Rehabilitative relationship between music therapy and the age of development

Pier Luigi Postacchini, 
psychiatrist, child neuropsychiatrist, psycotherapist

Andrea Ricciotti,
infantile neuropsychiatrist, psychiatrist, psycotherapist

In this paper we are trying to describe the connections between the concepts of music therapy, rehabilitation and age of development (childhood and adolescence). There are many models of music therapy, and there is also a continuing debate about the differences between therapy and rehabilitation. In Italy, the experiences of music therapy in child psychiatry are still relatively few compared to adult psychiatry.
Nevertheless, we think that music therapy could make an important contribution to both observation and treatment of psychiatric illness in childhood and in adolescence. This is due to musical language as non-verbal communication, which is the base upon which to build an interaction in all those cases where verbal communication is very difficult or impossible.

At the Conference "Music Therapy in Rehabilitation for the Age of Development", held at the S. Stefano Institute in Porto Potenza Picena in October 2002, the present essay formed the "key-note lecture", a definition which would maybe be acceptable if by it one intended an attempt to give an accurate picture of the state of the art in relation to the complex theme being dealt with, certainly not if one intended to dispense certainties.
In any case, this "lecture" has a rather unusual form. This derives from the fact that, putting together what each of us had been asked to contribute, we got the idea that our task was to define a sort of frame for the contents of the Conference.
The more we thought about it, the more this frame seemed to take the shape in our minds of the out-line of a Pythagorean triangle, with the concepts of Music Therapy, Rehabilitation and the Age of Development as its sides.
To tell the truth, there is also a fourth concept which should be involved in our discussions (as in fact it will be), which regards the Public Services, or in any case the organization of work in a multi - disciplinary team, but for greater geometric simplicity, we prefer to make reference to the triangle for the moment.
Having defined the existence of the triangle as a symbol of the high level of interconnection between the topics, we thought that it would be less boring to treat them in the form of a dialogue, with the heading: a sort of search for some key questions, with attempts to answer them attached, which would allow us to fairly accurately outline this very extensive field, on whose specific aspects the other speakers at the Conference have endeavoured to shed some light.
It might be appropriate to start from the music therapy angle by asking ourselves:
To what extent can we "isolate" the REHABILITATIVE dimension of music therapy (and to what extent can we consider this to be a useful exercise in order to obtain a greater clarity of definitions) if it is true that this discipline has both a THERAPEUTIC heart and an "EDUCATIONAL" one?
And there’s more. Since music therapy is a discipline that can theoretically be "used" in very different contexts such as retirement homes, psychiatric Day Centres, Intensive Care units, Developmental Neuropsychiatry Services:
How does the specificity of music therapy change depending on the contexts? 
It goes without saying that going further up on this side of the triangle, we should deal with the question of how many and which music therapies we are referring to, what are the epistemological paradigms and the methodological models used by these, what comparisons have been made as to their effectiveness and the possible differences in their suitability. Of all this we will limit ourselves to lifting the curtain on some or, to be more modern, opening links to them. One of these links is surely necessary to remind us of some fundamental definitions on the subject (1).
Another link refers to the models; we remind you that the last conference of the World Federation of Music Therapy (WFMT, Washington, 1999) identified 5, while in his last book Bruscia describes 6, that only to a very limited extent correspond to the WFMT’s 5.
The matter is therefore complicated. We would like to take this opportunity to hazard an idea which could certainly give rise to criticism, which is that many theoretical frameworks (and not only in music therapy) are much more fragile than the practical results that are obtained through their application.
So, rather than discuss models, we would prefer to briefly call to mind that sort of over-classification used by Bruscia between music IN therapy and music AS therapy, and also, within the latter, between MUSIC therapy, with a predominant "technical" component, and music THERAPY, with a predominant relational component.

This is a useful classification to partially understand why operators from different backgrounds make different use, in different settings, of the same communicative tool. However, from a quantum point of view, we prefer to think of the various options illustrated by Bruscia as possible configurations of the same molecule (or rather of the same discipline) within a system where, depending on the situation, the type of treatment and the therapist’s basic training lead to one particular type of set-up rather than another.
Assuming therefore that music therapy is the hypotenuse of the triangle, the two sides could be connected as follows:
How do the requirements of neuropsychiatric rehabilitation decline during development?
Clearly, also here each of the two concepts needs to be better defined. Neuropsychiatric rehabilitation originated, or was at least conceptualised, about fifty years ago specifically for the needs of the age of development, and only in the seventies did it start to establish itself as the leading concept in adult psychiatry. At present, there is agreement as to the definition of the more strictly technical part of intervention, kept for expert practitioners, as re-education, whereas the term rehabilitation indicates the whole strategy with which one operates throughout the entire impairment situation in order to reach preset objectives. Skipping any digression for the sake of brevity, and always favouring the pragmatic perspective, we believe that the functional diagnosis concept outlined by Moretti remains the tool that can offer the most dynamic view of rehabilitative processes in relation to the territory where they take effect (2).
In trying, now, to connect the sides and hypotenuse together, starting from the music therapy perspective, we could provocatively say that there are no plans or protocols for the age of development in music therapy. The amount that has been produced (and documented) in these parts in terms of music therapy interventions in the age of development is, today, certainly of the minority compared to the amount of work related to adulthood. After giving it considerable thought, we have excluded interventions in schools from the reckoning, not, of course, because they lack value, but because, without going too much into classificatory subtleties, we consider these to be mainly of an EDUCATIONAL-PREVENTATIVE nature, noting, of course, that important considerations and trials are underway on this theme which have allowed the field to be cleared of numerous naiveties and confusions that were present in the past (Borghesi, Strobino, 2002). 
Saying that there are no specific protocols leads us to ask whether this is only connected to specific difficulties regarding the age of development or also to other issues. Which issues? For example, the fact that, when the way is cleared for expressive therapies, it seems that the idea of working in accordance with guidelines, if not actual protocols, disappears. Terminological ambiguity may come into it in some way: why music therapy (but also physiotherapy, which nobody misconstrues), and not speech therapy (3)?
Neither does it help us to look at other specialist areas such as, for example, phoniatry, which aims towards precision even when it uses methods in vocal rehabilitation which from a psychodynamic point of view would be defined as expressive-supportive, like all those that have the sound-music element as a mediator (4), because for us the main subject of interest at least in this moment is neuropsychological pathology in all its complexity and limited propensity to be brought down to reasonably rigorous schemes.
If, for the sake of explanatory convenience, we try to break it down a little artificially into three branches: NEUROLOGY, NEUROPSYCHOLOGY (where we include language and learning difficulties) and PSYCHIATRY, and we take the latter, that is the treatment of mental illness or the more "mental" and thus least "precise" end of the highly debatable mind/body polarity, into more detailed consideration, it is easy to see how the most authoritative literature of recent years, upon which the technical-political direction of Regional Councils’ health offices is based, almost no longer talks of therapy, but rather rehabilitation in every possible form (cognitive rehabilitation, psycho-social rehabilitation, etc.). In the age of development, where the pressure of industrial marketing and the surge of biological reductionism have not managed to knock down the 8-year wall for the use of psychotropic drugs, psychotherapy is alive and well, albeit among many theoretical and practical problems: Public Services, where they exist, are often overloaded with requests and a psychotherapeutic intervention is "troublesome" because of the time it requires and the relative lack of specifically trained therapists.
There is another activity, in our opinion of therapeutic worth, which is specific to the age of development and which represents a fundamental resource for any team that has it available: psychomotility; at least that intended by psycho-motor therapy. And we still have to add that the "relationship" between the various techniques, made possible and necessary by the front line work of multi-disciplinary teams, together with the cultural osmosis between rehabilitative and psychotherapeutic competences, the latter especially in relation to the early stages of development, has produced intervention methods in the last fifteen years, such as "therapeutic" groups for children in the 0-5 bracket with developmental and language disorders, which follow the model proposed by Levi and Fabrizi in which a double synergy is exploited: the "transversal" dyadic and triadic child-children - practitioner interaction, and the interaction on the field between speech therapist and psychologist (or neuropsychiatrist). 
How much is there in this model of therapeutic and how much of rehabilitative?
Having said this, if we look at complex situations with severe diagnoses at a critical age which lead to disability and determine a demanding care charge according to the evaluation parameters of charges used by the Local Health Authorities, we can see that the guidelines brought forth from the various conference agreements talk of a mainly rehabilitative approach, among whose various integrated strategies we believe that MT doubtless finds adequate indications.
If we now move on to considering the area of language and learning difficulties, and/or the function of neuropsychologists, we can see that different criteria with greater methodological "rigour" may be put into effect here throughout the entire path: classification of the problem to definition of the objectives to application of the rehabilitative procedure to evaluation of the results. 
In a specific language disorder, even if serious, there can be an "interesting" development following the speech therapy intervention (which, to make things clear, is measured at least in centimetres and not in millimetres as in learning difficulties or psychosis), and this probably contributes to determining a different attitude in the rehabilitator who defines more precise programmes and, above all, defined in terms of time, as well as subject to checks. In this regard we could hypothesize the existence of two rehabilitative centres, one "hard", more clearly linked to the rigorous observation of the programme mentioned above and more connected to the areas of neuro psychology and physiotherapy (the "bodily" functions in whose perspective also cognitive development becomes measurable), and one "soft", of a psychiatric origin, less subject to checks and less tolerable of attempts of objectification.
Considering this for a moment from the perspective of macro systems, we could say that we find ourselves within the field of the oscillations of a pendulum which perhaps now is about to touch the extreme of rehabilitative pragmatism having touched the opposite extreme of therapeutic idealism in the 60s-70s. The oscillation of the pendulum has undoubtedly coincided with a cultural paradox: while during the 60s-80s we saw the evolution of technique, which became more attentive to the complexity of the individual considered in the context of his mind-body totality and to relational dynamics, also thanks to a sort of fertilization that psychodynamic theories carried out in the body of strict and plain rehabilitation of a legal-orthopaedic origin, in the 90s we saw the evolution (or regression) of thought which, apart from some important exceptions, led to a strong reappraisal of the concept of therapy to be seen. If this means that illusions of healing have been put aside, especially in certain serious case histories where the realistic idea of aiming towards the best possible social adaptation is accepted, or rather that technicality and efficiency are sneakily emptying the care of every humanistic ideal while they aim to make Health Authorities’ balance sheets break even, is a question which must seriously be asked. Certainly, even with all the risks of losing sight of the human element, which we already wrote about 7 years ago, it will be difficult to take away from the need for verifiability of procedures and controlling the cost/result ratio of interventions which is represented by the widespread paradigm of Evidence– Based Psychiatry (EBP).
So, with respect to this scenario, which with a little emphasis we could define as epoch-making, where is music therapy positioned? Has it felt the effects of these adjustments, and if yes, how much? Has it taken something from, and maybe given something to, the other intervention methods? This is a difficult topic. On the one hand we believe that this discipline is legitimately placed in the area of convergence between psychodynamic culture and acquisitions from the neurosciences which in the last ten years has enabled the construction of much more integrated mind models where equal importance is given to the basic neurophysiological structures and to the cognitive and emotional input which have a decisive effect on the structure itself, furthering its maturation. After all, when we talk about vulnerability factors and protection factors according to Liberman’s (1992) schematisation, we simply interconnect the biological polarity with the psychodynamic one in a harmonic and dynamic way. Both factors can be as much genetic-organic as social-relational. 
On the other hand we believe that we can outline a basic risk: even when music therapy is placed within an integrated context of multi-disciplinary and coordinated interventions with a clearly rehabilitative direction, it often seems not to take the parameters that rehabilitation involves into account. It may be that this is partly due to the fact that it uses sound-music language as a mediator, which, more so than the other artistic languages involved in art therapies, lays itself open to misunderstandings as to the presumed miraculous, or in any case evident, effects it directly produces on the client via mysterious mechanisms. It is the ambiguity of substantialism, which fuels a good part of the trash literature on the subject, from the child in a coma who wakes up to Berlusconi’s voice, to the idea that Mozart’s music improves intelligence while Debussy’s calms anxiety. This certainly doesn’t have repercussions on the effectiveness of music therapists provided that they have thorough training, but perhaps it creates, even unconsciously, false expectations in the clients. As to why it is music in particular that fuels such fanciful scenarios, the discussion is open. Many interesting things have been said and others could be added, but it is not a topic than can be expanded upon on this occasion. It should at least be mentioned, however, than when we talk about neuropsychological pathology in the age of development, any mechanism that can sustain irrational expectations suffers an exponential acceleration, for understandable reasons.
As regards training, another topic of crucial importance which should at least be mentioned, we can take stock approximately of the origins of those who have attended ConfIAM (Italian Confederation of Music Therapy Associations) courses and as a result say that relatively few rehabilitators have been seen coming to study music therapy, whereas we have seen many more teachers and musicians. There have probably been many practitioners, especially physiotherapists, who have applied music therapy techniques, even unconsciously, in their work within other settings (for example some Intensive Care units), but they have never communicated with formal music therapy. It seems that we could say that, barring exceptions, while the few rehabilitators who have become music therapists tend to lessen their methodological rigorousness, at the opposite extreme musicians feel themselves to be such masters of the sound-music mediator that they don’t feel the need to follow procedures.
At this point, however, we believe that the moment has been reached to ask ourselves if, other than creating all the problems we have discussed, music therapy can give us something beneficial in neuropsychological pathology in the age of development. We obviously think so. In particular, it appears that we can say that in music therapy the quality of the contact and the relationship with the client almost always improves, and this improvement is especially noticeable in situations where verbal communication is seriously compromised. All of this may seem rather generic, but in our opinion things don’t work all that differently to in other rehabilitative areas. It is true that the music therapist operates in very variable contexts, but in the end the speech therapist also finds himself giving his services in different situations and using different strategies. What is his common denominator? That he rehabilitates (we imagine) the various components of verbal language and of the phonatory apparatus, as the physiotherapist rehabilitates neuro-motor functions. On the other hand, the fact that even the most specific and sophisticated rehabilitative techniques have to pass through the relationship is by now confirmed thanks to the humanizing revolution of rehabilitation of the last 30 years (5). We take advantage of this to take the concept of intersubjectivity back from life sciences and from psychoanalysis: neither the client nor the therapist can be a blank sheet. Between the area to be treated and the technique to use is the therapist/client relationship, in which TRUST is the first system of emotional control required to build a mutual attachment, the basis of every rehabilitative journey.
And yet: from the perspective of a functional approach to neuropsychological pathology, all the more so if we are talking about subjects in the age of development, the distinction between cognitive and emotional functioning cannot be anything more than pure convenience. This is as long as, though pressurised by the validation requirements of the various EBP and Quality Assurance, we agree to recognize ourselves in the paradigm of the integration of functions within the basic neurophysiological structure and, even higher on the epistemological side, in the paradigm of the mind/body unity. In rehabilitative terms we work on the various functions with specific, specially designed strategies, but without ever losing sight of the fact that each function is integrated with the others, it influences them and is influenced by them.
So, maybe we can say that the music therapist’s job is simply to rehabilitate the emotional - relational functions that have become atrophic or that were never developed in the client, knowing that this may also have a positive effect, probably indirect and non-specific but important in any case, on the level of motivation with which the same client faces a rehabilitation of his cognitive functions (6). Music therapy rehabilitation is therefore probably a soft rehabilitation which is just now starting to set itself the problem of the duration/result ratio of treatment in a more rigorous way and which recognizes in itself a higher level of variables, some of which are still being defined and studied, in relation to speech and physiotherapy treatments. This shouldn’t seem strange if we think that, however they are defined, emotional- affective functions are less easily "measurable" than cognitive ones. But then the real problem, the real scientific challenge, within a music therapy or art therapy treatment (and this is where the most important interconnection point with psychotherapies is) is not demonstrating the fact that a child who didn’t communicate at all before eventually agrees to interact and is also less distressed, because when it takes place this is, after all, very evident. The problem is better understanding how the various passages and procedures that the therapist brings into effect work, or the possibility to describe the process. 
However, the art therapies have taken steps in this direction, outlining, for example, a sort of scheme which brings some key points of the maturing process, which should lead from the expression to the controlling of emotions, into focus (7).
This being the state of the art, it may be misleading to ask ourselves if music therapy is capable of affronting the other rehabilitative disciplines (especially the ‘hard’ ones) on their own territory, other than psychomotility and psychotherapy on the therapeutic side. Probably not yet. And that could be defined as the double problem of music therapy and the art therapies in general. But, the comparability of results is a huge problem in all of medicine, and therefore the important thing is to continue to observe and reflect without losing heart.
On the other hand, we believe that music therapy can provide a specific observational perspective, through the analysis of the client’s non-verbal communication, and that this perspective can usefully join the others already normally in use in the multidisciplinary teams that take care of the age of development. It thus enriches the overall view of a complex and many-sided reality such as that of a child, who the smaller he is the more redundancy of functions he has, making the precise decoding of these functions and the problems which make their development disharmonious correspondingly more difficult. The specificity of music therapy in this regard, if we reason by applying Stern’s concept of attunement, is given by the fact that, on clients that have a mainly non-modal functioning (serious learning disability, subjects with disorders of the conscience, but also physiologically very small children), it has a greater possibility of starting off a path which from a attunement based on non-modal perceptions leads to a synaesthetic, and thus transmodal, attunement, where there can therefore be a variation in the sensory- perceptive analyser between offer and response (with resulting evolutional stimulation). This is thanks to the fact that non-verbal sound-music language also works from a communicative point of view merely through the simple activation of the fundamental physical parameters of pitch, duration, intensity, timbre and intonation, which are the parameters upon which the very first vocal/tactile interaction between mother and child is based.
Much more could be added, but the job of a key-note lecture, however extended and atypical, is not to exhaust the topic but to lay the foundations for discussion. We would therefore like to conclude by saying that the interest shown in this theme by an Institute which also deals in an intensive way with adult neuropsychological pathology seemed significant to us, as it also seems important that, even amid a thousand problems, the model of the Department of Mental Health is established in the reality of the Local Health Authorities. This is of course important from a cultural point of view, but even more so because of the "political" effect in terms of ower: children do not vote, everything related to childhood is subjected by the adult world to an emotionally intense and superficial interest of a basically hysterical nature which, like all displays of hysteria, evaporates quickly, so much so that child services have stayed separate and they have also been more or less neglected (barring some happy oases), despite being bringers of high profile knowledge and procedures. We believe that the need to pay end-to-end attention to neuropsychological issues throughout the various stages of life starting from birth allows us to better calculate how much prevention and early rehabilitation pay in terms of the reduction of the seriousness of adult clinical manifestations, thus in the long run actually allowing us (we finish by uttering the only magic word capable of making the managers’ ears prick up) to save.

Notes
1) Among the many, we would like to mention two: that of Benenzon ("From a scientific point of view, music therapy is a discipline that deals with the study and research of the sound-human being unit (musical sound and not) with the objective of researching elements of diagnosis and therapeutic methods".
"From a therapeutic point of view, Music Therapy is a paramedic discipline which uses sound, music and movement to induce regressive effects and open channels of communication with the objective of activating the process of socialization and social integration through them"), and that of Bruscia ("Music therapy is a directed interpersonal process in which the therapist helps the client to improve, maintain or re-establish a state of well-being using musical experiences and the relationships that are formed through them as dynamic forces of change").

2) In this respect we will limit ourselves to mentioning the distribution of neuropsychological pathology according to a functional and no longer clinical- descriptive approach, which Moretti uses in directing rehabilitative work towards the prevention of disability (Basic neurophysiological structure – Type of lear-ning – Type of object relationship – Predictable complications).

3) The suffix "therapy", in an orthodox sense, brings us back to the idea of a curative activity (but also rehabilitative, which leads to further ambiguities) whose means should by rights strictly consist in what is indicated by the root (music therapy = curing through music). But things don’t always go that way because the root sometimes actually indicates the curative means (example: pharmacotherapy) and other times it indicates the object of the treatment itself (example: psychotherapy = curing the mind, and not only through words). Thus, "therapy" is sometimes a noun and sometimes an adjective. However, and it would be interesting to understand why, there don’t seem to be any misunderstandings on the concept of "physiotherapy". 
We can suppose that the historical "birthright" of orthopaedic rehabilitation plays a part, and also the fact that physiotherapy is commonly applied to the body, while music therapy is applied (or so we believe) to that not yet well defined something which for many doctors and health-care workers is the mind, upon whose disorders, at least until it is not brought back into the enclosure of scientific certainty, one can clearly try everything.

4) Perhaps this precision derives from the fact that, from a speech therapy perspective, language, even if meant as a function, is also a part of the body and thus subject to its precise laws?

5) In actual fact, the humanisation of the relationship with the client, at least as far as the medical figure is concerned, has even more remote roots if it is true that in 1959 Balint wrote that "when he gives medicine a doctor actually gives himself, just as a patient when he brings a symptom actually brings himself". 
Similarly, we could say that the therapist today, even if not reaching the profound contents of the client, gives himself in the relationship in any case even before he gives his techniques.

6) Here another file would be opened containing the question of the specificity/ non-specificity of the various factors that come into play in producing a particular therapeutic result. In short, we can say that in a good part of the clinical situations that we treat, the improvements observed derive from the additive effect of non-specific benefits in relation to the person in care, which are added to the specific benefits produced by the application of a particular treatment method (De Girolamo, 1993).
As far as this last aspect is concerned, Moretti (1996), referring to some authoritative considerations made by Whitman (1990), quite radically expresses the opinion that the more global the impairment upon which we work (typical example, learning disabilities) the lower is the gradient of specificity of the interventions carried out, even when we face methodologies which assume to have very technical elements. The "global" significance of a certain method makes its scientific validation impossible, but this doesn’t mean that it is not practically useful, and even necessary, and that it does not produce effects from a neurophysiological point of view. Here the epistemological question comes back, posing a further question, which could have been the first had we favoured this perspective: does MT refer to the scientific system or the humanistic one?
If we decide that the global non-specific component is prevalent, the problem solves itself.
Naturally, we don’t think this, despite reasserting the unavoidability of the humanistic roots.

7) This scheme can be summarised in this way, as elaborated by Ricci Bitti and Postacchini (1997):
1. How the intervention works on the process of regulation and re-elaboration of emotions
2. How one passes from spontaneous expressiveness to codified and intentional expressiveness
3. What is the role of learning of techniques
4. What level of symbolisation (symbolic elaboration) does each intervention reach
5. What are the short and long-term cognitive effects of each type of intervention
6. What are the more general short and long-term effects on the organism.* Report presented at the Conference "Music therapy in rehabilitation for the age of development", S. Stefano Institute of Porto Potenza Picena, October 2002.

The present essay aims to give an accurate picture of the state of the art in relation to the complex theme being dealt with

Many theoretical frameworks (and not only in music therapy) are much more fragile than the practical results

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