Dialogue in Music Therapy - Its Role and Forms

Dialogue is a fundamental human way of acquiring knowledge. Psychological descriptions of dialogue range from pre-natal ones to adult turn-taking. Scales have been devised to rate its well-functioning, and conversational analysis has been introduced to illuminate the interactive aspect within music. Case vignettes illustrate different kinds of dialogue with my own clients suffering from intellectual disabilities. With Lone, a focused training of turn-taking became possible, despite pronounced autistic behaviour. With Dennis I employed both turn-taking training and playing of arranged songs. The latter had the purpose of providing a relatively safe situation where initiative had to be shown. Asymmetric dialogue deals with the challenge presented by clients with contact disabilities. Ideas are stated on how to cope with scarcity of response. A hierarchical model of time-levels is presented in which levels are related to activities of the session, aiming at providing sustained structure as well as flexibility according to situations arising. The conclusion compares forms of dialogue described in the vignettes: "regular turn-taking", "communication at a "split-second level"" and "asymmetric dialogue." As a possible field of further research, studies of conscious/subconscious interaction in the human psyche as well as how different dialogue levels function together are suggested.


Philosophy
Dialogue comes from the Greek word "dialogos".One possible translation could be "through speech" or "through the word".It is a fundamental tool for our orientation in life and essential to learning and developmental processes.Music therapist Rudy Garred (2004) views music in the light of theologist Martin Bubers idea of "I and thou" as a fundamental ontological fact.In the view of Garred, music is closely embedded in this human condition and is, consequently, "constituted relationally" (p.v).It thus possesses a dialogical aspect which leads to discoveries of possibilities and, since the individual is encouraged to look beyond itself, to an "open outlook sceptical to enclosed systems of thought" (p.100).The publication of Garred (2006) made his analysis more widely available.
Dialogue may include imitation of the other.A classic "mimesis" notion laid down by Plato and Aristotle and carried on by modern writers such as Walter Benjamin and Theodor W. Adorno involves the imitation of nature as a fundamental way of gathering knowledge about the world (Mimesis, 2015a(Mimesis, , 2015b)).Related to his thoughts on work, Karl Marx (1867) could seem to have touched a similar idea when he employed the term "metabolism" (Stoffwechsel) between man and nature as a universal prerequisite of human existence.Man influences nature, but in the same process, "changes his own nature" as well, "develops its dormant potentialities" (p.160) [1] Viewed from theory of science, dialogue appears for Habermas (1971) as a special case of what he calls "communicative action" (kommunikatives Handeln) as a basic characteristic of the human sciences, opposed to "instrumental action" (instrumentales Handeln) of the natural sciences.A case in point is Freud's theory receiving a meticulous analysis and attempt at reconstruction.Freud was, according to this, working out his psychoanalytic method as a re-invention and clarification of dialogue, even if his writings testify to a considerable confusion in this matter on the level of theory of science.What was begun in the spirit of natural science on a medical background became a method belonging within the humanities.
Summarising: in the above, dialogue was described as an inevitable part of the human condition (Garred, 2004) -as a human action involving exchange by imitation (mimesis views) and as a method especially belonging in the human sciences (Freud according to Habermas, 1971).While these views differ, one might nevertheless see each of them as highlighting a relevant aspect of this notion.

Music Culture and Music Training
Music, whether for a concert, dancing or background listening, is often described in harmonic or rhythmic terms.Are we not often conceiving music as a solo expression, backed up by synchronous harmonic and rhythmic accompaniment?The function of harmony is to make parts melt together into chord patterns.This, of course, makes each part's independence less prominent.Independent melodies set up as counterpoint to each other, not just upper voices with a "second part", are less typical for the most part of what is consumed today.However, some independence still exists, as for instance bass contra melody, fill-ins, and on the rhythmic level.Examples in pure cultivation can be found, such as Bach's fugues or Bobby McFerrin's "circle song" practise consisting of putting different ostinato figures together.Whereas the parts in Bach's music belong to a plot written by one composer, different improvisers can create the circle song parts on the spot.They are thus polyphonic and independent of each other in a more radical sense.A new interest in music's interactive qualities appears in those forms of experimental music after 1950 that take interest in improvisation.Frederic Rzewski, one of many exponents for this movement, utters these words of praise quoted in Gronemeyer and Oehlschlägel (2007, p. 156) "An art form which aims for highest efficiency in times of highest urgency must be based on dialogue."[2] Even though describing and creating music as dialogue might not be not the habitual way in the culture surrounding us, alternatives do exist, particularly in avant-garde circles, with whom music therapists share a common interest.Wigram (2004) describes a programme of improvisation training for music therapists that includes the use of dialogue in differentiated forms, employing contrast or similarity according to different musical and therapeutic aims.

Psychology and Human Development
Describing the beginning of the human development spectrum, Lorenzer (1972, p. 41-44) refers to something that could be seen as dialogue in a truly embryonic state, namely the foetus' experience of alternating states of equilibrium / well-being and of disturbance.This can be seen as the simplest possible form of language -"spoken" by the surroundings to the foetus, so to speak.Such a view corresponds to the fundamental linguistic notion formulated by Saussure (1916, p. 42) that language consists of oppositions and identities.Niedecken (1988, p.101-102) elaborates further on Lorenzer's idea.Seen from our dialogic context it is interesting to note here that the shifts create a response from the organism and in a further development, signals perceived may become more differentiated and the organism may develop expectations to what will happen, based on certain patterns of signals.There is hence a beginning training of focusing attention outwards.
Through the work presented by such researchers as Stern, Jaffe, Beebe, andBenneth (1975), Trevarthen (2000) and in the compilation edited by Malloch and Trevarthen (2009), the term "communicative musicality" has been coined from the background of infant studies.Objects of study are dialogues, of which exist both a "coactional" form and regular turn-taking.
Following views from object relations theory we can see dialogue as a means of testing our inner fantasies against reality.Cf.Segal (1981, p. 45): "From the moment the infant starts interacting with the outer world, he is engaged in testing his phantasies in a reality setting".Reality may seem to "resist" our attempts to control it.According to Lacan (1949, p. 90), changes brought about in the course of human development create new urges and result in the lack of an appropriate self-image -situations that can only be mastered in the experience of "dialectics with the other".This emphasises motivation as a primary force in dialogue.
Even before modern psychology, German poet and essayist Heinrich von Kleist (1805) was a pioneer in describing effects of verbal dialogue at a grown-up level in an essay, the title of which has been translated as "On the Gradual Production of Thoughts Whilst speaking".The working out of verbal statements is greatly stimulated by talking to others: "An opposite human face is a peculiar source of excitement for the one who is speaking.And a look which signalises us that a half expressed thought has already been understood, will often grant us the expression of its second half (Kleist, 1805, para 2)".The fact that one has to focus perception sharply on another person may seem to temporarily interrupt the inner process, but it also stimulates it, since both the sensory and intellectual stimuli may call forth emotions and new thoughts.Paraphrasing the French proverb 'l'appétit vient en mangeant', Kleist 1805, para 1) states that "the idea comes while you talk".So "our" thoughts may be seen as belonging to a social network, not isolated.Kleist's idea seems to complement that of Lacan (1949) in stressing aspects of emotional arousal and of creativity coming from human contact.
Dialogue in its full-fledged form as turn-taking involves many mental capabilities and their skilful combination: we relate our emotions and ideas to the other and we receive feedback.This feedback accumulates so the longer the dialogue lasts.Further, we must focus our attention sharply, perceiving signals from others in exact and detailed ways, and thereby gather information.It trains personal expressiveness as well as the abilities to observe and to show empathy.In other words, psychology of perception, of personality, depth psychology, developmental psychology and maybe more are likely to be relevant backgrounds.Some music therapists have worked out descriptive scales by which the well-functioning of dialogue may be rated.Anne Steen Møller (1995Møller ( & 2002)), working with clients suffering from intellectual disabilities, describes four levels of contact.The first is an intuition within the therapist: I feel a contact between us.On the second level it has become possible to single out reactions from the other: I hear and see the contact.This could be in the form of observable movement, sound, or eye contact.Only at level three, the other becomes conscious of the contact, develops expectations and acts in order to obtain contact and to express reactions: Now you are in charge of the contact.At the fourth level, both parties are conscious of the contact: Our contact has the form of dialogue.Dialogue, clearly, is here equivalent to turn-taking.And there is a rule common to both parties governing the activity, which could be we alternate with soundmaking and listening.Pavlicevic (2007) designed a "Music Interaction Rating Scale" of to describe the responsiveness of chronic patients with schizophrenia (p.177).The steps are as follows -C means client: Level One -No musical contact Level Two -One-sided contact: no responsiveness from C Level Three -One-sided contact: non-musical responsiveness of C Level Four -Self-directed musical responsiveness of C Level Five -Tenuous, musically directed responsive contact Level Six -More sustained, musically directed responsive contact Level Seven -Establishing mutual contact Level Eight -Extending mutual contact Level Nine -Musical partnership This latter system may be employed both for coactional forms of dialogue and turn-taking ones.

Music Therapy Studies
Many authors have studied dialogues with clients who have communication difficulties or disorders.Holck (2002Holck ( , 2004Holck ( & 2006) ) refers to a number of these and discusses them along with presenting her own cases and thoughts.She provides a special focus on the structure of turn-taking and the way it functions, taking over concepts from conversational analysis.Cue signals indicate who is to speak and who is to be silent, and when the shift takes place.Thus, there can be turn-yielding, turn-maintaining, turn-denying and turn-requesting cues -both auditory and visual ones (Holck 2002, p. 46).Focus on the turn-taking actions as a crucial part of dialogue is also present in the work of Jacobsen (2012).As a part of a system for assessing parental communication competences, one of the quantitatively measured dimensions analysed from video recordings is "Turn Analysis Score".
Both Møller (2002), Holck (2002) and Jacobsen (2012) work on the background of psychodynamically oriented music therapy which is prominent with the Aalborg Music Therapy Education.Skrudland and Fønsbo (2003) investigate whether this approach can also be relevant for clients with intellectual disabilities -my clients from the case vignettes below belong to this group.They conclude that working with communicative relations, as typical of this method, is very well possible "regardless of functional level" (p.41), since relevant feedback from the client can occur anyway.According to them, when choosing a treatment method for the individual client one should focus on prospects of developing a relation rather than on the degree of functional level.-The notion of dialogue could seem to be "at home" both viewed psychodynamically, focusing on relations, and also when viewed from special education thinking more in terms of acquiring skills.Dialogue training can be "teaching communicative skills" or "developmental work" depending on the viewpoint, and so the notion might form a bridge between the two methods.

Defining Dialogue
So much communication and human activity could be interpreted as dialogue.What are the limits of the dialogue concept -what is NOT dialogue?Consider a music therapist playing with a client.In playing, the client concentrates entirely on his or her own process, and the therapist supports this by some musical action.Here, the exchange perspective might not be the primary one.Such efforts may shut out responding and turn-taking actions for a time, and instead of dialogue we could speak of grounding, holding, containing, or accompanying, in Wigram's (2004) terminology.A dialogical aspect, however, may reside in this activity being part of a mutual agreement -it can be perceived as part of a dynamic sequence of events based on exchange.
Interaction may possess characteristics of dialogue, but it is not always the case.For instance, vehicles in the street interact, even closely and attentively, but we would probably not call that dialogue.Maybe this would be because we perceive the activity as trivial, having no other aim than avoiding crashes and allowing a steady forward movement.In this way we do not attach a wider meaning to the actions beyond simple necessities.In order for dialogue to exist, it seems there must be essentially mutual contributions made, however sophisticated or not the mutual feedback may be.It also seems that for an activity to be called dialogue, it must contain at least some moment of interest pointing beyond itself.Dialogue, thereby, cannot be a purely automatic activity, but demands a certain quality of attention.
My working definition of dialogue is: an activity taking place between two or more human parties in which at least one party attaches interest to an exchange of feelings or information.
It then seems that "communication" can be called the next broader term, in which the exchange aspect needs not be depth-going, as for instance in courtesy and other rituals."Learning processes" involve depth and also seem to be broader yet.They take part not only between humans, but also between humans and the outer world in general.It appears thus, philosophically, that "dialogue" is the specific exchange activity involving individuals.The other two denote different broader contexts, of which dialogue could very well be a part.

Case Vignette: Regular Turntaking
Lone is a woman suffering from autistism spectrum disorder in the late part of her thirties who does not use words for communication.She has received music therapy in a small group with one more clients for a number of years.Duration of each session is slightly less than two hours, and the music therapy is given on a weekly basis, although vacation periods and a long summer pause results in a total of around 23 sessions per year.[3]Here, as in the following examples, the music therapy is part of the program offered by my employer SUKA (Special Education in Copenhagen Region), an association receiving public funds.It is thus independent of the institutions where clients live.Institutions apply for music therapy or other activities and SUKA decides according to its own priorities.
Lone's behaviour could be highly ritualistic, engaging in extended periods of hyperventilation and in autistic rituals which could consist of repeated manipulating of objects that would continue "automatically" to make sound for some time, such as letting a rattle-egg fall into a tambourine.This appeared to have a certain "hypnotic" quality of monotony.She also could make pirouette-like, fast turns when standing or walking or, at other times, make her own voice sounds, with smiling and laughing appearance.This, like the other activities mentioned, was however performed in a withdrawn state, with no possibility of me having contact with her to any important extent.
Before our first year together was over, she began on her own initiative to use the xylophone in a very different way.Here, she did not only make monotonous sound with a minimum of effort, but explored much more actively ways of playing and pausing, with more and different motor effort and obviously with interest in the process.She actively used feedback from what she heard, and was not just occupied by "hypnotising" herself.She had a variety of different ways of striking the instrument with one or two mallets -glissandi, repeated strokes with one hand or strokes using both hands which again could alternate or be more or less simultaneous, all of which could be freely mixed.She could also make eye contact during this activity, which she would also use when we met and I said hello to her.
During a period of approximately one year we had a time of intense experimentation with turn-taking dialogue -each session could be different from the previous one.There was a start with rather sporadic playing, and here I played another xylophone and making pauses in a way so as to invite her to take part.However, suddenly at one session she liked to play for a long time.Here, it felt appropriate for me to insist on taking some part too.And so, in periods during the improvisation, I played loudly, but with pauses, as if to say: "Please let me in". Figure 1 below attempts to depict my sound structures with steadiness and firmness as a primary characteristic, each lasting between four and 10 seconds.What happened therapeutically is an intervention with my own initiative, in the hope of becoming a partner in a dialogue with her.In a subsequent session I did something similar.But here, my contribution changed into loud exclamations that again relaxed as soon as there was contact, like "Listen to me".The shapes in Figure 2 attempt to depict bubbles like those of cartoons, filled with sound instead of words.Loudness of the sound dropped and was made diminuendo after some time, as the shapes may suggest.This change was a reaction from my side to the fact that she had begun to listen and to pay attention to me shortly after each of my utterances.

Figure 2. Sound bubbles -therapist saying "Listen to me!" [view full size image]
In the next example (Figure 3), a certain kind of "polite giving me attention" has been accomplished.I did not have to "raise my voice" so much in order to become noticed.She looked at me while I was playing, and I could, cautiously, extend my playing periods a little, like "Please, a moment longer!"In the next example again (Figure 4), I had, for a time, removed her xylophone in order to concentrate more on eye contact.I made vocal sounds; she answered primarily with looks, although also with occasional use of voice.These vocal sounds from my side were no longer very firm ones.The last example (Figure 5) portrays a typical situation six years later.We have had the opportunity to work on a long-term basis, and this has allowed me to better observe her process.At this stage she liked to play much of the time by herself, but she also granted me permission to participate.Here, I played the piano; she was still playing the xylophone.The turn-taking shifts were not surprising to her any longer.There was less of a spontaneous character in her shifts; the turn-taking having become more of a habit.The interesting and exciting thing to me, however, was that she accepted it as part of her usual attitude to me.I knew that we could have "interaction time" during which she would often direct her focus also outwards and have a focused perception of what I was doing.Interestingly, her turn-taking behaviour in music and her use of eye-contact when coming to music therapy was reported by the institution where she lived to be something special, not usual for them.Thus it could seem that the music opened up a new space for here to cultivate such behaviour and, hopefully, acquire useful skills to compensate for her autism.This case vignette illustrates how it was possible for a client with autistic spectrum disorder to work dynamically with turn-taking on a high level.On the Møller (2002) scale I would rate the score in the last example to being 3,5 (between next to highest and highest), on the Pavlicevic (2007) scale 6 (see above concerning these scales).It also seems to demonstrate the usefulness of applying conversational theory concepts to the study of dialogue (Holck 2002(Holck & 2004)).In this terminology, I used "turn-requesting cues" above all here, and there was a certain amount of "turn-yielding" cues from her side.

Case Vignette: Turntaking Training with Cue and Communication at the Splitsecond Level
Dennis is a well-functioning client in his fifties with verbal speech and good motoric abilities, although with some intellectual disability.For a number of years he did not speak altogether although he had the ability.Finally he began to speak again and uttered a wish to have violin lessons.Earlier, as a young man, he had had such lessons on a violin he still possessed, but at some point he left this activity.At the institution where he lived, the educators thought this was a promising development and that he might generally strengthen his social abilities by means of music.The music therapy takes place on similar conditions as described in the previous case vignette.
My own goal with his music therapy concerned strengthening his initiative by providing relevant musical challenges.We practised improvisation exercises, playing percussion with no pre-arranged rules.We also played rounds, with short, alternating contributions from each person.Dennis showed limited initiative when conversing, but he loved to play music.The violin was clearly his favourite instrument, but I used percussion for the next exercise, as it makes interaction considerably simpler.Participating in the sessions was also one more client who was lower functioning and his assistant.Hence it was desirable that activities could include both in some way.This was the case with both the percussion exercise described next and with the subsequent song exercise.
In my experience as a music therapist and improvising musician, the activity of rounds is known as a standard exercise, and I employ it as a turn-taking training activity.In our version, we played alternatingly for approx.half a minute each, or maybe less.What may be special here is that I strived to make the tempo of shifting as fast as he could cope with.I did so when Dennis was playing by making gestures of a turn-requesting kind.These could vary from just a short look to longer looks to leaning towards him and, in the strongest version, also pointing with my hand to the next person.In this way, I could pay attention not to use a stronger degree than would feel necessary to me.Likely, this would also be a degree leaving a certain amount of initiative to him.
"Initiative" seems a good word to designate actions, the details of which take place independently, with one's own responsibility, while still having been arranged and decided by others.It is an interesting paradox that Dennis had to accept taking a risk, plunge out into the relatively unknown, psychologically: to lose control -in order to obey my command when the change occurred in the song and remain connected to the process of following me.This aspect would remain active as long as the actions did not become mere routine.
In the previous example we could take our time to some degree and I could wait for him to become ready.The following activity was more difficult.
This activity is about Dennis playing a simple drone or two-note violin part that I had arranged within some well-known songs.I conduct when to start and stop and in some cases change tone with looks and shoulder movements.This could sound very fixed and contrary to improvisation practise.However, for Dennis it certainly requires some amount of independence, demanding a high degree of concentration and a very focused attention.This will be detailed below.Moreover, other forms of participating can be arranged with the other client during the songs, such as using a percussion instrument.
See Figure 6 for a description of the music context -a simple song that I play on the piano, and a violin drone accompaniment coming in at the refrain.The tiny fraction marked out with a red box is the decisive one for our coordination efforts.
Certain communication processes occur very fast -the breaking out of common laughter when someone in a group has told a joke, for instance, and other similar forms of "spontaneous agreement" on the emotional level.Trevarthen (2000) p. 68-69 has dealt with some musical, language-gestural and other non-verbal phenomena and their durations.He distinguishes several time levels and their psychological significance like this: Time levels below 200 milliseconds are "pre-conscious" Levels between 300ms -6 seconds are "conscious" Levels from 10 seconds and higher make possible that events can be "imagined and recalled".[4] So here we work partly with "pre-conscious" processes.Dennis has to react to the situation, there is no time to "stop and think".The situation might be comparable to grasping a ball being thrown.He has to plunge into musical action to make himself heard.What we will both perceive as a correct result lies within a tolerance of maybe 30 milliseconds.I might hesitate or speed up very slightly in the situation to meet him more exactly -but only within a very small range.
I believe this is a relevant challenge to show initiative for him, presenting an opportunity to go beyond conscious control and gain new experience.For myself, I find it a subtle and interesting issue to work with, therefore I can also show him my engagement so that the activity could become really a shared one.The explanations that follow is now an attempt to apply a microscope, as it were, on that which I find psychologically interesting in this short transition.
With the more complex figure in Figure 8, I wish to bring attention to the detailed feedback processes, as they appear in my interpretation on the basis of observing the musical facts and actions connected with them.Dot-and-dash vertical arrows depict eye contact, while those vertical ones with whole lines depict physical action.While waiting in Stage 1, Dennis is eager to begin but applies the necessary self-discipline and will look for the signal to come.A cyclic process with frequent checking must be involved here, as suggested by "etc.".This may take many seconds.At some point, this stage concludes with mutual eye contact, signifying that the shoulder sign is coming very soon.
Stage 2, in which the direct preparing for playing the tone takes place, has the highest degree of independence and is also the shortest.In the example stated here, all of this up-and downbeat process must take place in less than a second.Various songs employed have different tempos.Once perception and conscious identification of the shoulder signal take place, Dennis performs an autonomous process that has to be governed by his own tempo feeling and ability to anticipate the upcoming next beat.This has to be done with a precise handling of the bow, finally creating the onset of the tone.One may say that there is a natural tempo feeling guiding him to measure out the relevant time span, but it seems there can be no through-controlled "counting" or "spelling out" of it.In other words, the practical situation does not allow the unit to be sub-divided [5].And when counting is not possible, the process has to happen in a holistic way, solely by feeling.There is the potential danger of speeding up in panic or of the flow being blocked in panic.This preparing stage culminates just before reaching the onset of the tone.
Having reached the concluding Stage 3, there is the possibility of immediate triumph or slight disappointment, depending on the result.I suppose my reaction is very much what informs him on this.Then the drama is over, at least for some time.Before this point, tension has built up within us both.I suppose that my engagement in the process is a decisive factor for making the transition and its intricacies such an important task for him to solve, including my emotional response.
There is a striking contrast between the rather passive impression one could have from Dennis' verbal and other activity, and the energy, seriousness and initiative he invests in playing.I therefore hope for a transfer of these to his life outside music therapy.This case vignette has described turn-taking training with the use of differentiated degrees of "turnrequesting" cues.It has also attempted to demonstrate the way in which fast and complex processes form a part of the rhythmic coordination that takes place when there is a conducted joining in on what should be a common beat.Such processes take place outside the realm described by conversational theory with its types of cues.Some of the processes dealt with belong to what Trevarthen (2000) calls "pre-conscious." Case Vignettes and Various Thoughts: Asymmetric Dialogue Till now, we have dealt with examples in which participants could operate on relatively advanced levels.But people with intellectual disabilities often have different and more basic contact forms.This, of course, is connected to their developmental stage of concentration span, their abilities to focus attention, etc.In terms of the Møller (2002) and Pavlicevic (2007) scales, I often work within the lower half of the steps they describe.
So the dialogue can by necessity be an asymmetric one.Signs of contact as well as resources clients possess for expressing themselves may be sparse, and the therapist may need to wait for the "right moments" to appear, as well as to allow time enough for developments to take place.A number of my clients have what one might term contact disabilities, in various forms and to various degrees.By this I mean that communication in its totality appears difficult, beyond simple lack of verbal language.Sound, looks, gestures, touching each other do for instance not lead easily to a feeling of mutuality.Autism, psychic problems, impairment of hearing, vision and movement may be factors behind.My idea of asymmetric dialogue which is described in more detail below could be called a platform to be further adapted to the individual clients and situations.

"Patience Structure", "Narrative Structure" and the "Busking Musician"
Earlier in this article I described turn-taking with Lone.But before this took place, there was a more passive stage, with no turn-taking.For one lesson I devised a "patience structure".Inspired from European serial music of the fifties, this structure was to contain both short and long individual sounds or events, as well as both long and very long pauses (up to one or two minutes), in a way aiming at ever varying itself.
Thus, I could play sparingly and yet with some clear statements, while at the same time leaving space and even emptiness inviting for her initiative.Figure 9 aims to suggest just some of this unpredictability and irregularity of my contributions -see also the next figure.In this case, the music material consisted of (single) tones and sounds used in a free way, not fixed in traditional tonal patterns.This allowed us to use freely the sounds and expressive resources we had at hand.In other cases, however, I use commonly known songs.This may be in order to take advantage of the client's interest in them or in order to link to the activities of their institutions.
In the above "patience structure" example there were no individually discernible levels of micro-and macro structures, rather an integral structure comprising both.In my work with songs, however, and with various structuring of sessions, this endeavour of what could be called to sustain a multi-layered structure is different.
A meditative level seems to exist above that which can be "imagined and recalled" in the terminology of Trevarthen (2000) quoted above in connection with Dennis.Taking plenty of time, single events start to lose their individuality.This could be relevant when no single action will lead directly forward with any certainty -approaching the process so to speak in an indirect way.
Acting in the hope that a reaction might occur at some point could seem an extreme form of dialogue, but it is probably well-known to music therapists.[6]One might compare, a bit humourously, the situation of the music therapist in asymmetric communication to the busking musician, playing in a public place.Both are dependent on some positive response coming their way.They spend time waiting for it, and they also share the independence of deciding by themselves about their repertory!Alternative comparisons, maybe more favourably sounding ones, could include being in a meditative state of awareness or that of an explorer moving forward in unknown territory.

Creating a "Narrative structure" as a Technique for Varying the Musical Structure When Singing Songs
The following considerations in this and the subsequent chapter are not coined on specific persons but apply rather generally to a number of my clients with contact disabilities.
The music therapist has different goals from those of the busking musician, but needs also to keep up his or her inner motivation and directedness.Music making depends on sustaining an activity that wraps itself around both parties and their subjective beings.
One method to motivate myself is to find dramatic elements in the songs, to sustain and contrast them in a theatrical way.In this way I find moments of interest to engage in.It acts as an auxiliary structure for my musical performance -I have called it "narrative structure".[7]The point about this "narrative structure" is not that of making the literary contents clear to the clients.With those degrees of intellectual disability I work with, this is not to be expected.But clients have the possibility of perceiving the emotions contained in the contrasting dramatic situations in their own way.And I may achieve musical variation and, through it, more possibilities for stimulation and for arousing client's awareness.[8] The narrative structure does not only function as a means to call forth the therapists' own connectedness to the music-making.Like the "patience structure" described above, it also creates a multi-layered structure in time.Verses and the individual songs become building-blocks that extend the feeling of time passing, and allow for changes and reactions to take place.A possible tendency for me to be orientated towards details in a fixed way when sitting and observing the client and trying to communicate may be suspended so that a "net" is created that goes on to exist in time.I can then pursue an effort for some time and relax my decision-making.At the same time, the "masks" of the net also function as subdivisions of time in which I may engage in fast actions and occurrences.One could, so to speak, change time-sense at will.

The Session as a Multi-layered Musical Structure
A music therapy session may offer many opportunities for observing clients, for following up what they do and for possible interventions.At the start of a session, I may know there is time ahead, but not exactly what should happen or where to put the emphasis.Even if there are standard procedures, they may offer options, and in case of new inspiration, they could be replaced.
Generalising from my experiences with sessions of singing many songs, mixed with improvisations, I imagine the music process within a session as one "piece," one large, coherent structure.This may be conceived of as having different hierarchical levels -cf. the time-levels from Trevarthen (2000) quoted earlier in connection with Dennis.There were "pre-conscious" levels below 200 milliseconds, "conscious" levels between 300 ms and 6 seconds.Additionally, he spoke of levels from 10 seconds and higher making it possible that events could be "imagined and recalled".Separating these levels are useful when analysing, but of course they interconnect in real life and within individual sessions.On level I of the pyramid model in Figure 11, that of "overall planning within the session", there may in some cases be a fixed arrangement: In some of my groups, both songs and later free dialogue each have a place of their own in the agenda.

1.
In one case there is a 10 minutes period towards the end in which I and a fellow music therapist (for this particular group) are silent, although we may communicate in other ways -in order to secure a free space for their own sounding initiatives.This has been practised since 1990 following the idea of my co-therapist Henrik Ehland Rasmussen.

2.
Further fixed elements with some clients are Hello-and Goodbye-songs.

3.
It may happen that a fixed element (as it may with whatever element) serves as a "warm-up" one for the next -in which case it serves, even if maybe being static in itself, a dynamic purpose.Results of such dynamism could be outbursts by clients during the therapist's silence, or an intense activity after enjoyment of songs.
Individual songs or improvisations inhabit the next level, II", and they may be differentiated from each other by means of the "narrative structure" described above.In the course of events, new sections on level II could add up, or maybe they could even give rise to new directions for the rest of the time -and thus influence level I.
Songs may be well-known.One can therefore expect them to be part of what clients hear in everyday life, and part of the activities that educators conduct with them where they live.Because of such multiple occasions for training, they provide special opportunities for training concentration span and endurance in those cases where an entire melody is a really long time.
On levels III and IV short insertions have their place.Reactions of clients in sound, mimics, looks or gesture could influence my music.Pauses are an important element for me to react with or just to use in order to allow for a space where things might happen.Pauses and rests may be inserted between songs, verses, phrases or their subdivisions.Much experimentation can be done here without the song falling apart.I can recommend trying it out!A somewhat similar way to use pauses is this: I may in some cases play recordings of my own improvisations over songs in the piano so that I can be free to move around, sing along, and make gestures and come into closer contact.The pause or mute functions of the remote control allow me to insert pauses and make more dialogue and mutuality possible.
In live performance, tempo can also be varied.In these and still other ways, songs may be "stretched" and adapted to the situation and become a kind of open ritual.
With a feeling of such a structure, I may direct my attention onto higher or lower hierarchical levels as needed -and scan, for my own overview, on which level(s) the response from my clients are taking place.I can, so to speak, apply different "zoom lense" settings in my perception of the situation without losing myself, change time sense at will and thus shift freely between engaging in little details and jumping to a higher level and await possible responses of a slower kind.[9]All this may be seen as a formalisation of a common aspect of music-making in general, in which surrendering to the flow and paying attention to details are not necessarily opposed.
Both the "patience structure" and the use of songs described above enable me to "wait and see," and then to take up responses like looks, gestures and sounds when they occur.This may call forth smaller or larger modifications of the structure (to the extent that this is pre-conceived) or lead to new elements being introduced in the on going, building up process.For example, if there is a basis for it, I might depart from the structure of singing one song after another and engage in an improvised dialogue in music.
Asymmetric dialogues, in the examples treated here, rely on creating a sustained, yet flexible structure from the therapist's side.[10] This had as its basis a multi-layered conception of the musical structure that is capable of making a whole out of planned and unplanned elements, and of event durations ranging from split-seconds to very long.

Overview and Concluding Remarks
Some of the examples discussed till now appear in Table 1.The first column characterises the dialogue forms by the terms used in this article.The next column indicates the durations of contributions -they cover different time levels.As has become obvious by now, dialogue is not confined to the durations that characterise spoken conversation, although this might be the most common comparison.Other metaphorical comparisons, as touched upon before in the text, are then suggested in the following column.The two last columns recall the therapeutic points of interest -first in specific terms related to time levels, then, as a kind of "bottom line" in quite general terms.These general terms are, as also stated above the column, still related to the case vignettes, and further generalisations, for instance what working on different time levels "mean" for groups of clients, should proceed with caution.The general importance of dialogue that was considered in the introduction certainly takes on different shapes in actual life.As the case vignettes may suggest, even though the "turn-taking" stage may represent a higher developmental stage than the "pre-turn-taking" one, communication is a complex matter on any stage.Stages may intermingle, and so may also "pre-conscious" and "conscious" elements.Conscious turn taking seems to be a formal behaviour that can be extremely useful in social life, but the pre-conscious forms co-exist, contributing importantly to spontaneity and expressivity.
Because of this complexity, a possibly relevant notion in further psychological investigations of the multi-level dialoguing process could be that of "tertiary process" coined by André Green and his predecessor Lawrence S.Kubie (Olsen, 2002, p. 98, 956).It aims at understanding the intimate interaction of conscious and subconscious levels.
Further exploration of themes touched upon in this article could be within the broad research area known as "communicative musicality" -maybe with a view to describe how dialogue and turn-taking take place also on advanced levels, and how different levels interact.Shedding more light on these complex, but fundamental, psychological processes might in turn also benefit the work with clients such as those suffering from Autistic Spectrum Disorder and from intellectual disabilities.

Notes
[1]Here, and later with Kleist and Lacan, translations are by this author.
[2]Cf.Niedecken (1988, passim) who also deals with the relation between general music culture and music therapy.A summary of her discussion can be found in Bergstrøm-Nielsen (1988).
[3]Even if descriptions below are of individuals, the work takes place in groups of two clients and is thus only one aspect of the total activity.Often, there is an alternation between activities.However, dialogues Dialogue in Music Therapy -Its Role and Forms | Bergstroem-Nielsen ... https://voices.no/index.php/voices/article/view/771/6829 af 11 11-08-2015 10:58 described are only between the two of us.
[4]Working with computer sequencing and editing of music may provide insights into what would otherwise be not conscious.In this way I have learned, for instance, that piano chords with all of the notes beginning at exactly the same moment will sound mechanical and wrong.There may be an estimated span of up to 15 milliseconds within a "simultaneous" feeling or even more in this case.It is a fascinating thought that we may be able to sharpen our attention to fast processes in music and the messages they carry.-Working with short "click" sounds in an experimental setting, Wittmann and Pöppel (2000) found that even 2 to 3 milliseconds distance between sounds may give an impression of non-simultaneity -however, they assume that one can only discern their temporal order around an interval of 30 milliseconds.
[5] -at least for Dennis, and only with some degree of sophisticated effort in case a trained musician were to play it.
[6]This could vary according to clients, of course.Most of my clients did not make an explicit decision themselves to take part in music therapy.Educators on their behalf chose it for them.
[7]It is certainly possible to focus on and draw motivation from a variety of areas that may be part of the situation or reside in the behaviour and consciousness of participants!Collections of improvisation exercises exemplify such different approaches.For instance, Schwabe (1992) uses theatre-like elements in the form of children's' plays to a large extent.My own Bergstrøm-Nielsen ( 2009) deals with various other possibilities.
[9]I like to say, metaphorically, that the music therapist must incorporate both a psychologist who knows what to aim for in the therapy -and a musician who knows how to go there, how to find one's way through the landscape.This is why musical material and structure may assume strategic roles of their own.Niedecken (1988) and Lee (2003) also argue in this direction, each in their own way.Niedecken includes a discussion of music as a transitory object, p.23-24.
[10]One could, of course, for a different kind of clients, imagine an asymmetry turned the other way round: the client isvery active, the therapist's role involving much listening and some commenting.I am not dealing with this possibility here.

Figure 1 .
Figure 1.Sound structures with steadiness and firmness as a primary characteristic, each lasting between four and 10 seconds.[view full size image]

Figure 3 .
Figure 3. Therapist extending his playing -"Please, a moment longer!" [view full size image]

Figure 4 .
Figure 4. Dialogue between therapists' voice and Lone's looks.[view full size image]

Figure 5 .
Figure 5. Lone accepts to make room for the therapist.[view full size image]

Figure 7 .
Figure 7. Simplified description of acting on the upbeat cue.[view full size image]

Figure 8 .
Figure 8. Three stages of acting on the upbeat cue -process description.[view full size image]

Figure 9 .
Figure 9. "Patience structure" with variation of durations.[view full size image]

Figure 10 .
Figure 10.Transscription from a session with "Patience structure."[view full size image]

Figure 11 .
Figure 11.The pyramid model.[view full size image]