Musical Assessment of Child Perceptions in Changing Family Situations

Therapist’s Context

I am a white, queer, middle class, nondisabled settler on Coast Salish land¹ in the United States. I am a genderqueer woman², and I experience cis privilege based on the ways in which my body and gender are typically interpreted. I am the youngest child of Judy and Joe Gilman. I am currently a graduate student in the Masters of Music Therapy program at Slippery Rock University.

As a music therapist, I work with Native American³ children and families to provide support in response to trauma. Most of the children I work with have come into contact with Child Protective Services (CPS, the state agency responsible for protecting children who are at risk of or are currently experiencing abuse or neglect) or its tribal equivalent. I work primarily with preschool- and elementary school-aged children in public-school and community-based settings, in both individual and family-oriented sessions.

Need for Systems Assessments with Indigenous Youth

Indigenous children in the United States are at particular risk of being identified as victims of maltreatment. A 2007 report by the National Indian Child Welfare Association indicates that Native children are overrepresented in the CPS system: whereas 10.8 per 1000 White children in the United States were identified as victims of child abuse or neglect, 16.5 per 1000 Native children were identified as such. In my home state of Washington 22.9 per 1000 Native children were identified as victims of abuse or neglect. This disproportionality may be due in part to racial bias in the reporting and investigation of child maltreatment; however, a study by Font, Berger, and Slack (2012) suggested that racial bias in these investigations did not account for such overrepresentation entirely. Rather, intergenerational trauma and systemic oppression against Native people contributed to family risk factors and produced an environment in which child abuse and neglect were more likely to occur (Evans-Campbell, Walters, Pearson, & Campbell, 2012). Thus, this assessment reflects a systems approach aimed at reducing risk factors for abuse and neglect as well as promoting positive attachment and personal healing for children post-trauma (Cobbett, 2016; Miller, 1994).

Development of the Assessment

In the first three years of my work in this setting, I emphasized individualized trauma-responsive music therapy with children. However, I noticed that my clients’ most dramatic improvements (i.e. evidence of personally “feeling better” and demonstrating greater ability to engage in healthy relationships with others) did not necessarily follow particular breakthroughs in the therapy setting; they mainly occurred when children’s family situations stabilized. For example, I had worked with one client for a year to slowly draw her out of a generalized trauma response of withdrawal and dissociation. When a parent returned home after an extended absence, not only did this client’s demeanor shift dramatically to wider and more exuberant expression in the music therapy setting, but this change also quickly generalized to her relationships in the classroom and in play with peers.

Around the same, I took a graduate course on systems music therapy with Professor Susan Hadley at Slippery Rock University. This course included readings that described interpersonal systems within music therapy sessions (Kenny, 1989), in families (Cobbett, 2016; Jacobsen, 2017; Miller, 1994), and in larger communities (Stige & Aarø, 2012). I realized that I needed to take on a more systems-oriented approach, particularly addressing children’s micro-systems and meso-systems⁴ in order to support children more effectively. I began to provide family music therapy sessions for parent-child dyads, sibling groups, and family micro-systems (groups of people living together with family-type relationships). I also applied the systems approach to my individual sessions with clients, exploring their relationships to particular family members and their roles and positions within the family system as a whole.

In shifting the focus of my work, I recognized the need for an assessment that would musically approach the types of information that were most relevant to systems music therapy. Discerning children’s perspectives about their families was not only necessary to structure therapy treatment; when appropriate, it could also apply to dependency court cases, which typically relied on third party accounts of children’s experiences in order to determine children’s living situations. Often children had difficulty verbally describing their familial relationships due to fear regarding verbal disclosures, developmental limits to verbal processing, or states of withdrawal in particular settings. Caregivers could only represent their own perceptions of children’s feelings, and often new caregivers such as foster parents did not know many details of their children’s family histories. I began to see the music in sessions as an intersubjective space in which I could gain insight regarding children’s unique perspectives about their family relationships. Therefore, I referred to existing music-indigenous assessments (Bruscia, 1987; Jacobsen, 2012) to develop a musical assessment process aimed at gaining greater insight into an individual child’s perception of particular family relationships and the family system as a whole.

Clarification of Terms

For the purposes of this article, the phrase “children with changing family situations” refers to children who have experienced trauma related to some change in their family system. I chose this phrase as an indication that the assessment is relevant not only within an official child welfare institution, but for any child who has experienced family-related trauma. This population includes children in foster care and tribal equivalents, adopted children (particularly children adopted from foster care), children being raised by family members who are not their biological parents, children with one or more family member out of the home due to incarceration or drug treatment, children living in state-run group homes, children who have lost one or both biological parents through death or absence/abandonment, children whose parents re-enter their lives after a period of absence (e.g. parents returning from prison), and children whose parent or parents regain custody after a loss of custody. This is not an exhaustive list, and the assessment may be equally appropriate for children who have experienced family-related trauma not included here. An emphasis is placed on changes related to caregiving adults, but the assessment may aid in situations of trauma related to siblings as well. Conversely, some changes in family situation may not be experienced as traumatic; in that case, the assessment can still support the therapist’s understanding of the client’s family system, but the understanding of treatment may differ. Therapists should consider the cultural nature of childrearing to avoid perseverating on aspects of the client’s family system that are not highly relevant to the client.

The word “parent” in this article will refer to a biological parent unless otherwise clarified (e.g. “adoptive parent”). “Parent” as used here is a static descriptor that does not change circumstantially. The word “caregiver” will be used to describe a person who lives into the role of parent through presence with the child, showing love and affection for the child, and caring for the child’s daily needs. The caregiver is the person who is available for the child to form a primary attachment to at the time in which the music therapist knows the child. The caregiver role is dynamic and may change over the course of treatment. A child can have multiple caregivers at one time, e.g. a child who splits their time between the homes of two divorced parents or a child who lives with (and is cared for by) both their grandfather and their auntie. Of course, a child’s “parent” and “caregiver” is often the same person, even in the context of changing family situations.

The words “they” and “their” will be used in both plural and singular forms, as gender-neutral pronouns to describe clients, therapists, and family members. Gendered family roles will be included, but therapeutic implications are not at all gender-dependent. For example, the open-ended nature of the assessment allows children to identify mothers, fathers, and nonbinary parents without prompts based in heteronormative understandings of parenthood.

Systems music therapy

Systems therapy is grounded in the concept that individuals are always nested within multiple social systems, and that each part of a system both defines and is defined by the system as a whole (Radichel, nd). Examples of systems in which children are nested include their families, classrooms, schools, towns, churches or other religious/spiritual institutions, and the therapy relationship. According to systems theory, the whole system is greater than the sum of its parts; therefore, simply knowing each individual within a system does not yield the same understanding as relating to the entire system (Walker, 2012). Even in individual therapy, systems theory emphasizes a recognition and integration of the ways in which ecological and systemic factors impact the individual client. As the psychoanalyst Winnicott stated, “There is no such thing as an infant” separate from the primary caregiver who shapes and is reciprocally shaped by that infant (Winnicott, 1960). Therefore, systems theory shifts the focus of therapy toward questions related to relationships, communication patterns, roles, and attachments. The connections between people are as relevant as the people themselves.

In music therapy, Kenny (1985) has described music itself as a system which models and serves as an impetus for wholeness in relationships more broadly: “Music is the expressive connective tissue guiding us into wholeness. It is not only a metaphor, but a living model which resonates the deep truth and beauty contained in the phenomenon of wholeness” (p. 9). Thus, music therapists are in a unique position to enact systems therapy because our modality itself reflects the “expressive connective tissue” of interpersonal dynamics.

I chose to create an assessment that could be done with only one child present because in my practice, there are often practical barriers to entire families attending music therapy sessions. I wanted to find a way to approach family system-related questions even when only one child attended music therapy. Although the assessment process here takes place at an individual level (or more precisely, within a dyadic therapist-client system), its implications extend to help the therapist better understand the nature of the family system that surrounds the child, as well as the child’s position and role within the family.

Music-indigenous Assessment

Music therapists working with children in changing family situations have frequently relied on assessment tools from other fields or have focused on para-musical aspects of caregiver-child interactions in musical contexts (Jacobsen, 2017; Jacobsen & Killén, 2015; Jacobsen & Wigram, 2007; Pasiali, 2017). The Musical Assessment of Child Perceptions in Changing Family Situations (MACPCFS) is presented as a music-indigenous process of understanding a child’s relationship to their caregiver and their other family members. It draws upon existing music-centered music therapy approaches broadly and on Bruscia’s Improvisational Assessment Profiles in particular (Bruscia, 1987). In dyad and family work, this assessment may also complement Jacobsen’s (2012) music-indigenous Assessment of Parenting Competencies, providing therapists with knowledge both about caregiver competencies and about children’s unique perceptions of their family systems (including but not limited to their primary caregiver). Since the MACPCFS can be conducted with only a child present, it is uniquely accessible in cases where the child’s caregiver is unable to attend music therapy sessions, is in a state of flux, or is not someone the child considers to be a family member.

As an improvisation-based assessment, the MACPCFS also draws upon existing music therapy literature elucidating improvisation methods. Bruscia (1987) and Gardstrom (2007) have both described “givens” that shape the improvisation process. Each improvisation played by a child in the MACPCFS includes a vocabulary given (the instrument they choose to play) and a procedural given (the general time length set by the therapist). Each improvisation also includes what Wigram (2004) has referred to as “thematic play rules” and Bruscia (1987) defined as “referents,” in that the child is representing a particular person (p. 41, p. 413–414). Wigram has further described the facilitation of improvisational portraits and their therapeutic potentials, including the prompts, “Make a musical portrait of yourself as you are now,” and, “Make a musical portrait of another person in the group” (p. 187–188). The improvisatory portraits here represent extensions of these prompts to include group members who are not present, and to be applied as assessment rather than treatment. Finally, in improvisations wherein the therapist plays along with the client, “interpersonal givens” guide the therapist’s role in relation to the client’s play. The therapist’s role is described further below.

Music, Trauma, and the Brain

Music offers a necessary alternative to verbal processing for children who have experienced trauma, and musical experiences provide the therapist with a unique combination of both information and insight. Many children with changing family situations do not respond well to talk therapy (Tuomi, 2017). This may be partly related to the verbal processing required in traditional psychotherapy. Brain scans have shown that when survivors recall a traumatic event, Broca’s area – a speech center in the brain – shows markedly decreased activity (van der Kolk, 2015). As van der Kolk pointed out, “Without a functioning Broca’s area you cannot put your thoughts and feelings into words” (p. 43). The problem is compounded for children who have grown up with frequent or constant trauma due to abuse or neglect: in children with such complex trauma, toxic levels of stress hormones may stunt the development of brain architecture necessary for verbal processing (Palix Foundation, 2017). However, skills related to the right brain hemisphere are sometimes more highly developed in children with trauma histories than in those without. For example, Masten et al. (2008) found that children with trauma histories could sometimes read subtle changes in facial expression more adeptly than non-traumatized children, and Jacobsen (2017) noted that “emotionally neglected children who are able to cope better with being neglected can, as an exception, develop special creative abilities where they can express themselves and their inner world through creative mediums” (p. 201). This inverse combination of stunted left-brain development and enhanced right-brain development indicates that creative modalities – including representational play, visual art, movement, and music – may result in fuller and more accessible assessments for children with trauma histories than can be achieved through talk therapies alone.

Assessment of Child Perceptions

This assessment is not concerned primarily with the facts of children’s family systems. Rather, it is concerned with the child’s perception of their family situation. The factual information must be infused with meaning in order for the therapist to do relevant work. As Kenny noted, “Research that is both artistic and scientific would be concerned with issues of both truth and meaning, objectivity and subjectivity” (1989, p. 93). In this assessment, the client depicts family members through musical representations on an instrument of choice. Thus, music aids the therapist in observing and intuiting the nuanced, expansive ideas that the client conveys about each family member. The meaning is understood to be implicit in the music and is co-created by both client and therapist, both in their musical play and in their intersubjective interpretation. As Kenny stated, “Each participant plays and models forms that hold meaning for the individual creating the sound… When a pattern or form is intuitively embraced by client, therapist or both, the assumption is that this form holds meaning for the client and/or therapist” (1989, p. 106). Therefore, whereas a genogram⁵ can provide useful objective information regarding a child’s family history, the assessment provided here helps the therapist to better understand the client’s subjective experience of their family system.

Cultural Implications of the Assessment

The MACPCFS has cultural⁶ implications, especially in cross-cultural fostering or adoption, in that it can help the therapist start to understand where the client considers their primary familial ties to be and where there may be conflicts of alliance or identity. The assessment provides opportunities for the client to use a range of instruments to represent particular family members. The therapist provides instruments that reflect a range of ethnicities relevant to the client and their family. Further, as Stige (2002) has noted, music itself is a culturally grounded experience. Therefore, all music played in the assessment (by both client and therapist) will be informed by the respective participants’ unique cultural identities.

Overall Description

The client describes their family through a musical portrait. With an array of instruments at their disposal, the client identifies an instrument to represent themself, plays an improvisation of themselves on the instrument, and places the instrument into an open space on the floor (or other open space) in front of them. The client then chooses a family member to add into the portrait and repeats the process for that family member: choose an instrument, play an improvisation (either independently or with the music therapist), and place the instrument somewhere in relation to the first instrument. The process is repeated until the client is satisfied with the “portrait” of instruments on the ground as a representation of their entire family.

After the musicking aspect is complete, the therapist considers a set of reflexive questions to derive salient content from the child’s musical portrait. It is possible to respond to the reflexive questions based solely on memory of the musicking process, but not ideal. If consent is available from both child and caregiver/legal guardian⁷, the process may be recorded on video so that the therapist can view and hear the process as a reference while responding to the reflexive questions. Recordings of the musicking process will help the therapist notice a greater level of detail in the client’s representations, compare their own perceptions between participating and observing via recording, and uncover certain ways in which their personal cultural context and biases may have shaped the client’s experience. If video is not possible, the therapist may refer to a photograph or sketch of the musical portrait.

Setting the Space

The assessment should take place in a one-on-one setting. The session is recorded (if consented to) by a stationary video camera with view of the client and the open space in front of them. If possible, the assessment takes place with both client and therapist seated with direct access to the ground – either sitting directly on the ground, or on pillows or beanbags for comfort. This set-up can be adapted to maximize client mobility and comfort, as long as the client has access to an open space for the visual portrait. The therapist should have a wide array of instruments available to the client, all placed along one side of the floor-space so that the area in front of the client is open. Instruments provided should vary in size but should all fall within a range of size and weight that the child can lift and manipulate through space. The therapist should aim to provide the maximum possible level of variability in instruments, considering timbre, volume, size, appearance, physical/haptic texture, and cultural associations of the instruments. Multiples of each instrument or type of instrument should be included whenever possible.

Cultural implications of instruments.

The presence or absence of culturally relevant representations in the music therapy space – including instruments, images and artwork, language, and the therapist’s own expressions – will lead clients to respectively amplify or silence their own expressions of these aspects of identity. Emdin (2017) noted this phenomenon anecdotally when describing a series of interviews with a group of urban youth of color in the United States who aligned with Hip Hop Culture (KRS-One, 2009). Music therapists must evaluate the space and the resources provided to consider which of clients’ identities and associations may be privileged and which may be minimized in the assessment and in the music therapy space more generally.

If the therapist knows the child to have multiple ethnic or other cultural identities within their family system, the therapist can seek to provide instruments that relate to these identities. For example, electronic instruments such as music production centers (MPCs) may provide opportunities for children to represent or express ties to Hip Hop Culture. However, some instruments will not always be appropriate for use in the music therapy space; the therapist must navigate each introduction of new music opportunities uniquely with each client and family to avoid appropriation and essentialization.

In my practice, children often have some family members with Coastal Native identities, but not all family members or caregivers may share this ethnic identity. Children sometimes use synthetic versions of Coastal Native instruments⁸ to represent family members who signify this cultural tie for them. For example, in the composite case example below, the client uses synthetic buffalo drums to represent his grandparents: the keepers of his family’s tribal traditions. Contrastingly, he uses plastic egg shakers – an instrument more closely tied to White Western children’s music experiences – to represent several family members, including himself and his White, non-Native foster parents.

Steps of the musicking process.

The following steps constitute the process of creating the musical family portrait:

The therapist’s role in shared improvisations.

In family member improvisations, the client may play independently, or the therapist may choose to play along with the client to either amplify client expressions or represent the client in relation to that family member. Three cases may lead the therapist to play along with the client:

Analysis of the Musical Portrait

The process of creating a musical family portrait provides a plethora of information for the therapist to analyze in order to better understand the client’s perception of their individual family members and family system as a whole. Broadly, this information includes:

Each of these areas may carry meaning regarding the client’s view of each family member. However, due to the sheer amount of information, the therapist must prioritize the most salient relationships and the most salient elements that seem to represent these relationships.

Appendix A includes a list of reflexive questions for analyzing the portrait as a whole and representations of salient family members in particular. These questions are available for the therapist to consider while watching and listening to the recording of salient client improvisations. Not all questions will be relevant for all improvisations; they represent possibilities for analysis. Different sets of questions are provided depending on whether the client plays the improvisations independently or represents family members while the therapist plays the client instrument.

The reflexive questions.

A list of reflexive questions can be found in Appendix A. These questions have been chosen to highlight musical, instrumental, and visual qualities that relate to possible interpretations about the client’s view of their family relationships. For example, the energy with which a client plays in a particular improvisation may indicate the intensity of the relationship. The closeness of instrument placement in relation to the client instrument and other instruments may indicate family alliances and the client’s sense of this family member’s presence or proximity (whether the client feels positively or negatively about this presence could be interpreted through musical elements). The size of the instrument chosen may indicate how much space a given family member takes up in the client’s life. Levels of variability within a musical improvisation may indicate the client’s sense of a family member’s stability; it may also represent the client’s changing or conflicting feelings toward that family member.

The possible meanings of each element (instrument choice, order chosen, musical improvisation, and placement in the visual portrait) must be taken together to gain a holistic understanding of the client’s perspective. For example, a client could choose a small, soft, quiet instrument easily associated with family members who play only a gentle or minor role in the client’s life. However, if the client uses a high amount of energy in the improvisation – throwing the instrument to the ground or shouting while playing – there is reason to question the initial assumptions based on the instrument. Contrasting elements such as this can be explored further in music therapy after the assessment.

The list of reflexive questions represents a guide for the therapist to refer in order to structure the process of deriving meaning from the improvisation. The reflexive questions are largely informed by Bruscia’s (1987) Improvisational Assessment Profiles (IAP), and sections of the IAP itself can also assist the therapist in extracting meaning from the child’s improvisations. The therapist need not write responses to every question on the list; rather, therapists should distill the information by responding to those questions that address aspects of the improvisation which they find most salient. Conversely, the list of questions is not exhaustive, so therapists may need to record information that is not directly prompted.

The intersubjective space

While the assessment process here offers unique opportunities for insight regarding children’s perspectives, it also has the potential to cause harm if therapists misunderstand their personal interpretations as objective truths or do not acknowledge their own sociocultural position within the assessment and interpretation process. Therapists must recognize their own subjectivity in the assessment process and maintain transparency with the client about what the assessment process entails and represents. Rather than claiming to set aside personal biases, therapists must be unflinchingly aware of their own cultural and philosophical framework and internal biases. Therapists must employ reflexivity not only in analyzing the client’s play, but also in recognizing the ways in which their own presence, identities, facilitation, musical play, and analysis impacts the entire assessment process.

Next Steps

In family therapy settings, the individual family portrait assessment can go further into assessment through dyad and system play. When dyads in family therapy improvise together, their play can be read as indicative of their role relationships with one another. The music therapist can use the Integration and Autonomy profiles from Bruscia’s (1987) IAPs to better understand family members’ roles and relationships in the family system. The music therapist should pay particular attention to the texture scale in both profiles. As Bruscia states, texture “reveals the location and role of each character or part. A texture may reveal hierarchical structures, part-whole relationships, or role functions within the self, between two people, or within a group” (p. 455). This information is crucial for working with families because it allows the therapist to better understand how the individual client’s unique perspective (explored in the main assessment described) fits into the larger family system (the “next step” of assessment).