Abstract In my clinical practice with non-speaking clients on the autism spectrum, I have questioned my understanding of who the people I work with are and how that informs what we do together in therapy. This autoethnographic study provides a narrative account of my early music therapy practice informed by the question “How do I see you, and what does that mean for us?” Autoethnography provides a fitting framework for reflexive questioning, as it requires me as both researcher and participant to turn the lens inward and examine my own experiences as a music therapist. Through narrative dialogues about an impactful client encounter, I explore my clinical perspective in order to understand how I see my clients and how this impacts the world we create together during sessions. reflexivity, autoethnography, autism, clinical practice Autoethnographic Research Like improvised music, [first-person research] moves between dissonance and resolution, randomness and organization, and dissatisfaction and fulfillment while finding the “right” phrase, chord, rhythm, or harmony that completes the quest, or feels “complete enough,” or—as a sensory image—scratches the unreachable itch. (Woodward, 2015, p. 13) First-person research is a form of qualitative inquiry that “provides a means of individual, subjective description of phenomena, which can reveal insights into the human condition” (Hunt, 2016, p. 453). Through exploration of personal experiences and interactions, the researcher embarks on a meaning-making process that involves reflexive questioning to uncover unexplored meanings and values. The reflexive nature of music therapy clinical practice lends itself naturally to first-person research. In therapy, we “need knowledge of the client’s perspective of the experiences therapists provide in order to understand whether and how they are beneficial for clients. Conversely, we need knowledge of the therapist’s experience of working with clients in order to understand how and why we do this work, and the best ways of working with, and being with, clients” (Hunt, 2016, pp. 453–54). In this article, I describe my own clinical work with a particularly challenging client, using a methodology called autoethnography. In autoethnography, personal experience is valued as a source of knowledge and insight into a larger social or cultural context through the researcher’s exploration of significant life events (Ellis & Adams, 2014). Autoethnography was first termed by Heider (1975) to connect lived experience to a wider cultural, social, or political context through autobiographical exploration (Ellis & Bochner, 2000; Graham, Short, & Turner, 2013; Hayano, 1979). It developed in response to a crisis of representation, or the idea that “researchers could separate (researcher) selves from the research experience” in the 1970s and 1980s, leading to a desire for new ways of representation in social science research (Adams, Jones, & Ellis, 2014, p. 9). Autoethnography is located within aesthetics and humanities perspectives, as it combines characteristics of autobiography (personal experience) and ethnography (analyzing cultural experience) to write about past experiences (Ellis, Adams, & Bochner, 2011). In related professions such as music education, music performance, occupational therapy, and psychology, this approach has been used to understand human experiences that inform teaching and learning processes, as well as embracing reflexive therapeutic practice (Bartleet & Ellis, 2009; Gouzouasis & Ryu, 2014; Hoppes, 2005; Liggins, Kearns, & Adams, 2013; Muncey, 2010). Autoethnography uses sets of procedures that may be unfamiliar to music therapists because this form of storied writing is not built around traditional methodological structures. In its truest sense, autoethnography is about storytelling and is an unfolding process of self-exploration that mirrors Bruscia’s (2014) discussions of clinical reflexivity. In music therapy research, for example, Bruscia’s (1998) self-inquiry into his GIM experience marks an important stage in the development of this kind of first-person research, as he speaks specifically about his own awareness as a therapist interacting with clients. Woodward’s (2015) research also describes her firsthand experience as a music therapist working with children in Bosnia and Herzegovina as she attempts to understand her identity and effectiveness as a leader working in a culture different from her own. Autoethnography “implies connection: the stories we write connect self to culture; the way we research and write these stories blends social science methods with the aesthetic sensibilities of the humanities, ethnographic practices with expressive forms of art and literature, and research goals of understanding with practical goals of empathy, healing and coping” (Ellis & Adams, 2014, p. 255). During the research process, past experience is used as data to make sense of an event or interaction in the autoethnographer’s life (Adams, Jones, & Ellis, 2014; Ellis & Adams, 2014; Muncey, 2010). Exploration of personal experiences may be undertaken through first-person narrative or other artistic mediums such as photography, poetry, and music (Ellis, 2004; Muncey, 2010; Wall, 2006). Most often, autoethnographic writing includes exploration of an epiphany or transitional moment in the researcher’s life. Ellis (2004) writes: “I tend to write about experiences that knock me for a loop and challenge the construction of meaning I have put together for myself. I write when my world falls apart or the meaning I have constructed for myself is in danger of doing so” (p. 33). As autoethnographers attempt to express and articulate what they have learned from a particular experience, they are engaging in a form of qualitative inquiry (Richardson, 2000). Autoethnography values “being in dialogue with a self past, self now, and self in reflection” (K. Wimpenny, personal communication, October 30, 2016). For me, it was a way to deepen my understanding of my own clinical work with one particular client named Graham. It is important to understand that autoethnography is idiographic in the sense that this article is about my own journey to understanding my clinical work. You’ll see this includes not only how I frame and interpret my clinical encounters with Graham, but also the values that were embedded in this framing. This was important for me in order to recognize what my values were as a new therapist and how these values intersected with my training and interactions with clients. In presenting these, I’m not suggesting that your values are the same as mine, nor should they change. However, in reading about my work, you may find ways of relating to your own work, and particularly the values that inform your work. At first glance, many autoethnographies read like a form of non-fiction rather than clinical research, but there are a range of methodological processes available to the autoethnographer—most of which closely resemble creative writing strategies. Many autoethnographers describe the writing process as exploring a personal storyline and “looking for an opening or a ‘gap’ in the story where you can address a topic or experience that is missing, not well understood, or not told thoroughly or correctly” (Adams, Ellis, & Jones, 2014, p. 49). As this writing process emerges, autoethnographers make clear, creative decisions about what to write and may use artistic tools like snapshots, poetry, and descriptive prose to evoke memory and situate them in a larger framework (Ellis, 2004; Muncey, 2010). Writers may also move through a series of creative phases from idea formation to polishing a finished work and relishing the final product (Muncey, 2010). Because of the flexibility of the creative writing strategies available to autoethnographers, the onus is placed on the researcher to deeply explore their own experience of a phenomenon because there is no extant methodological procedure available to follow. My Autoethnographic Adventure In my journey, the process of writing about and reflecting on my early work with Graham has been both helpful and painful. The time I’ve spent reflecting on the moments I’m about to share with you has helped me see and understand the limits of my early clinical work, and has encouraged me to ask myself, “Who am I and what are my values?” for the first time as a professional. When I sat down to write, I wasn’t always sure what would come out; sometimes, I worked for hours and did nothing but think (and cry and struggle and question myself). Other days, words flowed with little effort, as though my fingers knew the answer to a question that my brain hadn’t quite figured out yet. Over the course of two years, I went through nearly 50 revisions of this document. Though it now flows like a story, there were many moments when I felt stuck in my research, unsure where the story would take me. In many ways, finding a way to complete the story was my work. However, like many good stories, mine may leave you with more questions than answers about my clinical work and Graham. This is simply the nature of storytelling. Finally, while this research was deemed exempt from IRB review, I still took many precautions to protect Graham’s identity. Prior to starting this project, I was no longer working as his music therapist, and was reflecting back on our time together (rather than writing about it while it happened). His name, age, and other details have been changed to conceal his identity. As I tell this story, remember that these words are my research findings. Graham was simply the client that set this study into motion. This story is more about me, and my unfolding understanding of my work with Graham, than it is about him. Meeting Graham Graham was 8 when I met him at his school. He was referred to me because he had qualified for music therapy service via the Special Education Music Therapy Assessment Protocol (SEMTAP), requested by his academic team because Graham was struggling to make progress on his educational goals. The first item Graham’s special educator requested we work on was a goal of learning to spell his name. I spent hours writing a name-spelling song, thinking, “I can do this! I know how to structure a successful activity.” I laminated a cute visual with cutout letters spelling G-R-A-H-A-M. I remember reading that he loved animals, and thinking “He’ll love this!” because each letter was shaped like a different animal. I packed my tote bag full of egg shakers, drums, and picture icons. I couldn’t wait to meet him. I was finally practicing on my own, and it was time to be the therapist I spent years preparing to be. What I wasn’t ready for was the way that Graham reached out and scratched me when I extended my hand to say hello. He sat before me, dysregulated and disconnected, his thin frame practically ready to explode out of that tiny plastic chair. When he began to wail unintelligibly, his hands rose to his face, flapping violently with a strange, asynchronous rhythm. I thought, “I can handle this. I’ve seen this before.” I powered on, singing the spelling song, not knowing what else to do—I’d seen similar behaviors in my earlier training. Ignore, extinguish, shape. Is he trying to avoid his work? For the next 30 minutes, he continued to cry and claw at me each time I tried to sing his name or encourage him to place those Velcro letters on the visual. It broke my heart, because I was so proud to start working independently with a client and I wanted him to engage with me. I sat in my car after that session and cried, thinking, “What am I doing? Why did that feel so wrong?” At one level, my work with Graham wasn’t wholly bad. I was prepared, the activity met the goal, and I had thoughtfully considered how to structure the experience. But what I thought he needed from me and what he actually communicated to me through his hands and voice were two entirely different things—which I didn’t understand. When he reached out to scratch me, I took it to mean that he didn’t like the activity, and by extension, he didn’t like me. When I looked at Graham through the lens of his behaviors, I saw his reaction as an aggressive behavior in need of extinguishing. Instead, he was more likely communicating that he couldn’t be in a relationship with me in the context I presented. Sending emotional distress from his body to mine was perhaps the only way for him to communicate his need for something different. I imagine that it was just as difficult for Graham as he lurched forward to make that first visceral connection with me as it was for me to receive it. When I think back to that first encounter, I can’t help but feel that the work I was tasked to do with him was not what he was asking—or needing—from me. The basic idea of me as a helper who structured experiences to meet specific goals was not meaningful for who he was as a person at that time. In many ways, there was a tremendous gap between how I thought I was supposed to be with him and how he was experiencing me. As I struggled to locate myself in this new relationship with Graham, I came to a very basic question: Who are you and what does that mean for us? Exploring “who you are and who we are” in Music Therapy While it’s not often explicitly articulated in our clinical practice literature, the way we think about and work with our music therapy clients reflects something about the way(s) we see them. At one level, this is a simple notion that feels self-evident. Our work defines our relationships, and the way we structure sessions is an expression of this understanding. In Graham’s case, his Individualized Education Program (IEP) goals created the framework for our first meeting. Initially, our relationship was that of teacher/therapist and student/client; I created a name-spelling song to address his academic goal, and our session was structured around the implementation of that experience. But this is only one dimension of the relationships we share with the people with whom we work. When I pause to think about my clients, the images, feelings, and narratives evoked from my work in sessions play an important role in shaping how I perceive them as people. In this way, I began to develop a coherent understanding of each of my clients, which both informs my work and creates the building blocks for how I construct them. In my first session with Graham, I saw our work together as defining our relationship, but Graham showed me the opposite: our relationship would define our work. As I sought to make sense of my first session with Graham (and those that subsequently followed), I became aware that something was missing from my thinking. Though his IEP goals addressed some important life skills, they didn’t provide a complete picture of Graham beyond his needs in the special education classroom. Yes, the anecdotal information in his IEP told me that he preferred to “self-stimulate with a soft fabric book” and that he quickly became “over-stimulated in a large group setting.” I knew that he only used his voice to vocalize and that he had great difficulty using any kind of communication device. But I started to wonder: isn’t there more to a person than this way of talking about them? I began to feel conflicted about my role as Graham’s therapist: while my job as a music therapist in a school setting was to address these specific academic goals, how could I do so successfully, and meaningfully, until I understood who Graham was as a person? Somehow, in the many descriptors that I learned to use to characterize students in educational settings, something of their humanity was so easily lost. Ontology and Navigating Therapeutic Encounters These kinds of questions are ontological in nature because they get at the heart of who I am as a therapist, and how I understand my work with clients. Ontology is the philosophical and metaphysical study of the nature of what it means to be human (Malloy & Hadjistavropoulos, 2004). Hiller (2016) writes that ontology can be described as “the study of what exists, what is in reality, what is real, or, in Crotty’s simplest form, ‘what is’” (p. 99). The concept of ontology can be traced as far back as Aristotle, who referred to it as the “first philosophy” in Book IV of Metaphysics, and later by Lorhard (1606) as “ontologia” (the science of being) (Simons, n.d.). A closely related construct is epistemology, or the study of knowledge and how knowledge comes to be produced (Edwards, 2012). Hiller (2016) describes epistemology as “how we come to know that which we believe we know” (p. 99). Ontology and epistemology are not linked to one specific school of thought, but rather, have been used to explore questions of existence, identity, and knowledge acquisition by philosophers such as Husserl (2001), Heidegger (1927), and Ludwig (1997). More recently, for example, Gobbo and Schmulsky (2016), Ripamonti (2016), and Wasserman (2001) have explored the multiple ways identities may be constructed by members of the autistic community. In essence, our ontological and epistemological foundations form the basis through which we understand ourselves, those we interact with, and the broader world around us. In music therapy clinical practice, ontology can be understood as the therapist’s interpretation of therapeutic encounters and how change is accomplished. This can include the ways in which the therapist understands him/herself, the client, the therapeutic process, and the overall purpose of therapy in the client’s life. Bruscia’s (1998) “modes of consciousness” is one of the earliest examples of a music therapist exploring ontological questions in music therapy. He examined the ways in which he shifted his consciousness in time, depth, and intensity to “be there” for a client during a challenging GIM session. In meeting his client’s needs, Bruscia discussed the importance of having freedom to shift his consciousness “in relation to three experiential spaces: the client’s world, [his] own personal world, and [his] world as therapist” (p. 495). He learned that accessing these different worlds, or modes, helped him more fully meet the complex needs of his clients. Whether I acknowledge it or not, I am always working to understand what my clients need to live meaningful lives; my job as a therapist is, in part, to help them get there. If I consider that a person is made up of deficits and non-functional behaviors, I tend to think about the person in terms of those needs. If I think about a person as wanting to be in the world but not having the necessary internal resources to do so, I may approach therapy in a completely different way. I may not always actively think about ontological questions when I am working with clients, and I may not always challenge or investigate my own ontological perspective, but it is always a part of my work. I began to form my ontological perspective during my early music therapy training as I learned from experienced teachers and supervisors in academic and clinical training settings. While my clinical perspective continues to evolve and deepen over time, this marked the first time I began to readily articulate it or challenge my basic notions of how I think about my clients and what impact this has on the ways we form goals, structure therapy, and interact. For me, it has been a gradual process; the more I work with children and teens on the autism spectrum, the more I find myself looking inward and asking these kinds of “who are you?” and “who am I?” questions. I think this questioning started for a number of reasons. As I started to work independently as a new professional, I quickly became disenchanted with my own understanding of my clients as I struggled to connect with them in therapy. While I understood and could easily repeat the textbook diagnostic criteria for autism, I found myself no longer able to adequately answer basic questions like “What does it mean to have autism?” or “Is autism a disorder, or just one way of being in the world…or both?” As a student, I might have described autism in terms of social and communication deficits, requiring support in areas like abstract thinking, relationship formation, and fundamental social skills. I might have answered yes without thinking, because my understanding of autism was that it was a disorder with a cluster of behavioral symptoms. My role as a music therapist was to provide treatment supports in these areas to help build and develop these necessary life skills. During Graham’s first session, I considered his social and communication skills to be the problem, and the reason that prevented him from engaging musically and even acting out physically. But when I think about it now, I think that the social and communication deficits uncovered in that encounter might have actually been mine. When I failed to interpret his reaction as anything other than a behavioral outburst, I missed a chance to see and hear Graham’s first attempt to communicate with me. If I had to summarize what he was trying to say, my best guess is that it would sound something like “Hi. Hello? This is different. I don’t like it. EXCUSE ME? Are you listening? This is REALLY not working for me. Stop, stop, STOP!” Tuning In to Other Voices As my questions about my clients’ needs grew from encounters like the one I am sharing here with Graham, I started to look for answers in a variety of places. As I did this, I found the writings of autistic self-advocates and disability rights advocates to be very helpful because they offered a firsthand perspective of the experience of disability that I hadn’t yet heard in my academic or professional career. I quickly realized that the writings of many different self-advocates contained shared experiences—in particular, the experience of living inside a body that doesn’t obey your mind. This concept was new to me, as I had previously understood external behaviors like loud vocalizations or aggressions as being a behavioral problem rather than a movement pattern happening outside my clients’ control. This new way of thinking about autism and my desire to learn how best to support my clients led me to read many blog posts, writings, and attend lectures exploring these topics. Ido Kedar (2015), a non-speaking autistic self-advocate and author, describes his own mind-body disconnect as follows: “I cannot stop my neurological forces from camouflaging my real essence,” he writes. “Inside there is a person who thinks, feels, jokes, and has a lot to see. On the outside, people see my odd movements” (n.p.). Emma Zurcher-Long (2015), a teenage blogger and public speaker who types to communicate, corroborates this feeling and compares her spoken “random nonsensical, declarations,” which she calls “mouth words,” to her own typed words. She writes that her mouth words “could be seen as traitors, belligerent bullies who seek the spotlight, but they are not. My mouth words are funny to me, but misunderstood by others. My typed words are hard for me, but understood by many. Mouth words are witty accomplices to a mind that speaks a different language entirely. There are no words, but instead a beautiful environment where feelings, sensations, colors, and sounds coexist” (n.p.). My reading soon led me to the Neurodiversity Movement, which advocates for acceptance of neurological differences while raising questions about the psychological impact of cure-based treatments, diagnostic labels of high and low functioning, and whether autism is a deficit or just a difference (Glannon, 2007; Kapp, 2013; Silberman, 2015). This movement helped me understand the ways disability may or may not intersect with identity, and how the nature of that intersection changes depending on your perspective. In a medical or pathological model, autism might be separated from a patient’s identity through medical diagnosis or descriptors (person with autism). I learned that in the disability rights community, many people prefer the identity-first language (autistic person) used in Deaf and Blind communities, arguing that this difference is integral to their personhood (Autistic Self Advocacy Network, n.d.; Brown, 2011; Sinclair, 2013). Reed (2014) challenges music therapists to consider disability as one aspect of identity in order to maximize therapeutic potentials: “When we define a person by means of a medical diagnosis, when we rely on that diagnosis to determine therapy, we are limiting our clients. We are asking them to overcome, rather than to become” (n.p.). I also encountered the concept of “presuming competence,” which involves assuming that a person with a disability has intellectual ability and a desire to be in the world, whether or not it has been demonstrated previously (Biklen & Burke, 2006). All of these perspectives challenged me to think about my own music therapy practice, including how I identify and articulate therapy goals, the collaborative nature of work in sessions, and the way I structure and implement interventions. Additionally, vastly different approaches to working with people on the autism spectrum have emerged over the past decade. These approaches were developed directly from encounters with clients and represent different time periods and understandings of autism. The role of the therapist, client, and how therapy could be undertaken stem directly from how best-practice was understood at that point in time—and this continues today. These include approaches that are strongly behavioral (Dawson & Burner, 2011; Hagopian, Hardesty, & Gregory, 2015; Virues-Ortega, 2010), developmental (Greenspan & Wieder, 2006; Mercer, 2015; Solomon, Necheles, Ferch, & Bruckman, 2007), sensorimotor (Donnellan, Hill, & Leary, 2013; Mostofsky & Ewen, 2011; Torres et al., 2013), and social (Oliver, 2009; Shakespeare, 2006). While not explicitly articulated in all orientations, each implies a different way of describing clients—a different type of “selfhood”— which impacts the relationships we share with them as therapists. Conceptualizing Clients and Structuring Therapy For example, in my early work, my perspective was primarily focused on skill building. In my understanding, this activity-oriented approach meant that through clear and structured therapy experiences, targeted goals could be monitored and achieved. These goals could be behavioral (reducing undesirable behaviors like hitting or increasing positive behaviors like in-seat time), social (greeting and interacting with peers), cognitive (following directions, demonstrating retention of academic skills), or other areas of need. Strategies like positive reinforcement (verbal praise or giving the child access to motivating items) and understanding what happens before, during, and after a behavior were helpful ways of understanding my role as a therapist, and how therapy could be implemented. In Graham’s first session, my understanding of him was as a confluence of behaviors that were preventing him from making progress on his academic goals. Of course I wanted to have a positive relationship with him; I wanted us to make music together, do good work, and use music to help Graham make progress on his academic goals. However, in the ways I applied this understanding, I wasn’t being particularly flexible, and focused more on fixing rather than relationship building and discovering who Graham was and how I could support him. When I compare this to the work of Zanders (2015), who emphasizes the importance of an integrative client-centered approach, it becomes easier for me to see that the approach I took at that time was only one perspective, and may not have been helpful to Graham. When Zanders began to work with John, a 13-year-old in foster care, he understood him first through an exploration of his personal background. When he describes John’s behaviors (suicide attempts, physical outbursts, emotional suffering), he does so in the context of John’s experiences living in unstable foster homes with abusive caretakers. As John and Zanders slowly move from sitting in silence during therapy sessions to developing a relationship through improvisation and songwriting, Zanders reflects on John’s therapeutic needs by questioning what should be the focus of his treatment, while remaining cognizant of John’s trauma and need for stability. Zanders emphasizes that they “worked together to find meaning in John’s life” and his role as a music therapist was to provide the necessary resources for John to find his own meaning (p. 103). As John’s needs were revealed over the course of therapy, Zanders’s reflexivity allowed them to move through distinct stages of therapy that were both developed by their work and informed by clinical theory, as one philosophical position or therapeutic model was not suitable at every stage of John’s treatment. While Zanders’s approach drew on a variety of clinical techniques such as cognitive behavioral therapy, psycho-education, and stress management, he notes that therapy primarily progressed “through the process of being both integrative (having multiple perspectives) and reflexive (learning from John)” (p. 107). While focusing on John’s immediate needs in therapy (internal and external stability and safety, emotional expression, developing resources, finding identity), Zanders also had to remain open, present, and flexible to understand how to guide their work together. When I reflect on these two very different ways of conceptualizing a client and structuring music therapy experiences, I am challenged to consider whether the way I first entered Graham’s world was in direct conflict with the kind of encounter he needed. I was less concerned with my relationship with Graham than I was with my role as a fixer, and probably just assumed that our relationship would come as a natural byproduct of making music together. The way I understood Graham at the time was that he was in need of external structure: activity-based interventions, visuals, and behavior management when needed. Now, I realize that imposing the structure I thought he needed may have led me to miss an opportunity to stop, listen, and be present with him. I wonder how different our first session would have been if, like Zanders, I had set my plan aside and simply sat with Graham in silence. Encountering Graham During my writing process, I came across old session notes from our early work together and began to view them as a source of data. Ellis (2004) emphasizes the importance of keeping initial drafts of field notes and autoethnographic accounts—no matter how much your urge to revise them—as they provide a point of comparison between past and present selves (p. 180). When I explore session notes from our first meeting, they tell me about how I saw Graham at that point in time. The language I used to describe him reveals so much about who he was and who I was (and how our relationship emerged over many, many sessions together). Session Date Session Time Session Type Session Notes Wed 12:15-1PM Indiv. First session. During the hello song and a shared drumming experience, G did not make eye contact with the therapist, did not interact with materials presented, and remained fixated on his book. Throughout the session, G would shove or throw items away from him to indicate that he was finished with them after a period of 5–15 seconds. The only item he did not immediately shove or throw was the cabasa, though he did throw it at MT after 30 seconds. He cried and engaged in self-stimulatory behavior throughout the session. Reading, Obj. 2: When presented with a letter strip containing each letter of his first name, G hit/scratched the therapist in the face and roughly grabbed her arm while loudly vocalizing. The MT removed the materials and G self-calmed by accessing items from his sensory bag. 5 minutes later, the MT presented name spelling materials a second time and he immediately pushed them away. Learning Behaviors, Obj. 4: Graham was presented with 6 new tasks and materials, and minimally engaged in 1 (held/examined cabasa before throwing it). Behavior Management, Obj. 1: Only complied in 1 teacher-directed task (holding cabasa) for 30 seconds w/o any aggressions or SIBs. Non-compliant for all academic tasks. Session Date Session Time Session Type Session Notes Wed 12:15-1PM Indiv. First session. During the hello song and a shared drumming experience, G did not make eye contact with the therapist, did not interact with materials presented, and remained fixated on his book. Throughout the session, G would shove or throw items away from him to indicate that he was finished with them after a period of 5–15 seconds. The only item he did not immediately shove or throw was the cabasa, though he did throw it at MT after 30 seconds. He cried and engaged in self-stimulatory behavior throughout the session. Reading, Obj. 2: When presented with a letter strip containing each letter of his first name, G hit/scratched the therapist in the face and roughly grabbed her arm while loudly vocalizing. The MT removed the materials and G self-calmed by accessing items from his sensory bag. 5 minutes later, the MT presented name spelling materials a second time and he immediately pushed them away. Learning Behaviors, Obj. 4: Graham was presented with 6 new tasks and materials, and minimally engaged in 1 (held/examined cabasa before throwing it). Behavior Management, Obj. 1: Only complied in 1 teacher-directed task (holding cabasa) for 30 seconds w/o any aggressions or SIBs. Non-compliant for all academic tasks. View Large Session Date Session Time Session Type Session Notes Wed 12:15-1PM Indiv. First session. During the hello song and a shared drumming experience, G did not make eye contact with the therapist, did not interact with materials presented, and remained fixated on his book. Throughout the session, G would shove or throw items away from him to indicate that he was finished with them after a period of 5–15 seconds. The only item he did not immediately shove or throw was the cabasa, though he did throw it at MT after 30 seconds. He cried and engaged in self-stimulatory behavior throughout the session. Reading, Obj. 2: When presented with a letter strip containing each letter of his first name, G hit/scratched the therapist in the face and roughly grabbed her arm while loudly vocalizing. The MT removed the materials and G self-calmed by accessing items from his sensory bag. 5 minutes later, the MT presented name spelling materials a second time and he immediately pushed them away. Learning Behaviors, Obj. 4: Graham was presented with 6 new tasks and materials, and minimally engaged in 1 (held/examined cabasa before throwing it). Behavior Management, Obj. 1: Only complied in 1 teacher-directed task (holding cabasa) for 30 seconds w/o any aggressions or SIBs. Non-compliant for all academic tasks. Session Date Session Time Session Type Session Notes Wed 12:15-1PM Indiv. First session. During the hello song and a shared drumming experience, G did not make eye contact with the therapist, did not interact with materials presented, and remained fixated on his book. Throughout the session, G would shove or throw items away from him to indicate that he was finished with them after a period of 5–15 seconds. The only item he did not immediately shove or throw was the cabasa, though he did throw it at MT after 30 seconds. He cried and engaged in self-stimulatory behavior throughout the session. Reading, Obj. 2: When presented with a letter strip containing each letter of his first name, G hit/scratched the therapist in the face and roughly grabbed her arm while loudly vocalizing. The MT removed the materials and G self-calmed by accessing items from his sensory bag. 5 minutes later, the MT presented name spelling materials a second time and he immediately pushed them away. Learning Behaviors, Obj. 4: Graham was presented with 6 new tasks and materials, and minimally engaged in 1 (held/examined cabasa before throwing it). Behavior Management, Obj. 1: Only complied in 1 teacher-directed task (holding cabasa) for 30 seconds w/o any aggressions or SIBs. Non-compliant for all academic tasks. View Large When I look at the language I used to describe Graham in that first session, it becomes clear that I was thinking about him as a group of problem behaviors: hitting, scratching, “self-stimming,” not making eye contact, throwing items when presented, fixating on a favorite book. Each time I read it now, I get the impression that what I really wanted when I wrote that note was for Graham to just comply and engage in more “appropriate” ways. Like Graham, I was also fixated on something: his external self. What is completely missing from the log note is any real sense of who he was as a person beyond my surface-level observations. So what did that mean for us? As I reflect back, I now understand that I didn’t see him as having any kind of coherent selfhood. I didn’t understand him other than in the context of how he acted during those first painful interactions, and that this understanding was in no way helpful to him. Reading my account of this session uncovers some raw, uncomfortable feelings, the strongest of which is that I may have failed Graham in a time when he was most vulnerable. He told me in no uncertain terms that while the activities I designed may have been appropriate for his goals, they were delivered in the wrong way, and at the wrong time. By jumping in with a predetermined plan without first attempting to understand who Graham really was, I missed an opportunity to lay the foundation for our ongoing work. The more I reflect on that session, the more I am struck by how our interaction must have felt for Graham, and even what it might have looked like externally. Perhaps it looked something like: Boy, confused and upset, throws cabasa at his (scared, unsure, almost tearful) therapist’s head, while they try to exist together in an enclosed space for 30 minutes. While I know now that my work with Graham would deeply change in the coming months, I can’t help but feel like his reaction to me (and my interventions) was his best attempt to communicate “Thanks…but no thanks.” Being with Graham As my understanding of Graham began to change through this reflexive process, so did the way I wanted to write about and reflect my new understanding of him—though our clinical work had long since come to an end. It started with a desire to write a richer narrative in reflection of our time together in order to more fully capture the complexity of him as a human being. This narrative exploration quickly began to transform into me trying to experience therapy from Graham’s perspective. What started as a clinical anecdote gradually morphed into something much more personal. I struggled to articulate his perspective, attempting to extrapolate it from my own memories of the different ways in which we moved in and out of connection and disconnection. But it never felt authentic to “be” him. In my writing, I came to realize that I can’t actually be inside Graham because I am only inside myself. I can’t fully know Graham’s experience because all I know is my own. But I can know something about Graham’s experience, and there is a great responsibility that comes with that. The act of opening myself up to Graham was different from trying to frame him within a particular theory of autism. It freed me from diagnostic criteria and session plans. It allowed me to simply connect with and describe my experience of being with him. When I did this, I began to realize that my experience of being with Graham was, at first, sensory-physical, and laden with images and raw emotions. From this perspective, this is how I experience being with Graham. When I walk into his classroom, the first thing I notice is not what Graham’s doing or where we are, but rather, his gray cloud of panic. This cloud rises from his body, which never stops moving, and his face, which is scared and confused. It’s the color of a stormy sky, and it’s blocking out the light. It consumes him, the room, the teacher, the space between us, and starts to rapidly surge towards me. I feel this in my body, and it reverberates spirals of confusion from my stomach outward to my head, knees and chest. It feels like everything inside me is twisting together in knots and I need to stop moving toward him to protect myself. I don’t want the cloud to touch me, but I know I have to move closer. When I take a step in his direction and pause to look at him, I am overrun with waves of exhaustion and desperation. I feel bad, so bad, and I want to help him, but I’m scared to come closer. I am falling apart at the seams to be with him in this moment and I become a gnarled tangle of questions. What do I do? What does he need? Where do we even begin? I can’t feel my feet, so I float off the ground toward the ceiling. I know we’re still in the classroom, but I’m suspended in his gray cloud. The cloud’s tendrils snake around my limbs and weigh heavily on my body. As I hang here, my experience of time begins to shift. I’m not thinking of seconds rhythmically ticking by on the clock. I’m not thinking about the two minutes I just walked down the hallway, a 30-minute session ahead of me, a 15-minute drive to another school at 11 o’clock. But I am receiving fragmented streams of awareness from my senses. I see Graham at his desk with hands flapping so fast I can barely focus on them. I hear another student drawing on the smart board, his stylus dragging with a loud scrape. I touch rough velcro, a sensory bag, a work bin. I smell stale Lucky Charms. I hear crying so raw that it splits my ears and almost asks me to join in. I taste something metallic and old. I’m not concerned with what’s before or next, but am only—and can only be— aware of what’s right now. I wonder how I’ll sing a welcome song from up here. Does it matter? I hum something in a minor key instead, and move one inch closer to the ground. The music we make together in our first few sessions is sucked into the canyon that divides us. I am high above and Graham teeters dangerously close to the edge. The gray cloud around us absorbs fragments of our music, like the cold, clanking beads of the cabasa as Graham touches one thread and I hold the handle, or the sound of an A minor chord ringing in our ears. At first, our music is too tonal, uncomfortably tonal. But I don’t know what else to play. I use familiar, predictable chords—I, IV, V—but he rarely acknowledges them. Some days, I allow myself to let go and get lost in humming and strumming, which brings me closer and closer to Graham on the ground. I finger pick a simple pattern and allow my voice to do the exploring. He looks at me, sometimes. When I sing about spelling, he cries and I fly back, hitting the ceiling again. I find that we are closest when I take my guitar and put it in the case. I move my chair farther away to sit in my own space and just listen to the sounds he makes. Sometimes, they’re painful cries; sometimes, the only sound I can hear is the frantic slapping of his hand on the table. When it feels right, I do my best to sound him using only my voice and his own repertoire of tones. It’s not always pretty, it’s not always rhythmic, and at times, I’m not sure if it’s even music. But this strange call and response ritual somehow holds us together in the same space and the same time. It gives us our first opportunity to study each other, to be with each other, and to create something together. It even allows the canyon between us to shrink, little by little, and the gray cloud grows thinner, slowly beginning to dissipate. We spring away from each other when the music is wrong, and find that it’s what separates us. In moments of shared silence or music, we slowly spiral toward and around each other like stars in an expanding galaxy. In these moments, the music is what allows us to connect. When I move into this space with Graham, I am struck by just how different this world is, and how different his experience of the world is from mine. When I am in this space, I experience his world as sensory-physical, and understand that the only way to be with him, in these moments, is to enter into this space with him. This change started when I simply put down my guitar and listened, without doing anything. I felt myself move from a stance of “doing to/for” to “being with.” As I opened up to his world, I felt my own awareness change, shifting from actively trying to make something therapeutic happen to just letting it unfold extemporaneously. One clinical moment, which happened quite unexpectedly, captures this—the “sneezy song.” One day, in the middle of a particularly melancholy hum that matched the tonality of Graham’s crying, I sneezed. I’m not a quiet sneezer by any stretch of the imagination, so my “AHCHOO” felt like it echoed for seconds. Graham immediately stopped vocalizing, whipped his head toward me, and did something that absolutely shocked me—he giggled. His eyes were fixed on the floor and his laugh was quiet, but there was no mistaking it. I could barely contain my own glee and quickly widened my eyes with dramatic flair. I gasped then sang, “Oh! Excuse me,” outlining an octave. He giggled again, this time a little louder. I rhythmically scooted my tiny plastic chair a few inches in his direction—thwomp, squeak, thwomp— then abruptly stopped to lean toward him. “Excuse me!” I sang again, looking expectantly at Graham. He smiled in response, and we repeated this game three more times. Soon, I found myself closer to him than I’d been in weeks, his dirty khaki-clad knee bouncing dangerously close to the edge of my chair. Neither of us were crying, clawing, or panicking. We were actually laughing, together. Our first real point of connection didn’t happen in the context of a structured song targeting goals or a picture-perfect moment crafted in advance of our session. Instead, I sneezed and he responded. We were just two people sharing a conversation with no expectations or predetermined plans. This helped me understand that one of the things Graham really struggled with was being disconnected, and that being connected to me in time, for a moment, was truly meaningful for him. In my original way of working with Graham, these thoughts weren’t in my consciousness. I wasn’t thinking about him being in the world with other people and what that experience might be like for him. I learned that what he needed was for me to just be there with him, and our music needed to be flexible and free to match that. Over time, I began to understand that my role was to help Graham learn how to come to my world, just as I went to his. Our “sneezy song” became a repeated point of connection that allowed Graham to experiment with his connection to me without fully leaving his own world. I could change the song in the moment to be more or less structured, and its familiarity was both comforting and exciting. Months later, Graham would regularly request it by pointing to a song icon and vocalizing his own interpretation of the melody. Implications for Graham’s IEP Goals During this process of reflection, I have also become aware of another structural element impacting our work: Graham’s IEP. The structure of his academic plan and his own way of experiencing music therapy sessions were two things that felt disconnected. Part of the challenge for Graham may have been that we were working together in a context where educational goals were the focus of clinical practice, whereas the nature of our work needed to be fundamentally different. While Graham’s IEP goals centered on spelling and language development, these appeared to have little meaning to him. As such, Graham’s IEP felt like a barrier that prevented us from working together, rather than a framework that shaped our work. My role as a music therapist in a public school setting was to support Graham’s IEP goals; but what do you do when different needs must first be met? For Graham, one was a means to the other; he was only able to engage in academic learning after his needs for shared time and connection were met. At the time, I believed my role was to support Graham’s academic self, using activities to shape sessions. While this approach may be a meaningful way to teach specific skills, it may also have limited the therapeutic potentials within our sessions and our therapeutic relationship in particular. Graham and I eventually found creative ways of working through and around the dissonance between the environment in which we were working and his core therapeutic needs, but this challenge, and the inherent differences in values that are often experienced by music therapists in school settings, continue for me today. Broader Considerations While autoethnography, by its very nature, encourages readers to find their own meaning in the reading experience, a number of themes emerged through this writing process that may warrant particular attention. The first is that in working with children on the autism spectrum, the theoretical approach one takes matters in relation to the client’s identity. That is, each clinical approach, whether it be behavioral, neurological, or developmental (etc.), implies a theory of personhood, which directly impacts the client. This is derived from basic questions such as “who are you?” and “what will we do together?” As a profession, this is not something we appear to talk about a lot, but it does appear to have a significant impact on our clients. A second, and related, theme that emerged concerns the position clinicians take in relation to their clinical work—their “treatment,” if you like. The extent to which we, as clinicians, remain treatment specific—that is, take a single perspective—or shift perspectives with the client in ways suggested by Zanders (2015) has not been adequately debated, particularly for children on the autism spectrum. In fact, the opposite often appears to be reflected in our recent research, wherein specific approaches are examined without broader considerations of when, in what context, and with whom these might be beneficial. Finally, education and training programs may benefit for more active debate about the ways they teach students and young professionals to think about their clients, and the impact this has on their clinical practice. In my own development, ontology mattered. By only framing clients in one way, it may limit students’ abilities to see their clients from alternative perspectives, which may in turn impact their clients’ well-being. Grappling with these questions in the classroom as students simultaneously experience clinical placements may be an ideal starting point for educators to offer alternative frameworks for client conceptualization. Opening the conversation in the safety of early clinical supervision may be helpful to students, particularly as their own clinical perspective begins to crystallize in internship and early professional work through deeper and more frequent client encounters. Closing Thoughts In this journey, I have learned to take ownership of my own values and the direct meaning these values hold in relation to my clinical work. I had to learn the hard way that reflexivity isn’t always easy, but is, in fact, necessary in co-constructing clinical spaces with clients. Autoethnography as a research method was critical to this process, as it gave me a creative platform to document and deeply explore my own experience. The process of reaching back into my first encounters with Graham was both painful and cathartic, and helped me understand why these early clinical experiences were critical in shaping my identity as a therapist. For me, this autoethnographic process started—and now, ends—with a question. How do I see you, and what does that mean for us? Reflecting on my time with Graham has helped me grasp the importance of this question not only in my work with him, but with each client I encounter as a music therapist. This process of locating myself through reflexive practices has helped me redefine my role as a therapist. In this shift, I understand myself as a co-pilot in therapy, rather than a chauffeur. My clients have moved from the backseat to the front seat, partnering with me to navigate everything from roadblocks to surprising discoveries. This structure allows me to work collaboratively with my clients, which can mean anything from living in the uncomfortable unknown to celebrating accomplishments together. Perhaps most importantly, it reminds me to look to my clients for answers when I’m not sure what comes next. Hadley (2014) had similar questions in her early work with Caroline, a disabled woman living in a residential facility. As she got to know Caroline, Hadley’s perspective shifted and she viewed her work as “no longer merely a job, but an intimate partnership of mutual giving, learning, and growth” (n.p.). I’ve also come to understand that clinical work isn’t value-free. The perspective I take when working with a client matters. The way I see my clients and the way I understand them directly impacts the work we do together in therapy. Hadley (2013) writes: “Sometimes, a dominant narrative takes hold and limits the ways in which people perceive themselves and others….When a narrative becomes rigid and limits perceptions, there is a need to foster alternative narratives, ones that allow for thicker descriptions, ones that are more liberating” (p. 374). When I understood Graham as having academic and behavioral challenges, this translated into structured interventions targeting these specific skills. When I located myself in a place of “being with” rather than “teaching” or “doing for,” the focus of our work—and subsequently, our music—expanded infinitely. Both of these perspectives have value; but for Graham, one was far more meaningful than the other. This process has therefore shown me that there is more than one perspective that can be taken when I think about my clients, and this speaks to my responsibility as a therapist. It also led me to recognize the importance of thinking about my clients from a broad range of perspectives to more fully understand what their needs might be. Moving fluidly between perspectives, as Bruscia (1998) and Zanders (2015) did, is a way of shifting consciousness, whether this means positioning myself as a clinician identifying deficits or as a human sitting with another human. In my capacity as a reflexive clinician, I also try to experience the session in some of the ways that Graham might, realizing this is never completely possible, and yet an important undertaking nonetheless. Finally, I have also learned that therapeutic time might not be experienced in the same way for everyone. It can be linear, cyclical, fragmented, or something else altogether. In this way, time plays a role in influencing my clinical decision-making, and subsequently, the music and interventions that unfold during sessions (Daveson, 2004). Graham appeared to experience time as fragmented moments, without continuity of experience. He also seemed to have difficulty experiencing shared time—that is, the experience of being in time with another. Understanding these differences helped widen my awareness of the differences and similarities between my own world and my clients’ worlds. 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Music Therapy Perspectives – Oxford University Press
Published: Oct 31, 2018
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