Improvisation in music therapy invites connection through a unifying experience that often involves the expression of some type of emotional content and is directed towards the growth of the client (Bruscia, 2014; Dillard, 2006; Graham, 2004; Seabrook, 2019; Strehlow & Lindner, 2014). Improvisation creates a sacred space, the musical space, for exploration and relationship (Kenny, 2006). This space can hold safety, relationship, spontaneity, receptivity, and creative potential. By participating in the creative process, the client is actively creating and therefore embarking toward change. Novel and innovative communication can be met with enthusiasm and acceptance from the therapist in this space (Graham, 2004; Polen, 2013; Swaney, 2017; Swaney, 2020). Deep connections can be made within the safety and acceptance present within the therapeutic relationship and musical space.

Communication and connection are accomplished through body movement, facial expression, melody, rhythm, and a felt sense of being united in an experience (Graham, 2004; Swaney, 2020). The therapist then becomes attuned to many possible methods a client uses to engage in the therapeutic space by entering an expressive relationship through improvisation (Cameron, 2017; Swaney, 2020). For some individuals, verbal processing leads to inauthentic experiences or resistance even when verbal language is their primary form of communicating with others (Gavrielidou & Odell-Miller, 2017; Polen, 2013). Improvisation can allow the therapist and client to engage in exploration and communication in a contained environment without the barriers that may come with verbal processing.

Therapeutic progress can often be characterized by periods of growth, and plateau as the client moves through stages of their therapeutic process. Pivotal and meaningful moments are sometimes used to characterize phases of therapy and can represent aspects of the therapeutic relationship (Gavrielidou & Odell-Miller, 2017). Significant moments in therapy occur when something new, different, pivotal, or especially meaningful happens and can be instrumental in client and therapist perspectives on the therapeutic process and relationship. Assigned significance and meaning of a moment in therapy is individual and unique to the therapist(s) and client(s) who were actively engaged in the therapeutic space together. Significant moments in therapy could be experienced as peak moments, moments of tension or sadness or anger, new insight, and/or a shared inner connection between the therapist and client. They occur at different intervals or frequencies at various points in the therapeutic process. In work with individuals who communicate beyond words, these significant moments have also been described as the familiar connections and indicators that the relationship was well established and motivating for connection between the therapist and client (Lee, 2014; Swaney, 2020).

Therapists who work with individuals diagnosed with intellectual and developmental disabilities (I/DD) have described significant moments in therapy as familiar interactions that demonstrate stability in the therapeutic relationship, a new or unexpected occurrence during a session, a felt sense of the impact of an interaction, recognition and connection to another (Lee, 2014; Swaney, 2020). Some therapists have reported the extended length of time necessary for developing rapport and building relationships with clients (Lee, 2014). In these instances, familiarity was highlighted as a core tenet of the relationship and significant to therapeutic progress. The client consistently responding vocally to the therapist indicated the status of their significant relationship. Additionally, significant moments have been sometimes identified as when something new or unexpected happens within a session (Lee, 2014; Swaney, 2020). Unrehearsed, self-initiated musical contributions, and changes in body position, movement and facial expression, characterized interactions that were perceived by the therapist(s) as significant in the change that was highlighted from prior interactions. These moments were often reported to develop from structured musical interactions that created familiar connection points between the therapist and client.

Gavrielidou and Odell-Miller (2017) found that structured music and interventions were more likely to evoke pivotal and significant moments within sessions. These moments could happen while engaging with both pre-composed and improvised music. Engagement with music includes movement, active musical creation, receptive music listening, and singing pre-composed songs (Polen, 2013). Significant moments often launched clients into the next phases of their therapeutic process and impacted emotional processing. The accessibility of feeling and expressing emotional content in a nonverbal and contained environment is important for individuals who communicate most authentically using methods beyond words and may also be experiencing extreme emotional needs (Graham, 2004; Polen, 2013; Swaney, 2017; Swaney, 2020).

Although individuals diagnosed with I/DD may also have co-existing mental health needs, there is little existing literature exploring deeper aspects of the therapeutic process for clients diagnosed with I/DD, and even less for those who communicate primarily using methods beyond verbal language (Adams & Oliver, 2011; Polen, 2013). Because of the perceived limits of processing emotional work with individuals who communicate beyond words, many counselors and other health professionals tend to avoid emotional processing within this population (Swaney, 2017). Although it has been supported that clients with “severe/profound” levels of I/DD experience emotion as deeply as a typically developing person, and can access music as a tool to process and express these feelings, there has still been debate over the abilities of individuals with I/DD diagnoses to express the same range of emotions as their typically developing peers (Adams & Oliver, 2011; Graham, 2004; Lee, 2014; Polen, 2013; Swaney, 2017; Swaney, 2020). Music therapy can provide a unique outlet for nonverbal communication and self-expression, while the various information sources available to the music therapist can contribute to our knowledge and understanding of how moments in therapy impact the therapeutic process, and how clients express emotion through sound, movement, and affect (Dillard, 2006; Gavrielidou & Odell-Miller, 2017; Graham, 2004; Polen, 2013; Stern, 2010; Swaney, 2017; Swaney, 2020).

Communication forms utilized in therapy by individuals diagnosed with I/DD can include, but are not limited to, reaching out, body orientation, facial expression, vocalizations, leading, eye gaze, gestures, head nods, Sign Language, pictures and icons, and voice output devices (Caldwell, 2013; Cascella & McNamara, 2005; Graham, 2004). These communicative actions have functions that cover a wide range of intentions including to convey their emotions, make a choice, make requests, indicate dissent. In improvisatory contexts, a space is created which allows for additional communication through melody, dynamic, rhythm, and other musical elements.

Body movement and gesture can help add meaning and context to verbal dialogue and are also used as a primary form of communication for some individuals (Caldwell, 2013). Temporal elements found within movement patterns can offer additional insight into communicative intent and synchronicity between client and therapist within musical and nonmusical interactions (Foubert et al., 2017; Stern, 2010). Caldwell (2013) posited that body movement and behavior have an underlying meaning that could be uncovered through investigation of the environment and interactional patterns. “We have to empty ourselves of any behavioral expectations and learn to ‘be with’ this person as they are at present, using their initiatives to respond in ways that have meaning for them” (p. 34). By experiencing full presence and openness to communication being transmitted from a variety of modalities, the therapist can gain a deeper understanding of a client’s internal experience (Caldwell, 2013; Dillard, 2006; Scheiby, 2005; Seabrook, 2019; Stern, 2010; Swaney, 2017; Swaney, 2020). Characteristics of musical interactions, in body movement, rhythm, and melody, can offer snapshots of the therapeutic relationship at a given moment in time and demonstrate a client’s growth over time (Caldwell, 2013; Foubert et al., 2017; Strehlow & Linder, 2014; Swaney, 2017; Swaney, 2020).

Strehlow and Lindner (2014) identified interactional patterns present in improvisational interactions with clients diagnosed with borderline personality disorder (BPD). Scenes were chosen to represent different phases of treatment for the participants included in the study. Interactional patterns were identified and defined in terms of musical characteristics, relation to the therapist, therapist’s feelings and inner thoughts, and the function of the music. Additionally, interpersonal temporal synchronicity between the client and therapist has been used as a method of assessing an individual’s ability to relate to another person (Foubert et al., 2017; Kleinlooh et al., 2021). Continued participation in successful interpersonal temporal synchronicity may have implications in improving temporal relational strategies as they impact attachment experiences. A large portion of therapeutic work with clients diagnosed with BPD is spent navigating the uncertainties of the client-therapist connection and finding balance between being over-involved or the client withdrawing and resisting the therapist. This is illustrated through the therapist’s role and feelings highlighted in each interactional pattern and inconsistencies in temporal relation (Foubert et al., 2017; Kleinlooh et al., 2021; Strehlow & Linder, 2014).

In addition to the musical contributions and body signs of emotional work, countertransference is a form of information about the improvisational interaction and how impactful or meaningful it may be in the therapeutic process. Joining in close proximity in musical exchange can bring forth countertransference, or an emotional reaction of the therapist to material brought into the therapeutic space by the client (Dillard, 2006; Scheiby, 2005). Countertransference can also serve as a tool for gaining insight into the client’s perspective and underlying issues not revealed in verbal discussion.

Dillard (2006) interviewed music therapists regarding their experience of musical countertransference in individual music therapy. Music communicated client perceptions of their experience in the therapeutic process and highlighted interpersonal dynamics within the therapeutic relationship. In these interviews, countertransference was identified as a strong desire to respond that may or may not align with their conscious views. It also presented as an emotional or physical sensation, i.e., “jarred and out of control” or “chills, a ‘flipping over in my stomach’”(p. 213). Therapists who were interviewed acknowledged that countertransference, when consciously understood, was a useful tool for further interpreting and understanding their clients’ experiences. Countertransference occurred with clients at significant points within the therapeutic process regardless of diagnosis.

Significant and pivotal moments in music therapy can be used to describe aspects of therapy, illustrate techniques, and inform clinical work and therapeutic progress for both the client and the therapist (Gavrielidou & Odell-Miller, 2017). Environments with appropriate structure, autonomy and safety, similar to those that can be created within clinical improvisation, encourage these moments to occur and can propel the client forward in their progress and provide an outlet for emotional expression (Dillard, 2006; Gavrielidou & Odell-Miller, 2017; Kenny, 2006; Polen, 2013; Seabrook, 2019; Scheiby, 2005; Strehlow & Lindner, 2014). These moments are crucial and necessary for growth and change. Better understanding and identification could impact the direction of the therapeutic progress, relationship, and growth. As the therapist is better able to guide the client through these periods of growth and change, the client is better able to incorporate these changes and progress in their own process (Dillard, 2006; Gavrielidou & Odell-Miller, 2017). Significant and pivotal moments as information sources could greatly contribute to the therapeutic process and relationship in the absence of verbal processing and communication between the therapist and client as is often the case in work with individuals diagnosed with I/DD.

Individuals who have experienced less access to emotional expression understood and accepted by mental health professionals can experience pivotal and meaningful moments in improvisation and could benefit from identification, validation, and processing of their emotions in therapy (Adams & Oliver, 2011; Polen, 2013). Information gathered from sources beyond verbal dialogue (nonverbal communication, musical improvisation, and countertransference) could contribute to the understanding and deepening of therapeutic growth (Adams & Oliver, 2011; Caldwell, 2013; Foubert et al., 2017; Gavrielidou & Odell-Miller, 2017; Lee, 2014; Polen, 2013; Strehlow & Lindner, 2014; Swaney, 2017). Given these understandings and the limited amount of existing literature acknowledging the impact of the therapist’s understanding and validating of emotional processing work within therapy with individuals diagnosed with I/DD, the purpose of this paper is to highlight specific significant moments within musical improvisations and their clinical implications.

The next four composite clinical excerpts are examples of significant moments in music therapy with individuals diagnosed with I/DD who have various communication methods and use music for self-expression. When sharing case examples of any kind, it is important to recognize and reflect on the fact that these are stories and moments in the lives of real people. While they can hold a great deal of weight and have the capacity to share knowledge that could benefit future clinicians and clients, these stories are often deeply personal and should be treated with great care and respect. Because of this fact, it is imperative to consider client preference and seek permission when hoping to share their stories with others. Permission for sharing their stories with others was gained in these instances directly from the clients involved in the creation of these composite cases.

Composite cases were selected in this instance as a method of further protecting the identities of clients involved, providing rich examples derived from work with multiple people, and offering input from a diverse range of people. Composite cases were created by combining aspects of different clients who had similar instances occur in their therapy and could bring together their similarities and unique features to create a cohesive case example. These excerpts demonstrate clinical work that is driven by a variety of information sources including musical elements, behavior, body movement, affect, verbal language, and therapist countertransference. Each excerpt is preceded by a description of the client and followed by a discussion of salient elements of each significant moment.

After each example is a discussion written in first person from the therapist’s point of view about their experience and how it relates to the literature. The therapist included in this paper is also the author. To situate the therapist’s narrative in these examples a short introduction is necessary.

I am a white, able-bodied, neurotypical, cisgender, heterosexual woman living and working in the southeast region of the United States. Through my parents’ work as therapeutic foster care providers, during my childhood and adolescence, I have had multiple siblings with whom I have had very close relationships who were diagnosed with various disabilities. This experience and my experiences as a person with an anxiety disorder have greatly shaped the ways in which I perceive and respond to events and people. At the time of these excerpts, I was a fairly new music therapist at an Intermediate Care Facility (ICF) in an interdisciplinary team with four other creative arts therapists. I practice from a lens that is informed by the social model of disability, disability studies, and humanistic therapy (Cameron, 2014; Goodley, 2014; Hadley & Thomas, 2018; Moore & Lagasse, 2018; Rolvsjord, 2014). Advocacy for the needs and interests of clients and empowerment of individuals to engage actively with the direction of their therapeutic journeys is an important aspect of my practice. Clinical improvisation is incorporated into the majority of sessions, which has allowed for me to have increased authenticity in practice through being flexible, perceptive, and responsive in the moment.

These composite examples provided application of the various types of communication used within sessions and how to incorporate them into a multifaceted understanding of the session. Alison’s typical method of communicating was through verbal language, but this often caused resistance and incongruent experiences in therapy when relying exclusively on verbal processing (Gavrielidou & Odell-Miller, 2017). Through connecting with her body in movement, Alison found connection with the therapist and the music that enabled her to find meaning in the message she had requested to hear from the music. By observing to Alison’s body positioning and the subtle changes in her movement patterns, the therapist gained a deeper understanding of what meaning the experience may have held. In the end, verbal processing proved to be unnecessary for Alison and the therapist following the movement improvisation. Harold combined many different forms of communication together to intricately address specific parts of the message he wished to share (Caldwell, 2013; Swaney, 2017). Harold had a working knowledge of the different resources available (gestures the therapist would recognize, picture cards available, words he could approximate, newly created communication cards, and song lyrics) and effortlessly moved between each method to generate discussion that led to musical processing of his grief. Ethan’s and Kate’s body movement, vocalizations, and musical characteristics provided additional insight into their processing needs and internal states (Caldwell, 2013; Graham, 2004). It also became evident that some behaviors, head-butting and self-injury, had an underlying cause that was not necessarily connected to the action itself (Caldwell, 2013; Swaney, 2017; Swaney, 2020).

In the institutional context where all of these individuals resided, these communications were frequently mis-labeled by professionals or missed altogether. Behaviors are often labeled without pause for reflection or consideration of context, which can lead to decisions and actions that do not actually support the needs being expressed by the individual (Caldwell, 2013; Swaney, 2017; Swaney, 2020). Movement and music, much like what is labeled as a “behavior” when working within the disability community, are external reflections of internal experiences. The two are both deeply connected to our bodies and internal rhythms, as our bodies are where our movement and music originate (Stern, 2010). By noticing shifts and changes in these external reflections, we are able to discover shifts happening internally and react appropriately to help provide safe spaces for authentic expression and processing.

Both Ethan and Kate had been discouraged from processing and expressing more difficult emotions by staff members because it was not understood how best to provide them the physical safety and tools to move through those spaces. Kate’s staff, who knew her very well and had been working with her for many years longer than the therapist had, frequently discouraged the therapist from conducting sessions when Kate was upset despite previous experience demonstrating that music was a space in which Kate could safely express and move through tougher emotional spaces. When Kate’s body movement patterns were accurately interpreted and supported, she was able to use them to communicate her needs and direct the musical support she received during the session. Ethan similarly used his body to direct the musical structure of the session by oscillating between more fluid movements and sudden bursts of syncopation within his body rhythms. His need for expression of the tension built within himself was met and supported musically, which allowed him to express and move through this emotional state and ultimate build rapport with the therapist.

Musical elements enabled the therapist to observe and interpret client response and engagement (Caldwell, 2013; Graham, 2004; Swaney, 2017; Swaney, 2020). Ethan responded to the guitar by matching pitch to the strings in his vocalizations and then experienced changes in both his temporal relation to music and the vocal range he used. His participation and connection to the music and the therapist was evident in his musical contributions (Swaney, 2020). Kate vocalized using first tense, closed syllables and then moved to long and open syllables that had a felt sense of release to them as the session progressed. Harold described musical elements that reflected his internal feeling state as a method of creating a space for him to feel and process his sadness (Polen, 2013).

Countertransference also played a role in each of these examples and impacted the therapist both during and after the session time. Countertransference can provide insight into the therapeutic relationship and the experience within the encounter when brought into conscious awareness and understood (Dillard, 2006). While this has not been frequently discussed in music therapy within this population, it is an experience that occurs regardless of diagnosis and perceived functioning level. It is important for music therapists to understand these reactions to their work and process these experiences so that they are consciously understood and the therapists can continue to serve clients with less risk of negative impacts of continuous and significant countertransference (Dillard, 6005; Scheiby, 2005).

People also experience shared moments of connection and understanding through movement and body communication (Dosamantes-Beaudry, 2007; Stern, 2010). Musically, various body movements and approaches shape the sounds created and provide insight regarding what experience or meaning is underneath the music. Physically, our motor system receives information from these experiences and is shaped by what we feel. Our interpretation of music, interactions, and experiences is frequently determined by our perception of the elements beyond the notes and rhythms and visible movements. This kinesthetic empathy can deepen our understanding of particular events within the therapeutic process and provide insight to possible future steps towards growth and development.

Within many areas of work that impact the disability community there are preconceived notions about what types of therapeutic growth and processing is achievable for people based on outside assessments of their abilities (Adams & Oliver, 2011; Graham, 2004; Lee, 2014; Polen, 2013; Swaney, 2017; Swaney, 2020). This can create problematic situations for disabled individuals seeking therapeutic support services throughout many different stages of their lives. Using experiences and information gained from observation and learning through example, future clients can receive increased access to nonverbal emotional processing in therapy sessions. Bringing together the vast number of communication and informational resources available to therapists working within the disability community can weave a new network of understanding and advocacy for depth of therapeutic practice.

Improvisation can empower the client and bring the therapist and client into a space of mutual responsiveness. The client then brings material into this space in a way that is autonomous, authentic, and accepted. The therapist can respond empathically, relying on intuition and present awareness, to match and meet the implicit needs and requests in the client’s offerings (Scheiby, 2005). This nonverbal method of self-expression allows for a greater ability to share thoughts, emotions, moments of connection, and more without the barriers and shortcomings of relying on verbal language. Because of this ability to interact, cultivate relationships, and participate in deep expression in a nonverbal manner, music therapy provides a unique space for clients to connect with and process emotional content using resources accessible to them beyond the limitations of words (Dillard, 2006; Graham, 2004; Polen, 2013; Swaney, 2017).

Communication and processing take many forms including movement, sound, silence, and others (Caldwell, 2013; Cascella, 2005; Graham, 2004; Swaney, 2017). Body based communication adds elements of embodied understanding and expression to otherwise primarily vision and sound-based strategies. Our rhythms and vibrations present in both visual and sound-based communications remain connected to our bodies and internal rhythms from which they originate (Stern, 2010). These realizations lead to our understanding that music and movement are inseparable from ourselves and are deeply connected to our bodies.

Significant and meaningful moments are present in work with adults diagnosed with I/DD and can serve as indicators of future therapy or achieved milestones (Gavrielidou & Odell-Miller, 2017; Lee, 2014). By remaining open to, and accepting of, information from all possible sources, both easily identified and more subjective, therapists may be better able to serve clients and proceed in partnership by incorporating information provided using information sources beyond words (Adams & Oliver, 2011; Caldwell, 2013; Gavrielidou & Odell-Miller, 2017; Lee, 2014; Strehlow & Lindner, 2014; Swaney, 2017). Deeper emotional work and support of emotional processing for adults diagnosed with I/DD could also be improved by therapists’ understanding and acceptance of these information sources (Dillard, 2006; Scheiby, 2005). Additionally, advocacy for change within the everyday environment to accept and support communicative intent of the expressions of people diagnosed with I/DD may also increase the ability of clients to generalize relational growth to other areas of their lives (Swaney, 2020).

It is hoped that by bringing this information together and providing clinical examples that music therapists will consider their own clinical work and how these principles apply. Increased awareness of these ideas and how they connect to music therapy with adults diagnosed with I/DD and using various communication methods has the possibility to inspire and change the way clinicians practice and view their work in this population. With new tools and information sources available, there are new and unexpected opportunities for insight for both therapists and clients alike.

There was no funding for this project.

Katelyn Beebe is a music therapist based in North Carolina, United States. She received a Bachelor of music performance and then went on to complete both the equivalency and Master of Music Therapy programs at Appalachian State University. Katelyn’s research interests include extraverbal communication in therapy, improvisational music therapy, and empowerment of clients to participate actively in directing their therapeutic journeys.