[Research]

Music Therapists’ Conceptualization of Clients’ Experience of Healing: Grounded Theory Analysis

By Eun-Young Hwang & Hwa-Jin Lee

Abstract

This study analyzed the meaning, distinctive features, and process of therapists’ perception of their clients’ experience related to healing in music therapy. Twenty Korean music therapists who work with a variety of clients were recruited to participate through purposive sampling. Corbin and Strauss’s (2008) grounded theory qualitative analysis method was used. Ten categories and nineteen subcategories were obtained. The central phenomenon was active participation in music therapy, which was influenced by client’s readiness. Clients’ experiences lead to healing through awareness of inner self, expression of emotions, and solving problems. These changes were related to the therapists’ interventions, professionalism and qualifications, and their use of music. It was concluded that the clients experienced four types of healing in their music therapy sessions: physical, emotional, social, and transformative.

Keywords: grounded theory; healing; music therapist.

Introduction

Music Therapy in Korea

Individuals who studied music therapy in the United States introduced music therapy to Korea in late 1990s. At that time, music therapy had caught wide attention as an effective therapeutic method for children with developmental disabilities and people with mental disorders. Since then, music therapy has attracted public attention and its demand has increased the need for professionals to implement clinical, evidence-based music therapy. As a result, music therapy programs were developed and professional associations have been established to increase effectiveness of therapeutic interventions in Korea (Chung, 2001; Hwang & Park, 2012).

According to the Korean Music Therapy Association 2013 survey, more than 1,000 music therapists are working in the field. The goals and objectives for music therapy in Korea vary by clinical settings, populations, and therapists’ personal philosophy. Behavioral approaches in music therapy were used exclusively in Korea until the mid-2000s when a variety of training methods, such as Nordoff-Robbins Music Therapy, Neurological Music Therapy, and Guided Imagery and Music, were introduced (Choi, 2005). Nowadays, many music therapists in Korea work not only in behavioral approach but also in psychodynamic approach for mental health (Jang, Park, & Hwang, 2012).

Despite material prosperity in modern society, the number of individuals who suffer from psychological problems such as depression and anxiety is increasing (Cho, 2011). In the past, people in Korea were interested in primarily their physical health; nowadays people are becoming just as concerned with their mental health, such as psychological well being. People in Korea associate mental health with healing. Therefore, healing is commercialized and popular in Korea, but has not been clearly defined (Lee & Park, 2014; Lee, 2015).

The Concept of Healing

The concept of healing has existed for a long time. According to Egnew (2005), healing is the noun form of the verb ‘to heal’ and the root of the word, hal, means ‘cure of disease’ rather than ‘healer of the sick (p.256). And he further explained that hal is connected through wholeness and spirituality. Taber (1969) described healing as a recovery to a normal state of being. More recently, healing is referred to as complementary and alternative medicine (Kim & Hong, 2013). While traditional medical fields focus solely on using scientific technology to examine patients’ bodies, complementary and alternative medicine fields focus on patients’ psychological, physiological, and spiritual well being (Gould & MacPherson, 2005). Therefore, the meaning of healing can be expanded beyond the treatment of diseases to include environmental, psychological, social, and cultural factors (Hong, 2014; Kim, 2014; Kim, 2013).

Researchers have noted that healing consists of a balance between body, mind, and spirit (Kim & Shin, 2015). Methods of healing include relaxation (Hui, Wan, Chan, & Yung, 2006; Laidlaw, Bennett, Dwivedi, Naito, & Gruzelier, 2005), aromatherapy (Fellowes, Barnes, & Wilkinson, 2004), movement/dance (Sandel, Judge, Landry, Faria, Ouellette, & Majczak, 2005), and yoga (Kim & Kim, 2012; Lim & Cheong, 2012). In Korean culture, healing appears to be minimized and is recognized simply as having peace of mind and physically relaxed state. However, Aigen (2014) suggested that healing can be a meaningful therapeutic concept and considered as therapy in non-Western countries such as Korea.

Music has been used in healing for thousands of years, influences the human body and mind (Apel, 1972; Lee, 2010; Tyson, 1981). Current music and medicine research has been seen to help the body maintain homeostasis and physiological changes (Chanda & Levitin, 2013). For example, listening to music decreases blood pressure and pulse rate, increases the degree of saturation of oxygen (Chan, 2007; Hays, 2006), helps with immune system (Hucklebridge, Lambert, Clow, Awarburton, Evans, & Sherwood, 2000), and maintains health and well-being by decreasing stress-causing hormones (Hirokawa & Ohira, 2003; Kim & An, 2012). The rhythm of music especially helps to restore homeostasis when our biological rhythms have been disrupted (Chopra, 1990). In addition, listening to music enhances body energy level and reduces physical and emotional tension (Thayer, Newman, & McClain, 1994); it also assists people express their emotions to maintain their psychological and emotional balance (Kang, 2011).

Purpose of the Study

For this study, researchers investigated therapists’ perceptions of their clients' healing experiences in music therapy. Even though clients’ direct expression may be the most important and valuable, the therapists’ reports were meaningful because they oversaw the whole treatment process and they are in a personal relationship with clients using empathy, countertransference, and other psychodynamic strategies associated with healing (Hwang & Choi, 2010).

A qualitative approach was considered the most appropriate method for researching therapists’ perceptions of their clients’ experiences. Among qualitative research methods, grounded theory was selected for this study because we aimed to develop a theory through gaining insight for stages and conditions that induced clients’ experiences rather than just reporting phenomenon. Grounded theory is one of the most commonly used qualitative methods in social sciences (Morse, Stern, Corbin, Bowers, Charmaz, & Clarke, 2009) and was developed for the task of “generating and testing theory”(Strauss, 1987, p. ⅺ). Its pioneers, Glaser and Strauss (1967), believed that developing a theory was essential for gaining greater insight into social phenomena, and that the theory should be developed through the researcher’s intimate acquaintance with and immersion in observationally derived data. Instead of determining at the beginning of the research what they considered was important to find out, they used a process of discovery to explore important themes and issues as they emerged during the grounded theory research process.

Grounded theory methods often begin with gathering various information about a given phenomenon and then identifying the core processes of that phenomenon through a series of coding processes, from which a basic theory governing its occurrence can be derived (Bryant & Charmaz, 2007). Therefore, the aim of this study was to explore therapists’ perceptions of their clients’ experiences during music therapy and categorize these experiences into perspectives of healing. This study included therapists’ reports of clients who had severe disabilities ranging from children to older adults.

To investigate the concept of healing through a qualitative approach, the following research questions were established:

What are the therapist’s perceptions during music therapy treatment?
How are healing and clients’ experiences related?
What are conditions that lead to client’s experiences related healing?

Method

Participants

The Institutional Review Board (IRB) of Sookmyung Women’s University in Korea approved this study. All participants were registered as members of Korean Music Therapy Association. Investigators used purposive sampling to select suitable participants (Charmaz, 2006; Corbin & Strauss, 2008). Participation was on a voluntary basis. Prior to the study, all participants signed informed consent forms. The respondents in this study had worked as music therapists for an average of 8.2 years.

A total of 20 music therapists participated in this study, and participants’ ages were as follows: eight participants were in their 30s (40.0%), 10 in their 40s (50%), and two in their 50s (10.0%). Work experience and major populations served by each participant are presented in Table 1.

Table 1. Information about Research Participants
Age group	Number of participants	Average amount of clinical experience (SD) (in years)	Specific participants
30s	8	7.4 (2.82)	2, 4, 8, 12, 13, 14, 15, 19
40s	10	8.8 (2.7)	1, 3, 5, 6, 7, 9, 10, 16, 17, 18
50s	2	9.3 (3.8)	11, 20

Data Generation

In this study, semi-structured in-depth interviews were conducted. First, the participants were asked two questions: ‘What kind of change have you observed about the clients through music therapy?’ and ‘What conditions lead to client’s experiences related to healing?’ Interviews lasted from 30-minutes to an hour and were recorded and transcribed for data analysis. Follow-up interviews were conducted to clarify ambiguous contents and confirm respondents’ meanings.

Data were collected and analyzed using the open coding method proposed by Corbin and Strauss (2008). Data were analyzed using three types of coding: open, axial, and selective coding. First, open coding involved generating concepts and identifying the properties and dimensions of the data. To form the initial concepts, investigators examined the transcribed data line by line, making notes on the meaning of each concept as it emerged, and naming concepts according to their meanings. The initial concepts were sorted and compared to generate categories and subcategories by grouping similar concepts. Second, axial coding was used to identify concepts and discover processes by linking subcategories to categories and connecting categories at the dimensional level. To identify the causal relationships between categories, investigators analyzed data in the order of subcategory, category, and concept. Elicited categories were analyzed in terms of the phenomenon of interest, along with the causal conditions, contextual conditions, intervention conditions, action/interaction strategies, and consequences. Last, selective coding was used to determine a core category from the coded data, selecting only categories that related to the core category.

Establishing Trustworthiness

For the qualitative researcher, the trustworthiness of research can be considered an amalgam of four different qualities: credibility, applicability, consistency, and neutrality (Lincoln & Guba, 1985).

Credibility: The extent to which the study, given its purpose, has been conducted in a way that is methodologically appropriate, based on confirmations from participants. Thus, the investigators allowed the participants to take part in the data analysis to verify that the transcripts were accurate.
Applicability: The extent to which the findings can be transferred from the context of the original research setting to another one, as evaluated by the primary participants. Thus, investigators documented interview contents and statements of respondents in details.
Consistency: The extent to which the data and findings are dependable, that is, that they will remain essentially the same with repeated observations within the same context or when different methods of data collection are used. Investigators maintained by keeping an audit trail.
Neutrality: The extent to which the findings are free of bias, as determined by whether they can be confirmed by colleague who analyzed the same data. Specifically, investigators maintained neutrality by referring to how personal bias was included.

Results

Open Coding

Nineteen subcategories were obtained during the open coding phase of data analysis (see Table 2).

Table 2. Categorization of Data through Open Coding (concept and subcategory)
Concept	Subcategory
Client experiences imagery during music for the first time. Client’s ordinary music gradually became lively. During the improvisation activity, client just played the downbeat in the beginning, but gradually began making music.	Client encounters music
Each client’s reaction is different. Client creates one’s own meaning, although there are negative responses.	Client’s responses is personal and Subjective
Client says hello to the therapist first. Client greets friends in a group.	Client initiates relationship.
Surprisingly, client’s anger is reduced after playing. Client suddenly becomes tearful. Client shows changes in facial expression during music therapy	Client experiences a change in emotion
Client wants to understand their current inner state. Client wants to know one’s own demands and needs.	Client has inner desire to know oneself.
Client recognizes that he/she has a problem, but does not understand how to solve it. Client needs courage if he/she shows a variety of defense mechanisms. Client needs a process of knowing about and developing the self.	Client feels he/she needs a change.
Music is always around the client.	Music is ecological.
Therapist can anticipate unexpected occasions. Therapist can deal with wounds of the self. As a person who has experienced healing, the therapist can guide the treatment process.	Experienced therapist is sensitive to client’s responses.
Therapist understands individual differences in response to music therapy. Communication with each other is needed. Therapist uses various ways of communication beyond verbal acknowledgement.	Therapist’s empathy and support are needed.
Music is related to the psychological elements. Melody and lyrics should contain messages. Music induces homogeneity and entrainment. Musical dynamic is similar to psychological dynamic.	Music reflects psychological issues.
Therapist shows one’s ability when music is tailored to a client’s needs. Therapist uses appropriate music for client. Change occurs in client when the music is tailored to the moment.	Music is an individualized approach.
Therapist needs education in both counseling and psychology. Therapist needs program development for clientele. Therapist needs therapeutic approach rather than conventional methods of therapy. Therapist should understand psychotherapy.	Various training is needed for therapist.
Approach of therapist depends on personal philosophies and training background. Therapist should have intuition. Therapist can match the conscious with the unconscious. Therapist can accept internal pain.	Therapist must utilize countertransference.
Client is able to look into his/her inner self. Client becomes aware of his/her underlying problems and develops self-love and self-respect. Client becomes aware of his/her defense mechanisms to confront his/her own problem. Client can understand the power of self-healing.	Client becomes aware of inner self.
While playing music, client can express the seemingly inexpressible. Client can resolve anger and experiences catharsis. Client can express emotions honestly.	Client expresses emotions properly.
Client can solve the problem through experience. Client can heal wounded heart. Client can understand the process of disease.	Client has power to solve problems.
Client changes facial expression, way of speaking, and verbal expression. Client shows positive changes in school life. Client expresses self affirmatively. Client changes relationships with family and others.	Client makes changes in daily life.
Client can gain greater self-esteem. Client can experience growth and development. Client discovers new self.	Client activates self-growth.

Axial Coding

In this study, 10 categories were obtained from 19 subcategories. In detail, the causal condition was client’s readiness, the phenomenon was active participation in music therapy, and the result was healing. Interaction strategies for the result were awareness of inner self (by client), expression of emotions (by client), and solving problems (by client); intervening conditions were the impact of music, therapist’s professionalism, and therapist’s qualification; and the contextual condition was the accessibility of music (see Table 3 and Figure 1).

Table 3. Categorization of data through axial coding (relationship among subcategory, category, and paradigm)
Subcategory	Category	Paradigm
Client encounters music	Active participation in music therapy	Phenomenon
Client’s responses is personal and subjective
Client initiates relationship.
Client expresses a change in emotion.
Client has inner desire to know one-self.	Client’s readiness	Causal condition
Client feels he/she need a change.	Client’s readiness	Causal condition
Music is ecological	The accessibility of music	Contextual condition
Experienced therapist is sensitive to client’s responses.	Therapist’s qualification	Intervening condition
Therapist’s empathy and support are needed.	Therapist’s qualification
Music reflects psychological issues.	The impact of music
Music is an individualized approach.	The impact of music
Various training is needed for therapist.	Therapist’s professionalism
Therapist’s must utilize countertransference	Therapist’s professionalism
Client becomes aware of inner self.	Awareness of inner self (by client)	Interaction
Client expresses emotion properly	Expression of emotions (by client)
Client has power to solve problems.	Solving problems (by client)
Client’s makes changes in daily life	Healing	Consequence
Clients achieve self-growth	Healing	Consequence

Figure 1. Paradigm model of clients’ experiences induced healing [view full size]

Causal conditions. Corbin and Strauss (2008) defined causal conditions as the events or incidents that lead to the occurrence of a certain phenomenon. From the analyzed data of this study, the causal condition for the phenomenon (i.e., participating in music therapy) was client’s readiness. When clients feel that they have a variety of problems and need to change, clients willingly participate in music therapy sessions. Therefore, client’s readiness becomes the causal condition that leads to participation.

Property and dimension of this category are shown in Table 4. In this context, property means expressive unit of category and the dimension of expressive level of category.

Table 4. Property and dimension of casual conditions
Category	Property	Dimension
Client’s readiness	Level	High–Low

Contextual conditions. Contextual conditions refer to the situations or problems that influence the phenomenon of interest; in particular, they manage and influence the action/interaction strategies for the specific phenomenon (Corbin & Strauss, 2008). In this study, the contextual condition of participating in music therapy was the accessibility of music. That is to say, because music is omnipresent and was perceived to create a safe and joyful environment that could help the client to participate without offending. Thus, accessibility of music becomes a contextual condition that influences the phenomenon, participation in music therapy. The property and dimension of this category are shown in Table 5.

Table 5. Property and dimension of contextual conditions
Category	Property	Dimension
Accessibility of music	Degree	Easy–Difficulty

Phenomenon. The phenomenon is the central idea or event that the data refers to and what participants control through a series of interaction strategies (Corbin & Strauss, 2008). The phenomenon in this study was active participation in music therapy. The property and dimension of this category are shown in Table 6.

Table 6. Property and dimension of phenomenon
Category	Property	Dimension
Active participation in music therapy	Level	High–Low

Intervention conditions. Intervention conditions refer to the general conditions that affect the phenomenon of interest via influencing the interaction strategies in a given situation or context (Corbin & Strauss, 2008). They directly affect these interaction strategies more than contextual conditions do. The intervening conditions that influenced interactions in this study were therapist’s qualifications, the impact of music, and therapist’s professionalism. That is to say, it is a condition to help client participate in music therapy session into change. The properties and dimensions of this category are shown in Table 7.

Table 7. Properties and dimensions of intervening conditions
Category	Property	Dimension
Therapist’s qualification	Level	High–Low
The impact of music	Degree	Strong-Weakness
Therapist’s professionalism	Level	High–Low

Action/interaction strategies. The action/interaction strategies are used for managing, carrying out, and responding to the phenomenon as it exists in a given context (Corbin & Strauss, 2008). In this study, strategies to induce healing from clients’ experiences through participation in music therapy were awareness of inner self (by client), expression of emotions (by client), and re-experiencing of problems (by client). These experiences become meaningful experiences of client and into experiences related healing. The property and dimension of this category are shown in Table 8.

Table 8. Properties and dimensions of action/interaction strategies
Category	Property	Dimension
Awareness of inner self (by client)	Level	High–Low
Expression of emotions (by client)	Level	High–Low
Solving problems (by client)	Level	High–Low

Consequences. Consequences are the results of the interaction strategies used to manage the phenomenon; they can be both unintended and intended (Corbin & Strauss, 2008). A consequence targeted in this study was healing; the property and dimension of this category are shown in Table 9.

Table 9. Property and dimension of consequences
Category	Property	Dimension
Healing	Width	Shallow–Deep

Selective Coding

Selective coding is the last phase of grounded theory analysis. The grounded theory ensures that the relationships between categories are logical and consistent (Corbin & Strauss, 2008). During this coding process, investigators linked the related categories systematically by examining how they were related to active participation in music therapy and healing.

In this study, clients’ active participation in music therapy was the most important incident that therapists recognized during music therapy session. By participating in music therapy with the trained therapists and the use of appropriate music, clients’ awareness of their inner self, expression of emotions, and solving their own problems were evident. Through these processes, clients experienced related healing, which lead to life changes and self-growth. Type of experiences related to healing were categorized in the process of selective coding.

Types of experiences related to healing. From the present study, investigators elicited four types of experiences described by the therapists about their clients’ active participation in music therapy. These experiences were categorized into four levels of healing developed by Verhoef and Mulkins (2012).

Physical healing. Therapists indicated that clients experienced at the physical level relaxed body movement and used verbal expressions with positive language such as “good” and “beautiful” when discussing their experience. They also stated that the children who participated in music therapy expressed comfort and stability, and showed less physical tension, thus, these clients’ participation in music therapy increased. Participants 1, 2, 7, 9, 13, 19, and 20 were classified as having clients who have experienced physical healing.
The following are few observation statements therapists reported:

While listening to music or playing instruments, clients showed positive changes in their contracted body posture, facial expression, attitude, and eye contact, and showed decreased levels of anxiety and irritation. (Participant 7)

Clients smiled and seemed relaxed. (Participant 9)
Emotional healing. Therapists reported that clients who experienced emotional healing acknowledged and expressed their emotions and showed change of attitudes. Therapists responded that clients also expressed their unrecognized emotions via instruments or voice. Therapists emphasized that selecting the appropriate music that reflects clients’ emotional states was important, because it helped clients explore their inner self. Participants 4, 5, 6, 8, 14, and 18 were classified as having clients who have experienced emotional healing. Below are some examples of therapists’ statements:

While listening to music, clients shed tears, expressed catharsis and the connection with their inner self. (Participant 14)

My client stated that the music satisfied her emotional needs as feelings of consolation and being loved. She also stated, in tears, that she had never been loved, but now she feels loved. (Participant 5)

It depends on the client’s problem… Even though clients did not say it directly… I have observed that clients acknowledged their feeling and received emotional support from music. (Participant 18)
Social healing. According to therapists’ reports, clients who experienced social healing in music therapy had positive interpersonal relationships in their environment. In addition, therapists stated that they must establish a good rapport with clients to develop a positive therapeutic relationship. Participants 11, 12, 15, 16, and 17 were classified as having clients who have experienced social healing. The following are a few observation statements therapists provided:

Family members stated that the client showed positive changes at home and school. She started to respond to the other group members and therapist during the playing instrument activity and even communicated and interacted with them in and non-musical ways. (Participant 15)

Adults with mental disorders usually displayed negative symptoms and hardly participated in any activities. However, when they participated in music activities, they showed positive changes in emotional states and social behavior. (Participant 11)

Children ran into the clinic and greeted the therapist and their friends with smiles. (Participant 12)
Transformative healing. Therapists stated that clients experienced transformative healing. Transformative healing involved discovering one’s purpose and meaning of life. Clients felt this type of healing like a reawakening or coming to life. Clients learned about themselves in deeper ways and developed a greater sense of acceptance for themselves. They felt that their living was fuller, more meaningful, and more conscious. When clients experienced this type of healing, they felt more comfort and more supportive by connecting with the self. This is type of healing required sympathy and support for clients. Participants 3 and 10 were classified as having clients who have experienced transformative healing. The therapsits provided the statements below:

Clients experienced self-comfort and self-healing through the process of meeting their selves and comforting them. Having connected with the unconscious state of mind through music helped clients to confront their problems. (Participant 10)

Clients looked like a new person. Their personality looked like more gentle, more spirituality and more accepted of selves and others. (Participant 20)

Conclusions and Discussion

This study used grounded theory to examine clients’ experiences of healing as observed by experienced music therapists during sessions. These perceptions of clients’ experiences were categorized into four levels of healing (Verhoef and Mulkins, 2012). The results indicate that clients’ experiences of healing are personal and they occur in various levels: physical, emotional, social and transformative level. The process of clients’ experiences related to healing was investigated.

Conclusions of this study are as follows. First, when the music therapist has professional skills, clients will demonstrate more interest in music therapy and will more likely experience healing (see Figure 1). Therefore, therapists must continue their education and training to increase knowledge of advanced methods in music therapy. In addition, music therapists must properly advocate for the profession so that potential clients are properly aware of the healing benefits of music therapy and can come into the therapeutic relationship ready to do healing work.

Second, healing is perceived in various forms. Healing does not just imply peace of mind. Rather, healing involves significant physical, emotional, social, and spiritual changes in one’s life. Therefore, the therapist should know that each client’s healing experience is unique depending on his or her needs in therapy, and is not just limited to one health domain.

Third, music can be a window into a client’s inner world and gives voice to those who do not feel that they are able to express themselves easily. Therapists must continue to evolve musically in order to provide clients with an array of music experiences where possible healing can take place. Above all, therapeutic presence and relationships, harnessed and developed within music experiences, is essential to provide clients opportunities to experience healing in music therapy.

Finally, in Korea, people perceive the term healing as only relating to helping those in need via food or exercise. It is our view that this cultural perception of healing is limiting, and that music therapists must be advocates to advance public knowledge. Even though the investigators of this study were able to elucidate the properties and dimensions of healing in music therapy, further evidence is needed regarding the concept of healing in relation to various health domains addressed in a music therapy context.

The interpretation of clients’ experiences in the music therapy process were completely based on therapists’ perceptions, which offer only one level of understanding and are influenced by a range of factors including their personal philosophy, education, and training. Therefore, the investigators hope that future studies might focus on therapist-specific variables to better elucidate the healing process through in-depth qualitative analysis. Last, a study investigating clients’ perceptitions of healing would be beneficial. Comparing and understanding how both the therapists and the clients experience healing in therapy would help bring a more holistic account of this concept in music therapy.

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