What is Clinical Improvisation?
Clinical Improvisation is a generative and creative process of musical intervention involving the client’s spontaneous creation of sounds and music. In clinical improvisation, client and therapist (or client and other clients) relate to one another through the music. Unlike jazz improvisation or other musical forms, clinical improvisation is not performed for an audience—it serves as the primary therapeutic medium through which assessment, treatment, and interpersonal connection occur.
The practice involves no sheet music, no predetermined structure, and no expectation of musical training. The client makes up music, musical improvisation, while singing or playing, extemporaneously creating a melody, rhythm, song, or instrumental piece. Improvisation may occur individually, in a duet, or in a group. The client may use any musical or nonmusical medium within their capabilities. The therapist employs sophisticated musicianship to match, support, challenge, or redirect the client’s musical offerings in ways that address specific therapeutic goals.
There are four basic types of music experiences, or methods, in which a client may be engaged: listening, re-creating, composition, and improvisation. Clinical improvisation stands apart as the most interactive and emergent of these methods.
Origins & Lineage
Clinical improvisation emerged as a formalized therapeutic discipline in the mid-20th century, though musical improvisation has been used informally in healing contexts across cultures for millennia. It was developed in 1958 by American composer and pianist Paul Nordoff and British special education teacher Clive Robbins. Nordoff and Robbins developed this approach for practical clinical purposes while working with the children at Sunfield Children’s Home in 1959.
Following a lecture-demonstration tour and a survey of facilities and music offerings for special needs children in Britain and Europe, Nordoff and Robbins began their American work in 1961 with pilot projects at the Day Care Unit for Autistic Children, Department of Child Psychiatry, University of Pennsylvania, and the Devereux Foundation. Beginning in 1962, the project included treatment, training, research and publication. This was the first NIH grant given to study music therapy with children with autism.
Every music therapist with an interest in clinical improvisation is familiar with Kenneth E. Bruscia’s 1987 tome, Improvisational Models of Music Therapy, which he deemed “the first book to extricate improvisation training from specific clinical models of music therapy.” The book contains an introduction to the fundamentals of improvisational music therapy (Unit One), a detailed synopsis of over twenty-five models of therapy that have been developed over the last thirty years (Units Two through Nine), and a synthesis of the various models into basic principles of clinical practice (Unit Ten). Bruscia’s taxonomy standardized technique language across diverse improvisation-based approaches.
Wigram’s (2004) book on individual and group improvisation expanded upon Bruscia’s (1987) work by providing instructional exercises to develop music and clinical skills along with a CD with audio examples of musical styles and tracks to practice improvising to various types of client musical production. By 2013, Debbie Carroll and Claire Lefebvre published their systematic guide to teaching clinical improvisation techniques, further codifying the field.
How It’s Practiced
They are divided into two interconnected categories: musical techniques (M) and verbal techniques (V). The musical techniques are grouped according to interrelated moments of a therapeutic encounter—establishing contact (M1), eliciting responses (M2), structuring responses (M3), redirecting responses (M4), and working with the client on deeper intrapersonal and interpersonal levels (M5).
Musical techniques include mirroring, matching, grounding, pacing, dialoguing, and reflecting. Imitating is a basic technique of empathy in which the music therapist copies or repeats a client’s response, after the response has been displayed. The music therapist focuses on any sound, rhythm, interval or even facial expression. The therapist might provide rhythmic structure when a client’s playing feels chaotic, or introduce melodic fragments to invite musical conversation.
In individual music therapy vocal and instrumental improvisation stimulates communication between client and therapist. As therapy proceeds, the client increasingly develops his or her capacity for spontaneous expression and interaction through music. Sessions typically last 30–60 minutes and are recorded for later analysis. The therapist might play piano, guitar, percussion, or other instruments while the client explores drums, xylophones, voice, or any available sound-making objects.
The verbal techniques—V1 and V2—are used to engage the client in a discussion before, during or after a musical improvisation (or recording of it), and are often used in combination with the techniques of M5 in order to clarify elements related to the client’s musical expressions. These discussions help clients reflect on what emerged musically and emotionally.
Clinical Improvisation Today
Clinical improvisation is practiced in hospitals, psychiatric facilities, special education schools, private practices, and community centers worldwide. Training programs based on the Nordoff–Robbins approach are offered in several countries, with established centers in the United Kingdom, the United States, Australia, Germany, New Zealand, and South Africa. The extensive recordings and documentation of the Nordoff-Robbins pioneering work (1959-1976) form the foundation of an archive that is continually being expanded and updated by current clinical work.
Music Therapy has been used at the Nordoff-Robbins center in work with those who have been diagnosed with Autism Spectrum Disorder (ASD), cancer, trauma, dementia and Alzheimer’s disease, neurological disorders, psychological disorders, visual impairment, sensory impairment, hearing impairment, physical impairment, learning disabilities, and learning delays.
Training in clinical improvisation requires musical proficiency, supervised clinical practice, and deep study of therapeutic relationship dynamics. Graduate-level music therapy programs typically include dedicated coursework in improvisation techniques, and specialized post-graduate certification programs exist for those seeking advanced training in specific models like Nordoff-Robbins or Analytical Music Therapy.
Common Misconceptions
Clinical improvisation is not recreational music-making. It is a disciplined therapeutic intervention requiring years of training. The therapist is not “jamming” with a client—every musical decision serves a clinical rationale tied to the client’s treatment goals.
It is not limited to clients with musical talent or training. The Nordoff-Robbins approach to music therapy is based on the belief that everyone possesses a sensitivity to music that can be utilized for personal growth and development. A client might strike a single drum in session, and that sound becomes the basis for therapeutic work.
Clinical improvisation is not the same as guided imagery and music (GIM), which involves receptive listening. Nor is it identical to drum circles or group singing, though these modalities may incorporate improvisational elements. The defining feature is the therapist’s real-time, responsive use of live music as the primary vehicle of therapeutic intervention.
It is not without contraindications. Some clients may experience overwhelm, dissociation, or heightened anxiety when asked to spontaneously create sound, particularly those with severe trauma histories or acute psychosis. Skilled therapists assess readiness carefully.
How to Begin
For seekers interested in experiencing clinical improvisation, locate a board-certified music therapist (MT-BC in the United States, or equivalent credential in other countries) who specializes in improvisational methods. The American Music Therapy Association (AMTA) and Certification Board for Music Therapists (CBMT) maintain searchable directories.
For clinicians seeking training, Kenneth E. Bruscia’s 1987 tome, Improvisational Models of Music Therapy remains foundational reading. Carroll and Lefebvre’s 2013 Clinical Improvisation Techniques in Music Therapy: A Guide for Students, Clinicians and Educators offers a systematic pedagogical approach. The Nordoff-Robbins Center at NYU Steinhardt offers workshops, certificate programs, and master’s degrees focused specifically on improvisational music therapy.
Observing live clinical improvisation—through supervised practicum, conference presentations, or documentary footage—is essential for understanding the nuanced, moment-to-moment responsiveness that defines the work.