CHAPTER 13
Music Therapy and the Path into Speech
The case study in this chapter first appeared in the British Journal of Music Therapy (Jones 2012) and is reprinted here with permission.
Introduction
In this chapter I describe my experience of being a music therapist and researcher working in nursery and primary schools with children with Selective Mutism (SM). I then describe a case study of how music therapy helped a boy with SM. A theoretical framework describing how music therapy could help children with SM is then presented, explaining key features such as musical conversation, physical freedom, emotional communication and the creation of a path into speech.
Beginnings of a research journey
When I was first referred a child with SM, I had no awareness of the condition. Music therapists often encourage referrals of children with low levels of communication and try to ensure that they do not get overlooked in an education system where the louder children tend to receive more attention. Being referred children who are silent in school fits within our clinical expertise and knowledge. We find that these children often respond extremely well to music therapy intervention, sometimes within just a few weeks. This experience has motivated me to start a research journey to explore how and why this is.
My initial searches for information on SM revealed a significant history of thought and development of interventions in this area. Two publications, Selective Mutism in Children (Cline and Baldwin 2004) and The Selective Mutism Resource Manual (Johnson and Wintgens 2001), are invaluable resources for developing strategies to support children with SM. They also made me consider my role as a music therapist within a context where so much had already been achieved. The internet has also provided a wealth of information, resources and support for parents of children with SM. However, my investigations of these online discussion and support groups revealed a level of dissatisfaction among parents and children with SM with the degree of awareness and the availability of interventions for SM. The use of anti-depressant medication now appears to be widespread in the United States for young children with SM, although this is not yet the case in the UK where a behavioural approach is more common. If alternative treatments such as music therapy are shown to be effective, could these be offered within a multi-modal team approach?
Two articles (Amir 2005; Mahns 2003) are useful in their description of music therapy for children with SM and complex emotional issues, but neither really reflects my experience and approach to what seems to me to be such an obvious and pragmatic intervention for these children. Roe (1993) describes an interactive therapy group ‘where all means of communicating – verbal and non-verbal – were accepted and encouraged’ (p.134), which resonates more closely with my perspective. Providing an opportunity for being heard through free musical self-expression without the pressure of speech surely offers all the right tools to move into confident speech. Paths into SM have been described, but music therapy can perhaps provide a path out. In this chapter I set out to explore and identify a place for music therapy on the pathway into speech.
What is music therapy?
Music therapy is the use of music as a medium for self-expression, understanding and change within a supportive therapeutic relationship. Music therapists aim to create a space in which children can express themselves freely and feel that they are being listened to, heard and understood. Music therapy has very different aims from music lessons. The aim of a lesson is to teach, whereas the aim of therapy is therapeutic change – for example, self-expression, greater happiness, self-confidence, speech (Darnley-Smith and Patey 2003).
Music therapy sessions are often non-directive and so as music therapists we usually take the lead from how the child presents in the room and as far as possible allow them to direct the sessions. Children sometimes request specific songs or styles of music but mostly we use free improvization to develop musical conversations and musical ‘play’. We often use a ‘Hello’ and ‘Goodbye’ song to help orientate children within the sessions. To help create a feeling of safety and ‘containment’, sessions should take place in the same space and at the same time each week.
I now briefly describe a case study of how music therapy intervention helped a child with SM.
Luis
Luis (not his real name) was a four-year-old boy with SM who was also learning English as an additional language by immersion only. He spoke another European language fluently at home and was referred to music therapy by his nursery school teacher who was concerned that he wasn’t speaking at nursery after 10 months. It is usually thought that a ‘silent period’ of up to six months should be allowed for a child learning English as an additional language before speaking in school (Toppelberg et al. 2005).
Luis received 11 weekly sessions of music therapy of 30 minutes duration, provided by a not-for-profit music therapy service funded by the school and a local charity. The sessions took place in the music room that was situated close to his nursery classroom. Over the course of the therapy Luis moved from his nursery class into his reception class. This case study used ‘meaningful moments’ to tell the story of the therapy process. ‘Meaningful moments’ are those key events in the therapy sessions where something important seems to be happening or changing for the child (Figure 13.1).
1ST MEANINGFUL MOMENT – SESSION 4 – 00.00–07.00 MINUTES
This moment highlighted the first dramatic change in Luis. After three sessions of appearing to feel very anxious about therapy, there was a rapid development of musical engagement in the sessions. Here Luis played the xylophone with expressive, playful sweeping motions, arcing his arms in the air in dance-like movements. After playing music that aimed to provide a feeling of safety in the previous sessions, I now felt that he was able to tolerate more direct responses to his music such as turn-taking and some tentative eye contact. Luis then used the recorder (an oral instrument) and was gradually able to take part in a confident musical conversation that ended with the recorder being played pointing up in the air.
Luis then started rearranging the instruments in the room. This became a feature of subsequent sessions but began in this moment, with him creating a circle of instruments around him. He played them at first in rapid succession but then became more free, expressive and loud, using two hands. These were quite large, loud percussion instruments. It also felt significant that he was engaging with making a lot of sound after many months of silence within school.
2ND MEANINGFUL MOMENT – SESSION 4 – 29.00–32.00 MINUTES
This moment was chosen because it was the first time that Luis made use of a lot of language in the sessions. In session 3 he had said the single word ‘toilet’, but in this moment he pointed and spoke in a way that suggested he wanted to engage in verbal interaction. In this moment there was a lot of verbal turn-taking. Despite me not understanding some of his speech, it seemed important to engage in a turn-taking ‘conversation’, ignoring inaccuracies in order to allow speech to evolve naturally, without the speech feeling too pressured and too important.
Figure 13.1: Diagram of therapy
3RD MEANINGFUL MOMENT – SESSION 5 – 12.00–20.00 MINUTES
This moment was chosen from the very next session and showed the quick succession of significant events in the therapy process. Before the session began, the nursery teacher had reported that Luis was ‘coming out of himself’ and that ‘whatever you are doing, it is working’. Within the classroom he had produced some loud screams and used occasional single words.
In my session notes I reported that there seemed to be ‘much less anxiety in the room’. The session began with some relaxed exploring of different instruments. The moment showed Luis repeatedly collecting instruments from around the room and building up a pile of them in the centre of the space. He gathered together keyboards, drums and boxes of small percussion instruments that he then tipped onto the instrument pile. He was happy and excited, and skipped and danced whilst collecting things. He vocalized ‘ooh’ excitedly and placed chairs in specific positions. Luis threw a cushion onto the pile, and then crashed some tambourines and cymbals on as well. This was all reflected by my sung commentary supported by a piano accompaniment that tried to match the happy but purposeful mood of the pile-building.
4TH MEANINGFUL MOMENT – SESSION 5 – 22.00–26.00 MINUTES
This moment happened a few minutes after moment 3. I decided to move over to the drums and Luis responded to this change by going over to the guitars and beginning a conversation with me about them. It felt significant when he spoke the words, ‘mine, all mine’ in reference to another guitar that he was getting out. Luis’ claim on the guitar and his sense of control and ownership of the therapy sessions seemed particularly important in this moment. The words ‘mine, all mine’ evolved into another quite extensive verbal conversation, again towards the end of a session. This time, however, it led into a formal ‘face-to-face’ guitar improvization, sitting on carefully arranged chairs. I commented in my notes that this felt like a concert.
5TH MEANINGFUL MOMENT – SESSION 8 – 03.30–04.30 MINUTES
This moment took place after the Christmas holidays when Luis moved from his nursery class into his reception class. Staff were concerned about how he would cope with this change and it felt important to show how the therapy developed after this transition. An initial conversation with his new teacher revealed her concern, when she described Luis as ‘not talking generally at all, but he did ask to go out in the snow with his friend’. Given his low levels of speech in the nursery setting, this was actually a significant improvement for Luis. I communicated this to the teacher, but she felt that set against other children’s normal speech Luis remained a concern for her.
This fifth moment was only a minute long and came near the beginning of session 8, the second session after the Christmas break. It was a moment of close musical interaction between Luis on piano and me on guitar. It can be described as a simple musical ‘conversation’, with intense, focused listening and clear musical reflection of his musical self-expression. The moment began with Luis playing a single note at the top of the piano and me responding with a high note on the guitar. He then developed a little melody on the piano that I again reflected on the guitar. Luis kept checking back and looking at me curiously to see how I would respond. There were more single-note interactions and then a longer descending melody initiated by Luis, closely followed by me reflecting the melody on the guitar. At the end of this intense interaction he moved to the window and pointed, saying ‘outside’.
6TH MEANINGFUL MOMENT – SESSION 8 – 12.00–20.00 MINUTES
This moment occurred a little later in session 8 and was chosen because it was the longest moment of shared musical interaction in all the therapy sessions. I had set up the room with large drums and cymbals in the centre as this had seemed to fit Luis’ musical preferences from previous sessions. Luis sat opposite me but was close enough to share some of the same instruments. The music and events were playful and free. He gave me some hand-bells that I then placed on the drum; eventually they fell off. He exclaimed in delight, accidentally hit the cymbal and then immediately afterwards he deliberately hit the cymbal. There was some ‘same time’ drumming (playing at the same time and stopping at the same time in a burst/pause sequence), which was directed by Luis.
Within these sessions I witnessed development in differing but connected aspects of the therapy. Parallel processes emerged that impacted upon each other and seemed to drive the therapy forward towards its positive outcome. These parallel aspects of the therapy process will now be discussed in the form of a theoretical framework.
Theoretical framework
The theoretical framework offers an explanation of the key elements of music therapy that are relevant in helping a child with SM (see Table 13.1 on following page).
Parallel layers of communication
The parallel layers of communication – musical, physical and emotional – are the therapeutic tools of music therapy that are available in each session. These are illustrated below using the case study.
MUSICAL CONVERSATIONS: ‘SHAPING’ AND ‘SLIDING-IN’ TO SPEECH
A key therapeutic process was that of Luis developing musical ‘conversations’ just prior to using speech. This was seen in his clear turn-taking using an oral instrument (recorder) along with my vocal responses that made this closely resemble a verbal conversation at the start of session 4. A verbal conversation then happened at the end of session 4. That this conversation occurred at the end of the session is also pertinent, as this is often the time when people share the most important aspects in a therapy session. In this instance I felt the need to extend the session slightly, which gave Luis even more control over the therapy space. The use of his voice enabled him to gain more control over his environment and I felt that it was important for him to experience this sense of power and self-expression, which had been missing from his school life.
Behavioural techniques for children with SM often involve either the ‘sliding-in’ of speech from home into the school or ‘shaping’ – eliciting speech within school (Cline and Baldwin 2004; Johnson and Wintgens 2001). Music therapy provides a low-pressure intervention in the place that ‘shaping’ might be used. It creates a space for musical self-expression as well as a detailed understanding of the tools necessary to develop a clear path into speech. This music therapeutic path makes it possible for the child to ‘slide in’ from the medium of music and sounds into the medium of speech through the use of oral instruments, vocalizations and singing. The individually tailored music therapy approach allows each child to discover and create their own path to speech, at a speed that respects their accompanying emotional needs. That music therapy offers a space in which to make sounds and be heard is the first step down this path. The importance of being ‘heard’ and feeling ‘listened to’ in a previously threatening environment after an extended period of silence in that setting is intrinsic to the usefulness and efficacy of the musical therapeutic process.
The use of instruments in other ways is also noteworthy, as children with SM often head quickly towards the louder instruments (Roe 1993). The therapy path for some children can also be quite short and they may quickly move through from oral instruments to vocal sounds, or via non-verbal singing to words. That the path is often loud and short is perhaps a measure of the frustration and then relief felt by children with SM who ‘can speak and want to speak, but don’t’ in the presence of certain people or situations (Johnson and Wintgens 2001, p.17).
Encouraging and supporting all vocal sounds enables the child to revisit the ‘babbling’ stage (Sylva and Lunt 1982) and, if necessary, to have the opportunity to develop confidence vocally before trying out actual words. Another child might ‘slide in’ by making very loud sounds with the instruments and make use of this volume of sound to disguise or cover initial trials at speaking. Other children will use different protective actions such as playing under a table or, like Luis, using words and instruments with their back turned to the therapist. In all these examples we can see how it is possible for a child to gradually move into speech whilst the therapist focuses on the musical communication, thus taking the pressure off the attempts at speech.
CONTROL AND EXPRESSION IN THE PHYSICAL REALM LEADS TO CONTROL OF THE VOICE
It is not uncommon for a child with SM to present as ‘frozen’ or physically restricted and therefore to have problems engaging with school activities such as physical education (Cline and Baldwin 2004). This idea was also understood and developed in the group work of Roe (1993), where children undertook physical activities in pairs in order to develop trust.
The importance of controlling the physical therapy space and of using dancing as another means of expression seemed significant for Luis. Being able to control instruments in a functional way, rearranging them and switching them on and off, seemed particularly important and symbolic, as SM can feel like a physical problem. Children with SM sometimes report later that they felt as if there was a physical constriction in their voice and throats.
The change in Luis’ physical presentation appeared to signify and trigger a sense of liberation which began with his expressive xylophone playing (session 4) and then culminated in his dancing around the room collecting instruments (session 5). This sense of physical self-expression, control and ownership became core themes in the therapy as a whole. In session 5 this led to the emergence of verbal self-expression and the statement ‘mine, all mine’.
THERAPEUTIC RELATIONSHIP PARALLELS MOTHER/INFANT INTERACTION: EMOTIONAL COMMUNICATION
Daniel Stern (2002) was interested in parent/infant interaction and described the function of early playful communication as primarily social and emotional using musical terminology. This provides a theoretical foundation for music therapy practice, where the development of a musical therapeutic relationship parallels this early parent/infant relationship. Within this therapeutic relationship it is possible to revisit and rework issues that arose at key developmental stages. For children with SM, music therapy offers them an opportunity to strengthen these communication skills through the use of musical self-expression within the setting that is causing them anxiety. With Luis, initially this was musical but it then moved into speech. As demonstrated in the case material, this focus on emotional communication is particularly relevant for SM where the therapeutic relationship can hold or contain some of the anxiety experienced by these children.
Therapeutic process
The therapeutic process is the emotional aspect of the music therapy that happens over the timespan of the intervention. The five stages in the process identified in the diagram are briefly discussed below in relation to the case study.
OFFERING A POTENTIAL SPACE
We know that children with SM can be extremely anxious and so finding the right space and developing rapport is crucial. The music room Luis and I used was very close to the nursery and so felt appropriate for a young child. Transitions were also important, and Luis and I spent a lot of time exploring frost, snow and puddles on our journeys to and from the music room.
CONTAINING AND PROCESSING ANXIETY
The role that anxiety plays for children with SM is crucial to acknowledge and think about in the therapy process. There are several issues that should be held in mind whilst developing an appropriate therapeutic approach:
1.Where has this anxiety come from?
2.Is it an extension of separation anxiety that has not been processed in the usual way through verbal self-expression and socialization in the nursery setting?
3.Is it social anxiety or simply anxiety about speech?
4.How can we reduce anxiety for this child?
Within the school environment the pressure of meeting educational targets creates anxiety for the teachers of a child with SM. This is then easily transferred back on to the child within the nursery. Luis’ nursery teacher certainly wanted him to speak before he went up to his reception class and the pressure of the understandable expectation could well have affected Luis and unwittingly increased his anxiety further. This has also been my experience in other schools, where I have heard teachers saying to children, ‘You have to speak before you go into reception.’ It is important to acknowledge how genuine intentions to help a child with SM can be extremely detrimental.
Music therapists are trained to provide emotional and musical support for an anxious child. The therapeutic term for this is ‘containment’ or ‘holding’. The role of containment is to acknowledge a child’s anxiety whilst also creating a safe space for them to transform this anxiety through musical self-expression and play.
BUILDING TRUST AND CONTACT THROUGH LISTENING AND ACCEPTING: THE ‘NO-PRESSURE’ APPROACH
Carl Rogers’ (1961) approach to psychotherapy refers to ‘un-conditional positive regard’ or warmth in the therapeutic relationship, which seems completely in agreement with Johnson and Wintgens’ (2001) ‘no-pressure approach’.
In the first meaningful moment, Luis arranged the instruments in a circle around himself. This suggested a strong physical defence, and when Luis’ improvization evolved it too became loud and strong. The anxiety he experienced in the first sessions resulted in a musical dialogue where we played with our backs turned to each other, which meant there was no possibility for direct eye contact. These all seemed to be examples of defence mechanisms against overwhelming communicative intrusions.
The role of defences was crucial to Luis’ therapy process and can be viewed generally in SM work as an important protective strategy that needs to be treated respectfully in order to then build a trusting therapeutic relationship.
GRADUAL DEVELOPMENT OF SHARED, MEANINGFUL COMMUNICATION AND ‘PLAYING’
Once the child has experienced this acceptance and trust, it becomes possible to move on and for the child to claim, own and then increase their participation in the therapeutic relationship. The therapy setting should then enable the child to express themselves in a variety of different ways. These can be musical, physical, emotional and verbal, as described in the first section of the framework.
Luis was able to extend his musical conversations in a more confident and deliberate way. The meaningful moments from session 8 exemplify this process, with the initial face-to-face, close interaction at the beginning of the session, followed later by an extended period of focused, shared music-making. As a result of this, Luis was then able to initiate and tolerate close musical connections, close physical proximity and face-to-face interaction. Humour also became an important feature of the sessions.
Significantly, after session 8 the class teacher said that she was ‘really pleased as he is talking lots in class.’
NEED TO END THERAPY: HEALTHY, CONFIDENT SEPARATION
The process of separation and ending was important in that it reworked some of the difficult separation experienced when Luis first attended the nursery. However, this time there was a sense of a healthy child who confidently wanted to go back to class to generalize the verbal communication skills developed within music therapy.
The generalization of speech can be supported by chatting during the transition from the therapy room back into the classroom. The use of a friend in the therapy sessions can be another way of supporting a child who is finding it tricky to generalize their speech from the therapy room.
Discussion
The case study described above and the theoretical framework developed from that study have shown that music therapy has the potential to help a child with SM.
This was a single case study, and so multiple case study research would be needed to test how the ideas in this chapter can help other children with SM. If music therapy is accepted as a useful intervention, then where should it sit in the care pathway for children with SM? It is important to acknowledge that a multi-modal team approach is currently considered best practice and that any new interventions should be discussed as part of this team approach. Would music therapy also be useful for those children with a more complex presentation such as SM and Autistic Spectrum Disorder?
Music therapy seems to have the ‘right tools in the toolkit’ to help a child with SM and to create a bridge between home and the anxiety-provoking classroom environment. It offers a ‘light touch’ low-communication-load approach, with the focus on musical interaction rather than speech. The confidence that musical self-expression can bring leads to experimenting in ways that mirror and move down a path towards speech. Musical ‘conversations’, the use of oral instruments, the use of vocal sounds hidden beneath the sound of a cymbal, humming, singing and vocalizing are all examples of possible steps along this path at a pace chosen by the child. Most importantly, after a period of silence, it is a space to feel heard.