Transformation in Improvisation An exploratory study of interpersonal interactions in musical improvisations of patients with borderline personality disorder

Interpersonal exchanges, interactions and bonding are particularly precarious for people with Borderline Personality Disorder (BPD). While research has achieved important theoretical and empirical progress, fundamental aspects remain poorly understood. Many patients show poor long-term outcomes in interpersonal functioning after a psychotherapeutic treatment.   Furthermore, given the difficulties with bonding for individuals with BPD, the caregiving/taking therapeutic relationship is challenging, leading to difficulties in initiating and maintaining participation in the treatment. Therefore, many BPD individuals remain untreated, showing substantial mortality and morbidity. This emphasizes the need to gain more insight in interpersonal functioning aiming to improve therapeutic treatment strategies for this population. 

Current research about interpersonal functioning in BPD has mainly concentrated on self-report questionnaires and experimental paradigms wherein the exchange of social signals between individuals, the hallmark of social interaction, was not the focus. In this doctoral dissertation, we propose joint musical improvisation as an alternative method to investigate interpersonal processes with BPD individuals, aiming to explore how musical improvisation may contribute to the current need to gain insight in and improve dysfunctional relationships in BPD. 

Clinical musical improvisation is a central method in music therapy in the treatment of psychiatric patients. The last decade, research in music therapy has mainly focused on the treatment of psychosis, autism and depression. However, to date little is known about the use of musical improvisation in the treatment of personality disorder patients. Therefore, this doctoral dissertation is conceived as an exploratory study with the aim to reveal the relationship between musical interpersonal exchanges and the psychopathology of BPD, using different research methods. This resulted in scientific underpinned hypotheses which can be investigated in future research.

Chapter 1 focuses on the phenomenon of interpersonal synchronization. In everyday social interactions people adapt spontaneously their behavior to those of the interaction partner such as the tempo of walking and the timbre of speaking. This way of adaptation often leads to the synchronization of behavior and plays an important role for the experience of bonding. In music therapy, clinical improvisation enabling embodied processes of synchronization between self and the other are at the centre.Therefore, clinical improvisation is a prominent context to study spontaneous interaction processes of synchronization. 

In chapter 1 a case-control study (n = 16) within a cross-sectional timeframe is described, examining whether the way in which a music therapist synchronizes with a BPD patient is significantly different from healthy control participants. A piano improvisation paradigm was developed in an ABA’ form. In sections A and A', the therapist plays a structured bourdon/drone bass accompaniment. In the B section of this paradigm, the therapist makes use of the free clinical improvisation as used in clinical practice.Results showed that over the course of the improvisation B section (free improvisation), controls’ synchrony with the music therapist became more precise whereas that of the BPD patients did not improve. These findings are in accordance with previous research where BPD is characterized by difficulties in maintaining bonding with others, but it was novel to find empirical evidence of such issues inthe way how people spontaneously synchronize with each other, and this within the context of a musical improvisation.

In order to clarify difficulties in spontaneous synchronization processes for music therapists, a qualitative case study was conducted in chapter 2. Six categories of impaired relational patterns were found in clinical improvisations with BPD patients: (i) associative-external, (ii) aleatory, (iii) sensitive, (iv) submissive, (v) agonistic and (vi) obsessive-rigid. This method of discovering more information about the functioning and processing of BPD patients during joint improvisations enables one to throw light on very detailed aspects of interactions at the nonverbal level.  

In addition, the outcome of a constructivist grounded theory analysis (within the same case study), showed how a healthy interaction is characterized by four embedded hierarchical levels of responsive behavior, defined as: receptive, shared, structural and flexible. These four levels have the function of initiating, facilitating and regulating an interpersonal interaction. They need to be embedded in each other in order to account for interactive dynamics in which we trust to take risks, to make mistakes and in which and which inspires us every day to engage in (un)familiar social realms. This is theoretically elaborated in chapter 3. This theoretical model enablesmusic therapists to track and monitor their work over several sessions, identifies new theoretical thinking and techniques to intervene appropriately where necessary.

Finally, the findings of a case-control study (n = 18) in chapter 4 demonstrated how the role of musical structure in a musical improvisation can be very meaningful in music therapy with BPD in order to regulate the musical interaction, facilitating experiences of bonding on a tolerable and less threatening way for patients with a BPD.

The findings in this doctoral dissertation are an important first step in the field of research in music therapy treatment for BPD patients, emphasizing the value of musical improvisation in music therapy. Based on our findings there are strong reasons to believe that music therapy may result in less threatening experiences of bonding, leading to a potential decrease in the number of individuals that drop out in (the beginning of) therapy, and contributing to the current need to make improvements in relational patterns (e.g., decreasing conflicts with caregiving/taking) where none could be made before in therapy with BPD population. Further longitudinal research is needed to test these hypotheses in music therapy treatment.