Plurimodal music therapy

1. Introduction

Version followed: the Plurimodal Approach (Abordaje Plurimodal en Musicoterapia, APM) as set out in the founders' English summary (Schapira & Hugo, Voices 5(2), 2005). Details the article leaves out come from Latin American applied theses and articles that cite the reference book, Schapira, Ferrari, Sánchez & Hugo (Eds.), Musicoterapia. Abordaje plurimodal (Buenos Aires: Ediciones ADIM, 2007). The 2005 article confirms the four axes, the nine song procedures, Eschen's rondo as an interpersonal setting, the three functions of recorded music and the SISS rules. The Ávila Osorio (2016) thesis confirms the five song modalities and six recorded-music modalities it describes, and a further Colombian thesis (Sastoque Rodríguez 2016) confirms the four axes and the expressive-receptive modes. The Argentine professional law (Ley 27.153) is cited through a legal summary. The 2007 book has no public preview, and no accessible article or thesis reproduces its step-by-step procedures [uncertain]. Procedures for unconscious evocative induction, the projective song questionnaire, sense expansion, the rondo and personalised edition, and the seventh recorded-music modality, therefore remain [uncertain]; any steps given for them are the writer's [synthesis].

What it is: a psychodynamically grounded framework for music therapy, not a single method. Diego Schapira and colleagues from ADIM in Argentina and Uruguay developed it from the 1990s; it had taken shape by the end of that decade. It was first used with psychiatric clients, then extended to other populations. The founders call it an "approach" rather than a "method" because they regard a method as rigid. Their one firm rule is that no sequence of steps, either for a whole process or for a session, can be standardised. The approach is "plurimodal" in two ways. In theory it draws on several music therapy models rather than one. In practice it gives equal weight to four axes of action: (1) work with songs; (2) therapeutic music improvisation (TMI/IMT); (3) a receptive technique, Stimulation of Images and Sensations through Sound (SISS; Spanish EISS); (4) selective use of recorded ("edited") music. The authors have taught it as a graduate course at the University of Buenos Aires, and it has been used in Uruguay, Chile, Peru, Colombia, Mexico and Brazil [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 35–36; Schapira 2019, author bio].

How change happens: the authors say a person's music-making carries their psychic structure. They call this "inner music" and "being in music". Defences, transference and unconscious material show up in sound, much as they do in words. The therapist reads that material through analogy and metaphor and responds musically and verbally, so that it can be expressed, worked through and given new meaning. What matters is the content of what the client sings or plays, not its aesthetic quality [source: Schapira & Hugo 2005; Morales Igua 2018, pp. 58–61].

2. Framework

The founders set out no fixed phases. They say the work is "not a sequence of different steps". Sessions are not pre-programmed. Each intervention is chosen from four things: (a) the therapist's analysis of the process so far; (b) the client's current theme and unconscious material; (c) the framework (encuadre); (d) what the therapist observes in the session, including transference and countertransference. The therapist keeps or drops a planned intervention depending on what happens in the moment [source: Schapira & Hugo 2005].

Operational sequence used in published applications (not prescribed by the founders):

Encuadre (framework). Agree time, place, frequency, fees or institutional terms, materials, recording and consent. The APM treats the framework, including songs and objects the client brings, as part of the therapeutic dynamic [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 37, 49].
Exploration and assessment. Typically about 3–5 sessions. One thesis planned 3 and extended to about 5. This stage covers: building the relationship; a ficha musicoterapéutica (intake form based on Benenzon: personal data, musical preferences and dislikes, sound-musical history, key musical moments); identifying the client's expressive-receptive modes (ME-R); and baseline improvisations analysed with Bruscia's Improvisation Assessment Profiles (IAPs) [source: Ávila Osorio 2016, pp. 47–51].
Formulating objectives. Write a dynamic hypothesis and goals, then choose which axes fit the client's ME-R [source: Ávila Osorio 2016, p. 51].
Intervention. Combine the four axes flexibly, with analysis and supervision after each session [source: Ávila Osorio 2016, p. 51; Schapira & Hugo 2005].
Evaluation and closure. Around 4 sessions in one thesis. This stage revisits material, consolidates insights and prepares for the ending. A meaningful song is often used to close [source: Ávila Osorio 2016, p. 52; Schapira & Hugo 2005 (song as session close)].

Session format: individual or group, usually weekly. Sessions in published applications ran about 40 minutes (individual) to 2 hours (group). One documented session template has four parts: warm-up (caldeamiento), central activity, closing activity and verbal conclusions [source: Ávila Osorio 2016, pp. 48–50; Cantillo-Guzmán 2024, p. 16–17]. Number of sessions: the founders give none. Published examples run 7 sessions (stage anxiety) and 14 sessions (special school), and one is open-ended palliative and paediatric oncology work [source: Cantillo-Guzmán 2024; Herrera Muñoz 2012 abstract; Hugo, n.d.].

Criteria for moving on [synthesis]: leave assessment once you can (a) state the client's ME-R, (b) name a working hypothesis about transference and defences, and (c) say which axes the client tolerates. Begin closure when goals are met and new material has stopped emerging, or when the frame ends, as in hospital discharge. Plan closure explicitly, because the receptive and song axes can bring up material in later sessions [source for later-session effects: Schapira & Hugo 2005].

Professional frame: the APM is a framework for trained music therapists. It is taught as postgraduate training (UBA; the ADIM team) [source: Schapira & Hugo 2005; Herrera Muñoz 2012 abstract]. In Argentina music therapy is a regulated profession under Ley 27.153 de Ejercicio Profesional de la Musicoterapia (sanctioned 10 June 2015; partly regulated by Decreto 603/2016). Only holders of a university licenciatura in music therapy, or a music therapist title from an accredited university (foreign titles revalidated), may practise, and they must register the title to obtain a matrícula from the national or provincial registry. Music therapists may work independently or in multi- or interdisciplinary teams, in private practice or institutions. The law bars acting beyond one's competence, delegating to unqualified staff and promising cures; unlicensed practice falls under the Penal Code. Provinces apply the law by adhesion or their own rules [source: Derecho en Zapatillas summary of Ley 27.153 and Decreto 603/2016; details are from that summary, uncertain]. Elsewhere practitioners need the local music therapy credential, for example HCPC registration in the UK or MT-BC (CBMT) in the USA. A psychotherapist without music therapy training should not run SISS/EISS or deep analytic improvisation. One applied author left out EISS because she had not been trained in it [source: Morales Igua 2018]. Non-music-therapists can use songs that clients bring as conversation material within their own scope, or refer to a music therapist, but should not call this plurimodal music therapy; in Argentina, practising music therapy without the title and matrícula would be unlicensed practice [synthesis].

3. Guiding principles

The 2005 article lists eleven theoretical commitments. Applied theses expand this to about fourteen. Each is given below with its practical meaning [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 36–38; Morales Igua 2018, pp. 58–61].

Biopsychosocial (-spiritual) unity. Assess body, psyche, social or cultural context and, in later versions, spiritual life. A change in one is expected to affect the others.
Psychodynamic thinking (the unconscious, psychic movement). Treat musical events as meaningful, not random. Keep neutrality, abstinence and free-floating attention while listening (rules named in Morales Igua 2018).
Psychic determinism. Link how the client plays and sings now to their history. Ask about the songs and sounds of earlier life periods.
Inner music (música interna). The client's sound production reflects their psychic structure. Read rigidity, chaos, silence or repetition as information.
Being in music (ser en la música; drawn from Nordoff-Robbins). Understand the person through the music they make, and meet them in it.
Defence mechanisms. Expect introjection, projection, identification and resistance to appear musically, for example always copying the therapist or refusing to stop.
Transference and countertransference. Monitor what the client plays towards you and what the music stirs in you. Take both to supervision.
Framework (encuadre). Hold time, space, materials and agreements steadily. Read what the client does with the frame, such as lateness or bringing music, as material.
Analogy. Use the musical relationship (who leads, who follows, who fills the silences) as a model of the client's relationships.
Metaphor. Use images and lyrics as symbolic representations of the client's world. Change the musical metaphor in order to change the experience.
Musical origins (Bruscia). Everyone has inborn musical capacities. Pitch the task to the client's musical developmental level, not to their training.
Expressive-receptive modes (ME-R; the 2005 English text uses "non-verbal expressive modes"). Identify each person's preferred bodily, gestural and sonic ways of expressing and receiving, and respect their cultural identity.
Social musical representations (RSM). Take seriously what a genre or song means socially to the client: identity, belonging, class, generation.
Therapeutic musicality. Adapt your own playing and singing to what the process needs, not to your taste. Your musicality is a clinical tool.
Plasticity / non-standardisation. Choose and combine axes for this client at this moment. Drop a plan that does not fit.
Equal weight of the four axes. Do not default to one technique. Consider all four when planning.
No "musical pharmacopoeia". Never prescribe a piece for a symptom. Music in SISS and recorded-music work is chosen as an interpretation of this person's process.
Aesthetics irrelevant. Never correct or judge the quality of singing or playing. Analyse its content.

4. Intervention inventory

This inventory covers the assessment tools and every technique named under the four axes in the sources. Where a source names a technique but gives no steps, the steps are marked [synthesis] or [uncertain]. The 2007 book's own instructions are not reproduced in any accessible source [uncertain]. All example language is illustrative and is not the founders' wording.

A. Assessment tools

A1. Ficha musicoterapéutica and sound-musical history

Purpose: map the client's musical identity, preferences, aversions and the songs tied to life periods. Use at intake and update throughout [source: Ávila Osorio 2016, pp. 47–49 (Benenzon-based form, adapted); Schapira & Hugo 2005 (client's sound history as a selection criterion)].
Steps: (1) Take personal data and the reason for referral. (2) Ask about musical training, instruments played, jobs involving music. (3) List favourite and disliked music, instruments and sounds. (4) Walk through life periods (childhood home, adolescence, key events) and ask what music was there. (5) Note sounds or songs linked to distressing events as possible triggers [trigger screening: synthesis]. (6) Record cultural and generational identity (RSM).
Example language (illustrative): "What music was playing in your house when you were small? Is there any music you can't stand, or that you'd rather we never use here?"
Watch for: flat or absent musical memories, which may signal defence or depression; strong aversions; songs tied to loss or trauma. These shape what you may use later in SISS and with recorded music.

A2. Identifying expressive-receptive modes (ME-R / NvEM)

Purpose: find out how this person expresses and receives through body, gesture and sound. Use it to choose which axes to use [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 38, 50].
Steps [synthesis on procedure]: (1) Offer a free choice of instruments, voice and movement over the first sessions. (2) Note what the client gravitates to and what they avoid: loud or quiet, rhythmic or melodic, voice or object, alone or together. (3) Note how they receive: listening, moving, visualising, talking. (4) Note cultural markers. (5) Summarise the ME-R in the notes and use it in the objectives.
Example language (illustrative): "Pick anything in the room you'd like to try, or just listen if you'd rather."
Watch for: a mismatch between what the client says they like and what they actually do.

A3. Improvisation analysis (IAPs + morphological factors)

Purpose: read intra- and inter-musical (intra- and interpersonal) dynamics from recorded improvisations [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 39–41; Morales Igua 2018].
Steps: (1) Record the improvisation, with consent. (2) After the session, rate it on Bruscia's six IAP profiles: salience, tension, autonomy, integration, variability, congruence. (3) Add Bauer's six morphological factors, as listed in the 2005 article: appropriation, transformation, order, effect, display, tool [uncertain: the sources do not define these factors]. (4) Compare across sessions. (5) Form hypotheses about defences and transference. Bring them to supervision.
Watch for: over-reading a single improvisation. Trends across sessions matter more. The IAPs require training in Bruscia's system [synthesis]. Artwork-style "diagnosis" from music is not supported. Do not treat musical features as proof of a disorder or of abuse; the IAPs and the ficha are descriptive clinical tools, not validated diagnostic tests [synthesis].

B. Axis 1: work with songs

The 2005 article names nine song procedures, in this order: creation, singing together, improvisation, conscious evocative induction, unconscious evocative induction, exploring material, free singing association, projective song questionnaire, sense expansion. It says the authors aim to systematise the use of songs, with goals and timing for each procedure, but it gives no steps [source: Schapira & Hugo 2005, re-checked]. The Ávila Osorio thesis describes only five of them: creation, singing together, improvisation, conscious evocative induction and free singing association [source: Ávila Osorio 2016, pp. 42–43]. Songs are treated as a "symbolic archive" of the past, a metaphor for the present and a sung expression of hopes and fears. The sung content (Negreiros' "musicants") is the analytic material [source: Schapira & Hugo 2005]. General screening applies: ask before using any song tied to trauma, loss or abuse [synthesis].

B1. Song creation

Purpose: give form to current feelings or narrative. Use mid-process when the client has words but needs containment. It also works for closure (one stage-anxiety case ended with songwriting) [source: Ávila Osorio 2016, p. 41; Cantillo-Guzmán 2024].
Steps: (1) Choose: a new song, or alter the lyrics, melody or rhythm of an existing one. (2) Gather words: themes, phrases from the session. (3) Choose a style the client identifies with (RSM). (4) Build verse and chorus together, with the therapist supplying harmony if needed. (5) Sing and record it. (6) Talk about what the song says [steps 2–6: synthesis].
Example language (illustrative): "You've said 'I keep carrying it' three times today. Shall we see if that line wants to be a chorus?"
Watch for: the client handing all decisions to you, which is transference to read. Working: the client owns the lyrics and returns to them later. A related example: adolescents in paediatric oncology made a combative version of a popular song [source: Hugo, n.d.].

B2. Singing together (canto conjunto)

Purpose: create a holding experience. The therapist's voice alongside the client's can lower anxiety. Use it early, with anxious clients, and in groups or families [source: Ávila Osorio 2016, p. 41; Hugo, n.d. (mothers and daughters singing to welcome a new family)].
Steps [synthesis]: (1) Let the client choose a known song. (2) Pitch it to their range. (3) Sing with them, then gradually reduce your volume if autonomy is a goal. (4) Afterwards ask what singing it was like.
Example language (illustrative): "I'll sing with you. Come in and drop out whenever you like."
Watch for: shame about the voice. Never correct pitch, since aesthetics are irrelevant.

B3. Song improvisation

Purpose: sung improvisation, either associative (free links to memories, images and sensations) or descriptive (singing about a given theme or state) [source: Ávila Osorio 2016, p. 41; Schapira & Hugo 2005].
Steps [synthesis]: (1) Set a simple vamp or ostinato. (2) Give the reference, for example "sing about this week" (descriptive) or "let any words come" (associative). (3) Follow and support. (4) Process verbally.
Example language (illustrative): "I'll keep these two chords going. Sing whatever comes, words or sounds."
Watch for: associative work may be too loose for people with intellectual disability or neurological conditions. Use descriptive work with them [source for this caution: Schapira & Hugo 2005 (stated for TMI)].

B4. Conscious evocative induction

Purpose: bring up a song linked to a theme or situation so it can be explored. Use when a topic stalls verbally [source: Ávila Osorio 2016, p. 41].
Steps: (1) Name the situation or person. (2) Ask the client to recall a song connected to it. (3) Invite them to sing, play, illustrate, dedicate or share it. (4) Explore the lyrics and the memory [step 4: synthesis].
Example language (illustrative): "If your father had a song, what would it be? Who would you dedicate it to?"
Watch for: grief surges. Working: new memories or emotion emerge, linked to the theme.

B5. Unconscious evocative induction

Purpose and steps: listed fifth of the nine song procedures in the 2005 article, separately from conscious induction. Neither the article nor the theses give a procedure (Ávila Osorio 2016 leaves it out), and the 2007 book's description is not publicly available [uncertain]. No published step-by-step procedure was found; a likely reading is a song that arises spontaneously (one "stuck in the head", or one the client starts humming) and is then treated as material. This is [synthesis] and should not be attributed to the founders.
Example language (illustrative): "You were humming something as you came in. Can you sing a bit more of it?"
Watch for: the client feeling exposed. Ask before exploring it.

B6. Exploring material (song)

Purpose: examine a song in detail (lyrics, melody, who sang it, when it was heard) as an archive of the client's history [source: Schapira & Hugo 2005 (named); procedure: synthesis].
Steps [synthesis]: (1) Listen to or sing the song. (2) Look at the lyrics line by line. (3) Ask which line "belongs" to the client. (4) Link it to the period and the people. (5) Note what is left out.
Example language (illustrative): "Which line of this song feels most like yours right now?"
Watch for: intellectualising about the song in place of feeling it.

B7. Free singing association

Purpose: vocal free association over a stable harmonic holding. The technique is taken from Diane Austin. Use it with clients who can tolerate regression and want depth [source: Ávila Osorio 2016, p. 42 (attributed to Austin); Schapira & Hugo 2005 (named)].
Steps: (1) The client chooses a harmonic base, usually two chords. (2) The therapist holds it steadily. (3) The client improvises vocally, first with sounds, then with words. (4) The therapist may support or echo. (5) Process afterwards [steps 4–5: synthesis; Austin's own procedure not summarised here, uncertain].
Example language (illustrative): "Start with just sounds on these chords. If words come, let them."
Watch for: overwhelm or flooding. Reduce intensity, return to the familiar, ground (see 5). Not for acute psychosis or fragile ego states [synthesis].

B8. Projective song questionnaire

Purpose: a projective questionnaire built around songs, to surface identifications and conflicts. It is listed eighth of the nine song procedures in the 2005 article. Its items and procedure are not published in the 2005 article, Ávila Osorio 2016 or the other accessible APM papers [uncertain]. Do not invent items. If you use songs projectively, use your own open questions (for example "a song for your childhood", "a song you wish someone sang to you"), present them as your own [synthesis], and do not treat answers as diagnostic.
Watch for: interpreting answers as fact rather than as hypotheses.

B9. Sense expansion (expansión de sentido)

Purpose and steps: listed ninth of the nine song procedures in the 2005 article, which gives no procedure; no other accessible source describes one [uncertain]. A cautious reading [synthesis]: widen the meanings a song holds for the client, for example by re-singing it in a different tempo or mode, or from another character's viewpoint, to open up new meanings. Do not attribute steps to the founders.
Example language (illustrative): "Let's sing it again slowly, as if it were a lullaby. Does it say something different now?"

C. Axis 2: therapeutic music improvisation (TMI / IMT)

The aim is to reveal intra-musical (intrapersonal) and inter-musical (interpersonal) dynamics. Aesthetic value is irrelevant. Each improvisation is designed by choosing three variables, with preparation beforehand and analysis afterwards [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 39–41].

C1. Designing an improvisation (setting × media × reference)

Purpose: tailor each improvisation to the client and to the moment.
Steps: (1) Interpersonal setting. Choose solo, client with therapist, or group (including Eschen's rondo, C2). (2) Media. Choose instruments, voice, body, or partners' bodies. (3) Point of reference. Choose one of four. Free means no theme. Descriptive means play a named state, person or situation. Associative means let memories and images come while playing. Oriented to the material means explore the sound properties of the instrument itself. (4) Give a short instruction. (5) Improvise and record. (6) Process verbally. (7) Analyse later (A3) [source: Schapira & Hugo 2005].
Indications as given: referential or descriptive improvisations suit neurotic clients. Associative improvisations are unsuitable for some people with intellectual disability or neurological conditions; use descriptive or material-oriented forms with them [source: Schapira & Hugo 2005].
Example language (illustrative): descriptive, "Play how this week has been, from Monday to now". Material-oriented, "Find every sound this drum can make".
Watch for: a client who always matches you (possible compliance or merger) or never meets you (possible avoidance). Working: more variability and congruence across sessions (IAPs).

C2. Improvisational rondo (after Eschen)

Purpose: a group improvisation form. The 2005 article adds Johannes Eschen's "improvisational rondo" to Bruscia's interpersonal-setting variable [source: Schapira & Hugo 2005, re-checked]. The article gives no procedure. The contents page of Eschen (Ed.) 2002, Analytical Music Therapy, shows only Eschen's introductory chapter and no chapter on the rondo, and the Ávila Osorio thesis does not mention it [uncertain].
Steps [synthesis, consistent with a rondo form]: (1) The whole group plays a shared refrain. (2) Members take turns at solo or small-group episodes. (3) The group returns to the refrain between episodes. (4) Process what each person's episode and the refrain felt like.
Example language (illustrative): "We'll all come back to this groove each time; in between, each of you gets a space of your own."
Watch for: who avoids their solo, who dominates, and who cannot return to the group.

C3. Clinical improvisation techniques used within TMI

Purpose: the therapist's in-the-moment musical responses. One APM thesis lists these (taken from Bruscia): imitation, repetition, guiding, creating spaces, extending, completing, introducing a change, making transitions. It also lists tension-profile moves: walking, calming, intensifying, containing [source: Morales Igua 2018]. These are Bruscia's techniques used inside APM, not APM inventions.
Steps [synthesis]: imitate or repeat to make contact. Create spaces (pauses) for the client to lead. Extend or complete a client's phrase to show it was heard. Introduce a change only once contact is secure. Use calming and containing when tension escalates. Intensify only with consent and enough ego strength.
Example language (illustrative): "I noticed I started copying you. What was it like to hear yourself played back?"
Watch for: your own countertransference pushing the music, for example rescuing silences. Take it to supervision.

C4. Verbal processing of improvisations

Purpose: link musical events to the client's life through analogy and metaphor [source: Schapira & Hugo 2005; Ávila Osorio 2016].
Steps [synthesis]: (1) Ask about the experience first, not the meaning. (2) Reflect one concrete musical event. (3) Offer an analogy tentatively. (4) Let the client accept, change or reject it.
Example language (illustrative): "When I got louder you stopped playing. Does that happen anywhere else?"
Watch for: premature interpretation. Some clients need the music without words for a while.

D. Axis 3: SISS / EISS (Stimulation of Images and Sensations through Sound)

The authors' own receptive technique, described as a modification of Bonny's GIM [source: Schapira & Hugo 2005]. It requires specific training [source: Morales Igua 2018, who did not use EISS for this reason]. Do not use it without that training.

D1. Building the SISS sequence

Purpose: create a sound sequence, made by hand for this person or group, that prevents habituation so images and sensations arise directly [source: Schapira & Hugo 2005; Cantillo-Guzmán 2024, p. 16].
Steps: (1) Choose fragments of recorded music to fit the client's process and ficha (selection criteria as in E1). (2) Vary each fragment's length from the one before so the client cannot settle into a pattern. (3) Draw fragments from different periods and contrasting styles [uncertain: whether "periods" means musical eras or the client's life periods differs between summaries]. (4) Adapt the total duration, fragment length and number of stimuli to the setting (shorter for ICU, children, elderly or neurological clients) [source: Schapira & Hugo 2005]. (5) Screen out music on the client's trigger or aversion list [synthesis].
Watch for: building the sequence from your own taste. The authors include the therapist's own resonance as a selection factor, which is a reason to be aware of it.

D2. Delivering SISS (three stages)

Purpose: reach images, sensations and unconscious or repressed material [source: Schapira & Hugo 2005].
Steps: (1) Relaxation. The client settles in a comfortable position. (2) Sound stimulation. Give one brief descriptive instruction with no title, theme or guided scenario (unlike GIM). The client listens to the sequence. The therapist does not engage in dialogue during the music. (3) Conclusion. The client puts into words, draws or otherwise integrates what came up [source: Schapira & Hugo 2005; Cantillo-Guzmán 2024, p. 16]. (4) Note that effects often appear in later sessions, so follow them up [source: Schapira & Hugo 2005].
Example language (illustrative): instruction, "Just notice whatever images or sensations come while the music plays." Conclusion, "What came? Where in your body did you feel it?"
Populations reported: originally neurotic adults. Later uses include older people, special-school children, neuromotor and neurological conditions, addictions, psychiatric disorders, health promotion, marginalised children, pregnancy, oncology, ICU and coma [source: Schapira & Hugo 2005].
Watch for: dissociation, panic, intrusive trauma memories. Stop the music and ground the client (see 5). Use caution or avoid with active psychosis, severe dissociation or recent trauma [synthesis]. Keep volume moderate (see hearing safety in 5).

E. Axis 4: selective use of recorded ("edited") music

E1. Selecting the music (three-source rule)

Purpose: choose recorded music that serves the process at this moment [source: Schapira & Hugo 2005; Ávila Osorio 2016, pp. 38–40].
Steps: weigh three sources. (1) Therapist. Musical knowledge, personal resonance and taste (checked in supervision), self-disclosure through the music, transference and countertransference, and the objectives. (2) Client. Sound history, current situation, plans, likes and dislikes, age, gender, cognitive level, group issues, non-verbal expressive modes, and music they bring. (3) The music itself. Genre, lyrics, instrumentation, period, number and gender of performers, social context, and its function in the session. The 2005 article names three functions: instruction (the music holds, completes and supports a verbal instruction), interpretation (the music says, points out or interprets something from within the transference) and association (the music mobilises different levels so that images and sensations linked to feelings can arise) [source: Schapira & Hugo 2005, re-checked; Ávila Osorio 2016, p. 39 (cognitive level)].
Rules of thumb given by the authors: to intensify, choose music that allows working through, which is not necessarily energetic music. Active relaxation does not require quiet music. A meaningful song can close a session [source: Schapira & Hugo 2005].
Watch for: "prescribing" pieces for symptoms, which the founders reject.

The modalities below are listed in an APM thesis [source: Ávila Osorio 2016, pp. 39–40]. The thesis says the axis "se desarrolla en 7 modalidades distintas" (p. 40) but names only six; the seventh is unidentified [uncertain]. The 2005 article classifies recorded music by function (instruction, interpretation, association; see E1), not by modality. Do not fill the gap with an invented modality. Steps are [synthesis] unless cited.

E2. Exploring the material

Purpose: explore music the client brings, in two stages under the therapist's guidance [source: Cantillo-Guzmán 2024, p. 16 ("two times"); Ávila Osorio 2016].
Steps [synthesis]: (1) Listen together. (2) Ask why this piece, why now, what it evokes and who it belongs to.
Example language (illustrative): "You chose this one for today. What made it the one?"

E3. Singing with recorded music

Purpose: singing over a recording gives security to clients who are shy about their voice [source: Cantillo-Guzmán 2024, p. 16]. Steps [synthesis]: play the track, sing along, gradually lower the track volume if autonomy is a goal.

E4. Instrumental accompaniment of recorded music

Purpose: the client joins a recording on an instrument, which offers structure and participation without exposure [source: Ávila Osorio 2016]. Steps [synthesis]: give a simple instrument, invite the client to find the pulse and then to add their own part.

E5. Listening to recorded music

Purpose: receptive listening followed by verbal processing [source: Ávila Osorio 2016]. Steps [synthesis]: set the focus (for example a body sensation, a memory or the lyrics), listen, then talk.

E6. Listening in movement

Purpose: the client expresses the music through the body. One case used this for pulse and breath regulation and to reduce muscle tension [source: Ávila Osorio 2016; Cantillo-Guzmán 2024 (session 1)]. Steps [synthesis]: clear the space, invite free movement, offer opt-outs (seated movement or just listening).
Watch for: falls and space hazards. No touch without explicit consent.

E7. Personalised edition

Purpose: named as the sixth modality in Ávila Osorio (2016, p. 40) with no description; no published procedure is available [uncertain]. A cautious reading [synthesis]: assemble a personal compilation or recording, such as a life-story playlist or a songbook of the process, which resembles the songbook mentioned in Hugo's oncology work [source: Hugo, n.d.].

5. Handling problems

The founders' own guidance on problems comes down to plasticity: drop a planned intervention that does not fit, choose the axis that fits the client's ME-R, and use transference and countertransference analysis with supervision [source: Schapira & Hugo 2005]. Everything else below is [synthesis] unless cited.

Stuck client or repetitive material. Change the axis rather than pushing harder. For example, move from verbal processing to a material-oriented improvisation, or from improvisation to a song the client brings. Treat the repetition as information first: rigid ostinatos and identical song choices are possible defences to name gently. [Axis switching: consistent with Schapira & Hugo 2005; specifics: synthesis]
Resistance in the music (refusing to play, constant imitation of the therapist, playing over everyone, or ironic performance). Reflect the musical pattern without judgement and offer a lower-exposure axis, such as listening (E5) or singing along with a recording (E3). Defences are expected in music therapy as in analytic work [source: Ávila Osorio 2016; Morales Igua 2018]. Example (illustrative): "It seems easier to follow me than to lead. We can stay with that for now."
Embarrassment about voice or skill. Restate that aesthetics are irrelevant [source: Schapira & Hugo 2005]. Start with group or joint singing, recordings to sing along to, or simple percussion.
Overwhelm, flooding, dissociation (most likely in SISS, free singing association and associative improvisation). Stop or fade the music. Orient the client to the room: feet, breath, naming objects. Switch to predictable rhythmic or familiar material. Contain with steady, slower playing (the "calming/containing" moves, C3). Process only once the client is regulated, and schedule a check-in, because SISS effects can surface in later sessions [later effects: Schapira & Hugo 2005]. Screen beforehand. Use descriptive or material-oriented forms and avoid associative or deep receptive work with active psychosis, severe dissociation, recent trauma or low ego strength.
Musical trauma triggers. Specific songs, genres, anthems, religious music, instruments (e.g. sirens, drums) or the client's own voice may be tied to abuse, war, loss or institutional experiences. Ask about them at intake (A1). Keep a do-not-use list, and check every SISS sequence and recorded track against it. Warn the client before introducing lyrics on charged themes. If a trigger is hit, stop, acknowledge it, ground the client, and do not "work through" it unless the client chooses to and it is planned.
Hearing safety. Keep recorded playback and amplified instruments at moderate levels, and avoid prolonged loud drumming in small rooms. Offer earplugs or ear defenders, especially to children, autistic and noise-sensitive clients, people with tinnitus or hyperacusis, and ICU or neonatal patients. Position speakers away from the client's ears. Give very low volume and short fragments for coma or ICU work (the authors adapt duration and number of stimuli by setting [source: Schapira & Hugo 2005]). Check headphone volume if you use headphones for receptive work.
Non-adherence and missed sessions. Treat attendance and what the client does with the frame (encuadre) as material to explore, in line with the framework principle [source: Ávila Osorio 2016]. Re-agree the frame explicitly, and lower the demand if the work has become too intense.
Ruptures. These include a client hurt by a song choice or interpretation, or a feeling that the therapist took over the music. Acknowledge it, invite the client's view, and repair musically too: offer the lead and play in support. Check your own countertransference and taste in supervision; the authors list the therapist's resonance and taste as factors in selection [source: Schapira & Hugo 2005].
Interpretation of music as "evidence". Do not treat improvisation profiles, SISS imagery or projective song answers as proof of trauma, abuse or a diagnosis. They are hypotheses to explore with the client.
Cultural mismatch. If the client's music is unfamiliar to you, let the client teach it and ask what it means socially (RSM). Do not impose "therapeutic" genres.
Medical, paediatric oncology and palliative settings. Expect constantly changing conditions. Plan lightly, shorten activities, and pick whichever axis the child or patient can manage that day. The approach is described as well suited to such settings for this reason [source: Hugo, n.d.]. Coordinate with the medical team. Music is an adjunct to, never a replacement for, medical care.
Children and young people. Get parental or carer consent and the child's own assent, including separate consent for audio or video recording. Follow safeguarding and mandatory-reporting duties if disclosures arise in songs or improvisations. Use descriptive or material-oriented improvisation and short SISS sequences. Involve parents in joint singing where appropriate (as in Hugo's mother–daughter singing [source: Hugo, n.d.]).
Groups. Watch for dominant players and silent members. The rondo form (C2) and structured turn-taking give everyone space. Agree group rules about not mocking each other's music.
Physical safety. Check instruments for sharp edges and choking-size parts with children. Disinfect shared wind instruments and mallets or use single-user ones. Clear floor space before movement work (E6). Use touch only with explicit consent and an easy opt-out.
Working outside scope. A psychotherapist without music therapy training should not run SISS or analytic improvisation. Refer to a qualified music therapist, or work jointly with one [source for training requirement around EISS: Morales Igua 2018].

Sources

Sources consulted:

Books cited via the sources above [uncertain]:

Schapira, D., Ferrari, K., Sánchez, V., & Hugo, M. (Eds.) (2007). Musicoterapia. Abordaje plurimodal. Buenos Aires: Ediciones ADIM.
Schapira, D. (2002). Musicoterapia. Facetas de lo inefable (cited in Schapira 2019).
Bruscia, K. Improvisation Assessment Profiles (cited in Ávila Osorio 2016 and Morales Igua 2018 as Bruscia 1999).
Ley 27.153 (2015). Ejercicio profesional de la musicoterapia (Argentina), and Decreto 603/2016 (cited via the legal summary above).

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