MUSIC THERAPY FOR PEOPLE IN A DISABILITY SITUATION: METHODOLOGY AND PROCESS

The research was constructed on the ground of the ideas of postpositivism, when the research data based on personal experience is of not lesser importance than “clinical” evidence. Our research aimed at answering the following questions: At what extent is music theory useful to people with mental disability? At what extent are the authorial methods of application of music theory designed by the investigators useful? At what extent are the participants able to express their feelings and evaluate the process of music therapy? The initial research results suggest that the authorial methods based on the ecological systems theory are effective and useful to the practice of social work in the Occupational Day Centre while providing services to individuals with mental disabilities. The obtained research data allows stating that the way chosen by the investigators to assess effectiveness of music therapy (filling in small books and conversations while filling them in) enables participants reveal their condition, feelings as well as evaluate the process of music therapy.


Introduction
The article presents the research which, as a means of students' scientific summer practice, was funded by the Research Council of Lithuania. The research reveals both possibilities of an individual who occurs in a situation of disability to receive service of music therapy and the benefit of this process, because each person wants to feel healthy and happy, to meet own emotional, psychological needs, to learn to react to surrounding environment more flexibly. Images on a television screen, incidents on the street or even a shop can be the triggers for a person with disability; such a person suffers much because of a quarrel at home with family or even neighbours. Our society seeks integrating individuals with disabilities: they attend kindergartens, institutions of education; however, after graduating from special centres or other institutions of education and not being able to enter the labour market, they spend their time at home or institutions providing social services. Staff of an institution providing various social, rehabilitation, medical services often suppose that if a person has a psychic, physical or complex disability, receives income because of their disability, therefore, he/ she does not experience any psychological, social or other problems in surrounding community. Usually, while providing care, occupational, treatment services, institutions do not provide any opportunity for people with disabilities to use the needed psychological support. Frequently, all services to clients of institutions are usually provided by one psychologist who, even highly willing, has no chance to allocate time for consultations to all receivers of the services: "Health is one of the most precious values of a man. Only a healthy person feels being happy, able to enrich the world and society with one's work, ideas, achievements. A healthy person feels being needed to oneself and others. Not only harmonious performance of internal organs is important. Equally, internal harmony (emotions, feelings, thoughts) is of great importance, too. Only when the body and soul are in harmony, a person feels being strong and sane." (Kriukeliene, 2008, 7).
The research was constructed on the ground of positivist ideas emphasising that personal experience-based data is of not lesser importance than "clinical" evidence. The investigation aimed at answering the following questions: At what extent is music theory useful to people with mental disability? At what extent are the authorial methods of application of music theory designed by the investigators useful? At what extent are the participants able to express their feelings and evaluate the process of music therapy? These and similar questions reflect the problem of the article.
In order to answer the said questions, a research was conducted as an alternative to currently existing practice of treatment of individuals with disabilities, which is usually based on pharmaceutical treatment, including psychotropic medicine. Social workers do not know, are not able and usually do not apply alternative methods, such as fine art or music therapy. The services provided by Lithuanian occupational day centres are not updated, instead they repeat every year. The researchers hold an opinion that people in a disability situation could be assisted by alternative methods, including music therapy. This method is increasingly promoted worldwide as a supplementing opportunity for treatment, education and elimination of daily routine in general. These methods help in cases of various mental, physical, complex disabilities, autism spectrum disorder, releasing accumulated emotions. Music therapy can be estimated as one of the opportunities to provide new, alternative services to people with disabilities, since they meet their diverse needs.
Deeper investigation of set research questions was grounded on the ecological systems theory which underlines that when changing the person's microsystem, in this case applying music therapy, all systems surrounding that person change, too. Major authors of the theory referred to by the investigators were Bronfenbrenner (Bronfenbrenner & Morris, 2006). Lithuanian authors J. Ruškus (Ruškus, 2010) and T. N. Liobikienė (Liobikienė, 2016). The basis of data collection and interpretation of music therapy consists of the interactional methodology approach whose choice was mostly influenced by Susan Bridges and Monaliza Maximo Chian's seminar on the method of interactional ethnography (Bridges & Maximo Chian, 2019). Moreover, the training on M. Bakhtin's ideas in relation to the impact of environments was referred to (Baranauskienė, 2018). M. Bakhtin influenced the investigators' attitudes towards application of creative sessions of music therapy based on improvisation intended for people with disabilities.

The meaning of art therapy in a disability situation
The developed countries worldwide pay much attention to improvement of the people's with disabilities quality of life, i.e. provision of material, physical, emotional, psychological support. Various programmes and methods helping individuals to maintain easier living being impacted by a disease as well as family members and entire society are being constantly updated and developed. Thanks to contribution of various social programmes, projects, organisations, individuals with disabilities are immediately included into the social life.
Scientists have it that music can be used for changing the awareness about the condition which would help revealing hidden emotions and stimulate creativity (Aleksienė & Lesinskienė, 2017;Vilkelienė, 2015, Virbalienė et al., 2016Wigram, 2004). Individuals with disabilities visiting social institutions exclusively undergo various negative psychological conditions being impacted by surrounding environment, also due to progressing effects of their disease. Usually, they are ill with severe or mild forms of depression, have low self-value and excessively sensitively react even to smallest problems. Simulation of positive emotions as well as occupational activities helping them to concentrate on a target and dissociate themselves from a negative emotional load are needed for people with disabilities. T. N. Liobilienė has it: "personal characteristics, lifestyle, relationships with environment are influenced by culture, social environment and their structures; on the other hand, under favourable conditions, a person may change and influence the changes of the microsystem" (Liobikienė, 2016, 37).
"It is believed that creation, especially artistic one, stimulates the pineal gland in person's brain, this way activating the entire endocrine system. Through creativity, the accumulated anxiety is being released, the "self" is being revealed at a greater extent (Torravice, 1978). Heath has it that "the ability to express in words, numbers, images, sounds of music, gestures improves adaptation because the past, the present moment can be grasped, consequences of the future activity can be predicted", as cited from L. Kriukelienė (Kriukelienė, 2008, 11). Throughout the world, the investigations on and benefit of music therapy for people with disabilities are being more intensively promoted; it is being applied from infancy to old age, from single-time to long-lasting activities being applied both individually and in groups, improving common condition, reducing the progress of diseases, including people with disabilities into society. Art therapy, including music therapy, aims at rendering the sense of completeness and as many positive emotions as possible to people with disabilities.
As J. Ruškus holds it, "[t]he power of music on human's emotions, the functioning of the entire organism is large. Contemporary science and medicine help understand that the language of music can reach the depth of brain. Music is being successfully applied to reduce blood pressure and pain, to relax. Both slow, calm and fast music make a remedial effect." (Ruškus, 2010, 40). "Music is endowed with remedial, developing and spiritual features", as stated by a music therapist Dono Campbello, cited from Ruškus (Ruškus, 2010, 40). Various investigations of music reveal the effect of music on treatment of various diseases in people with various disabilities (Kamioka et al., 2014;Aleksienė & Lesinskienė, 2017). As scientists hold it, management of emotions and stimulation of positive emotions are necessary for people with moderate and severe disabilities (Vilkelienė, 2015;Wigram, 2004). The earlier expressed statements are also proven by a research on the effect of music therapy conducted by Japanese scientists in 2014, concluding that "MT [music therapy] treatment has positive effects for the following: schizophrenia and/or serious mental disorders for global and social functioning, Parkinson's disease for gait and related activities, depressive symptoms, and sleep quality. We assume that the direct effects of MT are generally improvement of mental health and sense of rhythm, and reduction of pain. In addition, we assume that communication with other people improves through music, the sense of isolation disappears, and QoL [quality of life] rises." (Kamioka et al., 2014). People in a situation of disability more often have a possibility to feel the effect of music therapy applied to them to ensure comprehensive integration into society. "A person with disability in his/ her achievements may be equal to a healthy one; however, to achieve his/ her goal, one is forced to allocate much more endeavours, willingness, patience and time." (Kriukelienė, 2008, 7).
In Lithuania, the methods of music therapy are also being applied; nevertheless, there are not many specialists working in this field: "According to the Official Statistics Portal data in 2017, the resident population in Lithuania was 2812.713. Presently there are 15 professionally trained music therapists and 22 pioneers in music therapy recognized by the Lithuanian Music Therapy Association, who have gained experience in their many years of practice. That shows that the ratio is 0.001 therapist to 100,000 inhabitants. However, the number of music therapists is still small and the need for qualified specialists is increasing because of the wide possibilities of applying music therapy, both in work with children as well as with adults, in various medical, educational, and social spheres." (Aleksienė & Lesinskienė, 2017, 28).

Music therapy and our project
Usually, occupational music activities at the institutions of social services to people with disabilities are provided by the staff who have their educational background in social work but not music, arranging music activities according to their designed model of work, applying only those personal competences they have. Any descriptors of the procedures of the state or municipal level are not designed for a social worker providing occupational music activities to people with disabilities, even though music therapy could be an inseparable part of music activities; naturally, in such a situation, music therapy activities are not included into a descriptor of social worker's, as an occupational therapist's for music, position and because of the attitude, unawareness, inability of staff members providing social services at the discussed institutions the method of music therapy is not applied at all or, if applied, it happens very seldom.
This investigation was relevant to us personally because one of the investigators works in an institution providing social services to people with disabilities and, while providing occupational music therapy service in practice, she noticed that a specialist must create the work methods himself/ herself, since there are no guidelines to be applied by occupational specialists regulated by state institutions. Over eight years of work, the investigator observed the impact of music therapy and understood that it was not enough for the clients to listen to the music or take part while primitively singing. Moreover, it was observed that clients' emotional conditions when they enter an institution or occupational activities room make effect not only on themselves but also on other visitors and specialists. Usually, emotions of people with disabilities are very stormy, negative, full of aggression or sadness. The specialists have a difficult task to listen to the visitors and achieve the goals set jointly with them. The aim set by us as researchers was to understand the effect of music therapy on people with disabilities as an alternative to management of emotions and creation of positive environment.
As mentioned in the earlier sub-section, the construction of the research was based on the ecological systems theory. J. Ruškus has it that "[w]hen applying the ecological systems theory in social work, a precondition emphasising that people are systems themselves and depend on various systems existing in the environment which meet/ do not meet each individual's needs is maintained. An individual is a part of a larger system, for instance, a family, a small group, a community, various institutions (school, hospital, social institution), society, nation, state and other." (Ruškus, 2010, 73). Adults with disabilities usually spend their time in institutions providing social services funded by municipalities, where in most cases they are provided with various occupational, physical therapy activities; nevertheless, the instruments to solve emotional, psychological problems of people with disabilities are too mean. When allocating insufficient funding to institutions providing social services, psychologists, social workersoccupational specialists working here face high responsibility for improvement of psychological and emotional climate for people with disabilities, which impacts not only an individual himself/ herself but also the entire surrounding external and internal environments, one's relationships with family and relatives, various other institutions. A person with disability becomes an active participant of the system: "A system is an organised structure made of interrelated and interacting parts coordinating their actions to achieve the goal." (Liobilienė, 2016, 37).
Ch. Zastrow has it that "the object of the ecological systems theory is the relationship between individual and environment emphasising its disfunctionality (disorder). It is supposed that people develop and adjust to environment while interacting. The attention is focused on both internal and external factors", as cited from J. Ruškus (Ruškus, 2010). Referring to the hypotheses of likely investigations, application of music therapy to people with disabilities could be not only an instrument for improvement of institution's clients' emotional condition but also perfection of the emotional climate of an entire institution, including clients and staff. Citing J. Ruškus "from the point of view of the ecological systems theory, it is aimed at recovery of a balance between individual's needs and environmental conditions." (Ruškus, 2010, 75). As further J. Ruškus has it, the process of solution of the process employing the systems theory model comprises steps which in general could be divided as follows: definition of a client; definition of a target system; definition of an action system; intervention and testing; assessment and completion (Ruškus, 2010, 75, 76).
Grounding on practice and investigations of music therapist throughout the world (Swedberg Yinger, 2018;Letulė & Esa Ala-Ruona, 2016;Wheeler, 2015;Wigram, 2004), the methods were used to perform music therapy grounded on methodological provisions of mentioned authors and methods applied by an organisation "Dissmilis" employing music therapy for people with disabilities in Norway. The following methods have been used in music therapy: reflection, imitation, copying, match, empathic improvisation, method of a music dialogue, reflexion. While preparing for investigation of music therapy, researchers of the project used various percussion, keyboard, string instruments which were freely chosen and changed by participants of the project in the course of music therapy in compliance with performed activities or moods.
The aim of the project funded by the Research Council of Lithuania ("Development of Researchers', Other Researchers', Students' Scientific Competence through Practical Scientific Activities") is to provide higher quality music therapy services to people with disabilities while meeting needs. The objective of the research is to perform assessment of the effect of music therapy on people with disabilities while employing the method of interactional ethnographical data analysis. 5 adults with mild, moderate and severe mental disorders attending a subdivision of social care of the social services centre took part in the investigation. After receiving consent from the research participants, music therapy was being applied for 2 weeks. The research participants had 8 group music therapy sessions. Each activity of music therapy lasted for 45 minutes. Structured characteristics of the research participants are provided below: • Individuals with severe mental disorder, atypical autism, epilepsy, moderate mental disorder, moderate mental disorder with severely pronounced behavioural disorders and mild mental disorder.

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The age of the research participants varied from 24 to 41 years. The average age was 32 years.

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The participants live in urban territories.

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The sample comprising daily visitors of the institution was a major criterion in selection of the participants because implementation of the investigation focused on continuous application of music therapy sessions lasting for 2 weeks. Aiming to assess the effect of music therapy, the method of interactional ethnography was employed. The method of interactional ethnography is widely applied in foreign countries to carry out various scientific investigations; however, the form of this scientific research is innovative in Lithuania and meets the goals set by researchers; moreover, there is no data application of scientific investigation employing interactional ethnography to people with disabilities, therefore not only individuals with disabilities but also their parents and heads of institutions where the investigation proceeded were not aware of the form of this scientific investigation. "Interactional ethnography can be called an approach to social reality from a postpositivist stance." (Baranauskienė, 2018, 179). Before deciding about the research methodology, the investigators took part in academic seminars delivered by Susan Bridges and Monaliza Maximo Chian on the approaches of interactional ethnography. This seminar gave many insights and provided needed information to form the research framework. Interdisciplinarity became the goal of the investigators: on the one hand, what the investigators thought they knew, on the other hand, what the surveyed knew. Each of the participants of the project became a linking chain merging theory and practice in application of interactional ethnography. Investigators' focus on a person is also emphasised by M. Bakhtin. "Bakhtin makes emphasis on a human. Everything concentrates on a particular person: "Architectonics as visually necessary, purposeful dislocation of specific singular parts and aspects as well as relation in the complete whole are possible only when focusing on a particular person, a hero." (Baranauskienė, 2018, 180). I. Bairašauskienė supports the said ideas of the researcher: "Still, as Castanheira, Crawford, Dixon and Green have it, a major thing which is common to all sides is to investigate and reveal individuals, i.e. insiders, comprising a social group, which, as they state, is cultural knowledge, or insider meanings. Therefore, when performing ethnographical research, first of all, this major principle should be followed when investigating both society, family, social group or class of school students and social processes or single individuals." (Bairašauskienė, 2019, 209). Grounding on theoretical approaches of interactional ethnography, 2 video recorders filmed 8 activities of applied music therapy. Duration of each was 1 academic hour.
After each activity of music therapy, the research participants took part in a survey prepared in compliance with the authorial books designed by the project researchers (Latakienė & Baranauskienė, 2019). They were created with regard to participants' disability; therefore, the survey of them was based on a drawing, colour expression etc. The method of assessment of the effect of music based on such survey was chosen because of disability of the participants and their inability to read and write. Chosen colours and forms made it easy for the participants to render their emotions on paper and, being asked, they could express them in words. Books of the participants that were being filled out in the course of the survey were based on interpretational methods of fine art therapy (Kriukelienė, 2008;Lebedeva, 2013). The content of these books consisted of the following: emoticons expressing various moods, visual diagrams, selection of performed activities and enjoyed instruments, picture on a freely chosen topic depicting one's condition during music therapy. Each filling of the book was video recorded and lasted for 1 academic hour. The investigators sought to find out the selection of answers; therefore, after filling out the books, a verbal discussion (prepared in advance by the investigator) proceeded.
After application of all eight activities of music therapy, the results were detailed by using a structured oral group survey asking the participants openended questions. This survey aimed at finding out how participants assessed application of music therapy they experienced. Grounding on operationalization of the research object, a structured questionnaire was prepared reflecting five topics in its content the investigators were interested in: condition of participants; benefit of music therapy; topic of learning; discussion on what was not enjoyed and recommendations for the investigators. Such form of the investigation was chosen because of inability of the participants to read and answer presented questions in written. The entire survey was video recorded to provide conditions for the investigators to regard not only words but also emotional condition, nonverbal language while providing answers.

Initial results
The results were obtained in 3 ways: video recording, analysis of books and group survey.
The analysis of video recorded music therapy activities is time consuming; therefore, this article limits itself with presenting initial results obtained after analysis of the books and conversations that proceeded while filling them in. Individuals with disabilities who took part in the music therapy activities could express their moods and emotions through the answers provided in the books; moreover, the methods of colours allowed them to openly talk about their feelings and images displayed in their drawings. The analysis of the books allows drawing assumptions that continued activities of music therapy led to more complex drawings of project participants, the images seen and drawn in the books during music therapy became clearer, brighter and related to experienced good emotions or still unfulfilled dreams. The participants drew more different elements, symbols which were important to them and applied different colourful combinations motivating interpretation of their drawings by the images they saw during music therapy activities. Assumptions of the investigators are based on responses of the participants: "here I drew a submarine, a transparent one, where the bed of the sea is seen. You can go by this boat and see everything what is happening under the water. Here, diverse fish swim (...) I haven't been in a submarine, but I would like to" (respondent no. 2).
Grounding on the surveys, filled in authorial books, completed music therapy activities, the following tendencies are pointed out: • The participants had changing moods at the beginning of music therapy activities: from apathetical to "good" (in words of the participants) to "excellent", "fantastic", "very good" emotions as assessed at the end of the activities. The research participants felt an improved emotional condition.

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The participants felt more focused, did not think of negative things that earlier depressed them. They felt like being more able to concentrate their attention and were ready for other activities of the day.

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The participants of the project would say that they would like to have continuous music therapy activities after implementation the project ended. The participants supposed they wanted to take part in group activities of music therapy "every day" or "several times per week", all individuals with disabilities who took part in the survey would like to participate in music therapy activities.

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While assessing the data of the books, the investigators draw an assumption that those individuals who had moderate and severe mental disorder felt greater effect of music therapy, since the initial examination of them demonstrated higher retardation, lack of emotions and unpredicted changes of moods. In the course of the research, the investigators faced several unplanned difficulties which could alter the proceeding of the investigation: the time of investigation coincided with the period of summer holidays and clients attending an institution were on holiday. In the constructed research, the investigators determined to apply music therapy to people with severe mental disability; however, in the period of summer holidays, the investigators could not include a group of planned composition and they had to improvise and proceed with projected activities with those clients who attended the institution, which resulted in selecting research participants who had disabilities of different degree. The research sample and application of interactional ethnography require much more time than planned by the investigators; therefore, in order to not diminish reliability of the research, the materials collected throughout the investigation cannot be presently published because they are still under analysis.
Success of the research: application of music therapy to a group of people with disabilities helped the investigators to reveal groups of instruments and activities which were enjoyed by the participants the most; after application of music therapy was completed by the investigators, the individuals who took part in the music therapy investigation ask to continue application of music therapy in the course of music activities, which could be the cause for them to attend the institution even more often.

Conclusions
The research has proven the data of the scientific study holding it that music therapy brings obvious benefit to people with disabilities.
Initial results of the investigation allow stating that the authorial methods based on the ecological systems theory are effective and useful to social work practice of the Occupational Day Centre while working with people having mental disability.
The obtained research data allow us stating that the way chosen by the investigators to assess effectiveness of music therapy (filling in of books and conversations while filling them in) allow the participants to reveal their condition, feelings and evaluate the process of music therapy.
It is likely that the following analysis of the video recorded data will deepen the conclusions, reveal the benefit to the participants and allow enriching the process of music therapy.