The Plurimodal Approach in Music Therapy

By Diego Schapira & Mayra Hugo

Introduction

We will discuss the Plurimodal Approach in Music Therapy, which we have been developing and using for several years. This approach is currently taught as a graduate course at the University of Buenos Aires (Argentina) and it has been utilized in other Latin American countries such as Uruguay, Chile, Peru, Colombia, México, and Brazil. Even though it has been mentioned as a method, we have now decided to call it an "approach".

In the Spanish language, the word "method" implies a certain degree of rigidity. So we only have one rigid, non-negotiable principle: nothing can be standardized. Plasticity is what marks the growth and transformation of the approach's structure, both in the theoretical field and in its lines of action and resources. It represents a line of work in constant evolution that accompanies, modifies and organizes our personal and professional development. Subsequently, we cannot describe it as a "method". We feel it should be named "approach". There is not a sequence of different steps to be followed during the therapeutic process or during a session.

We have studied different music therapy theories and we realize there are important connections between them. We try to build bridges between different theoretical lines that allow us to work better with a larger theoretical basis to support our actions with our clients.

All of us involved with the Plurimodal Approach state that we have thought and created a few new concepts, but above all, we have borrowed theoretical concepts from many of our colleagues, which we have synthesized and interconnected. In the following explanation, you will probably find some very well known concepts, since they belong to other authors who we will mention in each case.

The Plurimodal Approach started to emerge during the 90s, and we can say it was born as such by the end of the decade. Its name refers to two dimensions: theoretical and practical. Regarding the theoretical dimension, it is "plurimodal" because it is not inscribed in a rigid way within any of the well known "music therapy theoretical models". We have considered concepts from different thinkers and different theoretical frames that we find useful and valuable. In its practical dimension, it is plurimodal because it considers all the lines of action as equally important and it does not use any technique, procedure or resource exclusively. It also considers that different techniques, procedures or resources are not necessarily auxiliary to privileged ones. As we will discuss later, there are four lines of action that interconnect many times, but all of them are equally important and necessary. Plasticity will allow the music therapist to establish which one or ones should be privileged according to the client or population s/he is working with.

It is worth mentioning that our training, both in Argentina and Uruguay, has been closely linked to the guidelines developed by Rolando Benenzon, with a major lack of knowledge of other music therapy theoretical models. There is no specific training in any other models in Latin America. The one Benenzon postulates is actually taught outside the academic field of the university. From this point, we started our search for a theoretical basis, and we went out looking for the theories of our colleagues all over the world.

The Plurimodal Approach is based on a tight relationship between theory and practice, and it is very client-centered. In other words, even though we consider music as the main language in Music Therapy, and we are aware of the cultural frame that our clients belong to, each process with each one of our clients is tailored according to his/her uniqueness. Its development started with psychiatric clients, but now has extended to other populations.

Music Therapy, as a theoretical body of knowledge, is sustained on different pillars that interrelate to each other to configure its actual framework. Each one of them has been constituted as a three-legged stand, where its components are, at the same time, indissolubly related, as we can appreciate in the next figure:

Figure 1: Foundation for Plurimodal Approach

 

We can see that one of these tripods is constituted by:

10. Psychological, sociological, medical, educative, musical, and anthropological theories.
11. Theories of Music Therapy.
12. The Logic of Interventions. It is on this one that we will focus to make a brief reference to the Plurimodal Approach.

Figure 1 shows the elements that sustain the Music therapy system. However, it could be interpreted as something static and rigid. This is why we thought about a second figure (Figure 2), which shows the internal dynamic relationship between the elements of the system. We could think about a "molecular" dynamic, in which the components of each sub-system interrelate, as each subsystem relates simultaneously with the others. It is important to consider that in this second figure the triangle A B C turns into the basis of the whole dynamic, and that the therapeutic epistemology now considered "knowledge" as music therapy, is also constituted by "knowing" that is neither theoretical nor therapeutic.

Figure 2: Knowledge - Language - Ethic

 

The Plurimodal Approach shares basic concepts with Mary Priestley's Analytical Model - which colleagues like Inge Pedersen, Benedikte Scheiby, Mechtild Jahn- Langenberg, Johannes Eschen, Susan Hadley, Diane Austin and other prestigious music therapists have developed and continued -, the psychoanalytic theory that sustains it, and a great part of its music therapy theory. However, it differs in the lines of action that it privileges for its interventions. We consider concepts from other models, methods and trends of theoretical music therapy as thoughts that we find to be highly valuable. These thoughts allow us to open up our understanding and comprehension of the music therapy phenomenon.

In 2003, Kimmo Lethonen commented on the Plurimodal Method (recently renamed Plurimodel Approach):

"I liked the idea of the Plurimodal Method, which is a a path towards holistic and existential music therapy. The model tries to integrate different theories, models and methods together. Every working music therapist is aware of the fact that different theories and models are just like different kinds of tools created in order to understand and work with a patient. (p.160) The Plurimodal Method of music therapy is a typical post modern model, which is taking the best parts of the existing theories and models and integrating them into the same holistic model." (p. 161)

In a brief summary of the theoretical foundations of the Plurimodal Approach, we can say that our approach:

1. Considers the human being as bio-psycho-social.
2. Considers the idea of "the unconscious."
3. Agrees with the idea that every person has a total record of his/her life experience, which conditions his/her present and his/her future (psychic determinism).
4. Agrees with the idea of the "inner music."
5. Considers that during the music therapy process, the same defense mechanisms that appear in an analytical psychotherapeutic process unfold.
6. Conceives the concept of music therapy transference.
7. Adheres to the concept of musical countertransference.
8. Considers the "framework" as a basic element that allows the musical therapeutic phenomenon to unfold.
9. Adheres to the postulates of "Musical origins."
10. Considers the concept of "analogy" in its conceptualization.
11. Considers the concept of "metaphor" in some instances, as for example, when using the SISS (Stimulation of images and sensations through sound) technique.

In its practical dimension, its name (plurimodal) is justified in the development of four lines of action, which interplay permanently along the development of the music therapy process. It is not only improvisational music therapy, nor is it music therapy working with imagery and music, nor is it using songs in different ways. There is a permanent interplay of its lines of action, which can be privileged or not taken into consideration, according to the population we are working with or the moment of the music therapy process which a client or group of clients is going through. The four lines of action are:

1. Therapeutic music improvisation.
2. Working with songs.
3. SISS technique (Stimulation of images and sensations through sound).
4. Selective use of edited music.

Every client we work with, who goes through a music therapy process within the Plurimodal Approach is considered a subject, an individual with his/her own psycho- physical reality, whose suffering is unique. At the same time, this subject presents to us his/her own "Non Verbal Expressive Modes" (NvEM). The music therapist has a duty to try to know them, maintain them and respect his/her cultural identity.

We consider that every individual has a total record of his/her life experience, which conditions his/her present, and his/her future. This means that each proposed technique, in each session, not only considers what can be observable, but considers that what is happening is conditioned by the client's present and by elements of his/her story which are activated in the session, as well as by the expectations and/or the consequences of the activation.

Subsequently, the sessions within the Plurimodal Approach are not programmed in advance. There is no standardized session structure, no program to develop. Even though we may have an idea of what will happen during the session, there is no previous plan for one session, except for the preparation of a sequential SISS structure for a specific and determined moment. However, even in these cases, the music therapist analyzes the convenience and opportunity of proposing this technique or resource and, if what happens during the session claims to go through a different path, the previously determined plan is discarded. What is privileged is the way to find the proper path in every moment, not a certain resource. So the proposals - that is to say, the interventions, instructions, and designations - respond to:

1. The analysis of the process that the Music therapist has practiced previously.
2. The displayed "theme" and the unconscious "material" brought by the client at the beginning of the session.
3. The elements with which the music therapist works during the session (framework).
4. The analysis made "in situ", by the music therapist, during the session.

Regarding point a), the music therapist conceives their client's treatment as a process, and has to elaborate a hypothesis based on the reality that the client goes through, and on the way s/he is starting his/her music therapy process. This implies, in the populations in which it is possible, both the analysis of the transference and of the clients' sonorous speech, and the analysis of the dynamic and group process in the case of collective sessions.

When we talk about "material", we refer to the client's "unconscious material" during the session. This is the object of analysis. Nevertheless, it is also important to consider the ways in which this material shows up, and that constitutes his/her non-verbal expressive modes. Sometimes it has to do with the way the client is dressed, or with the tone of his/her voice. At other times, it has to do with the client's direct references regarding experiences from previous sessions. The material can also appear in objects that the client brings to the session, like a recorded song or a CD or tape for the therapist to record in it a song that was played in some previous session. We consider all of this material as part of the client-music therapist dynamic.

Point c) refers to the elements that are part of the setting and constitute the variable material of the framework.

With the "in situ" analysis, we allude to the transference and countertransference analysis, but we will not deepen this item at this time.

Working with Songs

One of the privileged materials that music therapists have are songs. They have been created by practically every culture and have been transmitted through generations. They tell stories, recreate feelings, and describe situations. They are part of our daily life and they are hidden in our personal memory, building the sonorous history of each individual while they create and consolidate the cultural heritage of each community.

The environment we are in is also a world of songs. How can we use this huge amount of material incorporated in our unconscious, in music therapy processes? How could we not consider as part of the music therapy setting, those infinite musicants[1] built through our whole life? How can we not generate new musicants as songs, during the process each client goes through? When we sing, music gives us the perfect way to say something to ourselves. This is very useful for the client in music therapy because it can help him/her shape his/her thoughts, feelings, emotions and ideas, and help him/her get in touch with feelings that cannot find their way to the surface through spoken language. Songs carry a message, which acquires a unique meaning for each person. Songs carry musical significance, "musicants". We sing. It does not matter how we sing. That has to be one of the first agreements to establish within the musical therapeutic phenomenon no matter what is sounding in aesthetic terms. What is important is what flies in the voice, what the song enlightens in the darkness of the unconscious. What matters is the musicants because they will be the material to analyze. Songs constitute the symbolic archive of our past, the report or metaphoric exposure of our present and the melodic consolidation of our wishes, fears and anxieties regarding our future.

In the Plurimodal Approach, we use different ways of working with songs:

• Creation (composition).
• Singing together.
• Improvisation.
• Conscious evocative induction.
• Unconscious evocative induction.
• Exploring material.
• Free singing association.
• Projective song questionnaire.
• Sense expansion.

Obviously, many therapists use these same ways of working with songs. What is important for us is to be able to systematize the use of songs and to formulate goals or appropriate moments for each one of them.

Each stage of our lives is marked with songs: the ones that were sung to us in our early childhood ; the ones we learned in school; the ones we listened to again and again during our adolescence; the song we once shared with a date; the one coming from our neighbor's house that irritates us so much; those we pick up to loosen up after work at the end of the day. Songs are with us through a whole life. There are literally thousands of them treasured in our memory. They emerge when we need to say something to ourselves. Each song is a message to be decoded. Songs can try a love statement, express grief or loneliness, reveal a secret, make up stories, and show a wish. They have been conceived in intimacy, materializing in the musicants all kinds of affects, emotions and feelings.

The SISS technique

The stimulation of images and sensations through sound (SISS) is one of the 4 axes of action proposed by the Plurimodal Approach.

It consists in listening to a sequence of musical stimuli, tailored by a music therapist for a client's singular situation or for a group of clients during their therapeutic process. In a sense, this can be considered as a theoretical and practical modification of some of the postulates of The Bonny Method of GIM. Although there are a few similarities with The Bonny Method of GIM, it is considerably different in its origins, in its elaboration and in the way it is used. The SISS is a technique, an operation initiated by the therapist to generate a possible immediate response in the client and to contextualize his/her experience. Although SISS is designed to have an immediate effect, usually it has repercussions that come up in future sessions.

One of the characteristics of SISS compared to GIM, is that the therapist does not give instructions to place the client in a special scenario or offer a previous title for the experience. There is one only one instruction, which does not assume to be orientative or inductive, but assumes to describe the process that clients may go through during the experience. Another difference is that there is not a previous assessment of the moods that the selected musical stimulus could induct. Because of this, no standardized sequences are constructed. They are built taking into account the Non-Verbal Expressive Modes of the client or group of clients. Sometimes the same sequences are used with populations that share a cultural frame and the Non-Verbal Expressive Modes of those for whom sequences were created.

All types of music are used in SISS, with and without lyrics. The mood of intimacy and its related permeability that sometimes is reached within a session, allows the possibility of realizing or perceiving things from oneself. Music in SISS is not standardized. It is chosen by the therapist and it is selected considering both the development of the sessions and the things that happen during the sessions. Each session is specifically tailored. And this is one of the ways of emphasizing the unique work of music therapists. Music can be an instruction. Music, when selected by the music therapist within the SISS technique, is interpretation.

Selection has to do with stimulation of images related to the client's individuality, or it might be linked to the group process. For individual cases, a stimulus can be related to:

1. Client's history.
2. Client's current situation.
3. Projects or future situations.

As for groups, the musical selection will tend to stimulate things related to:

4. Emerging group issues.
5. Latent group issues.
6. Individual situations within the group.

The choice of stimulus is wide. In any of these six instances, erudite music can be used, accepting GIM's hypothesis that it has no fixed sense, which implies that the stimulated image has no limits in its content. This mainly occurs, indeed, when this kind of music does not belong to the patient's socio-linguistic group, and it is not part of his/her Non-verbal Expressive Modes. In the same vein, we sometimes appeal to jazz. However, we often use popular music. Since SISS is not a method but a technique, it can be used adapting it to the NvEM of the people that we are working with. There are no limits to its use, and it can probably be oriented towards particular historical moments and particular social segments. Music with lyrics is used for the same reason: to give the client the possibility to hear something relating to what he has been working with, in a different emotional state, and told by a different voice other than the music therapist's.

The sequences can have a variable duration, depending on the population to which they are applied. The selected stimuli are arranged as a sequence, that is to say, a series of musical expressions, in which each element presents variations in different dimensions. Initially, the length of each fragment is different within the sequence. It is never a full theme, but just a part of it. The idea is that each fragment lasts for a different period of time than the preceding fragment and the subsequent fragments, so as to avoid an accommodation from the client that would cancel the possibility of a surprise. Secondly, the parameter of variation is usually historical. This means that the stimuli that were chosen with a determined objective, may belong, if possible, to different moments of the patient's life, so they will promote the generation of images and sensations. The underlying idea is that the sequence stimulates different types of memories, and that traces in his/her biography, paintbrushes of his/her story, elements of his/her NvEM allow him/her to approach unconscious contents, repressed elements.

The SISS was initially used with neurotic adult patients. Then it was satisfactorily used with other populations, such as elders, children from special schools, patients with neuromotor disabilities, neurological diseases, addictions and psychiatric diseases. It is also currently used in the area of health promotion and protection, with children from marginal neighborhoods, in minority homes, with pregnant women, and in the area of Music Therapy in Medicine, with oncology, intensive care and comatose patients. It has adapted to each field of application, regarding the length of the total sequence, the margins of duration of the fragments, and the number of stimuli presented. In every case, the SISS has been an effective resource if the client or groups' NvEMs are taken into account.

Therapeutic Music Improvisation

Improvising means doing, making up or creating something without previous preparation. It implies creating something suddenly, with the available elements at the time. In art, to improvise means to create music in a spontaneous way while playing, in contrast to interpreting an already composed piece. In the Plurimodal Approach we think that therapeutic musical improvisation and preconceived notions of improvisation are distinguished as a tool or therapeutic resource by the quality of the objectives. Improvisation, in our Music Therapy context means the formulation of musical structures that reveal, through the emergent generation of the patient's intramusical contents, aspects of his/her intrapersonal universe; and based on the intermusical contents between the patient and his/her relationships, or between patient and music therapist, the interpersonal dimension. Through improvisation, the patient's NvEM, style, ways of relating, ways of expressing are revealed. The improvisational micro- cosmos can show us the individual's macro- cosmos of relationships.

One of the basic differences between musical improvisation and therapeutic music improvisation, is the fact that in the latter we do not search for the formulation of musical elements with an aesthetic purpose, but, as the revelation of the patient's structure of personality, his/her self revelations. In that sense, the artistic content of the generated sound product is of no importance. The important things are the musicants (musical significants) that imbue the musical improvisation in the Music Therapy context.

A therapeutic music improvisation (TMI) can have diverse shapes according to the desired objectives. It is not the same to propose a TMI in which the patient improvises alone, as it is to improvise with the music therapist. Nor is it the same to propose an instrument for the improvisation as to let him/her make a free choice. The techniques have been designed to allow an immediate reaction from the patient, in order to achieve the proposed objective.

In the Plurimodal Approach we always state that we take valuable theoretical developments from other colleagues, and there is no doubt that there is a lot written about the TMI. Kenneth Bruscia points out that in a proposed improvisational experience, three variables must be taken into account:

• Interpersonal setting.
• Media.
• Point of reference.

We have added some of Johannes Eschen's considerations to this proposal, since we believe that they create a good complement. When we refer to interpersonal setting, we have to consider if the client improvises alone, together with the music therapist, or with the group, and we include Eschen's "improvisational rondo" modality.(Eschen 2002) This determines the interpersonal context in which the patient will make music. According to the way the situation unfolds, the music therapist will determine the setting, or will leave the determination to the client.

When we talk about the media, we refer in some way to the use of music described by Priestley. That is to say, if the client uses musical instruments, his/her voice, his/her body as an instrument or his/her partners or therapist's body. "Each has its own projective significance, and each provides a different medium for expressing transference and countertransference" (Bruscia, 1998, p.6). Once again, the music therapist will determine whether the client will choose the media for improvisation, or if the therapist will establish it.

When referring to points of reference, we consider whether there is an a priori allusion or not that influences or determines the improvisation., for example, if a free improvisation is proposed, or if the client is engaged in describing something relating to the development of his process. This could be an image, an idea, a phrase, a feeling on which the improvisation will be based. At this point it is also useful to think about descriptive, associated or oriented material referred to in the TMIs, according to the character and the related objectives. The various points of reference are also related to the population that we are working with. In the case of neurotic clients, all forms of referential TMIs will be adequate, and they will be performed according to the therapeutic objectives that the music therapist establishes during the process or a specific session. However, associative TMIs would not be adequate or possible for clients suffering from some types of mental disabilities or neurological diseases, while the "descriptive" or "oriented to material" form of improvisation could be highly beneficial to some.

Once the improvisation takes place, the problem that arises is how to interpret it from a therapeutic perspective. During the first years of development of the Approach we exclusively used the IAPs (Improvisational Assessment Profiles) designed by Bruscia. However, quite recently we have included in the TMI analysis and some theoretical considerations of Morphological Music Therapy. We basically consider the six factors considered by the Morphological MT, identifying the origin factor, as an indicator of the global character of the improvisation. We consider that both tools (IAPs and Factors) are by themselves extremely valuable for the TMI analysis, and each one emphasizes particular elements. Nevertheless, combining both has made the understanding of them much easier. The identification of the origin factor, besides providing us greater information about the character of the TMI, exposes aspects of it that facilitate interpretation. This also provides additional information in the use of the Improvisational Assessment Profiles.

It is not the intention of this exposition to keep talking about the IAPs, since they have been published a long time ago. The six factors proposed by the Morphological Music Therapy are appropriation, transformation, order, effect, display and tool (Bauer, 2002).

Psychic problems and symptoms presumably can be described through these 6 factors. Since they also play an important role in Music Therapy, there is , according to Morphological Music Therapy, an essential coincidence between the acting in Music Therapy and the development of a psychic gestalt.

It is worth mentioning that we have found an important relationship between the IAPs and the six factors. For example, the factors of transformation and order refer to variability and integration profiles, and the identification of the effect factor leads us to focus on autonomy and tension profiles.

Selective Use of Edited Music

This line of action came up as a need to establish criteria for the use of edited music in the Music Therapy session. Based on the primary idea that music can have multiple meanings, therefore, there is not only one sense of application for a certain stimulus. Using edited music requires a great amount of plasticity. We firmly believe that there is no such thing as "music for" or a musical pharmacopoeia in which determined music can be applied as a remedy. The use of edited music, again, responds to the evaluation criteria that are implemented at the time. This is also a line of action, which is consistently tailored considering each moment of each client or group.

The criteria for selecting edited music are organized around 3 elements: therapist, client and music.

• From the therapist's viewpoint
• He/she will select according to the music s/he knows, according to those things that resound in him/her, according to his/her musical tastes.
• He/she will select according to the subjective level, that is, translated in what s/he can show or tell of his/her own self through the proposed music.
• He/she will set the objectives that ascribe to the conductor thread of the therapeutic process, taking into account the things that happened with the client or group of clients.
• He/she will consider the transference and countertransference aspects.
• From the client's viewpoint - We also consider some points that have already been mentioned from the therapist's viewpoint, as a reference, since it is important to maintain the continuity of the therapeutic process. In that sense, we consider:
• The client's sound history.
• His/her current situation.
• The immediate or long-term projects this person has.
• His/her musical likes and dislikes.
• His/her age and gender.
• If we work with groups, the clear and latent issues that have surfaced, as well as the situation of the people within the group.
• These points will be approached considering the Non-verbal Expressive Modes, to which we will respond through the music selection.
• From the music - Besides the Improvisational Assessment Profiles, within the line of music we propose to consider:
• The musical genre.
• The lyrics.
• The instruments used in it.
• The musical period to which the music belongs.
• The number of interpreters.
• The gender of the interpreters.
• The function of the music:
  1. Instruction: holds, completes and supports the verbal instruction.
  2. Interpretation: says, points out and interprets from the transference interpretation.
  3. Association: mobilizes in different levels, making it possible to associate images and sensations connected to feelings.

Intensification, for instance, does not require an active or very rhythmic music, but one that introduces and allows developing the things that come up in the sessions. It is not an introduction; it is a part of the session in which contents can be elaborated. In the same vein, an active relaxation does not necessarily demand quiet music; sometimes a song with a meaningful content can be used as a way to close a session.

Summary

The Plurimodal Approach, which has been summarily presented, was originated in the mid 90s in Argentina and Uruguay, and it is currently being used in several Latin American countries.

It is characterized by the construction of a supportive theoretical body that borrows from important Music Therapy thinkers, building bridges between different theories, and generating some concepts of its own. Another characteristic is that so far, we have established, four lines of action: therapeutic music improvisations, working with songs, SISS and the selective use of edited music.

The Plurimodal Approach does not privilege one way of working, and the music therapists that work with this approach must select the most appropriate resource, according to the client's characteristics, and to the therapeutic process moment.

Notes

[1] When we talk about musicants, we are referring to the concept first formulated by the Brazilian music therapist Martha Negreiros, the "musical significant", which is the cell of the musical language.

References

Bauer, Susanne (2002). La Musicoterapia Morfológica [The Morphologic Music Therapy]. Unpublished paper presented at II Jornadas Colombianas de Musicoterapia [II Colombian Music Therapy Journeys], Universidad Nacional de Colombia, Bogotá.

Bruscia, Kenneth (2003). Reconocer, Descubrir, compartir... en Musicoterapia. [Recognize, Discover, Share...in Music Therapy]. Buenos Aires: Ediciones ASAM.

Bruscia, Kenneth (1998). The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers.

Chagas, Marly (1990). Ritmo, Som, vida In Energia e Cura [Rythm, Sound, Life in Energy and Cure]. Quiron, Centro de Estudos e Práticas Transomáticas. Revista de Cultura Vozes, ano 84, volume 14 set/out Petrópolis: Editora Vozes, 585 - 592 [Quiron, Center of Transomatic Studies and Practices Voices Cultural Magazine, 84 (14) set/out Petrópolis: Editora Vozes, 585 - 592].

Eschen, Johannes (2002). Analytical Music Therapy. London: Jessica Kingsley Publishers.

Lethonen, Kimmo (2003). Towards Holistic and Patient-Centered Music Therapy. Nordic Journal of Music Therapy 12(2), 160-162.

Mendes Barcellos, Lia R. (2004). Musicoterapia. Alguns Escritos [Music Therapy. A Few Papers]. Enelivros. Brasil.

Milleco, L & Milleco R. (2001). E Preciso Cantar [We Need to Sing]. Rio de Janeiro: Enelivros Editora.

Priestley, Mary (1994). Essays on Analythical Music Therapy. Gilsum, NH: Barcelona Publishers.

Schapira, Diego (2002). Musicoterapia. Facetas de lo Inefable [Music therapy. Facets of the Ineffable]. Rio de Janeiro: Enelivros Editora.

Wigram, Tony; Pedersen, Inge. & Bonde, Lars Ole (2002). A Comprehensive Guide to Music Therapy. London: Jessica Kingsley Publishers.