Chapter 9.

The use of group vocal improvisation as a

music therapy technique in a mental health setting

Irene Pujol Torras

[email protected]

Abstract

Although group work and the use of voice and of improvisation techniques are three
common features in music therapy practices, a systematic review of the literature has
shown that the combination of these elements has been overlooked in the research.
This review also showed an association between using pre-composed material when
working with the voice and, on the other hand, using instruments when
improvising. This polarisation of instruments versus voice when addressing
production and reproduction techniques in music therapy is not made explicit in the
literature and therefore the clinical reasoning behind it might respond to decisions
other than clinically orientated. Instead, these implicit assumptions appear to have
become established practices in the music therapy discipline.
The present research project addresses the use of group vocal improvisation as a
specific music therapy technique and attempts to look at the differences in
therapeutic processes between this specific technique and a standard use of group
music therapy, mainly making use of instruments. The workshop will demonstrate
some of the techniques and will attempt to demonstrate their accessibility whilst
uncovering the clinical reasoning behind the use of group vocal improvisation.

Keywords:music therapy, voice, improvisation, mental health, group work.

This workshop was organised in four stages: an introduction and contextualisation
of the research topic, a presentation of the theoretical model and literature review, a
practical session of group singing with some discussion with the participants and a
clinical vignette at the end.

Introduction

There is extensive evidence (Carr et al., 2013; Grocke et al., 2014; Tague,
2013) about the benefits of music therapy in mental health settings, both in
individual and group formats. Group work offers benefits from a cost-

105
 Creative Practices for Improving Health and Social Inclusion

efficiency perspective and is also a platform to explore interpersonal

struggles or difficulties, which are be very relevant for the everyday
functioning and wellbeing of people suffering from a mental health illness.

The established use of group music therapy in mental health settings

consists mainly in improvising with a range of available instruments. In the
last decade there has been an increasing interest to address the voice as an
important element in music therapy, especially in community choirs (Clift et
al., 2008).However, the combination of improvisation and voicework in a
group setting has been overlooked in previous research.

Applying group vocal improvisation within a National Health Service

(NHS) outpatient clinic has involved in the presented study adopting an
initially directive approach that aims to come across as non-threatening,
accessible and not orientated towards vocal technique but more focused on
the exploration of creative sounds. The main aim of the sessions is to
provide an experience of being in a group, sharing something intimate about
one‘s identity and acknowledging one‘s one voice within the group‘s voice.

This emphasis on the relational dimension within an intersubjective non-

verbal medium that is strongly linked with emotional expression and sense
of self aims to tackle some of the key difficulties that mental health service
users encounter in their recovery journey. This is argued from an attachment
theory perspective, where the agentive Self starts to develop in early years
through safe and playful interactions with an emotionally attuned and
empathic caregiver. This leads to the integration of primitive modes of
experiencing internal reality (Bowlby, 1969).

Using the voice as a means for musical expression facilitates the emergence
of an environment where a focus towards these early modes of interaction

106
 Section 2. Creative practices, social inclusion and well-being

can be revisited and experienced in a playful and aesthetic context. This

provides the service users to begin to experience themselves and their self in
relation to others from a new perspective with the potential for them to shift
their perception of these patterns towards healthier and more accessible
relationships.

Theoretical Model

The uniqueness of the voiceas a central instrument in music therapy can be

looked at from different angles (Austin, 2008; Baker and Uhlig, 2011;
Warnock, 2011):

 Physicality: when singing, the body undergoes physiological

changes ranging from the breath to heart rate, from activation of
particular neural regions to physical vibration and resonance.

 Embodiment: the voice is the only instance where instrument and

instrumentalist are experienced at the same time. Therefore, this
provides an experience as both object and subject.

 Universality: everyone who can speak can sing, all cultures sing.
This means that everyone is naturally skilled in using the
modulation of the voice in order to communicate emotions and to
interact socially.

 Primal: both from a psychological and anthropological point of

view, the non-verbal modulation of the voice is a primal instrument.
It is the first means of communication for every baby with its
environment in a similar way as it was for the first humans in
prehistory.

107
 Creative Practices for Improving Health and Social Inclusion

The importance of the voice within music therapy has seen a recent increase
in interest that has been reflected in the literature, especially in the area of
the benefits of choral singing, as the literature review shows (Figure 1). Since
the research in group vocal improvisation as a specific technique was almost
inexistent, the literature review for the current PhD research project was
organised around the different immediately neighbouring areas as the
different categories of articles (A, B, C and D) reflect. Each category
encapsulates 3 of the 4 distinctive elements of GVI: group work, use of voice,
improvisation and music therapy.

Category A, for example, brings together articles focusing on therapeutic

group singing but without improvisation; category B instead shifts the focus
towards vocal improvisation in individual music therapy, losing therefore
the element of group work; category C has to do with GVI outside the field
of music therapy, therefore dealing with a performance and artistic practice
of a minor genre such as group vocal improvisation; finally, category D
accounts for articles on the music of group improvisation in music therapy
but mainly dealing with instruments.

108
 Section 2. Creative practices, social inclusion and well-being

Group singing activity

Group singing as
therapy (no
improvisation)

Vocal
improvisation in
individual music
therapy (no
group work)

Group vocal
improvisation
(no therapeutic
aims)

Group
Figure 1. Results of literature review in categories
improvisation in
The y axis represents the number of results obtained for each category through a
music therapy
systematic research of the literature. The Healthcare Database Advanced Search
(HDAS) was used to search five databases from the National Institute for Health
(no voice)
and Care Excellence (NICE): Embase, PsychInfo, MedLine, CINAHL and AMED,
The search was completed in November 2016.

During the workshop, participants were asked to say how comfortable they
feel in using their voice in front of others in a dynamic way, by positioning
themselves in a continuum from ―never‖ to ―all the time‖. Having shared
their experiences of group singing, the participants engaged in a gentle
physical and vocal warm up, including stretching, breathing exercises and

109
 Creative Practices for Improving Health and Social Inclusion

vocalisations. The main activities of the workshop involved doing short

improvisations with the sounds of each participant‘s name in a call and
response dynamic. The practical section of the workshop ended with
everyone learning a short ―circle song‖ in harmonic parts and then
introducing the possibility of adding improvisation on top of it.

After this, the participants were encouraged to share their comments about
the experience and what they thought a similar kind of activity could
provide in a mental health setting. The feedback was positive, with people
visibly smiling and some individuals surprised at the resulting sound of the
group. Some participants also shared how at the beginning they found it a
little exposing to sing in front of others and how they found the different
activities helpful in overcoming this sense of insecurity.

These comments were linked to the previous theoretical presentation and

they were categorised in the following broad categories:

 Synchronisation: rhythmical entrainment, ―being together‖ in the

music.

 Socialisation: feeling closer to one another, perceiving others more

positively.

 Energising: uplifting feeling, awakening sensation in the body and

alertness.

 Shared experience: feeling part of a group, collective endeavour.

 Interactive communication: intersubjective experience of dialogue

with others.

 Emotional expression: strong emotional connection and experience.

110
 Section 2. Creative practices, social inclusion and well-being

 Creativity: feeling that one could improvise easily, willingness to

―try things out‖.

 Preverbal dynamics: implicit affect attunment, vitality affects.

Clinical vignette

The workshop finished with a case study from one of the groups included in
this current PhD research project. The clinical vignette focused in a single
session towards the beginning of the formation of a closed group where
there were only two attendees. The two male participants (one in his 30s and
one in his 50s), both suffering from depression, engaged in conversation
about songs that they liked.

This apparent superficial way of getting to know each other was interpreted
by the therapist as an attempt to define a common identity for the group and
an effort to work out together what the group ―was about‖. After some
discussion, the therapist pointed out at this and suggested to write down the
titles of the songs that they had listed and to use those as lyrics for an
improvisation.

The titles were: ―I‘m changing‖, ―Summertime‖, ―I‘m feeling good‖, ―At
last‖, ―A house is not a home‖.

The therapist moved to the piano and started playing a few chords for the
patients to chose which ones they felt would be better for the piece. Once
they gave an orientation of the mood they wanted and chose the two chords
the therapist started playing them in alternation.

The improvisation lasted for about 10 minutes, during which they used the
mentioned titles and also started to change them to, for example: ―I‘m not

111
 Creative Practices for Improving Health and Social Inclusion

feeling good‖, ―Summertime, blue skies‖. The patients provided positive

feedback afterwards and they appeared to have gained a more robust sense
of group and trust.

Final thoughts

Bringing together the first hand workshop experience along with the clinical
vignette and the initial theoretical presentation afforded a rich reflection of
the different factors influencing and shaping the use of group improvised
singing as a means for therapeutic change.

The workshop proposed an organic way of working with the human voice
in an accessible way in order to explore emotions, relationships and
creativity. The initial findings presented from the literature search and form
the preliminary clinical work show good potential for the use of group vocal
improvisation as a powerful music therapy technique. At the end of the
present PhD research more data will be available to reflect further on the
clinical implications, strengths and limitations of this new technique.

This technique links organically with the development of music therapy as a

young academic and clinical discipline. Group vocal improvisation is
situated within a continuation with the foundational music therapy
literature describing the clinical use of improvisation (Wigram, 2004;
Bruscia, 1987) and attempts to make a contribution to a new area of research
involving the use of voice and improvisation in mental health settings.

112
 Section 2. Creative practices, social inclusion and well-being

References

Austin, D. (2008). The Theory and Practice of Vocal Psychotherapy: Songs of

the Self. London: Jessica Kingsley Publishers.

Baker, F. & Uhlig, S. (2011) Voicework in Music Therapy. Research and Practice.
London: Jessica Kingsley Publishers.

Bowlby, J. (1969).Attachment and loss. Vol. 1: Attachment. New York: Basic

Books.

Bruscia, K. (1987). Improvisational Models of Music Therapy.USA: Charles

Thomas Publisher.

Carr, C., Odell-Miller, H. & Priebe, S. (2013).A systematic review of music

therapy practice and outcomes with acute adult psychiatric in-
patients.PLoS One. Aug 2;8(8).

Clift, S., Hancox, G., Staricoff, R. & Whitmore, C. (2008).Singing and health: A
systematic mapping and review of non‐clinical research. Canterbury:
Canterbury Christ Church University.

Grocke, D., Bloch, S., Thompson, G., Newton, R., Stewart, S. & Gold, C.
(2014). Group music therapy for severe mental illness: a randomized
embedded experimental mixed methods study. Acta Psychiatrica
Scandinavica, 2014: 130: 144–153.

Tague, D.B. (2013). The Effect of Improvisational Group Drumming versus

General Music Therapy versus Activity Therapy on Mood, Session
Behaviors and Transfer Behaviors of in- Patient Psychiatric
Individuals. PhD dissertation, Florida State University.

113
 Creative Practices for Improving Health and Social Inclusion

Warnock, T. (2011).Voice and the Self in Improvised Music Therapy.British

Journal of Music Therapy, Vol. 25 No. 2.

Wigram, T. (2004). Improvisation: Methods and Techniques for Music

Therapy Clinicians, Educators and Students. London: Jessica
Kingsley.

114