While I was conducting the time-sampling analysis, I realised that one aspect I was interested in was not sufficiently represented by my coding system. Many resilience researchers have highlighted that having caring and supportive relationships with adults is one of the key protective factors for developing resilience (e.g. American Psychological Association, 2018; Luthar, 2006; Masten et al., 1990). My hypothesis was that individual music therapy sessions could provide autistic children with the experience of such a positive relationship with the music therapist and thereby foster resilience. My coding manual focused on aspects of the child-therapist relationship, measured by codes such as ‘Look’ or ‘Respond’, but it did not seem to pick up the overall quality of the relationship satisfactorily. It also seemed that simply adding more codes would not solve the issue, but that an additional measurement tool was necessary. This tool needed to provide an assessment of the child-therapist relationship with reference to the behaviour of the child. It should rate the relationship considering the emotional state of the child, the child’s ability to participate in reciprocal musical interactions, and the child’s ways of relating to the therapist to get an overall picture of the quality of relationship. Furthermore, the assessment tool needed to be user-friendly and quickly and simply implementable as the other analyses applied in the research study were already too time-consuming for another tool of similar complexity to be added.
A literature search disclosed three available assessment tools that focus on measuring the therapist-client relationship and are applicable to my client group. These are the Assessment of the Quality of Relationship (AQR; Schumacher & Calvet, 2007), the Nordoff- Robbins-Scale I: Child-Therapist Relationship in Coactive Musical Experience (Nordoff & Robbins, 1977), and the Music Therapy Session Assessment Scale (MT-SAS; Raglio et al., 2017). The AQR aims to assess and comprehensively classify the quality of the interpersonal relationship. Four different scales with seven or eight levels each focus on the instrumental quality of relationship, the vocal-pre-speech quality of relationship, the physical-emotional quality of relationship, and the therapeutic quality of relationship. The AQR is a microanalysis method that requires familiarisation and extensive training. It is based on a different music therapy approach which, for example, utilises special equipment, such as hammocks and trampolines, that I could not use in my study. It was thus not suitable as an additional assessment tool in my study. The Nordoff-Robbins-Scale I is a similarly elaborate measurement tool, which proved to be too extensive for the purpose of this study. It distinguishes seven levels of participation and seven levels of resistance and provides detailed rating criteria for each level. The structure of the MT-SAS, on the other hand, matches the needs for this study very well. Seven behaviours in the domains of countenance, non-verbal communication, and sound-music communication are rated as predominantly absent or predominantly present, which results in a total score that conveys
an overall impression of the relationship. Each item is defined in a succinct way. However, the seven items had too many overlaps with my coding manual (for example eye-contact, smiles, or anxiety) and the scale was thus not going to provide me with the additional information about the child-therapist relationship I was interested in.
After the review of the existing scales I decided to design a new bespoke assessment tool which I call Assessment of Child-Therapist Relationship (ACTR). The MT-SAS was an inspiration for me to use a similarly clear structure and the concise descriptions. The Nordoff-Robbins-Scale was helpful because it provided a comprehensive understanding of the interpersonal child-therapist relationship in a coactive musical experience. Furthermore, I adopted their format of a hierarchical scale but reduced their seven levels to five. I did this for two reasons. First, the two lowest levels could be collapsed in my assessment tool as the excerpts that were to be rated comprised positive moments of the sessions, making it unnecessary to distinguish between different expressions of anxiety and rejection. Second, the Nordoff-Robbins-Scale I was designed to be used for whole sessions. I only rated short session segments that did not require the same detailed distinctions between different nuances, because the displayed behaviour and observed relationship was usually not as multifaceted as during a whole session.
The ACTR provides five ranks that describe the quality of relationship as 1 = difficult, 2 = slightly difficult, 3 = moderate, 4 = positive, 5 = very positive. Each level is defined by three descriptions about (a) the child’s emotional state and way of being in the room, (b) the child’s ability to engage in reciprocal musical interactions, and (c) the child’s ways of relating to the therapist. The assessment manual and the blank rating form are shown in Figures 11 and 12, respectively. The completed rating forms can be found in the appendix. In this study, I rated each excerpt with one level. As I had selected four or five excerpts per session, the relationship rating resulted in four to five numbers per session. I calculated the mean of these numbers for each session, which allowed me to look at the development of the relationship mean scores for each child over the course of the 20-week therapy. Results of the ACTR analysis are presented in section 5.2.3.
Figure 11: ACTR manual
Assessment of Child-Therapist Relationship (ACTR)
5 = very positive (a) Child feels secure and confident.
(b) Child is able to be both responsive to the therapist and in charge of the interaction. Child is able to be creative, to use humour, to share emotions and to swap roles with therapist.
(c) Child seems to enjoy interacting with therapist and initiates communication. The relationship is characterised by mutuality and a sense of partnership
.
4 = positive (a) Child appears relaxed and comfortable, shows no signs of distress.
(b) Child is actively involved in music making. Child engages in turn-taking activities and responds to most prompts and musical suggestions.
(c) Child seems interested in interacting with therapist.
3 = moderate (a) Child appears mainly relaxed and comfortable, generally at ease in therapy situation.
(b) Child participates in musical activities and responds to some prompts or musical suggestions. Child may only be attentive for short periods of time so that meaningful interactions only occur occasionally. (c) Child tolerates therapist and seems somewhat interested in interacting with therapist.
2 = slightly difficult (a) Child seems uncertain, wary and uneasy. When approached too directly by therapist child might become anxious, distressed or withdrawn.
(b) Child responds reluctantly or with resistance to musical invitations. Child’s involvement in interaction can be evoked by interesting or matching music but is intermittent and fleeting.
(c) Child might accept therapist when interaction is on child’s terms but is mainly unresponsive to therapist 1 = difficult (a) Child appears anxious, distressed or withdrawn.
(b) Child’s engagement in musical interactions is prevented by being cut-off or isolated, or by reactions of panic, rage or rejection (such as pushing or throwing instruments).
(c) Child seems to be completely oblivious of therapist or child tries to actively block out and reject therapist by screaming, kicking, hitting or turning away.
(a) Child’s emotional state and way of being in the room (b) Child’s ability to engage in reciprocal musical interactions (c) Child’s way of relating to the therapist
Figure 12: ACTR rating form 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 2 3 4 5 Ø
Before I carried out the ACTR on all excerpts, inter-rater reliability was checked. The test was conducted on four sessions of five excerpts each, resulting in 20 excerpts. Two sessions each had been selected from two different children. For both children, one session was randomly picked from the first five, and one session from the last five therapy sessions of the child’s treatment because I speculated that this would result in a broader spectrum of the observed quality of relationship. As I had conducted the therapy sessions myself, I could not be blinded to the phase of the treatment period. The music therapist who carried out the second rating, however, applied the ACTR without knowing any details about the chronological order of the session excerpts. We obtained an exact agreement in 12 out of 20 excerpts. In all the remaining eight excerpts, our ratings differed by only one point (e.g. Rater A and B chose 4 = positive and 5 = very positive, respectively). As the data are measured on a continuous rather than a categorical scale, inter-rater reliability was assessed using intraclass correlation (ICC). To determine whether the two raters provided scores that were similar in absolute value, a two-way random-effects, absolute-agreement, single-measures ICC (McGraw & Wong, 1996), also called ICC 2,1 (Shrout & Fleiss, 1979), was chosen. The ICC estimate was 0.87 with a 95% confidence interval of 0.70-0.95, indicating good to excellent reliability (Koo & Li, 2016).