Orff Music Therapy
This article provides a brief introduction to Orff Music Therapy, an approach to music therapy developed in Germany by Gertrud Orff at the Kinderzentrum München in Munich, Germany. It has been used as a therapy with children with developmental delays and disabilities for over thirty years at the Kinderzentrum München. In the meantime, as a result of training courses, it is also used in numerous other institutions for children and youth with developmental disabilities in Germany. The development of music therapy within the clinical setting of social pediatrics and the use of elements of Orff-Schulwerk are two factors which have had a strong influence upon the philosophy, principles and practice of this form of music therapy. A brief discussion of the historical background, the theoretical foundations and the principles and practice Orff Music Therapy will provide the reader with an overview of Orff Music Therapy. Two clinical examples will illustrate this work.
Orff Music Therapy was developed by Gertrud Orff within the specific clinical setting of social pediatrics in Germany for use with children with developmental problems, delays, and disabilities. This makes it unique within the German music therapy "landscape." It has maintained this area of emphasis and is now used in Germany in numerous institutions in which children with developmental disabilities are treated, educated or cared for - various schools and day care centers for the developmentally disabled and institutions in which the developmentally disabled live. With time, developmentally disabled children become adults, and music therapists who are using this approach are beginning to put the method to use with handicapped adults.
Making Orff Music Therapy available to other institutions required that possibilities for training therapists be developed. In 1980, Gertrud Orff began holding seminars in Orff Music Therapy at the Deutsche Akademie für Entwicklungs-Rehabilitation in Munich, Germany, a private academy affiliated with the Kinderzentrum München, offering continuing education for professionals who work with the developmentally delayed and disabled. Since 1986, a three-year study course in Orff Music Therapy has been offered at the Deutsche Akademie für Entwicklungs-Rehabilitation, designed to train professionals whose area of work is with children and youth with developmental problems, delays and disabilities. The goal of this training is to enable professionals to use this approach to music therapy in their places of employment.
Additionally, a series of three intensive block seminars in Orff Music Therapy are offered at the Hochschule Magdeburg-Stendal in Magdeburg, Germany as part of the normal study course for music therapists at that institution. Students who study music therapy in other German state institutions of higher learning and who are interested in using music therapy to work with the developmentally disabled can complete practical course work at the Kinderzentrum München in the department of music therapy. These "Praktika," as they are called in German, are between four weeks and six months in length and are a required part of the students' training. Students completing practical courses by working with us in the department can become acquainted with Orff Music Therapy through practical work under supervision.
As mentioned above, Orff Music Therapy has been applied as a therapy for children with developmental problems and disabilities at the Kinderzentrum München for over thirty years. As is true of numerous approaches to music therapy, it was developed on the basis of practical experience within a clinical setting (Orff, 1980). The characteristics of the approach and the principles used in therapy were influenced greatly by the clinical setting and the musical background upon which the approach was developed (Voigt, 2001).
Orff Music Therapy was developed within the clinical setting of social pediatrics. This area of pediatrics was developed in Germany after the Second World War by Theodor Hellbrügge, whose work with children who had been raised in institutions led to the development of diagnostic instruments which enabled the diagnosis of developmental delays and developmental disabilities at a very young age (Hellbrügge, 1975). Hellbrügge soon recognized that medicine alone could not meet the needs of the children whose developmental problems were very complex. He included professionals from related disciplines in his concept. In addition to pediatricians, psychologists, physiotherapists, occupational therapists, Montessori-therapists, educators, social workers and pediatric nurses were considered to have important knowledge and skills necessary for diagnosing developmental problems and for advancing the development of children. He also involved the parents of the children in diagnostics and therapy. Gertrud Orff was asked to develop a form of therapy on the basis of Orff-Schulwerk. Music therapy was intended to support the emotional development of children with developmental problems (Hellbrügge, 1981; 1975). Hellbrügge coined the name "Orff Music Therapy" (Orff, 1976).
The goal of social pediatrics is to diagnose developmental problems at a very early age and thus, to make use of the unique possibilities of early childhood development by providing early treatment. Another very important area of emphasis of social pediatrics is the social integration of children with developmental problems (Hellbrügge 1981). The Kinderzentrum München, founded by Hellbrügge in the 1960's, is the largest centre for social pediatrics in Germany today. It is the "home" of Orff Music Therapy.
Although Gertrud Orff considered Orff Music Therapy and Orff-Schulwerk to be related, she did not consider them to be identical (Orff, 1980). Certain elements of Orff-Schulwerk were considered to be useful in the application of music therapy with developmentally delayed children. The following elements of Orff-Schulwerk can be found in Orff Music Therapy today as well.
First of all, as in Orff-Schulwerk, music is understood in the sense of musiké, "a total presentation in word, sound and movement" (Orff, 1980, p.9). "Playing with sounds," role play and rhythmic or melodic performance are examples of music in the sense of musiké. The word "music" is thus understood in its broadest sense and makes it possible for us to include children with developmental disabilities as active participants in the musical therapy setting (Voigt, 1999).
Secondly, improvisation is a central factor in Orff Music Therapy and includes spontaneous play as well as making music. Improvisation serves to provide a creative stimulus for the child. It is not only "free improvisation." The music itself can provide structure just through sound and silence. Improvisation as play provides the children with the possibility to explore and investigate, to put together sounds or objects, to "practice" by playing and to form associations (Orff, 1980; 1989).
A third element of Orff-Schulwerk also found in Orff Music Therapy is the instrumentarium. So-called Orff instruments are used as are other string instruments, keyboard instruments and percussion instruments (Voigt, 1999). The instruments encourage the child to participate actively and provide a means of interacting socially in the music therapy setting (Orff, 1980). Additionally, non-musical materials have their place within the instrumentarium used in Orff Music Therapy. Scarves, hand puppets, balls, chalk boards and other materials can be used by the child within the play situation to express him or herself in the sense of musiké (Voigt, 1999).
The fourth element of Orff-Schulwerk that plays an important part in Orff Music Therapy consists of the multisensory aspects of music. These aspects of music can help the therapist meet the needs of the child (Orff, 1980). Modalities can be combined; for example, children can feel sound while hearing it. Activities which are not limited to the acoustical aspects of music - for example, letting marbles roll along a metallophon into a hand drum or playing a drum so that balls will fly off it - can also serve to motivate a child to interaction, even if he or she is not yet willing or able to participate in musical activities (Voigt, 1999).
Basic Theoretical Foundations
As stated above, Orff Music Therapy was developed based on clinical experience in the work with children with developmental disabilities. The theoretical foundations of the therapy were established over time.
Gertrud Orff always stressed the positive developmental potential of children with developmental disabilities. She deemed it necessary to consider the strengths as well as the handicapping conditions of the children (Orff, 1980; 1989). This attitude corresponds closely to the basic premise of humanistic psychology (Bruscia, 1987; Plahl, 2000). The relationship between therapist and client was seen as a central factor in therapy with the therapist in the role of a mediator for the child (Orff, 1980, 1989).
The work within the area of social pediatrics led to a very strong emphasis on development and developmental processes in Orff Music Therapy. Knowledge from developmental psychology enables us to understand the influence of developmental delays on the child, his family and his environment and complements the humanistic philosophy of the approach (Voigt, 1999; 2001).
In Orff Music Therapy, then, the general development, the personality development and the family situation of the child are taken into account and procedures are adapted to meet the individual child's needs (Voigt, 2001). For this reason, Bruscia (1998) classifies Orff Music Therapy as developmental music therapy.
Principles and Practice
The basis for interaction within Orff Music Therapy is the concept of responsive interaction. This form of interaction combines humanistic philosophy with knowledge from developmental psychology. The therapist is willing to accept the child's ideas and initiative and to interact with the child at this level. Gertrud Orff used the word ISO, which means same or similar, to describe this type of behavior by the therapist. A second form of the therapist's behavior is provocation. Provocation is used when it is necessary to support the child by bringing new ideas and impulses into the therapy situation when difficulties arise in the child's action or interaction. In this case it is necessary for the therapist to adapt her support to meet the needs of the child and to involve the child actively in acquiring new competencies (Orff, 1980, 1989; Sarimski, 1993; Voigt 1999). Responsive interaction enables the therapist to adapt her procedures flexibly to correspond to the developmental level of the child and, at the same time, to support the child in acquiring new levels of competence (Voigt 1999).
Clinical Example 1: Petra
Petra (the name has been changed), was 5 years and 11 months of age when she was referred to Orff Music Therapy for the first time. She was diagnosed as having an unbalanced chromosome translocation, severe mental retardation and epilepsy. She had no expressive language and was limited in her language comprehension. Her reaction time was very long. She often showed stereotyped ways of playing.
After referral, Petra received music therapy during her one to two-week stay in the parent-child-ward at the Kinderzentrum München, which occurred several times a year over a period of six years. Her father was her primary care giver because her mother's profession required her to be gone a lot. He was present during all the therapy sessions. During the times in which they were not in Munich, he used activities from the music therapy sessions with Petra as possibilities for playing with her. Additionally, he shared ideas and principles which he had observed and experienced in therapy with her caregivers in the Kindergarten.
During her first block of therapy, Petra showed much stereotyped behavior and much time and patience was needed in order to establish contact and interaction with her. She often shook a string of beads in a stereotyped way. I accepted her interest in the beads and attempted to convert the activity into an interactive game. I rhythmically commented on the sound that the beads made over a period of eight beats, bringing this rhythmic "verse" to an end with the word "still" meaning "quiet" or "still." By changing the activity with the beads - raising them above my head at arm's length or stretching them to their full length - and commenting on this as well, using changes in the pitch of my voice or the length of the words to complement the action, I was able to hold her attention. She then began to actively participate in the game, pulling the beads down after I had put them up high or pulling on the beads when I said the word "long." Shaking the beads within the clear form described above became a refrain in our game.
In one of the music therapy sessions during her next stay two months later, she began rolling a marble back and forth monotonously, watching it closely and showing little or no interest in interacting socially. Before this, she had been playing the mouthpiece of a lotus flute. I began to "call" the marble by playing a flute mouthpiece myself, additionally verbalizing and using gestures to communicate that I wanted the marble rolled to me. Petra let the marble roll in my direction. I took it and requested that she "call" the marble, which she did! This interaction went back and forth for several minutes. Suddenly, Petra played her flute again after she had received the marble from me, thus communicating that she wanted to keep the marble for herself.
By interacting in this way, it was possible for me to provide Petra with a means of playing in interaction. During the earlier session described, she entered into interaction with me on the basis of her interest in shaking the beads, showing understanding of very simple forms of play when these were provided for her. However, her main interest seemed to be the beads themselves. In the second activity described above, responsive interaction enabled me to accept Petra's interest for the marble (ISO) and at the same time to initiate the use of the sound of the flute as a means of communicating (provocation). Petra was no longer playing alone with the marble, nor was the object the only point of interest; rather, we were interacting in a communicative way, using musical sounds, language, and gestures.
The application of music therapy, however, must be preceded by the establishment of indications for therapy. Developmental problems, delays, and disabilities are often very complex with one primary area affected by a delay also affecting other areas secondarily. Therefore, before indications can be established, pediatric and psychological diagnostics which result in a developmental profile of the child are necessary. On the basis of this profile and the diagnosis of the child, indications for therapy can be established. Only then is it possible to formulate goals for therapy which are adequate for the individual child (Voigt, 2001).
Evaluation of Clinical Example 1
Petra's developmental disability and the developmental profile described above helped us to establish indications for music therapy which were appropriate for her. She showed problems in contact and interaction, had difficulty in making herself understood. Her own spontaneous play behavior often consisted of stereotyped behaviors. These problems represented the indications for music therapy for Petra. On the basis of these indications, goals could be formulated which met Petra's developmental needs for the period of time in which she received diagnostics and therapy at the Kinderzentrum München.
In Orff Music Therapy there are four developmental areas in which indications for therapy are often established. These are the areas of social-emotional development, auditory development, language development and motor development. Problems in these developmental areas can serve as indications for music therapy. In some areas, such as in the area of motor development, music therapy supports other major therapies. In other areas, such as in the area of social-emotional development, music therapy can be the primary form of treatment for the child (Voigt, 1998).
Progress in therapy occurs through the observation of behaviour within the developmental context of the child and through follow-up examinations by the pediatrician and the developmental psychologist (Voigt, 1999). Both forms of evaluation are necessary in order to adapt indications and goals to the child's individual developmental processes during the course of therapy.
During her last stays at the Kinderzentrum, Petra communicated her wishes through behavior; she gave me an object, shook her head or nodded, made eye contact, and initiated well-known activities, etc. She showed much less stereotyped behavior and showed beginnings of understanding symbolic play, for example watching me roll her beads into "snails" to a song, waking them up and taking them out to "play" herself and then making me understand that she wanted to repeat this chain of actions. Similar observations were also made by the psychologist during diagnostics. The role of music therapy in supporting Petra's development in the area of social interaction and communication was clearly described in the final psychological report of Petra's progress during the time she was a patient at the Kinderzentrum.
Music Therapy in the First Year of Life
The spectrum of clients referred to Orff Music Therapy at the Kinderzentrum München is very broad. It includes children with language disorders, with mental retardation and with physical disabilities such as cerebral palsy. Children with autistic disorders or with visual or hearing impairments can also be found among the clients who receive music therapy. Problems in social-emotional development such as elective mutism, extreme shyness or aggressive behavior can also serve as indications for music therapy (Voigt, 1998). Gifted children who have problems relating to their peers represent a new group of children referred to Orff Music Therapy. A very special group of children who often receive music therapy are children within the first year of life who show signs of more than one developmental delay or disability. Because of the complex problems of these children, the most common goal in Orff Music Therapy for them is the development of interactive competencies - competencies which enable them to interact with persons and objects in their environment.
Working with Parents
Conducting music therapy sessions with children and their parents has become a very important part of Orff Music Therapy. It can be particularly important in music therapy with very young children with multiple developmental problems and disabilities. Because the child may not be able to respond as expected to suggestions for play or interaction or show behaviors that are difficult to understand, some parents may develop uncertainty in interaction with their child. Problems in accepting the child's delay or disability, in being able to recognize the child's strengths or feeling responsible for the child's developmental problems can also influence parent-child interaction negatively. Additionally, stress factors in every day life - for example health problems of the child, the need for extensive therapies or the care of siblings - can have an effect upon parent-child interaction. When this is the case, parents may need support so that problems in interaction between them and their child can be avoided or minimized (Voigt, 1998; 2002).
Examples of goals in working with parents are supporting successful interaction, supporting parents in using responsive interaction in playing with their child, providing ideas for play at the appropriate level for the child, supporting parental competence and helping parents develop techniques and principles for dealing with behavior problems (Voigt, 1998; 2002).
The starting point for Orff Music Therapy is the actual developmental level of the child. Simultaneously, the parents can be involved in therapy. They can observe the therapist as a role model in working with the child without the pressure of having to act themselves. In this way they can experience the strengths as well as the weaknesses of their children and receive ideas for ways of playing with them, not just for them. Parents can assist the therapist in handling their child. In this situation they are involved in a more immediate way than when they only observe, and they can experience the child's capabilities in play very directly. Parents can also participate actively in music therapy activities, playing with their child through responsive interaction using music, actively influencing the process taking place. In this way, the parent-child interaction can be supported, which, in turn, can support the development of a positive parent-child relationship (Voigt, 2002). The following example (Voigt, 2002) can help to illustrate working with a very young child and his parents.
Clinical Example 2: Mark
A boy (I will call him Mark), eleven months of age, was admitted with his parents to the parent-child ward at the Kinderzentrum München. He was diagnosed as having a severe cerebral motor disturbance with signs of spastic cerebral palsy and a disorder in the ability to swallow. He was also diagnosed as having a severe general developmental delay. Coughing or sneezing was not possible, resulting in life-threatening situations when Mark had a cold. In relation to motor development, he was just beginning to turn from his back onto his side. He did not respond when spoken to, but laughed when his parents laughed. It was also suspected that he had a visual disability. He received physiotherapy and therapy for the swallowing disorder.
Mark was referred to Orff Music Therapy. Due to his severe developmental problems, it was very difficult to assess Mark's development using the conventional methods. One indication for therapy during his first stay was the necessity for the assessment of development, using music therapy as a means of observing his behavior within a social situation of play. The other indication was the necessity to support parent-child interaction. Mark's health problems were so complex that interaction between his parents and him had been reduced mainly to bodily care.
Mark received five music therapy sessions during this time. Because of his severe motor disability, I worked with him mainly on the floor, since we have observed that these children are able to be more active when lying on their backs. His parents attended all sessions. At the beginning, they observed the course of therapy, assisted me in handling him when necessary and helped me to understand his vocalizations and behaviors. Later on, they were involved actively in the therapy session.
During the first session, I developed an interactive game with him on the basis of a German children's song about galloping ponies, placing bells around his hands. At first I moved his hands to the song so that sounds would be produced. When the song was over, I asked him where his "ponies" were. Even if he moved his hands spontaneously by chance, I reinforced his "answer" socially and answered him myself with my bells, repeating the song after the dialogue-like exchange. After nine minutes he moved his arm very distinctly up and down, and the bells rang very clearly. From this point on, he always answered in this way during the dialog part of the song.
During his first stay, this activity became one of the most important activities in working with Mark. Variations were developed when a new behavior was shown - for example, when the bells dropped off his hand - even if this occurred by chance at first. Mark's parents commented that they were pleasantly surprised at his activity. They usually perceived him to be very passive.
During the fourth session, Mark's mother was asked to participate actively using the game involving the "little ponies." At first, she needed a bit of cuing as to when to respond. However, within the activity she began to gain confidence in her ability to play with Mark using music, and she became clearer in giving him signals. The joy that both mother and child showed during this developing interaction was clearly observable and very touching.
Evaluation of Clinical Example 2
Mark's parents told me that the musical activities from this first stay had become part of the family's repertoire of games that they played. Eight months later, during Mark's third stay at the Kinderzentrum, it was possible to observe that the parent-child interaction had developed further. An activity had been begun in which I played the drum while Mark rolled back and forth between his father and me, laughing. His father offered him a mallet spontaneously without being cued. Mark then was very active in determining what happened. He rolled back to me, played on the drum and rolled back to his father, giving him the mallet. He then took the mallet back, rolled to me again, played the drum, rolled back to his father, repeating the sequence. He seemed to thoroughly enjoy himself, as did his father.
Our work in Orff Music Therapy with Mark during the period of time described above had enabled us to detect that he had more resources than were first observable. The development of interactive competencies, the ability to interact with objects and persons in his environment, was begun on the basis of these resources. Mark's parents had many worries because of his severe health problems. During the music therapy sessions, they had the opportunity to observe him in a musical play situation and discovered strengths in their child that they had not perceived before. At the same time, they discovered their own intuitive abilities for play and interaction and began to use these in order to play with Mark, not just to care for him physically.
Summary of the Model
Orff Music Therapy is a developmental approach to music therapy which was developed in Germany within the clinical setting of social pediatrics for the treatment of children and youth with developmental problems, delays and disabilities. Elements of Orff-Schulwerk have been incorporated in the therapy in order to enable these children and youth to participate actively in musical activities within therapy.
Orff Music Therapy is humanistic in philosophy and stresses the positive potential of children with developmental problems. At the same time, knowledge of the developmental problems is drawn from developmental psychology, enabling an understanding of the developmental processes of the children, including personality development, and of the problems which their parents and siblings face. Because of the complexity of developmental disorders, the establishment of indications for therapy is a prerequisite to beginning therapy. The process of therapy is then adapted to meet the needs of the children and their parents through the use of responsive interaction within a musical situation of play.
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