The Role of Music Therapy in the Treatment of a Girl with Pervasive Refusal Syndrome: Exploring Approaches to Empowerment

Article excerpt


Pervasive Refusal Syndrome (PRS) is a life threatening psychiatric disorder, which is characterized by a refusal to eat, drink, talk, walk or maintain any level of self-care. In this article, it is suggested that music therapy may provide a unique role that is supportive, validating and empowering for patients with PRS. The rare condition of PRS predominantly affects girls between 8--16 years of age who, if managed well, are expected to recover completely (Lask, 2004). Literature has linked PRS to the theory of learned helplessness and as such, has highlighted the need for patients to control the pace of recovery (Nunn & Thompson, 1996). The value of music therapy interventions to provide opportunities for choice and control, and thus empowerment, is well documented. Similarly, music therapy theory and practice supports the use of improvisation to provide affirmation, validation, and support. This article examines the role of music therapy in the treatment of an 11-year-old girl with PRS in an acute medical setting. It explores how choice provision and improvisation may foster empowerment through the promotion of opportunities for control, validation, and affirmation. Clinical vignettes illustrate how these interventions may establish a therapeutic relationship, provide acknowledgement, containment, and offer a nonverbal form of support for a patient with PRS.

Keywords: Pervasive Refusal Syndrome, empowerment, choice and control, supportive listening, vocal improvisation.


The aim of this paper is to explore approaches to empowerment in music therapy through clinical work with an 11-year-old girl with Pervasive Refusal Syndrome (PRS). Treatment occurred during two separate admissions over a total period of nine months in an acute paediatric medical setting. These admissions lasted approximately 5 and 2 months respectively. During both admissions Emma (1) participated in an average of two to three music therapy sessions per week. Music therapy interventions initially concentrated on providing opportunities for choice and control in a supportive and affirming space. As Emma's condition deteriorated, approaches to treatment shifted focus to offer affirmation, validation, and control through the use of silence, supportive listening, and vocal improvisation. Case material explores how music therapy may assist in the development of empowerment through choice and control and through facilitating experiences which support the emotional and often distressing reality of a child with PRS.

Literature Review

Pervasive Refusal Syndrome

Pervasive Refusal Syndrome (PRS) was first described by Lask, Britten, Kroll, Magagna, and Tranter in 1991. To date there are no validated diagnostic criteria for PRS. It is agreed that it may be described as a rare, potentially life threatening condition where patients present with varying degrees of refusal to eat, drink, talk, walk, or self-care (Lask, 2004; McGowan & Green, 1998; Nunn & Thompson, 1996; Thompson & Nunn, 1997). Onset of the illness is usually acute, precipitated by a viral illness or injury, and commonly accompanied by school refusal, social withdrawal, and strong resistance to treatment (Thompson & Nunn, 1997). PRS seems to predominantly affect girls between 8-16 years of age with a premorbid personality that is high achieving and anxious (Lask, 2004). A comprehensive assessment is recommended to rule out the possibility of an organic condition or other psychiatric illnesses (Thompson & Nunn, 1997). Despite similarities with eating disorders and refusal syndromes, PRS is considered to be a separate psychiatric illness (Lask, 2004).

In 1996, Nunn & Thompson proposed that PRS might be closely linked to Peterson, Maier, and Seligman's (1993) theory of learned helplessness, suggesting that children with PRS develop a learned expectation that they cannot control their environment. …