Concepts of context in music therapy.

In contemporary music therapy as well as in related interdisciplinary fields, the importance of context in relation to theory, research, and practice has been emphasized. However, the word context seems to be used in several different ways and conceptualizations of contextual approaches vary too. The objective of this theoretical article is to clarify traditions of language use in relation to context in music therapy. In reviewing and discussing the literature, we focus on the field of mental health care. When discussing issues related to context, this literature partly focuses on the surroundings of music therapy practice, partly on the ecology of reciprocal influences within and between situations or systems. On this basis, three types of context awareness in music therapy are identified: music therapy in context; music therapy as context; and music therapy as interacting contexts. The identified types of context awareness are exemplified through references to music therapy literature and then discussed in relation to two very different metaphors, namely context as frame and context as link. Implications for practice, research, and theory development in music therapy are suggested.

Introduction

The term context is not a typical entry in the index of music therapy books or a frequently used keyword in music therapy articles. For example, it is not included as an entry in the recently published international dictionary of music therapy (Kirkland, 2013). This does not reflect lack of use of the term in the literature, however. Full text searches for the term in the main music therapy journals give hundreds of results. Music therapists write about clinical contexts, community contexts, cultural contexts, everyday contexts, health-care contexts, historical contexts, modern contexts, musical contexts, personal contexts, political contexts, professional contexts, social contexts, theoretical contexts, and so on. On one hand, such varied uses signify a widespread acknowledgement of the importance of context. On the other hand, the situation reveals that the concept rarely has been given primary attention, which calls for an analysis of the concept of context in the discourse of music therapy.

The term context originates from the study of texts. One dictionary definition of context is “The portions of a discourse, treatise, etc., that immediately precedes and follow and are connected with a passage quoted or considered” (Webster’s Dictionary & Thesaurus, 2000). The origin of the word is a Latin compound of com- (together) and texere (weave). Within hermeneutics – the practice and philosophy of interpretation that grew out of various text-oriented disciplines – the principle of considering the context of any passage is key. In this tradition, non-contextualized interpretations are always considered problematic, and various versions of the hermeneutic circle have been developed, where relationships between part and whole and between pre-understanding and present understanding are considered carefully. These principles of interpretation have been transferred to a range of other disciplines, with the interpretation of culture within anthropology as a notable example (Geertz, 1973). As Aigen (2012, p. 2) recently noted, “In a variety of streams of intellectual thought in the late twentieth and early twenty-first century, the importance of context has been stressed.”

Music therapists were perhaps not among the first to pay attention, but scholars such as Ruud (1980/1995, 1987/1990) and Kenny (1982, 1989) have argued since the 1980s that music therapists must consider the relationships between practice, theory, culture, and context. As the new millennium emerged, two books on the history and cultural context of music therapy – edited by scholars outside the discipline (Gouk, 2000; Horden, 2000) – challenged music therapists to pay more attention to context. We agree with Ruud (2001) who described this criticism as “timely” in his review of the books, but in some ways, Gouk and Horden also knocked down doors that at least were in the process of being opened. The last 10 to 15 years have seen an increasing awareness about the significance of context in music therapy, with the emergence of community music therapy (Ansdell, 2002; Pavlicevic & Ansdell, 2004; Stige, 2002, 2003/2012; Stige & Aarø, 2012; Stige, Ansdell, Elefant, & Pavlicevic, 2010), music-centered music therapy (Aigen, 2005a), feminist perspectives (Baines, 2013;  Curtis, 1997, 2012; Hadley, 2006), resource-oriented music therapy (Rolvsjord, 2010; Schwabe, 2005), recovery-oriented perspectives (Chhina, 2004; McCaffrey, Edwards, & Fannon, 2011; Solli, Rolvsjord & Borg, in press), and also various articulations of how music therapy needs to be sensitive to multicultural developments (Bradt, 1997; Hadley, 2013; Jones, Baker, & Day, 2004; Moreno, 1988).

These developments do not reflect one shared understanding of context; some contributions elaborate on contextual worldviews, others on theoretical perspectives, and others again on adjustments of practice to specific cultural, social, or political contexts. In this article, we elaborate on relevant conceptualizations of context in music therapy, with the objective to clarify distinctions that can prevent misunderstandings and thus contribute in making this term more useful in music therapy theory, research, and practice. As we have seen, the notion of context is of relevance whenever we want to understand a human artifact or activity. We will explore how the literature on music therapy practice reflects an awareness of context and how this is related to various ways of understanding the concept of context. Our research questions are therefore: Is it possible to articulate different types of context awareness in the music therapy literature? And: Could similarities and differences in the understanding of context help illuminate other similarities and differences in the discipline and profession of music therapy? As we explain below, we focus on these questions through concentration on examples from the literature on music therapy in the field of mental health.

In working with the research questions, the long-lasting interest that both authors have taken in contextual perspectives – i.e., the first author’s elaborations of resource-oriented and feminist perspectives (Rolvsjord, 2006a, 2010; Rolvsjord & Halstead, 2013) and the second author’s work on culture-centered music therapy and community music therapy (Stige, 2002; Stige & Aarø, 2012; Stige et al., 2010) did establish a starting point and operate as a resource guiding the process. This previous engagement with the topic could of course also be described as a possible challenge to reasonable treatment of perspectives that differ from our own. Reflexivity in the process – cultivated both as self-reflection, dialogue, and mutual criticism – have been tools in balancing these possibilities (Finlay & Gough, 2003).

The investigation is a philosophical and theoretical one (see, e.g., Aigen, 2005b; Bruscia, 2005). The intention is to distinguish traditions of language use, clarify concepts, discuss links to relevant theories, and suggest implications for discipline and profession. A comprehensive literature review with a systematic content analysis would not be feasible, because the term context pops up in some way or another in virtually every text on music therapy, while it rarely has been given primary attention. So, the method of inquiry has been an interpretive one, where the texts referred to in the following will serve as examples. We used a selective procedure of sampling based in our pre-understanding of the literature, and we worked in a cyclical interpretive process where we carefully read and re-read texts that we expected could exemplify various traditions of language use (i.e., various concepts). This process, which could be described as hermeneutic and reflexive (Alvesson & Sköldberg, 2009), has been repeated until we felt that we had achieved saturation in the sense that a novel, meaningful expression was developed. In order to focus on the article, we have chosen to concentrate on music therapy in the field of mental health. This choice makes the amount of music therapy literature to be reviewed more manageable and it also positions our discussion in a broader discursive context that we think can be fruitful for this exploration.

The current debates in the broader context of psychotherapy research and mental health have made us aware of possible variations of uses of the term context that are also present in the music therapy literature. Therefore, we will start the article with a detour to the debates within psychotherapy theory on the differences between a medical model and a contextual model of therapy. This detour will direct the subsequent reflections on various concepts of context in the literature on music therapy practice. Given that the concepts of context are usually not discussed explicitly in the music therapy literature, the first step of our analysis is to offer a distinction of types of context awareness in this literature. The exploration is organized through use of the three headings music therapy in context, music therapy as context, and music therapy as interacting contexts. We will then address the second research question and explore two substantially different metaphors that seem to inform the notions of context in the literature, before we bring the reflections together in the final discussion. In other words, we structure our argument by first illuminating traditions of language use in the selected literature and then by reflecting more systematically on the implications of two metaphors that illuminate substantially different ways of understanding context.

The debates on medical and contextual models in psychotherapy

In the field of mental health, contextual perspectives have been articulated as a contrast or alternative to a medical model. The term medical model is then used broadly, to denote certain core assumptions that have been characteristic in medicine. In his seminal book, The Great Psychotherapy Debate, Wampold (2001a) argued that the medical model represents a specific way of understanding mental health problems and the practices related to them: First, the problem is understood as a disorder or complaint belonging to the patient. Second, the therapist is understood as an expert who is able to provide an explanation of the cause of the problem or disease. Third, it is possible to determine an appropriate mechanism of change. Fourth, a specific intervention could therefore be developed. Fifth, this specific intervention is regarded as the remedy or cure for the patient’s problem (Wampold, 2001a, p. 14).

In the literature, there are several accounts of the medical smodel. Both critical texts and texts in favor of the model seem to identify similar characteristics (see, e.g., Oates, 1996; Shah & Mountain, 2007).

Wampold (2001a, 2001b) argues that the medical model often has been a basis for psychotherapy. Even though psychotherapy is not medical in the sense that it is oriented toward physiochemical processes, it can be based on the same assumptions and take the same form as the medical model in medicine:

To summarize, the medical model presented herein takes the same form as the medical model in medicine, but differs in that (1) disorders, problems or complaints and rationale for change are held to have psychological rather than physiochemical etiology; (2) explanations for disorders, problems, or complaints and rationale for change are psychologically rather than physiochemically based; and (3) specific ingredients are psychotherapeutic rather than medical. Because the medical model of psychotherapy requires neither physiochemical nor mentalistic constructs, strict behavioral interventions would fit into this model. (Wampold, 2001a, p.16)

Thus, the medical model can be understood as a prominent meta-perspective in various health-care practices. The medical model has become a grand narrative or strong discourse (Alvesson, 2002), that is, a dominating way of thinking that often inexplicitly underlies practice. It is well established in music therapy also, for instance, as the central meta-perspective in Unkefer and Thaut’s (2005) book Music Therapy in the Treatment of Adults with Mental Disorders and in articulations of the treatment process in music therapy in texts by authors such as Cassity and Cassity (2006), Silverman (2003, 2005), and Davis, Gfeller, and Thaut (2008).

See Rolvsjord (2010) for a discussion of the medical model in the discourse of music therapy in mental health.

We have chosen to use the term medical model in this article referring to this dominating outlook. In the critical literature, several other terms have been used, such as illness ideology (Maddux, 2002), pathogenic model (Antonovsky, 1979), or disease model (Mechanic, 1999). In our interpretation, these conceptualizations refer to related meta-perspectives, but highlight different aspects in relation to various critical views. It is important to note that the critical literature does not necessarily imply that the medical model is inadequate, only that its limitations have not been acknowledged to the degree warranted. In fact, the medical model has many advantages; it reduces complexity and allows for accumulative research on causative agents, mechanisms of change, and curative interventions. For many diseases and disorders, this is very helpful. The problem with the medical model is one that often follows success; it has been transplanted to practices where there is less of a fit between the model and the problems and possibilities that people have.

In the field of mental health, critique of the medical model has been voiced for decades. The critics have been concerned with different dimensions which we will try to summarize in four points: First, many authors have critiqued the extensive focus on pathology and symptom reduction in the medical model and have argued that processes of health promotion and recovery should be highlighted more (Antonovsky, 1979; Davidson & Roe, 2007; Maddux, 2002; Seligman & Csikszentmihalyi, 2000). Second, extensive critique has been raised toward the idea that mental health problems can be understood as diseases or disorders belonging to the individual. The interactions of biological, psychological, social, and cultural processes need to be examined, according to this critique (Elkins, 2009; Engel, 1977; Illich, 1975; Mechanic, 1999; Szasz, 1979). A third point of criticism is concerned with the power-relations that are constituted and maintained by a model where the therapist is the expert providing explanations and interventions (Bohart & Tallman, 1999; Duncan & Miller, 2000; Furedi, 2004; Maddux, 2002). Fourth, critique of the medical model has also been linked to analyses that suggest that there is lack of evidence to support the assumption that change in psychotherapy is mainly due to a specific intervention (Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001a, 2007).

Some of the proponents of this critique have argued for the relevance of alternative perspectives. Antonovsky’s (1979) salutogenic model is an example well known also in the discipline of music therapy (Bruscia, 1998; Ruud, 1997, 1998). Some of these alternative perspectives have been articulated as social or contextual models. In psychotherapy, Wampold’s (2001a) notion of a contextual model is linked to the so-called dodo-bird verdict and the articulations of common factors in psychotherapy that followed. Findings from comparative studies and meta-analyses of comparative studies have suggested that specific interventions related to a range of psychotherapy models are equally effective (Lambert & Ogles, 2004; Luborsky et al., 2002; Wampold, 2001a). This evidence in turn resulted in a widened scope in psychotherapy research where common factors, such as hope and placebo, relationship, therapist, and extra-therapeutic factors rather than specific ingredients have been studied (Duncan et al., 2010; Lambert & Ogles, 2004; Norcross, 2002).

The reference to Alice in wonderland and the dodo-bird verdict was introduced by Rosenzweig already in 1936 (Luborsky, Singer, & Luborsky, 1976).

When Wampold introduces the term contextual model, he does not define it explicitly, only implicitly through descriptions of various key factors. Informed by the common factors tradition of research in psychotherapy, he stresses for instance relationship factors and therapist factors. Further, building on the perspective of therapy as a “culturally situated healing practice” (Frank & Frank, 1991), he advocates the relevance of a holistic approach that encompasses the whole therapeutic situation, including the social–cultural context, as providing potentials for change and development related to the client’s health. Thus, according to Wampold (2001a, 2001b, 2007), it is important to distinguish between a common factors model and a contextual model. Wampold emphasizes that the contextual model includes contextual factors that go beyond the common factors. These contextual factors are related to the client and therapist’s perceptions and understandings of the healing contexts (Wampold, 2001a, p. 26; Wampold, 2001b, 2007).

Context awareness in music therapy

What someone might mean when using the term “context” depends upon – context. This circularity is often challenging. Consider, for example, Pavlicevic’s (1997) book Music Therapy in Context. In a critical reflection, Horden (2000, p. 36) writes: “a book by a therapist working in South Africa which, despite its title, largely ignores a promising ethnographic context.” Horden focuses on music therapy in historical, social, and cultural contexts, while Pavlicevic (1997) seems to focus on music therapy in various theoretical contexts. Horden’s critique of Pavlicevic’s book is slightly unreasonable then, but hardly irrelevant. In our appraisal, he has a very good point when he argues that historical, social, and cultural contexts should be central to the theory and practice of music therapy. If we relate our professional practices to theories that neglect sociocultural contexts, we are promoting the idea that therapy is a privileged “non-context” for context-free learning (Lave, 1996, p. 27). Pavlicevic’s own writings the past decade have contributed to our understanding of the importance of this (e.g., Pavlicevic, 2010; Pavlicevic & Ansdell, 2004).

As highlighted in the Introduction, Ruud’s writings have been critical in introducing context awareness in music therapy theory. In his most recent book on music therapy and the humanities, he describes a contextual understanding in music therapy in the following way:

How we experience music and how music will affect us will depend on our musical background, the influence of the music we have chosen, and the particular situation in which we experience the music. In other words, in such a contextual understanding, the music, the person, and the situation work together in a relational or mutual relation where changes in any of these components will change the meaning produced. (Ruud, 2010, p. 57)

Ruud suggests that the influence of music often has been understood as unidirectional influence but that it could also be understood in more ecological terms, as evolving reciprocal influences. He also suggests that a contextual understanding points in the latter direction, and that it includes awareness of the immediate situation, our experience of it, our (inter)actions within it, as well as our history of relationships with other situations and experiences. Kenny’s work, not least her introduction of systems theories to music therapy (Kenny, 1985), has been instrumental in the development of this kind of ecological understanding of the field.

According to Ruud, then, a contextual understanding implies an interest in the multidirectional and mutual influences of a music therapy situation. This argument should not mislead us to assume that authors who focus on unidirectional influences of music do not take interest in context. An argument quoted in an American textbook on music therapy illustrates this:

Music is an integral part of most people’s life since it has many cultural and societal uses. Culture and society define music and determine how it is used. It is a basic premise in the field of music therapy that music of cultures other than one’s own has little or no meaning (Gaston, 1968)  and that one will not respond to or participate in it. (Gibbons, 1977,  as quoted in Davis, Gfeller, & Thaut, 1999, p. 296)

Gibbon’s argument illustrates that there is awareness about context – understood as the sociocultural surroundings of music therapy practice – in music therapy literature that hardly could be described as being congruent with a contextual model or contextual understanding, as these terms have been used here. If we combine the insights from the detour to Wampold’s contextual model with the above arguments about context and contextual understanding in music therapy, our appraisal could be summarized in four points: (1) many therapies and health-care practices, including music therapy, have, to a large degree, been influenced by the medical model, even when they are not oriented toward physiochemical processes, (2) the challenges that clients in music therapy experience are related to the interaction of biological, psychological, social, and cultural processes, and several authors have therefore argued that approaches that encompass the ecology of such processes are warranted, (3) such approaches have often – but not always – been linked to notions such as contextual model or contextual understanding, (4) reflections on the significance of historical, social, and cultural context are found in a range of texts in the music therapy literature, and this range cuts across the distinctions outlined above.

In our appraisal, this reveals that Wampold’s idea of a contextual model is helpful as well as potentially confusing. His contribution highlights the relevance of critical reflection on the influence of the medical model in various health-care professions and disciplines. It also highlights the significance of context in therapeutic practice. It does not really clarify the concept of context, however, and the broad range of approaches that are subsumed under the contextual model in Wampold’s writings suggests that it is a collection of more or less related perspectives and practices. We do not think that the confusion could be resolved by definition. Given the complexities and contingencies involved, it is probably not possible to give a single and precise definition of context (or of related notions such as contextual understanding or contextual practice). Clarification of established language use might be of help for future navigation in this complex landscape of theory and practice, however. We have seen that the music therapy literature partly focuses on the surroundings of music therapy practice, partly on the ecology of reciprocal influences within and between situations or systems. We will therefore make a distinction between three types of context awareness that are prominent in the music therapy literature:

Music therapy in context: awareness of the surroundings of music therapy.

Music therapy as context: awareness of the ecology of reciprocal influences within a music therapy situation.

Music therapy as interacting contexts: awareness of the ecology of reciprocal influences between various systems that music therapy is part of and relates to.

Music therapy in context

Context is inescapable in human activities. Obviously, it is possible to pay more or less attention to this fact, but music therapy always happens in a social, cultural, academic, and political context. In this respect, music therapy in context is a basic notion of relevance both for authors focusing on the effect of specific interventions and for authors taking a more ecological perspective. At the very least, all music therapy literature focuses (more or less explicitly) on how change achieved in the context of music therapy transfers to nonmusical contexts, everyday situations, and so on. This is, for instance, clearly articulated in Unkefer and Thaut’s (2005) book which exemplifies music therapy literature based on the medical model. Other music therapy authors go further and discuss more explicitly not only how various contexts are relevant for the client but also how these contexts might influence practice.

Obviously, music therapy may be situated in a range of contexts and communities. For example, music therapy practices in mental health are situated in medical and nonmedical institutions or in community contexts. Any health-care system, in turn, is situated in a larger context of society and culture, of social economy and political systems. These broader social, cultural, and political contexts influence a person’s health and the practice of therapy in complex ways (e.g., as contributing causes for illness and health, provision of health services, social support, stigmatization, and demoralization). Music therapy, as a therapeutic practice and a discipline, is influenced by the current ideas and philosophies about mental health and mental health care, as well as of music. Thus, music therapy unfolds in contexts where the social and cultural ideas of mental health and the politics of mental health care meet the social, cultural, and political contexts of music (Rolvsjord, 2010, p. 18ff).

There are several texts in music therapy that demonstrate the awareness of the institutional and socio-political contexts concerning music therapy practice in mental health care. An early example is Tyson (1981), who developed a concept of psychiatric music therapy that included practices in a range of institutional and community settings. More recently, music therapy in psychiatric services in Denmark is evaluated in a Danish report by Bonde, Hannibal and Pedersen (2012) in terms of institutional contexts and therapeutic/theoretical approaches, and discussed in relation to current Danish health-care politics. A similar evaluation of current trends in music therapy in non-private service settings in the USA is presented by Silverman (2007). Wilson (2005) discussed the changing service strategies in psychiatric services, and the changing politics of psychiatric hospitals. Procter (2004) discusses potentials for music therapy in nonmedical settings, and Baines explores the contexts of user-led services and anti-oppressive practice (Baines, 2003, 2013; Baines & Danko, 2010). Broader philosophical and political contexts of mental health care are also discussed by Rolvsjord (2010) and Solli (2012).

Similarly, many authors have argued that the musical–cultural context is important for the understanding of music therapy. One prominent aspect of this is that it becomes a part of the client’s belief systems related to their thoughts about how music therapy can contribute in their lives. Here Ruud’s (1998) emphasis of code competency and musical identity is the key. Further, the cultural or contextual turn in musicology has created greater awareness and new articulations of the culturally situated meanings of music. This implies also culturally situated values of music and awareness of politics of music. Similar awareness is seen in music therapy: First, the growing interest within the discipline in how music is used in other contexts than music therapy (e.g., Aigen, 2012; Solli, 2008) might be understood as an articulation of this level of context awareness. Second, the musical-cultural context can be related to the goals and aims for music therapy, such as the development of musical skills (Rolvsjord, 2001), improvement of communication and social skills (Gooding, 2011; Grocke, 2009; Hannibal, 2003), or the promotion of enablement and cultural capital (Procter, 2001, 2004, 2011). Third, concerns for music therapy have been articulated in terms of access to music (Aigen, 2005a; Rolvsjord, 2010; Ruud, 1996; Stige & Aarø, 2012).

Clearly, music therapy authors are more or less radical in their treatment of the idea of music therapy in context. In discussing the sociology of mental health and illness, Rogers and Pilgrim (2010) clarify a continuum of possible perspectives that we consider relevant here. On one side of this continuum, social causation approaches essentially accept the medical constructs, such as diagnoses, as facts, but investigate social causes as a supplement to biological causes. Other perspectives, such as critical theory or constructivist sociology problematize the notions of mental disorders and criticize and challenge the mental health-care system more extensively (Rogers & Pilgrim, 2010). Thus, there is no direct relationship between this type of context awareness and levels of critique or interest in ecological perspectives. Any practice of music therapy will ultimately be “in context”. The question is to what degree we perceive contexts as significant to the experience and development of music therapy.

Music therapy as context

While awareness of music therapy in context could be found implicitly or explicitly in a wide range of music therapy texts, including literature informed by the medical model, the notion of music therapy as context is clearly based in assumptions that diverge from this model.

In the music therapy literature, there are several contributions that highlight the interaction in the session as a context for development and change. Kenny’s (1989) theory of music therapy as a field of play is a prime example. In relation to music therapy for children and adolescents with autistic spectrum disorder, Wigram and Gold (2006) have provided an illustrative description of the reciprocal interaction in a music therapy situation:

The development of musical creativity involves a subtle process of learning patterns within musical structures and frames that then spontaneously develop variability in dynamics, tempo, duration and accentuation. For children with significant impairments in their basic innate skills in communication, this musical interaction provides a context and vehicle for reciprocal interaction and development that noticeably ameliorates a lack of sharing and turn-taking in play, as well as repetitive, rigid and somewhat unchanging patterns, and a need for sameness. Active music making promotes interest and motivation to a degree that leads to joint attention and tolerance of shared engagement. (Wigram & Gold, 2006, p. 536)

Rolvsjord (2006b, 2010) critiqued the extensive focus on the therapist’s intervention and the lack of awareness of the client’s contributions in the therapeutic process in music therapy in the field of adult mental health. Outlining a resource-oriented approach, critical to the medical model, she aligns with the common factors approach and the contextual model proposed by Wampold (2001a) that points in the direction of a complexity of personal, relational, and sociocultural factors influencing the process and outcome of psychotherapy.

In the past few years, the idea of therapy as context has also been revitalized by reflections instigated by the demand for evidence-based practice (EBP). The call for EBP is based on medical assumptions and the tradition of studying specific isolated interventions (as explicated in our detour to psychotherapy research). The fit with music therapy practice is not always obvious (Edwards, 2005; Wigram & Gold, 2012). Among music therapy researchers, this has contributed to a renewed awareness about how music therapy is a complex process, with implications for effect studies and randomized controlled trials (RCTs) (Erkkilä et al., 2011; Pedersen, 2013; Rolvsjord, Gold, & Stige, 2005; Talwar et al., 2006). The recent literature often uses the term complex intervention:

Complex interventions depend strongly on context variables such as therapist and setting, and it is therefore difficult to develop reliable evaluation strategies without endangering the intervention to lose its very substance…. (Wigram & Gold, 2006, p. 540)

One strategy has been to develop pragmatic trials in order to ensure enough therapeutic flexibility and to capture the complexities of music therapy processes (Gold et al., 2013; Rolvsjord et al., 2005). However, it could still be argued that the term complex interventions points too much in the direction of the therapist, so that the contextual nature of the process becomes veiled. It is also open for discussion whether RCTs – even in their most pragmatic outline – are capable of addressing the complexities of music therapy as context (DeNora, 2006).

Clearly, this level of awareness is in coherence with the contextual model articulated by Wampold (2001a). However, his notion of the contextual model as an “extension of common factors models and cultural healing” (Wampold, 2007, p. 865) suggests a possible continuum of ideas related to the notion of music therapy as context. This continuum includes contexts outside discrete therapy settings. In short, music therapy as context can link to music therapy in context in ways that request examinations of the relationships involved. Stige (2002) introduced the notion of culture-centered music therapy, which he explained as music therapy as culture, stressing, among other aspects, how music therapy is a situated social–musical process where relationships between contexts are conceived of as reciprocal and potentially constitutive. Obviously, there is need for a conceptualization of how contexts interact. Reflections on the ecological nature of contexts have been prominent in the music therapy literature lately, and this type of context awareness is what we now turn to.

Music therapy as interacting contexts

As we have argued throughout this article, the experiences as well as the outcomes of music therapy are related to broader social, cultural, and political contexts. With this third level of awareness, we point toward music therapy processes where activities are interlinked with and operate in interaction with a broader ecology of contexts, such as the local community of the client and therapist, the institutional context, the musical culture, the health-care politics, and the context of interdisciplinary academic discourse. The awareness of interacting contexts and the engagement with interacting contexts defines this level of awareness.

The possibility of working with relationships between various contexts has been explored quite actively in music therapy the last decades. One theoretical frame frequently referred to has been Bronfenbrenner’s (1979) ecological model (e.g., Elefant, 2010; Stige & Aarø, 2012). In his discussion of ecological areas of music therapy practice, Bruscia (1998) described this kind of context awareness in the following way:

The ecological area of practice includes all applications of music and music therapy where the primary focus is on promoting health within and between various layers of the sociocultural community and/or physical environment. This includes all work which focuses on the family, workplace, community, society, culture, or physical environment, either because the health of the ecological unit itself is at risk and therefore in need of intervention, or because the unit in some way causes or contributes to the health problems of its members. Also included are any efforts to form, build, or sustain communities through music therapy. Thus, this area of practice expands the notion of “client” to include a community, environment, ecological context, or individual whose health problem is ecological in nature. (Bruscia, 1998, p. 229)

The recent discourse about community music therapy might help us disentangle the complexities of interacting contexts in music therapy. With the conceptualization of community music therapy, a contextual practice that goes beyond the individual setting of therapy has been articulated (Ansdell, 2002; Stige, 2002, 2003/2012; Stige & Aarø, 2012). The developments in community music therapy illuminate how changes can be explored on a spectrum ranging from individuals to marginalized groups to the community at large. Community music therapy is described in terms of multiple and interacting systems (Stige et al., 2010). Practices described in terms of community music therapy often involve work with marginalized groups and aim as much toward social change as toward health and development understood in individual terms. Within mental health care, projects have involved possibilities for participation in music where other arenas for music-making have been difficult to access (Ansdell, 2010; Procter, 2004). Music-making is emphasized not only as affording belonging, but also as a possibility to have a voice in the broader social and cultural contexts (Ansdell, 2010; Krüger & Stige, 2013).

Awareness of interacting contexts does not preclude work in individual settings. In individual music therapy, clients and therapists may choose to explore possibilities for musical participation in between sessions, to invite people to sessions, to perform publicly material which has been developed in individual sessions, and so on (Ansdell, 2010; Rolvsjord, 2001, 2010; Stige, 2002, 2011; Turry, 2005).

If we link these examples to the discussion of complex interventions above, it becomes clear that we also need a notion of complex systems. This term makes use of the insights that complexity science affords (Begun, Zimmerman, & Dooley, 2003; Miller, McDaniel, Crabtree, & Stange, 2001). Complex systems usually include and are part of other complex systems (a clinic is composed of individuals and groups, for instance, and is simultaneously part of a broader community). Complex systems are adaptive to changes in their environment and they often change in nonlinear ways. Therefore, change in outcome is not proportional to change in input; systems self-organize, they might change relatively rapidly once a certain threshold level is achieved (Hawe, Shiell, & Riley, 2009). For music therapists working with mental health, this perspective suggests that a music therapy process could be understood as an event not only in the history of the individual but also in the history of the system. There is not only an interest in how music therapy can change people at the individual level, but also an interest in its capacity to change the relationships that link people, places and evolving events (Shiell, Hawe, & Gold, 2008; Stige & Aarø, 2012).

Crowe (2004) has developed a theory of music therapy based on complexity science, but with limited discussion of the sociocultural aspects of music therapy.

Such awareness is demonstrated in the BRIGHT projects described by Ansdell and DeNora (2012), focusing on the interaction between music therapy services in medical context and nonmedical contexts. We want to emphasize that awareness of and engagement with interacting contexts is not only a result of the therapist’s skilled engagement. The client’s active role in linking experiences across contexts must be acknowledged. Rolvsjord (2013) discusses the client’s role in pursuing change across various contexts where music therapy is offered in an individual setting but where the client is the active agent in linking experiences across contexts. Similarly, Veltre and Hadley (2012)  describe the active engagement of a group of young women negotiating identity in relation to representations of gender and race in their music culture and broader social and political contexts.

Implications for research include but go beyond the development of pragmatic RCTs, to include social network analysis, for instance (Shiell et al., 2008). Qualitative research strategies may include ethnographic studies or other qualitative designs that explore cross-contextual experiences (Mackrill, 2007). Awareness of music therapy as interacting contexts also invites examinations of how the field and discourse of music therapy interacts with larger discursive and political fields. In the Norwegian context, Ruud (1996) proposed that music therapy’s emphasis on inclusion in relation to music was stimulated by and in turn influenced various reforms in national politics on culture and music education. In a more recent text, Rolvsjord and Halstead (2013) discuss aspects of performance of gender and identity in relation to how music therapy interacts with popular music culture. Thus, the conceptualization of music therapy as interacting contexts implies increased awareness of our discipline as an agent in the ongoing construction of culture.

Two metaphors informing concepts of context

Having established the suggestion that context awareness in music therapy comes in at least three types, it is urgent to revisit the question of how context can be conceptualized and understood. What we have seen, is that context awareness seems to be present in a range of texts, also in literature which is closer to the medical model. Yet – and not surprisingly – there seems to be a broader range of context awareness in the literature that subscribes to cultural, contextual, and ecological perspectives. Across the proposed divide between medical model practice and more contextual practice, authors use the term context. The same term obviously is used for more than one concept, then.

Stige (2002) offers a distinction between context as concentric circles and context as dynamic links, through reference to a cultural psychology text:

A starting point for this discussion could be to reconsider our concept of context. As Cole (1996) has demonstrated, it is too limited to consider context as “that which surrounds.” True, musicking and other human activities always have an immediate context surrounding the actions themselves, and this context is surrounded by other context. We may, then, conceive of contexts as “concentric circles” surrounding acts and agents. Cole (1996) also underlines, though, that another concept of context sometimes is illuminating: context as “that which connects.” Agents do not restrict themselves to the immediate surroundings when they link events and experiences to other events and experiences. This process of linking constitutes a high degree of flexibility in meaning-making. (Stige, 2002, p. 96)

The notion of context as “that which surrounds” suggests that activities are colored by context, while the notion of “that which connects” implies that contexts and activities arise together, in mutually constitutive processes. The first notion suggests that context is understood as a pre-existing frame with a determinative effect on an activity, while the latter suggests that context is understood as evolving relationships constructed by the parties interacting. In the latter case, context is constitutive of the activity and vice versa (Levine, 1996),

In an attempt of summarizing these discussions, we therefore suggest that it is meaningful to distinguish between context as (given) frame and context as (dynamic) link. These two metaphors are offered as broad sensitizing notions that point in certain directions of theory development and research. They are not offered as exact theoretical categories. The first notion points at contexts as (relatively) stable surroundings that impact music therapy practice but exist independently of it. The second notion points at contexts as dynamic relationships that constitute and are constituted by music therapy practice. Understood as frames, contexts might restrict as well as augment possibilities of activity, where the impact can be ignored or employed. If we take the idea of constitutive contexts seriously, we are invited to review our interpretations of the dynamics of a music therapeutic interaction more substantially and embrace an ecological systems perspective.

We do not think of concepts as static and theory-forming, but as dynamic and theory-formed; their meanings evolve through use in theoretical structures and arguments (see, e.g., Risjord, 2010).

Concluding discussion

In this article, we have identified three types of context awareness in music therapy: music therapy in context; music therapy as context; and music therapy as interacting contexts. The fact that it was possible to identify these in the literature could be taken to indicate that context awareness is relevant in all music therapy practices, not only in those subscribing to contextual theory perspectives. Authors who conceptualize practice in terms of specific interventions are sometimes criticized for thinking of therapy as a privileged “non-context” for context-free individual change (Ansdell, 2002; Stige, 2002). Our reading of the literature shows that awareness of context is not necessarily absent, but usually limited to what we have called music therapy in context. Authors who conceptualize practice in terms of complex interventions usually develop perspectives that are compatible with the notion of music therapy as context. Finally, authors who conceptualize practice in terms of complex systems focus on music therapy as interacting contexts.

Based on the discussion in the previous section, we may ask if the identified types of context awareness that we observe in music therapy are representations of substantially differing notions of context. We propose that if the awareness is restricted to that of music therapy in context, the notion tends to resemble that of context as frame. In contrast, awareness of music therapy as context and/or as interacting contexts tends to implicate a notion of context as link. This makes sense in terms of the various degrees of involvement with context (both in practice and theory) that is characteristic of our distinctions. The notion of context as frame requires context awareness but a low level of interaction with context is characteristic. The two latter levels of awareness imply higher degrees of active involvement with contexts, which makes more sense if contexts are conceived in terms of constitutive relationships. However, as we have tried to explicate, there seems to be considerable variation concerning the levels of interaction with context involved in each type of awareness.

We started this article with a detour to the debates on medical and contextual models in psychotherapy. Throughout this article, we have referred to the idea of a medical model versus a contextual model. We pointed out that awareness of music therapy in context does not necessarily involve critique of the medical model, while the two latter levels of awareness would be more in coherence with a contextual model. We also pointed out that the contextual model, as described by Wampold (2001a), is somewhat vague when it comes to how broader sociocultural contexts are emphasized. To our understanding, a contextual model does not exclude therapy in individual settings but it demands that we move beyond the “treatment” of individuals and include relational, structural, and community levels in our conceptualizations of therapy.

It is important to emphasize, then, that the conceptual and theoretical differences that have been highlighted here do not translate directly to decisions about formats of practice. While music therapy practices integrated in various activities and events of a local community obviously could be supported by a notion of context as link, this could also be the case for practices based in individual sessions. The literature includes many examples of such practices where client and therapist together have been able to establish a range of dynamic links to broader contexts and communities. Format is a choice to be made relative to person and place. With the actual practice of music therapy, there is a continuum of engagement and interaction across contexts. There are good reasons to continue to develop practices in music therapy along a spectrum ranging from individual settings in medical contexts to open projects in a community. Several of the authors discussed in this article support this view and we find it relevant and interesting to notice that similar arguments have been developed within community psychology (Prilleltelsky & Prilleltelsky, 2006).

Our conclusion is therefore not that music therapy practices should be more open across contexts, but that there is a need for research and theory development that can inform music therapists when they encounter practical situations where such choices have to be made. Especially, there seems to be a need for theory development of music therapy both as a complex intervention and as an event within complex systems. Clearly, a critical stance will be needed regarding the socioeconomic and political conditions and implications of music therapy practices, whether they unfold in discrete clinical settings or in open communities (Edwards, 2011). Our awareness of context is crucial to the stories we tell about therapy (Ansdell, 2003); how we perceive the people we work with, how we understand health and illness, how we conceptualize therapy and change, and how we design our research. We have explored these issues in relation to the literature on music therapy and mental health. Broader explorations of implications for music therapy as discipline and profession are warranted.