Running Head: Steps Towards Independence
Steps Towards Independence: A case study about a young deafblind woman and her music therapy journey.
Tiana Dick (MTI) Berklee College of Music
This case study provides an overview of a 31-year-old female individual diagnosed with deafblindness. The music therapy sessions took place for the duration of 27 weeks (~six months), at two sessions per week. Each session was one hour in length.
This case study examines the use of improvisation and songwriting music therapy interventions to increase independence and self-confidence. Both the Nordoff & Robbins' approach and the Juliette Alvin approach are discussed as to their significance in influencing the interventions that were chosen. The client’s treatment plan is included, along with an example of a session plan, to examine the implementation of the improvisation and songwriting interventions. An example of a song that was composed by the client, has been analyzed to understand the client’s ability to express emotion and make independent decisions. This case study provides the outcomes of the music therapy treatment and how it was able to increase the client’s independence outside of the sessions. Additionally, the benefits and disadvantages of Telehealth music therapy versus in-person music therapy are revealed. This case study concludes with a final discussion on the findings of the music therapy sessions and the music therapy intern’s (MTI) rationale for recommending continued music therapy treatment.
Key Words: Deafblindness, Music Therapy, Improvisation, Songwriting, Telehealth, COVID-19.
Background and Setting
Emily (a pseudonym to protect identity), is a 31-year-old Caucasian female individual diagnosed with deafblindness. Deafblindness is defined as “someone who has a combined loss of vision and hearing,” (Canadian Deafblind Association of BC). For someone to receive a diagnosis of deafblindness, vision and hearing can not be used as a primary source of receiving or processing information. Clients must have a diagnosis of moderate to profound hearing loss (40dB ≤ hearing loss ≥ 90dB), and a diagnosis of moderate to severe/profound visual impairments (<20/60’ visual impairment >20/200’), (Fellinger et al., 2009). Emily has been evaluated to have a developmental age of 8 years due to her inability to make independent decisions for herself. As a deafblind person, Emily requires assistance to help her communicate with others and to understand her environment. Emily uses the assistance of an intervenor whose services are provided by a private agency through the government of Canada. Intervenors are defined as people “who provide intervention to an individual who is deafblind. The Intervenor mediates between the person who is deafblind and [their] environment to enable [them] to communicate effectively with and receive non-distorted information from the world around them,” (Sensity: Deafblind and Sensory Support Network of Canada). Emily chooses to speak english when assisted by her hearing aids, but has the capacity to utilize sign language when communicating with other deafblind individuals. When communicating with Emily using online documentation, she requires the font to be a minimum size of 22.
Emily has been working with an intervenor from a young age. She was able to attend W. Ross Macdonald School for the Blind in Southern Ontario where she was taught independent learning, living skills, and self-sufficiency. One of the additional programs offered at the school was music therapy. Emily attended both individual and group music therapy sessions from June 2000 to June 2015. Some of the goals that the certified music therapist (MTA) had for Emily’s individual sessions included increased self-confidence, decreased anxiety and decreased negative self-regard. The MTA talked about how Emily was often teased by her classmates while she was attending school. “She really just wanted to fit in and have friends and so in individual sessions, we explored [the] self through improvised music. In group sessions, Emily participated with other deafblind students with similar functioning levels, working on socialization and some gross motor areas.”
After Emily turned 21 and graduated from W. Ross, she moved back to her hometown to live with her family, where she continued working with an intervenor. After school, her goals remained similar in that her intervenor encouraged independence and positive self-regard. Her intervenor explained that, “she was extremely negative and had low self-esteem [...]. When she [would] comment something negatively, I would ask her to find the positive in it [...].” This helped Emily reframe her thinking to establish a healthier approach. The intervenor continued with “another huge goal [of] leading a healthy lifestyle by our eating habits and exercise. We did some research and did some meal planning and then we prepared those foods so that she could have homemade meals each and every day instead of processed food. [...] We [also] walked a lot.
At first it was extremely difficult to get her motivated (to walk) but now she absolutely loves it.”
Emily began attending church in 2020, a few months before her mom passed away. She started to build friendships and establish herself within the community at her church. When the Covid-19 pandemic began and restrictions were introduced, it was extremely difficult for her. She was “locked down in March and then her mom passed away in April. It was so painful. I (her intervenor), did interact with her the whole time [over] facetime and I would see her occasionally outside, socially distanced.” Emily was socially isolated for four months until her intervenor was approved to see her in person with PPE. Emily started receiving music therapy in September 2020.
Initial Music Therapy Assessment:
Emily was referred to Telehealth music therapy at the beginning of September. Through initial discussion it was agreed that she would participate in two weekly one hour sessions. The first few music therapy sessions were observed by the MTI and led by the MTA supervisor.
Identifiable goals began to emerge from the observation of decreased socialization due to the COVID-19 restrictions. Emily had expressed in the second session that she was having trouble falling asleep and staying asleep due to her anxiety. She explained that she would often get up in the middle of the night and walk around her room to calm herself. The treatment plan included long-term goals to see improvement over the course of treatment (three to four months), as well as short-term goals seen over three to four weeks. The MTI chose to include the goals of decreased isolation and symptoms of anxiety into her treatment plan as short-term goals.
The goal of emotional expression was chosen after four sessions reflecting on the benefits of providing Emily with a safe space to express herself and the potential benefit to her mental health goals. Through this strategy, the MTI observed Emily’s ability to comprehend emotional situations. She seemed unable to describe the feelings that she had around her mother’s death.
The MTI observed that she spoke very matter of factly when she spoke of her mother’s passing. The MTI chose to use lyric analysis interventions to encourage her to talk about her mom. When asked about how she related to lyrics of a song, she would usually restate the lyrics directly and often missed the overall message of the song. The MTI was unaware of Emily’s developmental age at the time, but the current assessment provided the MTI with evidence of a younger developmental age.
Over the next few weeks, The MTI assessed the benefits of introducing autonomy into the music therapy sessions as a potential goal area. The MTI asked Emily questions about her preferences for the session materials and gave her additional choices. After one specific session, Emily’s intervenor reached out to thank the MTI for including choices in the sessions. Emily’s intervenor mentioned that they had been working on making informed choices independently in their own work together. With this new information, Emily’s treatment plan was updated accordingly.
Emily’s Treatment Plan:
Name: Emily (E)
MT(Intern): Tiana Dick
Diagnosis/Community: Deafblind, Bereavement
Areas Identified Within Assessment
Increased independence through:
- Emotional Expression
- Decreased Isolation, increased socialization Decreased anxiety through:
- Increased relaxation
- Increased self-confidence, self-esteem
Goal #1: To increase independence through exploring autonomy.
Objective #1: The MTI will prompt E to make a minimum of 2 choices between 2-4 options during each music therapy session. E can be offered a choice between interventions that she would like to participate in, songs that she would like to hear,
Objective #2: E will participate in improvisation interventions for at least 15 minutes of every music therapy session. E will take turns creating sounds with the music therapist and will be encouraged not to imitate each sound the music therapist makes but to come up with something new each time. Options for instruments to use for improvisation will increase as E becomes more comfortable with improvisation.
Goal #2: To increase E’s emotional expression.
Objective #1: E will participate in at least one lyric substitution or songwriting intervention every other week.
Objective #2: E will participate in improvisation interventions for at least 15 minutes of every music therapy session. The MTI will prompt E to improvise while thinking of a specific emotion relayed by the music therapist. E will take turns creating sounds with the music therapist and will be encouraged not to imitate each sound the music therapist makes but to come up with something new each time. E will then participate in discussion around the sounds that were created to represent the emotion presented by the MTI.
Objective #3: E will participate in lyric analysis interventions in which she will pick one line of lyrics from a song, chosen by the music therapist, and discuss how she relates to the lyrics and why they are significant.
Goal #1: To decrease symptoms of anxiety and increased positive self regard.
Objective #1: E will be asked how she is feeling at the beginning and end of each music therapy session. E will be offered music assisted relaxation interventions when she indicates that she is feeling anxious during the sessions.
Session Plan: Mar. 9th 2021
Name: Emily (E)
MT(Intern): Tiana Dick Diagnosis/Community: Deafblind, Bereavement Recorded: Yes
Goals Identified in Treatment Plan: Increased autonomy, creative/emotional expression, positive self-regard and decreased symptoms of anxiety.
Song: Music assisted relaxation (Greenland visual and music)
Goal: Orientation/Socialization/Emotional Expression
Intervention: Have E listen to the music played by the music therapist and watch the scenery of the video. Ask her about how she is feeling before and after the intervention.
Song: Born this Way, Fight Song, or How Far I’ll Go (choice)
Goal: Autonomy/Emotional Expression/Positive Self-Regard
Intervention: Have E listen or sing along to the words of the song and have her analyze the lyrics once the song has been sung.
Song: Call and Response Improvisation (Band Lab)
Goal: Creative Expression/Autonomy/Positive Self-Regard
Intervention: Have E improvise first using rhythmic instruments and then give her the choice to transition into melodic instruments.
Song: Songwriting (songstory improvisation)
Goal: Autonomy/Emotional Expression/Creative Expression/Socialization
Intervention: Have E sing and record her song over Telehealth and then improvise over the recording. (next week if not completed in time for the end of the session).
Song: The Blessing
Intervention: Have E listen to the chords being played without the lyrics and then have her sing with the therapist.
Song: E’s Prayer
Goal: Orientation/Positive Self-Regard/Vocalization
Intervention: Have E sing her prayer along with the music therapist as an ending to the music therapy session.
As the MTI, my approach was focused around a combination of The Interactive Approach developed by Juliette Alvin and the Nordoff and Robbins Approach developed by Paul Nordoff and Clive Robbins.
Alvin’s Interactive Approach involved tension and release in music and matching it with the body’s physiological patterns of activity and rest (Vassiliki Karkou, and Patricia Sanderson). I considered the relaxation elements of Alvin’s interactive approach when looking at the different techniques used to promote relaxation. When I first started working with Emily, I observed my supervisor’s decisions for what interventions to start with. She had chosen to use a music-assisted relaxation intervention at the beginning of the first three sessions. Music-assisted relaxation (MAR), is used for stress reduction, anxiety management, meditation, and spiritual development. The music itself is approximately three to seven minutes in length, may have a melody, has predictable harmony, minimal dynamic changes, and a tempo between 58 beats per minute (bpm) and 78 bpm (Barbara L. Wheeler, 2015). I decided to continue providing music- assisted relaxation at the beginning of every music therapy session while also coupling it with other relaxation techniques. I usually focused the starting tempo on Emily’s visible respiratory rate or body movement when I led music assisted-relaxation interventions. If I matched my tempo (bpm) to her natural rhythms and then slowly lowered it, the effects of the relaxation were likely to be stronger. This music therapy technique is known as the iso principle (Annie Heiderscheit and Amy Madson, 2015). I also combined music-assisted relaxation with muscle tension release techniques and breathing techniques. First, I asked Emily about her week and how she was feeling. I would then request that she close her eyes and listen to the music I was improvising while focusing on her breath. After the relaxation intervention, I would ask her again how she was feeling, or if her feelings changed at all during the relaxation intervention. Approximately 90% of the time, Emily reported a positive change. Soon, Emily began to develop her own tools for coping with her anxiety through listening to her own chosen music and focusing on her breathing. She reported using this technique the most when she was having trouble sleeping. I began to reconsider the requirement of relaxation focused interventions and chose to ask Emily at the beginning of each session if she had a need for a relaxation intervention. If she mentioned that she was anxious when I checked in with her, I would ask her if she wanted to participate in music-assisted relaxation or if she would like to continue on with the other interventions. For the remainder of the music therapy sessions, the source of her anxiety was usually related to an upcoming eye procedure that happened once or twice per month. If Emily ever mentioned directly or indirectly that she felt that she couldn’t do something or didn’t want to try, I would encourage her to reframe her thinking. This was something that I learned later that her intervenor was doing regularly with her, especially around simpler tasks.
The other approach that I drew from is the Nordoff & Robbins approach. Although not trained in the Nordoff and Robbins approach, it was accessed to support this client because of its focused outcomes specific to improvisation. Nordoff & Robbins refer to the “natural capacity for musical perception and recreation” as the “music child” within every human being, (Barbara L Wheeler, 2015). Both the client and the therapist take part in discovering the unlimited potential for sound and creative expression within the music. They do this through collaborative clinical improvisation. Improvisation, in the context of music therapy, is “any experience in which the client actively participates in spontaneous music making with the therapist and/or other clients playing instruments, vocalizing, or sounding their bodies or other objects. In the Nordoff & Robbins approach, improvisation can “reach clients on a deep level, motivating them to take the next steps in their development, despite tremendous challenges.”
Importance of Improvisation and Songwriting:
There were two interventions that were especially successful in Emily’s music therapy treatment. The first intervention was clinical improvisation. Improvisation worked to tackle all of Emily’s goals including autonomy, creative and emotional expression, decreased isolation, increased socialization, and increased self-confidence.
The key to improvisation is that there is a lack of defined boundaries as to what you can consider musical. When you are improvising with a client, you are creating a space that is non- judgmental and safe to explore and to be authentic. This is dependent on the music therapist and how they set up the intervention to ensure the client feels successful. There are many different ways to improvise with a client in a session. For example, one way is to have both the client and the therapist interacting with each other in real time.
Because Emily’s sessions took place through Telehealth due to the pandemic, the option to simultaneously interact with each other was eliminated due to the audio delay across the platform. Instead, The MTI used a “call and response” method where both the client and the therapist were able to take turns musically interacting. One of the great things about improvisation is that there are no rules as to what is considered music. As long as the sound you are making fits into the musical elements of rhythm, melody, or harmony, you are making music. The MTI initially prompted Emily to use body percussion and then began to add additional options. When working on call and response, the MTI prompted Emily to avoid copying and repeating rhythms to encourage independence.
When the MTI first introduced improvisation to Emily’s sessions, the intention was to build rapport and increase socialization while also using improvisation as an assessment tool to gauge her level of confidence with herself and her abilities. Once improvisation became an objective for every session, The MTI began to experiment with other ways to improvise.
Focusing on autonomy, Emily was presented with many choices through improvising, she started making more informed independent decisions outside of the music therapy session as well. Her intervenor encouraged her to be spontaneous by “going for walks and having her choose what path they would take each time.” Over time, the number of options available could increase as Emily began to build more confidence in the choices she was making. The MTI asked Emily to download an app called Bandlab to give her access to a library of pre-recorded instrument samples. Bandlab allowed Emily to both play the instrument and save a recording.
The MTI encouraged Emily to improvise using five sounds that were selected by the MTI on the app. After improvising on the app, the MTI prompted Emily to explore the different sounds without the pressure to improvise on the instruments. After Emily appeared more comfortable on the app, the MTI prompted Emily to use any of the instruments offered by the app for future music therapy sessions. After four sessions, Emily was able to open the app, choose an instrument, and start the improvisation independently. The MTI observed Emily as having little to no hesitation in committing to whatever decisions she made in improvisation for the remainder of the music therapy treatment.
Improvisation also had a great impact on the goal of creative and emotional expression.
During some of the music therapy sessions, The MTI would ask Emily to think of a specific emotion. It could be one that she was feeling, one that she had felt in the past, or one that she would like to feel. The MTI then asked her to musically share what she thought that the emotion might sound like on her chosen instrument. The MTI would then prompt Emily to discuss the different sounds that she made and why they represented that specific emotion. Occasionally, this intervention prompted meaningful discussion on past experiences in which she related to that emotion.
The second intervention that made the most progress in the goal of emotional expression was songwriting. Songwriting is used in music therapy as an opportunity for clients to take their feelings and experiences and transfer them into words. It often helps the client see different perspectives on their experience and identify coping mechanisms and solutions. Lyric substitution is a type of songwriting in which the client is able to take an already written piece of music and change the lyrics to reflect a different subject or to simply make them more relatable to their personal experience. Emily seemed avoidant when it came to expressing emotion, especially around the subject of her mother’s passing. Emily showed avoidance by giving brief responses to the MTI’s questions. The great thing about songwriting is that it becomes a project that the client can work on and complete. It produces a final product that they can keep, share with other people, and be proud of. It was important in Emily’s treatment to encourage her when progress was made on a project that she was working on in the music therapy sessions. The MTI regularly reminded her about the work she was doing to answer tough questions and make choices between sounds to produce an original song.
Example: during the first month of the music therapy sessions, The MTI invited Emily to write a goodbye song that could be sung at the end of each music therapy session. The purpose of a “goodbye song” in music therapy is to provide the client with resolution for the session.
Emily chose to write the goodbye song in the style of a prayer. For Emily, a prayer seemed to be an appropriate choice to end the music therapy sessions because of how commonly church services are closed in prayer. Below are the lyrics to the prayer.
I pray that this week is good,
I pray that you help me through my anxiety,
I pray that you give me peace so that I can sleep,
I pray for my Dad, for you to give him strength to quit smoking, I pray for good health for [friend] and [friend],
I pray for good health for myself, I want to get to know you more,
I will always remember that you love me, Thank you heavenly father for loving me , Thank you for calling me your child,
Emily was able to choose the words and the chords from options given by the MTI and her intervenor. Through songwriting, Emily discussed her relationship with her father, her friends, religion, and she provided more information about the causes of her anxiety. After two weeks, the prayer was completed and the MTI provided Emily with a recording. Emily sang it with the MTI during the next few months to end the music therapy sessions. As songwriting continued, Emily became more confident in her abilities to creatively express herself. The MTI encouraged Emily to share her songs with her friends and family as another way to add to the goal of increased positive self-regard.
When working with Emily, the most observable factor that was prohibiting her from achieving her goals was a lack of confidence in her abilities. She was afraid of making the wrong choice, she would avoid making decisions by relying on the people around her to make them for her. Music therapy worked towards the goal of autonomy by increasing her confidence in her abilities through clinical improvisation techniques and songwriting techniques. Her ability to commit to her own decisions with little to no hesitation within the music therapy sessions, led her to start feeling more confident in the decisions she was making outside of the music therapy sessions. Her intervenor later explained in an interview that “I got so excited because I had never seen [Emily] making spontaneous independent decisions before. I wanted to distance myself because [normally] she would always look at me to prompt her, so music has really given her the freedom to be spontaneous.” Emily’s previous music therapist also observed her “willingness to accept self. Becoming independent after school and feeling confident in a productive role in society.”
Emily’s increased sense of confidence and positive self-regard also led to reduced symptoms of anxiety. Anxiety can present itself as avoidance in an individual, and it was observed to manifest with this client because of a struggle to process feelings associated with anxious thoughts. Emily was described by her intervenor as heavily reluctant toward putting herself in positions in which she would have to think for herself. As music therapy worked towards the goals of autonomy and increased confidence, she was no longer feeling as anxious about being spontaneous and she didn’t need additional prompting from her intervenor.
It’s important to note that the environment that Emily was in during these music therapy sessions was familiar and comfortable; she didn’t feel that she was being left alone to make decisions. Her intervenor was present for the majority of music therapy sessions and communicated that she was seeing improvement in Emily’s ability to be independent. She decided that she would leave the room for some of the sessions, but still be available if needed to further her independence. This gave the MTI freedom to work with her on a deeper level while still checking in with her to make sure that she was feeling comfortable. Once rapport was established in the therapist/client relationship, Emily was able to make great progress towards her goals.
It is important to recall that the music therapy sessions took place online through Telehealth. Through Telehealth, Emily was given full control of her environment for the music therapy sessions. From what has been shared by Emily’s intervenor, Emily can feel anxious in social situations with people that she does not know. Telehealth music therapy sessions added to Emily’s level of comfort because there was no physical presence around her other than her intervenor. Emily was able to begin and end the music therapy sessions independently through the use of her own devices (tablet, phone, etc.).
As a qualifying music therapist, my clinical recommendation is to have individual music therapy sessions transition to in-person sessions in addition to Emily joining a small online group music therapy session. My recommendation stems from the benefit of accessing additional improvisation interventions that are currently restrictive through the telehealth platform. It is possible that it could take longer to build rapport with Emily during in-person music therapy sessions, but the effectiveness of the treatment within the sessions will be more beneficial outside of the sessions. Emily could benefit from an additional goal of reduced social anxiety where she has complete control over her environment the same way that she was able to have complete control with optional assistance in our music therapy sessions. Telehealth group music therapy sessions could provide an environment conductive to success in the goal area of increased socialization. A future music therapist may find success in implementing improvisation, songwriting and lyric substitution interventions during each music therapy session. Music therapy sessions can continue to be an effective form of treatment for Emily to address the goals of increased autonomy, creative/emotional expression, positive self-regard and decreased symptoms of anxiety.
Amy Di Nino. N’s Music Therapy Treatment. 24 Mar. 2021.
Annie Heiderscheit, and Amy Madson. “Use of the Iso Principle as a Central Method in Mood Management: A Music Psychotherapy Clinical Case Study.” February 10, 2015, doi:10.1093/mtp/miu042.
Barbara L Wheeler. Music Therapy Handbook. The Guilford Press, 2017. Canadian Deafblind Association British Columbia.
Fellinger, J., Holzinger, D., Dirmhirn, A., van Dijk, J., & Goldberg, D. (2009). Failure to Detect Deaf-Blindness in a Population of People with Intellectual Disability. Journal of Intellectual Disability Research, 53(10), 874–881.
Lois Winsor. N’s Music Therapy Treatment. 14 Mar. 2021.
Ontario Ministry of Education. https://pdsbnet.ca/en/schools/w-ross-macdonald/about-
Sensity Deafblind and Sensory Support Network of Canada. https://sensity.ca/careers/#:~:text=Intervenors%20are%20professionals%20who%20provide,
Vassiliki Karkou, and Patricia Sanderson. Art Therapies: A Research-Based Map of the Field. https://books.google.ca/books?id=GNqRgVwBZT0C&lpg=PA132&dq=nordoff%20robbins