[Reflections on Practice]

Music Therapy and Theatre: A Community Music Therapy Socio-Cultural Proposal for the Inclusion of Persons with Autism Spectrum Disorders

By André Brandalise

Abstract

This article describes a meaningful therapeutic connection between music therapy and therapeutic theatre in Brazil. Through describing the relationship between these two fields, it aims to discuss another possibility of intervention in music therapy with people who have autism spectrum disorders (ASD). Theatre performance can expand therapeutic action physically and subjectively beyond the music therapy room, helping clients expand their creative world and increase possibilities for social interactions. This practice cannot be characterized as psychodrama or drama therapy, but rather the use of a specific music therapy process utilizing the theatre as a resource. In the case described, this resource incorporates an applied creative and therapeutic power within a group comprised of eight young adults, most of whom have been diagnosed with ASD. The creation and performance of many musical plays have resulted in collective creation and movement related to this group’s psychological, social, and cultural needs. The proposal presented is based on a Community Music Therapy perspective.

Keywords: Autism spectrum disorders, Community Music Therapy, theatre

---

Introduction

Theatre helps us to express
ourselves
brings us joy and music
in doing it
we talk, we think
how we feel
and much more
(Gabriel, a 30-year-old member of the Teatro Íntegro Company with ASD)

Gabriel is a 30-year-old man who has been my music therapy client since 1991, in the city of Porto Alegre (Southern Brazil). He has been enrolled in music therapy and is one of the responsible clients for teaching me that in the application of some therapeutic settings, the music therapy room may be limited. It was this situation that I faced in the process of working with Gabriel’s group. Since the very beginning of their music therapy process, there was an enormous amount of energy focused on the creation of elements that led me to combine music therapy and aspects of theatre (i.e., characters, puppets, costumes, songs, and lyrics related to the characters). This combination, which became part of Gabriel’s music therapy process, led him to verbalize the verse presented at the beginning of this article. As a music therapist, I began noticing that allowing this combination of music therapy and theater made my clients open to this kind of experience, which would enable me to offer a broader, creative, and transformative perspective to them. Small (as cited by Ansdell, 2005), explained that musicking could be broader. “Musicking is about the creation and performance of relationships…It is the relationships that it brings into existence in which the meaning of a musical performance lies” (p. 11).

The music therapy room should be able to expand its walls, allowing clients to take their creations outside as part of the transformative process. Gabriel’s group taught me how to facilitate a much more social and cultural therapeutic approach, leading me to incorporate Community Music Therapy (CoMT) into my music therapy philosophy. As a music therapist, facilitating an individual or group session that allows people to become more integrated socially and culturally is the main clinical rationale of my work.

CoMT is not easy to define; each professional may have an opinion and a unique definition for it. Among the different definitions, Stige and Aarø (2012) defined CoMT as questioning the idea that music therapists must always work with individuals and their pathology in clinical settings. More specifically, they defined CoMT as the exploration of social and ecological perspectives held by various individuals and communities and the encouragement of musical participation and social inclusion.

They (Stige & Aarø, 2012, p. 18) proposed the use of the acronym PREPARE to describe the seven following characteristics of CoMT:

P – Participatory: Refers to how processes afford opportunities for individual and social participation, how participation is valued, and how the idea of partnership is supported.
R – Resource-oriented: Reflects on the collaborative mobilization of personal strengths and social, cultural, and material resources.
E – Ecological: Refers to the reciprocal relationships among individuals, groups, and networks within a social context.
P – Performative: Refers to the focus on human development through action and performance of relationships in ecological contexts.
A – Activist: Refers to acknowledgement that people’s problems are related to limitations within society, such as unequal access to resources.
R – Reflective: Refers to dialogic and collaborative attempts at appreciating and understanding processes, outcomes, and their broader implications.
E – Ethics-driven: Refers to how practice, theory, and research is rights-based, with values informing human rights and the intention of realizing these rights guiding activity.

Gabriel’s group taught me how to conceptually understand the therapeutic characteristics of CoMT. They also taught me how to incorporate them into his group’s therapeutic process and into my personal and professional philosophy.

The Use of Theatre, Drama Therapy, Psychodrama, and Puppetry in Therapy

First, it is essential for me to emphasise the use of the phrase “therapeutic theatre” rather than drama therapy or psychodrama. According to my perception, one needs to have training in order to apply drama therapy or psychodrama. My intention, through the use of the term “therapeutic theatre” is to make clear that theatre is an element added to the group music therapy process.

Second, the reader will notice that I am citing theoretical frameworks from the 2000’s while describing the development of our work in the 1990’s. I cite studies that incorporate the elements of theater from the first publications of its therapeutic use in the 1980’s. In terms of music therapy, on the other hand, my intention is to focus on CoMT’s theoretical background and specific group process. These works are much more recent in our field.

The literature contains few articles discussing the therapeutic benefit of combining music, music therapy, and theatre. Among the few that do, Cohen (1985) discussed using music as part of group exercises and proposed the use of simple rhythmical patterns and singing. Combining music therapy with drama seems to be a rare practice. Salas (1990), a music therapist who works with children with special needs, proposed the use of playback theatre (p.2), defined as the enacting of a series of personal stories told by audience members on the spot by the theatre company.

Puppetry had begun being used in therapy in the 1940’s while theatre and drama therapy had been initiated in the late 1950s. However, in the United States the National Association for Drama Therapy was not founded until 1979 (Emunah, 1983; Gendler, 1986).These approaches have been used with various populations including: patients with psychiatric disorders, people with developmental disabilities, pre-school children, adolescents with different needs, older adults, people with Down Syndrome, people with bulimia, people with substance abuse issues, homeless people, people with combat-related post-traumatic stress disorder, male survivors of sexual assault, and patients with fibromyalgia.

The literature describes many of the benefits of the therapeutic use of theatre, drama therapy, psychodrama, and puppetry. These include facilitation of the exploration of unexpressed emotions (Emunah, 1983; Gendler, 1986; Goodrich & Goodrich, 1986; Koppelman, 1984), building of trust (Carp, 1998; Dunne, 1988; Emunah 1983; Johnson, 1986), stimulation of spontaneity, imagination, and concentration (Carp 1998; Emunah, 1983; Mulkey, 2004; O’Doherty, 1989), facilitation of the self’s access to the world (Dogan, 2010; Emunah & Johnson, 1983), stimulation of creativity and thinking (Koppelman, 1984), improvement in interpersonal relationships (Dogan, 2010; James & Johnson, 1997; Johnson, 1986; Koppelman, 1984; Schnee, 1996), coping with anger (Johnson, 1986), depression (Mackay, Gold, & Gold, 1987); the psychological effects of physical assault (Fryrear & Stephens, 1988), and/or immaturity (Mofett & Bruto, 1990), creating a safe therapeutic environment (Dunne, 1988), promoting self-acceptance (Fryrear & Stephens, 1988), stimulating the use of the body as an expressive instrument (Carp, 1998), alleviating psychological distress (Couroucli-Robertson, 2001), providing a sense of accomplishment and satisfaction (Johnson & Alderson, 2008), proposing a different perspective on life situations (Dogan, 2010), developing insight (Dogan, 2010), and decreasing pain (Horwitz, Kowalski, & Anderberg, 2010).

The Use of Music Therapy Combined with Theatre

As noted earlier, in 1991 I began working with Gabriel’s group in a private center. My work with this group, which comprised of six adolescents, most of whom had been diagnosed with ASD, led me to reflect on my working philosophy as a music therapist and how broad it could become. I began understanding, through the group’s creations in the music therapy process, that musicking should be facilitated with music and creativity, and should be strongly related to the culture and context. These elements would allow me to make my clinical perspective broader, more flexible, and more social.

With this specific group, I started reflecting on the possibility of associating music therapy with theatre. The music therapy group experience prompted several members to create stories, characters, puppets, costumes and, consequently, interactions among the created characters and puppets. I began perceiving in that moment that drama was therapeutically working side by side with music therapy, offering support and more therapeutic power to the group’s creative and transformative experience.

Theatre was not only functioning as an intermediary element between the clients and other therapists, but also served as a unique supportive territory for creativity in the therapeutic setting. I began understanding the importance of acknowledging this new area of therapeutic action as part of my clients’ culture and context.

Based on their creations, we started composing songs, and decided to create our first play. The group members verbalized that they wanted their story to be performed for their relatives. I believe that this therapeutic situation accords with what Stige (2002) proposed in terms of associating the music therapy process with the context in which clients belong.

We successfully presented “Padre São José de Portugal” (“Saint Joseph, Father of Portugal”), the first play that we created for parents and relatives in 1991. When we created a second play the following year, we found that more people wanted to see the presentation than we had expected. Therefore, we began thinking about obtaining a bigger space in which to perform outside of the center. The group members asked about the possibility of performing the stories at professional theaters in the city. This request posed a dilemma, as we knew that a new environment could cause problems for people with ASD due to the unknown and lack of predictability. After discussing in team meetings, we decided that it was important to take the risk of moving the performances out of the center. We knew, however, that even though all members could trust in the team’s support, we would be submitting them to unpredictable conditions. It would be a major therapeutic challenge, but also a possible turning point in terms of helping them to expand their worlds.

The clients greeted our decision with joy. In 1993 we had the first experience of performing in a professional theater in the city, and it went beautifully. The members performed with much motivation, “sounding” their contents with a broader “social voice.” They proved that they were able to express themselves and to have their voices heard in a context broader than the music therapy room and the rooms of the center. Again, I saw myself reflecting on the incredible power of music and music therapy.

Year after year, we created and performed new songs, stories, characters, in new performances held in, new theaters for new audiences. By 2001, the group had completed 10 years of music therapy resulting in the creation and performance of 10 plays in a project that I called: New Horizons of Creation.

The Foundation of Teatro Íntegro Company

By 2001, I had completed my advanced training in music therapy in Brazil,and then returned from New York University, where I had graduated with a Master’s Degree in music therapy. I moved back to my city (Porto Alegre in Southern Brazil), where I founded Centro Gaúcho de Musicoterapia (CGM). Based on the experience described earlier, I decided to create a semi-professional theatre company with this group and named it “Teatro Íntegro.” The parents were excited by this idea, and I received much support to start my work. The company which is comprised of eight young adults, most of whom have been diagnosed with ASD, meet once a week for 2 hours, has been operating for 13 years, and has performed 12 musicals in several city theaters to date.

The Therapeutic Team and Their Roles

The therapeutic team, for this specific approach with this specific group, is comprised of a music therapist (myself) and two co-therapists (Tiago Lewis and Carolina Veloso). My primary instrument is the guitar. My male co-therapist’s primary instrument is the keyboard and my female co-therapist’s primary instrument is the voice. We use all of these instruments in the therapeutic process.

In addition, besides relating with the clients, which is a fundamental part of the clinical work, they have different roles in this particular therapeutic dynamic which have to do with helping me and the group in the construction of the nine process stages which will be described in detail. For example, besides helping the group musically and with the story construction, Carolina is responsible for working on costumes and scenery. Tiago is the music director of the story creation and performance. He deals with soundtracks and studio recording. The procedure for producing the therapeutic plays consists of the following 9 stages:

STAGE 1: Creating characters, costumes, and scenery
The therapeutic process provides space for the creation of characters, costumes, and scenery. For instance, one of the members who makes puppets may bring one of his creations to the session. Based on how the puppet creator describes it, a song can be composed and other characters can be created in order to interact with the puppet. At the same time, other members write down ideas during the week and bring them to the following session to be read to everybody. Based on the ideas, more creation can occur.

STAGE 2: Creating a story
This dynamic can occur in different ways. It is my role, as the therapist-director of the play, to facilitate the organization of what has been created by the clients. For instance, it is my role to help them relate content that was brought by one member to a character that had been created by another member. The goal of this stage is to help the members establish relationships among their creations. In sum, the story is the combination of the content brought by each member. This stage ends when the members have created a draft of the script that narrates the beginning, middle, and end of a story.

STAGE 3: Creating a soundtrack
Before this stage begins, several songs have already been composed. At this stage, the members discuss the relationships between the songs and the context of their story, and decide which songs the group still needs to compose. They then start discussing and testing action sounds (to support a particular performance on stage, for example), musical themes, styles, lyrics, possible arrangements, and other elements (Figure 1).

STAGE 4: Hiring professional musicians to be part of the live band
With the arrangements made, the group decides which instruments and musicians must be incorporated into the band for the performance. One of the goals is to promote interaction between the clients and different instruments and musicians. For instance, for one of the plays, we hired musicians to play the violin and a cello, instruments with which the members were not familiar, and thus had the opportunity to experience.

STAGE 5: Completing the script
Once the story, characters, and soundtrack have been created, the script is concluded. The aim here is to guarantee that the performance is not overly long (a maximum of 40 minutes) and, that the story has an interesting rhythm (a balance between moments of tension and relaxation). The most important therapeutic understanding of this stage is that the script must function as a representation of a work routine providing support, consistency, and predictability. By work routine I refer to a structure that guarantees the necessary stability for the participants to feel safe and supported, as the other factors (i.e., the theater, lights, and audience) are unpredictable, which can cause anxiety and confusion.

STAGE 6: Constructing the scenery and producing the costumes
After the script has been completed, the company can hire professionals to construct the scenery and produce the costumes. Puppets are handmade by one the clients (Figure 2).

STAGE 7: Hiring stage support staff
After the script has been written and the scenery and clothing produced, the support staff can be hired. The stage support staff is comprised of a maximum of two therapists who have a previous relationship with the clients and can provide stage support during costume changes, toilet breaks, and other events. If the support therapist is a music therapist, he or she can also participate in the live band. The support staff responsible for the transportation and lighting must also be considered and hired.

STAGE 8: Promoting the performance
The music therapy team, together with the parents involved in the theatre program, is responsible for promoting the performance. The main purpose of this stage is to engage parents (ecology) in the process.

STAGE 9: Promoting social inclusion through the performance at a professional theater in the city of Porto Alegre
The musical performance is held in a rented theater for parents, relatives, professors, therapists, medical doctors, and all others involved with each of the company members who have been invited. The general public is also invited to attend. A main objective of this stage is to integrate clients, families, professionals, and regular audience.

The project thus focuses on the following:

• Stimulating group musicking, free expression, and creative freedom.
• Finding and facilitating the development of clients’ interests, potential and abilities.
• Being performative (showing development through action).
• Promoting intrapersonal and inter-personal relationships (i.e., the ecological element).
• Serving as a space for creative and therapeutic expression by doing the following:
  • Promoting a feeling of accomplishment and satisfaction in a resource-oriented way (“I am able to do it”).
  • Providing parents and relatives, in the audience, with personal engagement with their son/daughter/relative from a “safe theatrical distance” (i.e., the ecological element).
  • Promoting social inclusion via activism and participation.
  • Promoting integration among clients, professionals, parents, relatives, and the public in general (i.e., the ecological element).

The reader may ask: Where does music therapy fit in the nine stages? What characterizes this as music therapy? I consider music therapy fitting in all stages. When the clients start expressing their content for us, their music therapists, they are supported by us verbally and/or musically. Our therapeutic listening is active throughout the nine stages. Just to give another example: one of the group members loves to build puppets (Figure 2). Our music therapy role implies composing songs by and for the puppets he creates and relating the puppet with other characters of the play. There is also an understanding that the puppet is a media and extension of this person with ASD and that he is using it to express and communicate what he needs in his work in music therapy.

Final considerations

In the production of this article, three terms repeatedly arose for consideration: community, context, and culture. The purpose of this article was not to reflect on these concepts specifically but rather on how they can help promote a broad form of music therapy that can expand its limitations beyond the musical, verbal, and bodily creations of only therapists and clients and in a specific room. While doing so, it is always important to evaluate the ethical elements of confidentiality - the final “E” of the acronym proposed by Stige and Aarø (2012) – that may be involved when clients are exposing themselves publically. For those unable to make profound decisions by themselves, the therapist must determine which elements can be exposed publically and which should be kept in therapeutic confidence.

Very little is still known about the link between music therapy and theater. The purpose of this article that has been presented had many objectives. In the first place, it was to systematize and organize a music therapy approach where elements other than music seem to be therapeutically relevant for this particular group The possibility of connecting music therapy with theatre for certain therapeutic needs appears to be offered to individual holders of a communication disorder. However, such an approach may be used with the most varied levels of conditions depending on taking into consideration the necessity for adaptations according to each client or each group’s needs.

I believe that the most important message of this article is the need to apply music therapy in as broad a manner as possible in the treatment of clients whose worlds are limited by certain conditions. It is possible to expand the music therapy room by making it larger than the space within its four walls. The clinical practice of music therapy can be conducted in a broad manner by combining understanding of human nature, music, and creativity with that of history, culture, context, and ethics.

Theatre helps us to express
ourselves
brings us joy and music
in doing it
we talk, we think
how we feel
and much more
(Gabriel, a 30-year-old member of the Teatro Íntegro Company with ASD)

Finally I would like to briefly reflect on Gabriel’s lines, focusing on his last: and much more. I believe he is stating, “In here [the music therapy room] we talk, we think, and “much more.” I think “much more” may encompass the creative encounters, insights, and peak experiences that may be experienced throughout the therapeutic process.

In accordance with this article’s message, Gabriel’s verbalization of “much more,” reflects the need for music therapists to broaden their clinical eyes and ears. It is only by such means that music therapy will become more mature, and social, and thus able to offer greater space for the achievement and well-being of people with ASD and other conditions.

References

Ansdell, G. (2002). Community music therapy & the winds of change.Voices: A World Forum For Music Therapy, 2(2). doi:10.15845/voices.v2i2.83

Ansdell, G. (2005). Being who you aren't; Doing what you can't: Community music therapy & the paradoxes of performance. Voices: A World Forum For Music Therapy, 5(3). doi:10.15845/voices.v5i3.229.

Carp, C. E. (1998). Clown therapy: The creation of a clown character as a treatment intervention. The Arts in Psychotherapy, 25(4), 245-255. doi: 10.1016/S0197-4556(98)00029-X

Cohen, H. U. (1985). Conflicting values in creating theatre with the developmentally disabled: A study of theatre unlimited. The Arts in Psychotherapy, 12, 3-10. doi: 10.1016/0197-4556(85)90002-4

Couroucli-Robertson, K. (2001). Brief drama therapy of an immigrant adolescent with a speech impediment. The Arts in Psychotherapy, 28, 289-297. doi: 10.1016/S0197-4556(01)00120-4

Dogan, T. (2010). The effects of psychodrama on young adults’ attachment styles. The Arts in Psychotherapy, 37, 112-119. doi: 10.1016/j.aip.2010.02.001

Dunne, P. B. (1988). Drama therapy techniques in one-to-one treatment with disturbed children and adolescents. The Arts in Psychotherapy, 15, 139-149. doi: 10.1016/0197-4556(88)90021-4

Emunah, R. (1983). Drama therapy with adult psychiatric patients. The Arts in Psychotherapy, 10, 77-84. doi: 10.1016/0197-4556(83)90033-3

Emunah, R., & Johnson, D. R. (1983). The impact of theatrical performance on the self-images of psychiatric patients. The Arts in Psychotherapy, 10, 233-239. doi: 10.1016/0197-4556(83)90024-2

Fryrear, J. L., & Stephens, B. C. (1988). Group psychotherapy using masks and video to facilitate intrapersonal communication. The Arts in Psychotherapy, 15, 227-234. doi: 10.1016/0197-4556(88)90007-X

Gendler, M. (1986). Group puppetry with school-age children: Rationale, procedure, and therapeutic implications. The Arts in Psychotherapy, 13, 45-52. doi: 10.1016/0197-4556(86)90007-9

Goodrich, J., & Goodrich, W. (1986). Drama therapy with learning disabled, personality disordered adolescent. The Arts in Psychotherapy, 13, 285-291. doi: 10.1016/0197-4556(86)90029-8

Horwitz, E. B., Kowalski, J., & Anderberg, U. M. (2010). Theater for, by and with fibromyalgia patients – Evaluation of emotional expression using video interpretation. The Arts in Psychotherapy, 37, 13-19. doi: 10.1016/j.aip.2009.11.003

James, M., & Johnson, D. R. (1987). Drama therapy in the treatment of combat-related post-traumatic stress disorder. The Arts in Psychotherapy, 23, 383-395. doi: 10.1016/S0197-4556(96)00045-7

Johnson, D. R. (1986). The developmental method in drama therapy: Group treatment with the elderly. The Arts in Psychotherapy, 13, 17-33. doi: 10.1016/0197-4556(86)90005-5

Johnson, J. L. & Alderson, K. G. (2008). Therapeutic filmmaking: An exploratory pilot study. The Arts in Psychotherapy, 35, 11-19. doi: 10.1016/j.aip.2007.08.004

Koppelman, R. (1984). Hand puppetry with a chronic psychiatric population. The Arts in Psychotherapy, 11, 283-288. doi: 10.1016/0197-4556(84)90026-1

Mackay, B., Gold, M., & Gold, E. (1987). A pilot study in drama therapy with adolescent girls who have been sexually abused. The Arts in Psychotherapy, 14, 77-84. doi: 10.1016/0197-4556(87)90037-2

Moffett, L. A. & Bruto, L. (1990). Therapeutic theatre with personality-disordered substance abusers: Characters in search of different characters. The Arts in Psychotherapy, 17, 339-348. doi: 10.1016/0197-4556(90)90054-T

Mulkey, M. (2004). Recreating masculinity: Drama therapy with male survivors of sexual assault. The Arts in Psychotherapy, 31, 19-28. doi: 10.1016/j.aip.2003.11.003

O’Doherty, S. (1989). Play and drama therapy with the Down’s syndrome child. The Arts in Psychotherapy, 16, 171-178. doi: 10.1016/0197-4556(89)90020-8

Salas, J. (1992). Music in playback theatre. The Arts in Psychotherapy, 19, 13-18. doi: 10.1016/0197-4556(92)90059-W

Schnee, G. (1996). Drama therapy in the treatment of the homeless mentally ill: Treating interpersonal disengagement. The Arts in Psychotherapy, 23(1), 53-60. doi: 10.1016/0197-4556(95)00041-0

Stige, B. (2002). Culture-centered Music Therapy. Gilsum: Barcelona Publishers.

Stige, B., & Aarø, L. E. (2012). Invitation to community music therapy. New York, NY: Routledge.