The Importance of Session Structure (or lack thereof)

One of my clients, a six-year-old,  has a very short attention span and spends a lot of his time stimming with various little items. This particular client hasn’t been diagnosed with Autism, but presents with some similar characteristics due to his medical history. When I first started with Cx, I quickly decided that an improvisational approach might be the best way to build a rapport with him as he was self-driven, sang to himself almost constantly, and made little eye contact. My previous training with Nordoff-Robbins trained music therapists made me feel comfortable in approaching him with an open mind and in a way that I could reach him through a humanistic approach to develop rapport.

Luckily, it was a good instinct to follow for this client. He immediately began demonstrating extended eye contact when I began matching pitches that he was singing or jumping into the songs he was singing with him. He thought it was funny sometimes so I went along with that and used exaggerated affect to support those social cues; a tactic I find has been extremely successful with clients with autism. Check out more information about it here, as presented by Dr. John Carpente of Molloy College.

After about four months of great work, this client began to demonstrate some refusal behaviors when he did not want to do something. His nurse had reported that this was occurring in school, at home, and in all of his therapies. What I noticed when he began to refuse engaging in music is that he was DESPERATE to get to his stim toy or to pace around the room. So I knew I had to go back to the drawing board again.

Structure was the first thing that came to mind.

I started his next session using the “on/off” structure, as I like to call it. I started low, prompting the client to sit in his chair for “work” for two minutes of music therapy intervention. I allowed him to choose the instrument he wanted to play to make it more engaging and reinforcing for him. Once he was able to meet the two minutes, his nurse and I cued him to use his talker to ask for a “break”. He then had a three minute break to stim, walk, pace, or do whatever it was that he felt his body needed. After the alarm went off, he was prompted to come back for “work” again. This client is now up to five minutes of “work” and down to two minutes of “break” time. The best part is that he is so much MORE engaged in those five minutes than he ever was in the previous month. I feel like it was important that we developed the rapport, but I knew that this structure was going to help the client be successful in school.

I didn’t like the idea of calling part of our music therapy sessions “work” as a cue, however I made myself reflect on that feeling. Was I feeling that I didn’t like calling part of music therapy “work” because it meant part of music therapy isn’t fun?  After some time, I knew that it was my feelings only that made me hesitant about calling music “work”, and it was most important that my client was successful in music therapy and in other environments. Obviously, it was way more important that my client learned when it was “work” time versus “break” time. However, I think it’s important that we process and reflect when we have these feelings come up for ourselves, so that we take action on the most therapeutic path. To respond rather than react.

I also felt it was VERY important that I made time for the client to have his time to stim if he needed it. What was even more amazing was as soon as I made space and accepted my client for needing to stim, I feel as though our rapport has grown even more. Previous music therapists had actually recommended discontinuation of music therapy due to lack of engagement. This upset me that previous therapists were not flexible in their approach, decided that he didn’t fit “their” way.

As a therapist, it is our job to remove our own expectations and to get into the minds of our clients and map out a route to success that works for them, not us. I can hear one of my professors now with one of her favorite remarks that she told us everyday (and I love/thank her for it!),

“IT’S NOT ABOUT YOU!!!”

His success may look different and he may not be able to sit and attend for extended periods yet, but he sure is “working”, laughing, smiling, and musiking his way there.

Kate

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