Journal of Music Therapy

JOURNAL MUSIC
OF THERAPY
Spring 1994
Vol. XXXl No. 1
EDITOR
JAYNE M. STANDLEY The Florida State University
ASSOCIATE
EDITOR
BUSINESS
MANAGER
JANET P. GALLOWAY Hilton Head Island
ANDREA FARBMAN NAMT National Office
EDITORIAL
COMMITTEE
BRUCE M. SAPERSTON Utah State University JOSEPH SCARTELLI Radford University DAVID S. SMITH University of Georgia ALAN L. SOLOMON University of Evansville MYRA J. STAUM Willamette University LOUISE STEELE Cleveland Music School Settlement MICHAEL THAUT Colorado State University BARBARA L. WHEELER Montclair State College DAVID WOLFE University of the Pacific
ALICIA A. CLAIR University of Kansas ALICE-ANN DARROW University of Kansas ANTHONY DECUIR Loyola University AMELIAG, FURMAN Minneapolis Public Schools KATE GFELLER University of Iowa JUDITH JELLISON University of Texas CLIFFORD K. MADSEN The Florida Stats University CHERYL D. MARANTO Temple University CAROL A. PRICKETT University of Alabama
This paper
meets the requirements of
ANSl/NlSO
Z39.48-1992
(Permanence
of Paper).
journal of
music therapy
CONTENTS
Spring 1994 2 Psychiatric Music Therapy Assessment and Treatment in Clinical Training Facilities with Adults, Adolescents, and Children The Effect of Improvisational Music Therapy on the Communicative Behaviors of Autistic Children Effects of Performing Conditions on Music Performance Anxiety and Performance Quality Call For Papers Vol. XXXI No. 1 ARTICLES Michael D. Cassity Julia E. Cassity
Cindy Lu Edgerton
31
Melissa Brotons ,
63
92
Psychiatric Music Therapy Assessment and Treatment in Clinical Training Facilities with Adults, Adolescents, and Children
Michael D. Cassity Julia E. Cassity Southwestern Oklahoma State University New Horizons Community Mental Health Center This study sought to define and measure the common body of knowledge relating to psychiatric music therapy assessment and treatment as practiced in NAMT-approved clinical training facilities. Specifically, the study reported areas of nonmusic and music behavior assessed most frequently, specific component behavior and music behavior most commonly assessed within each ares, the type of music conditions employed most commonly to assess such component behavior, and the developmental level of the patients to whom the assessments were given. Developmental level was observed as a function of the degree of illness and chronological age of the patient, and nonmusic component behaviors were reported es specific problem-oriented behaviors. In addition, areas clinical training directors assessed most frequently when administering activity assessments were determined. The results indicated the existence of an extensive and significant relating to psychiatric music common body of knowledge therapy assessment and treatment.
The authors wish to express appreciation to the Oklahoma State Regents for Higher Education, Edward Daniel Dill, Ph.D. and Charles W. Chapman, Ph.D. for funding this study. Appreciation also is expressed to the music therapy clinical training directors who made this study possible, and to Jennifer Nail and Ann Kiser for clerical assistance. This study is dedicated to Professor Emeritus Charles Braswell for his 36 years of service to the music therapy profession at Loyola University, New Orleans. Inquires regarding this article should be addressed to Dr. Michael D. Cassity, Department of Music. Southwestern Oklahoma State University, Weatherford, OK 73096-3098.
Vol.XXXI, No. 1, Spring, 1994
Assessment is considered an important part of the practice of music therapy. The National Association For Music Therapy (NAMT) Standards Of Clinical Practice (1993) specify assessment as the first task of music therapists following patient referral and acceptance. Cohen and Gericke (1972) define assessment as the process of gathering information about a patients strengths and weaknesses for the purpose of program planning. The NAMT Standards for adult psychiatry, in addition to targeting areas for nonmusic assessment, require the assessment to be appropriate for the patients level of functioning. Similar areas of nonmusic assessment are targeted with developmentally disabled children (including psychiatric patients in infancy, childhood, and adolescence). The Standards for children also state that, when applicable, level of functioning or developmental level within these areas shall be reflected in the music therapy assessment. The music therapy assessment, therefore, should be appropriate in terms of the level of functioning and the chronological age (CA) of the patient. Assessment and programming appropriate to developmental level also is emphasized in related professions. According to the American Association on Mental Deficiency (Grossman, 1977), the appropriateness of assessment and programming for the mentally retarded is dependent upon CA and degree of retardation. The AAMD has specified adaptive behaviors which are appropriate for specific CA levels, and states that deficits in these adaptive behaviors should be the criteria for determining programming needs. The AAMD also provides examples of the highest level of adaptive behavior that may be expected given CA and level of mental retardation. The American Psychiatric Association (APA) also provides for diagnosis according to CA levels and degree or severity of illness. Degree of illness is rated in the Diagnostic and Statistical Manual Of Mental Disorders III-R (DSM-III-R) (APA, 1987) using the Global Assessment of Functioning Scale (GAF Scale). CA levels in the DSM-III-R include infancy, childhood, adolescence, and adulthood. Other types of developmental indexes used by related professionals include mental age (Terman & Merrill, 1960). social age (Doll, 1965), and perceptual age (Frostig, 1963). The assessment mandates of the NAMT Standards also are supported by music therapy research. With mentally retarded
Journal of Music Therapy
and developmentally disabled children in general, music therapists use music extensively to assessboth nonmusic and music behavior (Davis, 1992; Lathom, 1980). Cassity (1985) surveyed the practice of music therapy with trainable mentally retarded children according to the above AAMD CA levels. According to Cassity, music therapy assessment practices with the mentally retarded, including the types of behavior assessed and the music conditions used to assess the behavior, differ depending on the CA level of the patient. CA, therefore, is an important measure of the validity and appropriateness of music therapy assessment and intervention. Other types of developmental indexes utilized in the music therapy assessment are cognitive development (Jones, 1986; Rider, 1981) and developmental norms or milestones (Michel & Rohrbacher, 1982). Although the above studies have produced specific information about music therapy assessment, there has been a paucity of similar empirical research examining assessment practices in psychiatric music therapy. Two notable exceptions were studies which defined music therapy assessment practices with domestic violence patients according to CA level and sex (Cassity & Theobold, 1990). and a music/activity therapy intake assessment designed to collect data according to CA, diagnosis, and attitude (Braswell, Brooks, Decuir, Humphrey, Jacobs, & Sutton, 1986). Although the NAMT Standards indicate appropriate areas for assessment, little is known concerning the frequency with which music therapists actually assesssuch areas, the specific nonmusic and music component behaviors music therapists most commonly assess within each area, the type of music conditions they employ most commonly to assess such behavior, or the developmental level of the patients to whom the assessmentsare given. In addition, little is known concerning areas music therapists address most frequently when administering activity assessments. Such information was considered essential to defining adequately the common body of knowledge relating to psychiatric music therapy. Identification of the above information, therefore, was the primary purpose of the present study. Developmental level was observed as a function of the degree of illness and CA of the patient. Nonmusic component behaviors were reported as specific problem-oriented behaviors.
Vol.XXX/, No. 1, Spring, 1994 Method Subjects An initial letter of inquiry and a participation form were sent to all music therapists listed by the NAMT Directory of Clinical Training Facilities as clinical training directors (CTDs) at psychiatric facilities. Clinical training facilities which had been in existence for less than 1 year were excluded from the study. If the CTDs indicated a willingness to participate in the study, they were asked to indicate the type of patient(s) they preferred and were most qualified to assess by checking the CA level(s) of adulthood, adolescence, childhood, and/or infancy. If the CTDs checked adulthood, they were asked to specify adult male, adult female, or both. CTDs who indicated a willingness to participate in the study were subsequently sent a questionnaire designed to survey their assessment practices with the patients for whom they had indicated greatest expertise and preference. The survey population was restricted to clinical training directors (CTDs) partially because CTDs as a group probably are among the most (if not the most) experienced clinicians in the music therapy profession. Limitations have been associated with previous studies which have surveyed music therapy skills and practices without controlling for limited experience among the respondents (Jensen & McKinney, 1990). Another reason for limiting the survey population to CTDs was to obtain information which would assist educators in preparing preservice music therapists for clinical training. It was assumed that CTDs could provide the most accurate and representative information concerning assessment practices in clinical training facilities. Procedure Separate questionnaires were designed to survey assessment techniques with adult males, adult females, adolescents, and children. Assessment in infancy was not surveyed because an insufficient number of CTDs indicated they worked with such patients. The questionnaire for adults contained 23 areas, the questionnaire for adolescents contained 42 areas, and the questionnaire for children contained 20 areas of nonmusic behavior recommended for assessment in the music therapy literature. These areas had been extracted from a thorough review of
literature relating to psychiatric music therapy assessment (Adleman, 1985: Cassity & Theobold, 1990; NAMT, 1989, 1993; Wood, Graham, Swan, Purvis, Gigliotti, & Samet, 1974). CTDs were also requested to write in any additional areas they assessed that were not listed. From the list of 23 assessment areas, CTDs were asked to list the five areas they assessed and treated most frequently. and that they felt were most important in music therapy assessment and treatment. CTDs were next requested to list, for each of the five assessment areas they had just listed, two specific problem (nonmusic) behaviors they assessand treat most often. Next to each problem behavior, they also were requested to list two specific music conditions they used to assess and/or treat the problem. The procedure for constructing the section of the questionnaires relating to music assessment was the same as above with the exception that music areas were included. Areas of music behavior were derived from a review of music activities used in psychiatric music therapy (Carroccio & Quattlebaum, 1969; Cassity, 1976; Ficken, 1976; Freed, 1987; Noland, 1983; Rubin, 1976; Wood et al., 1974), and of developmental checklists, music behavior, and music curricula for exceptional children (Graham & Beer, 1980; Lathom, 1980; Michel & Rohrbacher, 1982). Finally, the questionnaire contained an example of a completed questionnaire item for nonmusic behavior and one for music behavior to guide the CTDs in furnishing the desired information. The two questionnaires designed for children were for children in the CA level of childhood and adolescence, and therefore reflected the CA levels recommended in the DSMIII-R (APA, 1987). Areas assessed most frequently during activity therapy assessment were determined by listing in the questionnaire 42 areas of activity therapy assessment suggested in the music therapy literature (Braswell, Brooks, Decuir, Humphrey, Jacobs; & Sutton, 1986; Cohen & Gericke, 1972; NAMT, 1989). CTDs were requested to choose 10 of the 42 areas, then rank order the 10 areas by assigning a 1 to the area they assessed most frequently and a 10 to the area they would assessleast frequently. The areas of nonmusic, music, and activity therapy assessment were each listed in alphabetical order, with the order of listing rotated among the questionnaires.
Vol.XXX,. No. 1, Spring, 1994
Following the construction of the questionnaire, a panel of five registered music therapists employed in NAMT-approved clinical training facilities assessed the clarity of the questionnaire items, the ease with which responses could be provided for the items, and the success of the questionnaire in surveying the topic (assessment techniques) it was constructed to survey. The panel did not participate in the study other than to judge the questionnaire. Of the five music therapists, four were eclectic and one was of psychodynamic therapeutic philosophy. The four eclectic music therapists agreed the questionnaire was appropriate for the purposes for which it was designed. The psychodynamic music therapist, however, indicated the questionnaire did not relate to her practice of music therapy. Caution must be exercised, therefore, in generalizing the following results to psychodynamic settings. Results Of the 100 psychiatric clinical training facilities identified, 65 agreed to participate in the study. Typical reasons for nonparticipation were there had been a recent change of clinical training directors, and/or the CTD did not have time to participate in the study. The percentages of CTDs returning the questionnaires for each CA level of patient were children, 61%; adolescents, 74%; adult male, 67%; and adult female, 73%. Respondent Characteristics The first part of the questionnaire dealt with respondent characteristics. As may be expected, most psychiatric CTDs were females between the ages of 30 and 39. The highest degree attained by CTDs varied depending on the CA of patient with whom they worked. Although all had a bachelors degree, only 19% of the CTDs working with adults had a masters degree. In contrast, 46% of the CTDs who worked with adolescents and 53% of the CTDs who worked with children had a masters degree. The typical CTD had graduated from an NAMT-approved music therapy program 9 years prior to the study, and was employed as a full-time clinical training director. As for the number of years of full-time experience in adult psychiatric music therapy, 41% indicated more than 9 years, 31% indicated 6-8 years and 20% indicated 3-5 years. Approximately 73% of
all CTDs were employed in free-standing psychiatric facilities, such as state or private psychiatric hospitals. Data were obtained concerning type of music therapy employed by giving CTDs the definition of activity therapy (English & English, 1958), music therapy as insight therapy with reeducative goals, and insight therapy with reconstructive goals (Wheeler, 1983). and asking them to indicate the percentage of time they used each in their clinical training program. The type of music therapy used by CTDs varied depending on the CA of the patient with whom they worked. Music therapy as activity therapy was used approximately 62% of the time with adolescents and children, and 37% of the time with adults. In contrast, music therapy as insight therapy with reeducative goals was employed 62% of the time with adults and 37% of the time with adolescents and children. Music therapy as insight therapy with reconstructive goals was used approximately 14% of the time with adolescents and only 2%)of the time with adults and children. This latter finding may seem questionable considering that reconstructive therapy most commonly is used with adults. However, when one considers the low level of functioning of the typical adult patient served by music therapists (as reported in the following paragraphs), along with the ineffectiveness of reconstructive therapy with low-level, chronic patients (Braswell, 1967), the finding is not surprising. When asked whether they assess music behavior, nonmusic behavior, or both, 83% of all CTDs indicated they assess both nonmusic and music behavior. Only 17% indicated they assessed nonmusic behavior only, and none assessed music behavior only. It appears that most CTDs do not administer standardized tests employed by other professionals. When asked if they administer to their patients standarded tests commonly employed by other professionals when assessing their patients, 94% indicated they do not. CTDs do, however, believe there is a need for certain assessment materials specifically designed for use by music therapists. Reflective of the above finding that more activity therapy is conducted with younger patients, the need for a standardized activity assessment increased as the CA of the patient decreased. Seventy-five percent of the CTDs who worked with children, 63% who worked with adolescents, and 51% who worked with adult patients indicated a need for a
Vol. XXX/, No. 1, Spring, 1994
standardized activity assessment. Seventy percent of all CTDs indicated a standardized test of music behavior was needed, 79% believed a standardized music therapy assessment of nonmusic behavior was needed, and 92% of all CTDs indicated a treatment manual of techniques, procedures, and practices used by psychiatric music therapists was needed. The need for a treatment manual was clearly the greatest need indicated by CTDs. One result of the present study was the production of such a manual (Cassity & Cassity, 1993). Patient Characteristics
CTDs spend a significantly greater mean percentage of time treating certain disorders, or diagnoses, than they spend treating other disorders with adult males (x2 = 55.72, p < .001), adult females (x2 = 68.16, p < .001), adolescents (x2 = 38.61, p < .001), and children (x2 = 51.83, p < .001). The types of disorders treated, from most to least frequently, are for adult male patients, psychotic disorders, affective disorders, substance abuse, personality disorder, anxiety disorder, and adjustment disorder. With adult females, CTDs most often treat psychotic disorders, followed by personality disorders, affective disorders, substance abuse, adjustment disorder, and anxiety disorder. With adolescents, the disorders are conduct disorder, affective disorder, adjustment disorders, substance abuse, anxiety disorders, and psychotic disorders. With children, CTDs most frequently treat conduct disorders, adjustment disorders, anxiety disorders, affective disorders, psychotic disorders, and least frequently, substance abuse. In an effort to obtain information on the degree of illness of patients treated by CTDs, CTDs were asked to rate the level of functioning typical of the majority of patients treated in their clinical training program using the Global Assessment of Functioning Scale (GAF) (APA, 1987). Endicott, Spitzer, Fleiss, and Cohen (1976) have concluded the relative reliability, validity, and simplicity of the GAF suggests its usefulness in a wide variety of clinical research settings. According to Endicott et al. (1976), the probability is about 95% that a rating given a patient will be within 11 points of his true rating, defined as the mean rating given him by a large number of profession-
10
als (p. 767). The GAF ranges from 1, representing the most severe symptoms, to 90, representing the mildest symptoms. The GAF is arranged into nine 10-point intervals, with each interval containing a verbal descriptor of typical patient symptoms. CTDs were asked to indicate, using the GAF, the level of functioning typical of the majority of patients treated in their clinical training program. CTDs indicated they treat patients of certain GAF levels significantly more frequently than other levels with adults (x2 = 114.06, p < .001), and adolescents and children (x2 = 70.51, p < .001). Specifically, 70% of the CTDs indicated the level of their adult patients to be between 21 and 40. The mean GAF rating was 36.5 with a median of 33. The following description applies to patients with a GAF rating of 31-40, therefore approximating the typical adult treated in psychiatric music therapy clinical training programs: Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). (APA, 1987, p. 12) CTDs gave somewhat higher GAF ratings to their adolescent than to their adult patients. When asked to indicate, using the GAF, the level of functioning typical of the majority of adolescents treated in their clinical training program, 87% of the CTDs indicated the level of their adolescents to be between 31 and 50. The mean GAF rating was 40.5 and the median was 41. The level of functioning of the typical adolescent treated in psychiatric music therapy clinical training programs therefore would border between the above descriptor and the following for patients with a GAF of 41 to 50: Serious symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., no friends, unable to keep a job). (APA, 1987, p. 12) Children were given the highest GAF ratings. Although 71% of all children were given GAF ratings of between 33 and 50,
Vol.XXX/, No. 1. Spring, 1994
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the mean GAF was 45.76 and the median was 45. The above descriptor therefore would approximate patients treated in psychiatric music therapy clinical training programs who were in the CA level of childhood. A cross tabs analysis of GAF rating and highest degree obtained indicated significantly more CTDs with a masters degree worked with adult male and female patients having GAF ratings above the median than below the median (p = ,006). Stated differently, 86% of the CTDs with a masters degree gave above median GAF ratings to their adult patients. Such differences were not observed for adolescents and children, where as many CTDs with masters degrees worked with patients having below median as above median GAF ratings. Assessment and Treatment: Nonmusic Behavior CTDs prefer to assess and treat certain areas of problems significantly more frequently than others with adults (x2 = 298.20, p < .001), adolescents (x2 = 126.27, p < .001), and children (x2 = 39.79, p < .001). Seventy-six percent of all adult problems and 85% of all adolescent problems assessed/treated by CTDs were either interpersonal, affective, or cognitive problems. With children, interpersonal, behavior, cognitive, and physical (including motor and receptive/expressive language) problems accounted for 82% of all problems assessed/treated by CTDs. The following results, therefore, were limited to the above areas of assessment since these areas represent the bulk of music therapy assessment practices. Also, only the most frequent patient problems within each assessment area were reported, with the types of music conditions employed most frequently by CTDs to assess/treat the problems. The remaining problems with their specific music conditions were too numerous to be included in the present report. For a comprehensive clinical manual of all areas and problems assessed/treated, and all specific music activities or conditions employed the reader is referred to Cassity and Cassity (1993). Interpersonal-sociolization. Interpersonal-socialization was the most frequent area assessed with adults (33%) and children (31%). and the second most frequent area of assessment with adolescents (31%). Although CTDs listed 36 different adult interpersonal problems, the frequency with which they were list-
12
ed significantly differed (x2 = 597, p < .001), indicating CTDs used music therapy to assess/treat certain interpersonal problems significantly more often than other interpersonal problems. The two interpersonal problems assessed/treated most frequently were withdrawn behavior and poor leisure skills. Of the two problems, the preference for assessing/treating withdrawn behavior approached significance (Z = -1.53, p = .063), indicating CTDs may consider withdrawn behavior to be even more important than assessing/treating poor leisure skills. It is interesting to note that the tendency for CTDs to assess/treat poor leisure skills among adult males more often than adult females approached significance (Z = 1.39, p = .0823). CTDs described their withdrawn patients as seclusive, exhibiting isolative behavior with minimal personal interactions or no verbalization, not feeling comfortable when in a group, not initiating conversation, preoccupied with personal problems, or depressed. Although CTDs reported five different music conditions for assessing/treating withdrawn behavior, the frequency with which they were reported differed significantly (x2 = 23.61, p < .001). CTDs chose, in order of frequency, music listening and instrumental activities significantly more often than singing, musical games, and movement/dance (x2 = 13.82, p < .001). Music listening activities consisted of music conditions requiring patients to work together on a cooperative task. For example, in one music condition patients were involved in a group discussion of song lyrics. In another, peer interaction and group discussion were facilitated by dividing patients into pairs, then asking them to select a song or recording to which they both could relate. Types of instrumental music conditions utilized to assess/ treat withdrawn behavior were improvisation and one-to-one instruction on a music instrument. Improvisation sessions were designed to elicit nonverbal and verbal group interaction. For example, in one improvisation activity patients took turns conducting the improvisation, after which the group discussed issues such as what it felt like to be the leader, how they communicated, and whether the communication techniques needed to be changed. The purposes of one-to-one instrumental instruction were to establish rapport and trust, and to prepare the
13
patient for ensemble participation or solo performance with the goal of increasing interpersonal interaction. CTDs assessed and treated 10 interpersonal problems of adolescents. Of these 10 problems, five were reported significantly more often than the other five (Z = -5.14, p < .00003). No significant differences occurred, however, in the frequency with which these five most frequent problems were listed. The five most frequent adolescent interpersonal problems assessed/treated by CTDs were, in order of frequency, uncooperative behavior, lack of awareness of self or others, withdrawal, inappropriate use of leisure time, and failure to engage in leisure activities. Although a variety of different music conditions were listed for assessing/treating uncooperative behavior, instrumental activities with a focus on cooperation was the music condition of choice. Examples included making the adolescents cooperation in a performance group dependent upon group success, and group improvisation in which the adolescent was given experience at playing, leading, and imitating improvisations. Adolescents who demonstrated lack of awareness of self or others were described as being detached, having poor peer relationships, not interacting appropriately with peers (e.g., not giving or receiving positive comments; excessively negative), and distancing others through sarcasm, anger, and other destructive defenses. Music therapists used a variety of treatments. Performance and improvisational groups, for example, were used to promote positive interaction, to redirect patient comments such as, I like the way that sounds to (patients name) played well, discussing peer reactions to positive/negative statements, and providing the patient with experience at supporting others by involving the patient in supported solos during group improvisation (e.g., the patient accompanies another patient, then takes a solo while being accompanied). CTDs also prefer to use music therapy to assess and treat certain interpersonal problems over others when working with children. Of eight interpersonal childhood problems CTDs reported assessing and treating, four were listed significantly more frequently than the other four (Z = -4.06, p < .00003). No significant difference occurred, however, in the frequency with which they listed the four most frequent problems. The four
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JournalOfMusicTherapy
interpersonal problems assessed and treated most frequently with children were disruptive or socially inappropriate behavior, withdrawal, uncooperativeness, and not sharing. Children exhibiting disruptive or inappropriate behavior were described as exhibiting disruptive outbursts to attract attention, breaking rules, making negative comments to peers resulting in peer rejection, and not making constructive suggestions. Although a variety of music conditions were suggested, the technique suggested four times most frequently was applied behavior analysis involving the use of contingent music. For example, music therapy activities such as singing, listening, moving, creating music, and playing instruments were made contingent upon appropriate behavior. Various types of point or token systems also were suggested for use with the music therapy activities. Childhood withdrawal was characterized by minimal or no verbal interaction, not participating in groupactivities, avoiding interaction with a lack of interest in peers, and excessive shyness. CTDs most often assessed and treated withdrawal by first using group instrumental activities, such as a rhythm band, to encourage nonverbal interaction with the therapist and peers (e.g., patient plays rhythm pattern on claves and the therapist/peer imitates; therapist/peer plays rhythm followed by the patient imitating). Verbal interaction was fostered by encouraging the patient to engage in appropriate verbal interaction with a peer during routine interactive music activities (e.g., Do you want the drum? "Hold the autoharp while I strum."). Affect. Affective problems were the most frequent type of problem assessed with adolescents (33%). and second most frequent problem assessed with adults (22%). Because affective problems were among the less frequently assessed problems with children (10%). these assessments were not discussed. CTDs used music therapy to assess and treat certain adolescent affective problems significantly more frequently than other affective problems (x2 = 55.40, p < .001). Of the adolescent affective problems reported, the two assessed and treated by most CTDs were the inability to identify/express feelings (33.33%), and manifest anger or rage towards others (25.49%). Adolescents with an inability to identify/express feelings commonly replied I dont know when asked how they felt, and demonstrated
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flat or inappropriate affect with a lack of congruity between affect and verbalization (e.g., their facial expression, body posture, language, vocal tone, and/or volume did not match their speech content). The three music conditions CTDs recommended for assessing/treating the inability to identify/express feelings were music listening with discussion, improvisation, and music composition. The frequency, however, with which these music conditions were recommended significantly differed (x2 = 25.30, p < .001), as music listening with discussion was recommended more often than improvisation (p = .059), and significantly more often than music composition (p = .011). CTDs used a variety of music listening with discussion techniques to assess/treat the inability to identify/express feelings. Examples of techniques were having patients identify feelings expressed by the singer/songwriter in popular song lyrics, and conducting a feeling card activity in which the patient, given a number of cards, selected the card with the word that matched the feeling projected in the music (e.g., frustration). In contrast, CTDs chose to use a different type of music condition than the above when assessing/treating adolescent anger or rage. Such patients were reported to be overly destructive to self, others, or property (e.g., yelling, fighting, hitting walls, and/or throwing chairs). The music condition recommended by a majority (54%) of CTDs was the use of instrumental improvisation as a nonverbal technique for fostering self-control and providing a constructive outlet for frustration, anger, and other intense emotions. With adult patients, there was an even greater consensus among CTDs in the assessment/treatment of the inability to identify/express feeling or emotion than there was with adolescents. Although 19 different adult affective problems were reported, 50% of the music conditions were designed to assess/ treat the inability to identify/express feeling or emotion. Stated differently, the frequency with which the 19 affective problems were reported differed significantly (x2 = 511.54, p < .001), with the inability to identify/express feeling or emotion reported significantly more often than low frustration tolerance, the second most frequent affective problem (Z = -6.27, p < .00003). As with adolescents, CTDs preferred to assess/treat the in-
16
ability of adults to identify/express feeling by using music listening with discussion. Music listening with discussion was chosen significantly more often than instrumental improvisation, the second most frequent music condition (Z = -2.01, p = .0222). During music listening with discussion, songs were chosen about specific emotions, such as fear, to help the patient identify and express specific feelings and appropriate ways of expressing them. The song discussion was then generalized to the patients life situation. The overall goal was for the patient to understand and accept feelings as a part of life. Cognitive. Cognitive problems were the third most frequent type of problem assessed with adults and adolescents (21%), and second most frequent problem assessed with children (17%). (Behavior, physical, and cognitive problems tied for second position with children.) As with affective problems discussed previously, CTDs used music therapy to assessand treat certain adult cognitive problems significantly more frequently than other cognitive problems (x2 = 196.40, p < .001). Of 22 adult cognitive problems reported, the two most often assessed and treated by CTDs were low self-esteem (26.79%) and delusions (12.50%). Of these two, low self-esteem was assessed significantly more often than delusions (Z = -2.26, p < .0119). Other adult cognitive problems assessed and treated, in order of frequency, were deficit problem solving, disorientation, deficit short- and long-term memory, poor decision-making skills, and denial of/withdrawal from problems. Of the above problems, delusions, deficit problem solving, and disorientation were assessed and treated significantly more frequently than deficit memory, poor decision-making, and denial of problems (Z = -10.71, p < .00003). CTDs preferred to use certain music conditions significantly more often than others to assess/treat low self-esteem (x2 = 23.90, p< .001). Of the five music conditions reported, instrumental/vocal performance was used significantly more often than music listening with discussion (p = .021), music composition (p = .004), interpretive drawing to music (p = .006). or musical games (p = .002). The instrumental/vocal performance activities were engineered to produce patient feelings of success, accomplishment, and peer acceptance. With adolescents, the three cognitive problems CTDs as-
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sessed/treated most frequently were low self-esteem, lack of problem-solving skills, and paranoid behavior (e.g., lack of trust of others; minor incidents considered a threat). Low self-esteem was assessed and treated more often than deficit problem-solving skills (p = .09), and significantly more often than paranoia (p = .019). Adolescents with low self-esteem were described as having a low sense of values/personal importance resulting in dysfunctional interpersonal interactions, making negative selfstatements, experiencing feelings of worthlessness, and lacking self-respect and self-confidence. As with adults, the music condition of choice for assessing/treating low adolescent self-esteem was vocal/instrumental performance activities administered both individually and in groups. The three most frequent cognitive problems assessed and treated with children were difficulty following directions, lack of directionality and spatial concepts, and low self-esteem. Following directions was assessed three times as often as self-esteem and twice as often as directionality and spatial concepts. When assessing the ability to follow directions, CTDs considered the difficulty of the instruction, the physical ability of the patient to follow the directive, the retention ability of the patient, and the ability of the patient to accept or listen to the instructions. A variety of music conditions were suggested for assessing/ treating the ability to follow directions, including rhythm instrument activities, group singing, and body action songs. Examples of specific activities were asking the patient to play a melodic/rhythmic pattern on the xylophone or drum during rhythm instrument activities, finding page numbers during group singing, and following one-step, two-step, and/or multi-step directions during body action songs or simple dances (e.g., clap your hands, then pat your knees, then stomp your feet to the tune, If Youre Happy And You Know It). Behavior. The assessment and treatment of overt behavior problems, as well as cognitive and physical problems, was the second most frequent type of problem assessed with children (17%). With adolescents, behavioral problems were the fifth most frequently assessed problem, accounting for 7% of the music therapy assessments administered by CTDs. Adult be havioral problems accounted for 10% of the music therapy assessment, and was the fourth most frequently assessed prob-
16
lem. Because of the relative infrequency of behavioral assessments with adolescents and adults, these assessments were not discussed. CTDs reported a variety of childhood behavioral problems, including, in order of frequency, lack of assertiveness, attention deficit, not taking turns, hitting peers, and poor eye contact. Unassertive children were described as not expressing their own needs, lacking inquiry skills, and not expressing true feelings or opinions independent of peer pressure (e.g., feels compelled to agree with the right answer, or the answer given by peers). When assessing the lack of inquiry skills, CTDs occasionally observed anxiety or fears, evasiveness, or preoccupations. Music conditions for assessing/treating unassertiveness employed both nonverbal and verbal techniques. An example of a nonverbal technique was having the patient conduct an instrumental ensemble in which the patient had to communicate dynamics, tempo, and when the music should start or stop. Verbal techniques included such activities as, during song discussion, encouraging each patient to state opinions which agreed with or differed from those stated by the majority of patients. The music therapist would at times facilitate such discussions by posing problem solving or conflicting situations. Physical. As indicated above, physical problems also were a second most frequent type of problem assessed with children (17%). Because physical problems accounted for less than 7% of adult assessments and were not assessed with adolescents, these assessments were not discussed. The physical problem assessed/treated most frequently with children was motor coordination, followed by physical communication/expressive language problems. Children with gross motor problems had difficulty performing basic movement tasks. Examples included awkwardness when walking, and running into people when in a group, CTDs unanimously chose music movement activities as the condition for assessing/treating such gross motor problems. Examples of activities were songs with lyrics that directed gross motor movements such as walking, skipping, hopping, and marching (Janiak, 1978), creative movement to music in which children would mirror or lead movements of peers, and activities requiring children to imitate ob-
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ject/animal movement such as walking like a turkey after doing the Thanksgiving Turkey Chant (Bitcon, 1976). Fine motor problems assessed/treated by CTDs were lack of finger dexterity, difficulty grasping or manipulating utensils as a result of impaired grasp function (e.g., palmer or pincer grasp), lack of eye-hand motor coordination, and inadequate grasp maintenance as evidenced by the excessive dropping of objects frequently resulting in disruptions to others and embarrassment to self. Unlike gross motor problems, instrumental performance activities were the music condition of choice for assessing/treating fine motor problems. Individual keyboard instruction emphasizing melodies and finger exercises involving all five fingers were employed to promote independent finger movement and general finger dexterity. For impaired grasp function, patients were involved in instrumental music activities which required them to push autoharp buttons to play the autoharp, grasp a guitar/autoharp pick, play finger cymbals, finger strum the guitar, and grasp mallets to play resonator bells or tone bars. Playing resonator bells also was suggested as one activity for remediating deficit eye-hand coordination. Grasp maintenance was developed by encouraging children to hold instruments such as the above, so they could participate in music activities. The intrinsic reinforcement of the music conditions appeared to motivate the childrens desire to exercise the above gross and fine motor functions. Assessment and Treatment: Music Behavior
Because of the above finding that 83% of all CTDs assess both nonmusic and music behavior, data were analyzed to determine procedures employed most frequently in assessing music behavior. CTDs prefer to assess certain types of music behavior significantly more frequently than others with adults (x2 = 148.77, p < .001), adolescents (x2 = 19.69, p < .01), and children (x2 = 18.29, p < .01). In addition, sex differences emerged among adult patients. Unlike with nonmusic assessments, significantly more music assessments were submitted for adult females (217) than for adult males (147) (Z = 3.62, p < .0006). A follow-up analysis of individual assessment areas revealed adult females were given singing assessments (Z = 2.01, p < .0222) and locomotor movement assessments (Z = -2.30,
20
p < .0107) significantly more often than were males. Listening to music (z = 1.41, p < .0778) and improvisation (Z = 1.22, p < .1112) approached significance as female assessments. Adult music assessments for which no significant or nearly significant sex differences occurred were playing instruments, composing music, and nonlocomotor movement to music. The two most frequent types of music behavior assessed with each CA level of patient followed by the percentage of time they were assessed in comparison to other types of music behavior were: listening to music and singing, adults, 51%; listening to music and playing instruments, adolescents, 47%; listening to music and singing, childhood, 49%. Procedures employed in assessing only the most frequent of these music behaviors are discussed in the following paragraphs. Listening to music. With adults, listening to music was assessed significantly more often than singing (Z = -2.63, p = .0043), playing instruments (Z = -3.46, p < .0003), improvisation (Z = -4.42, p < .00003), locomotor movement to music (Z = -6.69, p< .00003), music composition (Z = -8.16, p< .00003), and nonlocomotor movement to music (Z = -9.27, p < .00003). It is noteworthy that music composition may be more appropriately used with higher functioning patients than those in the present study. A cross tabs analysis of GAF, sex, and type of music activity revealed that music composition was employed significantly more often with male and female patients having above median GAF ratings compared to those having below median ratings (p < .006). When assessing adult music preferences, CTDs sought general information such as preference for a favorite style, performer, or composer significantly more often than more specific information such as familiarity with a variety of styles of music, recollections associated with musical preferences, or knowledge of musical qualities or characteristics (Z = -2.63, p = .0043). The music condition employed most frequently to determine music preference was asking the patient to express preference for a favorite music style, performer, or composer. This was sometimes followed by the therapist performing the preferred song for the patient and inviting the patient to join in the singing of the lyrics. The preference for using this music condition approached significance (p < .072) over the second most fre-
21
quent music condition of asking the patient to select from a collection of recordings or albums a song to play for the group, and was employed significantly more often than each of 14 other reported music conditions (p < .018). It is interesting to note that eliciting verbal preference by asking the patient was used significantly more frequently than administering a questionnaire to determine music preferences (p < .002). With adolescents, the preference for assessing music listening over playing instruments approached significance (Z = -1.43, p = .0764). Also, music listening was assessed significantly more often with adolescents than was improvisation (Z = -1.75, p = .0401), singing (Z = -1.75, p = .0401), composing music (Z = -1.75, p = .0401), or locomotor movement to music (Z -4.29, p < .00003). Unlike music listening assessment with adults, there was a nonsignificant tendency for the adolescent assessment to be focused toward obtaining specific rather than general information about music preference. The assessment of adolescent music preference also differed from adult assessment in that a variety of music conditions were reported with equal frequency, indicating a lack of consensus among CTDs as to which condition to use. Listening to music and singing were assessed with equal frequency with children (24.56%). Compared to other music behaviors, listening and singing were each assessed significantly more often than composing music (p = .015), nonlocomotor movement to music (p = .015), and improvisation (p = .011). Although listening and singing were assessed more often than playing instruments and locomotor movement to music, the difference was nonsignificant. However, viewed as combined data, listening, singing, and playing instruments were assessed significantly more often than composing, improvisation, and nonlocomotor (Z = -4.00, p = .00003). The music condition CTDs used to assess music listening with children was almost diametrically opposed to the condition they utilized with adults, and was a continuation of the trend established with adolescents. Having children identify specific information about music, such as characteristics, style, instrumentation, and tempo, approached significance in frequency over having children state their music preferences (p = .055). When assessing singing, CTDs most often observed the ability of children to sing on
22 pitch or in tune, match pitch, lyrics of songs. Activity Therapy Assessment
Journal of Music Therapy sing melodic phrases, and sing
Following are the IO adult activity therapy assessment areas considered most important by CTDs, followed by the source of the area, and the mean rank CTDs assigned each area: 1. Observation of patients nonmusic behavior (eye contact, attention span, posture, grooming, motivation, facial expression, conversation, etc.) (Braswell et al., 1986), 5.81. 2. Concentration, attention span, retention (Cohen & Gericke, 1972), 6.61. 3. Patients use of music (artistic, to reflect feelings or emotions as an escape, etc.) (Cohen & Gericke, 1972), 6.80. 4. Attitude toward music (Cohen & Gericke, 1972), 6.86. 5. Interpersonal relationships (Braswell et al., 1986), 7.11. 6. How patient perceives, perpetuates, or solves problems during music activity (Cohen & Gericke, 1972), 7.82. 7. Patient-directed questions (nonmusically oriented) to reveal the patients self-concept (Braswell et al., 1986), 8.00. 8. Type of music liked (Cohen & Gericke, 1972), 8.12. 9. Musical interest (NAMT, 1989), 8.49. 10. Abstracting (Cohen & Gericke, 1972). 9.00. The 10 activity therapy assessment areas considered most important by CTDs for adolescents were: 1. Interpersonal relationships, 5.39. 2. How patient uses music (artistic, to reflect feelings or ernotions, as an escape, etc.), 5.83. 3. How patient perceives, perpetuates, or solves problems during music activity, 6.70. 4. Concentration, attention span, retention, 6.78. 5. Observation of patients nonmusic behavior (eye contact, attention span, posture, grooming, motivation, facial expression, conversation, etc.), 7.09. 6. Patient-directed questions (nonmusically oriented) to reveal the patients self-concept, 7.26. 7. Creativity, ability, and impediments (Cohen & Gericke, 1972), 7.65. 8. Type of music liked, 8.57. 9. Attitude toward music, 8.83.
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10. How patient perceives, perpetuates, or solves problems during music activity, 8.91. For childhood, the activity assessment areas CTDs considered most important were: 1. Concentration, attention span, retention, 5.50. 2. Interpersonal relationships, 5.75. 3. Observation of patients nonmusic behavior (eye contact, attention span, posture, grooming, motivation, facial expression, conversation, etc.), 6.02. 4. How patient perceives, perpetuates, or solves problems during music activity, 6.69. 5. How patient uses music (artistic, to reflect feelings or emotions, as an escape, etc.), 6.88. 6. Creativity, ability, and impediments, 7.50. 7. Type of music liked, 8.38. 8. Attitude toward music, 8.50. 9. Rhythmic ability (Cohen & Gericke, 1972), 8.89. 10. Existence of handicapping conditions that may impair activity participation (Cohen & Gericke, 1972), 9.00. The rankings identified herein indicated that, although some music assessment was necessary when doing activity therapy, CTDs placed primary emphasis on assessing nonmusic rather than music behavior. The assessment of music behavior, such as type of music liked primarily was to facilitate the planning of appropriate music therapy activities. Discussion This study examined 200 patient problems CTDs treat in psychiatric clinical training facilities and 801 music conditions they employ to treat the problems to determine the extent to which a common body of knowledge exists in psychiatric music therapy assessment and treatment. It may be concluded that a common body of knowledge exists in psychiatric music therapy. The commonality is significant and extensive for all CA levels of patients, and encompasses patient diagnoses, level of functioning, areas of assessment, specific patient problems assessed and treated, and music therapy interventions. Implications for the practice of music therapy are discussed in the following sections.
24 Research
Because information in this study represents the common practice of music therapy, the information may be used as a framework and a guide in future psychiatric music therapy research. Experimental formats for future large-scale experimental testing of the psychiatric music therapy interventions identified in this study should be designed and distributed nationally for testing in music therapy clinical training facilities and other qualified psychiatric facilities. To enhance external validity, multiple testing sites should be assigned to test single interventions to determine their effectiveness at treating patient problems. The evaluational goals should be broad based, not only to determine whether patients are improving in daily life functioning, but also to assesswhether they are acquiring healthy living skills that may assist in preventing future problems. For example, Bruhn and Patterson (1992) found that senior citizens not receiving music therapy expressed significantly decreased life satisfaction. Assessment The present study indicated 79% of all CTDs believed a standardized music therapy assessment of nonmusic behavior was needed, and 92% of all CTDs believed a psychiatric music therapy treatment manual was needed. Although a treatment manual was produced (Cassity & Cassity, 1993), the task of producing a standardized psychiatric music therapy assessment remains. According to Cohen, Averbach, and Katz (1978), No profession, whether it is music therapy or another discipline, can legitimately attain true professional stature without a viable assessment system, not merely the completion of an assessment form (p. 92). The results of this study contain implications for the production of a standardized assessment. First, to enhance external validity or generalization to the survey population (clinical training centers/directors), any future standardized psychiatric music therapy intake assessment should be designed to assess patient problems music therapists assess most frequently, as reflected in-the present study. A second consideration relates to the need for such an assessment to be brief (Braswell et al., 1986; Cassity, 1985). If both brevity and external validity are to be achieved, the intake assessment
25
should, again, contain the patient problems/areas of assessment music therapists assess most frequently. A third consideration involves the format for administering such an assessment. Past literature indicates that one aspect of the music therapy assessment which uniquely distinguishes it from assessments given by other professionals is that behavior under music conditions may be different, sometimes radically different (Michel & Rohrbacher, 1982, p. iii). This especially is true in the sense that music therapy assessment is an ongoing process which continues during the treatment phase. The consideration proposed in this study, however, is that an initial psychiatric intake assessment may not always need to be administered under music conditions to distinguish it from assessments given by other professionals, if it were designed to assessproblems treated most frequently by music therapists. Assessments given by other professionals do not focus exclusively on problems treated most frequently by music therapists. Eliminating music conditions from the initial intake assessment would also contribute to brevity of the assessment. Such an assessment would be similar to diagnostic assessments administered by related professionals with the exception that it would assess patient music preferences as well as problems music therapists treat most frequently. Following administration of the intake assessment, the music therapy clinician could then use the clinical manual as a reference to suggested interventions applied most frequently by CTDs in treating the assessed problems. Such procedures were supported in the assessment instruments submitted by CTDs in the present study. An examination of the assessment instruments indicated that most instruments were designed to assessnonmusic behavior by interviewing the client or having the client fill out a questionnaire. These instruments did not, however, contain suggested music therapy interventions for assessing/treating patient problems, nor did they indicate the level of functioning of the patients for whom they were designed. Caution should therefore be exercised in any future attempts to describe music therapy practice by soliciting assessment instruments. Standards Information from the present study should be considered when formulating future standards of practice for psychiatric
26
music therapy. Numerous areas mandated for adult psychiatric assessment in the National Association For Music Therapy Standards Of Clinical Practice (1993) were infrequently assessed in NAMT-approved clinical training facilities. The Standards state under 2.9 that Music therapy assessment shall address the following areas (NAMT, 1993, p. 5). These areas, mandated for assessment, include motor development, physical abilities, speech development, sensory capacity, and sensory integrative functioning. In the present study, however, when CTDs were asked to list five assessment areas and ten problems they assessed most frequently, only 2.77% of the problems listed were motor, physical, or sensory integrative problems. In addition, assessment areas that were not among the five most frequently assessed areas were assessed by a minority of CTDs. Speech is another infrequently assessed area. Although CTDs reported adult speech problems such as difficulty or inability to communicate verbally with others, poor communication skills, poor quality of communication, speaking incoherently, and slurring speech, these problems represented only 3.88% of the total number of patient problems reported. This finding was supported by previous research, which also indicated adult speech problems were assessed by a minority of music therapists (Cassity & Theobold, 1990). Sensory capacity was assessed slightly less frequently than speech. Although music therapists reported assessing sensory problems such as internal thoughts, visual and auditory hallucinations, and difficulty coping with stress and tension, such problems accounted for only 3.70% of the problems CTDs reported assessing. Finally, because of the differing assessment needs of different CA levels of clients, it is recommended that the Standards provide for CA level differences within the category of Developmental Disabilities. Information from this study, previous research (Cassity, 1985; Cassity & Theobold, 1990), and future research could be used in writing assessment mandates for the proposed categories of Adolescence, Childhood, and Infancy. Competency Examinations
Consideration also should be given the findings of the present study when constructing future music therapy competency examinations. The present study indicated that a significant com-
27
mon body of knowledge exists in terms of areas assessed, specific problems assessed, and types of music therapy interventions used to assess/treat the problems. Although the Job Analysts Survey (The Certification Board for Music Therapists (CBMT), 1993) included some of the assessment areas and patient problems reported in the present study, appropriate music therapy interventions for the problems were not surveyed. If knowledge of commonly assessed areas and problems is considered important, then it would seem logical that music therapy interventions commonly used to assessthe problems should also be important knowledge. In addition to enhancing job analysis efforts, information from the present study, especially the clinical manual resulting from the study, could be used as a reference for determining the representativeness of solicited competency test items. Because of the significant differences in music therapy practice according to CA level indicated in this study and in previous research (Cassity, 1985; Cassity & Theobold, 1990), it also is recommended that future job analysis surveys and competency examinations enhance control over CA. The Job Analysis Survey (CBMT, 1993) requested respondents to check the CA of the population with which they spend most of their time and, in a second column, to check the ages of all other patients with whom they work. Using this procedure, it would have been difficult to determine CA differences in the data since many music therapists work with more than one CA level of patient or equally differing CA levels. The above procedure may thus have transformed CA into a confounding variable. Responses to survey items such as identify manifestations of clients affective state (CBMT, 1993, p. 5) may have been distorted since the importance of such an assessment is dependent on patient CA. In contrast, ratings for items uninfluenced by CA would not likely be distorted, such as observe client in musical and nonmusical situations (CBMT, 1993, p. 5). Such a combination of distorted and undistorted ratings would inhibit a valid comparison of the relative importance of each test item. Although it may be argued that overall ratings were sought, if the survey and the resulting examination are to accurately reflect current practice in the music therapy profession (CBMT, 1993, p. 1), then it is recommended that future surveys control for CA.
26
Education Finally, it is recommended that information from this study be used to coordinate education with clinical practice. The results of this study should serve as a guide for training students in clinical practices that they most likely will encounter during psychiatric clinical training. Although information produced from this study is not intended to provide a cookbook approach to music therapy, it should be useful in providing students with a knowledge of the most common practices employed in psychiatric music therapy. Such knowledge may serve as essential cognitive background for designing unique music therapy strategies for atypical patients. References
Adelman, E. J. (1965). Multimodal therapy and music therapy: Assessingand treating the whole person. Music Therapy, 5, 12-21. American Psychiatric Association (1967). Diagnostic and statistical manual of mental disorders-revised (DSM-III-R). Washington, D.C.: Author. Bitcon, C. H. (1976). Alike and different. Santa Ana, CA: Rosha Press. Braswell, C. (1967). Changing concepts in treatment. Journal of Music Therapy, 4, 63-66.
Braswell, C., Brooks, D., Decuir, A., Humphrey, T., Jacobs, K., & Sutton, K. (1986). Development and implementation of a music/activity therapy intake assessmentfor psychiatric patients. Part If: Standardization procedures on data from psychiatric patients. Journal of Music Therapy, 23, Bruhn, B., & Patterson, W. (1992). The effect of music therapyon senior citizens. Unpublished manuscript, Southwestern Oklahoma State University, Weatherford, OK. Carroccio, D. F., & Quattlebaum, L. F. (1969). An elementary technique for manipulation of participation in ward dances at a neuropsychiatric hospital. The influence of a music therapy activity upon peer acceptance, group cohesiveness, and interpersonal relationships of adult psychiatric patients. Journal of Music Therapy, 13, 66-76. Cassity, M. D. (1965). Techniques, procedures and practices employed in the assessmentof adaptive and music behaviors of trainable mentally retarded children. Dissertation Abstracts International, 46, 10A. (Ann Arbor, MichCassity, M. D. (1976). igan: University Microfilms International No. 85-27959, 2955). Cassity, M. D., & Cassity, J. E. (1993). Multimodal psychiatric music therapy for adults, adolescents, and children: A Clinical Manual. Weatherford, 126-141.
Journal ofMusic therapy, 6,
108-109.
OK: C&C Publications. Cassity, M. D., & Theobold, K. A. (1990). Domesticviolence: Assessmentsand treatments employed by music therapists. Journal of Music Therapy, 27,
179-194.
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Certification Board for Music Therapists (1993). CBMT Job analysis survey. Tucson, AZ: Author. Cohen, G., & Gericke, O. L. (1972). Music therapy assessment:Prime requisite for determining patient objectives. Journal of Music Therapy, 9, 161-189. Cohen, G., Averbach, J., & Katz, E. (1978). Music therapy assessmentof the developmentally disabled client. Journal of Music Therapy, 15, 88-99. Davis, W. B. (1992). Music therapy for mentally retarded children and adults. In W. B. Davis, K. E. Gfeller, & M. H. Thaut (Eds.), An introduction to music therapy: Theory and practice (pp. 84-89). Dubuque, IA: Wm. C. Brown Publishers. Doll, E. A. (1965). Vineland social maturity scale. Circle Pines, MN: American Guidance Service. Endicott, J.,Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The global assessment scale: A procedure far measuring overall severity of psychiatric disturbance.
Archives
& English.A. (1958). A comprehensive dictionary of psychological and psychoanalytical terms. New York: David McKay Company, Inc. Ficken, T. (1976). The use of songwriting in a psychiatric setting. Journal of Freed, B. S. (1987). Songwriting with the chemically dependent. Music Therapy Perspectives, 4, 13-18. Frostig, M. (1963). Frostig developmental test of visual perception (3rd ed.). Palo Alto, CA: Consulting Psychologists. Graham, R. M., & Beer, A. S. (1980). Teaching music to the exceptional child: A handbook for mainstreaming. Englewood Cliffs, NJ: Prentice-Hall, Inc. Grossman, H. J. (1977). Manual on terminology and classification in mental retardation. Washington, D.C.: American Association on Mental Deficiency. Janiak, W. C. (1978). Songs for music therapy. Long Branch, NJ: Kimbo Educational. Jensen, K. L., 61McKinney, C. H. (1990). Undergraduate music therapy education and training: Current status and proposals for the future. Journal
of Music Therapy, 27, 158-178. Music Therapy, 3, 43-51.
English, H. B.,
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33(6), 766-771.
Jones, R. E. (1986). Assessing developmental levels of mentally retarded students with the musical-perception assessment of cognitive development.
Journal children of Music
Lathom, W. (1980).
Therapy, 23, 166173. Role of music therapy in the education of handicapped and youth. Silver Spring, MD: National Association for Music assessment persons, research draft III.
Therapy, Inc. Michel, D., & Rohrbacher, M. (Eds.) (1982). The music therapy
profile
Silver Spring, MD: National Association for Music Therapy, Inc. National Association for Music Therapy, Inc. (1989). Sample job descriptions. Silver Spring, MD: Author. National Association for Music Therapy, Inc. (1993). Standards of clinical practice. Silver Spring, MD: Author. Noland, P. (1983). Insight therapy: Guided imagery and music in a forensic psychiatric setting. Music Therapy, 3, 43-51.
for severely/profoundly
handicapped
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Rider. M. S. (1981). The assessment of cognitive functioning level through musical perception. Journal of Music Therapy, 18, 110-119. Rubin, B. (1976). Handbells in therapy. Journal of Music Therapy, 13, Terman, L. M., & Merrill, M. A. (1960). Revised Stanford-Binet intelligence scale. Boston, MA: Houghton Mifflin. Thaut, M. H., & Gfeller, K. E. (1992). Music therapy in the treatment of mental disorders. In W. B. Davis, K. E. Gfeller, & M. H. Thaut (Eds.), An introduction to music therapy: Theory and practice (pp. 114-117). Dubuque, IA: Wm. C. Brown Publishers. Wheeler, B. L. (1983). A psychotherapeutic classification of music therapy practice: A continuum of procedures. Music Therapy Perspectives, 1, Wood, M. M., Graham. R. M., Swan, W. W., Purvis, J., Gigliotti, C., & Samet,
S. (1974). Developmental music therapy. Silver Spring, MD: National As8-12. 49-53.
sociation For Music Therapy, Inc.
The Effect of Improvisational Music Therapy on the Communicative Behaviors of Autistic Children1
Cindy Lu Edgerton Michigan State University The purpose of this study was to determine the effectiveness of improvisational music therapy, based on Nordoff and Robbins (1977) Creative Music Therapy approach, on autistic childrens communicative behaviors. Eleven autistic children, ranging in age from 6 to 9 years, participated in individual improvisational music therapy sessions for a period of 10 weeks. A reversal design was applied. The Checklist of Communicative Responses/Acts Score Sheet (CRASS), designed specifically for this study, was used to measure the subjects musical and nonmusical communicative behaviors. Results
strongly suggest the efficacy of improvisational music therapy
in increasing autistic childrens communicative behaviors. Significant differences were found between the subjects first session CRASS scores and those of their last sessions (p < .01). Also, abrupt and substantial decreases in scores were noted for all 11 subjects when reversal was applied. In the first description of children diagnosed with early infantile autism, Kanner (1943) devoted a large amount of attention to their communication deficits. Since then, research has continued to support Kanners observations of the numerous problems related to autistic childrens communication development. According to the National Society for Autistic Children (1978) and the American Psychiatric Association (1987), language development deficit is one of the symptoms necessary for a diagnosis of autism. The acquisition of language is crucial to the prognosis for autistic children. The presence of useful speech by 5 years of
1The author gratefully acknowledges Roger Smeltekop, M.M., RMT-BC, and Dale Bartlett, Ph.D., for their support and guidance throughout this study. Correspondence regarding this article should he addressed to Cindy Lu Edgerton, 443 Forest, Charlotte, Ml 48813.
32
age was one of the most significant distinguishing characteristics between autistic children rated as making poor adjustment and those who made good adjustment (Eisenberg & Kanner, 1956). Further research confirmed the finding that the degree of language development by ages ranging from 30 months to 6 years is predictive of later development (Bagley & McGeein, 1989; Brown, 1963; DeMyer, Barton, DeMyer, Norton, Allen, & Steel, 1973; Kurita, 1985). Rutter (1978) and Gillberg and Steffenburg (1987) found that functional language skills demonstrated by early school age were as powerful as intelligence in predicting autistic childrens later skills. In Kanners (1946) description of autistic children, he noted the following specific characteristics of their language deficits: muteness, immediate and delayed echolalia, metaphorical substitution, literalness, simple verbal negation, repetitions, and pronoun reversals. He concluded that both the mute and the verbal children were the same as far as meaningful communication was concerned. Current views of these characteristics focus on difficulties in pragmatics, or how language is used for various purposes, which are now seen as a universal feature of autism (Frith, 1989). Autistic children have been found to have deficits in means-end behaviors (Abrahamsen & Mitchell, 1990), verbal, gestural, and motor imitative skills (Dawson & Adams, 1984; Stone & Lemanek, 1990), spontaneous speech (Shapiro, Chiarandini, & Fish, 1974), initiation of contact with others (Watson, 1985), intentional communicative behaviors/vocalizations (Ball, 1978), communicative functions (Landry & Loveland, 1989; Wetherby & Prutting, 1984), social communication skills (Attwood, 1984; Kubicek, 1980), and prosodic development (Baltaxe, Simmons, & Zee, 1984). Frith (1989) points out that, even though more has been written on the language impairments of autistic people than on any other of their deficit areas, numerous questions remain unanswered. At least three-quarters of all speaking autistic children demonstrate echolalia, but it is not yet known why (Frith, 1989). The belief that echolalic behaviors serve no significant communicative purposes has been challenged. Echolalia and stereotypical language of autistic children can be analyzed according to communicative intent, comprehension, and structural changes.
33
The results of two major studies indicated that four of the seven types of immediate echolalia (Prizant & Duchan, 1981) and 9 of the 20 categories of delayed echolalia (Prizant & Rydell, 1984) are interactive. Tager-Flusberg (1985) stated, Echolalia and stereotyped language are now seen as primitive strategies for communicating, especially in the context of poor comprehension (p. 72). Throughout the research and literature pertaining to autistic children, structured intervention approaches are frequently recommended. A high degree of structure is seen as an essential element in autistic childrens treatment plans (Thaut, 1980). In reviewing the research of education approaches, Clarizio & McCoy (1983) found general agreement that autistic children learn best in structured environments, where both the stimuli and the childs responses are determined by the adult. Current trends in language intervention programs with autistic children are numerous. There has been a change in emphasis from teaching language skills to teaching communication skills due to the importance placed on functional communication. This shift focuses on accepting each childs language impairment and working toward his/her optimum potential in communication development (Schopler & Mesibov, 1985). The most recent intervention technique for people with autism is facilitated communication, a method developed by Rosemary Crossley (Biklen, 1990). This method is based upon a praxis theory, which presumes that autistic people have a neurologically based deficit, not in comprehension, but in expression. Facilitated communication uses an electronic typing device and allows for education through dialogue and personal expression. Only one research study on facilitated communication, conducted by the Intellectual Disability Review Panel (1989) in Melbourne, Australia, has been published to date. This study produced support both for people who claimed facilitated communication was valid and for those who doubted its validity. Intervention programs have demonstrated success in autistic childrens socialization and communication achievements. However, treatment appears to have only a modest effect on long-term language adjustment. Many reports from clinical observations and experiments with
34
Journal of
Music Therapy
autistic children emphasize their special responsiveness toward and unusual interest in musical stimuli (Applebaum, Egel, Koegel, & Imhoff, 1979; DeMyer, 1979; Kolko, Anderson, & Campbell, 1980; Rimland, 1964; Sherwin, 1953; Thaut, 1980). In studies investigating the use of structured music therapy techniques with autistic children, positive effects were found in the childrens prosocial behaviors (Stevens & Clark, 1969); attention span (Farmer, 1963; Goldstein, 1964; Mahlberg, 1973; Saperston, 1982); self-expression (Cecchi, 1990; Goldstein, 1964; Mahlberg, 1973); mental age (Goldstein, 1964); spontaneous speech (Miller & Toca, 1979; Watson, 1979); vocal imitation skills (Miller & Toca, 1979; Saperston, 1982); interpersonal relationships (Goldstein, 1964; Saperston, 1982); task accuracy (Burleson, Center, & Reeves, 1989); and shopping skills (Staum & Flowers, 1984). The literature most relevant to this investigation has focused on improvisational music therapy techniques. Saperston (1973) used improvised music to establish communication with an autistic child who had not previously appeared to experience any type of communication. Alvin and Warwick (1992) reported on the use of improvisation to facilitate interactions, to provide for self-expression, and to help develop a relationship of trust and enjoyment for autistic children and their mothers. Hollander and Juhrs (1974) used Orff Schulwerk activities to help severely autistic children invest in a meaningful group experience. Nordoff and Robbins (1964, 1968a. 1971, 1977) have done extensive work using improvisation with autistic children. Their technique, Creative Music Therapy, emphasizes the creation of musical improvisations which serve as a nonverbal means of communication between the therapist and the child. Numerous case studies by Nordoff and Robbins have illustrated and corroborated the many values of Creative Music Therapy. Working with a 3-year-old autistic boy, vocal and instrumental improvisation aided in establishing communication, providing a means of self-expression, improving interpersonal relationships, and decreasing pathological behaviors (Nordoff & Robbins, 1964). In another study, Nordoff and Robbins (1968a) used improvised music with a 6-year-old autistic girl who demonstrated progress
35
in increased vocabulary, self-expression, and the spontaneous use of personal pronouns. In establishing a therapist-client relationship with a 5-year-old boy who exhibited autistic features, Nordoff and Robbins (1977) used improvisational techniques through both drum/cymbal-piano and vocal interaction activities. Progress was noted in several areas, including an increase in vocabulary, development of spontaneous and communicative speech, development of conversational jargon, and acceptance of change and novel situations. Although numerous case studies have demonstrated many therapeutic values of Creative Music Therapy, no controlled experimental studies of improvisational techniques based on Creative Music Therapy were found. Therefore, the purpose of this study was to examine the effects of improvisational music therapy upon the communicative behaviors of autistic children. Specifically, the following research questions were proposed: 1. Is there a significant difference between the number of total communicative behaviors as measured by the Checklist of Communicative Responses/Acts Score Sheet (CRASS) demonstrated by autistic children in their first improvisational music therapy sessions and the number demonstrated in their last sessions? 2. Is there a significant difference between the number of Communicative Responses/Acts demonstrated by autistic children in their first sessions and the number demonstrated in their last sessions in each of the following subcategories of the CRASS: tempo, rhythm, structure/form, pitch, speech production, communicative-interactive, and communicative intent? 3. IS there a significant relationship between the subjects musical vocal behavior score changes and their nonmusical speech production score changes as recorded on the CRASS? 4. Will any changes in the autistic childrens communicative, social/emotional, and musical behaviors be observed by the parents, teachers, or speech therapists outside of the music therapy setting at the conclusion of the IO-week period? 5. Are there significant relationships between the autistic childrens overall CRASS score changes and the parents, teachers, or speech therapists total ratings on the Behavior Change Survey?
36
Method Subjects Eleven autistic impaired subjects (ten males and one female), ranging in age from 6 to 9 years, participated in this study. Subjects diagnosis of autistic impaired ranged from severely to mildly impaired. Deficits in communication skills were common to all of the subjects. Language ages, measured by standardized tests and/or observation and reported by speech therapists and/ or teachers, ranged from no formal means of intentional communication to 5 years. Five subjects were nonverbal, and four subjects demonstrated limited functional language skills. Materials/Settings The following musical materials were used in the treatment procedure: a piano, a snare drum with the snare removed, and a 16-inch cymbal. The snare drum and cymbal were mounted on adjustable stands. The height and tilt of the snare drum and cymbal were adapted for each child to allow for successful attempts at beating. A chair was available for the subjects, and the experimenter was seated on a piano bench. A variety of beaters were also available, including regular medium-weight drumsticks, both heavy and light tympani mallets, and one pair of brushes. A videocamera was also in the room. The study was conducted in three different settings: two elementary schools and a music therapy clinic. Two of the rooms were similar in size and content; the other was a music education room that was larger and contained a variety of musical materials/instruments. An area within this room which resembled the other two rooms was set up for the experiment. The experimenter and each child were alone in the room with the exception of a few unanticipated interruptions. Measurement The dependent variable in this study was communicative behaviors. Consultations with speech therapists and a search of relevant literature revealed no standardized test that evaluates musical and nonmusical communicative behaviors for autistic children. Nonmusical communicative responses of autistic children are evaluated through a variety of standardized tests. Nor-
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doff and Robbins (1977) developed a musical communicativeness scale with established reliability; however, this reliability was established using music therapists who were specifically trained in the Creative Music Therapy technique (C. Robbins, personal communication, May 26, 1992). Therefore, an original checklist, Checklist of Communicative Responses/Acts Score Sheet (CRASS), was constructed by the experimenter. Each of the behaviors listed on the score sheet was operationally defined. The CRASS was based on items from numerous rating scales and assessments for musical communicativeness, autism, and communication skills (Brigance, 1978; Bzoch & League, 1970; Krug, Arick, & Almond, 1979; Nordoff & Robbins, 1977; Ruttenberg, Dratman, Fraknoi, & Wenar, 1966; Stillman, 1978; Uzgiris & Hunt, 1975; Wetherby & Prutting, 1984). The CRASS was divided into two categories: musical and nonmusical. Communicative Responses were defined as verbal, vocal, gestural, or instrumental behaviors demonstrated by the child which are influenced by the experimenters improvisation, e.g., matches a fast basic beat, simultaneously imitates the rhythm of a melodic motif, participates in a rhythmic give-and-take, etc. Verbal, vocal, or instrumental behaviors initiated by the child in an attempt to influence the experimenters improvisation/behaviors or for the purpose of independent expression were categorized as Communicative Acts (e.g., creates a rhythmic pattern, develops a melodic give-and-take, spontaneously creates a new melodic phrase, etc.). Behaviors which served as prerequisite skills necessary for musical communication were also categorized as Communicative Acts (e.g., beats within a tempo range, vocalizes, etc.). Within the musical category, operationally defined Communicative Responses and Acts were listed under four subcategories: tempo, rhythm, structure/form, and pitch. In the nonmusical section, operationally defined behaviors were categorized according to speech production skills, communicativeinteractive skills, and communicative intent skills. The CRASS contained a total of 107 items, with 91 items in the musical category and 16 items under the nonmusical category. Sixty-nine items were categorized as Communicative Responses, and thirty-eight items were categorized as Communicative Acts.
38
Time interval sampling was used, with one lo-minute interval randomly selected prior to each 30-minute session. The sessions were videotaped for data collection purposes. During the one lo-minute interval, two observers independently recorded the communicative behaviors of each child using the CRASS. The observers were senior undergraduate music therapy students. A check was given for each behavior observed, with a maximum of one check recorded for each behavior, even if that particular behavior was repeated. The checks were then tallied, resulting in a total Communicative Responses/Acts score per subject per session. The second observer served as a reliability check throughout the study. Interobserver agreement was calculated for both occurrences and nonoccurrences using the following formula: agreements divided by the sum of agreements and disagreements. Interobserver reliability for occurrences ranged from 75% to 100%, with a mean of 86.2%. For nonoccurrences, interobserver agreement ranged from 77% to 100%, with a mean of 94%. The second measurement device used was the Behavior Change Survey, which was given to parents, teachers, and speech therapists for each subject immediately following the conclusion of the study. There were five questions related to communicative behaviors, six questions related to social/emotional behaviors, and two questions related to musical behaviors. A sevenpoint rating scale was used to indicate the number of changes seen in the subjects communicative, social/emotional, and musical behaviors. The numbers, in sequence from 1 to 7, represented the following descriptions: much less, somewhat less, slightly less, same, slightly more, somewhat more, and much more. Procedure A reversal design was used, consisting of the following phases: (a) intervention, (b) one-session withdrawal of intervention after a level of consistency in responses was achieved, and (c) reintroduction of the intervention. Each subject was scheduled for one 30-minute session per week for 10 weeks. Due to illnesses and unforeseen circumstances, two subjects were not able to attend all 10 sessions. One
Vol.XXXI, No. 1, Spring. 1994
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subject attended eight sessions, and the other subject attended nine sessions. Intervention consisted of improvisational music therapy, based on Nordoff and Robbins (1977) Creative Music Therapy approach. The experimenter created music to establish contact with the child, to enable the child to respond, and to facilitate development of the childs musical communicativeness. The experimenter played the piano and/or sang, and each child had opportunities to play instruments and to sing. The following two basic principles were followed with all of the subjects: (a) Each child was treated as competent, and it was assumed that he/she understood all that was said and was capable of musically expressing him/herself; and (b) total emotional support was provided for each subject, with the experimenter remaining as responsive as possible to each child and conveying acceptance of him/her. A hierarchy of musical experiences/activities was provided as a guiding reference for ongoing decisions made by the experimenter throughout the intervention sessions. Specific techniques used were decided in the course of the music therapy sessions, dependent upon the childs responses, capacities, and needs. Numerous techniques listed in the hierarchy (114 specific techniques) were available to the experimenter to allow for flexibility within each session in creating an atmosphere for the child in which optimal growth and development could occur. The experimenter worked freely within the hierarchy of musical experiences/activities. Many of these techniques were taken from the book, Creative Music Therapy, by Nordoff and Robbins (1977). A complete copy of the hierarchy is available upon request. The first intervention phase continued until consistency in responses was noted. Due to the fact that all subjects measured responses showed an ascending baseline by the sixth session, all reversal sessions occurred in Session 6. Reversal consisted of the experimenter playing and singing structured precomposed music as opposed to improvised music. During this phase, the experimenter continued to evoke, maintain, and/or develop the childs responses. Gestural invitations, verbal invitations, and reinforcements remained the same. The use of written music
40
added additional materials and decreased the amount of eye contact during the reversal phase. During the first 10 minutes of the reversal session, preselected music therapy activity songs were played and sung. The songs, chosen prior to implementation of the study, provided opportunities for each child to respond in all of the areas listed in the CRASS. Songs used during reversal included I Have a Song to Sing (Cross, 1989), Charlie Knows How to Beat the Drum (Nordoff & Robbins, 1962), Drum Talk (Nordoff & Robbins, 1968b), 3/4 and Strong (Dubesky, 1982), and Its Music (Dubesky, 1989). These songs were then repeated during the lo-minute data collection interval, which was randomly chosen prior to the session. Following the reversal, intervention was continued as explained above for the remaining sessions. Results Figure 1 shows group mean Communicative Responses/Acts for each session. An overall increase in total scores was noted for the group as a whole, along with an abrupt decrease in the total group mean score during the reversal (Session 6). Figures 2-12 show individual graphs for each subject. These figures reveal individual differences in the total number of Communicative Responses/Acts and in the degree of improvement in the CRASS scores over the 10 sessions; however, an overall trend was demonstrated, showing an increase in the CRASS scores during both intervention phases and a decrease in these scores during reversal for each individual. In the initial intervention phase, the level of change for all subjects was in an improving direction ranging from 8 to 40 points, with a mean of 18.3. Withdrawal of the intervention resulted in an abrupt and substantial decrease in the quantity of Communicative Responses/Acts. Decreasing level changes ranged from 9 to 37 points, with a mean of 19.3. This level was reversed immediately upon reintroduction of treatment procedures. Increasing level changes from the reversal to the reinstatement of intervention ranged from 10 to 43 points, with a mean of 22.6 During the second intervention phase, the level of change was in an improving direction and ranged from 6 to 17 points, with a mean of 11.3.
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Group Mean Scores

Responses
Sessions
Figure 1
Group Mean Communicative Responses/Acts across 10 Sessions
A positive acceleration trend was noted in both intervention phases for all 11 subjects. Trend stability within conditions was determined for both intervention phases for each subject. Criteria for trend stability was set at 80% of the data points falling within 15% along the trend line (Tawney & Gast, 1981). Ail 22 conditions showed a stable trend. The Wilcoxon Matched-Pairs Signed-Ranks Test was used to
Subject A
70 i
Figure 2 Communicative Respones/Acts of Subject A across 10 Sessions.
determine if a significant difference existed between subjects scores of their first and last sessions. Figures 2-12 show that all of the subjects last session scores were greater than their first session scores. Consequently, the differences between the scores were significant at the .01 level (T = 0). Taking into account that one of the characteristics of autistic children is resistance to change, questions emerged concerning the validity of the first session scores. Therefore, a statistical
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Subject B
Responses
70
I
4 5 6 7 6 9 10 Sessions
Communicative
Figure 3.
Responses/Acts of SubjectB across 10 Sessions,
analysis was computed to determine whether a significant difference existed between the subjects' third session scores and their last session scores. Using the third session scores instead of the first session scores in the analysis was based on the assumption that, by the third session, the subjects were not viewing music therapy as a change in their routine. Therefore, the third session scores may have been more accurate in portraying the communicative abilities of the children at the beginning of the
44
Subject C
30
10
Sessions
Figure 4
Communicative Responses/Acts ofSubjects C across 10 sessions
Study. Significance was achieved at the .01 level (T =0), thus

supporting the original analysis completed
Figure 13 shows group mean scores in each of the four musical subcategories of the CRASS across 10 sessions; Figure 14 shows the group mean scores in each of the three nonmusical subcategories of the CRASS across 10 sessions. Statistical analyses were applied to the subjects first and last session scores in all of the subcategories of the CRASS. The Wilcoxon Matched-Pairs
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Subject D
10
Sessions
Figure 5.
Communicative Responses/Acts of Subject D across 10 Sessions.
Signed-Ranks Test indicated significant differences at the .01 level between first session scores and last session scores for tempo (T = 0), rhythm (T = 0), structure/form (T = 0), pitch (T = 0), speech production (T = 0), and communicative-interactive (T = 0). Significant differences at the .05 level were found between first session scores and last session scores for communicative intent (T = 2.5). A Spearman Rank Correlation Coefficient was calculated be-
Subject E
Figure 6
Communicative Responses/Acts of Subjects Eacross 10 Sessions tween the musical vocal behavior gains and the nonmusical speech production gains as recorded on the CRASS. Table 1 shows each subjects total point gain in both of these categories. The coefficient corrected for ties was .645, which was significant at the .05 level (t = 2.532). These results indicate that, as musical vocal behaviors increased, nonmusical speech production be haviors also increased. The Behavior Change Survey was completed by 11 parents,
47
Subject F
Responses
Sessions
FIGURE 7. Communicative Responses/Acts of Subject F across 8 Sessions.
4 teachers, and 2 speech therapists. Thirty-three surveys were distributed and 29 were returned (58% return rate). Table 2 shows the means for each of the three categories as answered by the parents, teachers, and speech therapists. Most of the means fell between 4, which indicated no change, and 5, which indicated a slight change. Overall, the parents gave the highest ratings (M = 4.8), followed by the teachers (M = 4.7), and finally the speech therapists (M = 4.2). Changes were seen in all three categories by parents, teachers, and speech therapists.
48
Subject G
Responses
70 60
Sessions
FIGURE 8. Communicative Responses/Acts of Subject G across 10 Sessions.
The highest rankings were given in the musical category (M = 4.9). Both the communication and the social/emotional categories received a mean of 4.5. The Spearman Rank Correlation Coefficient was used to determine whether there were any correlations between (a) gains in CRASS scores and parent Behavior Change Survey ratings, (b) gains in CRASS scores and teacher Behavior Change Survey
49
Subject H
I*+ Responses
70
7
I
Communicative Responses/Acts of Subject H Across 10 Sessions.
FIGURE 9.
ratings, and (c) gains in CRASS scores and speech therapist Behavior Change Survey ratings. Table 3 shows each subjects gain in CRASS scores and his/ her total ratings obtained from the Behavior Change Survey. A significant correlation was found between the gains in CRASS scores and the parent ratings. The rho was ,773, which obtained significance at the .01 level (t = 3.658). The rho corrected for ties for gains in CRASS scores and teacher ratings was .217 and did not reach significance. The Spearman Rank Correlation
50
Subject I
10 hi 0 1 Sessions
Figure 10
Communicative Responses/Acts ofSubject Iacross 10 Sessions.
Coefficient, corrected for ties for gains in CRASS scores and speech therapist ratings, was .387 and did not obtain significance. Discussion Results of this study suggest that improvisational music therapy is effective in eliciting and increasing communicative behaviors in autistic children within a musical setting. These re-
123458789 Sessions
Figure 11 Communicative Responses/Acts of Subject, Jacross 9 Sessions
sults support numerous case studies and clinical experiences which suggest the effectiveness of improvisational music therapy (Alvin & Warwick, 1992; Hollander & Juhrs, 1974; Nordoff & Robbins, 1964, 1968a, 1971, 1977; Saperston, 1973). This study differs from current research available in the area of improvisational music therapy and communicativeness in autistic children in that objective methods of control, observation, and data reporting were applied.
Subject K
1.3 Responses
Figure 12 Communications Responses/Acts of Subject K across 10 Sessions.
Results of this study show that autistic children can make gains in communication when participating in a low-structured intervention. These findings are contradictory to current literature and research, in which structured approaches are frequently recommended. Do autistic children need more opportunities to experience spontaneity and creativity successfully? The improvisational approach not only allows for spontaneity and flexibility, but also allows for successful experiences. Within
FIGURE 13. Group Mean Scoresin Tempo, Rhythm, Structure/Form, Sessions.
and Pitch across 10
this spontaneity, music provides for sufficient predictability to give the child the amount of support he/she needs. Significant differences were noted between the number of each of the four musical communicative modalities used by the autistic children in their first sessions and the number used in their last sessions. In comparing these four modalities (tempo, rhythm, structure/form, and pitch), the group as a whole used
54
Nonmusical Subcategories of CRASS

10
12
10
Sessions Figure 14.

Group Mean Scores in Speech Production, Cummunicative-interactive, Communicative Intent across 10 Sessions. and
tempo most frequently in both the first and the last sessions. Also, the largest point gain from the first to the last session was noted in tempo for the group as a whole (M = 9.9). The other three modalities, in order of group mean decreasing point gains, were pitch (M = 7.7). rhythm (M = 5), and form (M = 4.6). One interpretation of these data concerns the rhythmic repetitive behaviors characteristic of autistic children. Colman
55
TAble 1 CRASS Musical

Gains A Vocal 23
Vocal Behavior
Gains and Nonmusical Subjects F G 8 19
Speech Production
B 26
c 9
D 32
E 21
H 12
I 36
J 11
K 3
Means 18.2
Speech
2.5
Note. CRASS = Checklist of Communicative Responses/Acts Score Sheet.
and his colleagues (1976) assert that there is a stability in the frequency at which repetitive behaviors occur. The modality of tempo consisted of beating/vocalizing in a steady tempo, matching the experimenters tempo, and beating/vocalizing and matching tempo variations. Because of the fundamentally rhythmic behaviors of autistic children, tempo may initially be one communicative modality in which autistic children can immediately experience success. Thaut (1980) suggested the possibility of rhythm being absorbed on a physiological level and bypassing the cognitive deficits of autistic children. His definition of rhythm encompassed both the tempo and the rhythmic modalities measured in this study. This could provide one possible explanation for the high levels of communicativeness found in the tempo mo-
Table 2 Mean Scores for Behavior Change Survey Categories as Rated by Parents
Teachers, and Speech Therapists
Communicative Behaviors 4.5 4.2 Social/Emotional 4.7 Musical 5.1 Overall 4.7 4.2 4.4 Behaviors 4.2
56
Table 3
CRASS Gain Scores and Total Behavior Change Survey Ratings Work-up for
the Spearman Rank Correlation Coefficient
Means
32.8
62.9
60.6
55.1
Note. CRASS = Checklist of Communicative dash indicates no score was available.
Responses/Acts Score Sheet. A
dality. However, as noted subsequently, subjects demonstrated minimal increases in the rhythm modality. Another interpretation of the increased amount of communicativeness found in the tempo modality concerns interactional synchrony. Condon (1976) reported that listeners move in exact synchronous relationships with speakers. In researching autistic children, however, Condon found that this synchrony is distorted (1975). The subjects in the present study were able to synchronize their drum beating with the ongoing music to varying degrees. One could posit that this synchrony facilitated communicative interaction through the music. Also, the music was synchronized with the childrens repetitive movements and vocalizations, using their levels of intensity, their rhythms, and their tempi. This could have created a sense of awareness, sense of control over their environment, and a new means of cornmunication. In the modality of pitch, gains ranging from 3 to 15 points were noted. All of the items in this modality were vocal responses. It is significant that all 11 subjects made gains in this modality.
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Overall gains were also noted in rhythm and structure/form. However, the gains were smaller than with the previous two modalities discussed. Both modalities demand more cognitive involvement as compared to tempo. Perhaps there is a connection between the cognitive deficiencies found in autistic children and the modalities of rhythm and structure/form. The significant correlation coefficient obtained between the musical vocal behavior gains and the nonmusical speech production gains (rs = .645, p < .05) indicates that, as musical vocal behaviors increased, nonmusical speech production behaviors also increased on the average. It has been stated that communication through music bypasses the speech and language barriers of autistic people; this could be one possible explanation for the observed increases in musical vocal behaviors. However, the significant relationship found between increases in musical vocal skills and increases in speech production skills leads to the question as to whether there is a cause-andeffect relationship. Further research is needed to examine this question. Results of the Behavior Change Survey indicated change in subjects behaviors; however, the change was minimal. Parents and teachers reported more changes than did speech therapists in all three categories. This could be due to the limited amount of time the speech therapists see the subjects as compared to the teachers and parents. Also, the placebo effect must be taken into consideration when interpreting these data. It is possible that the changes observed in the subjects behaviors could have been attributed to changes in the parents and teachers attitudes and expectations of the subjects since they were aware of the purpose of this study. The musical category was the highest rated category overall. This could have been influenced by knowledge of the subjects participation in the music therapy research study. It is possible that, due to this knowledge, parents, teachers, and speech therapists became increasingly aware of the subjects attraction to musical stimuli and demonstration of musical behaviors. A significant correlation was found between the subjects CRASS gains and the parents total Behavioral Change Survey ratings, which indicates that, on the average, parents of subjects who demonstrated the most CRASS gains rated their children
58
higher on the Behavior Change Survey than did the other parents. The question of possible generalization or transfer of learning from one setting to another emerges from this finding. The teachers and speech therapists total ratings were not significantly correlated with subjects CRASS gains. One possible reason for these differences might be that teachers and speech therapists use a more structured setting than do parents. Within the structured environment, opportunities for subjects to demonstrate spontaneity and use new skills may be limited. If this study is replicated, some changes should be considered. First, a larger number of subjects would increase the validity of the study. Also, a male:female ratio which is proportional to the actual ratio found in autism, which ranges from 1.4 to 4.8:1 (Gillberg, 1989), would help increase the generalizability of the results. Uncontrolled factors, including the various settings of the study and the decrease in eye contact and increase in materials during reversal, should be controlled in future studies. Another suggestion would be to increase the total number of sessions for each subject, which would allow for more sessions during the reversal phase. One change in the CRASS is also recommended for future research. An increase in the number of items in the nonmusical category would provide a more comprehensive look at the communicative behaviors of autistic children in music settings and would balance the nonmusical and musical sections of this measurement device. Future research studies in improvisational music therapy could be designed to study both the effects of specific techniques within improvisational music therapy and autistic childrens specific responses in the various musical communicative modalities. Other studies could focus on pragmatic aspects of autistic childrens communication in an improvisational music therapy setting, identifying and comparing the specific communicative functions in both singing and speaking contexts. Further experimentation might increase understanding of the communication deficits of autistic children. This increased knowledge could facilitate the development of intervention programs in which autistic children could express themselves and experience the joys of communication.
59
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Developmental issues and prognosis. In M. Rutter & E. Schopler (Eds.), Autism: A reappraisal of concepts and treatment (pp. 497-505). New York: Plenum Press. Saperston, B. (1973). The use of music in establishing communication with an autistic mentally retarded child. Journal of Music Therapy, 10, 184-188. Saperston, B. (1982). Case study: Timmy. In D. W. Paul (Ed.), Music therapy for handicapped children: Emotionally disturbed (pp. 42-57). Washington D.C.: Office of Special Education and the National Association for Music Therapy. Schopler, E., & Mesibov, G. (Eds.) (1985). Communication problems in autism. New York: Plenum Press. Shapiro, T., Chiarandini, I., & Fish, B. (1974). Thirty severely disturbed children. Archives of General Psychiatry, 30, 819-826.
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Stevens, E.. & Clark, F. (1969). Music therapy in the treatment of autistic children. Journal of Music Therapy, 6, 98-104. Stillman, R. (Ed.) (1978). The Callier-Azusa scale. Unpublished manuscript, The University of Texas at Dallas. Stone, W. L., & Lemanek, K. L. (1990). Parental report of social behaviors in autistic preschoolers. Journal of Autism and Developmental Disorders, 20, 513-522. Tager-Flusberg, H. (1985). Psycholinguistic approaches to language and communication in autism. In E. Schopler & G. B. Mesibov (Eds.). Communication problems in autism (pp. 69-88). New York: Plenum Press. Tawney, J. W., & Gast, D. L. (1984). Single subject research In special education. Columbus, OH: Charles E. Merrill. Thaut, M. (1980). Music therapy as a treatment tool for autistic children. Unpublished masters thesis, Michigan State University, East Laming. Uzgiris, I., & Hunt. J. (1975). Assessmentin infancy: Ordinal scales of psychological development. Urbana University of Illinois Press. watson, D. (1979). Music as reinforcement in increasing spontaneous speech among autistic children. Missouri Journal of Research in Music Education, 4(3), 8-20. Watson, L. B. (1985). The TEACCH communication curriculum. In E. Schopler & G. G. Mesibov (Eds.), Communication problems in autism (pp. 187206). New York: Plenum Press. Wetherby, A. M., & Prutting, C. A. (1984). Profiles of communicative and cognitive-social abilities in autistic children. Journal of Speech and Hearing
Research, 27, 364-377.
Effects of Performing Conditions on Music Performance Anxiety and Performance Quality

Melissa Brotons Willamette University The purpose of this study wee twofold: (a) To determine if there is a difference in physiological and psychological responses that measure performance anxiety between nonjury and jury conditions, and (b) to examine how open and double-blind jury conditions affect physiological, psychological, and behavioral components of performance anxiety and performance quality of music students. Sixty-four college music students in each of five instrumental areas and one vocal area participatedin this study. The experiment was a pretestposttest control group design with matching. Dependent variables were heart rate, scores of the State Anxiety scale of the State-Trait Anxiety inventory (STAI), performance quality ratings by judges, and behavior analysis of videotaped students performances. Results showed significant increases in heart rate (F = 130.01, df = 1, p = .0001) and STAI scores (F = 23.92, df = 1, p = .0001) between non-jury and jury conditions, but no significant differences (F (4, 59) = .95, p = ,444) occurred in heart rate, STAI scores, behavior, and performance quality due to open and blind jury conditions. Further analysis showed no association among variables suggesting that there may be different types of performance anxiety.
Performing arts medicine, as a new medical specialty, started receiving public attention in the last decade when research began to show that performers, among them musicians of all levels of training and expertise, probably suffer from a variety
This paper is a report of the authors dissertation research completed at The University of Oregon. Please address correspondence regarding this article to Dr. Melissa Brokons, Music Department Willamette University, Salem, OR 97301.
64
Journal ofMusic Therapy
of physical, psychological, and occupational stress problems (Lederman, 1989). Beethoven, Paganini, and Robert Schumann are examples of great musicians affected by these types of illnesses. In some cases, these problems become so severe that professional musicians must terminate their performing careers (Lockwood, 1989; Pearson, 1990). A review of Arts Medicine literature indicates that performance anxiety is one of the most often cited problems that musicians suffer (Goode & Knight, 1991). Performance anxiety, also known as stage fright, is a serious, debilitating problem which functionally impairs a large number of musicians. Some degree of stress and tension (adaptive anxiety) is experienced by most musicians, and some stress appears to be necessary to reach peak performances (Caldwell, 1990; Plaut, 1990). Excessive stress, however, becomes debilitating and leads to inefficient use of musical skills. When sufficiently adverse during performance, such anxiety can discourage performers from further study of music (James, 1988; Wolfe, 1989). Ely (1991) and Salmon (1991) identified four different manifestations of performance anxiety: 1. Physiological changes that take place within the body might include one or more of these characteristic traits: increased heart rate, sweating, shortness of breath, shaking, numb fingers, clammy hands, dry mouth, upset stomach, headache, dizziness, nausea, and diarrhea. 2. Psychological/emotional conditions, such as exaggerated feelings of apprehension, fear of failure, irritability, and generalized panic are the most common symptoms experienced at this level. 3. Cognitive problems, such as loss of confidence, lack of concentration because of the thoughts and worries about the performance situation, memory lapses, and inability to infuse life and color into the music are examples of disturbing mental processes that take place under stage fright (Hingley, 1985). 4. Behavioral changes, such as lips moistening, knees and hands trembling, arm and neck stiffness, shoulder lifting, and deadpan face are representative behaviors exhibited by performers with stage fright. Stage fright appears to have different origins and meanings depending on what components are emphasized and how they
65
are interpreted according to the different psychological theories. For instance, physiological theory has catered on the problem of unpredictable motor coordination as a result of the release of excessive adrenaline in an anxious situation (Havas, 1973; Nagel, 1990). Cognitive-behavioral theory attributes performance anxiety to negative thoughts and self-statements such as, I must be approved by the audience in order to feel good. These persistent thoughts psychologically enfeeble self-confidence and negate hours of preparation (Nagel, 1990). Several studies have been conducted which support this theory (Lehrer, Goldman, & Strommen, 1990; Tobacyk & Downs, 1986). Their results indicate that the degree of performance anxiety and its effects during performance are the result of the frequency and intensity of negative, even paranoid, types of thoughts before performance. Psychoanalytic theory views performance anxiety as a cluster of attitudes, traits, and unconscious conflicts that are developed during childhood and that become ignited in particular circumstances such as anticipating or giving a concert (Nagel, 1990; Plaut, 1990; Weisblatt, 1986). Furthermore, Brandfonbrener (1990) stated that performance anxiety is simply a manifestation of psychological problems and cannot be discussed appropriately in isolation.. Each symptom of every person must be evaluated within the context of that individuals psychological make-up (p. 1). Other variables not directly linked to any psychological theory are mentioned in the literature since they appear to have a relationship with performance anxiety. These variables are: types of musicians and jobs, type of instrument and repertoire typically associated with it, age, years of experience, and level of preparation (Ely, 1991). Several treatment modalities that ameliorate negative consequences of performance anxiety have been investigated and are described in the literature. Pharmacological forms of treatment, specifically beta-blockers, have been prescribed over the years mainly to reduce the adverse physiological symptoms of performance anxiety such as palpitations, hyperventilation, tremor, and nausea (Dubovsky, 1990; Hingley, 1985). The results of studies examining the effect of beta-blockers to reduce
1 66 Journal of Music Therapy
performance anxiety show that beta-blockers are effective as one means of temporarily controlling the negative somatic symptoms of performance anxiety (Nub&, 1991). This appears to be especially true when the medication is taken immediately before or at the beginning of a performance (Nettel, Kaser, & Vorkauf, 1982) and small doses are administered (Gates, Saegert, Wilson, Johnson, Shepherd, & Hearned, 1985). Furthermore, the results of a study conducted by Lehrer, Rosen, Kostis, and Greenfield (1987) show that beta-blockers can enhance different dimensions of performance such as intonation, evenness of vibrato. bow control, dynamic control, accuracy, memory, rhythm, and tempo. Although this type of medication has been shown to be safe for many musicians, there are potential risks in taking beta-blockers over long periods of time (Nies, 1990). Other studies have focused on examining the effect of different psychological treatments to reduce cognitive, behavioral, and physiological components of performance anxiety, especially among professional musicians. Behavioral techniques such as systematic desensitization, cognitive/attentional intervention, and biofeedback have proven to be very successful in reducing physiological and cognitive symptoms of stage fright while improving performance (Appel, 1976; Fogle, 1982; Mansberger, 1988; Wardle, 1975). Other techniques mentioned as effective for particular individuals are movement/physical exercise (Ristad, 1982); imagery (Dunkel, 1989; Trusheim, 1987); planning the performance well in advance (Caldwell, 1990); and the combination of relaxation training with hypnosis (Plott, 1986). Individual and group music therapy interventions, alone and in combination with other behavioral techniques, have also been shown to have a positive effect in reducing the performance anxiety of professional musicians (Mantello, Coons, & Kantor, 1990; Rider, 1987). It is interesting to note that up to the present time the focus of interest among researchers has been on professional musicians and their performance situations: concerts and recitals. The effect of different treatment interventions to ameliorate this problem has also been investigated with professional musicians. However, few studies have been conducted with music students or have examined performance situations other than concerts.
Vol. XXX/, No. 1. Spring, 1994
67
Researchers consistently have found that performance anxiety occurs because performers feel constantly evaluated and compared against a perfect standard (Gabbard, 1980). However, concerts and recitals have other aims besides being technically perfect. One of the purposes of concerts is to bring enjoyment to an audience. However, performances that are entirely aimed at evaluation are exams or juries that are commonly practiced throughout the musical world. Juries are periodic evaluations of performance that determine grading and advancement. Two types of juries commonly used in academic and professional settings are open and double-blind juries. In an open jury, the performer plays in front of judges, and both parties (performers and judges) know each other. This type of jury is widely used in colleges and universities as an audition procedure for acceptance into music programs and competitions for scholarships, chairs, and solo parts. In a double-blind jury, musicians perform behind a screen so that neither they nor the judges know each others identities. Sometimes audio recordings are used for evaluation purposes instead of live performances for this type of jury situation. This modality of jury is also used in colleges and universities for admission purposes and/or to grant scholarships, and mostly in job auditions. Limited objective information is available about the effect of stage fright on jury performance, and specifically how these two types of juries affect performance anxiety. Only one study was found that compared the effect of two simulated jury conditions on perceived anxiety and performance quality (Hamann, 1982). The purpose of this study was twofold: (a) To determine if there is a difference in physiological and psychological responses that measure performance anxiety between non-jury and jury conditions, and (b) to examine how open and double-blind jury conditions affect physiological, psychological, and behavioral components of performance anxiety and performance quality of music students. Method
Subjects
Subjects for this study were 64 music students representing five instrumental areas (woodwinds, brass, strings, piano, and
66
percussion) and one vocal area enrolled in undergraduate and graduate music programs at a large state university. There were 32 males and 32 females in the sample. Their age range was 18-64 years (M = 24.02; SD = 8.24). Subject selection criteria were based on each subjects willingness to participate and their commitment to pass juries during the school year. Facilities,
Apparatus, and Materials
All testing was done in the School of Music of a large state university. Heart rate was measured by using the Polar Vantage XL heart rate monitor model #45900. This piece of equipment had been used in previous studies and had shown to be suitable specifically to measure musicians heart rates while in a performing situation (LeBlanc, Campbell, & Codding, 1991). Perceived anxiety was assessed with a modified version of the State scale of the State-Trait Anxiety Inventory (STAI, Form Y-1) (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1980). The pre-jury form included the phrase, During practice time The post-jury ... , before the 20 items of the questionnaire. form had two items added. The first one was, During the jury ...,before the 20 items of the questionnaire, and the second at the end which asked the subjects to evaluate how well they had played for the jury. Items 3, 4, 6, 7, 9, 12, 13, 14, 17, and 18 of both forms were scored in reverse order. Performance quality was measured on a researcher-designed observation form that included eight items that were rated on a five-point rating scale (1 being excellent and 5 fair). Seven of these items referred to specific characteristics of music performance: (a) intonation, (b) rhythmic accuracy, (c) technical competency, (d) dynamics, (e) phrasing, (f) expressiveness/musicianship, and (g) tone quality. The eighth was a total performance rating in which a global assessment of the students performance was given. Subjects behavior was observed on a researcher-developed behavior observation form. It included a total of 23 behavioral indicators of nervousness in the following six categories: (a) feet and legs, (b) body, (c) arms and hands, (d) face, (e) instrument behavior, and (f) vocalizations. Subjects were observed from the time they started playing until the end of their performance. The procedure used was observation for 20 seconds followed
69
by a lo-second interval during which the observer(s) recorded the observations. Independent observations were obtained for 58% of the cases selected randomly. The Pearson product-moment correlation as a measure of interobserver reliability was calculated to be .99.
Design and Procedure

The experimental design used in this study was a pretestposttest control-group design with matched groups (one receiving an open jury condition and the other a double-blind condition). The pretest was the studio practice and the posttest the jury performance. Subjects were matched according to age, gender, years of formal training, and instrument, and then were randomly assigned to one of the two jury conditions (see Table 1 for groups equivalency). Two pretests were given to the music students. Subjects heart rates were measured at 5-second intervals during three 7- to 13-minute periods while practicing alone in a studio in order to obtain a heart rate baseline for subjects in a relaxed performing situation. During these three intervals, students also had the opportunity to learn how to wear the heart rate monitor properly and become accustomed to it while performing. The second pretest was a modified version of the STAI to get a score on how anxious they felt during practice (non-jury) time (Spielberger et al., 1980). This questionnaire was filled out after each practice period. After the last pretest period, subjects were told the condition to which they had been assigned to perform their jury (open or double blind). For the open jury condition, subjects (N = 32) performed a 5- to 10-minute composition during a normal jury situation. Prior to beginning the jury, the subjects completed a short prejury interview that included three questions: (a) Normally how do you feel in a jury situation? (b) How do you feel about the open/double-blind jury condition? (c) How prepared do you feel for this jury? They were rated on a four-point rating scale (I being very relaxed/prepared and 4 very nervous/not prepared). During the jury, their heart rate was measured, at 5-second intervals, starting 2 minutes before their performance and lasting until the end of the performance. These jury performances were videotaped in order to do a post-hoc analysis
70
Table 1
Subject Demographics M Age 22.94 Open Gender M YFT M: 15 7.73 v: Inst. 9(28%) M Age 25.09 Blind Gender M YFT M: 17 8.33 v: Inst. 9 (28%)
F: 17
w: 11(34%) B: 6 (19%) P: 1(3%) Perc: 2 (6%) s: 3 (9%)
F: 15
w: B: P: Perc: s:
7 (22%) 6 (19%) 2 (6%) 3 (9%) 5 (16%)
W: woodwinds; B: brass; p: piano; Perc: percussion: s: strings.

1t(31)= 1.051, p = .30. 2t(31) = 0.525, p = .60.
M: male; F: female; YFT: years of formal training; Inst.: instrument; V: voice:
of performance behavior. Immediately after their performance, subjects filled out another modified version of the STAI in order to get a measure of how anxious they felt during their jury, and they answered the questions of a post-jury interview, mostly for discussion purposes. The specific questions were: (a) How do you feel about the jury you just performed? (b) Were you nervous? (c) What aspects of the jury made you feel nervous? (d) Had you ever performed for a double-blind/open condition before? (e) (for subjects in the double-blind condition only) Did the blind condition have an effect on your nervousness? (f) Did the heart rate monitor bother you? (g) Did the video-camera bother you? In addition, two judges (own teacher of applied instrument and another teacher in the area) rated the quality of each students performance on a performance quality form. Interrater reliability for each questionnaire item ranged from .28 to .50. For the double-blind jury condition, the subjects (N = 32) completed the same pretests and posttests as the subjects in the open condition. In addition to having in-house judges, the subjects performances were audio-recorded, and they were informed that their performances also would be rated by unknown external judges. Neither the subjects nor the judges had any information about each other. The external judges evaluated the subjects performances using the same type of performance quality form that the in-house judges used.
Vol. XXX/, No. 1, Spring. 1994 Results
71
To determine if there was a difference in subjects heart rates and STAI scores between non-jury and jury conditions, the three baseline periods were first averaged to obtain a single baseline score for heart rate and STAI scores for each of the 64 subjects. Also, a mean was calculated from the heart rate sample taken during jury performance, and a total score was obtained from the STAI questionnaire completed after the jury performance. A one-way ANOVA was calculated for each of these two dependent variables. Results revealed a significant difference in heart rate (F = 130.01, df = 1, p = .0001) and STAI scores (F = 23.92, df = 1, p = .0001) between non-jury and jury conditions. Heart rate increased from a mean of 98.79 (SD = 13.85) during non-jury to 130.68 (SD = 17.90) during jury condition. STAI scores increased from a mean of 35.92 (SD = 9.70) during non-jury to 45.97 (SD = 13.26) during jury condition. These results indicate that juries were perceived as more stressful than practice time by these music students. Results of this study resemble findings from studies in the area of test anxiety, particularly in the sense that the context of test-taking is similar to that of a jury performance. Test anxiety appears to affect physiological (also referred as emotionality) and psychological (cognitive, evaluative) aspects of human response (Morris & Liebert, 1973). The same can be stated about musical performance anxiety, according to the results of this study. To determine if a difference in heart rate, STAI scores, behavior, and performance quality existed between jury conditions, data were analyzed using multivariate analysis of variance or MANOVA (MLGH module of the SYSTAT statistical package, Wilkinson, 1990). Evaluative results on the assumptions of normality, linearity, homogeneity of variance-covariance matrices and multicollinearity were satisfactory. Data points for analysis included: percentage of heart rate change between nonjury and jury conditions, difference scores between STAI prejury and post-jury scores, mean of behaviors displayed during jury playing, and performance quality mean. With the use of Wilks criterion, the combined dependent variables were not significantly affected by jury condition [F (4, 59) = .95, p = .44]. This result indicates that there were no significant differences in heart rate means, STAI difference scores, behavior
72 Table 2 Univariate F Tests Comparing Four Dependent Variables Between two Jury
conditions
Heart Rate
Change STAI Change Behavior Perf. Quality
88.03 500.64 .32 .004
1 1 1 1
88.03 500.64 .32 .004
.21 2.53 .62 .01
.65 .12 .43 .92
means, and performance quality ratings between open and double-blind jury groups.2 As seen in Table 2, the dependent variable that was closest to reaching significance was STAI change, indicating that this variable was the one that discriminated the most between the two jury conditions. The STAI change revealed higher perceived anxiety responses from subjects in the double-blind condition. These results were further confirmed by the results of the pre-jury interviews. More people in the double-blind than in the open jury condition felt nervous about their jury condition (45% and 19%, respectively). Table 3 presents the means and standard deviations of the four dependent variables for both jury conditions. It is clear that there was an increase from practice time to jury time in heart rate and STAI scores in both groups despite the high variability among subjects. The means of behaviors and performance quality in both groups, however, remained quite low, indicating the low presence of nervous behaviors and high performance quality. The category of behavioral responses most prevalent for each instrument seemed to be largely determined by the characteristics of the instrument as to what part of the body was free to move (see Table 4). For instance, pianists as well as some brass and woodwind players would play seated, while the rest were standing. Wind players used their faces to
2Because of the present controversy in using difference scores in statistical analysis, data from this study were also analyzed using Univariate analysis of Covariance. The results were virtually the same asthe MANOVAS. No significant differences were found in post-heart rate and post-jury STAI scroesdue to jury condition when the pretests were used as covariates.
73
TABLE 3
Means and Standard Conditions Deviations
for
Dependent
Variables
Under
Two Jury
M SD
34.26 22.36
7.67 12.07
2.19 .69
2.13 .76
31.92 18.29
13.47 15.61
2.33 .75
2.12 .51
HR: Heart Rate Change: STAI: State Scale of the State-Trait Anxiety Inventory Change: PQ: Performance Quality.
play their instruments, and the percentage of behaviors observed in their faces (bucal muscles) was very small (4% for woodwinds and 9% for brass). The specific behaviors frequently observed in each category were the following: 1. Feet and legs: shifting and tapping during playing and shuffling and pacing during measures of rest or in between movements of the piece. 2. Body: swaying during playing, and some big breaths during music rests or in between movements. 3. Arms and hands: Arm and hand movements, such as arms flapping to the rhythm of the music, were the most typical during performance. Touching the body, like drying ones hands or removing hair from the face were most common during nonmusic intervals. 4. Face: Head moving was the most prevalent action of the face during performance, and some lips moistening and jaw movements occurred during measures of rest and in between movements. 5. Instrument behavior: Adjusting, manipulating, inspecting the instrument, and touching the music stand before performance when not playing were most frequently observed. 6. Vocalization: No behaviors in this category were observed. Pooled within-cell correlations among the four dependent variables across both jury conditions indicate low relationship and independence (see Table 5). The highest correlation obtained was between State anxiety and performance quality, indicating that the higher the STAI scores, the higher the scores in performance quality (indicating poorer performance quality). This finding correlates with others in the area of test anxiety that showed that emotionality (physiological component) at the
74 TABLE 4
Percentage of Behaviors According
to Families
of Instruments Inst. Face BehaviorVocal N
Woodwinds
Brass Piano
Instrument Voice
Feet &legs 17%

37% 35%
52% 4.5% 3%
Body Hands
30%
20% 37% 16% 20% 22%
23%
19% 6% 9% 4%
24%
37%
4%
Percussion
strings
9% 51% 26% 19%
0% 6% 18% 3% 2% 5%
0% 0% 0% 0% 0% 1%
18 18 12 3 5 6
time of a test was not related to examination performance (Smith & Morris, 1976), and that the cognitive component (worry) may or may not be accompanied by the physiological one (Morris, Davis, & Hutchings, 1981). This finding suggests that there may be different types of performance anxiety depending on which component was prevalent in each individual (physiological, psychological, or behavioral). These performance anxieties may be aroused and maintained by different aspects of stressful situations. This speculation is supported by the (a) variety of answers to Question 3 of the post-jury interview, which asked subjects what aspects of the jury made them nervous, as well as (b) the high variability in heart rate and STAI scores. Discussion The results of this study clearly demonstrated that performance anxiety affected some physiological and psychological dimensions of music performance similar to the results of other studies (Ely, 1991; Gabbard, 1980). These findings also confirm the findings of previous investigations (Salmon, 1991; Salmon, Schrodt, & Wright, 1989) that performance anxiety affects musicians of all levels of training and expertise. In the present study, students with a variety of years of formal training and jury experience responded similarly with increased heart rates and more anxious feelings during open and double-blind juries than in practice conditions. The jury heart rate mean appears to be very high in this study, but because of a dearth of research that includes heart rate as a measure of performance anxiety, it is impossible to do any comparisons. It is important to mention that, despite this significant increase in heart rate from studio
75
TABLE 5
Pooled within-Cell Correlations Two Jury Conditions Among Four Dependent variables Across
Heart Rate Change STAI Change Behavior
1 .097 -.069 .099
PQ
1 -.085 .219
1 -.033
practice to jury condition, the majority of subjects in this study started with an accelerated heart rate during pre-jury periods. This finding confirms other findings that musicians have higher heart rates than other more sedentary individuals (Mulcahy, Keegan, Fingret, Wright, Park, Sparrow, Curcher, & Fox, 1990). This may he due to the exercise involved in playing an instrument or singing, or some psychological variables involved in performing music. The second major finding of this study was that, when the four constituents of musical performance anxiety, i.e., physiological (heart rate), psychological (state anxiety), behavior, and performance quality were compared according to the jury situation, there was no significant difference in response that could be attributed to type of jury condition. Although the intention of informing the students in the double-blind condition that they would be rated by unknown judges was to increase subjects apprehension, it did not seem to affect the students any differently in this study. This finding is further confirmed by the results of the interviews. Although a moderate percentage of students in the double-blind condition reported feeling nervous about the blind condition in the pre-jury interview (45%), after the jury the students acknowledged that the effect of the blind condition was even less stressful than at the time of performance (13%). Responses to the post-jury interview, such as, Once I got up there, I completely forgot about it, were common among students in the blind condition. The decrease in percentage of nervous reports from pre- to post-jury interviews concerning the double-blind condition may also be explained by the fact that playing an instrument or singing involves multiple tasks. This may enhance or hinder the problem of stage fright by
76
feeling more overwhelmed or becoming so involved in the playing/singing that any external variables are forgotten. Due to preoccupation with instrumental/vocal technique, subjects may have been less bothered by performance pressures. The means of the four dependent variables for both jury conditions indicate that the two variables whose means differ the most from practice time to jury time (heart rate and perceived anxiety) are the ones that were measured with two standardized instruments (heart rate monitor and State scale of the State-Trait Anxiety Inventory) as opposed to specifically constructed observation forms. This suggests that the standardized instruments may be more sensitive in discriminating small changes in anxiety. As far as behaviors observed during performance are concerned, except for instrument behaviors and touching the body, most behaviors observed would be considered normal in a performance situation. Those behaviors are part of musical interpretation and expressivity, and are not necessarily related to nervousness. Poise and charisma on stage are important attributes in becoming a successful performer. This is especially true for singers and becomes part of their evaluation. It would be peculiar and unusual to have musicians totally still while performing on stage. The other variable that needs some comment is performance quality. The means of this variable show that the quality of the performance in both groups was quite high. Thus, quality of performance was not differentially affected by the two jury conditions. An explanation for this finding is suggested by Middlestadt (1990), Salmon, Schrodt, and Wright (1989), and Wine (1982), who claimed that peak anxiety is reached before the performance, but that the problem is alleviated once the musician starts playing. Thus, neither the behavior nor the quality of the performance is affected. Because this study did not compare performance quality or behavior between non-jury and jury conditions, it is not possible to determine whether behavior and performance quality on stage were better or worse than in the practice room. Another explanation may be that the type of stress experienced by these subjects at the time of their juries was adaptive as opposed to debilitating (Caldwell, 1990; Plaut, 1990; Wolfe, 1989). That is, the amount of stress experienced
Vol. XXXI, NO. 1, Spring, 1994
77
by these students was facilitating as opposed to distracting so that their performances were enhanced instead of hindered. It would be a big step forward in the field of music performance anxiety if future studies could determine the point at which anxiety becomes detrimental to the performer. Future studies might also observe and record performance quality and behavioral movement in the practice room, in order to gather more information on how these variables are affected by stressful performance situations. The fact that the four variables are highly independent and that there was high variability among subjects in heart rate and STAI scores suggests that peoples anxiety may be triggered by different aspects of performance, and they probably respond differently to the situation. For instance, having judges and peers in the room was an aspect that concerned a high percentage of students. These two categories are a clear representation of fear of being evaluated. In the musical world there is a classic quote, Your peers are your worst critics, and this clearly was a concern for many students. Other fears stated were: messing up by not remembering words and/or music (worry component), not being able to control the shaking and the breathing (physiological component), feelings of insecurity by doubting the quality of the performance (worry), getting too excited (worry), and being in a different room (worry). Undoubtedly, changes in acoustical and spatial factors may alter the manner in which sounds are usually perceived, thus causing additional worries (Salmon, 1991). Do the findings of this study have any practical implications for helping music students with performance anxiety? The resuits indicate that juries are clearly sources of stress for music students. Because so many music therapy programs are located in schools of music or music departments of colleges and universities, this is a population easily accessible for treatment and investigation by music therapists. The field of music therapy has a considerable body of research on the use of music to reduce stress and anxiety (Hanser, 1985). Furthermore, a few studies have already applied some of these stress reduction techniques with anxious musicians (Appel, 1976; Montello, Coons, & Kantor, 1990; Rider, 1987). Further research is warranted, however, to determine the ideal therapeutic interven-
78
tion that promotes relaxation and yet allows concentration and arousal to be maintained for effective musical performance. It appears that the four components of performance anxiety manifest themselves quite independently. Music therapists interested in this field should have a clear understanding of how the human body functions and responds to different stressful situations so that they can help their patients with anxiety problems. Researchers interested in the area of musical performance anxiety must examine more fully individual differences in the experience of anxiety and the conditions that exacerbate anxiety. It would be helpful to start developing standardized scales that can clearly discriminate and identify which of the four factors of performance anxiety is most prevalent in each performer and the order in which they develop. Music teachers, for example, could individualize and start this process with students in order to know how best to help each student. According to the results of this study, it is erroneous to assume that every performer experiences anxiety in similar ways or for identical reasons. By studying individual differences, performers with different anxiety modes can be matched with the most appropriate treatment interventions. As a medical doctor pointed out, the health of our world, in the broadest sense, is highly dependent on our individual and collective creativity which is directly linked to the health of the creative among us-our artists and performing artists (Lippin, 1991, p. 4). References
Appel,
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Journal ofMusic Therapy, XXXI (1), 1994, 82 1994 by the NationalAsssociation for Music Therapy, Inc.
Call For Papers

The American Orff-Schulwerk Association will sponsor research poster sessions at its 1994 national conference in Philadelphia, PA, November 9-13, 1994. Research reports dealing with any aspect of music learning through movement, speech, playing, singing, improvisation, or composition in general music or music therapy settings would be particularly appropriate. A poster presentation format will be utilized, and the author(s) of each accepted paper will be expected to be present at the poster session in order to discuss the project with interested music educators. The author(s) will also be asked to furnish 100 copies of a report summary of two pages or less, as well as 10 copies of the complete report. The following guidelines will be in effect for the paper selection process: 1. Submit five copies of the completed study of no more than 12 pages and five copies of a 250-word abstract to: Cecilia Wang School of Music University of Kentucky Lexington, KY 40506-0022 Include both a self-addressed, stamped, letter-size envelope and a self-addressed, stamped postcard with the submission. 2. The authors name and institutional affiliation should appear only on a separate Cover page. 3. Papers submitted for the conference must comply with the Code of Ethics published in each issue of the Journal of Research in Music Education. 4. Submission must be postmarked by April 1 and received by April 15, 1994. 5. A qualified group of judges will screen the submitted reports; notification letters will be mailed by June 1, 1994. The abstracts and reports will not be returned.
For Your Information
Bulletin of the Council for Research in Music Education

No. 118 Fall 1993
Table of Contents
Articles of Interest
Teacher Knowledge in Music Education Research - Liora Bresler . . . .. . .. . . .. . .. . . .. . . . . .1
Eminence in Music Education ResearchasMeasured in the Handbook of Researchon Music Teachingand Learning - John Kratus . . . . . . . . . . . . . . . 21 Perception and Performance of Dynamics and Articulation Among Young Pianists - Cornelia Yarbrough,Donald Speer, and SharonParker . . . . . 33
RESEARCH PUBLICATION/PRESENTATION
CODE OF ETHICS
The following code has been approved by the National Research Committee of the National Association for Music Therapy and by the Executive Committee of the Music Education Research Council of the Music Educators National Conference.
INFORMATION
TO CONTRIBUTORS
Manuscripts should be addressed to Editor, JOURNAL OF MUSIC THERAPY, Center for Music Research, The Florida State University, Tallahassee, Florida 32306. Five copies of the manuscript must be submitted and must conform with the most recent style requirements set forth in the PUBLICATIONS MANUAL for the American Psychological Association (APA). For historical or philosophical papers. Chicago (Turabian) style is also acceptable. An abstract of 150-200 words should accompany the manuscript. Since manuscripts are sent out anonymously for editorial review, the authors name and affiliations should appear only on a separate page. Authors are also requested to remove all identifying personal data from submitted articles. Manuscripts will be acknowledged upon receipt by the Editor and will not be returned. Contributors can usually expect a decision concerning the acceptability of a manuscript for publication within 2-3 months after receipt. Accepted articles will ordinarily appear in print within 12 months after acceptance.

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JANET P. GALLOWAY Hilton Head Island

ANDREA FARBMAN NAMT National Office

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