Case Study Designs in Music Therapy

David Aldridge

• Publisher: Jessica Kingsley Publishers
• Year: 2004
• Print ISBN: 9781843101406
• eBook ISBN: 9781846420009
• Topic: Psychology
• Subtopic: Music
• Index: Psychology

Research and clinical work are often perceived as opposites in the field of music therapy. This book shows, for the first time, how these two areas of work can creatively complement one another, proving beneficial to both disciplines. Each chapter is written by a leading researcher and practitioner in the field, and the book covers a wide spectrum of approaches within different settings. Beginning with methodological and musicological approaches to case studies, the book then moves on to more specific topics such as the use of case studies in an interactive play setting and in music therapy with the elderly. Later chapters explore theoretical aspects, looking at a worked example of music and progressive change during therapy, and how case study designs can be used in practice. A must for all professionals working and studying within the music therapy area, this is also an informative and useful book for health researchers.

CHAPTER 1

A Story Told from Practice: The Reflective Inquirer in an Ecology of Ideas

David Aldridge

Language, before being a code or a depository of established meanings, is but a generalized style, a way of singing the world.

Maurice Merleau-Ponty quoted in Smith 1993, p.195

My colleague and I visited a man at his bedside in hospital. He was a participant in a research program and one of the treatment options was music therapy. As it was a controlled trial, he had given his permission to be part of the treatment group or the control group. Before the session started, he was given a questionnaire to complete.

We duly sang for him and his family. He and his wife talked about their life together, what songs they enjoyed singing, some from way back then, and we played some of those songs. They were also given a list of favourite songs chosen by other people in the hospital. Both identified songs from this list that they liked to hear and sing along with. Interspersed with these songs that we sang together were reminiscences about past events and a generous sprinkling of anxiety about the near future from the man and his wife. He had only just been admitted to the hospital and the first stage of the treatment was imminent that same evening. After we had sung, he asked, ‘Was that the music therapy or the placebo?’

Now most therapists when they talk to their colleagues will use such vignettes from practice. When we talk to each other, we tell stories that work on different levels of meaning. The above anecdote is a commentary on the possibility of ‘blinding’ in clinical trials, music therapy placebos and the questionable quality of my singing. It also points to the advantage of songs that bring out reminiscences and topics for conversation.

While we present lectures in formalised styles and write papers according to given formats, when we get down to talking about what happens to each other, then we use stories. And these stories are about people, about ‘cases’ we have worked with. This does not turn people into objects, we give those cases names, albeit pseudonyms. Case is an abstraction for talking about the generic. A case may be a person, it may be a collection of illustrative examples, it may be a group. In some instances it may be an event, like the implementation of a new service, or it may be a situation.

In this book we will be reading how such stories are expanded into case studies which are formed into case study research designs. This is a broad spectrum of methods, as the reader will see from the varying chapters. At the heart of this approach is a move towards a formalised rigorous presentation of practice by practitioners thinking deeply about the meaning of their work and its implications for practice. But these ideas do not stand alone, we put them out to be used by others, just as others will influence our writing and our talk. They form, then, an ecology of ideas. Hence, we have stories that are told from practice by the reflective inquirer in an ecology of ideas.

The aim of this book is to show how we can formalise our studies to understand what we do and to communicate this to others. Together we can contribute to a body of knowledge. I do not assume that research will necessarily improve practice, nor that practitioners who do not use research are any less able than those who do. Simply, we have a variety of ways to do practice-based research and case study design is a flexible form that adapts itself well to what we do.

Staying close to practice

We need an approach to music therapy research that stays close to the practice of the individual clinician; that is, the musician as therapist. Each therapeutic situation is seemingly unique. Yet we compare our cases and share our knowledge with each other. Research methods are means for formalising our knowledge so that we can compare what we do.

What I will be arguing for in this chapter is a flexible structure that can be applied to clinical practice (D. Aldridge 1996). The practice is allowed to remain true to itself, although any research endeavour, by the nature of its reflexive scrutiny, alters practice. In doing research we ask questions of ourselves as clinicians, and when we involve our patients in the process, then they too will reflect about what is going on. Indeed, Robson now uses the term ‘flexible designs’ as opposed to fixed designs, and case studies are categorised by him as flexible designs in the qualitative tradition (Robson 2002, pp.176–184).

Rich empirical inquiry

Case study designs are research strategies based upon empirical investigation. A particular case is identified and located in context, which may be social, temporal or spatial. It is the bounding of the case in a context that makes the case study a ‘case’ study – the case may be a person, several persons, a group or a situation. Because the case itself is specific, and the context bounded, some authors contend that it is difficult to generalise from such research (Gomm, Hammersley and Foster 2000; Robson 2002; Stake 1995). However, it is the very context-related feature of case studies that make the approach important for music therapy. Case studies relate what is being studied to real life situations and allow us to use a multiplicity of variables. Selecting cases is central to this approach as this selection is, in effect, the ‘population’ to be studied. The nature of that selection will also colour the study; selection on theoretical grounds will offer a different view from when the population is determined solely by the situation at hand. In the qualitative research literature there is an emphasis on determining which sampling method is to be used. Many of us have to be content with the people that we meet in practice as the population of our sample and I would like to introduce the term ‘reality sampling’ here as an expression for choosing who, or what, is introduced into the case study.

The classic source of reference for case study research has been Yin’s Case Study Research (Yin 1994), where he writes, ‘A case study is an empirical inquiry that investigates a contemporary phenomenon within its real life context, especially when the boundaries between phenomenon and context are not clearly evident’ (p.13). He goes on to say that there are opportunities for multiple sources of evidence and this comprehensive approach is beneficial in validating findings. We will see this use of multiple data in the following chapters where quantitative data is mixed with qualitative data to provide a rich source of material for interpretation.

Hammersley and Gomm (2000) say that the most important dimensions are those relating to the number of cases and the amount of detailed information. The fewer the cases that are investigated, the more comprehensive the information that can be gleaned. In Merriam’s (1998) definition from education research, this comprehensiveness is reflected as ‘…an intensive, holistic description and analysis of a single instance, phenomenon or unit’ related to field-oriented research (p.27).

What data are to be collected is the crucial focus of case designs. From an experimental perspective, where the data are fixed beforehand, then the data will be strictly controlled and the researcher will define the cases to be studied, as we will see in Tony Wigram’s chapter. However, some researchers will construct cases out of naturally occurring situations, as we will see in Trygve Aasgaard’s research relating to the life history of songs.

What is important is that case studies can incorporate multiple levels of analysis within a single study using mixed sets of quantitative and qualitative data (Eisenhardt 2002). We see this in Hanne Mette Ridder’s study where she sings with late stage dementia patients, correlating physiological changes with behavioural observations. Such designs are flexible as they respond to the needs of both the patient and the researcher. As patients change, so does the therapy. To incorporate this aspect of music therapy practice, we need to include flexible designs that occur in naturalistic settings.

In-depth approaches encourage a rich source of data sources from tape recordings, questionnaires, interviews, photographs, letters and observations. In my suicidal behaviour study I collected material from newspaper reports over a given time frame, from observations in a psychiatric hospital ward, letters from women who had attempted suicide, questionnaires and observations from an admissions ward in a general hospital and videotaped recordings from a family therapy day clinic (Aldridge 1985, 1998a). When we have such rich studies we can begin to generate theories. Building theories from practice examples is a particular strength of the case study approach for the arts therapies in general (Higgins 1993).

Historical context

The folk-lore of case study methods suggests that these designs emerged from the practice of experimental psychology and psychoanalysis. Such a myth ignores the simple fact that human ideas have been conveyed in story form for centuries. ‘Once upon a time …’ until ‘They lived happily ever after.’ reflects this basic narrative form. Bruscia (1991) endorses this position in his book of case studies in music therapy when he writes in acknowledgement, ‘To the individuals whose stories are told in these case studies’. When therapists of whatever therapeutic persuasion gather together their clinical discussions, they focus on cases; whether these be diverse, difficult or dangerous. Indeed, patient narratives are a valid form of health care research (Aldridge 2000b).

The origins of case study are nebulous, some authors citing a medical model (Robson 2002), others a sociological model from social worker’s case histories (Hammersley and Gomm 2000) and yet others an ethnological perspective (Stake 1995). There appears to be a consensus that the early work of anthropologists and ethnographers promoted case study perspectives and that this was strengthened further by the Chicago School of Sociology (Chapoulie 2002; Horn 1998). Later researchers were also to develop the theme of human stories written as biographies from lived experience and these were to achieve an elaborated form in dramaturgical studies of people and the situations we find ourselves in. Indeed, it was Ervin Goffman’s The Presentation of Self in Everyday Life (1959b) and a sequence of his other studies (1959a, 1961, 1990), which I read as a student, that was to have an influence on my own study of suicidal behaviour (Aldridge 1985, 1998a). Our patients tell us dramatic stories and these need to be reflected in the research that we do.

Making sense: the pursuit of ‘meaning’ in researching therapeutic realities

We are currently in an age of evidence based medicine. In music therapy we have been constantly challenged to provide a basis for what we do grounded in research results. To that end we have developed research traditions and provided a reasonable preliminary foundation that substantiates our work. This work is far from complete and, really, we have only just begun. While I have argued that we should indeed provide sound evidential basis for music therapy based on rigorous studies, we also need to consider what counts as evidence. This is not a new question and both general practice medicine and complementary medicine, now also appearing as integrative medicine, have also faced such a challenge (Aldridge 1988a, 1988b, 1991; Aldridge and Pietroni 1987a, 1987b).

Therapy occurs in a psychosocial context. Music therapy is a social activity. The way people respond in a therapeutic situation is determined by the way in which they understand that situation. By studying the way that people perform their symptoms in the context of their intimate relationships we glean valuable understanding of illness behaviour. Through real life case studies we have the virtue of continuing a close relationship with the natural social world of people of which we ourselves are part. The knowledge that we have of the world, and what counts as evidence, will not solely be gained from empirical sources but also from aesthetics, personal knowledge and ethical understanding. We have rich and diverse cultures and it is this rich diversity that we can utilise in understanding therapeutic practice.

Anecdotes as evidence

Music therapy is often dismissed as relying upon the anecdotal material of case reports, as if stories are unreliable. My argument is that stories are reliable and rich in information. We rely upon stories when we talk to each other, they are a common basis for communicating understandings in all cultures. What a case study does is offer a formal structure for these stories.

We are not alone in telling case stories. Detectives present cases and lawyers represent cases. Anthropologists and ethnographers develop narrative studies in exotic locations. Social workers, psychotherapists and counsellors all have their case study reports, often from not-so-exotic settings. Managers argue their case studies to improve situations. People who work with people are not only the luckiest people in the world, they are also hermeneutic people in the lived world; we abstract meanings from experience to inform each other as case studies. Although ‘case study’ itself is a catch-all term, the case study has regained stature in qualitative research and particularly amongst clinical practitioners.

While anecdotes may be considered bad science, they are the everyday stuff of clinical practice. People tell us their stories and expect to be heard. Stories have a structure and are told in a style that informs us too. It is not solely the content of a story, it is how it is told that convinces us of its validity. While questionnaires gather information about populations, and view the world from the perspective of the researcher, it is the interview that provides the condition for the patient to generate his or her meaningful story. The relationship is the context for the story and patients’ stories may change according to the conditions in which they are related.

Anecdotes are the very stuff of social life and the fabric of communication in the healing encounter. As Miller writes, ‘every time the experimental psychologist writes a research report in which anecdotal evidence has been assiduously avoided, the experimental scientist is generating anecdotal evidence for the consumption of his/her colleagues’ (1998). The research report itself is an anecdotal report. Stories play an important role in the healing process. Testimony about what has occurred is an important consideration. Indeed, we have to trust each other in what we say. We are witnesses to what happens. This is the basis of human communication and is at the heart of therapeutic practice.

Case study design will take these stories as a basic foundation. These are then formalised according to the needs of the teller and the listener. This forming of clinical experience into a structured case study narrative provides the relationship of our experience to the broader context of professional practice. We need to build bridges to those with whom we want to communicate. That will at times necessitate using the instruments that belong to their discourse in finding appropriate forms for reporting experience. While music therapists could see clearly what was happening when Cochavit Elefant showed videotapes of her singing with the girls in her study, it was the formalised study based on identified baselines that brought her work to a broader audience of professionals, as we see in Chapter 7. Similarly,

the work of Hanne Mette Ridder has provided an elaborated basis for understanding communication with the elderly demented using a set of structured data sources that other practitioners can relate to.

Understanding narrative forms

The point of these therapies is not so much to cure the individual as to develop forms of viable meaning. (Gergen 1997)

When we each come to tell the stories of our lives they are not of the substance of conventional research reports, nor of the quantified language of science. Our lives are best described in the dynamic expressions of a lived language. The essence of language is that of musical form which is the vehicle for the content of ideas (Aldridge 1989a, 1989b).

For those of us involved in the Family Therapy movement, core texts had been the books of Gregory Bateson (Bateson 1972, 1978). Everything became process, system and ecology with the intention of stamping out nouns. We see this perspective in Christopher Small’s book Musicking (1998) where he also references the same discourse as I have done in my earlier work. What we do as individuals is understood in the setting of our social activities and those settings are informed by the individuals that comprise them. Research as process, the collection of data, the outcomes of research and the ideas or theories we generate from that data have meaning within a social context – our research milieu. What convention...

Table of contents

• Cover Page
• Title Page
• Copyright
• Dedication
• Contents
• 1. A Story Told from Practice: The Reflective Inquirer in an Ecology of Ideas
• 2. Therapeutic Narrative Analysis as a Narrative Case Study Approach
• 3. ‘How Wonderful That I’ve Been Born – Otherwise You Would Have Missed Me Very Much!’
• 4. Song Creations by Children with Cancer – Process and Meaning
• 5. A Case Study in the Bonny Method of Guided Imagery and Music (BMGIM)
• 6. The Use of Single Case Designs in an Interactive Play Setting
• 7. The Use of Single Case Designs in Testing a Specific Hypothesis
• 8. Music and Sound Vibration: Testing Hypotheses as a Series of Case Studies
• 9. Music Therapy with the Elderly: Complementary Data as a Rich Approach to Understanding Communication
• 10. Cannabis, Brain Physiology, Changes in States of Consciousness and Music Perception
• 11. Guidelines for Case Study Design Research in Music Therapy
• References
• Bibliography
• Subject Index
• Author Index