View of The Competent Client and the Complexity of Dis-ability

[Special Issue on Music Therapy and Disability Studies]

The Competent Client and the Complexity of Dis-ability

By Randi Rolvsjord

Abstract

Clients and therapists in the interdisciplinary discourse of mental health and mental health care are described as dichotomous. In such a binary the client is defined in terms of weakness, pathology and passivity, while the therapist is described in terms of strengths, expertise and activity. This article aims to contribute to the destabilization of the client-therapist binary by offering a review of literature on competent clients. Perspectives from social models and cultural models in disability studies provide the theoretical frames for the discussion. Social constraints and oppression with regard to the dis-ability complex and discursive implications are discussed.

Keywords: ableism, competent client, disability studies, feminist perspective, mental health, music therapy



Introduction

I have been hearing voices for 34 years now, and it has not got any better. But luckily, I have a very good stereo and a huge collection of music, so that helps

The man uttering these words is a middle aged man, who is a client in music therapy in a mental health institution. He has suffered from severe mental health problems for more than half of his life, and he has used a broad specter of heath care services, including long term residency in a mental health institution. As part of a research project[1] focused on clients’ contributions in music therapy, he had agreed to take the role of informant, and I met with him for two interviews. I asked him to talk about his experiences with music therapy as well as his experiences with music in other life contexts. His story about the meaning that music and music therapy played in his life moved me deeply. “Music is everything to me” was a phrase he repeated several times during the interviews. Bjørn’s story was first of all a story about a life-long commitment with music. His participation in music therapy, for a period of eight years, had offered new possibilities for musical interactions that expanded upon his life-long commitment with music. Since childhood, he had been playing various instruments, and had participated in several ensembles and bands. While telling his story of his engagement with music, the conversation touched on different composers and artists across a variety of musical genres. He talked about classical composers and masterpieces, videos from rock concerts, rock groups and albums, jazz music and country artists. Indeed his collection of more than 3000 music CD’s, a collection far too big for his room at the institution, became a vivid physical confirmation of his impressive musical competence. As the quote beginning this article conveys, Bjørn’s competence in music was a resource that he used in his struggles living with mental illness. He used music to find meaning in life, in social interaction, and to cope with symptoms (such as the voices he hears). Despite the differing roles and differing levels of formal music education, his conversations with the music therapist were characterized by a common interest in music, and a shared competence when they talked about pieces of music, artists, recordings and performances.

Looking back, I have to admit that I was a bit taken aback by his competence and vast experience with music. His degree of knowledge in music surprised me, as I felt that it was strangely in contrast with the amount of health care services that he needed. My reactions here are perhaps not surprising, yet they are disturbingly accurately pointing towards some dilemmas concerned with the complexity of dis-ability and ability that I will try to put forward in this article informed by disability studies perspectives.

My reading of disability studies in this article is informed by two different perspectives. First, I have been involved with feminist theory and feminist approaches to research. Like the field of disability studies, feminist perspectives focus on marginalization and oppression, and seek to influence political change (Hesse-Bieber, 2014; Lykke, 2010; Rolvsjord & Hadley, submitted). Although disability studies and feminist studies are indeed separate academic discourses, they are also interwoven due to perspectives on intersectionality in both fields (Carbin & Ederheim, 2013; Garland-Thomsen, 2002; Goodley, 2014; Mertens, 2009). Intersectionality implies a broader view on social location that comprises and connects perspectives on gender, race, class and disability. Second, my work within music therapy and mental health has led me to approach perspectives that are critical of the medical model (Rolvsjord, 2004, 2006, 2010; Rolvsjord, 2013; Rolvsjord & Stige, 2013; Solli, Rolvsjord & Borg, 2013; Solli & Rolvsjord, 2014). This work has included perspectives from positive psychology, empowerment philosophy, contextual models in psychotherapy, and recovery models. In my understanding, there are clear similarities between these perspectives and disability studies with regard to the critique of the medical model, the focus on human rights and anti-oppressive practice, the focus on strengths and participation, and the critique of individualist models.

The theme discussed in this article, is linked to discourses in the interdisciplinary field of mental health and mental health care. Critique has been raised regarding a strong focus on pathology and problems over a focus on strengths and resources, and hence a tendency to define persons with mental health problems in terms of weakness and pathology to the neglect of their strengths (i.e. Antonovsky, 1979; Davidson & Roe, 2007; Furedi, 2004; Maddux, 2002; Seligman & Csikszentmihalyi, 2000). There are two interconnected aspects of such critiques that I will point out: First, there is a tendency to locate mental health problems in the individual, and subsequently to fail to recognize the demoralization and oppressive social contexts in which the individual resides (Becker, 2005; Becker & Maracek, 2008; Frank & Frank, 1993). Second, there is a tendency to use concepts when talking and writing about therapy that depict the therapist as an expert with power, and the client as weak and pathological (Duncan & Miller, 2000a; Furedi, 2004; Hubble & Miller, 2004; Maddux, 2002).

Informed by cultural and post-structuralist perspectives in feminist research (Barrett & Phillips, 1992; Lykke, 2010; Rolvsjord & Hadley, submitted; Søndergaard, 2002) and disability studies (Goodley, 2014), I intend to contribute to a further destabilization of such dichotomous conceptualizations by focusing on concepts of competent clients. Methodologically, this can also be linked to the strategy of “studying up” in feminist research (Harding, 2009; Sprague, 2005). This strategy involves focusing on disadvantaged groups in a way that contrasts the more usual interest in studying the problems of disadvantaged groups. I will provide an account of current research in music therapy and psychotherapy dealing with the clients’ competence, craft and/or agency in relation to the therapeutic processes, and discuss conceptualizations of competent clients from a disability studies perspective.


Lessons from Disability Studies

Before moving into research centered around competent clients, some theoretical frames in disability studies need to be outlined. Disability studies can be described as a family of related perspectives, and includes differing as well as conflicting strands. Shakespeare (2014) identifies three main strands: materialist approaches (i.e., the social model) that emphasize disability as a product of powerful social forces and arrangements (i.e., Freund, 2001; Oliver & Barnes, 2012); cultural disability studies that emphasize the cultural representations and discursive construction of disability (i.e. Davis, 2013; Godley, 2014; Snyder & Mitchell, 2006); and critical realistic perspectives that point towards disability as an interaction of biological realities and sociocultural constructions (i.e. Shakespeare, 2014). The diverse perspectives in the field of disability studies vary both in terms of how strongly they emphasize the social construction of disability (and implicitly the level of critique of the medical model), and what type of processes (i.e. social, political, cultural, discursive) are emphasized in the construction of disability. As argued by Goodley (2014), the materialist focus on social and economic aspects needs to be complemented by the focus on discursive politics in the cultural strand of disability studies. This resembles current epistemological positions in feminist studies that emphasize the interaction between materiality and constitutive processes in language (Hemmings, 2011; Lykke, 2010).

The discussion in this article is framed in the context of mental health and mental health care. It must be noted that mental health issues are somewhat at the outskirts of disability studies and disability theory. This may be due to several reasons, among others that mental health problems are understood as less chronic, that there is a lack of identification with a disability identity among people with mental health problems, as well as degrees of stigma connected to mental health problems that make people with physical impairments reluctant to identify with that group (Beresford, 2000; Beresford, Nettle & Perring, 2010). There are, however, clear similarities between the disability movement and movements in mental health such as the recovery movement and psychiatric system survivors movements that make a dialogue important (Beresford, 2000; Pilgrim & Cranie, 2013). Further, it is indeed quite common that people experience both mental health problems and physical impairments, due to bad luck, side effects of medications, side effect of mental illness, or other interactions between physical and mental illness.

Two important lessons can be drawn from disability studies that will be highlighted in the following: First, disability is not a problem of the individual. As much as it involves a person’s impairment, it is created at structural levels, with environments/societies that are not flexibly adapted to allow for variability of humanness. Thus, disability is a political problem as much as a medical one. Second, we need to allow for and embrace diversity rather than normalcy. This includes acceptance of the broad range of abilities and talents, acceptance of the “less-able” and of dependency. It is important to note that the focus on oppressive social structures in disability studies does not contradict or neglect illness and impairments, nor does it neglect people’s need for help and care.


The Social Construction of Disability

The various strands of disability studies emphasize, albeit to differing degrees, the social construction of disability. This implies both an inherent critique of the medical model that locates illness and disability in the individual, and a call for changes on structural levels to prevent and minimize disability. With the social model of disability (i.e., Oliver & Barnes, 2012), disability can be described as the societal reaction to (or lack of flexibility towards) an impairment, and most radically depict disability as oppression. A person in a wheelchair is not disabled before she meets obstacles that hinder her mobility. Likewise, someone deaf is not considered disabled in a deaf community, but is likely to be considered disabled in a community of hearing people (Freund, 2001; Oliver & Barnes, 2012). The social model then implies a shift of focus from the “effects” of the impairment to people’s experiences of social constraints, oppression and exclusion (Oliver & Barnes, 2012). Consequently, the discourse of disability studies offers an important correction in terms of the medical definitions of disability (Donoghue, 2003; Siminski, 2003).

When applying a social model of disability to mental health, social stigma is considered the main disabling barrier (Beresford, Nettle & Perring, 2010). Stigma can be related to three stereotypes linked to the public perception of mental illness: dangerousness (for example when people with mental illness are considered “ticking bombs”), blame (that people with mental illness are weak and therefore have themselves to blame for their problems) and benevolence (that people with mental illness are like children in need of someone making decisions for them) (Corrigan & Wassel, 2008). Such stereotypes can include public stigma, self-stigma, and label avoidance, and might therefore affect people with mental health problems in various ways. Public stigma might lead to both loss of opportunities and coercive treatments. Self-stigma might lead to loss of self-esteem and self-efficacy, while label avoidance might lead to lack of help from mental health services (Corrigan & Wassel, 2008).


Ableism and the Strive for Normalcy

A second concept central to the field of disability studies is ableism, a concept that may help us to understand the cultural and political aspects of disabling and oppressive structures, such as that of stigma. As explained by Wolbring (2008) “Ableism reflects the sentiment of certain social groups and social structures that value and promote certain abilities” (p. 253). Thus ableism may include a preference for certain normative abilities, and lead to the discrimination of people that are considered “less able”, for example by having a medical diagnoses or other classifications of impairment. The specific term dis-ability highlights the need to discuss disability in relation to ableism (Goodley, 2014). This highlights a complexity that accentuates two dimensions of dis-ability (the disability as well as the ability components), where both can be linked to levels of oppression.

Ableism includes strategies for fixing individuals that don't fit with the norm (in coherence with the medical model), and/or strategies for prevention and reduction of the amount of people “less-able” (Goodley, 2014). Extremely devastating implications of ableism have been seen across history. Historically the Nazi-German murders of people with physical and mental disabilities, and the more widespread sterilization of people with mental retardation serve as terrifying examples (Snyder & Mitchell, 2006). However, such preventive ableist strategies might still be relevant to discuss with regard to current practices in prenatal medicine, eutanacy (euthanasia), regulations of abortions, eugenics, etc. (Davis, 2013; Shakespeare, 2014).

More relevant for the discussion in this article, are considerations regarding the ableist strategy of fixing people. The increasing number of mental health diagnoses, categorized recently in the new version of the diagnostic manual DSM-5 (American Psychiatric Association, 2013), is pertinent to discuss. The DSM-5 can be seen as a result of a development in mental health that has increased the number of mental health diagnoses, and hence to some degree both limited the range of normalcy, and defined normal life challenges as pathology, in need of professional expertise and “fixing” (Davis, 2013; Furedi, 2004; Maddux, 2002). Davis (2013) discusses ableness in terms of the demands medical practices place on our conceptualization of normalcy. He argues that the DSM-5 “has elaborated a dizzying display of lifestyle illnesses that demands medical treatments to cure and normalize people. Sadness, shyness, obsession, sexual desire, anger, adolescent rebellion, and the like now fall under a bell curve whose extremes become pathologies” (Davis, 2013, p. 8). Such a medicalization of culture, here represented by developments in mental health diagnostics, strongly contradict a development in disability studies that replaced normal with diverse (Davis, 2013).

While historical versions of ableism may be linked to several political systems and ideologies, Goodley (2014) links the current version of ableism to tendencies of neoliberal politics, specifically meritocracy and entrepreneurship related to the production and consumption of (economical) value, within market rules. With the rationality of the market rules a “neoliberal-able subjectivity emphasize[s] individual over collectivity” Goodley, 2014, p. 27). This implies a tendency to impose values relating to the able body and mind, and a preference for independence, autonomy and self-actualisation, which is also strongly emphasized in current psychological perspectives (Becker & Maracek, 2008).


The Client-therapist Binary

In accordance with perspectives within poststructuralist approaches, cultural disability studies point to the binarisations of “the disabled” versus “the normal” as being of central importance. Implicit is the understanding that both normalcy and disability are constituted in relation to each other through social, economic and cultural practices (Goodley, 2014). According to poststructuralist theory, such binaries are part of the constitution of our language, and contribute to how we make meaning of the reality within which we live and construct our social world (Kristeva, 1984).

An array of other binaries, however, can also be considered of relevance and interact with constructions of “the disabled” and “the normal”, such as “victim-survivor”, “weak-strong”, “ill-healthy”, “active-passive” (Goodley, 2014). With such a network of binaries in mind it is relevant to deconstruct the relationship between the concepts of “client” and “therapist”. This binary is situated in the specific social practice of therapy, but interacts with a broader context of discourses that contribute to social and political structures that might be experienced as oppressive to people with mental health conditions.

Maddux (2002) argues that clinical psychology has adopted a language focused on pathology that “promote[s] a dichotomy between normal and abnormal behavior, clinical and non-clinical problems and clinical and non-clinical populations” (p. 14). By the use of terms like “clinical”, “treatment” and “patient” he argues that people who are seeking help are portrayed as “passive victims of intrapsychic and biological forces beyond their direct control who therefore should be the passive recipients of an expert’s ‘care’ and ‘cure’” (Maddux, 2002, p. 14). Such deconstructions of medical language that is also used in the discipline of music therapy may demonstrate how the concepts of client and therapist are connected to binaries that locate pathology and problems in the client, and solutions to solve problems or cure pathology in the therapist. Thus, while clients are portrayed in terms of weakness, therapists are portrayed in terms of strengths and expertise.

In my opinion, it is relevant to consider this portrayal of weak clients and expert therapists as a grand narrative. A grand narrative is linked to a dominating discursive ideology, to the extent that it is taken for granted (Alvesson, 2002). Problems with such a grand narrative are personal, social and political. At the personal level, the grand narrative is connected to experiences of stigma and devaluation of clients’ strengths. At the social level, the grand narrative involves an unequal distribution of power between collaborators in therapeutic work with implications for the experience of the relationship (Rolvsjord, 2006). On a political level, the grand narrative cultivates vulnerability and the need for professional expertise to care and cure a quickly growing number of conditions and life problems that are considered pathological (Furedi, 2004; Maddux, 2002).


Competent Clients

The clients that music therapists meet in mental health care practice have one or more mental health diagnoses. The diagnosis according to the systems of classification found in the ICD-10 (World Health Organization, 1992) or the DSM-5 (American Psychiatric Association, 2013) describes a certain set of symptoms that the client experiences. Besides experiencing such symptoms, the clients are as different as persons without diagnoses. Yet stories about clients in music therapy are also inflected with medical language that shapes our images of mental health clients, carrying connotations such as “weakness”, “pathology”, “passivity”, “dependence” rather than “strength”, “health”, “active” or “autonomy.” Based on a review of literature, the following sections identify four areas of competence that clients use in music therapy: 1) Musical competence; 2) theories of change; 3) reflexivity and agency in sessions of therapy; and 4) making use of therapy in everyday life.


Musical Competence

Clients in music therapy represent a wide range in terms of musical competence. Clients that choose music therapy may be professional musicians or music teachers with a high level of formal musical competence; others may have no formal education in music, but have acquired competence in music through cultural participation in music. Most likely their musical competencies are as diverse as the adult population in general. Whatever the case, music is important in people’s life, and is embedded in social structures across cultural locations. Thus, at the starting point of music therapy, we can assume with much certainty that people will have previous and varied experiences with music.

The differing previous engagement with music involves different types of musical competence. Rolvsjord (2010) identifies three types of competence with regard to everyday engagement with music: communicative musicality, musicianship, and musical experience skills.[2] Communicative musicality can be described as the innate capacity for musical relating (Trevarthen & Malloch, 2000). Musicianship consists of culturally located and learned skills and knowledge and includes formal as well as informal learning (Pavlicevic & Ansdell, 2009). By the term musical experience skills, Rolvsjord implies the competence involved in the appropriation of music in various contexts (DeNora, 2000). Of specific interest, then, is the experience and competence of health musicking (Stige, 2002, 2012), which includes the use of music for health promoting purposes such as emotional regulation, pleasure, social interaction, motivation etc. As a practice, health musicking cuts across professional realms (such as music therapy and community music) and people’s own everyday uses of music (Ruud, 2012). Hence, a person’s experience and competence in how music can be a health resource in their own life can be linked to experiences across contexts of professional and everyday life.

The extensive and varied uses of music in everyday life found in the research provides evidence for reflexivity and agency in musical appropriations (Bonde, Ruud, Skånland & Trondalen, 2013; Butterton, 2004; DeNora, 2000; Ruud, 2013; 1997; Skånland, 2011; 2013). However, it is important to acknowledge that an individual’s musical agency is also somewhat constrained by social and cultural expectations regarding music (Hesmondhalgh, 2013). Commitment to everyday life health musicking is not restricted to people who do not experience health problems (i.e. Batt-Rawden, DeNora & Ruud, 2005; Beckman, 2014; Rolvsjord, 2013; Sharma, 2014). However, clients with mental health problems have reported that their illness influences the possibilities they have for engaging with music (Ansdell & Meehan, 2010; Rolvsjord, 2010). Informed by social models and cultural perspectives in disability studies, it is tempting to suggest that such limited possibilities for musicking can be caused by social constraints as much as to the person’s own limited capacity due to her/his impairment or illness. The experience of public stigma and self-stigma, might for example influence a person’s likelihood to participate in a choir.


Theories of Change

The second area of competence that I will outline here is the client’s own theories of change. This includes their knowledge and experience about how change happens. The literature discusses three interrelated facets of this: 1) The culturally contextualized theories of change that a client (as well as a therapist) believes in; 2) the client’s personal experiences of how change happens in her/his life; and, 3) the client’s expertise specifically in relation to her/his experience with mental illness and with the mental health care system.

Frank and Frank, in the seminal book Persuasion and healing (1993), emphasize contextually and culturally situated beliefs as crucial to healing practices like psychotherapy. Important in this regard is the belief about how a therapeutic practice can be “healing”. Such beliefs are concerned with theories or explanations of illness, and with faith in the power or expertise of the “healer” or psychotherapist. The importance of such beliefs in therapy are documented in research identifying effects of placebo (on behalf of the client) and similarly the importance of the therapist’s allegiance (Wampold, 2001a; Wampold, 2001b). We face however a two-edged sword here, related to potential demoralization and fostering of vulnerability that such a belief in institutionalized health services may cultivate (Furedi, 2004).

Lampropoulos (2001) has identified similarities between change processes in various clinical and non-clinical contexts, which may indicate the relevance of previous experiences with change processes in various contexts for production of knowledge that can be used in other change processes. Bohart & Tallmann (1999) outline a repertoire of strategies for dealing with problems that people engage with both in their everyday life struggles and in therapy. Similarly, Duncan, Miller, Coleman, Kelledy and Kopp (2000) and Duncan and Miller (2000b) emphasize the importance of stimulating and making use of clients’ own theories of change in therapeutic encounters. More explicitly, Mackrill (2008) examined how clients use their own strategies for change in the process of therapy.

We can link this experiential competence to the concept of clients being experts of experience, a notion used to denote the specific knowledge of service-users, and of those who needed but were not offered certain health services (McLaughlin, 2009). The political requirements for user-involvement are an acknowledgment of the need for the competence and knowledge that users have from first-hand experience with illness, living with illness and with the health care system. Users’ competence is emphasised both in terms of the “expert patient” representing the users competence in her/his own illness, but also in terms of more general knowledge that might supplement or challenge existing professional knowledge and perspectives of illness and care (Tait & Lester, 2005). The importance of this knowledge is acknowledged in health politics as evidenced by the requirements for user-involvement at various levels (Borg, Karlson & Kim, 2009; Hickey & Kipping, 1998; Thornicroft & Tansella, 2005). Studies of users’ internet forums (Fox, Ward & O’Rourke, 2005; Hogle, 2012) and studies of user involvement projects (Elstad & Eide, 2009; Pilgrim & Waldron, 1998) have documented the usefulness of this competence in promoting change.


Reflexivity and Agency in Sessions of Therapy

The third area of competence that I will describe here is the competence that clients demonstrate through their reflexive interactions with the therapist. In psychotherapy research, Rennie (1994; 2000; 2001; 2007) has explored the client’s reflexive actions in the moment-to-moment interactions with the therapist in psychotherapy sessions. The findings from these qualitative Interpersonal Process Recall interview studies document how clients actively take control or even manipulate the events of the interaction in the session, in order to regulate the intensity, to change the focus of the interaction, and to contribute to the development of a good relationship with the therapist. Greaves (2006) described similar findings in her analysis of session transcripts from 13 cases. She identified four key themes of clients’ active involvement: 1) self-directed problem solving; 2) reconstruction and remoralisation of self; 3) mobilization and application of the therapist’s techniques; and, 4) nurturance and utilization of the therapeutic relationship. Theoretical discussions in the field of psychotherapy research add to such empirical studies by research based arguments for the client being an important common factor with regard to the outcome of therapy, as well as for the client being an active agent in the process of therapy (Bohart, 2000; 2004; Bohart & Tallmann, 2010; Hubble & Miller, 2004; Orlinsky, Rønnestad & Willutski, 2004)

In music therapy, Rolvsjord (in press) identified four categories characteristic of clients’ reflexivity and agency in music therapy, three of those connected specifically to the interaction with the therapist in music therapy session, which are: 1) “Clients’ initiatives” in the therapeutic process, which included the continuous choice of music therapy, suggestion of activities and the use of humor; 2) Clients’ “ways of exerting control in session”, which included active involvement with regard to emotional regulation and negotiation with the therapist related to focus and goals as well as types of activities and musical interactions; 3) “Clients’ commitment to the relationship”, which included ways clients nurtured commonalities with the therapist, how they contributed to the establishment of equal structures, and various ways they cared for the therapist. In a study of female prisoners’ participation in a performance project, O’Grady, Rolvsjord and McFerran (2014) explored resources that the participants brought into the process, and the implications of such investment of resources. Courage, readiness, exchange, support and trust were identified as resources invested in the process and which were found to contribute to a positive experience of participation for the women. Other studies in music therapy document facets of clients’ active contributions in interactions with the music therapist, without this being the main theme of the study. The studies of Ansdell & Meehan (2010) and Solli & Rolvsjord (2014) suggest clients’ experiences of self-determination are important for the therapeutic process. Trondalen (2004) identifies clients’ active role in the initiation of “breaks” in the improvisation with the therapist. Finally, Turry (2005) and Lee (1996) both describe a client’s active commitment in facilitating change in the relationship with the therapist.


Making Use of Therapy in Everyday life

Music therapy can be described as a social practice. It is a process that is described as culturally situated, and interacts with other social contexts (Rolvsjord & Stige, 2013; Stige, 2002). Thus, the meaning and usefulness of therapy is not only unfolding in therapy sessions, but within political and cultural locations in which it is organized and in interaction with other social life contexts in the client’s life (Dreier, 2009). Given the limitation in time and space (for example, one session each week in the local mental health centre), the clients are key to the interaction of therapy with other social contexts.

The relationship between therapeutic processes and the everyday life contexts of the client can also be linked to the concept of extra-therapeutic factors that are said to contribute to the outcome of therapy (Lambert, 1992; Lambert & Ogles, 2004; Wampold, 2001a, 2001b). The link between extra-therapeutic factors and the client’s contributions are considerable, and sometimes used interchangeably (Hubble & Miller, 2004). In addition to the client as a common factor, the extra-therapeutic factors refer to the client’s context, as well as to the structural (political) level, the “policy and agency context” (Drisko, 2004, p. 85).

Dreier (2008) and Mackrill (2008) studied how clients connect therapy with their everyday life using a cross-contextual qualitative design. Dreier (2008) explored how change processes in everyday contexts relate to participation in therapy sessions. Using the framework of social practice theory, he found that clients in their pursuit of change across contexts, made use of therapy as part of their everyday life. Mackrill’s study specifically focuses on the strategies that clients adopt across contexts in their pursuit of change (Mackrill, 2008).

In a single case study, Rolvsjord (2013) explored one client’s agency in terms of a cross-contextual pursuit of change, theoretically informed by Dreier (2008). The case demonstrates how the client’s commitment in the process of music therapy interacts with the client’s similar and continuous commitment in other life contexts. A single case study by Stige (2011) similarly indicates the client’s efforts with respect to continuity between the process in music therapy sessions and in the context of everyday life. A third single case study that should be mentioned here is Solli’s (2014) study that illustrated a client’s cross-contextual involvement in terms of the client’s use of music created in therapy to make social connections through the compilation of a CD, performances and the use of social media. Rolvsjord (in press) also identifies such cross-contextual investments as a core category in her multiple case study of the contributions of clients in music therapy in the field of mental health. The participating clients reported that they brought songs and other artifacts from other life-contexts and vice versa, and that they purchased instruments in order to develop new possibilities for music making outside of music therapy. In this way, clients created continuity between music therapy and their use of music in everyday life.


Discussion

In my review of literature in the field of disability studies earlier in this article, I identified two lessons of utmost importance for what would be discussed in this article: The social construction of dis-ability, and the importance of embracing diversity rather than normalcy. Taken together these two lessons concerning dis-ability reveal a complexity, where negative facets of labeling (like diagnoses and stigmatization) as well as positive aspects of membership in a minority group are connected to an identity of disability. However, Shakespeare (2014) notes that:

Radical social movement perspectives stress oppression as the basis for identity. Arguably, this still leaves disabled people in a pathologised situation. While the causation has shifted from the impaired body to the exclusionary society, disabled people are still rendered as victims, rather than agents. The bulk of disability studies literature casts disabled people in negative light, and discusses the woes of bodies that don’t work, in a society that does not care. (p.106)

The following discussion concerning the concept of competent clients, will center on the complexity of the interaction between our two lessons from disability studies.


Individual Agency versus Social Constraint

The first aspect of this complexity is linked to the relationship between individual agency and social constraint. Agency is a concept related to the dis-ability complex that, with a positive flavor, describes a person in charge of her/his life, within the constraints of society (Barnes, 2000). The social model of disability has highlighted the social construction of disability (Oliver & Barnes, 2012), pointing to levels of social oppression. For people with mental health problems, such social constructions of dis-ability might be connected to stigma (Beresford, Nettle & Perring, 2010). If a person diagnosed with schizophrenia wants to start singing in a choir, he or she may have some communication problems that affect the possibility to get to know other members. But the anxiety of the “able” members might be just as disabling to their communication and contact.

The term dis-ability is linked both to social models of disability and to perspectives on ableism (Goodley, 2014). With the dis-ability complex in mind there is a need to explore the social constraints and oppression also with regard to the ability component. One dimension of this is that the social construction of dis-ability includes both structures that construct disability, but also constructs and constrains a person's ability (agency). In both cases some of these constraints are related to ableism. With my attempt to destabilize the binary of the “weak client” and “expert therapist”, I have focused on the client in terms of her/his strengths, competence and agency. It is important however, to consider the levels of social constraints and oppression that limit a person’s possibilities of agency.

In this article, such restrictions of agency are connected to discursive politics in the broad and interdisciplinary literature of mental health and mental health care. The “weak client-expert therapist” binary has oppressive facets and contributes to the stabilization if not to the construction of disability/mental illness. However, discourse is not occurring in isolation. The client-therapist binary is interwoven with a therapy culture that may increase vulnerability (Furedi, 2004) by its well-intended attempts to help people and cure illnesses.


The Paradox of Competent Clients

The second lesson from disability studies is the call to embrace diversity rather than normalcy. Davis (2013) argues that the concept of diversity fits well with neoliberal ideology, with regard to the individualist values of self-actualisation, autonomy and personal gratification. However, he observes that it “seems like a certain incommensurability between the celebration of diversity and the normalization of disability” (Davis, 2013, p.9). In Davis’ argument, where medicalized bodies are concerned, the logic of the dichotomy of normal-abnormal, rather than on a discourse of diversity, is dominant. In such an ableist culture, a person’s value is connected to her/his able-ness (Goodley, 2014). Hence, there is a need for a politic that values the less able, and challenges the ableist ideology. This includes the recommendation to also consider the positive aspects of disability: “Disability is an identity, a way of life, not simply a violation of medical norms” (Davis, 2013, p. 9).

The risk, then, is that in my pursuit of the “competent client”, I might just end up reconstructing the client in an ableist fashion according to standards of normality, seeking the value of clients solely through their abilities. By promoting the strengths of clients am I contributing to an individualistic focus on well-being that is connected with values associated with a politics of ableism? Becker and Maracek (2008) propose a well-articulated critique of ideological foundations of positive psychology that might be relevant to consider here, due to a similar “positive” character of this project. They argue that positive psychology, with its focus on self-actualization and autonomy, implies levels of adaptation and normalization with regard to values of neoliberal individualism, to the extent that it ignores collectivism and social justice (Becker & Maracek, 2008). Thus, the discourse of positive health (such as a discourse of competent clients) might be as firmly situated in an ableist culture as the traditional medicalized discourse of pathology.

Both in terms of clients’ competence and clients’ disabilities then, the call for acceptance and respect for diversity is crucial. From a sociological perspective, Sennett (2003) analyses the politics of welfare service provisions, promoting a politics that respects difference but moves towards equality. He argues that the implications of political individualism that embraces self-actualisation and autonomy, and that equates “work with worth” (p. 111), is the shame of dependency:

Dependency has appeared like a coin with two faces, one private, the other public; on one side the need of others appears dignified, on the other side shaming. The dignity of dependence never appeared to liberalism a worthy political project. (Sennett, 2003, p. 125)

Political activism with regard to dis-ability then, needs both to foster respect for the less able as much as the able, and dignity of dependence, if we want to move away from the ableist attempt for normalcy.


The Dis-abled and Dis-ableing Therapist

With the purpose of challenging the client-therapist binary, I have focused on the representation of competent mental health care clients (in music therapy). With such a representation of the client, what are the consequences for the representation of the therapist? One possible strategy could be a further destabilization of the “therapist” end of the binary. The therapist should perhaps not only be represented as able, but as dis-able, and sometimes even dis-ableing? Obviously, as much as a client is not only weak, a therapist is not only strong. Therapists may have limited abilities in some areas, even though they have completed higher education. Indeed, quite often the music therapist will experience that the client has skills and expertise in an area that outranks the expertise of the therapist in the same area of knowledge.

The therapist can also, similarly to the client, experience disability (here including mental health conditions). However self-evident this might be (as therapists are humans like the clients), disability among music therapists, and the implications of their disabilities for their roles are almost absent from music therapy discourse. One interesting concept that is relevant here though is the wounded healer (Austin, 2002), which represents a dis-able therapist through the identification of weakness, but that transforms into a resource for the therapeutic collaboration. Interestingly, we tend to view such vulnerabilities in the therapist as strengths, by for example implying that these vulnerabilities make empathy possible. While moving back to the client end of the binary, strengths, such as musical competence for example are easily ignored or considered of less relevance regarding the therapeutic process. However, the dis-able therapist can also be constructed from ableist perspectives in cultural disability studies. Goodley (2014) identifies dis-ability in terms of “pathological behavior”, in a study of the social interaction of “normals” with people with a physical (and visible) impairment, to reverse the psychopathological gaze. The study points to the degrees that public stigma (in ableist culture) is associated with uncanny and inappropriate social interactions from “normals.”

The most detrimental consequence of the therapist’s location in ableist culture is that the therapist may in fact be dis-ableing. As disturbing as this suggestion might be, it is crucial to consider to what degrees the therapist contributes to the demoralization of the client through her/his good intentions of “fixing” the client. Although there is much focus in mental health care on the reduction of stigma, mental health professionals’ attitudes and stereotypes do not differ considerably from the attitude of the general public (Lauber, Nordt, Braunschweig & Rössler, 2006). Indeed, various types of discrimination against people with mental health conditions with regard to health care services are reported, including discriminations based in different diagnoses, and in term of provisions of treatment for physical conditions (Thornicroft, Rose & Kassam, 2007). A complex interplay is described (Schulze, 2007) in which mental health workers are simultaneously stigmatizers, recipients of stigma, and also contributors to de-stigmatization.

Another aspect of the potentially dis-ableing therapist is linked to an individualistic focus. In a critical examination of feminist therapy (specifically designed to help women in oppressive situations), Becker (2005) point towards the risk that therapy may just cause women to remain even more firmly situated within an oppressive context. She argues against individualist tendencies in therapeutic practice, suggesting that it may help the individual only to cope with the oppressive situation, rather than contribute to change the oppressive context. This is perhaps even more pertinent to consider with regard to the oppressive abelist culture, in which the therapeutic encounter itself seems to be firmly localized.


In Conclusion

This article has focused on the social constraints and oppression in relation to the dis-ability complex in terms of the discursive politics imbedded in the “therapist-client” binary. With the intention of destabilization of the therapist-client binary, the client’s competence has been explored through a review of research literature. Four areas of competence were discussed: Clients’ musical competence, clients’ theories of change, clients’ reflexivity and agency in sessions, and clients’ ways of making use of therapy in everyday life. It seems clear then, that the dichotomy of the “weak client” and the “expert therapist” is not a given. Surely, when clients are defined in terms of weakness and pathology, this implies a devaluation of their strengths and agency. Bringing perspectives from disability studies into this discussion adds levels of complexity with regard to the cultural and political ideologies that have been identified as ableism, which permeate therapeutic relationships and processes.


Notes

[1] The project A qualitative study of clients’ roles, competence and actions in resource-oriented music therapy is ethically approved by the Norwegian Regional Committees for Medical and Health Research Ethics, REK-vest.

[2] A similar categorization is presented in Pavlicevic & Ansdell, (2009) and Ansdell (2014)


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