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The Arts in Psychotherapy 38 (2011) 130–137

Contents lists available at ScienceDirect

The Arts in Psychotherapy

Naming the unnameable and communicating the unknowable’: Reflections on aombined music therapy/social work program

osie Maddick, MSW (Hlth), BA, GDipSoc Stud, GDipCrim ∗

oyal Talbot Rehabilitation Centre, 1 Yarra Boulevard, Kew, Victoria 3101, Australia

r t i c l e i n f o

eywords:usic therapy

ocial workpinal cord injury

a b s t r a c t

Spinal cord injury (SCI) is the sudden onset of a traumatic disabling condition. It impacts on peoplewith SCI physiologically, psychologically and socially. People face major life changes and the lifelongchallenges of disabilities that affect every aspect of their lives. This paper is a reflection on the impact of

djustment to injuryehabilitation

individual music therapy sessions and combined social work and music therapy group sessions, the musictherapy program (MTP), on adjustment to SCI. Reflections focused on data drawn from group discussions,semi-structured satisfaction interviews of 13 men with SCI, who had undergone primary rehabilitationin the Royal Talbot Rehabilitation Centre, Melbourne, Australia; findings from an independent evaluationof MTP; and practitioner perceptions. Three themes were identified during this reflection. These were:Music as a conduit; Music and the body; and Music as a connector. Reflections identify a number of

the M

benefits of incorporating

ntroduction

This paper is a reflection on the music therapy program (MTP)t the Royal Talbot Rehabilitation Centre (RTRC) in Melbourne,ustralia and its capacity to assist men to adjust to spinal cord

njury (SCI). The program utilises a combined music therapy/socialork approach. The inspiration for the MTP came from a young manith a recently acquired brain injury (ABI) who was undergoing

npatient rehabilitation at RTRC. He was a musician and memberf a band that toured Australia. His friendship circle included ausic therapist who suggested that music therapy would greatly

ssist him with the adjustment difficulties he was experiencing.sing skills and confidence gained in twice-weekly individualisedusic therapy sessions delivered by a qualified music therapist, heas eventually able to perform with his band again on a regular

asis. As credited by him, music therapy significantly contributedo his physical and cognitive recovery, engagement in rehabili-ation, emotional adjustment and self-expression. Music therapyessions were subsequently provided to a second person with anBI. Following considerable interest by the multidisciplinary reha-

ilitation team in the impact of music therapy on these two youngen, the integration of music therapy into rehabilitation practiceas supported. The MTP became an established program within

he Social Work Department. It was incorporated into the com-

∗ Correspondence address: Austin Health, P.O. Box 5555, Heidelberg, Victoria084 Australia. Tel.: +61 3 9496 5560; fax: +61 3 9496 5678.

E-mail address: rosie.maddick@austin.org.au

197-4556/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.aip.2011.03.002

TP in rehabilitation programs for men with SCI.© 2011 Elsevier Inc. All rights reserved.

prehensive RTRC therapy program provided to five clinical units:SCI, ABI, amputation, neurology and orthopaedics. The funding pro-vided for an independent evaluation of the MTP (Montague, 2005).As Bernstein (1976, p. 140), musician, composer, conductor andauthor, said: ‘[Music] can name the unnameable and communicatethe unknowable’ and, as argued in this paper, a sentiment highlyrelevant to the role of music as a therapy for men recovering fromacquired disabilities.

Literature review

The literature review provides the backdrop for combined musictherapy and social work programs for men with SCI undergoingrehabilitation by exploring the consequences of SCI and how itaffects people; the use of music therapy with people with SCI; groupwork in this context; and social work and music therapy.

SCI

Many types of accidents and illnesses can cause SCI and thephysical, psychological and social effects of the injury can varygreatly between individuals. SCI results in the loss of movementand sensation in the limbs and trunk of the body (Zedjlik, 1992).Quadriplegia or tetraplegia is an SCI that results in the loss of sen-

sation and movement in all four limbs and trunk. Paraplegia is SCIthat results in loss of sensation and movement in the legs or theentire trunk (Zedjlik, 1992).

While SCI is a catastrophic traumatic event for the injured per-son, it also profoundly changes the lives of families and significant

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thers. Physical consequences are sudden and traumatic usuallyesulting in permanent lifestyle changes (Galvin & Godfrey, 2001),ith different implications when compared to the usually slow

nset of chronic illness. Considerable changes alter every aspectf the person’s life at the time of injury. These include paraly-is of limbs (so that they cannot be moved or felt), balance, andhe inability to control the function of bladder, bowel and sexualrgans (Nielson, 2003). Emotional turmoil and psychological diffi-ulties related to these catastrophic changes have been reported.hese include rates of depressive disorders up to 40 percent, anx-ety disorders up to 30 percent and a suicide rate up to six timesigher than the general community (Galvin & Godfrey, 2001). SCIlso impacts on the person’s social life, involves multiple stressors,adically changed roles and financial difficulties that impact heav-ly on spouses (North, 1999). Persons with SCI also face a lifetime ofossible health complications such as pressure sores, and respira-ory and urinary tract infections that can lead to further extendedtays in hospital (Dorsett & Geraghty, 2008). Men in Australia incurhigher rate of SCI than women (AIHW: Norton, 2010).

djustment to SCI

A major interest in how people with SCI and their significantthers adjust to acquired disability is identified in the literatureDorsett, 2001). Adjustment is defined as “adapting to a new con-ition” according to the Spinal Cord Injury Information Networkebsite (SCIIN). Adapting well is critical to the quality of life for

n individual post injury. The significance of adjustment to SCI ishat the individual is forced to adapt to an unplanned, life-changingvent. Time is needed to adjust to the realities of acquired disabili-ies and changed lifestyles. People whose lives are disrupted by SCI

ay experience this as loss of control, physical function, dignityogether with loss of usual social and family roles (Dorsett, 2001).hysical and emotional recovery and adjustments that occur as aesult of SCI is a continuing process, unique for each person. Anndividualist, client-centred approach is essential for good clientutcomes.

A significant contribution to knowledge concerning adjustmentrocesses for persons with SCI is the distinction between reha-ilitation and recovery. Rehabilitation includes the ‘services andechnologies’ used to help people with disabilities adapt, whileecovery is ‘the lived or real life experience of persons as they acceptnd overcome the challenge of the disability’ (Deegan, 1988, p. 11).positive recovery can create a new sense of self and purpose as

he person accepts what he cannot do and starts to discover who hean be and what he can do (Deegan, 1988). Recovery involves thendividual accepting the diagnosis of SCI and regaining some con-rol over the situation through this acceptance, which should note confused with hope for improved functional outcomes (Dorsett,010). Adjustment may be viewed as a more passive process untilhe more active concepts of recovery and acceptance are consid-red.

Recovery from SCI that requires ongoing psychological adjust-ent and support for the adjustment process is an important

spect of rehabilitation. Unresolved negative emotions or socialehaviours may impact on the patient’s capacity to participate

n rehabilitation (Tamplin, 2006). North (1999) lists number ofactors that may predict a more successful adjustment to SCI.hese include being younger, female, having a sense of controlver one’s situation, good quality support from others and theommunity, and good communication with and information from

ealth professionals. In addition, strategies such as problem solv-

ng and active coping, as well as range of other resources toraw on have been linked to better adjustment (Galvin & Godfrey,001). Another study found that coping mechanisms used by peo-le who are better adjusted to SCI included protective strategies

erapy 38 (2011) 130–137 131

of emotional self-control, acceptance, positive re-evaluation andignoring the problem by living as before. On the other hand,people using coping mechanisms of escape or avoidance, con-frontation and self-blame were more vulnerable to psychologicaldistress or depression (De Carvalho, Andrade, Tavares, & De Freitas,1998).

Quality of life (QOL) research is particularly important for per-sons with SCI. In a meta-analysis of 22 such studies, Dijkers(1997) found that the average person with a SCI experiences alower QOL than one without such injury. Although not a sur-prising finding, Dijkers (1997) went on to highlight the need forknowledge of the factors that contribute most to QOL after SCIand the importance of obtaining this information from personswith SCI themselves to inform and assist the awareness of policymakers and service providers. A subsequent study of 15 per-sons with SCI provided some insight into this and identified ninethemes relevant to QOL for persons with a SCI: physical functionand independence; accessibility (to places); emotional well-being;stigma; spontaneity; relationships and social function; occupa-tion; financial stability; and physical well-being (Manns & Chad,2001).

Although each person’s situation is different, SCI commonlycauses multiple losses which continue to unfold over time.As well as primary losses in physical function and mobility,there are often secondary losses in areas such as relationships,occupation and accommodation (Manns & Chad, 2001). Griefis the emotional response to loss (Golden & Miller, 1998). Fora man with SCI, the loss of physical function induces feel-ings such as vulnerability, weakness and fear that can createinner turmoil by threatening perceptions of manhood (James,2001). Feelings of helplessness, vulnerability and weakness arenot necessarily private concerns. In many cultures, men havebeen socialized to keep such emotions to themselves, how-ever, evidence exists that feelings not expressed in words oractions may be expressed through physical pain or illness (O’Neil,1982).

Golden and Miller (1998) have provided theoretical perspec-tives on the less commonly understood masculine side of healingas distinct from the more explored feminine mode. While Goldenand Miller (1998) point out that men and women can useboth masculine and feminine methods of coping, their theo-ries concerning masculine methods of coping are relevant tothe participants in the MTP. Men are discouraged within cer-tain western cultures from openly expressing emotions as ameasure of strength and independence and their roles of pro-tector and provider require them to defend themselves and tobe alert to the safety, well-being and needs of significant others(Golden & Miller, 1998). However, for men dealing with per-sonal loss, a grieving state may reduce their ability to defend,protect and provide for themselves and others (Golden & Miller,1998). Characteristics of a masculine style of healing fromloss can include an initial sense of chaos, a more cognitive,action-oriented and independent approach with a preference tospending time alone to connect with the loss (Golden & Miller,1998).

Although men may be less inclined to express their emotionsverbally, it does not mean that the intensity is less acute thanthat felt by someone more able to express feelings verbally, andso it is important to accept a man’s silence and to be an effec-tive listener if and when he chooses to speak (Golden & Miller,1998). It, therefore, becomes important to seek more practical and

active ways to respond to their losses. Some men may respond tocreative activities including drawing, painting, sculpting, poetry,writing and music composition that provide safe but potentiallypowerful, active and practical ways to express and manage emo-tional vulnerability. Golden and Miller (1998) stress the importance

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f respecting the different ways men grieve that can be equallyxpressive without necessarily using words or shedding tears.

usic therapy and SCI

Music therapy is a broad field where definitions differ accordingo the treatment model and setting. A working definition proposedy Scheiby (1999) is that music therapy involves the use of “impro-ised or composed music” designed to effect therapeutic changeScheiby, 1999, p. 263). What happens musically and the client’selationship with the music therapist are both essential therapyomponents (Scheiby, 1999). Bruscia (1989) extended this defini-ion to one applicable to rehabilitation settings: ‘the use of musicalxperiences and the relationships that develop through them asmeans of helping clients who have been debilitated by illness,

njury or trauma to regain previous levels of functioning or adjust-ent to the extent possible’ (Bruscia, 1989, p. 98).Music therapy is differentiated from musical entertain-

ent/recreation by its capacity to address therapeutic goals.he capacity of music therapy to effect change provides a non-raditional means of externalising and working through the socialnd emotional issues that arise from both the acquired disabil-ty and the hospitalisation experience associated with it. Thesespects are of particular significance to the MTP. Music can createherapeutic opportunities that may otherwise remain inaccessi-le (Batt-Rawden, 2010). These non-traditional approaches maye especially relevant for men who may be reluctant to engage

n counselling (Humphries, 2001) preferring more active, task-entred responses that provide distractions to negative life eventsAli & Toner, 1996; Golden & Miller, 1998). Humphries (2001) notedhat some men do not hold positive perceptions of counselling ashe process itself is contrary to the man’s need to feel in control ofis life. This does not mean however that counselling is an inappro-riate intervention, rather, timing may be important as is the usef multi-interventions that include music or art therapy alongsideore traditional means.Music therapist, Bright (1978), discusses grief arising from losses

f competency, achievement and attractiveness, and changes inamily and other relationships that can become difficult or collapseuring long hospital stays of particular relevance to men with SCI.right (1978) suggests that music therapists working with peopledjusting to long-term disabilities need an awareness of differentusical tastes, a repertoire of music for various ages and resources

rom which people can choose. Therapists need to be sensitive toeople’s feelings regarding playing instruments, singing, listeningo music and disclosing inner feelings during musical or verbal con-ersation (Bright, 2002). In this way, music can go where wordsannot and can enable music therapists to assist people to adjustmotionally by expressing their grief.

Songwriting, where a person is supported to describe their expe-iences in song, is a useful technique in music therapy. Amir (1990,. 63) refers to an “improvised song” that has both verbal andusical components and is produced in the moment according to

he person’s “life force” with the guidance of the music therapist.mir (1990) presents an analysis of two music therapy sessions inhich a young man with quadriplegia wrote two improvised heal-

ng songs that reflected his struggle to cope with the impact of hisnjury and expressed his despair, grief, pain, frustration, optimismnd hope. His creativity remained intact despite the loss of otherapacities (Amir, 1990). In this way, songwriting can be a valuable

eans of shifting focus from illness or disability to the person them-

elves. It can also incur feelings of pride, provide comfort and beess threatening than other forms of creative writing (O’Callaghan,997). A new awareness can help the writer to reframe upsetting

ssues (O’Callaghan & Grocke, 2009).

erapy 38 (2011) 130–137

In rehabilitation settings, music therapy can address physical,cognitive or communication goals as well as helping people adjustto trauma and long hospitalisations. Methods most often usedin music therapy include improvisation, imaging, playing music,songwriting and discussion of songs (Scheiby, 1999). Persons areencouraged by the belief that there is music in all of us and thatno special musical talent is required to be involved. A review of theliterature identifies innovative music interventions of relevance forpersons with SCI. Batavia and Batavia (2003) reported on the use ofkaraoke with persons with high-level quadriplegia. These peoplehave little to no use of their arms and hands, and considerably lessrecreational options than those people with paraplegia. Karaoke, asa new form of active recreation for people with quadriplegia, pro-vided additional health benefits that included increased respiratorystrength, endurance, breath control and capacity, as well as satis-faction associated with the emotional and physical release (Batavia& Batavia, 2003).

Another innovation reported in the literature involved an elec-tronic music program enabling persons with SCI to play songs bymoving elbow joints into certain positions causing a computer tocommand a synthesizer to play the corresponding notes (Lee &Nantais, 1996). This was used to exercise and strengthen armsand hands, and increase participation in physical therapy whereprogress can be slow and discouraging (Lee & Nantais, 1996). Theintervention drew on music therapy knowledge that performingmusic makes disability seem secondary by accentuating abilities,that participation enhances self-esteem and interpersonal skills,and rhythm and emotional expression promote adaptation (Lee &Nantais, 1996).

Group work and SCI

Group work is used with people with medical conditions suchas SCI in common, as issues dealt with are shared by the entiregroup (Andrews, 1995). Common-theme groups provide helpfulinformation, encourage discussion, and generate mutual supportcritical during rehabilitation, while enabling the development ofcoping strategies and specific skills (Andrews, 1995). Group lead-ers create processes to support adjustment (Andrews, 1995). Useof group work in adjustment is supported by the work of North(1999). Potential advantages include modelling from peers, socialsupport and access to a range of views. However, effectiveness ofgroups versus individual interventions for those with SCI has notbeen widely researched (Galvin & Godfrey, 2001).

Social work and music therapy

Slivka and Magill (1986) highlight the benefits of collaborationsbetween social work and music therapy. They emphasise how wellthe two disciplines combined their caring approaches, sensitiv-ity and strengths to assist and comfort children and families ofadults with cancer. They identified the primary tasks of the musictherapist as songwriting, playing musical instruments and singingfamiliar songs, while the social worker provided play therapy, edu-cation and information to children and family support. Verbal andnon-verbal techniques used by both disciplines assisted communi-cation and the wellbeing of family members (Slivka & Magill, 1986).Future research to determine the transferability of combined socialwork/music therapy to other settings was recommended (Slivka &Magill, 1986).

Other works describe how social workers use music or music

therapy principles. In one example, a social worker used musicand other creative methods in end-of-life care with people ina hospital setting (Lethborg, 1994). Lethborg (1994) asserts thatmusic, memories, writing and visual images used by people forgenerations to express feelings could assist in working through

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ifficult issues with terminally ill people. In work with children,nother social worker used principles and practices from musicherapy to enhance engagement, expression and communicationLefevre, 2004). The keyboard, improvisation, recording music cre-ted, pre-recorded music, singing songs and song writing were usedo engage and work with children (Lefevre, 2004).

ethod

A thematic inductive analysis was conducted using a narrativeerspective that enabled an in-depth understanding of a person’sxperience, in this case, through both verbal and creative expres-ion (Larsson & Sjöblom, 2010). Through a narrative lens it isossible to understand how people construct the importance ofarticular experiences such as the MTP to their lives and chang-

ng identities (Riessman, 2002, 2003). The data corpus reflectedn and analysed includes: the experiences of the MTP drawn fromhe individual and group sessions; client feedback from satisfac-ion interviews; findings of a formal evaluation; and practitionererceptions. Data triangulation enhanced the credibility of theesearch (Whittemore, Chase, & Mandle, 2001). The critically reflec-ive process used was that described by Fook and Gardner (2007)nd Fook and Askeland (2007) where assumptions and acceptedorms are questioned, disconfirming evidence sought and para-oxes examined. In any qualitative approach the influence of the

nquirer on the analysis can never be discounted while awareness,isclosure and triangulation enhance trustworthiness. The author

s an experienced practitioner which lent greater understandingso the interpretation of data due to knowledge of technical andractical implications of SCI.

articipants

Participants were 13 men with SCI undergoing primary reha-ilitation in the RTRC, Melbourne, Australia, and who participated

n the MTP. At the time of injury, five were aged from 17 to 20ears. The ages of the other eight ranged from 28 to 59 years. Theost common cause of injury was road trauma (n = 7) and more

han half (n = 9) had quadriplegia, consistent with that reportedationally and internationally (AIHW: Norton, 2010; Stover, DeLisa,Whiteneck, 1995). Involvement in the program was by referral

nly. Participants could choose to be involved in the MTP for theuration of their rehabilitation which for people with SCI extendsver many months or more. Five of the men attended one to two 1-hessions per week for six to eight months. Six others attended one towo sessions per week over two months. Two men attended threend five sessions, respectively. Eleven of the men participated in aormal evaluation reported in Montague (2005) and all 13 partici-ated in a quality exercise that gathered qualitative data exploringheir satisfaction and experiences.

he MTP

Participants engaged in both individual and group sessions, eachomplementing the activities of the other. Session content waseveloped to meet group members’ interests and rehabilitationoals. Individual sessions were conducted as part of the formalehabilitation therapy program by the music therapist. Music ther-py techniques included songwriting, singing, work with hands andngers, relaxation, playing instruments, learning new instrumentsuch as the mouth organ, making music with significant others

nd voice therapy. Group sessions were conducted by the socialorker and music therapist on a weekly basis. It was considered

hat the potential combination of social work and music therapy,s supported in the literature (Slivka & Magill, 1986), would pro-ide a unique combination of skills to encourage member sharing

erapy 38 (2011) 130–137 133

and peer support. These activities utilised empathy, group facil-itation, and communication skills. The social worker and musictherapist worked in partnership to facilitate group activities includ-ing songwriting, discussions, music making and relaxation. Anotherfavourite activity involved members taking turns to choose a song,which was then played to the group, and then the person wouldshare with the group their reasons for the song selection.

Nine of the 13 referrals to MTP identified the encouragementof emotional expression as a goal followed by six referrals toassist with fine/gross motor skills. Other goals included pain man-agement; return to previous musical activities; assistance withbreathing; head/neck control; voice strengthening; and to increasemuscle endurance, balance and posture. Comments expressed anddiscussions on topics during group sessions were written downimmediately after these sessions. A critically reflective process wasconducted on this material as a professional clinical activity. Thewords of 11 songs composed by participants to express feelings andthoughts on emotional adjustment to SCI were compiled on a com-pact disc. The lyrics of these songs were transcribed and includedin the data corpus with the authors’ permissions.

The satisfaction interviews

An invitation to participate in interviews designed to providefeedback, explore the experiences of their participation in the MTPand its impact on their adjustment to acquired disability was sentto the 13 men who participated. All 13 agreed to be interviewedas part of an evaluative, quality activity. Guidance provided by therelevant ethics committee determined that ethical approval wasnot required for a quality improvement exercise.

The satisfaction interviews were conducted at 14 months using aquestionnaire, informed by the literature review and MTP content.The questionnaire used open-ended questions to elicit feedback,enquire about the difficulties participants experienced as a resultof their SCI and asked them to identify who or what assisted withthese difficulties. They were then asked for negative or positivefeedback about the MTP, including their experience with individualand group sessions.

To maximise feedback, interview options that included tele-phone, in person or in written form, were given due to differentfunctional abilities of persons with SCI and geographical disper-sion. Six face-to-face and six telephone interviews were conductedand responses written down. One written response was receivedby mail. No identifying information was retained.

The formal evaluation

An external consultant (Montague, 2005) conducted a formalevaluation that produced both quantitative and qualitative data.The evaluation was conducted in the same period and the samemen participated. Montague (2005) used a Likert scale to score theimpact of music therapy for participants (very significant = 4, signif-icant = 3, small = 2, no impact = 1). The views of participants, musictherapist and a member of the participant’s rehabilitation teamwere also explored. The findings of this evaluation complementedother data sources used in this reflection providing opportunity fora richer analysis.

Practitioner perceptions

As part of the quality clinical process, practitioners at RTRC,

whose work has a strong psychosocial focus, met as a group toprovide their observations and feedback about the program. Prac-titioners were psychiatrists, community spinal nurses, a clinicalpsychologist, the sexual health counsellor and a leisure worker.In this forum the social worker and music therapist also provided

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heir own insights into this process. Notes in the clinical recordshat recorded MTP involvement were also reviewed in this pro-ess. Information from this clinical review process was used in thiseflection exercise.

ata analysis

The data corpus was analysed using an inductive thematic anal-sis from a narrative perspective. A qualitative analysis enabledhe identification and reporting on meaningful themes (Braun &larke, 2006). First the material was read to gain an overall sensef the content and reread to determine commonalities in the mate-ial. The material was again read and common themes groupedogether. The themes identified during the analysis and relation-hips between themes were explored in depth using a criticallyeflective approach.

indings and discussion

Three major themes were identified in this reflection. Theseere Music as a conduit, Music and the body, and Music as a connector.

usic as a conduit [for emotional expression]

For most participants, music acted as a conduit for emotionalxpression or release in some way that assisted in their adjust-ent to acquired disability. Eleven of the 13 men identified that

he MTP was useful in helping with their emotional adjustmento injury while two did not. Both of these had a strong musicalackground and other issues such as pain and low mood. One ofhem later reported MTP as useful for pain management. Seven

en highlighted how the program greatly assisted them to expressheir feelings. Three spoke of music therapy as a positive activ-ty that made them ‘feel better’ and ‘kept their spirits up’. Three

en specifically referred to the importance of music therapy asn emotional outlet with comments such as ‘getting my feelingsut’ and ‘dealing with dark thoughts’. One man with a history ofanic attacks reported that relaxation to music reduced his anx-

ety. Similarly, other participants in the MTP identified activitiess essential, soothing outlets enabling the expression of variousmotions, something they did not consider possible through othereans.For those that described music as a conduit in some way, there

as no relationship between perceived musical talent and lackf it. One young man described a particular advantage of musicherapy was that ‘he could imagine he was elsewhere’ and thatmusic brought back [evocative] memories of good times’. For three

en music therapy served as a welcome distraction, shifting theirocus from their fears and concerns to a lighter present, wherehey could engage in positive, fun activities. Whether these activ-ties served as distractions, provided alternate spaces or enabledmotional expression, the three participants felt they were moreble to actively participate in other aspects of their rehabilitationrogram such as physical rehabilitation and counselling. Some ofhese benefits were a greater level of patience required to deal withhe frustrating limitations of physical functioning, improving moodnd enabling the three participants to raise significant emotionalssues that they previously found difficult to vocalise in an environ-

ent that was safe and non threatening and to people they ‘foundasy to talk to’. Individual sessions, particularly, seemed to provide

dditional privacy that supported easy engagement.

In the analysis, it became clear that emotional expression andts relationship to adjustment for participants were strongly facil-tated by individual songwriting. Through composing, participants

ere able to express the sometimes discordant, uncomfortable and

erapy 38 (2011) 130–137

distressing feelings associated with their current situations. Twoexamples of such song writing are presented in Appendices A andB.

Powerful emotions and real issues that confront people whoacquire SCI were expressed in these songs. After composing hisfirst song, one man reported that he felt more confident and able tofully engage in other aspects of his rehabilitation program. Baker,Kennelly, and Tamplin (2005) in a study of music therapy with peo-ple with acquired brain injuries found the two common themeslocated within clients’ songs concerns self reflections on feelings,attitudes and injury, and messages of regard for others importantin their lives.

One participant sang his own song at the official launch of themusic therapy program. His performance attracted media attentionincluding segments on two Melbourne television news programsthat evening. He indicated that he would never have been able toperform in front of an audience prior to his injury and attributedthis achievement to his participation in the MTP. Two others sang atthe RTRC Christmas Carols evening, another previously unimaginedrole, significant in terms of enhanced confidence and self-esteemwhich are commonly reduced by SCI. One man who felt especiallysatisfied with his uninhibited performance explained why he waspleased with his new attitude:

You need more front with a SCI! Previously, I could havewalked through issues and now I have to drive (wheel) throughthem!. . .

This was said with positive energy and renewed determination.Comments reported in the external evaluation expressed the

importance of music for emotional expression:

It kept me sane! You have so much taken away from you, sucha gaping loss; music therapy gives you something you can do.In a wheelchair you get very inhibited. Music gives you a way toexpress yourself and talk about your experience. Music therapybreaks the monotony and stops you becoming too institution-alised. It provides a break from the ‘prison term’ (Montague,2005, p. 32).

It had a positive effect on my mood. When you are there for along time, with others also for a long time, your mood can getvery low. Music therapy really helped me with that. It gave mea chance to do something I could do (Montague, 2005, p. 32).

In addition to the positive experiences expressed by the par-ticipating men, practitioner perceptions also identified positivebenefits. The psychologist viewed the MTP as invaluable foryounger men who may not easily communicate their feelingsdirectly, providing them a way to express themselves in anothercontext and to improve self-esteem by recording their own music.She also valued the capacity of the MTP in motivate greater par-ticipation in other therapies. The sexual health counsellor saw theMTP as having a nurturing capability providing an alternative toverbal expression of feelings. Both the psychologist and sexualhealth counsellor saw particular benefits for those people with pre-existing relationships to music. A community nurse working withone of one participant confirmed that participation in MTP hadimproved his emotional expression and confidence. The psycholo-gist working with one participant with depressed mood noted in hismedical record that, after starting the MTP, he was able to activelyraise low moods by listening to music. Consequently, he was able todiscuss low moods experienced and feelings of vulnerability. Simi-larly, his occupational therapist noted that he was more motivated

to attend her therapy sessions.

Though not all of the 13 men reported music as a conduit foremotional expression, for 11 of them participation provided emo-tional insights relevant to their short and long term adjustment.

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t made difficult feelings more manageable and no longer insur-ountable. For practitioners, the importance of such programs in

upporting engagement in other aspects of traditional rehabilita-ion and how creativity can support positive adjustment to SCI areighlighted.

usic and the body

Perhaps one of the most immediate implications of SCI is theffect on the body. Daily frustrations caused by limitations of func-ioning; coming to terms with physical recovery nearly almostnadequate and slow compared to the hopes and desires of the per-on; and feelings of helplessness and loss of masculine identity areommonly experienced by men with SCI.

Seven participants reported that the activities in which theyngaged during the MTP assisted in their physical rehabilitation.or the remaining six, their SCI was either too severe to addresshysical goals in music therapy, or upper limb function was notffected. Five participants found that playing musical instrumentsmproved function of their arms, hands and fingers.

It [MTP] helped my fingers. When I first started, I couldn’t holdthe shakers. I persevered and persevered and I’m still trying, butI am going to get there (Montague, 2005, p. 33).

They had pleasure in music making while simultaneously aidingheir physical rehabilitation. In particular, two men whose handaralysis ruled out playing other musical instruments, learning tolay the mouth organ was important. This was especially so for aormer guitar player who felt a gaping void with no hand functiono play his guitar. Improvement in respiratory function, increasedreath volume and control as noted in both men.

I worked on four key areas, breathing, holding the harmonica,balance in the chair and posture in the chair (Montague, 2005,p. 33).

Four of the men experienced physical pain related to their SCI.hree of these reported that music therapy shifted their focus fromhe pain and one participant reported continued benefit with painelief after the session.

High level SCI can also affect speech. The voice of one partici-ant was very soft on referral to the MTP and through participationegained his speaking voice. The music therapist provided activitiesimed at improving diaphragmatic breathing, voice projection andinging exercises to improve the quality and volume of voice. Hishysical improvement was closely aligned to improved confidence.

People could not hear me; I had problems with my voice.Because of music therapy, my voice changed, it got louder andlouder (Montague, 2005, p. 33).

Feedback provided by a speech therapist, also working with thisarticipant noted the improvement his speech. Changes, particu-

arly relating to the body, were also noted by the rehabilitationeam.

usic as a connector

Participation in the MTP also helped participants reconnectith others in two important arenas. They connected with peers

nd were able to gain benefit from shared experience and sup-

ort. Likewise, music provided a non threatening mechanism forommunicating strong and sometimes difficult feelings to the sig-ificant people in their lives in a way that would have been muchore difficult in the absence of musical expression.One participant noted:

erapy 38 (2011) 130–137 135

The group experience was very important too. It broke down agebarriers; we shared our experiences. There is no other therapythat has this activity. It’s strange really that there was nothingin any other therapies that meant we sat together and talkedabout our experience. Everyone found it valuable. I learnt morefrom fellow chair people in the whole 10 months I was in thesystem. Something like this should be part of the rehab curricu-lum. Everything is dominated by physio and OT. Music therapybreaks the monotony and stops you becoming too institution-alised. It provides a break from the ‘prison term’ (Montague,2005, p. 32).

All participants reported they enjoyed and looked forward toeach combined social work and music therapy group session, inparticular, the opportunity it provided for peer connections. Theysupported each other and broadened their viewpoints by sharingcommon experiences, feelings and music therapy activities. Theseactivities included sharing their favourite songs and music tasteswith the group, and group song writing. A song they wrote as agroup that expresses the emotions and frustration and a hopefuldetermination is shown in Appendix C.

Unlike the individual music therapy sessions, group mem-bers provided supportive peer interactions and combined differentmusical experiences, skills and backgrounds of younger and oldermen. An intense bonding experience occurred during shared musictherapy activities. One participant highlighted this connection:

We all talked in the group, sometimes about yourself, it was verymentally stimulating, you need this sort of thing when you areisolated out there (Montague, 2005, p. 34).

The common threads of SCI and music provided a comfortablesetting for group members. One member stated that the music ther-apy group, unlike regular counselling, allowed him to have moreinput into the content of the sessions. Montague (2005) identifiedthat the MTP provided one of the few opportunities for men to talkabout common issues with others with SCI and to provide supportand be supported by each other.

While peer support has an important role during and undoubt-edly post rehabilitation, it is family relationships that are often moststrained, particularly when difficult matters are not discussed. Onefamily member reported the following in Montague (2005):

Music therapy helped put into words his journey. It helped himsee there was a light at the end of the tunnel, there was a lifeahead. It was also something I could participate in with him. Wecould share his journey as a family and thank the people whosupported us. He wrote a song for me, it was really touching,hearing and knowing the mental turmoil he was going through,it was hard for him to express things verbally, but he could do itin the song. We gave it to lots of family members to help themunderstand too (Montague, 2005, p. 33).

And one participant discussed how the MTP helped communi-cation with his family:

. . .My family were really proud and very impressed. They wereall really amazed! My songs helped them understand how I wasfeeling. I felt I had a hidden talent coming out in the song writing.I felt I was really doing something, really developing a skill. Notlike the slog of physio, like learning to sit up (Montague, 2005,p. 32).

Practitioners also identified the connective aspects of MTP. Onepsychiatrist reported that MTP participation had reduced the men’s

feelings of isolation during hospitalisation by involving them inmusic and reconnecting them to mainstream society by playingfamiliar songs. The MTP enabled creative expression and healing ina way that is not provided by other programs.

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36 R. Maddick / The Arts in Ps

The capacity for social work and music therapy to work collab-ratively adds a vital dimension to the process of group work andraditional notions of service delivery. This professional partner-hip provides a unique combination of skills and transformativenterventions. The two disciplines bring together a broad range ofnowledge, skills, techniques and materials that can be applied tohis population.

What was surprising in the analysis is how important the MTPecame to participants and their families. It is common knowledgeor practitioners working with people with SCI that the physicalspects of rehabilitation such as physiotherapy become the focusnd the priority for most people and their families and these activi-ies are perceived to be most aligned to recovery and independence.o the value placed on these sessions and the interest of familiesndicated considerable benefit to people in ways not previouslyefined.

There are limitations to this reflective exercise in that thehemes identified are specific to this group and are not transferable.et reflecting on the MTP and its impact opens new possibilities foresearch. There also exists the possibility that participants soughto please in their responses yet use of secondary data provided by

ontague (2005), an independent evaluator, provided confirmingnformation.

onclusion

It can be inferred from this reflection that programs such as theTP have a place as more than an adjunct or recreational activity in

CI rehabilitation and should be incorporated as an accepted partf traditional rehabilitation programs. Likewise cross disciplinaryollaboration brings unique combinations of skills to music therapynterventions. Social work practitioners can play an important partn music therapy programs.

Men faced with the unfolding and accumulative losses asso-iated with SCI are challenged on a daily basis and engagementn programs such as the MTP can help people create new, posi-ive senses of self and renewed purpose. It can be hypothesizedhat engagement in the MTP accelerated a process of coming toerms with many issues that may have taken years to address in itsbsence.

cknowledgements

The author would like to acknowledge funding support fromhe Department of Human Services’ Slow to Recover Program,he William Buckland Foundation and the Diana Browne Trusthat made the MTP possible; funding from the Anna White Trusthat enables the MTP to continue; The Royal Talbot Rehabilitationentre; MTP colleagues, particularly Jeanette Tamplin for her pio-eering work; and importantly those people who participated inhe MTP. Also thanks goes to Dr. Patricia Fronek, Griffith University,or the support of this paper.

ppendix A.

pinal Blueso you ever get angry when you’re in your chair?ou look out the window with a vacant stareell all right, don’t get uptight

t’s still a long, long, long way to go

id you get your online lover and call her in?he saw your state and she’s pulled the pinell alright, another lonely night

itttin’ in the dark, hoping for a little lightHarmonica solo)

erapy 38 (2011) 130–137

Have you travelled over mountains just to try to find?Some friendly people of the kindred mindWell alright, ain’t it a pleasing sightIt ain’t, such a long, long way to go(Harmonica solo)

Do you ever get lonely when you’re by yourself?Lying in your bed and you call for helpWell all right, I do it every nightHanging in your hoist, swinging in your sling tonight

(Reproduced with author’s permission)

Appendix B.

“I am Still the Same”(To the tune of “Every Breath You Take” – Sting)

Verse 1Every day’s the same, look what I becameWhen the night is done and the morning comesI am still the sameLife is quiet now, with every passing hourThe busy times have gone and sad feelings comeI am still the same

ChorusNo one can know, how it feels to goFrom that to this, with everything I missAll that I had is lost; everything is goneWhen it’s said and done, I cannot walk or runI am still the same

Verse 2Sleepless nights, I lie awake and stareAt the ceiling, it’s more than I can bearIt’s like a bad dream, but I feel like no one caresHow could this happen to me, it’s so unfairI keep yelling out into the air

ChorusNo one can know, how it feels to goFrom that to this, with everything I missAll that I had is lost; everything is goneWhen it’s said and done, I cannot walk or runI am still the same

(Reproduced with author’s permission)

Appendix C.

Spinal Group SongSick of pushing round and round these hallsSick of looking at the same old wallsSick of being told how I should feelWhen I wake up, it’s all too real

Some tell me I’m luckyOthers say it could be worseBut I don’t feel that luckySometimes it feels just like a curse

Just want to go homeBack where I used to beI’ll pay my dues and I’ll beat my fearTo get a ticket out of here

Never chose to walk this pathJust been burdened with this taskDoin’ time but I ain’t done the crimeGotta keep movin’ on down the line

Some tell me I’m doin’ fineOthers say I’m doin’ wellProgress is just a matter of time

But sometimes it feels like a living hell

Just want to go homeBack where I used to beI’ll pay my dues and I’ll beat my fearTo get a ticket out of here

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R. Maddick / The Arts in Ps

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