Testing out Approaches

The Preliminary Study pointed towards the intertwining work of therapist, child, and parent in music therapy.25 I became convinced that, given its participatory nature, it was not possible to conceive of either the practice of music therapy, or its investigation, without giving appropriate weight to the work of all those within it. This conviction had implications at this bridging point, as I sought to bring the next phase into focus. Contextualising the study in a particular NHS narrative around patient involvement grounded my thinking at this point. I include here a limited review of the relevant literature which brought significant impetus and direction to the research process.

In 1999, Angela Coulter, then the Executive Director of the influential health charity the King’s Fund, wrote an editorial entitled, ‘Paternalism or Partnership?: Patients have grown up and there’s no going back’.26 _{Patient partnership, she proposed was ‘firmly}

on the agenda in the NHS’ (p. 719). Despite the amount of activity in the area since 1999, in 2012 Coulter reported on the effects as being ‘disappointing’, citing the

25 _{Figures 3:6 and 3:7 in chapter 3 both indicate the dynamic nature of each participant’s}

activity.

26 _{The King’s Fund works to improve health and care in England, and espouses a vision of}

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organisation as a whole to be insufficiently patient-centred (p. 4). A recent narrative review further fleshes out the picture of patient involvement during that period, noting the sporadic nature of change and the ‘power imbalances’ that permeate the

involvement process (Ocloo and Matthews, 2016, p. 629).27 The imbalance of power is commented on forcefully by Gibson et al who describe some models designed to encourage patient and public involvement as being:

[…] controlled by salaried involvement professionals with committed volunteers being allocated a secondary, relatively impotent and subservient, role in organizational and

bureaucratic labyrinths. (Gibson et al, 2012, p. 534)

Certainly, the organisational challenges of building patient involvement are deemed to be complex (Renedo and Marston, 2011; Armstrong et al, 2013; Filipe et al, 2017). Beyond the organisational considerations, however, lie ideological problems with the notion of ‘patient involvement’ itself (Centre for Patient Leadership, 2013; Seale, 2016). Involvement is often construed as a tokenistic invitation for lay representatives to

contribute to existing organisational structures and systems. The emerging concepts of ‘patient leadership’ (Centre for Patient Leadership, 2013) and later ‘shared leadership’ are intended to disrupt conventional healthcare dynamics of patient and provider, and signal a fresh approach to designing and offering healthcare (Seale, 2016). 28

Emerging models such as these challenge a status quo, seeking to value and utilise different knowledge, skills, and experiences in creating health and care services (Gibson et al, 2012; Filipe et al, 2017).

From Involvement to Crafting

This broader policy narrative steered the emerging perspective for the next phase. Framing the enquiry as an investigation of parental involvement became problematic. To do so risked presenting therapy in paternalistic terms as something into which a parent might be invited rather than, as the Preliminary Study suggested, something in which the activity is jointly generated with the parent. I needed to find another lens

27

Ocloo and Matthews (2016) note the terms variously used in the literature to denote

involvement including ‘consultation, engagement, participation, partnership or co-production’ (p. 327), which may imply greater or lesser degrees of involvement.

28

David Gilbert and Mark Doughty established the Centre for Patient Leadership, a collaborative venture arising in part from their own experiences as patients over significant periods of time. (www.engagementcycle.org/about-us/centre-for-patient-leadership)

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which offered a better ideological fit, and which mirrored more closely the detailed activities of all three in the trio as seen in the Preliminary Study.

Evident within the trio’s workings was what could be understood as the ‘craftsmanship’ of the individual and the individual in relation to others (Sennett, 2008). From a recent music therapy practice perspective, Rolvsjord (2016) has traced the frequent emphasis in literature on the therapist’s craft. This is particularly evident in terms of a prevailing discourse of interventions or techniques within a conventional medical model.

Rolvsjord argues for a reorientation of emphasis towards the client’s craft, described as ‘competence and efforts in using music in everyday life, and competence and efforts regarding the therapy sessions and therapeutic process’ (p. 561). In changing the emphasis, the therapist’s crafting role then shifts from ‘the intervening expert’ to someone who works collaboratively, seeking partnership with the client. However, examining ‘craft’, Procter (2014, p. 25) suggests, is often lost within what he terms the ‘triumphalist narrative’ of the professional expert.

Adopting a practice perspective that considers both therapist and client to be crafting therapy together has implications for the way music therapy is investigated. In an earlier paper addressing questions of what constitutes evidence, and for whom, DeNora argues the logic for an equitable approach, saying:

A focus on the music therapist’s craft as the active ingredient in music’s therapeutic effectiveness leads to the symmetrical concern with what the client does….If we are to understand the mechanisms of music’s effects, then, it is important to develop a symmetrical focus on both the music therapist’s and the client’s craft. (DeNora, 2006, p. 90)

The findings from the pilot study suggested that the crafting within the trio could not be understood in individualistic terms. Removing one voice rendered the whole

meaningless. Both from an ideological perspective and in terms of exploring further the ‘mechanisms’ through which the broadest manifestations of the trio appeared, it

became clear that a ‘symmetrical focus’ was necessary. As a research stance, I hoped this would enable me to resist privileging any one particular voice, activity, or role in my investigation, or pursuing an approach that centred the therapist.

149 Exploring Expertise

During the period in which the bridging work between the two studies took place, I read widely, particularly exploring healthcare literature in areas of parental involvement, participation, and crafting. In doing so, expertise began to emerge as a frequent theme. This sparked a curiosity in me. Could the participatory work of music therapy be interrogated in terms of expertise, and might this offer a way of both acknowledging the activity of all and resisting any grand narrative of singular professional expertise? Guided by these questions, I searched healthcare literature purposefully in order to uncover relevant literature. My focus lay in finding literature addressing expertise across and between professionals and families within children’s healthcare in particular. I begin here, however, with some broader thoughts on professional expertise, as suggested through contemporary literature.

A Broader Healthcare Perspective

Professional groups often have particular interest in understanding and defining their own specific areas of expertise. This is seen, for example, in recent papers within community nursing (Dickson et al, 2017) and speech and language therapy (Jackson et al, 2017). This is understandable, given the political imperatives there may be to achieve professional legitimacy, or to create the ‘triumphalist narrative’ of which Procter (2014) speaks. Jackson et al suggest that, in addition to core competencies, it is when practitioners are ‘seen to contribute to the community’ that they become known as experts, suggesting that it is in the relational turn that professional expertise comes to be understood (p. 614). Defining professional expertise may assume importance in relation to questions of practice, efficacy, and training, as seems evident in a number of papers in a recent psychotherapy journal (Hill et al, 2017; Reese, 2017; Goodyear et al, 2017). As Goodyear et al comment, ‘it will affect how we practice, how we prepare others for practice, and even the quality of care our clients receive’ (p. 56).

O’Shaughnessy et al stand out as relatively isolated voices, arguing against the notion of an individualised, absolutist therapeutic expertise:

We struggle to see how expertise can be decontextualized from a specific clinical interaction or setting and individualized into the characteristics of a single clinician. Said differently, we suggest that there are just as many ways of being an expert therapist as there are ways of knowing and being in the world. (O’Shaughnessy et al, 2017, pp. 95-96).

The authors suggest that it is in the therapist’s flexing in response to person, place, and moment that expertise becomes apparent. It is through this responsiveness that the

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therapeutic relationship becomes, in Rolvsjord’s words, ‘something evolving and unfolding between two human beings’, dynamic and respectful of what the other brings to the encounter (2016, p. 561).

The Danish psychologist and psychotherapist Ole Dreier, brings a further voice of interest to this discussion. His low-key definition of therapist’s expertise is that it consists ‘in a general knowledge from which a set of techniques are derived as

professional know-how’ (2008, p. 3). His research interest is not, however, concerned with those techniques, but rather with the work of clients, both in but particularly beyond sessions, in bringing about change (2008, 2011). That this is the way in which the work of therapy is accomplished is taken as self-evident, given the relatively insignificant amount of time client and therapist spend together each week. As he asks, if appointments last for an hour, ‘how then can sessions be so decisive as to trigger everything else?’ (2008, p. 17). The clear implication is that clients bring their own ‘know-how’, or expertise, to the therapy process.

In turning attention to the work of parents and professionals in, predominantly,

children’s healthcare, the negotiating and contesting of expertise and know-how can be seen to thread through the literature. Parents accrue and develop a wide range of specific skills and knowledge in relation to their child by virtue of being parents. These skills often become particularly enhanced when a child has particular medical or learning needs (de Geeter et al, 2002; Hayles et al, 2015). In contact with healthcare professionals, parents may hold an expectation that they will be included in their child’s care, and that their expertise will be valued (Balling and McCubbin, 2001; Heath, 2013). Such an expectation rests on the assumption that, given the often significant amounts of care parents provide at home, they have ‘acquired a more personalised understanding of their child’s specific needs and condition than the healthcare professionals’ encountered at any point (Heath, 2013, p. 90).

Despite the wealth of experience parents hold, there is a widely reported belief that their expertise is still not recognised by healthcare professionals (Kirk and Glendinning, 2004; Smith and Kendall, 2016; Swallow et al, 2013). Swallow et al, in a review of research literature, suggests it indicates that ‘parents believe their expertise is not valued by health professionals, and tension and conflict between parents and professionals are often reported’ (no pagination) Such tensions are explored by a number of writers who variously suggest the potential threat to professional identity (Heath, 2013), the misalignment of values between parent and professional (Denis-

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Laroque et al, 2017), and the inherent imbalances of power within the health and care encounter (Leiter, 2004) as possible contributory factors. Leiter offers a U.S.

perspective on the work accomplished between parents and professionals with children with additional needs, identifying the inherent inequalities on which successful

collaboration pivots:

Professionals are expected to create equality in a situation in which people are unequal in terms of power and resources. (Leiter, 2004, no pagination).

De Geeter et al (2002) further comment on the organisational values and ethos within which any interaction between parent and professional takes place. They note, ‘the degree to which parents can play an expert role depends to a large extent on how the facility envisages the relationship between parents and staff’ (p. 445). The facility, or institutional context, is a third figure, which itself may need to make cultural and training shifts if professionals and parents are to make optimal use of each other’s expertise (de Geeter et al, 2002; Leiter, 2004).

When parent and professional work in close partnership with each other, the specific context in which that partnership takes place shapes the ways in which it unfolds (Tourigny et al, 2008; Tourigny and Chartrand, 2015; Swallow et al, 2013; Sabadosa and Batalden, 2014). With a chronic healthcare condition, such as cystic fibrosis (CF),29 Sabadosa and Batalden suggest that the model of care involves far more than aiming towards the patient being at the centre of care. Rather, in order to manage the condition well, it requires ‘the interdependent cooperative work of patients, parents, families and the health professionals who have specialised in one or more aspects of the disease’ (p. 93). Of such cooperative work, Swallow et al note the need for a high degree of flexibility required to achieve this in the context of children with complex long- term needs, commenting:

A particular challenge that professionals identified was the fact that individual parents’ situations and possible responses to situations vary from one to the next, and from one day to the next. (Swallow et al, 2013, no pagination)

29

Cystic fibrosis is a genetic condition that affects the movement of salt and water from the cells. This results in the accumulation of sticky mucus in the lungs, digestive system, and other organs. www.cysticfibrosis.org.uk/what-is-cystic-fibrosis

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The authors report, however, that despite such flux in a parent’s perceived capacity to manage offering care, continuing to negotiate how much or little was possible at any given point was still at the core of the professionals’ approach.

Such negotiation takes place within ongoing temporal frameworks. For instance, Tourigny et al (2008) suggest that within the context of a children’s surgical day centre, frequented by children with complex health needs, time constraints limit the capacities of health professionals to work closely with parents. The child, as experienced through time, becomes a further influencing actor in the sharing of expertise (Swallow and Jacoby, 2001). While professionals begin a ‘chronic illness trajectory’ only on first meeting a child, a parent’s experience of the child’s illness has often started a long time previously. In listening to a parent and being able to ‘take their concerns for their child seriously’, the health professional and parent can begin, even in a first encounter, to build foundations for future contact (p. 762).

Tourigny and Chartrand (2015) suggest that within an in-patient hospital context, clarity is still lacking around issues of sharing expertise and working in partnership between parents and professionals. In noting the absence of clear models, however, they argue forcefully for a simple approach to care, voiced as follows:

We must partner with the experts, and those experts are the children and families themselves. (Tourigny and Chartrand, 2015, p. 11)

Contemporary Music Therapy Positions

The ideological and pragmatic concerns in sharing expertise within nursing literature find parallels in contemporary music therapy literature. Material specifically addressing music therapy practice with children and families highlights three distinct areas: the expertise of parents and family members (Gottfried, 2016, 2017; Thompson, 2017; Jacobsen and Thompson, 2017); the expertise of the music therapist (Thompson, 2017); and a shared expertise, indicating a partnership approach to therapy (Gottfried, 2016; Jacobsen and Thompson, 2017). An approach in which ‘everyone’s expertise or lived experience is recognized’ suggests equilibrium in practice (Jacobsen and

Thompson, 2017, p. 310). As discourse shifts, however, from expertise to expert and back, the sense of equilibrium becomes less stable and more problematic.

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A number of authors position parents firmly as experts (Pasiali, 2017; Haslbeck, 2017; Jacobsen, 2017). In asking parents to teach professionals favoured family songs to sing with infants in the NICU setting, Haslbeck suggests that ‘they become the expert and we the “students”’ (p. 37). Haslbeck’s comment highlights a strand running through current practice literature in which music therapists acknowledge the potentially disempowering experiences for families of the expert therapist, and

therefore seek to distance themselves from being identified in an expert role (Jacobsen and Thompson, 2017; Gottfried, 2016; Oscarsson, 2017). Gottfried states this strongly:

We should abandon the expert position, in which we hold the insights in our possession and give recommendations to the parents, but rather cooperate with each family and tailor the course of action to their specific needs and capabilities. (Gottfried, 2016, p. 166)

A tension emerges at this point, however, between the apparent disciplinary leaning to resist being positioned as expert, and an approach that retains the ‘expertise of the therapist’ (Thompson, 2017, p. 93). Jacobsen and Thompson (2017) address this tension explicitly. They propose a model within which the therapist moves along a vertical axis from expert to equal in relation to the system of the family, other axes being formed by a horizontal supportive/directive continuum and a diagonal linking ‘part of’ or ‘outside the system’ (p. 325).

One difficulty of the expert/equal model proposed is that any movement is only

considered as being made by the therapist. It is the therapist who can ‘shift between a given stance’, moving from expert to equal (Jacobsen and Thompson, 2017, p. 324). The model implies, therefore, that a family (and it is unclear here whether this refers to individual family members or a larger unit) is in the ‘equal’ position, being joined by the therapist, rather than moving into an expert position themselves. The model is situated in a discussion of the therapist’s role in working with families, which may explain any discrepancy with material elsewhere in the text. The difficulties it presents, however, serve to highlight the contentious nature of the territory. How do music therapists understand their own professional expertise, and the expertise of those they work with? And how might expertise appear and be negotiated, or not, within the fluid dynamic of music therapy with a child and parent? These questions, emerging from current healthcare and music therapy literature gave impetus to the next phase.

154 Towards a Working Definition

I have deferred, until this point, offering a definition of either ‘expert’ or ‘expertise’. This is wholly intentional: my interest is less in starting with a fixed idea of what expertise is, and more in approaching it by way of what expertise ‘does’. As such, I subscribe to the view expressed by Carr (2010), who, from an anthropological standpoint understands expertise as ‘something people do rather than something people have or hold’ (p. 18).30

In positioning it as something done rather than possessed, Carr makes the case for it being both interactional and ideological. By this, I understand her to mean that power and perceptions of power are frequently involved in how expertise is understood and negotiated.31

While recognising that expertise may be evident in the skills, practices, and knowledge bases of individuals, Eyal (2010, p. 3) notes that ‘either way it is about the stuff that they do, rather than their interests and identities’ that offers the greatest interest. Eyal and Pok 2011, no pagination), informed by Actor Network Theory, propose that expertise be defined as ‘a network of connecting together actors, instruments,

statements and institutional arrangements’. Expertise, they suggest, is to be found in what people do, in places, with each other and with things. Considered as a

meshwork, how, I wondered, might expertise be enacted along the interweaving trails of people, things, and places of music therapy? Might there even be different kinds of expertise at play, and if so, how might they be understood?

Educationalist, Ann Edwards (2010) proposes that while people may have core expertises, gained through training or experience, it is through what she terms

‘relational expertise’ that the skills and knowledge people bring interact. Defined as ‘an expertise which includes recognising and responding to the standpoints of others’, relational expertise offers the connective capabilities through which a shared,

expanded expertise is accomplished (p. 2). The Preliminary Study had suggested that the perspectives of others were multiple and not always recognised. With an explicit focus on expertise across all participating in music therapy, I wondered how differing expertise might be acknowledged, or not. Did music therapy afford an environment in