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Theoretical foundations and workable assumptions for cognitive behavioral music therapy in forensic psychiatry

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Theoretical foundations and workable assumptions for cognitive behavioral music therapy in forensic psychiatry
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  The Arts in Psychotherapy 40 (2013) 192–200 Contents lists available at SciVerse ScienceDirect The Arts in Psychotherapy Theoretical foundations and workable assumptions for cognitive behavioralmusic therapy in forensic psychiatry  ,  Laurien Hakvoort, MA, SRMTh, NMT a , ∗ , Stefan Bogaerts, PhD b , c , d a  ArtEZ School of Music, Van Essengaarde 10, 7511 PN Enschede, The Netherlands b Tilburg Law School, INTERVICT, School of Social and Behavioral Sciences, Forensic Psychology, Tilburg, The Netherlands c Kijvelanden Academy for Research, Innovation and Development (KARID), The Netherlands d Catholic University of Leuven, Leuven Institute of Criminology (LINC), Belgium a r t i c l e i n f o Keywords: Forensic psychiatryCognitive-behavioral music therapyTheoretical foundation a b s t r a c t This article offers a theoretical foundation for cognitive behavioral music therapy in forensic psychiatry.First, two cases are presented to give an insight into music therapy in forensic psychiatry. Secondlysome background information on forensic psychiatry is provided. The Risk-Need-Responsivity modelis explained as a starting point and the role of music therapy in this treatment is explained. The thirdpart offers a cognitive behavioral music therapy model and explains the (neurological) role of music andthe music therapist in the treatment of forensic psychiatric problems. The article ends with a few finalremarks.© 2013 Elsevier Inc. All rights reserved. Introduction Although a relatively small number of music therapists workin forensic psychiatry (approximately 150 worldwide; Codding,2002), they have produced quite a substantial number of articleson their work in this specific context (Compton Dickinson, Odell-Miller,&Adlam,2012;Crimmins,2010;Daveson&Edwards,2001;Davis & Thaut, 1989; Drieschner, 1997; Fulford, 2002; Gallagher &Steele, 2002; Hakvoort & Smeijsters, 2006; Hakvoort, 2002, 2007a,2007b; Hakvoort, Bogaerts, & Spreen, 2012; Hakvoort, Bogaerts,& Spreen, submitted for publication; Hoskyns, 1995; Meekums &Daniel, 2011; Reed, 2002; Rickson & Watkins, 2003; Rio & Tenney,2002; Santos, 1996; Sloboda & Bolton, 2002; Smeijsters & Cleven,2004; Thaut, 1989a, 1989b, 1992; Watson, 2002; Wyatt, 2002;Zeuch, 2001, 2003; Zeuch & Hillecke, 2004), until now no pub-lication has provided an explicit theoretical foundation for theeffectiveness of music therapy in the treatment of forensic offen-ders.Thisarticleaimstoprovidesuchatheoreticalbasisbyfocusingon the role of music, the music therapist and their influence onpatients’developmentduringmusictherapyinforensicpsychiatry.  The authors are thankful for the research funds provided by ArtEZ, Institute of the Arts and Forensic Psychiatric Center Oostvaarderskliniek. This study is part of aPhD-research at the Tilburg University.  The authors want to acknowledge Clare Macfarlane (PPC PI Vught) for proof-reading and her suggestions to correct our English vocabulary. ∗ Corresponding author. E-mail address:  L.Hakvoort@artez.nl (L. Hakvoort). The article consists of three main parts. The first part describeshow music therapy is used in forensic settings, with two casesusing treatment excerpts of the music therapy. One illustrates themusictherapytreatmentofagroupofforensicpsychiatricpatientsand the other an individual case. The cases show how the musictherapist affects and trains forensic patients by creating a specificmusictherapeuticprocessandtherapeuticalliance.Thesecondpartprovides a brief description of the overall treatment of forensicpsychiatric patients. This part includes a discussion of the specificcharacter of forensic treatment. Forensic psychiatry is character-izedbytheimportanceof“Risk-Need-Responsivity”factors(Bonta& Andrews, 2007) and a cognitive behavioral approach. The thirdpart of this article presents the theoretical foundations for the useof music therapy in forensic psychiatry. It discusses the functionsofmusicinforensicpsychiatryandhowthesefunctionscanbeuti-lized within a cognitive behavioral approach. Implications of thetheoretical foundations are further illustrated using the cases asexamples. Case 1: group music therapy to enhance social interaction andcoping skills “ . . . BlueSuedeShoes! . . . ”screamsRonintohismicrophone.Jimhitsallthetom-tomsandthecymbalsoneaftertheother,whilewildlyhittingthebass-drumwithhisfoot-pedal.PeteplaystheA power-chord as fast as his hand can move up and down andBen plucks the A-string on the bass guitar as strongly as he can.The noise is overwhelming, but as soon as the music therapistlifts her hands off the keyboard, they all four end at exactly the 0197-4556/$ – see front matter © 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.aip.2013.01.001  L. Hakvoort, S. Bogaerts / The Arts in Psychotherapy 40 (2013) 192–200  193 samemoment.Thelastchordof‘BlueSuedeShoes’stillvibratesinthemusictherapyroom.Benopenshiseyesandlooksaroundwithabigsmile.Notoneofthemspeaks,buttheyallbeamwithdelight. The therapist smiles and says: “Gentlemen, you havecompletedyourmusicalgoalverywell!Eachofyoustucktohisassignments and used his acquired skills.”These four men have been participating in music therapytogether for ten weeks. Ten weeks before the four of them wereassignedtomusictherapytoworkontheirsocialandcopingskills,suchaslisteningtoothers,takingotherconsiderationsintoaccountand learning to cooperate. The four men have quite a mixed back-ground. Pete and Ben both suffer from psychotic episodes and areunmotivatedfortreatment.Theyarenotallowedtomoveindepen-dentlythroughtheclinic.Ronismentallyretarded,hasanantisocialpersonality disorder, and is prone to aggressive out-burts. He is onmedication and quite motivated to participate in treatment. Jimsuffers from an antisocial personality disorder and brain-damageduetoseverealcoholabuse.Duringtheintakehehasstatedthatheneeds no treatment, he is doing well in the unit. He doesn’t under-standwhyheisassignedtomusictherapybytheheadoftreatment.Afterathoroughintake,Jimagreestocomebecausehelovestoplaydrums and the only drum-set available in the clinic is in the musictherapy room.During the first session Ben, Pete and Ron listen to Vertigo byU2, because it is one of the few songs they all appreciate. This willmake the wait for Jim (who is late) less problematic and with itsupbeat tempo might activate the three patients present. The firstactive musical assignment that was given is playing drums whilethetherapistplaysVertigoonthepiano.Ofthepatients,onlyRonisabletokeepthebeatsteady.Whenthetherapiststopsplaying,Petealso stops while the other two continue. Ron just does not listenand Ben is staring at him. The therapist prompts them to stop and judges that the assignment of playing drums and simultaneouslylistening to the others is too difficult for them.The therapist decides to start on a lower entrance level andchanges the assignment to all playing the djembe. For the next30mintheypracticetuning-intooneanother.Theystartwithexer-cises in following rhythms of just one person at a time. All kinds of drum assignments are played: looking at the person who has tostop, looking at one another, with eyes closed (except for the ther-apist). Ben is amazed that if he closes his eyes he can concentratebetteronthemusicandthepeoplearoundhim.Herealizesthatheis always focused on visual stimuli (suffer as he does from mainlyvisualhallucinations).Themusic,andespeciallytheclearstructureof the drum assignment, makes it possible to keep repeating thetasks. Jimentersthesession30minbeforeitfinishes.Heimmediatelydismisses the whole assignment as ‘boring’ and the next as ‘toosimple’.Jimrefusestoplaypercussion,congasordjembe.Heclearlystates he is not a child and that these assignments are for ‘sissies’.He only wants to play the drum-set. Suddenly no-one wants tocontinue the exercises they were practicing. The therapist doesn’twant to raise the tension in the music room but also ignores Jim’snegative attitude.The therapist asks each one to join in with ‘Blue Suede Shoes’(a song with an easier structure than “Vertigo”). The therapistreturns to the keyboard and asks Jim to play the drum-set. Ron,Ben and Pete keep their djembes. The latter three are very alertas to what happens musically and are very much focused onhow Jim acts. Jim plays the drum-set very loudly; he does notplay a fill, nor reacts to any break. As soon as the song endshe starts complaining. He fusses about the quality of the drum-set, he mocks that he misses an e-guitar and a bass-guitar in thesong, and he comments the lack of good musicianship in thisgroup.The therapist decides not to risk counter-transference and soasks them all to each tell one person what he would like himto change in the next run-through. Jim complains that a millionchanges are needed before this music can ever sound as it should.Because there is a tangible tension, the therapist asks Ben if hewouldbewillingtoplaythethreebass-notesoneitherkeyboardore-bass.EvenbeforeBencanreply,JimasksRontosing.Ronagrees.ThetherapistasksRonwhathewouldaskanotherpersontochangein his music. He asks Jim to play less loudly. It takes Ben and Petefar more time to formulate any request to another person. After anumber of suggestions by the therapist, Pete hesitantly asks if hecan play the e-guitar. Ben wants to move over, so he can play thebass on the music therapist’s keyboard.The next run-through of ‘Blue Suede Shoes’ is very tentative.Ron is singing softly keeping up with Jim’s high pace drumming,which Pete cannot match on the e-guitar. Jim does not stick to hisassignment and plays loudly, not listening to anyone else. Ben iscompletely focused on the therapist. He has lost the connectionwith the other three ‘musicians’, but is beaming. He successfullyplays the A(4 × )–D–A–E–A. The therapist paces the chords on thekeyboardtoJim’stempoandRon’ssingingbutthelatteronlyseemsto hear Jim. After the first verse and refrain, the therapist decidesto synchronize with Pete to support his efforts to play the correctchords.Hesmilesablinkofasecond(recognizingthathehasheardher),buthasdifficultieschangingtotheDchord,sotheconnectionislostagain.Afterthesecondverseandrefrain,thetherapiststops,immediatelyfollowedbyBen.Ittakesawhilebeforetheothersstoptoo.Each one of them is asked to repeat his assignment verbally forthis run-through and to state what are the most useful new skillstheyhavelearnedtoday.Pete,BenandRonmentionaskillfromtheattunement assignments. The therapist gives them the homeworktoapplythatskillatleastonceaday.Jimannouncesthatheshouldpractice his drumming skills. The therapist suggests that he cantry using pencils on his pillows and bed and try to play fills andbreaksaftereach7bars.Thetherapisttellsthegroupthattheywillcontinue the next session with attuning exercises to meet theirtreatment goals, necessary to perfect ‘Blue Suede Shoes’.One has to realize, that practicing 30min does not change pat-terns of inattention that have grown for years. These men have,however, been developing new paths in listening to one another,takingothersintoconsiderationandactivelyaskingotherstomakechanges, which after 10 weeks results in a mutual performance of this song, that meets the treatment goals. Case 2: individual music therapy to enhance anger management skills Ralph has been referred to music therapy due to his violentoutbursts. He is convicted for double homicide, multiple violentoutbursts and knife-fights. He is highly intelligent, suffers fromanti-social personality disorder and has been severely addicted tococaine and speed. In an extreme rage, Ralph can destroy things inhis direct surroundings without any inner warning (according tohimself). In the living-unit, group-workers and fellow-patients areverycautioustowardshim.Becausemusicisprobablylessdirectintriggeringaggressionandmighthelptogaininsightintoandcontrolhis anger, he was referred to music therapy anger management.Duringthefirstfoursessions,Ralphlistenstohisfavoritemusic(rock,blues,romanticandavant-gardeclassicalmusic).Ralphlikesto talk about what happens in the living-unit and what caused hisoffences. He states that he does not understand why people fearhim or where his violent outbursts come from. Besides talking, heis also easily persuaded to make music and to play together. Thetherapistneverrequireshimtodoanythingtoodifficultandalwayspraiseshimforallhisefforts;atherapeuticallianceoftrustisbuilt.  194  L. Hakvoort, S. Bogaerts / The Arts in Psychotherapy 40 (2013) 192–200 Hewantstolearntoplaythedrum-setproperly.Heeasilypicksupmore difficult assignments of coordinating his extremities whileplaying patterns and breaks on the drum-set. His hand-foot coor-dination is amazingly good. This is the starting point for workingon his need-factor: anger-management.InmusictherapyRalphworksonmoreactivewaysofdecreasinghis anger as soon as it floods him. He practices musically to stay intouch with the therapist while playing very loudly or very fast. Heenjoystheseexercisesandtransfersthisskilltotheunitbytrustinggroup-workers to direct him to his room when it is perceived thathe is becoming angry.In close collaboration with the psychotherapist, the therapistdecides to provoke musical situations that might offer Ralph someinsight into his aggressive outburst. Slotoroff’s (1994) drummingassignments were used in which the therapist disrupts his drum-ming. After the second beat on the drum Ralph stops the therapist,because he states that he is sensing tension. No physical or facialchangeisapparent.Thetherapistplaysagainandisstoppedassoonas she decreases the volume with even a slightest drop in decibels.Ralphisastonished;suchasmallchangeinhisexpectationtriggershis tension, after just a fraction of a second. He realizes that thishappens to him all the time. He gets agitated as soon as somethingdiffers even slightly from what he expects. He just ignores or evenblocks out this onset and thereby becomes completely unaware of the process of rising tension. He is suddenly aware of how easilyhe is angered and triggered into aggressive out-bursts. With thisinsight he returns to the unit.During the weekend Ralph had such a dramatic aggressive out-burst that he is placed in solitary confinement. The staff onlyapproachhimwithfourmenwearinghelmetsandshields.Hekicksand lashes out at anybody who comes near him. He refuses anymedication to help him diminish his aggression. He refuses to talkto the psychiatrist, but lets her know that there is one thing thatmight help him to cool down: music therapy.With every following contact Ralph repeats his demand. Thestaff decide that the music therapy might actually help Ralphdecreasehisrage.TheynegotiatewithRalphthatheshouldbehavefor three consecutive days and use medication. Then on Fridayafternoon he will be taken to music therapy. This gives the staff a couple of days to arrange safety precautions. Ralph agrees to thisplan. He accepts medication, talks to the psychiatrist, and the psy-chotherapist, and behaves cordially to group-workers and guards.He stays in the confinement room.Besidesphysicalalarmandguardsonthelookout(inthiscase),the safety and security in the music therapy room should comefrom musical distance and the therapeutic alliance (see later). Assoon as the music plays the next session, Ralph sits back and ten-sion leaves his body. Ralph starts talking about what happenedover the weekend. He realized how fast he was angered and thathe did not have the skills to stop this process. The rising tensionis audible in his voice, visible in his body posture and the musictherapist feels her own stress-level rise. To prevent guards frombursting into the music therapy room, or becoming victimized byRalph’s newly rising anger she decides to start making music withRalph.Ralphwalksovertothedrum-set.Themusictherapistsitsdownat the piano, so she can musically contain his drumming. He startsoff with a really high volume, high-speed pattern. His face is grim,his body posture tensed. The music therapist can hardly hear her-self play the piano, so she switches to the second drum-set in themusictherapyroom.Shemakessureshestaysasclosetohisvolumeand tempo as possible, while offering a holding for his drumming.After seven bars she plays a break, to create a structure with rests.Ralph reacts by adjusting his rhythmical patterns to the eight barmeasure. They play for over 30 min straight. The music therapistprevents any intensification, so the music does not get faster orlouder. Ralph continues to play with the same intensity (musi-cally and physically). When fatigue sets in techniques of calmingare applied (decrease of volume and deceleration). Ralph hearsthe change and follows the tempo and volume. His face and bodybecome more relaxed with every softer beat.Afterapauseofabout30sRalphsighsandstatesthatthemusictherapy helped him even better than he had hoped for. He has thefeelingthattheragehasvanished.ThemusictherapistrealizesthatRalph’s tension has only diminished for the moment. Forensic psychiatry: risks, needs and effective treatment According to the American Academy of Psychiatry and the Law(2005):“forensicpsychiatryisasubspecialtyofpsychiatryinwhichscientific and clinical expertise is applied to legal issues in legalcontexts embracing civil, criminal, and correctional or legislativematters.” In Europe forensic psychiatric patients are mainly off-enders who are placed under a code of law and sentenced tomandatory hospitalization (Gutheil, 2004). These patients are sen- tenced for committing a violent crime (e.g., rape, child molesting,armedrobbery,manslaughter,ormurder).Duetotheirpsychiatricorpsychologicaldisordertheseoffendersareheldtobenot,oronlypartly accountable for their crime (Van Marle, 2002).About 40 percent of the patients are diagnosed with cluster Bpersonalitydisorders(antisocial,narcissisticandborderline).Morethan one-third suffer from psychotic episodes or schizophrenia(Van Nieuwenhuizen et al., 2011). In most cases, co-morbidity is a core problem because almost all patients have various disor-ders imposed on these primary diagnoses (Van Gemmert & VanSchijndel, 2011). The most common (80 percent) sub-diagnosis isan addictive disorder (Van Nieuwenhuizen et al., 2011).The highly complex mixture of disorders and offences makestreatment complicated. Forensic treatment goals can be dividedinto two objectives. The first main objective is to protect societyfrom individuals who might threaten society’s safety. The secondmain objective is to treat forensic psychiatric patients in orderto prevent them from recidivism into (violent) offences (DouglasBroers, 2006).From a theoretical perspective, forensic psychiatric treatmentleans on the “Risk-Need-Responsivity model” (RNR, Bonta &Andrews, 2007) and Good Lives model (GLM, Ward & Stewart, 2003)relatedtotheviolentoffence.AccordingtoRNR,eachforensicpatienthastobeassessedonthefactorsthatinfluencehispersonalrelapse and offence risk. Major  risk-factors  that contribute to theprobability that a forensic psychiatric patient relapses into a vio-lent crime are: (a) a history of antisocial behavior, (b) antisocialpersonality, (c) antisocial cognition, (d) antisocial associates, and(e) substance abuse (Andrews, Bonta, & Wormith, 2006).Studies also suggest that changes in factors affect the probabil-ity of an offence-relapse. Andrews et al. (2006) reviewed a large number of meta-analyses with respect to risk-factors and posi-tive outcomes of treatment. They suggest that treatment goals forforensic psychiatric patients should focus on: “building problem-solving skills, self-management skills, anger-management andcoping skills, reducing substance abuse, creating (inter)personalsupport ( . . . ) and enhancing alternatives to drug abuse” (Andrewset al., 2006, p. 11). These are the “ need -  factors ”. Ward and Stewart(2003) propose that the criminogenic needs of patients can be metmosteffectivelyiftheirhumanneeds(suchaspositiveself-esteem,positivevalues)aremetaswell,whichresultsinthesocalled“GoodLives model.”Several preconditions must be met to optimize the condi-tions for an effective treatment of forensic psychiatric patients.The current state-of-the-art in research suggests that a cognitive-behavioral approach is most effective in the treatment of forensicpsychiatric patients (Allen, MacKenzie, & Hickman, 2001; Hollin,  L. Hakvoort, S. Bogaerts / The Arts in Psychotherapy 40 (2013) 192–200  195 1999; Landenberg & Lipsey, 2005; Marshall & Serran, 2000;Timmerman & Emmelkamp, 2005; Wormith et al., 2007). Thecommon emphasis in the cognitive-behavioral approach in foren-sic psychiatry is the “what works” principle (Hollin & Palmer,2006). These treatments include, among others, “Reasoning andRehabilitation,” designed for clients with mental disabilities(Ross & Fabiano, 1985), “Moral Reconation Therapy,” (Little & Robinson, 1988), and “Aggression Replacement Training” for juve-niles designed by Goldstein and Glick (1987).However, the need-factors are not always easy to influence(Polaschek, 2011; Walker & Bright, 2009; Ward & Stewart, 2003;Wormith et al., 2007). Moreover, ethical principles of treatmentintegrity may sometimes prohibit meeting the criteria (Polaschek,2011). Finally, ‘what works’ on a meta-analytic level does notalways work at the level of the individual forensic psychiatricpatient,ormayevenhavereverseeffects(Hubbard&Pealer,2009;Pawson & Tilley, 1997). One of the main reasons is that, due totheir mandatory hospitalization, forensic psychiatric patients areoften unmotivated to participate in treatment. Therefore, a thirdimportant type of factor taken into account is the “Responsivity”of the client (Bonta & Andrews, 2007). The responsivity principle is to “Maximize the offender’s ability to learn from a rehabilita-tive intervention by providing cognitive behavioral treatment andtailoringtheinterventiontothelearningstyle,motivation,abilitiesand strengths of the offender.” (Bonta & Andrews, 2007, p. 1). Polaschek (2011), Walker and Bright (2009), and Ward and Stewart (2003) suggest that forensic patients’ responsivity is opti-mized when the need factors of forensic psychiatric patients areaddressed at different levels. Responsivity can be enhanced if patients are addressed at their own level of readiness for treat-ment (Polaschek, 2011), for example through appealing to the patient’s interest (Ward & Stewart, 2003; Ward, Melser, & Yates,2007). Polaschek (2011) proposes to use multi-modal treatment andtoofferindividualtreatmentifapatienthasapoly-problematicbackground,forexampleapersonalitydisorder,lowself-esteem,ahistory of abuse, and drug abuse (Hubbard & Pealer, 2009). Cognitive behavioral music therapy in forensic psychiatry  For many forensic psychiatric patients, therapy is an obligationbutmusiccouldworkasmotivator,inspirer,reinforcement,oreven‘seducer.’Itoftenmeetstheresponsivitycriteria.Musictherapycanbe a part of the multi-modal treatment used in forensic psychiatry(Codding, 2002; Polaschek, 2011).Music therapy has to meet the standards of forensic psy-chiatric treatment to be effective. Therefore music therapy inforensic psychiatry tends to be cognitive-behavioral, addressingtheneed-factors,targetingtherisk-factorsbyappealingtopatients’responsivity to music.In general, music works as a (primary) reinforcer (Peretz, 2010)(See neurological foundations below for details). In addition to thepositive feedback from the music therapist, reinforcement oftensrcinates from both making music and the music itself. Patientsoftenexperiencesuccesswhilemakingmusic.Thesepositiveexpe-riencesmayrepresentquiteanachievementforforensicpsychiatricpatients who lived in, and grew up under, very rough and quitedamagingcircumstances.Theexperiencescouldevokeamorepos-itive self-esteem, and thus contribute to criteria in the GLM (Ward& Stewart, 2003).Most music therapists in forensic psychiatry report that theyapply a cognitive-behavioral approach (Codding, 2002). The treat- ment goals they set predominantly focus on need factors (Bonta& Andrews, 2007), such as: building self-management skills(Hoskyns, 1995; Watson, 2002), problem-solving skills (Rickson & Watkins, 2003; Wyatt, 2002), aggression or anger-management(Crimmins, 2010; Fulford, 2002; Hakvoort, 2002) and coping skills (Dijkstra & Hakvoort, 2006; Hakvoort, 2007a, 2007b; Reed, 2002).Some music therapy programs pay specific attention to promot-ing alternative behavior to drug abuse (Dijkstra & Hakvoort, 2010;Gallagher & Steele, 2002; Silverman, 2003, 2010).Fromacognitivebehavioralperspective,musictherapyfocuseson the (musical) behavior of the patient. Indeed, patients demon-stratedifferentbehaviorsduringmusictherapy:musical,verbal,aswell as physiological, motor, psychological, emotional, cognitive,perceptual, and autonomic behaviors (Wigram, Nygaard Pedersen,& Ole Bonde, 2002). These behaviors are observed and interpretedthrough the music therapists’ knowledge of music, musical behav-ior and music therapeutic diagnoses, as well as information takenfrom the judicial inquiries, psychiatric and psychological observa-tions and diagnoses (Codding, 2002; Hakvoort, 2007a). Behavioral patterns that might be interpreted as risk-factors are distilled, andneed-factors are formulated. Each of these needs is formulated interms of goal-oriented target behavior. Cognitive behavioral music therapy model: the theoreticalassumptions Cognitive behavioral music therapy in forensic psychiatryimplies that music is applied to alter the behavior of forensic psy-chiatric patients in order to meet their need and risk factors. ThautandWheeler(2010)suggestthattherapists’awarenessof,andabil-itytohandle,theneurologicalandphysiologicalpotentialsofmusicareimportantpreconditionsforasuccessfulmusictherapyprocess.During music therapy, the music therapist has to create situations,which inflict primary affective responses in the patient. Moreover,the music therapist has to develop further the patient’s primaryaffective responses into a new repertoire of cognitive and behav-ioral responses. The development of responses can be reinforcedwith the help of the patient’s neurophysiological arousal responsein the brain. During practice, repetition, and homework assign-ments,thislearningcyclecouldchangeapatient’sbehavior(Thaut& Wheeler, 2010).Incognitivebehavioralmusictherapy,inlinewiththecognitivebehavioral approach in general, the music therapist deploys musicinspecificwaystoelicitcoreelements(thereinforcementofappro-priate behaviors, experimenting with new behaviors, adjustingincorrect thoughts, relaxation and role-playing (e.g.,Landenberg &Lipsey,2005;Linehan,1993;Walker&Bright,2009)).First,patient’starget behavior is assessed during music therapy; risk- and need-factors are compared to the primary indication. Secondly, patientsare trained through musical assignments to acquire new skills.Thirdly,musicalassignmentsareemployedtoprovokemusicalandbehavioral reactions of patients. Musical situations are created inordertostimulatepatientstomodifytheirbehavior.Therepetitionof experiences helps patients to adjust more rapidly to new, oftenstress-enhancing, situations. Fig. 1 offers an overview of the treat- ment cycle that music therapists apply in a cognitive behavioralmusic therapy in forensic psychiatry. Step 1 . The first step is to assess and observe the risk and need-factorsofthepatientbeingreferredtomusictherapyandtojudgeif the risk or need-factors are really demonstrated, either during theintake or the process of making music. If this is not the case, musictherapy is not the indicated treatment. Case application .  Case 1 . Ron, Pete and Ben are unable to listentothegroup.Theyareeithercompletelyabsorbedwiththemselvesor by a single other person. They need to expand their skills to beaware and stay attuned to other people. Case 2 . Ralph becomes tensed as soon as he is making music.During  Step  2 the music therapist trains patients to acquirenew competences, practicing his need factors musically as well asbehaviorally. These competences are trained while making music.Common competences that are practiced in therapy vary from  196  L. Hakvoort, S. Bogaerts / The Arts in Psychotherapy 40 (2013) 192–200 1. Paent is assessed for manifestaon of risk-and need-factors2. Behavior (skill) are trained (process needs repeon and homework) 3. Music therapist creates musical situaon to influence affect 4. Emoons are mimicked in paent. Paent reacts behavioral and emoonal5. Important musical moments might influence cognions 6. Reacon channelled by applying new skills 7. Good behavior reinforced by music and music therapist 8. Repeon outside music therapy (Homework, modal-disciplinary treatment) Fig. 1.  Cognitive behavioral music therapy model. the expression of emotions in different ways (Hoskyns, 1995;Watson, 2002), the development of specific coping skills (Dijkstra & Hakvoort, 2006, 2010; Reed, 2002), training executive functions(Hakvoort & Dijkstra, 2012), expansion of social skills, or psy- chosocial functions (Rio & Tenney, 2002), competences in anger management (Drieschner, 1997; Hakvoort, 2002), to the develop- ment of conflict management skills (Zeuch, 2001, 2003; Zeuch &Hillecke,2004).Thetransferenceofthesemusicalskillstodailylifeis promoted through homework assignments. Case application .  Case 1 . Ben, Ron and Pete practice social andattunement skills for 30min. They practice them while playingdjembe with various slight adjustments to make the exercisesmusically attractive. If social skills were trained by role-playing(commonly used in cognitive behavioral therapy, e.g., Linehan,1993), the patients would have become fed-up after a number of practices. Because the music keeps sounding (and rewarding) andcan be adjusted to easier or more difficult rhythms, Ben, Ron andPete are stimulated to keep rehearsing those skills. Case 2 . Ralph is practicing guided winding-down techniques;techniques in which another person has to help him with dimin-ishinghisrage.Thiscanbeafirststepintrainingangermanagementtechniques. Steps 3–5 . If the patient demonstrates his ability to apply newskills during training, the music therapist moves on to the nextstep. The therapist creates musical situations that evoke specificbehaviors in a patient (Hakvoort & Smeijsters, 2006; Smeijsters &Cleven, 2004). These musical risk-situations include experiencesof moments of defeat, feelings of powerlessness, rejection, bore-dom or other stressful events (Hakvoort, 2007a). Studies on music and emotions show that the process of making music does notevokeactualemotionsinpatients,butonlymimicsemotionalreac-tions ( Juslin et al., 2010; Koelsch, Fritz, Cameron, von Müller, &Friederici, 2006; Koneˇ cni, 2010) (see paragraph on neurologicalfoundations). The musical situation and mimicked emotions dohowever provoke reactions in the patient—which is  step 4 .  Step 5 allows the patient to become aware of his reactions, perceptions,thoughts, and behaviors in the created musical situation. The dis-tance created by making music can make it easier for patients tocome to grips with their expressed behavior. They can perceivethe situation to be ‘just about playing music’. This allows them toproject negative reactions and inadequate behavior in the music,without ethical consequences. Case application .  Case 2 . Ralph is not aware of the onset of hisaggressive outbursts. The music therapist applies Slotoroff (1994)drumming techniques. This provides Ralph with an insight intohow he blocks his anger. In the next session, Ralph is extremelytense when coming to music therapy; the advantage is that he hitsthe drum-set instead of a person. His lack of impulse regulationis expressed in the music. He is not confined for this anger norre-offends. Steps 6 and 7  . In  step 6 , musical confrontations are furtherexpanded and repeated to stimulate the patient to demonstratethat he can apply the new competences independently. Often,patients also experience their limitations during this stage. In  step7   the music therapist provides guidance through verbal, social andmusical techniques to reinforce the correct behavior of the patient(as trained in  step 1 ). The therapist ensures that the music aftereach musical confrontation suits the patient needs, for example byadjusting harmony, tempo or volume. Caseapplication . Case1 .Themusictherapistaddressestheexec-utive and social functions of the patients (planning, listening,attuning to one another). She offers the possibility to ask otherpeopletochangesingleaspectsoftheirbehavior.Subsequentlysheenables the patients to apply and practice newly acquired compe-tences. Step 8 . However, a patient has to be able to apply his newlydeveloped skills during daily life, not only in music therapy.  Step 8 consists of the music therapy homework assignments to transfercompetences to daily life. This process needs modal-disciplinaryattention from music therapist, patient, and the complete treat-ment staff (Hakvoort et al., 2012). Neurological foundations for effects of music Following Clifton’s (1983) phenomenological definition ‘music’ is defined as ‘sequences of sounds and silences that the receiverorganizes into a meaningful form’. The sequences of sound consistof musical parameters, such as: tempo, duration, rhythm, pulse,dynamics, melody, bass-line, harmony, and composition. The waythe therapist and patient organize these sequences of sounds intoa meaningful form is influenced by their individual perceptions of music, their individual actions in music, as well as the interactionbetween these perceptions and actions.During treatment a music therapist is aware of the function of the (preferred) music of the patient (Bushong, 2002). Does this music help the patient to unwind, to get aroused, to think aboutpast events, to keep one’s mind from wandering or is it even ‘dan-gerous’ music (Horesh, 2003), evoking feelings such as craving or revenge? There exists neither ‘good’ nor ‘bad’ music; people canonlyuseorhavelearnedtousemusicinsuchawaythatitcanhelpthem or harm them (Garofalo, 2010).Recent research suggests that the brain as a whole reacts tomusic(Allurietal.,2012).Itisevidentbynowthatmusicinfluences the brain on many different levels. Many psycho-physiologicalreactions are stimulated or provoked by music (Taylor, 2010).Hodges (2010) provides an overview of studies on a wide array of such reactions. In addition, music has neurological influences too.Specific parts of the brain are activated, or calmed, by music. Fig. 2presents five major neurological and psycho-physiological influ-ences of music that are often used in cognitive behavioral musictherapyinforensicpsychiatry:(1)rewardsystem,(2)emotions,(3)cognitions, (4) forcing attunement, and (5) stimulating relaxation. Reward system BloodandZatorre(2001)reportthatlisteningtomusicincreasesthe activation of the vertical striatum, which includes the nucleusaccumbens: the “human reward system.” Stefano, Zhu, Cadet,Salamon,andMantione(2004)reportahigheramountofdopamine
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