Abstract
Therapeutic encounters are swathed in writing from referral and consent forms, clinical and process notes, evaluations and assessments to reports. However, there has been very little research into the broader meaning, function and context of writing in music therapy. In this article, I hope to encourage music therapists to think critically about the writing they produce and use in clinical practice. I draw on guidance from professional bodies, theories of memory, phenomenology, existentialism, the psychoanalytic perspectives on language of Lacan and Kristeva and post-modern ideas around the meaning and contextual understanding of a text through the writings of Foucault, Barthes and McLuhan. I encourage more reflexivity regarding the role of the music therapist’s self and intersubjective elements within the writing. I ask what influence the act of writing itself exerts on clinical practice and reflect on the role of language and its adequacy for describing the music therapy encounter. I further explore how music therapists contextualise the writing they produce, speculating on some of its functions in relation to the therapist, client and institution. In conclusion, I argue that clinical writing in all its forms potentially has a powerful impact on the therapy process as a whole.
Introduction
In this article, I hope to encourage music therapists to think critically about the writing they produce and use in clinical practice. I draw on guidance from professional bodies, theories of memory, phenomenology, existentialism, the psychoanalytic perspectives on language of Lacan and Kristeva and post-modern ideas around the meaning and contextual understanding of a text through the writings of Foucault, Barthes and McLuhan. I encourage more reflexivity regarding the role of the music therapist’s self and intersubjective elements within the writing. I ask what influence the act of writing itself exerts on clinical practice and reflect on the role of language and its adequacy for describing the music therapy encounter. I further explore how music therapists contextualise the writing they produce, speculating on some of its functions in relation to the therapist, client and institution. In conclusion, I argue that clinical writing in all its forms potentially has a powerful impact on the therapy process as a whole.
Although as music therapists our focus is working with clients in clinical sessions, a considerable proportion of our time is spent writing or using the writing of others to support us in this task. Aspects of this have led me to think more critically about my own experience of clinical writing in music therapy. For example, when receiving client referrals, there always seemed to be something missing from the information, however detailed, which was then revealed forcefully in the first encounter. I have also felt uneasy when writing reports because the narrative constructed to describe the therapeutic encounter sometimes simplified and reduced the client and process, not only through the filter of my own feelings, understanding and interpretation but also through the subtle exigencies of the writing itself.
I once had to use a faulty laptop for writing clinical and process notes which would shut down unpredictably, causing me to lose my work. When rewriting the session’s notes, it was impossible to reconstruct exactly the same text even though I was recalling the same events, with the same intentions. I wanted to understand the reasons for these differences. I have experimented with making verbatim and musical transcripts of sessions from audio recordings, but the results still felt unsatisfactory, as if something important was missing despite apparently capturing everything.
What we choose to include or omit from our clinical writing feels important to explore. I suggest that many factors beyond conscious selection and interpretation are at play, including the unreliability of memory and perception, embedded learning and subtler intersubjective, contextual and cultural influences. I explore these factors in the remainder of this article, but I begin by discussing the professional and legal backgrounds for clinical writing.
Guidance from professional bodies
The Health and Care Professions Council (HCPC) (2023: sec. 9) states that therapists must be able to ‘keep full, clear and accurate records’. Instead of specifying exactly what is required, it defers to ‘applicable legislation, protocols and guidelines’ (HCPC, 2023) which may vary between different clinical settings. The British Association for Music Therapy (BAMT) (2016: 2–3) provides useful guidance, ensuring that music therapists are aware of the distinction between compulsory clinical notes, which might be kept with any multidisciplinary team’s notes about the client, and process notes, which are highly recommended but not obligatory.
Clinical notes should include key information and need to be clear, short, jargon-free, sequential and understandable as a descriptive representation of the process (BAMT, 2016: 3). The British Association of Counselling and Psychotherapy (BACP) (2017) requires that their professional members keep accurate records of attendance as well as ‘reasoning behind decisions about significant interventions and general strategies; consultations with anyone else about the client . . . [and] any instructions given to the client and whether or not the client acted on these’ (p. 11).
Process notes record the therapist’s thoughts, feelings, reflections and therapeutic understanding about what is happening with and for the client in sessions. Along with clinical notes, they evidence the therapist’s duty of care (BAMT, 2016: 3). All notes are subject to various pieces of legislation around confidentiality (Department of Health, 2003), human rights (Human Rights Act, 1998) and data protection (Data Protection Act, 2018). From a legal perspective, therefore, it is important that they are a clear and contemporaneous account of what happened in the session. How clear and accurate this written account can actually be is, however, dependent on many factors, some of which are discussed in the following sections.
The unreliability of memory
We rely on our memory to reconstruct what happened in sessions, sorting, selecting and analysing the information for inclusion in our clinical writing. Our memory is fallible, however, and psychological research has shown its limitations. This is important, particularly if client safety is concerned, or we are called upon to give testimony in legal proceedings (Howe and Knott, 2015).
Tulving (1972, 2014) proposed that there are two types of memory:
Memory is influenced by associations (Buonomano, 2012), leading to false memories at encoding and recall. Associative activation can occur when related concepts are presented without mentioning the main concept (Howe et al., 2009; Otgaar et al., 2017). The same type of associative activation may occur in music therapy sessions when clients present certain clusters of similar behaviours, but with different underlying causes.
Internal states of arousal can also impact memory (Loos, 2019; Mather and Sutherland, 2011). Higher arousal narrows focus and filters out less relevant information (Feldmann-Wüstefeld and Vogel, 2019; Kuhl et al., 2007), leading to change blindness (Simons and Chabris, 1999).
Long-term potentiation, where neural pathways are strengthened through repeated use (Baudry et al., 2011; Nicoll, 2017), implies that we tend to notice what we have noticed before, forming a constant cycle of reinforcement. However, we also have a better memory for the unusual, known as the bizarreness effect (Geraci et al., 2013; Gounden et al., 2017). This suggests that a novice therapist might remember more of sessions than an experienced colleague who has seen it all before, while potentially finding it harder to attribute meaning to what happened (c.f. Bunt and Hoskyns, 2004 [2002]).
When re-reading notes, memories tend to coalesce around what is written. Verbal overshadowing occurs when verbalising sensory input alters and simplifies the information (Schooler and Engstler-Schooler, 1990). This can also occur when others describe the same event (Wilson et al., 2018) or when taking photos (Henkel, 2011; Soares and Storm, 2018). Dependence on technology can lead to digital amnesia, where people have lower recall of information but enhanced recall of where to access it (Baron, 2021; Sparrow et al., 2011).
People are generally overconfident about their memories and abilities (Johnson and Fowler, 2011) and underpredict how much they will forget over time (Kornell, 2011). This highlights the importance of writing notes and reports as close to the client work as possible, while being mindful of the limitations of our memory in general.
Phenomenology: interpreting perception
Biases in perception
For a phenomenologist, every account of a music therapy session in our clinical writing is an act of interpretation. What crosses the threshold of perception into memory is fraught with complexity. Spinelli (2005) suggests that ‘our experience of reality is always made up of an interaction between the raw matter of the world, whatever that may be, and what might be broadly called “our mental faculties”’ (p. 12). Our experience of what we call reality ‘emerges from the interaction or inter-relatedness of the two’ (Spinelli, 2005: 12).
Husserl’s concept of
Furthermore, our perception is dependent on ‘a variety of inferences derived from the neural signals . . . [these] may be more or less adequate, but never complete, or completely true’ (Spinelli, 2005: 37). Gestalt psychologists in the early 20th century discovered the tendency to see things as whole, rather than as their separate constituent elements. They claimed that we group things together according to their similarity, proximity, continuity and closure – the tendency to close or complete an incomplete pattern (Spinelli, 2005: 42–43). In addition, our motivational and attitudinal state, the
Our perception of others is also compromised along similar lines. Despite ‘the limitations of human experience, [through which] our perception of others undergoes continuous (if at times unaccepted or unnoticed) flux and alteration’ (Spinelli, 2005: 71), we nevertheless attempt to form a unified and consistent impression of others. This seems to trump accuracy and truthfulness: Spinelli (2005) writes, ‘we combine speculation and inference with direct data’ (p. 60). There are hidden biases present within perception dependent on many factors. These factors might stem from our motivations and biases around culture, gender, race, sexuality, religion, disability and so on. Perceptually, the truism of Anaïs Nin (1961) holds: ‘we see things not as
Phenomenologically ‘we can never know the real world, only the interpreted world – the world that emerges through our reflections upon it’ (Spinelli, 2005: 202). However, this is not a point of despair for our clinical writing. It merely nudges us to acknowledge the inescapable role of interpretation in making sense of the world and our work as music therapists.
Theoretical seepage
If we cannot help but interpret and create meaning from our experiences, then our theoretical orientation, established during and after training, probably influences our clinical writing. This influence may not be as obvious as assigning a specific theoretical label to a client’s behaviour. It may show up in the way we place the client in a web of implied discourse and by favouring certain interpretations over others when making sense of the therapeutic encounter.
We should consider whether our training and theoretical orientation essentially changes who we are, including how we perceive, comprehend and interpret our intersubjective encounters. This certainly seems to be suggested in a study by Hoskyns where the responses and observations of students, both at the beginning and ending of their training, to a video of vignettes of music therapy clinical work are compared to the response of an experienced therapist. Hoskyns found that the beginner students were more focused on single events and the individual behaviours of the client, whereas the more experienced students and the therapist moved ‘from a preoccupation with discrete events and a variety of assumptions to a more objective and balanced view of the whole interaction observed’ (Bunt and Hoskyns, 2004 [2002]: 187–188). Hoskyns asserts that ‘the overall effect of therapy training changes the quality and approach of therapists’ observation and listening’ (Bunt and Hoskyns, 2004 [2002]: 187). Apart from demonstrating that therapy training is a perceptually transformative process, this study also assumes that certain types of seeing, experiencing and understanding are, to use Hoskyns’ words, more
In addition, we might wonder if our theoretical orientation, conceptions of music therapy and sense of meaning conveyed in our clinical writing seep into our clients’ manner of making sense of their own lives. For Jung (1963), the therapist’s job is ‘to kindle a light of meaning in the darkness of mere being’ (p. 326). This might lead us to ponder whether clients feel that their music therapy is a success to the extent that they find their own lives meaningful through their own experience and understanding of what is conveyed, consciously or not, in music therapy.
Referrals, reports and existential unease
Regardless of how descriptive and filled with relevant information a referral might be, it is still an inadequate preparation for the first encounter with a client. May (1983) writes that ‘the grasping of the being of the other person occurs on a different level from our knowledge of specific things about him’ (p. 92). As the existential psychotherapist Cohn (1997) states, ‘there is no ‘history’ to be taken for there is no history
The first encounter with a client reveals more than any referral might show. Conversely, when writing reports at the end of the therapy, a kind of simplification of the client may occur that misses something vital. This vital element could be the extreme specificity of the intersubjective encounter generated by two people at a certain time and place. This is captured so tangibly in a music therapy coimprovisation but less easily in formal clinical writing created solely by the therapist.
The theoretical frame used to understand and describe what has happened during the course of therapy, however consciously or unconsciously used, also seems to exert a subtle influence. May (1983) questions, ‘and does not this patient, or any person for that matter, evade our investigations, slip through our scientific fingers like sea foam, precisely to the extent that we rely on the logical consistency of our own system?’ (p. 38). Perhaps not to the extent of us just ‘seeing merely a projection of our own theories
Music and words
Writing about music
The challenges around writing about music are well-known and are even greater in music therapy where an additional layer of complexity and metaphor is overlaid. Pavlicevic (1997) comments that we seem to feel that unless we can talk about the musical experience, then [1] the non-verbal experience is incomplete; [2] professional colleagues will think that we do not know what we are doing; and [3] our clinical grasp of the work will be questioned – we might be seen to be doing ‘just music’ (p. 11).
The importance of finding a way to communicate about all aspects of music therapy is noted by Mette Ridder (2007): ‘It is essential for our profession that we develop methods that document our clinical work; a documentation that can be applied to evidence-based practice’ (p. 64). For both clinicians and researchers, finding a way to describe and write about what happens in a music therapy session is challenging (see Ansdell, 1999), and many different research approaches have been created (Wosch and Wigram, 2007).
The music therapist’s own relationship to and understanding of the role of music within sessions also play a part in how meaning might be constructed and written about. Pavlicevic (1997) highlights two positions which she refers to as the
Music without words
Music therapists often use music, video clips or audio recordings to reveal the meaning of their work more vividly than written descriptions. Mette Ridder (2007) notes that video clips can quickly convey the music therapy approach and its various aspects to professionals unfamiliar with the field. A complete musical transcription could also represent what happened in the music, with advantages such as exactitude and portrayal of many dimensions of musical elements (Wosch and Wigram, 2007). However, there are difficulties in sharing this material with colleagues who do not read music and capturing fundamental expressive aspects of the experience. Like making verbatim transcripts of any spoken parts of sessions, there are several associated challenges: the time required to create the transcript, the overwhelming amount of generated material and the inappropriateness of audio recording for many clinical situations. To maintain client confidentiality, make the material accessible and useful and provide a comprehensible record of treatment, a degree of editing, selecting, sorting, categorising and explaining is essential.
Analysing a music therapy session or therapy process without words, entirely through the creation and performance of a piece of music, seems like an alluring idea. The music critic Keller (2001) created a method of musical analysis called ‘Wordless Functional Analysis’, where he composed a score that elucidated the structure and expressive elements of a piece of music without the accompanying text. In music therapy, this method would need to be adapted to reveal the relationships between the music as a representation of the client’s difficulties or reason for referral and how closely the music adheres or departs from its own grammar and cultural context. However, Pavlicevic (1997) notes that while ‘music generates and portrays the therapeutic relationship’ (p. 56), it cannot capture the essence and significance of the therapeutic relationship alone.
The actual meaning of the music itself within the therapeutic relationship might vary, compounding the challenges around finding ways to represent it. Ruud proposes that music might function in four ways: as a sound phenomenon, where the sensory aspects of the music and sound are important; a structural phenomenon, where the music refers to meanings implicit within the musical patterns and structures themselves; a semantic phenomenon, where the music refers to meanings beyond itself, and a pragmatic phenomenon, where the music mirrors the processes of interpersonal communication (in Bonde, 2007: 255). Depending on the client and context, any one of these properties might assume greater importance and influence in how we think about the musical aspects of the session. The question remains of how we might capture and honour the richness and often multiple meanings of the music in writing.
Music, metaphor and poetry
Inselmann (2007) writes ‘the main problem of evaluating music therapy is the translation of what the music is symbolising into verbal symbols’ (p. 164). Inevitably, something gets changed, or lost, in translation. For some researchers, embracing metaphorical and poetic language is a better fit when writing about music therapy. Leite (2003) suggests that to integrate the different aspects of music therapy, ‘the use of music-related metaphors to describe the psychological processes and interpersonal dynamics that may occur in therapeutic music making’ is preferable. Rykov (2011) advocates writing poetically about the musical encounter as she wants ‘the reader to really “get it”, to truly understand what music therapy means for the client’. She continues, ‘Poetry is a superior form for writing about nonverbal, embodied music therapy essence because poetry is so inherently musical’ (Rykov, 2011). However, she concedes that ‘nondiscursive writing in an evidence-based milieu is a questionable pursuit’ (Rykov, 2011).
Music therapists need to guard against relying on metaphor too greatly to describe the music. For Abrams (2007), ‘loosely descriptive, anecdotal and/or speculative reflections are insufficient, as they cannot properly ground meanings and new understandings’ (p. 92). Trondalen (2007) advocates a contrapuntal understanding of the music incorporating phenomenological and hermeneutic perspectives: ‘The researcher may describe the musical improvisation rooted in the client’s perception but add her own understanding of the musical processes, i.e. construct reality based on knowledge, language and historical situated-ness’ (p. 199). In effect, Trondalen is calling for a synthesis that might incorporate context, Ruud’s categories and multiple other perspectives, contrapuntally informing each other to produce a richer sense of holistic meaning.
The power of patterns on music and words
For the understanding of the music in the session, and our writing about the session afterward, patterns of musical and linguistic grammar determine certain aspects of both discourses. These might subtly shift their meaning. Phenomenologically, we tend to perceive, or even impose, patterns on sensory information (Spinelli, 2005), but these same gestalts are also at work in language and the language-like aspects of music (Pavlicevic, 1997). Pavlicevic (1997) writes, ‘Language may explain the event, describe it; language may construct the way that we see the event, and it may begin to operate independently of the event, becoming a discourse that is self-perpetuating’ (p. 8). For De Backer and Wigram (2007), ‘music searches for a structure . . . The music goes its own direction, and as a therapist one has to support that’ (p. 132). This independence of the music may be part of its function within the therapy session and might cultivate a client’s ‘symbolizing capacity’ (p. 132). They note that, ‘The music anticipates something which is not yet there, a type of structure, within which the patient possibly can enter’ (De Backer and Wigram, 2007: 132).
Pavlicevic (1997) notes that ‘writing about music therapy is always a compromise in colour and focus’ (p. 185) because in music therapy, ‘we remove ourselves from our more familiar mode, and immerse ourselves in the illusory, the immaterial, the intangible’ (p. 184). To communicate with other professionals about the work, the music therapist starts a dialogue where a ‘negotiation of meaning needs to take place at the descriptive level, as well as at the level of inference and interpretation’ (Pavlicevic, 1997: 15). For Priestley (1975), ‘the therapist must find the music in words and words in music and search all his [sic] working life for the meaning in both’ (p. 250).
Language and the therapist
The language speaks, not the subject
As therapists, our own relationship to language itself impacts what we choose to write. The French psychoanalyst Lacan suggested that language itself has its own form of agency and that the subject is irredeemably split from the language in which it talks and thinks. For Lacan, what is thought of as the
Therefore, for Lacan, it is futile to suppose that the subject has control over his or her own language. Language is merely something into which the subject is born. Meaning in a person’s discourse comes through the relationship between signifiers, rather than an objective signification of an action or object (Bailly, 2009: 50). Both therapists and clients cannot avoid the emotional and associational resonances (the relationship between signifiers or signifying chains) of particular words and what they might trigger. For example, to understand a client who says they just want to be ‘happy’ would involve investigating the unconscious associational chain of what ‘happy’ means for the client. ‘Happy’ might be linked to feeling ‘in control’, ‘feeling like I did when I was a child without responsibilities’ and ‘away from the current situation’ or something completely different. Consequently, for Lacan, for both the client and therapist using language in the therapy process is both more ambiguous and also richer in association; finding a clear way to represent and record what happened in a therapy session is harder and more complex.
Kristeva’s semiotic and symbolic
Kristeva, a French psychoanalyst and student of Lacan, developed a theory of language that emphasised the body’s role in the creation of meaning. Her theory seems to capture an important aspect of why a written transcription of words or music may not be a completely adequate way to record sessions. What seems to be lacking is what Kristeva describes as the semiotic mode of the signification of language. For Kristeva, the semiotic is not just a study of signs but ‘the extra-verbal way in which bodily energy and affects make their way into language’ (McAfee, 2004: 17). She pairs this with the symbolic mode of signification that attempts to use language purely to express meaning unambiguously.
These two modes of signification are not mutually exclusive. Kristeva asserts that the semiotic mode is always discharged into the symbolic, indeed ‘signification is meaningful because of the way the semiotic energizes it’ (McAfee, 2004: 18). The semiotic precedes the symbolic. It is the mobile interplay of the biological and psychological drives, expressed through rhythm, sound and sensory articulations. In literature, the semiotic corresponds most closely to poetry, but there is a direct corollary in music, dance and other art forms. A baby’s babbling and cooing are examples of the semiotic: Discrete quantities of energy move through the body of the subject who is not yet constituted as such and, in the course of his development, they are arranged according to the various constraints imposed on this body – always already involved in a semiotic process – by family and social structures (Kristeva in McAfee, 2004: 18).
However, the semiotic is always present as the substratum of all speech: ‘Because the subject is always both semiotic and symbolic, no signifying system that he produces can be either “exclusively” semiotic or “exclusively” symbolic and is instead necessarily marked by an indebtedness to both’ (Kristeva, 1986: 93). It would be impossible to record within a transcript the subtle, motile interplay of emphases, accents and articulations generated within speech – the semiotic leakage into the signifying act – just as it would be in the musical act, even though as musicians and therapists, we are perhaps very attuned to these aspects. This is one of the very elements that can impart such rich and important meaning to therapeutic work.
The notes speak, not the therapist
When rewriting my lost notes due to the faulty laptop, I found that I could not reconstruct them exactly as before. This led me to wonder whether using different words or grammar to describe the same events was important. It felt as though I was simply accessing some sort of underlying memory of an experience that many different forms of language might describe. However, it also felt likely that different word choices would represent subtle shifts in emotional tone or emphasis. Then, I pondered whether reconstructing the text word-for-word later, even if it were possible, could also alter its meaning somehow. It seemed important to explore the autonomy of the text itself and how far meaning was dependent on the reader, wider context and even its position in time.
From a literary, rather than therapeutic, context, some of these ideas are explored in the meta-fictional short story ‘ One particularly interesting insight is that with the irrevocable severing of the link between signifier and signified . . . the door becomes open for a kind of writing where identical texts can mean different things since they are, even if literally the same word for word, never the same or identical to themselves (de Toro, in Giskin, 2005: 105).
In the story, the literary critic protagonist believes that Pierre Menard’s version of
The clinical relevance of this can be highlighted with an imaginary example. It is easy to conceive of a situation where the
Another way in which the same text might assume multiple meanings is when it is read by different people. Post-modernists in France in the 1960s declared the absolute independence of texts from their writers. Barthes (1977 [1967]) in his famous essay,
Context
Contextualising the writing in clinical practice
Ideally, the ultimate beneficiary of all clinical writing in music therapy should be the client. However, it is more realistic to assert that it is produced for the therapist, to help process and account for the work; the institution, to assess the effectiveness of the intervention, and even the wider regulatory context, to monitor the efficacy and safety of both. It is noteworthy that, except in very rare circumstances, clients do not choose to access what is written about them. In the National Health Service (NHS; 2019), patients have the legal right to access their treatment notes, but very few actually do. The writing often seems to be
In terms of wider social and institutional contexts, one of the functions or consequences of writing may be to exercise power or control over an individual. Foucault (1977), when describing the history of the modern penal system in
The medium of music therapy itself produces a whole matrix of behaviours, in clients, therapists and institutions, that convey messages about power, control and normalising judgement (c.f. Myerscough, 2023; Pickard, 2022; Vencatasamy, 2023). McLuhan (1964) writes in the famous opening chapter of
Concluding thoughts
Whether directly or indirectly, clinical writing potentially has a powerful impact on the therapy process as a whole. For the therapist, the act of writing notes can help to shape thinking about, or emotionally process, the client work, acting as a type of auto-supervision. Our notes and the web of reflective and theoretical discourse that we spin around clients, whether consciously or not, allow us to tolerate being with the client when behaviour and attitudes become challenging. Therefore, the act of translating experience into discourse might help support the therapy and to sustain it in difficult circumstances.
The obligation to write notes might subtly influence what we choose to do in sessions. Music therapists must adhere to and be able to give evidence for an ethical stance within their practice. The act of writing notes is in part about being ethically accountable. Clinical writing perhaps encourages us to think both about the music therapist’s role within the therapeutic relationship and contributions to sessions in the here-and-now and to consider how these will be refracted through the prism of our notes
Finally, it is important to be aware of our memory and perceptual quirks and challenges to understand and potentially compensate for our natural vulnerabilities. An awareness of the limitations of the text itself and its potential to influence the way we act will allow us to approach writing with a little more understanding. Considering some of the meanings, roles and relationship of language to thought, meaning and intersubjectivity can assist us in expanding our perspective. Reflecting on clinical writing highlights the realisation that any encounter between two people is different from all others: Our translation of this into writing reflects this uniqueness. It is useful to consider who the clinical writing is for, who holds and constitutes meanings from it and why that is important. Moreover, we need to be aware of the forces that shroud the therapeutic encounter, being aware of the potentially oppressive and covert power dynamics that hide within the act of writing, and the meanings that texts might assume once produced.
Footnotes
Acknowledgements
The author would like to thank the peer reviewers and
