View of Project Bethlehem - Training Educators and Health Workers in the Therapeutic Use of Music in the West Bank

Project Bethlehem - Training Educators and Health Workers in the Therapeutic Use of Music in the West Bank

By Elizabeth Coombes

Introduction

In the ever-widening music therapy community, more and more opportunities are arising for Western trained music therapists to work in multi-cultural contexts within their own country. Additionally, there are increased possibilities for music therapists to work in countries other than their own native homelands. These opportunities, however, come with added considerations and responsibilities.

Traditionally, music therapy practice has insulated itself from the cultural context in which the work takes place. Mércèdes Pavlicevic (2004, p. 37) describes this when she remarks that, “Inside the existing and received canon of music therapy theory and techniques, a culturally neutral stance has preserved a comfortable seal between ‘inside’ and ‘outside.’”. The image of the “comfortable seal” (Pavlicevic, 2004) seems to invite contemplation of the consequences of a leak or, even more dramatically, a rupture. Indeed when a music therapist can acknowledge that in order to work appropriately and successfully within another context, a wider meaning of music therapy must be applied, a whole raft of issues rise to the fore. Quite simply, “The outside world is a part of the work that we are doing and, in fact, it is not outside at all; it is right here, within the room where we work. “Life” and “therapy work” are inseparable in the special, temporal or mental sense.” (Pavlicevic, 2004, p. 42).

The inherent complications and dynamic interactions of “inside” and “outside” were to provide many challenges during the work undertaken for Project Bethlehem, an ambitious scheme situated in the West Bank, devised by music therapist and project clinical leader Claire Tillotson.

Project Bethlehem aims to provide training and resources in two areas:

Once trained the music therapist would have the chance to work in the SOS organisation, benefitting from the understanding of music therapy gained by staff during the other strand of the project.

The West Bank is a landlocked area located in the Palestinian Territories. Its name derives from the fact that it is on the west bank of the Jordan River. Since 1967, the majority of the West Bank has been under Israeli Occupation following the Six-Day War. In 1993, the Oslo Accords stated that the political status of the West Bank was to be subject to a settlement between the Israeli and Palestinian leadership, and there remain many issues relating to any such agreement that are still under discussion today.

One of the consequences of the political situation in the West Bank is that freedom of movement for work, education and pleasure is severely restricted. In addition to this, the construction of the Israeli Security Fence in 2003 has had a further impact on the import/export of goods, education and careers. Job opportunities are limited, and there are few manufacturing industries in the area. These conditions mean that many Palestinians suffer from emotional problems arising from their living conditions. There are also long-established refugee camps in the West Bank, comprising people displaced following the 1967 conflict. These are supported by UNRWA (United Nations Relief and Works Agency), but although basic needs are catered for, there are high levels of unemployment, mental health issues and concomitant social difficulties.

Bethlehem is nowadays far from the “Little Town of Bethlehem” image portrayed in the famous Christmas Carol. It is something of a sprawling urban development with a population of 30,000, including three refugee camps. It comprises three main areas: Bethlehem, Beit Jala and Beit Sahour, with a combined population of 60,000. In recent years many people from Hebron, a large town to the south of Bethlehem, have migrated to this area, attracted by the possibility of earning money from tourism. Because Bethlehem contains many sites that lie at the very heart of Christian belief such as the Shepherds Fields, where the Star signifying the birth of Christ was first observed and the Church of the Nativity, Baby Jesus’ birthplace, this is a not unreasonable calculation. The population increase arising from this migration has, however, put a strain on the already overloaded infrastructure of the urban centre.

There is no doubt that the social conditions and emotional states arising from this situation have a devastating impact on the lives and futures of the people of Bethlehem in general. These effects are particularly noticeable in the behaviours of local children both in their homes and schools.

The lives of children living in Israel and the Palestinian Territories are hard for us to imagine. They continue to witness explosions, the shelling of houses, waves of arrests, civil violence and the constant presence of militia. In this atmosphere of conflict, little time and support is available for children to mourn their losses or to gain an understanding of the situation, and as a result many children remain emotionally isolated. Studies have found that a high percentage of children in the Occupied Territories show pronounced symptoms of psychological strain which require specialised therapeutic help.

Project Bethlehem Background

In early 2006, Claire Tillotson had instigated a training programme for healthcare professionals and educators in the West Bank. The idea for this Project had arisen from the McCabe Educational Trust, a charity whose remit is to provide enhanced educational opportunities for inhabitants of countries in which it organises pilgrimages. By creating a space where the music therapy techniques could be practised and thought about, she aimed to put in place a structure within which a music therapist could work, supervising staff using these techniques and carrying out music therapy sessions himself/herself. Presentations and workshops in Bethlehem had been well-received, with attendance at these events surpassing all expectations However, putting in place a more rigorous and wide-reaching training programme in the SOS Village and School; the organisation where the training was to take place, required a level of input that was not sustainable by two professionals with many other commitments. For this phase of the work a new partnership was created between Claire Tillotson, Project Bethlehem’s business manager Canon Paul Miller and Music as Therapy International (MasTInt). It was decided to use MasTInt’s model developed specifically for this kind of skills-sharing work following many successful such projects in Romania. This is set out briefly below. To facilitate this, a team of two comprising a music therapist (Elizabeth Coombes) and assistant musician (Hannah McCabe) were selected via a rigorous interview procedure to undertake this part of the Project. The team was fully briefed by the Project partners on how to implement the programme of work, and what the desired outcomes were to be.

Music as Therapy International

MasTInt was set up in 1995 with the goal of facilitating the development of music therapy in countries where music therapy provision was limited or non-existent. Local staff members in special schools and care homes were equipped with the skills, experience, materials and confidence to run music therapy programmes which could address the psychological, emotional and behavioural difficulties experienced by the children and adults in their care.

A model was developed, which allowed for a two-person team from the UK, consisting of a music therapist and assistant to spend six weeks with the local partners developing a music therapy programme that could then be owned and run by the relevant organisation.

The schedule for the six weeks is designed as follows:

Table 1: Schedule for the six weeks
Week 1  Observation of the setting/s 
Weeks 2/3  Music therapy sessions led by music therapist with local staff observing 
Weeks 4/5   Local staff to lead all or part of the music therapy sessions 
Week 6  Time to make up missed sessions/address specific issues 

A booklet or other resources (DVD, visual aids) is also prepared by the MasTInt team that is individual to each project. This is left for staff, having been translated into their language, so that they have something to refer back to and use as needed.

Subsequent to the initial six weeks, and depending on the local partners’ wishes, a follow-up visit may be offered once the staff had had a chance to lead sessions themselves for a period of time. This visit offers assistance with any issues that may have arisen, and, in conjunction with local partners, looks for ways to help and support this work in the future if needed.

The Local Partners

This term references the SOS Village and School. The following short description of the organisation provides some context for the work.

The SOS Children’s Charity operates in one hundred and twenty four countries worldwide. Originally set up in the aftermath of World War Two, it describes its aims on the SOS website as being to provide “a loving home for every child.” Each SOS Village consists of a number of houses each of which has its own House Mother. With the support of other health workers, she takes care of the children’s physical and emotional needs. In Bethlehem, the SOS Village has twelve houses, with a maximum occupancy of nine children in each house. Many children do have families in the West Bank, but for various reasons it is not possible for them to be cared for in their family home. The SOS Village provides a substitute home environment that is nurturing and caring.

Each House Mother builds a close relationship with the children. She provides the security, love and stability that each child needs to develop emotionally. Brothers and sisters are kept together in the same home as far as possible to foster their filial relationships. When the children reach the age of fourteen, they move into nearby Youth Houses which continue to provide a home for the young people until they are able to stand on their own feet and live independently. For the rest of their lives, however, these children regard their House Mother as their parent and keep in close contact.

The SOS organisation in Bethlehem also includes a school catering for children from ages four to sixteen years of age. The total number of students attending the school is approximately four hundred and fifty, the additional children and young people being drawn from the local community, generally comprising students from families who experience economic and social hardship.

Considerations in working as a music therapist in Bethlehem

As described in the opening paragraph of this article, there are many issues to take into consideration when delivering a project such as this. As a psychodynamically trained music therapist from the UK, I had worked with clients from a mixture of different cultural backgrounds. However, this was to be my first foray into working in another country. Additionally, the work was not just to provide music therapy, but to offer training for staff to facilitate them being able to work in this way when the Project’s initial input was ended.

Pavlicevic (2004, p. 47) talks about how destabilizing working in unfamiliar territory can be. She is careful to point out that this occurs not only on professional and clinical levels, but that it also finds its way into personal and musical levels. “After more than twenty years of practice, I felt de-skilled, uncertain of how any of my skills might be useful or appropriate.”

Zharinova-Anderson (2004, p. 234) states that a high degree of importance should be attached not only to the ethnic, social and cultural contexts, “but also all the contexts in which the work takes place – the therapist’s background, the ethics of the institution in which the therapist is practising (Proctor, 2002) as well as the wider context of the village/town/city/country where the client, the therapist and the wider community live (Pavlicevic, 2002).”

Bearing all this in mind, it was decided to offer a structured training programme that could be modified by staff to suit the needs of the contexts in which they were working. In this way, they could adapt the methods they would be taught to suit their own ways of working, developing their individual style of music therapy, a process described by Brynjulf Stige (2010). I had been assured by Claire Tillotsen that working using music presented no difficulties, although the Village residents and students at the school were all Muslim. As I was relatively unversed in the techniques and styles of Arabic music, I felt uncertain about using melody and voice. Because my training and expertise is in Western music, I was unsure as to whether using my skills in this area would amount to an imposition of my own music on these populations. However, I felt that my training as a music therapist would help me to use my music therapy skills “automatically, in spite of myself”(Pavlicevic, 2004, p. 39).

One further point; the work of Winnicott is referred to during the course of the article. Although using such a culturally-specific theoretical stance may seem at odds with the thoughts expressed here, it felt important for my own professional persona that I had a familiar starting point from which to build and develop this work. This was to help frame further questions as the Project proceeded.

The Project in action

The UK team arrived in Bethlehem in late October 2009 in the company of Paul Miller and Claire Tillotson who were to accompany us for three days. They would help with orientation thereby facilitating a smooth commencement to the work.

As a result of the work already undertaken by Claire Tillotson in the West Bank, the local partners (SOS Village and School) felt that music therapy techniques could provide them with additional skills to help the children in their care. They believed that using music as a therapeutic tool would provide opportunities for emotional expression, exploration of attachment difficulties and the building of trust. It was hoped that at the very least we would be able to stimulate playful engagement with the instruments and each other. Perhaps this could enable the children to “gain mastery over their world and their lives” (Pavilicevic, 2002, p. 112) through the medium of play.

In the SOS Village and School, it was clear that previous training offered by Claire Tillotson meant that the idea of music therapy was firmly embedded in the staff teams. They were aware of its expressive non-verbal possibilities and eager to learn more. Without this strong foundation, it would not have been possible to provide such a detailed introduction to music therapy. In addition to this, having a good resource of musical instruments provided the opportunity to use a broad range of activities that were suitable to the skills possessed by the trainees. This was very important, as only one staff member was a trained musician. The instruments had been provided by money raised specifically for this six week project. All the instruments were purchased from music shops in the West Bank.

In order to provide a clear overview of the Project, the two settings in which the work took place will be described. Finally, an evaluation of the Project will be given together with some thoughts as to how best sustain and develop this work.

The SOS Village

For the duration of the Project, my assistant and I were accommodated in one of the Houses. This provided an excellent opportunity to observe the daily routines of the Village which was invaluable in formulating the therapeutic goals appropriate to this setting.

During a meeting in the first week with the three staff who were to receive music therapy training in this setting, the following therapeutic goals were selected for the work in the Village:

Staff members were aware of the possibilities of emotional expression offered by music therapy thanks to previous work done by Claire Tillotson. They also understood that improvisation with the instruments presented opportunities to nurture and develop social skills and self-esteem. They were keen to foster a group culture, with the idea of the group acting as a self-regulating mechanism through music-making. With this in mind, musical activities were developed that could help staff work towards these therapeutic goals. We also discussed working with individual children, something that the trainees were keen to try.

The SOS School

During the first week of work in Bethlehem, observations of school life were made by sitting in on lessons and watching what occurred during break-times. The class sizes varied slightly. Generally, however, there were approximately twenty five pupils per class. There were no classroom assistants. The students’ concentration levels in the classroom were generally low, and they would get up and wander around or attempt to leave whenever they chose. Behaviour management was so time-consuming that in some lessons only ten minutes out of forty were dedicated to learning. The underlying tension present in many of the classrooms felt almost overwhelming, the teachers, however, were committed to delivering the curriculum as best they could.

Zharinova-Sanderson states that “we have to make efforts to understand the societies in which we are practising.” (2004, p. 234), and this seemed even more important than in the Village, possibly because of the greater social mix present and also because of the need for learning to take place.

As in the Village, a meeting was offered in which goals for the therapy groups could be discussed. It was also suggested that staff members work with an individual in addition to a group. Initially, the trainees seemed unsure about working one-to-one. It was explained that working in this way with a therapist could enable children with problematic socio-economic and emotional difficulties to explore aspects of self. This could then be helpful when thinking about the children’s difficulties in a group setting. Possibly the idea of working one-to-one was actually counter to the cultural norms present in this setting, as the idea seemed new to them, even though Claire Tillotson had undertaken some individual work in both School and Village. It may also have been that timetabling difficulties presented challenges in arranging one-to-one sessions in the School.

In the event, all those to be trained agreed to work with an individual as well as groups after this meeting, and the following therapeutic goals were set:

Some further explanation of these goals seems necessary.

The rather general statement in the first bullet point was selected by staff to provide some help in maintaining status quo in the classroom setting. As previously mentioned, difficult behaviours were a norm in lessons. Staff wanted to find new ways to reduce these behaviours and provide a situation more conducive to learning. These were, then, areas in which they felt students could make progress with the help of music therapy.

The term “focus” was one referred to by staff in the School and Village. While it does refer to concentration within the classroom setting, it also has a broader connotation. It embraces the idea of having a goal you wish to achieve in life, of having a direction or dream for the future. This seemed to be a very important idea in the minds of the staff, and it was possible to see why when the circumstances of the wider social setting were taken into consideration.

Something that the staff team was not at this stage able to think about was the notion of creativity and free play within these music sessions. A quote from Ralph Waldo Emerson, the noted Nineteenth Century American writer, came to my mind when observing the children here and in the Village; “It is a happy talent to know how to play” (Emerson, 1835, p. 116). I felt the ability to play was not fully developed in many of the children we worked with in the School and Village. Giving children a space in which they could play would facilitate healthy emotional development and growth, as demonstrated by Winnicott’s theories.

In his work “Playing and Reality”, Winnicott states that “Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.” (Winnicott 1971 p38).

Although the Project aim was not to train staff as psychotherapists or music therapists, it felt important to raise staff awareness of the importance of this aspect of music therapy. It seemed, however, important to start sessions before discussing this with them. Because of the very structured school day and the didactic nature of the educative style in the school maybe staff members could divine this for themselves. Perhaps then they could value it more and perceive its benefits, as they had come to this idea through their own experience.

SOS Village Clinical Work

At the initial staff meeting, three team members were identified as being available for training. Each one worked with one group and individual. The team in the Village consisted of a psychologist, a social worker and the activities organiser. The last of these was the only male member of the team.

In this setting, staff availability was more problematic. Although weekly feedback meetings were scheduled, only two such gatherings took place. Also, no evaluation meeting was possible in the last week due to staffing issues. This was unfortunate as this meant there was no opportunity for staff to voice their feelings about the work and its future.

No formal observations were undertaken in the Village. As such, this seemed unnecessary as we were living there, and so could see and participate in the daily routines experienced by staff and children. The social worker took on the task of choosing the children to participate in this Project. These selections appeared to be highly appropriate.

It was initially difficult to set up a timetable in the Village. This was because no children were available for work until after lunch, and staff had varying availability. Staff also finished work by 4pm, so this put further constraints on the timetable. Eventually, however, a timetable was established, although it did not remain consistent throughout the six weeks. It felt more important to get the work done without being too rigid about the timings; this could be stressed in the weekly meetings. As the Project drew to a close, however, these issues were being resolved, and it was becoming more apparent when would be good times to hold sessions.

As a whole, staff clearly had the ability to undertake this work. It was difficult in the time available to support staff in allowing the children to be the focus of the music and to follow their leads. It was clear, though, that staff were playful and eager to learn. Having a psychologist on the team meant that there was the opportunity for her to use her keen analytical eye to see what the therapeutic goals might be and how they could be achieved using music. An issue in the Village was the lack of a trainee with really good English; this did not seem to affect the workshops themselves, but it would have been helpful to have been able to give and receive more detailed feedback.

The sessions lasted for thirty minutes. This seemed to be the maximum time that the children could safely be contained and focussed in the space available for the work. It was difficult to ensure those not included in the sessions did not intrude into the therapy room, and on some occasions the Project assistant was employed to engage those not involved at that time in play outside, so that the work could continue uninterrupted.

Each session began and ended by using a Singing Bowl, a bronze vessel that sits comfortably in the palm of one’s hand. It is then played with a wooden stick, eliciting a ringing sound. This was passed around for everyone play if they so wished. I specifically brought this instrument to Bethlehem in order to use it to create a separate musical space that was clearly defined, and to offer the idea of taking turns, waiting and listening. Few people in the SOS were familiar with this instrument, although after a few sessions, it became strongly identified with the music therapy work for staff and pupils alike. From a theoretical point of view I was thinking of Winnicott’s “facilitating environment” (Winnicott 1965 p223), not just for the children, but also for the staff. Although I felt that Claire Tillotson had already been internalised by staff as a “good enough” mother, (Winnicott 1958 p78), now was the time for the idea of music therapy itself to become part of life at the SOS Village and School.

As the Singing Bowl was passed around, opportunity was given for people to introduce themselves if they wanted, to talk about something they had done or say how they were feeling. This and the other activities used in sessions can be referenced through the Project booklet. It is included as Appendix.

Although the basic shape of the activities was clearly explained, small developments were introduced during the Project, and, as they became more confident, by the staff themselves. It felt important not to overwhelm the trainees with ideas, but to show that a relatively small number of activities had an almost endless range of possibilities. As the time went by, the idea of improvisation was introduced to staff, and they were keen to use this technique. They began to see the value of this aspect of the work as it enabled relationships within the group to be worked on more deeply. By the end of the Project, staff appeared to have had sufficient input to enable them to lead sessions themselves.

Individual sessions were also initially programmed for thirty minutes. However, it was explained that this might be too long, and that staff should be flexible but consistent as to the length of this aspect of the work. Again, a strong structure was given to the sessions so that staff had a “secure base” (Bowlby 1973 p407) from which to build. It was suggested that improvisation be more of a feature in the individual work, so that the child was offered more autonomy if appropriate.

Set out below are some case studies of the work in this setting.

Case Studies – SOS Village

Maya

Boy and social worker in the SOS Village
Boy and social worker in the SOS Village

Maya a twelve year old girl with learning disabilities was chosen as the psychologist’s individual client. Maya’s mother had died at birth, and her father had abandoned her. She had come to the Village two years previously having never attended school. I was told that Maya had been abused physically and sexually, and had violent tendencies.

In the first session, Maya sat as though frozen in her seat. She was wary of her surroundings, even though she was very familiar with the room in which the work took place. She continually looked behind her and was nervous at the changing light and shadow in the room. However, she engaged with all the activities, although her attention span was short. She was demanding, and once she had decided she had finished something, she could not be cajoled into continuing or restarting.

The following week, Maya appeared more comfortable in the setting. She became much more domineering and physically aggressive, dictating what was happening. She was unable to share instruments and demanded that everything be done a certain way. After this session, I explained to the psychologist that we needed to gain Maya’s trust. This would help her have positive experiences of relationships with people that were mutual and not dependent on one dominating another. I could see there were enormous possibilities for Maya to develop her social awareness and explore her emotions using Music Therapy.

The psychologist was unable to attend session three, so I undertook that alone with Maya as she was very eager to work with music. With just the two of us there, Maya became even more demanding and aggressive, but was able to tolerate and show pleasure in sharing the small ocean drum. We also developed a “Hiding the Eggs” game, much to Maya’s delight. This involved using the small egg shakers. One person hid them around the room while the other person had to find them. Maya really enjoyed this activity, and was able to participate in it for a substantial length of time. As I worked through this game with Maya, I reflected that it felt as though no one had ever played with her like this before.

The fourth session was led by the psychologist. We used a wicker music box to contain the instruments as an aid to assist Maya in understanding boundaries and endings. The trainee herself seemed a little unsure of how to play with Maya, and the episodes of play she undertook with Maya could, I felt, have been extended. This was probably a confidence and practice issue; with experience, this aspect of the work could be developed. Certainly at the end of the sessions, the psychologist remarked “It is good to play with Maya. She needs much play”. I felt this showed that the benefits of working in this way with Maya and her problems had been understood, and hoped the work could continue. These experiences, in my view, could help Maya become better integrated into Village life as she developed her ability to form positive trusting relationships with adults and peers.

Group Led by the Activities Organiser

Group in the SOS Village
Group in the SOS Village

This group took place on a Sunday afternoon. Unfortunately this meant the trainee withdrawing from playing with the children to come into the activities room. The effect of this was that throughout the session, the children climbed up the doors and tried to gain access to the room, necessitating a lot of interruptions to the process as we tried to protect the space.

However this trainee engaged very well with the music and the group. There were three boys and one girl in the group, the girl being a very able and strong character. She often tried to dictate the content of what the boys were playing, pairing with one of the smaller boys to provide a characteristic beat to the free play. The Activities Organiser managed this well, finding ways of bringing the other children’s music to the fore, and added some delightful vocalisations to the instrumental mix. He was particularly sensitive to group members who had poor motor skills. One boy in particular, Abed, was easily frustrated by his lack of rhythmic awareness. The trainee was able to use his own playing to support and reflect the character of Abed’s music, and made the music space somewhere where Abed could have a satisfying experience and feel heard. This was in stark contrast to Abed’s school life, where he was considered disruptive and troublesome.

Comments on Music Therapy in the SOS Village

It was difficult to establish a programme of work in the Village, partly due to the lack of knowledge amongst staff of the following conditions:

However, it seemed that in this setting, the staff team was more able to think about the emotional lives of the children. There was much more opportunity for children to receive lengthy courses of music therapy as opposed to the school where they wanted a shorter programme of work to ensure the maximum number of children who could benefit did so. The problem of access to the instruments was solved by commissioning the making of a music hest by local carpenters out of olive wood. It is lockable and mobile, having wheels. This will ensure that the instruments are easily available for use.

It is clear that the potential and willingness to build on this work is there. With careful planning and support, there is every chance that music therapy can become an integral part of Village life.

SOS School Clinical Work

As in the Village, three trainees were selected. They consisted of the School social worker, the music teacher and the special needs teacher, the last of these being the only female on the team. Of the three trainees, the social worker had the opportunity to participate in many more sessions than the other two trainees because he was not tied down to a teaching schedule. Despite being very busy, he managed to find time to work with eight groups and one individual in a week. The other two trainees worked with one group and one individual. Scheduling sessions was more problematic with the music teacher as his position was only part-time. This meant making up any missed sessions was very difficult. A weekly staff meeting was also timetabled, although due to staff availability, only two meetings were held. Fortunately, the social worker was always eager to discuss the work and feedback to the project team. This meant that there was the opportunity for dialogue and discussion and a place where the work could be reflected upon.

Structure of the Sessions

Due to the fact that only one of the staff was a musician, it seemed important to give the work a strong structure to facilitate learning. Although it was possible that that this could work against the idea of a musical dialogue created through improvisation, giving staff a safe haven from which to begin their journey into music therapy felt just as valid.

Each session lasted for forty minutes, the same length as a lesson. Initially I thought this would be too long, but staff explained that the whole lesson time had to be utilised; it would be too disruptive for pupils to return to a lesson with only ten minutes left. I decided to conform with this to begin with, thinking that if it were untenable, maybe we could revisit this aspect of the schedule. In the event, forty minutes proved satisfactory for groups, although two of the three individuals struggled with the length of time. Staff agreed to monitor the length for individuals with twenty minutes being the minimum space offered.

As above, brief case studies are set out below, showing how the work developed in the School.

Case Studies – SOS School

Hissein

Boy and teacher in the SOS School
Boy and teacher in the SOS School

The music teacher worked with Hissein, a twelve year-old boy. Hissein had lived in the Village from babyhood. He was the youngest of seven children. His mother had died when he was a baby. His father’s subsequent remarriage had meant the children by his first wife were put into care. Hissein was a very likeable child who tried hard at school but found it very difficult to concentrate in lessons. His lack of academic achievement was a source of upset to him. Also during the time we were at the Village, his housemother of five years left, leaving Hissein tearful and angry.

I felt Hissein, who enjoyed music and had a good degree of skill in rhythmic playing, could benefit from one-to-one sessions. It could help him build a positive relationship with his teacher, and see school as somewhere where he could achieve.

At first the trainee did not understand why he was working with someone who was so musically able. I explained that music therapy was not concerned with the level of musical skill shown by a child; the goals were completely different. Gradually he was able to accept this concept and work with it. I felt it also helped him explore the therapeutic possibilities of co-improvised music.

Hissein found it difficult to use the Singing Bowl space to express himself verbally. Indeed, it became clear as the project progressed that the tension between providing a satisfactory training experience for staff and at the same time ensuring that clients were also catered for was an enormous challenge. In hindsight perhaps more time spent with the trainees helping them devise activities might have stimulated the emergence of a more culturally and contextually specific programme.

However, Hissein was very quickly able to engage with the musical activities, showing tremendous enjoyment of the following and leading roles. Soon it was possible to use free play with Hissein, moving between more rhythmically based improvisations and melodic lines. This enabled the teacher to see the musical and expressive possibilities in using this way of working; a way that was completely new to him. It meant that not only was Hissein able to begin building a positive non-verbal relationship with his music teacher, but that the teacher himself was also able to learn from his time with Hissein. An important moment in their work together, I felt, was when the teacher gave Hissein a melodic phrase to play while he improvised; the roles were then reversed. I had reservations about this when the idea was introduced; I thought it would be too difficult for Hissein. I was proved wrong. Showing great concentration, Hissein was able to perform this complex task. “I asked him because I knew he could do it”, his teacher said, then went on to talk about the emotional and creative possibilities of working in this way. It was clear that this brief introduction to music therapy had touched a chord within the teacher. Subsequently he was eager to learn about future training opportunities that could be offered in Bethlehem and the UK.

Grade 10 Group

Boy and Liz Coombes in the SOS School
Boy and Liz Coombes in the SOS School

The social worker wanted to work with a group of pupils aged fourteen who were all disaffected and difficult to manage in class. Indeed, they were so disruptive that any class they attended had no chance of becoming a place where learning could be facilitated. The group, comprising one girl (Samira) and three boys (Firaz, Mustafa and Hamza) received four sessions, although the last one was only attended by Samira and Hamza, the others being away because of a religious holiday.

At first I was unsure whether to change the activities I was offering as the students were teenagers. I worried that the students might find them babyish and irrelevant and therefore not wish to engage. Again, the tension between delivering a training project and respecting the needs of the clients’ became evident to me. I felt that the main focus of the project was to facilitate the continuation of this work after the team had left, so decided to keep to the established structure while being responsive to the mood and needs of the group. In the event, the group members engaged wholeheartedly with the work we did. The difference with this group to the others was, however, that they rapidly became more able and desirous of improvisation, and therefore this became a strong feature of the group’s experience.

After the initial session, Firaz said that this was the first time he had ever played music, and although I found it hard to believe this as I am sure he had had music lessons at School, the remark made me realise that he had deeply experienced the music and connected with it. Within a very short space of time, the group were able to improvise together, with some interesting pairings. The trainee encouraged them to make use of the piano as well. When Hamza expressed an interest in playing it the trainee went to the instrument to support him in his playing. As this staff member was in fact not a musician, I felt this showed great commitment to the idea of using music therapeutically, and no small amount of courage.

Hamza had considerable issues centring around self-esteem and confidence, and this manifested itself in excessive clowning in class. He was quick to seize on an opportunity for merriment and mockery, but not in any seriously unpleasant way. I imagined, however, that it might be very difficult to work with him in a class. I noticed that he had a tendency always to have the last musical word; whenever an activity was finished, he had to play another note. I remarked on this at the end of the session with the Singing Bowl, and was told that Samira had also raised the same point when she commented in Arabic on the group. This was a highly fortuitous coming-together of opinions, expressed in a very tolerant, light-hearted way. Hamza seemed pleased that he had been recognised in this way; it felt as though the group were moving towards an understanding and deeper knowledge of each other. The group were very keen to continue their work using music in this way, and a promise was made to them by the social worker that sessions would recommence in January.

Comments on Music Therapy in the SOS School

Staff members were eager to have the chance to learn these new skills. Other teachers also asked about training in these techniques. Positive experiences with Claire Tillotson meant that they were highly enthused by the work. As a whole, the trainees were extremely willing to try everything that was offered to them. This positive attitude rewarded them, as even in such a short space of time, improvements were reported by other teachers in the students the trainees had worked with. Pupils were thoroughly engaged in the process, and eager to attend the groups. The trainees asked class teachers for feedback about students involved in the scheme, and positive comments were received, detailing less violence in classroom situations, more positive attitudes shown in class and better “focus”. An evaluation meeting on the last day with the Deputy Head-Teacher was very encouraging. The staff members described their experiences in glowing terms, and were very upbeat and hopeful about the potential for positive changes in pupils with continued participation in this programme.

Difficulties encountered in the School were minimal. Often on arrival the timetable would have to be drastically changed because staff members often had to deal with unexpected situations. This had a deep impact on the schedule. Before the routine at the school became familiar, it was difficult to negotiate practical matters, but after a week or so it was possible to locate the people who could help with these issues. This meant that any problems faced at the SOS School were fairly easily solved or negotiated.

With regard to the trainees, there is no doubt that the social worker was the most enthusiastic member of the team. He had the chance to participate in many more sessions than the other two teachers, and therefore his progression in acquiring the necessary skills and knowledge was much quicker. The special needs teacher, although initially lacking in confidence, quickly realised that these skills were within her capabilities, something we were in no doubt about having observed her teaching. Although the music teacher participated in fewer sessions than these two trainees, he too was able to grasp the possibilities of this work.

On returning home, notification was received from the SOS that they were planning to restart sessions after Christmas 2009. A schedule was indeed set up, and sessions were run from January right up until our return to Bethlehem in May 2010 for a follow-up visit.

Overview

In the view of the UK team, staff members and children made significant progress during the six weeks of the Project. This opinion was supported by empirical evidence from the teachers and other health workers in the SOS. On arrival in October 2009, expectations were kept low if all that happened was that staff and children had fun with the instruments and people were encouraged to make music, then that would be sufficient. As it was, all staff led at least half of a session, with those at the School leading one whole one themselves. It can be seen from the booklet that a variety of issues key to the development of this work were covered. All the aspects covered in the booklet directly related to questions that arose during the sessions. As far as was possible, the booklet was tailored to suit staff members’ needs and help them begin to make the work their own.

There were a number of questions asked by the trainees at the end of the project: “When are you coming back?” “Can we come to the UK and see music therapy in action?” “Can we come and see how your schools work?” These remarks show how valuable this work has been; what needs to be determined now is how to sustain and develop it in a way that is appropriate to the setting.

The Follow-Up Visit May 2010

A positive response was received by MasTInt from SOS regarding the possibility of a follow-up visit by H and me. Early May 2010 was identified as an appropriate time to visit, coming as it did several months after our original training and before the school examination season got underway. The Project team therefore travelled to Bethlehem for one week with the aim of observing sessions and identifying areas of need for the staff’s further development.

Certainly, after the six weeks intervention of the previous year, it felt strange to be only visiting for one week. What could actually be achieved in such a short space of time and would further progress be made? Additionally had staff been running music therapy sessions? And if so, how were they going?

The SOS School

During the week-long visit two staff meetings were held, and each staff member was observed undertaking two group sessions. No individual sessions had been carried out as it seemed that staff did not feel comfortable working in this way, nor was it possible to fit this into the school timetable. It is possible that cultural considerations were an issue here, but there was not enough time, in the event, to investigate this aspect of the work. It was noted that the two teachers were actually doing music therapy sessions in their free periods in addition to the classes they had to take.

Of the work that was observed, it was clear that staff had found the booklet invaluable. Although they had not stuck slavishly to the activities offered, it appeared that this had provided a “good enough” (Winnicott 1958 p245) support, a “secure base” (Bowlby 1973 p407), if you will, from which they could develop new activities. It was possible to see that the children had made great strides in terms of working creatively, interacting appropriately and extending their concentration in the music therapy setting as the staff team had continued working with some of the same students. An important factor gleaned from observation was that staff members were also enjoying using music as a therapeutic tool.

In the final staff meeting at the school, the following suggestions were made by the MasTInt team:

The SOS Village

On returning, it was found that only one staff member was using music therapy. The psychologist and activities organiser both felt they were either too busy or that the work was not appropriate to their role in the Village. Subsequent discussion revealed that the psychologist’s role within the Village was ordinarily confined to working with the House Mothers. She stated she did not have time to programme in music therapy sessions with the children, and in any case, this was not her job. The activities organiser was rather more vague as to the reasons why he had not continued with the music therapy sessions. He simply stated he was too busy. Further enquiry revealed that generally any work considered to be therapeutic in the Village was carried out by the social workers. We wondered, therefore, why the psychologist and activities organiser had been selected for training if their roles did not allow for continuing practise. It may be that there was some issue of communication between the Village Director and staff, or, perhaps more likely, some underlying dynamic cause that we were unable to locate during the brief time of the project. However, the opportunity had been provided for staff members to try out these techniques, and maybe at some point in the future they might feel able to begin working in this way. At least they had a store of instruments to use and a portable music chest in which the instruments could be kept.

We observed the social worker leading one music group, although she had actually programmed in three groups and one individual per week. Using the booklet as a guide, she had invented many new activities, largely concerned with communicating effectively in pairs or resolving areas of conflict through playing music together. It was exciting to witness music therapy techniques being so confidently owned, and the development of the activities we had introduced. Again, the children were very eager to take part, even though some aspects of the session were clearly difficult for them emotionally. Because it was possible to observe some of the same children previously worked with, positive changes in their behaviour in the areas of social skills and emotional expression were noted.

For example, Abed, who had attended a group during our first visit was now able to attune his playing to others in the group more easily. When he struggled with holding to the group rhythm, he was able to recognise this and take his time to find a way of joining in with the music without becoming so visibly frustrated. Also, the children had formulated a series of written boundaries for the group, and had also given the group a name, “Tolerance”. This seemed very much in keeping with the theme of the activities the social worker had worked on.

In a meeting with the social worker, I made the following suggestions:

Conclusion

Because this Project is a living, growing entity, it feels very difficult to write a conclusion. In each setting in the SOS, the work has progressed differently, reflecting the needs specific to each component part of the organisation. It may be that this will continue. What we can say is that as local partners begin to own the music therapy work, exciting possibilities will arise.

Working creatively and therapeutically has benefitted not only the children participating in the work, but also the staff teams. They themselves have expressed satisfaction that the Project has provided them with opportunities to explore new ways of working. It will be interesting to learn what impact this has had on other areas of their work and of course, to see how music therapy develops as the other strand of the project comes to fruition.

With regard to my own work on this Project, as I have stated above, the task I was charged with led me to question my role and professional abilities as a music therapist. An emerging need and role that I fill has continued to grow throughout my continuing contact with the people I worked with in Bethlehem. This is best described as “to be there in order to listen to and share what (they) live through every day; to receive and witness their lives” (Pavlicevic 2004 p 40). My thinking to date around this Project has been that this is one of the most important aspects of my work there, and one that I feel a music therapist is eminently suited to fill.

The booklet prepared by Hannah McCabe and myself and left as a resource for the staff teams contains a page on which the words “Wait. Watch. Listen.” are writ large. I feel these words are and will continue to be my guidelines for any continuing support I am asked to give to this Project.

Acknowledgements

This work would not have been possible without the full support of all partners involved with every aspect of the Project.

I would also like to thank my husband, Dr Stephen Glascoe for his support which made the challenges of working on this Project weigh less heavily on my shoulders.

On the ground in Bethlehem thanks are also due to Issa Mussallam. His local knowledge and help with practical matters greatly facilitated the music therapy work.

References

Bowlby, J. (1973). Separation: Anxiety and anger. London: Pimlico.

Emerson, R.W. (1835). Selected journals 1841-1877. New York: Library of America.

Pavlicevic, M. (2002). South Africa fragile rhythms and uncertain listenings: Perspectives from music therapy with South African children. In Sutton, Julie P. (Ed.), Music, music therapy and trauma: International perspectives. London: Jessica Kingsley.

Pavlicevic, M. (2004). Learning from Thembalethu: Towards responsive and responsible practice in Community Music Therapy. In Ansdell, G. and Pavlicevic, M. (Eds.), Community Music Therapy. London: Jessica Kingsley.

Stige, B. (2010). Introduction. Music and health in community. In Stige, B, Ansdell, G, Elefant, C & Pavlicevic, M., Where music helps: Community music in action and reflection. London: Ashgate.

Winnicott, D.W. (1958). Collected papers: Through Paediatrics to Psycho-Analysis. London: Tavistock Publications.

Winnicott, D.W. (1965). The maturational process and the facilitating environment. London: Hogarth.

Winnicott, D.W. (1971). Playing and reality. London: Routledge.

Zharinova-Sanderson, O. (2004). Promoting integration and socio-cultural change: Community Music Therapy with traumatised refugees in Berlin. In Ansdell, G. & Pavlicevic, M. (Eds.) Community Music Therapy. London: Jessica Kingsley.

Appendixes

  1. Appendix : Music as Therapy. Trainee Handbook (pdf 189KB)
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