Art and music therapy in Brazil's public health system

1. Introduction

Version followed: Portaria GM/MS nº 849/2017 (which added arteterapia and musicoterapia, among 14 practices, to the Política Nacional de Práticas Integrativas e Complementares, PNPIC, created by Portaria GM/MS nº 971/2006), read together with the SUS procedure table entries created by Portaria SAS/MS nº 145/2017, the Ministério da Saúde PICS monitoring report covering 2017–2023 (published 2024), and Lei nº 14.842/2024 on the music therapy profession. Translations from Portuguese are my own.

What it is. This is not a single therapy and not a psychotherapy method in its own right. It is a public-health policy framework: since 2017 art therapy and music therapy are listed as Práticas Integrativas e Complementares em Saúde (PICS) that SUS services may offer and record, mainly in primary care (Atenção Básica / APS) and also in psychosocial care (CAPS). The policy defines the practices in one paragraph each and sets recording codes; it does not give a clinical protocol, session format, outcome target or training standard. Clinical method therefore comes from the professions (art therapists, music therapists) and from local service practice. [source: Portaria 849/2017 annex; Portaria SAS 145/2017; Relatório de Monitoramento PICS 2024]

Your role as a psychotherapist [synthesis]: in most SUS settings you will judge whether a user would benefit from an art or music therapy group or from a broader arts workshop; refer through the reference professional and the care plan (Projeto Terapêutico Singular, where used); hand over relevant risk information with the user's consent; agree with the facilitator how distress, disclosures and absences come back to the team; and keep psychotherapy and the PICS group distinct. Refer therapeutic music work to a music therapist under Lei 14.842/2024 and art therapy to a trained art therapist; do not present your own arts activity as either unless you hold that training.

Official definitions (paraphrased, my translation).

Arteterapia: a practice that "utiliza a arte como base do processo terapêutico" (uses art as the basis of the therapeutic process); individual or group; draws on expressive techniques such as painting, music and sculpture; aims to stimulate creativity and motor and relational development; for people of all ages, including for stress and trauma. The monitoring report summarises it as visual expressive work used therapeutically to examine conscious and unconscious content. [source: Portaria 849/2017 annex; Relatório 2024]
Musicoterapia: the use of "música e seus elementos (som, ritmo, melodia e harmonia)", in groups or individually, to address physical, emotional, mental, social and cognitive needs, including communication and expression. [source: Portaria 849/2017 annex; Portaria SAS 145/2017]

Core idea of change, as sources state it. The policy places these practices within integral, humanised care, health promotion and prevention. Practice reports describe change through creative expression and symbolic processing of distress, bonding with the team, socialisation and greater autonomy. These are the authors' observations, not measured outcomes. [source: posuscs page; Vale et al. 2021; CAPSi Maringá account]

Evidence status as sources give it. Portaria 849/2017 cites no clinical evidence; its justification is service presence (PICS found in over 5,000 establishments in the PMAQ evaluation) and WHO policy on traditional and complementary medicine. The 14 BIREME/PAHO–CABSIn evidence maps on PNPIC practices launched in 2020 did not include art therapy or music therapy. The Brazilian SUS reports are descriptive experience reports with no validated measures. Whether later evidence maps cover these two practices is [uncertain]. [source: Portaria 849/2017; PAHO 2020 news; Vale et al. 2021; Siqueira & Rodrigues 2023; Santos & Gonçalves 2023]

2. Framework

Because this is a policy rather than a manualised therapy, the framework below describes how the practice runs inside SUS, from authorisation to discharge. The stages are my organisation of the sources [synthesis]; facts within each stage are cited.

Stage A. Legal and professional eligibility (before any session).

Music therapy is a regulated profession under Lei 14.842/2024. Art. 3 allows practice by: (I) graduates of a recognised Brazilian bachelor's degree in Musicoterapia; (II) foreign graduates with a diploma revalidated in Brazil; (III) people who completed a lato sensu postgraduate course in Musicoterapia within 24 months of the law's publication; (IV) people who prove at least five years' practice as a music therapist before the law came into force, as the regulation will specify. Art. 5 lists competences, including music-therapy interventions in health, social assistance, rehabilitation and prevention, and planning, coordinating and evaluating clinical activity in health and social-assistance services. Art. 6: the music therapist is liable for acts done with intent or fault. The law creates no professional council and does not mention SUS; Art. 4 was vetoed. [source: Lei 14.842/2024, Câmara publication] The rules for proving five years' practice under Art. 3(IV) were not found [uncertain].
Art therapy is not a regulated profession. A 2024 Cofen opinion records that PL 3416/2015 (regulation bill) was still pending, that the CBO occupation code 2263-10 Arteterapeuta "não equivale à regulamentação profissional" (does not amount to professional regulation), and that UBAAT's recommended minimum of 520 hours of postgraduate training is a recommendation, not binding. A later bill, PL 4.815/2024, was approved by the Senate Social Affairs Committee in May 2026 and was heading to presidential sanction unless appealed; its final status and training criteria were not found [uncertain]. [source: Parecer Cofen 19/2024; Rádio Senado 21/05/2026]
Nurses: Cofen Resolução 739/2024 lets nurses practise art therapy "desde que capacitados" (provided they are trained), with a minimum of 120 hours for free courses. [source: Parecer Cofen 19/2024]
Recording eligibility is broader than professional eligibility. The SUS procedure Sessão de Arteterapia can be recorded under about 50 occupation codes, including Arteterapeuta (2263-10), psychologists (2515-10 and others), nurses, occupational therapists, physicians, social workers, physical-education professionals, nursing technicians and community health agents. Sessão de Musicoterapia has a parallel list that includes Musicoterapeuta (2263-05) but not Arteterapeuta. [source: Portaria SAS 145/2017] How the 2017 music-therapy list fits with the 2024 law's limits on who may practise as a music therapist was not found in sources [uncertain]. Practical reading: being allowed to record a code does not make a psychologist or nurse an art or music therapist [synthesis].

Stage B. Service set-up and recording.

Procedure codes: 01.01.05.006-2 Sessão de Arteterapia and 01.01.05.008-9 Sessão de Musicoterapia. Both are outpatient (ambulatorial) procedures, individual or group, for both sexes and all ages, recorded on BPA Individualizado, under Atenção Básica and PAB financing, with a table value of R$ 0,00 (no specific fee). [source: Portaria SAS 145/2017]
In APS, PICS are recorded in SISAB through e-SUS APS forms or the PEC electronic record; both codes are on the collective-activity code list. Specialised outpatient care uses SIA (BPA); establishments that offer PICS register service class 134 in CNES. Neither code is in the medium- and high-complexity (MAC) funded table. NASF teams are now eMulti teams (Portaria GM/MS nº 635/2023). [source: Relatório 2024]
Scale: in 2023 PICS were recorded in 4,640 municipalities (83%) and 18,970 establishments; practice-level data for art and music therapy are on pp. 138 and 182 of the report, not drawn on [uncertain]. [source: Relatório 2024]
Materials and instruments are often not funded: in the CAPS AD and UBS reports, residents bought supplies and brought their own guitar and speaker, and one programme ended for lack of funds. [source: Siqueira & Rodrigues 2023; Vale et al. 2021]

Stage C. Referral and entry. Sources describe three entry routes: open groups in primary care (for example a UBS waiting room, joined freely); group offers inside a CAPS for its registered users; and moving a user from a general arts workshop into an art therapy group when the team judges it useful. [source: Vale et al. 2021; Siqueira & Rodrigues 2023; CAPSi Maringá account] For music therapy, intake can include a ficha musicoterapêutica, an anamnesis of the client's musical history and the music they know. [source: Nascimento 2020] Formal referral criteria are not published in the sources [uncertain]. Referral through the service's care plan, and screening for the cautions in section 5, are my recommendations [synthesis].

Stage D. Session cycle. Formats found:

UBS open art group: 4 sessions, about 40 minutes each, every 15 days, 5–10 people. [source: Vale et al. 2021]
Art therapy workshops for health workers (SES-DF integrative-practices management): sessions Tuesday to Friday at lunchtime for a month, each in four phases (theme and sensitisation, free or guided art-making, showing the work and dialogue, closing reflection). [source: Santos & Gonçalves 2023]
CAPSi art therapy group: 34 sessions, compared with an arts workshop over the same period. [source: CAPSi Maringá account]
CAPS AD III music group: about 18 one-hour meetings over about five months (introductions, three songs with reflection after each, closing talk and song requests). [source: Siqueira & Rodrigues 2023]
Music therapy session shape: hello song, then improvisation, composition, parody or pre-selected songs, then goodbye song. [source: Nascimento 2020]

No source gives a standard session count. Criteria for moving on are not published. I suggest [synthesis]: move from an open or short group to a closed, longer art or music therapy group when the person attends regularly and wants deeper personal work, and the team agrees this fits their care plan; step down to an arts workshop or community activity when the goals are mainly social contact and leisure.

Stage E. Review, discharge and network work. The CAPSi team does matriciamento (shared-care support) with UBS, schools and juvenile-justice units, sharing activities and interventions. Participants' collected artworks were returned to them at the end of the SES-DF workshops. [source: CAPSi Maringá account; Santos & Gonçalves 2023] Structured outcome review is absent from the reports; add a brief review against the person's own goals at set points and at discharge, and record it in the shared care plan [synthesis].

3. Guiding principles

These are PICS inside SUS, not stand-alone treatment. They complement the person's care in the network. Practical meaning: coordinate with the reference team; never replace psychiatric, psychological or medical care. [source: Portaria 849/2017, Art. 2; synthesis]
Integral, humanised, bond-building care. Sources stress welcome (acolhimento), qualified listening and building a bond with the service. Practical meaning: the relationship and the person's ongoing link to the service count as outcomes in themselves. [source: Vale et al. 2021; posuscs page; Siqueira & Rodrigues 2023]
Art therapy is not an arts workshop. A CAPSi art therapist contrasts art therapy (focused on expressing inner content and working with symbols with the client) with arts workshops (focused on the finished product). Practical meaning: name which one you are offering, and record and supervise it accordingly. [source: CAPSi Maringá account]
Music activity is not music therapy. Lei 14.842/2024 defines who may practise as a music therapist. Singing groups run by other staff are music activities. Practical meaning: if you are not legally a music therapist, call your group a music workshop or activity and refer to a music therapist for therapeutic goals. [source: Lei 14.842/2024; synthesis]
Practise within your own competence and council rules. Recording permission is not training. Practical meaning: a psychologist, nurse or occupational therapist offering art-based work should hold specific training and follow their own professional council's rules (for nurses, Cofen Resolução 739/2024). [source: Parecer Cofen 19/2024; Portaria SAS 145/2017; synthesis]
The client's meaning comes first. The CAPSi account describes helping the patient interpret their own symbols, and argues that public exhibition of patients' work can conflict with respect for their subjectivity. Practical meaning: invite the maker's associations rather than reading the work for them; display only with explicit consent. [source: CAPSi Maringá account]
Artwork and music are not diagnostic evidence. No source here validates art or musical products as diagnostic tools. Practical meaning: do not infer abuse or disorder from images or music; record what the person said and did. [synthesis]
Client-chosen music and culture. In the CAPS AD group users chose songs (sertanejo, gospel and MPB were the most requested). Practical meaning: build the repertoire with participants, not around the facilitator's taste. [source: Siqueira & Rodrigues 2023]
Equity and low cost. Services are often in low-income areas with scarce materials. Practical meaning: plan with cheap, recycled or natural materials, and budget through the service before you start. [source: Vale et al. 2021; Santos & Gonçalves 2023]
Accurate, honest claims. Sources report qualitative impressions only. Practical meaning: describe benefits to users and managers in modest terms, and collect simple outcome data. [source: Section 1 sources; synthesis]

4. Intervention inventory

The policy itself names no techniques. The procedures below are those described in SUS policy texts and SUS practice reports; step-by-step detail beyond what a report describes is marked [synthesis]. Example language is my own illustrative wording, given in English with a Portuguese version (my translation), unless quoted.

4A. Service-level procedures

Recording an art or music therapy session in SUS

Purpose / when: Every session, so the practice is visible in national monitoring and in the person's record. [source: Portaria SAS 145/2017; Relatório 2024]
Steps: (1) Check your CBO code is on the list for the procedure (Section 2, Stage A). (2) In APS, record in e-SUS APS (collective-activity form for groups, or the PEC record) using 01.01.05.006-2 Sessão de Arteterapia or 01.01.05.008-9 Sessão de Musicoterapia. (3) In specialised outpatient services, record on BPA Individualizado (SIA). (4) Make sure the establishment's CNES lists the PICS service class 134. [source: Portaria SAS 145/2017; Relatório 2024] (5) Add a short clinical note (attendance, what the person made or played, what they said, risk observations, plan). [synthesis]
Example language: (illustrative, to a manager) "Each group session is recorded as 01.01.05.006-2 so it appears in SISAB." / "Cada encontro é registrado como 01.01.05.006-2 para aparecer no SISAB."
Watch for: Practice not appearing in reports because staff record it as a generic group or under a code their CBO is not linked to. The codes carry no fee (R$ 0,00), so materials need a separate budget. [source: Portaria SAS 145/2017; synthesis]

Intake and musical/creative history

Purpose / when: At entry to music therapy or a closed art therapy group, to learn the person's relationship with music or art and fit the offer to them.
Steps: For music therapy, take a ficha musicoterapêutica, an anamnesis that identifies music the client knows. [source: Nascimento 2020] Ask also about music or images linked to painful events, hearing problems, sound sensitivity, and preferences or dislikes; for art, ask about past experiences of art-making, materials the person dislikes or is allergic to, and fine-motor limits. [synthesis] The standard content of the Brazilian ficha was not found [uncertain].
Example language: (illustrative) "Which songs have been with you through your life? Is there any music you'd rather we didn't use here?" / "Que músicas acompanharam sua vida? Tem alguma música que você prefere que a gente não use aqui?"
Watch for: The CAPS AD report notes that people with a poor relationship with music, or who were very discouraged, did not join. Ask about this at intake rather than assuming everyone likes music. [source: Siqueira & Rodrigues 2023]

Matriciamento (shared-care support) with primary care and schools

Purpose / when: When a CAPS team supports UBS, schools or other services by sharing arts-based activities and interventions. [source: CAPSi Maringá account]
Steps: [synthesis] (1) Agree the question with the partner team (for example, a group for anxious adolescents at a UBS). (2) Co-facilitate one or two sessions to show the method. (3) Leave a written plan with materials list, session phases and safety points. (4) Agree who the partner staff contact for difficult moments, and when to refer to the CAPS.
Example language: (illustrative) "We'll run the first two meetings together; after that you lead and I'll come to supervision once a month." / "Fazemos juntos os dois primeiros encontros; depois vocês conduzem e eu venho para a supervisão uma vez por mês."
Watch for: Partner staff copying techniques without the therapeutic frame. Be clear what they can safely run as an arts workshop. [synthesis]

Moving a user from an arts workshop into art therapy

Purpose / when: When a CAPS user in a product-focused workshop would benefit from personal symbolic work. The CAPSi account describes a selectively mute patient who moved from workshop groups into an art therapy group and then spoke and wrote more. [source: CAPSi Maringá account]
Steps: [synthesis] Discuss with the reference professional; explain the difference to the user and family; agree goals; start in a closed group or individually; review at agreed points.
Example language: (illustrative) "In the workshop the focus is on what you make. In art therapy we also look together at what your pictures say to you." / "Na oficina o foco é o que você produz. Na arteterapia a gente também olha junto o que os seus desenhos dizem para você."
Watch for: Loss of a valued social group; keep the workshop available alongside if the person wishes. [synthesis]

4B. Art therapy formats and techniques

Four-phase art therapy workshop

Purpose / when: A standard session shape for groups, used in SES-DF integrative-practices workshops. [source: Santos & Gonçalves 2023]
Steps: (1) Present and set the theme, with group sensitisation (themes used included ancestry, self-knowledge, self-care, social stigma, insecurity, anxiety management and affectivity). (2) Art-making, free or guided by the facilitator. (3) Each participant shows their work, followed by dialogue among participants. (4) Closing and reflection on the meeting. [source: Santos & Gonçalves 2023] Timing suggestion: about 10/25/15/10 minutes in a one-hour session [synthesis].
Example language: (illustrative) Opening: "Today's theme is self-care. Take a moment to notice how you arrived." Sharing: "Would you like to tell us about your piece? Only what you want to share." / "Quer contar sobre o seu trabalho? Só o que você quiser compartilhar."
Watch for: Themes such as stigma or ancestry can stir strong feeling; keep the closing phase even when time is short. Working: participants in the report described feeling "mais despreocupadas" (less worried) after sessions. [source: Santos & Gonçalves 2023]

Free or guided painting

Purpose / when: Basic expressive work for any age; used in UBS and SES-DF groups (canvas, gouache, watercolour, brushes, paper). [source: Vale et al. 2021; Santos & Gonçalves 2023]
Steps: [synthesis] Lay out a limited palette; offer either a free choice or one prompt (for example "a place where you feel safe"); give a time signal before the end; invite a title; move to sharing.
Example language: (illustrative) "There's no right way to do this. You can start with a colour that catches your eye." / "Não existe jeito certo. Você pode começar por uma cor que chame sua atenção."
Watch for: Embarrassment about skill. It is working when the person engages for longer and talks about the work in their own words. [synthesis]

Natural and organic materials

Purpose / when: Low-cost sensory work; the SES-DF workshops used coffee powder, earth, kale extract, clay and water. [source: Santos & Gonçalves 2023]
Steps: [synthesis] Prepare the materials ahead; cover tables; offer gloves; give a simple prompt such as painting with earth tones; allow time for washing up.
Example language: (illustrative) "These colours come from coffee and earth. Notice how they feel on the paper." / "Essas cores vêm do café e da terra. Repare como elas ficam no papel."
Watch for: Allergies; clay dust (wet-clean, do not sweep dry clay); cuts; food materials around people with eating difficulties; tactile aversion in autistic or sensory-sensitive users. [synthesis]

Creative letter writing

Purpose / when: Used in the first SES-DF workshops, combining words and image. [source: Santos & Gonçalves 2023]
Steps: [synthesis] Invite a letter to oneself, to a part of oneself or to someone, which will not be sent; decorate or illustrate it; share only if the writer wants to.
Example language: (illustrative) "Write a letter that you won't send. You decide if anyone reads it." / "Escreva uma carta que você não vai enviar. Você decide se alguém lê."
Watch for: Low literacy (offer drawing or dictation instead); grief or risk content (follow up after the session).

Open waiting-room art group (primary care)

Purpose / when: Open, drop-in health-promotion offer in a UBS during the busiest shift. In Rio Branco: 5–10 participants (users, companions, children, some staff), four sessions of about 40 minutes every 15 days. [source: Vale et al. 2021]
Steps: (1) Introduce the project to people waiting. (2) Offer a hands-on activity (session examples: canvas painting; making games from recycled cardboard and bottle caps such as draughts, memory and noughts and crosses; a stress-management talk with breathing practice followed by dream-catcher making; mothers making covers for their children's health booklets, then conversation). (3) Use welcome and qualified listening throughout. [source: Vale et al. 2021] (4) Note anyone who may need follow-up and tell the team. [synthesis]
Example language: (illustrative) "While you wait, would you like to make something with us? You can stop when you're called." / "Enquanto espera, quer fazer alguma coisa com a gente? Pode parar quando for chamado."
Watch for: This is health promotion rather than therapy; people leave mid-activity; privacy in a public space. Do not invite personal disclosure here. [synthesis]

Craft-based making (dream catchers, origami, recycled games, booklet covers)

Purpose / when: Structured, achievable tasks that support motor and cognitive skills, socialisation and bonding. [source: Vale et al. 2021]
Steps: Demonstrate one step at a time; provide pre-cut parts for people with limited dexterity; pair participants. [synthesis]
Example language: (illustrative) "Let's do the first knot together." / "Vamos fazer o primeiro nó juntos."
Watch for: Scissors and sharp tools in mental-health settings (count tools in and out); frustration with fiddly tasks. [synthesis]

Collective story-building, drawing and mime

Purpose / when: Group activities listed in the UBS report (collective story-building, free drawing, mime, origami). [source: Vale et al. 2021]
Steps: [synthesis] One person starts a story or picture; each adds a part in turn; the group gives it a title and talks about it.
Example language: (illustrative) "Add one sentence or one drawing, then pass it on." / "Acrescente uma frase ou um desenho e passe adiante."
Watch for: Dominant members; give everyone a turn and allow passing.

Working with the maker's symbols (CAPS art therapy)

Purpose / when: The core of art therapy as distinct from a workshop: expressing unconscious content and helping the patient interpret symbols such as colours and images. [source: CAPSi Maringá account] Many Brazilian training courses follow a Jungian approach (example: a UBAAT-aligned postgraduate course). [source: posuscs page]
Steps: [synthesis] (1) Let the person describe the work first. (2) Ask open questions about colours, shapes, figures and their relationships. (3) Invite associations to the person's own life. (4) Offer tentative reflections and check them. (5) Keep each piece in a folder and look back over the series at review points.
Example language: (illustrative) "What do you notice when you look at it now?" "If this colour could speak, what might it say?" / "O que você percebe quando olha agora?" "Se essa cor pudesse falar, o que diria?"
Watch for: Imposing your own interpretation; using images as evidence of abuse or diagnosis (do not). Working: autonomy, self-reflection, emotional expression and initiative are the gains the CAPSi account reports. [source: CAPSi Maringá account]

Closing a cycle: returning the collection

Purpose / when: At the end of a cycle. SES-DF participants received their collections, which the authors described as showing progress in self-control and emotional expression. [source: Santos & Gonçalves 2023]
Steps: [synthesis] Lay out the person's works in order; invite them to look at the sequence; ask what has changed; agree whether they take the works home; get written consent before any photograph or exhibition.
Example language: (illustrative) "Looking at all of them together, what stands out?" / "Olhando todos juntos, o que chama sua atenção?"
Watch for: Pressure to exhibit work at events; the CAPSi account argues this can conflict with respecting the patient's subjectivity. [source: CAPSi Maringá account]

4C. Music therapy methods and group music activities

Under Lei 14.842/2024 the four methods below belong to the practice of a music therapist. Non-music-therapists in CAPS or UBS may run singing or listening groups as music activities but should not present them as music therapy. [source: Lei 14.842/2024; synthesis] Brazilian music therapy literature uses Bruscia's four musical experiences: "improvisação, re-criação, composição e audição" (improvisation, re-creation, composition and listening). This is as cited in Nascimento 2020; Bruscia's text is not drawn on, so the step detail below is [synthesis]. Named models taught in Brazil include music-centred, Creative (Nordoff-Robbins), GIM and Analytical music therapy; each requires its own training. [source: Nascimento 2020]

Hearing and space safety for all music work [synthesis]: keep acoustic volume moderate in small CAPS rooms; cap amplified speaker volume; place drums and cymbals away from ears; offer foam earplugs to people who want them; give sound-sensitive or autistic participants a seat near the door and quieter instruments; clean shared wind instruments or keep them for one person only; check instruments for sharp edges.

Hello and goodbye songs

Purpose / when: To mark the start and end of the session, as in the session shape Nascimento describes (hello song, central experience, goodbye song). [source: Nascimento 2020]
Steps: [synthesis] Use a short song that includes each person's name; keep the same songs across sessions for predictability; slow the goodbye song to help people settle before they leave.
Example language: (illustrative) "Let's sing everyone's name in, starting with me." / "Vamos cantar o nome de cada um, começando por mim."
Watch for: People who dislike being named aloud; let them choose a nickname or pass.

Improvisation

Purpose / when: Free or structured music-making with instruments or voice for expression and relating without words. Free improvisation is one of the options in the central part of a session. [source: Nascimento 2020]
Steps: [synthesis] Offer easy instruments (hand drums, shakers, a xylophone); start with a shared pulse; invite a solo, dialogue or "feeling" improvisation; the therapist supports with a harmonic instrument (guitar or piano are mentioned as typical); finish with a clear ending and talk about it.
Example language: (illustrative) "Play how today feels. There are no wrong notes." / "Toque do jeito que o dia de hoje está. Não existe nota errada."
Watch for: Escalating loudness and arousal (bring the group back to a quieter pulse); dissociation or flooding during very free improvisation, especially in psychosis or trauma (use more structure). [synthesis]

Re-creation: singing and playing known songs

Purpose / when: Singing or playing existing songs. This was the core activity of the CAPS AD III group. [source: Siqueira & Rodrigues 2023; Nascimento 2020]
Steps: Group format as reported: participants introduce themselves (facilitators first); facilitators sing three songs they chose, and participants may also choose; after each song participants are asked what they felt and thought; the session closes with open talk, suggestions and song requests for next time. Facilitators rehearsed for one hour before each meeting. [source: Siqueira & Rodrigues 2023] Print large-type lyric sheets [synthesis].
Example language: (illustrative) "What did this song bring up for you?" / "O que essa música trouxe para você?"
Watch for: Shyness at first, since some people found it hard to sing along early on. Progress in the report was more interaction over the sessions. [source: Siqueira & Rodrigues 2023]

Emotion-face cards after each song

Purpose / when: A low-demand way for quiet participants to name a feeling. [source: Siqueira & Rodrigues 2023]
Steps: Make six paper faces on sticks (happiness, sadness, anger, fear, shame, longing); after each song, each person raises the face that fits; invite, without pressing, a word about it. [source: Siqueira & Rodrigues 2023]
Example language: (illustrative) "Raise the face that matches how you feel now. If you want to say why, you can." / "Levante o rostinho que combina com o que você sente agora. Se quiser dizer por quê, pode."
Watch for: A first raised card can be a turning point. In the report one woman raised a card for the first time in the second meeting, later told her life story and asked for a song about her dead son. Have a plan for grief disclosures. [source: Siqueira & Rodrigues 2023]

Composition and parody

Purpose / when: Writing new songs or new lyrics to known tunes (parody), for self-expression and a sense of achievement. [source: Nascimento 2020]
Steps: [synthesis] Choose a familiar tune; brainstorm words about a theme the group chooses; fit the lines to the tune; record the result on a phone only with consent; keep the lyrics with the person's work.
Example language: (illustrative) "Let's write our own verse to this tune: what would you want to say about this week?" / "Vamos criar nossa própria estrofe nessa melodia: o que vocês querem dizer sobre essa semana?"
Watch for: Lyrics about drug use or self-harm. Take them seriously, follow up individually and do not censor them in the group. [synthesis]

Supporting members' own compositions and peer roles

Purpose / when: In the CAPS AD III group, a participant in long-term recovery became a volunteer, performed his own songs (which the group rehearsed and played) and supported peers. [source: Siqueira & Rodrigues 2023]
Steps: [synthesis] Invite the member to share a song; rehearse it as a group; agree a clear volunteer role and limits with the team; review the role if their own health changes.
Example language: (illustrative) "Would you teach us your song next week?" / "Você ensinaria sua música para a gente semana que vem?"
Watch for: Pressure on the peer during their own crisis. In the report he stopped attending during a crisis and returned after active outreach. [source: Siqueira & Rodrigues 2023]

Receptive listening with verbal reflection

Purpose / when: Listening to music, then talking about it. Listening is one of the four experiences, and in the CAPS AD group a reflection followed each song. [source: Nascimento 2020; Siqueira & Rodrigues 2023]
Steps: [synthesis] Agree the track with the person or group; set volume; invite them to notice body, images and memories; talk afterwards. Guided Imagery and Music (GIM) is a separate, trained method; do not improvise it. [source: Nascimento 2020 for GIM as a named model; synthesis]
Example language: (illustrative) "As you listen, notice what you feel in your body." / "Enquanto escuta, repare no que você sente no corpo."
Watch for: Musical trauma triggers. Songs tied to drug use, a violent relationship, a funeral or a religious conflict can trigger cravings, flashbacks or grief. Screen at intake, let anyone veto a track, and stop or change the music at signs of distress. [synthesis]

Client-led repertoire and song requests

Purpose / when: Builds ownership and cultural fit; CAPS AD participants requested sertanejo, gospel and MPB. [source: Siqueira & Rodrigues 2023]
Steps: Collect requests at the end of each session for the next one. [source: Siqueira & Rodrigues 2023] Keep a group song list and screen requests for lyrics that may glorify drug use or harm others in this group [synthesis].
Example language: (illustrative) "What shall we sing next week?" / "O que a gente canta semana que vem?"
Watch for: One person's taste dominating; rotate choices.

Active outreach to absent members

Purpose / when: When a regular stops attending, especially in crisis; outreach brought the volunteer back in the CAPS AD report. [source: Siqueira & Rodrigues 2023]
Steps: [synthesis] Tell the reference professional; contact the person by the agreed route (phone, community health agent, home visit); invite them back without blame.
Example language: (illustrative) "We missed you in the group. The door's open whenever you're ready." / "Sentimos sua falta no grupo. A porta está aberta quando você quiser voltar."
Watch for: Absence as a sign of relapse or risk; follow the service's risk procedures.

5. Handling problems

Problems that SUS sources report are cited. All other responses are my own synthesis [synthesis].

Service and system problems

No materials or instruments. Reported in the CAPS AD and UBS programmes, where residents paid for supplies themselves and one programme ended for lack of funds; there were also bureaucratic obstacles to funding from the CAPS and the Health Secretariat. [source: Siqueira & Rodrigues 2023; Vale et al. 2021] Response: before starting, put a costed materials list into the unit's planning; use recycled and natural materials (as in the reports); ask the municipal PICS coordination about supplies; do not depend on staff's own instruments. [synthesis]
Groups end abruptly (resident rotations, short projects). Several reported groups were run by multiprofessional residents over a few months. [source: Siqueira & Rodrigues 2023; Vale et al. 2021] Response: agree the end date at the start, tell participants, run a planned closing session, and hand over to permanent staff or refer to another offer. [synthesis]
Staff turnover and emotional strain. The CAPSi account reports instructors leaving because of emotional strain and lack of preparation, and the role being undervalued. [source: CAPSi Maringá account] Response: arrange regular clinical supervision, co-facilitation, and induction training before new staff run groups. [synthesis]
Scope confusion: "Can I call this music or art therapy?" Recording lists allow many professions to log sessions, but music therapy is now a regulated profession and art therapy is not yet. [source: Portaria SAS 145/2017; Lei 14.842/2024; Parecer Cofen 19/2024] Response: if you are not a music therapist under Art. 3 of the law, call your offer a music workshop or activity; for art, state your training honestly; refer to a music therapist or trained art therapist for therapeutic goals; check your own council's rules. [synthesis]
Managers want inflated claims. Response: report attendance and participants' own words, and add one brief, free outcome measure agreed with the team; do not claim effects the evidence does not show (Section 1). [synthesis]
Managers want exhibitions of users' work. The CAPSi account argues that display can conflict with respect for patient subjectivity. [source: CAPSi Maringá account] Response: ask for written, specific consent (and the guardian's consent plus the child's agreement for minors); allow withdrawal; anonymise. The UBS report published photographs of creations without describing consent. Do not copy that. [source: Vale et al. 2021; synthesis]

Client-level problems

Low engagement or "I can't draw / I can't sing". Some CAPS AD users did not engage, and some found singing along hard at first. [source: Siqueira & Rodrigues 2023] Response: lower the demand (emotion-face cards, shakers, collage-type tasks, listening); let people join as observers first; say explicitly that skill is not the point. Illustrative: "Just being here counts. Join in when you feel like it." / "Só estar aqui já vale. Entra quando tiver vontade." [synthesis]
Stuck client (same images or songs, no movement). Response: name the repetition gently; offer a new material or one changed element (a different colour or tempo); review the series of works together; check whether the goals still fit; discuss in supervision. [synthesis]
Non-attendance and dropout. Response: active outreach as in the CAPS AD report (Section 4C); agree a contact route at intake; treat sudden absence as a possible sign of relapse or crisis. [source: Siqueira & Rodrigues 2023; synthesis]
Overwhelm, flashbacks or cravings triggered by music or images. Response: stop or soften the stimulus (turn the volume down, switch the song, put the image away); ground the person (feet on floor, slow breathing, naming objects in the room); offer to step out with a co-facilitator; check them before they leave and inform the reference team. Prevent it by screening for trigger songs and themes at intake and keeping a veto list. In CAPS AD, avoid songs that glorify the substance unless they are worked with deliberately in individual music therapy. [synthesis]
Grief or trauma disclosure in a group (for example, the CAPS AD participant who asked for a song about her dead son). [source: Siqueira & Rodrigues 2023] Response: acknowledge it in the group, contain it, offer an individual follow-up the same day, and tell the reference professional. [synthesis]
Rupture through interpretation ("That's not what my picture means"). Response: apologise, return authority to the maker, and ask what it means to them. This matches the client-meaning principle (Section 3). [source: CAPSi Maringá account for the principle; synthesis]
Suicide or self-harm content in art or lyrics. Response: do not treat it as just art; carry out a risk assessment using the service's standard protocol; involve the reference team; safety planning, including means safety (storage and removal), as per service policy. [synthesis]
Psychosis and disorganisation in free improvisation or free art. Response: use structure (a clear pulse, simple forms, one prompt), keep sessions short, and end with a predictable closing song or ritual. [synthesis]
Group dominance or conflict. Response: turn-taking rules, rotating song choice, and naming group agreements at the start. [synthesis]
Physical safety. Response: count scissors and craft knives in and out in CAPS; use non-toxic water-based paints; wet-clean clay; check allergies (latex gloves, food-based materials); keep amplified sound moderate and offer earplugs; leave clear floor space when instruments and cables are out. [synthesis]

Children and adolescents (CAPSi, schools, UBS groups with children)

Children took part in the UBS waiting-room group, and CAPSi practice includes art therapy groups. [source: Vale et al. 2021; CAPSi Maringá account] Response: get guardian consent and the child's own agreement; involve families in the care plan; use age-appropriate materials and shorter sessions; never treat a drawing as proof of abuse. If a child discloses abuse or you suspect it, follow the service's child-protection procedure. Brazilian law requires notifying the Conselho Tutelar; The statute is not drawn on here, so check local protocol [uncertain]. [synthesis]

Privacy in public spaces. Waiting-room groups happen in view of others. Response: keep them to health promotion and creative activity; move any personal disclosure to a private consultation. [synthesis]

Sources

Sources:

Further reading (not drawn on): Bruscia's classification of the four musical experiences, cited only as reported in Nascimento 2020 [uncertain: original]. Portaria GM/MS nº 971/2006, Portaria GM/MS nº 702/2018, Portaria GM/MS nº 635/2023 and Cofen Resolução 739/2024 are cited as described in the sources above, not from their own texts. UBAAT and UBAM own websites and codes of ethics are not drawn on [uncertain].

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