The Arts in Psychotherapy 35 (2008) 162170

Using Orff-based techniques in childrens bereavement groups: A cognitive-behavioral music therapy approach
Dena M. Register, Ph.D., MT-BC a, , Russell E. Hilliard, Ph.D., LCAT, LCSW, MT-BC b
a

University of Kansas, 2241 Breckenridge Drive, Lawrence, KS 66047, United States b Seasons Hospice & Palliative Care, United States

Abstract Children affected by the death of a loved one can face multiple challenges including difculties identifying and dealing with emotions, impaired social interactions, distorted thoughts, and behavioral problems. The inclusive and engaging nature of musicbased therapeutic experiences provides children with a developmentally appropriate way to address a variety of needs. This article describes the use of Orff-based music therapy interventions in a cognitive-behavioral framework to assist children through the grieving process. The Orff-based music therapy program provides opportunities for emotional healing, building positive social relationships, cognitive reframing, and decreasing behavioral problems. The philosophy of cognitive-behavioral music therapy is articulated, and session goals and objectives are stated. Sample Orff-based music therapy sessions are provided with a rationale for their use. 2007 Elsevier Inc. All rights reserved.
Keywords: Music; Therapy; Children; Bereavement; Grief; Hospice; School; Cognitive; Behavioral

Grief and bereavement is an experience that everyone encounters at some point in the life process. While this can be a difcult experience at any age, it can be particularly trying for children to cope with the loss of a loved one. The literature is sparse regarding the use of music therapy for grieving children, however, there are many articles addressing bereavement needs and other forms of interventions. This article provides a brief background regarding some of the literature that is available on this topic and presents a clinical method for utilizing music therapy and Orff-Schulwerk techniques for addressing the needs of grieving children in the context of an 8-week, group therapy format. Coping with grief Wolfelt (1983) described common behaviors of children as they experience the grief process. These may include developmental regression, tantrums or acting-out behaviors, complaints of somatic concerns, engagement in caregiving behaviors, and decline in school performance. Some children may have disorganized thinking and can display strong emotional outbursts. Coping strategies among children vary, particularly during the grief process, creating an increased need for a broader range of coping mechanisms (Dowdney, 2000).

Corresponding author. Tel.: +1 785 864 9634. E-mail address: register@ku.edu (D.M. Register).

0197-4556/$ see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2007.10.001

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Stack (2003) studied bereavement in the pediatric intensive care setting and noted that childrens grief responses vary depending on factors such as age, maturity and previous exposure to the death of a loved one. Children under the age of 5 are typically unable to grasp the permanency of death. In contrast, children at around age 11 typically respond in a more adult-like (modeled) manner. The variety of reactions among children, as well as the response and modeling of the support system, affects the coping abilities of the child. Robb (1999, 2003) describes coping strategies of children at various developmental stages as related to hospitalization. Though this article focuses on hospitalized children, the stages and coping strategies synthesized and outlined parallel, in many ways, those of grieving children. For example, both hospitalized and grieving children seek support from trusted individuals. These children may also acquire information about the situation through observation or choose a tactic of distraction or avoidance to temporarily escape the situation. The desire for trust, autonomy and supporting the childs initiative are essential in their developmental progression and their ability to cope with loss. Dowdney (2000) notes that there is currently no conceptual research framework to test the hypothesis regarding coping and treatment of individuals who are grieving. As a result, the many variables and outcomes involved in supporting grieving children have not been sufciently explored. The author goes on to suggest a more qualitative approach as the best method for testing and articulating the needs and outcomes of these individuals. Curricula and grief support groups There are limited curricula available for addressing childhood grief. Black and Adams (1993) provided a schoolbased model using the expressive arts in childrens bereavement. The model employed the use of art interventions such as sculpting, painting, and body drawing. Cassini and Rogers (1994) manual provides assistance for school teachers in helping grieving students and encourages the use of active listening and the provision of basic death education concepts. A similar guide to helping grieving children was provided by Goldman (1994). Training programs for parents of grieving children have been devised and used to facilitate parental knowledge and support for grief work among children (Hare & Skinner, 1988). Manuals and programs for grief counselors encourage the use of a variety of interventions to facilitate remembering, emotional support, and problem solving (Knope, 1989; Seager & Spencer, 1996). These various programs utilize developmentally appropriate play-based interventions including visual art activities, movement, childrens literature and lms, and recorded music to address the needs of grieving children. There is currently no body of literature that investigates overall efcacy of a particular curriculum, nor does it support one type of intervention more than another. The focus of the small body of research literature available regarding childrens bereavement services addresses overall efcacy in either school- or community-based programs. Wassef, Collins, Ingham, and Mason (1995) investigated the efcacy of both school- and community-based programs in research literature that addressed the emotional and behavioral issues of students. The researchers found 29 articles in the educational, psychological, and psychiatric journals in the 5-year period prior to publication of their study and analyzed the merits of each based on the articles results. Of the studies evaluated in this work, only one addressed the needs of grieving children and adolescents. However, several additional studies discussed feelings or behaviors that may apply to grieving children or for which they may be at-risk. The single grief study discussed in Wassef et al. (1995) included only 16 subjects (8 adolescents and 8 children) in a grief support group that ran once per week for 8 weeks. Participants were inner-city students that experienced the death of a family member within 2 years prior to the study. Results indicated a decrease in the somatic symptoms of children in the group, there was no change in reported depression of either group (Opie et al., 1992). In a similar study (1992), Tonkins and Lambert (1996) evaluated psychotherapy techniques in the treatment of childrens bereavement. Results of this study indicated that participants in sessions during an 8-week curriculum displayed a signicant reduction in grief symptomatology as measured by parents and teachers. Wassef et al. (1995) concluded from the various articles reviewed that school-based support groups may provide the most effective means for identifying and reaching students. Results also supported the need for early intervention and management of emotional and behavioral issues in the context of students educational environment. Recommendations included comprehensive outcome measures comprised of student perceptions of change, behavioral measures, and school records and reports. In an effort to educate and stimulate the interest of teachers and school administration in identifying and addressing the needs of grieving students, Lawhon (2004) outlines facts and reactions of children who are grieving in addition to

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action steps that teachers and administrators can take to provide the children with support. This model addresses the primary need to educate both adults and children about a natural part of the life cycle and the difculties that may arise as a result. In contrast, Curtis and Newman (2001) reviewed all empirical evidence available from community-based support services for bereaved children. The researchers identied nine studies but were generally unable to identify generalized results due to weaknesses in the methodology and design of several studies. Like many other authors, they note the difculties in evaluating this type of work. While they were unable to conclude how effective various models were, information gathered did indicate that interventions do provide benets to both parents and children in a bereaved family. Philosophical orientation Bereavement affects the entire family-system. Therefore, children need a safe and supportive place to work through their grief. Bereavement groups provide structure in an often-chaotic emotional time for children and normalize experiences through the peer support process. Groups provide structure, positive social interactions, and afford opportunities for expressing emotions, learning basic death education concepts, reframing thoughts, and changing behaviors. Because grief encompasses a myriad of emotions (sorrow, anger, guilt, relief, resentment, peace, and others), opportunities for emotional identication and expression are important. Grief emotions are often experienced in a chaotic form without sequential stages or cycles, and this chaotic form can leave a child feeling overwhelmed with polarizing emotions. While some children may be able to verbalize emotions, others have difculties doing so. Engaging in live, musical dialogue affords opportunities for emotional expression and encourages children to improvise within a safe and structured environment. Children need validation for their emotions, and they need the emotional aspects of grief to be normalized. Cognitive-behavioral music therapy serves as the philosophical grounding for this curriculum. The cognitivebehavioral approach deals directly with cognitive information processing and helping the group or individual problem-solve emotional and social/interpersonal issues. This approach employs structural procedures, and emphasizes action-oriented interventions (Kendall, 2000). Orff-based music therapy is congruent with the cognitive-behavioral music therapy (CBMT) approach because it allows children to experience music-based decision-making, structure and problem solving in a manner that encourages emotional expression and validation. Additionally, participants discuss and practice these cognitive-behavioral changes in a socially supportive environment by engaging in action-oriented experiences and discussing behavior and thought patterns. While many children nd these thoughts and behaviors difcult to identify in more traditional therapies, music-based interventions create a more equalized environment where all participants can feel successful, comfortable and at ease. Myths about death and dying are common among children, and an important aspect of bereavement groups includes death education. Providing honest information about death and dying (e.g. explanation of cremation) confronts cognitive distortions (e.g. cremation hurts the body). The cognitive map of the grieving child may be detrimental (e.g. I wasnt a good girl, so my Daddy died, or I had a dream about him, so he died. I am a horrible kid.). Children with self-blaming cognition need to engage in cognitive reframing exercises to change the thought process. The group process confronts the faulty logic and replaces it with a more fact-based one. Cognitive deciencies (lack of thought) also occur among grieving children, resulting in impulsivity. Wolfelt (1992) theorized that many grieving children are often misdiagnosed with some other learning deciency or disability. Because teachers or administrators may not always be aware that a loss occurred, the childs grief reactions are mislabeled or misinterpreted as some type of deciency or disorder. The example provided is attention decit hyperactivity disorder (ADHD). Because the behaviors exhibited by children with this disorder may present in the same way by a child attempting to cope with the loss of a loved one, a misdiagnosis may lead to the unwarranted use of pharmacological interventions, a standard treatment for ADHD. Children with cognitive deciencies often engage in impulsive behavior because they lack forethought (Kendall, 2000). Cognitive deciencies can present in bereavement as children may engage in denial (conscious or subconscious) or avoidance. The cognitive deciencies caused by denial (child rejects the death) and avoidance (child refuses to talk or think about the deceased) can lead to impulsivity.

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Learning problem-solving techniques and increasing the range of coping mechanisms are important components of grief work for children and can help to change problematic behaviors. Behavioral problems are common and include: inattentiveness, acting-out, sleep and/or eating disturbances, somatic complaints, attachment-avoidance behaviors, and a decline in school performance. Learning to change behavior through behavioral contracts, role-play situations, contingency programs, and systematic reinforcement schedules are vital aspects of treatment. Music for coping and grief Robbs (2003) Contextual Support Model of Music Therapy provides a framework that functions as a springboard for music to promote positive coping skills in children. This child-centered approach encourages therapists to capitalize on the functions of music that support expression, identication, and decision making in children. Robb documented signicant outcomes of hospitalized children based on the use of this model. The use of music to motivate children to engage and participate within a structured environment that supports their autonomy develops and facilitates positive coping skills for children at a very difcult time. Dalton and Krout (2005) developed and investigated the Grief Process Scale to measure grief symptoms in adolescents engaged in song writing experiences. Participants in the music therapy sessions reported more of a decrease in grief symptoms than their counterparts in the control group. Though the number of participants in the study was a limiting factor, results suggest the possibility that engaging in music therapy interventions is benecial for adolescents as they work on processing their grief experience. Similarly, the effects of interventions on mood and behaviors of grieving children in a music therapy-based group were evaluated. Hilliard (2001) developed an 8-week, music-based curriculum that utilized the themes discussed in non-music curricula. Children were randomly assigned to a music therapy-based bereavement group or a wait-list control group. Pre- and post-test measures evaluated mood and behavior among grieving children. Data indicated that those participating in the music therapy sessions had signicantly lower grief symptoms and signicantly improved behaviors in the home as compared to those who did not participate. The use of Orff-Schulwerk in music therapy Orff-Schulwerk, developed by composer Carl Orff, is both a method and a philosophy of music education that parallels language learning. Music making begins with hearing and imitating, followed by making and improvising music and, over time, reading and writing music. This methodology is based on the idea that music can be created out of the natural, inherent rhythms in both movement and speech. The emphasis in this methodology is placed on child-centered, creative, active music making that allows children to express themselves (Shamrock, 1997). Gertrude Orff (1989) provides examples and rationales for Orff music therapy that include the concepts of initiative versus imitation in client-therapist interactions. These clinical examples are not presented as a cookbook, but rather an opportunity to examine the patientclient relationship and the numerous uses of music as a therapeutic medium for addressing the clients needs. Orff (1989) describes a condition as the lock and the methods of treatment, a search for a compatible key. Children frequently indicate a key in the course of a session, which opens up a variety of areas in the session. Each of these principles, when applied to social and emotional learning and sharing, parallels the principles of the cognitive-behavioral model. As previously discussed, cognitive-behavioral music therapy incorporates thoughts and actions of the individual and uses a specic structural procedure to bring about change. Likewise, Orff-based music therapy uses structured musical experiences to improvise and create. The exploration of emotions, social interactions, thoughts, and behaviors, in this creative, yet structured musical environment sets children up for success in dealing with overwhelming life experiences (Achey, Colwell, Grillmeister, & Woolrich, 2003). Development of the curriculum: group structure and material Childrens bereavement groups outlined in other curricula consists of eight weekly sessions. While sessions vary according to the specic needs of the individuals, formatting for each group remains consistent across the 8-week period. A common factor of the aforementioned curricula is presentation of topics covered in bereavement groups.

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A new topic is introduced each week with review of previously discussed information. Topics are described in detail below. Sessions began with a hello song or intervention including live music and greeting individuals by name. Group guidelines and material covered in the previous session were reviewed, with emphasis placed on the importance of condentiality. The Condentiality Rap was used to help children understand the concept of condentiality and to establish appropriate places and people with whom they can discuss or share information covered in the group. A song or intervention addressing the specic topic was presented followed by discussion and processing. Processing in a cognitive-behavioral model included identication, venting, validation, and problem solving. Each session concluded with a closing song or intervention that incorporated problem solving as related to the issues addressed in that particular session. Additionally, children were given a homework assignment to follow up with over the course of the week in an effort to change current behavioral patterns. Goals for the rst week included establishment of group rapport and group guidelines. Objectives included normalization of the grief process and the recognition that children are not isolated in their grieving. In addition to building rapport, it was imperative to teach group members that group meetings were time-limited in order to avoid a feeling of loss upon termination of the group. For example, the therapist said, We get to play together for eight weeks. Since this is our rst time together how many more times do we get to meet? It was necessary to review this information at the beginning of each group. The second session focused on death education and the physical issues surrounding death. Objectives for this session included dispelling myths about dying and gaining understanding about the life cycle from birth through death. The idea of change became the focus for week 3. The goal of this session was to discuss change as related to the death. Objectives included dening the concept of change and identication of specic circumstances or roles that differ for the individual as a direct result of the death. Sample session one provides an example of an Orff-based intervention appropriately used during the second and third week of the group. The goal of weeks 4 and 5 was to address emotions associated with the loss. Sadness was addressed on week 4 and anger on week 5. Objectives include identication of the ways children express each emotion and how those expressions function in their lives (i.e. they isolate themselves or get punished for acting out). Additionally, children identied healthy ways to express themselves as well as appropriate coping skills. Week 6 focused on the role of memories in grief work. Objectives included the identication and sharing of specic memories and emotional processing related to those memories as well as ways to honor the memory of their loved one(s). Validation of both positive and negative memories was imperative. The nal 2 weeks (groups seven and eight) focused on ways children can cope in the future and on moving forward. In keeping with a cognitive-behavioral music therapy model, this included the use of behavioral contracts, identication, and validation of new and existing relationships and support systems, as well as closure of the time spent together as a group. It was important to recognize the work children have done in the group over the course of the 8 weeks and the support they have provided for one another. The following interventions provide examples of Orff-based music therapy that address some of the needs discussed in this article. Sample intervention 1 Death and Change This intervention utilizes the Orff technique of verbal superimposed ostinati. Begin by speaking each line separately in rhythmic speech as notated. The group is then divided into sections and each section is assigned one line. Groups practice individually and then the clinician conducts the group in layering the three different lines. In order to make this intervention more challenging, you can add body percussion, such as clapping, stamping, tapping knees or snapping to the various rhythmic denominations. For example, a half note indicates a clap, while a quarter note indicates a stamp (Fig. 1). This session utilizes common examples of things in nature that change. Utilizing tadpole and caterpillar puppets to talk about change in the world around us is a concrete visual that young children relate to with relative ease. Discussion

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Fig. 1. Three-part vocal chant arrangement for Death and Change intervention.

following this intervention might include such questions as, What are other things that change? or Have you (or your family or environment) changed since your loved one has died? Giving children the opportunity to relay their experiences is paramount. Asking questions such as, What makes change so difcult? and What are some good points about change? help children share perspective and look for positive outcomes. This topic also gives the group an opportunity to discuss cultural aspects of grief. Questions such as, What do we do when someone is born? and How about when they die? help children recognize the various ways we deal with regular occurrences. This also provides an opportunity to discuss the many traditions and cultural differences regarding how people handle and talk about death. Sample intervention 2 Saying Goodbye This intervention begins with the therapist improvising a quiet, gentle accompaniment on the guitar while the group members take turns playing the rainstick. When the guitar stops, the individual holding the rainstick has an opportunity to share what they would have liked to say to their loved one before they died. Due to the intense nature of this portion of the session, children participate in the Boomwhacker intervention after sharing what they would have liked to say to their loved one in order to help elevate their mood. Divide children into three groupsA, B, and C (Fig. 2). The form used for this intervention is: Play section A, add section B, play A alone, add section C, sections A, B, and C play together and section A plays alone.

Fig. 2. Three-part Boomwhacker arrangement for Saying Goodbye intervention.

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Fig. 3. Orff arrangement of The Memory Song for Memories and Remembrance intervention.

This intervention provides an opportunity for group members to share something that would have liked to say to their loved one before they died. Additionally, this session provides validation of the range of emotions one feels as the result of a loss and reinforces the importance of a support system. Following the boomwacker intervention children are asked to name someone that they identify as supportive and with whom they can discuss their feelings. Sample intervention 3 Memories and Remembrance The Orff technique used in this intervention is storytelling using a tri-tonic melody, gestures, and improvisation (Fig. 3). The book The Tenth Good Thing About Barney by Judith Voirst, serves as the basis for this lesson. Introduce and teach the melodic theme as an introduction and coda. The chorus is used repeatedly throughout the story to establish a set form. Unpitched percussion instruments (such as claves, maracas, agogo bells, temple blocks, cabasas) paired with various characters in the book are played 0 as they are presented in the book. Some examples include:
Characters: Barney Boy Father Mother Annie Other words for selected instruments: Cried Funeral Good Things Brave Smart and funny and clean Cuddly and handsome Purr Heaven Ground Flowers

Implementation of this session occurred during the seventh week. However, this intervention also addresses goals in several of the previous sessions. For example, the focus may be around the physical act of dying, emotions, and/or change. This book provides a perfect introduction to help children discuss favorite memories of their loved one(s) and ways that their family honors that persons memory. An extension of this intervention is to allow group members to write individual verses to the melodic theme and invite parents to come and listen.

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Sample intervention 4 Feelings

This session meets goals outlined in weeks 4 and 5. The Orff technique utilized in this group is an aesthetic experience using sound color on barred instruments with a poem. Group members read the whole poem together. For each special word, those with various notations under them, children add different types of body percussion. For example, X indicates a clap, and ooooo indicates a snap. The poem is read with accompanying body percussion as notated. Next, each word accompanied with body percussion is assigned an unpitched percussion instrument, which is played in lieu of the body percussion sound. Barred instruments (such as xylophones, metalophones, and glockenspiels) in C pentatonic are added all mixed up so that children may play any two notes simultaneously. After practicing the various parts students perform the complete work beginning with a tremolo introduction in C pentatonic, followed by speech-only leading of the poem (with voice inection), reciting the speech with instruments, and ending with an instruments-only read-through. Having children write new verses using their feelings and experiences easily extends this intervention. The recognition that feelings can be unpredictable and may change from one day to the next is an important part of the grief process. There are a number of things that can cause feelings and as a result, behaviors, to change. Validating the childs right to have those feelings and devising a behavioral plan can be a crucial part of the childs ability to cope. Response of participants and recommendations Informal observations of children participating in Orff-based music therapy groups indicate that children respond in a very positive manner and that group attendance remains consistent throughout the 8-week period. Children respond positively to the structure provided by the interventions and frequently express, through positive verbalizations, their enjoyment of the music making experiences. Because the interventions provide a creative and active way to approach and discuss very difcult topics with grieving children, both attendance and on-task behavior to the topic are positively affected. Regarding on-task behavior to the material presented, it is not uncommon for children to move in and out of their discussions of grief many times in a brief period of time. Often they will share a piece of their experience at a time in response to specic questions posed by the therapist. Opportunities to take these keys, as previously described (Orff, 1989), and plug them into a musical expression or experience gives individuals the space they need to feel safe and comfortable sharing such personal, and often difcult, information with the group. As this cycle of feeling safe and comfortable in the group environment begins, children begin to respond and share experiences and feelings more freely. Observations of student participation and growth in these school-based bereavement groups are overwhelmingly positive. However, issues raised in the review of literature regarding the lack of empirically based research in this area makes it imperative to test this model in comparison to others. Future comparisons for efcacy of a particular curriculum might include a standard social work model or a creative arts-based model. Because of the positive outcomes of the previously tested music therapy model (Hilliard, 2001), it would be interesting to compare the two curricula with a non-music model utilizing the same measures to identify outcomes. The modeling, creation, and expression encompassed in Orff-based music therapy in combination with the principles

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of CBMT may be key to providing best practices music therapy to grieving children. Continued pursuit of empirical evidence regarding efcacy of music-based interventions to meet the needs of grieving children is essential to providing services of the highest quality and efcacy to this population. References
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