Norma Daykin
email: norma.daykin@uwe.ac.uk

Stuart Mcclean

Leslie Bunt

Creativity, identity and healing: participants' accounts of music therapy in cancer care

Keywords: cancer, creativity, music therapy, qualitative research

This article reports on fi ndings from a study of the accounts of people participating in music therapy as part of a programme of complementary and alternative medicine (CAM) in supportive cancer care. The article outlines the perceived effects of music therapy, which shares many characteristics with CAM therapies as well as offering a distinct contribution as a creative therapy. Hence in this article we draw on theories and writings from the sociology of CAM as well as those relating to music, healing and aesthetics in order to explore participants' accounts. The importance of identity and the role of creativity in processes of individuation are key themes emerging from the analysis.

While music and creativity are often seen uncritically as resources for health and well-being, we draw attention to the challenges and complexity of diverse responses to music, framed by personal biographies that are in turn often situated within socially constructed notions of aesthetics. We argue that in research on music therapy, as well as other CAM therapies, issues of identity can be key to an understanding of questions of therapeutic impact.

Background

This article reports on fi ndings from a study that explored the perspectives of service users on the role of music therapy in supportive cancer care. The aim of the research was to examine users' experience of group music therapy as well as their perspectives on music, creativity and healing. The role and meanings individuals' attached to creativity and healing are discussed with health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] reference to debates about social notions of musical creativity as well as wider debates about complementary therapies.

What is music therapy?

Music therapy is currently employed in many different health and social care settings and includes a diverse range or practices (Bunt and Hoskyns, 2002;Wigram et al., 2002;[START_REF] Hanser | Challenges of music therapy in a world of need[END_REF]. Formal music therapy only accounts for a proportion of the music activity that takes place in health care settings where unpaid carers, volunteers, nurses and performing musicians as well as professional music therapists may all be involved in music activity [START_REF] Bruscia | Defi ning music therapy, 2nd edn[END_REF]Wigram et al., 2002;[START_REF] Pothoulaki | Music interventions in oncology settings: A systematic literature review[END_REF]. The role of the professional music therapists focuses on those processes whereby music is the main agent of therapeutic change. Music therapy can be an individual or a group-based activity. It encompasses a range of activities including listening to music and music making using improvisation techniques (Bunt and Hoskyns, 2002;Wigram et al., 2002). Relaxation techniques such as guided imagery are often used alongside music therapy [START_REF] Korlin | Treatment effects of guided imagery and music (GIM) therapy[END_REF]Bonde, 2005aBonde, , 2005b)).

While music therapists are trained to a high level in music, this form of therapy does not demand any knowledge of music or instrumental ability of participants. Hence in group music therapy of the type discussed here a range of accessible instruments such as tuned and untuned percussion are used. The creative practices used by music therapists are underpinned by extensive training in, among others, psychodynamic, humanistic and transpersonal therapeutic approaches (Bunt and Hoskyns, 2002).

Music therapy is well established in a number of health care areas, particularly child and adult mental health and learning disabilities services. In the fi eld of cancer care, music therapy is an emergent discipline in the UK [START_REF] Aldridge | Music therapy references relating to cancer and palliative care[END_REF][START_REF] Kruse | Music therapy in United States cancer settings: Recent trends in practice[END_REF]. A directory of supportive and complementary therapies in UK cancer care lists 52 centres in which music therapy is offered (Macmillan Cancer Relief, 2002). The similarities and differences between complementary and alternative medicine (CAM) and music therapy have been explored in a survey of these centres [START_REF] Daykin | Music and healing in cancer care: A survey of supportive care providers[END_REF]. This study suggests that the organizational context of UK cancer care means that care providers may not clearly differentiate between the outcomes of CAM, music therapy and other creative and music interventions. The current study took place in a complementary therapy centre specializing in cancer care, and our research seeks to address this particularity of the context of music therapy provision.

In relation to cancer, music therapists seek to address a range of needs relating to physical symptoms and psychological concerns arising directly from the disease process as well as from chemotherapy medications and radiation treatments [START_REF] Rider | Treating chronic disease and pain with music-mediated imagery[END_REF][START_REF] Porchet-Munro | The supportive role of music: The active and passive roles music can play in palliative care[END_REF][START_REF] Standley | Music as a therapeutic intervention in medical and dental treatment: Research and clinical applications[END_REF][START_REF] Burns | A pilot study into the therapeutic effects of music therapy at a cancer help centre[END_REF]Bunt and Hoskyns, 2002;[START_REF] Hilliard | The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer[END_REF][START_REF] Hilliard | Music therapy in hospice and palliative care: A review of the empirical data[END_REF][START_REF] Kruse | Music therapy in United States cancer settings: Recent trends in practice[END_REF]. Music therapists also seek to address patients' spiritual and communal needs [START_REF] Aldridge | Music therapy references relating to cancer and palliative care[END_REF]. A wide range of goals of music therapy has therefore been identifi ed in relation to cancer care.

Assessing the subtle effects of therapies such as music therapy represents a signifi cant challenge for research. Differentiating the role of different contributors to arts and health has nevertheless emerged as a key task for arts therapy professions working alongside a range of creative practitioners in the growing arts and health fi eld (Daykin, in press). As a response, considerable attention has been paid to the development of experimental research designs [START_REF] Bartlett | The effects of music listening and perceived sensory experiences on the immune system as measured by interlekin-1 and cortisol[END_REF][START_REF] Burns | A pilot study into the therapeutic effects of music therapy at a cancer help centre[END_REF][START_REF] Kuhn | The effects of active and passive participation in musical activity on the immune system as measured by salivary immunoglobulin A (SigA)[END_REF]Vink and Buinsma, 2003;[START_REF] Gold | The use of effect sizes in music therapy research[END_REF][START_REF] Edwards | Possibilities and problems for evidence-based practice in music therapy[END_REF][START_REF] Pothoulaki | Music interventions in oncology settings: A systematic literature review[END_REF]. Qualitative research has also explored the effects of music therapy. In a discussion of research on music therapy and cancer [START_REF] Aldridge | Music therapy references relating to cancer and palliative care[END_REF] identifi es a number of areas of cancer care where creative expression may be of benefi t, including dealing with loss, relief of suffering, restoration of identity, empowerment and helping to fi nd meaning in challenging situations. In the review by [START_REF] Pothoulaki | Music interventions in oncology settings: A systematic literature review[END_REF] phenomena such as 'aliveness' (O' Callaghan and McDermott, 2004) emerge as key factors.

In this article we draw on two areas in order to provide a framework for understanding the impact of music therapy in cancer care. We begin by outlining key themes from research in CAM, since in the study context music therapy was offered as part of a broader CAM programme. Music and creative therapies share some common features with CAM therapies, including non-invasiveness in comparison with orthodox medicine, a focus on the psychosocial impact of disease [START_REF] Coward | The whole truth: The myth of alternative health[END_REF][START_REF] Sharma | Complementary medicine today: Practitioners and patients[END_REF][START_REF] Sharma | Medical pluralism and the future of CAM[END_REF][START_REF] Douglas | The construction of the physician: A cultural approach to medical fashions[END_REF][START_REF] Furnham | Reasons for using CAM[END_REF]. In relation to CAM therapies, as well as identifying these aspects that are particularly valued by patients [START_REF] Bakx | The 'eclipse' of folk medicine in western society[END_REF][START_REF] Downer | Pursuit and practice of complementary therapies by cancer patients receiving conventional treatment[END_REF][START_REF] Sollner | Use of complementary and alternative medicine by cancer patients is not associated with perceived distress or poor compliance with standard treatment but with active coping behaviour: A survey[END_REF][START_REF] Sparber | Use of complementary medicine by adult patients participating in cancer clinical trials[END_REF][START_REF] Walker | Patient care in multidisciplinary cancer clinics: Does attention to psycho-social needs predict patient satisfaction[END_REF] research has identifi ed a number of controversies. One of these is the emphasis on the impact of psychological state on recovery, about which there is little scientifi c agreement [START_REF] Watson | Infl uence of psychological responses to breast cancer and survival rates[END_REF].

Linked to this is the problem of individualism and consumerism in CAM [START_REF] Sharma | Complementary medicine today: Practitioners and patients[END_REF][START_REF] Cant | A new medical pluralism? Alternative medicine, doctors, and the State[END_REF][START_REF] Mcclean | The illness is part of the person': Discourses of blame, individual responsibility and individuation at a centre for spiritual healing in the North of England[END_REF]. Many CAM approaches emphasize the primacy of the individual, which manifests in an 'individualistic model' of health, over one that highlights social determinants. Such approaches potentially give rise to associated ideologies of blame and individual responsibility for illness [START_REF] Mcclean | The illness is part of the person': Discourses of blame, individual responsibility and individuation at a centre for spiritual healing in the North of England[END_REF]). Yet the ways in which individuals negotiate illness and healing are complex. Ethnographic research by [START_REF] Mcclean | Doctoring the spirit: Exploring the use and meaning of mimicry and parody at a healing centre in the North of England[END_REF][START_REF] Mcclean | The illness is part of the person': Discourses of blame, individual responsibility and individuation at a centre for spiritual healing in the North of England[END_REF][START_REF] Mcclean | An ethnography of crystal and spiritual healers in northern England: Marginal medicine and mainstream concerns[END_REF] has explored the contemporary socio-cultural milieu from which diverse CAM practices have emerged, and which helps to contextualize further increased personalization and individuation in health and healing. In particular, this research identifi ed the role of healing practitioners as 'bricoleurs', providing highly 'tailored' (e.g. personalized) treatments. Individuation is also identifi ed as a process through which patients use their encounters with therapists and therapies health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] to distinguish themselves from others, refl ecting the individual's unique capacity to relate health, illness and the body to the place of the self. This process of individuation and personalization can be viewed as a creative, innovative and empowering process.

In examining participants' acccounts of music therapy, also it is important to recognize the broader cultural context of music and aesthetics tics. While the positive benefits of music and creativity are increasingly recognized [START_REF] Staricoff | Arts in health: A review of the medical literature[END_REF], responses to music are complex and varied, and the effects of music may sometimes be perceived as negative [START_REF] O'callaghan | Pain, music creativity and music therapy in palliative care[END_REF][START_REF] Edwards | Possibilities and problems for evidence-based practice in music therapy[END_REF]. Musical creativity can serve as a form of distinction [START_REF] Bourdieu | Distinction: A social critique of the judgement of taste[END_REF] and responses to therapeutic creative experiences refl ect 'real' social processes involving power and resources [START_REF] Leip | Introduction[END_REF]. Musical creativity is infused with cultural meanings in western society, all of which help shape responses to music [START_REF] Leppert | The sight of sound: Music, representation and the history of the body[END_REF][START_REF] Mcclary | Conventional wisdom: The content of musical form[END_REF][START_REF] Williams | Constructing musicology[END_REF][START_REF] Clayton | The cultural study of music[END_REF]. Further, there are some problematic cultural assumptions surrounding musical creativity that may impinge on therapeutic processes if not addressed. These include constructions of talent as an innate characteristic that only some people possess, as well as the notion that creative success brings with it an expectation of marginalization, risk and suffering [START_REF] Alford | Orpheus wounded: The experience of pain in the professional worlds of the piano[END_REF][START_REF] Boyce-Tillman | Constructing musical healing: The wounds that sing[END_REF][START_REF] Williams | Constructing musicology[END_REF].

The impact of these notions was explored in a study by [START_REF] Daykin | Disruption, dissonance and embodiment: Creativity, health and risk in music narratives[END_REF] that drew on musicians' narratives following experiences of illness or injury that threatened, limited or prevented their established creative practices.

The study examined the way in which musicians drew on discourses of creativity in making sense of the biographical disruptions resulting from illness [START_REF] Bury | Chronic illness as biographical disruption[END_REF][START_REF] Bury | Illness narratives: Fact or fi ction?[END_REF][START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF][START_REF] Becker | Disrupted lives: How people create meaning in a chaotic world[END_REF]. While the study participants were professional musicians, the discourses on which they drew refl ect widespread ideas about music. These included a strong link between creativity and biography, with musical talent something that is a deep and innate aspect of the self. For the study participants, whether or not they were identifi ed as 'talented' in childhood affected their sense of entitlement to a creative identity in adult life. The need to claim, and reinstate, creative identity following illness was strong for this group, not just because of the fact that music was their livelihood. Quite often, claims to creative identity were ambivalent, and powerful and sometimes negative experiences of aesthetic judgement by others served to diminish participants' sense of well-being and hope for the future. Hegemonic notions of creativity therefore created a number of diffi culties for those seeking to engage with creative music making. Some participants developed alternative notions emphasizing spirituality, service and connection with others.

Music making in a therapeutic setting represents a potential space where hegemonic notions of creativity can be explored. The infl uence of these notions, as well as the benefi ts and risks associated with CAM therapies we have identifi ed, need to be considered when exploring the impact of creative arts in health care. This article reports on a qualitative study of patients' accounts of one-off group music therapy sessions in a community cancer care setting. The study did not seek to evaluate clinical benefi ts and risks; rather the study findings contribute to a broader understanding of the impact of music therapy as an emergent discipline within cancer care.

Methodology

This study used semi-structured interviews with 23 individuals following their participation in one of six 'one-off' group music therapy sessions held over a three-month period at a complementary therapy centre specializing in cancer care. Each session took place as part of a week of therapeutic interventions. Other therapies on offer included nutrition, massage, counselling and spiritual healing as well as art therapy. Participants were at various stages following a cancer diagnosis. They included those seeking to use alternative therapies as part of a lifestyle change following successful treatment as well as those seeking to maximize their quality of life having reached the end of the line in terms of what orthodox treatment could offer.

The music therapy group occurs at the midway point of the weekly residential programme at the centre. It is at this point that the therapist and care staff feel that the therapy offers the most potential benefi ts since the members of the group (the people with cancer and any of their supporters) have had time to get to know each other, to gel potentially as a group and to share their personal stories both in individual appointments with the residential doctor and psychotherapist and within the group. The music therapy session enables further expression and elaboration of any issues to be articulated within a primarily non-verbal context. Colleagues at the centre often report that the music therapy session enables a different perspective to occur for the members of the group, which can then be elaborated in the last two days of the residential programme.

Before attending the session, participants were given written information about the research. At the start of each session a brief introduction was given by one of the two interviewers (SM and ND) who invited participants to take part in the research. The interviewers then left the session. They did not participate in the music therapy, although as neither is a professional music therapist they each spent some time in preparation for the research as a participant observer in order to gain familiarity with the format and conduct of music therapy sessions.

Each session was attended by approximately eight to 10 participants and lasted for approximately one and a half hours. The music therapy session at this centre is atypical of general music therapy practice, given its 'one-off' nature and lack of opportunity to build up substantive therapeutic relationships over time. Nevertheless the view of the music therapist is that this session can be construed as a music therapy process in microcosm. There is a recognition therefore of the need to establish a sense of trust from the outset with clear and safe boundaries surrounding the session. A typical health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] session might begin with participants exploring and choosing from a wide range of attractive and accessible percussion instruments laid out in the centre of the room. Very often the music therapist begins by passing an instrument around the group as a means of opening the session, getting to know the names of the participants and to facilitate any associations with the sounds to be explored. At this stage in the session the participants are making their personal relationships to the sounds and the music they make. The instruments are then used to create a series of improvised musical 'pieces'. The fi rst of these is invariably led by the facilitator, who will often lay down a steady pulse as a means of aiming to provide a sense of security. Gradually the dynamics shift from personal relationships to the music to more inter-personal and inter-musical relationships [START_REF] Bruscia | Defi ning music therapy, 2nd edn[END_REF]. As each session progresses to a central point, participants become increasingly involved in shaping the music, sometimes discussing and negotiating what should be the overall form and mood of the piece before they begin playing, or playing spontaneously and giving and responding to changes in dynamics, rhythm and tempo as the piece progresses. There may be some discussion of the music afterwards but most of the sessions are usually devoted to playing. To close the session, a period of relaxed listening often takes place (sometimes with an opening image provided), the therapist selecting music after discussion of the musical tastes of the participants or as an intuitive choice in relation to the stage of the group process.

Out of each session three or four cancer patients volunteered to take part in the study. The ratio of females to males in the sessions was approximately 6:4 and this ratio was refl ected in the interview sample. After gaining written consent, telephone interviews were carried out. Telephone interviews were chosen for a number of reasons. First, we wanted to give participants a few days to refl ect on the therapy before they gave us their views: this meant that by the time the interviews were carried out participants were spread across the UK, and face-to-face interviews would have been impracticable. Further, we felt that the anonymity and distance provided by telephone interviews may help participants explore possible negative as well as positive experiences. A small number who did this became quite emotional during the interviews: in all cases, interviewees were directed to appropriate sources of emotional and practical support, and the offer of follow-up contact with the researcher was made should this be wanted. Interviews were tape-recorded and transcribed verbatim prior to analysis. Responses were confi dential and all accounts have been anonymized in subsequent reporting.

The interview data were analysed using constructivist grounded theory as outlined by [START_REF] Charmaz | Constructing grounded theory[END_REF]. A qualitative coding process was adopted in order to make analytic interpretations of the interview data. Essentially there were two phases to this coding process. First, each line or segment of data was coded using an initial descriptive or 'in vivo' (i.e. participants' phase) code. Second, by returning to the data in an iterative process we were able to apply a more focused procedure by using more selective and thematic codes that more succinctly captured that segment of data. In the process of constant comparison of interview data the more thematic and analytic codes were developed and honed. We used the computer software package Atlas ti. to assist in developing this thematic coding framework. The music therapist facilitator did not take part in any data analysis. Here we present an overview of the key themes that emerged from participants' accounts.

Creativity and cancer

The responses highlighted the value of personal creativity within participants' accounts of healing. The elements of creativity that were identifi ed seem to refl ect particular characteristics of cancer. For example, themes of choice and enrichment seemed to counter those of limitation and restriction following a cancer diagnosis and treatment. Power, freedom and release were also mentioned, in contrast with the lack of power felt by cancer patients.

Choice and enrichment

Central to the enjoyment of the music therapy session described by several participants was the theme of choice. Several participants talked positively about entering the room where the therapy was to take place and seeing laid out a wide range of interesting and diverse instruments from which they were invited to choose. This process seemed to be one of enrichment, expressed in the following example in relation to the richness, diversity and exoticness of the musical instruments used in the session.

I think what I enjoyed seeing was that there were instruments from many parts of the world, not all parts of the world but from many cultures and backgrounds … They are not just western musical instruments, we had some very simple African instruments, I liked that and what I like is he left it to us to choose and pick what we liked, so everybody went round feeling the instruments, plucking on the strings and choosing whatever they wanted, whether it was a percussion instrument or a string instrument or whatever. I really liked that, I liked the wide diversity and I felt very much at home, I myself chose the African drum, then those very simple things you wrap around your wrist and you shake your wrist and the maracas, which I absolutely enjoyed playing so I quite liked a wide diversity of musical instruments and I also played the Indian ankle bells … Overall it was absolutely fascinating. (Al)

Power, freedom and release

The music therapy session was described by many participants as energizing, and in their accounts the notions of power, as well as freedom and release, emerged. In terms of power, participants were not describing power over others or even necessarily personal power but the feeling of being able to infl uence directly a collective sound, as the following example illustrates: health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] It's a bit like driving a car for the fi rst time … under your power you are actually moving the car, and it's a huge feeling of elation that, 'I can do it! I made that car move, and I did it right and it didn't jerk, or whatever' and it was a bit like the music thing ... sort of 'I created that sound' or you know, it related to everybody, you know, you played a part in creating that sound and if it's not something you've had experience of before it was just wonderful. (Nina)

Freedom, release and the need to 'let go' emerged from many accounts as common themes:

I had a wonderful time, I felt like I was 10 or 11 again, I really got in to it, I really let my guarded side down and had a good old bash on the drums and all that sort of thing. (Lydia) Some participants spoke of expression providing both joy and a relief from other more negative emotions: I: What other things came out of the session? R: A sense of fun really, which may not sound signifi cant but for me, given where I had been at the start of the week in terms of my emotional state and completely seized by fear, that sense of joy and freedom and being able to express a lot was fantastic, it was almost a sense of relief. (Marie)

Music and healing

While many participants spoke about fun and frivolity, there was an underlying seriousness in their accounts. In some of these, 'fun' was seen as an essential counterbalance to a strict discipline required by the healing process. Others spoke more directly about freedom and release as being related to particular concepts of healing. These concepts refl ected the overall context in which the therapy was encountered: that of a CAM therapy centre. Hence the accounts sometimes focused on fun and enjoyment as part of a wider therapeutic discourse of psychoneuroimmunology, emphasizing the links between psychological state and physiological response: I: Were there any bits of that session that you particularly enjoyed? R: I just think the laughter that came out of it, it was just such good fun and it made me laugh … I let myself get in to things and I just felt like I got the endorphins going again, have you heard about endorphins? I: Yes … R: … I just think it centres the mind and it is quite healing actually and I've read a lot of reports about playing Mozart to school children etc. improves their concentration. It did make me feel good, I don't know whether it was the music because it was quite noisy music, there was no method in the madness, it was just really good fun. (Lydia)

Balance

The notion of balance was strongly emphasized within the broader programme of CAM offered at the centre, and participants' responses to music therapy are framed in part by this notion. The approach seems fairly demanding, requiring on the one hand strict dietary and lifestyle regimes that require constant vigilance; at the same time as requiring patients to demonstrate appropriate levels of expressiveness by 'letting go' in therapy and counselling sessions.

I: So what was going on for you, do you think? R: Mostly fun. I: How important is fun? R: Oh tremendous, I have quite a tricky form of cancer, I've got massive healing going on, it went to the liver very quickly and it's reduced enormously in both places but the liver is serious and I know that and I'm enjoying life whilst I can, which may be for quite a long time with the amount of healing there has been and it's been much fun. I think importantly I feel very balanced psychologically and spiritually with all this … I'm just comfortable with all this stuff and so when I say it was fun, it was fun because I felt free to express myself. R: I've also changed my diet to be as good as vegan … I have anything occasionally. That is with a view to healing … and at the centre that's what they encourage you to do. I think a lot of it is planned and carefully structured attitudes to the balance to different things. I'm looking forward to having a cheerful and sunny experience ahead of me, for instance we're taking a lot of energy planning a three-week holiday after my chemotherapy has fi nished as a celebration and when I'm there I'll let go and I'll have some red wine and some decent cheese and all the rest of it, which I don't have as the norm now. But when I come back I will go back to this fairly rigid and strict dietary approach so I do move around to all ends of the spectrum, I think this is the theme of the discussion with me. I: It is isn't it? R: Enjoying almost everything. (Anthony) These tensions between control and release were incorporated into accounts of music, hence this respondent described himself as having broad and eclectic musical tastes, at times favouring soft, meditative music and at times fairly boisterous music.

'Hopefulness' towards the future and a concern for 'balance' was, in part, also framed by participants' responses to the overarching philosophy fostered by the centre: I: I had the whole week to myself, no family, no children, and you can go and just be really selfi sh and fi nd out the things that pleased you for the week, and it did really bring to light that things are really out of balance in my life, so I'm hoping that once the chemotherapy's over I can start doing a few of those things. (Lydia)

Musical meaning and aesthetics

The above discussion suggests that participants' accounts of music therapy are infl uenced by the context in which this was undertaken, in this instance a CAM therapy centre specializing in cancer care. Yet participants also at times drew a distinction between music therapy and the other CAM therapies they experienced. When they spoke of the distinctive healing health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] contribution of music the accounts invoked broader notions of aesthetics and creativity. Hence the responses were often strongly evaluative: it was important to participants that the music was 'good'. I: Could you just describe to me some of things that happened in the session? R: We came in to the room and there were a lot of percussion instruments, I don't know how many, but all the chairs were in a circle and all the percussion instruments were in the middle. And L talked to us for a while and then asked us to choose one. He started by giving us a beat to do on each or our individual instruments, which all together sounded surprisingly good. It was amazing that it was just a simple beat, and he put a few twiddly bits in, and the whole thing sounded amazing. (Lydia) In this context, 'good music' meant a number of things. Sometimes, participants used external references to make comparisons and evaluate their experience of the session. For example, some alluded to music they had heard on the radio that the improvisation session had brought to mind. For most, 'good' also meant 'meaningful' music. Hence, participants who found the music 'good' were keen to stress its sense-making capacity:

We all had to, L led and we had to follow and it all gelled so beautifully, all our different instruments following his rhythm, all that method in madness thing. When he said, 'I'm going to start and you tag along with my rhythm', and I thought, how's that going to be done with all these different people and instruments? Towards the end it made such a lot of sense. (Al) Likewise, those who were critical of the experience and the sound they produced expressed their frustration in terms of the meaninglessness of the music.

The endorsement of the music by the facilitator, an experienced musician, was an important factor in underlining participants' sense of the aesthetic value of their music making: R: It was strange how ... I must call it music I suppose, L certainly called it music but um, would fl ow and get louder and we were all tuned into each other so, everybody seemed to realize what the group was doing and not what individuals were doing but what the group was doing so we were all getting louder and then softer and slowing down, speeding up but not without anybody … you know, without anybody saying that this is what we'll do next -everybody was tuned into each other, and probably into L because he was there and he was playing an instrument and … yes. (Karen)

Musical meaning and personalization: the importance of identity

Discussions of musical meaning often drew on references to musical biography. Hence, those who were able to connect positive elements of their personal biography with creative processes seemed more comfortable with the idea of therapeutic music making. certain degree of trepidation because I don't play any musical instruments … I'm not cynical but I had my own concerns about this sort of music therapy. And then we all sat down and introduced ourselves and I think L launched in to this visualization exercise with the water instruments from South America and we all had to close our eyes and when he was turning it over he asked us what images were coming in to our minds. Automatically the one that came to mind was waves lapping on the shore because I was brought up on an island … and there was a very strong water affi liation and connection and not only that, when he did it the second time but faster it sounded more like monsoon rain hammering on the corrugated iron roofs on the island, that was very evocative with the eyes closed. (Al)

The ability to 'make sense' out of music is clearly important. Here it is expressed as a competence, the lack of which was perplexing for some: R: We all had a musical instrument and we had to send a message to another person and then they replied and then you had to have a discussion about what your message was and what the reply was. I found that stressful because I didn't really know how to communicate with music like that or to understand what anyone else was saying … … I was the last person to be chosen and that caused me a few problems actually because in my head I said well someone's got to be last but I didn't like it that I was last because I was getting more and more tense about what I was going to do. I didn't like that bit, I found it diffi cult and didn't get anything out of that … I couldn't understand. I sing in a choir, I wouldn't say I was wildly musical but I enjoy music but I didn't, I couldn't understand the message. I: Did they explain it to you afterwards? R: Yes. I: In hindsight did it make any sense? R: No. I: What did they say it was? R: They were saying that, the person who sent the message said he would like to hear me sing, he was playing on the maracas I think, I think it might be something when you've done a bit more music you might be able to understand how to actually do it. (Tracey)

Hence, not all participants found the music 'good' or meaningful. As well as lack of skill, the range of instruments used was identifi ed as a limitation. R: There was virtually no sort of melodic instruments available, which I suppose to a certain extent is not unreasonable because anybody can bash a bit of skin can't they … but not everybody can get a tune out of a fl ute. So, you know, coming in with no music aptitude whatsoever, it's good to get some sound out … As far as the sessions were concerned, I think that my fi rst observation on the fi rst piece (if you want to call it that) that we did … it was a complete cacophony, people took various instruments and then basically hit them in fairly random fashion … … I quite like listening to um world music … in terms of bizarre rhythms and that sort of thing, and I didn't get anything out of the session that is equivalent to, say, health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] listening to 'Late Junction' on Radio Three. And yet you might argue that we were making music, or sort of noises, that weren't dissimilar to sometimes some things you hear elsewhere. (Ian)

Here, externally derived notions of aesthetic value clearly infl uenced the account of whether or not the music was 'good'. Yet more often, responses were framed in relation to sometimes deeply felt questions of identity stimulated by the session. As well as the celebration of choice and creativity, issues of regret emerged from the accounts: R: I'm going to try and be coherent because I started off with this feeling that this is what music represents to me ... When I was at school I did piano and violin and I just felt the sense of regret that I didn't do music anymore … The fi rst thing that happened is we formed a circle and the musical instruments had already been arranged and so we could see the instruments. And they looked very attractive and they were well chosen because they were instruments that you could make a reasonable sound on without having a lot of technical skill. But again it bought out this feeling of regret in me and then when L came in the room … he came in very exuberant and he had this very beautiful, fun shirt on with lots of patterns, so he came over as a person very full of vitality and again it almost made me feel like this is something that happens to other people, not me. (Tina)

These issues of regret were strongly connected with biography:

R: … and it so happened that it conjured up a memory from about 30 years ago when I was a student and I was invited to somebody's house … and this person had set up some musical instruments … for us all to go and improvise like we were doing and … that was a horrible experience because the instrument I was given was a violin on that occasion which I had learnt only to elementary level and so it was a terrible experience because … all the others had a continuous improvisation going between them and I couldn't join in and it just brought that back and so it was not a pleasant session for me. (Tina) The view that musical skill would enhance the experience of music therapy was not shared by all participants: I: Would that have made any difference do you think, in terms of the group? R: What, if you had musical ability? I: Yeah. R: No I don't think it would, I mean it … maybe it would make a difference in that maybe the person themselves, I feel, would be more constrained, because they'd kind of stick to what was right and be perhaps a bit frustrated that none of us actually knew what was right. But I don't know, that's just an assumption. But certainly everybody joined in and got a lot out of it and as far as I'm aware nobody, certainly nobody volunteered that they had musical talents, apart from one lady who could play the xylophone, and could play several tunes on it but that didn't matter at all. (Lou)

Here and in other accounts, the willingness to 'join in' and the group process itself infl uenced notions of aesthetic value.

Musical meaning and the group process

In most of the accounts, the group experience was presented as one of the most positive aspects of the therapy: I: Did you notice that the music therapy had a particular effect on the group? R: I think we were all, I don't think it was just me that was aware that as a team we were enjoying ourselves so we were a very close group. One of the guys picked this strange thing and he was in absolute hysterics every time he played it, it just started him off and that made us all laugh with him. I: Can you compare it with any other group activities? R: For me of the group activities it was the best. The art, although I enjoyed it, we didn't do it as a group. The 'bearing your soul' group activities didn't go down as well generally because a lot of people didn't feel comfortable with that … it was the most joined together thing we did as a group, where we were all doing the same thing at the same time … (Fran)

It is often diffi cult to separate musical meaning from the experience of the group process:

I: So what … so overall what did you particularly enjoy about the session? R: I think the fact that we could express things not in words … express emotions using the instruments … enjoyed some of the sounds, umm and I enjoyed our laughter, I think the fun that we had together as a group … (Helen)

In some accounts, more frustrating aspects of the session were discussed. In these, 'musical' aspects, such as the qualities of particular instruments, were also diffi cult to separate from those of people and interaction: 'I chose an instrument that actually disappeared amongst everybody else, because we had some very vigorous people there, and so a few times, you know when my arm ached, I thought you know I'll just listen' (Lou).

Not everyone was positive about the group process:

… there was a rhythm that was being beaten out L … now that was picked up ultimately by everybody there, which to a certain extent I found quite alarming, I thought that it became a marching type rhythm that he put out … and I thought that this is a good opportunity to demonstrate how easy it is to lead people into war … because from going from total chaos everybody was following exactly the same tune and marching off … I just felt that it was just alarming really that everybody lost their individuality and were following the herd … I: Ummm. R: That was my only overwhelming sentiment at that point. (Ian)

For one participant, the apparent closeness of the group brought out feelings of isolation: … he then said I now want each of you to play a little musical message to one other participant … there was not anybody in that circle to whom I had any natural inclination to send a musical message … I had the impression that nobody else had had my kind of experience, everyone looked as though they had really enjoyed it and that may not be true but it before I went to the centre, I decided to try and play the keyboard on my own because I was at home all day and I was worried and, you know, in a bit of a state, and I just started to try and learn the keyboard using my daughter's 'little-bopeep' sort of tune, and I found that really useful. So it's interesting that I actually did that you know, without consciously thinking that I'd better do some music therapy. I: And you found it helpful? R: Yeah, it really focused me and stopped me being so worried all the time, you know, and I kind of escaped on trying to concentrate on using two hands which is something I always wanted to do. So I see myself as somebody who has musical potential but have never realized it. (Lou)

Individuation: beyond music therapy

The interviews took place about a week after the session. Participants were asked about what had been happening since their time at the centre. The responses identify a range of new ventures, many of which are related to music and creativity, upon which they had embarked. R: … but anyway, I am going to join the steel band now … I: Oh are you? R: Yes … well, I've always been interested in drumming and rhythms … and going and having the music therapy, I thought well I've really enjoyed this, I've really liked making a rhythmical noise and then at evening classes I got on the list to join the steel band because I thought yes that's for me … I: It obviously had a big impression in that respect? R: Yes. (Karen)

The desire to embark on new creative and musical activities was presented as a direct result of their music therapy experience: I: Had you had that kind of exposure to those sorts of things before? R: No not at all … as a result of that and the fun I have I signed up for an African drumming course. I: Have you started yet? R: No tonight, so we'll see … (Marie) In these accounts, musical creativity seemed to offer a means of reinstating identities that had been damaged by the experience of cancer: R: One thing came out of it that I was going to take up the clarinet once I got the chemotherapy over' (Lydia).

In these accounts, hope, optimism and anticipation are present:

Creativity and loss

Not all participants formed such plans; regret and sadness also followed the week for some:

… If one were able to take it further it might be very different but when L said at the end I hope some of you will get a drum for Christmas or something and … I just thought that is never gonna happen … there is no way I'm going to get a drum and start playing, it just confi rmed this feeling that this kind of vitality is really something that is not there for me. I don't see how I can incorporate music in to my life … I don't know how it can come back. I have a lot of problems to deal with … apart from the cancer to do with I'm living in a place that I don't want to be living, in a situation that I don't want to be in and so on and so forth and I don't know how to change it. A lot of the feedback from my therapists at the centre was you have to stop complaining about not liking your situation and actually start changing it and I don't know how to do that at the moment …(Tina)

In this account, while authenticity and optimism seemed thwarted, there was a shift in the interview during which Tina seemed to re-evaluate her experiences, identifying a need for change and vitality in her life. Her account is ambivalent as she seemed unwilling completely to deny the possibility of hope:

Discussion

This study has explored service users' perspectives on the role of music therapy in cancer care. The therapeutic use of music in UK cancer care is widespread, supported by a range of beliefs about the value of creativity and its role in healing. The accounts suggest that music and creativity can be powerful and complex resources in the construction of healing among people with cancer. Our research therefore demonstrates the complexity of engaging with music as a creative therapy in cancer care.

A number of themes emerged from the accounts, particularly the importance of notions of creative identity in responding to illness. Within the accounts, creativity is contextual and contingent. Hence the particular aspects of creativity emphasized to some extent refl ect the impact of cancer on identity. These aspects include notions of choice and enrichment in the context of lives that felt denuded by a cancer diagnosis and treatment. Hence, experiences of choice, enrichment and so forth are contrasted with those of limitation, restriction, isolation and disempowerment. The accounts also demonstrate the wide variety of responses to music making: joy, power, freedom, release, fascination, love, togetherness, regret, loss and isolation were all present.

The data also demonstrate the contingent nature of 'therapeutic' experiences: what people get out of music therapy seems to depend to some extent on socially constructed notions of healing and music as well as concepts of the 'creative' (or uncreative) self. Positive transformations were often expressed, with several participants determined to introduce or reinstate creativity in their lives following their week at the centre. Not all accounts were so hopeful, and the data demonstrate the importance of sensitive, culturally aware facilitation of creative therapies in cancer care.

Since the music therapy sessions in question took place during a series of week-long healing programmes offered by a CAM centre, it is not surprising that participants' accounts were to some extent framed by notions of healing that were present during the week. We have therefore drawn on the CAM literature in order to highlight processes of personalization and individuation that provide insights into users' engagement with these therapies. We have highlighted the paradox of serious frivolity in music making, which refl ects CAM notions of balance and immune response. Many participants certainly viewed music therapy in this way, often drawing on a broadly similar 'mind-body healing' model proposed by some of the CAM care providers, hence the seriousness of 'fun' for these cancer patients. The research reveals the intensity of some of the demands of this approach on individuals who face the constant task of 'balancing' lifestyles, feelings, emotions and expression in the face of dire adversity Further, in this article we have shown how that discourses of aesthetics and creativity influence responses to music therapy. Hence we have explored notions of musical creativity as resources for health and well-being. While the purpose of the music therapy session was not to make 'good' music, questions of aesthetic value did emerge from the accounts, and it mattered to most participants that the music was both 'good' and meaningful. The context of the research to an extent framed definitions of creativity. While externally derived notions of aesthetic value sometimes influenced the accounts, these were more likely to be infl uenced by the specifi c context of the group process. This highlights the critical role of the facilitator in attributing meaning and value to participants' contributions.

Interestingly, nearly all the accounts draw on biographical material and notions of identity to assess the aesthetic value of their experience of music therapy. Hence, descriptions of 'meaningless music' were often followed with biographical statements centring on not 'being musical'. Here, hegemonic notions of musical creativity can be seen as negatively influencing participants' responses to music therapy. Hence, notions of musical 'competence' and 'talent' seem important as well as notions of 'authentic' musicality, whether apparent or latent. While for some, 'not being musical' did not represent a barrier to their enjoyment of the therapy, for others, the therapy served as health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] a reminder of particular past experiences in which they defi ned themselves or felt defi ned by others as lacking in creativity. The sense of having an 'authentic' musical identity, defi ned either in terms of latency or in terms of actual musical knowledge and competence, mediated, in some cases strongly, the experience of music therapy. Being 'at home' with creative processes (not necessarily possessing skill or expertise) was the key to 'getting something out of' the music therapy. At the same time, creative identities were shaped by the experience of therapy, with those who felt their latent creative identities stimulated going on to talk about the future using a language of hope and expectation.

This discussion reveals some of the benefi ts and potential risks of engagement with creative therapies, highlighting the importance of skilled facilitation of these. More broadly, we suggest that the use of music therapy, as well as other creative and CAM therapies, has a signifi cant relation to issues of identity. This is an important focus for research, which should not be limited to the perceived effi cacy or the consumption of these therapies. The diagnosis, treatment and users' experiences within CAM can be highly individualized, and this can be a strength in constructing healing [START_REF] Fraser | The medicine men: A guide to natural medicine[END_REF][START_REF] Johannessen | Individualised knowledge: Refl exologists, biopaths and kinesiologists in Denmark[END_REF][START_REF] Mcclean | An ethnography of crystal and spiritual healers in northern England: Marginal medicine and mainstream concerns[END_REF]. As Johannessen explains, such individualization or personalization of treatment helps the patient to imbue a chaotic illness event, such as a cancer diagnosis, with meaning: 'individualised explanations hold great potential for meaning in treatment … it is likely to create order in the personal chaos accompanying sickness ' (1996: 117).

This discussion surrounding identity and biographical resonance links with notions of aesthetics and identity. In our research, 'musicality' seemed to serve as a form of personal capital, upon which was predicated successful engagement with the therapy. Hence we suggest a framework for understanding experiences of creative therapies in which theories of personal innovation are brought together with those of discourses of aesthetics and creativity to examine a range of possible responses. We stress the point that creative identity, and not just creative activity, represents both a resource and a limit on health and well-being; diverse identities therefore need to be a stronger focus of analysis in research on the impact of alternative and creative arts therapies.

health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] Author biographies n o r m a d a y k i n is Professor of Arts in Health at UWE, Bristol, UK, where she leads a research programme examining the role of arts in diverse health care settings. She has researched extensively in sociological aspects of public health and her recent work examines the impact of creativity on well-being. She is trained in social sciences and music and her current research brings these two areas together, developing arts-based methodologies in qualitative research. s t u a r t m c c l e a n is Senior Lecturer in Medical Sociology at the University of the West of England, Bristol. His research interests include the resurgence of alternative medicine and healing practices in western societies, the role of creative arts in health and the global dimensions surrounding health. His book, An ethnographic study of crystal and spiritual healers in northern England: Marginal medicine and mainstream concerns, is published by Edwin Mellen. l e s l i e b u n t is Professor in Music Therapy at UWE where he is Programme Leader of the MA Music Therapy. He is a musician and registered music therapist with 30 years of experience working with both children and adults. His current clinical practice is in the field of adult cancer care and guided imagery in music. Leslie is the Founder Director of The MusicSpace Trust, a registered charity providing individual and group therapy through a network of community-based centres in the UK and Italy where he also teaches regularly. His recent research has concentrated on collaborative projects with colleagues at UWE.

R

  : Well I've always wanted to learn to play the drums [laughs] do something like that … so I suppose the feeling that I'd like, you know that I'd like to do that sort of thing more often but without specifi cally knowing how … you know saying I would buy instruments or umm … I've been to listen to music since … you know on Monday night I went to a gig and I'm going to something tonight, so you know bringing out a real sense of anticipation.(Helen) health: 11[START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF]

  Music represents the life force almost and it's something that you can't fake, you can't fake music and if you, you can make conversation with people and cover over things that you're feeling but you can't play music like that … Maybe it did serve a useful purpose in reminding me of certain things that perhaps I should not neglect so much in my life. It might have a helpful consequence in the future for that reason, it's possible.(Tina)

R:

R: Right, the fi rst thing we saw was the whole range of the assortment of musical instruments … and I thought my goodness, what is this. I went there with a

health: 11 [START_REF] Frank | The wounded storyteller: Body, illness and ethics[END_REF] looked as though they had and I didn't want to expose all that stuff to anyone and so it just, it was a painful experience, a painful session. (Tina)

Emergent musical identity

Musical identity was a major theme emerging from the accounts. The issue of competence has been discussed in relation to aesthetic responses. Here the theme of competence is analysed in more depth. First, we identify the notion of latent creativity that seemed to offer a means of successful engagement with the therapy.

Latent creativity

Few respondents sought to claim the status of musical 'expert'. While participants did not seek to claim musical expertise, several accounts stress the notion of feeling 'at home', being comfortable with the instruments and techniques used in the therapy: I: Have you got a background in music at all? R: No, I have relatives in professional orchestras … but I'm not musical at all, me. I: So would you revise that opinion after the (MT) session that you did? R: No defi nitely not. It would confi rm it. I: Did you enjoy the session? R: However, actually, quite interestingly L twice seemed to indicate that he found that he took a lead from me in the percussion stuff we did. I: That's interesting. R: And various people came up to me afterwards and said I was very vivacious in it and very dynamic so maybe I was really at home without realizing. I: Would that have been the same if it was anything else like art therapy or some other kind of therapy? R: No the art therapy was much more deep. If I gave myself marks out of 10 for music and art I'd give myself four out of 10 for music and one out of 10 for art. (Anthony)

Here, and in the following examples, 'being musical' is a hidden quality that can be 'brought out' by therapy: 'I think that people surprised themselves, um, and insisted that they weren't musical but you know, surprised themselves and found that they in actual fact made some quite good sound' (Karen). This sense of latent and emergent creativity was linked with accounts of cancer and healing: I: Do you have any sort of; do you see yourself as a musical person? R: No I don't really, I'm one of those people who learned, I learned the violin when I was little at school, very badly and I can't actually remember how to read music, and my children age 15 and 10, they play instruments and it's something I always think, oh gosh, you know, I should have done. But interestingly enough, when I was fi rst diagnosed and very upset and worried and frightened and it was