Music therapy collection

Music therapy David Aldridge Collected Papers

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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?

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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).

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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

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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 &

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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

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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

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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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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).

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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.

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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.

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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:

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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

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)

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

testing for progressive memory disintegration

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 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-

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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

l

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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.

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Schmuttermayer, R. 1983. "Possibilities for Inclusion of Group Music Therapeutic Methods in the Treatment of Psychotic Patients." Psychiatr-Neurol-Med-Psychol-Leip:.

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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.

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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.

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6:66-75.

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Zirnmerman, L. M. Pierson & J. Marker. 1988. "Effects of Music on Patient Anxiety in Coronary Care Units.''

Heart-Lung. 17:560-566.

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1989. "Effects of Music in Patients Who Had Chronic Cancer Pain." Western Journal of Nursing Resfirch.

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

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The Arts in Psychotherapy, Vol. 18 pp. 59-64.

Pergamon Press plc, 1991. Printed in the U.S.A.

PHYSIOLOGICAL CHANGE, COMMUNICATION, AND THE PLAYING OF IMPROVISED MUSIC: SOME PROPOSALS FOR RESEARCH DAVID ALDRIDGE, PhD*

Arms, hands, or legs do not behave; it is the total person who behaves (Condon, 1975, p. 45) In our music therapy research (Aldridge, 1988b; Aldridge & Verney (1988) one of the areas we have considered is what happens when people improvise music together. Our intention is to be able to demonstrate to ourselves and other practitioners the influence we believe music therapy has on the body of the patient. We hope to demonstrate, in our later investigations, the mutual relationship of physical changes in the therapist and patient during the process of improvising music together.

In trying to demonstrate this change we have looked for a simple physiological indicator. From a preliminary review of the literature about communication, suitable indicators emerged from the studies of cardiovascular change. The principal measures in such work were those concerned with changes in blood pressure and heart rate. Heart rate was chosen because it was a relatively easy parameter to observe and measure. Perhaps more significantly, it was a parameter acceptable to medical science with whom we, as a therapeutic discipline, are attempting to promote a dialogue.

An earlier paper (Aldridge, 1988a) mentioned the important factors associated with both biological form and musical form- time, phrasing, pitch, rhythm, and melodic contour. Similar considerations apply for studies of communication. The basic preverbal fundamentals of human communication are called supra-

segmentals-these are time, phrasing, rhythm, pitch, and voice tone (which would more accurately be called timbre). It is these qualities that are considered by music therapists when they assess tape-recorded sessions of improvised music therapy.

The literature that first alerted us to these factors concerned chronic heart disease and Type A behavior (Dielman et al., 1987; Dimsdale, Stem, & Dillon, 1988; Friedmann, Thomas, Kulick-Ciuffo, Lynch, & Suginohara, 1982; Linden, 1987; Lynch, Long, Thomas, Malinow, & Katchor, 1981; Smith & Rhodewait, 1986). Heart disease patients were described in terms that owed as much to a musical basis as they did to a physiological process. Loud, fast speech using a limited range of voice timbre, and speech patterns that interrupted the responses of a partner, appeared to reflect qualities music therapists heard in their descriptions of patients when they creatively improvised music (see Table 1). Although these qualitative descriptions may only be regarded as noise in the formal terms of grammar, they provide the essential expressive context for communication.

It seemed important to compare apparently similar statements from two different theoretical backgrounds to see if there was any commonality between them.

As heart disease is such an important problem in both mortality and morbidity throughout the Western world, it made sense to propose h o w a discipline like improvised music therapy could offer a tool for both assessment and treatment.

The medium of improvised music offers possibilities for extremely varied communication and has a

*David Aldridge is research consultant to the Musiktherapie Abteilung, Universitat Witten Herdecke, Beckweg 4, D 5804 Herdecke (Ruhr), West Germany.

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DAVID ALDRIDGE Table 1 Speech characteristics, physiological changes, and musical components Type A behavior

Type B behavior

increased voice volume fast speech rate short response latency emphatic voice hardlmetallic voice accelerated end of sentences

voice quieter slower speech rate longer response latency less emphasis melodic voice

volume tempo phrasing articulation timbre

less mutuality try to keep control increased reactivity

increased mutuality

relationship

increased heart rate high cardiovascular arousal which is maintained

decreased heart rate situational arousal returns to low level quickly

increased heart rate

decreased heart rate

cognitive processing more thoughts and words

attention to the environment better performance of recognition/perceptual tasks

subtlety beyond that of interview techniques that are confounded by verbal content. In addition, in improvised playing there is both the possibility of hearing what may be pathological in terms of restriction and inflexibility under challenge, and that which indicates positive possibilities for growth and change. This is accomplished by an essential feature of the therapy of performance. The patient is an active participant, not a passive recipient, in the process of assessment or therapy.

Time A central, albeit contentious, area of coronary heart disease research has been that of Type A behavior pattern, which is characterized by 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" (p. 969).

In this view we are "the embodiment (both literally and figuratively) of the values of that society . . ." (p. 971). The individual is caught in the contradictions of self-demand and societal demand, which for some people may become pathogenic.

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At the center of this cultural construction (Helman, 1985) is the notion of time. The predominant form of Western time is monochronic. This form is conceived as an external order imposed on the individual. It 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.

However, there is an alternative conceptualization of time that is personal rather than public. This is time as kairos. It is polychronic, and closer to the emerging biological understanding of physiological times that are rhythmically entrained (Johnson & Woodland-Hastings, 1986), 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.

Apart from these notions, there is also the qualitatively different time encountered in ritual, in prayer, and contemplation, during sex, or while dancing.

Most are aware of the difference between an hour spent in the company of a lover, which seems like

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PHYSIOLOGICAL CHANGE, COMMUNICATION, AND PLAYING OF IMPROVISED MUSIC minutes, and an hour spent in an administrative meeting, which can seem like days.

Some authors (Dossey, 1982; Helman, 1987) suggest that when we try to impose a fusion between external clock time and personal physiological time our physiology is affected.

. . . 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 hours,' deadlines, diaries, appointments and timetables all affect the physiology of modem man, and help construct his world view and sense of identity. (Helman, 1987, p. 974) There may then be a tension between private and public time resulting in stress and anxiety.

In music 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 in improvised music and, apart from promoting experiences that differentiate and develop those conceptualizations, an experience of a timeless qualitative reality can also be promoted.

When illness is categorized in Western medicine the time concepts of acute and chronic are used. The presence of chronic illness is causing many problems for the delivery of health services throughout modem society and promoting a debate about the way in which such illness can be tackled in the latter part of the twentieth century. However, it may be that conceptualizations of illness to acute and chronic dimension of a linear reality are limiting, and it may be necessary to consider a concept of kairotic illness.

This illness may entail a personal attempt to maintain identity in the face of imposed environmental constraints and would be similar to the way in which family therapists talk about personal solutions to a problem located within an ecology of family members, cultural constraint, and individual development (Aldridge, 1988c; Bloch, 1987). These concepts of time (development) and space (relationship) are fundamental to our culture whether it be in terms of science or art.

Cardiovascular Change and Communication Lynch (Friedmann et al., 1982; Lynch et al., 1981) carefully explored the relationship between human

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communication, principally talking, and elevations in blood pressure and heart rate. Reading out loud or talking to another person produced rapid and significant rises in heart rate. From this work he suggested that certain hypertensive individuals experience difficulties with communication, and that individual elevations in blood pressure may be manifested symptoms of difficulties with communication.

These communicational difficulties were then related to the personality traits attributed, albeit contentiously, to Type A individuals with coronary heart disease. Patients classified as Type A had been observed to speak fast, loud, have a tendency to interrupt, and use emphatic gestures. Friedman et al., (1982) proposed that tempo and volume were important characteristics of communication. Although tempo and volume were correlated with cardiovascular change, this correlation was not dependent on the affective content of conversation and, therefore, independent of cognitive processes. This finding is important for music therapists in the Nordoff-Robbins (1977) tradition who state that there is physical change during the process of music therapy and that it is not necessary to use only a psychotherapeutic model for change in music therapy.

The recommendations of this earlv research for patients with hypertension were to modify speech rate and volume using breathing techniques, and to control communication style. If cardiovascular response is a process out of the range of conscious awareness, then presumably cognitive approaches are likely to be only partial. Music therapy, with its intrinsic factors of tempo and volume a s direct performance, may be better suited to changing communicational style than the so-called talking-therapies.

A feature of assessing Type A behavior and physiological reactivity has been some form of assessment using an interview (Dimsdale, Stem, & Dillon, 1988). Unfortunately, these interviews have presented a rather negative picture of the Type A person as competitive, hard driving, ambitious, impatient, and often hostile. Yet, within these descriptions there are other categories of classification that are concerned with elements of speech stylistics. These speech stylistics are easier to objectify and are less like personal value judgments. For our research purposes they are also translatable into musical terms.

Some researchers (Dielman et al., 1987; Linden, 1987; Siegman, Feldstein, Tomasso, Ringel, & Lating, 1987) recognize the following characteristics for assessing global Type A behavior:

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DAVID ALDRIDGE voice volume, speed of speaking, accelerated speech at the end of statements, Â duration of silent pauses, Â duration of subject's responses, Â interruptiveand non-interruptivesimultaneous speech, response latency (the amount of time between the time the question is asked and the subject's answer), and voice timbre.

These researchers also go on to assess interaction patterns with the interviewer that they see as hostility and verbal competitiveness. Verbal competitiveness is "a tendency to take control of the interview away from the interviewer by interrupting, asking for unnecessary qualifications, or raising the voice to drown out the interviewer's interruptions" (Dielman et al., 1987, p. 459).

These stylistic qualities and interactions can be observed in musical improvisation, and without the need for negative connotations of hostility. In the context of a spoken interview it is important to remember that the content of some of the questions may indeed be hostile or challenging. A further difficulty is that although speech rate and volume can be measured, hostility, impatience, and competition can only be assessed subjectively with poor interrater reliability.

Speech variables have been significantly correlated with coronary difficulties. These are: voice volume, voice emphasis, Â speed of speaking, short response latency (Dielman et al., 1987), voice volume, frequency of non-interruptive and interruptive simultaneous speech (Siegman et al., 1987).

voice; it also includes those gestures and movements that accompany vocal behavior. Condon (1975) calls these coordinated sounds and movements the quanta of behavior or "linguistics-kinesics. " In the playing of improvised music may be seen how the person moves and also hear how the patient communicates nonverbally. It is this musico-kinesic behavior that contributes to the assessment of how a person plays. A central feature of this assessment i$ the elusive quality of intentionality. The movement of the body provides an indicator of whether the patient is playing with the therapist and intends to play the instrument, or that the patient is just going along with the music. These kinesic considerations are also an important indicator of self-synchrony within the person-either as bilateral synchrony (right and left hand playing together), or at the level of hearing and responding to what is heard.

Music therapy, in the improvised sense used here, is also dependent on the relationship between the patient and the therapist-an interactional synchrony.

It may be that a vital aspect of communication, which is missed by some researchers, is not the ability to produce sound but the ability to listen and respond appropriately to sound. Smith and Rhodewalt (1986) consider this circular process of listening and responding. They suggest an interactional understanding where people with Type A behavior not only respond in a certain way but also provoke situations that will allow them to respond in a characteristic fashion.

Â

These variables need not be discovered in a provocative or challenging manner (Siegman et al., 1987).

Short response latency and accelerated speech are also expressions of anxiety.

Music therapy can also offer a context for cornmunication. It is not provocative in a hostile sense, and has the possibility to promote all the elements inherent in speech stylistics without the confounding aspect of affective components. These variables can be heard in a way that is not solely voice dependent. Communication is not only concerned with the use of the

David Aldridge

Heart Rate and Attention While some researchers were studying the implications of heart rate and communication, others were studying the relationship between a process like attention, which is classically attributed to the brain, and emotion, which is related to the body. This mind-body unity debate heralded an era of interest in holistic medicine.

Sandman (1984a,b) began investigating the relationship between physiological responses and stressful, neutral, or pleasant stimuli. In particular he was interested in the apparent relationship between attention and emotion where attentional style could influence physiological responses to affective stimuli. His work was based on the premise that the viscera, the muscles, the heart, and the endocrine system provided peripheral information to the brain and provided a context wherein perceptions gained meaning.

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PHYSIOLOGICAL CHANGE, COMMUNICATION, AND PLAYING OF IMPROVISED MUSIC In this approach there appeared to be two general categories of attentional styles. One, field-independent subjects, appeared to use bodily information more readily than others and made accurate perceptual judgments about the environment even though presented with distracting perceptual information.

Such subjects appeared to have a broad and differentiated range of physiological responses to various stimuli. For these subjects there was a concordance between how they said they felt and how they responded physiologically. The other, field-dependent subjects, tended to base their perceptual judgments on distracting external information, and used this external information to assess their own state.

When reacting to stimuli they were less emotionally complex; rather than exhibiting a range of qualitatively different reactions they responded with different levels of arousal.

The implications for music therapy from these preliminary findings are that we may also hear such field dependent or independent characteristics in the musical playing of the patient. For example, some patients may have an extensive repertoire of playing styles and be able to play both rhythmically and melodically while listening to themselves and to the therapist in the overall context of the music. Yet others may have a limited range of playing styles and, in response to changes in the music, may only change particular musical parameters (i.e., play louder or faster).

We speculate that repertoires of coping responses can be heard musically, and these reflect quantitative, differentiated physiological responses. It is this link that we wish to demonstrate in our physiological experiments. Note that these observed patterns are considered either musically or physiologically. We are not necessarily invoking any descriptions of psychological state.

Sandman was to develop his work further. He was interested in the pronounced, and paradoxical, decrease in heart rate of field-independent subjects in response to stressful information. He began to demonstrate that a learned heart rate deceleration could bring about an improved attention to the environment.

Thus, he argued, by controlling heart rate, attention could also be influenced.

Awareness of the environment was partially regulated by interactions of the brain and the heart. When heart rate was low, subjects perceived stimuli significantly better than when heart rate was high. This

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view was also supported by indications that when heart rate decelerated, there was an increased blood flow to the brain. There appeared to be "a fortuitous or purposeful synchronization between physiological systems" Sandman, 1984b, p. 118), and it appeared that the hemispheres of the brain were "tuned" (Sandman, 1984a; Walker & Sandman, 1979; Walker & Sandman, 1982) by the cardiovascular system.

These findings challenged the classical view that intellectual abilities were the sole province of the brain and promoted further investigations of links between both mind and body where the cardiovascular system influences the brain and behavior. In some patients "an inviolable relationship exists between the brain and the cardiovascular system that may be a biological marker for psychiatric state" (Sandman, 1984a, p. 255).

These researchers speculate that the heart has an influence on consciousness or awareness. The impact of heart rate is dynamic and fluctuates between suppressing and liberating the left and right sides of the brain. When heart rate increases, it is indicative of cognitive processing and a rejection of the environment; when heart rate decreases, there is a switch to environmental attention. The cardiovascular system reflects a person's intention to receive information. If this is so, music therapy is a sensitive tool for discerning the physiological state of a person as a whole. This tool is not fragmented by introducing a measuring instrument between researcher and subject that limits responses to a narrow mechanical range.

We anticipate that we can hear how changes in the improvised musical playing are reflected in changes in the heart rate of the patient. Hypotheses about a patient listening only to him or herself and not listening to another may be heard in their fast, or accelerating, heart rate.

If, as is also inferred in this literature, intellectual abilities are not solely begun and terminated in the brain but are whole body phenomena, then the active playing of the patient in music therapy is most important. The patient is involved physically in this therapy, is not expected to sit still and answer a questionnaire, or remain stationary while being monitored. He or she is asked to play. This improvised playing encourages the use of soma and psyche. To play rhythmically is a whole-person activity. To play rhythmically with another person is an extension of this activity that includes vital components of relationship.

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DAVID ALDRIDGE Conclusion In creative music therapy lies the possibility to hear in a dynamic way the individual as a whole self as well as in relationship with another person. We can hear the person coming into being as he or she creates a relationship in time. In addition music therapy offers individuals a chance to concretely experience the self in time, to literally hear their own self coming into being. If human survival is concerned with a repertoire of flexible coping responses to both external and internal demands, then in the playing of improvised music may be heard the creative way in which a person meets those demands. It could be that illness is a state where there is: (a) a restriction in the ability of the person as a whole to improvise creatively (i.e., develop new solutions to problems), or (b) a limited repertoire of coping responses.

By promoting creative coping responses we may be establishing the possibilities for renewed health.

These are based on the creative qualities of the whole person that promote autonomy. This catalyzation of self-healing properties is a central feature of the art of medicine that can work in concert with the science of medicine.

The videotape-recorded material of music therapy and experimental session is the rudimentary vehicle for research development. Such recordings are rich in visual and aural data. Not only can those acts that are quantifiable be counted, but those phenomena that are not amenable to counting but are qualitatively essential to health can also be experienced and described.

We may discover in this work that, in terms of biofeedback, the playing of improvised music offers the subject an experience richer and more immediate than the filtering of physiological parameters through an external machine. In this way the person remains the supreme and sensitive instrument of his or her own understanding both literally and figuratively. The next stage for formulating research studies is to observe and record the correlations between the heart rates of subjects and the musical changes that occur when they are playing improvised music. From these observations it should be possible to develop a means of demonstrating physiological change in the context of a musical relationship, and then go on to observe particular patient populations to investigate links between improvised playing, physiological parameters, and ill health.

References Aldridge, D. (1988a). Music as identity: A contribution to the

David Aldridge

assessment of personal health. Proceedings of the First Znternational Conference of Cerebral Dominance. Munchen.

Aldridge, D. (1988b). Research in a hospital setting. Holistic Health, 18, 9-10.

Aldridge, D. (1988~).Treating self-mutilatory behaviour: A social strategy. Family Systems Medicine, 6, 5-19.

Aldridge, D., & Verney, R. (1988). Creative music therapy in a hospital setting: A preliminary research design. British Journal of Music Therapy, 2, 1 4 1 7 .

Bloch, D. (1987). Familyldiseaseltreatment systems: A co-evolutionary model. Family Systems Medicine, 5 , 277-292.

Condon, W. (1975). Multiple response to sound in dysfunctional children. Journal of Autism and Childhood Schizophrenia, 5 , 37-56.

Dielman, T., Butchart, A., Moss, G., Harrison, R., Harlan, W., & Horvath, W. (1987). Psychometric properties of component and global measures of structured interview assessed Type A behavior in a population sample. Psychosomatic Medicine, 49, 458-469.

Dimsdale, J., Stem, M., & Dillon, E. (1988). The stress interview as a tool for examining physiological reactivity. Psychosomatic Medicine, 50, 64-71.

Dossey, L. (1982). Space, time and medicine. London: Shambala.

Friedmann, E., Thomas, S., Kulick-Ciuffo, D., Lynch, J., & Suginohara, M. (1982). The effects of normal and rapid speech on blood pressure. Psychosomatic Medicine, 44, 545-553.

Helman, C. (1985). Psyche, soma and society: The social construction of psychosomatic disorders. Culture, Medicine and Psychiatry, 9, 1-26.

Helman, C. (1987). Heart disease and the cultural construction of time: The type A behaviour pattern as a western culture-bound syndrome. Social Science and Medicine, 25, 969-979.

Johnson, C., & Woodland-Hastings, J. (1986). The elusive mechanism of the circadian clock. American Scientist, 74, 29-36.

Linden, W. (1987). A microanalysis of autonomic activity during human speech. Psychosomatic Medicine, 49, 562-578.

Lynch, J., Long, M., Thomas, S., Malinow, K., & Katchor, A. (1981). The effects of talking on the blood pressure of hypertensive and normotensive individuals. Psychosomatic Medicine, 43, 25-33.

Nordoff, P,, & Robbins, C. (1977). Creative music therapy. New York: John Day. 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 potentials of the brain during diastole. International Journal of Psychophysiology, 2, 111-1 19.

Siegman, A., Feldstein, S., Tomasso, C., Ringel, N., & Lating, J. (1987). Expressive vocal behavior and the severity of coronary heart disease. Psychosomatic Medicine, 49, 545-561.

Smith, T. W., & Rhodewalt, F. (1986). States, traits and processes: A transactional alternative to the individual difference assumptions in Type A behavior and physiological reactivity.

Journal of Research in Personality, 20, 229-25 1.

Walker, B., & Sandman, C. (1979). Human visual evoked responses are related to heart rate. Journal of Comparative and Physiological Psychology, 4, 7 17-729.

Walker, B., & Sandman, C. (1982). Visual evoked potentials change as heart rate and carotid pressure change. Psychophysiology, 19, 520-527.

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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.

1

91

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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

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MUSIC AND T H E S E L F

93

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-

.

.a

David Aldridge

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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-

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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

95

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.

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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

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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.

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Journal of the Royal Society of Medicine Volume 82 December 1989

743

Music, communication and medicine: discussion paper

D Aldridge RID

Medical Faculty, Uniuersitat Witten Herdecke, Beckweg 4 D-5804 Herdeke (Ruhr), FRG

Keywords: music therapy; physiology; communication; child development; rhythm entrainment

'The body of the speaker dances i n time with his speech.

Further, the body of the listener dances i n rhythm with that of the speaker!'

(Condon and Ogston, p 338)

Physiology and communication At the molecular level the immune system and nervous system communicate with each other. Psychological stress and social stress influences the immune system, sometimes adversely. The relationship between neuroendocrine and immune systems is one of mutual comm~nication~,~.

Our bodies are engaged in a continuing communicative process out of the range of conscious awareness. These communications are vital for life. We can, as Rossi5 says

In our work as a department of music therapy within the faculty of medicine in a West German teaching hospital we have begun to explore links between the playing of improvized music as therapy and the practice of medicine. Music therapists work with physicians within the hospital as complementary '. . . conceptualize a fairly complete channel of information practitioners. We have attempted to develop a transduction between mind a s it is experientially encoded common language by which patients are described. in the limbic-hypothalamic system filter, and the autonomic This language calls upon the art of medicine as much endocrine, immune, and neuropeptide systems that transmit as it does upon the science of medicine. Our contention their "messenger" molecules to the organs and tissues and is that human beings have a personal identity which to the cellular, genetic, and ultimately molecular levels'. is musical1. When we search for a metaphor which (P 52) informs the way we describe ourselves then we can In this approach mind and body are united within a say that we are symphonic, rather than mechanic, rhythmic context of communication which enables beings. healing to take place. At the core of this work is the The main argument of this paper is that musical idea that the suprachiasmatic nucleus of the hypocomponents are the fundamentals of communication; thalamus is a regulator of the ultradian (within a and that rhythm, in particular, is the musical day) rhythms7 responsible for autonomic system aspect of communication fundamental to the way regulation and cerebral dominance5.When the normal in which we relate to ourselves and to others. periodicity of these rhythms is disturbed by stress then Communication in this sense is not solely restricted psychosomatic reactions may occur. The restoration of to the transmission of information, but is also an integrated rhythmic hypothalamic response should concerned with the establishment and management be an important factor in the process of healing. It of relationships2. is feasible then that music therapy is an ideal medium If this argument is true then music is a powerful for promoting such integration and regulation through and subtle medium of communication which is rhythm. isomorphic with the process of living3y4 and music therapy can be a powerful therapeutic medium for Synchrony, rhythm and communication promoting communication.

'Curative chronobiotics may be visualized for disease such The focus for understanding communication is how as certain emotional disorders or rheumatoid arthritis - if, the human being can maintain a coherent identity in and only if, rhythm alternation can be recognized to be a personal and interpersonal milieu. This continually etiologically significant" (p 487). maintained coherence is a creative act. None of us as For communicationto occur there has to be an element human beings are islands isolated in the universe. We of predictability by which events are structured. This are organisms which act and interact with the communication occurs within a matrix of time and is environment. We experience the world and attempt manifested as particular rhythms. These may be the to influence it. Communication is the process by which circadian rhythms (literally about a day) of temperwe interact with our environment which includes the ature and sleep in humans, the shorter ultradian interpersonal milieux of our friends, colleagues and (within a day) rhythms of autonomic system regulation lovers. It is the medium by which we negotiate our and metabolic processes, or the shorter periodicities self image in those relationships and integrate of respiration, peristalsis and heart rate7-9.These are ourselves with others. the regulatory mechanisms by which self synchrony Dialogue and exchange of information, the regulation is maintained as a process of internal communication. of interpersonal distance and personal boundary, The work of C ~ n d o n ~ O clearly - ~ ~ shows the intethe mutual expression of human emotion and the gration in terms of verbal behaviour, including sharing of ideas are based upon communication. silence, and bodily gestures. There is a self syn- o141~076818gl These are located within a matrix of time which is c o n o u s organization to h and movement which 120743-041~02~0010 not static. Sequence, order and phrasing, the fundais essentially rhythmic. Rhythm provides the means Q1989 mentals of musical form are vital elements in by which behaviour is organized. maintaining coherence whether in physiological The Royal systems, personal development or interpersonal However, Condon12goes on to write that as human Society of relationships. beings we also communicate with other people. This Medicine David Aldridge Collected music therapy papers 33

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Journal of the Royal Society of Medicine Volume 82 December 1989

he calls 'interactional' synchrony. We are active participants in communication. When we listen we move synchronously with the articulatory structure of the speaker's speech. As the speaker moves with his own speech, then so does the listener too. What is 'sent' and 'received' are inseparable in the ordered context of communication. This gives additional support to the idea, to which some music therapists refer, when they say that therapist and patient are 'united in the music'. In Condon's words12

alone, or words themselves seem inadequate. The communication of passions, love, ecstasy or anger are rarely dependent solely on words. At such times vocalizations and gestures are far more subtle and 'meaningful' than words.

--------- L _ l _ _ . Â ¥ _ __-..__-L

c---rt

Child development and rhythmic interaction The development of language and socialization in the infant depends upon learning the rhythmic structure of synchronization13.From birth the infant has the genetic basis of an individually entrained 'But what flows through them is a similar order; so that what physiology, ie a self synchronicity. The infant has its is sent and what is received are understood and shared by own time as 'kairos'. Yet, the process of socialization, both speaker and listener. What all aspects of this process and the use of language depends upon entraining have in common is the propagation and reception of order.

There is no "between" i n the continuum of order.' (p 56). those rhythms with those of another, ie an interactional synchrony as 'chronos'. This interactional As rhythms are entrained, or synchronized, within synchrony could reflect those neural timing mechthe individual, then the listener will entrain with the anisms which form the ground of communication emergent rhythmic structure of the speaker, singer where interactional cycles of attention and affect or player. By watching the movement of the listeners are entrained with homeostatic mechanisms in the body as well as by observing the way in which the nervous system16. listener plays it is possible to glean some ideas about Lester et aZ.17 investigated the synchronization of their perceptual involvement. neonatal movement and the speech sounds of the adult talking to the baby. They argued that the ability of Phrasing the infant to attend to social stimuli was related to A central feature of both musical and biological form the infant's capacity for self regulation. Cycles of is phrasing. When we speak in dialogues then we rhythmic interaction between infants and mothers, must know when a phrase is ending, and how to begin they argued, reflected an increasing ability by the infant another. This occurs in speech by accented differences to organize cognitive and affective experience within in a rhythmic context. When we listen we give a the rhythmic structure provided by the parent. continuous feedback by small motions and gestures However, this was not a one-sided phenomenon. of our heads and bodies, and vocalizations. When a Infants produce forms of expression and gesture that are phrase is coming to an end there is an increase or not imitations of maternal behaviour18J9.Both baby change in such activity13. and mother learn each others rhythmic structure and Interactional synchrony between people, and the comodify their own behaviour to fit that structure. ordination of phrasing in communication, cannot be Arousal, affect and attention are learned within the explained as reaction or as a reflex response to sound rhythm of a relationship. or movement. Synchronization is achieved by a shared This is the method employed in music therapy. The interaction in a rhythmic context known to both rhythmic structure of the patient is discovered by participants. The basis of such mutual knowledge is the therapist, and the patient is then met within that both physiological, in that we share common rhythmic structure. physiologies, and cultural14. The forces which bind Stern et al.20studied the non-verbal behaviour of us together, which are the essence of our mutuality, mothers and infants. They found two parallel modes are musical. of communication.

Non-verbal communication and relationship One form of communication was that of CO-action.

As the preceding paragraphs suggest, communication In this form both mother and infant vocalize together. occurs in a context of relationship. Peggy Perm2writes These authors suggest that coactional vocalizing is that 'All emotions are an indication of how someone else an early pattern of behaviour which is structurally is to behave' (p 17). All too often when we consider and functionally similar to mutual gaze, posture communication in the context of therapy we concentrate sharing and rhythm sharing. It occurs during the on the semantic bases of communication when it is the highest levels of arousal and is indicative of emotional relational aspects of the interaction which are primary. tone. In adults CO-active vocalizing occurs in situations Language and non-verbal behaviours are powerful of interpersonal arousal such as intense anger, organizers of personal and social actions2J4. In sadness, joy or lovemaking. studying communication the role of verbal behaviour The contrasting form is that of alternation. This mode is often over-emphasized, and the role of non-verbal of communicationis that found in conversationwhere behaviour neglected. This places a n emphasis on the speaker and listener alternately exchange roles. It is 'what' of communication (ie the content of communia dialogic pattern and valuable for the exchange of cation)rather than the 'how' of communication (ie the symbolic information. This alternative mode is regulation of that communication). The non-verbal valuable for the acquisition of language. It allows aspects of communication indicate how the content information to be sent by one person while being is to be received. Watzlawick et al. l5 call this process processed by the other. However, it is a separate 'metacommunication'; a communication about a pattern to that of CO-action. communication. For example; the comment 'Oh, very CO-actionemphasizes the event of communication itinteresting' can have quite a different meaning self, rather than the content of the communication. according to the tone of voice and gesture used to Simultaneous vocalization promotes mutual experiDavid Collected music therapy 34 deliverAldridge it. ence andpapers may be essential to the process of bonding and Sometimes information which is too powerful or feeling of relatedness. These two structurally different L - ---__---:--^.-.3

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Communication and pathology If musical elements are essential to communication, then the improvized musical playing of people may make manifest both underlying pathology and possibilities for growth and change.

Condon and Ogston1Ă&#x201A;compared normal and pathological behaviour between patients and therapists using the medium of film. Human interaction was filmed. The films were then viewed repeatedly one frame a t a time, and analysed. Each frame was numbered and sequences of frames analysed according to speech and vocalization correlated with body movements. The authors call this the study of 'linguistics-kinesics'1Ă&#x201A; (p 38).

When the same authors studied a chronic schizophrenic patient they found that there was a noticeable lack of head movements and rigidity of posture in the patient compared to the relatively free head movement of normal speakers. The expressive qualities of speech and movement were severely restricted. A selfdysynchrony also appeared in the schizophrenic patient where body movements appeared to be laterally separate.

In the micro-analysis of films of depressed patients

by Condon1Ă&#x201A; prosodic features of pitch, stress, phrasing and timbre were found which seemed indicative of underlying pathology; 'A marked laxity of articulatory movements characterizedthe speech of these patients. With its sparing use of pitch and accent, their voice had a dead listless quality: changes of pitch covered a narrow tonal range and were predominantly stepwise rather than gliding; hovering tones appeared at the end of sentences, . . .intonations tended to occur in the same stereotyped patterns; and emphatic accents were either rare or absent entirely. Their speech gave an impression of being slow and halting because of the frequent appearance of hesitation pauses interrupting the flow of their phrases' (p 344).

This work resulted in Condon postulating a continuum of degrees of delayed response to sound with autistic-like behaviour at the severe end and learning disabilities a t the milder end. (While not evident as a motor abnormality during conversation, these children had difTiculty with reading and mathematics).

The observed children responded to an immediate actual sound but also appeared to respond again to that same sound with a delay 'by as much as % to a full second'll (p 47).

He gives the example of a 2% year old child throwing a block on a table. The block lands on the table and the child picks up another such block. The childs' hands suddenly move in a jerky and seemingly bizarre manner. Microanalysis of the film revealed that the child's body moved synchronously with the sound of the brick hitting the table. At a later time, 16 film frames, the jerky hand movements occurred.

These hand movements were isomorphic with the sound and movements which occurred 16 film frames earlier. (There were 24 film frames per second). By delaying the film sound to coincide with the movement the child was seen to move in precise synchrony.

It was possible to see and hear the occurrence of a sound on film and predict the occurrence of a bodily movement 16 frames later without any sound occurring at that time.

In children with a delayed response to sound their behaviour appeared to be dominated by that delay. Furthermore, these children often lacked a co-ordination between hearing a sound and visually locating that sound. These children were literally out of time with the sensory structure of their world.

The entrainment of vision and sound gives an important spatial location in the world. To communicate we need to be entrained both within ourselves and with our environment. A delay in sound processing can lead to estrangement from the world and personal incoherence.

It is evident from this description that these are also musical qualities, and if the improvized playing of a depressed patient was heard then a music therapist would be making similar comments.

Discussion Fraser et aLZ1showed similar discriminating linThe basic elements of human communication are guistic profiles of schizophrenic and manic patients. musical. Physiological, psychological and social activity There was a continuum of linguistic degeneration occur in a context of time which is dynamic and the across the psychotic spectrum. In an experimental structure of which is musical. At a fundamental level control group 'normal' subjects produced fluent, human activity is organized as a hierarchy of complex and error free utterances. Schizophrenic rhythmic entrainment; within the individual as selfpatients produced dysfluent, simple and error ridden synchrony, and within relationships as interactional speech. synchrony.

Interestingly, when these patients improved clinically When the breakdown of this synchronous besentences became more tightly constructed and pitch widened in range and became more melodically haviour occurs then pathology is evident. The varied. Again clinical improvement can be heard in restriction of musical aspects of communication,pitch, stress, articulation, timbre and fluency, appear to the musical (prosodic or suprasegmental) aspects of speech style. be indicative of psychopathology. An improvement Condonl1continued to develop this diagnostic work in these qualities appears to be evident in a return to health and the maintenance of a coherent further studying the integration of body motion and speech across many dimensions, particularly in the identity. field of autistic-like behaviour. His frame by frame It is possible to hypothesize that improvized music filmed micro-analysis of patients with various syntherapyzz is a powerful tool for promoting dromes like petit mal, Huntington's chorea, autism, communication in terms of personal and interpersonal integration. Alternative creative dialogues may be stuttering, parkinsonism and aphasia, led him to believe that there may be some relationship between encouraged within the person such that they are not estranged within themselves, or estranged from their problems and an underlying dysfunction in sound processing. Many of the behavioural mannerisms he others. Furthermore, clinicians, no matter in which observed in children appeared to be related to a discipline they have their origins, may be advised to multiple response to sound; there was both a n attend to the musical components of communication.

In this way the arts, as well as science, may inform immediate response and a delayed response to a sound David or Aldridge Collected music therapy papers 35 the practice of medicine. event, 'dyssynchrony'.

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References 1 Aldridge D. A phenomenonlogical comparison of the organization of music and the self. Arts in Psychotherapy 1989;16:(in press) 2 Penn P. Coalitions and binding interactions in families with chronic illness. Fam Systems Med 1983;1:16-26 3 Aldridge D. The development of a research strategy for music therapists in a hospital setting. Arts in Psychotherapy 1989;16:(in press) 4 Aldridge D. Physiological change, communication and the playing of improvised music. Arts in Psychotherapy 1989;16:(in press) 5 Rossi EL. From mind to molecule: A state-dependent memory, learning and behavior theory of mind-body healing. Advances 1987;4:46-60 6 Tee DE. Another look a t the interaction of psyche and soma. Complementary Med Res 1987;2:1-2 7 Moore-Ede MC, Czeisler CA, Richardson GS.Circadian timekeeping in health and disease. N Engl J Med 1983;309:469-79 8 Reinberg A, Halberg F. Circadian chronopharmacology.

Ann Rev Pharmacol1971;11:455-92 9 Johnson C, Woodland-Hastings J. The elusive mechanism of the circadian clock. Am Sci 1986;74:29-36 10 Condon WS, Ogston WD. Sound film analysis of normal and pathological behavior patterns. J Nerv Ment Dis 1966;14:338-47 11 Condon W. Multiple response to sound in dysfunctional children. JAutism Childhood Schizophrenia1975;5:37-56 12 Condon W. The relation of interactional synchrony to cognitive and emotional processes. In: Key MR, ed. The

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relationship of verbal and non-verbal communication.

The Hague: Mouton, 1980:49-65 Kempton W. The rhythmic basis of interactional microsynchrony. In: Key MR. ed. The relationship of verbal and non-verbal communication. The Hague: Mouton, 1980:68-75 Key MR. The relationship of verbal and non-verbal communication. The Hague: Mouton, 1980 Watzlawick P, Beavin JH, Jackson DD. Pragmatics of human communication. New York: WW Norton, 1967 Linden W. A microanalysis of autonomic activity during human speech. Psychosom Med 1987;49:562-78 Lester BM, Hoffman J , Brazelton TB. The rhythmic structure of mother-infant interaction i n term and proterm infants. Child Dev 1985;56:15-27 Murray L, Trevarthen C. The infant's role in mother-infant communications. J Child Long 1986; 1315-29 Trevarthen C. Facial expressions of emotion in motherinfant interaction. Human Neurobiol 1985;4:4-21 S t e m DN, Jaffe J, Bebbe B, Bennett SL. Vocalizing in unison and in alternation: two modes of communication within the mother infant dyad. Ann NY Acad Sci 1975;263:89-100 Fraser WI, King K, Thomas P, Kendell RE. The diagnosis of schizophrenia by language analysis. Br J Pyschiatry 1986;148:275-8 Nordoff P, Bobbins C. Creative music therapy. New York: John Day, 1977 (Accepted 25 May 1989)

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

Pergamon Press plc, 1991. Printed in the U.S.A.

0197-4556191 $3.00

+ .00

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.

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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

David Aldridge

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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Journal of the Royal Society of Medicine Volume 83 June 1990

rhythm of breathing. The unit staff were asked to be quiet during this period and not to carry out any invasive procedures for 10 min after the contact.

There were a range of reactions from a change in breathing (it became slower and deeper), fine motor movements, grabbing movements of the hand and Intensive care treatment is a highly technological turning of the head, eyes opening to the regaining of branch of medicine. Even in what may appear to be hopeless cases, i t can save lives1 through consciousness. When the therapist first began to sing the application of this modern technology. Howthere was a slowing down of the heart rate. Then the heart rate rose rapidly and sustained an elevated level ever, albeit in the context of undoubted success, until the end of the contact. This may indicate a n intensive care treatment has fallen into disreattempt at orientation and cognitive processing within pute. Patients are seen to suffer from a wide range of problems resulting from insufficient com* ~ . measurement the communicational c o n t e ~ t ~EEG showed a desynchronization from theta rhythm, to munication, sleep and sensory deprivation2s3 and alpha rhythm or beta rhythm in former synchronized lack of empathy between patient and medical staff. areas. This effect, indicating arousal and perceptual Many activities in an intensive care situation appear activity, faded out after the music therapy stopped. to be between the unit staff and the essential Some of the ward staff were astonished that a patient machines, ie subjects and objects. To a certain extent patients become a part of this object world. We propose could respond to such quiet singing. This highlights a difficulty of noisy units such as these. All communithat improvised music therapy can be a useful cation is made above a high level of machine noise. adjunctive therapy in such situations both for the patient and the staff.

Furthermore commands to an 'unconscious'. patient In these situations of intensive monitoring and are made by shouting formal injunctions, ie 'Show me machine support, particularly in the case of comatose your tongue', 'Tell me your name', 'Open your eyes'. patients, we may ask of ourselves 'Where is the self Few attempts are made a t normal human communiof the patient?'. Needleman4 reminds us that the cation with a patient who cannot speak or with whom staff can have any psychological contact. It is as if power of scientific thought has been to organize our perceptions i n such a manner that we can survive in these patients were isolated in a landscape of noise, ! the world. Hence the value of scientific medicine and and deprived of human contact. instrumentation. However, he goes on to say that A benefit of the music therapy was that the staff science has also neglected the human body as an were made aware of the quality and intensity of the instrument of knowledge and a s a vehicle for senhuman contact. In the intensive care unit environsations as direct as ordinary sensory experience, but ment of seemingly non-responding patients, depena s subtle as consciousness. dent upon machines to maintain vital functions and At the suggestion of a hospital neurologist a music anxiety provoking in terms of possible patient death, then it is a human reaction to withdraw personal therapist began working with coma patients. To investigate this approach further the work was contact and interact with the machines. This is monitored i n an intensive treatment unit. Five further exacerbated by a scientific epistemology which patients, between the ages of 15 and 40 years, and emphasizes the person only as a material being and which equates mind with brain. with severe coma (a Glasgow Coma Scale score A period of calm was also recognized as having between 4 and 7) were treated. All the patients had been involved in some sort of accident, had sustained potential benefit for the patient. What some staff fail to realize is that communication is dependent upon brain damage and most had undergone neurosurgery. rhythm, not upon volume. We might argue that such The form of music therapy used here is based on the unconscious patients, struggling to orient themselves principle that we are organized as human beings not in time and space, are further confused by an in a mechanical way but i n a musical form; ie a atmosphere of continuing loud and disorienting ranharmonic complex of interacting rhythms and melodic contour^^-^. To maintain our coherence as beings in dom noise. For patients seeking to orient themselves the world then we must creatively improvise our then the basic rhythmic context of their own breathing identity. Rather than search for a master clock which may provide the focus for that orientation. This raises coordinates us chronobiologically, we argue that we the problem of intentionality in human behaviour, are better served by the non-mechanistic concept of even when consciousness appears to be absent. It is musical organization. Music therapy is the medium also vital that staff in such situations do not confuse by which a coherent organization is regained, ie 'not acting' with 'not perceiving'. linking brain, body and mind. In this perspective the We can speculate that the various body rhythms self is more than a corporeal being. have become disassociated in such comatose states.

Each music therapy contact lasted between 8 and The question remains then of how those behaviours 12 min. The therapist improvised her wordless singing can be integrated and where is the seat of such based upon the tempo of the patient's pulse, and more integration.

Improvised singing appears to offer a number of importantly, the patient's breathing pattern. She pitched her singing to a tuning fork. The character of possible benefits for working with coma patients in the patient's breathing determined the nature of the terms of human contact and promoting perceptual singing. The singing was clearly phrased so that when responses. Human contact through singing, rather than speaking, also suggests that the fundamentals any reaction was seen then the phrase could be repeated. of human communication are musical in form. In this Before the first session the music therapist had met way we have the a r t of medicine within the science the family to gain some idea of what the patient was of medicine. Perhaps the skills of human communilike a s a person. On contacting the comatose patient she would say who she was, that she would sing for cation may become part of medical and nursing David Aldridge Collected music therapy papers 41 education5, particularly in the context of intensive the patient in the tempo of his or her pulse and the

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Where am I? Music therapy applied to coma patients

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care. 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.

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 her?, and then for ourselves as fellow human beings, 'Where am I?' This 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 entitylO.

D Aldridge Medical Faculty, Universitat Witten Herdecke Beckwig 4,D5804 Herdecke, FRG

D Gustorff Znstitut fur Musiktherapie, Medical Faculty, Universitat Witten Herdecke

H J Hannich Wilhelms-Universitat Klinic fur Aniisthesiologie und operatiu Intensivmedizin Albert-Schweitzer-Strasse 33, D4400 Miinster, FRG

References 1 Hannich H. Uberlegen m m Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaft 1988;13:238-44 2 Wilson L. Intensive care delirium. Arch Intern fed 1972;130:225-6 3 Ulrich R. View through a window may influence recovery from surgery. Science 1984;224:420-1 4 Needleman J. A sense of the cosmos. New York:Arkana, 1988 5 Aldridge D. A phenomenological comparison of the organization of music and the self. Arts in Psychotherapy 1989;16:91-7 6 Aldridge D. Music, communication and medicine. J R Soc Med 1989;82:743-6 7 NordoffP, Robbins C. Creative music therapy. New York, John Day, 1977 8 Sandman C . Afferent influences on the cortical evoked response. In: Coles M, Jennings JR,Stern JA eds.

Psychological perspectives (festscrift for Beatrice and John Lacey). Stroudberg, PA: Hutchinson and Ross, 1984 9 Sandman C. Augmentation of the auditory event related to potentials of the brain during diastole. Znt J Physiology 1984;2:111-19 10 Mindell A. Coma: key to awakening. Boston: Shambala, 1989

regarding HIV infection, but also of general medicine in preparation for Finals. Fortunately, a gynaecologist friend of my parents had trained in Sydney and introduced me to a consultant immunologist there, Professor Ronal Penny. Thus I came to Barts students are no different from most final year spend my elective a t St Vincent's Hospital, Sydney. medics in the need to choose a destination for the I was extremely fortunate in being funded by elective period. This need occasionally encompasses the Guildchrist Foundation, the Clothworkers Trust a desire to journey to a warm and exotic part of the and my Medical College, all in the City of London. world yet a t the same time is concerned with gaining some medical experience. It is surprisingly difficult It was interesting that none of the London-based to combine these two intentions especially since hot AIDS organizations were able to provide any assistance despite my protocol covering the very serious climates are often associated with many outdoor temptations which can divert thought away from negative social aspect of neuropsychiatric complications of HIV infection. study and learning.

The public image of the AIDS victim has been the My elective months were spent in Sydney, Australia, a choice governed by my previous special infected homosexual or drug addict. Sydney, with its studies in HIV and AIDS. This interest began in 1985 large population of both these sources of patients, also has people from every walk of life professing beliefs when I joined St Mary's hospital for one year to study 'Infection and Immunity'. From that time, the subject and carrying out behaviour that, as in all cosmoof AIDS and the management of the immunopolitan society, has no norm. AIDS is making its grim inroad, indifferent to stereotyping. During compromised patient began to appear more frequently my time in Sydney, I saw many aspects of inpatient, in medical journals. The neuropsychiatric complications of HIV infection were of particular interest outpatient, community and laboratory care of HIV infection. It is a sad game of numbers that the since they demonstrated links between the immune system, opportunistic infection and psychological Australian population is not much more than a symptoms in patients who practised diverse lifestyles. quarter that of the UK, but contains as many recorded cases of AIDS. The field of neuropsychiatric compliThe extent to which the AIDS epidemic will domications was too vast for deep investigation in nate current medical practice in the UK is still unclear. the limited time of the elective period. My work covered a broad overview of the illness and gave me My concern was to use my particular academic knowledge to support the clinical experience obtained a deep understanding of compassion.

'AIDS patients? Did you wear a mask. I hope on elective. However, I had not had any direct you wore rubber gloves!' This was the reaction personal involvement in the management of HIV of several of my fellow students on my return infection and for that reason alone was keen to London. I must say that, to an extent, these to spend some time attached to a unit where intimations of fear and caution echoed my own there a possibility of some teaching, not only Davidwas Aldridge Collected music therapy papers 42

AIDS afterthought

0141-07681901 060M6~021~02 Q

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Music Therapy and Intensive Care Keywords: MUSIC, COMA, INTENSIVE CARE

Patients in intensive care often suffer through insufficient communication, inadequate sleep, sensory deprivation"2 and lack of empathy between patient and medical staff. Many activities in intensive care appear to be simply between unit staff and objects, and to a certain extent patients become a part of this object world. We propose that improvised music therapy can prove valuable in this context both for the patient a i d the staff.

At the suggestion of a hospital neurologist a music therapist began working with patients in intensive care.

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 had been involved in some sort of trauma and had sustained brain damage, and four had undergone neurosur@ry. Music therapy is based on the principle that we are organized as human beings not in a mechanical, chronobiological way but in a musical fashion i.e. a harmonic complex of interacting rhythms and melodic contour^."^"' To maintain our coherence as beings it seems we must creatively maintain our identity. Music therapy is the medium by which coherent organization is regained, linking brain, body and mind. In this perspective the self is more than simply a corporeal being.

Each music therapy contact lasts between eight and twelve minutes. The therapist~mprovisesher wordless singing based upon the tempo of the patient's pulse, and more importantly, the patient's breathing pattern, pitching her singing to a tuning fork. The character of the patient's breathing determines the nature of the singing which is clearly phrased so that when any reaction is seen the phrase can be repeated.

Before the first session the music therapist meets the family to gain some idea of what the patient is like as a person. O n meeting the comatose patient she introduces herself and tells him she will sing in the tempo of his or her pulse and rhythm of breathing. The Unit staff are asked to be quiet during this period and to avoid invasive procedures for ten minutes after the contact. There is a range of reactions including a change in breathing (it becomes slower and deeper), fine motor "Normal score 15, worst score 3

movements, grasping movements of the hand, turning of the head and eye opcning. When the therapist first begins to sing heart rate slows. Then it rises rapidly and sustains an elevated level until the end of the contact. This may indicate an attempt at orientation and cognitive processing.6" The EEG shows 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.

Neurones linked to cardiac rhythm have been identified in the medulla and there is a synchronous relationship betwccn the contraction of the heart and the 'ascending' wave of the EEG alpha rhythm.' It is possible that the rhythmic co-ordination of the cardiovascular system with cortical rhythmic firing is of primary importance for cognition.

Furthermore, sleep disturbance is a major problem in intensive care units and the effect of a disturbed waking1 sleeping rhythm upon other metabolic cycles may be critical. The rhythmic entrainment of cardiovascular and somatic activities may be a key clement in recovery. This means that we must consider activity of the the total 'behavio~ral'~ patient including rhythmical integration of independent systems with major tidal rhythms of the body.

A patient's response to quiet singing highlights a difficulty of noisy, busy, often brightly lit units where communication is hindered by continuous background noise. Shouted commands to an unconscious patient include formal injunctions, i.e. "Show me your tongue", "Tell me your name", "Open your eyes". There may be few attempts made at normal h u m a n communication where the patient cannot speak or where there is restricted physiological access. It is as if he were isolated in a landscape of noise, and deprived of human contact.

One benefit of music therapy is t o of the remind the staff of the imnortance ' quality and intensity of human contact.

Whilst life support and monitoring devices are essential they encourage a mechanistic approach which sees the patient simply as a biological complex.

A period of calm may also benefit the patient. What some staff may fail to recognize is that communication depends on rhythm, not simply upon volu m e . Such unconscious patients, struggling to orient themselves in time and space, are further confused by an environment of continuing loud, disorientating random noise and bright light.

For these patients the basic rhythmic context of their own breathing may provide the required focus for orientation.

This raises the problem of intention in human behaviour even when consciousness appears to be absent. It is also vital that staff do not confuse "not responding" with "not receiving".

We can further speculate that the various body rhythms become disassociated in comatose states and following major surgery. The question remains then of how rhythms can be integrated and where is the seat of such integration. It is very likely that it is a property of the whole organism. The environment of the patient includes the vital component of human contact and there is reason to believe that the essential basis of this contact too is rhythmiImprovised singing appears to offer a number of possible benefits for intensive care both in terms of human contact and promoting perceptual responses.

Better responses to singing, rather than speaking, suggests that the fundamentals of human communication are musical in form. In this way we have the art of m e d i c i n e w i t h i n t h e science of medicine.

1. Wilson L. Intrnsivr ciiri* ik-lirium. A r h w tifhitfrwl h<rilic h r 1972; 130: 225-h.

2. Ulrich R. View 111rtiui;h<i wiiulunv in.iy i n f l ~ n ~ i irfoivery i~t~ from surgrry. Srii-iirr 1QM.224: 420-1.

3. Aldndge D. A plienon~.'ii~~Iugit'al annparistin of the orpni?.ationof music.ind tin-self An'. in Piyhllit'riily I'W*; ll>.'ll-

7.

!+c also Yingling CD, liosobuchi V, llarrington M (1990) I'.KX asa prcilirtor of rortm'ry from coma. laurel 336: 873and Siwtr R (1990) Effectsof auditory stimuli on comatose pitients wilt head injury. Heart 1111d l.un{ I t : 37.3-H.-Kilitur

INTENSIVE & CRITICAL CARE DIGEST Vol. 10 No. 1 MARCH 1991

David Aldridge

Collected music therapy papers

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Journal of the Royal Society of Medicine Volume 86 February 1993

Music and Alzheimer's disease -assessment and therapy: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Universitat Witten Herdecke, Beckweg 4, D-5804Herdecke BRD, Germany Keywords: dementia; Alzheimer's disease; music psychology; music therapy; mental state examination

Dementia is an important source of chronic disability leading to both spiralling health care expenditure among the elderly and a progressive disturbance of life quality for the patient and his or her family. With anticipated increases in the population of the elderly in Europe, then it is timely to find treatment initiatives in the Western world which will ameliorate the impact of this problem. Music therapy while not offering a cure for such a disease may be in a position to offer amelioration of the impact of the disease and provide a valuable adjunct to diagnosis.

The diagnosis of Alzheimer's disease is prone to error and authors differ as to the difficulty of making a precise diagnosis. In the early stages of the disease the symptoms are difficult to distinguish from those of normal aging, a process which itself is poorly understood. A second source of error in diagnosing Alzheimer's disease is that it is masked by other conditions. Principle among these conditions is that of depression which itself can cause cognitive and behavioural disorders.

Clearly Alzheimer's disease causes distress for the patient. The loss of memory and the accompanying loss of language, before the onset of motor impairment, means that the daily lives of patients are disturbed.

Communication, the fabric of social contact, is interrupted and disordered. The threat of progressive deterioration and behavioural disturbance has ramifications not only for the patients themselves, but also their families who must take some of the social responsibility for the care of the patient, and the emotional burden of seeing a loved one becoming confused and isolated.

A brief cognitive test, the Mini-Mental State Examination (MMSE), has been developed to screen and monitor the progression of Alzheimer's disease.

As a clinical instrument it is widely used and well validated in practice. As a bed-side test the MMSE is widely used for testing cognition and is useful as a predictive tool for cognitive impairment and semantic memory without being contaminated by motor and sensory deficits. The items which the MMSE fails to discriminate (minor language deficits), or neglects to assess (fluency and intentionality) may be elicited in the playing of improvised music. A dynamic musical assessment of patient behaviour, linked with the motor co-ordination and intent required for the playing of musical instruments used in music therapy, and the necessary element of interpersonal communication,may provide a sensitive complementary tool for assessment1.

Ravel, the composer, began to complain of increased fatigue and lassitude. Following a traffic accident his condition deteriorated progressively. He lost the ability to remember names, to speak spontaneously and to write. Although he could understand speech he was no longer capable of the coordination required to lead a major orchestra. While his mind, he reports, was full of musical ideas, he could not set them down. Eventually his intellectual functions deteriorated until he could no longer recognize his own music. Even in a composer of his standing, with what we may guess was a progressive dementing illness, his active music-making capabilities deteriorated, albeit after speech failed.

However, the responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon. While language deterioration is a feature of cognitive deficit, musical abilities appear to be preserved. This may be because the fundamentals of language itself are musical, and are prior to semantic and lexical functions in language development.

Although language processing may be dominant in one hemisphere of the brain, music production involves an understanding of the interaction of both cerebral hemispheres. In attempting to understand the perception of music there have been a number of investigations into the hemispheric strategies involved. Much of the literature considering musical perception concentrates on the significance of hemispheric dominance. Gates and Bradshaw2 conclude that cerebral hemispheres are concerned with music perception and that no laterality differences are apparent. Other authors suggest that two processing functions develop with training where left and right hemispheres are simultaneously involved, and that musical stimuli are capable of eliciting both right and left ear superiority. Similarly, when people listen to and perform music they utilize differing hemispheric processing strategies.

Evidence of the global strategy of music processing in the brain is found in the clinical literature. In two cases of aphasia3 singing was seen as a welcome release from the helplessness and a means to communicate thoughts externally. Berman4 suggests that recovery from aphasia is not a matter of new learning by the non-dominant hemisphere but a taking over of responsibility for language by that hemisphere. The non-dominant hemisphere may be a reserve of functions in case of regional failure.

Little is known about the loss of musical and language abilities in cases of global cortical damage.

Any discussion is necessarily limited to hypothesizing as there are no established baselines for musical Music and dementia performance in the adult population. Aphasia, which Late in adult life, at the age of 56 years, and after is a feature of cognitive deterioration, is a complicated completing two major concertos for the piano Maurice phenomenon.

David Aldridge Collected music therapy papers While syntactical functions may remain 44

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Journal of the Royal Society of Medicine Volume 86 February 1993

Table 1. Features of medical assessment and musical assessment Medical elements of assessment

Musical elements of assessment

Examples of improvised playing

Continuing observation of mental and functional status

Continuing observation of mental and functional status

¥Improvisationusing rhythmic instruments (drum and cymbal) singly or in combination, ¥improvisationusing melodic instruments ¥singin and playing folk songs with harmonic accompaniment

Testing of verbal skills, including element of speech fluency

Testing of musical skills; rhythm, melody, harmony, dynamic, phrasing, articulation

Â¥playin tuned percussion (metallophone, xylophone, chime bars) demanding precise movements

Cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left co-ordination).

Cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left co-ordination).

¥alternat playing of cymbal and drum using a beater in each hand ¥co-ordinate playing of cymbal and drum using a beater in each hand ¥co-ordinate playing of tuned percussion

Testing for progressive memory Testing for progressive memory disintegration disintegration

Â¥th playing of short rhythmic and melodic phrases within the session, and in successive sessions

Motivation to complete tests, to Motivation to sustain playing achieve set goals and persevere improvised music, to achieve in set tasks musical goals and persevere in maintaining musical form 'Intention' difficult to assess; 'Intention' a feature of improvised but considered important musical playing

¥th playing of a rhythmic pattern deteriorates when unaccompanied by the therapist, as does the ability to complete a known melody, although tempo remains ¥th patient exhibits the intention to play the piano from the onset of therapy and maintains this intent throughout the course of treatment

Concentration and attention span

Concentration on the improvised playing and attention to the instruments

Â¥th patient loses concentration when playing, with qualitative losses in the musical playing and lack of precision in the beating of rhythmical instruments

Flexibility in task switching

Flexibility in musical (including instrumental) changes

Â¥initiall the musical playing is limited to a tempo of 120 bpm and a characteristic pattern but this is responsive to change

Mini-mental state score Ability to play improvised music influenced by educational status influenced by previous musical training

malthough the patient has a musical background this is only of help when she perceives the musical playing, it is little influence in the improvised playing

Insensitive to small changes

Sensitive to small changes

Â¥musicachanges in tempo, dynamic, timbre and articulation which a t first are missing are gradually developed

Ability to interpret surroundings

Ability to interpret musical context and assessment of communication i n the therapeutic relationship

Â¥th patient develops the ability to play in a musical dialogue with the therapist demanding both a refined musical perception and the ability of musical production

longer, it is the lexical and semantic functions of The patient often spontaneously sang without error naming and reference which begin to fail in the early in pitch, melody, rhythm and lyrics, and spent long stages. Phrasing and grammatical structures remain periods of time listening to music. Beatty6 describes giving an impression of normal speech, yet content a woman who had severe impairments in terms of becomes increasingly incoherent. These progressive aphasia, memory dysfunction and apraxia yet was failings appear to be located within the context of able to sight read an unfamiliar song and perform on semantic and episodic memory loss illustrated by the the xylophone which to her was an unconventional inability to remember a simple story when tested. instrument. Like Ravel, she no longer recalled the Musicality and singing are rarely tested as features name of the music she was playing. of cognitive deterioration, yet preservation of these Swartz and his colleagues7 propose a series of abilities in aphasics has been linked to eventual perceptual levels at which musical disorders take recovery, and could be significant indicators of hierplace: archical changes in cognitive functioning. Jacome5 (i) the acoustico-psychologicallevel, which includes found that a musically naive patient with transcortical changes in intensity, pitch and timbre. mixed aphasia exhibited repetitive, spontaneous (ii) the discriminatory level, which includes the whistling and whistling in response to questions. discrimination David Aldridge Collected music therapy papers of intervals and chords.

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Journal of the Royal Society of Medicine Volume 86 February 1993

structure which begins to fail in Alzheimer patients. (iii) the categorical level which includes the categorical A loss of rhythmical context would explain why identification of rhythmic patterns and intervals. patients are able to produce and persevere with (iv) the configural level, which includes melody rhythmic and melodic playing when offered an overall perception, the recognition of motifs and themes, tonal structure by the therapist, and would suggest a global changes, identification of instruments, and rhythmic failing in cognition while localized lower abilities are discrimination. retained. (v) the level where musical form is recognized, Music therapy appears to offer a sensitive assessment including complex perceptual and executive functions tool. It tests those prosodic elements of speech producof harmonic, melodic and rhythmical transformations. tion which are not lexically dependent. Furthermore, In Alzheimer's patients it would be expected that it can be used to assess those areas of functioning, while levels (i), (ii) and (iii) remain unaffected, the both receptive and productive, not covered adequately complexities of levels (iv) and (v), when requiring no by other test instruments; ie fluency, perseverance in naming, may be preserved but are susceptible to context, attention, concentration and intentionality. deterioration.

In addition it provides a form of therapy which may It is perhaps important to point out that these stimulate cognitive activities such that areas subject disorders are not themselves musical, they are disto progressive failure are maintained. Certainly the orders of audition. Only when disorders of musical anecdotal evidence suggests that quality of life of production take place can we begin to suggest that Alzheimer patients is significantly improved with a musical disorder is present. Improvised musical music therapy accompanied by the overall social playing is in a n unique position to demonstrate this benefits of acceptance and sense of belonging gained hypothetical link between perception and production. by communicating with others. Prinsley recommends Descriptions of musical perception emphasize the music therapy for geriatric care i n that it reduces the importance of context where different levels of individual prescription of tranquilizing medication, attention occurring simultaneously against a backreduces the use of hypnotics on the hospital ward and ground temporal structure. Musical improvisation helps overall rehabilitation. He recommends that with a therapist, which emphasizes attention to the music therapy be based on treatment objectives; the environment utilizing changes in tempo and volitional social goals of interaction co-operation; psychological response, without regard for lexical content, may be goals of mood improvement and self-expression; intelan ideal medium for treatment initiatives with lectual goals of the stimulation of speech and Alzheimer's patients. The playing of simple rhythmic organization of mental processes; and the physical patterns and melodic phrases by the therapist, and goals of sensory stimulation and motor integration8. the expectation that the patient will copy those The understanding of musical production may well patterns or phrases, is similar to the element of 'registration' in the mental state examination. offer a clue to the ground structure of language and While improvised musical playing is a useful tool communication in general. It is research in this realm of perception which is urgent not only for the underfor the assessment of musical abilities, it is also used within a therapeutic context. In this way assessment standing of Alzheimer's patients but in the general and therapy are interlinked; assessment providing the context of cognitive deficit and brain behaviour. criteria from which to identify therapeutic goals and develop therapeutic strategies.

Acknowledgment: The author would like to thank the music therapist Gudrun Aldridge for access to the audio-tape If we are unsure as to the normal process of cogrecording of her clinical work, and her clinical insights into nitive loss in aging, we are even more in the dark working with the elderly. as to the normal musical playing abilities of adults.

The literature suggests that musical activities are preReferences served while other cognitive functions fail. Alzheimer 1 Aldridge D. Music, communication and medicine: dispatients, despite aphasia and memory loss, continue cussion paper. J R Soc Med 1989;82:743-6 to sing old songs and to dance to past tunes when 2 Gates A, Bradshaw J. The role of the cerebral hemigiven the chance. However, the production of music, spheres in music. Brain Lung 1977;4:403-31 and the improvisation of music appears to fail in the 3 Morgan 0, Tilluckdharry R. Presentation of singing same way in which language fails. Unfortunately no function in severe aphasia. West Indian Med J 1982; established guidelines as to the normal range of 31:159-61 4 Berman I. Musical functioning, speech lateralization and improvised music playing of adults is available. the amusias. S Afi Med J 1981;59:78-81 Improvised music therapy in our experience appears 5 Jacome D. Aphasia with elation, hypermusia, musicophilia to offer the opportunity to supplement mental state and compulsive whistling. J Neurol Neurosurg Psychiatry examinations in areas where those examinations are 1984;47:308-10 lacking (Table 1). First, it is possible to ascertain the 6 Beatty WW, Zavadil KD, Bailly RC, et aL Preserved fluency of musical production. Second, intentionality, musical skills in a severely demented patient. Znt J Clin attention to, concentration on and perseverance with Neuropsychol 1988;10:158-64 the task in hand are important features of producing 7 Swartz K, Hantz E, Crummer G, Walton J, Frisina R. Does musical improvisations and susceptible to being heard the melody linger on? Music cognition in Alzheimer's in the musical playing. Third, episodic memory can disease. Semin Neurol 1989;9:152-8 8 Prinsley D. Music therapy in geriatric care. Aust Nurses be tested in the ability to repeat short rhythmic and J 1986;15(9):48-9 melodic phrases. The inability to build such phrases may be attributed to problems with memory or to a An extended list of references can be obtained from yet unknown factor. This unknown factor is possibly the author. involved with the organization of time structures. If rhythmic structure is a n overall context for musical production, and the ground structure for perception1, (Acceptedpapers 30 December 1991) itDavid can be hypothesized that it is thisCollected overarching Aldridge music therapy 46

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Journal of Clinical Gempsychologv, Vol. 4, No. l, 1998

Music Therapy and the Treatment of Alzheimer's Disease David ,41dridge1

Ahheimer patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. Quality of life expectations become paramount in any management strategy, and music therapy appears to play an important role in enhancing the ability to actively take part in daily life. Improvised music. therapy appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking. It is possible to ascertain the fluency of musical production, perseverance with the task in hand, and episodic memory. The inability to build phrases may be attributed to problems with memory or to an yet unknown factor. This unknown factor is possibly involved with the organization of time structures. Thus, music therapy offers an assessment tool sensitive to small changes.

Certainly, the anecdotal evidence suggests that quality of life of Ahheimers patients is significantly improved with music therapy accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others.

KEY WORDS: rhythm; phrasing; intentionality; quality-of-life; music-therapy; memory.

INTRODUCTION

At the age of 56, the composer Maurice Ravel began to complain of increased fatigue and lassitude. Following a traffic accident, his condition deteriorated progressively (Henson, 1988). He lost the ability to remember names, to speak spontaneously, and to write (Dalessio, 1984). Although he could understand speech, he was no longer capable of the coordination required to lead a major orchestra. 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 own music. We would speculate now that he had been suffering from Alzheimer's disease.

In this paper; the value of music for the sufferers of Alzheimer's disease will be discussed. In particular, there will be a focus on music as therapy. '~edizinische Fakultat, Universitat Witten Herdecke, Alfred Herrhausen Stra. 50, 58448 Witten, Germany.

David Aldridge

Job Title: JCG1 Article: M0 Kevboardino: MTW/Nov. 23. 1997

. therapy papers Collected music

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MUSIC AS THERAPY There are two principal ways of doing music therapy: "active music therapy" which requires that the patient, or a group of patients play musical instruments, or sing, with the therapist; and, "passive music therapy" whereby the patient, or a group of patients, listen to the therapist who plays live, or recorded, music to them.

In active music therapy, the music is often improvised to suit the individual patient.

In passive music therapy, the music is often chosen to suit particular patients.

Within each of these two main approaches, there are varying schools throughout the Western world, some based on the work of particular teachers, and some are more eclectic and based on psychotherapeutic approaches. Music therapy has been reviewed in the medical and nursing press and the principle emphasis is on the soothing ability of music and the necessity of music as an antidote to an overly technological medical approach. Most of these articles are concerned with passive music therapy and the playing of pre-recorded music to patients emphasizing the necessity of healthy pleasures like music, fragrance, and beautiful sights for the reduction of stress and the enhancement of well-being. The overall expectation is that the recreational, emotional, and physical health of the patient is improved (Aldridge, 1993b).

After the Second World War, however, music therapy was intensively developed in American hospitals (Schullian and Schoen, 1948). Since then, some hospitals, particularly in mainland Europe, have incorporated music therapy carrying on a tradition of European hospital-based research and practice (Aldridge, 1990; Aldridge, Brandt, and Wohler, 1989). In recent years, there has been a move to develop an academic tradition of research that attempts to begin a clinical dialogue with other practitioners through research practice (Aldridge, 1989, 1991a,b, 1993a; Aldridge, Gustorff, and Hannich, 1990).

MUSIC, COGNITION AND LANGUAGE As in Ravel's demise above, the responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon (Swartz, Hantz, Crummer, Walton, and Frisina, 1989). While language deterioration is a feature of cognitive deficit, musical abilities appear to be preserved. This may be because the fundamentals of language, as we have seen in previous chapters, are musical, and prior to semantic and lexical functions in language development.

Although language processing may be dominant in one hemisphere of the brain, music production involves an understanding of the interaction of both cerebral hemispheres (Altenmuller, 1986; Brust, 1980; Gates and Bradshaw, 1977). In attempting to understand the perception of music, there have been a number of investigations into the hemispheric strategies involved. Much of the literature considering musical perception concentrates on the significance of hemispheric dominance. Gates and Bradshaw (1977J'conclude that cerebral hemispheres are concerned with music perception and that no laterality differences are apparent. Other investigators (Wagner and Hannon, 1981) suggest that two processing functions develop with training where David Aldridge

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left and right hemispheres are simultaneously involved, and that musical stimuli are capable of eliciting both right and left ear superiority (Kellar and Bever, 1980). Similarly, when people listen to and perform music, they utilize differing hemispheric processing strategies.

Evidence of the global strategy of music processing in the brain is found in the clinical literature. In two cases of aphasia (Morgan and Tilluckdhany, 1982), singing was seen as a welcome release from the helplessness of being a patient.

The authors hypothesized that singing was a means to communicate thoughts externally. Although the "newer aspect" speech was lost, 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 in case of regional failure.

Little is known about the loss of musical and language abilities in cases of global cortical damage, although the quality of response to music in the final stages of dementia is worth noting (Norberg, Melin, and Asplund, 1986). Any discussion is necessarily limited to hypothesizing as there are no established baselines for musical performance in the adult population (Swartz et al., 1989). Aphasia, which is a feature of cognitive deterioration, is a complicated phenomenon. While syntactical functions may remain longer, it is the lexical and semantic functions of naming and reference which begin to fail in the early stages. Phrasing and grammatical structures remain giving an impression of normal speech, yet content becomes increasingly incoherent. These progressive failings appear to be located within the context of semantic and episodic memory loss illustrated by the inability to remember a simple story when tested (Bayles et aL, 1989).

Musicality and singing are rarely tested as features of cognitive deterioration, yet preservation of these abilities in aphasics has been linked to eventual recovery (Jacome, 1984; Morgan and Tilluckdhany, 1982), and could be significant indicators of hierarchical changes in cognitive functioning. Jacome (1984) found that a musically naive patient with transcortical mixed aphasia exhibited repetitive, spontaneous whistling and whistling in response to questions. The patient often spontaneously sang without error in pitch, melody, rhythm, and lyrics, and spent long periods of time listening to music. Beatty et al. (1988) describe a woman who had severe impairments in terms of aphasia, memory dysfunction, and apraxia; yet, she was able to sight read an unfamiliar song and perform on the xylophone which to her was an unconventional instrument. Like Ravel (Dalessio, 1984), an elderly musician who could play from memory (Crystal, Grober, and Masur, 1989) no longer recalled the name of the composer, she no longer recalled the name of the music she was playing.

Swartz et aL (1989) propose a series of perceptual levels at which musical disorders take place: (1) the acoustico-psychological level, which includes changes in intensity, pitch, and timbre; (2) the discriminatory level, which includes the discrimination of intervals and chords; (3) the categorical level, which includes the categorical identification of rhythmic patterns and intervals; (4) the configural level, which includes melody perception, the recognition of motifs and themes, tonal David Aldridge

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changes, identification of instruments, and rhythmic discrimination; (5) the level where musical form is recognized, including complex perceptual and executive functions of harmonic, melodic, and rhythmical transformation.

In Alzheimer's patients, it would be expected that while levels (l), (2), and (3) remain unaffected, the complexities of levels (4) and (5) when requiring no naming, may be preserved but are susceptible to deterioration.

It is perhaps important to point out that these disorders are not themselves musical, they are disorders of audition. Only when disorders of musical production take place can we begin to suggest that a musical disorder is present. Improvised musical playing is in an unique position to demonstrate this hypothetical link between perception and production. Rhythm is the key to the integrative process underlying both musical perception and physiological coherence. When considering communication, rhythm is also fundamental to the organization and coordination of internal processes, and externally between persons (Aldridge, 1989). Rhythm offers a frame of reference for perception (Povel, 1984).

Rhythm too plays a role in the perception of melody. The perceptions of speech and music are formidable tasks of pattern perception. The listener has to extract meaning from lengthy sequences of rapidly changing elements distributed in time (Morrongiello, Ti-ehub, Thorpe, and Capodilupo, 1985). amporal predictability is important for tracking melody lines (Jones, Kidd, and Wetzel, 1981; Kidd, Boltz, and Jones, 1984). Kidd et a i (1984) also refer to melody as having a structure in time and that a regular rhythm facilitates the detection of a musical interval and its subsequent integration into a cognitive representation of the serial structure of the musical pattern. Adults identify familiar melodies on the basis of relational information about intervals between tones rather than the absolute information of particular tones. In the recognition of unfamiliar melodies, less precise information is gathered about the tone itself. The primary concern is with successive frequency changes or 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. One may not be aware of certain changes and become either out of tune or out of time; such a loss of rhythmical structure, which appears outwardly as confusion, may be a hidden factor in the understanding of Alzheimer's disease.

What is important in these descriptions of musical perception is the emphasis on context where there are different levels of attention occurring simultaneously against a background temporal structure (Jones et al., 1981; Kidd et a i , 1984). Musical improvisation with a therapist, which emphasizes attention to the environment (Sandman, 1984; Walker and Sandman, 1979; Walker and Sandman, 1982) utilizing changes in tempo and volitional response (Safranek, Koshland, and Raymond, 1982), without regard for lexical content, may be an ideal medium for treatment initiatives with Alzheimer's patients. The playing of simple rhythmic patterns and melodic phrases by the therapist, and the expectation that the patient will copy those patterns or-phrases, is similar to the element of "registration" in the mental state examination.

While improvised musical playing is a useful tool for the assessment of musical abilities, it is also used within a therapeutic context. In this way, assessment and

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therapy are interlinked; assessment providing the criteria from which to identify therapeutic goals and develop therapeutic strategies.

MUSIC THERAPY AND THE ELDERLY Much of the published work concerning music therapy with the elderly is concerned with group activity (Bryant, 1991; Christie, 1992; Olderog Millard and Smith, 1989) and is generally used to expand socialization and communication skills, with the intention of reducing problems of social isolation and withdrawal, to encourage participants to interact purposefully with others, assist in expressing and communicating feelings and ideas, and to stimulate cognitive processes, thereby sharpening problem-solving skills. Additional goals also focus on sensory and muscular stimulation and gross and fine motor skill development (Segal, 1990).

Clair (1990a,b) has worked extensively with tlie elderly and found music therapy a valuable tool for working in groups to promote communicating, watching others, singing, interacting with an instrument, and sitting. Her main conclusions are that although the group members deteriorated markedly in cognitive, physical, and social capacities over an observation period of 15 months, they continued to participate in music activities. During the 30-minute sessions, group members consistently sat in chairs without physical restraints for the duration of each session and interacted with others regardless of their deterioration. This was the only time in the week when they interacted with others (Clair and Bernstein, 1990b). Indeed for one 66-year-old man, it is the sensory stimulation of music therapy that brought him out of his isolation such that he could participate with others, even if for a short while (Clair, 1992).

Wandering, confusion and agitation are associated problems common to elderly patients living in hostels or special accommodations for Alzheimers' patients. A music therapist (Cloutier, 1993) has tested singing with the an 81-year-old woman to see if it helped her to remain seated. After 20 singing sessions, the therapist read to the woman to compare the degree of attentiveness. While music therapy and reading sessions redirected the subject from wandering, the total time she sat for the music therapy sessions was double that of the reading sessions (214.3 min vs. 99.1 min), and the time spent seated in the music therapy was more consistent than the sporadic episodes when she was being read to. When agitation occurs in such elderly women, then individualized music therapy appears to have a significantly calming effect (Gerdner and Swanson, 1993). In terms of reducing repetitive behavior, musical activity also reduces disruptive vocalizations (Casby and Holm, 1994).

The above conclusions are supported by Groene (1993). Thirty residents (aged 60-91 years) of a special Alzheimer's unit,'who exhibited wandering behavior, were randomly assigned to either mostly music attention or mostly reading attention groups where they received one-to-one attention. Those receiving music therapy remained seated longer than those in the reading sessions.

One of the central problem of the elderly is the loss of independence and self-esteem, and Palmer (1977, 1983, 1989) describes a program of music therapy David Aldridge

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at a geriatric home designed to rebuild self-concept. For the 380 residents, ranging from those who were totally functional to those who needed total care, a program was adapted to the capacities and needs of individual patients. Marching and dancing increased the ability of some patients to walk well; and for the nonambulatory, kicking and stamping to music improved circulation and increased tolerance and strength. Sing-along sessions were used to encourage memory recall and promoted social interaction and appropriate social behavior (Palmer, 1983, 1989). It was such social behavior that Pollack and Namazi (1992) report as being accessible to improvement through group music therapy activities. It is the partcipative element, that appears to be valuable for communication, and the intention to participate that is at the core of the music therapy activity which we will see in the following section.

Music therapy has also been used to focus on memory recall for songs and the spoken word (Prickett and Moore, 1991). In ten elderly patients, whose diagnosis was probably Alzheimer's disease, words to songs were recalled dramatically better than spoken words or spoken information. Although long-familiar songs were recalled with greater accuracy than a newly presented song, most patients attempted to sing, hum, or keep time while the therapist sang. However, Smith (1991) suggests that it is factors such as tempo, length of seconds per word, and total number of words that might be more closely associated with lyric recall than the relative familiarity of the song selection.

In a further study of the effects of three treatment approaches (musically cued reminiscence, verbally cued reminiscence, and music alone) on the cognitive functioning of 12 female nursing home residents with Alzheimer's Disease, changes in cognitive functioning were assessed by the differences between pre- and postsession treatment scores on the Mini-Mental State Examination. Comparisons were made for total scores and subscores for orientation, attention, and language. Musically cued and verbally cued reminiscence significantly increased language subsection scores and musical activity alone significantly increased total scores (Smith, 1986).

Prinsley (1986) recommends music therapy for geriatric care as it reduces the individual prescription of tranquilizing medication, reduces the use of hypnotics on the hospital ward, and helps overall rehabilitation. He recommends that music therapy be based on treatment objectives, the social goals of interaction cooperation, psychological goals of mood improvement and self-expression, intellectual goals of the stimulation of speech and organization of mental processes, and the physical goals of sensory stimulation and motor integration. Such goals as stimulation of the individual, promoting involvement in social activity, identifying specific individualized behavioral targets, and emphasizing the maintenance of specific memory functions is repeated throughout the music therapy literature (Prange, 1990; Smith, S., 1990, 1991). Similarly, Smith, D. S. (1990) recommends behavioral interventions targeted at the more common behavioral problems (e.g., disorientation, age-related changes in social activity, sleep disturbances) of institutionalized elderly persons.

In a study of mu& therapy in two nursing homes, life satisfaction and self-esteem were significantly improved in the home where the residents participated in the musical activities in comparison with a matched control group that had no music therapy (VanderArk, Newman, and Bell, 1983).

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MUSIC THERAPY WITH AN ALZHEIMER'S PATIENT- A CASE STUDY In improvised music therapy, the music therapist plays the piano improvising with the patient who uses a range of instruments and voice. This work often begins with an explanatory session using rhythmic instruments, in particular the drum and cymbal; progressing to the use of rhythmic/melodic instruments such as the chime bars, glockenspiel or xylophone; developing into work with melodic instruments (including the piano); and the voice. An emphasis is placed on a series of musical ,improvisations during each session, and music is the vehicle for the therapy. Each session is audiotape-recorded, with the consent of the patient, and later analyzed andindexed as to the musical content. No musical training is required of the patient although it is essential to discover the musical background of the patient. They are asked about to which music they like to listen, and perhaps more importantly, to which music did they dance when they were younger.

A 55-year-old female patient came to outpatient treatment at a general hospital for ten weekly sessions. Each session lasted 40 minutes. Her son drove her to each session as she was unable to find her way alone using public transport. Her sister had died with Alzheimer's disease and the family were concerned that she too was repeating her sister's demise. Her memory had begun to fail and she became increasingly disturbed. The patient was referred initially to the hospital when she, and her son, became aware of her own deteriorating condition. At home, she was experiencing difficulties in finding items of clothing and other things necessary for everyday life. She could not cook for herself anymore and was unable to write her own name. While wanting to speak, she experienced difficulty in finding words. She also appeared to be depressed, and in the light of her sister's death, and her own knowledge regarding her current predicament, it seemed reasonable to make this assumption. As she had previously played the piano for family and friends, although without any formal training, music therapy appeared to have potential as an intervention adjuvant to her medical treatment.

In all ten sessions, she demonstrated her ability to play a singular ordered rhythmic pattern in 414 time using two sticks on a drum. However, a feature of her rhythmical playing was that in nearly all the sessions, the patient would let control of the rhythmic pattern slip such that it became progressively imprecise, losing both its form and liveliness. The initial impulse of her rhythmical playing, which was clear and precise, gradually deteriorated as she lost concentration and ability to persevere with the task in hand. However, when the therapist offered an overall musical structure during the course of the improvisation, by playing herself a known piece of music, then the patient could regain her precision of rhythm.

In the rhythmical playing on drum and cymbal, the therapist attempted to develop the patient's attention span through the use of short repeated musical patterns and changes in key, volume and tempo. She hoped that through changes in the sound to steer the patient to maintaining a stable musical form. This technique helped the to maintain a rhythmical pattern and brought her to the stage which she could express herself stronger musically. The therapist also searched for other ways to develop variety in rhythm by moving away rom the repetitive pattern played by this patient.

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A change in the patient's ability to improvise was shown when the patient recognized, and could repeat rhythmical patterns in a musical dialogue and thereby brought into a musical context. In the last session of therapy, the patient was able to change her playing in this way such that she could express more strongly by bringing into line her thoughtful and expressive playing. It was this ability to become rhythmically flexible when brought into the form of a dialogue that is a fundamental feature of encouraging communicational competence.

From the first session of therapy, the patient made it quite clear her own intent to sit at the piano and play whatever melodies she chose and to find the appropriate accompaniments. This wish and the corresponding willpower to achieve this end, was shown in all the sessions. It was possible to use this impetus to play as a source for improvisation. She laughed with joy at the success of playing and often asked to repeat a successful accomplishment. Lapses and slips in her rhythmical playing could be carried by the intent and expression with which she played. While her overall intention to play was preserved, her attention to that playing, the concentration necessary for musical production and the perseverance required for completing a sequence of phrases progressively failed and was dependent on the overall musical structure offered by the therapist.

At the end of the treatment period, she was able to cook for herself and could find her own things about the house. The psychiatrist responsible for her therapeutic management reported an overall improvement in her interest in what was going on around her, and in particular that she maintained attention to visitors and conversations. The patient regained the ability to sign her name, although she could only write slowly. While wanting to speak, she still experienced difficulty in finding words.

It appears that music therapy had a beneficial effect on the quality of life for this patient, and that some of the therapeutic effect may have been brought about by handling the depression associated with her failing cognitive abilities and the forebodings of a future reflecting her sister's fate. While the patient came to the sessions with the intention of playing, her ability to take initiatives was impaired, mirroring the state of her home life where she wanted to look after herself, yet was unable to take initiatives. This stimulus to take initiatives in the music was seen as an important feature of the music therapy by the therapist and appears to have a correlate in the way in which the patient began to take initiatives in her daily life.

Active music-making promotes interaction between the persons involved, thereby promoting initiatives in communication. Furthermore, the implications for the maintenance of memory by actively making music is significant. As Crystal et al. (1989) found in an 82-year-old musician with Alzheimer's disease, there was a preserved ability to: (1) play previously learned piano compositions from memory, although the man was unable to identify the composer or titles of each work, and (2) learn the new skill of mirror reading while being unable to recall or recognize new information.'This woman could remember some old songs, but also learned new melodies arid retained them from session to session.

A contraindication for music therapy with such patients who are aware of their problems is that the awareness of further cognitive abilities as experienced in the

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"fable I. Features of Medical and Musical Assessment

Medical elements of assessment

Musical elements of assessment

Continuing observation of mental and functional status

Continuing observation of mental and functional status

Testing of verbal skills, including element of speech fluency

Testing of musical skills; rhythm, melody, harmony, dynamic, phrasing, articulation

Cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left coordination).

Cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left coordination).

Testing for progressive memory disintegration

Testing for progressive memory disintegration

Motivation to complete tests, to achieve set goals and persevere in tests

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 the 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

playing may exacerbate any underlying depression and demotivate the patient to continue. For this patient, she was painfully aware that she could no longer find the harmonies with her left had required for the accompaniment of her favorite songs. This too was another sign of her failing cognitive ability. However, what appeared to be of value from the music therapy sessions (as can be seen in Tables I and 11) is that active musical playing provides a basis from which assessments of varying competencies can be made. Not only is it possible to discern a variety of motor abilities and cognitive competencies, including episodic memory, there is the further advantage of assessing intentionality and perseverance throughout episodes of playing and the session itself. This form of assessment is not based on a verbal competence; and furthermore, the patient is not aware that she is being tested.

CONCLUSION

Alzheimer patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. Indeed, fun and enter-

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0

Table 11. Musical Elements of Assessment and Examples of Improvised Playing Examples of improvised playing Musical elements of assessment Improvisations using rhythmic instruments Testing of musical skills; rhythm, melody, (drum and cymbal) singly or in combination harmony, dynamic, phrasing, articulation 0 Improvisations using melodic instruments Singing and playing folk songs with harmonic accompaniment Cortical disorder testing; visuospatial skills

Playing tuned percussion (metallophone, xylophone, chime bars) demanding precise movements

Cortical disorder testing; ability to perform complex motor tasks (including grip and right left coordination)

Alternate playing of cymbal and drum using a beater in each hand Coordinated playing of cymbal and drum using a beater in each hand Coordinated playing of tuned percussion

Testing for progressive memoxy disintegration

0

The playing of short rhythmic and melodic phrases within the session, and in successive sessions

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

The playing of a rhythmic pattern deteriorates when unaccompanied by the therapist, as does the ability to complete a known melody, although tempo remains

"Intention" a feature of improvised musical playing

The patient exhibits the intention to play the piano from the onset of therapy and maintains this intent throughout the course of treatment

Concentration on the improvised playing and attention to the instruments

The patient loses concentration when playing, with qualitative loss in the musical playing and lack of precision in the beating of rhythmical instruments

Flexibility in musical (including instrumental) changes

Initially the musical playing is limited to a tempo of 120 Bp and a characteristic pattern but this is responsive to change

Ability to play improvised music influenced by previous musical training

Although the patient has a musical background this is only of help when she perceives the musical playing, it is little influence in the improvised playing

Sensitive to small changes

Musical changes in tempo, dynamic, timbre, and articulation which at first are missing are gradually developed

Ability to interpret musical context and relationship

The patient develops the ability to play in a musical dialogue with the therapist demanding both a refined musical perception and the ability of musical production

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tainment are all part and parcel of daily living for the elderly living in special accommodation (Glassman, 1983; Jonas, 1991; Kartman, 1990; Smith, 1992). Quality of life expectations become paramount in any management strategy, and music therapy appears to play and important role in enhancing the ability to actively take part in daily life (Lipe, 1991; Rosling and Kitchen, 1992). However, the production of music, and the improvisation of music, appears to fail in the same way in which language fails.

Improvised music therapy appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking. First, it is possible to ascertain the fluency of musical production. Second, intentionality, attention to, concentration on, and perseverance with the task in hand are important features of producing musical improvisations and susceptible to being heard in the musical playing. Third, episodic memory can be tested in the ability to repeat short rhythmic and melodic phrases. The inability to build such phrases may be attributed to problems with memory or to an as-yet unknown factor. This unknown factor is possibly involved with the organization of time structures. If rhythmic structure is an overall context for musical production, and the ground structure for perception, it can be hypothesized that it is this overarching structure which begins to fail in Alzheimers patients. A loss of rhythmical context would explain why patients are able to produce and persevere with rhythmic and melodic playing when offered an overall structure by the therapist. Such a hypothesis would tie in with the musical hierarchy proposed by ~wartz'(l989), and would suggest a global failing in cognition while localized lower abilities are retained. However, the hierarchy of musical perceptual levels proposed by Swartz may need to be further subdivided into classifications of music reception and music production.

Music therapy offers an assessment tool sensitive to small changes (see Tables I and 11). It tests those prosodic elements of speech production which are not lexically dependent; that is, rhythm, melody, harmony, dynamic, phrasing, articulation.

Furthermore, it can be used to assess those areas of functioning, both receptive and productive, not covered adequately by other test instruments (i.e., fluency, perseverance in context, attention, concentration, and intentionality). In addition, it provides a form of therapy which may stimulate cognitive activities such that areas subject to progressive failure, as in progressive memory disintegration, are maintained. There is a possibility to promote both visuo-spatial skills needed in playing instruments and the concentration needed to maintain that playing over a period of time. The playing of instruments apart from its therapeutic value is enables an assessment of grip strength and right-left coordination.

Certainly, the anecdotal evidence suggests that quality of life of Alzheimers patients is significantly improved with music therapy (McCloskey, 1985, 1990; Tyson, 1989) accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others (Morris, 1986; Segal, 1990).

Unfortunately, most of the literature concerning cognition and musical perception is based.On audition and not musical production. Like other authors, we suggest that the production of music, as is the production of language, a complex global phenomenon as yet poorly understood. The understanding of musical production may well offer a clue to the ground structure of language and communi-

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cation in general. It is research in this realm of perception which is urgent not only for the understanding of Alzheimers patients but in the general context of cognitive deficit and brain behavior. It may be as Berman (1981) suggests, that the nondominant hemisphere is a reserve of functions in case of regional failure and this functionality can be stimulated to delay the progression of degenerative disease. We may need to address in future research the coordinating role of rhythm in human cognition and consciousness whether it be in persons who are losing cognitive abilities, or in persons who are attempting to gain cognitive abilities.

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Aldridge, D. (1990). The development of a research strategy for music therapists in a hospital setting.

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Aldridge, D. (1991a). Aesthetics and the individual in the practice of medical research: A discussion paper. J. Roy. Soc. Med. 84: 147-150.

Aldridge, D. (1991b). Creativity and consciousness: Music therapy in intensive care. Arts Psychother.

18(4): 359-362.

Aldridge, D. (1993a). Music and Alzheimers' disease-assessment and therapy: A discussion paper. /. Roy. Soc. Med 86: 93-95.

Aldridge, D. (1993b). The music of the body: Music therapy in medical settings. Advances 19(1): 17-35.

Aldridge, D., Brandt, G., and Wohler, D. (1989). towards a common language among the creative art therapies. Arts Psychother. 17: 189-195.

Aldridge, D., Gustorff, D., and Hannich, H. (1990). Where am I? Music therapy applied to coma patients (editorial). L Roy. Soc. Med 83(6): 345-345.

Altenmuller, E. (1986). Brain correlates of cerebral music processing. Eur. Arch. Psychiat. 235: 342-354.

Bayles, K A., Boone, D. R., Ibmoeda, C. K, et a t , (1989). Differentiating Alzheimer's patients from the normal elderly and stroke patients with aphasia. L Speech Hear. Disord. 54: 74-87.

Beatty, W W, Zavadil, K D., Bailly, R. C. et at (1988). Reserved musical skills in a severely demented patient. Int. J. Clin. Neumpsychot 10: 158-164.

Berman, I. (1981). Musical functioning, speech lateralization and the amusias. South African Med. 3. 59: 78-81 .-

Brust, J. (1980). Music and language: Musical alexia and agraphia. Brain 103: 367-392.

Bryant, W (1991). Creative group work with confused elderly people: A development of sensory integration therapy. Brit. J. Occup. Ther. 54(5): 187-192.

Casby, J. A., and Holm, M. B. (1994). The effect of music on repetitive disruptive vocalizations of persons with dementia. Am. Occup. Ther. 48(10): 883-889.

Christie, M. E. (1992). Music therapy applications in a skilled and intermediate care nursing home facility: A clinical study. Act. Adapt. Aging 16(4): 69-87.

Clair, A. (1992). Music therapy for a severely regressed person with a probable diagnosis of Alzheimer's Disease. In Bruscia, K (ed.), Case Studies in Music Therapy, Barcelona Publishers, Phoenixville, PA Clair, A. A. (1990). The need for supervision to manage behavior in the elderly care home resident and the implications for music therapy practice. Music Ther. Perspect. 8: 72-75.

Clair, A. A., and Bernstein, B. (1990a). A comparison of singing, vibrotactile and nonvibrotactile instrumental playing responses in severely regressed persons with dementia of the Alzheimer's type.

J. Music Thm 27(3): 119-125.

Clair, A. A., and Bernstein, B. (1990b). A preliminary study of music therapy programming for severely regressed persons with Alzheimer's-type dementia. J. Appl. Gerontol. 9(3): 299-311.

Crystal, H., Grober, E., and Masur, D. (1989). Reservation of musical memory in Alzheimer's disease.

J. Neuml. Neuqsury. Psych& 52(12): 1415-1416.

Dalessio, D. (1984). Maurice Ravel and Alzheimer's disease. JAMA 252(24): 3412-3413.

Fitzgerald Cloutier, M. L (1993). The use of music therapy to decrease wandering: An alternative to restraints. Music Ther. Perspect. ll(1): 32-36.

Gates, A., and Bradshaw, J. (1977). The role of the cerebral hemispheres in music. Brain Lung. 4: 403-431.

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Gerdner, L. A., and Swanson, E. A. (1993). Effects of individualized music on confused and agitated elderly patients. Arch. Rychiatr. Nursing 7(5): 284-291.

Glassman, L. A (1983). The talent show: Meeting the needs of the healthy elderly. Music The% 3(1): 82-93. .Groene, R. W (1993). Effectiveness of music therapy: Intervention with individuals having Senile Dementia of the Alzheimer's type. 1. Music The% 30(3): 138-157.

Henson, R. (1988). Maurice Ravel's illness: A tragedy of lost creativity. Brit. Med. Clin. Res. 296(6636): 1585-1588.

Jacome, D. (1984). Aphasia with elation, hypermusia, musicophilia and compulsive whistling. J. Neurol.

Neumswg. Psychiat. 47(3): 308-310.

Jonas, J. L (1991). Preferences of elderly music listeners residing in nursing homes for art music, traditional jazz, popular music of today, and country music. L Music Ther. 28(3): 149-160.

Jones, M,, Kidd, G., and Wetzel, R. (1981). Evidence for rhythmic attention. 1. Exp. Psychol. 7: 1059-1073.

Kartman, L L (1990). Fun and entertainment: One aspect of making meaningful music for the elderly.

Act. Adapt. Aging 14(4): 39-44.

Kellar, L, and Bever, T (1980). Hemispheric asymmetries in the perception of musical intervals as a function of musical experience. Brain Lang. 10: 24-38.

Kidd, G., Boltz, M., and Jones, M. (1984). Some effects of rhythmic context on melody recognition.

Am. J. PsychoL 97(2): 153-173.

Lipe, A W (1991). Using music therapy to enhance the quality of life in a client with Alzheimer's dementia: A case study. Music The%Perspect. 9: 102-105. ~ h ~ l o s kL e ~J., (1985). Music and the frail elderly. Act. Adapt. Aging 7(2): 73-75.

McCloskey, L J. (1990). The silent heart sings. Special issue: Counseling and therapy for eiders. Generations 14(1): 63-65.

Morgan and Tilluckdharry, R (1982). Presentation of singing function in severe aphasia. West Indian Med. J. 31: 159-161.

Morris, M. (1986). Music and movement for the elderly. Nursing Times 82(8): 44-45.

Morrongiello, B., Trehub, S., Thorpe, L, and Capodilupo, S. (1985). Children's perception of melodies: The role of contour, frequency, and rate of presentation. J. Exp. Child Psychol. 40(2): 279-292.

Norberg, A, Melin, E., and Asplund, K (1986). Reactions to music, touch and object presentation in the final stage of dementia. An exploratory study. Int. Nursing Stud. 23(4): 315-323.

Olderog Millard, K A, and Smith, J. M. (1989). The influence of group singing therapy on the behavior of Alzheimer's disease patients. J. Music The%26(2); 58-70.

Palmer, M. (1989). Music therapy in gerontology: A review and a projection. National Association for Music Therapy California Symposium on Clinical Practices (1987, Costa Mesa, California). Music T!ier. Perspect. 6: 52-56.

Palmer, M. D. (1977). Music therapy in a comprehensive program of treatment and rehabilitation for the geriatric resident. J. Music Thm l4(4): 190-197.

Palmer, M. D. (1983). Music therapy in a comprehensive program of treatment and rehabilitation for the geriatric resident. Act& Adapt. Aging 3(3): 53-59.

Pollack, N. J., and Namazi, K H. (1992). The effect of music participation on the social behavior of Alzheimer's disease patients. J. Music The%29(1): 54-67.

Povel, D. (1984). A theoretical framework for rhythm perception. Psychol. Res. 45: 315-337.

Prange, F! (1990). Categories of music therapy at Judson Retirement Community. Music The%Perspect.

8: 88-89.

Prickett, C. A, and Moore, R S. (1991). The use of music to aid memory of Alzheimer's patients.

J. Music T l m 28(2): 101-110.

Prinsley, D. (1986). Music therapy in geriatric care. Aust. Nurses J. 15(9): 48-49.

Rosling, L. K, and Kitchen, J. (1992). Music and drawing with institutionalized elderly. Miniconference in Music and Geriatrics (1990, Coquitlam, Canada). Act. Adapt. Aging 17(2): 27-38.

Safranek, M., Koshland, G., and Raymond, G. (1982). Effect of auditory rhythm on muscle activity.

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Segal, R. (1990). Helping older mentally retarded persons expand their socialization skills through the use of expressive therapies. Special Issue: Activities with developmentally disabled elderly and older adults. Activ., Adapt. Aging 15(1-2): 99-109.

Smith, B. B. (1992). Treatment of dementia: Healing through cultural arts. Pride Inst. 1. Long Term Home Health Care ll(3): 37-45.

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Smith, D. S. (1990). Therapeutic treatment effectiveness as documented in the gerontology literature: Implications for music therapy. Music Thez Perspect. 8: 36-40.

Smith, D. S. (1991). A comparison of group performance and song familiarity on cued recall tasks with older adults. L Music Ther. 28(1): 2-13.

Smith, G. H. (1986). A comparison of the effects of three treatment interventions on cognitive Functioning of Alzheimer patients. Music Ther. 6a(l): 41-56.

Smith, S. (1990). The unique power of music therapy benefits Atzheimer's patients. Activ.,Adapt. Aging 14(4): 59-63.

Summer, L (1981). Guided imagery and music with the elderly. Music Ther. l(1): 39-42.

Swartz, K.. Hantz, E., Crummer, G., Wilton, J., and Frisina, R (1989). Does the melody linger on?

Music cognition in Alzheimer's disease. Semin. Neural. 9(2): 152-158.

Tyson, J. (1989). Meeting the needs of dementia Nws. Elder l(5): 18-19.

VanderArk, S., Newman, I., and Bell, S. (1983). The effects of music participation on quality of life of the elderly. Music Ther. 3(1): 71-81.

Wagner, M., and Hannon, R (1981). Hemispheric asymmetries in faculty and student musicians and nonmusicians during melody recognition tasks. Brain Long. 13: 379-388.

Walker. B., and Sandman, C. (1979). Human visual evoked responses are related to heart rate. L Comp.

PhysioL Psychol. 93: 717-729.

Walker, B., and Sandman, C. (1982). Visual evoked potentials change as heart rate and carotid pressure change. Psychophysiology 19: 520-527.

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0197-4556192 $5.00 + .OO Copyright 0 1992 Pergamon Press Ltd.

The Arts in Psychotherapy. Vol. 19, pp. 243-255, 1992 Printed in the USA. All rights reserved.

TWO EPISTEMOLOGIES: MUSIC THERAPY AND MEDICINE IN THE TREATMENT OF DEMENTIA DAVID ALDRIDGE, PhD and GUDRUN ALDRIDGE, Dipl, MT*

In earlier papers it has been suggested that it is possible for music therapists, creative arts therapists and medical practitioners to work together so that they may negotiate a common language (Aldridge & Brandt, 1991; Aldridge, Brandt, & Wohler, 1989).

This paper extends that debate further into another clinical realm, that of dementia in the elderly.

Dementia is an important source of chronic disability leading to both spiralling health care expenditure among the elderly and a progressive disturbance of life quality for the patient and his or her family. In the United States the cost of institutional care for patients with dementia is estimated at over $25 billion a year (Steg, 1990). If 4% to 5% of the US elderly population suffer from dementia, then it can be estimated that 1.25% of the adult population are suffering with the problems of severe dementia. Other estimates of the same population suggest that 15% of those over the age of 65 will have moderate to severe dementia with projections to 45% by the age of 90 years (Odenheimer, 1989). Current estimates are that over 60% of those cases of dementia result from Alzheimer's disease (Kalayam & Shamoian, 1990).

Dementing illnesses, or acquired cognitive disorders, have been recognized for centuries, but little progress was made in specific diagnoses until the evolution of the nosologic approach to disease and early clinical descriptions of neurosyphilis and Huntington's chorea in the 1800s. Such descriptions were further supported by concurrent understandings that suggested the influence of the brain on behavior. The

first histopathological characterizations of cognitive disorders were made possible by developments in the optical microscope. Thus, Alzheimer (1907) was able to see the neuronal degeneration and senile plaques in the brain of a 55-year-old woman with progressive memory impairment and identify the disease that today bears his name.

Although cognitive impairment is evident from behavior, and neurohistopathology can recognize neuronal degeneration, the diagnosis of Alzheimer's disease is prone to error, and authors differ as to the difficulty of making a precise diagnosis (Odenheimer, 1989; Steg, 1990). In the early stages of the disease the symptoms are difficult to distinguish from those of normal aging, a process that itself is poorly understood. To date, there exist no normative established values of what is cognitive impairment or memory loss, or what neurochemical and neurophysiological changes accompany normal aging. It is, therefore, extremely difficult to establish criteria for determining abnormal changes from a normal population and the researcherlclinician must in part rely upon within-the-subject designs to indicate progressive deterioration.

A second source of error in diagnosing Alzheimer's disease is that it is masked by other conditions (see Table 1). Principal among these conditions is that of depression, which itself can cause cognitive and behavioral disorders. In addition, it is estimated that 20% to 30% of patients with Alzheimer's disease will have an accompanying depression (Kalayam & Sha-

*David Aldridge, a frequent contributor, is a research consultant to the medical faculty of Universitat Witten Herdecke, Germany and European Editor of The Arts in Psychotherapy.

Gudrun Aldridge is a music therapist.

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Table 1 Differential Diagnosis of Alzheimer's Disease Differential Diagnosis Multi-infarct dementia and other forms of cerebrovascular disease Parkinson's disease Progressive supranuclear palsy Huntington's disease Central nervous system infection Subdural haematoma Normal pressure hydrocephalus Multiple sclerosis Seizure disorder Brain tumor Cerebral trauma Metabolic disturbance Nutritional deficiency Psychiatric disorder Substance abuse or overmedication Taken from Steg, R. 1990, Determining the cause of dementia.

Nebraska Medical Journal, 75 (4). 59-63. Reprinted with permission.

moian, 1990) thereby compounding diagnostic problems further.

Clinical Descriptions of Dementia The clinical syndrome of dementia is characterized by an acquired decline of cognitive function that is represented by memory and language impairment.

Whereas the term dementia itself is used widely throughout the medical literature, and in common usage, to describe cognitive impairment, it is generally applied to two conditions: dementia of the Alzheimer's type (DAT) and multi-infarct dementia.

The course of Alzheimer's disease is one of progressive deterioration associated with degenerative changes in the brain. Such deterioration is presented in a clinical picture of episodic changes and a pattern of particular cognitive failings that are variable (Drachman, O'Donnell, Lew, & Swearer, 1990).

Mental status testing is one of the primary forms of assessing these cognitive failings, which include short and long-term memory changes, impairment of abstract thinking and judgment, disorders of language (aphasia), and difficulty in finding the names of words (anomia), the loss of ability to interpret what is heard, said and felt (agnosia), and an inability to carry out motor activities, such as manipulating a pen or toothbrush, despite intact motor function (apraxia).

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When such clinical findings are present, then a probable diagnosis can be made; a more definite diagnosis depends upon tissue diagnosis (see Table 2).

Although dementia of the Alzheimer's type begins after the age of 40, and is considered to be a disease of the elderly, the influence of age on prognosis is not as significant as the initial degree of severity of the problem when recognized (Drachman et al., 1990).

Disease severity, as assessed by intellectual function, appears to be the most consistent predictor of the subsequent course of the disease, particularly when accompanied by a combination of wandering and falling, and behavioral problems (Walsh, Welch, & Larson, 1990). However, the rates of decline between subgroups of patients are variable and a patient's rate of progression in one year may bear little relationship to future rate of decline (Salmon, Thai, Butters, & Heindel, 1990). Some authors (Cooper, Mungas, & Weiler, 1990) suggest that an as yet unproven factor, other than declining cognitive ability, may also play a part in the associated abnormal behaviors of anger, agitation, personality change, wandering, insomnia and depression, which occur in later stages of the disease.

Clearly, Alzheimer's disease causes distress for the patient. The loss of memory and the accompanying loss of language, before the onset of motor impairment, means that the daily lives of patients are disturbed. Communication, the fabric of social contact, is interrupted and disordered. The threat of progressive deterioration and behavioral disturbance has ramifications not only for the patients themselves, but also their families, who must take some of the social responsibility for care of the patients and bear the Table 2 Diagnostic Evaluation of Dementia Diagnostic Categories Complete medical history Mental status examination Complete physical and neurological investigation (including investigation for infection of central nervous system if suspected) Complete blood count and blood chemistry tests (including vitamin B 12 levels) Thyroid function tests Serology for syphilis Computerized tomography (CT) or magnetic resonance imaging (MRI), electroencephalography (EEG), or positive emission tomography (PET) scanning

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA emotional burden of seeing a loved one becoming confused and isolated.

Finally, it must also be borne in mind that the elderly depressed can exhibit a pseudodementia (Caine, 1981) whereby Alzheimer's is mimicked (see Table 3). Such patients recover and show no sign of residual intellectual impairment.

Assessment of Dementia A brief cognitive test, the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975), has been developed to screen and monitor the progression of Alzheimer's disease. The test itself is intended for the clinician to assess functions of different areas of the brain, and is based upon questions and activities (see Table 4). As a clinical instrument it is widely used and well validated in practice (Babikian, Wolfe, Linn, Knoefel, & Albert, 1990; Beatty & Goodkin, 1990; Eustache, Cox, Brandt, Lechevalier, & Pons, 1990; Faustman, Moses, & Csemansky, 1990; Gagnon, Letenneur, Dartigues, Commenges, Orgogozo, Gateau, Alperovitch, Decamps, & Salamon, 1990; Jairath & Campbell, 1990; Summers, DeBoynton, Marsh, & Majovski, 1990; Zillmer, Fowler, Gutnick, & Becker, 1990). A bedside test, the MMSE is widely used for testing cognition and is useful as a predictive tool for cognitive impairment and semantic memory (Eustache et al., 1990) without being contaminated by motor and sensory deficits (Beatty & Goodkin, 1990; Jairath & Campbell, 1990).

Elderly patients scoring below 24 points out of a

245

possible total score of 30 are considered demented.

However, this scoring has been questioned on the grounds of its cut-off point of 24 as the lower limit, particularly for early dementia (Galasko, Klauber, Hofstetter, Salmon, Lasker, & Thai, 1990); and, that it is influenced by education (Gagnon et al., 1990).

Poorly educated subjects with less than eight years of education may score below 24 without being demented.

Further criticisms of the Mini-Mental State Examination (MMSE) have been that it is not sensitive enough to mild deficits, but it could be augmented by the addition of a word fluency task and an improvement in the attention-concentration item (Galasko et al., 1990). In addition, the MMSE seriously underestimates cognitive impairment in psychiatric patients (Faustman, Moses, & Csemansky, 1990). An important feature neglected by the MMSE is that of "intention" or executive control (Odenheimer, 1989), which refers to the ability of the patient to persevere with a set task, to reach a set goal or to change tasks.

The items the MMSE fails to discriminate (minor language deficits), or neglects to assess (fluency and intentionality), however, may be elicited in the playing of improvised music. A dynamic musical assessment of patient behavior, linked with the motor coordination and intent required for the playing of musical instruments used in music therapy, and the necessary element of interpersonal communication, may provide a sensitive complementary tool for assessment (Aldridge, 1989a) (see Table 5). This would not make music therapy a diagnostic tool. It would not be possible to say that patients played in a partic-

Table 3 Features Differentiating Pseudodementia From Dementia Pseudodementia

Dementia

Onset can be dated with some precision Symptoms of short duration before medical help is sought History of previous psychiatric dysfunction Patients usually complain much of cognitive loss Patients make little effort to perform even simple tasks Behavior often incongruent with severity of cognitive impairment Nocturnal accentuation of dysfunction uncommon "Don't know" answers typical Marked variability in performance on tasks of similar difficulty

Onset can be dated only within broad limits Symptoms can be of long duration before medical help is sought History of previous psychiatric dysfunction unusual Patients usually complain little of cognitive loss Patients struggle to perform tasks Behavior usually compatible with severity of cognitive impairment Nocturnal accentuation of dysfunction common Near-miss answers frequent Consistently poor performance on tasks of similar difficulty

After Caine (1981). Mental status changes with aging. Seminars in Neurology, I ( l ) , 39, Thieme Medical Publishers. Reprinted with permission.

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Table 4 Mini-Mental State Examination Item Orientation for time Orientation for place Registration Attention for calculation Recall Naming Repetition Three stage verbal command Written command Writing Construction Total

Component

Score

year, season, month, date and day state, county, city, building and floor Subject repeats "rose," "ball" and "key" Serial subtraction of 7 from 100 or spell "world" backward "Rose," "ball" and "key" Pencil and watch No ifs, ands, or buts Take a piece of paper in your right hand, fold it in half, and put it on the floor Close your eyes A spontaneous sentence Two interlocking pentagons

5

1 3 1 1

Taken from Galasko, D., Klauber, M , , Hofstetter, C . , Salmon, D., Lasker, B. & Thai, L. (1990). The Mini-Mental State Examination in the early diagnosis of Alzheimer's disease. Archives of Neurology 47 (l), 49-52.

ular way before they had the disease, or that their particular performance was a consequence of the disease, but it would provide a useful tool for assessing current ability. From this platform of current ability, linking musical assessment to medical diagnosis, it would be possible to recognize a broad spectrum of therapeutic changes, including improvements or deterioration~,which would not be confined to verbal abilities alone.

Music and Dementia Late in adult life, at the age of 56, and after completing two major concertos for the piano, Maurice Ravel, the composer, began to complain of increased fatigue and lassitude. Following a traffic accident, his condition deteriorated progressively (Henson, 1988).

He lost the ability to remember names, to speak spontaneously, and to write (Dalessio, 1984). Although he

Table 5 Features of Medical and Musical Assessment Medical Elements of Assessment

Musical Elements of Assessment

continuing observation of mental and functional status testing of verbal skills, including element of speech fluency 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 "intention" difficult to assess, but considered important concentration and attention span flexibility in task switching mini-mental state score influenced by educational status insensitive to small changes ability to interpret surroundings

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continuing observation of mental and functional status testing of musical skills; 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 sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form "intention" a feature of improvised musical playing concentration on the improvised playing and attention to the instruments flexibility in musical (including instrumental) changes ability to play improvised music influenced by previous musical training sensitive to small changes ability to interpret musical context and assessment of communication in the therapeutic relationship

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'

could understand speech, he was no longer capable of the coordination required to lead a major orchestra.

Whereas his mind, he reported, 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 own music.

However, the responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon (Swartz, Hantz, Crummer, Walton, & Frisina, 1989). Although language deterioration is a feature of cognitive deficit, musical abilities appear to be preserved. This may be because the fundamentals of language itself are musical and are prior to semantic and lexical functions in language development (Aldridge, 1989a; 1989b; 1991b).

Although language processing may be dominant in one hemisphere of the brain, music production involves an understanding of the interaction of both cerebral hemispheres (Altenmiiller, 1986; Brust, 1980; Gates & Bradshaw, 1977). In attempting to understand the perception of music there have been a number of investigations into the hemispheric strategies involved. Much of the literature considering musical perception concentrates on the significance of hemispheric dominance. Gates and Bradshaw (1977) concluded that cerebral hemispheres are concerned with music perception and that no laterality differences are apparent. Other authors (Wagner & Hannon, 1981) suggested that two processing functions develop with training where left and right hemispheres are simultaneously involved, and that musical stimuli are capable of eliciting both right and left ear superiority (Kellar & Bever, 1980). Similarly, when people listen to and perform music they utilize differing hemispheric processing strategies.

Evidence of the global strategy of music processing in the brain is found in the clinical literature. In two cases of aphasia (Morgan & Tilluckdharry, 1982), singing was seen as a welcome release from the helplessness of being a patient. The authors hypothesized that singing was a means to communicate thoughts externally. Although the "newer aspect" of speech was lost, the older function of music was retained, possibly because music is a function distributed over both hemispheres. Berman (1981) suggested 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 in case of regional failure.

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Little is known about the loss of musical and language abilities in cases of global cortical damage.

Any discussion is necessarily limited to hypothesizing as there are no established baselines for musical performance in the adult population (Swartz et al., 1989). Aphasia, which is a feature of cognitive deterioration, is a complicated phenomenon. Although syntactical functions may remain longer, it is the lexical and semantic functions of naming and reference that begin to fail in the early stages. Phrasing and grammatical structures remain, giving an impression of normal speech, yet content becomes increasingly incoherent. These progressive failings appear to be located within the context of semantic and episodic memory loss illustrated by the inability to remember a simple story when tested (Bayles, Boone, Tomoeda, Slauson & Kaszniak, 1989).

Musicality and singing are rarely tested as features of cognitive deterioration, yet preservation of these abilities in aphasics has been linked to eventual recovery (Jacome, 1984; Morgan & Tilluckdharry, 1982), and could be significant indicators of hierarchical changes in cognitive functioning. Jacome (1984) found that a musically naive patient with transcortical mixed aphasia exhibited repetitive, spontaneous whistling, and whistling in response to questions. The patient often spontaneously sang without error in pitch, melody, rhythm and lyrics, and spent long periods of time listening to music. Beatty (Beatty, Zavadil & Bailly, 1988) described a woman who had severe impairments in terms of aphasia, memory dysfunction and apraxia yet was able to sight-read an unfamiliar song and perform on the xylophone, which to her was an unconventional instrument. Like Ravel (Dalessio, 1984), and an elderly musician who could play from memory (Crystal, Grober, & Masur, 1989) but no longer recalled the name of the composer, she no longer recalled the name of the music she was playing.

Swartz and his colleagues (Swartz et al., 1989, p.

154) proposed a series of perceptual levels at which musical disorders take place: (a) the acoustico-psychological level, which includes changes in intensity, pitch and timbre; (b) the discriminatory level, which includes the discrimination of intervals and chords; (c) the categorical level, which includes the categorical identification of rhythmic patterns and intervals; (d) the configural level, which includes melody

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perception, the recognition of motifs and themes, tonal changes, identification of instruments, and rhythmic discrimination; (e) the level where musical form is recognized, including complex perceptual and executive functions of harmonic, melodic and rhythmical transformations.

In Alzheimer's patients it would be expected that while levels (a), (h) and (c) remain unaffected, the complexities of levels (d) and (e), when requiring no naming, may be preserved but are susceptible to deterioration.

It is perhaps important to point out that these disorders are not themselves musical; they are disorders of audition. Only when disorders of musical production take place can we begin to suggest that a musical disorder is present. Improvised musical playing is in a unique position to demonstrate this hypothetical link between perception and production.

Rhythm is the key to the integrative process underlying both musical perception and physiological coherence. Barfeld's (1978) approach suggested that when musical form as tonal shape meets the rhythm of breathing there is the musical experience. External auditory activity is mediated by internal perceptual shaping in the context of a personal rhythm. When considering communication, rhythm is also fundamental to the organization and coordination of internal processes, and externally between persons (Aldridge, 1989a).

Rhythm offers a frame of reference for perception (Povel, 1984). Musical tones played 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, or respiratory activity within the body that also have qualities of pitch, timbre and duration.

Rhythm too plays a role in the perception of melody. The perceptions of speech and music are formidable tasks of pattern perception. The listener has to extract meaning from lengthy sequences of rapidly changing elements distributed by time (Morrongiello,

David Aldridge

Trehub, Thorpe, & Podilupo, 1985). Temporal predictability is important for tracking melody lines (Jones, Kidd, & Wetzel, l98 1; Kidd, Boltz, & Jones, 1984). Kidd et al. also refer to melody as having a structure in time and that a regular rhythm facilitates the detection of a musical interval and its subsequent integration into a cognitive representation of the serial structure of the musical pattern. Adults identify familiar melodies on the basis of relational information about intervals between tones rather than the absolute information of particular tones. In the recognition of unfamiliar melodies, less precise information is gathered about the tone itself. The primary concern is with successive frequency changes or 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. One may not be aware of certain changes and become either out of tune or out of time; such a loss of rhythmical structure, which appears outwardly as confusion, may be a hidden factoiin the understanding of Alzheimer's disease.

What is important in these descriptions of musical perception is the emphasis on context where there are different levels of attention occurring simultaneously against a background temporal structure (Jones, Kidd, & Wetzel, 1981; Kidd, Boltz, & Jones, 1984). Musical improvisation with a therapist, which emphasizes attention to the environment (Sandman, 1984; Walker & Sandman, 1979, 1982) utilizing changes in tempo and volitional response (Safranek, Koshland, & Raymond, 1982), without regard for lexical content, may be an ideal medium for treatment initiatives with Alzheimer's patients. The playing of simple rhythmic patterns and melodic phrases by the therapist, and the expectation that the patient will copy those patterns or phrases, is similar to the element of "registration" in the mental state examination.

Although improvised musical playing is a useful tool for the assessment of musical abilities, it is also used within a therapeutic context. In this way, assessment and therapy are interlinked, assessment providing the criteria from which to identify therapeutic goals and develop therapeutic strategies.

Music Therapy With an Alzheimer's Patient Nordoff-Robbins music therapy is based upon the improvisation of music between therapist and patient (Nordoff & Robbins, 1977). The music therapist plays the piano, improvising with the patient who uses a range of instruments. his work often begins

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA with an exploratory session using rhythmic instruments, in particular the drum and cymbal, progressing to the use of rhythmiclmelodic instruments such as the chime bars, glockenspiel or xylophone, developing into work with melodic instruments (including the piano) and the voice. In this way of working, the emphasis is on a series of musical improvisations during each session, and music is the vehicle for the therapy. Each session is audiotaped, with the consent of the patient, and later analyzed and indexed as to musical content.

In the case example below, music therapy is used as one modality of a comprehensive treatment package. The patient is seen on an outpatient basis for 10 weekly sessions. Each session lasts for 40 minutes.

She is unable to find her way on public transport and is brought to the hospital by her son.

Frau X was a 55-year-old woman who came to the hospital for treatment. Her sister, now dead, had Alzheimer's disease, and the family was concerned that she was repeating her sister's demise as her memory became increasingly disturbed. She began playing the piano for family, friends and acquaintances at the age of 40, although without any formal studies. Given this interest, music therapy appeared to have potential as an intervention adjuvant to medical treatment.

Initially the patient was referred to the hospital when she and her son became aware of her deteriorating condition, although the disease was in its early stages. At home she was experiencing difficulties in finding clothing and other things necessary for everyday life. She could not cook for herself anymore and was unable to write her own signature. When wanting to speak, she experienced difficulty in finding words.

It may be assumed, given the family background, and her own understanding of her failings, that the cognitive problems were exacerbated by depression and likely to be a pseudodementia.

Rhythmic Playing In all 10 sessions Frau X demonstrated her ability to play, without the influence of her music therapist, a singular ordered rhythmic pattern in 414 time using two sticks on a single drum. This rhythmical pattern appeared in various forms and can be portrayed as seen in Example 1.

A feature of her rhythmical playing was that in nearly all the sessions, during the progress of an improvisation, the patient would let control of the rhythmic pattern slip so that it became progressively im-

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Example l . Rhythmic playing by the patient on a drum using a beater in her right hand.

precise, losing both its form and liveliness. The initial impulse of her rhythmical playing, which was clear and precise, gradually deteriorated as she lost concentration and ability to persevere with the task in hand.

However, when the therapist offered an overall musical structure during the course of the improvisation, the patient could regain her precision of rhythm. As suggested earlier, to sustain perception an overall rhythmical structure is necessary, and it is this musical gestalt (i.e., the ability to provide an overall organizing structure of time) that fails in Alzheimer's disease.

The patient reacted quickly to changes in time and different rhythmic forms, and incorporated these within her playing. Significantly, she reacted fluently in her playing to changes from 414 time to 314 time, often remarking " . . . now it's a waltz. . . ." With typical well-known rhythmical forms (e.g., the Habaner rhythm) in combination with characteristic melodic phrases, she laughed, breathed deeply, and played with intent.

These rhythmical improvisations, using different drums and cymbals, were played in later sessions on two instruments together. The patient had no difficulty in controlling and maintaining her grip of the beaters. Similarly, she showed no difficulty in coordinating parallel or alternate-handed playing on a single instrument although she played mostly with a quick tempo (120 beats per minute). However, the introduction of two instruments brought a major difficulty for the patient. She stood disoriented before the instruments, unable to integrate them both in the playing. It was only with instructions and direction from the therapist that the patient was able to coordinate right-left playing on two instruments, and changes in the pattern of the playing were also difficult to realize (see Examples 2 and 3).

What did remain throughout the improvisations was the inherent musical ability of the patient, in terms of tempo (ritardando, accelerando, rubato) and

Example 2 . Dialogic playing on the drum.

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ALDRIDGE AND ALDRIDGE difficulty in playing them, which may have been compounded by visuo-spatial difficulties (e.g., it is easier to strike the surface of a drum than the limited precise surfaces of adjacent chime bars).

Example 3. A change in the pattern of playing.

Harmonic Playing dynamic (loud and soft), which she expressed whenever she had the opportunity. This would also accord with Swartz et al. series of perceptual levels at which musical disorders take place (i.e., levels-(a) the acoustico-psychological level, (b) the discriminatory level, which includes the discrimination of intervals and chords, and (c) the categorical level, which includes the categorical identification of rhythmic patterns and intervals).

Melodic Playing Melody is a natural expression of motion that arises and decays from moment to moment. In this motion, the size of the intervals provides an enormous melodic tension that itself has a dynamic power. The experience of melody is itself an experience of form.

As a melody begins, there is the possibility to grasp a sense of the immediacy of the whole form and prepare for the aesthetic pleasure of deviations from what is expected. This element of tension between the expected and the unpredictable has been at the heart of musical composition for the last 200 years. In addition, it is melody that leads the music from the rhythmical world of feeling into the cognitive world of imagination.

When Frau X played, her melodies were always lively. She knew many folk songs from earlier times and was able to sing them alone. After only a few notes played by the therapist on the piano, she could associate those notes with a well-known tune. However, when the patient tried to play a complete melody on the piano, or other melody instrument alone, it proved impossible. Although beginning spontaneously and fluently, she had difficulty in completing a known melody.

Melody instruments, like the metallophone and the xylophone, which were previously unknown to the patient, remained forever strange to her. At the introduction of a new melody she would often seek a melody known to her rather than face the insecurity of improvisation. When the therapist sat opposite her and showed her which notes to play she then was able to follow the therapist's finger movements. When presented with a limited range of tones, she also had

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At the beginning of the very first session after entering the therapy room, Frau X set her eyes on the piano and began to play spontaneously "Happy is the Gypsy Life." She easily accompanied this song harmonically with triads and thirds. The second song she attempted to play proved more difficult as she failed to find the subdominant, whereupon she broke off from the playing and remarked ". . . that always catches me out." This pattern of spontaneously striking up a melody, and then breaking off when the harmony failed, was to be repeated whenever she tried other songs like "Happy Birthday" and "Horch was kommt von drauBen rein." She showed a fine musical sensitivity for the appropriate harmony, which she could not always play. In the playing of the drum, her musical sensitivity in her reactions to the contrasting sound qualities of major and minor was reduced, but overall she had a pronounced perception of this harmonic realm of music. As in tests of language functioning, the production of music is impaired while perceptual abilities remain.

Changes in the Musical Playing of the Patient In the rhythmical playing on drum and cymbal, the therapist attempted to increase the patient's attention span through the use of short repeated musical patterns and changes in key, volume and tempo, hoping that the patient would maintain a stable musical form.

This technique helped the patient to maintain a rhythmical pattern and brought her to the stage where she could express herself stronger musically. Above the emphasis of the basic beat in the music, the therapist searched for other ways to respond to and develop a variety in rhythmical patterns by moving away from the repetitive pattern played by the patient. In a quick tempo the patient was able to maintain a basic beat for a certain time. As soon as the tempo changed and became slower, or the music varied with the introduction of a semiquaver, the stable element of the music was disturbed and took on a superficial character.

A further change in the improvising was shown when the patient recognized, and could repeat, rhyth-

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA mica1 patterns, which were frequently realized as a musical dialogue and brought into a musical context.

In the last session of therapy, the patient was able to change her playing in this way so that she could express more strongly by bringing into line her thoughtful and expressive playing (see Example 4).

A crucial point in the music was when she chose to play for a bar on the cymbal. Although after a while she trusted herself to play without help on two instruments, she could not come to grips with a new personal initiative on these instruments. This was also reflected in her continuing difficulty with what were initially strange instruments, like the temple blocks.

She also expressed her insecurity about how to proceed and needed instructions.

The patient displayed few changes in her dynamic playing. She reacted to dynamic contrasts and transitions, but powerful forte playing was only achieved in the last session. At times her playing had a uniform quality of attack, which gave it a mechanistic and immovable character. It was not possible for her to build a freely improvised melody from a selection of tones. It was as if she was a prisoner of the search for melodies of known fixed songs; therefore, the therapist chose the free form of improvising on rhythm instruments.

Intentional Playing From the first session of therapy the patient made quite clear her intent to sit at the piano and play whatever melodies she chose and to find the appropriate accompaniments. This wish, and the corresponding willpower to achieve this end, was shown in all the sessions. It was possible to use this impetus to play as a source for improvisation. In the sixth session, Frau X improvised a rhythmical piece in 414 time, which the therapist then transformed with a melodic phrase.

At the end of the phrase the patient laughed with joy at the success of her playing and asked to play it again. The original lapses and slips in the form of the rhythmical playing could be carried by the intent and expression with which she played. Although her overall intention to play was preserved, her attention to that playing, the concentration necessary for musical

25 1

production and the perseverance required for completing a sequence of phrases progressively failed and was dependent on the overall musical structure offered by the therapist.

Clinical Changes At the end of the treatment period, which also used homeopathic medicine, she was able to cook for herself and find her own things about the house. The psychiatrist responsible for her therapeutic management reported an overall improvement in her interest in what was going on around her, and, in particular, that she maintained attention to visitors and conversations. The patient regained the ability to write her name, although she could only write slowly. While wanting to speak, she still experienced difficulty in finding words. The medical practitioner with overall responsibility for the patient used no validated clinical assessment procedure for mental state examination.

It appears that music therapy had a beneficial effect on the quality of life for this patient, and that some of the therapeutic effect may have been brought about by handling the depression. Indeed, it may be that the patient was suffering from a pseudodementia confounded by her own anxiety and depression regarding the demise of her sister. Although the patient came to the sessions with the intention of playing music, her ability to take initiatives was impaired.

This situation reflected the state of her home life, where she wanted to look after herself, yet was unable to take initiatives. This stimulus to take initiatives was seen as an important feature of the music therapy by the therapist, and appears to have a correlation in the way the patient began to take initiatives in her daily life. Active music making also promotes interaction between the persons involved, thereby promoting initiatives in communication that the patient also enjoyed, particularly when she accomplished playing a complete improvisation.

A contraindication for music therapy with patients who are aware of their problems is that the awareness of further cognitive abilities as experienced in the playing may exacerbate any underlying depression and demotivate the patient to continue.

Conclusion

Example 4. Change in the form of the patient's playing.

David Aldridge

If we are unsure of the normal process of cognitive loss in aging, we are even more in the dark as to the normal improvised musical playing abilities of the

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elderly. Any further activities will depend upon some baseline assessment of musical improvising ability.

The literature suggests that musical activities are preserved while other cognitive functions fail. Alzheimer patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. However, the production of music and the improvisation of music appear to fail in the same way that language fails. Unfortunately, no established guidelines for the normal range of improvised music playing of adults is available.

Improvised music therapy appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking (see Table 6), although such a hypothetical claim awaits further investigation. First, it is possible to ascertain the fluency of musical production. Second, intentionality, attention to, concentration on and perseverance with the task in hand are important features of producing musical improvisations and susceptible to being heard in the musical playing. Third, episodic memory can be tested in the ability to repeat short rhythmic and melodic phrases. The inability to build such phrases may be attributed to problems with memory or to a yet unknown factor. This unknown factor is possibly involved with the organization of time structures. If rhythmic structure is an overall context for musical production and the ground structure for perception, it can be hypothesized that it is this overarching structure that begins to fail in Alzheimer's patients. A loss of rhythmical context would explain why patients are able to produce and persevere with rhythmic and melodic playing when offered an overall structure by the therapist. Such a hypothesis would tie in with the musical hierarchy proposed by S w a m (Swartz et al., 1989, p. 154) and would suggest a global failing in cognition while localized lower abilities are retained.

However, the hierarchy of musical perceptual levels proposed by Swartz may need to be further subdivided into classifications of music reception and music production.

Music therapy also appears to offer a sensitive assessment tool. It tests those prosodic elements of speech production that are not lexically dependent.

Furthermore, it can be used to assess those areas of functioning, both receptive and productive, not covered adequately by other test instruments (i.e., fluency, perseverance in context, attention, concentration and intentionality). In addition, it provides a form of therapy that may stimulate cognitive activities so that areas subject to progressive failure are main-

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tained. Certainly the anecdotal evidence suggests that quality of life of Alzheimer's patients is significantly improved with music therapy (Tyson, 1989), accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others (Morris, 1986). Prinsley recommended music therapy for geriatric care in that it reduces the individual prescription of tranquilizing medication, reduces the use of hypnotics on the hospital ward and helps overall rehabilitation. He recommended that music therapy be based on treatment objectives, the social goals of interaction cooperation, psychological goals of mood improvement and self-expression, intellectual goals of the stimulation of speech and organization of mental processes, and the physical goals of sensory stimulation and motor integration (Prinsley, 1986).

In further research, single-case within-subject designs with Alzheimer's patients appear to be a feasible way forward to assess individual responses to musical interventions in the clinical realm. (These can be extended to include multiple baselines.) Such studies would depend upon careful clinical examinations, mental state examinations and musical assessments.

Unfortunately, most of the literature concerning cognition and musical perception is based upon audition and not musical production. The production of music, as is the production of language, is a complex global phenomenon as yet poorly understood. The understanding of musical production may well offer a clue to the ground structure of language and communication in general. It is research in this realm of perception that is urgent not only for the understanding of Alzheimer's patients, but in the general context of cognitive deficit and brain behavior. It may be, as Berman ( 1 98 1) suggested, that the nondominant hemisphere is a reserve of functions in case of regional failure, and this functionality can be stimulated to delay the progression of degenerative disease. Furthermore, it is important to point out that when the overall rhythmic pattern failed for the patient described above, the patient was able to maintain her beating in tempo. A similar situation may apply to coma patients who cannot coordinate basic life pulses within a rhythmic context and thereby regain consciousness (Aldridge, 1991a; Aldridge, Gustorff, & Hannich, 1990). We may need to address in future research the coordinating role of rhythm in human cognition and consciousness, whether it be in persons who are losing cognitive abilities or in persons who are attempting to gain cognitive abilities.

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA Table 6 Comparative Elements of Two Therapeutic Epistemologies: Medicine and Music Therapy in the Treatment of Patients With Dementia Medical Elements of Assessment

Musical Elements of Assessment

continuing observation of mental and functional status

continuing observation of mental and functional status

testing of verbal skills, including element of speech fluency

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

cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left coordination).

cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left coordination).

testing for progressive memory disintegration

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 the 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

We had set out to negotiate a common language between practitioners, and this was achieved. Although the clinical benefits of music therapy for patients with dementia or pseudodementia remain speculative, a common language to discuss and compare

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Music Therapy Examples improvisations using rhythmic instruments (drum and cymbal) singly or in combination improvisations using melodic instruments singing and playing folk songs with harmonic accompaniment playing tuned percussion (metallophone, xylophone, chime bars) demanding precise movements alternate playing of cymbal and drum using a beater in each hand coordinated playing of cymbal and drum using a beater in each hand coordinated playing of tuned percussion the playing of short rhythmic and melodic phrases within the session, and in successive sessions the playing of a rhythmic pattern deteriorates when unaccompanied by the therapist, as does the ability to complete a known melody, although tempo remains the patient exhibits the intention to play the piano from the onset of therapy and maintains this intent throughout the course of treatment the patient loses concentration when playing, with qualitative loss in the musical playing and lack of precision in the beating of rhythmical instruments initially the musical playing is limited to a tempo of 120 bpm and a characteristic pattern but this is responsive to change although the patient has a musical background this is only of help when she perceives the musical playing, it is little influence in the improvised playing musical changes in tempo, dynamic, timbre and articulation, which at first are missing, are gradually developed the patient develops the ability to play in a musical dialogue with the therapist demanding both a refined musical perception and the ability of musical production

therapeutic changes has been developed, which is the first step in a continuing program of research dialogues. The next step is for other therapists to attempt correlations with their elderly patients to see if our hypotheses stand up to practical clinical investigation.

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Our experiences suggest that it is important to consider a period of active assessment separate from therapy, and that assessment must also incorporate time for orientation to the music therapy setting, the relationship, the instruments and the activity of improvising.

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Aldridge, D. (199 1b). Physiological change, communication, and the playing of improvised music: Some proposals for research.

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Swartz, K., Hantz, E., Cmmmer, G., Walton, J., & Frisina, R. (1989). Does the melody linger on? Music cognition in Alzheimer's disease. Seminars in Neurology, 9 (2), 152-158.

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International Tinnitus Journal, Vol. 11, No. 2, 163–169 (2005)

Auditive Stimulation Therapy as an Intervention in Subacute and Chronic Tinnitus: A Prospective Observational Study Martin Kusatz,1 Thomas Ostermann,2 and David Aldridge3 1 Tinnitus

Therapy Center, Krefeld and Dusseldorf; 2 Department of Medical Theory and Complementary Medicine and 2,3 Faculty of Medicine, University of Witten Herdecke, Germany

Abstract: Tinnitus is a noise, a ringing, or a roaring sound in the affected ear and is becoming an increasingly serious problem for health care systems. Integrative treatment concepts are currently regarded as promising therapeutic approaches for managing tinnitus. The aim of this study was to present the results of auditive stimulation therapy, a program of music therapy developed specifically for tinnitus treatment. We collected data on outpatient treatment results from 155 tinnitus patients and evaluated them in a prospective observational study with three defined times of measurement (start, end, and 6 months after the end of treatment). Apart from anamnestic data and subjective evaluation of treatment, the major outcome parameter was the score of the tinnitus questionnaire. To evaluate effectiveness of the therapy, we calculated effect sizes (according to Cohen). Fifty-one percent of the patients were male, and the mean patient age was 49 years. Of the 155 patients, 137 (88%) were capable of gainful employment, which means that they fell in the age range between 18 and 65 years. The duration of tinnitus was more than 6 months for 80% of patients, and 43% had been suffering from tinnitus for more than 3 years. In general, all subscales of the tinnitus questionnaire showed highly significant changes (t-test, p .01) between the measurement points “start of therapy” and “end of therapy,” whereas no significant difference was found between the measurement points “end of therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at a level recorded at the end of the therapy; we did not observe a reduction to the level prior to treatment. The values for the effect sizes mostly ranged between medium ( 0.5) and high ( 0.8). Closer investigations indicated that a combination of music therapy and psychological training rendered the best effect sizes. This study demonstrated that music therapy is an effective integrated treatment approach and offers a way to make progress in tinnitus treatment.

Key Words: effectiveness; music therapy; outcome research; tinnitus such cases, only the person afflicted perceives the sounds. These may occur as rustling, whistling, whirhe term tinnitus is derived from the Latin tinnire ring, ringing, or droning sounds. High-frequency sounds (“ringing”) and is defined as the perception of are perceived far more often than are low-frequency sound in the absence of any appropriate extersounds [2], and a hearing impairment is detectable in nal stimulation. A basic difference separates objective more than 50% of all cases. and subjective tinnitus. The term objective tinnitus is The incidence of patients experiencing tinnitus in used for ear sounds based on genuine physical vibraGermany and the Western world is approximately 10%. tions-oscillations that may be perceived by others or Some 1–2% of the population is severely disturbed by even measured [1]. This type of tinnitus is rather rare, tinnitus, which may disrupt everyday activities and whereas subjective tinnitus is far more frequent. In sleep [3]. If the symptoms continue for 6 months, we consider the condition to be chronic, the degree of Reprint requests: Prof. Dr. David Aldridge which differs considerably from person to person and

T

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affects patients in different ways [4]. A decompensated tinnitus is accompanied in most cases by other complaints (e.g., depression, anxiety, impaired sleep and concentration, sensitivity to noises, and the like) [5–7]; consequently, intervention is required. Several treatments of chronic tinnitus have been proposed and implemented [8]. Among complementary therapies, homeopathy and acupuncture are proposed [9–11]. Although several case studies reported efficacy of these treatments, the empirical support in well-controlled studies is still weak [12,13].

Today, such integrative therapy concepts as cognitive-behavioral treatment compiled from counseling, relaxation therapy, music therapy, and pharmacological preparations (lidocaine, neurotransmitters) are regarded as promising therapeutic approaches for managing tinnitus [7]. In particular, music therapy offers the chance of a global treatment approach for tinnitus patients [14]. Harmony, for instance, as a connecting link between rhythm and melody also has a social function.

Rhythm may also influence biological parameters via tempo accentuation and meter [15]. These components form the theoretical background for auditive stimulation therapy (AST), the music therapy (MT) program evaluated in this study.

THERAPY AST is a complex program of MT originally employed in the treatment of chronic pain and developed specifically for tinnitus treatment. It consists of a total of 10 therapy sessions and employs specifically developed receptive music programs in combination with an education program. Musical self-control (MSC) training is a music program designed on the basis of music psychology and MT, the effectiveness of which was demonstrated in a clinical study [16]. The objective of MSC training is to improve patients’ control of ear sounds and to relieve their feelings of helplessness. Ringing in the ear or strange sounds bring about alterations in perception. If we encourage the ability of selective hearing, we can promote some sounds in the hierarchy of perception and ignore other sounds or regulate them until they become hardly perceptible. Such training improves (i.e., lowers) the level of sensitivity to sounds.

Finally, the objective of AST is to bring about a change in sound perception that induces relaxation, reduces anxiety, and stimulates changes in unfavorable behavior patterns, thus improving the emotional state.

The education program is aimed at alterations on a cognitive level.

The outpatient therapy (duration, 2 weeks) with AST consisted of a total of 38 hours of therapy (20-hr psychological training, 10-hr MT [AST], 8-hr kinesi-

Kusatz et al.

Figure 1. Complete 2-week program of auditive stimulation therapy (AST) as a function of hours of therapy per day. (A admission; PT psychological therapy; MO motor therapy.)

therapy) and also included counseling by ear, nose, and throat experts, orthopedists, and dentists. Figure 1 shows the complete 2-week program of AST with its different modules.

METHODS At the Tinnitus Therapie Zentrum Krefeld (Germany), we performed an observational study on a multimodal treatment concept (Krefelder-Modell) being applied on an outpatient basis for subacute and chronic tinnitus over a projected period of 2 years. Data on treatment were collected and evaluated in a prospective observational study using several standardized questionnaires immediately before and after therapy and at follow-up after 6 months. Apart from anamnestic data, the questionnaires asked for a subjective evaluation of treatment results. The tinnitus questionnaire designed by Goebel and Hiller [17], now the recommended standard tool throughout Germany, was used at all times for measurement. Included in the evaluation were only those questionnaires in which more than 90% of the questions were answered properly.

We included a total of 155 patients in this evaluation. Sufficient follow-up documentation for assessment was available for 111 patients (71.6%). Figure 2 shows the questionnaire instruments used and the patient flow in this study.

For an evaluation of the efficiency and sustained success of the therapy, we applied the t-test to show significant differences of tinnitus questionnaire scales after therapy. We carried out subgroup analysis of outcome measures according to the degree of tinnitus severity. Therefore, the tinnitus questionnaire results were grouped in the following clinically relevant groups: minor tinnitus (0–30 points); medium tinnitus (31–46 points); serious tinnitus (47–59 points); and very serious tinnitus (60–84 points).

As the treatment concept presented in this study (Krefelder-Modell) is a multimodal concept, the differ-

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Figure 2. Patients and questionnaire instruments. (AST auditive stimulation therapy.)

ent elements of treatment can be compared to achieve more detailed results on the efficiency of the MT training program (AST). Kinesitherapy having received a distinctly lower rating by patients, only the two treatment elements rated as most successful were compared with respect to their effectiveness: psychological training (PT) and music therapy (MT).

To evaluate effectiveness of the therapy and to render the results comparable with each other and also with other treatment facilities in the health care sector, we calculated effect sizes according to Cohen [18] and corrected according to McGaw and Glass [19].

PATIENTS One hundred thirty-seven patients (88.38%) were of wage-earning age (i.e., between 18 and 65 years). Table 1 shows that the duration of tinnitus was longer than 6 months for 80% of patients. A total of 43.3% had been suffering from tinnitus for more than 3 years; 33.5% of those interviewed reported that tinnitus developed gradually. Every second patient (50.3%) said tinnitus set in suddenly; 16.1% did not answer this question; 76.8% said tinnitus occurred continuously; and 21.3% reported that tinnitus occurred with interruption. Three patients (1.9%) had no comment. Almost all patients (94.8%) reported times at which tinnitus was particularly intense. In contrast, only 75.5% said that at times tinnitus was barely perceptible.

Patients were also asked how often they resorted to seeking assistance through the health care system over 6 months before treatment, and they had the option of

several possible answers. Seventy-four patients answering this question (47.74%) reported 111 individual consultations (main consultation with ear, nose, and throat specialists), which means an average of 1.5 consultations per patient approximately. Before treatment, patients were also asked about previous treatment; 137 patients reported a total of 304 instances (i.e., an average of 2.2 treatments per patient). The major treatments were infusions (78.8%).

RESULTS The total score of the tinnitus questionnaire (Tinnitus Fragebogen [TF]) at the different measurement points is shown in Figure 2. The follow-up sample with regard to the TF total score did not differ significantly from that of the general population, which has been demonstrated [16]. Therefore, Figure 3 shows the mean scale values of the tinnitus questionnaire before and after outpatient tinnitus therapy (n 146) and also at follow-up after 6 months (n 106).

In general, all subscales showed highly significant changes (t-test, p .01) between the measurement points “start of therapy” and “end of therapy,” whereas we found no significant difference between the measurement points “end of therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at a level recorded at the end of the therapy; we did not observe a reduction to the level before treatment. Approximately 80% of the patients with a disease severity of medium to very serious at least moved to a clinically improved stage (e.g., from very serious to serious). The

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Kusatz et al.

Table 1. Sociodemographic and Anamnestic Data Characteristic

Male

Female

Total

Gender

51%

49%

100%

Age Mean Standard deviation Median

48.9 yr 12.1 yr 52 yr

48.7 yr 15.5 yr 50 yr

48.8 yr 13.9 yr 51.5 yr

Marital status Single Married or established partner Divorced or living separated Widowed

16% 74% 10% —

17% 64% 9% 9%

17% 69% 10% 5%

Graduation Secondary school Secondary modern school High school, A-levels University or college

55% 25% 7% 13%

43% 29% 18% 9%

49% 27% 13% 11%

Profession Laborer Clerk Self-employed Unemployed

33% 40% 4% 24%

13% 48% 3% 37%

23% 44% 3% 30%

Duration of tinnitus 6 mo 6–12 mo 1–3 yr 3–5 yr 5 yr

20% 16% 20% 14% 30%

20% 16% 22% 10% 32%

20% 16% 21% 12% 31%

Loudness, ear-ringing: 0 (not at all) to 10 (maximum) Mean (95% CI) Standard deviation Median

6.5 (6.0–7.0) 2.2 6

5.5 (4.9–6.1) 2.8 5.5

6.1 (5.7–6.5) 2.5 6

Disruption, ear-ringing: 0 (not at all) to 10 (maximum) Mean (95% CI) Standard deviation Median

7.0 (6.4–7.6) 2.6 7

6.4 (5.7–7.1) 3.0 6

6.7 (6.3–7.1) 2.8 7

Restrictions, ear-ringing: 0 (not at all) to 10 (maximum) Mean (95% CI) Standard deviation Median

5.8 (5.1–6.5) 3.0 6

4.5 (3.8–5.2) 3.2 4

5.2 (4.7–5.7) 3.2 5

Figure 3. Total score on the tinnitus questionnaire (TF) at the different measurement points, according to degree of disease severity.

details of this transition process will, however, be the subject of a following evaluation using Marcov-chains methods.

We determined the values of effect sizes for individual subscales and for the total score. The values for the effect sizes were all in the range of medium ( 0.5) to high ( 0.8), with the exception of the scale somatic disorders, and are illustrated in Figure 4.

In a comparison of the individual therapies, AST was responsible for a surprisingly high percentage of the positive total result and clearly was preferred by patients, despite the fact that psychological training was twice as long (20 therapy session hours as compared to 10 for MT). For further analysis of these findings, we

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helped them to cope better with ringing in the ear, 40% of patients described the success as excellent, 29% as good, and 16.8% as satisfactory. At a follow-up 6 months after the end of the therapy, the question was whether any ear ringing was still perceivable; 3.2% of patients reported none at all; 30.8% had a temporary absence of ear ringing; some two-thirds of patients continued to perceive noises during the 6 months after the therapy ended, but these had noise that had been clearly reduced.

In summary, 52.3% indicated further positive changes after the therapy was concluded.

Figure 4. Changes (on the tinnitus questionnaire) of scale values in effect sizes. (E emotional distress; C cognitive distress; I intrusiveness; A hearing problems; SI sleeping problems; SO somatic complaints.)

calculated effect sizes at measurement times and related to the patients’ subjective evaluation. Figure 5 illustrates the calculation of effect sizes.

A combination of MT and PT renders the best therapeutic effect. MT alone ranked in second place, and PT was third. The combination of MT-PT comprises the partial therapies MT and PT, and this suggests that the share of MT in this result is higher than that of PT. In addition, MT shows excellent effect sizes over longer periods, a clear indication of the quality of the concept of AST as to contents and didactic implementation. The results appear to confirm in particular the intention of enabling patients to continue independently with MT and to make autonomous use of receptive music programs. The most expressive results in this context certainly are those of the follow-up, as the data from these particular patients are available for all measurement times. In retrospect, they were able to come to a conclusive evaluation for themselves.

In answer to the question of whether the therapy

Figure 5. Changes in effect sizes (total, n 143; follow-up, n 105) depending on patients’ preferred therapy. (MT subgroup of patients favoring music therapeutic elements; MT PT subgroup of patients who were indecisive between music therapy and psychotherapy; PT subgroup of patients favoring psychotherapeutic elements.)

CONCLUSION An analysis of the tinnitus problem, particularly from a traditional perspective, suggests a general confusion among most experts, although many scientists have explored the problem. A great variety of models and treatment approaches are available, the effectiveness of which is still inconclusive. The standard therapies in Germany include medication to improve blood circulation or, with increasing frequency, infusions as part of a hospitalization period, with disproportionate side effects as compared to the severity of the complaints [20].

In this study, we were able to demonstrate that the multimodal concept achieves highly significant changes.

The calculation of effect size, according to the tinnitus questionnaire results, illustrates that the most significant effect sizes occurred in the area of psychological stress and total score changes. In comparison with effect sizes of other studies with hospitalized patients and outpatients summarized in a meta-analysis by Schilter [21], the advantages of this treatment concept become evident. With an overall effect size of 0.63 from pretherapy to follow-up, other multimodal therapeutic strategies range far behind the results of the therapeutic approach described in this study. Medical treatments (e.g., tocainide, lidocaine, carbamazepine) or other remedies have effect sizes in the same magnitude; however, these therapies have side effects, such as tremor, vertigo, giddiness, and nausea [21]. Therefore, our nonpharmacological intervention achieves the high effect sizes of the drug-based therapies without their concomitant side effects. The Krefelder-Modell treatment concept alone uses an MT training program embedded within a complex treatment approach, indicating that the advantage— compared to other treatment forms—is principally the influence of the specific MT intervention.

If we assume that tinnitus is not a disease but a symptom of an underlying process, singular symptom– oriented approaches will fail [2]. Sixty-one percent of patients state that professional medical help was not of much use—a shockingly high figure in view of the numerous medical interventions. Much suggests a holistic

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treatment approach, in which ringing in the ear is viewed as a sign of particularly high stress. The question of whether the symptom is of a somatic or a psychosomatic nature seems to be of no importance in the treatment of subacute and chronic tinnitus. An analysis not only of the biological but of the psychological and social needs of patients [22] provides a more comprehensive insight into and understanding of their situation. MT AST is seen as salient to their problems among patients and as highly effective, perhaps because we are not making a direct, singular psychological intervention but an intervention in the same modality as that in which the symptom is experienced. By accommodating sound control within an ecology of other sounds, itself within a stressreduction context, we are offering a form of self-control that is adapted to a personal environment [23–25]. On this extended basis of our knowledge about hearing, we should be able to develop for affected patients coping strategies that address the causes of the problem directly and thus render the symptom superfluous.

Our follow-up interview of patients after 6 months showed a high degree of sustained therapeutic success.

Furthermore, these interviews provide important feedback for therapists and show longer-term positive treatment results, specifically in the areas of well-being and reintegration of patients in their family environment, as amply demonstrated in our study. We hear frequently that therapy success in most cases becomes evident over time. If a reorientation in terms of perception takes place, the consequences of this reorientation, as therapeutic effects, are best seen in follow-up assessments.

The subjective symptom of tinnitus is a phenomenon that the unaffected cannot easily understand, as defining a cause is difficult in most cases. Hearing of sounds that are normally located externally is suddenly directed internally and, therefore, is difficult for others to imagine. The affected individual suffers from a personal noise problem that is inaudible to others; consequently, others lack understanding. Musicians, however, understand this concept as part of their daily practice [26]. “Only inner anticipatory hearing makes musical interpretation possible. This phenomenon is most obvious in Ludwig van Beethoven who composed without being able to hear. Accordingly, listening must also be seen as an internal process of perception” [14].

Neugebauer reminded us that a sensory stimulation must not necessarily result in a conscious perception, nor must a sensory experience necessarily be caused by a physical stimulus. The specific way in which music therapists or musicians hear may indeed be helpful or suitable in understanding tinnitus patients and also in explaining—taking a composer as an example—how such experiences of internal hearing may also be observed in different settings in which they are absolutely

Kusatz et al.

normal and by no means pathological. Aldridge [25] suggested that the purpose of MT is that patients are enabled to generate expressive potentials that reveal new possibilities for becoming healthy. In the context of ear ringing, MT might help to create a context of meanings that integrates the sounds or noises into the music and thus removes them from conscious perception, which would clearly promote recovery. Sounds no longer perceived as disturbing, once brought under control, are perceived as musical.

This study demonstrates that MT is an effective treatment approach and offers a way to make progress in tinnitus treatment. Music has an esthetic aspect; it is part of our cultural heritage. How we integrate sounds into our daily life and how they become perceived as noise or music is a complex activity involving the physiological, the psychological, and the social. A therapeutic intervention that incorporates these understandings appears to offer considerable benefits, not as a cure but as a healthy adaptation.

REFERENCES 1. Feldmann H. Pathophysiologie des Tinnitus. In H Feldmann (ed), Tinnitus. Stuttgart: Thieme, 1992:33–70.

2. Pilgramm M, Rychlik R, Lebisch H, et al. Tinnitus in der Bundesrepublik. HNO Aktuell 7:261–265, 1999.

3. Rosanowski F, Hoppe U, Kollner V, et al. Interdisciplinary management of chronic tinnitus: II. Versicherungsmedizin 53(2):60–66, 2001.

4. Wilhelm T, Ruh S, Bock K, Lenarz T. Standardisierung und Qualitätssicherung am Beispiel Tinnitus. Laryngorhinootologie 74:300–306, 1995.

5. Duckro PN, Pollard CA, Bray HD, Scheiter L. Comprehensive behavioural management of complex tinnitus: A case Illustration. Biofeedback Self-Reg 9(4):459–469, 1984.

6. Goebel G, Keeser W, Fichter M, Rief W. Neue Aspekte des komplexen chronischen Tinnitus: II. Die verlorene Stille: Auswirkungen und psychotherapeutische Möglichkeiten beim komplexen chronischen Tinnitus. Psychother Psychosom Med Psychol 41:123–133, 1991.

7. Goebel G. Studien zur Wirksamkeit psychologischer Therapien beim chronischen Tinnitus. In G Goebel (ed), Ohrgeräusche–psychosomatische Aspekte des komplexen chronischen Tinnitus. München: Quintessenz, 1992:87–102.

8. Kröner-Herwig B. Psychologische Behandlung des chronischen Tinnitus. Weinheim: Psychologie Verlags Union, 1997.

9. Park J, White AR, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: A systematic review. Arch Otolaryngol Head Neck Surg 126(4):489–492, 2000.

10. Simpson JJ, Donaldson I, Davies WE. Use of homeopathy in the treatment of tinnitus. Br J Audiol 32(4):227–233, 1998.

11. Weihmayr T. Managing tinnitus with natural healing. When

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it whistles and rings in the ear. Natural Healing Series: 18.

Tinnitus. Fortschr Med 116(10):48–49, 1998.

19. McGaw B, Glass GV. Choice of metric for effect size in meta analysis. Am Educ Res J 17:325–337, 1980.

12. Biesinger E. Die Behandlung von Ohrgeräuschen. Stuttgart: Georg Thieme Verlag, 1999.

20. Bork K. Juchreiz nach Hydroxiethystärke: Auch bei Intensivepatienten häufig. Arznei-telegramm. 31(6):53, 2000.

13. Ernst E. Complementary and alternative medicine in the practice of otolaryngology. Curr Opin Otolaryngol Head Neck Surg 8(3):211–216, 2000.

14. Neugebauer L. Schöpferische Musiktherapie bei Patienten mit chronischem Tinnitus. In D Aldridge (ed), Kairos III: Beiträge zur Musiktherapie in der Medizin. Göttingen: Hans Huber Verlag, 1999:42–50.

15. Mosonyi D. Psychologie der Musik. Darmstadt: TonosEdition, 1975.

16. Kusatz M. Auditive Stimulation Therapy AST—Intervention in Subacute and Chronic Tinnitus. Hanover: Proceedings of the Fifth Triennial Conference of the ESCOM, 2003:45–49.

17. Goebel G, Hiller W. Qualitatsmanagement in der Therapie des chronischen Tinnitus. OtorhinolaryngologiaNova 10(6):260–268, 2000.

18. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Erlbaum, 1988.

21. Schilter B. Metaanalyse zur Effektivität medikamentöser und psychologischer Therapien bei chronischem subjektivem Tinnitus. Frankfurt: VAS-Verlag, 2000.

22. Aldridge D. Leben als Jazz. In D Aldridge (ed), Kairos II, Beiträge zur Musiktherapie. Göttingen: Verlag Hans Huber 1998:5–6.

23. Aldridge D, Gustdorff D, Neugebauer L. A preliminary study of creative music therapy in the treatment of children with developmental delay. Complementary Ther Med 3:197–205, 1995.

24. Aldridge D. Music Therapy Research and Practice in Medicine. London: Jessica Kingsley, 1996.

25. Aldridge D. Musiktherapie in der Medizin. Göttingen: Verlag Hans Huber, 1999.

26. Neugebauer L. Das Pfeifen nervt nicht mehr so. Musiktherapeutische Umschau 4:326–335, 2001.

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The Arts in Psychotherapy, Vol. 18, pp. 113-121.

0

Pergamon Press plc, 1991. Printed in the U.S.A.

0197-4556191 $3.00

+

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MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE DAVID ALDRIDGE. PhD and GUDRUN BRANDT, Dipl. MT*

This paper presents two comparative views of inflammatory bowel disease. One is from the general medical literature; the other is that of a music therapist who has played extensively with patients who have the disease. The music therapist was unaware of the medical descriptions of the disease when she made her descriptions of the musical improvised playing of such patients. It is apparent from both sets of descriptions that they have elements in common such that a dialogue can occur between medical practitioners and arts therapists. Some implications for the treatment of patients with inflammatory bowel disease are also discussed.

colitis always affects the rectum and sometimes the entire colon.

These are not generally highly fatal diseases, but they are important for public health concerns in that their incidence is early in life, therapy often involves surgery, there is a risk of developing intestinal cancer in later life, and there are enormous social costs involved in chronic illness (Sanderson, 1986). These ailments cause great personal embarrassment and discomfort for the patient, often resulting in a restricted lifestyle and a miserable existence (Robertson, Ray, Diamond & Edwards, 1989). Any therapeutic endeavors must attend to enhancing the life quality of the patient.

Inflammatory Bowel Disease Inflammatory bowel disease is a term that refers to a collection of diseases affecting the bowel. These diseases are characterized by the presence of chronic inflammation of the gastrointestinal tract that cannot be ascribed to any specific cause. The most common of these maladies are ulcerative colitis and Crohn's disease. Both have a common insidious onset resulting in chronic symptoms that may include severe episodic diarrhea, colicky abdominal pain, weight loss, nausea and vomiting, and pus, blood or mucus in the stool.

Although there are common symptoms in inflammatory bowel disease, Crohn's is distinguished from others because it generally affects the terminal ileum and the right colon, sometimes the whole bowel (Calkins & Mendeloff, 1986), but rarely the entire digestive tract although it can affect any part of the alimentary canal (Strober & James, 1986). Ulcerative

Epidemiological Factors

The etiology and pathogenesis of both ulcerative colitis and Crohn's have not yet been clarified.

Diagnosis is difficult. A significant time may elapse between the onset of first symptoms and a definite diagnosis. As the diseases share similar symptoms, diagnosis is problematic (Bruce, 1986; Shivananda et al., 1987). The incidence of ulcerative colitis appears to be more frequent in modem Western society and is increasing (Calkins & Mendeloff, 1986).

The primary age ranges for the incidence of inflammatory bowel in both sexes are between 15 to 25 years and between 55 to 60 years (Calkins & Mendeloff, 1986; Shivananda et al., 1987). Children under six years of age appear to be resistant to the development of Crohn's; between the ages of 6 to 10 years ulcerative colitis, but not Crohn's, occurs with increasing frequency.

*David Aldridge is a research consultant to the medical faculty of Universitat Witten Herdecke, West Germany. Gudrun Brandt is a music therapist.

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There is an increased frequency of inflammatory bowel in families of patients who suffer from it, with a mixture of both Crohn's and ulcerative colitis. This has suggested that there may be a genetic basis for the disease (Sanderson, 1986; Strober & James, 1986) although this genetic base remains as yet undiscovered. Such diseases may be inherited as behaviors that are learned in family contexts and passed on from generation to generation.

Diet Because of the nature of the malady, dietary intake has been considered one of the most important environmental exposure factors of the digestive system.

Among patients with Crohn's, one possible causative factor is increased sugar consumption. Dietary fiber, increased milk products, carbohydrate, protein, and total calorie consumption have also been implicated (Persson & Hellers, 1987).

The studies have proved to be problematic because dietary exposure may have occurred many years prior to the diagnosis, or the prolonged onset of the disease may lead to the alteration of dietary practice. For example, patients may increase their consumption of refined sugar in an attempt to compensate for loss of energy or loss of weight as a consequence of the disease.

Liquid elemental diets developed for the space programs in the United States have been used for the treatment of Crohn's. Although the efficacy of such a diet is not known (Sanderson, 1986), the results are shown to be as helpful as high dose steroids for the remission of small bowel Crohn's in children. Children treated in this way experience an acceleration of growth.

The use of nutritional supplements may have a small role to play in helping extremely sick children to obtain some calories, but this approach is seen as beneficial only in the short term (Clark, 1986).

Patient enthusiasm for the diet wanes in the long term because it is unpalatable. Bruce (1986) also commented that an elemental diet worsens the difficulties of young people with the disease by placing them in a regressed position that allows the mother to exercise absolute control as she did when they were infants.

What is lacking in dietary studies is a perspective that it is not necessarilv the content of the food that is important but the way it is eaten, the situation in which it is eaten, and the conditions in which it is

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digested. The preparation of food, the way it is eaten, and the way that waste products are disposed of are also closely patterned by culture. The offer of food and its acceptance are also of great symbolic value (Helman, 1985; Kleinman, 1978).

Zmmunological Factors As it has been difficult to establish an infectious cause for inflammatory bowel disease. some researchers have sought an immunological basis (Kett, Rognum & Brandzaeg, 1987; Strober & James, 1986; Trabucchi, Mukenge, Barrati, Colombo & Fregoni, 1986; Van Spreuuwel, Lindeman & Meijer, 1986).

Crohn's disease begins as the product of an underlying inflammatory process. The presence of increased numbers of macrophages and mast cells appears to be an important feature. The specific physiologic function of mast cells remains unknown, but they are known to contain inflammatory mediators, such as histamine, and may play a role in allergic reactions.

Although a pathogen has not been found, somehow natients become sensitive to the constituents of their own gut flora, which has widespread negative effects on the entire immune system. Patients react negatively to their own body, a rejection of a part of their very own self.

Modem researchers have taken the old idea that emotions influence the health status of people and have developed the sciences of psychoneuroimmunology - the study of the effects of psychological factors on the immune system (Baker, 1987; Blalock & Smith, 1985), and of neuroimmodulation - the study of the mechanisms whereby the nervous system modulates the activity of the immune system (Baker, 1987; Stein, Keller & Schleifer, 1985; Trabucchi et al.. 1986). Emotions influence health status as disturbances to the immune system by specific interactions between the nervous system, immune and endocrine systems. This suble combination of physiological mechanisms is designed to recognize and deal with nonself or altered material. What is self and nonself are crucial decisions isomorphic with the physiology and psychology of the persons and the family with whom they dwell.

Chronic stress has also been shown to alter the immune system (Baker, 1987; Patterson, 1988; Stein et al., 1985) and thereby recovery. Immunological descriptions of inflammatory bowel disease also suggest a similar process, a transient infection provoking

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MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE an immune response that is exacerbated by psychological factors. Strikingly, patients with bowel disease often attribute the onset of their disease to a stressful event (Robertson et al., 1989). This is literally a gut reaction to a significant life event.

Psychological Factors There is a long history u i associating somatic symptoms and emotional disturbance. If inflammatory bowel disease is, as some researchers believe, a motility disorder of the gut, then that motility is sensitive to the emotional state of the person. Highly anxious patients may produce symptoms at times of emotional distress (Lask, 1986).

Although psychiatric illness and psychopathology are not more prevalent in patients with inflammatory bowel disease (Clouse & Alpers, 1986), there does appear to be some evidence of depression in patients with Crohn's (Tarter, Switala, Carra & Edwards, 1987) but this appears to occur only in those with persistent disease activity (Robertson et al., 1989).

High levels of neuroticism (a score of more than 12 on the Eysenck Personality Inventory) are associated with these patients and they become more introverted as the disease progresses (Robertson et al., 1989).

The search for causative psychological factors has been in vain principally because of the insidious onset of the disease. Although most researchers accept that psychological difficulties are sequelae of the disease and that stress and emotional difficulties exacerbate it, no factors appear to be causative. Traditionally, ulcerative colitis has been regarded as a psychosomatic illness. Psychoanalysis has taken the view that such illness has its origins in the mental mechanisms used to cope with the emotions. From this perspective, the disease represents a reaction to a real or threatened loss of the mother, or someone else on whom the patient is dependent. Ulcerative colitis patients are seen as rigid, controlling, and dependent.

Recent psychoanalytic approaches have observed that inflammatory bowel disease patients have a tendency to somatize their problems, and that they have difficulty in expressing emotions verbally (Bruce, 1986; Stanwyck & Arnson, 1986). This state is termed "alexithymia." To spare themselves emotional pain, these patients project those problems into bodily functioning. Hence, the situation in which some patients with bowel disease appear to be coping well with difficult life situations.

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There appears to be a clearer link in children between abdominal pain and emotional upset (Bruce, 1986). Abdominal pain is common in children, and the gut appears to mirror the emotions better than any other body system. Furthermore, clinicians working with children with bowel disease remark that abdominal pain appears to be a common occurrence in the repertoire of distress management in the families of those children (Bruce, 1986; Lask, 1986). There appears to be a vicious circle where the physical symptoms of the disease lead to stress and behavioral problems. These problems then provoke physical symptoms and aggravate pre-existing organic pathology. The children and the family are affected. If the family cannot cope, and there is a family repertoire of distress management by an escalation of physical symptoms, then the symptoms of the children are exacerbated further.

Lifestyle Factors and the Patient's View Patients with inflammatory bowel disease have been described in the literature in a negative and limited way. They are seen as dependent, restricted in their relationships, sexually and emotionally inadequate, depressed, isolated, demanding, angry, and lacking in self-confidence (Joachim & Milne, 1987).

A lack of self-confidence is hardly surprising given that there is such a negative perception of their patients by practitioners, combined with the difficulties of the disease itself. A number of researchers have attempted to present patients' views of the problem. As both a nurse and a sufferer, Neufeldt (1987) wrote that the most difficult part of the disease is its unpredictability, and that the symptoms themselves frequently cause depression. The bouts of nausea, vomiting, and diarrhea lead to loss of sleep, listlessness, and nutritional deficiencies. This combination of embarrassing symptoms, and the randomness of onset of those symptoms, is socially disruptive for the working life and home life of the patient.

Joachim and Milne (1987) investigated the impact of inflammatory bowel disease on the lifestyle of patients. These patients said that, overall, their disease greatly decreased their satisfaction with life. Yet, paradoxically, they reported minimal influence on a day to day basis. This appears to represent the observation frequently made by clinicians that these patients appear unwilling to complain about specific problems, or they deny that problems exist in the face

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ALDRIDGE AND BRANDT of evident personal and relational turmoil.

In an attempt to understand the relationships between biological, psychological, and social phenomena, Helman (1985) examined the self-perceptions and explanatory models of patients with ulcerative colitis. He found that most patients had a multi-causal holistic model of their disorder. Tension, anger, frustration, stress and uncertainty were seen as attacking the body and were separate from the self. Similarly, when their own personalities were seen as contributory to the chronicity of their condition, that personality was seen as separate from the self. These causal attributes, he argued, are learned from various medical encounters and are part of the culture. This notion of nonself was also applied to organs of the body. Weakness in an organ could be hereditary, constitutional, or acquired. Somehow the weak organ was separate from the self, but responsive to interactions with other people. The disease or organ then becomes a public interface between the self and the environment and is responsive to outside forces separate from the inside self.

In Helman's view (1985), the image a person has of the disease is a natural symbol whereby the physiological process of the disease is understood:

. . . the symbol organizes both social and emotional experiences, and helps define certain emotions, thoughts, personality traits, and parts of the body as either 'self or 'non-self'. Defining some of these as 'non-self' can bring the patient's self image closer to the normative order of contemporary life - to social values of independence, fitness, youthfulness, contentment and social success and control the bodily functions and emotions. (p. 15) Not only does this image that persons have affect their physiological state, this image may also affect the way that they perceive, and are perceived by, members of their family (Aldridge, 1990~).

Family Perspective

A family systems perspective of bowel disorder emphasizes that the functions of the gut, the patient, the family, and the treatment system evolve together (Bloch, 1987; Stierlin, 1989). In this view, the process of chronic illness begins by a random disequilibrating event. This could be a transient infection or a stressful life situation. Pain ensues. This event occurs in the context of a relationship. The patient has

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a family, and the event is given meaning by the patient and the family. We know that some viruses do not kill the host cell, but transform it so that it has an altered function, particularly in terms of immunocompetence (Bloch, 1987).

A similar situation occurs in the family context where a disease event is handled in a particular way (Aldridge, 1990~).Experiences surrounding gut pain are organized around a set of beliefs about what the cause of the pain is, what it means, and how it is to be handled (i .e., a repertoire of distress management).

Not only do the patient and the family of the patient share similar meanings about an illness, and what counts as disease, they also share a similar immune context. In this way, a random event such as an infection may find that its host is not only the patient but the immunocompetence and beliefs of the family milieu.

Approaches to Treatment

It appears that inflammatory bowel disease is best approached from an holistic perspective that integrates different understandings. Although surgical interventions will still be necessary, it is important to remember that the sequelae of surgery are not only physical. Surgery can be traumatic, leaving the patient with a sense of anger, resentment, feeling both anxious and depressed, and having to adapt to a new lifestyle. These psychological and social consequences may best be handled by a team approach that includes people who comprehend the day to day living situation of patients within their relational setting.

Lask (1986) and Bruce (1986), in their work with children, approach their treatment from such a family systems perspective and recommend the use of a physician, surgeon, psychologist, social worker, nurse, and stoma therapist. Stress management techniques can be used to reduce anxiety and communication skills, whereas psychotherapeutic activities can be used to control excessive worry (Freyberger, Kiinsbeck, Lempa, Wellman & Avenarius, 1985; Milne et al., 1986; Svedlund, Sjodin, Ottosson, & Dotevall, 1983).

A feature common to many reports about the treatment of inflammatory bowel disease is that it is intractable to therapeutic endeavors. Furthermore, the patients themselves are described quite negatively, which may be in part because of their inability to communicate in verbal terms about their emotional

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MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE distress. What is often ignored is that the communication medium for these patients is essentially nonverbal. Symptoms are the forms of communication that symbolize the distress of these patients. For practitioners dependent primarily on forms of communication that are predominantly verbal there is a disparity between modes of communication.

Implications for Music Therapy There are no psychological factors that are necessary or sufficient to cause intestinal disease in susceptible individuals. However, it is clear that there are certain psychological or social factors that can either influence the course of the disease or provide a context for the disease to develop. The presence of beliefs about self and nonself appear to befundamental in these patients, linking immunocompetence, individual psychology, and familial status.

Although psychological factors may not be causal, they are important for recovery. Therapeutic endeavors may be better directed to actively stimulating the immunocompetence of the patient. If the mind does influence the immune system, there is a battery of therapeutic interventions available. As the main mode of communication about distress for patients with the bowel disorder is nonverbal, then nonverbal therapies appear to be an esstential part of a coordinated therapeutic approach.

Music therapy stimulates positive emotions, enhances coping responses, is isomorphic with the form of physiological systems (Aldridge, 1989, 1990b, in press b) and appears to be an ideal therapeutic medium. The motility of the gut is rhythmic and it seems reasonable that music therapy could restore, or promote, rhythmic flexibility. Similarly, the processes of the immune system too are rhythmic in their ultradian cycle. Music may provide the substrate for entraining various physiological sub-systems. Essentially music can "tune" the communicational context that unites the central and peripheral nervous systems and the immune system.

It has been shown that positive experiences, such as laughter when incorporated into a coping style, have a beneficial influence on the immune system (Dillon & Baker, 1985). If this is true of laughter, we may expect that the greater range of positive experiences available in creatively playing music, if incorporated as a coping style, will have a healing effect via the immune system. Note that the word "incor-

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porated" literally means taken into the body. It may also be necessary for clinicians from other disciplines to communicate with their patients nonverbally if symptomatology is the currency of communication (Aldridge, 1990b).

Finally, we must attend to the symbolic aspects of the disease for these patients so that they are no longer separated from the self that feeds them. In this sense, the playing of improvised music gives the disease itself an objective appearance as a played reality.

Patients are then offered a chance to change in the concrete sensual realm of their own existence.

W

The Musical Playing of Patients With Bowel Disease Our task has been to build bridges between the work of medical practitioners and creative arts therapists (Aldridge, in press a, 1990a; Aldridge, Brandt & Wohler, 1990). One way to promote a dialogue between practitioners is to compare differing realms of description. In the following sections we compare the features of the improvised musical playing of patients with the features we find in the medical literature.

Fourteen adult patients with ulcerative colitis, and 12 adult patients with Crohn's disease were seen over a period of two years. The average number of weekly sessions was seven per patient and each therapeutic contact lasted for half an hour. It must be ernohasized that this research is descriptive and in the first stages of exploration. The significant factor is not the number of patients but the characteristics of playing (i.e., playing with more patients of those would have yielded no more characteristics) and how those characteristics compare with descriptions from another discioline - medicine. All the sessions are recorded on audiotape and later indexed.

The method of therapy used is one of creative musical improvisation initiated by Nordoff and Robbins (1977) but adapted later at the University of Witten Herdecke for working adult patients. The music therapist plays the piano improvising with the patient, who uses a range of instruments. This work often begins with an exploratory session using rhythmic instruments, in particular the drum and cymbal, progressing to the use of rhythmiclmelodic instruments such as the chime bars, glockenspiel, or xylophone, developing into work with melodic instruments (including the piano), and the voice. In this

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way of working, the emphasis is on musical improvisation and music as the vehicle for the therapy.

Ulcerative Colitis A prominent feature of the way these patients play is that they appear to have no personal connection with what they are playing. They appear to play with a distance from what they are playing. This distance is evident in their posture. When they are strong enough to stand, their posture is often such that both feet are not firmly on the ground (i.e., their legs are crossed). The drumsticks are held loosely in the hands with the inner wrist uppermost, and they play from the wrists without involving the whole body. This seemingly uncommitted posture makes it difficult to play a clear beat on the drum. When the drum is beaten, the beats are loose. The patient allows the beater to fall and rebound rather than make a directed intended beating movement. A characteristic of the drum playing is that these patients play with alternate hands (right, left, right, left) and they seem to have difficulty in coordinated playing using both hands together.

Rhythmic playing. This lack of coordination is reflected in patients' rhythmic playing, which has a limited range and often occurs as typical rhythmic patterns: J

JJ

J JJ

J

n

J J J

J J7 J

n

JY J l2 continuously; or ~7 J continuously

J J J

This rhythmic playing does not follow the natural accenting, but is syncopated. Often the playing is on the upbeat before the bar starts, and begins with a small drum roll giving the music a military air. The playing itself goes on and on without any rhythmic phrasing. This lack of flexibility is reflected in the tempo of the musical playing where the patients constantly attempt to return to a fast tempo.

Harmony. Generally, there is an intolerance by the patient for strong harmonies in the piano playing of the therapist and contact becomes lost, particularly when diminished minor, fifth, or augmented chords are played. This intolerance is indicative of an emotional distance between the patients and the music particularly when there is an increase in musical tension. For example, they stop playing before a musical climax is achieved.

Melody. In the construction of melodies, these

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patients are flexible and full of imagination. However, this has a mechanical quality as if the playing were an intellectual exercise and never really gripped the patient internally. Although able to construct and copy melodies, there is an inability to sustain a melody. This gives the impression that the same music could go on and on repetitively without any direction to it, and without the patients taking any initiatives, as if they were passive participants in an unrelenting process. This also appears to be a suitable description for the process of chronic disease.

Crohn's Disease These patients appear very stiff in their upper body movements. They too have difficulties in coordination and mostly alternate between left and right handed playing on the drum.

Rhythmic playing. Because of the coordination difficulties, these patients' playing often sounds like a gallop. Similarly the rhythmic structure is disordered and gives the impression of going on and on without end. As with ulcerative colitis patients, there seems to be no means of initiating an end to this repetitive music and consequently they appear to avoid coming into contact with the music. This is also reflected in their inability to respond to tempo changes, giving the musical playing a quality of immovability.

Harmony. When using specific harmonies, notably the sixth and diminished chords, their response is one of vulnerability. Sometimes they cry; sometimes they stop playing altogether, walking away from the instruments, or they continue to play indifferently and mechanically with even less contact to the music.

Melody. The melodic playing on the xylophone or glockenspiel is rhythmically quick, unsustained, and has no internal logic. The intervals between tones are chaotic (i.e., wide then narrow). This melodic playing, similar to that of the colitis patients, is generally quiet. There is an overall feeling of emotional distance in their playing and they give the impression that they are totally at the mercy of the situation.

Overall, Crohn's and ulcerative colitis patients have a similar lack of dynamic to their playing, which is limited and rigid - a feature that is reflected in the activity of their gut.

Process of Therapy Generally, these diseased patients require many sessions before any improvement is apparent. The

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MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE Table 1 Comparative elements of two therapeutic epistemologies descriptive elements from the medical literature 0

elements of the musical playing

separation of self and nonself lack of gut motility increasingly introverted restricted in their relationships rigid

difficulty expressing feelings appear to be coping well with life in the face of internal turmoil 0 dependent

Ă&#x201A;

intractable to change

coordination problems finally disappear and there is more stability and control of the hands. The rhythmic playing becomes more definitive and there is an apparent form to the phrasing and tempo. Overall, there is less rigidity in the playing and the patients appear to sense the bigger musical form in which they are playing. However, what remains is the impression that they never really come to grips with the music and that they still play with an empty passivity as if they were not tuned to their own bodies. Finally, the musical give and take in the therapeutic relationship is difficult and they appear isolated from their musical partner, the therapist.

Conclusion There are correlations between findings in the literature that describe patients with inflammatory bowel disease and their musical playing (see Table 1).

Although the patients say that they have fun playing, there remains an underlying intractable emotional distance within the playing and within the therapeutic relationship. Any therapeutic endeavors with these patients must take into account their personal and relational difficulties, which suggests that an early psychotherapeutic contact be made in the process of treatment. This reinforces the idea of a team approach to chronic problems and emphasizes the value of the art therapies both for providing relief and for their

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not tuned to themselves, uncoordinated lack of rhythmic flexibility, unresponsive to tempo changes and lack of rhythmical phrasing Ă&#x201A; quiet playing with no personal contact within the playing difficult to contact in the musical relationship repetitive playing returning to the same tempo and rhythmic pattern, unresponsive to tempo changes intolerant of particular harmonies appear to be going along with the music but an underlying chaotic structure no initiatives within the music and dependent on the therapist 0 difficult to treat requiring many sessions

impact on life quality in the face of a disease intractable to modem medicine.

Furthermore, the apparent correlation between descriptive elements found in the literature and in the work of the music therapist, initially blind to the content of the medical literature, suggests that a common language between practitioners is not such a fanciful idea. A common language is achievable in reality if confined initially to simple observations at the level of description or usage (Aldridge et al., 1990). Although the two perspectives share common descriptions, the creative arts have the possibility not only for the description of pathology but to play with what is seen as a limitation, and use it as a possibility for change.

Recommendations for Further Research Apart from securing a basis for clinical discussion, these descriptions are the basis for futher research.

They provide the concepts from which hypotheses can be generated (Aldridge, 1988, 1990a). It should be possible for music therapists from other institutions and backgrounds to play with patients suffering from inflammatory bowel disease and discern similar characteristics of playing. Similar findings, or the rejection of what we have found, will be a significant move in establishing a clincal validity for music therapy concepts.

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Eisler, Szmulker and Dare (1985) found that clinical descriptions were not subjective and could be used by family therapists of differing schools to discriminate between differing family styles of behavior recorded on videotape. It should be within the compass of music therapists from other schools to discern whether or not there are similar characteristics in the playing of these patients recorded on audiotape.

It may also be possible for other creative arts therapists to find comparative elements that show similarity with these descriptions.

The playing characteristics of this group of patients need to be compared with the playing characteristics of another group of patients with a differing chronic problem (i.e., chronic heart disease, chronic depression, osteoarthritis) to determine the characteristics common to chronicity as distinct from those of the particular diseases. In addition, this work would be strengthened by establishing the musical playing characteristics of a group of healthy adults.

It seems a given that psychological factors influence the immune system. We can hypothesize that the creative arts therapies also increase the immunocompetence of our patients. Further cooperative research between clinicians and practicing therapists that demonstrate this link will enhance the status of the creative arts therapies and provide the physical evidence to support our therapeutic intuitions. The time has come when music therapists and other creative arts therapists must work together for mutual benefit.

This work will enhance the service they offer their patients.

References Aldridge, D. (1988). The single case in clinical research. In S. Hoskyns (Ed.), Proceedings of the Fourth Music Therapy Research Conference (pp. 3-10). London: City University.

Aldridge, D. (1989). A phenomenological comparison of the organization of music and the self. The Arts in Psychotherapy, 16(2), 91-97.

Aldridge, D. (1990a). The development of a research strategy for music therapists in a hospital setting. The Arts in Psychotherapy, 17(3), 231-237.

Aldridge, D. (1990b). Music, communication and medicine. Journal of the Royal Society of Medicine, 82, 743-746.

Aldridge, D. (1990~).Making and taking health care decisions.

Journal of the Royal Society of Medicine, 83, 720-723.

Aldridge, D. (in press, a). Aesthetics and the individual in the practice of medical research: A discussion paper. Journal of the Royal Society of Medicine.

Aldridge, D. (in press, b). Physiological change, communication and the playing of improvised music: Some proposals for research. The Arts in Psychotherapy.

Aldridge, D., Brandt, G., & Wohler, D. (1990). Toward a

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common language among the creative art therapies. The Arts in Psychotherapy, 17(3), 189-195.

Baker, G.H. (1987). Invited reivew: Psychological factors and immunity. Journal of Psychosomatic Research, 31, 1-10.

Blalock, J.E., & Smith, E.M. (1985). The immune system: Our mobile brain? Immunology Today, 6, 115-1 17.

Bloch, D. (1987). Family 'disease' treatment systems: A coevolutionary model. Family Systems Medicine, 5, 277-292.

Bruce, T. (1986). Emotional sequelae of chronic inflammatory bowel disease in children and adolescents. Clinical Gastroenterology, 15, 89-104.

Calkins, B.M., & Mendeloff, A.I. (1986). Epidemiology of inflammatory bowel disease. Epidemiological Reviews, 8, 6091.

Clark, M.L. (1986). The role of nutrition in inflammatory bowel disease: An overview. Gut, 72 (Sl), 72-75.

Clouse, R.E., & Alpers, D.H. (1986). The relationship of psychiatric disorder to gastrointestinal illness. Annual Review of Medicine, 37, 283-295.

Dillon, K.M., & Baker, K.H. (1985). Positive emotional states and enhancement of the immune system. International Journal of Psychiatry, 15, 13-17.

Eisler, I., Szmulker, G., & Dare, C. (1985). Systematic observation and clinical insight - Are they compatible?An experiment in recognizing family interactions. Psychological Medicine, 15, 173-188.

Freybexger, H., Kunsbeck, H.J., Lempa, W., Wellmann, W., & Avenarius, H.J. (1985). Psychotherapeutic interventions in alexythmic patients with special regard to ulcerative colitis and Crohn patients. Psychotherapeutic Psychosomatics, 44.72-81.

Helman, C. (1985). Psyche, soma and society: The social constmction of psychosomatic disorders. Culture, Medicine and Psychiatry, 9, 1-26.

Joachim, G., & Milne, B. (1987). Inflammatory bowel disease: Effects on lifestyle. Journal of Advanced Nursing, 12, 483487.

Kett, K., Rognum, T.O., & Brandzaeg, P. (1987). Mucosal subclass distribution of immunoglobulin G-producing cells is different in ulcerative colitis and Crohn's disease of the colon.

Gastroenterology, 93, 9 19-924.

Kleinman, A. (1978). Culture, illness and care. Annals of Internal Medicine, 88. 251-258.

Lask, B. (1986). Psychological aspects of inflammatory bowel disease. Wiener klinische Wochenscrift, 29, 544Ă&#x192;â&#x20AC;&#x2DC;547 Milne, B., Joachim, G., & Niehardt, J. (1986). A stress management programme for inflammatory bowel disease patients.

Journal of Advanced Nursing, 11, 561-567.

Neufeldt, J. (1987). Helping the IBD patient cope with the unpredictable. Nursing, 17, 4 7 4 9 .

Nordoff, P,, & Robbins, C. (1977). Creative music therapy. New York: John Day. Patterson, J.M. (1988). Families experiencing stress. Family Systems Medicine, 6, 202-237.

Persson, P.G., & Hellers, G. (1987). Crohn's disease and ulcerative colitis: A review of dietary studies. Scandinavian Journal of Gastroenterology, 22, 385-389.

Robertson, D., Ray, J., Diamond, I., & Edwards, J. (1989).

Personality profile and mood state of patients with inflammatory bowel disease. Gut, 30(5), 623-626.

Sanderson, I.R. (1986). Chronic inflammatory bowel disease.

Clinical Gastroenterology, 15, 71-87.

Shivananda, S., Pena, A.S., Nap, M,, Weterman, I.T., Mayberry, J.F., Ruitenberg, E.J., & Hoedemaeker, P.J. (1987). Epide-

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MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE miology of Crohn's disease in Regio Lieden, the Netherlands.

Gastroenterology, 93, 966-974.

Stanwyck, D., & Arnson, C. (1986). Is personality related to illness? Advances, 3, 4-15.

Stein, M,,Keller, S., & Schleifer, S. (1985). Stress and neuroimmodulation: The role of depression and neuroendocrine function. Journal of Immunology, 135, 827-833.

Stierlin, H. (1989). The psychosomatic dimension: Relational aspects. Family Systems Medicine, 7(3), 254-263.

Strober, W., & James, S.P. (1986). The immunologic basis of inflammatory bowel disease. Journal of Clinical Immunology, 6 , 415-432.

Svedlund, J., Sjodin, I., Ottosson, J.O., & Dotevall, G. (1983).

Controlled study of psychotherapy in irritable bowel syndrome.

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Lancet, 2 , 589-591.

Tarter, R.E., Switala, J., Carra, J., & Edwards, K. (1987).

Inflammatory bowel disease: Psychiatric status of patients before and after disease onset. International Journal of Psychiatry, 17. 173-181.

Trabucchi, E., Mukenge, S., Barrati, C., Colombo, R., & Fregoni, F.W. (1986). Differential diagnosis of Crohn's disease of the colon from ulcerative colitis: Ultrastructure study with the scanning electron microscope. International Journal of Tissue Reactions, 8, 79-84.

Van Spreuuwel, J.P., Lindeman, J., & Meijer, C.J. (1986).

Quantitative analysis of immunoglobulin-containing cells in gastrointestinal pathology. The International Academy of Analytical and Quantitative Cytology and Histology, 8, 314-320.

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The Arts in Psychotherapy. Vol. 22, No. 3. pp. 189-205, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0197-4556195 $9.50 + .00

Pergamon

A PRELIMINARY STUDY OF CREATIVE MUSIC THERAPY IN THE TREATMENT OF CHILDREN WITH DEVELOPMENTAL DELAY DAVID ALDRIDGE, PhD, DR. RER. MED. DAGMAR GUSTORFF and DR. RER. MED. LUTZ NEUGEBAUER*

This paper has two main purposes. The first is an attempt to demonstrate that creative music therapy is a viable therapeutic form for developmentallydelayed children, and in doing so elucidate what it is in the therapy that is valuable. For referring patients, paediatricians and payers (possible funding agencies and third-party medical insurers) alike, we need to present evidence that the work that we are engaged in has a value that makes sense to them. Although we, as therapists and researcher, are convinced of the value of our own work according to our criteria, we too are seeking ways to understand how what we do is effective. The process of looking at clinical practice, sometimes from a different perspective, gives the possibility to gain a valuable insight into what we are doing, to promote that work in other settings and to broaden the basis of our teaching.

The second purpose is to present an integrated approach to music therapy research that combines both a quantitative approach, as shown by measuring changes, and a qualitative approach, as argued from the interpretation of empirical data. Although this second purpose may seem rather unorthodox, the reason underlying it is that we hope to show that in music therapy research we can creatively adapt techniques and forms of argumentation to suit our needs and that we do not have to take a polarized stance either for or against qualitative or quantitative methods. Indeed, to maintain an ideological position is to fall into the trap of methodolatry on one hand or scientism on the

other. Research methods are simply tools for structuring our thinking and gathering the evidence that we will use to support our arguments. In some ways we are rehearsing a debate that has already been comprehensively argued in both the fields of nursing (Dzurec & Abraham, 1986, 1993) and social psychology (Shadish & Fuller, 1994). By relating both sets of information it may be possible to generate insights not available from the two types of information separately (Heyink & Tymstra, 1993).

The overall aim of our research then is to present our work with children suffering from a variety of developmental challenges and propose that by using a particular form of assessment available to other music therapists we can see quantitatively that a beneficial change occurs. The reason for that change, we will argue, is attributable to specific qualities of creative music therapy.

The music therapy approach taken here is based upon that of Nordoff and Robbins (1977) improvised music therapy, which has its origins in working with handicapped children. However, although there is a wealth of case study material in the music therapy literature concerning music therapy with children and a considerable literature suggesting the value of music therapy for child development (Wilson & Roehmann, 1987), there have been few controlled studies of Nordoff and Robbins music therapy with handicapped children.

An important feature of childhood development is

'David Aldridge is Professor for Clinical Research Methods at the University of Witten Herdecke, Germany.

Dagmar Gustorff and Lutz Neugebauer are CO-Directors of the Institute for Music Therapy at the University of Witten Herdecke

David Aldridge

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the acquisition of speech and the ability to communicate meaningfully with another person. Music therapy encourages children without language to communicate and has developed a significant place in the treatment of mental handicap in children. How such communication is achieved, and how in some instances it leads to speech, are as yet unknown. Indeed, the very ability to develop and achieve speech in normal children is a miracle of daily living that continues to baffle linguists and psychologists. Although this paper makes no attempt to solve the riddle of how speech is brought about, we will attempt to demonstrate how music therapy helps developmentally-challenged children progress toward a richer communicative life.

Developmental delay can be the consequence of various difficulties, physical, mental or social (Peterson & Schick, 1993). Children who are developmentally challenged experience the same emotional conflicts and difficulties as normal children; however, they are also more likely to experience rejection when they fail to meet standards of expectation associated with their chronological age. This rejection can lead to behavioral disturbances. The successful social integration of children with developmental delay relies upon a sensitive and adaptable social environment, as does the sequence of development itself. If the environment is both modified to meet the needs of the children and to enhance communication possibilities according to their potential, then we may expect fewer behavioral problems. Children who are developmentally delayed face the same developmental tasks and challenges and have the same needs to be loved, stimulated and educated, as normal children.

What they face is a progression that may be slower and perhaps limits their future capabilities. Our therapeutic task is to respond to abilities and potentials so that those limitations themselves are minimized. If both environment and the individual are important for developmental change, the therapist provides, albeit temporarily, an environment in which individual change can occur.

Child Development and Challenges to Theory Child development itself is subject to various theories and is a continuing source of active academic debate. All children are now conceived of as very active constructive thinkers and learners, rather than passive copiers of what is given to them (Case, 1993; Lewis, 1993). Children select and transform what is

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meaningful for them from the context within which they find themselves. What. is selected and transformed is in pan in accordance with their cognitive abilities, yet these abilities are not separate from other related developmental processes. Each child may differ in his or her development. Furthermore, children not only take from the environment, they too give out signals that modify their environment. Infants give clues to their mothers about how they expect them to react. Improvised creative music therapy, with its emphasis on activity within a dynamic personal relationship, may play a role in encouraging development particularly when it focuses on communicative abilities.

The idea that children change in regular stages that are governed by their biology and that they become progressively better in a linear evolutionary development is being challenged (Florian, 1994; Ross, Friman & Christophersen, 1993; Spieker & Bensley, 1994; Wagner, Torgesen & Rashotte, 1994). Morss (1992) called for an interpretative, as opposed to a causal-explanatory, approach to human experience and proposed that studies of infancy are often studies of scientists studying infancy, and, like Sipiora (1993), found that the infant under study is often absent. Sipiora criticized Piaget for skewing the natural choice of questions answerable only by children to those of an adult consciousness. Pure observation cannot always distinguish children from their beliefs and it is the inner life of the children, what they wish to communicate, that should be the focus of our attention (Florian, 1994; Wagner, Torgesen & Rashotte, 1994). Siege1 (1993) reminded us that this debate is not entirely new and, interestingly for the creative arts therapies, that nonverbal tasks are the best means of representing the thinking of very young children. She also emphasized that Piagetian developmental stages are not supported empirically and what may seem to be an orderly sequence of acquisition may indeed be an artefact of the way in which tasks are structured. The outcome of this debate is that in understanding children we are encouraged to study processes not products, that those processes when related to assessment will always occur in a dialogue between child and therapist.

If we return briefly to the secondary purpose of this paper, we can propose that a qualitative method of research will be necessary to look at this process of developmental change as it occurs between therapist and child, and a quantitative method can help us to identify specific changes

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CHILDREN WITH DEVELOPMENTAL DELAY The above challenge to Piagetian orthodoxy is based partly on a questioning of the orthodoxy of the spoken word as being primary (Siegel, 1993). Some authors are concentrating on how children perform in the world, which is a "world-of-others," as the principal focus for attention. Play is seen as a mental act including unconscious fantasies and wishes, a physical act that is observable and a necessary awareness that what is being enacted is "play." Play, when defined by its functions, facilitates the libidinization of the body and is an area of importance bridging the realms of the personal and the social (Mash, 1993).

For Vygotsky (1978), this intermediary realm, the distance between what children can do on their own and what they can do with the help of an adult, is referred to as the proximal zone. It is such a "zone" that we find in creative music therapy. Musical activity is based upon what the child can do in musical play, but the potential of what the child can do further is based upon what child and therapist are capable of together. Furthermore, with an emphasis on the activity of musical playing within the context of a personal relationship, the libidinization of the body is achieved as a communicative act.

In our work we emphasize the role of the therapist as encouraging and providing the context in which musical communication takes place. The therapeutic relationship is a relationship that mirrors the primary relationship of learning to communicate in which development emerges. Vandenberg (199 l ) reminded us that looking, hearing, smelling, sucking and grasping are some of the early reflexes for assimilating objects and the basis from which cognitive development emerges. At birth, children are most responsive to the human voice through hearing. It is this orientation to the social world of others that is of such importance.

The special relationship with others is something that is "elaborated from those primitive forms of attunement" (p. 1282). This is a reflection of the position taken by Stem (Neef, 1993) that the infant has a core self that is in a relationship with the core self of the other, and this relationship forms a crucial axis of development. The symbolic world of the child is imbued with the relationship with the caregiver and others of significance. Our proposal is that such a relationship is essentially "musical. " Aldridge (1989) has emphasized the importance of rhythmic interaction for the development of language and socialization in the infant. From birth the infant has the genetic basis of an individually entrained physiology (i.e., a self-synchronicity). The infant has

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its own time, yet the process of socialization and the use of language depend upon entraining those rhythms with those of another. Cycles of rhythmic interaction between infants and mothers reflect an increasing ability by the infant to organize cognitive and affective experience within the rhythmic structure provided by the parent. This organization, however, is not a one-sided phenomenon. Infants produce forms of expression and gesture that are not imitations of maternal behavior. Both baby and mother learn each other's rhythmic structure and modify their own behavior to fit that structure. Arousal, affect and attention are learned within the rhythm of a relationship.

The competence of infants is not solely a quality inherent within the individual. Individuals are located in particular environments, those of their significant relationships. Gaussen (1985) criticized maturational models of child assessment in that they do not take into account the variability and individual differences of the developmental processes. Assessment methods rely on how the child responds and moves; they tell little about what the child knows and responds to.

Such a criticism echoes that of the authors above who wish to know more of the inner life of the child, a life that is not solely dependent upon intact motor responses.

Nevertheless, communication is dependent upon motor coordination, and motor responses, as we shall read below, are important indicators that a child is developing. For the parent, rather than the theoretician and psychologist, the pragmatics of understanding the child are based upon what that child can do.

Furthermore, communication is also dependent upon doing. What that "doing" means is important, but achieving that "doing" and coordinating with another person are primary. Hence the value of nonverbal therapies and the establishment of a communicative relationship before the complexities of lexical meaning are necessary.

Motor Development: Gesture and Communication

The development of children demands many integrated skills. One important skill is to control motor activity, that is, to be able to draw and write, handle a knife and fork, play with a ball and run. Children who do not master such activities are often labelled as clumsy, whereupon they meet with disapproval from their peers and often family members. On reaching play-school or school age these children find them-

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selves facing ridicule. Such ridicule may then lead to a lack of self-esteem and confidence, which is further exacerbated by social withdrawal (Winemiller & Mitchell, 1994). Once such children find they cannot perform "properly" they give up trying. The consequences of such personal and social handicap as clumsiness or perceptual-motor dysfunction remain into adult life.

There are three main processes assumed to be necessary for the performance of motor skills: kinesthesis, muscle control and timing (Laszlo & Sainsbury, 1993). Kinesthesis is the sense that conveys information about the position and movement of the body and limbs. This sixth sense, referred to by Sacks as "proprioception," is a sense we have in our bodies and is that continuous but unconscious sensory flow from the movable parts of our body (muscles, tendon, joints), by which their position and tone and motion is continually monitored and adjusted, but in a way which is hidden from us because it is automatic and unconscious.

(Sacks, 1986, p. 42) Proprioception is indispensable for our sense of self in that we experience our bodies as our own.

Muscle control refers to the way in which movement is directed and controlled spatially. These movements must also be coordinated and this involves timing.

Laszlo (Laszlo & Sainbury, 1993), however, argued that kinesthesis is the overarching factor that unites both direction and timing in the control of posture, in error detection and in memorizing movements. Indeed, the coordinating of action involves the whole body and, von Hofsten (1993) asserted, can only be understood as a purposive dynamic future-oriented interaction between the organism and the external world. Actions originate not from reflexes, but from spontaneously produced, purposeful controlled movements (i.e., actions develop through action). Yet this action must be structured and thisstructure is that of time. Active music therapy would seem to be an ideal medium for encouraging purposeful controlled movement in a time structure that is formed yet flexible.

Gestures also help us understand what a child means and at what stage of understanding a child is in (Alibali & Goldin-Meadow , 1993; Goldin-Meadow , Alibali & Church, 1993). Gesture is spontaneous and often idiosyncratic, whereas speech conforms to an established form. Some expressive events may be better encoded in communications as gestures for some

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children at their stage of understanding in that gesture maps the phenomena closely. Indeed gestures in a communication dialogue are preverbal and do not need the extra abstract and lexical dimension of speech. It is such gestural activities that are actively utilized in the repertoire of play songs used in the Nordoff and Robbins approach.

Active music therapy then would seem to be a relevant therapy form as it concentrates on, and fosters, the use of purposive coordinated movements that occur in a context of time and relationship, offering a form for communication without words.

Developing Children and Music Therapy Twelve patients were assessed, selected and randomly allocated into two groups of six children (see Figure 1). Each child was to receive individual music therapy. This formed a treatment group and an initial non-treatment group to serve as a waiting-list control.

The non-treatment group received music therapy after waiting for three months, while the previously treated children had a break from therapy. Our intention was to stay as close to the clinical practice of music therapy as possible. This intention influenced the timing of the treatment stages in that a course of music therapy treatment takes about three months followed by a three-month pause. Similarly, we could only ever take on six new patients in one treatment period. All the subjects of this study would receive music ther-

Figure I . Allocation of children to treatment groups and study design.

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CHILDREN WITH DEVELOPMENTAL DELAY apy, and the maximum treatment delay after intake would be for three months.

Entrance criteria were that the children should be 4-6.5 years in chronological age with a developmental age of 1S-3.5 years and that the selected children had no previous experience of music therapy. Children were excluded from the study if they had a physical problem that was degenerative, if they were currently receiving psychopharmaceutical treatment or if they were currently attending another form of creative art therapy. Playschool or kindergarten attendance was not interrupted.

The use of waiting list controls and alternating treatment periods met our ethical demands for the treatment of children in terms of clinical research in that both procedures mirrored our normal practice.

Furthermore, the study was clearly explained to all the participating parents and caregivers of the children, who were assured that refusal to take part in the study would not disqualify their childrenfor treatment. Similarly, all participants were asked to give permission for the use of the data as part of a research project and for possible publication.

Referrals were from a local paediatrician who assessed the children before treatment began (at intake).

We had previously set the criteria for the clinical assessment of developmental change (see below). A medical student, trained in the assessment of children, saw the children and their caregivers every three months to assess any clinical changes according to the medical criteria (Tests 1 , 2 , 3 , and 4 after intake). She was initially "blind" as to whether the children were in the treatment or non-treatment group.

The main assessments were developmental according to psychological and functional criteria (the Griffith's test, see below), and musical according to the Nordoff and Robbins rating scales. Music therapy sessions were recorded on audiotape and later indexed according to music therapy criteria.

Our main hypothesis was that there would be greater developmental changes in the music therapy treatment group, in the first session of the treatment period, compared with the no-treatment group. Our secondary hypothesis was that by the end of the two treatment sessions both groups would have changed equally.

The Griffiths Scale and the Nordoff and Robbins Rating Scale F ,

Ruth Griffiths, as a psychologist, spent a great deal of time observing babies and small children. From

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these observations she developed a series of scales that could be used to gain insight into areas of leaming in young children. The function of these scales was not to say categorically what the reason may be for a child's slowness to learn, rather to diagnose those areas of a child's capability and to provide a profile of capabilities from which the child may respond to treatment. This emphasis on the positive potential of the scales was attractive initially for our work as it reflected, and had features complementary with, the approach of Nordoff and Robbins music therapy (see Table 1) in focusing on the inherent potential~of the child rather than concentrating on the known pathologies. Reading her book (Griffiths, 1954), which was written 4 0 years ago, is a fascinating insight into the rigor of a scientist who clearly has a love for children, and how that rigor can be applied in the assessment of behavior. Sometimes creative arts therapists criticize science for seemingly leaving out the individual and thereby losing any relevance for treatment. With Griffiths, however, there is a constant reminder that these scales were crafted from a devotion to the lot of those children who were in need so that we, as carers of those children, could better our own observations to meet their needs.

There are six subscales that have equal degrees of difficulty. Each subscale tests a different avenue of learning with the intention of discovering true potentialities in the handicapped child (Griffiths, 19701 1984, pp. 171-172). Once such potentials are recognized, help can be brought as early as possible when needed. Indeed, the tests are intended to educate the carers and the educators about the needs of the child.

Although the central plank of the work is to provide a differential diagnosis of mental status (see Figure 2), that diagnosis is clearly linked with potentials for treatment.

Attempts were made by Nordoff and Robbins as early as 1964 to develop rating scales for individual music therapy (Weaver & Clum, 1993). However, these evaluative scales proved to be difficult to compose and adequately meet the complexity of musical responses. Two years later, scales for evaluating autistic children in the day center were adapted for music therapy use and evolved as Scale 1. ChildTherapists Relationship in Musical Activity and Scale 11. Musical Communicativeness.

Scale I evaluates the relationship between child and therapist as it develops from what may be total obliviousness, through limited response to a stability and confidence in the mutuality of playing music together. It must be stressed that it is in the musical

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ALDRIDGE, GUSTORFF AND NEUGEBAUER Table l A comparison of contents of the Griffiths Scales and the Nordoff and Robbins Rating Scales Griffiths' Subscales

Nordoff and Robbins Rating Scales

A: Locomotor Development pushes with feet, lifts head, kicks vigorously, begins to crawl, climbs, can walk on tiptoe, catches a ball. hops and skips.

B: Personal-Social Scale responds to being held, smiles, resists adult taking a toy away, anticipatory movements, plays "pat-a-cake," plays with other children, has a special friend.

C: Hearing and Speech most intellectual of the scales, indicative of hearing problems; startled by sounds, vocalization other than crying, searches for sound visually, listens to music*, listens to conversations. rings bell, likes rhymes and jingles, enjoys s t o r y - b k , develops words and speech, names objects, defines by use, comprehends sentences.

D: Hand and Eye Co-ordination (observe the hands of the child) follows visually moving objects, uses hands for exploration, points with fingers, likes holding toys, plays with bricks, scribbles freely, builds a tower, folds paper, copies shapes, draws recognizable figures and objects.

E: Performance Tests measures skill in manipulation, speed of working and precision with an awareness of the child's eagerness and persistence; searches for a toy under a cup, manipulates cubes and boxes, opens screw-topped jars, makes patterns.*** F: Practical Reasoning recognition of differences in size and categorizing as "bigger," this scale measures the ability to reason in "embryo." Any child before he or she can express ideas verbally can look, listen, think and learn the foundations of knowledge and the way in which the mind works in apprehension of the environment.

Scale 11: Musical Communicativeness musical communication is realized through 3 modes of activity; instrumental, vocal and bodily movement.

Scale I: Child Therapists Relationship in Musical Activity Item 1-3. Child appears oblivious to the therapists, fleeting signs of awareness, awareness of the situation leads to rejection.

Item 6: Child comes to the session with obvious pleasure and establishes a consistently recurring positive response to the therapy situation.

Scales I and 11: Musical Communicativenesst Ranges from uncommunicative, non-responsive beating which is disordered, impulsive or haphazard or compulsive beating of inflexible tempo or pattern**; leading to child beats with some musical organization, and recognizes salient components of the music, rhythm or melody or harmony. Child finds musical activity meaningful and satisfying.

Child communicates with others and communicates his understanding of musical objectives.

The child comes to the session with obvious satisfaction and pleasure, and enjoys being active in the music.

Scale 11: Musical Communicativeness Musical communication is realized through 3 modes of activity; instmmental, vocal and bodily movement.

Scale 11: Musical Communicativeness His beating shows an awakening recognition and some anticipation of salient components of the music; rhythmic pattern, melodic rhythm, change of dynamics, phrase structure.

Scales I and 11: Musical Communicativeness~ He adopts and sustains the mode(s) of musical response available to him, shows purposeful involvement with the musical activity. The child's interest centers strongly upon particular musical activities which he finds meaningful and satisfying. He pursues these activities with purposefulness.

*There is an overall neglect of musical ability. **Moves from pathology to ability, yet lacks the neutrality of the Griffiths' scales which assess all stages as milestoneslpotentials ***There is, however, no mention of musical patterns. tAfter Item 6 the Nordoff and Robbins scales converge.

activity that the relationship is developed, and the vocabulary used to evaluate the performance of the child is mainly musical. Whereas Nordoff and Robbins stress that the evaluation is of the relationship itself, the language itself places emphasis on evaluat-

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ing the child (i.e., we would not expect that the therapist is totally oblivious of the child).

Scale I1 attempts to evaluate both the state of musical communication in the session and, "provides an index to the personality development of a child

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CHILDREN WITH DEVELOPMENTAL DELAY

ievereiy retarded childv Severe hearing loss

'

M n ' s syndrome

A = locomolor development = personal-social relationship C = hearing and speech

B

Slow child

Average ability chi!d

D = hand and eye cocxdination E = performance tests F = practical reasoning

Figure 2. Examples of Griffith's profiles for varying groups of children.

through assessing the character and consistency of the musical communicativeness he manifests'' (Nordoff & Robbins, 1977, p. 193). The scale includes three vocal and body modes of activity-instmmental, movement, which provide an aggregate rating on l 0 levels of communication ranging from "no communicative response" through active participation to an intelligent musical commitment. Both scales are rather rough and ready and have never really been validated in clinical practice. Indeed, after level 6, both scales converge and could be conceivably collapsed into one scale. However, the scales do provide an available clinical guide to practice and evaluation.

Results A clinical trial, even with limited numbers, is an exercise in good will, good planning and good fortune. Although planning to treat 12 children, we "lost" 4 children in the study, lost in the sense that 4 children could not be included in the end results for a variety of reasons. One boy during the first sessions of music therapy was discovered to be profoundly deaf rather than being mentally handicapped and developmentally delayed, which meant that he had to be finding seems to point to fitted with hearing aids. T h i ~ music therapy assessment as a valuable diagnostic method for developmenta!ly delayed children simply because it brings attention to active hearing in an almost naturalized setting. One other child had been abused by a member of her family and it was not

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possible to continue the full program of treatment and assessment. Two children came from families of ethnic minorities and it was both difficult to get them to music therapy sessions and to maintain the continuity of follow-up.

By the end of the study there were two unbalanced groups, similar in chronological age, but different in mental age despite the random allocation. We see in Figure 3, which illustrates the Griffiths subscale scores for the children in both groups, in comparison with Figure 2, that the children range from what is considered to be severely delayed to the "slow" child. Five, out of the eight children, failed to score on the practical reasoning scale (Subscale F). Subscale F is heavily dependent upon speech and represents the general language deficits in these children.

However, we see by the final assessment sessions, Figure 4, that all the children have developed some capacity for practical reasoning. Indeed all the children improve, as would be expected. Children develop with or without music therapy. But the rate at which they develop and how this is possibly influenced by music therapy is the subject of this study.

We see in Figure 5 that the changes in the Griffiths scores do indeed differ according to which group the children are in. During the same period of time from intake, the first treatment group (A) changes more than the children who are on the waiting list (measured at Test l). When the waiting list group is treated and then tested (at Test 21, and the children who were treated take a rest, the newly treated children start to

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Group A

im

lm

80

E

60

6 L m

g

40

CJ

20

0 Kathlean

Sophie

David

Zena

'

Tomrny

Group B lrn

7

A B C D E F

l

Salty

A = locomotor development B = personal-social relationship C = hearing and s p c h

A B C D E F

l

Suzie

D = hand and eye coardination E = performance tests F = practical reasoning

NOW lhal four of lhe children in Gmup A. and one chiid in Gmup B, do not score on the practical reasonong scale

Figure 3 . Griffiths Quotient intake profiles.

catch up in their development. Such differences can be demonstrated at a level of statistical significance (at Test l df = l , F = 7.072, P = 0,045) and support our initial hypotheses that music therapy will bring about an initial change. Although it appears clear that music therapy does make a difference to the development of these children, it does not immediately tell us why music therapy helps or what indeed is changing specifically. It makes sense here to look at

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the individual subscale changes of the Griffiths scale.

When we look at the subscale changes (see Table 21, there are significant differences between the groups. First, there is a continuing significant difference on the hearing and speech subscale and the statistic points to a significantly changing ability to list& and communicate. The personal-social interaction subscale (B) also proves to be the significant differentiator at Tests l and Tests 3. After Test 3, the

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CHILDREN WITH DEVELOPMENTAL DELAY Group A

'T----

David

Kathleen

Sophie

Zena

Tornrny

D = hand and eye coardination E = pcrfomance tests F = practical reasoning

A = locomotor development B = personal-social relationsh~p C = hearing and speech

Figure 4 . Griffiths Quotient final assessment profiles.

children in Group A have received two treatment periods of music therapy. It must be noted here that Tests 2, 3 and 4 are all made after children have been treated at least once with music therapy. Music therapy seems to have an effect on personal relationship, emphasizing the positive benefits of active listening and performing, and this in turn sets the context for developmental change. Howevtx, the groups also differ initially on hand-eye coordination (subscale D), and this is not surprising given that the playing of musical instruments demands such manipulative and perceptive skill.

David Aldridge

Although focused listening in a personal-social relationship sets the scene for music therapy and provides the context in which change can occur, a further investigation of the data reveals an important variable related to hand-eye coordination that is correlated with significant clinical changes when the children are tested. Subscale D, which measures hand and eye coordination and is taken to be demonstrative of nonverbal communication (Muenzenmaier, Meyer & Ferber, 19931, is significantly correlated with change throughout the series of test times. At Test l (Pearson r 0.915, Bonfen-oni p 0.001) and Test 2 (Pearson r

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ALDRIDGE, GUSTORFF AND NEUGEBAUER

Q no music therapy

A with music therapy

no music therapy

no music therapy

with music therapy

with music therapy

no music therapy

-

l

Group A

Group B

n e s e changes are lhe mean changes from when the children were measured at inlake; lhaf is, lhe inlake is the baseline, zero. The test scores, l ,2,3 and 4 are the mean changes in the Griffilhs quotienls for each group at three months, six months, nine monlhs and one year fouowing the inital measurement at intake. Note at test 4 in Group B lhere appears to he a regression in the changes.

Figure 5. Group differences in Griffiths test score means changes from intake.

0.903, Bonferroni p 0.002), hand-eye coordination is correlated with the hearing and speech scale change, scale C. A change occurs on both scales of nonverbal communication and potential verbal communication.

Furthermore, at Test 3, hand-eye coordination is correlated with changes in the performance tests, scale E (Pearson r 0.902, Bonferroni p 0.033), and later at Test 4, hand-eye coordination is correlated with changes in practical reasoning (Pearson r 0.933, Bonferroni p 0.010). The active element of musical playing, which demands the skills of hand and eye coor-

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dination and listening, appears to play a significant role in developmental changes.

Case Vignettes Although it may be unorthodox to include clinical case studies alongside statistical reasoning, we believe that a time has come when we can have the freedom to add some variety to the way in which our work is presented. There are no statutes that say case vignettes are banned from such work and, as most of us know from reading the work of other clinicians,

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CHILDREN WITH DEVELOPMENTAL DELAY Table 2 Effect of treatment group on subscale scores Subscale

Test time

A: locomotor development

Test l error Test 2 error Test 3 error Test 4 error Test 1 error Test 2 error Test 3 error Test 4 error Test l error Test 2 error Test 3 error Test 4 error Test l error Test 2 error Test 3 error Test 4 error Test 1 error Test 2 error Test 3 error Test 4 error Test 1 error Test 2 error Test 3 error l Test 4 error

B: personal-social

C: hearing and speech

D: hand-eye co-ordination

E: performance tests

F: practical reasoning

SS

DF

MS

F

P

Univariate F tests: *significant p < 0.05; **significant p < 0.01

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ALDRIDGE, GUSTORFF AND NEUGEBAUER what we often really need to know is how the statistical relevance comes to have any clinical relevance.

In these two examples we see that although clear developmental changes accessible to assessment take place, it is the qualitative subtleties of personal meaning that play an important role for the parents. In the first study, a clear quantitative change takes place in the Griffiths test score (see Figure 7). In the second example, although no clear objective change occurs in the test scores over time (see Figure 6), the parents see important qualitative changes that they perceive as improvements.

Dora Dora, the child of a mentally handicapped mother and a socially disturbed father, was adopted at birth.

While experiencing feeding difficulties she put on weight. She was developmentally delayed, hyperactive and often uncontrollable. As a baby she received physiotherapy because she started to walk late and, at the time therapy began, was still in diapers. Her major problem was presented as episodes of agitation and restlessness after which she appeared to have lost much of what she had previously learned. Following such episodes she said that she would fall or her head would fall off. An electroencephalogram showed no obvious signs of pathology. Socially she was distant from other children and adults, was extremely anxious in the presence of others and protected her eyes with her arms clamped to the sides of her head. She would not listen to others or make eye contact. Sometimes her voice had a strange "fairy-tale" character.

She had been seen by a child psychiatrist.

At the beginning of the music therapy Dora cried a lot and had t o be held in the arms of the CO-therapist throughout the session. When he tried to put her down she cried even louder. Eventually she responded to the musical structure offered to her and, although making no eye contact with the therapist at the piano, rang a small bell with her finger. Gaining in confidence, while remaining in the arms of the cotherapist, she played the cymbal continuously. When asked if she had finished playing, she replied clearly that she had. Eventually, in the fourth session, she had confidence to play a drum alone. Now there was no crying and she looked confidently at the therapist.

The therapist had composed a special "Good-bye song" for her and she sang, too! By the tenth session, her musical playing was formed and she played a crescendo alone.

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At first Dora told her adoptive mother that she would not come to music therapy, but, after the first few sessions, appeared to come gladly. At home she displayed both sympathy for others and sadness. That she herself could be emotional was an important experience for her mother. Similarly, Dora made it clear she was happy to see her mother and said that she loved her. Although previously distant, she now cuddled others and was happy to be cuddled. After two music therapy sessions Dora began to sleep well, and sleep alone, which was a great benefit for the parents.

When she had an episode of agitation she said that she no longer needed to be held and could manage alone.

Instead of using single words, she combined words together as phrases and could say "I," "we" and "you" in the proper context.

After the second treatment block, she became dry during the day. The table in her bedroom, once used for changing her diapers, became a desk. Although not being particularly comfortable at the kindergarten, she started to make friends.

Sophie Sophie was a much wanted child, as her mother had previously miscarried twice. Although being able to sit alone at four months, she failed to crawl and failed to pull herself up to stand. There appeared to be no organic cause for such delay. The physiotherapist found that Sophie had difficulties with both her fine and coarse motor control. Although able to hear normally, she failed to speak. Sophie also played alone and was not interested in distractions. After a virus infection and a fever of up to 42 degrees centigrade when she was unconscious for a short time, she became very anxious. An electroencephalogram showed no obvious signs of irregularity.

In the first session Sophie clung to her mother and was carried into the therapy room by the CO-therapist, on whose arm she remained. Her hands shook, she whimpered and was very anxious. She played a small bell and a chime bar so quietly that they could hardly be heard.

In the second session she was also very withdrawn and came crying into the room. However, with the support of the CO-therapistshe played single tones on the piano, sat on the CO-therapist's lap and played separately both drum and cymbal.

By the fourth session she was able to come into the therapy room alone and, after a while, came to the piano where she played single unrelated tones, which

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CHILDREN WITH DEVELOPMENTAL DELAY at times accidentally met the music played for her by the therapist. Sophie was very insecure in the musical pauses and immediately retreated from rhythmical impulses. However, in the fifth session she played more often in relationship to the music, using both hands to beat the drum in parallel and alternately. She was surer in the therapeutic relationship and made considerably more effort to play, even when it was manually difficult for her.

After this treatment period Sophie's mother described her as being much freer in daily life. For example, she investigated alone the family's newly acquired caravan. When travelling on the local bus, she greeted the child next to whom she sat. When the door bell rang, she opened the door. When she wanted to play with her mother she would find the toys herself, a reverse of the previous situation. She showed more initiative. Furthermore, although speaking in a general babble, she could remember words and situations. If misunderstood, she would become annoyed and show it.

In the next treatment period her playing on Intake

Test1

Test?

Test3

20 1

drum and cymbal at first remained impulsive. But, by the seventh session she came happy and expectant directly to the piano where she played with more security.

A significant change came about in the eighth session where she was constantly active and the musical aspects of her playing were more recognizable. She could accompany, and play, changing tempi, decide between loud and soft playing, repeat musical motifs and brought some continuity to her playing that was no longer spoiled by small distractions. Her accidental changes were supported in the music so that they became parts of the musical whole, and she worked hard to maintain the musical relationship.

In the following ninth session Sophie's playing sounded ambivalent and not so related as in the previous week. She seemed withdrawn and unsure in what she did. However, by the next session she was restored to her previous level of progress and was able to express herself in diverse musical activities. With help, she was able to play the drum with parallel and alternative arm movements and by the final session Test4 Kathleen Ă&#x201A;

David

A

Sophie

+

Zena

X

Tomrny

No With No With MT MT MT MT These changes are the individual changes in the overall Griffiths test score from when the children were measured at intake. The intake score for each child is now the baseline, zero for indicating further comparative changes from the original scores. The test scores, 1.2.3 and 4 are the changes in the Griffiths quotients for each child at three months, six months, nine months @ o n e year following the inital measurement at intake. With MT = the children had music therapy treatment before this test and after the last test. No MT = the children had no music therapy prior to this test and after the previous test.

Figure 6. Changes in the Griffiths test scores for treatment group A from intake to final assessment

David Aldridge

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202

had many developed musical improvisational possibilities at her disposal.

Sophie's mother described her daughter as being much more capable of playing with her brother, and both able to dress herself and put on her shoes. Although she was defiant when asked to repeat a word, for instance, she babbled more and often repeated the first syllable of a word that she had heard. Sophie was more independent. On visiting a friend of her mother's, Sophie had gone to the refrigerator to fetch a drink when no one had understood that she was thirsty. She had become much more aware, and appeared to be surprised by her own capabilities. The consequences were that she became braver and more energetic in taking new things on, would play with others and sit next to her brother or her parents. On going to bed, she took her teddy bear with her along with other cuddly toys. For her mother it was a personal breakthrough when Sophie allowed her hair to be cut and styled and agreed to wear a slide in her hair.

Although the individual developmental profiles of Intake

Test1

Test2

both the above children can be seen in Figures 6 and 7, it is important to emphasize here the role of parental observation. When therapeutic change occurs, the primary arena for expression of that change is not solely in the therapy room. What parents are expecting is that children will be different at home. These changes are often subtle and too varied for a standardized questionnaire. Therefore, the personal interview with the parents is of equal importance for understanding changes in children. How we weave subjective and objective results together is the creative nature of our inquiry, and we can do this once we have established the criteria, fpr the way in which our data are collected.

Discussion Children will develop. Some develop slower than others, and for an even smaller minority that development is delayed through a variety of causes. We argue, like others before us, that music therapy can facilitate development and enhance its rate in those

Test3

Suzie

No With No With MT MT MT MT These changes are the individual changes in the overall Griffiths test score from when the children were measured at intake. The intake score for each child is now the baseline, zero for indicating further comparative changes from the original scores. The test scores, 1.2.3 and 4 are the changes in the Griffiths quotients for each child at three months. six months, nine months and one year following the inital measurement at intake. With MT = the children had music therapy treatment before this test and after the last test. No MT = the children had no music therapy prior to this test and after the previous test.

Figure 7. Changes in the Griffiths test scores for treatment group B from intake to final assessment.

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CHILDREN WITH DEVELOPMENTAL DELAY children whose development is in some way impaired. When we speak of developmental change we are in the main speaking about the ability to communicate either nonverbally or verbally. Indeed, the parents of the children treated in this study had an expectation that what they and their children did together would make some sense to them, that their children could communicate needs, desires and emotions, and that they, too, the parents and caregivers, could communicate their feelings to the children. That Sophie could show both sadness and happiness were considered to be important for her mother. That she could also cuddle was a significant milestone in the emotional relationship of child and mother.

In this study we have gone some way to fulfilling our first purpose in demonstrating that developmental change can be perceived according to standardized testing in the context of clinical research. The Griffiths test is acceptable to us and to referrers in that it is based upon a broad base of clinical observations and makes sense when applied to the lives of the children being assessed. Like music therapy itself, the emphasis is on eliciting the potential of the children.

We can say that children, when they partake in improvised creative music therapy, achieve significant developmental milestones in comparison with those children who are not treated. Later, when a comparison group of children is treated, they too rapidly achieve developmental goals. It must be mentioned here that at no stage in the study was music therapy targeted to specific developmental achievements or aimed at particular behavioral activities.

What we were interested in was what developmental changes took place, rather than trying to manipulate children so that targeted changes occurred. The reason for not specifying behavioral goals is that creative music therapy is not based on such a behavioral plan of identifying specific clinical aims that would detract from the essential aim of making music together. As all the children were so completely different, as is the nature of developmental delay, the same target variable could not apply to all the children. Furthermore, as this was a preliminary study, we could not know what we were to focus on before we had made the study. However, there is a paradox inherent in creative music therapy in that we emphasize the musical activity as paramount in therapy, yet it is the behavioral changes that we champion as therapeutic success.

Our initial purpose was also to discover what it is

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in the activity of making music that is important.

Clearly, the activity of listening, in a structured musical improvisational context, without the lexical demands of language, is a platform for communicational improvement. The building blocks of language, rhythm, articulation, sequencing (Alien, Barone & Kuhn, 1993), pitch, timbre (Annett, 1993) and turntaking (Blampied & France, 1993) are musical in nature. Focused listening to another person, we would argue, is also a prerequisite of effective mutual communication and dialogue. Furthermore, musical dialogue in the music therapy relationship seems to bring about an improvement in the ability to form and maintain personal social relationships in other contexts.

Hand and eye coordination, which is dependent on a wider body awareness, appears to be the third vital component in developmental change. That hand movement plays such an important role is also supported by the literature emphasizing the role of nonverbal communication and gesture in the subtle aspects of emotional expression (Barrett, 1993), the acquisition of language (Millard et al., 1993) and in cognitive development (Alibali & Goldin-Meadow, 1993; Goldin-Meadow, Alibali & Church, 1993). The active playing of a drum demands that the child listen to the therapist who in turn is listening to and playing for him or her. This act entails the physical coordination of a musical intention within the context of a relationship. We would argue that this unity of the cognitive, gestural, emotional and relational is the strength of active music therapy for developmentally challenged children.

In addition, the importance of the visual system in generating speech is necessary to bear in mind.

Shuren , Geldmacher and Heilman ( 1993) proposed that there is a visual semantic system storing codes for concrete words and picture names and a verbal system for conceptual knowledge of a more abstract type.

Both systems work together, yet the second is more dependent upon internal stimuli or self-generated dialogues. The activation of hand and eye together in this study, visual-semantic and gestural, may have had an influence on the speech-related practicalreasoning sub-scale F, which all children exhibited by the end of the study.

The proximal zone, where child and therapist play together, awakening a potential and extending the possibilities of the child, appears to be an important concept for music therapy and is critical in achieving new creative possibilities in the therapeutic relation-

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ALDRIDGE, GUSTORFF AND NEUGEBAUER ship. Although the musical therapeutic relationship is the domain of this zone, the means of achieving this relationship is in the encouragement of active listening. Yet, such listening is also related to performing.

The intention to communicate is brought into a structure so that communication can be achieved as performance. In this case the structure is musical, has the advantage of flexibility and is built upon the capabilities of the individual child. His or her own capabilities, no matter how limited, are brought into the mutual realm of musical relationship with the therapist and therefore are open to variety and, thereby, development.

The caregivers of the children in this study said that a benefit of music therapy was that they could enjoy their children and what the children did began to make more sense. If through this "making sense" a child achieves independence by the expression of needs, desires and wishes, and the ability to act accordingly, then we have gone some small way in our study to demonstrate a benefit of creative music therapy. Listening and performing in the musical relationship, that is, action and purposeful movement in a relational context, appear to be the building blocks of developmental change and of relevance for cognitive change. That these factors are pre-verbal, and not language dependent, would argue for the importance of creative arts therapies in the treatment of developmentally delayed infants.

Our secondary purpose was to find a suitable research approach integrating quantitative and qualitative methods. We have used empirical data that can be analyzed statistically, but, as in all statistical methods, the analysis must be applied and interpreted. By using multivariate techniques, we have chosen to investigate the relationship between variables as shown by our data. The relationship between variables, although suggested as significant by the analysis, must be interpreted as clinically significant by the researcher and further validated by the clinicians. As Dzurec and Abraham (1986) remarked: In other words, for the researcher using multivariate analysis, as for the researcher using phenomenology, meaning is not inherent in data as they are analysed, but is implied by the researchers view of reality and the construction of reality to be conveyed in a given situation.

Hence attribution of meaning to objective data collected using either multivariate analysis or phenomenology is a subjective task. (p. 61)

David Aldridge

The above work needs to be validated with a larger population of children and is best considered as a pointer in a general direction rather than as a conclusive statement. We found the clinical controlled trial to be a rather clumsy approach for our purposes. Even a small number of children are radically different in their capabilities. The treatment approach could not, in practice, be blinded from the assessor in the first phase as parents would ask her when their child would eventually get to music therapy. What did emerge was the importance of a reliable assessment instrument such as the Griffiths profile that could be systematically applied over longer treatment, and no treatment, periods. Longitudinal single case designs would appear to be appropriate for further studies. Ideally, we would have also used a child musical development scale if one had been available. The Nordoff and Robbins scales are not reliable instruments for comparative research, but they d o provide a guide to individual assessment. For future researchers, it is important to repeat that the interview with the parents or caregivers is of equal value in that subtle individual and relational changes are reported that would otherwise escape the attention of a questionnaire or formal assessment instrument. A qualitative study would emphasize in the future the relationship between the musical processes of change and the various changes as they occur in the life of the child at home. We would want to ascertain that patterns of communication occurring in the music therapy sessions could indeed be transferred to other situations with siblings or caregivers.

Although we can make generalizations from the above work, it is important for music therapists as researchers to stay in contact with the single child.

This does not invalidate group research methods. As we see here, the comparison of groups has alerted us to significant changes. Hopefully, future research will reflect the creative tensions between generalizibility and specificity-what we can say about music therapy with children in general and what happens to the individual child in the process of therapy. Quantitatively, we have assessed changes through the collection of data according to a particular instrument, the Griffiths test. Qualitatively, we have interpreted those data to develop inferences from what is observed.

References Aldridge, D. (1989). Music, communication and medicine: Discussion paper. Journal of the Royal Society of Medicine.

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CHILDREN WITH DEVELOPMENTAL DELAY Alibali, M., & Goldin-Meadow, S. (1993). Gesture-speech mismatch and mechanisms of learning: What the hands reveal about a child's state of mind. Cognitive Psvchologv. 25. 468523.

Alien, K. D., Barone, V. J., & Kuhn, B. R. (1993). A behavioral prescription for promoting applied behavior analysis within pediatrics. Journal of Applied Behavior Analysis, 26(4), 493502.

Annett, M. (1993). Biological asymmetry and handedness. International Journal of Behavioral Development. 16(4), 629-630.

Barren, K. ( 1993). The development of non-verbal communication of emotion: A functionalist perspective. Journal of Non-Verbal Behavior. 17(3), 145- 169.

Blampied, N. M., & France, K. G. (1993). A behavioral model of infant sleep disturbance. Journal of Applied Behavior Analysis, 26(4), 4 7 7 4 9 2 .

Case, R. (1993). Theories of learning and theories of development.

Educational Psychologist. 28(3), 219^233.

Dzurec, L., & Abraham, I. (1986). Analogy between phenomenology and multivariate statistical analysis. In P. Chinn (Ed.), Nursing research methodology: Issues and implementation.

Gaithersburg, MD: Aspen.

Dzurec, L., & Abraham, I. (1993). The nature of inquiry: Linking quantitative and qualitative research. Advances in Nursing Science, 1 6 ( \ ) , 73-79.

Florian, J. E. (1994). Stripes do not a zebra make, or do they?

Conceptual and perceptual information in inductive inference.

Developmental Psycholog\. 30( l), 88- 101.

Gaussen, T. (1985). Beyond the milestone model-A systems framework of infant assessment procedures. Child Care.

Health and Development. I I . 131- 150.

Goldin-Meadow, S., Alibali, M., & Church, R. (1993). Transitions in concept acquisition: Using the hand to read the mind.

Psychological Review, 100(2), 279-297.

Griffiths, R. (1954). The abilities of babies. London: University of London Press.

Griffiths, R. (1 984). The abilities of young children. High Wycombe: ARICD. (original work published 1970) Heyink, J., & Tymstra, T. (1993). The function of qualitative research. Social Indicators Research. 29. 29 1-305.

Laszlo, J. l., & Sainsbury, K. M.(1993). Perceptual-motor development and prevention of clumsiness. Psychological ResearchĂ&#x192;â&#x20AC;&#x2DC;Psychologisch Forschung, 55(2), 167- 174.

Lewis, J. M. (1993). Childhood play in normality, pathology, and therapy. American Journal of Orthopsvchiatp, 63(1), 6- 15.

Mash, E. J. (1993). Rochester symposium on developmental psychopathology (vol 3)-Models and integrations. Canadian Journal of Behavioural Science-Revue Canadienne Des Sciences du Comportement. 25(4), 628-632.

Millard, T., Wacker, D. P., Cooper, L. J., Harding, J . , Drew, J . ,

Plagmann, L. A., Asmus, J . , Mccomas, J., & Jensenkovalan, P. (1993). A brief component analysis of potential treatment packages in an outpatient clinic setting with young children.

Journal of Applied Behavior Analvsis. 26(4), 475-476.

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I NdevelopmenCI~O~ Morss, J . (1992). Making W ~ V ~ S - D ~ C O ~ Sand tal psychology. Theoretical Psychology, 2(4), 445465.

Muenzenmaier, K., Meyer, I., & Ferber, J. (1993). Childhood abuse and neglect-Reply. Hospital and Community Psychiatry. 44(12), ll93-ll94.

Neef, N. A. (1993). Introduction. Journal of Applied Behavior Analysis, 26(4), 4 19.

Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day. Peterson, L.. & Schick, B. (1993). Empirically derived injury prevention rules. Journal of Applied Behavior Analysis, 26(4), 45 1-460.

Ross, L. V., Friman, P. C., & Christophersen, E. R. (1993). An appointment-keeping improvement package for outpatient pediatrics-Systematic replication and component analysis. Journal of Applied Behavior Analysis, 26(4), 4 6 1 4 6 7 .

Sacks, 0. (1986). The man who mistook his wife for a hat. London: Pan. Shadish, W., & Fuller, S. (1994). The social psychology of science. London: Guilford Press.

Shuren, J., Geldmacher, D., & Heilman, K. (1993). Nonoptic aphasia: Aphasia with preserved confrontation naming in Alzheimer's disease. Neurology. 43. 1900- 1907.

Siegel, L. S. (1993). Amazing new discovery-Piaget was wrong.

Canadian Psvcholo~v-Psychologie Canadienne, 34(3), 239245.

Sipiora, M. (1993). Repression in the child's conception of the worl&A phenomenological reading of Piaget. Philosophical Psychology, 6(2), 167- 180.

Spieker, S. J., & Bensley, L. (1994). Roles of living arrangements and grandmother social support in adolescent mothering and infant attachment. Developmental Psychology. 30(\), 102-1 11.

Vandenberg, B. (1991). Is epistemology enough? An existential consideration of development. American Psychologist, 46(12), 1278-1286. von Hofsten, C. (1993). Prospective control: A basic aspect of action development. Human Development. 36, 253-270.

Vygotsky, L. (1978). Mind in society. Cambridge, MA: Harvard University Press.

Wagner, R. K., Torgesen, J. K., & Rashotte, C. A. (1994). Development of reading-related phonological processing abilities-New evidence of bidirectional causality from a latent variable longitudinal study. Developmental Psychology, 30( 1), 73-87.

Weaver, T . L., & Clum, G. A. (1993). Early family environments and traumatic experiences associated with borderline personality disorder. Journal of Consulting and Clinical Psychology, 6/(6), 1068-1075.

Wilson, F., & Roehmann, F. (1987). Music and child developmem. St. Louis, MO: MMB Music.

Winemiller, D. R., & Mitchell, M. E. (1994). Development of a coding system for marital problem solving efficacy. Behaviour Research and Therapy. 32( l). 159-164.

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Psychometric Results of the Music Therapy Scale (MAKS) for Measuring Expression and Communication

Music and Medicine 2(1) 41-47 ª The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1943862109356927 http://mmd.sagepub.com

Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG), Dipl.

Psychologist,1 Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist,2 Kirstin Goth, Dr. phil. nat., Dipl. Psychologist,3 Fritz Poustka, Prof. Dr. med., Professor emeritus,3 and David Aldridge, PhD, FRSM4

Abstract The Music Therapy Rating Scale (MAKS), originally developed in 1996, was evaluated again in 2009 using a sample of 62 children from a psychiatric unit and from different primary schools, with measures at three different time points during therapy process.

The scale is intended as an objective rating of a client’s musical behavior. The evaluation of the scale was to determine any possible ambiguity or weakness in the discriminatory power of the scale items. After excluding such items, the results show high reliability (a > .75) and good objectivity with trained raters (r > .70) for the two main scales and a significant sensitivity to change.

Keywords musical communication, musical expression, music therapy, rating scale MAKS

There has been an urgent need for evaluation in music therapy over the past years, and specific assessment instruments for music therapy are still missing, especially for patients who cannot be evaluated by verbal tests (Aldridge, 1996; Tischler, 2000). It is important in clinical practice that we describe in detail the patient’s mental state and psychic structure. Therefore, we need to identify specific criteria for the assessment of a client’s musical expression. The question remains as to how we interpret what we hear in a musical context in terms of both relationship and expression and the implications of this interpretation for therapy.

Music Therapy Rating Scales Music therapy rating scales already exist in the literature (for an overview, see Phan Quoc, 2007; Sabatella, 2004). Many of them, however, are neither specific to music therapy nor validated. In Germany, semantic differentials are often used for describing improvised music during music therapy intervention. These differentials are bipolar adjective lists with scales divided into five or seven intervals to rate a subjective impression of what is heard. They were used by music therapy researchers in the 1990s due to a shortage of specific scales for music therapy (Burrer, 1992; Inselmann & Mann, 2000; Pechr, 1996; Steinberg & Raith, 1985; Steinberg, Raith, Rossnagel, & Eben, 1985; Vanger, Oerter, Otto, Schmidt, & Czogalik, 1995; Zahler, 2002).

David Aldridge

As specific music therapy rating scales, Bruscia’s Improvisation Assessment Profiles are often used in music therapy research in English-speaking countries (Bruscia, 2001), but these have yet to be validated. Maler’s (1989) scale is partly validated but is very complicated in applying ratings and is no longer implemented. The Nordoff/Robbins rating scales (Nordoff, Robbins, Fraknoi, & Ruttenberg, 1980a, 1980b), used primarily with children with disabilities, are now under evaluation. Schumacher’s Assessment of the Quality of Relationship (Schumacher, 1999; Schumacher & Calvet, 2007; Schumacher & Calvet-Kruppa, 1999) is currently being evaluated for its application to people with mental disorders other than autism. Pavlicevic’s Music Interaction Rating scale (Pavlicevic, 1991, 2007), describing the patient’s level of contact during musical improvisation in music therapy, has been validated for use with psychiatric patients. The challenge of

1

Freies Musikzentrum, Munich, Germany University of Wu¨rzburg, Wu¨rzburg, Germany 3 Goethe University, Frankfurt am Main, Germany 4 Nordoff-Robbins-Zentrum, Witten, Germany (nordoff_robbins@mac.com) 2

Corresponding Author: Dorothee von Moreau, Institut fu¨r Musiktherapie, Freies Musikzentrum, Munich, Germany Email: dvmoreau@web.de

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Table 1. The Music Therapy Rating Scale (MAKS): Expression and Communication Subscales MAKS Expression scale: rating improvised solo playing (14 items) (Dealing with the instrument) Range of melody (TR) Initiative (IN) (Form/musical figure) Form (FG) Structure (ST) Variation (VR) (Vitality/dynamics of expression) Suspense/tension (SP) Power (SK) Vitality (LB) Flow (SF) Dynamics (DY) (Quality of expression) Sound quality (KQ) Quality of expression (AU) Clarity of emotions (EA) Resonance/involvement (EL)

Communication scale: rating improvised duo playing with the therapist (13 items) (Engagement) Autonomy (AT) Inner participation (BT) (Formal aspects) Need of space (RA) Length of playing intervals (DA) Logic structure (LA) (Regarding the other) Reference (BZ) Intensity of contact (KI) Contact behavior (KV) Variability in acting (VV) Dominance (DO) (Quality of expression) Quality of flow (DQ) Quality of affects (AQ) Quality of play (SQ)

For scoring purposes, all items were divided into seven levels. Each level was operationalized, creating precise descriptions to avoid ambiguity (of some items; see Table 2).

This scale was validated in 1996 by an initial evaluation process with 52 raters on the basis of 10 video scenes of different adolescent patients in a psychiatric clinic (Moreau, 1996, 2003). Scores allowed significant differentiation between clients with various psychiatric disorders (p < .001). The results for objectivity (mean interrater correlation: Kendall’s tau ¼ .4 for the Expression scale and .3 for the Communication scale) needed to be improved, but the retest results suggested that a training of the raters may slightly improve the score for objectivity.

The experiences of Plum (Plum, Lodemann, Bender, Finkbeiner, & Gastpar, 2002) and Isermann (2001), testing the practicability of the scale in a clinical context with adults with schizophrenia, encouraged us to revise the scale and to reevaluate it in a clinical setting.

Aim and Hypotheses

Hypothetical categories are in brackets.

The main task of the actual study was to evaluate the MAKS again with trained raters, according to the general psychometric criteria of objectivity and reliability and to establish its usefulness, clinical applicability, and relevance.

measuring the music therapy outcome with young and adolescent psychiatric patients, however, has not been addressed.

A question remains about whether scales, conceptually based on developmental psychology, are appropriate for children without developmental disabilities or severe psychiatric disorders, but who are, nevertheless, unstable in both emotional expression and social interaction. We identified the need for a music therapy rating scale specifically for measuring musical behavior on more than one dimension in order to depict the client’s behavior that included dissent, inconsistency, and ambivalence. A rigorous scale could then be used for the initial assessment process and for a final assessment at the end of therapy, making it a useful tool for an evaluation of therapy outcome. While we have diagnostic scales, we have no rating scales for assessing therapeutic change.

1. Testing reliability shows to what extent the scales are free of measurement error. The a priori criterion for accepting reliability according to psychometric standards (see Bortz & Do¨ring, 2006) was set at a Cronbach’s alpha greater than .75.

2. The objectivity of a scale shows to what extent the raters agree in their judgment. The a priori criterion for accepting objectivity according to psychometric standards was set at a Pearson’s interrater correlation greater than .7.

3. Sensitivity to change shows to what extent the scale will detect the development of the client’s musical expression or communication skills throughout the duration of therapy. The a priori criterion for accepting the hypothesis was significance (tested by MANOVA with the factors Psychopathology and Time of Measurement), p < .05, for the within-subject factor Time.

Development of the Scale and First Results of Validation

Methodological Design Procedures

Development of the Music Therapy Rating Scale (MAKS) began in 1994 with a survey of music therapy experts (Moreau, 1996). In a process of item testing and reduction, the scale has been modified in clinical practice for several years. For the final version, the MAKS was composed of two subscales. One, the Expression scale, is 14 items for rating a client’s improvisational musical performance in a solo playing. The second, the Communication scale, is 13 items for rating a client’s improvisational musical performance in duo playing with the therapist (for an overview of the scale’s categories see Table 1).

For the rating of the children’s musical behavior, we produced video recordings of each child in a standardized assessment session of about 15 minutes at three measurement points in time (t1 ¼ at the beginning, t2 ¼ in the middle, and t3 ¼ at the end of music therapy treatment or music workshop). In each assessment session, the child was asked to play by hand a large African drum alone, and then in a second episode to play it together with the therapist. During the duo play, the therapist was instructed to answer the child’s offering on contact with

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Table 2. Music Therapy Rating Scale (MAKS) Item Examples: Expression and Communication Subscales Expression scale: Initiative (frequency of the client’s own ideas) No initiative (only plays when requested and/or offered assistance)

Very low-level initiative (reproduces only familiar musical patterns)

Low-level initiative (1-2 ideas)

Normal High-level initiative initiative (2-3 ideas) (3-4 ideas)

Very high-level initiative (more than 4 ideas)

Extreme-level initiative (cannot restrain him- or herself)

Communication scale: Dominance (level the client places him- or herself under or above the therapist) Strongly subordinate (does not play or falls silent)

Moderately subordinate (conformist)

A little subordinate (partly conformist)

empathy and to stay cautious neither to force nor to push the child’s reactions more than necessary. From the videos of each assessment session, the therapist chose a representative scene of solo playing of 20 to 30 seconds for the rating of musical expression and a representative scene of duo playing with the therapist of 30 to 40 seconds for the rating of musical communication. The therapist decided which part of the video was typical or representative of the child’s behavior at that time of treatment. Finally, we had six video episodes for each participant, containing one solo and one duo scene from each time segment (t1, t2, t3). These video scenes from all children were assembled in random sequence and recorded on CDs for rating by three independent observers who had been trained in using the MAKS. These raters, three music therapy colleagues from different music therapy training backgrounds and with 3 to 5 years’ music therapy experience with children, watched the videos and scored the musical behavior of the children using the MAKS.

A little dominating (decisive, inviting)

Moderately dominating (influential)

Strongly dominating (overwhelming)

Distribution of main diagnoses

30

25

20

15

10

5

0

F90

F91

F92

F93

F94

F98

F84

F44 healthy

Figure 1. Main diagnoses (International Classification of Diseases, Version 10) of the children’s sample.

Instruments For the evaluation of the children’s improvisational solo and duo play, we used the Expression and Communication scales of the MAKS, as described above. In addition, the children’s parents filled out a personality questionnaire, the Junior Temperament and Character Inventory (JTCI 7-11 R; Goth, Cloninger, & Schmeck, 2003; Goth & Schmeck, 2008). The personal nurse at the hospital or the parents, for the nonclinical group, filled out a short psychopathology questionnaire, the Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001; German translation, Woerner et al., 2002).

Participants Thirty-eight inpatients from a university hospital for child and adolescent psychiatry attended group music therapy sessions over a period of 4 weeks to 10 months, depending on the length of their hospital stay. Most of the patients had a main diagnosis of hyperkinetic disorder, F90, according to the International Classification of Diseases, Version 10 (ICD-10), and most had multiple diagnoses (see Figure 1).

In addition, 24 healthy children from different primary schools attended a music workshop of 10 sessions over a period

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Equal

of 3 to 4 months. We selected only boys and only those children without impaired intelligence to assure that the groups were homogeneous in gender and cognitive ability—although the children differed in age (see Table 3).

Neither group differed in creativity (ANOVA p ¼ .958, tested

by JTCI 7-11 R), but they differed significantly in all other categories of temperament and character (ANOVA p < .010, tested

by JTCI 7-11 R). We found significant differences in the SDQ total score (w2 test p ¼ .025), in the categories prosocial behavior (w2 test p ¼ .000) and problems with peers (w2 test p ¼ .008).

However, to our surprise, there were aspects of psychopathology in both groups. Some healthy controls displayed severe or minor social and emotional problems. The clinical group was poorer in both psychosocial adaptation and social skills.

Results Reliability The results for scale reliability were taken from the data of the 62 children’s first assessments (t1) at the beginning of therapy.

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Table 3. Characterization of the Clinical Sample

Age (years, months) Sex

Inpatient participants (n ¼ 38)

Control participants (n ¼ 24)

9, 9 (+1, 7) Male

8, 1 (+1, 5) Male

The intelligence score (IQ) in the clinical group was taken from axis III of the International Classification of Diseases, Version 10 (Remschmidt et al., 2002). In the healthy group, IQ was controlled by school.

Table 4. Reliability of the Expression (A) and Communication (K) Subscales for Each Rater (G, C, B)

Expression scale A: alpha (rit)

A: alpha* A: rit-range* Communication scale K: alpha (rit) K: alpha* K: rit-range*

G

C

B

.80 FG (.23) ST (–.16) EA (.15) .88 .39-.74

.72 FG (–.20) ST (–.01) .83 .36-.74

.75 FG (.11) ST (–.22) EA (.21) .83 .27-.81 (KQ)

.85 DA (.01) BZ (.08) .88 .34-.85

.76 DA (.03) BZ (.13) .78 .21-.64 (KV)

.81 DA (.11) BZ (–.02) .84 .23-.72 (LA)

For the subscales, alpha and rit ¼ results for all items; alpha* and rit-range* ¼ results with reduced items. FG ¼ form; ST ¼ structure; EA ¼ clarity of emotions; DA ¼ length of the play the client takes compared to the therapist; BZ ¼ reference or extent of extraverted or introverted orientation.

We analyzed the ratings of each single observer separately to get an idea of the stability of these results. A first analysis on all items of the Expression scale and all items of the Communication scale showed a Cronbach’s alpha coefficient greater than .70, but the corrected item total correlations of some items were below the criterion of .3 (see Table 4).

As these items (FG ¼ form; ST ¼ structure; EA ¼ clarity of emotions; DA ¼ length of the play the client takes compared to the therapist; and BZ ¼ reference or extent of extraverted or introverted orientation) also had low objectivity scores, they were removed for a new analysis (in Table 4, see alpha* and ritrange*). The results then fulfilled the criterion alpha of greater than .75, and the range of the corrected item total correlation was improved too.

Objectivity The scale’s objectivity was measured by the interrater correlation of all three raters (Pearson’s coefficient) for each single item to detect nonobjective items. We took the data of all children and all assessment sessions. These results were compared to the results gained in the first evaluation process (Moreau, 1996), and the results gained immediately after the rater training. Almost all items of the Expression scale fulfilled the 44

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criterion (marked by the black line; see Figure 2) in one of the contexts (initial study in 1996, after training situation, and actual study)—except those items that were already mentioned in case of reliability: FG (form), ST (structure), and EA (clarity of emotions). In the Communication scale, we identified the items KI (intensity of contact) and DQ (dynamic quality) as not showing sufficient psychometric properties.

For the total score analysis of the Expression scale and the Communication scale, we used only those items with sufficient discriminatory power and that loaded on a stable factor in the factor analysis. Based on this selection criteria, the total score of the Expression scale, (without items FG ¼ form, ST ¼ structure, EA ¼ clarity of emotions) showed an interrater correlation of r ¼ .9, and the total score of Communication scale (without items RA ¼ need of space, DA ¼ length of playing intervals, BZ ¼ extent of extraverted or introverted orientation or reference) was r ¼ .7.

Sensitivity for Change We tested sensitivity for change by MANOVA analysis with the factors Psychopathology (SDQ total score) and Time of Measurement (t1, t2, t3). For this analysis, we took the MAKS Expression total score and the MAKS Communication total score (all items of each scale except the weak items, as described above). The analysis of the solo plays showed significant changes over time in musical expression (withinsubject factor time: p ¼ .023). Analyzing the duo plays, we had even stronger effects of significant changes in musical communication (within-subject factor time: p ¼ .001). We can conclude that the MAKS is sensitive to discrete changes in musical expression and communication.

Discussion After excluding the weak items for all total score analyses, the total scores of the Expression scale and the total scores of the Communication scale present sufficient objectivity and reliability. The results on the level of item with different training conditions suggest that good training is absolutely necessary for using the scale.

The items of form (FG) and structure (ST) did not show sufficient interrater, nor corrected total item correlations.

These items are ambiguous in operationalization, difficult to rate, and do not contribute to explaining musical expression skills. Other items like length of the play the client takes compared to the therapist (DA) and the extent of extraverted or introverted orientation (BZ) need better training. Children in a psychiatric setting often change their orientation while playing with an adult person and hardly show stable patterns.

The items clarity of emotions (EA) or intensity of contact (KI) can be removed from the scale. Ratings of intensity of contact or clarity of emotions do not depend on observable behavior but on the rater’s personal impression. The scale has limitations when asked to portray the quality of various

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A

0.7

0 TR

IN

FG

ST

VR

SP

SK

LB

SF

DY

KQ

AU

EA

EL

B

0.7

0 AT

BT

RA

DA

LA

BZ

actual study

KI

KV

training

VV

DO

DQ

AQ

SQ

initial study

Figure 2. Objectivity (Pearson’s correlation coefficient ¼ y-axis) of the items (x-axis) of the Expression scale (Figure 2a) and the Communication scale (Figure 2b).

emotions or the intensity of contact between persons. On the other hand, the item inner participation (BT), operationalized by attention, is easier to observe.

The MAKS is a rating scale constructed by music therapy experts specifically for evaluating music therapy. The accurate description of each interval of the items allows a detailed reflection of a client’s musical behavior. Therefore, the MAKS is more precise than semantic differential tests and presents a wider field of musical expression or communication skills as the scales examine more than one aspect of behavior. Inconsistent, or contradictory behavior of the client may be portrayed comparing the solo- and the duo-playing conditions and also comparing different aspects of musical expression, for example, tension (SP) and loudness (SK), or tension (SP) and movement (LB).

during music therapy. As an interval scaled rating instrument, the scale allows strong statistical methods for data analysis. When the week items are eliminated, the scale fulfills the necessary psychometric standards of reliability and objectivity when it is used by well-trained raters. It is sensitive to change and can portray a child’s development during therapy.

For further research, we have to determine group-specific characteristic profiles with regard to diagnosis, age, and/or gender to be able to give a clear diagnostic statement related to a patient’s MAKS profile.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Conclusion

Funding

The MAKS is a scale constructed specifically to evaluate the musical expression and communication skills that occur

We would like to thank Andreas-Tobias-Kind-Stiftung, Hamburg, Germany, for financial support for this study.

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References Aldridge, D. (1996). Music therapy research and practice in medicine: From out of the silence. London: Jessica Kingsley.

Bortz, J., & Do¨ring, N. (2006). Forschungsmethoden und Evaluation fu¨r Human- und Sozialwissenschaftler [Research methods and evaluation for human and social scientists]. Heidelberg, Germany: Springer.

Bruscia, K. E. (2001, March 02). Response to the forum discussion of ‘‘IAP’s’’ on the Nordic Journal Web site, http://www.hisf.no/njmt/ forumiaplist.html Burrer, S. (1992). Musiktherapeutishe Einzelfallforschung: Rating von 20 Improvisationsausschnitten aus einer musiktherapeutischen Behandlung [Single case research of a music therapy process: Rating of 20 scenes of musical improvisation from music therapy].

Unpublished thesis, Fachhochschule Heidelberg.

Goodman, R. (2001). Psychometric properties of the Strengths and Difficulties Questionnaire. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1337-1345.

Goth, K., Cloninger, C. R., & Schmeck, K. (2003). Das Junior Temperament und Charakter Inventar fu¨r das Grundschulalter—JTCI 7-11 [The Junior Temperament and Character Inventory for children of elementary schools—JTCI 7-11]. University Clinic for Psychiatry and Psychotherapy with children and adolescents, University of Frankfurt, Frankfurt am Main, Germany.

Goth, K., & Schmeck, K. (2008). Das Junior Temperament und Charakter Inventar: Eine Inventarfamilie zur Erfassung der Persoenlichkeit vom Kindergarten- bis zum Jugendalter nach Cloningers biopsychosozialem Perso¨nlichkeitsmodell [The Junior Temperament und Character Inventory: An inventory system for rating the personality from nursery school up to youth according to Cloninger’s Biopsychosocial Model of Personality]. Go¨ttingen, German: Hogrefe.

Inselmann, U., & Mann, S. (2000). Emotionales Erleben, Ausdruck und Kommunikation in Musikimprovisationen. Eine qualitativquantitative Einzelfallstudie [Emotional experience, expression and communication in musical improvisations: A qualitativequantitative single case study]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 50, 193-198.

Isermann, H. (2001). Einzelfalluntersuchung einer Gruppenmusiktherapie mit schizophrenen Patienten [A case study of group music therapy with schizophrenic patients]. Unpublished thesis, Hochschule Enschede.

Maler, T. (1989). Klinische Musiktherapie. Ausdrucksdynamik, Ratingskalen und wissenschaftliche Begleitforschung im Luebecker Musiktherapie-Modell [Clinical music therapy: Dynamics of expression, rating scales and scientific research within the Luebeck music therapy model]. Hamburg, Germany: Dr.R.Kraemer.

Moreau, D. v. (1996). Entwicklung und Evaluation eines Beschreibungssystems (MAKS) zum Ausdrucks- und Kommunikationsverhalten in der Musiktherapie [Development and evaluation of a rating system (MAKS) on expression and social behavior in music therapy].

Unpublished thesis, University of Wu¨rzburg, Wu¨rzburg, Germany.

Moreau, D. v. (2003). MAKS: A scale for measurement of expressive and musical behavior. Music Therapy Today, 4(4). Retrieved July 25, 2003, from http://www.musictherapyworld.net 46

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Nordoff, P., Robbins, C., Fraknoi, J., & Ruttenberg, B. (1980a).

Ratingskalen fu¨r improvisatorische Einzel-Musiktherapie. Teil I [Rating Scales for Improvisational Individual Music Therapy: Part I]. Musiktherapeutische Umschau, 1, 99-121.

Nordoff, P., Robbins, C., Fraknoi, J., & Ruttenberg, B. (1980b).

Ratingskalen fu¨r improvisatorische Einzel-Musiktherapie. Teil II [Rating Scales for Improvisational Individual Music Therapy: Part II]. Musiktherapeutische Umschau, 1, 185-202.

Pavlicevic, M. (1991). Music in communication: Improvisation in music therapy. Unpublished dissertation, University of Edinburgh, Scotland.

Pavlicevic, M. (2007). The Music Interaction Rating Scale (schizophrenia) (MIR(S)): Microanalysis of co-improvisation in music therapy with adults suffering from chronic schizophrenia. In T. Wosch & T. Wigram (Eds.), Microanalysis in music therapy: Methods, techniques and applications for clinicians, researchers, educators and students (pp. 174-185). London: Jessica Kingsley.

Pechr, M. (1996). Musikalische und psychologische Parameter in experimenteller Therapiemusik—Depressive und Normalgesunde im Vergleich zweier Messinstrumente [Musical and psychological parameters in experimental therapy music—A comparison of depressive and healthy persons using two instruments of measurement]. Musiktherapeutische Umschau, 17, 115-128.

Phan, Quoc, E. (2007). Forschungsansaetze zur Operationalisierung von emotionalem Ausdruck und Interaktion in der musiktherapeutischen Improvisation [Research approaches to the operationalising of emotional expression and interaction in music therapy improvisation]. Musiktherapeutische Umschau, 28, 351-361.

Plum, F. J., Lodemann, E., Bender, S., Finkbeiner, T., & Gastpar, M. (2002). Gruppenmusiktherapie mit schizophrenen Patienten.

Entwicklung des Kontaktverhaltens, des improvisatorischen Spielausdrucks und der Psychopathologie [Group music therapy with schizophrenic patients: Development of social behavior, improvisational expression and psychopathology]. Nervenheilkunde, 10, 522-528.

Remschmidt, H., Schmidt, M., & Poustka, F. (2002). Multiaxiales Klassifikationsschema fu¨r psychische Sto¨rungen des Kindes- und Jugendalters nach ICD-10 der WHO [Multiaxial Classification Chart for Psychic Disorders of Children and Young Adults according to ICD-10 of WHO]. Bern, Switzerland: Huber.

Sabatella, P. E. (2004). Assessment and evaluation in music therapy.

An overview from literature and clinical practice. music therapy today. Music Therapy Today, 5(1). Retrieved February 6, 2006, from http://www.musictherapyworld.net Schumacher, K. (1999a). Musiktherapie und Saeuglingsforschung [Music therapy and infant research]. Frankfurt am Main, Germany: Peter Lang.

Schumacher, K., & Calvet, C. (2007). The ‘‘AQR-instrument’’ (Assessment of the Quality of Relationship)—An observation instrument to assess the quality of a relationship. In T. Wosch & T. Wigram (Eds.), Microanalysis in music therapy: Methods, techniques and applications for clinicians, researchers, educators and students (pp. 79-91). London: Jessica Kingsley.

Schumacher, K., & Calvet-Kruppa, C. (1999b). The AQR: An analysis system to evaluate the quality of relationship during music therapy.

Nordic Journal of Music Therapy, 8, 180-192.

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Steinberg, R., & Raith, L. (1985). Music psychopathology II: Assessment of musical expression. Psychopathology, 18, 265-273.

Steinberg, R., Raith, L., Rossnagel, G., & Eben, E. (1985). Music psychopathology III: Musical expression and psychiatric disease.

Psychopathology, 18, 274-285.

Tischler, B. (2000). Ist Musiktherapie empirisch begruendbar? [Is music therapy empirically reasonable?] Musiktherapeutische Umschau, 21, 312-323.

Vanger, P., Oerter, U., Otto, H., Schmidt, S., & Czogalik, D. (1995).

The musical expression of the separation conflict during music therapy: A single case study of a Crohn’s disease patient. Art in Psychotherapy, 22, 147-154.

Woerner, W., Becker, A., Friedrich, C., Klasen, H., Goodman, R., & Rothenberger, A. (2002). Normative data and evaluation of the German parent-rated Strengths and Difficulties Questionnaire (SDQ): Results of a representative field study. Zeitschrift fu¨r Kinder- und Jugendpsychiatrie und Psychotherapie, 30, 105-112.

Zahler, E. (2002). Frei improvisierte Musik in der Musiktherapie als Medium fuer Ausdruck und Kommunikation von Emotionen. Eine musikpsychologische Studie zur musiktherapeutischen Grundlagenforschung [Free improvised music in music therapy as a medium for expression and communication of emotions: A music psychology study for music therapy basic research]. Unpublished thesis, University of Vienna, Austria.

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Bios Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG), Dipl. Psychologist, is a psychological psychotherapist with clinical practice at the University Clinic of Child and Adolescent Psychiatry and Psychotherapy in Wu¨rzburg and Frankfurt am Main, Germany, and chairperson of the postgraduate music therapy training BWM at the Freies Musikzentrum in Munich, Germany.

Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist, is a professor at the Institute for Psychology, University of Wu¨rzburg, Wu¨rzburg, Germany.

Kirstin Goth, Dr. phil. nat., Dipl. Psychologist, is a psychologist in the Department of Psychiatry, Psychosomatics and Psychotherapy for Children and Young Adults at Goethe University, Frankfurt am Main, Germany.

Fritz Poustka, Prof. Dr. med., professor emeritus, Clinic for Psychiatry, Psychosomatics and Psychotherapy for Children and Young Adults at Goethe University, Frankfurt am Main, Germany.

David Aldridge, PhD, FRSM, is codirector of Nordoff-RobbinsZentrum, Witten, Germany.

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J Autism Dev Disord (2007) 37:1264–1271 DOI 10.1007/s10803-006-0272-1

ORIGINAL PAPER

Use of Songs to Promote Independence in Morning Greeting Routines For Young Children With Autism Petra Kern Æ Mark Wolery Æ David Aldridge

Published online: 22 November 2006 Springer Science+Business Media, LLC 2006

Abstract This study evaluated the effects of individually composed songs on the independent behaviors of two young children with autism during the morning greeting/entry routine into their inclusive classrooms.

A music therapist composed a song for each child related to the steps of the morning greeting routine and taught the children’s teachers to sing the songs during the routine. The effects were evaluated using a single subject withdrawal design. The results indicate that the songs, with modifications for one child, assisted the children in entering the classroom, greeting the teacher and/or peers and engaging in play. For one child, the number of peers who greeted him was also measured, and increased when the song was used.

Keywords Music Therapy Æ Child Care Program Æ Inclusion Æ Autism Æ Transitioning Æ Collaborative Consultation

P. Kern Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, USA M. Wolery Department of Special Education, Vanderbilt University, Nashville, USA D. Aldridge Chair of Qualitative Research in Medicine, University of Witten-Herdecke, Witten, Germany P. Kern (&) School of Music, University of Windsor, 401 Sunset Avenue, Windsor, ON, N9B 3P4, Canada e-mail: PetraKern@prodigy.net

Introduction Providing early intervention services to young children with autism spectrum disorders is supported by substantial research and program evaluation data (Dawson & Osterling, 1997; National Research Council, 2001).

Some of this research argues for providing services in inclusive classes in community-based programs (Strain, McGee, & Kohler, 2001). However, for children with autism to benefit from such placements, attention must be given to their individualized learning needs (Strain et al., 2001).

Children in early childhood classes experience multiple transitions each day between activities and routines as well as to and from the classroom. Examples are initial arrival at the classroom, engaging in play, moving from one area of the classroom to another, going outdoors and coming back from outdoors, moving to a snack area, and going to a cot for naptime (Alger, 1984; Baker, 1992). Young children often spend large amounts of time in these classroom transitions (Carta, Greenwood, & Robinson, 1987).

For many young children with and without autism, the initial transition into a classroom each day can result in crying, clinging to the caregiver, and active avoidance of the class. Their parents and other caregivers may be uncertain about how to respond to these behaviors (Alger, 1984). These behaviors also may result in similar reactions from classmates and avoidance of the entering child (Osborn & Osborn, 1981).

Transitions, including the initial daily transition into the class, may be difficult for young children with autism (Dawson & Osterling, 1997; Mesibov, Adams, & Klinger, 1997). In addition, they may lack an understanding of symbolic gestures such as waving

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hello or good-bye or at least may engage in these greeting behaviors less than age mates (Hobson & Lee, 1998). Recommended strategies for promoting successful transitions of children with autism include using (1) structure and predictable routines (Marcus, Schopler, & Lord, 2001; Trillingsgaard, 1999), (2) visual cues (Bryan & Gast, 2000; Schmit, Alper, Raschke, & Ryndak, 2000), and (3) songs (Baker, 1992; Furman, 2001; Gottschewski, 2001; Williams, 1996).

Songs are a common occurrence in early childhood classes and are used by a wide range of professionals for skill promotion, entertainment, and expression of emotions (Enoch, 2001; Furman, 2001; Humpal, 1998).

In music therapy, ‘‘hello’’ and ‘‘good-bye’’ songs are used frequently to establish predictable routines and structure, provide undivided attention, and communicate a welcome (Bailey, 1984; Nordoff & Robbins, 1995). Using songs to promote successful transitions is recommended for young children with autism (Furman, 2002; Humpal & Wolf, 2003; Snell, 2002), but no previous study evaluated greeting and good-bye songs on the performance of young children with autism during the morning arrival time.

Studies on interest in music and relative strength of musical abilities in some children with autism (Applebaum, Egel, Koegel, & Imhoff, 1979; Thaut, 1987, 1988) and the effectiveness of music therapy interventions (Bunday, 1995; Kostka, 1993; Wimpory, Chadwick, & Nash, 1995) suggest music therapy is a viable treatment option for individuals with autism.

For instance, songs have been used to supplement the use of social stories to support social interaction in children with autism (Brownell, 2002; Pasiali, 2004).

Key recommendations for educating young children with autism (e.g., individualization, structure and predictability, emphasis on strengths and individual needs) can be incorporated in music therapy protocols or are part of the nature of music itself (American Music Therapy Association (AMTA), 2002). Although not studied systematically, music therapy can include embedding music therapy principles and strategies into ongoing routines of children’s days using a collaborative and consultative model of service delivery (Furman, 2001, 2002; Snell, 2002).

The purpose of this study was to evaluate the effects of individually composed greeting songs implemented by classroom teachers on the independent performance of two young children with autism during the morning greeting routine. Three research questions were asked: (1) Does the use of an individually composed song, sung by teachers, increase appropriate independent performance during the morning arrival routine of young children with autism; (2) Can classroom teachers

apply the principles important to music therapy in a particular routine, and (3) Does use of the song increase interactions between the child with autism and his peers?

Method Participants Two boys, Phillip and Ben, with autism participated in the study. Phillip was a 3 year 5 month-old African American, and Ben was a 3 year 2 month-old European American. Licensed psychologists who were not involved in the study used the DSM-IV criteria (American Psychiatric Association, 2000) when establishing their diagnoses. On the Childhood Autism Rating Scale (Schopler, Reichler, & Renner, 1988), both boys were placed in the mild to moderate range.

Prior to the study, Phillip and Ben had been enrolled for 10 months in an inclusive community-based child care program affiliated with an university. They were selected for the study on the request of their parents and classroom teachers and therapists.

Both boys had limited speech, and the Picture Exchange Communication System (PECS) (Bondy & Frost, 1994) was being used. Ben was beginning to use a few functional words. Phillip and Ben showed limited social interactions with peers, played primarily when supported by adults, and engaged in stereotypic behaviors. Both children exhibited difficulties with transitions, although objects were used successfully with some transitions other than the morning arrival transition. The morning arrival transition was problematic for both boys. Phillip would refuse to enter the classroom, scream, or lie on the floor. Ben would hold on to his caregiver, cry, and ignore efforts of the teachers to welcome him. Phillip and Ben were interested in and responded well to music. They preferred listening to selected musical pieces, and participated in classroom musical activities.

Other participants included the target children’s classmates with parental consent (n = 13), the target children’s respective caregivers (n = 2), and classroom teachers (n = 5). The class size of Phillip’s class was seven children (including him) ages 2 to 3 years and included both males and females from different ethnic groups. Five of his classmates were developing typically, and one had disabilities. Ben’s class had eight children (including him) ages 3 to 4 years and included both males and females from different ethnic groups. Five of the children were developing typically and two had disabilities. All adults in the classroom

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participated based on their schedules, which included staggered start times to cover the entire child care day. They had diverse educational backgrounds, ranging from high school diploma to Baccalaureate degree with certification in early childhood education.

Their teaching experience ranged from 1 to 4 years.

Phillip and Ben’s caregivers (a mother and nanny, respectively) participated in the study on a daily basis by bringing them to their classrooms and participating in the greeting time procedures. The teachers and caregivers did not have prior experience with music therapy interventions.

Setting The inclusive university-affiliated child care program in which the study occurred held accreditation from the National Association for the Education of Young Children (NAEYC) and the State’s highest quality ranking for child care programs. The classrooms followed the recommended practice guidelines of NAEYC (Bredekamp & Copple, 1997) and the Division for Early Childhood (Sandall, McLean, & Smith, 2000). Specialists such as music therapists, occupational therapists, speech language pathologists, physical therapists or special educators worked with the individual child or a group of children in the ongoing classroom routines or as a consultant to the classroom teachers (McWilliam, 1996). Cubbies for children to place their personal items were located in the hall outside each classroom.

The study occurred during the morning greeting routine. In the mornings, children arrived individually over a 1.5 h period. The usual routine was for each child, and his/her parent, to place personal items in the child’s cubby and then enter the classroom together.

All children would be greeted by, and greet, the teacher and peers, then engage in play. The classroom curriculum allowed free play during the morning arrival time. Children engaged in different play areas by themselves or with each other. The parents signed the child in and had a brief conversation with the teacher before saying ‘‘good-bye’’ to the child and leaving the classroom.

Materials Before the study, the teachers used a laminated picture (10 · 10 cm) communication symbol (Mayer-Johnson, 1992) showing a waving stick figure and the word ‘‘Hello’’ printed on the top using 18 pitch letters and the Arial font. This symbol was used in the study to assist the target participants in greeting classroom

teachers and peers, regardless of their language and communication skills when entering the classroom in the morning.

The first author composed a greeting song unique to each target participant.1 The music was composed to match each child’s personality with the lyrics conveying the demands of the desired five-step morning greeting routine (see below). To emphasis the detachment from the caregiver, step four, which reflected the ‘‘good-bye’’ part, differed musically in melody and mood from the other steps. All other steps followed the same melody, but used different lyrics.

Some of the lyrics were flexible to allow the children to choose different peers and describe the daily weather condition. A practice CD containing the song and the song transcriptions were given to the teachers and caregivers during a staff/caregiver training session.

The intention of the songs for both children was to ease the transition from home to school, to increase their independent performance (i.e., independent functioning) during the five-step morning greeting routine, and to support their interaction with peers (i.e, engaging in greeting peers).

Design Single subject research designs were used. For Phillip, an A-B-A-B withdrawal design (Aldridge, 2005; Tawney & Gast, 1984) was used. The baseline condition (A) consisted of the existing greeting routine, and the treatment (B) involved using the song during the greeting routine. For Ben, a modification of this design was used; specifically, an A-B-C-A-C design.

The baseline (A) was the existing greeting routine, the treatment (B) was the use of the song during the greeting routine, and the C condition was a modification of the song. Staff/caregiver training activities occurred prior to baseline measures.

Baseline Condition (A) In the baseline condition, the child and caregiver entered the center, placed the child’s belonging in his cubby in the hallway, and picked up the picture symbol showing the stick figure waving ‘‘Hello,’’ which was attached with Velcro to the child’s cubby.

They then entered the classroom, and a classroom teacher initiated the greeting routine, which was similar to that used with classmates. Five steps were followed: (1) the target child enters the classroom 1

Interested readers can contact the first author to get a music score.

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independently; (2) the target child greets a person (teacher or peer) in the classroom verbally and/or hands over the picture symbol; (3) the target child greets a second person (teacher or peer) in the classroom verbally and/or hands over the picture symbol; (4) the target child says/waves ‘‘good-bye’’ to the caregiver, who leaves the classroom; and (5) the target child engages in appropriate play with a toy or material found in the classroom. A system of least prompts (Wolery, Ault, & Doyle, 1992) was used to assist the target child in responding independently to each step of the greeting routine and ensure the child completed each step of the routine.

Staff/Caregiver Training Activities Initially, the first author consulted with the caregivers and teachers to identify realistic intervention goals and acceptable procedures for use in the greeting routine.

Before baseline measures, she composed and recorded the individual songs, and gave them to the caregivers and teachers. During a circle time in the children’s classrooms, the first author led the children and teachers in learning and singing the songs. She also gave precise instructions to the teachers and caregivers about how to approach and assist the target children in greeting and interacting with peers musically. The teachers were encouraged to include all peers who would come forward voluntarily to greet the target child in the greeting routine during all phases (baseline, intervention, and reversal). Staff training ended after 2 weeks when the teachers and respective caregiver sang the song correctly and indicated that they were comfortable with the procedures.

Intervention (B) In the intervention condition, the procedures used in the baseline were continued. The only change was the use of each child’s greeting song. The songs had lyrics matching each of the five steps of the greeting routine.

The teacher began singing the song as the child entered the classroom, and sang the lyrics for each step as it was occurring.

Modified Intervention (C) For Ben, the number of independently completed steps did not change substantially with the introduction of the song. Based on an analysis of the situation, we concluded Ben began to cry when separating from his caregiver and this interfered with independent performance of the steps. Thus, the fourth step (saying

‘‘good-bye’’) was eliminated, and his caregiver left the classroom as Ben entered it. Other procedures remained the same.

Response Definitions and Measurement Two adult behaviors and five child behaviors were measured through direct observation using event recording. Data were collected during morning arrival time, when the teachers and peers were present. The observation started when the target child and his caregiver entered the classroom. The observation ended when the target child picked up a toy/material in the classroom, even if he had not said ‘‘hello’’ or ‘‘good-bye.’’ Data collection sessions lasted between 2 and 10 min. Phillip was observed for a total of 28 sessions across 2 months. Data collection for Ben was initiated 5 months later, and occurred in 31 sessions over 3 months.

The adult behaviors were: Prompting was defined as a teacher or caregiver assisting the child in performing a step in the routine. This assistance was either verbal (e.g., ‘‘Say, Hello’’) or physical (e.g., the adult put her hand on the child to help in the exchange of the picture). No adult prompt was defined as the teacher or caregiver not giving a prompt for a step of the greeting routine.

The child behaviors for each step of the routine were as follows. Independent response was defined as the child performing the behavior required in each step of the routine without any adult assistance.

Prompted response was defined as the child performing the step of a routine but receiving adult prompt to do so. No response was defined as the child not responding, even when prompted. Error was defined as the child either not following the sequence of the routine or engaging in an appropriate behavior not prescribed by the routine, and Inappropriate response was defined as the child engaging in problematic behavior (i.e., tantrums). These categories were coded for each of the five steps of the morning greeting routine. An additional category was added for Ben to identify the number of classmates with and without disabilities who greeted him independently during the routine. This category was added because of informal observations with Phillip indicating peer greeting behavior changed during the course of the intervention. The number of peers greeting independently was defined as peers receiving the ‘‘Hello’’ symbol from Ben without verbal or physical prompting from an adult. Some observations were videotaped with a Panasonic AG-195 Camcorder and analyzed immediately afterwards.

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Observer Training and Interobserver Agreement Before the baseline condition, a music therapist (first author), a special educator and a research assistant observed and recorded the behaviors of teachers and children in the morning greeting routine. Training was concluded when inter-observer agreement was at 80% for three consecutive observations. During the study, inter-observer agreement checks occurred in a mean of 22% of the observations for each condition and child.

The percentage of agreement was calculated using the point-by-point method (Tawney & Gast, 1984). The number of agreements were divided by the number of agreements plus disagreements with the quotient multiplied by 100. Overall, inter-observer agreement ranged from 75 to 100%, with a mean of 94%.

Phillip’s performance steadily moved toward independence. After 10 sessions in intervention, Phillip’s performance appeared consistent, as evidenced by three consecutive sessions with four independent steps at the same level; thus, the intervention was withdrawn.

Phillip’s performance immediately decreased and by the second day of the second baseline condition, his performance returned to the initial baseline levels with two independent steps (again entering the classroom and finding a toy to play with). After three days, the song intervention was re-introduced. Immediately, Phillip’s performance increased. After four sessions, Phillip’s performance was equal to his performance at the end of the initial intervention condition. His performance remained steady at this level until the ninth session of intervention where Phillip performed all of the steps of the routine independently.

Results

Ben

Phillip

In the initial baseline condition, Ben’s performance was stable as shown in Fig. 2. In the majority of the sessions, he had one independent step completed, entering the classroom independently. On session four of the first baseline condition, Ben did three independent steps.

With the introduction of the song intervention, Ben’s performance was variable. Ben responded in the majority of sessions with one independent response, as in the baseline condition. In four of 12 mornings, Ben completed more than one of the steps independently.

Given the lack of substantial change in his performance, the ‘‘good-bye’’ step was eliminated and the caregiver left the classroom as he entered (Condition C). This produced an abrupt and sharp increase in the number of steps completed independently. He consistently had three of four steps done independently. After five sessions of stable performance, the intervention was

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During the initial baseline condition, Phillip’s performance was stable as shown in Fig. 1. In all sessions except the fourth, Philip completed two steps of the routine independently. In the fourth session, he did not do any step independently. The steps he did independently were entering the classroom and finding a toy with which to play. With the introduction of the song intervention, Phillip’s performance initially dropped to one step independently (entering the classroom), but after two days of song intervention, Phillip’s performance was back at baseline level. By the forth day of intervention, Phillip’s performance was above baseline level and by the sixth session, Phillip’s performance was consistently higher than the baseline level. The trend during the intervention condition indicates

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Fig. 1 Number of independent responses performed by Phillip during the morning greeting routine in baseline and intervention sessions

Fig. 2 Number of independent responses performed by Ben during the morning greeting routine in baseline, intervention, and modified intervention sessions

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withdrawn. An immediate decrease in his independent behavior occurred. With the re-introduction of the intervention, the data resulted in an abrupt and sharp increase in the number of independent steps. Ben completed all four steps independently. This high level of performance was stable during the last condition.

The number of peers who greeted Ben without adult prompting are shown in Fig. 3. During the initial baseline condition, no peers greeted Ben during the greeting routine. With the use of the song intervention, two peers greeted him independently on 9 of 12 days, and four, three, and one peer greeted him on the remaining days. With the modified intervention, two peers greeted him on three of five days, but on one day no peers greeted him and on the other day, one peer greeted him. The removal of the song in the second baseline resulted in more variable data. Two peers greeted him independently on two of five days; on the second day, three peers greeted him, but on the last two days, one peer greeted him. The reintroduction of the modified intervention resulted in two peers greeting him on three of four days, with one peer greeting him on the first day of the condition. Thus, initiation of the song intervention resulted in an increase in the number of peers greeting Ben, but withdrawal of the song in the second baseline did not result in data patterns similar to the first baseline. Neither the modification of the intervention nor the withdrawal of the song intervention returned the peers’ behavior to baseline conditions, with the exception of one day.

Discussion

Number of Peers Greeting Ben

This study evaluated the effects of embedding a music therapy intervention (using original greeting songs) in the morning arrival routine on the independent functioning of two young boys with autism. It also examined Baseline

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Fig. 3 Number of peers greeting Ben during the morning greeting routine in baseline, intervention, and modified intervention sessions

whether teachers could implement the songs in the context of that routine after receiving consultation and training from a music therapist; and, finally, whether use of the songs influenced classmates’ greetings to one target child. As shown, the data support the use of individualized songs implemented in this manner to facilitate independent entry into classrooms. As such, it adds to the literature on how to include young children with autism in inclusive classrooms (Strain et al., 2001).

In this study, individualized greeting songs matching the participants’ personality (based on the music therapist’s judgments) and the demands of the morning greeting routine were effective in facilitating a smooth transition from home to the child care program. These findings support the recommendation to use songs to ease transitioning for individuals with autism (Baker, 1992; Furman, 2001; Gottschewski, 2001).

These effects occurred, with the teacher rather than the music therapist implementing the songs in the morning greeting routine. The teachers did not use songs for this purpose prior to this study, did not know the songs until they were taught by the music therapists, and did not have formal musical training or experience with music therapy interventions. In addition, the training time was relatively short. This study replicates and extends earlier studies showing that classroom teachers can embed intervention strategies successfully into ongoing routines, when training and monitoring were provided (Kemmis & Dunn, 1996; Venn et al., 1993). However, despite their success, teachers were challenged with parts of the musical characteristics of the songs. For example, in both cases the teachers did not implement the change in music indicating the good-bye part of the songs (step four of the greeting routine). Interestingly, and perhaps coincidentally, it was exactly this part that distressed both target children. This raises the question if the implementation of the change in music signaling the ‘‘goodbye’’ part would have changed the target children’s performance during this step. No data are available to suggest the change in the music would produce positive outcomes, but future research should examine this possibility. Other explanations exist for the children’s difficulty with this step such as the lack of understanding of conventional gestures and the fact that it signaled the caregiver leaving. Clearly, high quality staff development activities and ongoing collaborative consultation seem to be critical components for appropriate and successful implementation of teachermediated interventions using music therapy principles.

In this study, maintaining teacher’s comfort level, motivation, and monitoring of the teachers’ use of the procedures were needed.

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The use of the songs also potentially had positive effects on peers’ greeting behavior and interaction toward the target children. This was noted informally for Phillip and then measured formally for Ben. Peers volunteered in singing and greeting the target children during their morning arrival time, or participated by giving their input to the song (e.g., statements about the weather condition) while engaging in other activities. The song intervention seemed to pique the interest of peers and evoke a positive view toward Ben. This change seemed to be affected by the intervention alone and was not contingent on Ben’s performance. That is, the greeting song motivated the peers to interact with Ben, but his performance did not change until after the peers had regularly greeted him. However, the number of peers greeting him did not return to the levels of the initial baseline during the second baseline condition.

The teachers, parents of the target children, and parents of other classmates reported the intervention was effective and valuable. The mother of one of Phillip’s peers said that before the intervention her child was intimidated by Phillip’s inappropriate behavior at greeting time. With the implementation of the song, this classmate ran to school hoping to arrive before Phillip so he could participate in Phillip’s greeting song. Phillip’s mother reported she was very pleased by the success of the intervention and requested further songs for other challenging situations. Ben’s caregiver said: ‘‘I think this was perfect for Ben. He had a hard time leaving me in the mornings, but with the help of the Good Morning Song the transition became much easier for Ben.’’ After evaluating the song intervention with Phillip’s classroom teacher, she came to the following conclusion: ‘‘Transitions into the classroom were stressful for the children, parents, and teachers. The Hello Song allowed us to implement a simple intervention each day. The song is great, and helped all of us tremendously.’’ These comments, the teachers willingness to use the song intervention within daily classroom routines, and the request for new songs addressing other challenging behaviors (i.e., waiting and hand washing) is some evidence of the social validity of the procedures and effects.

This study has several limitations; for example, only two participants were studied because of their need for intervention during the morning arrival time. Replication of this study for additional participants is recommended. Further, for Ben, a modification was needed before the song was successful. Thus, it is unclear whether the modified intervention would have been effective if Ben had not experienced the original intervention. Also, the music therapist composed original

songs for each child; thus, these data do not indicate whether a teacher, without assistance from a music therapist, could adapt a pre-composed song (referred to as the ‘‘Piggybacking’’ technique) and produce similar results. Another limitation concerns the lack of maintenance and generalization data.

This study suggests future studies should focus on the effects of songs in other challenging routines for young children in inclusive classes. Similarly, studies focusing on using songs to promote other skills (e.g., social and communicative abilities) should be implemented. Finally, systematic studies of the effects of songs designed for young children with autism should contain measures of the effects on their peers. Do such songs change the behaviors and attitudes of peers toward their classmates who have autism?

Acknowledgement This study is a part of a series of single case studies investigating embedded music therapy interventions for the inclusion of young children with autism spectrum disorders in a community-based, university-affiliated Family and Child Care Program. The authors wish to acknowledge Dr. Ann N. Garfinkle for her contributions to the study. Gratitude also goes to the children and families, teachers and colleagues for their participation, dedication, and collaboration in this study.

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Furman, A. (2002). Music therapy for learners in a community early education public school. In B. L. Wilson (Ed.), Models of music therapy interventions in school settings (2nd ed., pp. 369–388). Silver Spring, MD: The American Music Therapy Association, Inc. Gottschewski, K. (2001). Autismus aus der Innenperspektive und Musiktherapie [Autism from an inside-out perspective and music therapy]. In D. Aldridge (Ed.), Kairos V: Musiktherapie mit Kindern: Beitraege zur Musiktherapie in der Medizin (pp. 40–57). Bern; Goettingen; Toronto; Seattle: Verlag Hans Huber.

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Wimpory, D., Chadwick, P., & Nash, S. (1995). Brief report: Musical Interaction Therapy for children with autism: An evaluative case study with two-year follow-up. Journal of Autism and Developmental Disorders, 25(5), 541–552.

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0197-4556193 $6.00 + .OO Copyright 0 1993 Pergamon Press Ltd.

The Arts in Psychotherapy, Vol. 20, pp. 285-297, 1993 Printed in the USA. All rights reserved.

HOPE, MEANING AND THE CREATIVE ARTS THERAPIES IN THE TREATMENT OF AIDS DAVID ALDRIDGE, PhD*

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?

Michel Foucault (in Rabinow, 1986, p. 350) The general proposal of this paper is that the creative arts therapies have a significant role to play in the treatment of AIDS patients. Not only do they offer an existential form of therapy that accepts patients as they are and affords them an opportunity to define themselves as they wish to be, they are primarily concerned with aesthetic issues of form and existential notions of potential rather than concepts of pathology. That the persons are infected with a virus recalcitrant to medical initiatives is a given and is inarguable. What the persons will become and how a personal future is defined, a future admittedly restricted and often tragically curtailed, are matters for joint therapeutic endeavor between therapists and patients and are not accessible to a normative medical science (Aldridge, 199la).

The end stage of our therapeutic endeavor is that the patients will die. This raises important questions about the nature and goals of therapy, with important implications for establishing the criteria for measuring or assessing the efficacy of our therapeutic endeavors.

Many of the considerations we need to make, particularly with the dying, are not amenable to operational

definition and thereby elusive to measurement (Feifel, 1990). However, they are amenable to artistic expression in that they can be written as poetry, acted as drama, moved as dance, drawn, sculpted and painted as art, told as stories and played as music.

Creative arts therapies (music therapy, art therapy, dance therapy, drama therapy and poetry therapy) have been developed for use in predominantly psychotherapy settings. Some creative arts therapists have developed the work with the dying in hospice settings (Dessloch, Maiworm, Florin, & Schulze, 1992; Frampton, 1989) and Lee (199 1) has developed the use of music therapy both with cancer patients in the hospice setting and with AIDS patients.

The following sets out some considerations that we may wish to incorporate into our treatment and research initiatives. As the treatment of AIDS patients occurs predominantly in a medical setting, it is necessary to present some of the medical understandings of the problem in the first part of this paper. Those medical understandings, however, are partial. Medicine is a restricted set of practices from the repertoire of our possible healing strategies. What we also need are understandings gained from existential psychology and the creative arts themselves. Such understanding~will be attempted in the latter part of this paper.

AIDS Definition AIDS (Acquired Immunodeficiency Syndrome) is clinically complex. The process begins with infection

*David Aldridge is Associate Professor of clinical research methodology in the medical faculty of Universitat Witten Herdecke, Germany, and European Editor of The Arts in Psychotherapy.

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through the bloodstream with the Human Immunodeficiency Virus (HIV). Initially there are no obvious symptoms. However, after about 4 weeks flu-like symptoms may occur, indicating an immune reaction.

This reaction is the body's normal way of removing infections. What then occurs is the most dangerous part of the viral activity that makes HIV so intractable to treatment. The immune system is in part composed of "helper cells." It is these cells that act as a host to the virus which then changes their structure. Every time an immune reaction occurs in the body the virus is replicated. What was formerly "helping" is now "infecting. " However, it must be stressed that not all HIV-infected patients will undergo this process of seroconversion (i.e., changed immune status).

The stage is set for the development of AIDS, the development of which varies from individual to individual. As the immune system deteriorates there are increasing possibilities for opportunistic infections. It is often these infections from which the patient eventually dies. As a condition, AIDS was characterized by the following symptoms: (a) common infections, like pneumonia, to which the body has no immunity, (b) the development of malignancies like rare skin cancers and (c) neurological disorders sometimes leading to dementia. However, a new AIDS definition has been proposed by The Centers for Disease Control in the United States regardless of symptomatic expression to include those people who are seropositive for HIV and have a particular white blood cell count (CD4 T-lymphocyte) of less than 200Ipl (Editorial, 1992; Nelson, 1992). The result of such a decision for research is that it will be easier to define cases. In practice such a decision means that the incidence of AIDS will rise sharply. Recently new AIDS indicators of the disease have been recognized as pulmonary tuberculosis, recurrent bacterial pneumonia and invasive cervical cancer. The inclusion of pulmonary tuberculosis has "more to do with efforts to control tuberculosis among HIV-infected populations than its value as an indicator of severe immunodeficiency" (Editorial, 1992 p. 1200; Nelson, 1992). We see here that even in the apparently simple process of case definition, considerations of social control are raised, echoing the stigmatization of tuberculosis patients in the earlier part of this century.

Immunity, Life Events and Social Context AIDS is how the immune system reacts between viral infection and the development of AIDS and is David Aldridge

dependent upon the individual. However, the social and psychological conditions in which the infected persons live are also contributing factors to the development of AIDS. As we are now becoming increasingly aware of the influence of lifestyle upon immune capabilities (Ader, 1987; Darko, 1986; Solomon, 1987), it is in this arena of contact that we may be best able to offer therapeutic help. An already weakened system is further weakened by the threat of a lingering death, social isolation and condemnation. The contact between arts therapists and patient is the opposite to that of isolation in that it offers the patient the chance to be a partner in a creative process that is without stigmatization.

There is a considerable bodv of work on the relationship between life events and psychological disorder, which has been extended to working with AIDS patients (Atkins & Amenta, 1991; Blaney et al., 1991; Dew, Ragni, & Nimorwicz, 1991; Ross, 1990).

In a study to determine the extent to which stigmatization influences mental health in 80 homosexual men, there were significant associations between life events and mental health. Events related to AIDS had the highest correlations (Ross, 1990). Ross suggested that the impact of life events may be amplified by stigmatization and that degree of life change is associated closely with psychological dysfunction. He concluded that life events, which are related to both stigmatization and related emotional distress, are significant predictors of psychological dysfunction.

For every patient living with the diagnosis of AIDS or a positive HIV test result this means a turning point in his or her life. It is existential uncertainty and unpredictability that lie at the root of post diagnostic problems. Although the need for early treatment is evident, this also means a personal exposure to social scrutiny. AIDS is seen as threatening, as is no other current disease. This is in part exacerbated by information campaigns. Once the diagnosis is made, the whole texture of social life and intimate relationships changes radically. Any future perspective on life is inhibited by the possibility of repetitive stays in hospital and a deteriorating physical and mental status.

Physical problems go hand in hand with emotional problems, and these occur in a context of personal relationships. The consideration of physical, emotional and relational problems together is sometimes known as the biopsychosocial model (Engel, 1977; Sadler & Hulgus, 1990). Using such a model, Wolf et al. (1991) evaluated 29 symptomatic and asymptomatic HIV-infected homosexual/bisexual men between

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS 18 and 45 years old in the areas of psychiatric1 psychosocial, neuropsychological, family and irnrnunological functioning. The outcome measures were mood disturbance, psychological distress and white blood cell count (CD4). The most significant other family member, as selected by each subject, completed family measures. The subjects experienced psychological distress and neuropsychological problems. Coping was related to enhanced mood as was perceived social support, which was also related to lower psychological distress. Higher levels of neuropsychological functioning (verbal memory, visual memory, motor speed and visual-motor sequencing) were associated with enhanced psychosocial functioning andlor immunological status. The authors concluded that it is important then to make longitudinal studies using a multidimensional approach in which HIV-infected persons and their most significant other family members are evaluated.

The suicide rate in persons with AIDS is significantly higher than in the general population (Cohen, 1990; Grant & Hampton Atkinson, 1990). Grant (Grant & Hampton Atkinson, 1990) remarked that although some subgroups of HIV-positive individuals (e.g., military samples) may be at heightened risk for suicide, systematic studies showing an increased risk for suicide are lacking. Schneider considered suicidal ideation among relatively asymptomatic HIV-positive gay men as a cognitive coping strategy that may alleviate emotional distress (Schneider, Taylor, Hammen, Kemeny, & Dudley, 1991). Certainly the picture is complex. Risk factors for suicide in the general population include hopelessness, impulsivity, substance abuse disorder, recent illness, recent hospitalization, depression, living alone and inexpressible grief. These factors are present in particular AIDS patients who are depressed, lonely and isolated and at high risk for suicide. Marital break-up or a failing relationship that eventually ceases is a significant feature leading to such loneliness. As Blaney remarked (Blaney et al., 1991), the lack of social support is a strong predictor of psychological distress and is implicated in the control of chronic disease. Suicidal behavior may be the end stage of a process of increasing psychological distress related to both failing health status, because of increasing symptoms, and increasing isolation.

Help-Seeking In a longitudinal survey of help-seeking and psychological distress among San Francisco gay men David Aldridge

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(Hays, Catania, McCusick, & Coates, 1990), those men reported high levels of anxiety, depression and help-seeking from their social networks. High percentages of AIDS-diagnosed men sought help from all sources (peers, professionals, family), whereas nondiagnosed men were more likely to seek help from peers. Regardless of the men's HIV status, peers were perceived to be the most helpful source. Family members were less likely sought and were perceived as least helpful. However, in other studies, family and friends appear to play an important, if sometimes ambiguous, role in caregiving. The psychological burden of the families and health workers involved in their treatment of AIDS patients is probably greater than that of any other medical condition (Maj, 1991).

In a study by Atkins and Amenta (1991), family adaptation to AIDS and to other terminal illnesses was compared by measuring the number of stressful events experienced by the family after diagnosis and role flexibility in response to medical stressors.

Families of AIDS patients had significantly more stress, more rules prohibiting emotional expression, lower trust levels and more illness anxiety than other families.

In young children with AIDS, with the exception of transfusion-infected children, there is necessarily the presence of an infected adult, usually the mother.

The problem in such a situation is not that of a child with a fatal illness but that of an entire family. In a study of 30 natural caregivers (mostly mothers but also fathers, aunts and grandmothers), most of the caregivers were economically disadvantaged and needed help in coping with stress and their life situation (Reidy, Taggart, & Asselin, 1991). Their need to confide in others was frequently not met although they responded well to medical care, support and advice.

Social and Ethical Aspects Few diseases since syphilis in the 19th century and tuberculosis in the early part of this century have raised the ethical, scientific and economic questions that AIDS has. The moral responsibility of the therapist to offer unconditional care for the patient has been threatened. The scientific principles of placebo trials and safe drug testing procedures have been consistently challenged by the community of AIDS activists (Faden & Kass, 1990), and the cost of health care provision for European and American health care systems is potentially crippling. Furthermore, the dis-

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ease has struck our modem society at its most vulnerable point in raising the issue of how we care for the sick, the poor and those we label as deviant (Ackerman, 1989; Ribble, 1989). Not only are patients infected with a recalcitrant virus, they are often infected by our attitudes of intolerance and condemnation (Johnston, 1988).

As some of those persons contracting the AIDS virus are likely to belong to groups that are socially vulnerable-homosexual men and women, the urban poor of ethnic minorities and drug users-the challenge of offering treatment is one that reaches into the ethical resources of our healing communities. It is precisely the source of contracting AIDS that causes many of the ethical problems. At a time when apparently choice of sexual orientation was becoming a matter of personal preference rather than solely genital dominance, and the tolerance of homosexual and lesbian activity was increasing, the AIDS virus served once more to condemn groups of people to the state of potential deviancy (Faden & Kass, 1990).

Fear of contagion, coupled with prejudices about lifestyle, are undoubtedly strong factors of influence in the way that some caregivers treat their patients. A wide range of emotional reactions by the caregiver may occur from refusal to provide care, resulting in rejection, to a total immersion in the infected person's needs, leading to burnout. Because irrational fears and attitudes play an important role in conditioning these reactions, education alone for the caregivers may not be sufficient to change behavior. Counselling sessions and mutual support groups are often the most appropriate contexts where fears and concerns can receive an individually tailored response, and where formal and informal caregivers can be helped to manage stress.

In contrast to other terminal illnesses, patients can often clearly say where, when and under what circumstances they contracted the disease. It is these circumstances that form the axis of judgment about the illness~eitherinnocently infected victims or irresponsible deviants. The conditions governing the attribution of the status sick (Parsons, 1951) are that the sick: (a) do not form groups, (b) recover within a prescribed time, and (c) are not causally responsible for their own demise. The last two of these conditions are violated by patients infected with the HIV virus.

Furthermore, the AIDS activists who encourage sufferers to form groups and advocate for changes in treatment and support on their own behalf are threatening a longstanding social requirement that the sick David Aldridge

remain divided and powerless. Furthermore, as a proportion of the AIDS-infected population is drug users, the very virus is associated with an already socially stigmatized group. As Ribble (1989) pointed out, a nurse may feel a strong empathy for the sexuallyinfected partner of an intravenous drug user, yet significantly less empathy for the infected drug user.

Maintaining Integrity and Hope The immune system is the biochemical part of our identity. It is not only a system of reaction, but also a proactive system. Its actions are projected into the future to develop, restore and maintain our physiological identity based upon the experiences of today and yesterday. Immunological reactions are not only effects caused by aggressive stimuli; they are also meaningful memories of our physiological makeup.

The immune system is the major integrative network within our bodies that facilitates our biological adaptation (Wiedermann & Wiedermann, 1988).

For the HIV-infected patient the task is one of maintaining an identity, the source of which is partially and perpetually self-corrupted (in that the DNA material of some cells is changed). This itself calls for both an acceptance of self and the realization of a creative new self. It also calls for a massive new alignment of bodily immune regulation. Positive emotions are known to be beneficial for the immune system. Yet, it is possible to go further and say that the qualitative aspects of life-hope, joy, beauty and unconditional love-are also vital and beneficial in therapy. This is precisely the ground in which the creative arts can have their own being. Patients can explore and express their being in the world, which is creative and not limited by their infection. From such a perspective we might expect that, although physical parameters may fluctuate or deteriorate, lifequality measures or existential indicators would show improvement.

A significant existential beneficial factor in enhancing the quality of life is hope. Hope has been identified as a multifaceted phenomenon that is a valuable human response even in the face of a severe reduction in life expectation. Herth's (1990) study explored the meaning of hope and identified strategies that were used to foster hope in a sample of 30 terminally-ill adults. Cross-sectional data were collected on 20 of the subjects and longitudinal data were collected on 10 of the subjects in order to provide a clearer understanding of the hoping process during the

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS dying trajectory. Hope was defined by Herth as an "inner power directed toward enrichment of 'being'. " With the exception of those diagnosed with AIDS, overall hope levels among subjects were high and were found to remain stable over time. Seven hope-fostering categories (interpersonal connectedness, attainable aims, spiritual base, personal attributes, light-heartedness, uplifting memories and affirmation of worth) and three hope-hindering categories (abandonment and isolation, uncontrollable pain and discomfort, devaluation of personhood) were identified.

Hope, like prayer (Saudia, Kinney, Brown, & Young, 1991), is a coping strategy used by those confronted with a chronic illness, which involves an expectation that goes beyond visible facts and can be seen as a motivating force to achieve inner goals.

These goals change. Although a distant future of life expectancy no longer exists for AIDS patients, life aims can be redefined and refocused. With the progression of physical deterioration, the future becomes less defined in time but in the meaning attached to life events in relationship to meaningful others. In later stages there is a shift toward less concrete goals and a refocusing on the self to include the inner peace and serenity necessary for dying (Herth, 1990). Music therapy, for example, with its ability to offer an experience of time that is qualitatively rich and not chronologically determined, is a valuable intervention.

The arts therapies, with their potential for bringing form out of chaos, should offer hope in situations of seeming hopelessness and are, therefore, a means of transcendence. This idea of transcendence, the ability to extend the self beyond the immediate context to achieve new perspectives, is seen as important in the last phases of life where dying patients are encouraged to maintain a sense of well-being in the face of imminent biological and social loss (see Figure 1).

Implications for Treatment For many AIDS patients, personal relationships are deteriorating. Either friends die of the same illness or social pressures urge an increasing isolation. Spontaneous contacts are frowned upon and the intimacy of contact is likely to be that of the clinician rather than the friend. Creative arts therapies can offer an opportunity for intimacy within a creative relationship. This is both nonjudgmental and equal. Once David Aldridge

more the patient is encouraged to creatively form a new identity.

Working with a therapist in a creative way to enhance the quality of living can help patients make sense of dying (Aldridge, 1987b). It is important for the dying, or those with terminal illness, that approaches be used that integrate the physical, psychological, social and spiritual dimensions of their being (Con, 1993; Feifel, 1990; Gary, 1992; Herth, 1990).

The intensification of the inner life through artistic activity helps provide a refuge from the emptiness of existence in a threatened future, but also provides a platform from which the next existential spring can be made. Having AIDS changes the experience of time.

Many of those who have the disease are young. Suddenly they are faced with a provisional and uncertain existence. Without a goal it is difficult to live for the future. To do something positive, to create, to play, is to take life seriously. The creative act is to take the opportunity to live. The creative act gives us the possibility to realize something of value in the world.

Whereas passive appreciation of art and beauty enhances our aesthetic appreciation, the act of creation offers a way forward into the future. For those who are suffering, the creative act, no matter how small, offers the chance to achieve something concretely (Frankl, 1963). By painting, singing, dancing, acting or making music together we can bring the emotion of suffering into the world in a concrete form. Suffering made external as expression and brought into form by art gives the individual the chance to grapple with the meaning of that suffering and thereby bring about change. To quote Frankl (1963): Whenever one is confronted with an inescapable, unavoidable situation, whenever one has to face a fate that cannot be changed, such as an inoperable cancer, just then is one given a last chance to activate the highest value, to fulfil the deepest meaning, the meaning of suffering. For what matters above all is the attitude we take toward suffering, the attitude in which we take our suffering upon ourselves. (p. 178) The meaning of life is discovered in concrete acts of creation that are aesthetic. What is internal is expressed externally as form. By bringing onto paper, or forming as sound, by moving the body in a sequence of dance or creating a narrative with dramatic intent, the individual takes responsibility for answering the

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DAVID ALDRIDGE Coping with physical changes

Anticipation of pain Management of pain Management of the physical consequences of illness (nausea, incontmence)and change m physical appearance Management of the physical consequences of treatment

Coping with personal changes

Loss of hope, fitness and identity Anxiety and depression about the future Loss of role in family and in employment Frustration and helplessness

Coping with relationship changes

Resolution of conflict Change in parental roles Anxiety about the future welfare (emotional and financial) Anticipated hospital contacts and treatment Anticipated loss of a family member or partner Planning the future Social isolation Changes in family boundary, and of family and marital emotional distance Negotiation of dependendindependence Saying 'good-bye' and talking about dying Handling the above personal and physical changes within the context of an intimate relationship Changes in, and loss of, sexual activity

Coping with spiritual changes

Feelings of loss, alienation and abandonment Understanding suffering Accepting dependency Handling anger and frustration Forgiving others Discovering peace Discussing death Grieving Planning the funeral Discovering hope and the value of living

Figure l. Coping requirements and changes associated with terminal illness. It must be emphasized that these changes have ramifications at differing levels. Personal changes have implications for an intimate relationship within the family and throughout the social environment (Aldridge, 1987b, p. 214).

questions life asks. These questions of meaning are answered in what we do, that is, concrete activities performed for individual destinies. Thus, the creative act retains its individuality and cannot be prescriptive.

Furthermore, such an act is aesthetic; it brings into form, making coherent and manifest what is unintelDavid Aldridge

ligible and hidden (Arnheim, 1992). As Langer (1953) wrote, "The function of art is to acquaint the beholder with something he has not known before" (p. 22). Each situation is unique and needs a creative response. In this sense, the creative act is one similar to play, which lies between the most personal, inti-

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS mate and subjective sphere and the external world of objects (Winnicott, 1951) in that it bridges the internal world of the individual with the external world of the therapeutic relationship (Robbins, 1992).

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 and thereby unconventional. In artistic expression we have the possibility of making perceptible an inner experience. Music, drama and visual art are concerned, not with the stimulation of feeling, but the expression of feeling. It may be more accurate to say here that feelings are not necessarily an emotional state, but more an expression of what the person knows as inner life (Aldridge, 1989).

Our treatment initiatives should also be made early in the patient's illness, soon after diagnosis, so that a relationship is made with the patient and with the carers (See Figure 2). The therapeutic relationship offers intimacy at a time when often the individual is threatened with isolation and rejection. We can help our patients discover their own sense of meaning by their living out their lives in individual creative acts within the context of the therapeutic relationship.

Robbins (1992) referred to such situations as "creative holding environments" (p. 178). What we need are time and the opportunity to maintain long-term stability in the relationship, although the physical consequences of the disease continually remind us of the precariousness of corporeal existence. It is this very balance between the temporal aspects of the body and the existential act of living in that body that is at the crux of the therapeutic act.

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Research Suggestions Because of the nature of the disease and its individual progression it will be necessary to formulate research designs that follow individual patients over time (see Figure 3). Such designs are longitudinal.

There have been calls elsewhere for such longitudinal designs, combining scientific and artistic intellectual rigor, which follow individual patients as they chart their course through the depths and shallows of their illness (Aldridge, 199la). In any such study it is also necessary to consider a recurring theme heard from varying perspectives. This theme concerns the necessity to include the views of the partners, or immediate family, of patients in any long-term therapeutic initiatives (Wolf et al., 1991).

To carry out such long-term research, which follows the course of an illness, it is necessary to develop a core team of practitioners and researchers who will remain with a project for its duration. The establishment of such a team is dependent upon adequate research funding, sufficient academic support and personal supervision for the personnel to sustain interest in a field of work notorious for the toll it takes on the professionals involved. As research interviews and therapeutic practice can be emotionally demanding, it is imperative to implement adequate supervision, a feature accepted in therapy but often neglected in research.

As the field of practice is changing rapidly, it is important to maintain a review of the current literature. There are a number of databases that provide background information about the field of AIDS re-

start early after diagnosis consider creative arts therapies as diagnostic tool develop a stable team, encourage long-term stability include the caregivers or partner in the therapy plan establish a support group for the professional caregiving team promote teamwork and identify common aims be ready for changes in physical status of the patient integrate the physical, psychological, social and spiritual be aware of the existential anxiety of working with AIDS patients; death, contagion, sexuality and disempowerment Figure 2. Treatment recommendations.

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promote prospective longitudinal studies develop a stable core research team, academic and clinical establish ethical guidelines for the use of collected information install procedure for continuing current literature review gather data from patients and their partnerdfamilies consider creative arts therapies as diagnostic tool identify appropriate health measures; life quality scales, hope index, diary recordings establish art and music archive of patient creations distinguish parameters for discerning treatment costs propose specific hypotheses for doctoral studies Figure 3 . Research recommendations.

search and that will furnish the research team with valuable insights from other practitioners.

With neurological problems a feature of HIV infection, it should be possible to explore the contribution the arts therapies can make to the detection of behavioral and functional changes. Creative arts therapies appear to offer sensitive assessment tools. They can be used to assess those areas of functioning, both receptive and productive, not covered adequately by other test instruments (i.e., fine motor behavior, perseverance in context, attention, concentration and intentionality). In addition, they provide forms of therapy that may stimulate cognitive activities so that behaviors subject to progressive failure are maintained (Aldridge & Aldridge, 1992).

Buckwalter (Buckwalter, Cusack, Kruckeberg, & Shoemaker, 1991) described the outcomes of a study involving family members of communicationimpaired long-term care residents in a collaborative nursingtspeech language pathology intervention designed to increase the residents' communication ability. Family members provided memorabilia and artifacts or produced audio or videotapes for use in conjunction with a speech therapy program. Findings revealed that, despite a minimal improvement in speech ability, there was a dramatic increase in family members' satisfaction. As peers, partners or family play an important role in the process of therapy and are susceptible to considerable distress too, we must include assessments of their perceptions of therapeutic change.

Quality of life has become accepted in the assessment of cancer treatment programs. If the HIV virus David Aldridge

is endemic to populations and there is no cure for AIDS, our research endeavors must include some appraisal of life quality (Catalan, 1990). To this end, the use of established life-quality scales alongside individual assessment protocols will provide therapists with feedback about the impact of their work on the everchanging life of the patient.

There are varying life-quality scales in existence that have been tested for reliability and validity (Aaronson, 1989; Bowling, 1991; Clark & Fallowfield, 1986; Gold, 1986; Oleske, Heinze, & Otte, 1990; Porter, 1986; Spitzer, 1987). The Hospital Anxiety and Depression scale was developed from clinical experience as a brief rating instrument to detect the extent of mood disorders as distinguished from the physical illness of the patient. Zigmond and Snaith (1983) purposefully excluded all items relating to physical disorder, retaining only items relating to psychic symptoms that are valuable with AIDS patients whose physical condition may deteriorate but psychological condition improve. As a scale in daily use, it has proved to be reliable, easily understood by patients and easy to administer and evaluate by clinicians (Clark & Fallowfield, 1986). Because the Hospital Anxiety and Depression scale is a self-report questionnaire, the patient gives an account of his or her own perception of life quality. The generally accepted, but cruder, Karnofsky Performance Scale (Karnofsky, Abelmann, & Craver, 1948), while weighted toward the physical dimensions of life quality, is physician rated and considered to be flawed in that there are discrepancies between what doctors perceive and what patients perceive.

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS It is important to understand when using such scales that "quality of life" has a multiplicity of meanings and, therefore, to some therapists the scales may seem naive and limited. Those researchers who have developed the scales know themselves that such limitations exist. Rather than develop an unwieldy global package, some researchers have concentrated on specific items gleaned from a factor analysis of many previously posed questions with an eye to developing a refined clinical instrument.

In addition to the quality of life, the fostering of hope is seen as a valuable activity in patient care (Herth, 1990, 1991). Herth's Hope Index is a useful screening tool that assesses hope over time and validates nursing diagnoses of hopefulness and hopelessness. Hope is a complex concept with many dimensions, yet it is possible, using such a scale, to assess the way in which patients view their future.

The message from all of this is to select the required test from a number of suggestions according to the particular research question being asked that is appropriate to clinical practice. Clinical scales are generally designed as a guide for practice and are easy to administer. Research instruments are often comprehensive in scope, time-consuming to administer (occasionally requiring training) and evaluate and rich in material. Using previously validated questionnaires builds bridges between small initiatives and a greater body of knowledge, helping the researcher to see the value of his or her work.

Although a research approach in itself, the patient diary (Murray, 1985) is an important part of an evaluative index. The patient diary is rather a catch-all term in that some researchers will collect daily data according to specific rating scales as above. These could be more appropriately termed calendar methods. An extension of daily rating and subjective commentary would appropriately be called a diary. The detailed daily recording of patient commentaries involving introspective accounts may be likened to a journal and is the least formal, in experimental terms, of the three approaches mentioned here (Aldridge, 1991c, 1992).

In diary studies, the principal collector of data is the patient. One of the tasks of research scientists working in the field of clinical practice is to discover what happens in the context of the patient's daily life and to make some attempt to discover how his or her problem impinges upon his or her daily routine. Similarly, it is important to discover who in the family of that person is involved at the time of onset of the David Aldridge

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symptoms and in the management of those symptoms.

The use of subjects making their own assessments of symptomatology offers a nonintrusive means of gathering data. Perhaps as significantly, the diary also offers the patient a neutral stance whereby the symptoms are assessed methodically and in accordance with a particular framework designed to be ultimately beneficial.

The use of diaries has several advantages. First, there is the opportunity to provide a daily scoring that eliminates recall error and in general produces consistent reporting. Second, there is a comprehensive view of the person's health and the relational context of that health status vis a vis other family members.

Third, symptoms are treated as episodes rather than solely static events. Fourth, diffuse conditions are included that may not be disabling or necessitate intervention but that contribute to the profile of the patient's symptomatology. Finally, diaries provide an opportunity to see the way in which problems develop over time and the way in which treatment initiatives can influence such developments. When studying complex chronic problems, the contextual information over time also illustrates how psychological or social factors enhance or complicate the clinical picture. There is no reason why the recorded data should only be concerned with symptomatic change. A journal could include poems, drawings and descriptions of dreams.

A benefit of using calendar and diary methods is also one of the drawbacks. The data are rich and varied but these cause problems for analysis; there can be too much data. Furthermore, patients can become sensitized to their own problems and hence concentrate more and more on those problems. This is a confounding factor for single-case research designs in general where the research process itself becomes a treatment variable. However, for discovering what a patient considers to be important about the treatment process, diary methods are very useful. In the case of AIDS patients, feedback, throughout a long therapy process involving various therapeutic initiatives, is a valuable feature.

The above measures are concerned with the health status of the patient from a particular medical orientation, albeit broad in its incorporation of psychical, emotional, psychological, relational and social dimensions. What is clearly missing is the collection of material from the creative arts activities.

A standard method for active music therapy is to make an audio or video recording of the therapy ses-

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DAVID ALDRIDGE sion and then index this recording after the session.

Such material is then available for assessment according to given criteria and for evaluation for validation by peers. Similarly, graphic (Niederreiter, 1990; Oliveri, 1991) and plastic material produced in the studio can be saved to show a progression during the course of the therapy. This work can also be photographed when each item is completed or at stages during the course of creation. With new advances in computer technology, it is possible to develop photographs as prints and to commit the same images for archiving electronically on a compact disc. Such images then can be saved in a database, displayed later on a monitor screen and incorporated into research documents. By saving images over time, it is possible to gain an overview of recurring elements, variations and changes in composition and form.

Although it is difficult enough for music therapists to agree on an established language for research, there are grounds to believe that active cooperation is possible among creative arts therapeutic disciplines (Aldridge, Brandt, & Wohler, 1990). It is important that a research structure be established so that creative arts therapists meet regularly to discuss their work and, in doing so, develop a common language. Our experience is that changes in form, whether sculpted, painted, drawn or played, occur concurrently. The task we face is to correlate such changes in the creative therapies with changes according to other measures of health outcome. Furthermore, we need to establish our expectations of patients in their first therapy sessions. We know little about how adults spontaneously create in various media (i.e., sing, move, draw or paint) particularly when they are previously untutored and unpracticed.

With the extended costs of health care for the AIDS patient playing a significant role in health-care delivery, when medical insurance support is likely to be exhausted or, for the poor, nonexistent (Faden & Kass, 1990), the financial burden of health care is going to fall onto the shoulders of the wider community. Any new initiatives will need to establish the cost of treatment over time. Although the creative arts therapies are labor intensive and time consuming, the potential savings in using fewer expensive pharmaceutical products, lesser long-term use of medical facilities and possibly extended survival rates are valuable (Krupnick & Pincus, 1992). The estimates of such costs will depend upon developing methodologies that include clinical outcome measures (e.g., the above-mentioned quality of life scales), functional David Aldridge

outcome measures (e.g., the ability to care for the family, number of days lost from work) and the costs of health-care utilization. To do this we need to establish the routine inclusion of cost data in our studies and establish clinical outcome criteria that make sense for the patients, clinicians and therapists involved and the policymakers responsible for third-party methods of reimbursement (Aldridge, 1990).

McCormick, Inui, Deyo, and Wood (1991) observed that AIDS has become a chronic disease and the demand for long-term care has increased. The authors studied a cohort of hospitalized persons with AIDS to determine the proportion and characteristics of 120 AIDS patients who could appropriately be cared for in long-term care facilities with skilled nursing on the medical wards of five Seattle tertiary care hospitals. The appropriateness for long-term care was determined by the patients' physicians, nurses and social workers according to four admission criteria: (a) impaired activities of daily living, (b) diagnosis of central nervous system illness or poor cognition, (c) living alone and (d) weight loss. One-third of hospitalized persons with AIDS were considered appropriate for care in long-term settings, accounting for onethird of the days AIDS patients currently spend in hospitals. These patients can be identified early in hospital stays using a simple clinical index based on the criteria above.

In formulating such a research proposal it is apparent that the suggestions are general. We must develop specific research studies, but as yet have limited experience. The research tradition in the creative arts therapies is limited. Music therapy, in particular, has no established research methodology, although there is a body of research material in the music therapy and medical press (Aldridge, 1993a, 1993b). There are, however, research methods and clinical outcome measures that can be utilized from other spheres of practice. A priority must be to get started doing research as a series of longitudinal pilot studies.

Cautions About Practice and Research The creative arts can be used as adjuvant therapies complementary to medical initiatives in palliative care. In modem scientific medicine, people are transformed into the subjects of research. They are classified into disease groupings. This subjectification, and the conditional requirement that they remain passive to keep the status "sick" not "deviant," is chal-

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS lenged by AIDS patients. In contrast, the creative therapies expect patients to be active self-defining agents. The requirement is that the patients are moral (i.e., actively partaking and self-defining) when they are sick and suffering, not that they be subjected to our morality and definition (i.e., passive and judged).

Foucault challenged us to find a new truth that is creative and performed free from the politics of medical authority (Rawlinson, 1987). It is this freedom of truth and practice that we must encourage with our AIDS patients. The therapist and the patient can challenge the notions that we must always be able to do something and that everything humanly significant is subject to measurement.

At the center of the AIDS debate is a massive existential anxiety that patients and we as therapists face. This anxiety is based upon the confrontation with death, the fear of contagion, the challenge to our sexual orientation, the exercise of power over another and the reality of poverty in a material world. Death, the inevitable end process of living, so often ignored, comes into the foreground, and thereby the normal expectation of medical endeavor, that the patient will recover to a state of normative health, is challenged.

Contagion, the fear of being invaded, is ever present.

Despite our knowledge of the transmission of the virus, our fears of contagion have little to do with such rationality. For example, in talking with general practitioners and oncologists about working with cancer patients, the difficulty for the doctors was the fear of "catching cancer," an irrational fear in a purportedly rational scientific enterprise (Aldridge, 1987a).

Sexuality, which we learn to express and which we take for granted as part of our identity, is seen as a matter of choice and preference not as solely dictated by our genetic makeup. The notion of "sex" makes it possible to group together in an artificial unity anatomical elements, biological functions, conducts, sensations and pleasures suitable to the scrutiny of modem scientific medicine (Dreyfus, 1987).

Foucault (1988, 1989) described such a tendency, to normalize all aspects of human behavior and bring them under medical control, as bio-power. The effect of this power on the patient is that he or she responds in the same way to every situation as if the possible responses had become reduced to one form. For Foucault, the therapeutic act is to bring about a change in such structuring, to give the life of the patient the stability and the uniqueness of a work of art, as we read in the introductory quotation to this paper.

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We know too that patients are socially vulnerable and that their caregivers, particularly in the face of children with AIDS, are disadvantaged. Poverty is a challenge to us all in that no matter what therapeutic skills we bring to bear and no matter how we strive for our own empowerment, we are continually faced with the blight of material neglect. How we care for the poor, the sick and the dying, no matter how they contracted their disease, is both a matter of our own personal responsibility and a collective measure of our humanity (Aldridge, 1991b) .

Conclusion The creative arts therapies, with their emphases on personal contact and the value of the patient as a creative productive human being, have a significant role to play in the fostering of hope in the individual.

Hope involves feelings and thoughts and necessitates action (i.e., it is dynamic and susceptible to human influence). Stimulating the awareness of living in the face of dying is a feature of the hospice movement where being becomes more important than having.

The opportunity, offered by the creative arts activities, for the patient to be remade anew in the moment, to assert an identity that is aesthetic in the context of another person, separate yet not abandoned, is an activity invested with that vital quality of hope and true to the quotation at the beginning of this paper. For the therapist, hope is a replacement for therapeutic nihilism enabling us to offer constructive effort and sound expectations (Menninger, 1959).

Any therapeutic tasks must concentrate on the restoration of hope, accommodating feelings of loss, isolation and abandonment, understanding suffering, forgiving others, accepting dependency while remaining independent and making sense of dying. Creative arts therapies can be powerful tools in this process of change, which can be accommodated within an overall rubric of quality of life. Although quality of life scales exist for the general clinical population of cancer patients, they fall short of meeting the requirements for individual patients. Expectations of life quality differ. Furthermore, the elusive life qualities inherent in creative activities-joy, release, satisfaction, simply being-are not readily susceptible to rating scales. We can, however, hear them when they are played, see them when they are painted or danced and feel them when they are expressed dramaturgically.

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Creative arts therapies appear to open up a unique possibility to take an initiative in coping with disease or to find a level to cope with near death. It is this opening up of the possibilities that is at the core of existential therapies (Dreyfus, 1987). Rather than patients living in the realm of pathology alone, they are encouraged to find the realm of their own creative being. If the progress of this disease, AIDS, is an increasing personal isolation, then the therapeutic relationship is an important one for maintaining interpersonal contact, a contact that is morally nonjudgmental, where the ground of that contact is aesthetic and expressive, not scientific and repressive. Furthermore, the therapeutic question is not "What am I?, ' ' a question that lies in the realm of categorization and cognition, but "How am I?," which is one of being.

Finally, in our treatment initiatives and research projects it is necessary to care for the caregivers, who will include the family, friends or partner of the patient. We must also bear in mind the psychological burden on health workers themselves. Although working with couples and families may be alien to some individual therapeutic directions, the overwhelming burden of care and suffering of daily living lies outside of the clinic. When clinical care is necessary, we are also best guided to attend to ourselves and colleagues, too, as we accompany our patients on the long journey that awaits us all. Social disruption, isolation, conflict and neglect are the doors to the house of despair. Creative &S therapies must respond to those who enter that house, but at a social level where we must be the architects of change. People will die. It is what we contribute to the quality of their living that is of importance.

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

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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

OO F

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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

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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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0965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2005.01.004

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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-

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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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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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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)

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IFSS

−.303 .762

−.507 .612

−1.224 .221

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BDI

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−.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.

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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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14. Magee W. A comparative study of familiar pre-composed music and unfamiliar improvised music in clinical music therapy with adults with multiple sclerosis. London: Royal Hospital for Neuro-disability; 1998.

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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.

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32. Aldridge D. Music therapy research and practice in medicine. London: Jessica Kingsley; 1996.

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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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lournal of the Royal Society of Medicine Volume 80 April 1987

Clinical assessment of acupuncture in asthma therapy: discussion paper

D Aldridge P

~ D

P C Pietroni FRCGP MRCP Department of General Practice, St Mary's Hospital Medical

School, London Keywords: acupuncture, asthma, complementary therapy, controlled trials

This paper is concerned with reviewing the use of acupuncture for the relief of chronic bronchial asthma, for it is our intention to embark upon a controlled clinical trial of acupuncture therapy in the context of general medical practice. A secondary property of this paper is a discussion of clinical trial methodology as applied to a complementary therapy.

Acupuncture Acupuncture is a therapy which has gained some recognition both within the realms of popular practice and, perhaps more importantly, within the realm of medical practice. The practice of acupuncture is a collection of procedures which include the insertion of needles at specific points of the body for both the relief of pain and the treatment of disease, with moxibustion and cupping.

Traditional descriptions of acupuncture are concerned with the flow of vital energy, called ch'i, along fixed paths called meridians. These are linked together with each other and the organs of the body.

Flow of energy along these paths has a circadian rhythm, so that at times and season it may vary.

Energy in this context has a bipolar character; it can be positive called 'yang', and negative called 'yin'.

The energy within the body, ch'i, reflects both the vitality of the universe and society l.

For a body to be healthy in this system of description, the flow of ch'i in the meridians is normal and balanced. Essentially the process is one of maintaining balance, i.e. becoming healthy or losing health.

Diagnosis, too, is seen as a process and takes into account many factors. It includes a patient history of changes in behaviour, appetite and emotions. The state of the skin, eyes, breath and tongue are noted for colour, consistency and odour. There are also special techniques for the evaluation of the flow of energy in the 12 meridians, electrical measurements of skin resistance, and the palpation of skin subcutaneous tissue.

Although the mode of action of acupuncture is not known precisely, there are a number of suggestions which propose that the mechanism is linked with the secretion of endorphins2. Yu and Lee3 suggest that acupuncture relieves that part of the bronchoconstriction which does not arise from the constriction of smooth muscle as a result of chemical mediators.

The effect of acupuncture in asthma is mediated through modification of the reflex component of 0141-0768/87/ bronchoconstriction.

Other writers invoke the prox04022203,~0200/0 imity of the central nervous system projections of the @ 1987 acupuncture simulation site and the pain path as the The Royal rationale for the selection of treatment loci, humoralSociety of biochemcal mechanisms, neuromechanisms, and the Medicine

David Aldridge

bioelectric mechanism1.It has been pointed out, however, that these descriptions are made by 'scientific apologists'1.

It is more likely that acupuncture represents many phenomena and that a primary difficulty, as discussed later, lies in a treatment modality that is underpinned by an Oriental philosophy being subjected to an explanation by the differing theoretical understanding of modern Western medicine.

Asthma Asthma is a condition characterized by symptoms which are present over long periods of a patients' life.

The number of people with asthma in the United Kingdom is estimated to be about two million - a number too great for the hospital services to provide continuing care. Although the condition is often mild and readily treated, for those persons with a chronic condition the illness is composed of recurrent crises and debilitation. Gregg4estimates that the incidence of asthma in the population is increasing, and in a form that is frequently more severe than in the past.

The general practitioner is in a position to identify the incidence of asthma, to be involved in preventive measures and to offer early treatment. Many persons seen in hospital outpatient departments could be managed just as easily in the context of the general practitioner clinic5.

Asthma is often refractory to pharmacotherapy, the side effects of which can be distressing. A low-risk form of treatment such as acupuncture could constitute an advancement in the management of asthma6, particularly if used in the context of general medical practice which utilizes elements of patient education and a self-care perspective.

Clinical controlled trials of asthma A literature search was carried out using the Medline database through St Mary's Hospital Medical School library. The criteria for the search were English language papers on 'asthma therapy' and 'acupuncture' published in the past ten years. Eight studies were discovered having a controlled trial methodology which used either a 'placebo' or 'no treatment' control group3v612.

Although these trials ostensibly used a controlled trial methodology, there were many inconsistencies.

First, most of the trials had few subjects; the largest trial had 111subjects but the rest had no more than 25. Second, there was a large disparity in the age ranges; in one trial the ages ranged from 6 to 71 years.

Third, the clinical entities were wide-ranging.

The predominant conclusion of the controlled trials was that at best acupuncture resulted in only

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modest improvement in the 'objective' assessment of airways impedance. These objective measures were mainly concerned with expiratory flow rates, airway conductance and thoracic gas volume. A greater perception of symptom relief was made subjectively by the patients using self-report measures and diary techniques, a point that will be discussed further later in the paper.

Clinical evaluations Two t r i a l ~ were evaluations by ~ ~ , essentially ~ ~ clinicians of clinical practice. A range of symptoms associated with asthma were covered, the treatment approach being varied according to the presenting symptoms. The number of treatment sessions was not standardized but varied according to the symptoms and symptomatic improvement.

The criteria for improvement were subjective and included the assessments of both practitioner and patient. Cioppa13 found that 67% of the patients improved with acupuncture treatment. The conclusions of this research were that acupuncture appears to: (a) relieve muscle spasm; (b) be useful in subacute onditions; (c) be something other than hypnosis; (d) acilitate manipulation; (e) have an immediate effect; (/) give complete remission - not only palliation - in many cases; (g) give a sense of well being; (h) be a valuable adjunct to standard practice. Fuller14 also considered acupuncture to be effective in treating chronic asthma and recommended its use.

The remaining papers were a collection of miscellaneous reports and letters about the clinical application of acupuncture, the relationship to general medical practice, and replies to letters15z1.

Hossrizzdescribed the use of acupuncture massage for the relief of asthma in children. This entails a number of techniques using pressure a t acupuncture sites, friction and manipulation. Hossri also used hypnosis in combination with these techniques.

Acupressure, the substitute of digital pressure for needling at specific sites, has been used in medicine and dentistry both for the relief of pain and tensionz3- 2 5 .

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iscussion here is a disparity between the claims of acupuncturists as to positive clinical benefit, and the findings of the clinical trials research, which demonstrates little 'objective' change but does emphasize 'subjective' change. Such difficulties bedevil the assessment of alternative or complementary therapies, particularly since there is a confusion between different levels of measurement - i.e. between that which is measurable in terms of quantity such as gas volume, and that which cannot be readily subjected to such quantification such as 'feeling better'.

A more serious critique concerns the controlled trial methodology itself. The trials studied here failed to provide a sample size with sufficient power to make any valid conclusions from the statisticsz6.Furthermore, the trials really did not investigate 'acupuncture'. The process of standardizing the treatment approach removed from the practice itself that which is the essence of the treatment. By restricting needling sites to specific loci, limiting the number of treatment sessions and abdicating the use of traditional diagnostic practices, the trials were really reduced to testing the insertion of needles a t particular points. It is therefore not surprising that needling as 'acupunc-

David Aldridge

ture' in these trials differed from needling as a 'placebo' or 'sham' acupuncture. What the trials failed to do was realize that even though methodology can be applied, if it is applied without understanding simply as a formula then no significant findings emerge. To do this abdicates both responsibility in science and real discovery. Science is not methodology;methodology serves science.

How can we as scientists say that we have subjected a practice to adequate investigation when we remove from the process that which is essential?

When applied rigidly, clinical trials remove the interaction between the subject and the researcher. It is this very interaction which is at the very heart of clinical practice, and which cannot be removed no matter how impersonal we may wish to be. The separation of the disease from the person loses those very qualities which we need to understand. Diseases may be treated as aggregates and submitted to statistical analysis, but it is individual persons in whom those diseases are located and who confront us in our surgeries.

Another feature of the clinical trial methodology was that asthma was seen as a homogeneous clinical entity. There was no consideration that the symptoms were located within persons who perceived their symptoms differentially, or that asthma in a 6-year-old is qualitatively different from that in a 71-year-old.

Asthma appears to be tractable to acupuncture when treated by committed clinicians who use traditional techniques. The clinical trials have not investigated acupuncture as a treatment modality, but 'needling techniques'. The challenge for clinicians and researchers is to examine rigorously the practical effects of acupuncture treatment but from a perspective which involves the whole person and the totality of the treatment process.

The way forward It is our intention to carry out a pilot study of acupucture treatment and education classes in the management of chronic asthma. Our referrals will be taken from hospital outpatients where the patients will be assessed by an external researcher, who will also carry out the post-trial blind assessment. Of 150 patients who will be recruited to the study, 50 will be randomly allocated to an acupuncture treatment; another 50 oatients will be allocated to education classes; and the third group of 50 patients will be offered continuing general practitioner contact only.

All groups will be asked to complete a diary for the eight-week treatment period, and a t a later follow-up period.

The acupuncture treatment method will be determined by the acupuncturist. There-willbe no definite fixed number of treatment sessions, but it is anticipated that the acupuncturist will attempt to keep within the eight-week timescale. The acupuncture sites will not be controlled, and it is expected that the acupuncturist will use a traditional pulse diagnosis.

The data collected will cover a broad spectrum of information concerned both with the symptoms and illness behaviour, as follows: (1) impact of asthma upon health (using the Nottingham Health P r ~ f i l e ~ and ' * ~ life ~ style data (Social Problem Q~estionnaire*~), and locus of control30;

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(2) diary recording of events3133,asthma attacks, use of medication/bronchodilator, night-time disturbance, time off work, crisis consultations, GP home visits and scores for wheeze, breathlessness, chest tightness and cough; (3) qualitative measures of practitioner, patient and family satisfaction; (4) knowledge and skills of patient about the management of asthma; (5) peak expiratory flow.

The education classes will consist of direct teaching about allergens and triggers of asthma (physical, psychological and relational); the correct use of medication, where appropriate, and the bronchodilator; and what asthma is in terms of airway impedance. Building on this basis there will be an opportunity for each person to identify through the diaries their own particular triggers.

A number of complementary strategies will be introduced, including dietary understandings, specific breathing technique, the use of relaxation techniques and stress management. It is anticipated that the people involved in this project will be able to personalize these strategies according to their own lifestyles and the contexts in which they become symptomatic.

This pilot study will attempt to meet our earlier criticisms of controlled trials. Acupuncture will not be restricted solely to needling, and a range of data will be collected which will include the physical, the psychological, the relational and the familial.

Acknowledgment: This research is funded by the Wates Foundation.

References Millman BS. Acupuncture: Context and critique. Ann Rev Med 1977;28:223-34 Guillemin R, Vargo T, Rossier J. Beta endorphin and adrenicorticotrophin are secreted concomitantly by the pituitary gland. Science 1977;197:1367 Yu DYC, Lee SP. Effect of acupuncture on bronchial asthma. d i n Sci Molec Med 1976;51:503-9 Gregg I . The quality of asthma in general practice - a challenge for the future. Family Practice 1985;2:94-100 Arnold AG, Lane DJ, Zapata E. Acute severe asthma: Factors that influence hospital referral by the general practitioner and self referral by the patient. Br J Dis Chest 1983;77:51-9 Dias PLR, Subramanian S, Lionel NDW. Effects of acupuncture in bronchial asthma: a preliminary communication. J R Soc Med 1982;75:245-8 Shao JM, Ding YD. Clinical observation of 111 cases of asthma treated by acupuncture and moxibustion.

Journal of Traditional Chinese Medicine 1985;5:23-5 Christensen PA, Laurensen LC, Taudorf E, Sorensen SC, Weeke B. Acupuncture and bronchial asthma.

Allergy 1984;39:379-85 Berger D, Nolte D. Acupuncture in bronchial asthma: body plethysmographic measurements of acute bronchospamolytic effects. Comparative Medicine East and West 1977;5:265-9

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10 Tashkin DP, Bresler DE, Kroenig, RJ, Kerschner H, Katz RL, Coulson A. Comparison of real and simulated acupuncture and isoprotenerol in metacholine-induced asthma. Ann Allergy 1977;39:379-87 11 Tashkin DP, Kroenig RJ, Bresler DE, Simmons M, Coulson AH, Kerschnar H. A control trial of real and simulated acupuncture in the management of chronic asthma. J Allergy Clin Immunol1985;76:855-64 12 Takishima T, Mue S, Tamura G, Ishihara T, Watanabe K. The bronchodilating effect of acupuncture in patients with acute asthma. Ann Allergy 1982;48:44-9 13 Cioppa FJ. Clinical evaluation of acupuncture in 129 patients. Diseases of the Nervous System 1976;37:639-43 14 Fuller JA. Acupuncture. Med JAust 1974;ii:340-l 15 Alien M. Activity generated endorphins: a review of their role in sports science. Can J Appl Sport Sci 1983;8:115-33 16 Rebuck AS. The outpatient management of asthma.

Ann Allergy 1985;55:507-10 17 Donnelly WJ, Spyykerboer JE, Thong YH. Are patients who use alternative medicine dissatisfied with orthodox medicine? Med JAust 1985;142:53941 18 Bodner G, Topilsky M, Greif J.Pneumothorax as a complication of acupuncture in the treatment of bronchial asthma. Ann Allergy 1983;51:401-3 19 Hayhoe S. Effects of acupuncture in bronchial asthma J R Soc Med 1982;75:917 20 Marcus P. Effects of acupuncture in bronchial asthma.

J R Soc Med 1982;75:670 21 Rosenthal RR, Wang KP, Norman PS. All that is asthma does not wheeze. N Engl J Med 1975;292:372 22 Hossri CM. The treatment of asthma in children through acupuncture massage. Journal of the American Society of Psychosomatic and Dental Medicine 1976; 23:3-16 23 Weaver T. Acupressure: An overview of theory and application. Nurse Practitioner 1985;10:38-42 24 Kurland D. Treatment of headache pain with autoacupressure. Diseases of the Nervous System 1976; 37:127-9 25 Penzer V. Acupressure in dental practice: Magic a t the tips of your fingers. Journal of the Massachusetts Dental Society 1985;34:71-5 26 Lewith GT, Machin D. On the evaluation of the clinical effects of acupuncture. Pain 1983;16:111-27 27 Hunt SM, McEwen J , McKenna SP. Measuring health status: a new tool for clinicians. J R Coil Gen Prac 1985;35:185-8 28 Hunt SM, McEwen J , McKenna SP. Social inequaliti and perceived health. EffectiveHealthCare 1985;2:1514 29 Corney R, Clare AW. The construction, development and testing of a self report questionnaire to identify social problems - a pilot study. Psychol Med 1985; 15:637-49 30 Lefcourt HM. Locus of control. New Jersey: Lawrence Erlbaum, 1982 31 Barry DMJ, Marshal1 TH, Rothwell RPG. Asthma and diaryltreatment cards. NZ Med J 1985;98:556 32 Freer CB. Self care: a health diary study. Med Care 1980;18:853-61 33 Murray J. The use of health diaries in the field of psychiatric illness in general practice. Psychol Med 1985:15:82740

(I

(Accepted 9 September 1986)

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