 Using Music Therapy in Eating Disorder Treatment A parent recently asked me to handover to the community team about my music therapy approach to working with their daughter. They felt it might be helpful to capture this approach to using music therapy with adolescents with eating disorders. My eating disorder work is as part of the team working in an acute adolescent mental health program. So, mine is a small part of the work being done by the young person, their family, and the team. If you have read any of my other writings, you’ll know that I struggle with the use of mental health diagnoses and labels. I get it; they are helpful and, sometimes, necessary. I just struggle with the assumptions that are inevitably associated with the labels, and the weight that comes with a diagnosis – be it, the weight of permanence, or the weight of being broken, and different from everyone else around me. They feel like additional shackles that people who are already struggling must carry. So, eating disorders, or more intimidatingly, Eating Disorders, are some of those labels that I’d rather not use. However, “people who express their distress through their engagement with food” is annoyingly clunky. So, for brevity’s sake, I’ll stick with eating disorders in this post. I have the privilege of working as a Registered Music Therapist with some young people with eating disorders. Much is understood and written about eating disorders, and quite a bit also on music therapy and eating disorders. I have attached some links so won’t go over the research evidence here. My time with these young people has identified a few things that I often focus on. What you may notice is that they fold back onto each other. For example, safety leads to self-regulation, which leads to increased feelings of safety. Most of these next points are true for all my therapy work regardless of referral reasons. Firstly, every moment is therapy. Every greeting, every smile, every eye contact, every game of UNO, every walk together, every offer of a drink of water, every conversation had with or in front of a client, every moment of music shared, played, sung, listened or danced to… everything, musical or not, has opportunities for therapeutic growth. Therapy starts with safety, self-regulation, and agency. Nothing happens without safety. I start a therapeutic relationship with my “2 Rules”. Firstly, “make mistakes”. I’ll come back to this one later. Secondly, I give them some version of… “I get excited playing music. So, if I am in your space or if you feel uncomfortable in any way, please tell me. If I don’t take the hint, please leave the room or do whatever you need to feel safe”. This tells the client that their safety is primary. It tells them that they are at least in some way responsible for that safety, and that they have some agency in keeping safe. It also tells them it’s okay to get excited and have fun. Lots of us struggle with self-regulation. This is true regardless of whether you are a patient or a clinician, a child or an adult. Self-regulation is complex, so let’s simplify it to: having some control over our physical and emotional responses. Without self-regulation, it is difficult to absorb and integrate the changes that we seek through therapy. Playing or moving to music helps to entrain our brain and body to connect to a beat. This gives clients an experience of themselves as regulated. It builds neural pathways and rewrites some personal (and often, family) narratives about their capacity to regulate. As already touched on, agency is a big part of my therapy. Giving clients a scaffolded experience of having power to decide some things builds the foundations for their increasing comfort with personal responsibility. This might be as small as choosing a song, or whether they talk about something deeply distressing. Most of my therapy is play-based. Play is the easiest way for people to learn and grow – regardless of age. Playing together assumes that we are positively connected (therefore, there is safety). It often has a rhythm of back and forth; and rhythm is inherently predictable and regulating, which helps us to feel safe. The back and forth offers some insight into collaboration and being in control when they lead; therefore, an experience touching on agency. Somewhat paradoxically, play can be a gateway to serious conversations. The rhythm and predictability of the connection bring a safety and trust that, time and time again, has allowed clients to share and explore elements of their deep and vulnerable distress. The therapeutic rhythm created in music therapy also allows therapist and client to move between serious and playful with an unspoken, dynamic flow. Such a dynamic space gives the client agency to co-lead the conversations. They can set the boundaries and direction of the conversation, which offers experiences of being in control. Power dynamics are such an important consideration in therapy. In addition to my 2nd Rule, which communicates their power in the relationship, I always seek permission to touch the client’s fingers (if needed to help them play an instrument). Whenever possible, I sit on the ground, regardless of whether they are in a chair, so that I am looking up at them, not down at them. I have the client co-lead as much of the session as possible. I am playful and speak with them as an equal; albeit an older, more life-experienced equal. This also feeds into the idea that they are experts in their lives. So, we both enter the space as experts in areas that inevitably intersect. I think of this approach to power as elevating them while holding them safe. Not only is the client an expert in their life, but also in their musical interests. Whatever they like, is okay by me (apart from anything intended to be derogatory or hateful – which would open a reflective conversation – i.e. a therapeutic moment). By acknowledging their expertise over mine, I can respond honestly if their shared music doesn’t appeal to me. This can open a conversation about whether we need to like the same things, and how it feels to hold different opinions from other people. Individuating, or developing a separate sense of self, is a crucial part of adolescence. So, creating opportunities to practice this can be useful for clients with an eating disorder, as they often have an underdeveloped sense of self. This focus on supporting the development of a confident internal voice is also reflected in the expressive therapy technique of affirming self-reflection and participation rather than any creative output. As a general rule, I avoid “teaching” instruments in my therapist role. I am not there to instruct on how to be a good musician. However, numerous skills can be developed through music that are tools for therapeutic progress; skills such as self-regulation, self-reflection, self-expression, deep listening, attunement, collaboration, connection, resiliency, self-kindness, tolerance, open-mindedness, body connection and awareness, and more. Any musical success can be reframed as therapeutic progress. For example, being able to play a passage on the guitar or keyboard is not valued for the musical skill, but for the self-regulation, body connection, and putting aside the internal critical voice. This challenges the client’s narrative around their capacity to be calm, connected, and kind to themself. So, learning an instrument in music therapy can be the gateway to these skills. But always, my therapist lens dominates my approach and dictates my responses. I explicitly encourage curiosity and problem-solving in my sessions. This agency strategy comes out as trying new things, making mistakes, and cheeky banter. I then affirm this willingness and courage to explore and take appropriate risks. These exchanges create opportunities for success, which builds social confidence. There is a therapy concept called “Window of Tolerance”, where therapists aim to keep their clients within the window between too easy and too hard. My music therapy work modifies this approach by keeping the clients at their “Edge of Tolerance”. The justification is that a playful, power-adjusted therapeutic relationship, when combined with the intrinsically regulating and grounding capacities of playing, singing, sharing, or moving to music, keeps clients feeling safe, connected, and capable. With these elements grounding them, the client can almost continually work at their therapeutic growth edge. Their agency and the dynamic flow also allow us to seamlessly adjust if we ever cross over the edge. One factor commonly causing psychological distress is the feeling that people must be perfect. This is particularly true for people with an eating disorder. Despite the research evidence showing how perfectionism is a damaging personality trait, many of us still wear it as a badge of honour. Creating music inevitably involves making mistakes; and when playing music together, there is a rhythmic momentum that pulls us along. This force seems to have an intrinsic pull to keep us together, which challenges our habits of being distracted (& interrupted) by mistakes. Once people have explicit permission to make mistakes, they tend to find it easier to stay connected to the shared music and can often ignore the distractions. To paraphrase Gabor Mate, when playing music, people will often sacrifice perfection for connection. In other words, they release their need for perfection to maintain connection to a shared beat and other people. Lots of mistakes mean lots of opportunities to experience imperfection. It means lots of moments where we can rewrite personal narratives about the need to be perfect. So many times in my sessions, playing music has opened the door for people to accept imperfection, which they have later transferred into other settings. The explicit expectation and, often, celebration of mistakes finds a crack in their protective armour of perfection. The temporal nature of music means that, unlike writing an article or painting a picture, we can’t go back to fix it. We can only keep going and try again. What also amazes me is that clients are often aware that they have unconsciously made music a judgment-free zone. It is one of the few places where they recognise the value of effort over output. Another element of my sessions is that I pepper in a little psycho-education. When the focus is on the musical connection and play, I can offer occasional reflections. Commonly, this is about neuroplasticity and the capacity to change, or about our brains connecting via mirror neurons, or reminding the client how amazing their brain is because, despite all of what they have on their plate, it is staying calm under the relentless pressure of playing music. Sometimes, it is about how our brains adapt to their environment and how they might develop maladaptations to protect us. Part of the reason for this education is to challenge existing narratives about a broken brain, and about the client’s capacity to make change (again, feeding back to agency). There is a concept passed to me by a clinical supervisor. It says that we see ourselves based on what is reflected back to us. In other words, if you smile and make eye contact with me, or if you listen openly to me, this contributes to a sense that I am worthy of respect. It communicates that I have some social value. So, one of my therapeutic tools is to reflect back to clients that they are likeable, fun and capable. This works therapeutically on different levels. It reinforces our therapeutic relationship and generates investment by the client in our sessions. It may also subtly challenge any existing negative personal narratives. Instead of seeing them as their diagnosis or disorder, I find ways to see them as awesome, clever, and competent. Their competency may not be in interpersonal or musical skills, but the competency of being brave and trying – both attributes laying the foundations for broader success. People come to therapy to “change their minds, their lives, and the ways they relate to others” (Dr Gwen Adshead). Once the client’s individual needs are understood (be they expressed as an eating disorder or something else), the therapist can put the diagnoses and labels aside and support clients to feel safe, regulated, and empowered. By giving them a positive experience of themself as “connected and valued” (Dr Gwen Adshead), we can embed these concepts as the personal narratives that help guide them through their life. Music therapy is just one of the ways we can do this. With warm regards, Dave Additional links: Dr Gwen Adshead: https://www.bbc.co.uk/programmes/articles/1hQF5SLbjPBb8sDr9zHDbKX/bbc-reith-lectures-2024-four-questions-about-violence 
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Written with my Registered Music Therapist colleague, Dr Matthew Breaden, this case study explores the use of songwriting as part of a Music Therapy program with a young girl with Batten Disease. Press here —>tinyurl.com/ym4tfj74  To cite this article: Breaden, M., & Anthony, D. (2021). As Batten Disease disconnects, music therapy connects: A case study. Australian Journal of Music Therapy, 32(2).
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AuthorDave Anthony is a Registered Music Therapist with more than 20 years of professional experience. He has spent most of that time working in complex trauma and currently works in an acute adolescent mental health unit, private practice mental health, and for recreativ mind:health. ArchivesCategories |
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