[Reflections on Practice]
By Susan C. Gardstrom & James Hiller
In this paper, we explore client resistances in group music therapy with women and men in residential treatment for substance use disorders (SUDs). We describe how we have encountered resident resistances on women's and men's units within a gender-specific treatment facility and offer suggestions for pre-empting and addressing such resistances, offering both nonmusical and musical strategies and techniques. We emphasize a person-centered approach and an experience orientation, in which we view our primary responsibility as providing opportunities for the men and women to engage meaningfully with music, self, therapists, and other residents in order to identify problems and explore alternatives and personal resources.
Keywords: substance use disorders, addictions, resistances
In this paper, we explore client resistances in group music therapy with women and men in residential treatment for substance use disorders (SUDs). To our knowledge, no English publications have been dedicated to this topic. Our interest in and frame of reference for understanding resistances in this clinical setting comes from our work as supervisors of undergraduate practica in a 28-day residential treatment facility situated just over a mile from our university. The clients, hereafter referred to as residents, range in age from 17 to 65 years and represent a wide variety of biographies, environments, and current life situations. Some have sought treatment voluntarily; others have been court-ordered to attend. 
At the facility, SUDs are viewed as relating to a complex and widespread web of biological, psychological, social, and spiritual risk factors. As such, treatment revolves around not only identifying and addressing biological and hereditary aspects of the “disease of addiction” but also around emotional, interpersonal, and spiritual correlates and considerations. Lifetime abstinence is considered essential to sustained recovery.
Psychologists, counselors, social workers, nurses, and individuals who are themselves in recovery lead both psychoeducational and process-oriented groups. Psychoeducational presentations focus on subjects such as biological mechanisms and outcomes of use (tolerance, withdrawal, medical complications), nutrition, communication skills, boundaries, coping skills, attitudes of recovery, and relapse prevention. Process-oriented sessions focus on subjects such as personal histories of use, defenses (denial, rationalization), past and present traumas, family of origin dysfunction, and present family dynamics (violence, co-dependency). Residents also receive regular individual counseling services and are encouraged to use external supports to recovery, such as Alcoholics Anonymous and Narcotics Anonymous and personal sponsors. Chaplaincy services are available for residents who desire spiritual and religious counseling (www.novabehavioralhealth.com)
We have enjoyed an ongoing affiliation with the facility since 2008. It is the only one in our county with gender-specific treatment units, which some argue are more effective than traditional, co-ed units, particularly for women with SUDs (NIDA, 2015; Straussner & Brown, 2002; Weissman & O’Boyle, 2000). We provide music therapy to two units: Women’s Residential (WR) and Men’s Residential (MR). We hold 50-minute process-oriented music therapy sessions two times per week on each unit. Group size ranges from 7 to 14 residents, and because of the facility’s rolling admission process, nearly every group is comprised of both returning and new residents. Although music therapy is a complimentary service provided by our university program—as such, we have volunteer status—it is afforded visible administrative support: sessions appear on the posted treatment schedule, eligible residents are expected to attend every session, a staff member is present in the room, and staff regularly confer with music therapy teams regarding treatment needs and outcomes. Moreover, the facility has allowed data collection for three separate music therapy research projects (Gardstrom & Diestelkamp, 2013; Gardstrom, Klemm, & Murphy, 2016; Gardstrom, Neforos, & Wllenbrink, 2013).
Our clinical practice at the facility is person-centered . We espouse the belief that each resident’s inherent tendency is to develop to their fullest human potential and that our fundamental job is to offer “assists to the client’s own self-healing process” (Bohart, 2012, p. 9). We believe that music therapy can help the residents to reclaim lost or diminished wisdom, capabilities, and strengths as they move toward the healing and wholeness that they desire and deserve. We emphasize personal choice and agency, encouraging every individual in the group to take from each session whatever works to best advantage in their self-defined trajectory. We strive to develop and maintain relationships with the residents based on genuineness and respect. We attempt to accept without condition all that they say and do (except if residents were to be verbally or physically abusive toward others) and to extend a nonjudgmental attitude to their musical preferences and responses. What this also means, of course, is that, while we work to circumvent and diminish resistances, we honor the residents’ right to resist treatment.
We think integrally , drawing upon various practices as informed by resident need. To be sure, we are predominantly experience-oriented. In this way of working, we do not predetermine specific response outcomes for the residents; rather, we suspend expectations of outcome (Sutton, 2012) and allow clinical aims to unfold. As such, our primary responsibility is to provide opportunities for the residents to engage meaningfully with music, self, therapists, and other residents. In an experience orientation, music functions predominantly as a medium of experience through which the residents can identify problems and explore alternatives and personal resources (Bruscia, 2011).
It bears noting that at times the residents may articulate needs that point to a different way of working—one in which a desired outcome is predetermined (e.g., decreased anxiety) and in these cases, we design and facilitate a music encounter as a means to this particular end. In outcome-oriented work such as this, music functions predominantly as a means to a nonmusical end.
Since the term therapeutic resistance was first coined by Freud and his contemporaries (Thoma & Kachele, 1994), the construct has been interrogated from a number of different theoretical orientations. A music therapist’s orientation naturally influences how they define resistances—even what they call it —, what actions they perceive as manifestations of resistances, and how they view the role and function of the music, the therapist, and other group members in pre-empting, triggering, and addressing such resistance, as relevant.
From a psychodynamic perspective, resistances are viewed as the client’s attempt to avoid or diminish anxiety resulting from awareness of repressed memories, emotions, thoughts, and drives (Messer, 2002). In music therapy, resistances are evident in a client’s actions, words, and music. In the case of music-assisted imagery, resistances also may present themselves in the imagery. Music therapists work to reveal the client’s emotional conflicts and “work through” them or, in more contemporary practices, to remediate deficits in the client’s ego stemming from early and traumatic life experiences (Austin, 1998; Austin & Dvorkin, 1998; Bruscia, 1998; Priestley, 1975).
From a cognitive-behavioral perspective, resistances are viewed as any attempt on the part of the client to avoid changing unhealthy thinking patterns and the negative emotions and self-defeating behaviors associated with these cognitions (Leahy, 2003). In music therapy, resistances are evident in a client’s refusal to engage with musical and nonmusical activities within the session (e.g., refusing outright to play an instrument or speak during a discussion) or failure to complete homework assignments in between sessions. Music therapists who embrace this viewpoint work to circumvent resistances—some employ musical and nonmusical contingencies to elicit and sustain more desirable responses—but may also challenge counter-therapeutic beliefs and avoidant behaviors when they arise (Luce, 2001; Reitman, 2011).
Less has been written about resistances from a person-centered approach to psychotherapy and music therapy (Patterson, 2014). In what does exist, resistances are portrayed as a natural human response to unpleasant or dangerous feelings attached to perceived threats to the self. As such, a person-centered music therapist likely would not view the resistant client as unmotivated, defiant, recalcitrant, noncompliant, and so forth—the psychotherapy literature is replete with these and other seemingly pejorative terms —but rather as self-governing, resilient, and tenacious in their efforts to preserve the current structure of the self. From a person-centered stance, resistances are believed to be triggered, in part, by a therapist’s judgment, evaluation, and interpretation of client’s behaviors and actions (Patterson, 2014). Nordoff and Robbins (2007), who practiced improvisational music therapy, used the term resistiveness to describe the client’s self-erected barriers to the therapeutic process. They conceptualized this dynamic as emerging in relation to the therapist, not the music, and propose that an inverse relationship exists between a client’s resistiveness and participation in music making such that resistances decrease as participation increases (Bruscia, 1987). They also noted that an indispensable aspect of the therapist’s work is “to raise the level of relationship through treating expressions of resistiveness as means of intercommunication” (Nordoff & Robbins, 1977, p. 190, italics original). Like the cognitive-behavioral music therapist, the person-centered clinician works to avoid resistances but addresses them as they arise by communicating empathy for and acceptance of the client’s self-protective tendencies.
Although variously named and defined, resistances can be understood broadly as a form of communication about the client’s emotional vulnerabilities (Messer, 2002) and their attempts at self-protection, whether against the anxiety attached to awareness of unconscious and traumatogenic material, distress or ambivalence associated with change, or real and perceived threats to the self. We should mention, also, that clients’ reactions to confusion, fatigue, medications, and sensory overload may lead to disengagement and thus be misinterpreted as resistances; as such, the therapist is wise to consider context, solicit client feedback about therapeutic processes, and interpret with caution, that is, to refrain from assuming that resistances are operating.
Moving forward, we offer the following core beliefs and observations about resistances as a context for the subsequent discussion about our work on WR and MR:
In what follows, we describe how we have encountered resident resistances on WR and MR within each of the four methods of music therapy. We then offer suggestions for pre-empting and addressing such resistances, offering both nonmusical and musical strategies and techniques.
In our sessions at the facility, we draw from all four music therapy methods: receptive, improvisation, composition, and re-creative. Factors that equally inform our decisions about which specific methods to use at any given time include the following: 1) therapist assessment of residents’ needs and interests, both before and during the session; 2) resident input regarding their needs and interests, both before and during the session; 3) needs and interests emerging spontaneously and sometimes unexpectedly during the session; and 4) situational considerations, such as time, space, and availability of materials. Additionally, while planning and facilitating, our reflections on previous encounters with client resistances as related to particular individuals or particular music therapy methods often help us to anticipate and thus more skillfully pre-empt and address subsequent occurrences.
Refusal. We encounter general resistances across all four methods, as evidenced by outright refusal to participate. Statements and postures representing this refusal include the following:
Avoidance. We also see responses that may be considered avoidant:
Pre-empting and addressing resistances. On WR and MR, we consistently employ a few strategies aimed at pre-empting resistances, as follows:
Two specific chants are intended to reinforce the safety of the circle. The idea here is to diminish the women’s anxieties about revealing their authentic selves. The first is “Come As You Are” (Gardstrom, 2016a):
Come as you are to the circle.
Come as you are and be heard.
For here we honor all vict’ries you sing.
And here we honor all hardships you bring.
And here we honor all manner of things,
So come as you are to the circle.
The second is “Come to the Circle” (Gardstrom, 2016a), which is an invitation to move beyond fear, invest in the group process, and reap the benefits of treatment:
Come to circle, come without fear
Join with the circle, let your heart be here
Give to the circle whatever you can give
And take from the circle what you need to live
Other songs are meant to empower the residents to let go of any thoughts, feelings, or attitudes that do not serve them in their desire for healing and wholeness. “Surrender” (Moffett, 2002), a spirited chant aligning with steps 1 - 3 of The 12 Steps (Alcoholics Anonymous, 2014), has emerged as a favorite:
I step into the flow, then I let go
I open my mind, my heart and my soul (2x)
I surrender, I surrender, I surrender
I open my mind, my heart and my soul
I open my mind, my heart and my soul
Harder hitting is “Poison” (Gardstrom, 2016b), which again affirms the notion of letting go of physical, emotional, and mental burdens:
Poison in my body, poison in my soul
Poison in my head -- I’m gonna let it all go (2x)
There’s no need to hang on to this tension
There’s no need to hold on to this pain
There’s no need to cling to stinkin’ thinkin’
And just to make it clear, I’m gonna sing it again
Receptive methods are “those in which the client assumes the role of a listener in the music experience… Although the client is not making music, he is called upon to actively respond to what he hears, in overt and covert ways” (Gardstrom & Sorel, 2015, p. 117). We have used three receptive variations regularly in our work on WR and MR: song communication, song discussion, and music-assisted relaxation (MAR).
Although song communication and song discussion are distinct receptive variations, they are closely related, and we find that resistances manifest similarly; thus, we will address them together in this section.
The essence of song communication is that a resident selects a song at the therapists’ request to communicate something about themselves to the group. The song may relate to their past life experiences, present feelings about treatment, future aspirations, and the like. The song is presented, usually via a recording, and residents and therapists listen to the song together and then explore what the resident intended to communicate and any emergent thoughts and feelings. For women and men with SUDs, song communication can function as a means of sharing something deeply personal that they have not yet been able to reveal and to experience the feelings that accompany this genuine self-disclosure. Sometimes there is shame, but most often there is a sense of relief. Either way, the disclosure can promote empathy among group members for the person who is disclosing.
Song discussion is a similar experience in which the therapists and residents listen to a song together and then discuss the song’s meaning and relevance to their lives. Unlike with song communication, however, the therapists pre-select suitable song material on the basis of whatever therapeutic themes the group may need to explore together. The therapists prepare a “listening set” to focus the residents’ listening process (e.g., “Take note of anything that seems meaningful for you in the music or the lyrics or both.”). The therapists then present the song either live or via a recording and facilitate the discussion following the presentation (Gardstrom & Hiller, 2010). Among women and men with SUDs, song discussion allows for exploration of themes related to use and abuse, treatment, and recovery, and “functions as supportive therapy—helping clients to experience meaningful connections and a decreased sense of isolation as they communicate with others” (Gardstrom & Sorel, 2015, p. 117).
Resistances manifested. We have found that resistances manifest in the following ways as song communication and song discussion unfold:
Before the listening (when the resident is responsible for selecting a song)
Before the listening (when the therapist is responsible for selecting a song)
During the listening
After the listening
Pre-empting and addressing resistances. We suggest three distinct strategies for pre-empting resistances to song communication and song discussion:
When we encounter resistances, we may employ the following strategies in the moment:
Anxiety is prominent among women and men with SUDs (Brady et al., 2013). Music listening for relaxation purposes has been used on both WR and MR units. Murphy (2013) suggested that MAR is useful in all stages of recovery and can help clients learn how to “manage symptoms of stress and anxiety” (p. 451). Instrumental recorded music is used most often to support progressive muscle relaxation (PMR)(Jacobsen, 1938).
Resistances manifested. Even when requested by the residents themselves, MAR with PMR sometimes yields resistances to physical and mental relaxation. Lowering of physical defenses may be disagreeable because muscular tension often carries psycho-emotional meanings. When we quiet our bodies, slow our breathing, and consciously relax our large and small muscle groups, we may find that emotions we have harbored “come to the surface” and demand expression. This, in and of itself, can be an unwelcome experience for the individual. In group psychotherapy, this emotional outpouring can lead to an unpleasant sense of vulnerability as others bear witness to it, particularly among men, who receive strong societal and cultural messages to disavow or hide their emotions from others and among both women and men who have lost access to the “true self” as their addictions progressed.
Resistances to MAR are manifested in the following ways:
Pre-empting and addressing resistances. With both MAR and music imagery (see below), it is the case that certain individuals in the group are unable to assimilate into the process as it unfolds; yet they choose to remain in the session room. They sit quietly with eyes open, gazing around the room or out a window, but they do not follow through with suggested directions. In this case, we typically do not address what we observe, mostly due to the importance of maintaining a fluid, well-paced procedure, and one that is focused on each individual’s inner experience. It is important that the process is uninterrupted for the benefit of those members who are deeply engaged. Diverging from the sequential procedures to attempt to re-engage certain individuals would “break the flow” for the other residents, thereby potentially disrupting their movement toward the desired relaxation and imagery responses.
One strategy that we have employed to bypass resistances when introducing MAR with PMR for the men, in particular, is as follows:
Articulating benefits. We emphasize what other residents have voiced about the immediate benefits of MAR, such as decreased state anxiety, increased sense of control in dealing with difficult feelings, and experiencing rejuvenation in the middle of a day. We also emphasize long-term benefits; MAR can serve as a sleep aid, and learning how to relax with the support of music is a coping skill that may help them to maintain sobriety after discharge from the facility.
We have used both live and recorded instrumental music to support the process of music imagery (MI) toward connecting with inner emotional states and improving self-awareness. In particular, these experiences aim at evoking positive imagery in non-altered states of consciousness. We are particularly mindful that all MI experiences have the potential to evoke disturbing images and feelings, particularly among individuals who have experienced trauma and those diagnosed with psychiatric disorders (Bruscia & Grocke, 2002; Eyre, 2013). In this regard, we make sure to have facility staff in the room and to give the residents in-the-moment tools for managing disquieting responses, such as opening their eyes to stop the flow of imagery and raising their hand to signal a need for individual therapist attention while the group continues in the experience.
On WR, the women are invited to assume a comfortable position in their chairs, close their eyes as able, and focus on slowing and deepening their breathing. As a feature of this induction, we may use MAR (see above). We then provide a positive “seed image” (Borling, 2011), such as the following: “Imagine yourself in a safe place, whether that be a room in a home or someplace outdoors, such as a beach or field. As the music begins, allow it to join you like a friend in this safe place and bring you something that you need.” At this point, we may play an instrumental recording or improvise on a melodic theme on a Native American flute with an ostinato accompaniment on a frame drum or small djembe. The listening portion is generally brief (less than five minutes), owing primarily to resident distractibility and session length. Processing always occurs and typically takes the form of discussion or mandala drawing and discussion about their mandalas.
Resistances manifested. Following are some possible manifestations of resistances in music and imagery experiences:
Pre-empting and addressing resistances. To pre-empt the women’s tendencies to resist MI, we have employed the following strategies:
A warm-up such as this provides an opportunity for the residents to “dip their toes in the water”—that is, to acclimate to some of the idiosyncrasies of a listening experience. They can practice closing their eyes and quieting their bodies and minds. They can try their hands at shifting their perception away from multiple sights and sounds in the session environment and their racing thoughts  and directing it toward a singular musical stimulus. In the brief processing that follows the listening, the women can practice talking in the group. There is no pressure for them to access emotions or generate imagery, although this may occur. We have found that these experiential understandings through brief perceptual listening form a foundation for a less intimidating and more pleasant subsequent imagery experience. Our sense is that resistances to emotionally-focused music imaging are pre-empted through these strategies because the women come to realize that a) they are able to focus on the music for brief periods of time and thus can be “successful,” b) they can relax and allow the images to come forth, c) the music cannot control their inner experience without their permission, and d) they will “survive” and the therapists and group will support them in expressing any and all distressing feelings or images that arise.
Once we are “in” the experience, we attend carefully to pacing:
We use instrumental improvisation on both WR and MR units. Generally speaking, instruments consist of freestanding drums (djembes, tubanos), smaller hand-held drums (doumbeks, bodhrans), and hand-held rhythm instruments (cabasas, guiros). Both referential (theme-based) and non-referential improvisations are employed.
Resistances manifested. We interpret the following responses as potentially indicative of resistance:
Pre-empting and addressing resistances. Our efforts at pre-empting resistances take place during the presentation of the materials and the procedures.
If we sense, see, or hear that a client’s level of engagement is diminishing during the actual music making, we might employ one or more of the other techniques. For instance, if a client recedes from an improvisation or becomes “stuck” in their playing and seems to need new musical materials in order to re-engage, the therapists might establish eye contact with the resident and then use modeling to demonstrate varied ways of playing, thereby providing new musical ideas in hopes of re-igniting the motivation to play. We might leave spaces within our own musical phrases as a means of inviting a resident to fill in these spaces with a unique musical response. We might introduce changes of tempo, meter, and dynamics in an effort to re-arouse and entice a resident to join us with their own playing. If a resident is in close proximity, we might offer our instrument to share (technique of intimacy) or, if the resident seems willing, make sounds on their instrument. (This technique should be employed only when there is no risk of violating the resident’s protective boundaries.)
In composition methods, residents engage in generative processes of creating original music, most typically song material. One particular variation, song transformation, has been used on both units, although more frequently on MR.
In our experience, resistances during the process of composition may not only thwart individual healing but also may lead to interpersonal strain within the group. For example, members might recede from the discussion out of frustration with the negotiation process, thereby forfeiting their opportunity to contribute, and leading to a sense of defeat or resentment toward certain members. Moreover, a resistant process often leads to a less than satisfying final product (song), one that lacks internal integrity, aesthetic value, or meaning for the group.
In song transformation, the residents alter certain aspects of a pre-composed song through a creative process. Typically, the residents engage in rewriting lyrics, guided by a theme that is relevant to recovery and determined by the residents themselves. A cloze procedure (Freed, 1986) is most often employed, in which the therapist removes certain words or phrases from the original lyrics, leaving blanks to be filled in with original ideas.
In collective song transformation, the therapist guides the group members to negotiate with one another new lyrics to be placed within the remaining song structure. In so doing, the residents: exercise creativity; take risks by generating and giving voice to ideas and feelings relative to addiction, treatment, and recovery; open themselves to the ideas and opinions of others; provide support and feedback to peers; and experience both the frustrations and satisfactions of investing in the collaboration to create a potentially meaningful and often aesthetically pleasing product. The participants typically perform completed songs, and residents may request a print copy of the newly composed lyrics.
Sometimes the group members work individually to develop song lyric ideas in their own quiet space and time. They are then invited to share their finished products with other group members. Some residents do not share; some read through their original lyrics; others elect to sing them with musical assistance from the therapist.
In both collective and individual song composition, a culminating discussion of both the creative process and the final product usually occurs after the performance. Residents sometimes describe feeling proud of their work during these sessions, which suggests that the experience may boost self-esteem.
Resistances manifested. Collective and individual song composition present different intrapersonal and interpersonal challenges for residents. In fact, such challenges may influence the therapist’s decision to engage the group in one or the other process. Because of the differential challenges, we note that general resistances manifest variously in each. During collective song composition, we see more resistances to interpersonal intimacy and the feeling of vulnerability that can result from sharing one’s personal thoughts and feelings with another. However, intrapersonal resistances may also manifest during collective composing as an individual experiences the challenges of generating and accepting responsibility for highly personal lyrical ideas. During individual song composition, we see resistances primarily to intrapersonal exploration and insights as residents meet the challenge of generating and articulating self-referential lyrics.
We interpret the following responses as potentially indicative of resistances:
Pre-empting and addressing resistances. In preparation for facilitating a song transformation, we form predetermined thematic ideas to offer as suggestions, but only when the group is unable to determine its own theme or when residents’ suggestions are too far afield from a topic related to addiction, treatment, and recovery. Specific in-the-moment strategies for diminishing resistances are as follows:
The nature of group re-creative experiences is that each member plays a specific role in reproducing a musical model. Examples include imitating rhythmic patterns on a handheld rhythm instrument, singing a pre-composed song with frame drum accompaniment, and playing tone chimes to realize an instrumental piece. In some long-term addictions treatment settings, bands or choirs might be established (Murphy, 2013). The processes involved in re-creative music therapy are essentially musical as an individual asserts effort to learn and perform a musical part within the ensemble. Verbal processing of re-creative methods may occur but is not a necessary or required aspect of the process. Clinical benefits range from individual self-esteem building and strengthened interpersonal bonds to enhanced sensorimotor and expressive music skill development.
There are a few reasons to believe that clients with SUDs might engage more readily with re-creative methods than with the other previously described methods. First, there is greater emphasis on the didactics of learning and rehearsing music and less focus on the personal, emotional experiences of the participants. Further, learning and rehearsing means “bite-sized” encounters with the music, such that participants do not experience emotional flooding that seems to be more common in sustained music experiences. In group settings, the nature of engagement during performance seems to be less emotional in that the song or piece being performed is not so much a reflection of the individual’s life or present state of being as it is a culmination and reflection of a group process.
Whereas it would seem that these “nonthreatening attributes” of re-creation would promote a willingness to engage, in all honesty, we have been minimally successful at moving past resistances from the men and thus have seldom used re-creative experiences with them. It is our sense that the residents on MR tend to compare themselves to models in popular culture—singers and bands with a high level of musical skill and celebrity status. Accordingly, if residents perceive themselves as having some skill on popular instruments such as guitar, bass guitar, keyboard, and drum set, they may be less apt to resist re-creative experiences involving these instruments. In fact, they may request opportunities to individually showcase their talents for others. Yet, given the transient nature of the MR unit and our time limitations—as noted above, we meet only two days per week for 50 minute sessions—, it is not feasible to establish a selective performance ensemble on the unit. With a group of 10 residents with heterogeneous skills and interests, then, we are required to use basic instruments and simplistic arrangements, which the men tend to perceive as meaningless and perhaps even juvenile.
Additionally, it seems difficult for the men to ascertain how re-creative experiences, with their focus on performance, are directly related to treatment, which has a distinct emphasis on identifying unhealthy patterns of response and on developing new and immediately applicable coping skills. That is, the men have trouble understanding how rehearsing and reproducing the melody of a song, for instance, might support their sobriety and recovery once they leave the facility.
More fundamentally, we have encountered fairly consistent reluctance among the men to expose any aspect of incompetence as might be revealed in structured music making, a tendency that seems less acute in improvised music making where there are no preconceived standards of proficiency. Fragile egos and enculturated perceptions about masculinity as related to expression of artistic creativity (and thereby of personal emotions) are further barriers on this particular unit.
Emotional socialization is different for women; thus, we encounter little opposition on WR. We have used tone chimes for harmonic support to singing and have arranged pieces such as “Lean On Me,” “Stand By Me,” and “Fight Song” for vocal and instrumental re-creation, employing solo and group singing and a variety of tonal and rhythm instruments (e.g., chromatic bells, electronic keyboard, frame drums, tubanos, cabasas, claves). To date, the residents’ comments after the fact have been wholly positive, but it is important to note that certain women disclose that, although they were attracted to the idea of singing and playing, they were initially reluctant to engage because (as with the men) they were fearful that they would not be able to learn their prescribed part or “measure up” to the group’s expectations. Perceptions of incompetence appear to be less of a barrier for the women than the men, however, as these residents tend to spontaneously and verbally support one another in taking risks and enthusiastically praise one another’s accomplishments. In processing how they have been able to quickly move past their resistances, the women make statements such as, “I said to myself that I’ve overcome a lot more than this in my life,” “I know in my heart that no one is here to judge me,” and “I realized that everyone is probably a little scared to try something new.” In fact, once a particular group of women have experienced vocal and instrumental re-creation, they often request continuation of this from session to session. They have identified that these experiences promote a sense of personal pride and group solidarity, and that the enjoyment of singing and playing together contributes to desired changes in emotional states.
The purpose of this article has been to offer our ideas relative to client resistances in group music therapy, with a focus on adults with substance use disorders. We have offered strategies and techniques that have helped the residents to avoid and diminish general resistances, as well as those arising within each of the four music therapy methods and their variations. Exploration of our countertransference reactions to client resistances and our own resistances to the therapeutic process, while absolutely relevant, lay beyond the scope of this article and deserve separate attention due to the complexity and presumed length of such an examination.
Although we share our ideas with the hope that they will assist other clients and clinicians, it would be naïve to proliferate the notion that the strategies and techniques themselves are what make the difference between a client who minimally engages and one who engages fully in the therapeutic process. There are many, many factors that influence therapeutic engagement, not the least of which are the unique characteristics and dispositions of the therapist. As McConnaughy (1987) wrote:
… it is the character and interpersonal style of the therapist that determine the nature of the therapy that is offered to clients. The actual techniques employed by therapists are of lesser importance than the unique character or personality of the therapists themselves. Therapists select techniques and theories because of who they are as persons: the therapy strategies are manifestations of the therapist's personality. The therapist as a person is the instrument of primary influence in the therapy enterprise (p. 303).
In this regard, what we have presented herein is an outgrowth of our unique biographies, the clinical approach we take with our clients, and concerted reflection on our experiences in music therapy with women and men who are attempting to reclaim their lost lives. We advance that, contrary to myths articulated by some practitioners, music can be invasive and is not always non-threatening (Gardstrom, 2008). It can push or pull a client into difficult emotional territory where fear and memories of trauma, betrayal, and abuse—even the pains of loving—are alive and, indeed, worthy of resisting. Yet we also recognize that music can support, guide, and nurture a client along the path of discovery and recovery. Relative to resistances, the music therapist’s charge remains to reflexively create meaningful opportunities for clients to develop a health-promoting relationship with music and to act with patience, respect, and compassion throughout the process.
 As therapists, we also manifest resistances in this clinical context, which may be addressed in a subsequent report.
 The majority of these people have an opioid use disorder, characterized by significant time spent in activities related to their drug of choice, craving, tolerance, withdrawal, and seven other criteria. See http://pcssmat.org/wp-content/uploads/2014/02/5B-DSM-5-Opioid-Use-Disorder-Diagnostic-Criteria.pdf
 Although therapist interpretations are not foundational to person-centered practice, in our attempts to fully understand and ultimately better serve our residents, we find it helpful at times to consider their musical responses as potentially symbolic of inner experience. For instance, we may interpret a resident’s improvised rhythmic play as indicative of their emotional energies or their instrument choices as representative of aspects of their identity (Bruscia, 1987).
 This terminology stems from Bruscia’s (2011) Ways of Thinking in Music Therapy, in which he defines and describes three distinct orientations to clinical practice, which, when flexibly and reflexively applied to address a client’s priority health need, reflect an integral practice.
 For consistency and ease, we reluctantly use the term resistances in this report. The plural form reflects that authors in the literature have labeled many discrete forms, such as resistances to experiential forms of therapy, resistances to interpersonal intimacy, and so forth.
 Messer (2002) wrote, “resistance should not, and need not, be viewed as the enemy of therapy. In fact, the term itself is in some ways unfortunate. It leads the therapist to think in oppositional terms rather than to view resistance for what it is: the inevitable expression of the person’s manner of relating to their inner problems and to others” (p. 158).
 Racing thoughts are a common symptom of opioid withdrawal.
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