the therapeutic process. He feels that acknowledging our power helps us to be more responsible to the people we work with.

My own position is to emphasise mutual empowerment.  Perhaps my practice of music therapy is less effective than others, but my experience is that I am not able to take responsibility for the therapeutic outcomes; this is something I am enthusiastic about, and energetic towards, but not responsible for.  This is also in keeping with common factors research into the effectiveness of psychotherapy (Duncan, Miller, & Sparks, 2007).  If people do not wish to sing when I have suggested singing, there is only so much I can do.  If people choose to play, but not to discuss what they have played, I am often unable to convince them to do so.  Their agency is a critical dimension of the therapeutic encounter, combined with my capacity to create the conditions wherein the desire to participate can happen. 

Randi Rolvsjord (2010) elaborates her position on the concept of empowerment in the context of adult mental health, and I have a well-thumbed copy of her contribution to the topic and have commented on it previously (McFerran & Campbell, in-press). It has always confused me that she also likes to use the word client.  I have no doubt that she has been reflexive in considering this language, which reminds me about how important it is to consider the ways that words are used in different contexts.  Another heavily reflexive Norwegian, Brynjulf Stige (2002), points to Wittgenstein’s ideas to explain this contextualized use of language as it has come to be understood in the past century.  Perhaps words do not provide a direct mirror of reality, but rather point to meanings that are co-created in a given social context. Therefore it is easy to see that my use of the word client may be different to Randi and Jason’s use of it.

Another colleague, Grace Thompson, has been instrumental in influencing my own thinking on this topic, informed by her work in the Early Childhood Intervention sector where partnership with families has become the dominant model.   The sector has worked hard to illuminate implicit or explicit assumptions about the helper’s knowledge and resources being ‘superior’ to the local knowledge held by families (Davis, Day, & Bidmead, 2002, p. 47) and ultimately to provide alternative models to the expert helper.  The importance of collaborative relationships has been emphasized, and the use of language that suggests anything other than mutually empowering relationships has been considered detrimental to the success of the collaboration. 

This is obviously not a topic that is restricted to the music therapy profession.  A quick Google search reveals discussion on this topic from a range of fields and Jason Kenner discovered an article in psychiatry where ‘patient’ is reported to be the preferred language according to a sample of users/consumers/patients/clients in the UK (Simmons, Hawley, Gale, & Sivakumaran, 2010).   

My own conclusion is that the word client is convenient, simple and universally used within music therapy.  I continue to struggle with its relevance to my own work and cannot help but associate it with a classic treatment model that I no longer find useful.  However, I acknowledge that it may be the most appropriate term in some contexts.  In private practice, I can see that the word ‘client’ might be the most appropriate word, especially if the individual is paying for therapy.  In hospitals it makes sense that patient would be the preferred term, and I see no reason why a music therapist would introduce the use of the term client in contrast to that.  In education it is helpful to use the word student.  In work with young people in the community or in mental health care, another colleague, Cherry Hense, confirms that ‘young person’ is the preferred language in her institution.  I can see now see that it is just as inappropriate to reject the word ‘client’ as it is to accept it without conscious reflection.  My own issues with the word are local and grounded in my experiences of how that language is used and obviously this is not the same as other people’s experiences.  But I would argue that it requires due consideration and should not be a term that is used without critical reflection.  I guess I still don’t like it.

Davis, H., Day, C., & Bidmead, C. (2002). Working in partnership with parents: The parent adviser model. London: Harcourt Assessment.

Duncan, B. L., Miller, S. D., & Sparks, J. (2007). Common factors and the uncommon heroism of youth. Psychotherapy in Australia, 13(2), 34-43.

McFerran, K., & Campbell, C. (in-press). Music therapist’s use of interviews to evaluate group programs with young people: Integrating Wilber’s quadrant perspectives. Nordic Journal of Music Therapy.

Rolvsjord, R. (2010). Resource Oriented Music Therapy. Gilsum, NH: Barcelona Publishers.

Simmons, P., Hawley, C. J., Gale, T. M., & Sivakumaran, T. (2010). Service user, patient, client, user or survivor: describing recipients of mental health services. The Psychiatrist, 34, 20-23. doi: 10.1192/pb.bp.109.025247

Stige, B. (2002). Culture-centered music therapy. Gilsum, NH: Barcelona Publishers.

First Published on www.voices.no
McFerran, Katrina (20012). Who is my "Client" . Voices: A World Forum for Music Therapy. Retrieved September 03, 2012, from http://www.voices.no/?q=fortnightly-columns/2012-who-my-client

Reconsidering Resilience

I went to a seminar on Resilience yesterday, presented by a famous child psychiatrist called Bruce Perry.  Although I wasn't wildly impressed by the way that he used basic research to support loosely related theoretical propositions, he alerted me to a constructionist discourse on resilience that I thought made a lot of sense.  Ok, that's the end of the ranting in big words.  The idea he presented was beautiful in its simplicity and I want to share about it.

He dared to suggest that perhaps resilience is not a personal trait.  There has been a huge interest in studying 'resilient' people and trying to work out why they cope better with trauma than other people, and this research has all been based on the assumption that it is a personal capacity.  This has been a vexed stream of investigation, mostly because when they looked closely, resilience seemed like something that couldn't be learned.  Research seemed to suggest that some people are just born resilient and others aren't.  Martin Seligman went so far as to suggest that we all have a set-point for happiness.  Some people are genetically predisposed to be happy, and others, well, a bit gloomy.  Not much you can do about it. Interesting theory I guess, but not very helpful.

But Michael Ungar has proposed a novel way of explaining resilience that resonates with my experiences as a human being and a music therapist.  He says that resilience is displayed when people negotiate the processing of an adverse experience by navigating towards available resources.  So firstly, resilience isn't a personality trait, it's an action.  Second, that action doesn't happen once, it's a process that is ongoing for as long as the challenging experience is being dealt with.  And the third point is what Bruce Perry stated so emphatically; that the quality of the social networks is therefore what confers resilience (the Europeans would probably use the word 'affords' rather than confers, but it was nice to hear a more familiar word:).  Because if you are dealing with a challenging situation and trying to 'navigate towards helpful resources' and there is none around, then you will just sail around in circles, usually within yourself.  Or if it looks like there are people that can help, but they seem to fade away like a mirage when you try to access them, you're just left sitting there, out at sea.  But if you have something bad happen and the people around you get up underneath you to help you cope, then you're going to be more resilient.  Doesn't that make sweet sense?

And what I loved even more was the way it supports our new MusicMatters in Schools program.  Along with my co-directors Kate Teggelove and Lucy Bolger, I've been experimenting with a new way of contributing as a music therapist in schools.  It is about fostering musical cultures in schools that promote wellbeing and connectedness; flourishing musical cultures where students make music often and teachers use music in classrooms and differences are transcended while diverse groups jam, sing and dance together in all kinds of ways.  We have been focused on partnerships with schools and collaborations with students, rather than providing expert services.  And it was all in the name of supporting young people before they needed more clinical care.  We were fostering resilience, and now, I can better understand why that seemed the right way to do it.  Because making music with others strengthens your social networks and it improves the quality of your connections with peers and teachers, and THAT makes navigating to helpful resources much easier.  How about that. Thank you Michale Ungar. 

Power and Love

Power and Love are two words that are rarely spoken in the music therapy literature.  Love, like spirituality, has often been considered too soft; too open to misinterpretation.  Love does not share the same space as evidence-based practice, and therefore it always seems to be regarded as a little bit dangerous.  Discussions of power are avoided for different reasons.  We love to talk about 'empowering' others as music therapists, but we don't like to talk about the power that we have.  Adam Kahane (Power and Love, 2010) suggests that "This problem of love that conceals power often shows up in the helping professions, where power is always present bur frequently indiscussable." (p. 48)  I think he has a point.

I have been thinking a lot about power in my discussions with the music therapy students this year.  I have been arguing that focusing only on people's strengths is a form of denial.  For those that know me, it goes without saying that I find an exclusive focus on pathology even more abhorrent.  I have been using language from Ignatian Spiritulity to emphasise the importance of 'discernment'.  It's not so different to assessment in traditional, clinical music therapy language.  In relation to practice, it involves having understanding and compassion for the unique challenges that people face, in balance with a recognition of their capacity and resources. 

In my own music therapy journey, I now think that I have been overly focused on strengths.  To some degree, I have been in denial of people's limitations.  Music is such a wonderful tool for adopting a positive perspective after all.  Teenagers who will not speak to their counsellor will happily write a song that details their emotional journey.  Children with profound disabilities are able to reach out and connect in music whilst not being able to communicate in any other traditional way.  Older people with dementia can sing all the lines of their favourite songs, but cannot hold a conversation.  The examples are endless, and I love them all.  It feels so good to engage with the healthy aspects of someone who is usually seen through the lens of their limitations.  So what's my problem?

Adam Kahane has articulated it better than I can.  "Love without power is sentimental, and anemic, or worse. Power without love is reckless, and abusive, or worse." (p. 53)  Sometimes my music therapy work can be a bit sentimental.  It's full of assumptions about the fact that beautiful relationships create a space for personal growth.  These ideas are deeply grounded in my study of humanistic theory and the core tenet of unconditional positive regard.  You might notice that unconditional positive regard is not discerning, or at least, not overtly.   Ken Aigen seems enamoured with these kinds of ideas too, and I love reading about his deep commitment to the power of musical relationships (see Music Centred Music Therapy).  But I've been thinking about how easy it is to deny how mutually satisfying it is to be in these relationships.  Randi Rolvsjord begins to delve into this in her theoretical treatise and her ideas are pointing in the same direction, but perhaps with a little more restraint than I am advocating (see Resource Oriented Music Therapy).

I continue to believe that mutually empowering relationships can lead to change - they afford opportunities for change (to use the language made popular by Tia De Nora).  But the relationship  needs to be actively in service of that change.  I have been expecting it to just lead there, naturally, through extended music making.  As I become more interested in creating systemic change that leads to personal and social justice for many more people, I am beginning to recognise that ensuring the benefits of mutually empowering, musical relationships extend beyond the therapy room takes a huge effort.  Grace Thompson turned me on to this years ago, and I've been allowing it to influence my thinking and direct my research ever since.  Another voice has been that of Lucy Bolger, who keeps demanding that we turn our attention to developing sustainable programs, music therapy that doesn't always need a music therapist...

I know, it breaks every definition of music therapy in the book.  But that's what I'm wondering about at the moment.  Is this precisely the unspoken power dynamic that we could become conscious of in music therapy discourse?  Do we need to be needed in order for music therapy to be helpful.  It's interesting, isn't it?

Does music therapy do any harm?

I was reading an article today on potential of eLearning in university environments (Conole, 2010, Journal of eLearning and Knowledge Society). This author was pointing out how very few academic environments have truly fulfilled on the promises made – for “personalisation, student-centred learning, to support new forms of communication and dialogical learning and enriched multi-model forms of representation” (p.13).  But what really caught my attention was the author’s reference to NO SIGNIFICANT DIFFERENCE being evident in studies of eLearning vs. traditional learning.

It suddenly occurred to me that perhaps we music therapists have been approaching the idea of statistical significance all wrong.  Instead of comparing our programs to other existing programs and being disappointed that we are not SIGNIFICANTLY MORE effective, we should be comparing ourselves to other equivalent programs of excellence and showing that we are NOT SIGNIFICANTLY WORSE! 

The author had used the argument in the way that music therapists do.  Under controlled conditions there was no evidence that eLearning was better.  But to my reading, as an interested and detached observer of the phenomenon, that was all I needed to hear – that it was no worse.  Times are moving forward and the only thing standing in the way of eLearning would be if it were detrimental to student learning.

Similarly, music therapy is an appealing and engaging form of therapy in many contexts.  There is often strong support from families and participants for music therapy programs, but funding is often not forthcoming, perhaps because of the lack of evidence. The argument we should be making is that the evidence shows that music therapy is doing no harm and that it is also desirable to consumers.  We should be conducting investigations to make sure that it is not detrimental, instead of constantly focusing on analysis of results to identify which dimensions we can claim statistically significant improvements on.    The best outcome we should be hoping for is equivalence, since I think we would all agree that we find music therapy as effective as other means of achieving therapeutic outcomes, but not necessarily more?  Or perhaps that’s just me?

Do we really have to take sides?

I was lucky enough to participate in a discussion today where a group of mature and thoughtful music therapy researchers debated how much our beliefs influence our research.  Earlier this week I sat with a group of enthusiastic and insightful music therapy students as we grappled with how our beliefs influence the therapy that we do. I learned a great deal from both, but I wanted to take the chance to consider two different approaches to this kind of learning.

If I adopted a dualistic approach, which I often have, I would be inclined to simplify the discussions by offering  a group of ideas to choose between.  This provides a structure for thinking and talking and allows us to acknowledge different ideas.  I have used this method quite consciously in response to my own experience of being confused by thoughtful people asking me to share my opinions on issues that I barely understand and therefore cannot really make an argument about.

But I am increasingly unable to rely on this favourite old strategy of mine.  I am finding it difficult to see the divides between perspectives anymore, and I often end up gazing at the overlap, which is even less helpful if I am trying to facilitate thinking and discussion.  Ken Wilber's concept of integral thinking is my saving grace in trying to understand why this has happened and how I am increasingly experiencing things.

It's not just that I can see the different perspectives and just don't feel like aligning myself with only one of them.  It's more like the perspectives are meeting and greeting one another and then transcending the false divides that seem to exist between them.  For me, this is the same experience as when you sing, or make music, or go to a concert with a whole group of strangers that you don't know (Christopher Small described this aptly as musicking).  You feel connected to one another in a deep understanding and sharing way, but you are a whole entity in yourself at the same time.  You neither lose yourself, nor maintain your need to distinguish yourself.

Not surprisingly then, this sounds as though my views on music and knowledge are integrating with my spiritual beliefs.  But instead of feeling all lined up and neat, it feels greater than, and expanded. 

My conclusion is that integral living works for me and I live integral thinking on my best days.  But then, of course, there's the other days ...

Music and learning - how does it help?

The state of music in Australian public schools is fairly poor.  According to 'Music: Play for Life' only 23% of public schools offer a substantial music curriculum. Compare that to 88% in privately funded schools.  So what is the motivation for private schools to be spending significant budget on some pretty serious music programs?

I think there are three main reasons.  The first is culture - high culture in fact.  In Australia the association between having cash and understanding music is well established.  Most funding of  cultural events is bolstered by philanthropic donors, and although the cost of attending is not exorbitant, nor is it particularly cheap.  So participation in the arts can indicate a status.  And perhaps more importantly, a substantial music education means that people have the skills and capacity to appreciate complexities associated with many genres of Western Art and Jazz music.  So kids that go to well-funded private schools are more likely to appreciate high culture.

But there are two other arguments for including music in the curriculum that schools find interesting - and these are related to learning outcomes.  It is quite easy to blend these two perspectives together, to make an over-simplified mega-argument, but I think it is very important to be clear about which is which.  Nikki Rickard wrote a chapter in our recently released book (Lifelong Engagement with Music: Benefits for Mental Health and Well-Being: Nova Publishers) that really clarified my thinking on this.

One perspective is that learning an instrument improves cognitive functioning in maths and literacy.  The other perspective is that targeting particular learning outcomes with musical strategies improves those outcomes, potentially in maths and literacy.  Am I making the difference clear? Let me explain  a little.

There are studies that show groups of children who have instrumental lessons do better in maths (in some studies) and literacy (in others) than a comparable group of children who have not had music lessons.  These are mostly small, individual studies and there is not a strong body of evidence to support this contention due to limitations in methodologies and number of participants.  But many people do accept this argument because they picture the high achievers in their local school context and they notice that those students are also studying music.  So anecdotal experience matches the hypothesis and the idea is more easily taken up by teachers, parents and the media.  Nikki points out that it is important to note that improvements have not been measured as resulting from generalist music classes in primary school - this is about specialist music tuition improving cognitive capacity .

The idea that music can be used to enhance learning through careful inclusion of tailored musical activities that target specific outcomes is different.  This is about embedding music within curriculum goals, where music contributes to the targeted outcome, often alongside other strategies.  Again, there are individual studies that show comparatively better learning outcomes for those students where music was involved.  Music has been used as a mnemonic aid throughout history after all - to learn times tables in mainstream schools, body parts (Put your finger on your nose, on your nose), emotion recognition (If you're happy and you know it, clap your hands) and much more.  Music therapists frequently draw on these possibilities in special education contexts, writing songs that are specific to the skill to be learned.  This is also powerfully illustrated when people have dementia and can't remember where they are nor recognise their children, but they can sing the words to a song from their youth.

These are distinct arguments, are they not?  And yet I have not always found it so easy to distinguish them.  The most popular form of simplified blending is to argue that music is good for learning.  Well, yes it can be.  But exactly how this is so is worth noting.  Simple exposure is probably not going to do it -but it might be fun (which might motivate you to get on with your study;)

Ahhh, life is beautifully complicated.

learning to blog

My interest in blogging was first piqued by a music therapist turned blogger in the United States named Kristen Chase.  She had written a fantastic book on music therapy assessment, but when I tried to find what university she had attached herself to, I discovered she had become a famous blogger, who gave great advice to new mom's.  She called herself the 'Mominatrix' and she was brilliant
http://www.imperfectparent.com/mominatrix/
So I was inspired, but inactive.

Then I then had the opportunity to contribute a couple of blogs in response to an almighty furor that erupted when I took my research on teenagers and music to the media to try and drum up some participants for my next study

http://www.metalsucks.net/2011/11/09/just-a-lot-of-noise-about-nothing-dr-katrina-mcferran-responds-to-justin-foleys-response-to-her-study-on-teens-music-and-depression/

http://www.metalinsider.net/guest-blog/exclusive-dr-katrina-mcferran-responds-to-reaction-towards-her-study-on-music-and-mood

I really appreciate the opportunity to write without having to provide evidence that my ideas have been inspired by the ideas of others - and this is fundamental academic currency.  So in this place, out in the real world, I want it taken as a given that I have read, well, you know, quite a lot of stuff and that it is all in my head somewhere, informing my thoughts, even when they seem innovative.  I promise to reference appropriately in all other forms of writing.  I do.  God bless blogging!

Trying to communication through language

There is no doubt in my mind that the words we use set the scene for the meaning we are trying to convey.  Perhaps it is obvious from that statement that I don't perceive  the relationship between the person communicating and the person receiving the message to be particularly simple. 

I know from my personal experience that I often try and explain something, either in person or via email, and the person I am communicating with can receive a very different message to what I intended. 

I also know from my writing that it can be laborious to try and find the right word to really convey what it is that I mean.  The thesaurus (as well as the spell check) is my friend and I consult with her often.  And then despite my best efforts, I often come back to a manuscript and have no idea what I was talking about.  Especially if it has been a while.

So I agree with both the philosophers and the structuralists who suggest that words are signposts.  And I am familiar with research that suggests in F2F communication it is as much your body language and your facial expressions, as it is your / my words.

I've heard and read many arguments about the politics of language, but today I was reading about the perspectives of Richard Rorty (as constructed by Peter Reason, a great Action Research author, in Volume 1, Edition 1 of the Action Research journal, back in 2003 - kindly shared with me by Lucy Bolger).  Rorty is a pragmatist, who studied with an older philosopher (John Dewey) whose ideas first caught my attention.

Rorty talks about the need for creating new language when we want to convey new concepts.  This is a position I have rejected emphatically for quite some time, and as with most things I am certain about, it turns out that I wish to change my mind.  Some of you will have heard my rants about stupid words like 'musicking' (should be musical participation) and 'affordances' (should be potentials) and 'reflexivity' (should just be reflections).  But in truth I have come to love each of these words because of the very special meanings they have and the ways that they are used to convey something particular that has a strong meaning to those people who find that notion important.  I've been playing with the idea of musical wellbeing myself - but more of that on another day.

Rorty provides and eloquent justification for this by explaining how using language that comes from another school of thought, and group of people who agree to that school of thought (aka Kuhn's paradigms), conveys those beliefs.  And using that language puts the new ideas into a reactionary position - rather than a creative and innovative one.  Anyway, he does say it better, with some scaffolding ideas from Peter Reason:

"If we want to argue persuasively for a new view of phenomena ... we are caught in a 'contest between an entrenched vocabulary which has become a nuisance and a half-formed vocabulary which vaguely promises great things' " (Reason, p. 105, quoting Rorty at the end, 1989, p.9)

I ended up at Rorty precisely because of this dilemma.  Paradigm thinking suddenly felt like too much of a reaction against qualitative/quantitative thinking. So dualism had become four columns (five, including a participatory paradigm, as per the SAGE handbook of Qualitative Research - the birthday present I bought myself 5 years ago:) and now post-paradigm thinking is emerging, and mixed methodology gurus are trying to find the philosophical (epistemological / ontological) underpinnings of that.  Dewey's pragmatics does have a lot to offer.

The next piece that Reason offers is about our values in relation to the kinds of research we do and the language we use to describe it. 
"We need to tell imaginative stories of new possibilities rather than build political theories" (p.111)

To me, this speaks to feminine ways of knowing, rather than knowledge derived from masculine styles.  Intuitive sensing of the next step, rather than a pre-defined plan of attack that explains where we are going before we even begin.  My personal development work with the Feminine Power school that is aligned with Wilber's Integral group has opened my mind to the possibility that I don't need to know where I am going in the future, I only need to know where I want to step next.  This may be obvious, but for me it was similarly empowering and helped me realise that I was trying to shape my life according to a way of knowing that I do not believe in.

So I retract my belief (and accompanying statements) that people who make-up words are wankers.  And as I journey forward into better understandings about the ways that mutually empowering and creative relationships can build a better world, I may even make up the odd word.  Watch out!