Developing a Music Therapy Programme within a Person Centred Planning Framework
Introduction
This report describes the development of a music therapy programme in a day facility for adults with disabilities in the west of Ireland with particular reference to person centred planning (PCP). PCP is a model for service provision for people with disabilities which puts the interests, goals and abilities of the focus person at the centre of the decision-making process. This contrasts with more traditional methods of service delivery based on the medical model of disability.
The article compares the core features and outcomes of the PCP process with concepts which have informed the author’s personal orientation to music therapy as derived from literature on humanistic music therapy, community music therapy and music therapy for empowerment. Implications of coordinating the music therapy programme with the PCP process as implemented at the facility are also suggested. Coordination of the music therapy programme with the PCP process is considered a valid means of addressing client needs in a client-centred, resource-based manner while also providing a shared vocabulary and common goals for communicating with family members, service workers, professionals and administration.
Development of the Music Therapy Programme
I began working as a music therapist with Enable Ireland in late 2006. Enable Ireland is a voluntary national organisation which provides services for children and adults with developmental disabilities all over the Republic. I was contracted by an adult day facility within this organisation in the west of Ireland. This facility provides therapies, training and opportunities for personal development to adults in the locality.
A music therapy service had been running in this facility for two years before I became involved in a professional capacity. When I took over the music therapy programme the service was in a state of transition. The facility was undergoing renovations, so it was necessary to conduct music therapy sessions off-site for the first six months as the interim facility was not conducive to music therapy. Initially, I was contracted for only two hours per week. Service users travelled to sessions by bus. This did not always allow for flexibility in terms of planning but it was noted it did provide a sense of independence for those who were attending music therapy. However, I felt quite isolated in my work. For the first period of off-site sessions, I had little contact with facility management, other therapists, key workers or advocates.
Through my work with the clients, both on an individual and group basis, issues of independence, empowerment, individuation and expression became apparent. At this time my work was influenced by descriptions I had read and heard presented in course lectures in my training of community music therapy, humanistic music therapy and music therapy with reference to empowerment theory. As such the programme focused on providing an open, client-centred space with the intention of providing opportunities for developing strengths and resources rather than addressing so-called pathology. It was important to me that clients feel a sense of control over the means of promoting their own well being. Working collaboratively with my clients within an open space and relying on their input felt a natural and responsive way of working to me.
When the newly renovated facility opened I had the opportunity to create a music therapy space within a room in the facility and at the same time came more into contact with the community as a whole. The scope of the music therapy programme broadened as I received more self-referred clients from the community of service users. As well as the more clinical work of addressing certain clients’ needs in terms of communication, self-regulation, social engagement and mental health; many service users were now also seeking access to music therapy as a means of self-development. Some wished to learn an instrument, experiment with music technology, or compose songs; while others simply requested a space to “chill out” and take a break from their busy training schedules. In recognition of the value of music therapy to the service users and to satisfy the increased demand, funding was increased to expand the service. The programme now consists of a two days of sessions with the number of service users accessing it having grown from seven to twenty-seven.
Current Music Therapy Service
The current music therapy service at Enable Ireland Adult Services is influenced by concepts from humanistic music therapy, community music therapy and music therapy as a form of empowerment. A variety of methods are used to help service users to develop strong musical identities, explore diverse forms of expression and deepen relationships within the community in a client-centred context.
Groups use singing and discussion as a way to develop their identities and relationships with each other. This has been valuable to long-standing groups as the service users negotiate their relationships with each other as they individuate. New service users have also benefited from joining music therapy groups as it has helped them to make new friends in a context which is motivating and familiar. In Ireland, group singing is a common social activity, particularly in traditional music circles, where “sessions” are informal and anyone may join in. Group members may choose a song for themselves or for another member, creating significant opportunities for interaction and expression. There is a great variety of tastes in the group and a major outcome of the groups has been the growth in acceptance of each others’ differences.
Lyric analysis has allowed group members to explore various themes, such as the transitory nature of negative mood states, childhood memories and representations of self concept. This has always been an incidental feature of sessions, where the group’s own discussions lead to these analyses, rather than lyrical material being presented by the therapist.
Song-writing and performance have also given groups a sense of communal pride and accomplishment. Instrument playing facilitates non-verbal communication and promotes awareness of self and others.
Individual sessions offer clients opportunities for self-expression, relaxation and emotional support within the context of the therapeutic relationship.Clinical issues relating to communication, behaviour, movement and withdrawal are also addressed. Again, the pervasiveness of music in Irish culture has often influenced the structure of sessions. High energy Irish songs are popular with clients and have been effective as part of music therapy sessions focusing on drive reduction, while clients have also been able to access childhood memories and other positive associations through their relationship with Irish music.
Music instruction is a much requested activity and currently some service users are learning violin, keyboard and guitar respectively. They have shown their work through performance and have all named the performance as an important part of the process for them. Adapting the instruments (using open tunings for example) and developing accessible forms of notation has sometimes been necessary. Outcomes of the instruction relate to positive self-concept, mastery, choice making and self-expression, cognitive stimulation and engagement as well as musical proficiency.
Musicians in the community are now beginning to collaborate on projects of mutual interest. For example a man learning to play guitar has recruited a keyboard player and a group of singers to practice and perform the anthem of their favourite football team.
Music technology plays an important part in providing access to music. Service users have used the technology resources (MIDI instruments, microphones, audio interfaces, sampling software and sequencers) to create original music, remixes and compilations as well as for group improvisation. The resources used give service users as much control over the music making process as possible as well as providing the opportunity of sharing their music by making CD’s. A grant has been awarded for the setting up of an in-house radio station which will be one way for the service users to share their creations with the wider community.
A Christmas concert offers service users the opportunity to experience themselves as a musical community. The concert is not only a way for those who already access music therapy to share their experiences, demonstrate their abilities and take pride in their work, but also a way for new ideas to come from the community as a whole.
Clip 1: G. wrote a country song based on ideas that had come from our discussions in individual sessions. The chorus "talking helps me feel better/it takes the pressure off" is included here. The drums and keyboards were recorded using MIDI and drum loop software, with G. deciding on the exact parameters. A software sequencer was used for overdubbing the instruments and double-tracking the vocals. An audio interface was used to connect a microphone to the computer and add reverb to the vocals. G. is looking forward to creating an album's worth of such material.
Talking Helps Me Feel Better [.wav, 5,24 MB]
Person Centred Planning
As more and more referrals began to come from service users themselves, I felt the importance of collaboration and negotiation as the basis of the beginnings of therapy, rather than a referral from another professional – especially when the goals were not based in addressing a deficit or difficulty, but in enhancing ability, creating opportunity and promoting wellbeing. At the same time, I wished to address these issues in a systematic manner, fitting into the work of the community as well as possible. As such, I became more aware of the person centred planning process as implemented at the facility and began to see many parallels between this process and the developing music therapy programme.
The provision of services within Enable Ireland is based on the Social Model of Disability. This model “focuses attention on the person not the impairment. Access, inclusion and equality are considered for people with physical disabilities as for people without” (Enable Ireland, 2005, p. 33). As such, services, supports and activities are provided based on the expressed needs, abilities and interests of the service users. This is achieved through person centred planning (PCP), where each service user has the opportunity to direct and design his or her own service. The process is “firmly embedded in the work of the organisation as a basic requirement of a partnership approach to service delivery” (Enable Ireland, 2005b, p. 7).
The person centred planning process is the defining feature of the service offered by Enable Ireland adult services. The PCP process develops a holistic personal profile with the service user setting objectives based on personal aspirations and using a capacity searching approach. This process “assists participants to identify their strengths, needs, abilities and preferences resulting in the formulation of individual person centred plans based upon realistic goals” (Enable Ireland, online).
Features of Person Centred Planning
Person centred planning can be implemented in different ways but each approach is based on common features (O’Brien, 2000).
Capacity Driven. Firstly, PCP is driven by capacity, not deficit (O’Brien, 2000). O’Brien, O’Brien and Mount explain that as such PCP “does not ignore disability” (2000, p. 20), rather attention is shifted to the identification of capacity in the focus person, as well as in friends and family, community and service workers. Specific limitations are considered, but only so that creative ways can be developed for the person to pursue their chosen lifestyle (O’Brien et al., 2000). This contrasts with the traditional service model where service delivery is dictated by the general type of impairment; for example, learning difficulty, sensory impairment or loss of mobility. This usually involves an assessment where the impairment is quantified and analysed as to its effect on the person’s life (Sanderson, 2000).
Focus on the Individual. Person centred planning must therefore focus on the individual rather than the group. This individual and his or her wishes are the most important reference for the entire process (National Disability Authority, 2005). As Sanderson (2000) puts it:
Traditional planning has sought to fit people into existing service models and solutions, an available ‘bed’ or a place in the day centre. Person centred planning describes the support needed from the perspective of the person, and then designs a unique arrangement for getting that support. (p. 7)
Flexible, Dynamic and Informal Process. Person centred planning is characterised by a flexible, dynamic and informal process (O’ Brien, 2000) based on learning through shared action (O’Brien & Lovett, 1992). The aim is to find “creative solutions rather than fitting people into boxes ... about problem solving and working together” (Sanderson, 2000, p. 8). This is not an easy process and requires clarity, commitment and courage of those involved. Treated simply as a technique, the person centred planning process will have little to offer the focus person (O’Brien & Lovett, 1992).
Collaboration, Not Competition. An additional challenge is for those involved in the process to ensure that collaboration rather than competition defines the process (O’Brien, 2000). O’Brien et al. (2000) suggest that it may be likely that the perspectives of the focus person, family members, friends and professionals may differ or even conflict. Person centred planning requires “collaborative action and fundamentally challenges practices that separate people and perpetuate controlling relationships” (O’Brien & Lovett, 1992, p. 6). The focus person is considered the first authority on his or her life with dialogue with other people – family, friends, or service workers – building on this (Sanderson, 2000). Professionals involved must recognise “personal commitment and knowledge [as] the basis of involvement and authority rather than administrative responsibility or professional role” (O’Brien et al., 2000, p. 19).
Shared Understanding. Ultimately, shared understanding about the focus person will reflect those things which are most important to them, both in their present experiences and in their desires for the future. Through the person centred planning process the person begins to experience tension between what is desirable and what exists (O’Brien and Lovett, 1992). This energises action for:
Positive change, the final feature person centred planning (O’Brien, 2000).
Outcomes of Person Centred Planning
Outcomes of the person centred planning process are considered in terms of five essential accomplishments or “valued experiences” which ensure inclusion in a community and promote quality of life (O’Brien, 2000). O’Brien elaborates:
Each points to experiences which it makes sense for a person to seek more of; together they indicate a balance of experiences to make effort worthwhile. History shows that people with disabilities are likely to miss these ‘ordinary positive experiences’. (2000, p. 134)
Community Participation. This is the experience of being part of a network of growing relationships and is considered a significant outcome of a mindfully implemented PCP process (O’Brien, 2000). Valuable activities provide active opportunities for a person to meet variety of people and develop variety of relationships.
Choice. The experience of choice is also important as it expresses and defines identity (O’Brien, 2000). Smull (2000) identifies three concepts as influencing the degree of choice a person has: preference, opportunity and control. These are complex concepts for focus persons and those helping to implement to negotiate (Smull, 2000). For example, in the satisfaction of a preference, capacity may influence control while timing may influence opportunity (Smull, 2000). In addition, it is in increasing the power held by people with disabilities that choice is maximised (O’Brien et al., 2000) which “challenges the culture of most human service agencies” (O’Brien & Lovett, 1992, p. 8). Traditional service delivery tends to value uniformity and predictability more than the needs of the individual (O’Brien & Lovett, 1992).
Contributing. By developing the skills to perform functional and meaningful activities, a person with a disability experiences a sense of competence and of contributing. This usually involves focused effort on the part of all who participate in the process – providing opportunities, instruction and assistance (O’Brien, 2000). Valuable experiences “increase a person’s power to define and pursue objectives which are personally and socially important” (O’Brien, 2000, p. 135).
Community Life. Community life is defined by the experience of community presence; the sharing of ordinary places (O’Brien, 2000). This may need to be achieved by changing common patterns of community life, the aim being to reduce segregation, denial of opportunity and the perpetuation of stereotypes (O’ Brien & Lovett, 1992). Valuable experiences increase the number and diversity of spaces a person may have access to while (O’Brien, 2000), as the PCP stimulates “community hospitality and enlists community members in assisting focus people to define and work towards a desirable future” (O’Brien & Lovett, 1992, p. 6).
Dignity. Finally, O’Brien defines the experience of dignity as essential in ensuring inclusion and promoting quality of life (2000). Honest person centred planning can only be achieved by respecting the dignity of the focus person (O’Brien & Lovett, 1992). Dignity is experienced when a person has a “valued place among a network of people and a valued role in community life” (O’Brien, 2000, p. 135). Valued activities “challenge limiting negative stereotypes and provide access to valued roles” (O’Brien, 2000, p. 135). Developing ways to communicate the importance of respect and equality to others involved with the focus person is also helpful (O’Brien & Lovett, 1992).
Parallels in Music Therapy Literature
There are many parallels between the above concepts and some of the descriptions of community music therapy, humanistic music therapy and articles which discuss music therapy with regard to empowerment theory. Of course there is overlap between the descriptions themselves; however for the purposes of this article, they will be taken separately.
Humanistic Music Therapy
Although humanistic psychology is not referred to directly in literature describing person centred planning, there is a common focus on the self-directed development of the person. Humanistic psychotherapy, or person centred counselling is rooted in the concept of “unconditional positive regard” (Rogers, 1961, p. 47) and the conviction that each client contains within them the means for overcoming the obstacles in their lives; that they are the driving force of their own therapy.
Certain music therapy approaches, such as Orff Music Therapy (Voigt, 1999), Creative Music Therapy (Aigen, 1996), as well as the approach described by Boxill (1985, 1997) draw on humanistic psychology; embracing the belief that the person should be viewed as a whole, not merely the sum of their parts.
Boxill’s work, in particular has been a particularly strong influence on the music therapy programme at Enable Ireland. Boxill developed an approach to music therapy with people with developmental disabilities which focuses on developing the awareness in a client of self, others and environment (1985). Among the concerns (drawn from humanistic psychology) of such an approach, Boxill (1997) lists creativity, emotional wellbeing, basic needs gratification, naturalness, self-growth, self-actualisation, courage, and responsibility. Humanistic concepts such as intrinsic learning, “which leads the person toward participation in the external world and affords personal fulfilment and wholeness” (Boxill, 1985, p. 72) and human relationships “which lead a person on the path to becoming a developed self” (Boxill, 1985, p. 72) are emphasised as essential elements of the music therapy process and have corresponding requisites in the person centred planning process.
Empowerment
Person centred planning is concerned with increasing the power people with disabilities have over their lives as well as the sharing of power between those helping to implement the process (O’Brien et al., 2000); family, friends, professionals or administration. As such the requisites of the process are echoed in descriptions of the music therapy process from the perspective of empowerment theory.
Daveson recommends that music therapists blend empowerment theory with clinical methods so that they “are provided with opportunities to enable themselves and the people accessing their programs” (2001, p. 36). She emphasises participation, ownership, growth and collaboration as qualities required to promote empowerment within the therapeutic process. Brown’s action dimensions of empowerment (1991; cited in Daveson, 2001) read much like the core features of PCP (O’Brien, 2000). They are to affirm people's humanness and uniqueness, link people with resources and hence, open up greater life opportunities, provide an open space, establish a sense of togetherness and to connect people with each other encouraging them to work together, legitimise or validate individual or group experiences and to develop a heart for justice and compassion, a mind for analysis and hands for skilful, sensitive and disciplined action.
Similarly, Rolvsjord states that:
Therapeutic effort within a philosophy of empowerment implies focus on the client’s resources and potentials rather than on their weakness or pathology. Thus, it involves recognition and acknowledgement of resources and potentials as well as development and learning of skills and competences which will promote self-determination and participation. (2006, para. 18)
Rolvsjord, Gold & Stige (2005) give a list of therapeutic principles for a resource-based approach to music therapy which include focusing on a client’s strengths, potentials, the recognition of competence and collaboration with clients over goals and methods of working.
Community Music Therapy
Literature discussing Community Music Therapy (CoMT) has also been useful in developing the music therapy programme at the facility. The parallels between the music therapy process and the PCP process are perhaps most obvious when viewed from this perspective within a community; collaboration and positive change are core features of both approaches.
In its ultimate aim to “move clients from therapy to community” (Ansdell, 2002, para. 86), CMT shows its congruence with the PCP model, and both reflect the shift in the philosophy of service provision in many parts of the world over the past decades. Ruud has suggested that “the focus of CMT seems to lie in its insistence upon therapy becoming more relevant to the actual social life of the clients and specifically his/hers partaking in the society at large” (2004, para. 3). Ansdell states that the overall aim of CMT is “to cultivate musical community wherever the therapist and clients find themselves, and to negotiate this with an awareness of social and cultural context” (2002, p. 86).
A music therapist working from this perspective aims at helping a client experience “different aspects of inter-personal relatedness, emotional exploration, celebration or communal feeling ... working directly with the manifestations of pathology – though the ultimate aim is to get beyond pathology” (Ansdell, 2002, para. 86). As in PCP, collaboration is encouraged between music therapists and musicians in the community as well as other therapeutic disciplines (Ansdell, 2002).
Implications of Coordinating the Music Therapy Programme with the PCP Process
As the music therapy programme at Enable Ireland continues to develop, its aim will be to embody the features of person centred planning. The experience of music making itself, either as a form of personal expression, skill development or group activity is strongly considered to be a “valued experience” (O’Brien, 2000) which could satisfy all of the outcomes of the PCP process. The coordination of the music therapy process with the person centred planning process is still at a very early stage, however certain implications have become apparent.
Awareness of the core features of PCP and the aimed-for outcomes have helped to refine the music therapy programme while maintaining the influence of the aforementioned music therapy concepts. The core features have been useful in guiding my participation in sessions as a therapist while the outcomes serve as overarching goals which can be refined and individualised as therapy progresses. Session structures and methodology are decided through collaboration and experimentation and goals are an emergent property of the therapeutic process. Service users at Enable Ireland are building up an impressive body of compositions and music skills and are deepening their relationships with one another by sharing them. It is hoped that through projects such as the radio station, service users can bring their skills, experiences and aspirations into the broader community.
The coordination of the music therapy programme with the PCP process also has implications outside of the immediate therapeutic situation. The implementation of PCP at this particular facility is built around the concept of the “circle of support” – a group of people chosen by the focus person to help them define and achieve their goals. As mentioned above, this requires the sharing of information and expertise as part of a dynamic, informal process. This could be considered PCP’s analogue of the multi-disciplinary team. As a format for facilitating communication and collaboration between those included by the focus person, the PCP model can promote understanding of the music therapy process and elicit support, creativity and commitment from everyone involved to help the focus person achieve their goals.
At a time when health cutbacks are part of daily life in services in Ireland and staffing difficulties are prevalent, highlighting these similarities to Enable Ireland’s administration has been effective in maintaining the role of music therapy in the lives of the service users. A shared vocabulary with common goals now exists which will no doubt improve communications and service and maximise the commitment and effort of everyone involved.
Conclusion
Person centred planning is a process of continual listening and learning (Sanderson, 2000) and I am happy to define my own music therapy programme by these terms. The challenge for this programme will be the successful coordinating of music therapy methods and goals with the particular approach to PCP used by Enable Ireland to facilitate person centred planning in a manner which accounts fully for the therapeutic process. This will no doubt involve reconsidering and redefining my role as a therapist; a territory I look forward to mapping in collaboration with the community at Enable Ireland.
References
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