An Investigation of Music Therapists’ Experiences of Verbal Dialogue in Music Therapy Sessions

Introduction

This paper presents an exploratory investigation of issues relating to music therapists’ understandings of verbal dialogue and the perceived benefits and challenges of engaging in verbal dialogue with clients. Basic counselling or communication skills have an established place throughout many music therapy sessions, specifically to: open and close sessions, gather information and provide feedback about clients’ musical experiences, establish trust, and to facilitate genuine encounters (Grocke & Wigram, 2007; Lindblad, 2016). However, the applicability of verbal interaction remains a divisive topic within the literature (Aigen, 2014), with some authors arguing that the therapeutic impact of musical engagement may be diminished if processed through higher cognition. Bruscia (2006) acknowledged that verbal dialogue may play a pertinent role with certain client groups but may be ineffective or inappropriate when working with others (nonverbal clients, for example). Certain theoretical approaches to music therapy place a greater emphasis on the use of verbal dialogue than others. For example, psychodynamic approaches have a strong verbal element (Priestley, 1994), while creative music therapy places greater emphasis on musical interaction (Nordoff, Robbins, & Marcus, 2007). As a communicative medium, music has been described as “supra verbal” as it facilitates the expression of feelings and emotions that cannot be put into words (Beckwith, 1997; Grocke & Wigram, 2007). Garred (2006) maintained that it is likely that the primary motivation for engaging with music therapy stems from the inherent qualities of music itself. This makes music therapy an accessible medium to clients for whom verbal therapies are unsuitable, be this through disability or other barriers to engagement.

A number of authors have outlined the importance of context and relationship within the music therapy process. For example, Garred (2006) explained that the music in music therapy always exists within a “situation” which involves a therapist and a client relating to one another. Thus, the function of music in this instance is never as an “object” but as an inter-relational process that can only be understood within the context of that “situation.” Similarly, McCaffrey (2013) posited that clinical musical improvisation can be understood as a form of inter-subjective discourse which promotes a deeper understanding of self in relation to others. Depending on circumstances, this understanding may or may not be supported through verbal processing, described by Nolan (2005) as “the talking that facilitates the therapeutic process during, and in response to, music making or music listening” (p.18). Nolan (2005) outlined the application of verbal techniques in providing clarity about the musical experience, developing client awareness across a number of domains, and providing the therapist with a means of obtaining pertinent information about the client and how to proceed. In this regard, verbal processing has been described as a dynamic process that unfolds over the course of therapy and refers more specifically to the process of assisting clients to make sense of their musical experiences.

Lindblad (2016) recognised the “supra verbal” qualities of music while simultaneously acknowledging the importance of words for comprehending and clarifying the musical experience on a conscious level. In a qualitative study of three music therapy sessions, three primary functions of verbal dialogue were identified. These included: 1) establishing trust to bring about a genuine encounter, 2) deepening the experience of the present moment, and 3) clarifying the client’s life story. The sessions were carried out with research volunteers who had agreed to participate in a single, one-time music therapy session for the purpose of the study. Lindblad noted that verbal dialogue formed a dominant part of each session, and that in one case the therapist might not have used music at all if she had not been taking part in a research study which required her to do so. This was supportive of Nolan (2005) who noted that while verbal dialogue is rarely discussed in detail in the literature, it is likely to be widely used in practice.

The dearth of literature and resources on the topic of verbalisation in music therapy has been highlighted by previous authors (Lindblad, 2016; Schwartz, 2019). Grocke and Wigram (2007) suggested that comprehensive training in counselling skills was not necessary for music therapists but stressed that some basic skills could equip practitioners when exploring and processing music experiences with their clients. Grocke and Wigram (2007) also identified verbal dialogue as an inherent and inevitable part of the therapeutic process stating that “therapists talk with their clients, if for no other reason than to greet them at the start of a session and to get a sense of how the therapy is progressing” (p. 26). They listed seven ways in which music therapists engage verbally with their clients, to:

The skilled helper approach developed by Egan (1994) introduced the SOLER acronym which outlined a set of skills which enable helping professionals to engage empathetically with their clients. These include: S – sitting squarely, O – open attitude, L – leaning toward, E – eye contact, and R – relaxed posture. Egan also outlined six skills fundamental to effective verbal communication which include active listening, reflecting, paraphrasing, open questions, probes (to elicit more information), and focused questions. Using Egan’s model as a guideline, Grocke and Wigram (2007) suggested a further four skills which are necessary for practicing music therapists which include: providing choice; being comfortable with silence; establishing, developing and maintaining a therapeutic presence; and, closing a session.

Gooding (2017) suggested that the microskills model, also referred to as microcounseling, may provide a suitable framework for the verbal processing skills required by music therapists due to its applicability within a wide range of theoretical frameworks and its grounding in ethical practice. Gooding contended that this model could be easily integrated into music therapy training programmes as it was developed to teach basic counselling skills in a short period of time. The microskills model can be adjusted to accommodate varied levels of experience as well as particular theoretical orientations and areas of speciality.

The most thorough account of the role and application of verbal skills in music therapy was recently published by Schwartz (2019). This book delineates various forms of “communication” inherent in music therapy practice while offering practical guidelines for determining when and how verbal skills should be employed during the music therapy process, with consideration to a range of situational and contextual factors. This resource has bridged a gap in the literature by providing a comprehensive reference point for aspiring and practicing music therapists. Nonetheless, a gap remains regarding the first-hand perspectives and experiences of professionals working in the field. The present research project sought to address this gap by interviewing qualified music therapists who regularly use verbal dialogue as part of their clinical practice. A variety of terms such as verbal processing (Nolan, 2005), verbal exchanges (Schwartz, 2019), and verbal dialogue (Lindblad, 2016) have been used in the existing literature to describe the types of verbal communication that can occur within music therapy practice. The term verbal dialogue was deemed most appropriate for the purpose of this study and will be applied herein, in order to investigate the breadth of spoken exchanges that occur between client and therapist throughout the course of a music therapy session.

Methodology

Findings

Individual interviews were conducted with three professional music therapists about their experiences of implementing verbal dialogue with clients as part of their clinical music therapy practice. Participants were assigned the pseudonyms Lily, Jane, and Brian. The following themes emerged during analysis across each of the interviews: content and function of verbal dialogue, the use of verbal dialogue may contribute to professional ambiguity, returning to the music, and the dyadic relationship between verbal and musical exchange.

Discussion

The present study sought to provide a preliminary inquiry into the experiences of Irish music therapists employing verbal dialogue within their music therapy practice. The self-reflective narratives that emerged in this study exposed verbal dialogue as a pertinent clinical issue, which participants were eager to explore in more detail. Four primary themes emerged, the content and function of verbal dialogue, the use of verbal dialogue may contribute to professional ambiguity, returning to the music, and the dyadic relationship between verbal and musical exchange. Although the use of verbal dialogue may contribute to professional ambiguity emerged as a compelling individual theme, issues relating to professionalism maintained such a strong presence throughout each interview that the researcher found it challenging to consider it in complete isolation from other themes. The authors hope that the present discussion will illustrate this undercurrent of professionalism with greater coherence. Many of the concerns that emerged appeared to reflect hesitations regarding participants’ personal sense of professional identity, rather than revealing concerns about the professional community on a whole. However, issues surrounding professional identity have arisen previously within the Irish context (McCaffrey, 2013) and may warrant further attention. This may partly reflect the fact that, unlike their counterparts in the United Kingdom, Irish music therapists still await statutory recognition.

Within the theme of content and function of verbal dialogue the contribution that verbal dialogue makes in maintaining authentic relationships with clients was identified. Participants believed that casual verbal interactions were necessary to “normalise” the concept of music therapy. This finding is congruent with service user accounts of music therapy in adult mental health settings, where ambiguity surrounding the concept of music therapy has been identified as a potential challenge in the initial stages of therapy (McCaffrey, 2018). The process of “normalising” also appeared to serve an additional function of neutralising power dynamics within the relationship, with one participant, Brian, commenting on the human quality of these exchanges.

Additionally, participants made a clear distinction between instructional skills and processing skills, with the implication that verbal processing skills overlap on some level with psychotherapeutic skills. This reflected Nolan’s (2005) description of the role of verbal processing in music therapy and Schwartz’ (2019) distinction between various forms of verbalisation during the music therapy process (e.g. verbal framing, verbal exchanges, verbal interactions, and verbal interventions). They also reported encountering a range of verbal interactions in their sessions, from everyday exchanges to personal disclosures that held meaning for the client. It appeared, for the most part, that participants did not actively seek out sensitive information from their clients but that clients were forthcoming with personal issues due to the sense of trust and safety they experienced within the therapeutic environment. It could be argued that the emphasis on the therapeutic relationship, which is central to music therapy practice (Bruscia, 1998), may invite personal disclosures regardless of whether these are actively sought or encouraged by the music therapist. Therefore, music therapists may require training to prepare them for such verbal disclosures even if their preferred style of working does not place emphasis on verbal dialogue.

Surveys conducted with student music therapists have previously revealed verbal and communication skills to be a domain that requires greater attention on training programmes (Clements-Cortes, 2015). While not all music therapists may require the same level of competence in verbal techniques due to working with non-verbal populations, there may be a basic level of training that is appropriate for entry-level graduates to ensure that they are equipped to deal with diverse verbal scenarios. This corresponds with Grocke and Wigram’s (2007) recommendations that comprehensive counselling skills are not essential to music therapy practice, but some training is evidently beneficial. Edwards and McFerran (2004) previously made recommendations about educating music therapy students about sensitive topics such as childhood sexual abuse, stating, “It is a challenging responsibility to ensure that students are prepared for the work that awaits them in the field, and in particular are alerted and appropriately prepared for the requirements of working therapeutically with vulnerable populations” (p. 335). The present authors concur that addressing potentially triggering topics within the safety of a training programme may buffer distress if these issues arise unexpectedly for students on clinical placement.

All participants expressed a confidence in music as their chosen therapeutic medium and spoke clearly about the benefits that music can bring about. However, two of the three participants expressed ambiguous feelings in relation to their perceived roles and responsibilities regarding the verbal material they encounter during their sessions. While all participants noted that maintaining a balance between verbal and musical interaction was their preferred style of working, specific concerns arose for Lily and Jane in relation to how much time should be spent in the “verbal space” and knowing how and when to direct clients back towards the music. Brian did not share in this uncertainty, expressing confidence in the capacity of music therapists to develop necessary verbal skills throughout their career. This pointed to an important contrast in perspective which mirrors long-standing debates over the role of verbal dialogue in music therapy (Aigen, 2014). It is possible that preferred approaches to practice and experiences of different working environments influenced participants’ perceived sense of professional boundaries. While participants did not identify a need for limitations to be placed on the quantity of verbal material music therapists engage in, they emphasised the responsibility held by individual practitioners to seek additional training or support where necessary and to recognise when a referral to psychotherapy may be more appropriate. While differences in opinion emerged, participants were united in their concern for the welfare of their clients, expressing a strong commitment to their overall role as “therapist”. Personal psychotherapy, clinical supervision, continuous professional development (CPD) and professional experience were credited as avenues for developing appropriate verbal skills, particularly within the early years of professional practice.

A prominent theme which emerged naturally across each interview was the concept of “returning to the music” when verbal dialogue was unsuitable or when the therapeutic process had become blocked. This theme reflected participants’ strong belief in the benefits of their primary therapeutic medium and represented a stage in the interview process where participants began to reclaim a sense of trust in their professional ability. Embedded within the concept of “returning to the music” were deliberations regarding the ways in which verbal dialogue may hinder progress by facilitating avoidance or diluting the embodied experience of music-making. However, while Lily and Jane spoke clearly about taking deliberate actions to guide clients “back to the music”, Brian asserted that the therapeutic process moves back toward the music naturally. His description of the music as his “co-therapist” revealed a nuanced perspective on how the client’s process becomes guided in the direction of music. A larger data set may have permitted deeper inspection of these nuances, nonetheless, the concept of “returning to the music” was a common theme across participants.

Although conflicting thoughts regarding verbal dialogue emerged within, between, and throughout the interviews, as each interview unfolded it became clear that both music and verbal exchange were viewed as valuable tools with which to support the therapeutic process. Improvisational music was described as a “felt” or “lived” experience which may supersede verbal dialogue at times. Participants identified moments where music could be employed skilfully to move beyond “blocks” in cognition. It was equally recognised that verbal processing could assist clients to cognitively consolidate this “felt experience”, presenting opportunities for insight to develop. The perceived role of the music therapist was to intuitively gauge whether the client’s process was best supported through musical engagement or verbal reflection from moment to moment. Additionally, it was observed that verbal dialogue is embedded in particular music therapy methods such as song-writing and lyric analysis. Short (2013) previously outlined some of the unique verbal scenarios encountered by music therapists when navigating the provocative lyrical content that may be introduced by clients when exploring rap as their chosen musical genre. It is evident that the verbal scenarios encountered by music therapists may be unique in certain settings.

While the term “verbal dialogue” was intended to refer solely to spoken exchanges, it became apparent that participants’ understanding of “dialogue” was not limited to verbal exchanges. The breadth of communicative exchange in music therapy has been described by Schwartz (2019) as comprising words, language and speech; musical interaction; and gestures, physical actions, affect and posture. Participants in this study illustrated how music therapists often facilitate meaningful communicative interactions with clients whose capacity for verbal dialogue is limited. Clinical examples provided by Jane and Brian demonstrated that in order to facilitate such exchanges music therapists employ an expansive communicative repertoire which amalgamates verbal dialogue, vocalisations, and other musical techniques. It is therefore likely that rather than viewing the musical and verbal realms as mutually exclusive, music therapists generally possess a broader definition of the concept of “dialogue” or “communication” than spoken language permits. This may provide a partial explanation for the professional uncertainties that arose for participants when considering the musical and verbal realms in isolation. Participants appeared to resolve these concerns by determining that music and verbal dialogue operate as a dyad within the music therapy context, each affording unique possibilities but ultimately enhancing the therapeutic potential of the other. The dynamic interplay between conscious awareness and embodied experience has previously been delineated in relation to the art therapy process by Blomdahl and colleagues (2018). Their description of the “inner dialogue” as a private, unfolding experience of self is echoed in the present finding that music and language exist within a “dyadic” relationship which supports the unfolding internal and external processes of the music therapy client.

In respect of the present findings, the authors wish to make some recommendations for the incorporation of verbal skills training on education programmes and for future research.

Limitations

An obvious limitation to the present study was the small participant pool. Some interesting contrasts in opinion emerged in the data set which may have been possible to explore further had the study included a larger data set. While the small scale of the study limits the generalisability of findings, the authors suggest that some of the emerging themes may offer a foundational reference point for future enquiry into this topic.

The present study was completed as part of an academic programme, thus placing time constraints on elements of the analysis process. As a result, sufficient time was not available to engage in a member-checking process. This limitation was buffered through ongoing consultations with the lead researcher’s academic supervisor (the second author of this publication) and through maintaining an ongoing reflexive journal which was consulted regularly during the data analysis phase. However, it is acknowledged that member-checking would have minimised researcher bias and increased the validity of interpretations.

While conducting and analysing interviews, it occurred to the lead researcher that the term “verbal dialogue” may have been too limiting to the topic of the research. Much of what was discussed throughout the interviews could better be described as “interactions” or “exchanges”, and the skills required for these forms of communication were not solely applicable to spoken language as the term “dialogue” might imply. The distinction between various types of verbalisations in music therapy has been delineated more recently by Schwartz (2019). Additionally, all three participants had experience working in mental health settings, where it was acknowledged that verbal skills are particularly relevant. This meant that each participant had experience in negotiating verbal scenarios, identifying verbal skills as an integral element of their work. While this provided rich information on the use and necessity of these skills within certain contexts, it did not provide space for an alternative view. While reference was made to verbal exchanges with people with dementia and special needs, participants emphasised that their experience in mental health was more relevant to the topic. In hindsight, it may have been possible to extract richer information on other populations had the researcher probed participants further.

Recommendations

Based on the present findings, the authors support recommendations for basic verbal skills training on music therapy programmes. Previous authors have outlined paradigms which may be suitable for inclusion without over-loading already burdened programmes (Gooding, 2017; Grocke & Wigram, 2007; Schwartz, 2019). Training programmes may wish to focus on supporting trainees to facilitate the verbal elements of widely-used music therapy methods such as songwriting and lyric analysis and how to skilfully shift between the verbal and musical domains during pivotal moments in sessions. It is appreciated and advised that individual qualified practitioners must take responsibility for seeking additional training when pursuing specialised clinical domains. However, basic confidence in these core areas may contribute to overall professional competence upon entering the field.

In light of the present findings, the authors propose that education programmes provide some pre-emptive support to trainees regarding the array of verbal exchanges they could encounter in clinical practice. Future research may help to quantitatively establish specific areas of educational need, however initial recommendations relate to social issues identified during analysis including: family and relationship issues, grief and loss, trauma, personal identity, and gender and sexuality. Equipping trainees with a basic awareness of such issues may help to buffer feelings of overwhelm and enhance their capacity to respond appropriately in moments of uncertainty. Furthermore, while previous authors have begun to identify specific functions of verbal dialogue in music therapy (Grocke & Wigram, 2007; Lindblad, 2016) additional research with clinical populations may generate new insights.

It is important to acknowledge that the participants chosen for this study were highly experienced in their work, and thus further research with student or newly-qualified music therapists may help to identify whether there are distinct verbal scenarios that music therapists find difficult to deal with in their early years of practice. Specific issues emerged in relation to participants’ sense of professional identity. It may be worth exploring whether these issues are unique within the Irish music therapy context, or whether they are shared internationally. The authors also suggest that interdisciplinary research across the creative arts therapies may greatly enhance our understanding of this issue as the application of verbal skills is not isolated to music therapy practice.

Conclusion

The current study presented a preliminary exploration of the experiences of three music therapists on their use of verbal dialogue in music therapy practice. The interviews provided a rich data set which produced four central themes as a result of thematic analysis: content and function of verbal dialogue, the use of verbal dialogue may contribute to professional ambiguity, returning to the music, and the dyadic relationship between musical and verbal exchange. The topic of professionalism maintained a strong presence throughout each interview. Participants expressed concerns about ethical practice, professional responsibility, and remaining within their sphere of knowledge and expertise. Participants expressed a strong faith in music as their chosen therapeutic medium while acknowledging the interweaving nature of the verbal and musical dimensions of their practice. This study supports the findings of previous research by recommending the incorporation of basic counselling skills training on music therapy training programmes. The authors also propose that education surrounding social issues which impact upon clients may provide trainees with additional support and preparation for the types of verbal encounters that are likely to arise in clinical practice. Future research into student experiences of verbal dialogue may help to better inform specific areas of educational need.

About the authors

Siobhán Nelligan is a Music Therapist specialising with children and adolescents. She has a strong background in mental health, developmental disability and trauma-informed practice. She holds a BA (Hons) Psychology, MA Community Music, and an MA Music Therapy. Siobhán has extensive experience working with children and young people in a variety of contexts including community settings, primary and post-primary schools, mental health services, palliative care, and residential care settings. She currently works in a dual capacity as an Assistant Psychologist and Music Therapist with children and young people in care who have experienced complex developmental and relational trauma. Siobhán is experienced in the therapeutic application of creative and play-based mediums and is interested in collaborative, attachment-focussed and somatic approaches to therapy.

Tríona McCaffrey is a lecturer on the MA Music Therapy at the Irish World Academy of Music and Dance, University of Limerick, Ireland. She has a background in mental health practice and holds a BA (Music and Irish), MA and PhD (Music Therapy), and a Graduate Diploma in Psychology. Tríona is particularly interested in the role of music therapy in promoting mental health recovery and is co-founder of the Alliance for Recovery Research in Music Therapy, an international research group dedicated to active involvement of mental health service users in music therapy research. Her PhD focused on service user evaluation of music therapy in mental health, employing interpretative phenomenological analysis and arts-based methods to highlight service user’s personal experiences. Tríona is also article editor for Voices: A World Forum for Music Therapy.