Music Therapy Thesis

THE PRACTICE OF MUSIC THERAPY FOR ADULTS WITH MENTAL
HEALTH PROBLEMS: THE RELATIONSHIP BETWEEN DIAGNOSIS AND

CLINICAL METHOD
By Helen Odell-Miller
A thesis submitted in partial fulfilment of the requirements for the degree of PhD at
Aalborg University
Declaration: This thesis, in part or in its entirety, has not previously been submitted
for assessment with a view to being awarded a degree or prize at any institution of
higher education in Denmark or abroad.
Signed:………..
Date:…………..
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ACKNOWLEDGEMENTS
I am extremely grateful to the many people who have given their time, generosity and
support towards the research, including anyone not listed here who knows that they
helped towards the completion of this thesis. I am particularly grateful to Tony Wigram
my supervisor, who encouraged me to apply for a scholarship at Aalborg University. He
has patiently facilitated the process of the research, through his teaching, supervision,
generosity of time and energy. I am also grateful to all the PhD students and staff at
Aalborg University, who provided stimulation, encouragement and hospitality during the
process, particularly during PhD courses.
Without the support, encouragement and enthusiasm from colleagues and students at
Anglia Ruskin University; and members of The Cambridgeshire and Peterborough
Mental Health Partnership NHS Trust; this PhD would not have been possible. Special
thanks go to David John, Linda Davies, Amelia Oldfield, Eleanor Richards, Paul Jackson,
Helen Loth, the Arts Therapies and Complex Cases teams, and many others.
I am indebted to the centre participants in the study, who gave their time and energy
anonymously. Thanks to them and their patients, for their ideas and thoughts.
I am highly indebted to Philip Hughes, who meticulously and generously acted as

Research Assistant, and whose expertise and patience knew no bounds. Thanks also to
those who advised on the project professionally, and who contributed more personally:
Christian Gold, Rachel Darnley-Smith, Joy Schaverien, Pauline Etkin, Frankie Williams,
Inge Nygaard Pedersen, Richard Mason, Niels Hannibal, John Lewis, Heather Juby,
Chess Denman, Jules Mackenzie, Mary Brunning, Jane Hewson, Sally Greaves, Fiona
Gilmore, Helen Patey, Sanne Storm, Stephen Nicolas, Ian de Massini and Cambridge
Voices; my friends and extended family.
Finally, thank you to Michael Miller my husband, and to my children Sam and Benj for
their consistent patience, support, tolerance, sense of humour and generosity.
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ABSTRACT
This Doctoral study is in two parts: Part I includes five published research articles by the
author. These relate to the author’s quest for defining how music therapy is placed in the
field of adult psychiatry, both clinically and theoretically, and to how it defines itself in
relation to psychoanalytic theory within its own community, and in the external world of
health care services. Part II includes a survey-based research project carried out across
five established music therapy clinical centres in Europe designed to answer the main
question: ‘How are different approaches and techniques of music therapy defined in adult
psychiatry, for people between 18-65 years old, which link diagnosis to treatment?’ The
research design includes statistical and qualitative analysis. Main findings show that
music therapy centres in the study variably define what they do and why they do it,
linked to diagnosis. Outcomes show that reasons for this are linked to training and
clinical judgement. Specific findings show that there are some distinct differences
between techniques used for psychotic disorders and non-psychotic disorders. Techniques
involving symbolic thinking are more prevalent for non-psychotic disorders, for example.
Outcomes also show a prevalence of use of approaches drawing on psychoanalytic theory
with a strong emphasis on techniques of free and structured musical improvisation for all
diagnoses. The study concludes that there is a need for further research and changes in
attitude towards music therapy training, in order to more clearly define music therapy
treatments for adults with mental health problems.
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CONTENTS
Page
Frontispiece.......................................................................................................................... i
Acknowledgements............................................................................................................. ii
Abstract .............................................................................................................................. iii
CONTENTS (PART I) ...................................................................................................... iv
CONTENTS (PART II) ..................................................................................................... vi
List of Tables ................................................................................................................... xix
List of Figures ................................................................................................................ xxiii
List of Appendices .......................................................................................................... xxv
CHAPTER 1: INTRODUCTION TO THE THESIS AND TO PART I............................ 1

1.1 Introduction to the thesis............................................................................................... 1
1.2 Introduction to Part I..................................................................................................... 3
CHAPTER 2: MUSIC THERAPY AND ITS RELATION TO PSYCHOANALYSIS..... 5

2.1 Introduction to the publication in Chapter 2 ................................................................. 5
2.2 Music therapy and its relation to psychoanalysis ......................................................... 6
2.3 Discussion of Chapter 2 .............................................................................................. 37
CHAPTER 3: ONE MAN’S JOURNEY AND THE IMPORTANCE OF TIME............ 39

3.1 Introduction to Chapter 3 ............................................................................................ 39
3.2 One man’s journey and the importance of time: Music therapy in an NHS mental
health day centre ............................................................................................................... 40
CHAPTER 4: ARE WORDS ENOUGH? MUSIC THERAPY AS AN INFLUENCE IN

PSYCHOANALYTIC PSYCHOTHERAPY ................................................................... 51
4.2 Are words enough? Music therapy as an influence in psychoanalytic psychotherapy52
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CHAPTER 5: INVESTIGATING THE VALUE OF MUSIC THERAPY IN
PSYCHIATRY: DEVELOPING RESEARCH TOOLS ARISING FROM CLINICAL
PERSPECTIVES .............................................................................................................. 72
5.2 Investigating the value of music therapy in psychiatry: developing research tools
arising from clinical perspectives (original page numbering) ..................73 (then 119-140)
5.4 Conclusion to Chapter 5.............................................................................................. 75
CHAPTER 6: AN INVESTIGATION INTO THE EFFECTIVENESS OF THE ARTS

THERAPIES FOR ADULTS WITH CONTINUING MENTAL HEALTH PROBLEMS76
6.2 An investigation into the effectiveness of the arts therapies for adults with continuing
mental health problems (original page numbering) ..................................77 (then 122-139)
6.3 Discussion of Chapter 6 and conclusion to Part I of the thesis................................... 78
References from the Discussion Sections of Part I........................................................... 80
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CHAPTER 7: INTRODUCTION TO PART II OF THE THESIS: THE PRACTICE OF
MUSIC THERAPY FOR ADULTS WITH MENTAL HEALTH PROBLEMS: THE
RELATIONSHIP BETWEEN DIAGNOSIS AND CLINICAL METHOD.................... 83
7.1 Introduction................................................................................................................. 83
7.2 Rationale and background to the study....................................................................... 84
7.3 Introduction to the research study............................................................................... 89
7.4 Further research considerations .................................................................................. 91
7.5 Consideration of the research questions ..................................................................... 93
7.6 Summary of the survey ............................................................................................... 95
7.7 Summary of Chapters in Part II .................................................................................. 96
CHAPTER 8: LITERATURE REVIEW: HISTORY AND BACKGROUND................ 99

8.1 Introduction................................................................................................................. 99
8.2 Theoretical and clinical approaches: interventions in psychiatry ............................. 102
8.2.1 Introduction to theoretical approaches in music therapy in adult psychiatry
with or without links to diagnosis.......................................................................... 102
8.2.2 Approaches linked to diagnosis .................................................................... 105
8.2.3 Approaches not linked to diagnosis .............................................................. 109
8.3 Approaches and techniques in music therapy for specific diagnostic groups .......... 111
8.3.1 Overview of approaches and techniques linked to diagnoses for psychotic
disorders................................................................................................................. 111
8.3.2 Techniques with non-psychotic disorders compared with schizophrenia..... 119
8.3.3 Example of a detailed analysis of approaches and techniques linked to
diagnosis for psychotic disorders........................................................................... 120
8.3.4 Approaches and techniques linked to diagnosis for eating disorders ........... 125
8.3.5 Approaches and techniques linked to diagnosis for personality disorders ... 129
8.3.6 Approaches and techniques linked to diagnosis for depression and anxiety 130
8.4 Categorising approaches and techniques relating to diagnosis in adult psychiatry .. 131
8.5 Research reporting method, guidelines, protocols and types of intervention in
psychiatry........................................................................................................................ 143
8.5.1 Introduction to studies in adult psychiatry linked to diagnosis..................... 143
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8.5.2 Research studies in adult psychiatry relating to psychotic disorders............ 144
8.5.3 Research studies in adult psychiatry particularly relating to depression and
anxiety.................................................................................................................... 155
8.6 General research relating to approach and method................................................... 157
8.7 Summary ................................................................................................................... 160
CHAPTER 9: METHOD ................................................................................................ 161

9.1 Introduction............................................................................................................... 161
9.2 Design ....................................................................................................................... 161
9.2.1 Choice of design ........................................................................................... 161
9.2.2 Considerations and influences for the design ............................................... 162
9.3 Participants................................................................................................................ 167
9.3.1 Participant inclusion criteria ......................................................................... 167
9.3.2 Participating centres...................................................................................... 167
9.3.3 Distribution of diagnoses for the different centres ....................................... 170
9.4 The Questionnaire..................................................................................................... 170
9.4.1 Summary of the questionnaire and considerations for the design ................ 171
9.5 The procedure ........................................................................................................... 180
9.6 Methods of analysis and processing data.................................................................. 183
9.6.1. Summary ...................................................................................................... 183
9.6.2 Discussion ..................................................................................................... 184
CHAPTER 10: QUALITATIVE ANALYSIS................................................................ 187

10.1 Introduction: Qualitative data analysed with quantitative summaries by diagnosis187
10.1.1 Distribution of Diagnoses for the Different Centres................................... 188
10.1.2 Summary of Figures 10.1-10.5 ................................................................... 190
10.2 Schizophrenia.......................................................................................................... 190
10.2.1 Introduction to approaches and techniques with schizophrenia ................. 190
10.3 Summary of salient elements from qualitative data for each approach: Schizophrenia
......................................................................................................................................... 193
10.3.1 Introduction................................................................................................. 193
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10.3.2 Supportive Psychotherapy (SP) .................................................................. 194
10.3.3 Client-Centred (CC).................................................................................... 195
10.3.4 Behavioural (B)........................................................................................... 195
10.3.5 Psychoanalytically Informed Music Therapy (PIMT)................................ 196
10.3.6 Developmental (D)...................................................................................... 197
10.3.7 Analytical Music Therapy (AMT) .............................................................. 198
10.3.8 Creative Music Therapy (CMT) ................................................................. 199
10.3.9 Activity-Based (AT) ................................................................................... 200
10.3.10 Guided Imagery in Music (GIM).............................................................. 200
10.4 Summary of salient elements from qualitative data for each technique:
Schizophrenia.................................................................................................................. 201
10.4.1 Introduction................................................................................................. 201
10.4.2 Free Improvisation with Minimal Talking (FI) .......................................... 201
10.4.3 Free Improvisation with Talking/Interpretation (FT) ................................. 203
10.4.4 Free Improvisation with Structures such as turn taking or ‘play rules’ (FS).....
................................................................................................................................ 204
10.4.5 Theme Based Improvisation (TBI) ............................................................. 205
10.4.6 Activity Based: Tea dance, choir, workshop/structured musical activity (AT).
................................................................................................................................ 206
10.4.7 Singing Composed Songs (MT).................................................................. 207
10.4.8 Song-Writing (SW)..................................................................................... 208
10.4.9 Musical role play/musical psychodrama/art & psychodynamic movement
(MP) ....................................................................................................................... 208
10.4.10 Receptive music using live music e.g for reminiscence (RL) .................. 209
10.4.11 Receptive Music Using Recorded Music (RR)......................................... 210
10.4.13 Music for Relaxation (MR)....................................................................... 210
10.5. Summary: Approaches and techniques; schizophrenia.......................................... 211
10.6 Bi –Polar Disorders................................................................................................. 214
10.6.1 Introduction to approaches and techniques with bi polar disorders............ 214
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10.7 Summary of salient elements from qualitative data for each approach: bi-polar
disorders.......................................................................................................................... 216
10.7.1 Introduction................................................................................................. 216
10.7.2 Supportive Psychotherapy (SP) .................................................................. 216
10.7.3 Client –Centred (CC) .................................................................................. 217
10.7.4 Behavioural (B)........................................................................................... 217
10.7.5 Psychoanalytically Informed (PI) ............................................................... 217
10.7.6 Developmental (D)...................................................................................... 219
10.7.7. Analytical (AMT) ...................................................................................... 219
10.7.8 Creative Music Therapy (CMT) ................................................................. 219
10.7.9 Activity-Based therapy (AB) ...................................................................... 220
10.8 Summary of salient elements from qualitative data for each technique: Bi-polar
disorders.......................................................................................................................... 221
10.8.1 Introduction................................................................................................. 221
10.8.2 Free Improvisation with Minimal Talking (FI) .......................................... 221
10.8.3 Free Improvisation with talking/interpretation (FT)................................... 222
10.8.4 Free Improvisation with Structures such as turn taking or play rules (FS) 222
10.8.5 Theme-Based Improvisation (TBI)............................................................. 223
10.8.6 Activity-Based: Tea dance, choir, workshop/structured activity (AT)....... 223
10.8.7 Singing Composed Songs (MT).................................................................. 223
10.8.8 Song Writing (SW) ..................................................................................... 224
(MP) ....................................................................................................................... 224
10.8.10 Receptive music using live music eg for reminiscence (RL) ................... 225
10.8.11 Receptive music using recorded music (RR)............................................ 225
10.8.13 Music for Relaxation as part of MT programme (MR) ............................ 226
10.9 Summary: Approaches and techniques; bi-polar disorder ...................................... 226
10.10 Depression............................................................................................................. 227
10.10.1 Introduction to approaches and techniques: depression............................ 227
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10.11 Summary of salient elements from qualitative data for each approach: depression
......................................................................................................................................... 230
10.11.1 Introduction............................................................................................... 230
10.11.2 Supportive Psychotherapy (SP) ................................................................ 230
10.11.3 Client –Centred (CC) ................................................................................ 231
10.11.4 Behavioural (B)......................................................................................... 231
10.11.5 Psychoanalytically Informed (PI) ............................................................. 231
10.11.6 Developmental (D).................................................................................... 232
10.11.7 Analytical (AMT) ..................................................................................... 232
10.11.8 Creative Music Therapy (CMT) ............................................................... 232
10.11.9 Activity-Based therapy (AB) .................................................................... 233
10.11.10 Guided Imagery in Music (GIM)............................................................ 233
10.12 Summary of salient elements from qualitative data for each technique: depression
......................................................................................................................................... 234
10.12.1 Introduction............................................................................................... 234
10.12.2 Free Improvisation with Minimal Talking (FI) ........................................ 234
10.12.3 Free Improvisation with Talking/Interpretation (FT) ............................... 234
10.12.4 Free Improvisation with Structures such as turn taking or play rules (FS)235
10.12.5 Theme-Based Improvisation (TBI).......................................................... 236
10.12.6Activity-Based: Tea dance, choir, workshop/structured activity (AT)...... 236
10.12.7 Singing Composed Songs (MT)................................................................ 236
10.12.8 Song Writing (SW) ................................................................................... 237
(MP) ....................................................................................................................... 237
10.12.10 Receptive music using live music eg for reminiscence (RL) ................. 238
10.12.11 Receptive music using recorded music (RR).......................................... 238
10.12.13 Music for Relaxation as part of MT programme (MR) .......................... 239
10.13 Summary: Approaches and techniques; Depression............................................. 239
10.14 Anxiety.................................................................................................................. 240
10.14.1 Introduction to approaches and techniques with anxiety.......................... 240
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10. 15 Summary of salient elements from qualitative data for each approach: Anxiety 242
10.15.1 Introduction............................................................................................... 242
10.15.3 Client –Centred (CC) ................................................................................ 243
10.15.4 Behavioural (B)......................................................................................... 243
10.15.6 Developmental (D).................................................................................... 244
10.15.7 Analytical Music Therapy (AMT) ............................................................ 245
10.15.9 Activity-Based therapy (AB) .................................................................... 245
10.15.10 Guided Imagery in Music (GIM)........................................................... 246
10.16 Summary of salient elements from qualitative data for each technique: Anxiety 246
10.16.1 Introduction............................................................................................... 246
10.16.2 Free Improvisation with minimal talking (FI) .......................................... 247
10.16.3 Free Improvisation with Talking/Interpretation (FT) ............................... 247
10.16.5 Theme-based improvisation (TBI)............................................................ 248
10.16.6 Activity-Based: Tea dance, choir, workshop/structured activity (AT)..... 249
10.16.7. Singing Composed Songs (MT)............................................................. 249
10.16.8 Song Writing (SW) ................................................................................... 249
10.16.9 Musical Role Play/Musical Psychodrama/Art & Psychodynamic Movement
(MP) ....................................................................................................................... 250
10.17 Summary: Approaches and techniques used with patients with anxiety .............. 251
10.18 Eating Disorders.................................................................................................... 252
10.18.1 Introduction to approaches and techniques with eating disorders ............ 252
10.19 Summary of salient elements from qualitative data for each approach: Eating
disorders.......................................................................................................................... 255
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10.19.1 Introduction............................................................................................... 255
10.19.3 Client Centred (CC) .................................................................................. 256
10.19.4 Behavioural (B)........................................................................................ 256
10.19.6 Developmental (D).................................................................................... 258
10.19.9 Activity–based (AT) ................................................................................. 259
10.20 Summary of salient elements from qualitative data for each technique: Eating
disorders.......................................................................................................................... 259
10.20.1 Introduction............................................................................................... 259
10.20.3 Free Improvisation and Talking/Interpretation (FT)................................. 260
10.20.4 Free Improvisation with Structures such as ‘turn-taking’ or ‘play rules’ (FS)
................................................................................................................................ 261
10.20.5 Theme Based Improvisation (TBI) ........................................................... 261
10.20.6 Activity-Based (AT) ................................................................................. 261
10.20.8 Song Writing (SW) ................................................................................... 262
(MP) ....................................................................................................................... 262
10.21 Summary: Approaches and techniques used with patients with eating disorders 264
10.22 Personality Disorders (PD) ................................................................................... 265
10.22.1 Introduction to approaches and techniques with personality disorders .... 265
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10.23 Summary of salient elements from qualitative data for each approach: Personality
disorders.......................................................................................................................... 267
10.23.1 Introduction............................................................................................... 267
10.23.3 Client-Centred (CC).................................................................................. 269
10.23.4 Behavioural (B)......................................................................................... 269
10.23.5 Psychoanalytically-Informed (PI)............................................................. 270
10.23.6 Developmental (D).................................................................................... 271
10.23.9 Activity-Based (AB) ................................................................................. 273
10. 24 Summary of salient elements from qualitative data for each technique : Personality
disorders.......................................................................................................................... 274
10.24.1 Introduction............................................................................................... 274
10.24.3 Free Improvisation and Talking/interpretation (FT)................................. 275
10.24.5 Theme-based Improvisation (TBI) ........................................................... 277
10.24.6 Activity-Based (AT) ................................................................................. 278
10.24.8 Song-Writing (SW)................................................................................... 280
(MP) ....................................................................................................................... 280
10.24.10 Receptive music using live music (RL) .................................................. 281
10.24. 12 Guided Imagery in Music (GIM)........................................................... 283
10.25 Summary: Approaches and techniques with personality disorders ...................... 284
10.26 Other approaches .................................................................................................. 285
10.27 Conclusion ............................................................................................................ 288
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CHAPTER 11: QUANTITATIVE ANALYSIS............................................................. 289
11.1 Introduction: Approaches and techniques for all centres........................................ 289
11.1.2 Data analysis of approaches........................................................................ 291
11.2 Supportive Psychotherapy ...................................................................................... 291
11.2.1 Summary ..................................................................................................... 293
11.2.2 Conclusion .................................................................................................. 293
11.3 Client-Centred......................................................................................................... 293
11.3.1 Summary of significant results ................................................................... 295
11.3.2 Conclusion .................................................................................................. 295
11. 4 Behavioural ............................................................................................................ 296
11.4.1 Summary of significant results ................................................................... 297
11.4.2 Conclusion .................................................................................................. 298
11.5 Developmental ........................................................................................................ 298
11.5.1 Summary of Significant Results ................................................................. 299
11.5.2 Conclusion .................................................................................................. 300
11.6 Psychoanalytically Informed .................................................................................. 300
11.6.2 Conclusion .................................................................................................. 302
11.7 Analytical Music Therapy....................................................................................... 303
11.7.2. Conclusion ................................................................................................. 304
11.8 Creative Music Therapy.......................................................................................... 305
11.8.2 Conclusion .................................................................................................. 307
11.9 Activity-based ......................................................................................................... 307
11.9.2 Conclusion .................................................................................................. 309
11.10 Guided Imagery in Music (GIM).......................................................................... 309
11.10.1 Summary of Significant Results ............................................................... 310
11.10.2 Conclusion ................................................................................................ 311
11.10.3 Data analysis of techniques....................................................................... 311
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11.11 Free Improvisation with Minimal Talking............................................................ 311
11.11.1 Summary of significant results ................................................................. 313
11.11.2 Conclusion ................................................................................................ 313
11.12 Free Improvisation with Talking/Interpretation.................................................... 314
11.12.2 Conclusion ................................................................................................ 316
11.13 Free Improvisation with Structures....................................................................... 316
11.13.2 Conclusion ................................................................................................ 318
11.14 Theme-Based Improvisation................................................................................. 319
11.14.2 Conclusion ................................................................................................ 321
11.15 Activity-Based ...................................................................................................... 321
11.15.2 Conclusion ................................................................................................ 323
11.16 Singing Composed Songs ..................................................................................... 323
11.16.2 Conclusion ................................................................................................ 325
11.17 Song-Writing......................................................................................................... 326
11.17.2 Conclusion ................................................................................................ 328
11.18 Musical Role-play/Musical Psychodrama/Art & Psychodynamic Movement ..... 328
11.18.2 Conclusion ................................................................................................ 330
11.19 Receptive Music (live).......................................................................................... 331
11.19.2 Conclusion ................................................................................................ 333
11.20 Receptive (Recorded)............................................................................................ 333
11.20.2 Conclusion ................................................................................................ 335
11.21 GIM....................................................................................................................... 336
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11.21.2 Conclusion ................................................................................................ 338
11.22 Music for Relaxation............................................................................................. 338
11.22.2 Conclusion ................................................................................................ 340
11.23 Summary ............................................................................................................... 340
11.23.1 Approaches and techniques with high levels of agreement about use, across
centres .................................................................................................................... 341
11.23.2 Approaches and techniques with mixed levels of agreement about use
across centres ......................................................................................................... 341
11.23.3 Approaches and Techniques with high levels of agreement of lack of use342
11.24 Conclusion ............................................................................................................ 343
CHAPTER 12: DISCUSSION AND CONCLUSION ................................................... 345

12.1 Introduction............................................................................................................. 345
12.2 Main findings .......................................................................................................... 346
12.3 Summary of main findings...................................................................................... 346
12.3.1: Finding 1: There were differences between the centres as to the level of
detail they provided to support decisions they made, make linking approaches and
techniques to diagnosis. ......................................................................................... 346
12.3.2 Finding 2: Music Therapy Approaches with a Supportive Psychotherapy
Approach or a Psychoanalytically Informed Approach were used most often, and
ranked first or second in every diagnostic category............................................... 347
12.3.3 Finding 3: The Techniques Free Improvisation with minimal talking and
Free Improvisation with talking/verbal interpretation are ranked highest for all
diagnoses, but with some additional differences between psychotic disorders and
non-psychotic disorders. ........................................................................................ 348
12.3.4 Finding 4: For psychotic disorders, using Composed Songs is ranked joint
first with either Free Improvisation with Minimal Talking, or Free Improvisation
with Talking/Interpretation, for both Schizophrenia and Bi-polar disorders, and
there is less emphasis upon using techniques requiring symbolic thinking........... 349
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12.3.5 Finding 5: For non-psychotic disorders, techniques that require more
symbolic thinking such as Theme based Improvisation, Musical Role Play and use
of other media, as well as Free Improvisation using structures such as play rules are
ranked jointly first, or near the top of ranking orders for the diagnoses of anxiety,
depression, eating disorders, and personality disorders......................................... 349
12.3.6 Finding 6: Schizophrenia and personality disorder diagnoses are given the
highest percentage of music therapy treatment input across all centres. ............... 350
12.3.7 Finding 7: Personality disorder receive the most attention from music
therapy centres in the study, concluded both from the amount of qualitative data
collected and the fact that in three out of five centres personality disorders are a
major percentage of case load, from 25% ~ 50%. ................................................. 350
12.3.8 Finding 8: Psychotic disorders, incorporating bi-polar disorders and
schizophrenia, emerged as a priority group in all centres...................................... 351
12.3.9 Finding 9: Anxiety and depression receive the least attention from music
therapy centres in the study, concluded both from the amount of qualitative data
collected and the fact that in some cases only two out of five centres said they saw
people with this diagnosis as their main diagnosis. ............................................... 351
12.3.10 Finding 10: Respondents were often unable to link their yes and no answers
with specific reasons as to why they did or did not use a particular technique or
approach, and this was often related to lack of training in some cases. ................ 352
12.3.11 Finding 11: Music therapists’ descriptions of method using case studies as
examples (whether or not linked to specific diagnoses), often appeared similar
across centres, but were defined and categorised under different approach titles. 352
12.4 Discussion of diagnoses related to approach and technique................................... 353
12.4.1 Introduction................................................................................................. 353
12.4.2 Clinical implications: Findings for psychotic disorders ............................. 354
12.4.3 Links to recent research: Schizophrenia ..................................................... 355
12.4.4 Clinical experience linked to findings: Schizophrenia ............................... 356
12.4.5 Further clinical implications: Schizophrenia .............................................. 358
12.4.6 Clinical implications: Bi-polar disorder...................................................... 361
12.5 Clinical implications: Findings for non-psychotic disorders .................................. 362
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12.5.1 Depression................................................................................................... 362
12.5.2 Anxiety........................................................................................................ 365
12.5.3 Eating disorders .......................................................................................... 367
12.5.4 Personality disorders: approaches and clinical implications ...................... 369
12.5.5 Personality disorders: Clinical implications, techniques ............................ 371
12.5.6 Group music therapy: Personality disorders ............................................... 373
12.6 Clinical Applications: Cumulated results on approaches and techniques .............. 376
12.6.1 Introduction................................................................................................. 376
12.6.2 Approaches and techniques with high levels of agreement of use ............. 376
12.6.3 Approaches and techniques with mixed agreement regarding usage ......... 377
12.6.4 Approaches and techniques with high levels of agreement of lack of use . 379
12.7 Problems of definition and specialist categories..................................................... 382
12.7.1 Introduction................................................................................................. 382
12.7.2 Psychoanalysis and Music Therapy ............................................................ 382
12.7.3 Activity, Task-based and Community Music Therapy ............................... 385
12.7.4 Holding and Reorganising Therapy ............................................................ 387
12.7.5 Body and Voice........................................................................................... 387
12.8 The limitations of the study .................................................................................... 387
12.9 Implications for music therapy education............................................................... 391
12.10 Future research directions and further clinical implications................................ 394
12.10.1 Introduction............................................................................................... 394
12.10.2 Future Research in Schizophrenia ............................................................ 395
12.10.3 Research in Personality Disorders ............................................................ 396
12.10.4 Final Conclusion ....................................................................................... 398
REFERENCES ............................................................................................................... 401

SUMMARY OF THE THESIS (IN ENGLISH) ............................................................ 419
DANSKE RESUME AF PhD-AFHANDLING ............................................................. 429
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LIST OF TABLES
Table 8.1 Summary of Pedersen’s approach related to schizophrenia ........................... 113

Table 8.2 Summary of Jensen’s approach related to schizophrenia ............................... 115
Table 8.3: Reported Methods of Intervention by diagnosis (summarised from Unkefer
1990 pp 174-214)............................................................................................................ 136
Table 8.4 Taxonomy of Programs and Techniques in Music Therapy for Mental
Disorders ......................................................................................................................... 138
Table 8.5 A summary of the four research studies cited in the Cochrane Review (Gold et
al. 2006) .......................................................................................................................... 146
Table 9.1: Profiles of the services involved taken from the survey................................ 169
Table 9.2 Example of an excerpt from questionnaire: 7.1 Music Therapy
Approach/Model ............................................................................................................. 176
Table 9.3 Music Therapy Technique .............................................................................. 177
Table 10.1 Scores for use of approaches with patients with schizophrenia................... 191
Table 10.2 Scores for use of techniques in group work| with patients with schizophrenia ...
......................................................................................................................................... 192
Table 10.3 Scores for use of techniques in individual work with patients with
schizophrenia .................................................................................................................. 193
Table 10.4 Scores for use of approaches with bi-polar disorder..................................... 214
Table 10.5 Scores for use of techniques in group work| with clients with bi-polar disorder
......................................................................................................................................... 215
Table 10.6 Scores for use of techniques in individual work with clients with bi-polar
disorder ........................................................................................................................... 215
Table 10.7: Scores for use of approaches with depression ............................................. 228
Table 10.8 Scores for use of techniques in group work| with patients with depression . 229
Table 10.9 Scores for use of techniques in individual work with clients with depression ....
......................................................................................................................................... 229
Table 10.10 Scores for use of approaches with anxiety.................................................. 240
xix
Table 10.11 Scores for use of techniques in group work with patients with anxiety ..... 241
Table 10.12 Scores for use of techniques in individual work with clients with anxiety 241
Table 10.13 Scores for use of approaches with eating disorders.................................... 253
Table 10.14 Scores for use of techniques in group work with patients with eating
disorders.......................................................................................................................... 254
Table 10.15 Scores for use of techniques in individual work with clients with eating
disorders.......................................................................................................................... 254
Table 10.16 Scores for use of approaches with personality disorders............................ 266
Table 10.17 Scores for use of techniques in group work with patients with personality
disorders.......................................................................................................................... 266
Table 10.18 Scores for use of techniques in individual work with clients with personality
disorders.......................................................................................................................... 267
Table 11.1: Supportive Psychotherapy - Results for Settings and Diagnoses ................ 292
Table 11.2: Supportive Psychotherapy - Results for Centres ......................................... 292
Table 11.3: Client-Centred - Results for Settings and Diagnoses .................................. 294
Table 11.4: Client-Centred - Results for Centres............................................................ 295
Table 11.5: Behavioural - Results for Settings and Diagnoses....................................... 297
Table 11.6: Behavioural - Results for Centres................................................................ 297
Table 11.7: Developmental - Results for Settings and Diagnoses.................................. 299
Table 11.8: Developmental - Results for Centres........................................................... 299
Table 11.9: Psychoanalytically Informed - Results for Settings and Diagnoses ............ 301
Table 11.10: Psychoanalytically Informed – Results for Centres................................... 302
Table 11.11: Analytical Music Therapy - Results for Settings and Diagnoses .............. 303
Table 11.12: Analytical Music Therapy - Results for Centres ....................................... 304
Table 11.13: Creative Music Therapy - Results for Settings and Diagnoses ................. 306
Table 11.14: Creative Music Therapy - Results for Centres .......................................... 306
Table 11.15: Activity-Based - Results for Settings and Diagnoses ................................ 308
Table 11.16: Activity-Based - Results for Centres ......................................................... 308
Table 11.17: GIM - Results for Settings and Diagnoses ................................................ 310
Table 11.18: GIM - Results for Centres.......................................................................... 310
xx
Table 11.19: Free Improvisation with Minimal Talking – Results for Settings, Diagnoses,
Groups and Individual Work .......................................................................................... 312
Table 11.20: Free Improvisation with Minimal Talking – Results for Centres.............. 313
Table 11.21: Free Improvisation with Talking/Interpretation – results for settings,
diagnoses, groups and individual work........................................................................... 315
Table 11.22: Free Improvisation with Talking/Interpretation – results for centres........ 315
Table 11.23: Free Improvisation with Structures – results for settings, diagnoses, groups
and individual work ........................................................................................................ 317
Table 11.24: Free Improvisation with Structures – results for centres ........................... 318
Table 11.25: Theme-Based Improvisation – results for settings, diagnoses, groups and
individual work ............................................................................................................... 320
Table 11.26: Theme-Based Improvisation – results for centres ..................................... 320
Table 11.27: Activity-Based – results for settings, diagnoses, groups and individual work.
......................................................................................................................................... 322
Table 11.28: Activity-Based – results for centres........................................................... 323
Table 11.29: Singing Composed Songs – results for settings, diagnoses, groups and
individual work ............................................................................................................... 324
Table 11.30: Singing Composed Songs – results for centres.......................................... 325
Table 11.31: Song-Writing – results for settings, diagnoses, groups and individual work327
Table 11.32: Song-Writing – results for centres............................................................. 327
Table 11.33: Musical Role-Play – results for settings, diagnoses, groups and individual
work ................................................................................................................................ 329
Table 11.34: Musical Role-Play – results for centres ..................................................... 330
Table 11.35: Receptive (Live) – results for settings, diagnoses, groups and individual
work ................................................................................................................................ 332
Table 11.36: Receptive (Live) – results for centres........................................................ 332
Table 11.37: Receptive (Recorded) – results for settings, diagnoses, groups and
individual work ............................................................................................................... 334
Table 11.38: Receptive (Recorded) – results for centres................................................ 335
Table 11.39: GIM – results for settings, diagnoses, groups and individual work .......... 337
Table 11.40: GIM – results for centres ........................................................................... 337
xxi
Table 11.41: Music for Relaxation – results for settings, diagnoses, groups and individual
work ................................................................................................................................ 339
Table 11.42: Music for Relaxation – results for centres................................................. 340
xxii
LIST OF FIGURES
Figure 10.1: Centre A Diagnoses.................................................................................... 189

Figure 10.2: Centre B Diagnoses .................................................................................... 189
Figure 10.3: Centre C Diagnoses .................................................................................... 189
Figure 10.4: Centre D Diagnoses.................................................................................... 189
Figure 10.5: Centre E: Diagnoses ................................................................................... 189
Figure 11.1: Supportive Psychotherapy - bar chart of yes and no percentages .............. 291
Figure 11.2: Client-Centred – bar chart of yes and no percentages................................ 294
Figure 11.3: Behavioural – bar chart of yes and no percentages .................................... 296
Figure 11.4: Developmental – bar chart of yes and no percentages ............................... 298
Figure 11.5: Psychoanalytically Informed – bar chart of yes and no percentages ......... 301
Figure 11.6: Analytical Music Therapy – bar chart of yes and no percentages.............. 303
Figure 11.7: Creative Music Therapy – bar chart of yes and no percentages................. 305
Figure 11.8: Activity-Based – bar chart of yes and no percentages ............................... 307
Figure 11.9: GIM – bar chart of yes and no percentages................................................ 309
Figure 11.10: Free Improvisation with Minimal Talking – bar chart of yes and no
percentages...................................................................................................................... 312
Figure 11.11: Free Improvisation with Talking/Interpretation – bar chart of yes and no
percentages...................................................................................................................... 314
Figure 11.12: Free Improvisation with Structures – bar chart of yes and no percentages
......................................................................................................................................... 317
Figure 11.13: Theme-Based Improvisation – bar chart of yes and no percentages........ 319
Figure 11.14: Activity-Based – bar chart of yes and no percentages ............................. 322
Figure 11.15: Singing Composed Songs – bar chart of yes and no percentages ............ 324
Figure 11.16: Song-Writing – bar chart of yes and no percentages................................ 326
Figure 11.17: Musical Role-Play – bar chart of yes and no percentages........................ 329
Figure 11.18: Receptive (Live) – bar chart of yes and no percentages........................... 331
Figure 11.19: Receptive (Recorded) – bar chart of yes and no percentages................... 334
Figure 11.20: GIM – bar chart of yes and no percentages.............................................. 336
xxiii
Figure 11.21: Music for Relaxation – bar chart of yes and no percentages.................... 339
xxiv
LIST OF APPENDICES
(provided on a separate Data CD)
APPENDIX I: Centre A Questionnaire

APPENDIX II: Centre B Questionnaire
APPENDIX III: Centre C Questionnaire
APPENDIX IV: Centre D Questionnaire
APPENDIX V: Centre E Questionnaire
APPENDIX VI: Ethical Procedures, Participant Information Sheet and Questionnaire
Guidelines
APPENDIX VII: Data Tables
APPENDIX VIII: Five-Stage Model
APPENDIX IX: Tables of Qualitative Data Related to Diagnosis
APPENDIX X: Summary of Pilot Project on Musical Change
APPENDIX XI: Blank Questionnaire
APPENDIX XII: Blank Questionnaire Summarised
APPENDIX XIII: Detailed Information on the Centres
xxv

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THE PRACTICE OF MUSIC THERAPY FOR ADULTS WITH MENTAL

HEALTH PROBLEMS: THE RELATIONSHIP BETWEEN DIAGNOSIS AND

I am highly indebted to Philip Hughes, who meticulously and generously acted as

CHAPTER 1: INTRODUCTION TO THE THESIS AND TO PART I............................ 1

CHAPTER 2: MUSIC THERAPY AND ITS RELATION TO PSYCHOANALYSIS..... 5

CHAPTER 3: ONE MAN’S JOURNEY AND THE IMPORTANCE OF TIME............ 39

CHAPTER 4: ARE WORDS ENOUGH? MUSIC THERAPY AS AN INFLUENCE IN

CHAPTER 6: AN INVESTIGATION INTO THE EFFECTIVENESS OF THE ARTS

References from the Discussion Sections of Part I........................................................... 80

CHAPTER 8: LITERATURE REVIEW: HISTORY AND BACKGROUND................ 99

CHAPTER 9: METHOD ................................................................................................ 161

CHAPTER 10: QUALITATIVE ANALYSIS................................................................ 187

CHAPTER 12: DISCUSSION AND CONCLUSION ................................................... 345

REFERENCES ............................................................................................................... 401

Table 8.1 Summary of Pedersen’s approach related to schizophrenia ........................... 113

Figure 10.1: Centre A Diagnoses.................................................................................... 189

APPENDIX I: Centre A Questionnaire

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