This article presents and discusses three examples of relational processes in music therapy collaborations with adolescents in care of child welfare services. Theory on relational work in psychology, child welfare, and music therapy will be presented in order to describe the theoretical foundation of our approach. We reflect on different aspects of the therapeutic relationship, such as the distribution of roles and responsibilities between the therapist and adolescent, the need for patience, and the value of the musical cooperation in the relationship. Bordin’s theory on the therapeutic alliance functions as a framework for the discussion. We conclude that music activities can be a beneficial approach for giving adolescent in child welfare positive relational experiences with adult caregivers.
Date received: 28 March 2018
Date accepted: 17 September 2018
Publication date: 1 November 2018
In our work as music therapists we meet adolescents who have experienced challenging relationships with adults, and we have observed how music and music therapy can play an important role in their day by day functioning and development. By working systematically over a long period of time, we have seen how the relationship between the adolescent and therapist grows through cooperation and mutual recognition, and how music can be a tool for establishing a positive relationship. The aim of the present article is to discuss our experiences through three illustrative cases and to inform and reflect on our approach to music therapy with adolescents in child welfare.
Norwegian music therapy has a basis in humanistic philosophy (Ruud, 2008) and has developed and adapted to different theoretical approaches as part the process of expanding to the various contexts. In the context of child welfare, three theoretical approaches have been described (Krüger, Bolstad, & Stige, 2016); (1) An educational approach, focusing on the acquisition of knowledge and different social skills (Krüger, 2008,, 2016; Rickson & McFerran, 2014); (2) a community oriented approach, grounded in a human rights perspective (Curtis & Vaillancourt, 2012; Krüger 2012,, 2018; Stige & Aarø, 2012); and (3) a relationally oriented approach, where psychological theory is more dominant (Trondalen, 2016a; Zanders, 2015). The present article will focus on the latter and describe how music can be used as a tool in relational work with adolescents in child welfare.
Despite the extensive research on music therapy in child welfare settings in Norway, the number of employed music therapists in child welfare settings is still quite few. Most of the therapists, including the authors of the present article, are working in a private child welfare service. In our practice we use a two-part practice model: The Music Factory and Come Closer.
The Music Factory offers individual sessions where the music therapist meets adolescents either in their home or in a practice room fit for music therapy. The adolescents are informed about the Music Factory by the institution leader or foster parents as early in their stay as possible. They choose if they want to meet the music therapist and participate at the Music Factory, though the social workers will try to motivate them to attend. The first meeting is most often in the adolescents’ home, where he or she is likely to feel most comfortable, while some adolescents prefer to have the first meeting in the practice room. Sometimes the following sessions continue in their home, and the music therapist brings the necessary equipment. In other cases, the sessions will move to a practice room, which usually is equipped with guitars, bass, keyboard, drum set, djembes, PA system, and tools for making beats and recording music. The music therapist may also visit the adolescent in periods when they, for various reasons, may not be able to come to the practice room. The sessions usually take place once a week, and lasts for 30 – 90 minutes. The activities are largely based on the interests and wishes of the adolescent, for instance listening to and discussing music, writing songs, and learning to play instruments. By the end of each semester the Music Factory organizes a concert where the adolescents are invited to participate. This is usually arranged in collaboration with Come Closer.
Come Closer is an independent1 culture group where adolescents in child welfare and aftercare2 cooperate with music therapists to create and participate in cultural activities. In our practice, Come Closer offers the same activities as the Music Factory but is usually aimed towards groups of adolescents. There is also a stronger focus on playing in bands, writing songs, and recording and performing music.
Later in the article we will discuss different aspects of the practice that are related to the therapeutic alliance among the adolescents and the music therapists, including defining goals for the sessions and how responsibilities are shared3. Before that, however, we will present a short summary of theoretical perspectives on relationships that form the base of our relational approach.
In psychological theory the understanding of the therapeutic relationship has been discussed throughout the last century, but it has gained greater attention the last two decades. This is in line with a larger “relational turn,” affecting among others infant studies, developmental psychology, neuropsychology, and music therapy (Binder et al., 2006; Trondalen, 2016a). In a historical perspective one can draw a line to recent theories from Freud’s psychoanalytical theories and the reactions they generated in society. Sullivan was among those who moved away from Freud’s focus on the human mind and suggested that psychology should be understood in the context of continuous human interaction (Ellman, 2005). The object relations theorists Winnicott and Kohut further contributed to research on human need for meaning and human interactions, and Bowlby’s attachment theory put the spotlight on the importance of care and availability of parents (Bettmann & Friedman, 2013; Binder et al., 2006; Holmes, 2017). Rogers, with his person centred therapy, made a platform for a psychotherapeutic approach where the client’s health related problems and the technical skills of the therapist was given less significance, while attention was drawn to relational factors such as empathy, authenticity and acceptance (Ardito & Rabellino, 2011; Tobin, 1991; Trondalen, 2016a).
In 1979, Bordin introduced his theory on the therapeutic alliance, which is still considered highly relevant in psychotherapy (Ardito & Rabellino, 2011; Ryum & Stiles, 2005; Tryon & Winograd, 2011). This theory suggests that the alliance consists of three mutually dependent factors: (a) agreement on the goals of the treatment, (b) agreement on the tasks, and (c) the development of an emotional bond between the therapist and client, based on feelings of trust, acceptance and confidentiality (Bordin, 1979; Horvath & Luborsky, 1993; Trondalen, 2016a). Recent theories have moved away from parts of Bordin’s theory, especially the idea that the alliance is necessary for therapeutic change. Instead, the alliance is considered a constantly changing part of the therapeutic relationship and in some cases a goal of therapy rather than a precondition (Bei, Colli, & Ligiardi, 2007; Krause et al., 2011; Safran & Muran, 2006). It is also worth noting that despite the central position of the therapeutic alliance in treatment, there are still other aspects of the therapeutic process that might affect the outcome, for instance, the methodology, as well as factors related to client and therapist, such as personality or motivation. Especially the ability of the therapist to be flexible when building relationships seems to affect the treatment positively to a larger extent than the client’s ability to do the same (Del Re, Flückiger, Horwath, Symonds, & Wampold, 2012).
It is only recently that research has focused on the specific challenges that adolescents bring into the therapeutic alliance4. Adolescents have more problems related to authorities than other age groups. They may consider the treatment as forced upon them and may for different reasons be unfit for dialogue centred methodologies (Drury, 2003; Oetzel & Scherer, 2003; Rubenstein, 2003; Shirk, Caporino & Karver, 2010). Myrstad (2009) explains the difficulty of finding a suitable form of treatment as adolescents often are too old for the play-based treatments that are aimed towards children but not yet old enough for the traditional psychoanalytic methods developed for adults. Thus, approaches that facilitate and promote creativity, resources, and experiences of mastery may be more suitable for this group.
The relationships between adults and children are of great importance in theory and research concerning child welfare, which is apparent in how Bowlby’s attachment theory has been a central part of the theoretical foundation of the Norwegian child welfare services (Blakely, 2015; Halvorsen, 2018). However, further research on how relational approaches can be applied within the field is necessary. Especially as the children express their need to be acknowledged and appreciated by adults (Bunkholdt, 2015; Paulsen et al., 2017; Thrana, 2014). In 2015, the Regional Centre for Child and Youth Mental Health and Child Welfare Services in Norway published a report on the psychological wellbeing of children in residential care5. They found that adolescents with attachment disorders have a special need for long lasting, stable relationships, both with peers and adults. Relocation is considered a significant challenge in this situation, in addition to adolescents testing relationships (Kayed et al., 2015). Studies on aftercare show that the need for stable relationships also exists among the older adolescents in child welfare, to promote feelings of safety and continuity (Paulsen, 2016a).
Long lasting, stable relationships do not only have a value as such, but can also facilitate increased involvement and autonomy in the adolescent. Backe-Hansen (2016) explained how children’s involvement is connected to relationships, both positively and negatively. For instance, good relationships, based on trust, respect and mutual recognition will make it easier for the child to express their opinions towards adults (Paulsen, 2016b; Thrana, 2014). Several studies confirm these findings and also demonstrate another aspect; when children experience a high degree of involvement in a relationship, they experience it as especially positive (Gallagher, Smith, Hardy, & Wilkinson, 2012; Paulsen et al., 2017; van Bijleveld, Dedding, & Bunders-Aelen, 2015). However, the caregiver and the adolescent may have different perceptions of the power balance in the relationship. The caregiver may believe that they are facilitating involvement and participation, whereas the adolescent perceives the power balance as unclear or uneven. Studies suggest that this may have a negative impact on the adolescent’s life (Bessell, 2011; Paulsen, 2016b). The previously mentioned report shows similar results, as institution leaders considered the adult-adolescent relationship to be more positive than did the adolescents (Kayed et al., 2015). This indicates that the Norwegian child welfare services have further need for methodology that focuses on positive relational experiences which facilitates user participation on the adolescents’ premises (Backe-Hansen, 2016; Jensen, 2014; Paulsen, 2016b).
Adolescents in care of child welfare will, to a greater extent than the general population, have experienced abuse, neglect of care, and traumatizing situations, making knowledge of trauma and trauma-informed care highly relevant when working with this group (Kayed et al., 2015; Lehmann, Havik, Havik, & Heiervang, 2013). A trauma can be defined as an experience that surpasses what a human manages to handle and integrate in a coherent meaningful story of themselves. Repeated experiences of this nature in the child’s care system create a highly increased risk for developing relational traumas, which can develop into psychological and physical health issues (Bath, 2015; Blindheim, 2012; Gallitto, Lyons, Weegar & Romano, 2017). The window of tolerance is helpful as a model of understanding the range of activation in which an individual function optimally (Siegel, 2012). When activated within this range, a person is attentively present in the situation and learning and development is most likely. The window of tolerance is shaped by experience and interaction with caregivers, and traumatic and overwhelming experiences in early childhood combined with lack of regulating support from caregivers can result in a narrow window of tolerance6. Through cooperation in music therapy in safe relationships, it is possible to gradually expand this range for the child through building relationships and emotional regulation (Krüger, Nordanger, & Stige, 2017; Nordanger & Braarud, 2014).
Norwegian music therapy literature on child welfare has to a large extent been influenced by Krüger’s doctoral thesis, where he studied a community-oriented approach to music therapy with adolescents in care of child welfare (Krüger, 2012,, 2018; Strandbu, Krüger, & Lorentzen, 2016). In this work, he took the previously mentioned children’s right-perspective, while other parts of his work review music therapy in an educational setting (Krüger, 2008,, 2016). Krüger’s research is mostly focusing on groups and addresses the adolescents’ relationship with peers, child welfare services, and communities in general. The relationship between the music therapist and adolescent is given less attention.
Literature on a relational approach in music therapy with adolescents can be found if we search outside the context of child welfare. Music therapist and professor Trondalen has written several texts on relational music therapy, demonstrating this theory in practice with both mother and child groups and young persons with eating disorders (2004,, 2016a, 2016b). Both Stene (2009) and Fugle (2009) approach music therapy practice with adolescents from a psychoanalytical perspective based on Stern’s theories on intersubjectivity. A more thorough investigation of how music therapy can be understood from relational psychoanalytic theory can be found in studies from Denmark (Pedersen, 2014), where music therapists are educated in a more psychoanalytically informed methodology compared to Norway. However, there are few music therapists employed in child welfare services in Denmark and accordingly few publications combining this methodology within the current context (Jacobsen, 2014). McFerran (2000; 2016) and McFerran et. al (2010) has published research addressing adolescents’ use of music and use of psychodynamic music therapy in groups with bereaved teenagers, but as with Krüger’s research, the relationship between adolescent and therapist is not highlighted. In a case study with an adolescent in child welfare, Fairchild (2018) described a growing recognition in literature of participants as active agents in the therapeutic relationship (see Bohart & Wade, 2013; Rolvsjord, 2015), but we must look towards Zanders (2015) to find a case study from child welfare where the main focus is on the relationship between therapist and adolescent in practice. This makes his study one of the few texts that combines music therapy practice with adolescents in child welfare and theory from relational psychotherapy.
To summarize, there is a solid theoretical foundation to justify a relational approach in music therapy, but there are only a few examples where this theory is applied in child welfare settings. We will therefore present three cases from a relationally oriented music therapy practice in child welfare, followed by a discussion based on Bordin’s theory on the therapeutic alliance.
The three following cases are written by Wilhelmsen and are all acquired from her practice. The current adolescents and/or their caregivers have approved the text for publishing, and have been given the opportunity to give feedback. The adolescents are all girls, and it is worth mentioning that this is a coincidence rather than a deliberate selection of participants. However, we have chosen relationships that have lasted over at least three years with the aim of illustrating their development over time.
«Come in», I hear a feeble voice responding. You sit in your bed reading. A warm, thick air poor of oxygen fills the room. «Hey! Oh, it’s so dark in here, do you mind if I pull back the curtains and open the window a bit?» I ask. «Ok», you respond. «Are you ready to record?» I ask. You nod your head. «Mhm». We made a song about different kinds of cats; «Fat cat, lazy cat, grumpy cat, happy cat, silly cat, talking cat, all kinds of cats» The plan is to record it and make a music video.
First time I met you was about three and a half years ago. I immediately got to experience your wonderful openness and urge for storytelling. You tell all kinds of stories, from your own life and from all the manga you read. Sometimes you get so eager for me to know the characters and understand the storyline that you fetch the book and show me the pictures, and we watch the anime vignette on YouTube. You could tell stories for hours, and I suppose that’s what you’d rather do; «I just have to show you this one!». «And just ONE more».
We recorded some cover songs that you like, “Family Portrait” by Pink; “If Today was Your Last Day” by Nickelback but how interested you are in playing seems to vary. You have many stories about your family and we started to write a song about sisterhood. You laugh when you tell me how you quarrelled with your younger sister. Sometimes life is a lot to handle and it’s hard to get up. You spend the day in bed reading, sketching, and drinking tea. It’s alright if I come by a just for a little while and we listen to music, talk, or find some weird photos of cats for our video.
After a while, you started coming to my music room. At first every other time, and after some more time all our meetings were in the music room. You didn’t want to perform at the end of term concert, instead we made a quiz to host together. We made small music vignettes to each category of the «Christmas quiz with Sara and Chris», and we laughed so much! We continued making quizzes for the end of term concerts, and we got better and better at it. «It’s a tradition now», you said before our third quiz. Since then you have taken a break from music therapy. I have met you occasionally and you always give me a hug and tell me how and what you are doing and what books you read. I think you know that you are always welcome to my music room when or if you want to.
In this case we see how the music therapist visits the adolescent’s home and meets her where she may be most comfortable. This implies seeing her on days when she is tired and perhaps not motivated for other activities, but still she accepts that the music therapist comes to visit. Home visits permit another set of roles and opens for a different balance of power than when the adolescent meets the therapist in their office or studio, as the therapist becomes the guest.
The relationship between the therapist and adolescent in this example is friendly, and it is clear that humour is central to their dialogue. The adolescent is eager to tell stories, and the therapist takes the role of a listener. She is attentive, confirms what the client is telling her, and avoids directly challenging the adolescent. Still, we see examples of how she tests some limits, for instance by asking the adolescent to sing at a concert and opening the curtains and airing out the room when she enters. These are minor actions that show how the therapist is not only supporting but also brings wishes and expectations into the collaboration. Despite the relationship being friendly, it is still affected by one of them being the more responsible adult. In other words, one might understand the distribution of power as the adolescent deciding the content of the activities (including talking rather than playing) and the therapist being responsible for the overarching framework of the situation and being sensitive towards the adolescent’s mood and window of tolerance.
The social worker at your institution had already asked if you wanted to participate in music therapy, and you declined. But the manager said that you were very interested in music and told me to come see you and tell you about the different music activities, the Music Factory and Come Closer. «I’m sure you can explain better than us what it is», he said. And I’m glad I got to visit you, because we have played a lot together since then. You were 14 and lived in an institution/shared accommodation with two or three other teenagers. The first time I came, you were sitting very quietly on the couch. The manager had told me that you played your guitar a lot and that you wrote your own songs. I asked you about this, and you confirmed with a nod and a modest smile. I told you a bit about the Music Factory and Come Closer and asked what kind of music you like. You didn’t say much; you nodded, said yes and no, and showed me a couple of songs on YouTube. At the end of our short conversation you agreed to come to my music room and give the Music Factory a try.
The first time in the music room you showed me one of the songs you had composed at your guitar; so calm and beautiful; C - dm - Fmaj7 - dm. But it wasn’t long before you turned to the drums and said you wanted to learn how to play them. We started with the basics and you picked the tunes: Tracy Chapman’s «Fast Car», Johnny Cash’s «Hurt», Echosmith’s - «Cool Kids»: «I wish that I could be like cool kids, cause all the cool kids they seem to fit in». We agreed that this seemed familiar and related to this feeling, but we didn’t really have long conversations in our sessions. Sometimes I wondered what you were really thinking and if you enjoyed our sessions at the Music Factory. Whenever I asked you, you would nod and say it was «ok». But you were a fast learner, and you showed up to all our appointments. I took this as positive signs. At the house concert before the summer, our two-person band had its debut. We played three songs, and you had invited your best friend. I was really proud, and you seemed proud too. You played louder than ever on the cymbals during the climax of the song, and hid a smile by bending your head. I was very happy when I got a hug before you left.
After the summer, you started participating at Come Closer and played with the other adolescents. I remember you realized you shared your favourite band with one of the guys there; «for the first time in my life», you said. He also played the drums, and whenever the two of you were playing together, you would change between the guitar and the drums. You still didn’t say much, but you would tell me the new songs you’d heard and that you wanted to play, and always told me in advance if you couldn’t make it to our sessions. At one point you moved away from our institution and had to quit the Music Factory. But you wanted to continue coming to our Sunday sessions at Come Closer, even though you would have to drive one and half hours back and forth. I noticed that you started participating more verbally, in the discussions about music during lunch breaks. You would present well thought-out and reflective opinions on the content and meaning of the music we listened to.
We played at another house concert before Christmas, with two other adolescents and students7. You invited your parents as well as your friend and some social workers at your new institution. Your parents seemed so proud, and they still come to every concert we have. In December last year we and one of the other adolescents from Come Closer went on a trip to another city to participate at a concert with other adolescents. Our part of the concert went really well. You played both the guitar and the drums, and you said that you were so touched by the other performances. At Christmas Eve you sent me a text message, «Merry Christmas <3» it said.
As described in the previous example, relationships can be established in just a few meetings. In the present example, time becomes an important factor. We see an adolescent who is reserved, almost secretive about whether or not she is enjoying the sessions. The interest in music is evident, but the motivation for establishing new relationships is less apparent.
As a music therapist in child welfare services, it is important to make sure that the adolescent experiences their participation as voluntary. Therefore, a consistent challenge is to assess whether the adolescent genuinely wishes to meet the therapist, or if they participate because they feel obligated and dare not disappoint the adults or the music therapist. In this example the adolescent declines participating at first, but the institution manager thinks that she might change her mind if she meets the therapist. Even though the adolescent agrees to meet the therapist again, it may be difficult evaluating whether she actually wants to participate, or if she accepts because it is hard to reject someone face-to-face. The therapist tries to investigate this matter by asking the adolescent directly but receives brief replies. To assess the wellbeing of the adolescent, the therapist then looks for subtle signals, like steady attendance, a smile, or a hug. Thus, when the therapist receives a message at Christmas Eve, the message becomes more meaningful than its content “Merry Christmas <3”; it seems that the relationship may be important to the adolescent after all.
The adolescent gradually gets more engaged in the relationship to the therapist and other participants in the group. This process is probably parallel to the adolescent’s progress outside the music therapy sessions and should also be considered as consequences of external factors. However, the relationship with the music therapist is a part of this developmental process, and the increased degree of participation in conversations may be related to increased feelings of safety. The adolescent’s performance in front of others, in this example parents and peers, may also have an extended value. The therapist aims to work with the adolescent’s resources and tries to adapt the practice to their goals. It is therefore common that one experiences a different side of the adolescent than what appears to parents and other caregivers. A performance may thus have a twofold purpose: (1) A ritual where the therapist and adolescent perform what they have been working on, confirming their collaboration and relationship, and (2) showing the audience the adolescent in a different role; a musician.
«Could you leave now?» you asked. We had played together for a few minutes on a MIDI keyboard. I tried to captivate you by playing with different rhythms and sounds. You didn’t want to be captivated, that was quite obvious. «I could just come back some other time, if you want?», I answered. «Yeah, but could you leave now?»
About a year passed between our first and second meeting. You had just moved into an institution for adolescents the first time I met you. The institution manager told me that you enjoyed listening to music, and I came to visit you. We talked a bit, and you showed me some music that you liked. The week after you were admitted to an adolescent psychiatric clinic and got a diagnosis that implied you would stay there for some time. When your stay was over you moved to another institution, and I started visiting you every other week. You remembered well which songs you had shown me one year earlier. At first, we listened to music together, and you showed me some more songs that you liked. Sometimes you would ask if you could braid my hair. We also translated some songs in your mother tongue - a language I don’t understand. You would sing and I’d play the guitar. Once you were wondering «Why are you here?». I was surprised by your question, and I couldn’t find a better answer than «I’m here because I like music and I think you do too, so I thought maybe we could make music together?». «Ok», you answered.
You often asked me to leave, maybe just minutes after I’d arrived. Sometimes we would just take a break, you would walk around a bit, stop, breathe, and then we would start again. Other times you were determined that you wanted to end the session. I always said «That’s all right, I’ll come back some other time». I have to admit that you somewhat tried my patience, but occasional good moments made me think that the Music Factory could be positive for you in the long run.
In the springtime the second year of our collaboration we started a project: to make a music video. You picked the song and had many ideas. We planned for several weeks and filmed for many hours. I directed the video and you seemed satisfied with the result; you laughed and said you looked really cool. After this point you started coming to my music room once a week, and we started writing songs. We wrote both in Norwegian and English and you had so many thoughts to put on the paper. I feel that our songs have given me a better understanding of your thoughts and how they affect you. Lately it seems to me like you can better explain why you do the things you do and why you want to go home. That makes it easier for me to understand.
«Sweetheart you’re the best
school is a mess
Testing my head, testing my head
I cry cry all day
I have nothing to say
I just wanna be alone
I don’t need you along
I don’t hurt nobody, it doesn’t mean something
It’s like I’m living in the dark
I dance, I wanna dance all day
It’s all gonna be ok»
This case illustrates how the therapist may occasionally be rejected, and that it can be difficult to understand the reasons behind the rejection. Using the window of tolerance as a model of understanding, it is clear that the adolescent is in her way expressing that she cannot handle the initiative of the music therapist. Based on previous experiences in the relationship, the music therapist considers whether a break might be helpful, or if it would be better to end the session. Time and patience are important factors when building the relationship, as the music therapist experiences that the adolescent can be open and cooperative in one moment, and retreated and rejecting in the next.
We notice that the adolescent does not get captivated or inspired to take part in the music, but engages more in the collaboration when more concrete plans of making a music video are suggested. While working with this article, the therapist reflected on how she, in hindsight, could see that it might have been more productive to have a set plan from day one. This example shows that despite our goal to adapt the content of the activities to the wishes of the adolescents it might in some cases be useful to have a more detailed plan based on knowledge about the adolescents’ resources and general functioning. This is a dilemma that one might experience in practice: we usually wish to start the relationship with a face-to-face meeting and avoid basing our impression on extensive predefined information. In some cases, an introduction to the adolescents’ background and general functioning may be beneficial to better prepare and adapt the therapeutic approach to (what we presume are) their needs.
In order to discuss the therapeutic relationship in music therapy in child welfare, we will reflect upon some of the themes brought up in the case studies and see how they relate to the previously reviewed theory. We will base these reflections on Bordin’s three conditions for a therapeutic alliance to discuss different themes associated with the development of a good relationship with adolescents. It is worth noting that we do not necessarily consider Bordin’s three factors to be fully comprehensive of all aspects that are central in the therapeutic alliance in music therapy. Rather, we consider the theory as a platform for a discussion around the relationship between adolescent and music therapist. We will use the abbreviations C1 / C2 / C3 as references to the case examples.
In order to start the process of establishing a therapeutic relationship, one must agree on whether or not the adolescent is going to attend the music therapy at all. C2 describes a case where the adolescent at first declines the offer, until she meets the therapist. This is not unusual, as many may be sceptical towards the therapy part of the music therapy. Adolescents in child welfare interact with therapy in different forms on a daily basis, and it might seem excessive to meet yet another helper instead of for instance a music teacher. Music therapists in child welfare will therefore at times be careful with the use of the term music therapy when talking to the adolescents and instead describe the sessions as music workshops (see Krüger, 2012; Krüger & Stige, 2013). Our experience is that most of the adolescents in child welfare participate in music therapy because they are interested in music, not because they are looking for therapy. Still, it is worth emphasizing that the therapist is conscious and transparent about their education, role and intention, and does not attempt to trick the adolescents into participating in something they are not comfortable with.
If the adolescent agrees to participate, the two will also have to agree on certain goals for the sessions. Despite the adolescent not considering the meetings as therapy, the music therapist will often have a therapeutically oriented mindset, thinking more about the health-related aspects of the activities. Considering this, one may question our honesty and authenticity as therapists, as we in conversations with adolescents will often avoid describing some of our goals for the sessions. Still, the adolescents also likely have hidden motives for participating, which the therapist should respect. Maybe they are attending first and foremost to get a break from the institution, or because they are allowed to smoke in the breaks. Agreement on content and goals can thus be considered as a compromise between the therapist and the adolescent, where they agree on certain aspects of the sessions, but allow the respective parts to have intentions that the other person does not know about.
In the initial faces of the therapeutic relationship the conversations around goals will often be based on the interest of the adolescent and how these can be brought into the sessions. Some, like the girl in C2, have specific goals like getting better at playing an instrument, while C1 and C3 are examples of adolescents with many different interests. As the adolescents change and grow in their interests and musical competence, new goals will be available, like performing at a concert (C1) or make a music video (C3). Usually it is the therapist who suggests these activities and thereby also the goals, but the suggestions are based on the adolescent’s wishes. This distribution of responsibilities is further discussed as part of Bordin’s second factor of the therapeutic alliance: agreement on tasks.
Reaching the goals that are agreed upon requires effort from both the therapist and the adolescent. Even “passive” activities like music listening involve the adolescent selecting the music or engaging in dialogue with the therapist around what they are listening to. Other activities require that the adolescent spends energy on learning an instrument or writing lyrics and perhaps spends time outside the sessions to prepare for the sessions. At the same time, the adolescent can demand the same effort from the therapist, familiarizing themselves with the music that the adolescents are listening to and preparing the songs that the adolescent chooses. This creates a type of egalitarian cooperation. The therapist will often be technically better at playing instruments, but the adolescent will have more knowledge on genres and artists. In musical interaction they are equally interdependent on the other’s contribution, and in the dialogue they both bring in some sort of knowledge or expertise. This contributes to reallocating the traditional roles of therapist and client (or adult and adolescent).
The three cases show three different cooperative relationships where the therapist takes various roles. In C1, the therapist is almost a friend, who gradually challenges the adolescent to cross boundaries and expand her window of tolerance. In C2 the therapist is closer to the role of a teacher, while in C3 she is more of a helper and takes more of a traditional therapist role, as the adolescent’s challenges are more prominently featured in the relationship than in the other cases. Still, there are similarities between the three relationships, for instance how both parties are contributing towards a musical product. We can draw a line to theory on relational music therapy, where Irvin Yalom’s (2002) metaphor “fellow travellers” is used to explain how the therapist and the client meet in interaction. In Yalom’s terms the therapy is considered part of both the client’s and the therapist’s lifelong journey, and for a period of time they can meet and travel together (Trondalen 2016a; Yalom, 2002). In music therapy with adolescents this metaphor can function as an illustration of how the two persons meet through the music, either by playing or listening together. If a playthrough of a song is especially successful, both contributors feel a sense of mastery, and emotional music might correspondingly affect the listeners in a similar way. Shared experiences of mastery and joy in musical interaction (“flow”) may potentially strengthen and deepen the bond between the participants (Wilhelmsen, 2012).
To summarize, the distribution of tasks and responsibilities often are characterized by the music therapist making the adolescent a responsible partner in a cooperative relationship and thus demanding a certain level of participation. Taking part in both active and passive music activities implies opening up to the other person, as playing an instrument or sharing a song that one likes, involves exposing a personal side of one self. By participating in music therapy, one enters a situation where both parties have to be personal and vulnerable, which creates unique opportunities for relational work (Rolvsjord, 2010; Stene, 2009; Trondalen, 2016a).
We regard Bordin’s last factor as being the most complex to discuss, considering how the development of every emotional bond between two people is unique. In other words, it is difficult to select a few overarching points on how music therapists bond with adolescents in child welfare, as every case will be different. Additionally, every relationship is experienced through two different sets of eyes, and the parties will have unique perspectives on qualities of the therapeutic alliance (Bachelor, 2013; Bohart & Wade, 2013). Still, there are some general trends in how these bonds are developed, for instance that the therapist’s flexibility and ability to adapt to the clients’ needs is considered especially valuable in therapeutic processes. From the adolescents’ perspective it is also apparent that the need to be seen and recognized is a repeating factor, echoing in studies on relationships with adults (Paulsen 2016a,b; Thrana, 2014).
As music therapists we use music as a tool to establish a platform for mutual recognition. C2 is an example of how the music therapist can recognize the adolescent by listening to and discussing their music preferences while continuing to take their wishes seriously and adapt the activities to these. In this context it might be relevant to look towards Rogers’s client centred approach to psychotherapy, which is considered especially useful in situations where one wishes to establish feelings of safety (Malt, 2016). In line with Rogers’s relational factors, the music therapist actively listens to the music and avoids problematizing the preferences of the adolescent, while at the same time being honest when reacting to and discussing the music. By focusing on the music, the therapist can demonstrate that she accepts and recognizes the adolescent, and thus creates a potentially safe platform for further cooperation (Rolvsjord, 2010; Trondalen, 2016a).
Time and stability are important factors when developing trust as a part of the therapeutic alliance. Adolescents who have experienced many relocations and short stays often have few close relationships with adults (Kayed et al., 2015), and the music therapist can in these situations represent such a continuous relationship which the adolescent rarely experiences. The three cases demonstrate that a long-term perspective is important, as the adolescent’s former experiences may complicate the possibilities for establishing trust and other fundamental factors in a therapeutic relationship.
Finally, we highlight the value of the small signs as part of the development of a positive relationship. In C2 and C3 the therapist searches for signs confirming that the adolescents are enjoying being with the therapist, and it is natural to assume that the adolescents are also looking for signs that the therapist likes them. A small action as sending a text message saying “Merry Christmas <3” means a lot for the therapist, and for the adolescents the most fruitful relationships are characterized by a feeling that the person is willing to walk “the extra mile” for them (Thrana, 2014). In a relational music therapy practice, the therapist’s ability to be a compassionate fellow human being (a fellow traveler) is more decisive for the relationship than the methodology or theory being applied.
With this article, we have discussed how music can be used as a tool in relational work with adolescents in child welfare, based on Bordin’s theory of the therapeutic alliance. Relational needs are highly individual, and music therapy is not necessarily appropriate for all adolescents. Still, we see a potential in how music therapy can facilitate a form of cooperation where the differences and asymmetries between adults and adolescents are less clear. Music is a flexible tool that can function as a mutual interest between the therapist and adolescent, and music therapy activities can easily be customized to the needs and wishes of the adolescent. The creative collaboration also requires openness and vulnerability from the involved parts, which over time can build a relationship based on mutual recognition and safety.
To end, we emphasize that this article is written from the viewpoint of two music therapists, and cannot represent a complete investigation of the therapeutic relationship, based on the current case examples. More research is therefore needed on the adolescents’ perspective and experience, in order to increase our knowledge of the therapeutic relationship in music therapy.
 By independent we mean that the group is self-sustaining and self-directed, independent of the child welfare services. Aleris Ungplan, the municipality, in addition to different organizations and foundations, funds the group.
 Aftercare is offered to adolescents after they move out of institutions and foster care, normally from the age of 18-23, as a part of process towards an independent adult life.
 Throughout the article we will distinguish between the therapeutic relationship and the therapeutic alliance in line with Bordin’s theory, using the latter term when discussing the alliance as explained below and using the therapeutic relationship when referring to the overarching relationship between the adolescent and the therapist.
 Some researchers consider Bordin’s alliance as unfit for adolescents, emphasising that the theory was developed with adult clients in mind. However, as of now, there is little consensus on how to best conceptualize the alliance in therapy with adolescents (Ormhaug, 2015; Shirk, Karver, & Brown, 2011).
 Eight percent of the children and adolescents who are in care of Norwegian child welfare services live in residential care (Barne- ungdoms- og familiedirektoratet, 2017). The adolescents presented in this article all live in this type of home-like institutions. They may house one to four adolescents and are staffed with environmental therapists working shifts of 2 to 4 days.
 For more literature on developmental trauma disorder see Perry (2014).
Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 1-11, https://dx.doi.org/10.3389%2Ffpsyg.2011.00270.
Bachelor, A. (2013). Clients’ and therapists’ views of the therapeutic alliance: Similarities, differences and relationship to therapy outcome. Clinical Psychology and Psychotherapy, 20(2), 118-135, https://doi.org/10.1002/cpp.792.
Backe-Hansen, E. (2016). Barn og unges medvirkning i barnevernet – hvorfor og hvordan? [Child and youth participation in child welfare – why and how?] In K. Stensæth, V. Krüger, & S. Fuglestad (Eds.), I transitt – mellom til og fra. Om musikk og deltagelse i barnevern (pp. 37-48). Oslo, Norway: NMH-Skriftserie fra Senter for Musikk og Helse.
Barne- ungdoms- og familiedirektoratet (2017). Barnevernsstatistikk [Child welfare statistics]. Retrieved from https://www.bufdir.no/Statistikk_og_analyse/Barnevern/
Bessell, S. (2011). Participation in decision-making in out-of-home care in Australia: What do young people say? Children and Youth Services Review, 33(4), 496-501, https://doi.org/10.1016/j.childyouth.2010.05.006.
van Bijleveld, G. G., Dedding, C. W. M., & Bunders-Aelen, J. F. G. (2015). Children’s participation within child protection. Child and Family Social Work, 20(2), 129-138, https://doi.org/10.1111/cfs.12082.
Binder, P. E., Nielsen, G. H., Vøllestad, J., Holgersen, H., & Schanche, E. (2006). Hva er relasjonell psykoanalyse? Nye psykoanalytiske perspektiver på samhandling, det ubevisste og selvet. [What is relational psychoanalysis? New psychoanalytical perspectives on cooperation, the unconscious and the Self]. Tidsskrift for Norsk Psykologiforening, 43(9), 899-908.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: theory, research & practice, 16(3), 252-260, https://dx.doi.org/http://dx.doi.org/10.1037/h0085885.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change: A task force on participants, relationships and techniques factors. Journal of Clinical Psychology, 62(6), 631-638, https://doi.org/10.1002/jclp.20256.
Curtis, S., & Vaillancourt, G. (2012). The children’s right to music project. Voices: A World Forum for Music Therapy, 12(3), https://dx.doi.org/https://doi.org/10.15845/voices.v12i3.676.
Del Re, A. C., Flückiger, C., Horwath, A. O., Symonds, D., & Wampold, B. E. (2012). Therapists effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642-649, https://dx.doi.org/https://doi.org/10.1016/j.cpr.2012.07.002.
Fairchild, R. (2018). “Everything changed when i got these drums”: A collaborative case reflection. Voices: A World Forum for Music Therapy, 18(1), https://dx.doi.org/https://doi.org/10.15845/voices.v18i1.957.
Gallagher, M., Smith, M., Hardy, M., & Wilkinson, H. (2012). Children and families’ involvement in social work decision making. Children and Society, 26(1), 74-85, https://dx.doi.org/https://doi.org/10.1111/j.1099-0860.2011.00409.x.
Gallitto, E., Lyons, J., Weegar, K., & Romano, E. (2017). Trauma-symptom profiles of adolescents in child welfare. Child Abuse & Neglect, 68, 25-35, https://doi.org/10.1016/j.chiabu.2017.03.011.
Halvorsen, T. (2018). Glimt fra tilknytningsteoriens historie. [Moments from the history of attachment theory]. Norges Barnevern, 95(1), 50-69, https://dx.doi.org/https://doi.org/10.18261/issn.1891-1838-2018-01-05.
Holmes, J. (2017). Attachment, psychoanalysis, and the search for a 21st-century psychotherapy practice. Psychoanalytic Inquiry, 37(5), 309-318, https://dx.doi.org/https://doi.org/10.1080/07351690.2017.1322425.
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61(4), 561-573, https://dx.doi.org/http://dx.doi.org/10.1037/0022-006X.61.4.561.
Kayed, N. S., Jozefiak, T., Rimehaug, T., Tjelflaat, A. M., & Wichstrøm, L. (2015). Resultater fra forskningsprosjektet Psykisk helse hos barn og unge i barnevernsinstitusjoner [Results from the research project Child and youth mental health in child welfare institutions]. Regionalt kunnskapssenter for barn og unge – psykisk helsevern, NTNU.
Krause, M., Altimir, C., & Horvath, A. (2011). Deconstructing the therapeutic alliance: Reflections on the underlying dimensions of the concept. Clínica y Salud, 22(3), DOI, 267-283, http://dx.doi.org/10.5093/cl2011v22n3a7.
Krüger, V. (2008). Musikkterapi som læring i et praksisfellesskap - en fortelling om et rockeband. [Music therapy as learning in a community – a story about a rock band]. In E. Ruud & G. Trondalen (Eds.), Perspektiver på musikk og helse: 30 år med norsk musikkterapi (pp. 397-411). Oslo, Norway: NMH- Skriftserie fra Senter for Musikk og Helse.
Krüger, V. (2012). Musikk - Fortelling - Fellesskap: En kvalitativ undersøkelse av ungdommers perspektiver på deltagelse i samfunnsmusikkterapeutisk praksis i barnevern [Music – Narration – Community: A qualitative study of young people’s perspective on participation in a community music therapy practice in child welfare] (Unpublished doctoral dissertation). Bergen, Norway: University of Bergen.
Krüger, V. (2016). Musikk som ressurs for ungdommers livslange læringsbehov - et tverrfaglig eksempel fra skolen og barnevernets praksis. In K. Stensæth, V. Krüger, & S. Fuglestad (Eds.), I transitt – mellom til og fra. Om musikk og deltagelse i barnevern (pp. 63-80). Oslo, Norway: NMH-Skriftserie fra Senter for Musikk og Helse.
Krüger, V. (2018). Community music therapy as participatory practice in a child welfare setting - a Norwegian case study. Community Developmental Journal, https://doi.org/10.1093/cdj/bsy021.
Krüger, V., Bolstad, N., & Stige, B. (2016). Hvorfor og hvordan utvikle musikkterapi i barnevernet: Om tjenesteutvikling og forskning som samspillende sosiale praksiser. [Why and how to develop music therapy in child welfare services: About service development and research as interacting social practices]. Norges Barnevern, 93(3), 322-338, https://doi.org/10.18261/issn.1891-1838-2016-03-04-14.
Lehmann, S., Havik, O., Havik, T., & Heiervang, E. (2013). Mental disorders in foster children: A study of prevalence, comorbidity and risk factors. Child and Adolescent Psychiatry and Mental Health, 7(39), https://dx.doi.org/https://doi.org/10.1186/1753-2000-7-39.
Malt, U. (2016). Klientsentrert terapi [Client-centred therapy]. https://snl.no/klientsentrert_terapi%0b.
McFerran, K. S. (2016). Contextualising the relationship between music, emotion and the well-being of young people: A critical interpretive synthesis. Musicae Scientiae, 20(1), 103-121, https://doi.org/10.1177/1029864915626968.
Oetzel, K. B., & Scherer, D. G. (2003). Therapeutic engagement with adolescents in psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 40(3), 215-225, https://dx.doi.org/https://doi.org/10.1037/0033-322.214.171.124.
Owen, J., & Hilsenroth, M. J. (2014). The importance of therapist flexibility in relation to therapy outcomes. Journal of Counseling Psychology, 61(2), 280-288, https://dx.doi.org/https://doi.org/10.1037/a0035753.
Paulsen, V. (2016b). Ungdom på vei ut av barnevernet: Brå overgang til voksenlivet. [Young people leaving the child welfare system: A sudden transition to adulthood]. Norges Barnevern, 93(1), 36-51, https://doi.org/10.18261/issn.1891-1838-2016-01-04.
Paulsen, V., Aune, J. A., Melting, J. K., Stormyr, O., & Berg, B. (2017). Relasjonen som plattform i møte med ungdom i barnevernet. [The relationship as a platform for meeting youth in child welfare]. Norges Barnevern, 94(2), 84-95, https://dx.doi.org/https://doi.org/, https://doi.org/10.18261/issn.1891-1838-2017-02-02.
Perry, B. D. (2014). The neurosequential model of therapeutics: Application of a developmentally sensitive and neurobiology-informed approach to clinical problem solving in maltreated children. In K. Brandt, B. D. Perry, S. Seligman, & E. Tronick (Eds.), Infant and early childhood mental health. Core concepts and Clinical Practice (pp. 21-32). Washington, DC: American Psychiatric Publishing.
Rolvsjord, R. (2015). Five episodes of clients’ contributions to the therapeutic relationship: A qualitative study in adult mental health care. Nordic Journal of Music Therapy, 25(2), 159-184, https://doi.org/10.1080/08098131.2015.1010562.
Rubenstein, A. C. (2003). Adolescent psychotherapy: An introduction. JCLP/In Session, 59(11), 1169-1175, https://dx.doi.org/https://doi.org/10.1002/jclp.10208.
Ruud, E. (2008). Et humanistisk perspektiv på norsk musikkterapi. [A humanistic perspective on music therapy in Norway]. In E. Ruud & G. Trondalen (Eds.), Perspektiver på musikk og helse: 30 år med norsk musikkterapi [NMH-publikasjoner 2008;3], pp. 5-28). Oslo: Skriftserie fra Senter for Musikk og Helse.
Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy: Theory, Research, Practice, Training, 43(3), 286-291, https://dx.doi.org/https://doi.org/10.1037/0033-3126.96.36.1996.
Shirk, S. R., Caporino, N., & Karver, M. (2010). The alliance in adolescent therapy: Conceptual, operational, and predictive issues. In D. Castro-Blanco & M. S. Karver (Eds.), Elusive alliance: Treatment engagement strategies with high-risk adolescents. Washington, DC: American Psychological Association.
Shirk, S. R., Karver, M. S., & Brown, R. (2011). The alliance in child and adolescent psychotherapy. Pyschotherapy, 48(1), 17-24, https://doi.org/10.1037/a0022181.
Strandbu, A., Krüger, V., & Lorentzen, M. (2016). Musikkteater som barneverntiltak. Identitet, fritid og kvalifisering til videre deltagelse. [Music theatre as a child welfare initiative: Identity, leisure, and qualification for further participation]. In K. Stensæth, V. Krüger, & S. Fuglestad (Eds.), I transitt – mellom til og fra. Om musikk og deltagelse i barnevern (pp. 231-249). Oslo, Norway: NMH-Skriftserie fra Senter for Musikk og Helse.
Tobin, S. (1991). A comparison of psychoanalytical self-psychology and Carl Rogers’s person-centered therapy. Journal of Humanistic Psychology, 31(1), 9-33, https://doi.org/10.1177/0022167891311002.
Trondalen, G. (2004). Klingende relasjoner: En musikkterapistudie av “signifikante øyeblikk” i musikalsk samspill med unge mennesker med anoreksi [Sounding relationships: A music therapy study of “significant moments” in musical interplay with young people suffering from Anorexia Nervosa] (Doctoral dissertation). Oslo, Norway: Norges Musikkhøgskole.
Trondalen, G. (2016b). Musikkterapi som anerkjennelse. En mor-barn gruppe innenfor rammen av barnevernet. [Music therapy as recognition. A mother-child group in the context of child welfare services]. In K. Stensæth, V. Krüger, & S. Fuglestad (Eds.), I transitt – mellom til og fra. Om musikk og deltagelse i barnevern (pp. 107-125). Oslo, Norway: NMH-Skriftserie fra Senter for Musikk og Helse.
Tryon, G. S., & Winograd, G. (2011). Goal consensus and collaboration. Psychotherapy, 48(1), 50-57, https://dx.doi.org/http://dx.doi.org/10.1037/a0022061.
Wilhelmsen, C. (2012). Flow and music therapy improvisation (Masters’ thesis). Bergen, Norway: University of Bergen. Retrieved from http://bora.uib.no/handle/1956/7141.
Zanders, M. L. (2015). Music therapy practices and processes with foster-care youth: Formulating an approach to clinical work. Music Therapy Perspectives, 33(2), 97-107, https://doi.org/10.1093/mtp/miv028.