Art therapy is also sometimes known as art psychotherapy and this dual title reflects some of the perceived differences, and at times lively debates, within this profession.

Art therapists, as other psychotherapists, owe a debt to Freud and Jung and their successors. However, their initial inspiration was the art form and therefore the route to clinical practice has been rather different than the traditional psychoanalytic path. This influences the theoretical base of the practice.

In Britain the first art therapists were artists who became interested in working in psychiatric hospitals, at first as volunteers. In the 1950s art therapists worked in studios in the large psychiatric hospitals that provided inpatient treatment for a variety of psychiatric disorders. These artists knew that art was a significant factor in healing for some of their patients. They were untrained in psychiatry and psychotherapy and there was little theory to confirm their intuition and so they deferred to the knowledge and experience of the medical practitioners. Much creative collaboration took place in this way, for example, between the artist and art therapist Adamson (1984) and the psychiatrist Cunningham-Dax (1953). The art therapist created an attentive presence and a studio environment for patients to make art but they did not interpret the pictures (Lyddiatt, 1971; Thomson, 1989). If the medical director or the resident psychiatrist took an interest, the patients would take their pictures to him for interpretation.

It was similar with Champernowne (1969, 1971), a Jungian analyst, who founded a therapeutic community for the arts called Withymead (see Stevens, 1986) in the west of England. Here many British art therapists, including Nowell Hall (1987) and Edwards (1989), began their lifelong professional interest in art therapy. Champernowne too considered that the art therapist would elicit material but, she as the psychotherapist, attended to its significance within the treatment. This hierarchical division of roles fostered a split between the facilitation of the art process and an analysis of its meaning.

In the USA the history was a little different in that the more significant influence in the early days of the profession was Freud. Naumberg (1953) was a pioneer, working and writing in the 1950s to bring together art and psychotherapy. She discussed the transference and the therapeutic relationship, which in Britain at that time received little attention. Kramer (1958, 1971) also in the USA was more inclined to the former position and has probably stayed closer to the art process for the many years that she has continued her dual practice as an artist and art therapist. Rubin discusses the importance of these and other early figures in the USA (Rubin, 2001).

Since those early days a great deal has changed in the training, professionalism, and therefore the international recognition of art therapy as a mode of treatment. However, the legacy of this history is to be found in the creative theoretical debates that continue within the profession today. The question of where the healing in art therapy lies is often a factor. An artificially polarized characterization of the debates might represent three different categories of art therapy, in which the artwork and the therapeutic relationship take different positions. Elsewhere (Schaverien, 1994, 2000) I have differentiated these by according them the titles of art therapy, art psychotherapy, and analytical art psychotherapy. This artificial division is intended to draw out some of the differences in the practice. The same art therapist might offer all of these forms of art therapy at some time. I propose imagining each of the three categories to be a picture made up of a figure–ground relationship.

• Art therapy. In art therapy the picture and its creation is the foreground of the therapeutic process. The therapeutic relationship would be the background from which the art process emerges. The art therapist is a facilitator and witness but does not usually interpret the artwork.

• Art psychotherapy. In art psychotherapy the therapeutic relationship is the foreground and the picture the background. The pictures illustrate the therapeutic relationship or recount some aspect of the history in visual form. They may even record the transference but are essentially the backdrop for the person-to-person transference and countertransference relationship. Here the picture may sometimes be used as an illustration of the state of the artist but attention to the therapeutic relationship may reduce its power.

• Analytical art psychotherapy. In analytical art psychotherapy the two are interchangeable. The pictures interrelate with the person-to-person transference and countertransference dynamic but neither figure nor ground has priority; they are of equal status, creating an alternating focus, which integrates the picture fully within the transference.

The hypothetical practitioner of art therapy might consider the art to be healing in itself and therefore the art therapist is the ‘midwife’, providing the right conditions for this to take place. This practitioner might provide a combination of art materials, space, and quiet attention so that a natural healing process will be facilitated. Little interpretation or intervention is needed from the art therapist. Such an approach has been written about in an original way by Simon (1992, 1997). There is little doubt that this process has worked admirably for many of the more disturbed inpatient populations of large psychiatric hospitals over many years (see Skailes, 1997; Wood, 1997; Maclagan, 1997). Criticisms might be:

• that respect for autonomy of the image, which this approach fosters, may result in the artworks being overidealized, or

• that when the content of the artwork is overwhelming to the artist it needs to be discussed (its implications need to be mediated verbally in order for its archetypal power to be depotentiated).

To continue this artificial separation of the theoretical positions I turn to the practitioner of art psychotherapy. This person might consider mediation of the dual facets of the therapeutic relationship—the transference and the artwork—through the spoken word to be essential. The criticism of this approach might be that too much emphasis on the therapeutic relationship reduces the image to a mere description of psychological states. Consequently, the artwork is reduced rather than given its full power of expression.

There is agreement between art therapists, from whatever theoretical position, that the process of making art is healing. It is the means of its mediation that is sometimes questioned. In the first case the archetypal power of the image may be overwhelming and in the second it may be reduced. The analytical art psychotherapist might aim to take account of both through attention to the transference–countertransference dynamic. This is because the integration of the material that is evoked within the artwork needs to take place. Interpretation of the pictures as well as analysis of the artist's relation to them is vital if experience is to be mediated to the point at which the unconscious becomes conscious. This approach is not without its critics and timing is crucial; if the image is interpreted too soon—before it has had time and space to work its nonverbal healing—the patient may experience this is an intrusion. Therefore the process needs to be addressed according to the needs and ability of each patient.

The questions that exercise art therapists could be summarized as those regarding whether the healing lies in the art alone or whether it occurs when art is mediated within a therapeutic relationship. Similar creative debates are to be found in the literature of the other arts therapies.

The cultural context is considered to be important and, in therapeutic practice, attention is given to the inner world, the intrapersonal experience, and outer world, the sociocultural context in which the therapy takes place. In the state sector in Britain art therapists work in all kinds of settings in the National Health Service (NHS), in community mental health teams, psychiatric and general hospitals, social services, psychotherapy departments, prisons, palliative care, and child and family departments. They also work in private clinics and in private practice but this is less common than the state sector.

In the USA and in Europe the client groups and treatment principles are similar but the training and licensing requirements are different. For example, in some countries it is more common for the art therapist to work in private practice. In order to be licensed to practice there is a requirement of a recognized qualification as a psychologist or psychotherapist as well as an art therapy qualification. What is common is that art therapists throughout the world work with similar patient populations and client groups. They employ a range of behavioral and psychodynamic approaches depending on the interest of the individual practitioner and the needs of the client group (see Rubin, 1987 for the diversity of approaches to art therapy). Art therapists work with individuals, adults and children, and with patient groups, institutional groups, and families.

The integration of art materials within a consulting room involves thought about the layout of the room and the messages conveyed by their presence. Most art therapists work in a room that can accommodate a certain amount of mess. There is usually a wide selection of art materials available as well as a table and chairs. A sink is a useful asset in the art room so is a large selection of different sizes of paper, clay, and sometimes a potter's wheel and kiln. Storage is an important consideration as it is usual for the art therapist to keep the artwork for the patient or art therapy group in a folder, or folders, between sessions. Therefore a plans chest or set of storage shelves gives an important nonverbal message about the ways in which the artworks are valued. It is clear that, as a form of psychotherapy, art therapy makes a different impression on the prospective client from the moment they enter the room.

The assessment for art therapy will include an interview and then possibly several sessions of art therapy to see if making art becomes meaningful for the person. Thus the response to the expectation of engaging with art materials will be significant.

Art therapy may be particularly relevant for those whose condition is not immediately amenable to verbal expression, for those who cannot speak their pain. Art offers a medium for symbolic expression in states that cannot be symbolized in any other way. However, it is significant that not all art is symbolic. Therefore in assessment attention will be given to the way the person relates to the art as well as to the therapist. Understanding of the difference between sign and symbol is important in order to observe this. Art therapists often work successfully with patients suffering from psychotic illnesses and eating disorders. In each of these disorders the problem centers on a concrete form of relating and the lack of ability to symbolize. Through the unconscious use of the art materials and images produced in art therapy a relationship is built where the ability to symbolize may develop (Killick and Schaverien, 1997).

In order to give a sense of the processes involved, here is a brief case vignette from private practice. Ms A, a single woman in her early forties, was referred for art therapy by her general medical practitioner. She had no previous history of psychiatric problems and had a successful professional life. However, since her mother died a few months earlier she had been suffering from anxiety and depression. Ms A explained that, as the eldest of three girls and the only unmarried daughter, she and her mother had always had a close relationship. She was therefore shocked after her mother's death when something in her snapped. A family friend had remarked that Ms A was lucky because she had had a happy childhood and she was shocked to find herself denying it. Subsequently she became overwhelmed as memories of her mother's physically abusive behavior flooded her conscious mind. She tried to tell her sisters but they did not appear to remember the incidents in question or to believe her. Thus Ms A began to doubt the validity of her own memories and yet the impact was such that she knew them to be true.

For the first sessions she seemed almost unaware of my presence and ignored the art materials as she recounted a number of painful memories. She kept repeating them; as if trying to establish the validity of these recollections. In the fourth session, indicating the art materials, I suggested that she might find it helpful to put the incidents down on paper so that she could show me what had happened. At first she tentatively drew the scene she wanted to describe using diagrammatic figures to demonstrate. She explained the layout of the room and the relative positions of her mother and herself. As she spoke my role was that of facilitator and witness of her account.

The content of the pictures, in this case, is less important than their long-term effects. At last there was someone to whom she could report the incidents of injustice that she was remembering. On one occasion there were three figures in the picture. The third was not discussed and it was drawn in a rather tentative manner. As this figure was not mentioned in Ms A's account of what the picture revealed I pointed it out to her and asked her what that figure was doing. It was as if it was the first time Ms A had noticed that figure, although she had drawn it. She stopped and then after a shocked silence she told me that she now remembered that her father had witnessed the abuse without intervening. Therefore, although it was the mother who was beating the child the father was complicit. This was the first awareness of his involvement and it was the picture that brought it to the fore.

Gradually over the weeks these incidents multiplied and so the pictures. Each week I would keep the picture for her in a folder in the art room. Over the 2 years of this therapy she would return to her pictures often and compare them. She would notice things about them that had previously been unnoticed. Very gradually they did not have the same power for her as before. She could look at them without the overwhelming affect that had accompanied the remembering of the incidents.

Ms A could have told me of the memories of these incidents. In fact to begin with she did; however, it was important for her to be able to externalize them. Once they were on paper they were outside of her. In this way she could stand back from her own experience and witness it herself. She was able to see and come to terms with them. I propose that it was in the making and the viewing of these rather rudimentary pictures that a process of transformation in her psychological state came about.

There is an increasing research-based literature on art therapy emerging in both the UK and the USA. In the USA diagnostic assessments and psychological profiling through pictures generated for the purpose are more common than in Britain. This indicates a difference in the present developments and research bases in the two countries. The interested reader is referred to Art Therapy: the Journal of the American Art Therapy Association, The Arts in Psychotherapy, and Inscape for up to date research.

During the last 15 years, a consistent body of art therapy literature in Britain has developed, starting with Art as therapy (Dalley, 1984) and Images of art therapy (Dalley et al., 1987). In 1997 the profession of art therapy achieved State Registration in the UK. This was the result of long and persistent negotiations within the NHS by members of the council of the British Association of Art Therapists. Waller (1991) has documented the history of this up to 1982, when art therapy first became a recognized profession within the NHS. Wood (1997) has traced the history with specific reference to patients with a history of psychosis and this has been developed in her, as yet unpublished, research (Wood, 2000), which documents the process of art therapy with patients with a history of psychosis.

A critical approach to the processes involved has developed and it is no longer enough to claim, for example, merely that art is healing in itself. Such statements need to be backed up by critical argument and clinical research. The existing research means that such claims are beginning to be substantiated with clinical data and theoretical discourse (Gilroy, 1992; Gilroy and Lee, 1995; Gilroy and McNeilly, 2000). Case and Dalley (1990, 1992) describe art therapy with children, informed by psychoanalytic theories. Maclagan's interest ‘outsider art’ as well as art therapy is developed in a number of papers including Maclagan (1989, 1997). I have explored the particular effects of the concrete nature of the pictures in the transference and countertransference relationship. My research is informed by Jungian theory and in particular The psychology of the transference (Jung, 1946), psychoanalytic theories and the philosopher Cassirer (1955a,b, 1957; Schaverien, 1991). Further, in Desire and the female therapist (Schaverien, 1995) the ‘aesthetic countertransference’ is explored in relation to the gaze of the artist and the return gaze of the picture.

In the USA the founders, Naumberg whose approach was psychoanalytic, Kramer whose approach is very centered on the art in art therapy, and Rhyne whose Gestalt art experience influenced many. The next generation includes Rubin (1987) whose book Approaches to art therapy was influential and McNiff (1994). Then there is a flurry of activity in the present including Malchiodi and Hyland Moon. However, most art therapists draw on the particular theories that seem to apply to their own client group or experience of art in therapy.

It might be assumed that those who are ‘good at art’ or who have attended a fine art program would be the most suitable candidates for art therapy. However, this is not always the case as such a person might be too skilled at concealing to benefit from the process. It is partly the unexpected nature of what is produced that makes art therapy so effective and lack of skill or previous ability contribute to this. When there is a need for the unconscious material to press to the fore through visual expression previously unskilled people may find themselves surprisingly visually articulate. It is as if, when the unconscious needs to express itself, the ability is there.

It has sometimes been thought that art therapy should be restricted and not applied with patients in psychotic states. However, this has been widely challenged by research in art therapy where it has become clear that this client group, if appropriately understood and monitored, benefits from the experience of nonverbal expression in a contained setting. A number of art therapists have written in detail about this (see Killick, 1991; Killick and Greenwood, 1995; Killick and Schaverien, 1997; Wood, 2000).

Art therapy has come a long way since its beginnings in hospitals and it now operates from an increasingly strong theoretical research base. We look forward to publications such as that planned by Andrea Gilroy (2004 forthcoming) whose book with regard to art therapy that is evidence based will be a welcome addition to the field.

Music therapists are most commonly employed in special needs education services, or in health service settings, as part of psychological treatment services or therapy services in which increasingly arts therapies departments are established particularly in Mental Health and Learning Disability NHS Trusts. Increasingly in line with NHS modernization, music therapists work in community-based teams, as part of community mental health or learning disability teams or within Primary Care Trust. Referral is usually by doctors, nurses, psychologists, occupational therapists, and psychotherapists. As arts therapists are allied health professionals, there should usually be an Resident Medical Officer for any case. Some music therapists work privately or are funded by the Charity sector such as the National Autistic Society, Alzheimer's Disease Society, Music Space, and Nordoff-Robbins. International patterns of employment and the levels of established music therapy vary from country to country, and few countries have State Registered Music Therapists. In the UK all professional training is at postgraduate level. In some countries in Europe there is no agreement about what constitutes basic training for a music therapist. In the USA most music therapy training is at undergraduate level with some at postgraduate level. A variety of theoretical approaches, is found and some from behavioral schools particularly in the USA. In some European countries such as Belgium and Denmark training is established within a strong psychoanalytic framework. This variety means that it is difficult to give a true international view. However, where possible this is given and as music therapy is more established in the UK than in most countries, the perspective here focuses upon UK practice.

In music therapy, patients are offered the opportunity make live music, either improvised or precomposed, on instruments and with voice, with the music therapist who is a trained musician and music therapist. Music therapy can also involve listening to taped or pre-composed music with therapeutic intent.

No musical ability is required by the patients, although cases showing the benefits of treatment range from those who are accomplished musicians to those who have no previously acquired musical skills. The patient's expression through music and the therapist's attunement, through their training as a musician and therapist, facilitates the development of other therapeutic processes.

Musical improvisation is often the focus of the therapy, particularly in the UK, where the underlying rationale is that active music making reflects the patient's current state. This in turn can lead to an understanding of internal and external, interpersonal and intrapersonal changes, which may be desirable. A variety of instruments is used including tuned and untuned percussion, piano, and single line instruments. In other countries, particularly the USA there is a predominance of receptive techniques where listening to music, such as in Guided Imagery in Music (GIM) is the focus of the therapeutic process (Bonny, 1978). However, the method of live musical improvisation or community-based performance (Pavlicevic and Ansdell, 2004) with therapeutic intent, is most predominant in Europe.

In this method, owing to the time element and rhythmic dimensions of music, an immediate intense experience of the ‘here-and-now’ is provided by music therapy. Interactions can be ‘played out’ within improvisations, and it is fundamental to this way of working that the therapist responds to this. It is also important to recognize when music-making might be encouraging defenses, such as when a patient becomes fixed upon musical structures, for example steady repetitive duple-time phrases, instead of expressing feelings of distress and chaos in a more irregular rhythmic pattern.

The role of the music therapist is crucial in facilitating the patient's expression, particularly when the latter seems stuck or tentative. This is sometimes understood in symbolic terms as a parental role. For example, in some cases, harmonic input from the piano can inhibit patients from being able to work through their own problems. However, there are times when the opposite is true and the basis for someone exploring a problem is that a musical dialog with a supportive role taken by the therapist is necessary. Here, considerations of transference and countertransference are essential.

During the last 20 years, music therapists have become more concerned with finding a theoretical framework in order to understand therapeutic processes in more depth, but also in order to relate to other disciplines such as neurology, psychiatry, medicine, psychology, psychoanalysis, and musicology.

Music therapists have particularly contributed to an understanding of early interaction, and ideas from music therapy might be particularly useful to the psychoanalyst or psychotherapist working with regressed or less verbal patients. The music therapist, similarly to a mother in early mother–baby interactions can respond to the tiniest nuances to show listening, understanding, and meaning, without words.

As Davies and Richards (2002) write in their book about analytically informed group music therapy:

Stern (1985) uses musical metaphor to describe processes that have always been in the music therapists’ vocabulary such as ‘affect attunement’ and therefore already we see that much can be gained by paying attention to the forms of interaction music offers.

In the same book Davies and Richards (2000) also draw attention to inventiveness, another prelinguistic phenomenon often lost in adulthood, and of the directness that music encompasses along with its capacity for embracing of emotional complexity and contrast. They draw attention to a discussion about music by Langer (1942) where she celebrates the ambivalence of music, and as a result, its capacity to be true to life because music cannot be directly translated into words.

The uniqueness of music therapy is often marked by its emphasis and focus on live improvised music. In order to enhance the understanding of the relationship between therapist and patient within this complex dynamic, music therapists have drawn upon psychoanalytic theory, particularly concepts of transference, countertransference, object relations, and attachment theory during the last two decades. In Odell-Miller (2001), this influence is addressed, and literature referring to the debate between music therapists regarding this subject is summarized. More recently (Odell-Miller, 2003), music therapists have also begun to address what it is about music therapy process that could influence psychoanalysis. This topic is discussed here in the light of music therapy, but the arguments might well apply to other arts therapies, as highlighted in the book Where analysis meets the arts (Searle and Streng, 2001).

It is useful here to describe the universal element that links music therapy with psychoanalytic thinking. Each discipline is concerned with encouraging the spontaneous expression of the person: in music therapy this takes the form of musical improvisation while in psychoanalysis this takes the form of free association.

In considering the history of music therapy it will be seen that while the origin of musical improvisation as a focus for the music therapy relationship owes much to this particular art form, the actual function of music therapy has developed in two directions. The first has gradually incorporated the psychoanalytic concepts of transference, countertransference, and projective identification into the music therapist's therapeutic vocabulary as a means to try and understand the musical relationship between the patient and the therapist. The second has tried to maintain an entirely musical understanding of the relationship between therapist and patient (Ansdell, 1995). Without describing in detail where the specific differences between these approaches lie it might be suggested that in the first approach music therapy could be in danger of becoming a mere adjunct to psychoanalysis, while in the second approach the value of the therapy might be too dependent on musical analysis, without looking at a wider clinical picture.

Priestley (1994), a British music therapist was the first to articulate some of the connections between psychoanalysis and music therapy in the early 1970s, and interestingly at that time her ideas were taken up in Germany rather in Britain. I suggest that this is because music therapy in Britain was founded by musicians, and upon musical and developmental theories as mentioned above, and that therapists were not ready for this viewpoint. One example of Priestley's use of music as an extension to psychoanalytic theory is found in her ideas about musical structure, and its function as taking the place of a superego function when working with repressed emotion. This has been taken up by others such as Nygaard-Pederson (2002) in Eschen (2002).

Relating through music is a different experience than that of words, and the structure of music including rhythm, pitch, duration, and timbre, and its emotional and interactive nature offers something unique particularly for those who find words difficult. However, despite this unique quality, music therapy has sometimes been thought of as a form of modified psychotherapy, which uses a mode of nonverbal communication to facilitate the relationship and rapport between patient and therapist, but in this way of thinking there is a danger that the music is seen as an adjunct, thus missing the very essence of its therapeutic value. Existing literature also reflects more of a ‘middle ground’ using the term psychoanalytically informed approach where the detail of how music therapists integrate psychoanalytic theory into the practice of music therapy in varying ways is explored. Examples are numerous, but there has been debate about the balance of music and psychoanalytic thinking, and the danger of the loss of music if psychoanalytic theory ‘takes over’. There is also debate about the richness and clinical rigor that psychoanalytic thinking can bring to the music therapy relationship, and whether it is possible to define musical transference and countertransference. Some examples of texts that together summarize the development of how music therapy draws upon psychoanalytic theory are given here (Woodcock, 1987; Towse, 1991; John, 1992; Priestley, 1994; Brown, 1999; Streeter, 2000; Odell-Miller, 2001; Davies and Richards, 2002).

To conclude this section, we might wonder what music therapy might have to offer psychoanalysis, as we know Freud, while rather puzzled by music as discussed in Odell-Miller (2001), derived his early theories from practicing hypnosis. Here the patient loses him or herself in terms of becoming out of touch with conscious processes through hypnosis. Musicians might play a whole piece of music as if in a trance, where there is little conscious recollection of the experience of having played a piece of music. This points towards the fact that musical interaction might have something to offer in the realm of dreams and repressed emotion and memory as a way of speeding up or ‘unsticking’ the verbal and thinking processes.

A recent text (Wigram et al., 2002) comprehensively summarizes research in the field from an international perspective, and current models and frameworks of practice. It is clear from this that there is a growing trend for music therapists to take a more psychotherapeutic approach in all clinical fields, although in the USA developmental and behavioral approaches are still more prominent. The clinical fields where music therapy is seen to be most beneficial are learning disabilities (particularly adults and children on the autistic spectrum), psychiatry (particularly schizophrenia and dementia), and new areas are those of palliative care, including bereavement and personality disorders. In the field of autism music therapists have worked with the theoretical and clinical ideas of Ann Alvarez. Music therapy, and other arts therapies could therefore be seen to challenge psychoanalytic orthodoxy, while also developing through its influence. Rather than viewing music therapy and other arts therapies, with their emphasis on action through art forms, as a form of acting out or intrusion within the psychoanalytic arena, these therapies can have a positive influence in this arena. Particularly where there are nonverbal or regressed states encountered, a musical or nonverbal relationship might enhance and perhaps challenge some established aspects of psychoanalysis as suggested by Alvarez (2002).

Music therapy is an effective treatment for people with communication disorders or difficulties. This might relate to their diagnosis but also to their current state, perhaps of not having easy access to words and therefore a less verbal approach is indicated.

In all fields careful consideration is given as to the appropriateness of different methods and approaches, and with those who are psychotic or who have dementia a more directive, structured, and less ‘psychoanalytic’ approach may be necessary. A useful textbook with clear guidance from around the world is found in Improvisational models of music therapy (Bruscia, 1987). Similarly, in a more recent book The dynamics of music psychotherapy (Bruscia, 1999) an international perspective is given illustrated by case studies about the particular approaches used in a psychodynamic framework by music therapists around the world, with examples showing a range of techniques ranging from song-writing, song and instrumental improvisation, and receptive techniques. From this it is clear that cultural and historical considerations vary enormously and there are no absolute models or protocols that are always practiced with a certain patient group, although researchers are constantly trying to articulate approaches and outcomes more clearly.

Emerging clinical evidence and research findings suggest that music therapy might be as effective as other treatments, particularly in some fields such as dementia and autism (Wigram et al., 2002), so there is much to be gained from multidisciplinary exchange.

Many patients seeking therapy have been deprived of relationships, and musical interaction can often give the direct experience of recognizing and showing that this deprivation has been heard, processed, and given meaning. This can happen in a way that words might not be able to address owing to their inherent lack of ‘affect’ in some cases, or total absence, in others.

The growing body of research and evidence base in the arts therapies is in the form of both qualitative and quantitative research projects. The ongoing evidence base is reflected in the professional journals and books published and also in conference proceedings worldwide. In the UK, for example The Royal College of Psychiatrists has included arts therapies research presentations in recent conferences and there are also arts therapies research centers beginning on a small scale, but growing at universities such as Goldsmiths College, University of London, Hertfordshire University, Sheffield University, and Anglia Polytechnic University, Cambridge.

The Department of Health publication in the UK Treatment choice in psychological therapies and counselling (2001) mentions arts therapies as additional treatments for people needing psychological treatments, alongside therapies such as psychotherapy, cognitive-behavior therapy, and cognitive analytic therapy. Although the evidence base is too large to summarize here, important key documents are listed and a few projects can be mentioned. For example in a recent HEFCE report Promoting research in nursing and allied health professions, arts therapies evidence in the field of autism and dementia is mentioned (Odell-Miller, 1995; Wigram, 2000). Specific outcomes are that music therapy increases levels of engagement significantly in a long stay ward for older people with mainly diagnoses of dementia. Furthermore in a controlled study, music therapy shows higher mean levels of engagement in the same population than in reminiscence therapy treatment, although the results were not statistically significant. The study also showed that music therapy treatment applied weekly shows general increased levels of engagement in this population than when music therapy is applied randomly (Odell-Miller, 1995).

There is a wealth of literature in a variety of fields forming an evidence base now including palliative care, learning difficulties and the autistic spectrum, trauma, forensic psychiatry, eating disorders, adult mental health, dementia, and other areas.

Wilkinson et al. (1998) show that regular drama and dance therapy sessions in a controlled study can reduce levels of depression in a small sample size group study. Wigram (2000) sites several studies that show how music therapy increases levels of communication for people with autism, and Odell-Miller (2002a), while finding that a randomized controlled trial did not show significant results (for many practical and methodological reasons), show in a qualitative analysis, that the specific relationship and rapport with the arts therapist and the arts media are central to the patient's perception of how arts therapies work in the field of adult mental health.

To illustrate the music therapy clinical process, this case pays particular attention to the psychotherapeutic aspects of the process. The case vignette is of a 35-year-old man with manic depression, who was seen individually for music therapy over a period of 4 years. The case is written up in detail in the book Where psychoanalysis meets the arts (Searle and Streng, 2001). Early sessions consisted of music, which seemed symbiotic in nature, where the music therapist seemed drawn into the countertransference as a nurturing maternal figure. One example of change taking place literally musically, but helped by an understanding of the countertransference is as follows. In session 9 the patient reveals a very destructive aspect of himself, expressing loud violent-sounding cymbal playing for 4 minutes. During this, the therapist plays the drum, trying to provide some rhythmic structure and stability, while at the same time supporting him in his need to express himself and release tension. This was a turning point in the therapy—as the therapist provided rhythmic language through improvised drum beats in order to help the client find order within chaos, at the same time as validating his emotional state by showing this in her playing, reflecting the powerful ‘affect’ in the room. If taped, examples of intense cymbal playing, sounding loud and uncontrolled could be heard. The therapist gradually used more regular drum beating and also some irregular in order to support the patient in this form of expression. There is also a ‘rallentando’ at the end, precipitated by a gradual subtle slowing down of the therapist's drum beats in order to encourage the music to end, as a boundary was necessary. The qualities of music that enable ‘real’ time to be experienced through musical interaction are vital here. The patient had been using the cymbal in this way for 4 minutes. It was important for the destructive side of his life to be expressed with the therapist in the session in order to help him in the therapy, and for the therapist to survive this and to return the following week. At this point verbal interpretation was not appropriate, but in the following weeks the experience provided the material for the possibility of helpful interpretation as described in the full case discussion in Odell-Miller (2001). It is difficult to see how this crucial experience of playing the cymbal, or something like it, could have taken place without the musical context, unless some destruction to objects or people had taken place.

The second musical example, of an interaction from the last few months of his therapy, shows a supportive role taken by the therapist from the piano, using predictable harmonic progressions to follow support and interact with the patients playing on a metallophone. There is a sense of integration here, and acknowledgment of an interaction—a consideration by the patient of this relationship both musically and socially. At the start of therapy he had no way of showing consideration for others, was suicidal and depressed, had been violent towards his ex-wife, was estranged from his three sons, and he found it difficult to relate to the therapist. Sessions moved between music and words, re-creating some patterns of relating (which seemed to represent early relationships), which were very significant due to the fact that his mother suffered from schizophrenia and had been unable to look after him. He became able to respond to the therapist's music and there was a sense of two people able to ‘give and take’: neither merged nor ‘cut off’. This musical experience led to further understanding of his feelings and behaviors, and provided the basis for interpretation and understanding. For example, a lullaby quality of many early sessions was prevalent. While the patient's music was often still somewhat rigid, by the end of the therapy, there were points of fluidity. After 4 years of individual weekly music therapy he managed to stop his destructive violent behavior in relationships, and said he was helped by the improvisations. We see here the importance of the active relationship with the therapist, while maintaining the therapeutic boundaries of the sessions. The understanding of the patient's life events was possible with improvisation being a vehicle for expression and integration of previously unintegrated states. The therapy took place in a day clinic and is described in detail in Odell-Miller (2001).

We see from this case that improvisation is a creative act, difficult to describe in words, and its inclusion is central to music therapy technique. When people are ill, physically or mentally, they often atrophy—they feel unconnected within themselves and with their surroundings. This is supported by research findings, which found that people with learning disabilities, schizophrenia, autism, and other related disabilities lacked synchronicity within themselves, and in relation to interactions with others, in comparison with nonpathological populations. The possibilities for re-creating synchronicity are particularly potent within musical improvisation, and it can also offer something essential to the relationship between patient and therapist, where there is less radical impairment, but where words and thinking are temporarily unavailable. Many psychotherapists are increasingly interested in this interactive area as being essential to the therapeutic process, for example as shown in the Interpersonal Theories of the Conversational Model.

Improvisation allows for the patient to become spontaneously involved in an interaction that can take on its own shape and form with the therapist's input guiding this. It can take on a dream-like quality. Patients are often surprised at the manner or mood of their expressions, pointing towards a similar process to the unconscious, at work. Articulating this in words has always been a problem for music therapists and while psychoanalytic theory has supplied some mechanisms for doing this, the very nature of what the following definition of musical countertransference is describing, indicates in itself what music therapy might offer to psychoanalysis. It lies at the heart of what musical interactions can articulate in terms of atmosphere, and implication: those things that cannot be easily spoken.

It seems clear that people for whom music therapy rather than another treatment is helpful, are likely to be those who find independent listening and thinking difficult and need a transitional space (the therapy session), and some assistance in which to do this (the music therapist). For example, a live musical interaction through improvisation is like an active communication that requires some effort, but at the same time taps into the spontaneous flexibility of the brain to adapt and even manipulate its surroundings. It is well known that mood can change following a musical experience. Many can make these connections alone, and understand meaning within those moments, but for some, a live interactive experience through music therapy might be the only way of thinking and feeling and developing an identity. The value of improvisational music therapy rather than passive listening therapy is in the fact that it encourages thinking and feeling, and helps relate to others, for people who may need some assistance with this.

The emphasis upon nonverbal interaction and active participation mirrors some of the recent developments in psychological therapies such as the cognitive therapies. Not much has been said here of Jungian psychology. This is because there is more widely known about its tribute to art as a central element of unconscious processing as written about by many including and art therapist and Jungian analyst Schaverien (2001). Casement makes a case for psychoanalysis to become less focused upon the content of words and linguistic analysis and more upon the expressing dimension of how communication is happening and upon what the patient is trying to bring to our attention. Good psychoanalytic practice naturally strives for this, but where fragile interaction, and an intense awareness of rhythms, timbres, and tempo are necessary, music therapy provides a framework that includes listening, attending, attuning, responding, and interpreting, within an attitude that can be reflective, vital, and thoughtful all at once.