Nordic Journal of Music Therapy

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Autism and music therapy. Intersubjective

approach and music therapy assessment

Alfredo Raglio , Daniela Traficante & Osmano Oasi

To cite this article: Alfredo Raglio , Daniela Traficante & Osmano Oasi (2011) Autism and music
therapy. Intersubjective approach and music therapy assessment, Nordic Journal of Music Therapy,
20:2, 123-141, DOI: 10.1080/08098130903377399

To link to this article: https://doi.org/10.1080/08098130903377399

Published online: 09 May 2011.

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Nordic Journal of Music Therapy
Vol. 20, No. 2, June 2011, 123–141

Autism and music therapy. Intersubjective approach and music

therapy assessment
Alfredo Raglioa*, Daniela Traficanteb and Osmano Oasib
a
Children’s Neuropsychiatric Daily Center, Cremona, Italy; bCatholic University of
Sacred Heart, Department of Psychology, Milan, Italy
(Received 6 June 2009; final version received 5 September 2009)

Autism is a pathology in which the communicative and relational deficit

is quite clear. After giving an up-to-date general view to the nosographic
aspects and to the interpretative models of the Autistic Disorder, the
authors focus on an improvisational music therapy approach in an
intersubjective theoretical perspective. Coherently, with the theoretical
frame and the clinical evidence, important process indicators were
extrapolated into the analysed session. By using an appropriate coding
scheme made to evaluate the music therapeutic process, the authors
present an example analysis about the coding of some music therapy’s
sessions of a clinical case of infantile autism. Such analysis highlighted
the occurred changes within the sessions and it can be considered a
useful tool for a longitudinal evaluation of the music therapeutic
treatments.
Keywords: autism; music therapy; intersubjective approach; relationship;
music therapy assessment

Introduction
In the last few years the definition, the hypothesis about the origin and the
perspectives of intervention related to autism underwent many changes.
In the early definitions (Kanner, 1943; Asperger, 1944) autism was
included among the premature ‘‘psychosis’’ or the ‘‘infantile schizophrenia,’’
while in the 1980s it was no longer classified in the area of infantile
psychosis, but it was part of the new category of Pervasive Developmental
Disorders. The essential features of Autistic Disorder are the presence of
markedly abnormal or impaired development in social interaction and
communication, and the presence of limited, repetitive and stereotyped
behaviours, interests and activities. Moreover in Autistic Disorder there are
the delay of the development of spoken language or total lack of it, and the
imaginative play is often absent or markedly impaired (American

*Corresponding author. Email: raglioa@tin.it

ISSN 0809-8131 print/ISSN 1944-8260 online

Ó 2011 The Grieg Academy Music Therapy Research Centre
DOI: 10.1080/08098130903377399
http://www.informaworld.com
124 A. Raglio et al.
Psychiatric Association [APA], 2000). About the nature of Autistic Disorder
it is a shared opinion that the origin of the autism is a disorder or an
alteration of the neuronal development that is itself determined by genetic or
neuropathological elements.
The complex interactions among these elements give rise to specific
deficits related to different areas of the emotional, cognitive, social and
motor skills development in each patient diagnosed with autism. In this
perspective, Frith (1989) underlined the impossibility of evaluating the
patient with Autistic Disorder in terms of presence/absence of capabilities
specific for his/her age and the need to carefully consider the prevalent
deficit of the patient him/herself.
Starting from the 1990s, some authors (Meltzoff & Moore, 1992, 1994;
Meltzoff & Gopnik, 1993; Gopnik, Capps, & Meltzoff, 2000; Meltzoff &
Prinz, 2002) focused their attention on the development of the ‘‘social mind’’
and on the process of social referencing. Their hypotheses are based on
infants’ innative ‘‘capacity to register equivalences between the body
transformations they see and the body transformations they only feel
themselves make. On this account there is a primitive supramodal body
scheme that allows the infant to unify acts-as-seen and acts-as-felt into a
common framework’’ (Meltzoff & Gopnik, 1993, pp. 342–343). Generally
speaking, we can assume two different forms of the nativist position. The
modularity nativism (Leslie, 1991; Leslie & Roth, 1993) postulates there are
innate constraints on the form that a theory of mind may take; the starting-
state nativism considers that children are innately equipped with certain
kinds of information about the nature of persons (Meltzoff, 1995). The
autism’s development is interpreted in different ways by these different
perspectives.
From the psychoanalytic point of view, Target and Fonagy (1996)
stressed the importance of ‘‘the object’s capacity to create a world for the
child in which he may experience himself as a feeling, wanting, thinking
being’’ (p. 461). Ascribing a mental state to the child with his/her behaviour,
the caregiver allows the foundations of a core sense of mental selfhood. In
this way, Target and Fonagy stressed the emotional component of theory of
mind, not only the cognitive one.
Recent studies showed a neurophysiological and neurofunctional basis
to imitation, empathy and mentalization. In particular, the existence and
activation of mirror neurons (Gallese, 2003) gave an empirical evidence of
intersubjectivity. This discovery leads to the creation of the sense of social
identity and to the development of the individual competence of relation-
ship. When a subject observes an action, the nervous circuit that controls the
action activates: this way an automatic simulation of the action is induced in
the mind of the observing subject. It is an implicit understanding of others’
behaviour (Gallese, Eagle, & Migone, 1996; Rizzolatti, Fadiga, Gallese, &
Fogassi, 1996; Gallese, 2001, 2003).
 Nordic Journal of Music Therapy 125
The embodied simulation theory (Gallese et al., 2007) rejects both the
standard forms of simulation theory and the theory based on psychology
concepts such as beliefs and desires. Embodied simulation is ‘‘a mandatory,
nonconscious, and prereflexive mechanism that is not the result of a
deliberate and conscious cognitive effort aimed at interpreting the hidden
intentions in the overt behavior of others’’ (Gallese et al., 2007, p. 143). In
this perspective not only the intentional attunement, but also the empathic
mirroring, is based on the neuronal mirror system along with the embodied
simulation that is supposed to be involved.
In Autistic Spectrum Disorders there is an impairment that makes it very
difficult to establish visual contact and share attention with others, and to
imitate or understand others’ behaviours or intentions, emotions and
sensations. In these conditions meaningful relational contacts could hardly
grow up. From a different point of view, we can observe the consequences of
the Autistic Disorder: not only in both symbolic and non-symbolic imitative
behaviour (Rogers, 1999), but also in the understanding of the facial
expression of the emotions in others (Snow, Hertzig, & Shapiro, 1989;
Hobson, Ouston & Lee, 1988, 1989). Recent empirical studies (Dapretto
et al. 2006; McIntosh, Reichman-Decker, Winkielman, & Wilbarger, 2006)
suggested the presence of neural correlates of these deficits and confirm the
hypothesis that a dysfunction of the mirror neuron systems produces a
malfunctioning of the embodied simulation mechanisms and consequently a
deficit of the ‘‘intentional attunement’’ (Gallese, 2006).
The concepts of share manifold of intersubjecitivity and intentional
attunement are the common ground of some of the most meaningful
psychoanalytic contributions derived from the experimental research about
the first mother–child relationship (Trevarthen, 1979, 1984, 1998). Tronick
and Emde underlined the relevance of this intersubjective relationship to the
foundation (construction) of the Self. We refer to the Mutual Regulation
Model and to its point of view that the mother–child emotional exchange is
always present (Tronick, 1989). This model describes the microregulatory
social-emotion process of communication that can generate dyadic
intersubjective states of shared consciousness. Tronick introduces the
hypothesis of Dyadic Expansion of Consciousness, to which ‘‘. . . each
individual is a self-organizing system that creates its own states of
consciousness – states of brain organization – which can be expanded into
more coherent and complex states in collaboration with another self-
organizing system. When the collaboration of two brains is successful, each
fulfills the system principle of increasing their coherence and complexity’’
(Tronick & Members of the Change Process Study Group, 1998, p. 296).
Generally speaking, the child would be spontaneously able of agency and of
relational contact with the other; but, as Emde (1983) and Emde &
Buchsbaum (1989) pointed out, the mother’s emotional availability in
receiving the child’s signals and in self-regulating in turn on them would lead
126 A. Raglio et al.
to the continuity of the affective development and of the affective core of
Self.
Already in 1975, Stern highlighted how in the early mother–child
interactions there is a variety of behaviours such as movement, head and
body tone, look and face expressions and vocalizations (Stern, Jaffe, Beebe,
& Bennett, 1975) that gradually organize coherently in respect to the
communication of emotions and affects. From this perspective, also
‘‘. . . dance and music are examples par excellence of the expressiveness of
vitality affects’’ (Stern, 1985, p. 56) and help determining the conditions of
the affect attunement starting from which a sense of the Self is born. Stern
(1998) significantly used an image taken from the common experience of
concerts to describe the exchanges between the dyad during breastfeeding,
by comparing the mother with an orchestra director. Like him/her, the
mother uses several ways (shakes, swings) and adapts her volume when
speaking in order to keep the child at the right arousal and attention level.
Inside an intersubjective perspective such as this one, the child is sometimes
the director.
In the intersubjective interactions between mother and child, Stern
(1985, 1993, 1995) underlined the extraordinary role of emotions. They
characterize the experience of the present and future relationships.
According to the author, emotions lose the Darwinian categorical
connotation, to obtain a vital connotation, with which Stern (1985, 1993)
underlined the dynamic and kinetic elements of emotional experience.
The value of the research programme of the Boston Process of Change
Study Group (BPCSG) was to ground on empirical evidence the
development and changes on the dyads. Sander and his pioneer work
(Sander, 2008) inspired this programme: each living creature is set up as a
system and he finds himself in a smaller or bigger state of coherence and
integration. Many studies of BPCSG consisted of a careful study of the
process in fieri during the meeting between the mother and the child, or in
the session between the therapist and the patient (Boston Process of Change
Study Group [BPCSG], 1998, 2002; Beebe & Lachmann, 2002). More
recently Stern (2004) confirmed what resulted from these studies, under-
lining that specific meeting moments in the dyad can be found inside the
process (moving along). They can modify the intersubjective relationship
through reciprocal influence.

Music therapy and intersubjectivity

The music therapist aims at creating and developing a relationship with the
patient through a sonorous dialogue. We are considering a kind of music
therapy that referes to sonorous-musical improvisation technique. In such
an approach the patient is free in creating sonorous-musical productions,
opening a communicative channel with the music therapist; in turn the
 Nordic Journal of Music Therapy 127
music therapist can start a sonorous-musical production in the attempt of
beginning a dialogue with the patient. In this way the dialogue is co-created
by the patient and the music therapist through a reciprocal influence,
modifying the intersubjective area. It creates new mental schemes and
encourages new emotional mental sets that lead the person to change.
Generally speaking, sound is an extremely important element in
determining the affect attunements (Stern, 1985) and it gives rise to meeting
moments (Stern, 2004). According to Stern, through these moments the past
lives again, but they especially create a possible link between present and
future, favouring on one side processes of change and on the other side the
preservation of personal identity. New intersubjective areas are developed,
which modify the relationship and lead to a more intense sharing of
emotions in a logic of co-creation and sharing. This helps the patient to
modify his/her own internal world, through moments of meeting and
attunement that have a therapeutic function and lead to more consciousness.
Sound and music are particularly close to the process of co-creation and
sharing, since they are in progress and come true the moment they are taking
place. This mainly non-verbal process is based on an implicit relationship
and takes place spontaneously, before other mental work: for example,
processes of working through and symbolization take place (Langer, 1953;
Bryce Boyer 1992; Pavlicevic, 1997; Robarts, 1998; Wigram & De Backer,
1999; Di Benedetto, 2000; Mancia, 2004; Malloch & Trevarthen, 2008).
From the technical point of view, improvisation in music therapy can
reflect the vitality affects (Stern, 1985). We think that the theoretical-
applicative characteristics of music therapy give a good opportunity of
intervention on autistic patients.
Music therapy can be considered as an essentially non-verbal approach
and is therefore potentially effective in the Autistic Spectrum Disorder
(Nordoff & Robbins, 1977; Oldfield, 2006; Kim, Wigram & Gold, 2009). In
this context, music therapy can help to develop the communicative and
social interaction skills (Gold, Wigram & Elefant, 2006; Boso, Emanuele,
Minazzi Abbamonte, & Politi, 2007).
Stern’s (1985, 2004) and Trevarthen’s (Trevarthen & Aitken, 2001)
researches underline how sound and vocal exchanges are at the base of the
process of emotion regulation in the mother–child relationship (De L’Etoile,
2006). Trevarthen (2001) points out how musical improvisation in autism
stimulates emotional sharing, regulates anxiety, increases motivation and
encourages the patient to have the pleasure of contact through a more
understandable communication.
Despite this, Gold et al. (2006) underline that there are no evidence-
based studies about the above mentioned considerations. According to the
authors, these studies are characterized by the almost complete lack of
control groups and randomization process, by a short therapeutic
intervention and by the involvement of a small number of patients. Besides,
128 A. Raglio et al.
the studies in scientific literature refer to approaches based on musical
listening and its effects, more than on music therapy based on sonorous-
musical improvisation. Moreover, the studies taken into account by Gold
et al. (2006) show positive changes regarding communicative capabilities
(Edgerton, 1994; Schumacher, 1999; Schumacher & Calver-Kruppa, 1999),
while contrasting opinions can be found in the results of the music
therapeutic treatment described in two previous reviews (Whipple, 2004;
Ball, 2004).
With reference to the music therapeutic process, Wigram (2004)
underlines some problems in every modality of evaluation used until now:
(a) a lack of shared instruments; (b) a lack of researches about observation
instruments in music therapeutic sessions; and (c) the non-systematic use
and limited diffusion of these observation instruments. Besides what is
highlighted by Wigram (2000, 2004), and Wigram and Gold (2006) the
experience the authors observed in some music therapeutic health centres
convinced us that the observation/evaluation is often about rather static
descriptive data. These data marginally concern the dynamics that involve
the patient and the music therapist.
From this perspective we consider the Improvisation Assessment Profiles
(IAP) by Bruscia (1987) and Music Improvisation Rating (MIR) by Pavlicevic
(Pavlicevic & Trevarthen, 1989). In particular, Bruscia identifies some profiles
of improvisation that define and interpret the patient’s sonorous-musical
behaviour, with the opportunity of comparing these behaviours with what
was expressed by the same patient in other situations. Instead, Pavlicevic
describes different levels of responsivity and emotional involvement of the
patient with respect to what is suggested by the music therapist. This point of
view is quite close to the kind of evaluation described in this article. However,
we found it useful to set up a new observation tool in order to specifically seize
the quality of the intersubjective relationship. This is also coherent with the
theoretical reference framework described above (Raglio, Traficante & Oasi,
2006, 2007).

Materials and methods

The observed case
The videotapes of three sessions of music therapy of a seven-year-old
autistic child diagnosized with Autistic Disorder (F 84.0–299.00) were
considered. At the time of the first observation he had reached a
development corresponding to 17 months of age, as results are obtained
using the normative evaluation of the scale for motor skills development for
early childhood (Italian adaptation of the Echelle de de´veloppement
psychomoteur de la pre`miere enfence, Brunet & Lézine, 1955). The child
showed a functional development corresponding to 18 months of age, with
evolutionary potentialities up to about 24 months, as results are obtained
 Nordic Journal of Music Therapy 129
using the functional evaluation of the scale PEP-R (Psychoeducational
Profile – Revised Edition, Schopler, 1990). The biggest difficulties were
observed in the linguistic–communicative area of imitation and in the
cognitive area, even if in the cognitive area there are different evolutionary
potentialities. The best capabilities were found in the area of global and
specific motor skills, and of perception.
At the symptomathologic scale CARS (Childhood Autism Rating Scale,
Schopler, Reichler, & Rochen Renner, 1988) he obtained a score of 36/60,
which can be referred to the area of moderate autism. The biggest difficulties
were detected in the verbal communication, imitation, and in the contact
with objects in motor skills. The first clinical assessment showed that the less
impaired behaviours were observed in the area of their relationship with the
others and in adaptation to change.
The treatment took place on a weekly basis and the family agreeded on
the use of video recordings for research purposes.

The music therapy approach

This is an active approach (free sonorous-musical improvisation), which
implies the prevalence of non-verbal and sonorous-musical aspects in the
direct patient–music therapist relationship. In the intersubjective perspec-
tive, the interaction based upon the use of musical instruments (melodic,
rhythmical and ethnic) can facilitate expressive and organizational processes
and could lead the patients and music therapist to moments of affect
attunement (Stern, 1985). The music therapist, through the use of sonorous
parameters (timbre, dynamic, agogic, etc.), promotes the (co-)regulation
(Tronick, 1989; Fogel & Lyra, 1997; Trevarthen, 2001) of emotional
components (vitality affects) (Stern, 1985, 2004). The patient and the music
therapist build a dialogue in which the sonorous-music interaction can
reflect the emotional state and can favour an empathetic relationship.

The instrument
The instrument described and used in this work is the Music Therapy Coding
Scheme (MTCS) (Raglio et al., 2006). This is an instrument that can be used
during the assessment: in this case the aim is to define possible diagnostic
criteria that support clinical data or sustain music therapy treatment intake.
This instrument can also be used to evaluate the process of the music
therapeutic treatment. In agreement with what was stated by Wigram
(2004), we think that the analysis of the improvised musical material can
show specific behaviours that give elements to identify the direction, the
process and the result of therapy.
MTCS is a coding scheme for the patient–music therapist interaction
during music therapy sessions of 30 minutes, performed with the
130 A. Raglio et al.
improvisation technique. The behavioural classes considered are: non verbal
communication, sonorous-musical communication, the direction of the
look and the facial expression, and verbal communication. The MTCS is a
video-based, patient–therapist interaction assessment method measuring
both the affective and the behavioural characteristics expressed by the
patient and the therapist in a dyadic interaction during a music therapy
session. Coding was accomplished with a continuous method with the
software The Observer Video-Pro 5.1 (registered trademark of Noldus
Information Technology bv).
We mainly focused on those indexes considered indicative of the origin
of moments of affective attunement.

Procedure
The video recordings were performed with a fixed camcorder put in a corner
of the music therapy room, to allow a goodshot of the music therapist–
patient dyade. The first, the tenth and the twentieth sessions of the entire
therapeutic process were analysed.
Video recordings were coded by two music therapists. The observers
underwent training, coding the video recordings of other subjects, to reach
an adequate level of agreement.

Analyses
The data were submitted to two levels of analysis to see the changes in
time:

(1) the differences in the occurrence of the emerging behaviours of affect

attunement in the music therapeutic setting, such as attuned
movement, approach to the other, approach to the other and the
instrument, physical contact, looking at the other, attuned produc-
tion and variations, between each session and the following one, and
between the first and the last session were evaluated through chi-
square (eventually with Yates’s correction);
(2) the behavioural sequences in interactions between the music therapy
and the patient were analysed by the sequential analysis (Bakeman &
Gottmann, 1997) and represented on trasition diagrams. To perform
such analysis, all the episodes of sonorous production in each session
were detected, and for each of them it was considered how many
times after an individual music production started by one of the two
partners, moments of shared sonorous-musical interaction could
take place, in which the two partners tried to stay with the other. The
result could be a successful attuned production, or a less successful
disattuned production. Even the cases of nulle response, in which
 Nordic Journal of Music Therapy 131
after the production of one member of the dyad there was no
response by the other, were considered.

Results
Interobservers’ agreement was evaluated through Cohen’s k coefficient. For
the patient’s coding the mean value was .71; for music therapists’ coding the
mean value was .80 (Table 1).

(a) Analyisis of the change of attunement indexes

In Figure 1 we report an exemplifying plot of co-presence in the same time
(in the patient and in the music therapist) of some indexes of affect
attunement. In fact from 420 to 450 seconds there are moments in which
patient and music therapist are making attuned production (with variations),
‘‘looking at each other’’ and showing the body movements in relation to
sonorous-musical production (attuned movements). This clashes with the
moment of more emotional involvement and sharing.

Table 1. Cohen’s K coefficient, by subject and by session.

Session Patient Music therapist

st
1 .70 .75
10th .73 .86
20th .70 .78

Figure 1. Episode of co-presence (among other behaviours) of some indexes of

affect attunement: Looking at each other, Attuned movements, Attuned production,
Variations.
132 A. Raglio et al.
The analysis emphasized a progressive increase in physical contact (1st v.
10th session: chi-square ¼ 7.64, p 5 .01; 10th v. 20th session: chi-square ¼
12.46, p 5 .001; 1st v. 20th session: chi-square ¼ 31.48, p 5 .001) and in
looking at each other (1st v. 10th session: chi-square ¼ 29.68, p 5 .001; 10th
v. 20th session: chi-square ¼ 90.23, p 5 .001; 1st v. 20th session: chi-
square ¼ 183.36, p 5 .001). The attuned movement considerably increased
between the 1st and the 10th session (chi-square ¼ 4.25, p 5 .05), but there
is no difference between the 1st and the 20th session. Instead, in the approach
to the other, there is an increase between the 10th and the 20th (chi-square ¼
10.04, p 5 .01) and the result reached in the last session is quite different
from the 1st session (chi-square ¼ 12.05, p 5 .01). The approach to the other
and the instruments showed a meaningful change between the 1st and 20th
session (chi-square ¼ 5.36, p 5 .05) (Figure 2).
The attuned production in Figure 3 was considered in relation to the
total time of the sonorous production in the single session. There is an
increase of the percentage of time in which the two partners play together in
an attuned way between the 1st and 10th session (chi-square ¼ 3.81,
p 5 .05). Between the 10th and 20th session a decrease of such modality of
communicative exchange is detected, but the difference is not remarkable,
and the 1st and 20th session do not differ between each other. We observe an
increase in the rates of variations in relation with the total time dedicated to

Figure 2. Rates (frequency/minute) of five target-behaviours in the three sessions.

 Nordic Journal of Music Therapy 133

Figure 3. Percentages of time spent in attuned sonorous-musical production and

rates of variations (frequencies/minute of production time) in the three sessions.

the sonorous production: the differences are not remarkable between the 1st
and 10th session and between the 10th and 20th session, while they are
significant between the 1st and 20th (chi-square ¼ 4.62, p 5 .05).

(b) Analysis of the interactive sequences

The results of the sequential analysis can be represented in transition
diagrams, in which the direction of the arrow shows the temporal
sequence of the described events, and the numbers correspond to the
percentage of cases in which this sequence is observed. We conventionally
comment on the sequences that happened in a percentage of cases higher
than 20%.
Figure 4 shows that in the 1st session MT turns 50% of the sonorous-
musical proposals of PZ (individual production) into an attuned production,
and he lets PZ play alone (null response) 46% of the times. Instead PZ (null
134 A. Raglio et al.
response) does not reply to 85% of the proposals of MT (individual
production). In 94% of the times an attuned production finishes in a non-
production interval (null response).
Figure 5 shows that in the 10th session MT lets PZ play alone (null
response) in 68% of the times and only in 26% of situations turns PZ’s
individual production into an attuned production. The percentage of times

Figure 4. 1st session: transition diagram at Lag 1 among Individual production,

Attuned production, Disattuned production, Null production.

Figure 5. 10th session: transition diagram at Lag 1 among Individual production,

Attuned production, Disattuned production, Null production.
 Nordic Journal of Music Therapy 135
in which PZ does not reply (null response) to the sonorous-musical
proposals of MT is 70% and the amount of attuned production, starting
from the sound produced by MT (individual production), is 22%. It is
interesting to notice that in this session there are sequences in which they
pass from an attuned to a disattuned production (38%), to later go back to
the attuned production (60%).
In the 20th session (Figure 6) PZ does not reply (null response) to the
solicitations of MT (individual production) in 87% of times. Instead MT
(null response) lets PZ (individual production) play alone in 79% of times
and only in 21% of situations it turns PZ’s individual production into
attuned production. In this session neither of the two partners directly
replies to the other with a disattuned production.

Discussion and clinical implications

The study’s goal is not to show the effectiveness of music therapy treatment,
but to observe the process and analyse its content from a clinical, relational
and music therapeutical point of view. Yet it is important to consider that
the observational techniques detect the behaviours of the patient and of the
music therapist analysed in parallel, in the theoretical perspective of
intersubjectivity (Trevarthen, 1998; Tronick et al., 1998; Stern, 2004).
In the clinical case presented some parameters that classify moments of
affect attunement are analysed. From a sonorous-musical point of view two
behaviours were particularly considered: attuned production and the
variations. The attuned production expresses the intersubjectivity of the

Figure 6. 20th session: transition diagram at Lag 1 among Individual production,

Attuned production, Disattuned production, Null production.
136 A. Raglio et al.
relationship and it confirms the prevalence of exchanges with the music
therapist from the communicative–relational point of view. These exchanges
are more meaningful if related to the progressive increase of variations
during the treatment. In fact the variations show an intense activation of the
subject and a creative and not stereotyped aspect of sonorous-musical
communication. It is important to underline that it diverges from the autistic
communication (Snow et al., 1988; Rogers, 1999; Hobson et al., 1988, 1989)
and that it is an important element in the evolution of the music therapeutic
treatment.
Even some remarkable observations related to the patient’s non verbal
behaviours emerged. Physical contact, looking at each other, attuned
movement and approach to the other have remarkably increased. The
behaviour of approach to the other and to the instruments increased,
although not remarkably. It is extremely important to consider that these
behaviours improved, showing a higher level of relationship, emphasized by
a higher physical contact with the music therapist, with the increase of the
patient’s physical movements towards the music therapist. We similarly
detected a remarkable increase of looking at the music therapist. The
patient’s attuned movement, observed in the 20th session during the
sonorous-musical production, shows his high level of emotional involvement
and his meaningful body participation in the interaction. We can also
consider that in an autistic patient the above is a very important sign: a
positive change that can be found in the music therapeutic treatment.
The analysis of interactive sequences is effective to verify the linking of a
consecutive series of behaviours in the intersubjective relationship. In the
area of intersubjectivity there are other examples of how the analysis of
behavioural sequences can suggest the evolution of the dyadic relationship
(Emde et al., 1989; Tronick, 1998; Fogel, Lyra & Valsiner, 1997). Our
analysis substantially considers how many meeting moments music therapist
and patient create (Stern, 2004), based on sonorous-musical attunements.
Thanks to the transition diagrams it is possible to grasp the quality of
observed interactions, detecting the development and degree of complexity
reached by them. In particular, in the 10th and in the 20th sessions it was
interesting to notice the presence of the linking of a consecutive series of
interactive exchanges, that from being attuned become disattuned, to later
become, again, an attuned production. This process presents analogies with
the relationships in which moments of communicative exchanges that
strengthen the relationship alternate with others in which the interaction
stops, or is not shared by one of the partners. This shows a gradual
development and increase of linking of a consecutive series that shows an
increase of the interaction moments and an enrichment of the relationship in
a music therapeutic process.
The study of interactive sequences helps the analysis of the behaviour
expressed by music therapist in the various situations of the relationship: in
 Nordic Journal of Music Therapy 137
some moments the attunement is easier and more immediate than in others,
when there are difficulties in understanding the behaviour of the partner, or
there are reflective moments, in which the music therapist elaborates his/her
own emotions, later turning them into a sonorous-musical reply.
Therefore, MTCS (Raglio et al., 2006) is a specific descriptive and
quantitative instrument, useful to detect the changes in the music
therapeutic relationship (process) and therefore potentially applicable with
therapeutic and clinical purposes, with other instruments.
The above mentioned sonorous-musical and non sonorous-musical
behaviours are important indexes of change, especially if we consider their
co-presence in the moments of affect attunement (Stern, 1985). So it is possible
to notice different levels of involvement in the patients’ relationship both from
a quantitative and from a qualitative point of view. We think that the
development of these sonorous-musical and relational indexes during the
treatment can show also the potential therapeutic results reached through the
music therapeutic treatment. At the same time we are aware of the limitations
of our study. Further researches with similar patients and with similar
material and method need to confirm the positive results presented here.

Notes on contributors
Alfredo Raglio is a music therapist, teacher, supervisor, and researcher. He has worked
in the neuropsychiatric, psychiatric and neurological field since 1990, and carries out
research activities in collaboration with Italian institutions of research (Department of
Psychology, Catholic University of Milan; Department of Rehabilitation Medicine,
IRCCS Istituto Auxologico Italiano, Milan; Sospiro Foundation, Cremona;
Laboratory of Neuropsychology, Department of Clinical Neurosciences Fondazione
IRCCS Neurological Institute Carlo Besta, Milan, etc.). He is also a teacher of
Research Methodology in Music Therapy at Conservatory of Music of L’Aquila, the
Music Therapy School in Assisi and in others courses of music therapy. He is Member
of the Italian Professional Music Therapy Association Advisory Board. He published
several scientific articles and books about clinical and research topics.
Daniela Traficante, PhD in Social and Developmental Psychology, Researcher in
Developmental and Educational Psychology at the Catholic University of Milan
(Italy). Teacher in the following academic courses: Methods and techniques for the
infant behaviour observation; Advanced methods for the research in developmental
and communication psychology; and Psychometric Statistics. Research interests
include: observation techniques and data analysis; attachment bonds in childhood
(child-caregiver; child-teacher) and in adulthood (to the partner and to the family of
origin); language acquisition.
Osmano Oasi, PhD in Social and Developmental Psychology, Department of
Psychology, Catholic University of Sacred Hearth (Milan, Italy). He is psychologist,
psychotherapist and psychoanalyst (Italian Psychoanalytic Society). He is also a
researcher of Dynamic Psychology at the Faculty of Psychology. His main research
interests concern the assessment process, pathogenic issues and psychodynamics
treatment in severe mental illness such as Spectrum Autistic Disorder, Schizophrenia,
Major Depression and Borderline Personality Disorders. Between theoretical
subjects, particular attention for some recent model of psychoanalysis is given.
138 A. Raglio et al.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed.). Arlington, VA: American Psychiatric Publishing.
Asperger, H. (1944). Die ‘‘Autistischen Psychopathen’’ im Kindesalter. Archiv für
Psychiatrie und Nervenkrankheiten, 117, 76–136.
Bakeman, R., & Gottman, J.M. (1997). Observing interaction: An introduction to
sequential analysis. Cambridge: Cambridge University Press.
Ball, C.M. (2004). Music therapy for children with autistic spectrum disorder. London:
Bazian Ltd.
Beebe, B., & Lachmann, F.M. (2002). Infant research and adult treatment: Co-
constructing interactions. Hillsdale, NJ: The Analytic Press.
Boso, M., Emanuele, E., Minazzi, V., Abbamonte, M., & Politi, P. (2007). Effect of
long-term music therapy on behavior profile and musical skills in young adults
with severe autism. Journal of Alternative and Complementary Medicine, 7,
709–712.
BPCSG. (1998). Non-interpretive mechanisms in psychoanalityc therapy. The
‘something more’ than interpretation. International Journal of Psychoanalysis,
79, 903–921.
BPCSG. (2002). Explicating the implicit: The local level and the microprocess of
change in the analytic situation. International Journal of Psychoanalysis, 83,
1051–1062.
Brunet, O., & Lézine, I. (1955). Echelle de de´veloppement psychomoteur de la pre`miere
enfence. Manuel d’instructions, Editions Scientifiques et Psychotechniques. [Scale
of psychomotor development for early childhood. Operating Manual]. Siene:
Clamart (Italian translation and adaptation, Florence [1967]: OS).
Bruscia, K. (1987). Improvisational models of music therapy. Springfield, IL: Charles
C. Thomas Publisher.
Bryce Boyer, L. (1992). Roles played by music as revealed during counter-
transference facilitated transference regression. International Journal of Psycho-
analysis, 73, 55–70.
Dapretto, L., Davies, M.S., Pfeifer, J.H., Scott, A.A., Sigman, M., Bookheimer,
S.Y., & Iacoboni, M. (2006). Understanding emotions in others: Mirror neuron
dysfunction in children with autism spectrum disorders. Nature Neuroscience, 9,
28–30.
De L’Etoile, S.K. (2006). Infant-direct singing: A theory for clinical intervention.
Music Therapy Perspectives, 24(1), 22–29.
Di Benedetto, A. (2000). Prima della parola. L’ascolto psicoanalitico del non detto
attraverso le forme dell’arte [Before speech. Psychoanalitic listening of the non-
said throughout the forms of art]. Milano Franco: Angeli.
Edgerton, C.L. (1994). The effect of improvisational music therapy on the
comunicative behaviors of autistic children. Journal of Music Therapy, 31, 31–62.
Emde, R.N. (1983). The prerepresentional self and its affective core. The Psycho-
analytic Study of the Child, 38, 165–192.
Emde, R.N., & Buchsbaum, H.K. (1989). Toward a psychoanalytic theory of affect:
II. Emotional development and signaling in infancy. In S.I. Greenspan & G.H.
Pollock (Eds.), The course of life (2nd ed., pp. 193–227). Madison, CT:
International University Press.
Fogel, A., & Lyra, M.C.D.P., Valsiner, J. (1997). Dynamics of development in
relashionship. In F. Masterpasqua & P.A. Perna (Eds.), The psychological
meaning of chaos: Translating theory into practice (pp. 75–94). Washington, DC:
American Psychological Association.
 Nordic Journal of Music Therapy 139
Frith, U. (1989). Autism: Explaining the enigma. Oxford: Basil Blackwell.
Gallese, V. (2001). The ‘‘shared manifold’’ hypothesis. From mirror neurons to
empaty. Journal of Consciousness Studies, 8(5–7), 33–50.
Gallese, V. (2003). The roots of empathy: The shared manifold hypothesis and the
neural basis of intersubjectivity. Psychopathology, 36, 171–180.
Gallese, V. (2006). Intentional attunement: A neurophysiological perspective on
social cognition and its disruption in autism. Brain, 1079, 15–24.
Gallese, V., Eagle, M.N., & Migone, P. (2007). Intentional attunement: Mirror
neurons and the neural underpinnings of interpersonal relations. Journal of the
American Psychoanalytic Association, 55(1), 131–176.
Gallese, V., Fadiga, L., Fogassi, L., & Rizzolatti, G. (1996). Action recognition in
the premotor cortex. Brain, 119, 593–609.
Gold, C., Wigram, T., & Elefant, C. (2006). Music therapy for autistic spectrum
disorder. Cochrane Database of Systematic rewievs, 2, CD004381.
Gopnik, A., Capps, L., & Meltzoff, A.N. (2000). Early theories of mind: What the
theory can tell us about autism. In S. Baron-Cohen, H. Tager-Flusberg & D.J.
Cohen (Eds.), Understanding other minds. Perspectives from developmental
cognitive neuroscience (2nd ed., pp. 50–72). Oxford: Oxford University Press.
Hobson, R.P., Ouston, J., & Lee, A. (1988). Emotion recognition in autism:
Coordinating faces and voices. Psychological Medicine, 18, 911–923.
Hobson, R.P., Ouston, J., & Lee, A. (1989). Naming emotion in faces and voices:
Abilities and disabilities in autism and mental retardation. British Journal of
Developmental Psychology, 7, 237–250.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2,
217–250.
Kim, J., Wigram, T., & Gold, C. (2009). Emotional, motivational and interpersonal
responsiveness of children with autism in improvisational music therapy. Autism,
13(4), 389–409.
Langer, S.K. (1953). Feeling and form. New York, NY: Charles Scribner’s Son.
Leslie, A.M. (1991). The theory of mind impairment in autism: Evidence for a
modular mechanism of development? In A. Whiten (Ed.), Natural theories of
mind: Evolution, development and simulation of everyday mindreading (pp. 63–78).
Oxford: Basil Blackwell.
Leslie, A.M., & Roth, D. (1993). What autism teaches us about metarepresenta-
tion. In S. Baron-Cohen, H. Tager-Flusberg & D.J. Cohen (Eds.), Under-
standing other minds: Perspectives from autism (pp. 83–111). Oxford: Oxford
University Press.
Malloch, S., & Trevarthen, C. (2008). Communicative musicality: Exploring the basis
of human companionship. Toronto: Oxford University Press Canada.
Mancia, M. (2004). Sentire le parole. Archivi sonori della memoria implicita e
musicalità del transfert [Feeling the words. Sonorous archives of implicit memory
and transfert musicality]. Torino: Bollati Boringhieri.
McIntosh, D.N., Reichman-Decker, A., Winkielman, P., & Wilbarger, J. (2006).
When the social mirror breaks: Deficits in automatic, but not voluntary,
mimicry of emotional facial expressions in autism. Developmental Science, 9(3),
295–302.
Meltzoff, A.N. (1995). Understanding the intentions of others: Re-enactment of
intended acts by 18-month-old children. Developmental Psychology, 31(5), 838–850.
Meltzoff, A.N., & Gopnik, A. (1993). The role of imitation in understanding persons
and developing a theory of mind. In S. Baron-Cohen, H. Tager-Flusberg & D.J.
Cohen (Eds.), Understanding other minds: Perspectives from autism (pp. 335–
366). Oxford: Oxford University Press.
140 A. Raglio et al.
Meltzoff, A.N., & Moore, M.K. (1992). Early imitation within a functional
framework: The importance of person identity, movement, and development,
Infant Behavior and Development, 15, 479–505.
Meltzoff, A.N., & Moore, M.K. (1994). Imitation, memory, and the representation
of persons. Infant Behavior and Development, 17, 83–99.
Meltzoff, A.N., & Prinz, W. (Eds.). (2002). The imitative mind: Development, evolu-
tion, and brain bases. Cambridge: Cambridge University Press.
Nordofff, P., & Robbins, C. (1977). Creative music therapy: Individualized treatment
for the handicapped child. New York, NY: John Day.
Oldfield, A. (2006). Interactive music therapy, a positive approach – music therapy at a
child development centre. London: Jessica Kingsley.
Pavlicevic, M. (1997). Music therapy in context: Music, meaning and relationship.
London: Jessica Kingsley.
Pavlicevic, M., & Trevarthen, C. (1989). A musical assessment of psychiatric states in
adults. Psychopathology, 22, 325–334.
Raglio, A., Traficante, D., & Oasi, O. (2006). A coding scheme for the evaluation of
the relationship in music therapy sessions. Psychological Reports, 99, 85–90.
Raglio, A., Traficante, D., & Oasi, O. (2007). Comparison of music therapy coding
scheme with the Music Therapy Checklist. Psychological Reports, 101, 875–880.
Rizzolatti, G., Fadiga, L., Gallese, V., & Fogassi, L. (1996). Premotor cortex and the
recognition of motor actions. Cognitive Brain Research, 3, 131–141.
Robarts, J. (1998). Music therapy for children with autism. In C. Trevarthen, K.
Aitkin, D. Papoudi & J. Robarts (Eds.), Children with autism: Diagnosis and
interventions to meet their needs. London: Jessica Kingsley.
Rogers, S. (1999). An examination of the imitation deficit in autism. In J. Nadel & G.
Butterworth (Eds.), Imitation in infancy (pp. 254–279). Cambridge: Cambridge
University Press.
Sander, L. (2008). Living systems, evolving consciousness, and the emerging person: A
selection of papers from the life work of Louis Sander. New York, NY: The
Analytic Press.
Schopler, E. (1990). Psychoeducational profile revised (Pep-R). Spiral-bound
paperback, Austin, TX: Pro Ed.
Schopler, E., Reichler, R.J., & Rochen Renner, B. (1993). Childhood autism rating
scale. Los Angeles, CA.: Western Psychological Services.
Schumacher, K. (1999). Musiktherapie und säuglingsforschung [Music therapy and
research on sucklings]. Frankfurt am Main: Perer Lang.
Schumacher, A., & Calver-Kruppa, C. (1999). The AQR – an analysis system to
evaluate the quality of relationship during system therapy. Nordic Journal of
Music Therapy, 8, 188–191.
Snow, M.E., Hertzig, M.E., & Shapiro, T. (1988). Expression of emotions in young
autistic children. In S. Chess, A. Thomas & M.E. Hertzig (Eds.), Annual progress in
child psychiatry and child development (pp. 514–522). New York, NY: Brunner/
Mazel.
Stern, D. (1985). The interpersonal world of the infant. New York, NY: Basic Book.
Stern, D. (1993). The role of feelings for an interpersonal self. In U. Neisser (Ed.),
The perceived self: Ecological and interpersonal sources of self-knowledge (pp.
204–215). New York, NY: Cambridge University Press.
Stern, D. (1995). The motherhood constellation. A unified view of parent–infant
psychotherapy. New York, NY: Basic Book.
Stern, D. (1998). Babies and music: Some reflections on the temporal aspects of an infant
daily experience. In E. Darbellay (Ed.), Le temps et la forme [Time and Form].
Geneva: Cahier de la Faculté des Lettres, Musicologie, Université de Genève.
 Nordic Journal of Music Therapy 141
Stern, D. (2004). The present moment in psychotherapy and everyday life. London:
Norton & Company.
Stern, D., Jaffe, J., Beebe, B., & Bennett, S.L. (1975). Vocalizing in unison and in
alternation: Two modes of communication within the mother–infant dyade.
Annals of the New York Academy of Sciences, 263, 89–100.
Target, M., & Fonagy, P. (1996). Playing with reality: II. The development of psychic
reality from a theoretical perspective. International Journal of Psycho-Analysis,
77, 459–479.
Trevarthen, C. (1979). Communication and cooperation in early infancy. A
description of primary intersubjectivity. In M. Bullowa (Ed.), Before speech:
The beginnings of human communication (pp. 321–347). London: Cambridge
University Press.
Trevarthen, C. (1984). Emotion in infancy: regulators of contact and relationships
with persons. In K. Scherer & P. Ekman (Eds.), Approaches to emotion (pp. 129–
157). Hillsdale, NJ: Lawrence Erlbaum.
Trevarthen, C. (1998). The concept and foundations of infant intersubjectivity. In S.
Braten (Ed.), Intersubjective communication and emotion in early Oontogeny (pp.
15–46). Cambridge: Cambridge University Press.
Trevarthen, C. (2001). Autism, sympathy of motives and music therapy. Enfance, 1,
86–99.
Trevarthen, C., & Aitken, K.J. (2001). Infant intersubjectivity: Research, theory, and
clinical applications. Journal of Child Psychology and Psychiatry, 1, 3–48.
Tronick, E.Z. (1989). Emotions and emotional communication in infants. American
Psychologist, 44, 112–119.
Tronick, E.Z., Members of the Change Process Study Group. (1998). Dyadically
expanded states of consciousness and the process of therapeutic change. Infant
Mental Health Journal, 19(3), 290–299.
Whipple, J. (2004). Music in intervention for children and adolescent with autism: A
meta-analysis. Journal of Music Therapy, 8, 6–24.
Wigram, T. (2000). A method of music therapy assessment for the diagnosis of
autistic and communication disordered children. Music Therapy Perspectives, 18,
13–22.
Wigram, T. (2004). Improvisation. Methods and techniques for music therapy
clinicians, educators and students. London: Jessica Kingsley.
Wigram, T., & De Backer, J. (1999). Clinical applications of music therapy in
developmental disability, paediatrics and neurology. London: Jessica Kingsley.
Wigram, T., & Gold, C. (2006). Music therapy in the assessment and treatment of
autistic spectrum disorder: Clinical application and research evidence. Child:
Care, Health and Development, 32(5), 535–542.