Aesthetics and creativity by David Aldridge

Aesthetics and the body David Aldridge Collected Papers

ALDRIDGE

The Music of the Body: Music Therapy in Medical Settings What strikes me is the fact that in our society, art has become something which is related only to objects and not to individuals, or to life. That art is something which is specialized or done by experts who are artists. But couldn't everyone's life become a work of art? Why should the lamp or the house be an art object, but not our life?

David Aldridge

If w e consider our human biology in terms of musical form rather than mechanical construction and our response to biological challenges as a repertoire of improvisations, w e may find that disease restricts our ability t o improvise new solutions to challenges-in musical terms, restricts our ability to play improvised music.

David Aldridge, Ph.D., is associate professor of clinical research in the Faculty of Medicine at the University of Witten Herdecke in Germany, and the European editor for the journal The Arts in Psychotherapy. He is the coeditor (with George Lewith) of a handbook of clinical research methods for complementary medicine (Hodder and Stoughton 1992).

-Michael Foucault (in Rabinow 1986)

The use of music as a healing agent appears to be common to many cultures. Since David first played to soothe King Saul, there has been the recognition that music can bring relief to the afflicted. That the affliction in Saul's case is usually presented as depression, though it might well have been an acute episode of asthma, only serves to emphasize both the difficulty of historical interpretation and the generalness of reports about music as therapy. An earlier article in Advances, Robert Omstein and David Sobel's "Coming to Our Senses" (19891, reminds the reader of the necessity of enjoying the senses for the promotion of health. This paper goes one step further and presents the use of music as therapy, as it appears in the medical literature during the last decade. (References to psychiatric settings have been excluded.) T h e medical and nursing press contains a series of overviews about music therapy, ranging from letters to full-scale articles. The principle emphasis in this material is on the soothing ability of music and on the value of music as an antidote to an overly technological medical approach (Bailey 1985; Brody 1988; Carlisle 1990; Fischer 1990; Harcourt 1988; Harvey & Rapp 1988; Kartman 1984; McDermit 1984; Morris 1985; Olivier 1986; Ornstein & Sobel 1989; Paren t-Bender 1986; Pouget 1986; Rowden 1984; Stem 1989; Thomas 1986; Wein 1987; Ziporyn 1984). Most of these articles are concerned with what is called passive music therapy-the playing of

ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993

David Aldridge

Aesthetics and the body

ALDRIDGE

Music therapy has been studied as an aid in treating specific medical problems, including coronary care, cancer pain management, and neurological disorders.

usually prerecorded music to patients-and they emphasize the necessity of healthy pleasures like music, fragrance, and beautiful sights in reducing stress and enhancing well-being. Music therapy is actually more varied and more complex. In some methods the patient is indeed a "passive" listener, and live, or recorded music, is played at the discretion of the therapist. But even in this situation, some therapists challenge the term "passive," insisting that listening is an active process. This is supported, for example, by an approach that uses imagery stimulated by selected musical passages (Bonny 1978; Bonny 1975; Ornstein & Sobel1989). Other methods of music therapy consist of or include active playing of musical instruments and singing, individually or in groups. Some of these approaches incorporate musical improvisation as the key component of the therapeutic activity. There is growing evidence to support the claims of music therapists that music can contribute to healing, although the research methodologies used to substantiate such claims often lack scientific rigor or are unconventional in their approach. It is important to emphasize that some music therapists reject quantitative research outright. They believe that such methods discount the important individual and qualitative aspects of their work as artists working in medical settings, and seek to find alternative forms of research suitable to the arts in clinical practice. Some believe that the study of music therapy provides an opportunity to develop expressive quality-of-life measures for people with serious illnesses, measures that are not solely based on verbal reporting (Aldridge 1989c; Aldridge 1991a).

Readers may be surprised to learn that music therapy has been studied as an aid in treating a variety of medical problems, including coronary care, cancer pain management, and neurological disorders. In this article, we shall move from general considerations to specific observations. We begin with the general use of music in hospital settings, and then turn to detailing the use of music therapy to treat particular problems.

Music Therapy in General Medicine For a while after World War I1 music therapy was intensively used in American hospitals in the rehabilitation of the wounded, with the aim of raising their morale and as a relief from the tedium of hospital life (Schullian & Schoen 1948).Psychiatrists were quick to see the benefits of music for enhancing mood and promoting relaxation in their patients. Since then some hospitals, in mainland Europe particularly, have incorporated music therapy within their practice (Aldridge & Verney 1988; Goloff 1981; Jedlicka & Kocourek 1986; McCluskey 19831, carrying on a tradition of European hospital-based research into the use of music as therapy (Leonidas 1981). The postwar European initiatives were concerned with rehabilitation and psychiatry. However, with the development of the perspectives of psychosomatics, and with a growing tolerance of alternative and complementary medical initiatives, music therapy in Europe has been applied to a wide range of medical problems, including cancer care, the treatment of patients with severely compromised immune systems, the management of pain, and the relief of anxiety. The nursing profession in particular has promoted the general value of music therapy, especially in the United States, and, even when music therapists are not available (Cook 1981), has championed its use as an important nursing intervention (Cook 1986; Fletcher 1986; Frandsen 1989; Frank 1985; Glynn 1986; Grimm & Pefley 1990; Keegan 1989; Kolkmeier 1989; Marchette, Main & Redick 1989; Moss 1987; Mullooly, Levin &

David Aldridge

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Feldman 1988; Prinsley 1986; Rice 1989; Sammons 1984; Updike 1990; Walter 1983). At the same time little work has been published about the benefits of music therapy in general medicine. The overall expectation is that the recreational, emotional, and physical health of the patient is improved (Goloff 1981).

Music, t h e H e a r t , and Respiration To explore the specific physiological effects of music, we begin with the effects of music on heart rate and blood pressure in healthy people. If music can influence such physiological parameters in healthy individuals, the findings would support the possibility that music can be used therapeutically for patients who have problems with heart disease or hypertension. As we consider studies in this area, we shall be led to examine the different conceptualizations of time and their possible relation to health and disease. The effects of music on the heart and blood pressure have been a favorite theme throughout history. We can trace the medical study of such effects to an early issue of The Lancet. In 1929, two researchers (Vincent & Thompson 1929) made an attempt to discover the effect on blood pressure of listening to music on the gramophone and radio. Subjects were divided into "musical," "moderately musical," and "nonmusical" groups. The criteria for musicality were not defined, except to mention that the ideal "musical" group were "interested amateurs of good taste and emotional susceptibility, who can, and habitually do, enjoy music in a naive manner without the exercise of too much critical f.iculty." People with varying degrees of musical competence responded differently to volume, melody, rhythm, pitch, and type of music. Melody produced the most marked effect. When the music began, a rapid fall in blood pressure occurred in the "musical" subjects. However, during the music, a change in melody, particularly if the music was soft, resulted in a rise in blood pressure. Volume also produced an apparent, although less ADVANCES, The]ournal of Mind-Body Health

David Aldridge

If music can influence physiological conditions like heart rate or blood pressure in healthy people, then perhaps i t can be used therapeutically t o help patients with heart disease or hypertension.

marked, effect in the least musical groups. In general, listening to music was accompanied by a fall in blood pressure when the music began. However, during the music, blood pressure rose slightly in correlation with changes in melody, rhythm, pitch, and volume, according to the musical susceptibility of the listener. . M o r e recently, in 1972, a valuable paper by Bason and Celler (1972) found that the human heart rate could be varied over a certain range by synchronizing the sinus rhythm-that is, the normal heart rhythmwith an external auditory stimulus. An audible click was played to the subject at a precise time in the cardiac cycle. When the click occurred within a certain range of the cycle, the heart rate could be increased or decreased up to 12 percent in a period of 3 minutes or less. Fluctuations in heart rate caused by breathing remained, but these tended to be less when the heart was entrained with the audible stimulus. When the click was not within the appropriate range of the cardiac cycle, no change would occur. Bason's paper is important for supporting the proposition often made by music therapists that meeting the tempo of the patient is the initial key to therapeutic change. An extension of this premise, that musical rhythm is a pacemaker, was investigated by Haas and her colleagues (Haas, Distenfeld & Axen 1986). In this study, the researchers examined the effects of musical rhythm on the respiratory pattern, a pattern that serves both metabolic and behavioral functions. Metabolic respiratory pathways are located in the lower pons and medulla, whereas the behavioral respiratory pathways are located mainly

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in the limbic forebrain structures which lead to vocalization and complex behavior. There appear to be so-called pattern generators in the brain and spinal cord capable of synchronizing metabolic and locomotor activity, thereby reinforcing an underlying unconscious rhythmic relationship between the two. Because there are metabolic consequences of active music making inseparable from neural activity, the researchers chose listening to music as the stimulus condition. Haas hypothesized that the external musical activity would have a direct influence as a pacemaker on respiratory patterns but would have only minimal effect in itself on metabolic changes and afferent stimuli-that is, would not induce any gross motor movements. Twenty subjects were involved in this experiment. Four were experienced and practicing musicians, six had formal musical training but no longer played a musical instrument, and the remaining ten had no musical training. The subjects first listened to a metronome set at 60 beats per minute and tapped to that beat on a microphone after a baseline period. The subjects were then randomly presented five stimulus conditions: four musical excerpts to which they also t a p ped along, and one period of silence. Respiratory data, including respiration frequency and airflow volume, were collected, along with heart rate and carbon dioxide released at the end of the breath, to measure gross metabolic changes and chemical respiratory drive. The researchers found no appreciable changes in heart rate during the experiment indicating metabolic changes. But they also found that breathing was coordinated with the musical rhythm, expressed in the finger tapping. For nonmusically trained subjects there was little coordination between breathing and musical rhythm, while for trained musicians there was a tighter coupling of breathing and rhythm. The Haas study, then, suggests that motor activity-finger tapping here-and respiration can be synchronized by an external musical rhythm. This finding fits related findings in other studies-that muscle activity decreases when one performs a motor task accompa20

David Aldridge

nied by a musical rhythm similar to the rhythm of the subjects' normal heart rate (Safranek, Koshland & Raymond 1982); that respiratory rhythm follows the rhythm of music within certain limits of variability (Diserens 1920); and that, perhaps most intriguingly, there is a relationship between disturbed functional cardiac a r r h y t h m i a s with disturbed respiration-and musical rhythmic ability (Richter & Kayser 1991). I n the last study, the researchers Kayser and Richter hypothesized that patients with cardiac arrhythmias perform worse in perceiving and producing rhythm than do healthy controls. Thirty-one patients with functional cardiac arrhythmias were compared with 31 control subjects. Subjects were required to mark on a sheet of paper rhythmic patterns played for them on a tape recorder, and to tap synchronously with repeating patterns on the tape recorder. Patients with dysrhythmias had significantly poorer abilities in musical perception and rhythmic anticipation than healthy controls. Patients with a rapidly beating heart (tachycardia) showed a particularly poor sense of rhythm perception and synchronization.

Time and the Musical Expression of Disease Studies such as this support the hypothesis that people with disease may perceive, and respond to, music differently than do healthy people. It may be that different diseases differently affect the responses we have to music. If we consider our human biology in terms of musical form rather than mechanical construction and our response to biological challenge as a repertoire of improvisations, we can view disease as a restriction of our abilities to improvise new solutions to challenges-in musical terms, a restriction of our abilities to play improvised music (Aldridge 1989a, Aldridge 1991~). In regard to heart disease, for example, it is entirely possible to describe the differences in Type A and Type B behavior in musical language, suggesting that the Type A behavior, said to constitute a risk factor for

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Table 1 Musical Elements in Contrasting Characteristics of Type A and B Behavior Type A Behavior

Type B Behavior

Musical Components

increased voice volume fast speech rate short response latency emphatic voice hard metallic voice less mutuality trying to keep control increased reactivity increased heart rate higher cardiovascular arousal maintained

voice quieter slower speech rate longer response latency less emphasis melodic voice increased mutuality less need for control moderate reactivity decreased heart rate cardiovascular arousal returns to lower level

volume tempo phrasing expression/articulation timbre musical relationship musical relationship responsive tempo dynamic

The table lists the contrasting characteristics of Type A and B behavior end then identifies the musical element that one could ascribe to such characteristics. Is the behavioral disturbance of heart disease something like a disruption of musical patterns? Could music therapy be used to help regulate such disturbances?

heart disease, may express a repertoire of body response which is "musically limited." Table 1 identifies the musical components in the contrasting traits that distinguish Type A and B behavior. The Type A behavior pattern has been characterized as an expression of the way in which an individual responds to, and provokes, environmental demands. Helman (1987) refers to this view of the cause of heart disease as a cultural construction that involves the "unique social and symbolic characteristics of Western time." In this view, we are "the embodiment (both literally and figuratively) of the values o f . . . Western society." The individual is caught in the contradictions of selfdemand and societal demand, which for some people may become pathogenic. At the center of this cultural construction is the notion of time. The predominant form of Western time is monochronic. Time is conceived as an external order imposed on the individual. Such a view developed from the need of a modem industrialized society to have a universal public order by which the means of production could be coordinated

and the actions of many individuals regulated. In this form, deadlines have to be met, the passage of time is linear, and its measurement is quantitative. This is time as chronos, and the concept is contained in the idea of chronic illness. However, there is an alternative conccptualization of time that is personal rather than public. This is time as hiros. It is polychronic, and closer to the emerging biological understanding of physiological times that are rhythmically entrained (Johnson 19861, not to an external clock, but to the person as a whole organism. In this conceptualization, time is in a state of flux; it is concerned with flexibility and the convergence of multiple tasks. Time is seen as springing from the self. We may have to consider the idea of heart disease as a kairotic illness where personal biological time is out of step with external imposed time. Some authors do indeed suggest that when we try to impose a fusion between external clock time and personal physiological time, our physiology is affected (Dossey 1982, Helman 1987). Helman writes:

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Aesthetics and the body

ALDRIDGE

Western society is unique in trying to impose a fusion between clock time and individual physiology-between rates of bodily movement, speech, gestures, heartbeat, and respiration-and the small machine strapped to the wrist or hung on the wall. "Rush hour," deadlines, diaries, appointments, and timetables all affect the physiology of modem [people], and help construct hidher world view and sense of identity.

In music therapy there are possibilities to experience these varying aspects of time as they converge in their seamless reality. The tension between personal and public time may be heard when improvised music is played in music therapy. Apart from stimulating experiences that differentiate and develop those conceptualizations, music therapy may promote an experience of a timeless qualitative reality essential in particular to the recovery of patients with heart disease.

Relieving Anxiety and Stress in Cardiac Patients Now we turn to the direct use of music in coronary care.* Several authors have investigated the relationship between heart rate and anxiety in the settings both of hospital care (Bolwerk 1990; Bonny 1983; Davis-Rollans & Cunningham 1987; Gross & Swartz 1982; Guzzetta 1989; Philip 1989; Wein 1987; Zimmerman, Pierson & Marker 1988) and of dentistry (Lehnen 1988).The intent usually has been to reduce anxiety in chronically ill patients or to treat anxiety in general (Chetta 1981; Daub & Kirschner-Hermanns 1988; Fagen 1982; Gross & Swartz 1982; Heyde & von Langsdorff

*The relationshipbetween listening to music and changes in respiration has been investigated in various situations other than coronary carewith college-student subjects (Formby et al. 19871, psychotherapy patients (Fried 19901, various chronic illness groups undergoing group psychotherapy (Gross & Swartz 1982), orthopaedic and abdominal surgery patients (Lehmann, Horrichs & Hoeckle 1985), chronic lung disease patients (Tiep et al. 1986), and in a study of mental stress and exercise (Brody 1988). 22

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1983; Lengdobler & Kiessling 1989; Schmuttermayer 1983; Standley 1986; Zimmerrnan et al. 1989). A hospital situation fraught with anxiety for the patient is the intensive care unit. For patients who have suffered a heart attack, and whose heart rhythms are potentially unstable, the setting of the coronary care unit is itself likely to be anxiety provoking, an experience that may reinforce the physiological and psychological reactions that initially led to the cardiac distress of the patient. Several authors have assessed the use of tape-recorded music delivered through headphones to reduce anxiety and so reduce stress (Updike 1990) in patients in intensive or coronary care clinics. Bonny has identified a series of musical selections for tape recordings that she believes has sedative effects (Bonny 1983; Bonny & McCarron 1984; Bonny 1975) and also selections that can induce relaxation and help the patient engage in imagery (Bonny 1978),but none of these assertions has been empirically confirmed. However, Updike (19901, in an observational study, supports Bonny's impression that there is a decreased systolic blood pressure, and a beneficial mood change from anxiety to relaxed calm, when sedative music is played. Davis-~ollans(Davis-Rollans & Cunningham 1987) describes the effect of a 37minute tape of selected classical music on the heart rate and rhythm of 24 coronary care unit patients. (The selections consisted of the first movement of Beethoven's Symphony No. 6, the first and fourth movements of Mozart's Eine klein Nachtmusik, and Smetana's The Moldau.) Twelve of the patients had had heart attacks and another 12 had a chronic heart condition. Patients were exposed to two randomly varied &?-minuteperiods of continuous monitoring, one period with music delivered through headphones, the other a control period without music during which the background noise of the unit was heard through the headphones. The heart-attack and chronic-heart-condition patients showed no differences. Eight patients reported a significant change to a happier emotional state after listening to the music (a result replicated in

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Figure 1 Emotional State of 24 Cardiac Patients Before and After Listening to Music Selections (12 patients with heart attacks, 12 with chronic heart conditions)

tranquil

happy satisfied

worried

sentimental romantic

sad depressed

both happy, satisfied and tranquil

other

The shifts in feelings occurred from listening to music over headphones. There were no significant differences between the responses of the patients who had heart attacks and the patients who had chronic heart conditions. No changes in feelings were produced by the control intervention of listening to the background noise of the coronary care unit over headphones.

Updike's observational study [Updike 1990]), although there were no significant changes in specific physiological variables during the music periods. Relevant here is the argument bv Cassem and Hackett (1971) that relieving depression is beneficial to the overall status of coronary care patients. Figure 1 displays the various emotional shifts in the patients that appeared after listening to the music. A study by Guzzetta (1989) sought to determine whether relaxation and music were effective in reducing stress in patients admitted to a coronary care unit with the presumptive diagnosis of acute myocardial infarction. In this experimental study, 80 patients were randomly assigned to a relaxation, music therapy, or control group. The relaxation and music therapy groups participated in three sessions over a two-day period. The relaxation group received a tape-recorded relaxation induction. The music therapy group received the relaxation induction and a 20minute musical tape selected from three alternative musical styles (soothing classical music, soothing popular music, and nontradi-

tional music defined as "compositions having no vocalization or meter, periods of silence, and an asymmetric rhythm"). Stress was evaluated by peak (apical) heart rates, peripheral temperatures (low in cardiac patients), cardiac complications, and qualitative data. T h e data revealed that lower apical heart rates and raised peripheral temperatures occurred more often in the relaxation and music therapy groups than in the control group. The incidence of cardiac complications was also lower in the intervention groups. Finally, most intervention subjects believed that such therapy was helpful. Thus, both relaxation and music therapy were found to be effective modalities of reducing stress in these patients, with the combination of relaxation and music listening more effective than relaxation alone. It should be noted further that apical heart rates were lowered in response to music over a series of sessions, thus supporting the argument that the effect of music therapy on physiological parameters occurs over time, and is therefore adaptive.

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The positive finding of this study is in contrast to the failure of Zimmerman and colleagues (Zimmennan, Pierson & Marker 1988) to find an influence of music on heart rate, peripheral temperature, blood pressure, or anxiety. However, Zimmerrnan's study allowed for only one intervention of music.

reasons for this overall reduction in anxiety may have been that after four days the I situation had become less acute, the setting had become more familiar, and the fact that by then a diagnosis had been confirmed. , In all these studies patients listened to , music (or other sounds), and in thiscontext it is relevant to recall the different possibilities suggested by earlier-noted studies in which Zimmennan examined the effects of people in effect become the music makers. listening to relaxation-type music and focused on self-reported anxiety and on selected phys- , In the study by Bason and Celler (1972), the researchers influenced heart rate by first iologic indices of relaxation in patients with suspected myocardial infarction. Seventy-five , matching the heart rates of their subjects with a musical rhythm. This finding suggests that patients were randomly assigned to one of in studies on the influences of music on heart two experimental groups-one group listened to taped music over headphones, the other to ' rate, the music should match the individual patient. Matching also makes psychological "white noisef'*-or to a control group. The sense, since different people have varied reacSpielberger State Anxiety Inventory (Spieltions to the same music. Further, because berger 1983) was administered before and improvised music necessarily "meets" the after each testing session, and blood pressure, tempo of the patient, it may be that such heart rate, and digital skin temperatures were playing will have a larger impact than does measured at baseline and at 10-minute inter"passive" listening to music. vals for the 30-minute session. The study The finding of Haas and colleagues revealed no significant difference among the three groups in state anxiety scores or phys(19861, that listening coupled with tapping synchronizes respiration pattern with music iologic parameters. Analyses were then conrhythm, additionally suggests that active ducted of the combined experimental groups music playing can be used to influence and showed that significant improvement physiological parameters and that this synoccurred in all of the physiologic parameters. This finding reinforces the benefit of rest and chronization can easily be developed (Aldcareful monitoring of patients in the coronary ridge 1989a). care unit, but adds little to the understanding of music interventions. Bolwerk (1990) set out to relieve the Cancer Therapy, Pain state anxiety of patients in a myocardial inManagement, farction ward using recorded classical music and Hospice Care (Bach's Largo, Beethoven's Largo, Debussy's Prelude to the Afternoon of a Faun). Forty adults Cancer and chronic pain can require comwere randomly assigned to two equal groups, plex coordinated resources that are not only one of which listened to relaxing music medical but also psychological, social, and during the first four days of hospitalization, communal (Aldridge 1988; Coyle 1987; Fagen the other of which received no music. There 1982; Frampton 1986; Frampton 1989; Gilbert was no controlled "silent condition." While , & von Langsdorff 1983; Walter 1977; Heyde there was a significant reduction in state anxi- I 1983). Hospice care in the United States and ety in the treatment group, state anxiety also England has similarly attempted to meet the fell comparably in the control group. The need for the varied palliative and supportive services that provide physical, psychological, "White noise" or "synthetic silence" is an attempt and spiritual care for dying persons and their to block out environmental noise. In this case it was families (Aldridge 1988; Coyle 1987; Frampa tape recording of sea sounds, which themselves ton 1986; Heyde & von Langsdorff 1983; Jacob were rhythmic (Philip 1989; Zimmennan 1989). l

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1986). In all these settings, supportive services In a study of chronic pain, patients are based upon an interdisciplinary team of playing self-selected tape-recorded health care professionals and volunteers. music reported not only a reduction Music therapy is sometimes included in the emotional experience of in such services. In the Supportive Care Program of the suffering but also a reduction in Pain Service to the Neurology Department the actual sensation of pain. of Sloan-Kettering Cancer Center, New York, a music therapist was part of the supportive team along with a psychiatrist, nurse-cliniaan, neuro-oncologist, chaplain, and social actual physical sensation of pain, according to worker (Bailey 1983; Coyle 1987). Music the patients, was also reduced. This would therapy was used to promote relaxation, to reduce anxiety, to supplement other pain appear to confound the common belief that control methods, and to enhance commumusic therapy primarily induces qualitative nication between patient and family (Bailey emotional experiences and to support the 1983,1984,1985). Depression was a common contention that music therapy can have a feature of the patients in the program, and direct influence upon sensory parameters. music therapy was thought to relieve this In addition to reducing pain, particustate and enhance the patient's quality of life. , larly in pain clinics (Godley 1987; Locsin 1981; A better researched phenomenon is Wolfe 19781, music has been offered during the use of music to control chronic cancer chemotherapy as a form of relaxation and pain, in studies that usually favor tapedistraction (Kammrath 1989) to bring overall recorded interventions rather than the element of live performance. Combinations of 1 relief (Kerkvliet 1990) and to reduce nausea and vomiting (Frank 1985). Using taped pharmacological and nonpharmacological music and guided imagery in combination pain management are acceptable in modem with pharmacological antiemetics, Frank medicine (McCaffery 1990), with nonphar(1985) found that state anxiety was signifimacological interventions generally being cantly reduced, resulting in less vomiting used as a form of distraction. even though the experience of nausea re, mained the same. Although Frank's study This is the approach of a study by Zimmerman and colleagues (Zimmerman, was not controlled, leading to the possibility 8 that the reduced anxiety may have been due Pozehl, Duncan & Schmitz 1989) who investo the natural fall in anxiety levels at the end tigated whether playing self-selected taped 1 of a chemotherapy treatment, the study music combined with suggestions of relaxconsisted of patients who had previously ation, affected patients suffering with chronic pain. The study sought to determine from , experienced chemotherapy and who were self-reports whether the music provided 1 conditioned to experience nausea or vomiting additional relief to patients receiving pain 1 in conjunction with chemotherapy. That the subjects of the study felt relief and vomited medication. In both the experimental and the less is an encouraging sign in the use of music control groups, the blood level of analgesic was controlled. Music was found to decrease 1 therapy in minimizing the distressing effects 1 of chemotherapy. the overall level of the pain experience as In the control of pain, time to listen, reported by patients randomly assigned to the l ,l separated from the surrounding influence of music treatment group. Furthermore, there I the hospital unit by the use of headphones, was a significant reduction in the sensory, as may itself be an important intervention. This well as the affective, component of the pain as may be the underlying import of a study by measured by the McGill Pain Questionnaire Rider (1985) who found that perceived pain (Melzack 1975)-that is, not only was sufferl ing as an emotional experience reduced, the 1 was reduced in a hospital situation in reI

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Music appears t o be a key in helping patients w i t h seemingly hopeless neurological devastation regain their "lost" language capabilities.

In infants the ability to reciprocate the communication of another person is an important I element in communicative competence (Murray & Trevarthen 1986; Street & Cappella 19891and is vital in acquiring speech (Glenn & Cunningham 1984). Music therapy strate1 gies for neurologically damaged adults I attempt to utilize the same processes of reciprocation with the expectation that they will stimulate those brain functions that support, precede, and extend functional speech recovery, for these brain functions are essentially musical and rely upon brain plasticity. Combined with the ability to enhance word retrieval, music can be used to improve breath capacity, encourage respiration-phonation patterns, correct articulation errors caused by inappropriate rhythm or speed, and prepare the patient for articulatory movements. In this sense music offers a sense of time which is not chronological, which is not accessible to measurement, and which is vital in the coordination of human communication (Aldridge 1989a; Aldridge 1991~). Jacome (1984) tells of a stroke patient who was dysfluent and had difficulty finding words. Yet, he writes, the patient I

sponse to classical music delivered through headphones. It could be concluded from his work that isolation from environmental sounds, canceling out external noise, has a positive benefit for the patient regardless of inner content, whether the alternative is music, relaxation induction, or silence.

Neurological Problems Neurological diseases often result in physical and/or mental impairment, and in many cases their abrupt appearance are traumatic for the patient and his or her family (Jochims 1990). Music appears to be a key in recovering former capabilities, language capabilities especially, in what at first can seem like hopeless neurological devastation (Aldridge 1991b; Jones 1990; Sacks 1986). For some patients with brain damage following head trauma, the problem may be the temporary loss of speech (aphasia). Music therapy can play a valuable role helping a person regain his or her speech (Lucia 1987). Melodic Intonation Therapy has been developed to fulfil1 such a rehabilitative role (Naeser & Helm-Estabrooks 1985; 0'Boyle & Sanford 1988).This therapy involves embedding short propositional sentences into simple, often repeated, melody patterns to which patients tap their fingers. Changes of inflection, pitch, and rhythm in the melodies are selected to parallel what would be the natural speech prosody of the chosen sentence. The therapy stimulates articulation, fluency, and the shaping procedures of language, all of which are akin to musical phrasing, and this encourages the singing of familiar songs. Singing within a context of communication motivates a patient to communicate and thus promotes, it is hypothesized, the act of intentional verbal behavior.

David Aldridge

frequently whistled instead of attempting to answer with phonemes.. . he spontaneously sang Spanish songs without prompting with excellent pitch, melody, rhythm, lyrics, and emotional intonation. He could tap, hum, whistle, and sing along. . . . Emotional intonation of speech [prosody], spontaneous facial emotional expression, gesturing, and pantomirnia were exaggerated.

From this case study Jacome goes on to recommend that singing and musicality in aphasics be tested by clinicians, which Morgan recommended in a case of aphasia 1 following stroke (Morgan & Tilluckdharry 1982) Evidence of the possible global strategy of music processing in the brain-the possibility that both brain hemispheres are involved in this processing-is found in the clinical literature. For example, in reporting i I on two cases of aphasia, Morgan and ~ i l l u c k i dharry (1982) describe spontaneous singing by the patients as a welcome release from the 1 helplessness of being a patient. The authors l

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hypothesized that singing was a means to communicate thoughts externally which could not be articulated vocally in speech. Although the "newer aspect" of speech was lost in the damage of the dominant hemisphere for language, the older function of music was retained, possibly because music is a function distributed over both hemispheres. Berman (1981) suggests that recovery from aphasia is not a matter of new learning by the nondominant hemisphere but a taking over of responsibility for language by that hemisphere. The nondominant hemisphere may be a "reserve" of functions available in case of regional failure, indicating an overall brain plasticity (Naeser & Helm-Estabrooks 1985).Similarly, language functions may shift across hemispheres with multilinguals as compared with monolinguals (Karanth & Rangamani 1988), or as a result of learning and cultural exposure where music and language share common properties (Tsunoda 1983). That singing is an activity correlated with certain creative productive aspects of language may be an important point in this context. An example is the case of a 2-year-old boy of above-average intelligence who experienced seizures, manifested by tic-like turning movements of the head (Herskowitz, Rosman & Geschwind 1984). He induced seizures, consistently, by his own singing but not by listening to or imagining music, and also induced them by his recitation and by his use of silly or witty language such as punning. (Seizure activity as registered on an electroencephalogram correlated with clinical attacks and was present in both temporocentral regions, especially on the right side.) Aphasia is also found in elderly stroke patients, and music therapy, as reported in case studies, has been used effectively in combination with speech therapy to restore speech (Lehmann & Kirchner 1986). Gustorff and colleagues (Aldridge, Gustorff & Hannich 1990) describe the application of creative music therapy to coma patients who were otherwise unresponsive. By matching her singing with the breathing patterns of the patient, Gustorff stimulated

The responsiveness t o music of patients w i t h Alzheimer's disease is a remarkable phenomenon.

changes in consciousness which are both measurable on a coma rating scale and apparent to the eye of the clinician.

Problems of the Elderly The psychosocial rehabilitation of older persons is one of the main problems in health policy (Haag 1985).About onequarter of the over 65-year-olds face psychic problems, and are without adequate treatment and rehabilitative care. The development of ambulatory, community-based services as well as intensive support for existing self-help efforts are clearly necessary. Music therapy has been suggested as a valuable part of a combined treatment for the elderly (Dcllmann-Jenkins, Papalia Finlay & Hennon 1984; Fenton & McRae 1989; Gilchrist & Calucy 1983; Gross & Swartz 1982; Lehmann & Kirchner 1986; Morris 1986; Prinsley 1986; Rcnner 1986).

Music and Dementia in the Elderly At the age of 56 Maurice Ravel, the composer, began to complain of increased fatigue and lassitude. His condition deteriorated progressively (Henson 1988);and he lost the ability to remember names, to speak spontaneously, and to write. While his mind, he reports, was full of musical ideas, he could not set them down (Dalessio 1984). Eventually his intellectual functions and speech deteriorated until he could no longer recognize his music. In other words, he showed many of the features now associated with the condition known as Alzheimer's disease. The responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon (Swartz et al. 1989). Despite the language deterioration of such patients musical abilities appear to be preserved. Beatty and colleagues describe a woman who had severe aphasia, memory dysfunction, and

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apraxia (an inability to perform intentional movements), yet was able to read an unfamiliar song and perform on the xylophone, which to her was an unconventional instrument (Beatty et al. 1988). In a case study Aldridge and Brandt (1991a) suggest that music therapy is an important diagnostic tool in recognizing cognitive and motor impairment in the elderly, and a useful therapeutic adjunct in patient care. Even though the patient they describe may have been suffering from a pseudodementia, the discussion further articulates the value of using music therapy for the treatment of the elderly, demented or depressed. Table 2, which draws on this discussion, compares the medical assessment of Alzheimer's disease with an assessment based on music therapy. Certainly the anecdotal evidence suggests that the quality of life of Alzheimer's patients is significantly improved with music therapy (Tyson 19891, accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others (Morris 1986). Prinsley (1986) recommends music therapy for geriatric care, maintaining that it reduces the use of tranquilizing medication and reduces the use of hypnotics on the hospital ward and helps overall rehabilitation. He recommends that music therapy aim at specific treatment objectives: the social goals of interaction and cooperation; the psychological goals of mood improvement and self-expression; the intellectual goals of the stimulation of speech and organization of mental processes; and the physical goals of sensory stimulation and motor integration. Such approaches also emphasize the benefit of music programs for the professional carers (Kartman 1984)and the families (Tyson 1989) of elderly patients.

Assorted Findings and Possibilities A full examination of the possible use of music therapy would cover a variety of only partially explored areas. The following seem to be the most important:

David Aldridge

Breathing Training Fried (1990) presents a general overview of the use of music in breathing training and relaxation. Breathing training in itself is believed to have a physical benefit for anxious patients by enabling them to increase tidal volume-the amount of air moved in a single breath-without excessive loss of carbon dioxide (hypocapnia). Typically, anxious patients have relatively rapid shallow chest breathing and may hyperventilate. Music and breathing have been used to induce alternate states of consciousness, and Fried's paper correlates the characteristics of consciousness and the role of music in altering those states, reinforcing the findings of McLellan (19881, who identifies the qualities of music which can be used to invoke calm and inner peace. Nursing approaches have also utilized the anxiety-relieving effect of music in combination with massage and breathing exercises to relax patients, and to facilitate postoperative recovery (Keegan 1989).

Anesthesia The ability of music to induce calm and wellbeing has also been used in general anesthesia (Keegan 1989; McCluskey 1983). Patients express their pleasure at awakening to music in the operating suite, the music having been played "openly" before the beginning of the operation, and then through earphones during the operation (Bonny & McCarron 1984). In certain instances, it appears that surgical patients are aware of the music being played during an operation. In a study by Lehmann and colleagues (Lehmann, Homchs & Hoeckle 19851, patients undergoing elective orthopaedic or lower abdominal surgery were given either a placebo infusion (.9 percent sodium chloride) or the analgesic tramadol in a randomized and double-blind manner, to evaluate the efficacy of tramadol as one component of balanced anesthesia. Postoperative analgesic requirement and awareness of intraoperative events-tape-recorded music offered via earphones-were further used to

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Table 2 Comparison of Medical and Musical Assessments of Alzheirner's Disease Medical Elements of Assessment

Musical Elements of Assessment

continuing observation of mental and functional status

testing of verbal skills, including speech fluency

testing of musical skills, including rhythm, melody, harmony, dynamic, phrasing, articulation

cortical disorder testing: visuo-spatial skills and ability to perform complex motor tasks (including grip and right/left coordination)

testing for progressive memory disintegration

motivation to complete tests, to achieve set goals and persevere in set tasks

motivation to sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form

"intention" difficult to assess; but considered important

"intention" a feature of improvised musical playing

concentration and attention span

concentration on improvised playing and attention to the instruments

flexibility in task switching

flexibility in musical (including instrumental) changes

mini-mental state score influenced by educational status

ability to play improvised music influenced by previous musical training

insensitive to small changes

sensitive to small changes

ability to interpret surroundings

ability to interpret musical context and assessment of communication in the therapeutic relationship

assess the effects of tramadol. Although anesthesia proved to be quite comparable in both groups, striking differences occurred with respect to intraoperative awareness: while patients receiving placebo proved to be amnesic, 65 percent of tramadol patients were aware of intraoperative music. The ability to hear music during an operation is also reported by Bonny (Bonny & McCarron 1984).

Musical Hallucinations l

1 1

Hallucinations may occur in any of our senses, and auditory hallucinations take various forms-as voices, cries, noises, and, rarely, music. However, the appearance of musical hallucinations, often in elderly patients, has generated interest in the medical literature (Aizenberg, Schwartz & Modai 1986; Berries 1990; Fenton & McRae 1989;

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How music therapy can be i n c o v o rated into medical practice requires extensive research studies. Unfortunately, music therapists and their medical colleagues have created something of an impasse whereby each side demands a style of research unacceptable t o the other.

of-the-ordinary experiences of women are more often labeled pathologically.) Age, deafness, and brain disease affecting the nondominant hemisphere played an important role in the development of hallucinations; on the other hand, psychiatric illness and personality factors were found to be unimportant. For these patients, the application of music therapy to raise the ambient noise level, to organize aural sensory input by giving it a musical sense and thereby countering sensory deprivation, and to stimulate and motivate the patient seems a reasonable approach.

Gilchrist & Kalucy 1983; Hammere, McQuillen & Cohen 1983; McLoughlin 1990; Patel, Keshavan & Martin 1987; Wengel, Burke & Holemon 1989). When such hallucinations do occur they are described as highly organized vocal or instrumental music. In contrast, the ringing or other noises in the ears known as tinnitus is characterized by unformed sounds which sometimes may possess musical qualities (Wengel, Burke & Holemon 1989).

Immune Effects

T o some, case histories of patients with musical hallucinations suggest an underlying psychiatric disorder (Aizenberg, Schwartz & Modai 1986; Wengel, Burke & Holemon 1989). The hallucinations may be exacerbated by dementia occurring with brain deterioration (Gilchrist & Kalucy 1983). Fenton and McRae (1989) maintain that patients with musical hallucinations and hearing loss become anxious and depressed. Fenton challenges the association of musical hallucination with psychosis and previous mental illness. His explanation points to the degeneration of the aural end-organ whereby sensory input, which ordinarily suppresses much nonessential information, fails to inhibit information from other perception-bearing circuits. Other investigators argue for a central brain dysfunction as evidenced by measures of brain function (Gilchrist & Kalucy 1983). In a study of 46 subjects with musical hallucinations (Berrios 19901, the hallucinations were far more common in females. (The attribution of hallucinations to women in particular should be regarded with a degree of caution. As compared to men, out-

David Aldridge

Work referring to the influence of music therapy on immunological parameters is slim. Lee (19911, who has written of the necessity for working with HIV and AIDS patients, emphasizes the value of music therapy. However, Lee fails to be clear about clinical objectives. There remains the possibility that immunological parameters may be influenced by creatively improvising music. Research on this possibility should aim at linking musical analyses with clinical information about immune reactions such that therapeutic correlations could be attempted (Aldridge 1991b&c; Aldridge & Brandt 1991b; Aldridge, Brandt & Wohler 1989) and the results could be related to the current initiatives being made in psychoneuroimmunology.

Conclusion Music has the power to stimulate and to calm, to soothe and to inspire. Playing music undoubtedly benefits people. The elderly are stimulated, the depressed are encouraged, and the tired are invigorated. How music therapy can be incorporated into medical practice requires extensive research studies. Unfortunately, music therapists and their medical colleagues have created something of an impasse whereby each side demands a style of research unacceptable to the other. We can hope that in our general search for methods suitable for researching the human condition (Aldridge 1991a1, we can find ways

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Table 3 Comparison of Medical and Musical Assessments of Bowel Disease Medical Elements of Assessment

Musical Elements of Assessment

separation of self and "nonself"

not tuned to oneself, uncoordinated

lack of gut motility

lack of rhythmic flexibility, unresponsive to tempo changes, lack of rhythmical phrasing

increasingly introverted

quiet playing with no personal contact within the playing

restricted in relationships

difficult to contact in the musical relationship

rigid

repetitive playing, returning to the same tempo and rhythmic pattern, unresponsive to tempo changes

difficulty expressing feelings

intolerant of particular harmonies

appears to be coping well with life in the face of internal turmoil

appears to be going along with the music but an underlying chaotic structure

dependent

no initiatives within the music; dependent upon the therapist

intractable to change

difficult to treat, requiring many sessions

of working together in the future that will generate some flexibility in clinical research. As we have seen, some recent approaches have shown that the two vocabularies of medicine and music have areas of commonality (Aldridge 1989a, 1991b&c; Aldridge & Brandt 1991a&b; Aldridge, Brandt & Wohler 1989). One example of such commonality was illustrated earlier in Table 2, which compares the medical and musical assessments of Alzheimer's disease. Table 3, which compares the medical and musical assessments of bowel disease, provides another example. Gregory Bateson (1972) has reminded us of the need for the arts to accompany the science of modem medicine: The point which I am trying to make in this paper is not an attack on medical science but a demonstration of an inevitable fact: that merely purposive rationality unaided by such phenomena

as art, religion, dream and the like, is necessarily pathogenic and destructive of life; and that its virulence springs specifically from the circumstances that life depends upon interlocking circuits of contingency, while consciousness can only sec such short arcs of such circuits as human purpose may direct. What we may have to consider is that the human being is composed not as a machine but rather as a piece of music which is improvised in the moment (Aldridge 1989b). From such a perspective we may search for common themes among groups of individuals and identify particular repertoires of healthy activities, but each person will have his or her own song. For those of us who are doctors, our task is to encourage our patients in the articulation of their individual singing. Perhaps in the future we will be encouraged to 1 understand how each one of us as a person l 1 can become our own work of art. I

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Renner, M. 1986. "Means for the Activation of the Elderly. Music for Fun." Krankenpf-Soins-Infirm. 79:85-86. Rice, T. 1989. "Music in Hospitals: 'It Seemed Like Heaven'." Nursing Standard. 4:18-19. Richter, R. & M. Kayser. 1991. "Rhythmic Abilities in Patients with Functional Cardiac Arrythmias." 7th Meeting of the European Society for Chronobiology. Marburg May 30-June 2. Rider, M.S. 1985. "Entertainment Mechanisms Are Involved in Pain Reduction, Muscle Relaxation, and Music-Mediated Imagery." Journal of Music Therapy. 22:183-192. Rowden, R. 1984. "Music Pulled Them Through." Nurs-Mirror. 159:32-34. Sacks, 0.1986. The Man Who Mistook His Wifefor a Hat. London: Pan. Safranek, M., G. Koshland, & G. Raymond. 1982. "Effect of Auditory Rhythm on Muscle Activity." Physical Therapy. 62:161-168. Sarnrnons, L. 1984. "The Use of Music by Women during Childbirth." Journal of Nurse Midwifery. 29:266-270. Schmuttermayer, R. 1983. "Possibilities for Inclusion of Group Music Therapeutic Methods in the Treatment of Psychotic Patients." Psychiatr-Neurol-Med-Psychol-Leip:. 35:49-53. Schullian, D. & M. Schoen. 1948. Music and Medicine. New York: Henry Schuman. Spielberger, C. 1983.Manual for State Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, Inc. Standley, ).M. 1986. "Music Research in Medical/ Dental Treatment: Meta Analysis and Clinical Applications." journal of Music Therapy. 23:56-122. Stem, R. 1989. "Many Ways to Grow: Creative Art Therapies." Pediatric Annals. 18:645, 649-52. Street, R.J. & J. Cappella. 1989. "Social and Linguistic Factors Influencing Adaptation in Children's Speech." Journalof Psycholinguist Research. 18:497-519.

Swartz, K., E. Hantz, G. Crummer, J. Walton & R. Frisina. 1989. "Does the Melody Linger On? Music Cognition in Alzheimer's Disease." Seminars in Neurology. 9:152-158. Thornas, E. 1986. "Music Therapy." South African Medical Journal. 70:717-718. Tiep, B., M. Bums, D. Kao, R. Madison & J. Herrera. 1986. "Pursed Lips Breathing Training Using Ear Oximetry." Chest. 90:218-221. Tsunoda, T. 1983. "The Difference in the Cerebral Processing Mechanism for Musical Sounds Between Japanese and Non-Japanese and Its Relation to Mother Tongue." In Musik in der Medizin. Edited by R Spintge and R. Droh. Berlin: Springer Verlag. Tyson, J. 1989. "Meeting the Needs of Dementia." Nurs Elder. 1:18-19. Updike, P. 1990. "Music Therapy Results for ICU Patients." Dimension in Critical Care Nursing. 9:39-45. Vincent, S. & J. Thornpson. 1929. "The Effects of Music on theHuman Blood Pressure." The Lancet. 1:534-537. Walter, B. 1983. "A Little Music Why the Dying Aren't Allowed to Die." Nursing Life. 3:52-57. Wein, B. 1987. "Body and Soul Music." American Health. 6:66-75. Wengel, S., W. Burke & D. Holemon. 1989. 'Musical Hallucinations. The Sounds of Silence?" Journal of the American Geriatric Society. 37:163-166. Wolfe, D. 1978. "Pain Rehabilitation and Music Therapy." Journal of Music Therapy. 15:162-178. Zirnmerman, L. M. Pierson & J. Marker. 1988. "Effects of Music on Patient Anxiety in Coronary Care Units.'' Heart-Lung. 17:560-566. Zimmerman, L., B. Pozehl, K. Duncan & R Schmitz. 1989. "Effects of Music in Patients Who Had Chronic Cancer Pain." Western Journal of Nursing Resfirch. 11:298-309. Ziporyn, R. 1984. "Music Therapy Accompanies Medical Care." The Journal of the American Medical Association. 252:986-987.

ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993

David Aldridge

Aesthetics and the body

The A r t s in

P.syclior/~er(~pv. Vol.

16 pp. 91-97. *" I'c~-g:imon Press plc.

1989. Printed

in the U.S.A.

0197-4556189 $3.00 + .OO

A PHENOMENOLOGICAL COMPARISON OF THE ORGANIZATION OF MUSIC AND THE SELF DAVID ALDRIDGE, PhD*

This paper is concerned with an understanding of musical perception and how it is linked with the identity of the whole person. An extension of the understanding is the notion of being as it is characterized by the tradition of phenomcnological philosophy, which looks toward "being in the world" as a unified experience. This phenomenological approach sees a corrclation between music form and biological form. By regarding the identity of a person as a musical form that is continually being composed in the world, a surface appears on which to project our understanding of a person as a physiological and psychological whole being. The thrust of this endeavor is to view people as "symphonic" rather than "mechanic." By considering how persons come into the world as whole creative beings one can speculate on their potential for health and well-being.

most scientists would recognize here a gap in scientific knowledge and would not want to deny the fact of a connection. The problem in understanding the perception of music is inherent too in understanding personal health. Health is complex, yet how is one to make a unified sense of the complexity that avoids fragmentation and reduction? Furthcrmore, how can one begin to understand qualitative aspects of personal life as they are expressed in terms of hope, joy, and beauty, which complement increasingly sophisticated quantitative knowledge of the human body? Although there have been many attempts to describe the process underlying the perception of music there has been little success in presenting any satisfactory explanation. The perception is not limited solely by the acuity of the ear (Longuet-Higgins, 1979) and all that impinges on the listener, but is achieved in combination with the conceptual structure imposed by the listener. In this way the knowledge of the phenomenon is intimately linked with the phenomenon itself. Both the knower and the known are part of the same process. Perception in this sense is an holistic strategy. Much scientific research into the perception of music has concentrated on those aspects that can be measured quantitatively. In this way nature is organized according to the concepts that are imposed on it. This is the analytic mode of consciousness that is predominantly a product of the

The Perception of Music As Dennis Fry (1971, p. 1) wrote, In the case of music there is also continuously interaction between the physical character of the musical stimulus and its physiological and psychological effects so that a more thorough study of music would demand at least the combining of a physical, physiological and psychological approach. Modern science has relatively little information about the links between physics, physiology and psychology and is certainly not in a position to specify how the effects are related in music, but *David Aldridge is

research consultant to the

Musikthcrapicablcilnng,

Univcrsitiits Witten

Herdecke, D5084 West

Germany.

David Aldridge

Aesthetics and the body

DAVID ALDRIDGE

verbal intellectual mind (Burtoft , 1980) where phenomena are represented by number, and variables in equations are represented by quantities. This paper attempts to dcmonstnite the need for a phenomenological understanding tliat is isomorphic with the medium of music itself. An holistic consciousness that is qualitative, nonverbal, and participatory appears in the very phenomenon of music. What is more, Hie clement of participation by the knower spciiks directly to the aspect of music as performiincc, ; i n aspect that is sadly neglected by many reseiirc11ers who reduce research into the perception of music to a restricted range of received sounds. Heidegger (1962) emphasized the intuitive element in the comprehension of phenomena. When music is heard, the phenomenon becomes its own explanation. It is that which shows itself in itself. Perhaps one can begin to understand people as they come into the world, as music, i.e., composed as a whole. The explanatory idea of a Frame of Reference is a common theme among a number of writers referring to musical perception and brain function (Longuet-Higgins, 1979; Safranek, Koshland, & Raymond, 1982; Steedman, 1977; Walker, 1979). Walker suggests an "Ursatz" (the essential underlying principle) to music thiitis aii all-embracing thought unifying the music and giving a musical structure accessible to analysis. However, he also states that this musical structure is ultimately unknowable (i.e., beyond analysis). In this explanation lies the perennial difficulty of seeking a unifying explanation by an analysis into parts. Somehow that which is intuitively sought is lost in the process of description. What results is a statement that what is sought is unknowable, rather than a questioning of the analytic method of knowing. This situation also prevails in the understanding of personal health. According to the philosophy of empiricism, knowledge of the world is gleaned through experience. This knowledge comes through the senses. However, there is more to this sensory knowledge than meets the ear. There is always a nonsensory factor involved-that of cognitive perception, the dimension of the mind. This cognitive perception is a process ol' organizittion where meaning is imposed upon wh.11 is 1ie;iri.I. I n this way a seemingly nieaningless ground ol' sound is given meaning. To perceive tlien is lo

David Aldridge

give meaning to what is heard, an act of identity. However the nonsensory process of cognition is transparent, or rather silent, and appears as if hearing were solely a sensory experience. The process of discovery in science is also one of the perception of meaning. What appears to be empirical is indeed cognitive. If the ohenomenon of music is considered as a unified whole the question arises whether this unity is imposed on the senses by the mind, or whether it is the phenomenon itself that is a whole. To a great extent organizational frameworks are imposed on experience; hence there are descri~tionsthat call for a framework of reference in the perception of rhythm and of melody. However, there is a danger of being blinded to this imposed organization and thus to believe that this is the way the phenomenon really is. Once an attempt is made to synthetically reproduce the act of n~usical perception the framework analogy is seen as limited. Longuet-Higgins' (1979, 1982) careful and inspiring work demonstrates the utility of a frame of reference approach using tempo and meter for the perception of rhythm. This approach fails, as he remarks, when it is understood how a particular choice of phrasing affects the rhythm. Furthermore, the perception of atonal and arhythmic music are still mysteries to analytical methods. Yet one can hear and play arhythmically and atonally. However, there is an approach to understanding phenomena as unified wholes. The roots of this approach are in the work of Goethe's scientific consciousness and the work of Franz Brentano (Bortol't, 1986). Both of these men were to be influential in the development of phenomenology. Goethe perceived the wholeness of the phenomena not as imposed by the mind but by a conscious act of experience. This experience could not be reduced to an intellectual construction in terms of the way the phenomena are organized. Bortoft uses the following example to explain this change of consciousness:

. . . if we watch a bird flying across the sky and put our attention into seeing flying, instead of sccing a bird which flies (implying a separation between an entity 'bird' and an action 'flying' which it performs), we can experience this in the

Aesthetics and the body

MUSIC AND T H E S E L F

mode of dynamical simultaneity as one whole event. By plunging into seeingjlyit~gwe find that our attention expands to experience this moment as one whole which is its own present moment.

primacy of the word in speech, and to understand speech in terms of phrasing, rhythm, pitch, and melody, a different consciousness emerges. This consciousness reflects a different range of logics (P. 31) to the predicatory logic of language. Here are dynamic, movement, interval, and time-the very In this phenomenological approach sounds are essences of music and of biological function. heard as sensory information and as a unified I f consideration is given to what constitutes experience, which is music as consciousness. people as identity attention may be better diHow then can personal health be perceived as ;I rected to how they are composed not only in unified experience? qiiii~i~i~i-dvc terms of bones and blood, but how Iliey are composed as musical beings in regard to Language as Music relationship patterns, rhythms, and melodic contours. This may reflect the original biblical notion Whether or not music is a language is ;I riintlml in the beginning was "logos" (i.e., order). In ning debate through the literallire I-dnliiig lo I he music lies the phenomenon of a person coming perception of music. Morley (1981) iusis1.s lli:il into order. It may perhaps be that when a sense music is a form of conin~unic;itioii ;in;iloi:oiis Io . speech in that it has cadences :incl piincti~;i~iot~. ol' l liat order is lost a person experiences a loss of 11:illh. Perhaps the restructuring of the primicy of l:in, guage over music to suggest Ihiil lii~igii;igeis ; I Hemispheric Processing form of music may be more enlightening. I t could be that speech is analogous to music and lhiil I he In support of the above argument, the realm of musical components of speech are ;ibilicittecl in cerebral processing and music perception may favor of the literal content. ;ilso be examined. Although language processing Most in academic life rarely question Hie primay be dominant in one hemisphere of the brain, macy of the word. As a form of conimunicu~ion music processing involves an holistic underthe word appears to be central to endeavor standing of the interaction of both cerebral whether written o r spoken. Underlying this conhemispheres (Altenmullcr, 1986; Brust, 1980; cern with language is an analytical consciousGates & Bradshaw, 1977). ness. A subject-predicate gramnitir is used that In attempting to understand the perception of gives a structure to language. This very strucmusic there have been a number of investigations ture, in turn, structures consciousness. l l is ;I into the hemispheric strategies involved. Much feature common to Western culture; in the beol' the literature considering musical perception ginning was "the word." To write that creittion concentrates on the significance of hemispheric beean with the "word" hides the fact thal the dominance. Gates and Bradshaw (1977) conclude author is a writer whose consciousness is structhat cerebral hemispheres are concerned with tured by the medium used. music perception and that no laterality differIt might profitably be asked "How would a cnces are apparent. Other authors (Wagner & musician communicate this primal understanding Hannon, 1981) suggest that two processing funcof consciousness? What is 'in the beginning' for a tions develop with training where left and right musician?" In communicating in a different way hemispheres are simultaneously involved, and perhaps communication with a different conthat musical stimuli are capable of eliciting both sciousness may take place. This understanding right and left ear superiority (Kellar & Bever, may also explain the difficulty ofwriting and talk1980). Similarly, when people listen to and pering about health using a verbal analytic language form music they utilize differing hemispheric when there is concern with a realm of bchavior processing strategies. necessitating an holistic mode of consciousness. Perhaps an expression of health is something that could better be sung or played. To move from a position that advocates the Evidence of the global strategy of music pro-

David Aldridge

Aesthetics and the body

cessing in the brain is found in the clinic;il literiiture. In two cases of aphasia (Moigan A 'I illuckdharry, 1982) singing was M-CII ;is ;I wclconurelease from the helplessness ofheiiq; i i p;itii.~i~t. The authors hypothesized thal singing w;is ; I means to communicate thoughts externally. Although the "newer aspect" of speech was losi, the older function of music was rcl;iincd, possibly because music is a function di~trihi~teil over both hemispheres. Berman (1981) suggests that recovery from aphasia is not a matter OS new learning by tinnondominant hemisphere but a taking over of responsibility for language by that henlisphere. The nondominant hemisphere may be a reserve of functions in case of regional failure. A less defensive alternative explanation is that the strategies underlying musical proccss are those same strategies underlying biological process and (lie maintenance of the identity of the organism. Rhythm Rhythm is the key to the integrativc process underlying both musical perception and physiological coherence. Barfeld's ( 1978) approach suggests that when n~usicalform as tonal shape meets the rhythm of breathing there is the niusical experience. External auditory activity is mediated by internal perceptual shaping in the context of a personal rhythm. It is interesting to speculate here on the meaning of context, not as a container but as coiz textere, which is a weaving together. One pattern is then woven against another to produce an interference pattern, the basis for matter. Sound is woven together witli' rhythm. When considering communication, rhythm is fundamental to organization. Before any consideration of content one must connect rhythmically with another person and establish some commonality. This connection of rhythms is seen as the phenomenon of entrainment, which occurs in the circadian rhythms of temperature and sleep. Should they lose entrainment, then jet lag takes place. Scientists observing such phenomena often attempt to find an underlying mechanism for entrainment (Johnson & Woodland-Hastings, 1986), a master clock ils it were. However, when moving from a mechanical perspective a musical analogy for coordinating rhythm might be more appropriate.

David Aldridge

The rhythms and pulses that entrain the rhythmic patterns of the human body are nonmaterial. The senses-hearing, smell, taste, sight, touch-in addition to balancing and moving are integrated as a musical form. It is rhythm that provides the ground of being, and a rhythm of which being is generally unaware and that is perhaps the gestalt of identity. Dossey (1982) writes of disorders of time being particularly prevalent in modern society. This may be rephrased as disorders of disrupted rhythm. The work of Safranek et al. (1982) demonstrates that subjects use a preferred personal tempo in the performance of a motor task. This personal tempo is reflected as a functional reflex in the muscle. However, by introducing a n~usicalrhythm while a musical task is being performed, which is different from that of the personal tempo of the subject, then a different response is invoked in the subject. The authors see this as a "volitional response." Control over seemingly involuntary movements can be achieved by meeting the personal tempo of a subject and thcn changing to a slower, even beat. Meeting this tempo has been a central strategy in hypnotherapy. The existence and role of a personal tempo are refined even further in creative music therapy (Nordoff & Robbins, 1977). It may be inferred thcn that people become aware of the ground of their being not in verbal logic, but in a logic analogous to the ground of their own functioning (i.e., music). In this sense insight is had about a person. not in a restricted verbal intellectual sense, but as being- in the world. The frame of reference approach mentioned e;irlier is used indirectly by Povel (1984) to understand rhythm. Tones in sequence are seen as having a dual function. They are characterized by pitch, volume, timbre, and duration. They also mark points in time. These tones then produce both structure in time and of time. When tones are used in sequence only as temporal concepts they can be thought of as providing a temporal grid, which is a time scale on which the tone sequences can be mapped for duration and location. It might profitably be asked what the isomorphic events in terms of physiology are that would meet such a dual function. There may be regular sequential pulses of metabolic, cardiac, o r respiratory activity within the body that also have qualities of pitch, timbre, and duration. What is important in these descriptions of musi-

Aesthetics and the body

MUSIC A N 1) '1'1-l l< S171 , I T cal perception is the emphasis on conlexl where there are different levels of ;itlcntion ocenri i i i f ; sin~ultaneously against a bachgromnl Iciiipoi ; I I structure (Jones, Kidd, & Wct/x'I, 1981; Iiukl. Boltz, & Jones, 1984). Recent research in cardiology has eniph.isi/.cd the relationship between changes in bre;itliii~g patterns, personal tempo, and hypertension. The work of Lynch and his associates (I~iieilniiinn, Thomas, Kulick-Ciuffo, Lynch, & Suginoh;ira, 1982; Lynch, Long, Thomas, Malinov, & Katcher, 1981) has highlighted the link, between hypertension and fast speaking. A feature of type A behavior in patients with hypertension is that their blood pressure, which is alre;idy high, shows an increase when they comniunic;ite. Such patients are seen to have diffici11tie-i in communication. They often appear disconnected from their feelings and have an underlying sense of hopelessness regal ding their ; h i l i t y lo cornmunicate effectively. When people do not expect to communicate effectively their blood pressure rises. Because they do not expect to be understood they do not listen. By not listening they miss the chance to lower their blood pressure. Attention to the environment (i.e., listening) is seen as promoting a deceleration in heart late and a decrease in blood pressurc. Yet, attention to the self is seen as promoting heart rale (Sandman, 1984; Walker & Sandman, 1979, 1982). Changes then in tempo, and the promotion of listening o r sounding, will have implications for cardiac and respiratory activity. Lynch et al. (1981) suggest therapeutic activities to proniote a reduction in hypertension utilizing slow and deep breathing. Playing improvised music as pure communication, with its absence of verbal content and its primary component of rhythmic activity related to personal tempo and volitional responsc (Safranek et al., 1982), may be the ideal medium for achieving such change. It is important to introduce a word of caution here. The motor act of communicating is not the cause of the elevated blood pressure. Blood pressure is elevated whenever communication takes place. The elevation points to a process beyond the motor act, which is intent, a feature also evident in change of muscle activity (Safranek et al., 1982). This switch from physiology being proactive rather than merely reactive is a significant feature of modern physiological rcsearch (Walker & Sandman, 1979, 1982).

David Aldridge

Kliylhin too plays a role in the perception of iiirlnily. The perceptions of speech and music are (01~iiidabletasks of pattern perception. The lisI C I I V I hiis to extract meaning from lengthy seqiirin..cs of rapidly changing elements distributed in I ime (Morrongiello, Trehub, Thorpe, & I'oililupo, 1985). Temporal predictability is important for tracking melody lines (Jones et al., 1981; Kidd et al., 1984). Kidd et al. also refer to melody as having a sinicture in time and that a regular rhythm acilitates the detection of a musical interval and its subsequent integration into a cognitive represcnt;ition of the serial structure of the musical ptitt ern. Adults identify familiar melodies on the basis of relational information about intervals betwccn toncs rather than the absolute information ol"p;irlicular tones. In the recognition of unfamiliar melodies, less precise information is gathered iihoul the tone itself. The primary concern is with successive frequency changes o r melodic contour. The rhythmical context prepares the listener in advance for the onset of certain musical intervals and therefore a structure from which to discern, or predict, change. 'Die implication of this work is that change, whether it be melody o r rhythm, is dependent on a global rhythmic strategy. To extend this understanding to biological processes, it can be hypothesized that differences in contour (melody) (as in the release of hormones, fluctuations in temperature) and changes in rhythm are detected in reference to a global rhythmic context of the body. This global context may be regulated by the heart or breathing patterns, or may be an emergent property of the varying rhythmic patterns of the body. Disruption in this overall global strategy will influence a person's ability to detect new or changed nontemporal information (Cuddy, Cohen, & Miller, 1979; Jones e t al., l98 1 ; Kidd et al., 1984). One may not be aware of certain changes and become either out of tune o r out of time. Conclusion The perception of music requires an holistic strategy where the play of patterned frequencies is recognized within a matrix of time. People may be described in similar terms as beings in the world who are patterned frequencies in time.

Aesthetics and the body

A phenomenological approach presses the scimusic). Music is the ideal medium to discover entist to understand phenomena as dircct cxpcrihow people are composed and how they come ences before being translated into thoughts and into the world as whole beings both to create and feelings. The practice of creative music therapy sustain identity. Not only can such personal exadopts such a position. A person is invited to pression be recorded for analysis, it can be heard improvise music creatively with a therapist. It and experienced directly as a whole. may be inferred from this playing that one is hearing a person directly in the world as a dircct References expression of those patterned frequencies in a matrix of time. Rather than subject a person to Altenmuller, E. (1986). Brain correlates of cerebral music processing in Ihe human. European Archive's q / ' P s y c l ~ i measurement, to be reduced to what is quantifiairy. 23.5, 342-354. able, he or she may be experienced directly. This Btirteld, 0. (1978). The case for t i ~ ~ ~ l i r o p o s o p hLondon: y. experience requires no verbal translation as in Rudolf Steiner Press. psychotherapy. What can be heard is the person Bcrnian, 1. W. (1981). Musical functioning, speech lateralizabeing in the world. An extension of such imlion and the amusias. South Afkican Medical Journal, 59, 78-8 1. provised playing as an expression of the whole llortoft, H. ( 1986). Goethe's scientific consciousness. Instiperson is that tendencies to play in differing ways tute for Cultural Research (Monograph Series No. 22). may be heard. There may bc limitations in Tunbridge Wells, England. rhythm, melody, or musical structure. By chiilB ~ L I J. s ~C. , (1980). Music and language: Musical alexia and lenging personal tempo one may he;ir the extent agraphia. Briiiii, 103, 367-392. Cuddy. L. L., Cohen, A. J., & Miller, J. (1979). Melody of his o r her intent. recognition: the experimental application of musical rules. If musical form and biologic;il lonn are Cuiiiulidii Journal of'Psychology, 33, 148- 157. I isomorphic, improvised music nii~yiilso pix~vitlc l k i s s c y . L. ( 1982). Spiicc, l i n (~I I I ~inccliriiir. Boulder, CO: Shanibliaki. an holistic strategy for thc ;isscssniei~t01" Iie;il~li 'cinstein, A. R. (1966). Symptoms as an index of biological and well-being. Feinstein ( 1900) st rcssivl I lir ini-. tic1i:ivior in human cancer. Nature. 209. 241-245. portance of clinical logic i n tlic ili;i^ini,sis 01' Ii'icdni;~nn,E., Thomas, S. A . , Kulick-CiutTo, D., Lynch, J . cancer, and the iniportancc 01' iillowin~i,~ l i rpii .l,& Suginoliiira, M. (1982). The cl'l'ects of normal and tient to speak: "The complexity ol' I I I ~ I I Ii ~ ~ c n ~ i i s r ? ; rapid speech on blood pressure. I'syclio.so~~~iitic Modicinc, 4-1, 545-553. the difficulty of studying hiimi~iidisciise, Iml i 1 l . s ~ I'ry, 0. ( 1971). Sonic (:/fic~.so f music. Institute for Cultural enables a diseased man 10 I i i l k . 11is ilcscriplion 01' Kcsearch (Monograph Series No. 9). Tunbridgc Wells, symptoms gives crucial iiilbi~n~iilioii;ilionl IInlingland. diseased structures under iiivcstij~:a~ioii"(p. liiiles, A., & Bradshaw, J. (1977). The role of the cerebral Speech itself is limiting both in conleiit ;nul in hcniisphcrcs in mu5ic. Brain ond Lang~iai".~,4. 403-43 1. l-lcidcgger, M. (1962). Being u ~ i dtime. London: SCM Press. form. The creative playing ol' improvised music .lohnson, C. H., & Woodland-Hastings, J. (1986). The elusive offers an holistic form of assessment tliul is rcliirnechanisni of the circadian clock. American Scienti.sl 74. tional, noninvasive, and nonvcrlx;i, ;ind l l i i i l 29-36. allows the identity of the patient to be revealed Joncs, M. R., Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic attention. Journal ofE,vperi~rienliilPsychology, and experienced in the world. This context 7. 1059-1073. allows the expression of tendencies that have poKclliir, L. A., & Bever, T. G. (1980). Hemispheric asymmettential~for those states called health and illness. rics in the perception of musical intervals as a function of If music is an earlier form of communication musical expcricncc. Brain mid L t i i i f i i d ~ i ' 10, , 2438. Kidd, G . , Boltz, M,, & Jones, M. R. (1984). Some effects of than language, and the processing strategies lor rhythmic content on melody recognition. Amrriciin Jourthe perception of music are distributcd over both mil o f ' l ' s y r l i o l o ~ y ,97, 153-173. hemispheres, it is possible to infer that this holisLonguet-Higgins, H . C. (1979). The perception of music. tic strategy is closer in developmental terms to I ' r ~ c c r d i ~ i f of s the Royal Society qf London, 205, 307physiological processes and autonomic activity 322. Longuet-Higgins, 1-1. C. (1982). The perception of musical than language. There is an emerging tolerance rhythms. fJcrwpfion, / I , 115-128. and even acceptance of the inllucncc of 1:mgii;tge Lynch, .l. J., Long, J. M., Thomas, S. A., Malinov, K. L., & on physiology. However, there is a more subtle Katchcr, A. H. (1981). The effects of talking on the blood and more precise medium with potcntials lbr pressure of hypertensive and normotensive individuals. representation and influence (i.e., the playing of Psyclioso~~iulic Medicine, 43, 25-53. -!8I.").

David Aldridge

Aesthetics and the body

MUSIC AND THE SELF Morgan, 0. S., & Tilluckdharry, R. (1982). Presentation of singing function in severe aphasia. West Indian Medical Journal, 31, 159-161. Morley, J. B. (l98 1). Music and neurology. Clinical am1 Ex' periine~ztulNeurology, 17, 15-25. Morrongiello, B., Trehub, S. E., Thorpe, L. A., & Podilupo, S. (1985). Children's perception of melodies: The role o l contour, frequency and rate of presentation. Journal of' Experimental Child P.sycliolof~,40, 279-292. Nordoff, P., & Robbins, C. (1977). Crcutivc music tlu-nipy. Individualized treatment / o r tlie luinciicapped cliilcl. New York: John Day. Povel, D. J. (1984). A theoretical framework Ibr rhythni pcrception. Psycholofical Rfsecircli, 45, 315-337. Safranek, M. G., Koshland, G . F., & Raymond, G . (1982). Effect of auditory rhythm on muscle activity. l'l~y,\icul TIti-rapy, 62, 16 1- 168.

David Aldridge

Sandman, C. A. (1984). Afferent influences on the cortical evoked response. In M. Coles, J. R. Jennings, & J. A. Stern (Eds.), Psycliological perspectives (Festschrift for Beatrice and John Lacey). Stroudberg, PA: Hutchinson & Ross. Steedman, M. J . (1977). The perception of musical rhythm ;ind metre. Perception, 6, 555-569. Wiigncr, M . T., & Haniton, R. (1981). Hemispheric asymm e t r i c ~ in faculty and student musicians and nonmusicians duriny melody recognition tasks. Brain and L t ~ t ~ g u a g e13, , 379-388. Walker, A. (1979). Music and the unconscious. British Medicul Jmirnul, 2 , 164 1-1643. Walker, B. B., & Sandman, C. A. (1979). Human visual evoked responses are related to heart rate. Journal of Comparative rind I'liysiolofficul Psychology, 93, 7 17-729. Walker, B. B., & Sandman, C. A. (1982). Visual evoked potcntiiils change ;is heart rate and carotid pressure change. Psyrliopliysiolo~y,19, 520-526.

Aesthetics and the body

Complementary Therapies in Medicine (2005) 13, 25-33

8 9 10 11 12 13

Functionality or aesthetics? A pilot study of music therapy in the treatment of multiple sclerosis patients夽 D. Aldridge a, ∗, W. Schmid b, M. Kaeder c, C. Schmidt a, T. Ostermann d a

Chair for Qualitative Research in Medicine, University of Witten Herdecke, Alfred-Herrhausen-Str. 50, D-58448, Germany b Institute for Music Therapy, Faculty of Medicine, University of Witten Herdecke, Germany c Gemeinschaftskrankenhaus, Herdecke, Germany d Department of Medical Theory and Complementary Medicine, Faculty of Medicine, University of Witten Herdecke, Germany

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Summary Introduction: Neuro-degenerative diseases are, and will remain, an enormous public health problem. Interventions that could delay disease onset even modestly will have a major public health impact. The aim of this study is to see which components of the illness are responsive to change when treated with music therapy in contrast to a group of patients receiving standard medical treatment alone. Material and methods: Twenty multiple sclerosis patients (14 female, 6 male) were involved in the study, their ages ranging from 29 to 47 years. Ten participants formed the therapy group, and 10 the matched control group matched by age, gender and the standard neurological classification scheme Expanded Disability Status Scale (EDSS). Exclusion criteria were pregnancy and mental disorders requiring medication. Patients in the therapy group received three blocks of music therapy in single sessions over the course of the one-year project (8—10 sessions, respectively). Measurements were taken before therapy began (U1), and subsequently every three months (U2—U4) and within a 6-month follow-up without music therapy (U5) after the last consultation. Test battery included indicators of clinical depression and anxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale), a self-acceptance scale (SESA) and a life quality assessment (Hamburg Quality of Life Questionnaire in Multiple Sclerosis). In addition, data were collected on cognitive (MSFC) and functional (EDSS) parameters. Results: There was no significant difference between the music-therapy treatment group and the control group. However, the effect size statistics comparing both groups show a medium effect size on the scales measuring self-esteem (d, 0.5423), depression HAD-D (d, 0.63) and anxiety HAD-A (d, 0.63). Significant improvements

KEYWORDS

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Music therapy; Matched control group; Self-acceptance; Self-esteem; Depression; Anxiety; Functional scores; Aesthetic

夽 This project was supported by Schering gmbH.

* Corresponding author. Tel.: +49 2302 926 780; fax: +49 2302 926 783.

E-mail address: davida@uni-wh.de (D. Aldridge).

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D. Aldridge et al. were found for the therapy group over time (U1—U4) in the scale values of selfesteem, depression and anxiety. In the follow-up, scale values for fatigue, anxiety and self-esteem worsen within the group treated with music therapy. Discussion: A therapeutic concept for multiple sclerosis, which includes music therapy, brings an improvement in mood, fatigue and self-acceptance. When music therapy is removed, then scale scores worsen and this appears to intimate that msuic therapy has an inﬂuence. © 2005 Elsevier Ltd. All rights reserved.

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sures by which therapeutics are evaluated, and adopt a pragmatic approach to living as well as possible in the context of a chronic condition.10 Although complementary and alternative medicine approaches are being asked for by patients suffering with multiple sclerosis, only a limited number of studies have explored arts and music therapy recently. O’Callaghan,11 for example, encourages patients to write songs using expressive elements related to positive feelings for other people, memories of relationships and expressions of the adverse experiences resulting from living with the illnesses. In a controlled pilot study Wiens et al.12 demonstrated a potential strengthening effect of music therapy—–with a focus on breathing and speech—– on the respiratory musculature of multiple sclerosis patients. Respiratory muscle weakness is characteristic of individuals with advanced multiple sclerosis and can result in repeated infections of the lung. Based on experiences with a music-therapy group of 225 hospital inpatients with multiple sclerosis who participated in a 6-week group musictherapy program,13 music therapy appeared to offer psychological support, relieve anxiety and depression and possibly help with the difﬁcult process of coping with the disease individually. Magee,14—17 also makes use of well-known, precomposed songs and spontaneous improvisation on instruments and their attitudes change from a “disabled self-concept” to a more ‘‘able self-concept’’. In a further study,18 the authors showed improvements in mood state following music therapy, although depression was not directly affected. Studies into factors governing the quality of life for multiple sclerosis patients are interesting in this context. They reveal that patients and their physicians have different perspectives. Physicians determine quality of life mainly with physical and functional parameters, while patients themselves see psychosocial well-being, emotional stability and ways to cope with multiple sclerosis-induced stress as the most important factors.19 High levels of depression and anxiety are associated with people with MS who seek complementary approaches, al-

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Neuro-degenerative diseases are, and will remain, an enormous public health problem. Interventions that could delay disease onset even modestly will have a major public health impact. These diseases are disabling to the sufferers, there is a loss of normal motor functioning, a change in mood, and a gradual loss of cognitive abilities1,2 including auditory problems3 and memory changes,4 and sensory processing.5 These multifarious problems worsen during the course and stages of the disease.1 Furthermore, the patient does not suffer alone; these losses have an impact upon family and social life. Multiple sclerosis is the most frequent inﬂammable disease of the central nervous system among young adults. It is an autoimmune disease with additional genetic and environmental factors6 and considered to be one disease in the general class of neurodegenerative diseases. Disease progression differs considerably from patient to patient, so that while we may talk about stages of the diseases there is no typical multiple sclerosis patient but rather a heterogeneous group of patients where generalizations do not really apply.7 As there are no curative therapeutic interventions, we are reliant upon a palliative intervention. While medical approaches will undoubtedly focus on a functional strategy for treatment, we cannot ignore that these diseases have implications for the performance and appearance of the person in everyday life. Therefore, we need therapeutic approaches that include aesthetic performance as well as functional performance.8 Multiple sclerosis patients show increasing interest in complementary and alternative therapies.9 One reason is their general disappointment with conventional medicine, since causal treatment is not possible; another is a wish to play a more active role in coping with the disease and a demand for a wider range of therapies to meet psychosocial needs as well. Patients say that by using a complementary medical approach then they take personal responsibility for health, reframe the mea-

Introduction

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Patients Twenty multiple sclerosis patients (14 female, 6 male) were involved in the study, their ages ranging from 29 to 47 years, with episodic, secondary chronic and primary chronic progression and an average disease duration of 11 years. Ten participants formed the therapy group, and 10 the control group. The groups were comparable in the standard neurological classiﬁcation scheme Expanded Disability Status Scale (EDSS).21 The EDSS of both groups was 2.6 on average, which means that the participants were between normal functions (score: 0) and disability that precludes full daily activities (score: 5.5). Exclusion criteria were pregnancy and mental disorders requiring medication. All participants were informed of the content and details of the study and gave their written consent to publish the material, especially the video sequences from the music-therapy sessions. The Ethical Committee of University of Witten Herdecke examined the protection of data privacy and the ethical aspects. Patients were matched by the researcher administering the trial for age, gender, stage of disease and the standard neurological classiﬁcation scheme EDSS. The basis for the recruitment population was from patients coming for their regular check-ups to the general hospital. A patient was allocated to the treatment group. The next consecutive patient, if matching the previous patient, would be allocated to the control group. If not, that patient would be allocated to the treatment group until the treatment group was complete. Subsequently, 10 matching control patients were allocated. The patients in the therapy group received three blocks of music therapy in single sessions over the course of the project (8—10 sessions, respectively). Patients in the matched control group were promised music therapy after the waiting period. The music-therapy approach used for this study is based on the Nordoff Robbins approach.22 Both patient and therapist are active. Music-making on instruments, or singing, and the music itself that emerges, all are potential possibilities for activity,

Methods

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A matched control trial was implemented using a battery of indices before therapy began (U1), and subsequently every three months (U2—U4) and within a 6-month follow-up without music therapy (U5) after the last consultation. The test battery included the following instruments.

Indicators of clinical depression and anxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale) The Beck Depression Inventory (BDI) is an established and reliable questionnaire for assessing the severity of depression and offers an instrument suitable to compare this study with other clinical studies.23 Patients with multiple sclerosis are considered to be impaired in identifying emotional states from prosodic cues,24 so it makes sense to use such an inventory. The Hospital Anxiety and Depression Scale (HAD) is a self-administered, bidimensional instrument developed to screen for clinically signiﬁcant depression and anxiety in medical populations (Zigmond, 1983, p. 657). Somatic items are excluded to avoid the confounding effect of physical illness. While it is recognised that patients with multiple sclerosis have a high lifetime risk for major depression, less is known about affective instability and how symptoms like irritability, sadness and tearfulness affect a subject’s overall degree of psychological distress.25 Clinically signiﬁcant anxiety, either with or without depression, was endorsed by 25% of patients, three times the rate for depression.26

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encounter and experience. Individual themes and musical developments emerged for each individual patient; some wanted to sing and dance, others wanted to be sung to, and others wanted to play an instrument or brought their own instruments with them. There were no expectations of previous musical education. The patients wanted recordings of their sessions and their individual selections were recorded onto compact discs. They played them to their partners or friends or just listened to some pieces and remembered the condition and feelings of the situation. There was a high degree of willingness on the part of all patients to take part in the study, so that all rounds of interviews were completed, and 85% of all music-therapy sessions took place.

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though this may be an underlying factor of chronic illness.20 The aim of this study is to see which components of the illness are responsive to change when treated with music therapy in contrast to a group of patients receiving standard medical treatment alone.

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Hamburg Quality of Life Questionnaire in Multiple Sclerosis The Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) is a disease-specific quality of life instrument for MS. There are 38 items about physical, psychological and social functions and questions about symptoms, progression of the disease and general impairment.29 People suffering with multiple sclerosis identify depression and social function as important components of quality of life (Somerset, 2003, p. 608) and including preferences for health states and treatment alternatives in the decision to initiate treatment for individual patients is seen as an important treatment consideration.30 In addition, data were collected on cognitive (MSFC) and functional (EDSS) parameters. The EDSS describes the state of disability of an MS-patient and ranges from 0 (normal) to 10 (death due to MS). It is a classification scheme that insures all participants in clinical trials are in the same class, type or phase of MS.21 It is also used by neurologists to follow the progression of MS disability and evaluate treatment results. Because of its strong emphasis on ambulation, the EDSS is insensitive to changes in other neurological functions and to cognitive dysfunction in MS. The Multiple Sclerosis Functional Composite (MSFC) is a multidimensional instrument to assess disability of MS-patients. It has three parts, testing the function of legs and walking-ability, the functions of arms and hands and the cognitive functions.31 The IFSS is a scale that assesses incapacity and fatigue. For an evaluation of the efficiency and sustained success of music therapy, Wilcoxon-test statistics of outcome-measures differences from U1 to U4 between the groups were applied to show significant differences. Additionally, effect-sizes were calculated according to Cohen18 and corrected according to McGaw and Glass19 .

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Fig. 1 shows the development of the outcomemeasures in the course of time with therapy from U1 to U4 and up to U5 in the follow-up. At the start of the study (U1) there was no significant difference between therapy group and control group on the varying scale measures. Significant improvements were found within the therapy group over time (U1—U4) in the scale values of SESA (p = 0.012) for depression (BDI, p = 0.036; HADS-D, p = 0.035) and anxiety (HADS-D subscale anxiety, p = 0.13). Significant differences were found for the control group in regard to the subscale anxiety (HADS-A, p = 0.031), while the values for depression and self-acceptance did not show any significant differences over time (U1—U4). No differences were found for the functional and physiological values (MSFC, EDSS) and quality of life (HAQUAMS). The latter is probably because the HAQUAMs quality of life is mainly assessed from statements of physical well-being and mobility thus reflecting scores on the functional scales. However, there was no significant difference in the improvement from U1 to U4 between the musictherapy treatment group and the control group (see Table 1), although effect size statistics comparing both groups show a medium effect size on the scales measuring self-esteem (d, 0.5423), depression HADD (d, 0.63) and anxiety HAD-A (d, 0.63). In the follow-up, scale values for fatigue, anxiety and selfesteem worsen within the group treated with music therapy. The use of p-values and effect size are used as guides in this study as to what may be interesting as hypotheses for further studies, or if further studies are warranted. They are intended as exploratory statistics rather than confirmatory. This is a pilot study and there are considerable limitations both in terms of the sample size and a bias in terms of matching in that there was no random allocation to the treatment group. Considering the correlations between the scale scores differences between T1 and T4, we found correlations between the HAD depression index and self-acceptance, and depression on the BDI and HAD anxiety and depression (see Table 2). We could, therefore, reduce our battery of tests to the Hospital Anxiety and Depression scale in any future trial.

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The Scale for the Evaluation of Self-Acceptance (SESA) is a 35-question scale translated from an original scale that assesses the acceptance of self and others.27 Social support, and coping behaviours, are important for persons afﬂicted with multiple sclerosis. A healthy conception of oneself is central to coping effectively with the day-to-day stresses of modern living. The onset of any neurological disease, with either actual visible deﬁcits or potential future disability, threatens the integrity of that concept.28

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Discussion

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This study tried to identify factors to be inﬂuenced with a music therapeutic approach in treating patients with multiple sclerosis. Music therapy

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Functionality or aesthetics?

Figure 1 Outcome measures over time. U1—U4: treatment phase, U5: follow-up. Dashed line: control-group, full-line: music-therapy group. BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADSD: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability, MSFC: Multiple Sclerosis Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC: Multiple Sclerosis Functional Composite.

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Table 1

Wilcoxon signed rank test comparing therapy and matched control group.

EDSS MSFC IFFS SESA BDI HADS-A HADS-D HAQUAMS

Music-therapy group, median [25%ile, 75%ile]

Control group, median [25%ile, 75%ile]

Wilcoxon signed rank test, p signiﬁcance (two-tailed)

2.3 [1.4; 3.5] 0.23 [−0.21; 0.47] 34.0 [24.3; 45.0] 115 [79; 125] 13.0 [6.5; 19.0] 9.0 [4.8; 11.8] 5.5 [3.8; 7.0] 2.3 [2.1; 2.5]

2.5 [1.5; 3.6] 0.14 [−0.45; 0.34] 22.5 [12.8; 47.5] 110 [99; 128] 7.0 [3.0; 20.0] 8.0 [3.75;13.25] 6.0 [1.5; 9.5] 2.0 [1.8; 2.4]

0.76 0.61 0.22 0.59 0.33 0.54 0.84 0.07

Difference between intake and end of treatment scores (Wilcoxon signed rank test) z Asymptotic signiﬁcance (two-tailed)

EDSS

MSFC

IFSS

−.303 .762

−.507 .612

−1.224 .221

SESA

BDI

HADS-A

HADS-D

−.533 .594

−.972 .331

−.613 .540

−.205 .837

HAQUAMS −1.837 .066

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there is no cure. This frequently life-long process for patients starting when multiple sclerosis is diagnosed obviously demands a range of therapeutic possibilities which must also consider and encourage a patient’s creative abilities.33 What we need to establish is which of the varying parameters is subject to inﬂuence by music therapy, which was the aim of this study. In this study various outcome-parameters were evaluated for their possible appropriateness for showing effects of music therapy. These were both functional and affective. We included many parameters because although the clinicians involved knew that something positive was happening, there was no clear indication of what this was and how to measure it. Through this study we now have an idea of what changes and from this basis can develop hypotheses for a controlled study.

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Correlation of the differences in scales between T1 and T4. SESA

SESA BDI HAD-A HAD-D

BDI

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can be considered as a part of a treatment strategy for two reasons. One, it offers a means to improve communicative performance.18 Second, it promotes the presentation of a self that may be considered as handicapped or degenerating but can be performed as satisfying and whole—–and that is a matter of aesthetics.8,32 We know from the limited, principally anecdotal, music-therapy literature that there are potential benefits from music therapy in terms of enhancing mood and improving self-identity. While there are numerous projects aimed at finding medical relief for suffering and the treatment of disease, we are reminded that disease-related problems influence patient’s mental behaviour and this has ramifications for relationships. A major confrontation for those offering treatment, as it is for the patient, is that the problem worsens and

−0.37 (0.11)

HAD-A −0.33 (0.15) 0.57** (0.01)

HAD-D **

−0.61 (0.04) 0.49* (0.03) 0.41 (0.07)

HAQUAMS 0.03 (0.89) 0.13 (0.59) 0.12 (0.62) 0.01 (0.96)

Levels of significance are printed in parentheses. BDI: Beck Depression Inventory, HAD-AS: Hospital Anxiety and Depression Scale—–anxiety, HAD-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis. ∗∗ Correlation is significant at the level 0.01 (two-tailed). ∗ Correlation is significant at the level 0.05 (two-tailed).

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BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability MSFC: Multiple Sclerosis Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC: Multiple Sclerosis Functional Composite.

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In a final interview, 9 out of 10 music-therapy participants in the study described how important it was to become personally active in their treatment. All 10 participants reported an immediate improvement in their well-being during sessions. In eight participants, this improved state continued for some time and was confirmed by partners or friends. This is also confirmed by improvements in the self-acceptance and depression scales but not by quality of life scores. Differences over time in the depression scores and self-acceptance scores are highly correlated with each other that may reflect their common conceptual background. Seven participants described an enhanced perception of themselves with an increasing self-confidence over the course of the therapy. They were increasingly able to let themselves be surprised by the music as it emerged and by their own previously undiscovered musical skills. Music and music therapy are experienced by patients as ‘‘something moving’’ that shifts negative thoughts about the disease into the background and offers a means of expression for feelings of security, freedom and pleasure.38 One participant relates how she met a friend in the University that she had not seen in a long time, after treatment. They talked for a while and it was only on parting that she told her friend that she has multiple sclerosis. This was a shift in her perception of herself as first and foremost ‘‘a sick person’’ to a normal person with other priorities in life. What is evident from this study is that in assessing music therapy in terms of meeting patients’ needs then we cannot simply take a functional approach alone. Multiple sclerosis patients have a variety of needs, some of these are psychosocial and some of these are also aesthetic. An aesthetic therapy offers the opportunity to experience the self not as solely degenerative but also as creative. This is a major turn around in selfunderstanding and is reflected in both self-esteem and an improvement in mood. We are not denying that these patients have a degenerative disease, simply that these patients are not themselves degenerate. In the face of pathology, even in sickness, we have the potential to be active creative agents. Music therapy emphases creative dialogue as an remedy in the face of a dialogic degenerative disease.35

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recognition of their abilities rather than pathologies, and a possibility for them to exercise their own agency.

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Positive changes are shown in patients’ depressed mood, which are also reflected in the self-acceptance scale. Given that patients with a chronic disease are also stigmatised,34 and this spoiled identity is further exacerbated by the concept of degeneration,35 then any intervention that improves mood and enhances selfacceptance is valuable in mitigating stigma. We know from the anecdotal literature that music therapy is important for establishing and recreating self identity.15,32,36 Perhaps we should not simply consider these diseases as neurodegenerative but as dialogue-degenerative diseases, where there is a breakdown in dialogue between the sufferer and the community. There were no recognizable changes in motor and functional abilities. The form of creative music therapy used here is efficacious for promoting a positive self-identity and relieving the emotional burden on a patient but not for improving functional abilities. Improvements in patients of the therapy group with regard to relieving anxiety and depression, and above all with regard to improved self-acceptance, are a consequence of the qualitative changes brought about in music-therapy encounters. The change in the subscale anxiety of the HADS-D in both groups may be an indication that regular professional patient care helps reduce depression in multiple sclerosis sufferers. Standard therapeutic practice is that patients only attend for contact with a practitioner or treatment when there is a flare up in symptoms. Being recruited into a trial and being regularly assessed is also perhaps an important variable for therapeutic contact. There is a worsening of the music-therapy group scale scores at follow-up when music-therapy treatment is withdrawn, particularly with regard to selfesteem. This may be argued as evidence of the temporary effect of music therapy or that music therapy does indeed have an effect and we see how the patient responds when the therapy is withdrawn. The importance of therapeutic contact is reflected in a qualitative analysis of the data. Two hundred and twenty-six music-therapy sessions were documented on video and evaluated with the help of episodes and generation of categories.37 What emerged from the qualitative aspects of the study were parameters concerning contact between therapist and patient, coping with the situation, the sharing of musical roles, and an ability to structure time and the possibility to initiate changes in play. These factors reflect the needs of these patients for a deeper personal contact, a

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16. Magee W. ‘‘Singing my life, playing myself’’: music therapy in the treatment of chronic neurological illness. In: Wigram T, Backer JDe, editors. Clinical applications of music therapy in developmental disability, paediatrics and neurology. London and Philadelphia: Jessica Kingsley Publishers; 1999. p. 201—23. 17. Magee W. Identity in clinical music therapy: shifting selfcontsructs through the therapeutic process. In: Miell D, editor. Musical identities. Oxford: Oxford University Press; 2002. p. 179—97. 18. Magee W, Davidson J. The effect of music therapy on mood states in neurological patients: a pilot study. J Music Ther 2002;39(1):20—9. 19. Rothwell PM, Dowell, Mc Z, Wong CK, Dorman PJ. Doctors and patients donˇıt agree: cross sectional study of patients’ and doctors’ perceptions and assessments of disability in multiple sclerosis. Br Med J 1997;314:1580— 3. 20. Sparber A, Wootton JC. Surveys of complementary and alternative medicine: part V. Use of alternative and complementary therapies for psychiatric and neurologic diseases. J Altern Complement Med 2002;8(1):93— 6. 21. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an Expanded Disability Status Scale (EDSS). Neurology 1983;33:1444—52. 22. Nordoff P, Robbins C. Creative music therapy. New York: John Day; 1977. 23. Aikens JE, Reinecke MA, Pliskin NH, Fischer JS, Wiebe JS, McCracken LM, et al. Assessing depressive symptoms in multiple sclerosis: is it necessary to omit items from the original Beck Depression Inventory? J Behav Med 1999;22(2):127—42. 24. Beatty WW, Orbelo DM, Sorocco KH, Ross ED. Comprehension of affective prosody in multiple sclerosis. Mult Scler 2003;9(2):148—53. 25. Feinstein A, Feinstein K. Depression associated with multiple sclerosis. Looking beyond diagnosis to symptom expression. J Affect Disord 2001;66(2/3):193—8. 26. Feinstein A, O’Connor P, Gray T, Feinstein K. The effects of anxiety on psychiatric morbidity in patients with multiple sclerosis. Mult Scler 1999;5(5):323—6. 27. Berger EM. The relationship between expressed acceptance of self and expressed acceptance of others. J Abnorm Psychol 1952;47:778—82. 28. Jiwa TI. Multiple sclerosis and self esteem. Axone 1995;16(4):87—90. 29. Gold SM, Heesen C, Schulz H, Schulz K-H. Disease speciﬁc quality of life instruments in multiple sclerosis: validation of the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS). Mult Scler 2001;7:119—30. 30. Prosser LA, Kuntz KM, Bar-Or A, Weinstein MC. Patient and community preferences for treatments and health states in multiple sclerosis. Mult Scler 2003;9(3):311—9. 31. Fischer JS, Rudick RA, Cutter GR, Reingold SC. For the National MS Society Clinical Outcomes Assessment Task Force (1999). The multiple sclerosis composite measure (MSFC): an integrated approach to MS clinical outcomes assessment. Mult Scler 1999;5:244—50. 32. Aldridge D. Music therapy research and practice in medicine. London: Jessica Kingsley; 1996. 33. Kriz J. Grundkonzepte der Psychotherapie. Weinheim: Psychologie Verlags Union; 1994. 34. Goffman E. Stigma. Notes on the management of a spoiled identity. Englewood Cliffs, NJ: Prentice-Hall; 1963. 35. Aldridge D. The creative arts therapies in the treatment of neurodegenerative illness. In: Trias G, editor. Music therapy

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We have used effect sizes here, although modest, to provide a platform for other studies that will no doubt improve on what we have attempted. This exploratory study has indicated the potential beneﬁts of music therapy as an aesthetic intervention concerned with the performance of self in everyday life. At some stage we will also need to consider multi centre trials.

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therapy traces. Music Ther Today (online). Available at http://musictherapyworld.net; 2002, December. 38. Schmid W. Music therapy with people suffering from multiple sclerosis. In: Trias G, editor. Music therapy and art therapy in neurodegenrative diseases. Barcelona: Fundaci´ on ‘‘la Caixa’’; 2003.

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and art therapy in neurodegenerative diseases. Barcelona: la Caixa; 2003. p. 37—46. 36. Aldridge D. A phenomenological comparison of the organization of music and the self. Arts Psychother 1989;16:91—7. 37. Aldridge D, Aldridge G. Therapeutic narrative analysis: a methodological proposal for the interpretation of music

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The challenge of creativity David Aldridge To make a challenge is both to claim and to accuse. It can also mean to invite or summon, to call into question, to make demands on, and is a call to engage in some sort of activity. This is what I shall be talking about in the course of this paper: how creativity challenges us to engage. I am also aware, however, that the word is related to Latin caluminia - the word we know as calumny, and that is to make a false claim. As soon as we talk about being creative, then, we are prey to hubris and the possibility of making claims for something that we perhaps do not possess. The modem meaning of creativity is to produce, to cause to grow, to cause to come into existence (from the Latin creare), and also means to be engaged in creative work. Yet, in earlier centuries, to make the claims of being creative would suffer the consequence of being branded a blasphemer. After all, there was only one Creator. It is thus perhaps as well to begin by reminding ourselves of this ancient wisdom; for 'creativity' can surely inflate the ego beyond the boundaries of what is reasonable. Creativity, the breakthrough moment of 'Aha' or 'Eureka', is common to both the arts and the sciences and the biologist, Konrad Lorenz reminds us that all discovery has the same origin.' Biologically and conceptually, the earliest phases are the same. Day by day our senses observe and our subconscious stores data and ideas that are shuffled into theories and hypotheses, ideas that eventually merge into consciousness like underground water emerges as a spring of consciousness or a fountain if it is channelled. The process of creativity is allied to how children acquire language. While they learn to use words, the epistemological process of knowing, thinking and deciding is not word dependent. Language comes late in the epistemological narrative. We know about the world by being in it. Experience is lived and only through living can we experience its significance. Our bodies know and therefore communicate a bodily sense of being here, but we create our knowledge as a process of being and acting in the world. How we describe that process - how that knowledge becomes expressed as words - is a part of the narrative. Eventually, when leaving those bodies, we must call upon another set of knowledge, which some of us refer to as spiritual. The soul has its own epistemology, its own way of knowing. Improvised music, then, is the consequence of this expressive stream that Contact 129,1999,3-11 C 3 Copyright Contact 1999

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comes before words. I shall return to this idea later when I consider dialogue. The challenge for counsellors and therapists is to promote the creative moment. It is more likely to occur in the prepared person than the unprepared. Or as the Sufi's say: the person has to be turning in this or her sleep. It's no use if they are asleep, they are better left undisturbed and if they are already awake, then there is no need to d o anything. How we understand creativity and how we bring that into our daily lives is a challenge - a call to engagement - and as we are talking here about working in the hospice, a call to engagement in the lives of others. Modem thinking about creativity concentrates less on the created product and emphasises more the process of creating. Rather than isolating the artist and the finished work, there is an emphasis on the artist and the spectator, or in many cases, the performer and the participator. We have then a move from an objective aesthetic, where objects are discussed, to that of a relationship. And it is here that we have the relevance for counselling and the creative arts therapies. It is this concept of relationship that offers a bridge to the consideration of intimacy.

Intimacy When we come to consider intimacy; then we have another word that is as challenging as creativity. Intimate denotes a warm personal relationship that is deeply personal, private or secret (from the Latin intitvtis - a very close friend - innermost, deepest). Because of the intimations of secrecy and closeness, the term has, in recent years, become euphemistic for a sexual relationship. It is this connotation that bring us difficulty in using intimate in its broader sense; for we have to explain with what we are becoming intimate. In therapy, as in friendship, it is the intimacy of two souls. For the dying, the body is being left behind, and the sexual creativity of reproduction is no longer appropriate. What is necessary is that closeness of human warmth where selves experience understanding. We need to be intimate with the other to come into dialogue, in that dialogue we experience ourselves through others. Creativity is that coming into being with another, being made new, the basis of which is intimacy. Again, we see how the idea of creating something new, that idea of reproductive fruitfulness, could easily be translated into a sexual understanding. And for those of us that have had the opportunity to work creatively, then it is that same vitality and excitement that imbues creative work whether it be artistic or scientific. This intimacy, like creativity as we read earlier, is not language dependent, it allows for the privacy and primacy of expression within relationship. It is not public like language and therefore not social in its broadest sense. Although to talk about it we have to translate that

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experience into language that is culturally dependent. The experience itself, the knowledge of the world, its epistemology, can be based upon sounds, smells, movements or images. Again, if we reflect upon the sensuality of experience, then we see how intimacy can easily be misinterpreted in terms of sexual connotation. In the intimate creative moment we can experience the consequence of being ourselves as we appear in a relationship. This enables us to express our inner potential for being, something new can emerge, and emerges in the company of another human being. I sometimes think, watching and listening to music therapy sessions, that this is maybe the first time that a person has had chance to listen to themselves, albeit through dialogue with the other. We see and hear ourselves reflected in and through the other and this is a central core of music therapy technique. Creativity and intimacy also have a relationship to prayer. If prayer is resting intimately in God, then what emerges as an answer to prayer is also an expression of creativity - something new emerging from an intimate relationship.

Dialogue When we engage communicatively with another then we partake in creating dialogue. A central feature of dialogue is the need to listen to the other. The 'other' is necessary because it allows a distance from narcissism and room for disclosure.* The self is opened up to the potential of 'what can be', where the power to speak arises at the threshold of intelligibility. The creative arts are the domain of this threshold of intelligibility, such that what can be expressed is expressed but not necessarily in words. Dialogue is the common logos (word) running through two persons together. We are thus endowed with a structure in which our expressions can find a mutual form. Discourse is always with others. We need the other to share the world with and thus experience the very consequences of our being. When we engage in dialogue then we are participating in a reciprocal engagement in truth. We allow something to be seen. We allow something to be heard. We avoid one-sidedness by listening for what governs the dialogue and that is the logic of the mutuality of the form. This is often expressed as harmony between people. Such harmony is not the pursuit of homogeneity but the search for tolerance where we endure the tension of self and other. Listening is important in dialogue because it is only be entering into the depth of human suffering that we can discern the potential for change. If we allow the other to disclose themselves, then we have the allowance of difference and the potential for an acceptance of the other. Unfolding ourselves in this space of reciprocity allows both distance and intimacy to emerge, whereby we can hear the distance between us. Such relationship allow for companionship, whether this is friendship or the more formal relationships of counselling and therapy. If we

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introduce the concept of silence into this world of relationship, then we leave behind the world and its public sphere and experience the other in privacy. Silence may be the primary realm where we experience the intimacy of conversation. From out of this silence, music and the creative arts can build bridges into a public world of language through varying media of expression. Inspiration The link between heart and the organs of sense is not simple mechanical sensationalism; it is aesthetic. That is, the activity of perception or sensation, in Greek is aisthesis which means at root 'taking in' and 'breathing in' - a gasp, that primary aesthetic response3 If we are listening, and listening at the deepest level, then we are taking in the other person, and it is this 'taking in' that is seen as being fundamentally aesthetic, which gives us a link to the arts therapies, but also provides us with a link to the concept of inspiration and creativity. Inspiration is often seen as a basis for those significant moments in our lives that we relate to being creative. The ancient Muses inspiring creativity, where transcendental knowledge was brought to human beings, achieved this by whispering, breathing and ~ i n g i n gIt. ~is this inspiration that seems to get the process of creativity going, where an expectant sensitivity of the imminent allows something new to emerge. Again, I would return us to the importance of silence, prayer and meditation for the creative process to begin. A feature of such conditions is an openness to other realms of perception that are sometimes referred to a synaesthetic and are invariably described as being vital and direct and rarely willed. Creativity then, which is not language dependent, takes place in an intimate relationship of mutual acceptance from out of which emerges something that is new. The possibility is of transcendence and that I shall be arguing later is the basis of hope, and hope is the spiritual force that drives our therapeutic endeavour^.^ Music therapy in t h e hospice Within the past decade music therapists have developed their work with people who have life-threatening illnesses and with those who are dying. Working together, in a creative way, to enhance the quality of living can help patients make sense of dying. It is important for the dying, or those with terminal illness, that approaches are used that integrate the physical, psychological, social and spiritual dimensions of their being6 In addition, how we care for the sick and dying, no matter how they contracted their disease, is a matter of our own personal responsibility and a collective measure of our humanity.

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Hospice care has met this multi-faceted challenge and creative arts therapies are being increasingly used in such situations. One of the concepts of hospice is to maximise the available quality of life for the terminally-ill resident? in the face of impending death. To achieve privacy for patients and their families, while optimising medical capability, has been a singular aim for many hospice planners. As part of this designed environment, the quality of art works and the aesthetics of the sound environment makes sense too, and this has led to co-operative initiatives between artists, musicians and clinical staff. Indeed, some clinicans believe that the physical environment has an impact on the treatment process and its outcome.' Such considerations are not new, in the ancient Persian system traditional forms of architecture were related to rhythms in music thus defining sacred spaces within the house as within the soul.8 Recently architects and artists have also taken up the challenge to meet the health care needs of patienk9

Creativity But why be creative, what are the value of the arts in such a situation? Surely modem science has enough to offer us at this time? There lies the difficulty, for although modem medicine uses a scientific basis for much that it does, there are also other perspectives on the world that art and religion bring. Indeed, William James criticises the scientific ways of viewing the world as colourless and lifeless and we need to develop a vivid face on the world.1Ă&#x201A; Enabling another to communicate is at the basis of the creative arts therapies. That this communication must not be words alone is at the heart of music therapy." However, whether we use words, vocal sounds or noises, we have a being in the world that is essentially articulated as form, and in the performance of this form - I should say forming - we give creation to that which is within us. When we perform music together, or articulate a poem, then the difference 'me' and 'the other' falls away, and that is perhaps the key to much of what we do as artist-therapists. But forming alone, as an active element, is not enough, there has to be a stuff of which ideas are realised. Music is sensuous. Tones have timbre and can be heard. It is in the forming of the sensuous that we find the creative act, whether it being making music, painting, sculpting or dancing. In another context I propose that our very identity is a work of art, akin to a piece of music that must be daily improvised.12Part of our work in life is to clarify that identity we have of ourselves, and to acknowledge that we need others. This principle is a basis of therapy, whereby one person helps the other to clarify their true self. That is why we also fall in love, so that our true self is realised by another. One knows oneself by being known by another. Finding out who we are is not simply asking ourselves the question 'Who am I?' but discerning

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our potential self in another. Thus, falling in love, or the creative intimacy of the therapeutic relationship, are chances we take with another to discover who we are. It is a basic act of recognition. Recognition in the creative act of coming into being and is fundamental to the mutual recognition of mother and infant.13 That is why creative intimacy is important for the therapeutic relationship but demands an awareness such that professional boundaries are not transgressed. A basic tenet of psychotherapy has been that therapists need supervision to manage such dilemmas of distance and is vital for the protection of both therapist and patient. Norman Fischer writes: Aesthetically the work of art creates a world with its own logic, one that is simply not dictated by the facts. The two ideas, a work of art with its own logic and of ethical principles that in reflecting on the world present reasons that are not in the world, are united through the common denominator of distance.14 This tension of intimacy and distance reflects the inner tensions of arts that are also therapies. There is an internal aesthetic that must comply to an external pragmatic; individual creativity conforming to a public expectancy within a helping relationship. This is the challenge of creativity in the arts therapies.

My friend George Each individual composes the music of his own life. If he injures another he breaks the harmony, and there is discord in the melody of life.l5

I would like to conclude with an example of how music, at the initiative of a friend who was dying, promoted various creative responses from family and friends. My friend George was diagnosed as having a chronic form of leukaemia. We were both at that time in our mid-thirties. We both had families, each having children of the same school ages, and we both were moderately successful in our careers in healthcare practice. All seemed rosy in the garden. We both liked to run. George, however, decided that he needed a challenge in his life and running a marathon would be just what he needed. So, to satisfy the race rules, he went for a medical check-up. Until then he felt well enough to run. Check-ups are dangerous. Something was very wrong with his blood, he discovered. Within days he was in hospital awaiting a bone-marrow transplant. Road runner to invalid in one fell swoop. In the hospital he couldn't sleep and asked me to help him with relaxation techniques and hypnosis that he was already acquainted with through his reading, not practice. These simple technique? worked, and when he was first released from hospital we talked about what other techniques could be used to combat what was to be a long and tiring series of treatments. I use the word combat here as that was

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exactly as George saw the task before him, an uphill struggle against an unseen enemy. That was his metaphor, a battle, and from that he gained strength. Through the following months we used guided imagery to bring about a progressive relaxation and to help him through the anxiety of the consultations and to motivate him through treatment. I worked closely with his haematologist and oncologist who too was interested in how we could address the many problems facing George as it became clear that the techniques to heal his bone marrow were without success. Each treatment would bring expectations and each set of tests would end in despair. George was a believer in technology and his beloved technology was letting him down. We also went to the same church and I guess his beloved God was letting him down too. At that time the local church was engaged in a healing ministry. Friends and family would work with the parish priest to visit the sick, to administer the sacrament of healing and to celebrate the Eucharist in the patients home. This was an ecumenical initiative that brought many people together within a small community. Some medical practitioners were actively supported as the parish served a local general hospital, others were sceptical but saw little threat from a wellmeaning laity. A contact with the local hospice was also encouraged as the healing ministry of the church offered a long-term contact before the acute stages of dying. George and his wife were pleased to have other congregation members into their home. While the future looked bleak, there was temporary relief and always the opportunity for him to talk about what was important at the time with his friends. This could be planning the future schooling of the children, the best possible diet for promoting energy, the meaning of the sacrament of the blood of Christ (to someone with leukaemia this has an urgent meaning), or what relaxation technique to use next. One day we knew that the bone marrow changes would not work. George was dying. His oncologist didn't know what to d o and I didn't know what to do. So standing awkward and helpless in George's living room one day, I had to admit to him that I was running out of ideas. Now, how do you say that as a practitioner of any persuasion? But it was true, and George was my friend, and that made it even more tragic. 'Why don't you sing for me', he said. At that time I had not heard of music therapy. I couldn't chicken out and ask for a music therapist. So, I sang. We sang. We were both fans of the English folk song revival and had similar record collections. From our common geographical backgrounds we enjoyed the robustness of the 'Watersons'. We could also belt out a convincing repertoire of Church hymns even though the words may not have been entirely correct and true to the original. In that moment, music brought us to another level of intimacy within a friendship that was important. If the reader has an image of boys in a choir then he or she will not be far wrong.

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We had of course prayed and meditated. I was teaching meditation techniques to other groups at that time. But music was something that we could d o together, the mutuality of listening and singing had an extra dimension. And it was in the use of songs that we could explore those feelings about our lives that we would not have addressed in conversation. As Englishmen, there were some things that we didn't talk about openly, like tenderness and vulnerability. Indeed, we had been actively encouraged not to talk about such things, particularly at school, as people would think we were sissy. Yet, such expressions were going to be vital because George had a family that needed his tenderness and he needed theirs in return. Expressing his vulnerability, previously disguised as irritation, would be an important milestone along his own personal way towards death. In a world where emotions are expressed publicly, it can all too often seem that only the loudest, coarsest expressions are appreciated. Yet many of us know that what contributes to our value is those feelings that are private and subtle. Music therapy, with its potential for the quiet and the delicate, as well as the loud and the coarse, lends itself to the exposition of that which we may call sublime. The church group coming to visit him also sang for him too. From these songs, George could plan his funeral and it was through these songs that we had our deepest personal memories of him. It was in song too that I could express to George what friendship meant to me and what happens when friends don't see each other any more. In song, we had both the possibilities for creating personal intimacy, of saying what lay upon our hearts. But there was also a social function of shared music. Family and friends could gather together and sing with him, there were the possibilities of expression already present in well-known songs that could be activated for those who were singing. Songs took George into the future of his funeral where he would be remembered, but we could also remember him too. Undoubtedly this helped us in our grieving. But there is another important factor in that when I hear those songs today I remember our friendship, George and his family, in all its depth and closeness. This reminiscence is also important for those who grieve and remain. Endnotes 1. See 11. Cavanaugh, 'The precursors of the Eureka moment ~1.sa c o m m o n ground between science and theology', Zy-fon 29,1994, 191-203. 2. See F. Schalow, 'Language and the roots of conscience: Heidegger's less travelled path', Human Studies 21, (1998), 141-156, pl43. . 1. Hillman, The Thought of the Heart, Dallas: Spring 1981, p31, 4. See T. Hart, 'Inspiration: Exploring the experience and its meaning', fonrriiil qf Hiiiiinuiftic Psychology 38, 1998, 7-35. 5. See D. Aldridge, 'Hope, meaning and the creative art therapies in the treatment of AIDS', The Arts in Psyc/iot/icrnpy 20. 1993, 285-297.

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6. See D. Aldridge, 'Families, cancer and dying', Family Practice 4, 1987, 212-218; D. Aldridge, Music therapy research and practice in medicine. From out of the silence. London: Jessica Kingsley 1996; A Greisinger et al, 'Terminally ill cancer patients. Their most important concerns', Cancer Practice 5, 1997, 147-154; ].A. Kotarba and D. Hurt,' An ethnography of an AIDS hospice: Toward a theory of organizational pastiche', Symb Interact 18,1995,413438. 7. See J-L. Gross and R. Swartz, 'The effects of music therapy on anxiety in chronically ill patients', Music Therapy 2,1982, 43-52. 8. L. Bakhtiar, Sufi: Expressions of the Mystic Quest. London: Thames and Hudson 1976. 9. See P. Scher, Patient-focused Architecturefor Health Care, Manchester: The Faculty of Art and Design, The Manchester Metropolitan University 1996. 10. See D. Capp, 'Erikson's "Inner Space": Where art and religion converge', Journal of Religion and Health 35, 1996, 93-115. 11. See G. Ansdell, Music for Life. Aspects of Creative Music Therapy with Adults. London: Jessica Kingsley 1995; K. Bruscia, Case studies in music therapy. Phoenixville, PA: Barcelona Publishers 1991; L. Bunt, Music therapy: an art beyond words. London: Routledge and Kegan Paul 1994; C. Lee, Lonely waters. Oxford: Sobell House 1995. 12. See D. Aldridge, Music therapy research and practice in medicine. From out of the silence. London: Jessica Kingsley 1996; D. Aldridge, 'Lifestyle, charismatic ideology and a praxis aesthetic' in S. Olesen et al. (eds), Studies in Alternative Therapy. Odense: Odense University Press 1997. 13. See D, Capp, 'Erikson's "Inner Space": Where art and religion converge', Journal of Religion and Health 35, 1996, 93-115, 14. N. Fischer, 'Frankfurt School Marxism and the ethical meaning of art: Herbert Marcuse's The Aesthetic Dimension', Communication Theory 7,1997,362-381, p377. 15. Sufi Inayat, Khan, The Bowl ofsaki. Geneva: Sufi Publishing Co. Ltd 1979.

David Aldridge is Professor of Clinical Research, Faculty of Medicine, Wittenmerdecke University, Germany

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New Reviews Editor We are delighted to announce the appointment by the Trustees of John Swinton to the post of Reviews Editor. We would also like to extend our grateful thanks to Andrew Jones whose term of office ended at the beginning of the year.

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The Arts in Psychotherapy, Vol. 18, pp. 359-362.

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REFLECTIONS CREATIVITY AND CONSCIOUSNESS: MUSIC THERAPY IN INTENSIVE CARE DAVID ALDRIDGE, PhD*

' . . however great the organic damage . . . there remains the undiminished possibility of reintegration by art, by communion, by blocking the human spirit; and this can be presented in what at first seems at first a hopeless state of neurological devastation." (Sacks, 1986, p. 37)

sidered. It raises questions about the location of the self in patients who are comatose, about the nature of communication with patients who are unconscious, and challenges medicine to realize the human body as an instrument of knowledge. Some aspects of modem medicine have become increasingly technological. Such is the case of intensive care treatment. Even in what may appear to be hopeless cases, it can save lives (Hannich, 1988) through the application of this modem technology. However, albeit in the context of undoubted success, intensive care treatment has fallen into disrepute. Patients are seen to suffer from a wide range of problems resulting from insufficient communication, sleep and sensory deprivation (Hannich, 1988; Ulrich, 1984), and lack of empathy between patient and medical staff. Many activities in an intensive care situation appear to be between the unit staff and the essential machines (i.e., subjects and objects). To a certain extent, patients become a part of this object world. Improvised music therapy can be a useful adjunctive therapy in such situations both for the patient and the staff.

The neurologist Oliver Sacks reminds us of the necessary balance we must bring to our work with patients in the field of medicine. All too often we are concerned with testing the patient for deficits, for measuring and for assessing problem-solving capacities. As a balance he urges us to consider the narrative and symbolic organization of the patients, so that we consider their possibilities and abilities. In this way what seems to be damaged, ill-organized, and chaotic becomes composed and fluent. This is the function of the creative arts; through art and play we realize other selves elusive to measurement and fugitive to assessment. Furthermore, there is a quality of time that is apparent in arts activities that is "intentional7' and involves the will of the patients where their spirits are set free. When we consider the situation of intensive care, where patients are often damaged, disorganized, intubated, machine-regulated, often unconscious, and unable to communicate, then we must consider a way of introducing activities that will stimulate communion with those patients. In this paper the ground of consciousness is con-

The Music Therapy Sessions At the suggestion of a hospital neurologist, a music therapist began working with patients in intensive

*David Aldridge is a research consultant to the medical faculty of Universit'at Witten Herdecke, Germany. He thanks Dr. Wilhelm Rimpau for the initiation of this work, Dagmar Gustorff for her pioneering of these skills in difficult conditions, and Professor H.J. Hannich for his providing the circumstances for the further exploration of this work. 359

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care (Gustorff, 1990). To investigate this approach further, the work was monitored in the intensive treatment unit of a large university clinic. Five patients, between the ages of 15 and 40 years, and with severe coma (a Glasgow Coma Scale score between 4 and 7) were treated. All the patients had been involved in some sort of accident, had sustained brain damage, and most had undergone neurosurgery. The form of music therapy used here was based on the principle that we are organized as human beings not in a mechanical way but in a musical form (i.e., a harmonic complex of interacting rhythms and melodic contours) (Aldridge, 1989a, 1989b; Nordoff & Robbins, 1977). To maintain our coherence as beings in the world we must creatively improvise our identity. Rather than search for a master clock that coordinates us chronobiologically, we argue that we are better served by the non-mechanistic concept of musical organization. Music therapy is the medium by which a coherent organization is regained (i.e., linking brain, body, and mind). In this perspective, the self is more than a corporeal being. As Sacks (1986) wrote, "the power of music or narrative form is to organize" (p. 177). What music and narrative structure organizes is the recognition of relationships between elements, not in an intellectual way, but direct and unmediated. With coma patients we see signs of activity, albeit often machine supported, but totally disorganized. The person exists, sometimes in what is described as a vegetative state, but hardly ''lives. " Each music therapy contact lasted between eight and twelve minutes. The therapist improvised her wordless singing based on the tempo of the patient's pulse and, more importantly, the patient's breathing pattern. She pitched her singing to a tuning fork. The character of the patient's breathing determined the nature of the singing. The singing was clearly phrased so that when any reaction was seen the phrase could be repeated. Before the first session the music therapist met the family to gain some idea of what the patient was like. On contacting the comatose patient, she said who she was, that she would sing for the patient in the tempo of his or her pulse and the rhythm of breathing. The unit staff were asked to be quiet during this period and not to carry out any invasive procedures for ten minutes after the contact. There was a range of reactions from a change in breathing (it became slower and deeper), fine motor

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movements, grabbing movements of the hand, and turning of the head, eyes opening to the regaining of consciousness. When the therapist first began to sing there was a slowing down of the heart rate. Then the heart rate rose rapidly and sustained an elevated level until the end of the contact. This may have indicated an attempt at orientation and cognitive processing within the communicational context (Nordoff & Robbins, 1977; Sandman, 1984a, 1984b). Electroencephalogram (EEG) measurement of brain activity showed a desynchronization from theta rhythm, to alpha rhythm or beta rhythm in former synchronized areas. This effect, indicating arousal and perceptual activity, fades out after the music therapy stops. If we consider that cells firing with a cardiac rhythm have been recorded in the medullary area of the brain, and that there is a synchronous relationship between the contraction of the heart and the "ascending" wave of alpha rhythm (Sandman, 1986) of brain activity, then it is possible to hypothesize that the rhythmic coordination of the cardiovascular system with cortical rhythmic firings is of primary importance for cognition. What we have is a weaving together of basic primitive human rhythms, which produce an interference pattern that itself may be that of cognition. It is proposed here that the rhythmic coordination of basic functions in the human body (Jones, Kidd, & Wetzel, 1981; Kempton, 1980; Kidd, Boltz, & Jones, 1984; Lester, Hoffman, & Brazelton, 1985;Longuet-Higgins, 1982; Povel, 1984; Rozzano & Locsin, 1981; Safranek, Koshland, & Raymond, 1982; Steedman, 1977) is a fundamental healing activity. The Ward Situation Sleep disturbance is a major problem in intensive care units and the effect of a disturbed waking1 sleeping rhythm upon other metabolic cycles is critical (Johnson & Woodland-Hastings, 1986; MooreEde, Czeisler, & Richardson, 1983; Reinberg & Halberg, 1971). The rhythmic entrainment of cardiovascular and somatic activities may be the key ground for recovery. This means that we must consider the total "behavioral" (Engel, 1986) activity of the patient so that seemingly independent systems are integrated. The context (i.e., Latin, con textere = weaving together) of this integration is rhythmical involving the coordination of the major tidal rhythms of the body and timing mechanisms within the hypothalamus in the brain.

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MUSIC THERAPY IN INTENSIVE CARE As an organizational problem, we must look to the ways in which staff are employed in work shifts. It can occur that patients throughout 24 hours are constantly in contact with nursing staff who are in their own activity cycle, no matter what time of day or night. For rhythmically disoriented patients, no wonder that there are sleep problems when they must respond to constant activity with caregivers who themselves are physically unsynchronized with the patient. Nursing staff, although synchronized with management needs and hospital routine, may need to attend to the sleeplactivity rhythm of the patient. In response to the music therapy, some ward staff are astonished that patients can respond to quiet singing. This highlights a difficulty of noisy, busy, often brightly lit units. All communication is made above a high level of machine noise. Furthermore, commands to an "unconscious" patient are made by shouting formal injunctions (i.e., "Show me your tongue," "Tell me your name," "Open your eyes"). Few attempts are made at normal human communication with a patient who cannot speak or with whom staff can not have any psychological contact. It is as if these patients were isolated in a landscape of noise, and deprived of human contact. A benefit of music therapy is that the staff are made aware of the quality and intensity of the human contact. In the intensive care unit environment of seemingly non-responding patients, dependent on machines to maintain vital functions and anxiety provoking in terms of possible patient death, then it is a human reaction to withdraw personal contact and interact with the machines. Although the machines themselves are of vital importance, they present data that are independent one from another, and that are often considered in isolation, whereas the integration of the systems being measured is the clue to recovery. This is further exacerbated by a scientific epistemology that emphasizes the person only as a material being and that equates mind with brain. At yet another level, we must consider the fixed chronological pulses of machines. If human activity is based on pulse, the nature of those pulses is that they are variable within a range of reactivity. Those pulses are lively and accommodate other pulses to form interacting rhythms. This is not so with machines; they are fixed in their range. Therefore, what is a variable in human activity (the tempo of varying pulses) becomes a constant in these patients. The task then is to introduce coordinated variety with the intention to heal, something that as yet machines

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cannot do. Perhaps the key lies in the fact that it is the consciousness of the therapist that stimulates the consciousness of the patient, and this consciousness is not divorced from the living rhythmic reality of our physiology. A period of calm is also recognized as having potential benefit for the patient. What some staff fail to realize is that communication is dependent on rhythm, not on volume. We might argue that such unconscious patients, struggling to orient themselves in time and space, are further confused by an atmosphere of continuing loud, disorienting random noise, and bright light. For patients seeking to orient themselves, the basic rhythmic context of their own breathing may provide the focus for that orientation. This raises the problem of intentionality in human behavior even when consciousness appears to be absent. Reflexes do not occur in a vacuum; they are conditional occurring in a context of other behavioral activity. If bodily systems are proactive, as well as reactive, then purposive behavior and consciousness may require the context of human communication to function. It is also vital that staff in such situations do not confuse "not acting" on the behalf of the patient with "not perceiving. " We can further speculate that the various body rhythms have become disassociated in comatose states and following major surgery. The question remains of how those behaviors can be integrated and where the seat of such integration is. It is quite clear that integration is an organizational property of the whole organization in relationship with the environment and not located in any cell or any one organ. The environment of the patient includes the vital component of human contact and there is reason to believe that the essential ground of this contact too is rhythmical. Communication, Contact, and Consciousness Improvised singing appears to offer a number of possible benefits for working in intensive care both in terms of human contact and promoting perceptual responses. Human contact as communication is a creative art form. Although what we know from machines is valuable, there are other important subtle forms of knowledge that are best gleaned through personal contact with the patient. Mindell (1989) took the courageous step of attempting process-oriented psychology with comatose patients, accompanying them on their great symbolic journey. The drama of

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our contact with such patients at a time of existential crisis points to a fundamental aesthetic of living systems creatively realized so that we, as artist therapists, can go beyond the confines of a soulless technology. This is not to deny that technology and its benefits, simply to remind us of our human intention as it is realized in art, play, drama, music. What we may also need to consider in future is not how to observe more, but how to question the quality of what we are observing and the premises on which this observation is based. In such situations of intensive monitoring and machine support, particularly in the case of comatose patients, we may ask of ourselves, "Where is the self of the patient?" Needleman (1988) reminds us that the power of scientific thought has been to organize our perceptions in such a manner that we can survive in the world. Hence the value of scientific medicine and instrumentation. However, he goes on to say that science has also neglected the human body as an instrument of knowledge and as a vehicle for sensations as direct as ordinary sensory experience, but as subtle as consciousness. He writes ". . . it is not simply the intellect which science underestimates, it is the human body as an instrument of knowledge-the human body as a vehicle for sensations as direct as ordinary sensory experience, but far more subtle and requiring for their reception a specific degree of collected attention and self-sincerity" (p. 169). The question still remains for us as clinicians and scientists when faced with a patient in coma or a persistent vegetative state, "Where is the person and how can I reach him or her?" and then for ourselves as fellow human beings, "Where am I?" What part of the therapist is contacting the unconscious patient? Could it be that if the musical form of our communication touches our patients, as singing, we can also attend to how we speak with the patients in their breathing patterns, and then attend to them with the very form of our own bodies. This ability to communicate with unconscious patients raises further the ethical issues of decisions about terminating life support when the brain and the person are no longer seen as one and the same entity (Mindell, 1989). When patients are not responding it may be that we are not providing them with the human conditions in which, and with which, they can respond. We as therapists are those conditions that are the context for healing to take place.

David Aldridge

References Aldridge, D. (1989a). Music, communication and medicine. Journal of the Royal Society of Medicine, 82, 743-745. Aldridge, D. (1989b). A phenomenological comparison of the organization of music and the self. The Arts in Psychotherapy, 16, 91-97. Engel, B.T. (1986). An essay on the circulation as behavior. The Behavioral and Brain Sciences, 9 , 285-3 18. Gustorff, D. (1990). Lieder ohne Worte. Musiktherapeutische Umschau, 11, 120-126. Hannich, H.J. (1988). Uberlegen zum Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaft, 13, 238-244. Johnson, C., & Woodland-Hastings, J. (1986). The elusive mechanism of the circadian clock. American Scientist, 74, 29-36. Jones, M,, Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic attention. Journal of Eqerirnental Psychology, 7 , 1059-1073. Kempton, W. (1980). The rhythmic basis of interactional microsynchrony. In M. Key (Ed.), The relationship of verbal and non-verbal communication (pp. 68-75). The Hague: Mouton. Kidd, G., Boltz, M,,& Jones, M. (1984). Some effects of rhythmic content on melody recognition. American Journal of Psychology, 97, 153-173. Lester, B. M., Hoffman, J., & Brazelton, T. (1985). The rhythmic structure of mother-infant interaction in term and proterm infants. Child Development, 56, 15-27. Longuet-Higgins, H. (1982). The perception of musical rhythms. Perception, 11, 115-128. Mindell, A. (1989). Coma: Key to awakening. Boston: Shambala. Moore-Ede, M. C., Czeisler, C. A., & Richardson. G. S. (1983). Circadian timekeeping in health and disease. New England Journal of Medicine, 309, 469-479. Needleman, J. (1988). A sense of the cosmos. New York: Arkana. Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day. Povel, D. (1984). A theoretical framework for rhythm perception. Psychological Research, 45, 315-337. Reinberg, A., & Halberg, F. (1971). Circadian chronopharmacology. Annual Review of Pharmacology, 11, 455-492. Rozzano, G., & Locsin, R. (1981). The effect of music on the pain of selected post operative patients. Journal of Advanced Nursing, 6 , 19-25. Sacks, 0. (1986). The man who mistook his wife for a hat. London: Pan. Safranek, M., Koshland, G. & Raymond, G. (1982). Effect of auditory rhythm on music activity. Physical Therapy, 62, 161-168. Sandman, C. (1984a). Afferent influences on the cortical evoked response. In M. Coles, J. Jennings, & J. Stem (Eds.), Psychophysiological perspectives: Festschrift for Beatrice and John Lacey. Stroudberg, PA: Hutchinson & Ross. Sandman, C. (1984b). Augmentation of the auditory event related to potentials of the brain during diastole. International Journal of Physiology, 2, 111-1 19. Sandman, C. (1986). Circulation as consciousness. The Behavioural and Brain Sciences, 9, 303-304. Steedman, M. (1977). The perception of musical rhythm and metre. Perception, 6 , 555-569. Ulrich, R. (1984). View through a window may influence recovery from surgery. Science, 224, 420421.

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Notes on the Phenomenon of "Becoming Healthy": Body, Identity, and Lifesfyle David Aidridge

Being "healthy," like being "creative," musical,^' or "spiritual," has become, for many, a part of their "lifestyle." What's more, health is often seen as a matter of the individual self working on the body. l l i s means, in effect, that our bodhs often become our selves. ABSTRACT In modem timesl health is no longer a state of not being sick. Individuals are choosing to become healthy and, in some cases, view themselves as pursuing the activity of being well. Being recognized as a "healthf' person has become an-important feature of a postmodem identity. Rather than seeing people adapt strategies of personal health management in response to sickness, we see them strive for health through an assemblage of activities like dietary practices, exercise practices, aesthetic practices, psychological practices,.spiritual practices. As a result of this individual~m,in which people demand an active role in their own health care, health is emerging in modem society as a commodity that expresses personal worth, social values, and existential principles.

I. The New Big P i c t u ~ In modem times, health is no longer a state of not being sick. Individuals are choosing to becm healthyl and they often present themselves as people pursuing the activity of being well. The change from attributing to oneself the status of "being sick" to engaging in the activity of "becoming well," is one aspect of a modem trend in which individuals choose to define themselves rather than accept an identity imposed by others-their culture, societyl COI~UXIUN~.

David Alddge, Ph.D., is a pmfessor of Clinical Research Methods at the Univmitdt Witten

For a sizeable number of people, being recognized as a "healthy" person is an important feature of a postmodem identity. Being "healthy," like being ''creative," "musical," or "spiritual," has become, for many, a matter of "lifestyle" (Fumham 1994). Today, instead of just seeing strategies of prsonal health management in response to sickness, the usual approach to health (Aldridge 19941, we see an assemblage of activitiedietary practicesl exercise practices, aesthetic practices, psychological practices, spiritual practicedesigned to promote health and prevent sickness. This shift away from authority and orthodoxy toward democratization and choice reflects a change from a belief in the certainties of science and religion to a relativist position in which people "make up" their own minds and work on their own health. The ideas of health and of being healthy are complex, of course. Nonetheless, today health is most often thought of as being located within the body, albeit lip s e ~ c is e paid to the mind. Health is not usually seen as an effect of social policies, or an expmssion of a person's relationship to a spiritual power. It is most often a matter of the self working on the body. In the process, our bodies often become our selves. Many examples show how the body has become the focus of the modern notion of health. As one illustration, consider, for men, the muscular body of body builders. White and Gillett (1994) see male body building as a reaction to the erosion of power that men feel in the face of emancipatory forces challenging the ideology of gender difference. In the rhetoric of body building, the muscular self-madebody, developed through techniques (diet and training) and display, is seen as natural and socially desirable. To its owner, it conveys a feeling of superiority and expresses an approved image of the body, thereby bringing coherence and meaninsz. ', Of coursel not everyone celebrates the developed body. Some find it offensive. This is the nature of "lifestyles." Still, the developed body represents in a highly dramatic way, the manipulation of the body to achieve a standard of health. It also illushates the problems of viewing health as an individual matter. As White and Gillett (1994) write: "E3ecausereal power is located in economic and political struckml body building constrains the construction of identity to the pursuit of self-as-commodity. And, ironically, the elusiveness of the muscular ideal makes the self-hansformation process . . . a self-disciplinary dream rather than a lived reality."

Herdeck W'ittm, Germany).

David Aldridge

Aesthetics and the body

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In the writings of many health care practitionersf particularly in alternative medicine, health is seen in terms of an individual being "balanced" in a kind of ecological context. This attitude reflects the romantic notion of an individual relating directly to the cosmos. comparable considerations hold for women who are fat. Erdman (1994) observes that size and shape are i n t l u e n d by cultural aesthetic factors put forward both by the media (in terms of fashion and leisure activities) and by medicine. She reminds us that the "fat is bad" perspective is a madem socially constructed reality that links women's selves with the look of their bodies and that ignores evidence showing that fat is healthy. Erdman notes that the body is regularly used to evaluate personal worth and characterl and that the ideal body size varies fmm epoch to epoch. In terms of today's evaluation of fat, she calls for information showing that fat people do not eat more than thin people; that they can be healthy and that health benefits may accompany being fat; that weight is not always controllable by diet; and that fat people are as emotionally diverse as thin people. Body size and shape are aspects of personal identity, and how the body is interpreted-in what one might call the aesthetics of health beliefs-helps give both men and women a sense of who they are and how they should behave. (Such health beliefs also play an active part in how we mgnize illness and what we recognize as illness and the therapy we choose to beat it [Aldridge 1!292].) symbolic meanings-the bridge ktween cultural and physiological phenomena-are the loci of power within which &ess is explained and conklled. In the move from authority to lifestyles, such loci are now shifting from trained health professionals to increasingly better-educated and healthanscious consumers. I write fmm E m p e l and herel as a consequence of the collapse of state socialism and the challenges to traditional authority, many people no longer find it possible to think of themselves as relating to a given social order. The writings of many health care practitioners, particularly in altemative medicinel rarely express the idea that health care (or spiritual well-being) has a social dimension that benefits communities. Insteadl health is seen in terms of an individual being "balanced" in a kind of ecological context. This attitude reflects the romantic notion of an indi-

David Aldridge

vidual relating directly to the cosmos (Tsouyopoulus 1984). Broadly speaking, individuals are seeking to b a t themselvmtheir bodies, primarily-with an eclectic health strategy that includes a wide palette of activities. They do this with the support of chosen infonned advisers who fulfil1 the role of facilitators. In the process, health care consumers are blumng the role between traditional health care s e ~ c e s delivered , at times of crisis, and preventive strategies based on consumerism.

11. Making Health Care a Commodity As health care initiatives respond to consumer demand (Aldridge 1994), health becomes a commodity. In a general way people always choose how they wish to maintain and promote their own health. But now they are moving outside the socially established boundaries of medicine. Much of the new demand for health care options enters on what is currently regarded as "complementary" or "altemative" medicine. One probable reason for this development is that complementary practitioners accept a patient's involvement in his or her own health care. Other possible reasons are that complementary therapies frequently involve a psychosocial approach to health problems, and that the patient's search for health is understood in terms of reasons and intentions and not just a matter of an ill body. According to Downer and colleagues (19941, there is a turning away fmm orthodox medical care because of dissatisfaction with what might be called its singlemindedness and a paralld demand for the mixed pluralistic health care and the psychological benefits of hope and optimism found in complementary approaches. There is not so much a crisis of l i s t e ~ n gon the part of the orthodox doctor, as is often claimed, but rather a dissatisfaction with what the doctor embodies. It should be noted that in the patient's search for h a b e n t , formal health care delivery often comes late in the chain of decision making. It is only health professionals who emphasize the formal health care network-that is, a "top down8'approach. In a consumer-based approachl health care is determined by the needs of the users-that is, a "bottom up" approach. Today, in Europe at least, health care decision makers are considering how to deliver health care in a pluralist culture that acknowledges modem scientific, traditionall and comple mentary medicine. A consumer-based health plan that emphasizes choice and includes alternative medicines will be necessary to encourage

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111. Meditation as a Consumer Activity for the Body W~ththe pressure of individual choice, and the secularkation of what were once traditional medical disaplines, we find an increasing interest in techniques of health care that are available to both the lay public and professional practitioners-that isI techniques that are not the sole prerogative of clinicians to dispense. This situation is perhaps best exemplified by the modem practice of meditation, which has been lifted from its traditional context and made to serve the body. Meditation is the central plank of several ancient spiritual disciplines, particularly those arising in the fist. In the case of traditional Buddhist practicesI for example, meditation has played a significant role in a master's guiding of a novice. We should note that in almost all the ancient traditions, both teacher and pupil, monk and novice have been male, and the content of the teaching has not been negotiated, but firmly based on fixed disciplines of practice and embedded in ritual. Meditation, traditionally, has been located in a cultural context that determines waking, sleeping, eating, postureI clothing, and physical appearanceI all with the aim of controlling the pupil's mind and promoting the aims of spiritual enlightenment. In many modem Western altemative health care initiativesI meditation is removed from such a context of spiritual disciplineI and is secularized. While some p u p s and individuals claim that they are "spiritual" in that they use meditation, more usually meditation is used as a mindbody technique without any reference to spirituaipracticeI A recent book, Mind-Body Mdicine, subtitled How to Use Your Mind fir Better Health (Goleman & Gurin, eds. lW3), produced by the publisher of this pumalI the Fetzer Institute {renowned for i& contribution to the mind-body debate) in combination with Consumer Reports Books, provides ample material of the -1arization of meditation. Although meditation is frequently discussed in the b&k by different contributors, it is never discussed by a spiritual teacher. Of the 33 contributing authorsf all but one are trained in medicine or psychology. The one eccentric author is a free-lance writer concerned with health psychology and promotion. The general attitude towad meditation is suggested by a one-sentence comment of the editorsIDaniel Goleman and Joel Gurin. In an ADVA~CESThe Journalof Mind-Body Health

David Aldridge

There is a turning away from orthodox medical care because of dissatisfaction with what might be called its single-mindedness. The problem is not so much a crisis of listening on the part of the orthodox doctor, but rather a dissatisfaction with what the doctor embodies. introductory chapterf they unself-c~nsciously note: "It costs next to nothing, for example! to leam the 'relaxation responsen-a basic method of meditation that is now used to treat a range of physical problem." What was once a spiritual practice to escape the self is here seen in terms of the physical benefits of an overtly psychological tethnique (reduced to the one form of the relaxation response), mamed to the benefits of cost effectiveness.' I n a chapter on the relaxation response by its developerIHerbert Benson (whose h k I The Rehmtion Respnse [1976], the editors report, is still "the self-help book most often prescribed by American psychologists''), the relaxation response is seen as a stress-reducing phenomenon regulating the "physiological machinery" of the body (Eknson 1993). The response was originally part of a meditation technique. Now the biological effects of the response have been elevated to a central position, relegating the mind to an epiphenomenon and excluding any considerations of spiritual development or cultural relevance. The-sole purpose d the response is to maintain biological regularity in what is always a potentially challenging environment. When Benson refers to other techniques of meditation, he again only considers the biological effect: "Rather than practicing transcendental meditation, individuals simply repeated the number one on each exhalation and passively disregarded any intrusive thoughts. As we dicted, we found changes that were indistinguishable from those of earlier findings with transcendental meditation." The editors also reduce disease prevention to individual choice. They write, "One reasonable alternative, among many [to the current health situation] is to emphasize disease prevention by encouraging a healthy lifestyle-including mindbody methods-particularly for group of people at risk for specific disease." Thus, disease prevention is taken from its former context of community health care and is both individualized and psychologized amongst an unspoken plurality of opportunities, even while the language retains the paradigm of modem scientific medicine, that there are groups at risk for specific diseases.

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In modern descriptions of alternative healing, the body is a stage on which the chosen self and its interad'on with culture &wess thetnselves. Coqvoreality bkomes spirituality. The circle closes upon itself, body and soul are indeed united. As for prayer, Benson recommends that religious patients use a prayer when they elicit the relaxation response and that nonreligious patients use any sound or phrase with which they are comfortable. The idea that prayer may have a content, or indeed a focus, is nowhere discussed. That the relaxation response may be a more powerful tool than the author recognizes is sugg&ed by an anecdote he tells concerning Xbetan Buddhist monks. "In an amual ritual, these monks shed almost all of their clothes, wrap themselves in icy sheets on a near-freezing night, and proceed to enter a state of deep meditation. . . . By doing this they are able to raise their skin temperature to levels warm enough to dry the sheets." That this technique may not be an isolated incident and may be part of a meaningful set of practices, other than self-laundry is not considered. The relaxation response, as a subset of meditation techniques, is used here like other "body" mastery techniques, such as body building, exercise, and dieting, to gain and demonstrate extreme control in the face of that modem peril, "stress." Indeed, it is seen as a "natural" response and the opposite of stress. Human beings, then, in their natural state, constitute a collection of physiological responses.

I n another chapter, Jon Kabat-BM, director of the Stress Reduction Clinic at the University of Massachusetts Medical Center, d&cribes the health benefits of the ancient Buddhist practice of mindfulness meditation (Kabat-Zinn 1993). While the emphasis is on the techniques of mindfulness, the ultimate secular goal is that of stress duction. The author describes an eightweek program in which inner strengths are .mobilized and behavior changed. While he notes that mindfulness is a complex disapline, the focus of the chapter is on ihe partiGpants as patients and on the capacity of the practice to ameliorate specific illness problems, for example, the relief of chmnic pain. "Preliminary clinical studies suggest," the author writes, that the mindfulness training program can "improve a range of physical symptoms; reduce pain, depression, and anxiety; enhance feelings of trust and connectedneis; and help motiiate 54

David Aldridge

patients to take better care of their health." Other benefits of this psychological approach are "increased trust and oneness, along with other positive psychological changes" and "a profound change in people's outlook on themselves in relationship to the world." In a world where people are suffering, where they are isolated and demoralized, this plan appears to replicate the positive goals of the prayer p u p s suggested for the elderly in the black coinmunity (Aldridge 1993), albeit expressed in different terms. The marginalized, the sick, and the lonely are encouraged to pin a p u p , whose aim is to motivate them to take care of themselves. Identity is c o n f e d by positive action. The chapter ends with the following comment: "Mindfulness meditation involves a significant commitment to oneself. More than a technique, it is really a way of life. Many of those who practice it find that it can deeply enhance their mental and physical well-being. As one patient who is HIV-positive put it, Mindfulness gave my life back to me."' These sentences envision no commitment to a community of fellow believers, nor any acceptance of a taught doctrine; instead, they express only a commitment to self as lifestyle. What is ironic about this romantic notion of individual freedom, with its emphasis on individualism in terms of beliefs, desires, and practices, is that it is occurring at a time of social fragmentation and reorganization. More important, however, is the point that while particular psychological techniques are borrowed from spiritual traditions, within today's context of cultural insecurity the body of the person becomes the vehicle for expressing one's beliefs and desires.

N.Health in a World of Choice It is clear that in our modem cultures, several belief systems operate in parallel, and can coexist. In regard to health, patients have begun to demand that their understandings about health play a role in their care, and practitioners themselves (some of them) are making efforts to learn about complementary perspectives. Health and disease are not fixed entities; they are concepts used to characterize a process of adapting to the changing demands of life and the changing meanings given to living. Negotiating what counts as healthy is a process we are all involved in. We negotiate as well the forms of treatment, welfare, and care that we choose to accept as adequate or satisfactory (Aldridge 1990). The question is: What is the context within which this negotiation occurs? To glean an answer, we need to cast a wide net.

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OBSERVATIONS with the questioning of hierarchical orthodoxies#there has been a diminution in the established ritual practices that reflect a social order. Indeedl as I have notedl in some circles of discoursel ''social" no longer appears a valid term, being supplanted by the term ecological. (I-Iowever, the ''ecology of the mind" explicated by Gregory hteson [l9721 is rarely mentioned in modem alternative healing textsl mind being firmly located within the personal self. A supposed rejection of Cartesian dualism by the writers of su& texts onJy s e ~ e to s emphaiize that duality.) Spickard (1994) reminds us that modem people construct their identities from various sources. Modem identity is eclectic, composed from a palette of cultural altematives. As in the age of Romanticism, when revolution demanded a new way of being, the primacy of the perceiver is once more being emphasized. Subjectivity becomes paramount, an emphasis that reifies the individual at the same time that it creates the risk of isolating the individual by an overcommitment to subjectivity. Similarly, while postmodernism is perhaps itself characterized by a revolt against authority and tends toward selfreferentiality, its very eclecticism simultaneously leaves the individual valued but exhausted of significancewhat Gergen (1Wl) refers to as "the saturated self." B-ster-smith (1994) suggests that the inflated potential for self-hood that becomes possible when one is dislocated from traditional value sources increases the potential for despair, and while some individuals rise to the challenge of pluralism, others pin p u p s that offer reassurance in the form of an orthodoxy of beliefs and actions. The danger in modem Europe is that the romantic notion of individualism becomes perverted into nationalism as the dislocated individual seeking to construct his or her own identity pins a p u p intent on limiting the freedom of others to define themselves. Consensus is fragile in a context where individual demands are reified. If the self in modem society is always being constructed to meet the variety of life's contingencies#we move away from h e model in which one generation initiates the next generation into the truths of established beliefs. Insteadl there is a p 1 of experts and advisers to whom we can tum when coktructing a system of beliefs. In some modem alternative healing approachesl traditional forms of teaching by initiation and of learning by discipline are rejected in favor of an eclecticism that takes techniques and locates them within a set of meanings improvised according to the situation. This action itself is political. Rejecting given orthoADVAN-

The Journal of Mind-Body Health

David Aldridge

What most health professionals singularly fail t o see is that our current thinking about health is dominated by a medical thinking that ignores much of the reality of the people w e intend t o treat and support. doxies and demanding freedom to engage in the project of realizing one's "self" is a "politics of life-decisions concerning life-styles'' (BrewsterSmith 1994). The notion of lifestyle is critical in describing modem approaches to health care use and its delivery. No longer is there a given human nature. Insteadl the self-interpretingpractice of being human enables us to h&e vi$ng natuqes. It follows, then, that the activity of healing is not fixed on a single accepted orthodox worldview but allows for the possibility of r e p lady interpreting the self as new. In modem descriptions of alternative healing, for example, the body is a stage on which the chosen self and its interaction with culture express themselves. Corporeality becomes spirituality. The circle closes upon itself, body and soul are indeed united.

V. The Task of Practitioners If the b "i narratives ~ of modernism are now being replaced by individual sets of meaning made locally with the particular people with whom one seeks to live (Warde 19941, then, as practitioners, we need to understand more about the person who sits before us in our consulting m m . How that person creates an identity will suggest how that person will resolve his or her problems. How that person wants to be identified will guide his or her health care activities. Some people will seek medications, others will imbibe herbal preparations, others will want to be physically manipulatedl others will want to be psychically manipulated, others will exchange energies both subtle and cosmic, some will search for the laying on of hands in a ritual way (whether from a medical doctor or a spiritual healer, each of whom q u i r e s a brand of faith), some will sing to relieve their souls, others will jog for the "heart's" content. Each of thesel the body builder and the disciple, the artist and the atheist, the athlete and the allopath, will demand that the practitioner recognize who and what he or she is as a person, and base treatment decisions on that recognition, The route to treatment will be guided by an itinerary pertinent to personal identity. Health is something that is done, a performing art.

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Today, health is an activity that has sensual ramifications that are associated with pleasurable activities that are themselves integrated with an overall sense of "lifestyle," all of which has little to do with standard exhortations to follow health care prescriptions. What most health professionals singularly fail to see is that our current thinking about health is dominated by a medical thinking that ignores much of the reality of the people we intend to treat and support. Few people, when they are sickl immediately respond by seeking a health care practitioner (Andersen 1995). Certainly even fewer consult a health care practitioner about staying healthy. As researchers acd practitionersI our focus suggests why. Outside of the formal setting in which we think about the lofty matters of health, wel like other people, eatl drinkl amuse ourselves, love o& nearest and dearestI walk the dog, chase pieces of leather a m s s field (a skill of both dogs and football players)-without thinking of the possible medical consequences of such activities. The fact is, our health care assumptions may be so n a m w that they have little relevance for others who do not bow down at the altars of epidemiology and empiricism. Contrary to the approach of established medicine, many lay appraisals of health care activity are based on holistic considerations that include feelings of m& and vitality (Anderson & Lobe1 1995).

If established medical practitioners ignore changes of mood (or only acknowledge the moods that might be potentially pathological), and if modem scientific medicine generally regards the philosophy of vitality as invalid, then we should not wonder that fewer people come to us for help. Ifl as for example in haditional Chinese medicineI health seeking becomes a pleasurable activity, so as to support "a body that cannot only taste sweetness but be sweet, not only report painful symptoms, but also dwell on and cultivate the quiet mmforts of health" (Farquhar 1994)#then maybe we can understand that the seeking of a positive identity in a postmodem world is an activity that can be enjoyed without experts and the grand narratives of science and medicine. We may indeed have to leam to seek out those personal and local truths that our patients am themselves choosing to embody.

David Aldridge

VI. Self and Society It may appear in the preceding obsemations that I have set self against society, and have chosen society. In one sense this is true. I worry about the overemphasis on the self. But in another sense, I am merely describing an historical shift. The last decade of the twentieth century has seen a change in the relationship between self and society. The individual is becoming disconnected from a traditional commitment to society. There is a disenchantment with the collective#and a new type of commitment is being seen (Wade 1994). Individuals are being socialized in a postmodern society as consumers with a choice of lifestyles. Lifestyle has become a kind of commodity. While on the one hand, our autonomy is restricted in the field of employment (if we can find employment), how we choose to define ourselves and with whom we choose to define ourselves are matters of personal freedom. An anomaly of this situation is that personal perceptions of health, well-being, and life satisfaction may be at odds with a health professional's assessment of an individual's health status ( A l b ~ c h1994). t Still, promoting and maintaining our health is one area of choice in the plethora of consumer activities intimately related to our identity. The body builder, eating efficiently for the production of a body mass, will consume differently than the computer freak who surfs the intemet and eats fast food for a fast lifestyle. Both will differfrom the jogging yogurt eater who consumes vegetables to purify his or her material self and meditates for the salvation of the planet. A11 of these people may work in the same office in your municipal building.

1 would like to consider three issues of health care in relation to the arguments I have sketched here. The first area concerns AIDS educational campaigns to encourage safe sex among gay men. Such educational material has assumed that there is an homogenous culture to which gay men belong and that behavioral change will follow as a logical consequence from reasoned exhortation. Gold (1995) argues otherwise. The encouragement to have safe sex, Gold argues, overlooks the reality of hedonism in sexual contact. For some gay men, the constellation of sexual gratification, recreational pleasure, and the maintenance of a particular lifestyle, tied-up as it is with a gay identity, does not have health care as a principal strategy for living, even in a climate of AIDS prevention. Human beings live with optimism and zest, to enjoy life, not necessarily io prevent illness. Any interventions

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OBSERVATIONS aimed at changing behavior in gay men to pmmote a safer-sex culture will need to accept that there are p u p s of men with differing lifestyles and expectationsl and some men may not be benign and benevolent toward a wider community. A second issue alluded to earlier, comes from the field of dieting and exercise as they relate to body shape. Females in Western industrialized cultures are now expressing concern about their bodily shapes and are actively engaged in altering how they appear. The female body is the interface between the woman herself! as a person, and her social identity. Feelings about the self are related to feelings about the body and how that body appears to others. Slimness has become popularly d a t e d with elegance! selfantmll social attractiveness, and youth @umhamllitman & Sleeman 1994). Such associationsare alm key elements in the sales pitch of many consumer products. While personal lifestyles of dieting for fitness and presenting a powerful potent body may be health enabling, these very activities, paradoxically, are involved in the generation of eating disorders. The encouragement of excessive individualisml while promoting autonomy, may be at the expense of a woman's integrity as a whole person. She is comected to a set of cultural values that threaten to destroy her health when discomected from the relations that may offer a social meaning to her personal identity. Excessive emphasis on the individual body as dislocated from the social body is reflected in the egoism that Durkheim argued was a classic source of suicide Warde 19941.) A third issue is concerned with cigarette smoking in the young. While educational campaigns to curb adult smoking has had a considerable impactl campaigns have failed to make any impact on the prevalence of young smokers (Lynch 1995). Lynch argues that this failure is because educational campaigns singularly fail to understand the reasons why young people smoke. These reasons may not be homogenousl and certainly will not follow the causal sensible lo@cof most health care professionals. Image is seen as a powerful factor in influencing smoking behavior! as is the need to be "an individual." Thus, campaigns aimed at curbing enpyment, emphasizing a sensible conformity to an artificially constructed larger p u p of adolescent smokers falsely assumed to be homogenous, will be doomed to failure.

In these examples, we see that hedonism, the enpyment of the body, the maintenance of a self-image! and pursuing an active! seemingly healthy lifestyle! can be health promoting but! in some instances, can be deleterious to health. The A D V A N m The Journal of Mind-Body Health

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pursuit of excessive individualism may lead to a disentanglement from social relationships that are vital to maintaining checks and balances to counter extremes of possibly deleterious living. There is no easy reconciliation of this problem. The ramification of all this for health care is that instead of a top-down approach in promoting health care, we must consider targeting interventions aimed at small p u p s in which individuals are embedded. Even within church p u p s we know there are small p u p s of individuals who have differing interpretations and adopt differing lifestyles (Spickard 1994). w e have to understand how people "do" their lives, not simply what they think and say about their lives. It is in the body that individual identity is expressed today, and the body is the interface between the individual and society. It is what\peopledo together that binds them to the groups with whom they "perform" their lives. This performance is wrapped up with lifestyle, leisure activities, exercise, dieting, dress, In this sense, 'lifestyler'-making sense of the world-is not something that canbe read about in books. It is an activity. Swimming cannot be learned by reading about it, or by gathering a band of expert swimmers to tell you about their experiences, nor by attending a conference of hydiphysicists. At &me time we have to jump into the water and through experience swim. The body grasps what it needs to do, though having a teacher in the water certainly helps. So too with health and a change in "lifestyle." If we wish to encourage people to do something differently, we have to understand that the process will be intimately comected with their identities as individuals and with the people who validate the identities. Change is brought about by influencing small p u p s and understanding their way of being in the world. To this must be added the point that health care professionals are no longer the p u p with whom our patients wish to identify-and with the rates of suicide, marital disruption, and drug abuse among healthy professionals, who can blame them. One factor that we must take into account is that the serious business of living can also be fun. While we know a lot about health care activities and their impact, we know little about the importance of leisure activities and their ramifications for health. Positive emotions! according to new thinking, influence our health status for the better. Optimism and a sensual pleasure in everyday activities and situations are valuable for promoting personal health and the absence of symptoms, while a sense of -

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OBSERVATIONS enpyment, coupled with a zest for living, appear to play a significant role in the subjective assessment of health (Wenglert & Rosen 1995). To repeat, health is an activity that has sensual ramifications that are associated with pleasurable activities that are themselves integrated with an overall sense of "lifestyle," all of which has liffle to do with standard exhortations to follow health care ~rescri~tions. ' How such optimism and sensual pleasure is passed on to those living in poverty will be the proving p u n d of the postmodernist argument and its reification of individualism. That the poor may continue to smoke and drink as -ature comforts in a harsh world may lend credibility to the argument that sensual pleasures and leisure activities, even when there is no work, are important arbiters of health care activity as it relates to daily living. $

REFERENCES Albrecht G. 1994. "Subjective Health Assessment." In: Measuring Health and Medical Outcomes. Jenkinson C (d.) b. n d o m UCL Press. Aldridge D. 1990. Waking and Taking Health Care Decisions." Journal of the R q a l Society of Medicine. am-3. Aldridge D. 1992. 'The Needs of Individual Patients in Clinical Research." Advances. &M. Aldridge D. 1993. "Is There Evidence for Spiritual Healing?" Admnccs. 94-21,824 Aldridge D. 1994. "Unconventional Medicine in Europe." Mcunccs. 10:52-60. Andersen JO. 1995. "Lifestyles, Consumption and Alternative Therapies."lNRAT International Seminar M a d 29-22. Tmnse, Denmark. Andersen M & b b e l M. 1995. "Predictors of Health Self-appraisak What's Involved in Feeling Healthy?" Bask and Applied %&l P ~ ~ ~ h ~ 16:lZl-36. logy. Bateson G. 1972.Steps to an Ecology of Mind. W Ballantine. Eienson H. 1993. "The Relaxation Response." In: MindBody Medicine. Goleman D & Gurin J (eds.). NY consumt?l Reports Books. Brewster-Smith M. 1 W . "Selfhood at Risk: Postmodern Perils and the Perils of Postmoder~sm." A m ' c n n Psychologist. 49:4&11. Downer S, Cody M,McCluskey P, W~lsonP, Arnott S, Liiter T & Slevin M.1994. "Pursuit and Practice of

Complementary Therapies by Cancer Patients Receiving Conventional Treatment.'' British Medical Journal. m 8 6 - 9 . Erdman C. 1994. "Nothing to Lose: A Naturalistic Study of S i Acceptance in Fat Women." In: Ideals of Feminine Beauty. Philosophical, Social, and Cultural Issues. Callaghan K (d.). Westport, CE Greenwood Press. Faquhar J. 1994. "Eating Chinese Medicine." Cultural Anthmpology. 9~471-97. Fry D. 1971. Some Effectsof Music. Tunbridge Wells, England: Institute for Cultural Research (Monograph Series No. 9). Furnham A. 1 W . "Explaining Health and Illness: Lay Pemptions on Current and Future Health, the Causes of Illness and the Nature of Recovery." Social Science and Medicine. B71525. Furnham A, Titman P & Sleeman E. 1994. "F'erception of Female Body Shapes as a Function of Exercise." Journal of Social Behuuior and Personality. 9335-52. G e ~ e K. n 1991. The Saturated Self: LXlemms - ofldentity in Contempony Life. NY B a s i c b k s . Gold R. 1995. "Why We Need to Rethink AIDS Education for Gay Men." AIDS G r e . 7:ll-9. Goleman D & Gurin J, eds. 1993. Mind-Body Medicine. NY: Consumer Reports Book. Kabat-Zinn J. 1993. "Mindfulness Meditation: Health Benefits of an Ancient Buddhist Practice." In: MindBody Medicine. Goleman D & Gurin J (eds.). NY: Consumer Reports Books. Lynch P.1995. "Adolescent Smoking-An Alternative Perspective Using Personal Construct Theory" H d t h Education Research. 10:187-98. Spickard J. 1594. "Body Nature and C u l t u in ~~ Spiritual Healing." In: Johanesyn H, L a u M L & Olesen S (4s.). Studies in A l t m t i w 7'herapy 2. Odense, Denmark: Odense University Press. Tsouyopoulus N. 1984. "German Philosophy and the Rise of Modem Clinical Medicine." 7Xeowtical Medicine. 15:267-2. Tsouyopoulus N. 1994. "Postmodemist Theory and the Physician-patient Relationship." Theoretical Medicine. 15267-2. W a d e A. 1994. "Consumption, Identity, Formation and Uncertainty." Sociology. 28:877-98. Wenglert L & R m n AS. 1995. "Optimism, Self-esteem, Mood and Subjective Health." Personal and Individual LXffmce. l&fi!3-61. White G & Gillett J. 1994. "Reading the Muscular Body: A Critical Decoding of Advertisements in Flex Magazine." Sociology of Sports Journal. 11:lS-39.

ADVANCES: The Joumal of Mind-Body Health is published in January, April, July, and October. The production schedule requires that calendar items be received thm months prior to publication.

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ADVANCES:The Journal of Mind-Body Health

Aesthetics and the body

Vol. 12, No. l

Winter 1996

Pergamon

SSDI 0197-4556(95)00066-6

THE BODY, ITS POLITICS, POSTURE AND POETICS DAVID ALDRIDGE, PhD*

carnal sociology based on the writings of MerleauPonty that concerns itself with what the body does, the active body in social life. This carnal sociology will reveal the way that "self," "society" and "symbolic order" are constituted through body work and is a contrast to an externalizing sociology that alienates the doing agent from her, or his, body. I, too, refer to the body politic, as it is through this body that we choose to influence others and not solely by words. Actions shout. Performance whispers. Movement seduces. A body of work can convince. Yet even moving away from these analogies, the body can be used in a political role. Suffragettes chained themselves to railings to accent their cause. Monks have immolated themselves to highlight their plight. While carrying out a research project into suicidal behavior in 1983 (Aldridge, 1993), I came across a group of patients on a hospital ward who were systematically starving themselves and another group of women who were mutilating themselves. Although the process of self-starvation was considered to be a consequence of a disease, anorexia nervosa, the explanations underlying the self-mutilation were more concerned with deviance than with sickness. Differing discourses were invoked for differing behaviors involving disturbed relationships with the body. At the same time, within a cultural context, the Irish patriot-or terrorist depending on which set of descriptions the reader wishes to invoke-Bobby Sands, was starving himself to death in jail. No one described this behavior as being an illness or considered that Bobby Sands was anorexic. The problem was seen as being a legitimate action, for some, in the line of traditional Irish martyrs. For others, the British Government, his

We can easily enough understand that acting and dancing are the projection of the body into an aesthetic medium-for in those cases the body is, in some way, the aesthetic medium. Nor should we have difficulty understanding that we apprehend an actor's or a dancer's performance through our own body. (Benzon, 1993b, p. 274) The initial impulse for this volume came out of discussions with fellow creative arts therapists in practice and from discussions about research. At the heart of this debate lay the dualism underlying mind and body and how often the mind, and its influence on the body, was ignored in many medical discourses. Indeed, already some readers will be raising their hands in horror saying how can he write such things. Some will insist upon a Cartesian dualism of mind and body, arguing for separate phenomena. Others will no doubt be crying "Reductionist," asserting that mind and body cannot be separated, and it is such a separation that has confounded our thinking regarding the creative arts therapies. I must confess a sympathy for the latter argument and have in various publications argued for an holistic perspective on human beings as Beings in a phenomenological sense. However, I believe that we are indeed in danger of losing that very understanding that is central to the corpus of our work, the body. Crossley (1994) pointed to the subtle distinctions that social scientists make about the body: "The sociology of the body addresses itself to the epistemological, ethical, and aesthetic technologies which variously discipline, adorn, punish, celebrate, etc. 'the body' " (p. 43). Yet, he called for a

*David Aldridge is Professor for Clinical Research Methods, Faculty of Medicine, WittedHerdecke University, Germany. 105

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act was an illegitimate claim to political status. The axis o f judgment was not that o f health and illness but that o f legitimacy of behavior. My question was, at the time, " I f Bobby Sands' behavior of self-starvation was seen as a means to gain political concessions, what political concessions within the family were to be gained by young women starving themselves to death"? (Aldridge, 1985). Similarly, I questioned the role o f martyrdom by daughters in families. At the same time, my Family Therapy colleagues were referring to the works o f Selvini Palazzoli (1974) and Minuchin, Rosman and Baker (1978)who saw the refusal to eat as a messageladen activity in a particular relational context, the family. The body, and what we do with it, has ramifications for both the person and those with whom their life is performed. From a Foucauldian perspective, the body is a surface on which the social is inscribed (Rail & Harvey, 1995). In these families o f self-starvation the role o f feeding and nurturing was evident in the body o f the presented patient. Liebermann (1995) refers to a "rule" in families where a member starves herself as being preoccupied with the "tyranny o f appearances" ( p . 136). For the young women who were mutilating themselves, the pain o f their varying personal and relational difficulties was indeed inscribed upon their bodies. Posture also refers to the stance that we take with our bodies. Again there is a relational element that places our personal identities for validation within a cultural milieu. How the body is presented to the world is related to our understanding o f who we are and how we wish the world to react to us. It is a performance and, in being a performed reality, is the location for a therapeutic endeavor. Whether we consider the performance o f music, dance, movement or dramaturgical evocation, the body is involved. Even as far as painting and sculpture we find descriptions o f the process o f creating that is pertinent to the body. Fashion and dress are examples o f performances that are relevant for many young people within our culture. In performance art we have the deliberate choice o f clothes and their colors in deliberate ritual transactions (Phelan, 1995). Perhaps the supreme manifestation o f body and art is skin and painting, the tattoo. Poetic refers to the performance that our bodies have that may be beautiful. This is not simply the body beautiful as perceived, the commodity of advertisements and as image. This is the body as done. A body performed, as personal form realized with the basic materials that one has to hand or foot. The mu-

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sicologist/semiologist Nattiez (1990) referred to the aspect o f performance as "poietic process" and the aspect o f listening, and making sense, as "esthesic process," with the reality o f the work itself as a material object, "the trace." In health terms we can also see the process of becoming healthy and what we do to become healthy, the understanding of our own health and the material traces that those activities leave in our bodies. Indeed the body, like the musical work, is the trace o f our health activity. By concentrating on the modern sense of self, there is also a focus on the body. Our corporeality is both objectified and subjectified in that the body has become the major site o f subjectivity and agency (Waterhouse, 1993). When identity is constructed and traditional values, like gender, are challenged, there are times when individuals seek to establish identities that can be variously interpreted. White and Gillett (1994) illustrated this in terms o f the muscular body o f bodybuilders that are seen as a reaction to the erosion o f power felt by men in the face o f emancipatory forces that seek to challenge the ideology of gender difference. "Bodywork," a term that occurs in numerous complementary medical approaches, locates cultural disciplines within a particular site, the body. The body becomes a commodity; it is seen as natural and culturally desirable and is developed through techniques (diet and training) and display. The individual is linked to the social. Feeling naturally superior, with a muscular self-made body, brings a link with social desirability and thereby coherence and meaning. However, this identification,within a plurality o f cultural identifications, may be interpreted as offensive to others who are not masculine or, indeed, not so muscular. Furthermore, as White and Gillett argued, Because real-power is located in economic and political structures, bodybuilding constrains the construction o f identity to the pursuit o f self as commodity. And, ironically, the elusiveness o f the muscular ideal makes the self-transformation process . . . a self-disciplinary dream rather than a lived reality. (p. 35) Erdman (1994) reiterated this point with regard to women who are fat. A woman's size and shape are influenced by cultural aesthetic factors that include those put forward by the media, in terms o f fashion and leisure activities and medicine. She reminds us that the "fat is bad'' perspective is a modern sociallyconstructed reality that emphasizes women's selves as

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THE BODY. ITS POLITICS, POSTURE AND POETICS located in how they look and simultaneously ignoring the evidence that fat is healthy. An historical perspective serves to highlight the importance of the body in judging personal nature and that the ideal body size varies from epoch to epoch. She argues that information showing that fat people do not eat more than thin people, that they can be healthy and there maybe health benefits related to being fat, that weight is not always controllable by diet and that fat people are as emotionally diverse as thin people. She challenges the notion that fat equals pathology and invites women to trust their bodies and voices as a part of the diversity of human sizes and to see themselves as "beautiful, functioning and healthy, no matter what their shape or size" (p. 172). Thus is the aesthetic related to the functional. Although body size and shape are aspects of personal identity, it is how the body is interpreted, the aesthetics of health beliefs that play an important role in forming identity. Such beliefs play an active part in how we recognize illness and what therapy we choose (Aldridge, 1992). Meanings provide a bridge between cultural and physiological phenomena. The diagnosis of a medical complaint is also a statement about personal identity (van der Geest, 1994) and the stigma that may be attached to such an identity (Crossley, 1995; Goffman, 1990). Symbolic meanings are the loci of power whereby illness is explained and controlled. Such loci are now shifting from the educated health professionals and therapists to the increasingly better-educated, and health-conscious, consumers. These consumers are no longer passive in their consumption and may perhaps better be regarded as performers. The social stage on which our dramas are enacted is daily life. For some, the screen upon which their personal story is projected is the skin. Health, the Body and a Performed Identity In modern times, health is no longer a state of not being sick. Individuals are choosing to become healthy and, in some cases, declare themselves as pursuing the activity of being well. Being recognized as a "healthy" person is, for some, an important feature of a modern identity. Being "healthy," being a "creative" person, being a "musical" person and being a "spiritual" person are all considered to be possible significant factors in the composition of an individual's lifestyle. Rather than strategies of personal health management in response to sickness, we see an assemblage of activities like dietary practices, exercise prac-

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tices, aesthetic practices, psychological practices, spiritual practices designed to promote health and prevent sickness. These activities are incorporated under the rubric of "lifestyle" and sometimes refer to the pursuit of "emotional well-being" and are intimately bound up with how a person chooses to define him or herself. Thus modern identities are constructed and, although these identities are bound up with cultural values, focus primarily on the body. The body is the canvas upon which our various identities are painted, the stage upon which our various dramas are performed or, from my own particular perspective, the music that we perform. My preference for a musical metaphor is because music can be understood horizontally-it occurs in time, and vertically-there is the component of harmony, several voices performing together. Furthermore, although music can be an individual activity, it also occurs as an activity with others, and is above all cultural-sounds are recognized as music through cultural attribution. In addition, we need to consider that "body work" as an aesthetic achievement, this embodiment of culture, this corporeality of expression, is a pleasurable activity, often recreational and simply not medical. Indeed, the body is expressive. The Expressive Body The dynamic interplay of maintaining our personal identity is an expressive activity akin to improvising music (Aldridge, 1989). Some young people do regard themselves against a background that is musical and some people refer to themselves as being "musical" (Ruud, 1995). An extension of the understanding is the notion of being as it is characterized by the tradition of phenomenological philosophy, which looks toward "being in the world" as a unified experience. This phenomenological approach sees a correlation between musical form and biological form. By regarding the identity of a person as a musical form that is continually being composed in the world, a surface appears on which to project our understanding of a person as a physiological and cultural being. The thrust of this endeavor is to view people as "symphonic" rather than "mechanic." By considering how persons come into the world as whole creative beings one can speculate on their potential for health and well-being. What links the performance of music and the performance of health is the element of participation.

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If we can argue from a conventional perspective that medical traces, plots and graphs of physiological change are articulate forms of an inner reality, so can we argue that the objects of art represent an expressive reality. Art products exist as articulate forms; they have an internal structure that is given to perception. However, whereas the graph is a regularized form whereby factors internal to the individual, as content, are charted upon given externally derived axes, as form, the art object is both expression and the axes of that expression (i.e., form and content). Whereas science requires the graph for regularitythat is uniform-art requires that forms are given a new embodiment; they can be set free to be recognized-that is, unique. A reliance on machine expressions of our inner realities assumes that all that we are is measurable and material. A performed expression assumes the possibility of becoming something new, and that surely is the goal of many therapies, is traditionally the role of development and strikes at the very heart of a culture trying to maintain the status quo. However, once we accept the status quo as being in a continual state of flux, then performing health reflects an ecological reality. We can begin to understand people as they come into the world as works of art, composed as a whole yet continually improvising on varying themes to adapt to life's contingencies. Those themes are our identities, the performance of which is our health repertoire. In terms of sickness, our repertoire may be reduced to the singular litany of pain (Aldridge, 1991). Thus is performance restricted. The Expression of Health Thus feelings lose nothing by not being expressed. Perhaps they even gain in sincerity and intensity the less they are verbalized . . . there is a fundamental communication which embraces all forms of existence and which, because of its immediacy, must abandon the medium of words. (Herrigel, 1988, p. 97) If consideration is given to what constitutes people as identity, attention may be better directed to how they are composed as musical beings in regard to relationship patterns, rhythms and melodic contours. Perhaps when a sense of that order is lost a person experiences a loss of health. When we seek to establish order, the flexible, kairotic, performed order of music, song or dance, then perhaps we are moving toward health. In the same way we could argue from

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traditions of Indian and Oriental medicine that the pursuit of changes in breathing and posture or the rhythmical changes from herbal medications are establishing an order of the same dynamic dimension. The problem of causal thinking is that, although the influence of nature on the individual is explained, there is no allowance for the spontaneity of the living being (Tsouyopoulus, 1984). Therefore any change, whether it be described as developmental or therapeutic, must include an element that is dynamic. What is being argued here is that our struggle to maintain our identity-whether it be regarded as immunological or psychological-is indeed a dynamic process of equilibrium and self-regulation that demands spontaneity (Tauber, 1994). Achieving the new becomes an intentional act, promoting sustaining activities by creating the optimal conditions-physical, psychic and cultural-that some may call an ecology (Bateson, 1978, 1991) and others may refer to as a milieu (Tsouyopoulos, 1994). Expressive arts represent such a spontaneous activity. Improvisation demands the maintenance of a theme that must change to gain liveliness. So are our lives improvised, from the cellular to the cerebral, to maintain our identities intact. In all such processes, listening to each other is a central method for gaining information and maintaining credibility, whether it is the cell communicating with the cell, person with person or community with community. However, we must return once more to the central role of the body in modem society. The relationship with the self is with the body; it is here that we have the interface of internal and external. How we encounter the unfolding of our experience is reflected in our bodies. The body tells us how language works, the meta-communication as it were. The reason that the expressive arts as therapies are so powerful is that they emphasize the lived body as being sensed, not only as being said. So expressing ourselves as a musical identity, or as danced piece, even as a dramatic event, may stay closer to the reality of symptoms as they are expressed. Expressive culture is the projection of the body into an expressive medium. Manipulation of that medium is expressiveness, and culture is dedicated to understanding how to use that medium. Form is given to feelings and cognitions. Symptoms too are bodily expressions involving feelings and cognition~,sometimes conforming to a medical interpretation, but also demanding an existential interpretation that cannot be spoken. From this perspective, we can perhaps understand that some seemingly chronic diseases, and predominantly those seen as psychoso-

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THE BODY. ITS POLITICS, POSTURE AND POETICS matic, are problems that are being dynamically expressed upon the stage of the body and sometimes fail to be interpreted adequately in the context of treatment. Although symptoms are the embodiment of distress, it is in the arena of their performance that we are engaged as practitioners and researchers. The means we use to understand that drama is being questioned by those persons who claim an identity other than that of the stigmatized sick. How we enter into that drama as practitioners with those whom we label patients is currently a challenge to our healing identities. If the big narratives of modernism are now being replaced by our own personal sets of meaning made locally with those whom we seek to live (Warde, 1994), then we need to understand more about the person who sits before us in our studio. How that person creates an identity will be indicative of how that person will resolve his or her problems. How that person seeks to be identified will guide his or her health care activities. Some will seek medications; others will imbibe herbal preparations; others will seek to be physically manipulated; others will seek to be psychically manipulated; yet others will exchange energies both subtle and cosmic; some will search for the laying on of hands in a ritual way-whether it be from a medical doctor or a spiritual healer (both require their own brands of faith); some will sing to relieve their souls and others will dance to their heart's desire. Each of these, the bodybuilder and the disciple, the artist and the atheist, the athlete and the allopath, will demand a recognition for whom they are as a person, and for that recognition to be included in treatment decisions. Indeed, the route to treatment will be guided by an itinerary pertinent to personal identity. Health is something that is done, a performed art. What we singularly fail to see is that our current thinking about health is dominated by a medical thinking that ignores much of the reality of the persons we intend to treat and support. Few people, when they are sick, respond by seeking a health care practitioner (Andersen, 1995). Perhaps even fewer consult a therapist about staying healthy. What we do, outside of an academic life thinking about such lofty matters, is eat, drink, sing, dance, amuse ourselves, love our nearest and dearest, walk the dog, chase pieces of leather across field (both dogs and football players), without thinking of medical consequences. Maybe our health care assumptions are so narrow that they have little relevance for others who do not bow down at the altars of epidemiology and empiricism. Many lay ap-

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praisals of health care activity seem be based upon holistic considerations that include feelings of mood and vitality (Andersen & Lobel, 1995). If, as in traditional Chinese medicine, for example, health seeking becomes a pleasure, that sequesters "a body that can not only taste sweetness but be sweet, not only report painful symptoms, but also dwell on and cultivate the quiet comforts of health" (Farquhar, 1994, p. 493) then maybe we can understand that the seeking of a positive identity in a post-modem world is an activity that can be enjoyed without experts and the grand narratives of science and medicine. We may indeed have to learn to seek out those personal and local truths that our patients are themselves choosing to embody; maybe these truths are better played, in the widest sense, than said. Perhaps the consequences of prolonged fun, extended enjoyment and drawn-out pleasure are beneficial and that most of our nonclients and patients know this. Only we as practitioners, locked in with our patients, have forgotten a basic truth. What I am arguing for is that if science is a creative doing of knowledge, then the way that we can do knowledge about being human is not restricted to instrumentation through machines, rather, knowledge is something that can be sung or played or danced or acted. Underlying this approach is a philosophy of the world that moves away from a solely materialistic perspective to a perspective that sees the world as a living organism improvised in the moment in which we are all taking part. This is a move away from the Cartesian position that separates mind and body as reflected in cogito ergo sum-I think therefore I am. What I am proposing here is ago ergo sum-I perform therefore I am. We have properties that are concerned with a created knowledge. As clinicians and researchers our task is to ask of ourselves, and then of our patients, "How can we create ourselves as a work of art?" (Barnason, Zimmerman & Nieveen, 1995; Tang, Yao & Zheng, 1994). The implications of this thinking for clinical and research practice is that we can encourage people to develop an articulacy of self based on their own expressive realizations as music or pictures or stories. A major criterion, then, for assessing therapeutic change will be aesthetic. (When we consider, for example, those patients suffering with anorexia nervosa, their criteria are personal and principally concerned with the aesthetic of the body in contrast to many of their clinicians who are concerned with criteria that are medical. Both sets of criteria are present

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in our culture.) In terms of research documentation, we need not solely rely upon the graph and the chart as the traces of change, but the story that the person tells, the picture that he paints or the song that she sings will also have validity. The Papers In This Issue In the following pages the reader will see several of these issues raised as they occur in the context of therapy. Patrizia Pallaro, a dancelmovement therapist, brings to our acquaintance the "performed self" of the body as personal agency. She argues for the emergence of the personal identity as the child separates from the mother. It is the maintenance of a coherent personal and social identity that is at the crux of many of our artistic endeavors. In this way our identities are created, improvised anew, not simply given (Aldridge, 1989). Another dancelmovement therapist, Marcia Plevin, describes the course of recovery in therapy for a woman who has abused varying substances. She uses the striking metaphor of someone coming to her senses. In many ways this is what lies at the heart of much of our work where we come to our senses quite new and fresh. Indeed, in music therapy many of us have the impression that, before we can actively improvise with others, there is the need to come to the sense of listening first. We know too that to be able to draw accurately we have to be able to see clearly. In terms of child development, it is the active integration of senses that proves to be central (Aldridge, Gustorff & Neugebauer, 1995). There is every reason to believe that such sensory integration, as it occurs in performing together, stays with us through our creative lives. It is this level of performance, too, that Stephen Levine takes up in his paper concerning the expressive body and the way that body is sometimes experienced as fragmented. He relates his writing to ideas put forward by Jacques Lacan and Merleau-Ponty. It is the work of the latter that has perhaps had a significant impact on many current writers about the body in that Merleau-Ponty concentrates on the "lived body." Roger Grainger also broadens the debate to include sociological aspects of the body as they may be applied to the creative arts. Ilene Serlin also widens the psychological and cultural debate about the alienated body, grounding her ideas in statements taken from psychiatric patients. Peter Kellermann gives a concrete example of such

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fragmentation as pain in his description of psychodrama with a young woman named Eva. Jacquelyn Gillespie gives examples of how the body is rejected by women who have eating disorders and how their discontent with an inner self is projected into images that can be externally viewed. Michael Gunter reminds us of Freud's proposal that the ego is formed from body sensations and goes on to describe the value of body representations for psychotherapy in terms of both intrapsychic and interpersonal processes. Living As Jazz Classical music is the expression of a fully formed culture. Jazz, however, is the creation of people under constant pressure to conform to conditions imposed on them. (Benzon, 1993a, p. 408) Music and the expressive arts represent a spontaneous activity. Improvisation demands the maintenance of a theme that must change to gain liveliness. So are our lives improvised, from the cellular to the cerebral, to maintain our identities intact. In all such processes, listening to each other is a central method for gaining information, negotiating relationship and maintaining credibility whether it is the cell communicating with the cell, person with person or community with community. If our selves require a spontaneous adaptation to survive, if our existence depends upon expression, then living is jazz. The body has a central role in post-modem society. The relationship with the self is with the body; it is here that we have the interface of internal and external. How we experience the unfolding of our experience is reflected in our bodies. The body tells us how language works, the meta-communication as it were. The reason that the expressive arts as therapies are so powerful is that they emphasize the lived body as being sensed not only as being said. Expressing ourselves so, as a musical identity, or as a danced piece, even as a dramatic event, may stay closer to the reality of symptoms as they are expressed. Expressive culture is the projection of the body into an expressive medium. Manipulation of that medium is expressiveness and culture is dedicated to understanding how to use that medium. Form is given to feelings and cognition~.Symptoms too are bodily expressions involving feelings and cognitions, sometimes conforming to a medical interpretation, but also demanding an exis-

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THE BODY. ITS POLITICS, POSTURE AND POETICS tential interpretation that cannot be spoken. From this perspective, we can perhaps understand that some seemingly chronic diseases, and predominantly those seen as psychosomatic, are problems that are being dynamically expressed upon the stage o f the body and failing to be interpreted adequately in the context o f treatment. Although symptoms are the embodiment o f distress, it is in the arena o f their performance that we are engaged as practitioners and researchers. The means we use to understand that drama is being questioned by those who claim an identity other than that o f the stigmatized sick. Patients perform their lives before us. How we come to realize that potential as enhancing, as aesthetic, is the task o f the creative arts therapist. Demonstrating the benefit that that performance may have for people in their daily lives is the task o f creative arts therapy research. Benzon (1993b) reminded us that the evolution o f an expressive culture, however we project our experiences into an expressive medium, depends upon our ability to use that medium. Hence the need for the skilled practitioner, the artist therapist who can orchestrate, compose, choreograph with the patient. W e have to understand how people "do" their lives, not simply what they think and say about their lives. It is in the body that individual identity is expressed, and the body is the interface between the individual and society. It is what people do together that binds them together with the groups with whom they perform their lives. This performance will be bound up with lifestyle, leisure activities, exercise, dieting and dress. In the sense, "lifestyle" is not something that can be read about in books, it is an activity. Making sense o f the world is an activity achieved through the body. Swimming cannot be learned by reading about it or by gathering together a band o f expert swimmers to tell you about their experiences nor by attending a conference o f hydrophysicists. At some time we have to jump into the water and, through experience, swim. The body grasps what it needs to do. Having a teacher in the water certainly helps. So too with health and a change in lifestyle. I f we wish to encourage people to do something differently, we have to understand that it will be intimately connected with their identity as a people and those with whom that identity is validated. Change is brought about by influencing small groups and understanding their way o f being in the world. Music therapy offers the chance to do something differently. A new iden-

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tity can be performed. However, the patients are not left alone to find their own way; the music therapist accompanies them. Rather than describe the way forward for someone, we accompany them along part o f the way reviving the old notion o f therapist as one who attends to the needs o f a fellow traveller as well as the musical accompanist who provides a basis from which the other can perform. One factor that we must take into account is that the serious business o f living can also be fun. Although we know a lot about health care activities and their impact, we know little about the importance o f leisure activities and their ramifications for health. Positive emotions, according to new thinking, influence our health status for the better. Optimism and a sensual pleasure in everyday activities and situations are valuable for promoting personal health. The absence o f symptoms and a sense o f enjoyment coupled with a zest for living appear to play a significant role in the subjective assessment o f health (Wenglert & Roskn, 1995). Once more, health may be described as an activity with sensual ramifications concerned with pleasurable activities that are themselves integrated with an overall sense o f lifestyle. This may be more appealing than our current unilateral exhortations to follow expert health care prescriptions based on warnings and denial. Music has a vast potential for pleasure. Music is to be played. Play can be a serious business, as any child will remind us. Perhaps for adults too we can be reminded that play is not a trivial activity, and a little bit o f fun is a powerful medicine. As a personal note I would like to express the difficulty that I have with the writings o f a number of authors who continue to write about anorexics and bulimics or a case o f particular disorder. Surely i f in the creative arts therapies we are trying to put forward an argument that we offer an endeavor that positively challenges the fragmentation o f modern living, against alienation, then a significant step forward would be for us to start talking about people we work with, not cases. The people with whom we perform are not solely explained by a disease classification system. As Lee (1995) reminds us, there is no natural history o f anorexia nervosa, only a social history, and the biomedical classification is a cultural fallacy. How can we hope to make any headway for the expressive arts as having a unique value that respects the whole individual i f we continue to use art as an allopathic medication. T o do so would require us merely to give a shot o f painting after meals or the right measure o f music three times a day perhaps with a prescription

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for dance before going to bed. Is this really what encouraging the creative body is all about, performing with cases? Although I understand the need for disease classification, it is my personal wish that in the creative arts therapies we can speak about the person who has a problem that may be classified according to a particular system. But that person is not a disease or a case. Finally, there is an old notion taken from the Christian Bible, reflected in other doctrines, that although we are many we are one body (Aldridge, 1987). Although many of our endeavors are to encourage others to perform themselves authentically, we can sometimes discern that what is performed by our sisters and brothers has ramifications for the way in which we have our own being. References Aldridge, D. (1985). Suicidal behavior: An ecosystemic approach. unpublished doctoral dissertation. The Open University. Aldridge, D. (1987). One body: A guide to healing in the Church. London: S.P.C.K. Aldridge, D. (1989). A phenomenological comparison of the organization of music and the self. The Arts in Psychotherapy, 16, 91-97. Aldridge, D. (1991). Physiological change, communication, and the playing of improvised music: Some proposals for research. The Arts in Psychotherapy, 18, 59-64. Aldridge, D. (1992). The needs of individual patients in clinical research. Advances, 8(4), 58-65. Aldridge, D. (1993). Observational methods: A search for methods in an ecosystemic research paradigm. In G. Lewith & D. Aldridge (Eds.), Clinical research methodology for complement a p therapies. London: Hodder & Stoughton. Aldridge, D., Gustorff, D., & Neugebauer, L. (1995). A preliminary study of creative music therapy in the treatment of children with developmental delay. The Arts in Psychotherapy, 22, 189-205. Andersen, J. 0. (1995). Lifestyles, consumption and alternative therapies. Troense, Denmark: International Network for Research in Alternative Therapies, internal seminar March 22nd. Andersen, M,, & Lobel, M. (1995). Predictors of health selfappraisal: What's involved in feeling healthy? Basic and Applied Social Psychology, 16, 121-1 36. Barnason, S., Zimmerman, L., & Nieveen, J. (1995). The effects of music interventions on anxiety in the patient after coronary artery bypass grafting. Heart and Lung, 24(2), 124-132. Bateson, G. (1978). Mind and nature. Glasgow: Fontana. Bateson, G. (1991). A sacred unity. New York: Harper Collins. Benzon, W. (1993a). The United States of the blues: On the crossing of African and European cultures in the 20th century. Journal of Social and Evolutionary Systems, 16(4), 401438. Benzon, W. L. (1993b). Stages in the evolution of music. Journal of Social and Evolutionary Systems, 16(3), 273-296.

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Crossley, N. (1994). Merleau-Ponty: The elusive body and carnal sociology. Body and Society, 1(1), 43-63. Crossley, N. (1995). Body techniques, agency and intercorpereality: On Goffman's relations in public. Sociology, 29(1), 133149. Erdman, C. (1994). Nothing to lose: A naturalistic study of size acceptance in fat women. In K. Callaghan, (Ed.), Ideals oj feminine beauty. Philosophical, social, and cultural issues. 161-174. Westport, CT: Greenwood Press. Farquhar, J. (1994). Eating Chinese medicine. Cultural Anthropology, 9(4), 471497. Goffman, E. (1990). Stigma. Notes on the management of spoiled identity. London: Penguin. Herrigel, E. (1988). The method of Zen. London: Penguin Arkana. Lee, S. (1995). Self-starvation in context: Towards a culturally sensitive understanding of anorexia nervosa. Social Science ana Medicine, 41(l), 25-36. Liebermann, S. (1995). Anorexia nervosa: The tyranny of appearances. Journal of Family Therapy, 17(l), 133-138. Minuchin, S., Rosman, B., & Baker, L. (1978). Psychosomatic families: Anorexia nervosa. Cambridge, MA: Harvard University Press. Nattiez, J.-J. (1990). Music and discourse. Towards a semiology OJ music. Princeton, NJ: Princeton University Press. Phelan, P. (1995). The contemporary body. Australian Feminisi Studie.~.21, 24-29. Rail, G., & Harvey, J. (1995). Body at work: Michael Foucault anc the sociology of sport. Sociology ofsport Journal, 12, 164-179 Ruud, E. (1995). Music in the media: the soundtrack behind the construction of identity. Young. Selvini Palazzoli, M. (1974). Self starvation: From the intrapsychii to the transpersonal approach to anorexia nervosa. London Chaucer. Tang, W., Yao, X., & Zheng, Z. (1994). Rehabilitative effect oi music therapy for residual schizophrenia. British Journal (4 Psychiatry, 165(suppl.24), 3 8 4 4 . Tauber, A. (1994). A typology of Nietzsche's biology. Biology anc Philosophy, 9, 2 5 4 4 . Tsouyopoulus, N. (1984). German philosophy and the rise of mod. em clinical medicine. Theoretical Medicine. 5. 345-347. Tsouyopoulos, N. (1994). Postmodernist theory and the physician. patient relationship. Theoretical Medicine, 15, 267-275. van der Geest, S. (1994). Christ as a pharmacist: Medical symbol: in German devotion. Social Science and Medicine, 39(5), 727732. Warde, A. (1994). Consumption, identity-formation and uncer. tainty. Sociology. 28(4), 877-898. Waterhouse, R. (1993). The inverted gaze. In D. Morgan & S. Scot (Eds.), Body matters (pp. 105-121). Brighton: The Falmei Press. Wenglert, L., & Rosin, A. S. (1995). Optimism, self-esteem, moo( and subjective health. Personal and Individual Difference 18(5), 653-661. White, G., & Gillett, J. (1994). Reading the muscular body: P critical decoding of advertisements in Flex magazine. Sociology of Sport Journal, 11, 18-39.

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The Arts in Psychotherapy, Vol. 17, pp. 189-195.

0 Pergamon

Press plc, 1990. Printed in the U.S.A.

0197-4556190 $3.00

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PERSPECTIVE TOWARD A COMMON LANGUAGE AMONG THE CREATIVE ART THERAPIES DAVID ALDRIDGE, PhD, GUDRUN BRANDT, DipMT, and DAGMAR WOHLER, DipAT*

As creative arts therapists, we believe it is important for our work that we learn a language that unites us so that we may work together (Moreno, 1988; Schmais, 1988). The art therapies use different expressive faculties but the source of these expressions is an underlying comrnonality of form and pattern. Within our research program (Aldridge, 1990) we are discovering that language as it is based in clinical practice (i.e., in the studio and the therapy room). It is hoped that the patient, who is the focus of our work, benefits from our common endeavor. Our intention is to be able to share a common currency of ideas among ourselves as creative artists and with our medical colleagues as therapists (Aldridge, 1989a, in press; Aldridge, Gustorff & Hannich, in press). In this paper the work of two creative arts therapists will be presented. One is a Nordoff-Robbins trained music therapist; the other is an art therapist working from the teachings of Rudolph Steiner. Both therapists work together in a West German hospital where research methods are being developed to encourage creative arts therapists to share their ideas. The Nordoff-Robbins(1977) approach,itself grounded in anthroposophy, emphasizes the congruence between musical form and the self (Aldridge 1989b). Musical experiences are essentially those of form and order that are continually being creatively realized by the person. As a means of treatment, creative music therapy in this context attempts to mobilize the creative potentials of the patient toward a restoration

of the state we call "health." Anthroposophical medicine recognizes that many illnesses and problems arise when one is estranged from his or her own creative capacities (Barfeld, 1978; Fulder, 1988). Illness occurs when we become literally out of time, out of touch, and out of tune with ourselves and others (Aldridge, 1989a, in press). This lack of harmony, of loss of rhythmical coordination can be expressed in artistic activities-in movement and dance, in drawing, painting and sculpting, in speech, drama and story telling, and in the processes of creating and playing music. Expression as the Function of Art and Science The function of art is to acquaint the beholder with something he has not known before. (Langer 1953, P. 22)

Both science and art are activities that attempt to bring certain contents of the world into cognition. The contention of this paper is that when we study human behavior, and in particular what it means to be sick, to become well again, or to live through the process of dying, then both forms of acquaintance are necessary for research in therapeutic practice. Although the aesthetic may appear to occupy a pole opposite to the scientific, we may propose that both poles are necessary to express the life of human beings. This is not to deny that scientific approaches can be applied to the creative arts therapies, rather to

*David Aldridge is research consultant to the medical faculty of Universitat Witten Herdecke, West Germany. Gundmn Brandt is a music therapist. Dagmar Wohler is an art therapist.

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emphasize that there are complementary methods of research-the aesthetic, which is concerned with Beauty, and the scientific, which is concerned with Truth. Neither are exclusive. However, it is important to redress the balance in research activities concerned with the healing arts from the scientific toward the aesthetic. Both art and science bring an appreciation of form and the expression of meaning. Maps, traces, and graphs are articulate forms of an inner reality. So are the objects of art. They exist as articulate forms; they have an internal structure that is given to perception. However, whereas the graph is a regularized form whereby the individual, as content, is charted upon given axes, the object of art is both the expression and the axes of that expression (i.e., form and content). European Tradition: Der Blaue Reiter Art does not reproduce the visible, rather it makes visible. Formerly we used to represent things visible on earth, things we either liked to look at or would have liked to see. Today we reveal that reality that is behind all living things, thus expressing the belief that the visible world is merely an isolated case in relation to the universal, and there are many more latent realities-Paul Klee. (Grohmann, 1987)

In the tradition of Western modem art, music and the graphic arts have shared an impulse for similar vocabularies. "Der Blaue Reiter," a group of artists, poets, writers, dramatists, dancers, and musicians who gathered together around 1911 in Munich, were interested in a synthesis of the arts based on a spiritual idealism (Budde, 1989; Gollek, 1989; Hall, 1977; Vergo, 1977). They shared a community of interests where inner striving was a critical factor. This inner experience represented a mysterious reality that lay beyond the appearance of things. Their belief was that such complex and universal visions of the mysterious might require several artistic media as vehicles for their revelation, and these media were often presented together in the form of theatrical pieces. Their first annual yearbook (Lankheit, 1989) compiled essays about primitive art, dramatic productions, poetry, new songs, and anessay on the relationship between the arts and writing by the composer Schoenberg (himself an amateur painter). Kandinsky, a founder of the group with Franz Marc, recognized that there was a parallel between his own painting and

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the musical ideas of Schoenberg. Through the influence of Scriabin, Kandinsky was stirred to produce an amalgam of music, movement, and light in Der gelbe Klang (literally "the yellow sound"). Schoenberg also conceived and designed a stage piece, "Der Gliickliche Hand," which included original words, scenic design, costumes, music, and detailed instructions for lighting closely correlated with the music. An important idea in this group was that of the correspondence between particular colors and musical tones. Scriabin's work included a "clavier 6 lumikres" that projected light not sound according to a system of notation as part of his composition "Prometheus." The idea was that the playing of particular keys would bring light not sound into the concert hall. Synaesthesia, the hearing of colors and the seeing of sounds, was not a new phenomenon. Various healing traditions have also attempted such correlations between qualities, color, and music (McClellan, 1988). The problem of such correlation lies in that each tradition has its own idea of which color corresponds with which musical tone. This highlights the problem for us as creative arts therapists seeking a commonality of language. At which level will we find correspondence? At too concrete a level we find that there is no generalizable significance (i.e., at the level of corresponding tones whether they be color or sound). However, we may be able to find correspondence at the next higher level of description, which is that of structure (i.e., the elements of form, order, pattern, dynamics, and orientation). We suggest below that it is this level of structural correspondence that may provide the ground for a common therapeutic discourse.

Klee Paul Klee, a painter and member of Der Blaue Reiter group, claimed that in his painting such formal structural elements and their mutual relationships were analogous to musical thought. He saw the mystery of creation as the secret key to the source of all Becoming. As he wrote in his 1914 diary (Grohmann, 1987) "What is really essential, really productive is the Way-after all becoming is superior to Being." Each work of art becomes a symbol of creation as the terrestrial life represented the cosmic. He put forward a fourfold way of studying nature that includes the artist, the object, the earth, and the universe. The artist explores the object's inner being,

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TOWARD A COMMON LANGUAGE its cross sections (anatomy), its vital functions (physiology), and the laws governing its life (biology), its ties with the earth as a static, concrete object, and its ties with the universe as a whole as abstract dynamic form. The creative forces in the universe are seen reflected in the artist; the artist becomes both creator and creative where the world becomes both object and state of mind. He takes from Goethe, whose writing greatly influenced anthroposophy (Barfeld, 1978), the principle that the totality of cosmic laws are reproduced exactly in the tiniest leaf as the laws governing the universe are reproduced in the artist. Klee sought, as did the other artists in the group, a liberation from representation in the arts. This represented a European spirit of idealism where the inner life of depth gave rise to images on the surface. The formal elements of painting, and the relationships between those elements, were analogous to musical thought. This thinking was developed by other Bauhaus artists at this time who were not interested in teaching painting as such, but in the understanding of form. The rhythm of structure and pattern as repetition of form were seen as common elements in the grammar of this form in the creative arts. Variety within repetition was a natural form common to botany as it was to modem music and the paintings of Klee. The notion of interval within a field was an abstract component that could be realized in various expressive forms (i.e., musical intervals as sound and chromatical intervals as color). In the following case example we will see how such comparisons of form and relationship are central to descriptions of the therapeutic process. The creative arts therapies presented here then lie within a continuing tradition within the arts. Case Study Frau M was 36 years old when she first came for therapy. From her early childhood she was responsible for bringing her alcoholic father home from the pub. Her parents had little money and she was forced to find a job as a clerical assistant while she was still young. Between the ages of 19 and 23 she suffered epileptic fits. This condition led to frequent job changes because she was ashamed to face her colleagues. At the age of 28 Frau M married, and then had two

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children. In her marital relationship she felt herself to be unimaginative, nagging, and without initiative. She was excessively perfectionist about housework. There appeared to be no balance within her life and work and she felt unable to develop any sustained interests. This created a deep-rooted problem of self-esteem, which in turn fed the current moods of depression she experienced. At the time of her stay in the hospital she was diagnosed as suffering from nervous depression. Her hospital therapy, from which the following examples are taken, occurred over a period of five weeks. Art Therapy Frau M had daily one-hour sessions of art therapy. In her free painting she applied the watercolor paints so thickly that no play of light and dark was generated. The colors, therefore, appeared to be lifeless and dull, with no tension between dark and light areas. There was a great disorientation in the way in which she handled the paint. This was seen in the rapid undirected actions of the abrupt movements with the brush away from her body. These brush movements increased when she was nervous, and the completed picture appeared turbulent and restless. She often kept to the corners of the paper, which offered some points of orientation, becoming lost toward the center of the picture. Furthermore, the structure of the painting into top and bottom was difficult, as it was to find a color focus or center within the picture itself. Frau M was reliant on external stimuli from the therapist and only could be induced to pause and observe by encouragement. It was, therefore, difficult for her to prepare the next stage of painting by looking at her picture and absorbing the qualities of the colors. When offered a structure in the form of a repetitive carefully oriented task she became calmer and more ordered in her movements. Her abrupt movements became relaxed. It was through the use of intensive structured therapist intervention that she found a center of focus and awareness of the need for an inner base from which she could work to achieve personal security.

Music Therapy Frau M was seen weekly for half-hour sessions. In the first few sessions the following characteristics

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emerged from her musical activity. She played in a heavy, fast, and disordered way on the small drum, interspersed with occasional recognizable rhythmic patterns without being influenced by the music the therapist was playing on the piano. Her tempo was basically fast and she was unable to vary it on her own initiative. She had a tendency to become set in her playing. This was also visible externally in the movements she made while playing (i.e., they remained on the drumskin so that individual sounds could not develop freely). When asked to play on two instruments together (e.g., a large and small drum, or with two beaters together) she played in an unconnected way with no relationship to the music. During the first session her lack of receptivity to current external experiences was evident in her too rapid, unbalanced reactions. This was noticeably clear in her melodic playing. Any sustained melodic lines were interspersed in quick sequences of notes that disturbed the overall context. In her own melodic arrangements on the xylophone or glockenspiel she lost any direction in her melodic playing. This loss of direction was also evident if there were gradual increases in volume or tempo. However, it was possible to stabilize her playing by musical means. Uniform consecutive chords played quietly brought a musical coherence to her playing, which by the end of the therapeutic period was free of incoherent sections. She was able to reproduce rhythmic patterns in a clear and conscious way and sustain these over a longer phrase. In dialogic playing, a fluent interplay was created between the therapist and Frau M. Within this musical form she attempted to generate new sound possibilities and effects, such as playing with her fingertips and playing at the edge of the drum. A sense of security seemed to appear within the joint musical activity, which was expressed by her being able to sustain a recurring rhythmic figure in various musical contexts with only minimal musical accompaniment from the therapist at the piano. A feature of the therapeutic success was in drawing her into a quiet slower tempo and maintaining this over time. This gave her the opportunity for a greater perception of the musical processes and an inner receptivity to experience. She experienced and produced intervals and caesuras; she could sing alone with melodic lines and complete them alone when the therapist left her to do so. Thus, she was able to construct her own melodic phrases forming a logical

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melodic line. The random and uncontrolled aspects of her playing were increasingly replaced by a consciously structured and directed way of playing resulting in logically structured improvisations with greater stability of form. Results

The therapeutic changes in Frau M over the five weeks of her stay were also confirmed in the medical report of her general condition. It was noticeable that she manifested similar behavior in both types of therapy. These were seen in her limitations in handling form as expressed in the realms of color and sound. Her inability to relate to what she did, which was expressed in her extreme disorientation, could also be seen in her painting and heard in her playing. Both therapists were struck by Frau M's basic receptivity, her willingness to participate in artistic activity, and her strength of will that led her to attempt to overcome her limitations in both art forms. Her outer willingness was in stark contrast to her inner flexibility and emptiness. In both forms of therapy her actions were reinforced and moved quickly into a stereotypical sequence as soon as she had to continue on her own without considerable support from the therapist. As far as expression was concerned, both the paintings and playing showed no internalization and hardly any expression of feeling came to the surface. However, despite the seeming rigidity, changes took place. The decisive factor in the development of the therapy was an experience of her own disorientation. With this realization she struggled to find a personal order to her existence. She was encouraged to do this within the ordered forms of painting and musical improvisation. Her confidence grew as she handled sound and color largely through repetition and imitation. The next stages in the therapeutic progress would have been to encourage her such that she would be moved from within herself to perform creatively, although the first signs of such an impulse were emerging. We propose then that the process of artistic creation offered her opportunities for a new orientation and new directions in life. As Susanne Langer wrote: What it (art) does to us is to formulate our conceptions of feelings and our conceptions of visual, tactile and audible reality together. It gives us forms of

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TOWARD A COMMON LANGUAGE Art Therapy Elements

Music Therapy Elements

quick, abrupt

fast and slow: tempo

repetition

pattern

fixed in her way of painting

set in her playing

brush stroke movements

drum stick movements

relationship to the medium

relationship to the medium and reactions to the experience

develop an idea

play a melodic line

disorientation in handling the paint

disorientation in the music

sustained development of an idea

music sustained over a phrase

new creative possibilities

relationship between elements

musical intervals

structure and form

dynamic; light and dark

dynamic; loud and soft

lifeless and dull colors

qualities of musical expression

internal/external

internallexternal

prepare for the next stage

construct melodic phrases from what has gone before

orientation; center of focus

orientation within the music

Figure I . Some common elements of description in therapeutic usage.

imagination and forms of feeling, inseparately: that is to say, it clarifies and organizes intuition itself. (Langer, 1953, p. 397)

It is quite clear from these descriptions that there are common elements in both languages (see Figure 1). These elements are mainly concerned with formal structure-form, pattern, orientation within time and space, dynamic qualities, repetition, the way in which the patient performs, and expressive qualities. There are other elements that are also concerned with commonalities related to the therapeutic experience, the relationship to the medium, relationship to the therapist, and relationship with Self. A Common Language In our Western culture, the concepts of time and space are used as major axes of construing in both

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science and art. However, although in modem scientific medicine the uses of time and space are regularized into objective qualities subjected to measurement, in the arts, space and time have no fixed reference; they are relative to the moment, the place, and the person. Hence, the differing notions of chronos and kairos, mechanical time and timeliness. There are also fundamental differences in the language that we use to understand science and that we use in the arts. Science is based on empirical data and a written language that exists "out there," as does this page to the reader. This language is built on a grammar that orders subject, object, and predicate, and thereby influences understanding. The content of understanding is always subjected to a given linguistic form for objectification. Written language is based on nouns that become fixed (Bateson, 1978). The arts are based on verbs, and doing is all important. Arts as performed are predicated on quite different grammars-those of dynamics, of process, of becoming and being in action. There is a difference between the grammar of psychology, for example, and the grammar of dance. What the arts offer is a common grammatical structure based on performance where space and time are lived and experienced directly often out of the verbal realm. Showing rather than saying. When words are used in the arts they are sometimes used in a different dimension according to another grammatical structure (i.e., as in the case of poetry, improvised drama, or singing). In our attempts to find a common language then it is also important to emphasize that talking about therapy is always at several steps removed from the actual activity in which we partake. Dancing, painting, singing, acting, doing therapy are different activities from talking about dancing, talking about singing, talking about painting, and talking about doing therapy. We need to emphasize that there are different levels of reporting. Level 1. Experience. Here we have the phenomenon as it is experienced. This is what transpires in the therapy session. It lives and exists in the moment, and is only partially understood. It cannot be wholly reported. We can see, feel, smell, taste, and hear what is happening. These are the individual expressive acts and known in modem linguistics as parole (Burgin, 1989). Level 2. Description. We can talk about what

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happens in the therapeutic situation in the particular terms of our artistic disciplines. These descriptions are relatively objective and accessible to verification. For example, we can talk about the particular notes and rhythms in music therapy and the particular colors and patterns in art. We can play our recorded tapes or show our pictures. This is the shared element of language, usage, which is available for systematic study and is part of our common everyday discourse. Level 3. Interpretation. When we come to explain what happens in terms of another system (i.e., to transpose the musical changes into terms of academic psychology, psychotherapy, or a system of medicine) or to say what the relationship between the activity is and the process of healing, then we are involved in interpretation and have strayed to yet another stage removed from what has happened. This is the underlying abstract ground within language, langue. It is only our hubris that attempts to say that we know what the process of healing in therapy is. In medicine it is possible to know how to bring broken bones together in the correct position to heal, but impossible to describe the actual process of healing. At the level of performance what passes in the therapeutic session exists for itself. Everything else is an interpretation and depends on language and is therefore an imposition of a subject predicate grammar on a dynamic activity. However, as therapists working together with patients, we do need to talk to each other about what happens and what we do. Our contention is that we can find a common language at Level 2, usage, which is based on descriptions of the artistic process yet not too far removed from the activity of therapy itself, parole. Too often, the therapeutic process is described at level 3 (i.e., that of interpretation and inference) where, although there may be a unity in the grammar of verbal discourse, langue, there is a loss of conceptual coherence. Our languages in the arts have commonalities. They are those of pattern and interval, which are based on the logics of time and space. Notions of rhythmic repetition and pattern go hand in hand, one in time the other in space. There is the embracing notion of form, which in the abstract is that of an underlying essence but when expressed is that of the concrete reality of the piece as performed, whether this be a painting, a play, a poem, or a partita. We can also talk in structural terms of melodic

David Aldridge

lines or themes, of dynamics and tempo, of articulation and expression, of timbre and tonal changes. In therapeutic terms we have the ideas of form expressed in terms of seemingly random behavior, as loss of coherence in the forming of the piece; initiation and innovation, activity, and passivity; the ability to orientate the form within the prescribed space or time; the relationship between the patient and the therapists; in the dialogue between patient and therapist in terms of listening and acting, openness to new ideas.

The Politics of Self and the Language of Therapy When we come to interpret what takes place in therapy we can also rely on artistic terms. Creativity is a process that exists within a framework of the aesthetic. We propose that the status of health is the striving for creative realization. Within the individual the ability for self-regulation is based on a repertoire of improvisational possibilities. Although it is essential to have a standard repertoire of responses for everyday life, it is also necessary to improvise solutions when necessary (Aldridge, 1989a,b). This is as true of the biological as it is of the musical as it is of the dramaturgical. There exists a balance between stability and change; both the conventional and unconventional lie in a healthy tension. For example, the music therapist talks about the patient's ability to maintain the logic of a sustained melodic line alone. For Frau M this was her melody according to her inner logic. We can assume that this was a part of therapeutic change in that the patient found and expressed her own inner logic. Yet this individual expression was contained within the context of a relationship. The personal and the social were balanced. The classification of activities is a political act: it is a way of saying "See this activity in this way." The feminist movement has alerted us to the right to call our own activities by the names we give them. When we come together to establish a united voice in the healing arts we must be aware that we are making a political statement within the field of healing. We are saying that what we do is not psychological but artistic, and that the terms we use have their own legitimacy. Our task then is to negotiate those terms among ourselves. Although we may differentially express creativity, improvisation, form, structure, dynamic, time, and space within our own therapeutic modalities, we do need to learn a language based on these concepts such that we can maintain a unified

Aesthetics and the body

TOWARD A COMMON LANGUAGE discourse about what we do. This is not a new endeavor within the tradition of Western art, particularly European art, and it should be possible to extend this discourse into the realm of therapy.

of healing is a practice in which we can participate as creative arts therapists from our own cultural foundations. Perhaps the time, like the idea, has come when we can articulate our own healing purposes in a common language.

The Role of the Aesthetic in Healing At the center of this therapeutic work is the creative art in performance or composition. The creative expression is not the same as cathartic expression. Whereas personal emotive expression may be the first step in the process of healing, the continuing therapeutic process is to give articulation to a broad range of human feelings. Although playing music passionately can lead to an emotional catharsis, it lacks the intensity of form that articulates the whole range of personal aspiration (Langer, 1953). When we introduce form and order into the creative act then we promote a higher form of human articulation. This is the process of healing-the escape from emotive fragmentation to the creative act of becoming whole. Our inner lives in all their depth and richness are given coherence and presented externally as created form. In this way we help our patients to articulate their inner realities as beautiful. This is the manifestation of the aesthetic. We have a cultural tradition within twentieth century modem art where music, poetry, art, drama, and dance are considered together. This was prefigured by the late nineteenth century movement in German culture, which also expressed the role of the healing arts as a necessary antidote to the rigorous soulless advance of technological medicine. The international movement known as Expressionism, which began in the early part of this century and was based on those nineteenth century Romantic ideas, embraced concepts of personal liberation and placed a passionate emphasis on heart and spirit. It stood against the disintegration of communities and the personal isolation caused by increasing urbanization and industrialization (Kellner, 1988). These ideas are still available to us today. The art

David Aldridge

Aesthetics and the body

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.OO

ARTISTS OR PSYCHOTHERAPISTS? DAVID ALDRIDGE, PhD*

Europe is attempting to become a community with a common identity. At its borders, countries, formerly united under coercion, are struggling to maintain their national identities and cast off a communal identity. In their claims to national identity some groups are demanding not only the cultural rights of religious practice and the freedom to use their own language, but also territorial rights that impinge in some cases on the existence of others. Furthermore, inside the community not all nations are happy with the idea of becoming a United Europe. Within the arts therapy professions in Europe there is also a struggle for identity, either to be united as arts therapists within a general congruent understanding of psychotherapy or to be creative arts therapists united as arts therapists. This latter position of artistic harmony also may be glossing over the reality that some creative arts therapist professional groups cannot agree among themselves whether or not to be united. Indeed, some groups claim the territory of arts therapies with the intention of restricting the practice of others. It is difficult to understand how such practitioners can claim to be actively involved in the healing process when within their own practice there is such a wound caused by division and rejection. The Second European Conference in Arts Therapies Education addressed the issue of professional identity in terms of training, as you will read in the following papers. Anneke Nijenhuis has been active in promoting arts education in Holland and Europe and her clear insight into the problems and positive attempts to bring people together was evident in her keynote speech. Colin Teasdale raises the issue of how we manage clinical placements for students.

When we consider the future of the arts therapies in Europe, and the possibility of modular training between cooperating institutions located in different countries, the correct placement of the student and his or her clinical supervision will play an important role. David Edwards continues this theme of supervision in training, emphasizing the role of learning various skills that promote the identity of the creative arts therapists as professional practitioners. Henk Smeijsters returns us to the debate about professional identity clarifying what it is about music therapy that identifies it as a creative arts therapy and what it is that distinguishes music therapy as a psychotherapy. The tension remains. Artists are engaged in clinical practice, some of which is located in an overtly psychotherapeutic setting. Some of those artists have indeed chosen a form of training that is based on principles of psychotherapy and wish to be known as psychotherapists. Others, however, have chosen to use their art therapeutically as artists. Here lies the core of the dilemma. As soon as we enter the realm of therapeutic practice we must begin to use a language that describes that practice. We have no commonly acceptable therapeutic language as yet, for example, in describing what goes on in music therapy. We do, however, have an acceptable language for describing what is happening musically. And there is the problem, the change from the language of the medium of the therapy to the therapeutic language describing clinical change. The elements of a therapeutic language are borrowed, often unwittingly, from other practices. However, the meanings they acquire in their new settings are often corrupted from their original psychothera-

*David Aldridge is European Editor of The Arts in Psychotherapy.

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peutic meanings, which infuriates psychotherapists, but it is only in the nature of living languages that words gain their meaning in the contexts in which they are used. As feminists have reminded us, the words that we use to describe our own experiences belong to us and should not be submitted to the political dominance of the language of another group. The classification of activities is a political act; it is a way of saying, "See this activity in this way." We have the right to call our own activities by the names we give them. In our attempts to find a common language for the creative arts therapies, and thereby negotiate a professional identity, it is also important to emphasize that talking about therapy is always several steps removed from the actual activity in which we partake. Dancing, painting, singing, acting, doing therapy are different activities from talking about dancing, talking about singing, talking about painting and talking about doing therapy. There are different levels of reporting experience. We have the phenomenon as it is experienced. This is what transpires in the therapy session. It lives and exists in the moment and is only partially understood. It cannot be wholly reported. We can see, feel, smell, taste and hear what is happening. These individual expressive acts are known in modem linguistics as parole (Aldridge, Brandt, & Wohler, 1990). We can talk about what happens in the therapeutic situation in the particular terms of our artistic disciplines. These

David Aldridge

descriptions are relatively objective and accessible to verification. For example, we can talk about the particular notes and rhythms in music therapy and the particular colors and patterns in art. We can play out recorded tapes or show our pictures. This is the shared element of language, usage. When we come to explain what happens in terms of another system (i.e., to transpose the musical changes into terms of academic psychology, psychotherapy or a system of medicine) or to say what the relationship between the activity is and the process of healing, we are involved in interpretation and have strayed to yet another stage removed from what has happened. This is the underlying abstract ground within language, langue. No doubt the debate will continue. Either our identities remain fixed and we are as we are defined or our identities are forever in negotiation. At whatever level we choose to become actively engaged in the process of definition, as being identified and identifying, there will be challenge and acceptance. Hopefully, we will develop a climate of tolerance so that what and how we are will contribute to the community of those engaged in the task of healing rather than further promoting the wounds in our modem society. Reference Aldridge, D . , Brandt, G . , & Wohler, D. (1990). Toward a common language in the arts therapies. The Arts in Psychotherapy, 17. 189-195.

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Aesthetics and the individual in the practice of medical research: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Universitat Witten Herdecke, Beckweg 4, D-5804 Herdecke (Ruhr), Germany Keywords: complementary medicine; research; clinical controlled

'Art does not reproduce the visible, rather it makes visible. Formerly we used to represent things visible on earth, things we either liked to look a t or would have liked to see. Today we reveal that reality that is behind all living things, thus expressing the belief that the visible world is merely a n isolated case in relation to the universal, and there are many more latent realities' Paul Kleel

Similarly there is often a split in medical science between researchers and clinicians. One group seeing themselves as rational and rigorous in their thinking and others as sentimental and biased which in turn elicits comments about inhuman treatment and reductionist thinking. Neither of these stances alone is true, each perspective has something to offer the other. However, the predominating ideas in published medical research are those of natural science as informed by statistical data.

Introduction There is a demand made of practitioners of complementary medicine by the wider community that they validate their work with clinical studies. This is Historical context often countered by complementary practitioners with The science of statistics developed in 18th century the argument that scientific methods are often France as part of the centralized apparatus of the inappropriate to the study of these forms of medicine. State. 'Statistics' as the science of state was the A similar cry is also heard in orthodox medicine that empirical numerical representation of the resources the strict methodology of science is often found available to the State and formed the components of wanting when applied to the study of human a new power rationality. Health care became, as it behaviour. This has stimulated calls for innovation is now, a political objective, as well as a personal in clinical medical research2. What we may need objective. Health, from this perspective, is seen as the then in clinical research is to facilitate the emergence duty of each member of society and the objective of of a discipline which seeks to discover what media are all. Individual needs are subsumed within the goals available for expressing clinical change. These media of the collective, the private ethic is informed by the may be as much aesthetic as they are scientific public ethic and objective empirical data are the thereby emphasizing the a r t of healing in parallel means by which goals are assessed (see Table 1). These with the science of healing. As Langer3 writes: 'The data are related to the economic regulation of health function of art is to acquaint the beholder with care delivery (health as commodity); public order (the something he has not known before' (p 22). regulation of deviance), and hygiene (the quality of Both science and art are activities which attempt food, water and the environment). to bring certain contents of the world into cognition. From this viewpoint we have the notion of health The contention of this paper is that when we study care, and knowledge about that health care, which is human behaviour, and in particular what it means to be sick, to become well again or to live through the process of dying then both forms of acquaintance are Table 1 . Comparative and complementary perspectives on health research necessary for the practice of research in medicine. In medical research most of the modern initiatives for that research have come from the field of natural Individual perspective Scientific perspective science. Such research when applied to the study of human behaviour is partial and neglects the State regulation of health Personal regulation of health important creative elements in the process, and Constancy predictability and Creative irrationality: being practice of healing. This is not to deny the scientific, control: the future is based on and becoming rather to emphasize the aesthetic such that both may past data be considered together. Unfortunately the tension of Technology of the body: Techniques of the self: music, understanding both elements of human understanding observations, examinations art, personal narratives and results in one or the other being denied. Such is the and case reports poetry current situation in modern medicine. However, the Objective statistical reality Subjective and symbolic realcontinuing problems of chronic illness and human based on instrumentally ity based on the senses and suffering urge us to go beyond our partisan beliefs and monitored data human consciousness look again at how we know as well as what we know. The health of the body is a n Self maintains its own This is literally the a r t of re-search. imperative of the State identity The problem facing the clinician is that he must Scientific Aesthetic often mediate between the personal needs of the patient and the health needs of the community. These Time as chronos Time as kairos needs David are informed Aldridge by differing epistemologies. Aesthetics and the body

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(iii) The reliability of our knowledge is only as good as the underpinning hypothesis. Inevitably the reliability of a trial when extended to a broader population is an act of induction6. (iv) Persons are not experimental units, nor are the measurements made on persons isolated sets of data. While at times it may be necessary to make this split we must be aware that we are making the act of separating data from persons. (v) People do not live in isolation. Life is rather a messy laboratory and continually influences the subjects of our therapeutic and research endeavours. Even more daunting is the fact that subjects influence themselves. (vi) There is no such thing as a purely 'physical' treatment7. Treatment always occurs in a psychosocial context. Medicine is a social as well as a natural science. The way people respond in situations is sometimes determined by the way in which they have understood the meaning of that situation. The above criticisms reflect one of two fundamentally differing approaches to science. One is to develop precise and fixed procedures that yield a stable and definite empirical content. We have this in controlled trial methodology. The other approach to investigation depends upon careful and imaginative life studies which although lacking some of the precision of technical instruments have the virtue of continuing a close relationship with the natural social world of people. (vii) As clinicians the concern for the subject prevails over the interest of society at large and scientific medicine as an institution. Individual persons are not treated as a means to some collective end in clinical A critique of scientific methodology Implicit in much criticism of complementary medical practice, although we may subscribe to a notion of community health. The Declaration of Helsinki research is the notion that there are 'right' premises for doing science. The implication is that there is States8: 'In any medical study, every patient - including a common map of the territory of healing, with those of the control group, if any - should be assured particular co-ordinates and given symbols, for finding of the best proven diagnostic and therapeutic method'. our way around and that the orthodox map of The clinical judgement of the doctor is on the side scientific medicine is the only one. Any different map is seen as deviant, and any challenge to the of the individual patient even if it means the corruption of a research project. When clinicians, who construction of that map as heretical4. Similarly, when we speak of scientific or experiare bound by contracts for treatment, take part in mental validity, that validity has to be conferred by clinical trials then the dilemma is revealed. Either they fulfil their individual contract for treatment with a person or group of persons on the work or actions the patient, or they abdicate that contract and fulfil of another group. This is a 'political' process. With their obligations to the research contract which are the obsession for 'objective truths' in the scientific concerned with group benefit. This raises further the community then other 'truths' are ignored. As conceptual issues for health care of whether 'health' clinicians we have many ways of knowing; by intuition, through experience and by observation. If is an individual or a societal concept. Are we as we disregard these 'knowings' then we promote the clinicians committed to improving the health of idea that there is an objective definitive external truth individuals we see, or are we directed to improving the health of the communities we serve? which exists as 'tablets of stone' to which only we, Scientific medicine emphasizes one particular way the initiated, have access. of knowing and this seems to maintain the myth that to know anything we must be scientists. If we consider Methodological issues people who live in vast desert areas they find their While clinical controlled trial methodology may way across those trackless terrains without any appear to be scientifically sound a number of articles understandings of scientific geography. They also have questioned the scientific premises of such methods: know the pattern of the weather without recourse to what we know as the science of meteorology. In a (i) A random selection of trial subjects cannot be similar way people know about their own bodies and achieved because any group of patients comprises a have understandings about their own lives. They may highly selected non-random group. not confer the same meanings as we do, yet it is those (ii) Group generalizations from research findings meanings and particular belief about health to which raise problems for the clinician who is faced with the individual person in his or her consulting room. we might best be guiding our research endeavours. Individual variations are mocked by the group While as clinicians we may help to bring about a average5. change behaviour by technical means, it is the 75 David Aldridge Aesthetics and the in body regulated by the State. The objects of that health care (patients), the practitioners of that health care (clinicians), and the providers of that health care (health and State insurance) are informed by the same epistemology. Such was the strength of modern science, it offered a replicable body of knowledge in the face of the ever increasing solipsism of metaphysics in the 18th century. From a modern scientific stance the body is to be manipulated as an object of the State to whose ends it serves. Such manipulation is served by the processes of classification and normalization. People are observed, classified and analysed as 'cases' according to their deviance from a given norm. Disease becomes a category like any other rather than the unique experience which it is. The epistemology of this normative process is that of natural science which emphasizes reason, constancy and predictability. In the face of death and disruption the imperative of health is to maintain continuity and control. It is a philosophical assumption that the positive instance of an hypothesis will give ground for further instances. However, there is no logical necessity which will safeguard our passage from past to future experiences. It is also ironical that modern statistical methods were developed by the agriculturalist Fisher. It was possible in his work to develop hybrid strains of plants which produced identical, albeit sterile, specimens which could be grown in large numbers for statistical comparison. However, for our purposes human beings cannot be reared like cabbages.

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person who we have to rely upon to describe the meanings and implications of that change. This also leaves out the burgeoning problem for us as scientists for explaining how a change in meaning can bring about a change in behaviour.

The art form presents the whole intelligible form as an intuitive recognition of inner knowledge projected as outer form: subjective is made objective but in the terms of the subject. In artistic expression we have the possibility of making perceptible an inner experience.

Art and science Conclusion A time has come when we can judge our research on 'What it (art)does is to formulate our conceptions of feelings 'whether it makes a powerful and important contribuand our conceptions of visual, factual and audible reality tion to the cumulative e ~ i d e n c e on ' ~ a particular together. It gives us forms of imagination and forms of feeling, inseparably; that is to say, that it clarifies and issue rather than whether or not it formally proves organizes intuition itself'. (p 397)3 a point. This recognition of subjective data is occurring at a time when an emphasis is being placed Research from this standpoint is not science in that on the 'whole' patient. it has no generalizable reference. The importance Balint showed us that it is not solely scientific skills of such work is in its particular subjective and which help us to fully understand the patient. It is unconventional reference. While the aesthetic may possible to have a descriptive science of human appear to occupy a pole opposite to the scientific, we behaviour which can be based upon the aesthetic. In may propose that both poles are necessary to express this way we can ask of our research that it expresses the life of human beings. what it is to be human, what it is to be well and what Both art and science bring an appreciation of form it is to fall sick. and the expression of meaning. Maps, traces and As modern living provokes ever more anxiety then graphs are articulate forms of an inner reality. So are the present search for scientific solutions based upon the objects of art. They exist as articulate forms; predictability, and the attempted control of nature by they have an internal structure which is given to technology continues. This retreat from the anxiety perception. However, while the graph is a regularized of dying and its emphasis on the material prevents form whereby the individual, as content, is charted us from understanding the true process of living. How upon given axes, the object of art is both the can we then offer hope and comfort to the sick and expression and the axes of that expression, ie form the dyinglO? and content. The politics of medicine, and the technology of In expressive art sensory qualities are liberated modern medicine which serves it, places the existence from their usual meaning. While science requires the of the individual in question. Personal means of graph for regularity, art requires that forms are given health are concerned with a subjective reality which a new embodiment; they can be set free to be is symbolic. As human beings we are capable of selfrecognized. In this way qualitative form can be set regulation, and the foundations of this regulation are free and made wholly apparent in direct contrast to not confined to objective criteria. In many cases we the questionnaire method where inner subjective are mysterious to ourselves. We have properties which realities are submitted to an external objective form. are concerned with a created knowledge. This is not to deny the use of the questionnaire, rather As clinicians and researchers then, how are we to to emphasize the possibility of considering expressive face the problem of how to constitute an ethics of forms when we wish to discover what the quality of existence not solely founded on a scientific knowledge life is. Sensual qualities then become of vital import of the self which is comparative to group norms, to the whole, not to be rated on a scale, but intrinsic to but one in which the principal act is creative? the total gestalt. Our task is to ask of ourselves, and then of our In this way of researching we are concerned with patients, 'How can we create ourselves as a work showing rather than saying. of art?' ll. The implications of this thinking for research practice is that we can encourage people to develop Expression The artistic symbol negotiates insight not reference. an articulacy of self based on their own expressive realizations. These may be expressed in the form of It expresses the feelings from whom it stems and is music, or pictures or stories. We can encourage people a total analogue of human life. The symbol and that which is symbolized have some common logical form, to document their journeys through life not as the ie they are isomorphic. accumulation of material quantities of flesh and blood but in sounds, words and pictures. The documentary Science negotiates reference not insight. That which of life's journey through a chronic illness may be is within the individual is placed within a context. realized in a series of case notes. However, it can also Music and art are concerned, not with the stimube possible to document that journey as a series of lation of feeling, but the expression of feeling. It may photographs which are far more eloquent for the be more accurate to say here that feelings are not travellers. The preservation of the values of humanity necessarily 'emotional state', more an expression of within our culture are as much in the hands of the what the person knows as inner life, which may exceed the boundaries of conventional categorization. cliniciadresearcher as artist as they are in the By encouraging non-verbal forms of expression we cliniciadresearcher as scientist. can learn and utter ideas about human sensibility. Human behaviour cannot be studied from one point A reliance on verbal methods alone assumes that of view only. Within the total repertoire of medicine we can know and speak about all that we are. A it is necessary to have different approaches to understanding the world: the scientific and the reliance on machine expressions of our inner realities aesthetic. This position, of multiple understandings, assumes that all that we are is measurable and material. an body acceptance of orthodox clinical trials 76 David Aldridge Aestheticsoffers and the

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together with a promotion of new understandings12. By doing so differing studies inform each other. It is vital that we pursue academic rigour in our experimentation. But not by burying our heads in the sand. Rigour without imagination leads to stagnation just as imagination alone leads to anarchy. Modern clinical medical research can combine the two. A combination of rigour and imagination is necessary to meet the challenges of health care. Our intellectual endeavours should be astute enough to see that science can accommodate multiple viewpoints13-l5 and search for a reconciliation of difference within the framework of the scientific, which is Truth, and the aesthetic, which is Beauty. References 1 Grohmann W . Klee. London: Thames and Hudson, 1987 2 Hart JT.Where is general practice going? New Doctor 1984;33:8-10 3 Langer S. Feeling and form: a theory of art. London: Routledge & Kegan Paul, 1953 4 Watzlawick P. The invented reality. New York: W W Norton & CO,1984 5 Barlow DH, Hersen M, Jackson M. Single-case experimental designs. Arch Gen Psychiatry 1973;29:319-25

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6 Burkhardt R, Kienle G. Basic problems i n controlled trials. J Med Ethics 1983;9:80-4 7 Heron J. Critique of conventional research methodology. Complementary Medicinal Research 1984;1:12-22 8 Declaration of Helsinki. Recommendations guiding doctors in biomedical research involving human subjects. Adopted by the 18th World Medical Assembly, Helsinki, Finland, 1964, and as revised by the 29th World Medical Assembly, Tokyo, Japan, 1975 9 Pringle M . A minority interest: why? BMJ 1984; 289:163-4 10 Aldridge D. One body: a guide to healing in the Church London: S:P:C:K,1987 11 Rabinow P. The Foucault reader. London: Penguin, 1986 12 Touw-Otten F , Spreeuwenberg C. Multi-disciplinary research between natural and social sciences i n general medical practice. Fam Pract 1985;2:42-5 Howie JGR. Research i n general practice: pursuit of knowledge or defence of wisdom. BMJ 1984;289:1770-2 Rose AT. Chronic illness i n general practice. Fam Pract 1984;1:162-7 Freeling P. Health outcomes i n primary care: an approach to problems. Fam Pract 1985;2:177-81

(Accepted 25 April 1990)

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