Nordic Journal of Music Therapy

ISSN: 0809-8131 (Print) 1944-8260 (Online) Journal homepage: www.tandfonline.com/journals/rnjm20

Autistic spectrum disorder and music therapy: theory

underpinning practice

Theo Dimitriadis & Henk Smeijsters

To cite this article: Theo Dimitriadis & Henk Smeijsters (2011) Autistic spectrum disorder and
music therapy: theory underpinning practice, Nordic Journal of Music Therapy, 20:2, 108-122,
DOI: 10.1080/08098131.2010.487647

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Published online: 19 Aug 2010.

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Nordic Journal of Music Therapy
Vol. 20, No. 2, June 2011, 108–122

Autistic spectrum disorder and music therapy: theory

underpinning practice
Theo Dimitriadis* and Henk Smeijsters

Faculty of Health and Care, KenVak Research Centre, Zuyd University of Applied
Sciences, Heerlen, The Netherlands
(Received 20 April 2009; final version received 4 March 2010)

The autistic spectrum disorder (ASD) has been and still is a major arena
for practice in music therapy; arguably it is the client group with which
music therapy has the highest reputation. Whether we talk about practice
based evidence or evidence based practice, music therapy clinicians and
researchers are nowadays more and more frequently required to provide
theoretical and scientific evidence, which explains (or attempts to explain)
not only how but also why music works as a therapeutic medium with this
particular client group. Autistic individuals very often demonstrate a
significant interest in music and its components: rhythm, pitch, harmony,
or timbre; they seem to be more able to communicate through sound,
whereas they tend to avoid other kinds of interaction, for instance tactile
contact. In this paper the authors attempt to give possible explanations on
why music can be such a unique tool for the treatment of the autistic
individual. Theories from different fields, such as developmental
psychology, neuropsychology, musicology, and psychotherapy have been
put together in order to find a bridge between theory and practice. The
paper underlines the necessity for workable theories which are tailored to
the needs of music therapy practice. Suggestions for future theory building
work on this particular client group are offered.
Keywords: music therapy; theory; analogy; autism (ASD); vitality
affects; core consciousness; core-self

Older and current interpretations on autism/autistic spectrum disorder

Since Kanner’s (1943) and Asperger’s (1944) original descriptions of
‘‘autistic disturbances of affective contact’’ and ‘‘autistic psychopathy’’
respectively, our understanding of autism has progressed to the point where
it is seen as a spectrum of difficulties rather than a singular condition
(Humphrey & Parkinson, 2006).The Greek eautóV (eautos ¼ self) was the
keyword for the description of those individuals for whom it was initially
thought that they were ‘‘immensely preoccupied with themselves.’’

*Corresponding author. Email: [email protected]

ISSN 0809-8131 print/ISSN 1944-8260 online

Ó 2011 The Grieg Academy Music Research Therapy Centre
DOI: 10.1080/08098131.2010.487647
http://www.informaworld.com
 Nordic Journal of Music Therapy 109
At the lower-functioning end of the spectrum are those who would
previously have been described as having classic (or Kanner’s) autism, many
of whom fail to develop functional speech (Howlin, 1998) and often have
additional learning disabilities. At the other end of the spectrum are those
described as having Asperger syndrome and high-functioning autism, who
usually develop adequate linguistic and intellectual faculties. All individuals
on the autistic spectrum experience problems in communication and social
development, and often display ritualistic and stereotyped behaviour and
resistance to change.
Autism affects the coherence and flexibility of motivation and
consciousness (Condon & Ogston, 1966). It reduces the impulse of
awareness to seek new experience, and the capacity of a person’s purposes
to react in novel, creative ways to the contingencies of experience.
Individuals have difficulty being aware of the intentions behind other
persons’ actions, with comprehending the tools people use and with
distinguishing the meanings of language (Trevarthen, Aitken, Papoudi, &
Roberts, 1998). Other people feel that the company of people with autism
lacks companionship. Nevertheless, the autistic individual is sensitive to how
others behave (Trevarthen, 2002).

The role of music therapy: a brief introduction

Back in 1978, Juliette Alvin, the pioneering British music therapist, wrote
about a common feature present in all autistic clients: their response to
music. Her book Music Therapy for the Autistic Child was:
An attempt to describe what long-term music therapy can achieve with some
autistic children through skill, patience, understanding and love, and without
unwarranted claims or ambitions. (Alvin, 1978, p. vii)

It has been more than 30 years since the first publication of this book
and without doubt many things have changed in the field of research on
music therapy and autism. Numerous studies have been published since then
on the same subject (Brown, 1994; Pavlicevic, 1997; Robarts, 2000; Oldfield,
2006a; Poismans, 2008), most of which involved case studies, qualitative
studies and expert opinions. Following the model of the Evidence Based
Medicine (EBM),1 music therapy research on ASD has been enriched in the
last few years by a number of quantitative studies: (among others) a
randomized controlled trial – RCT (Kim, Wigram, & Gold, 2008, 2009), a
systematic review (Gold, Wigram, & Elefant, 2006) and a meta-analysis

1
Evidence Based Medicine (EBM) aims to apply the best available evidence gained
from the scientific method to medical decision making. It seeks to assess the quality
of evidence of the risks and benefits of treatments (including lack of treatment)
(Timmermans & Mauck, 2005, 18–28).
110 T. Dimitriadis and H. Smeijsters
(Whipple, 2004). Despite their questionable applicability to the music
therapy practice, these studies can be a useful reference point for the
clinicians who are often required to provide ‘‘good’’ evidence2 on the effects
of music therapy. Music therapy has inevitably become more and more
science based; it remains, however, a developmental, musical, and inter-
personal process (Pavlicevic, Ansdell, Procter, & Hickey, 2009) which can
contribute to the social and emotional integration of a person with an ASD.
Apart from the evidential support, the validation of a treatment, such as
music therapy, must be without doubt respectful to theories about why
music can be a powerful therapeutic tool for the autistic client’s treatment.
This paper focuses on the theoretical background, which is there to support
what happens in the musical relationship between therapist and autistic
individual. The authors attempt to go beyond the ‘‘traditional’’ music
therapy literature and seek answers to the question ‘‘why music therapy can
be effective with ASD’’ in the fields of developmental psychology,
neuropsychology, and psychotherapy. Moreover, the ideas of the music-
centred music therapists, who propose a musicological model to help
understanding what happens in the musical interaction, are also presented in
this paper.

A perspective from developmental psychology

The views of Daniel Stern (1985, 1995) are generally regarded as a ‘‘safe
common base’’ (Bonde, 2003, p. 69) for developmentally oriented theory
within many clinical fields in music therapy, including ASD. They are
important because they are music based and thus are able to capture the
essential characteristics of music therapy. Stern’s concepts of affect
attunement and vitality affects give us a perspective from developmental
psychology that shows that the musical is the psychological and vice versa
(Smeijsters, 2003, 2005).
In his book The Interpersonal World of the Infant, Stern (1985) initiates
the term affect attunement. Affect attunement is the performance of
behaviors that express the quality of feeling of a shared effect without
imitating the exact behavioral expression of the inner state (Stern, 1985,
p. 142). When a baby experiences joy (form of feeling), he/she will

2
An example of the comparison between ‘good’ and ‘less good’ evidence is presented
in the following Evidence Hierarchy (Kuiper et al., 2008). The ‘least prestigious’
evidence is, according to the list, an expert’s opinion:

(1) Systematic Reviews or meta-analyses of RCT’s

(2) RCT’s
(3) Clinical Controlled Trials (CCT’s)
(4) Case reports, qualitative studies
(5) Expert opinions.
 Nordic Journal of Music Therapy 111
express this joy in a smile on his/her face (visual modality). The mother
can then answer by smiling too (same modality). What Stern found out
was that mothers are used to answering in different modalities. For instance
they make a sound (auditory modality) that lasts as long as the smile,
and goes up and down like the baby’s lips and cheeks. The baby perceives
this as an empathic answer to his/her joy. In this case the inner
experience (the feeling of joy) corresponds to a perceptual form (smiling),
which is then transposed to the auditory modality (sounds) to communicate
empathy.
What the mother does in her interaction with the baby is not a
stereotypic boring sequence of mirroring repeats, back and forth, because
the mother constantly provides a theme-and-variation format with slight
changes in her contributions at each dialogic turn. In an example of the
affect attunement the mother makes a vocalization ‘‘uuuuuuuuh . . .
uuuuuuuuh!’’ which matches the baby’s physical effort to move/stretch
towards a toy (Stern, 1985, pp. 139–140).
There are three general features of behavior that could be matched (and
thereby form the basis of attunement): intensity, time, and shape.
Stern presents a broken-down version of these three dimensions with
more specific types of match:

(1) Absolute intensity

(2) Intensity contour
(3) Temporal beat
(4) Rhythm
(5) Duration
(6) Shape.

He described all the dynamic, kinetic qualities of emotions, thoughts, and

behaviors as the vitality affects of the human psyche. Some of these vitality
affects are, among others, bursting, blowing out, drawn out, crescendo,
decrescendo, fleeting, surging, etc., which should be distinguished from
categorical affects such as being happy, sad, or angry (Stern, 1985, p. 54).
Terms that someone would think they are strictly musical (e.g.
crescendo, decrescendo) have been used in order to describe forms of
feeling. This has been a valuable ‘‘gift’’ for theory building work in music
therapy:

When it is possible to describe music with the same dynamic kinetic terms
as surging, fading away, crescendo, drawn out and so on, which have been
used by Stern when describing vitality affects, then we may conclude that
this explains why there is analogy between musical and psychological
processes. When it is possible to describe the musical and psychological
processes by means of the same dynamic terms, the analogies between
musical forms and forms of feeling are apparent. (Smeijsters, 2005, p. 70)
112 T. Dimitriadis and H. Smeijsters
It is worth noting here that, although a large portion of the vitality affects can
be described in musical terms, they are beyond musical concept.3 It is because of
the vitality affects that music has such an impact on us (Stern, 2009). Vitality
forms are regarded as ‘‘a feeling domain unto itself’’ and not as phenomena that
belong to any specific modality (auditory, visual, etc.) or to any specific domain
(e.g. emotions, cognitions, sensations, or motivations).
Trevarthen’s description of intersubjectivity is very close to Stern’s affect
attunement. Intersubjectivity is the psychological ability to have and share
purposes, interests, and emotions, to be ready to exchange these intrinsic
psychological events with other persons, so as to gain new ideas and goals
from them (Aitken & Trevarthen, 1997, quoted in Trevarthen, 2002).
Similar to Stern, Trevarthen has written on the infant musicality and the
musical qualities of mother–infant communication. Trevarthen and Malloch
(2009, p. 8) state that the engagement of the musicality of an autistic
individual by another can be ‘‘a lifeline to human society.’’ The theory of
communicative musicality entered the literature of developmental psychology
(Malloch, 1999) in an attempt to explain the foundations of sympathetic
action between communicating human beings. Trevarthen suggests that this
theory has enriched our understanding of what interpersonal awareness or
intersubjectivity is (Trevarthen, 2002, p. 88). It might help us ‘‘perceive the
problems faced by a confused and withdrawn autistic individual in a busy
and impatient human world’’:
. . . we live, think, imagine and remember in movement. To capture the essence
of movement and its values we use the metaphor ‘‘musicality’’. To recognise
that our experience in movement is shared by a compelling sympathy we call
this activity ‘‘communicative’’. We believe that our learning, anticipating and
remembering, our infinite varieties of communication including spoken and
written language, are all given life by our innate communicative musicality.
(Trevarthen & Malloch, 2009, p. 9)

Damasio’s theory of consciousness in relation to emotional process

The ideas of Stern on vitality affects are closely related to the writings of the
neuropsychologist Antonio Damasio. In his groundbreaking book The
Feeling of What Happens (1999) he makes a distinction between different
forms of consciousness, which correspond to different forms of self (see
Figure 1).
(1) The unconscious proto-self involves unconscious biological processes
(e.g. digestion), and body reactions (e.g. self-healing, sensorial
reactions, etc.). The proto-self has no powers of perception and
holds no knowledge. It does not occur in one place only and it

3
D. Stern personally announced this during the Sixth Nordic Music Therapy
Conference in Aalborg, Denmark.
 Nordic Journal of Music Therapy 113

Figure 1. Damasio’s different forms of conscience.

emerges continuously out of interacting signals that span varied

orders of the nervous system.
(2) The (conscious) core-self: this corresponds to the core consciousness,
which provides the organism with a sense of self about the moment
(now) and about one place (here). The scope of the core
consciousness is in the here and now. The core-self is ceaselessly re-
created for each and every object with which the brain interacts. This
area of consciousness is non-verbal and it is not related to cognition.
It has one single level of organization, it is stable across the lifetime
of the organism and it is not depended on conventional memory,
working memory, reasoning, or language.
(3) The (conscious) autobiographical self: this corresponds to the
extended consciousness and provides the organism with an elaborate
sense of self (an identity and a person – you or me, not less). It
involves cognitive functions such as language, memory, attention,
etc. It is not an independent variety of consciousness: it is built on
the foundation of the core consciousness. What is also important is
that it evolves across the lifetime of the organism.

Hierarchy: there is no consciousness (and certainly no life) without the

proto-self. Also, the extended consciousness doesn’t exist without the core-
consciousness. According to Damasio, the core-self doesn’t necessarily need
the autobiographical self to exist.

From consciousness to emotions: primary, secondary and background

Emotions are ‘‘complicated collections of chemical and neural responses,
forming a pattern,’’ they are about the life of an organism, and their role is
114 T. Dimitriadis and H. Smeijsters
to assist the organism in maintaining life. All emotions use the body as their
theatre (internal milieu, visceral, vestibular, and musculoskeletal systems).4
Primary or universal emotions are happiness, sadness, fear, anger,
surprise, and disgust. Some examples of the secondary or social emotions are:
embarrassment, jealousy, guilt, or pride.
Damasio points out that when we sense that a person is tense, or edgy,
down or cheerful without a single word having been spoken to translate any
of these possible states, we are detecting background emotions. Well-being or
malaise, calm or tension can be detected by subtle details of body posture,
speed and contour of movements, eye movements, etc.
Background emotions and background feelings determine to a great
extent the mood and the energy level of the organism and greatly affect the
processes of thinking, feeling and acting. Damasio (1999, p. 287) agrees that
his notion of background emotions is very close to Stern’s vitality affects.
They both refer to a dynamic level of feeling. This dynamic level of feeling
can be influenced by parameters like rhythm, tempo, intensity and shape, as
described previously. When something has an influence to the background
feelings, then this might cause changes in the human psyche. This can only
happen in the here-and-now, in what Stern called the present moment, the
moment where the experience is without language (thus non-verbal). This
kind of ‘‘felt experience’’ brings the background feelings/vitality affects in
motion.

Music therapy with ASD from a (neuro)psychological point of view

What have all these widely and frequently cited theoretical terms to offer to
the current music therapy practitioner? Can they help music therapists gain
a better understanding on the efficacy of music therapy with ASD? And up
to which point might they be a source of inspiration for music therapy
theorists and researchers?
Damasio’s analysis of the core and extended consciousness related to the
feeling of an active body and to emotions in intimate and more consciously
cultivated relationships can enrich the experience of a musician who has
learned how to facilitate emotional regulation and shared experience for a
person whose autism isolates them from casual human relations. As
described previously, the experience of the core-self in the present moment5 is

4
According to Damasio (1999) feelings and emotions are not exactly synonyms:
feelings are inwardly directed and private, whilst emotions are outwardly directed and
public. It is through feelings that emotions begin their impact on the mind, but the
full and lasting impact of feelings requires consciousness, because ‘‘only along with
the advent of a sense of self do feelings become known to the individual having
them’’ (Damasio, 1999, p. 36).
5
According to Stern (1995) a present moment ‘‘. . . contains the essential elements to
compose a lived story. This is a special kind of story, because it is lived as it happens,
 Nordic Journal of Music Therapy 115
non-verbal and non-cognitive. Therefore it can be better expressed in
another medium, other than language. Communication through the use of
sounds involves a different means of interacting, which is far from the
‘‘realms’’ of language. An autistic individual, who, as noted at the beginning
of this study, often has problems with distinguishing the meanings of
language, might find him/herself more at ease in a situation where the use of
language is minimized to the absolutely necessary. As a result, music therapy
approaches the potential changes in the autistic client’s life from a totally
different angle, than verbal therapy does.
Stern’s parameters of the vitality affects, such as tempo, rhythm,
intensity, shape, crescendo, and decrescendo, are the quintessence of the
musical interaction between therapist and client. Smeijsters’ theory of
analogy describes the connection between these vitality affects and music. He
proposes that playing, singing, and listening to music sounds the inner
psyche of the client who plays, sings/vocalizes and listens to music. In music
therapy the client expresses his/her inner self in music. The client doesn’t
only ‘‘tell’’ a story about him/herself : he is him/herself in music. The music
therapist meets the client in his/her music and then aims to change his/her
forms of feeling by changing his/her musical forms (Smeijsters, 2003, pp. 71–
85).
There is an analogy between being in music and being in the experience.
Active or creative music therapy takes place in the experience, in the present
moment, and involves the core-self/core consciousness. The scope of creative
(or active) music therapy is the same with that of the core-self: the here and
now. Interacting In the medium of music, thus in a non-verbal way, is a
representation of how the client interacts Out of the medium, as well as an
auditory indication of what happens in the client’s core-self in the present
moment. Therefore, changes in the core-self might be influenced by changes
in the musical medium.
When, for instance, a client with an ASD rigidly repeats the same
rhythm or melody all the time, the behavior in music sounds his/her ‘‘inner’’
compulsion (behavioral motif). The music therapist can help him/her accept
and imitate slight changes in rhythm or melody, in order to experience new
musical motifs (Smeijsters, 2005, p. 73). We believe, therefore, that the
experience and ‘‘discovery’’ of new motifs in the medium, thus in the musical
interaction, can bring about changes in the life of the autistic client out of the
medium. The music therapist offers the client the opportunity to experience
new motifs of feeling in the here-and-now musical interaction. These
processes involve the conscious, non-cognitive, and non-verbal core-self of
the client (Smeijsters, 2008a). Through experiencing new motifs of feeling,

not as it is put into words afterwards. It is non-verbal and need not be put into
words, even though it could be with difficulty . . . it is made up mostly of feelings that
unfold, a sort of untold emotional narrative’’ (p. 55).
116 T. Dimitriadis and H. Smeijsters
the client also experiences new behavioral motifs. One of the most important
goals of music therapy with any client group is without doubt to give the
client the opportunity to ‘‘experience the different’’ and incorporate
potential changes in his/her everyday life.
Music therapists often find close connections between Stern’s mother-
and-child affect attunement and the music therapy relationship. The
therapist attunes to the sounds of the client and, according to the goals of
therapy, gives a musical response, which is similar to the mother–infant
interaction, as described previously by Stern and Trevarthen. In her work
with autistic children Schumacher (2001) also relates the musical interaction
between therapist and autistic child to the interaction between mother and
child. She developed an assessment scale, similar to the Nordoff–Robbins’s
one (1977, 2004), which makes it possible to assess the levels of attunement
in the musical interaction, particularly when working with autistic
individuals. Schumacher (1994, quoted in Oldfield, 2006b) refers to two
stages in music therapy work with children with an ASD. In the first phase
she establishes contact with the child by putting the child’s spontaneous
movements, vocalizations, and percussion playing into a musical context. In
the second stage she establishes communication through engaging in a form
of playful exchange.
Stern’s description of mother–infant games as vitality affects relate easily
to Nordoff and Robbins’ concept of interactive music therapy, which is
responsive to the timing and expressive quality of each patient’s initiative.
Referring to the well known case study of Edward, a boy with ASD,
Nordoff and Robbins (1977) state that:
. . . the music accepts and meets his state, while it matches, accompanies and
enhances his expression. (p. 99)

Wigram (2004, pp. 81–111) presents different methods of musical

interaction which might be used in the treatment of ASD. His description of
empathic techniques, such as mirroring, imitating, and copying, seems (at
least to some extent) close to Stern’s affect attunement. When the music
therapist musically mirrors what the client does, he/she attempts to meet
him/her exactly at their level and achieve synchronicity with the client.
Matching the autistic client’s music serves as a means of reassuring and
validating his/her playing. Reflecting is a more complicated technique and
involves the therapist’s ability to reflect back the client’s mood at that
moment, instead of just repeating his/her music. In order to do so the
therapist has to be able to detect background emotions in the (musical, thus
non-verbal) relationship and put them into music. In this way the therapist
attunes to the client’s mood, reflects it in his/her music, providing a frame
where the therapeutic relationship can take place. Clive Robbins described
it as ‘‘the creation of a non-threatening environment through music’’
(2004) . It is not just imitation of the sounds that the client does, but rather a
 Nordic Journal of Music Therapy 117
theme-and-variation music which aims at the expression of the core-self of
the client in the here-and-now contact.
An autistic client shows difficulties in initiating and maintaining contact
with another person. Improvised music therapy, which is immediately
responsive to any musical ‘‘statement’’ the client may make, can engage the
pleasure in human contact and promote intimate and developing commu-
nication, engendering a relationship of affection and trust, and encouraging
more coherent purposefulness, awareness, and memory. Even when verbal
communication is severely reduced or impossible, the client is still offered
the opportunity to express him/herself (Trevarthen, 2002, p. 94). The
therapist uses the intrinsic communicative musicality of the client in order to
open awareness for communication and facilitate meaningful speech for
those with little language.
Improvised, responsive or ‘‘creative’’ music therapy (Nordoff &
Robbins, 1977, 2004), by mirroring the core impulses of motivation and
emotional states, offering rhythmic coherence, continuity and balance of
emotional change, and a ‘‘narrative’’ of feeling, can reach the sensibilities of
an autistic client and give form and consistency to motivation (Aldridge,
1996; Robarts, 2000; Wigram, 2000). It can improve disturbed autistic
client’s alertness, calming excesses of action, and giving coordination to
movement. It can aid regulation of emotion and moderate the bodily
expression of moods, reducing anxiety and stress.

Can a music-centered theory underpin the practise without the need for
psychological thinking?
Not all music therapists agree with the idea of building a music therapy
theory based on evidence from psychology and psychotherapy. Music-
centred therapists present a more alternative way to conceive and monitor
music therapy that rejects neuroscientific, psychodynamic or developmental
theories as irrelevant to music as a cultural activity.
There is a growing body of literature (Lee, 1996, 2003; Ansdell, 1995,
2003), which suggests that it is possible to provide safe therapeutic
encounters without reference to non-music derived theory (Streeter, 1999),
and that music therapy theory should preferably spring from an under-
standing of creative musical processes alone. Ansdell (1995) claims that an
extra-musical theory tends to delete the object (the music) while a
musicological one deletes the subject (the player or listener). Colin Lee’s
approach of ‘Aesthetic Music Therapy’ (2003) puts less (or no) emphasis on
the psychological thinking, and rejects the developmental or psychodynamic
interpretations of the musical relationship. There is no need to go back to
the mother–infant relationship to explain the process of music therapy with
autistic clients, or with any clients. What is important is to be able to live
and experience the musical interaction in the here and now; otherwise the
118 T. Dimitriadis and H. Smeijsters
focus of attention moves away from the musical component of music
therapy.
According to this school of thinking, many music therapists’ initial use
of Stern and Trevarthen’s work tended to reduce music in music therapy to
just preverbal proto-music (Pavlicevic & Ansdell, 2009). Stige (2003, 2004)
very eloquently writes that:
. . . no person moves directly from protomusicality to musicking. Musicking,
based on human protomusicality, involves appropriation of music as culture.
(Stige, 2003, p. 173)

Music-centered music therapy researchers stress the importance of the

relationship between musical and social experience. Pavlicevic and Ansdell
(2009) suggest that two functions are activated by this relationship: music in
the service of human communication, and music in the service of human
collaboration (p. 362). A potential challenge for future theorists might be to
investigate how the natural processes of musicality develop to serve
complementary purposes, e.g. self-expression, engagement in intimacy
with one other person, and sharing of communal sense of meaning in a
group that recognizes forms of art.
The early interaction theories, although they seemed tailor-made for
music therapists, did not pay sufficient attention to cultural and communal
perspectives on music therapy. These theories emphasized the nature of
music-therapeutic dyadic relationships, at the cost of attention to groups
and communal events in music therapy. It is important to note that the
musicality of infants quickly leads to the enjoyment of ritual forms, of
action games, and baby songs that are traditional. Autism not only prevents
such easy sharing of narratives of musical experience, but also responds to
efforts to overcome this isolation.
Community music therapy (Pavlicevic & Ansdell, 2004) finds inspiration
in the theory of communicative musicality, and is able to use this theory
critically as a foil to help develop broadening models. However, the pioneers
of this recent development in music therapy believe that Malloch’s
suggestion of communicative musicality provides a necessary but not
sufficient theoretical platform. In order to explain how music therapy works
in broader contexts, beyond dyadic psychotherapy oriented forms of
relatedness, they suggest a new function, called collaborative musicing,
which couples cultural learning (musicianship) and direct social participa-
tions (musicing) (Pavlicevic & Ansdell, 2009, p. 358).

Conclusion
According to Smeijsters (2003, 2008a, 2008b), arts therapies should develop
theories that are art based: consequently music therapy should develop
music based theories. Nevertheless ‘‘these theories should be supported by
 Nordic Journal of Music Therapy 119
psychological and psychotherapeutic evidence, because arts therapies are
meant to ameliorate handicaps’’ (Smeijsters, 2003, p. 72). The ambition of
creating a ‘‘General Music Therapy Theory,’’ such as the Theory of Analogy,
didn’t seem to gain acceptance from all schools of thinking in music therapy.
Bonde (2003) writes that such a theory underestimates the importance of the
aesthetic form or musical meaning:

I do not think that the ‘‘psychologically satisfying or significant’’ in music

therapy is very different from ‘‘the musically/aesthetically satisfying or
significant’’. . . of course our clients are not and must not be music students
or even amateur musicians. However, musical and aesthetically meaningful
statements are more helpful to clients, than random expression in sound. (p.
70)

Music therapists who work with clients with an ASD might agree that
any kind of sounds may be used in order to establish communication
channels with a withdrawn or isolated autistic individual. It is, thus, not the
aesthetically meaningful that invites the client to join the musical
interaction; it is the communicatively meaningful, which doesn’t necessarily
sound musically pleasant. In addition, as Smeijsters has stated elsewhere:
. . . a theory of aesthetics cannot explain why music influences personal
experience . . . the aesthetic feeling is therapeutic if it changes the inner self and
the social self . . . it is too simplistic to describe music therapy in purely musical
terms. (2008b, pp. 19–23)

Music therapy takes place in the here and now and can engage the
autistic client’s core-self because it is non-verbal and non-cognitive,
therefore it doesn’t depend on the intelligence level of the client. It might
also cause changes to the background feelings that influence the behavior
and emotional world of an autistic individual. That happens because in the
musical interaction the vitality affects, as described by Stern, play a
significant role in the non-verbal therapeutic relationship. The experience of
different musical motifs corresponds to the experience of different emotional
and behavioral motifs because of the (previously described) analogy between
the musical and the psychological.
It might be interesting for future theory building work to analyze how
particular music styles influence the background feelings of the autistic
client. In addition, if a skilled music therapist has to be able to detect these
background feelings (for instance client’s wellness or imbalance), would that
have anything to do with the psychoanalytically oriented counter-
transference (i.e. the therapist’s own feelings and thoughts for the client,
based on their therapeutic relationship)?
It is common practice for music therapists to record and audit the
sessions with clients on the autistic spectrum. Thinking and planning are
necessary before and especially after the music therapy session. In Damasio’s
120 T. Dimitriadis and H. Smeijsters
terms, thinking, planning, wording, and reviewing belong to the area of the
extended consciousness; arguably, a music therapist has to be able to shift
between his/her core and extended consciousness in order to communicate
with and suggest changes to the client’s core-self. Furthermore, current
practitioners need to base their treatment on widely recognized theories,
often borrowed from the realms of developmental psychology and
neuropsychology. The music therapist has to be convincing enough to the
parents/carers of the client and especially to other professionals, who
sometimes see music therapy as just a nice activity. Music therapy theories
built on the scientific and practise based evidence can be extremely useful for
the therapist who quite often struggles to prove that what happens in the
musical interaction with the client is objectively effective and far from just
therapeutic intuition or wishful thinking.
A strictly music-centered thinking seems helpful, but not enough to
cover the vast range of the interpersonal communication, both conscious
and unconscious. However, recent developments in music-centered music
therapy, such as the Community Music Therapy, might help researchers and
theorists look at the music as a cultural/social event, rather than exclusively
a dyadic mother–infant interaction. It appears that the greatest difficulty lies
in the fact that music therapists have no choice but to use words in order to
describe something that is beyond words; they need to use language for
something that happens beyond language; they must use cognition, which
according to Damasio belongs to the extended consciousness, in order to
describe experiences in music which aim at or involve the core-self of the
client. Damasio (1999) suggested that language is the translation of
something else: the translation of the very experience in the present
moment. This very experience, the musical give-and-take, should be the
cornerstone of any attempts to explain the power of music with the
communicatively disabled client with ASD.

Notes on contributors
Theo Dimitriadis, Music Therapist (N-R), student at the Master of Arts Therapies
Program, at Zuyd University of Applied Sciences.
Prof. Dr Henk Smeijsters, Head of Research of the KenVaK Research Centre for the
Arts Therapies, and Head of Studies of the Master of Arts Therapies at Zuyd
University of Applied Sciences.

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