Critical points and levels of depth in the therapeutic process

Within the outcome-oriented framework, the lyric creation process was overwhelmingly identified as the place where the most important 'therapy work' transpires. Clinicians influenced by CBT and working within the mental health field suggested that as the songwriter explores a topic fully, his beliefs, methods of perceiving or solving problems, and his habitual patterns of thinking are brought to the fore, reexamined, and new responses and actions identified. While this might occur during all phases of the songwriting process, it is most evident during the lyric creation process. As these approaches are focused on facilitating change in a planned and structured way, the lyrics contribute to shaping thought patterns and transforming behavior. Within the neurorehabilitation approaches, the lyrics created contain the information that needs to be later recalled (behavior recall songwriting). During restorative songwriting, the creation of lyrics is the primary place where executive functioning and conversational pragmatics are assessed and addressed.

Discussing the meaning of the song creation can be a vital part of cognitive-behavioral approaches. Sometimes as a person is creating lyrics, there is a stream of consciousness occurring; he volunteers thoughts, feelings, and images without too much reflection, and he shares the rapidly changing thoughts as they move in and out of his mind. This stream of consciousness reveals thought distortions and habitual thinking. Returning to the lyrics for reflection may result in increased awareness of and sensitivity to thought patterns. Without such awareness, there is little chance that cognitive distortions will be addressed because change is difficult if a person is not able to recognize faulty thought patterns.

The refining of the song stimulates further insight and cognitive reframing, and can lead to a commitment to action. Song lyrics are not typically long, rich, or detailed descriptions of a person's experiences or events, but are pithy and designed to tell his story. This brevity demands that the listener exercise a degree of interpretation to understand the meaning of the song. Given this, every word must count and communicate the songwriter's intentions as precisely as possible. With this in mind, and on the assumption that there is sufficient time available, the refinement process is an ideal space for the songwriter to critically reexamine the lyrics he has created and further reflect on his therapeutic journey and future actions. Sometimes the reflections on words such as 'try' or 'want to' can generate discussions about a songwriter's commitment to change. These words suggest a desire for change, but without full commitment to taking action. In changing these words to 'will', he is declaring his intention to act.

Sharing the song with others, particularly significant others, can be an important step in the process of readiness for change (Prochaska et al., 1994). When a person shares his songs, he is declaring his intention to act and change his behavior. Sharing can also be a means to communicate to family and significant others that he is about to embark on a difficult and challenging journey, and would benefit from support as he navigates a new way of being in the world. One of the actions needed for change may simply be to be genuinely honest with others; sharing a song creation may be the first step in this process.

Replaying or singing the song plays an important role in both behavioral and neurorehabilitative approaches. In behaviorist traditions, hearing or singing the song is the reward and a symbol of achievement. Conversely, for those subscribing to theories of neuroplasticity, replaying and/or singing the songs is a means for the songwriter to learn and recall important information.

Outcome-oriented songwriting within hospital environments is often brief, and focuses on strengthening a person's level of independence, functional abilities, capacity to cope outside the safe hospital environment, and to live a meaningful life. Clinicians practicing within outcome-oriented songwriting approaches consider deep exploration of what is underpinning the songwriter's life challenges as inappropriate and potentially contraindicated. Clinicians are therefore more likely to practice within supportive activities-oriented or re-educative insight- and process-oriented models (Unkefer & Thaut, 2002; Wheeler, 1983).

The behaviorist approaches to songwriting align most closely with the supportive activities-oriented therapy. Successive approximation songwriting, contingency songwriting, behavior recall songwriting, and lyric repetition approach songwriting as an activity that supports change at a very surface but functional level. These songwriting approaches are designed to directly modify behavior rather than address the causes of the behavior.

Insight- and process-oriented songwriting is evident during the implementation of transtheoretical songwriting. During the early stages of 'readiness for change', a songwriter uses songwriting to gain insight and become more aware of his behavior. As he prepares for and implements action, the songwriting program can take on a re-educative role. These approaches do not reach the depth needed for processing or correcting the underlying cause, but rather seek to assist the songwriter to have a better understanding of his present self and how it impacts on his life and the lives of others. Similarly, re-educative-oriented levels are reached during songwriting for cognitive restructuring and during psychoeducational songwriting. The emphasis on enhancing the songwriter's understanding of his illness and ways to challenge thinking patterns is very much in the 'here and now'.