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Taking Forward Music Therapy : Shaping The Future
CENTER FOR MUSIC THERAPY EDUCATION AND RESEARCH Mahatma Gandhi Medical College and Research Institute, Pondicherry Sri Balaji Vidyapeeth
PROCEEDINGS of 2ND INTERNATIONAL CONFERENCE on “CURRENT TRENDS IN MUSIC THERAPY EDUCATION, CLINICAL PRACTICE AND RESEARCH”
23.06.2015 Pondicherry
Edited by Dr. SUMATHY SUNDAR DR. VELLORE A.R.SRINIVASAN
Published by Center for Music Therapy Education and Research, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pondicherry
Editorial Board Patrons Shri. M.K. Rajagopalan, Chairman Prof. Dr. Rajaram Pagadala, Chancellor Editor-in-Chief : Dr. Sumathy Sundar Advisory Board
Executive Editors
Prof. Dr. K.R. Sethuraman
Prof. Dr. A.R. Srinivasan
Prof. Dr. N. Ananthakrishnan
Prof. Dr. B. Sivaprakash
Prof. Dr. S. Krishnan
Ms. A.N. Uma Members Dr. S. Srirangaraj Dr. V.R. Hemanth Kumar Dr. Sobana Jaiganesh Mrs. Asha Suresh Babu Ms. Vijay Chitra
Center for Music Therapy Education and Research, Sri Balaji Vidyapeeth (Deemed to be University, Declared Under Section 3 of the UGC Act 1956) Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkupam, Pondicherry - 607402, India. Phone : +91 413 2615449 to 58 Extn : 205 Fax : +91 413 2615457 Email : musictherapy@mgmcri.ac.in www.sbvu.ac.in/cmter-center-for-music-therapy-education-and-research
S.No.
Content
Page No.
1
Chairman's Message - Shri M. K. Rajagopalan
5
2
Chancellor's Message - Prof. Rajaram Pagadala
6
3
Vice-Chancellor's Message - Prof. K.R. Sethuraman
7
4
Dean's Message - Prof. N. Ananthakrishnan
8
5
Welcome Address - Prof. Dr. Vellore A.R. Srinivasan
9
6
Presidential address - Dr. Amy Clements-Cortes
10
7
Vote of Thanks - Dr. Sumathy Sundar
13
Scientific Program
14
Key Note Address . Music Therapy In Neurological Rehabilitation: Evidence-based Practice And Research - Prof. Dr. Gerhard Tucek
16
9
.
CMTER Model of Music Therapy - Dr. Sumathy Sundar
21
10
.
The Effects of Music Imagery Relaxation in Medical Setting - Dr. Maria Montserrat Gimeno
30
Music Therapy as a Community Service for Hospitals: Community Music Therapy from Hospitals - Dr. Lucy Bolger
38
The Limbic System as the Seat of Emotions: Indian Classical Ragas (musical Modes) as Modulators of Emotions - The Need for Evidence Based Studies - Dr. Vellore A.R. Srinivasan
44
Musical Interaction to Facilitate Communication Skills in Children with Autism - Dr. Baishali Mukherjee
50
8
11
12
13
.
.
.
14
.
Effect of Music Therapy on Immunology - Dr. Parin N Parmar
61
15
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Music Therapy Clinical Experiences – Where Everything Comes Together - Prof. Dr. Gene Ann Behrens
67
16
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The 'Aha!' Moment Experiments and Experiences of Composing for Music Therapy - Arnab B. Chowdhury
70
17
.
Specific Requirements and Adaptability of Musical Instruments for Therapeutic Settings - Aurelio C. Hammer
85
Organizing Committee CHIEF PATRON Shri M K Rajagopalan, Chairman, SBECPT PATRONS -Prof. Dr. Rajaram Pagadala, Chancellor, SBV Prof. Dr. KR Sethuraman, Vice Chancellor, SBV Prof. Dr. N Ananthakrishnan, Dean, Research and PG Studies Prof. Dr. M. Ravishankar, Dean (Administration) ADVISORY BOARD Prof. Dr. S. Ravichandran-Deputy Director, MGMC&RI Prof. Nirmal Coumare-Medical Superintendent, MGMC&RI Mrs. Asha Suresh Babu -PS to Chairman Mr. Kannan Aiyer-GM, Finance ORGANIZING COMMITTEE Dr. Vellore A.R. Srinivasan-Organizing Chairman Dr. Sumathy Sundar-Organizing Secretary Mr. Joseph Naresh -Treasurer MEMBERS Dr. Sobana Jaiganesh - Ms. Bhuvaneswari Ramesh Dr. Sakthi Devi - Dr. Prasanya Ms. Anbu - Ms. Malini Pon Angel
Shri M. K. RAJAGOPALAN Founder & Chairman, SBECPT
Date: 20 05 2015
Chairman's Message It is my privilege and honour to welcome you all to the 2nd International Conference on Music Therapy slated on 23 06 2015 at our university Sri Balaji Vidyapeeth, a health sciences institution of higher learning in Pondicherry, India. Since the inception, the thrust areas for our university are: Integrative medicine, blending modern medicine with complementary and alternative medicine, and the development of unique and innovative postgraduate courses. SBV follows a holistic health system, informed by evidence derived from a critically appraised knowledgebase (SBV AIM HIGH). In a pioneering step towards integrating complementary therapeutic approaches with modern medical care, SBV introduced music therapy as a mind body medicine into patient care in 2010 and simultaneously initiated relevant research. SBV has been regularly conducting international conferences since the last three years to create opportunities for world leading experts to get together and share their knowledge on music therapy applications and research. This conference second in the series with the theme "Current Trends in Music Therapy Clinical Practice, Training and Research" has planned exciting technical sessions with high quality scientific contributions from both international and national experts on the subject in the form of a key note speech. paper presentations, review papers, short video communications, poster sessions and a panel discussion. I am sure this would be a very good forum for discussion on advances made in areas of patient care, education and research for music therapy practitioners, students, educators and researchers to exchange their expertise and experiences. I do hope that all of you will have a good learning time and the conference proceedings will be a good compilation of present knowledge and advancements made on this subject which will be used by health care and allied health care professionals for integration of music therapy in their work. Thank you all for joining me during this exciting event. I take this opportunity to thank the members of the organizing committee who have worked hard to make this conference a great success.
M.K. Rajagopalan Chairman
5
6
Prof. K.R. Sethuraman, MD, PGDHE. Vice -Chancellor
Message
A music therapist uses music in all of its facets to help clients improve their physical and mental health. Music therapy has been shown to be effective in improving one's health in several domains (cognitive function, motor skills, emotional development, social skills, and quality of life) by using musical experiences (singing, free improvisation, listening to, moving to music etc) to achieve treatment goals. It is a well established complementary therapy. Controlled studies combining modern medical practices with music have shown varying results. We need to carefully choose areas where Music therapy is useful without any adverse effects. An example: Music in the Operating Room (OR) is known to have beneficial effects on patients. Specifically, music has been shown to decrease pain, stress, and anxiety, the demand for analgesic and anaesthetic drugs. From a surgeon's point of view, music facilitates achievement of higher speed and accuracy of task performance. However, with regard to its effect on surgical staff, music is thought to be distracting, reducing the staff's ability to cooperate and coordinate. (Surg Endosc (2013) 27:719–723. DOI 10.1007/s00464-012-2525-8). According to this study, the surgeon and the patient seem to benefit while the other staff in the OR seem to be distracted. Therefore, this conference on "Current Trends in Music Therapy Education, Practice and Research" is timely and will shed light on one of the pathways for 'evidence-based integrative medical practice', which is the current trend in the 21st Century. We record our appreciation of Dr Sumathy Sundar, the head of Music therapy and Prof N Ananthakrishnan, the head of SBV-AIMHIGH, set up to promote integrative therapy in Sri Balaji Vidyapeeth for taking the initiative to organize this international conference.
Prof. K.R. Sethuraman
7
8
PROF. DR. VELLORE A.R. SRINIVASAN Registrar, Sri Balaji Vidyapeeth Organizing Chairman
Welcome Address Welcome to Pondicherry and welcome to CMTER, the abode of Music Therapy education and Research at Sri Balaji Vidyapeeth. CMTER which has originated due to the yeoman efforts and vision of the respected Chairman Sri M.K.Rajagopalan, Chancellor Prof. Rajaram Pagadala, Vice-Chancellor Prof. K.R.Sethuraman and Dean ( Research & PG studies) Prof. N.Ananthakrishnan deems it a privilege to host the 2nd International Conference on Current Trends in Music Therapy education, clinical Practice and research. As you may all agree, the very purpose of using music as an intervention is to help accomplish individual goals essentially within the favoured domain/relationship of the professional who administers music therapy and the person who receives the same. Music therapy and medicine, in recent years have been receiving wide attention, as a perfect and objective adjuvant in the scenario of modern medicine and therapeutics. Evidence-Based Music therapy is the need of the hour as related to the analysis and modulation of physiological and psychological effects/changes. The physiological changes in humans are attributed to the actions of the central nervous system (CNS) which includes brain and spinal cord and the subsequent effects of the CNS on the organs/organ systems, as effected through the autonomic nervous system (ANS). The psychological attributes of an individual are also taken into consideration while actively implementing Music therapy, a facet of the MIND BODY MEDICINE. In the present context, rehabilitation as related to Neurology, use of imagery techniques in Mind Body Medicine and optimal exploitation of the ANS, endocrine system and immunology are pivotal. The need for the development of a model that music therapy department would cater to patient care, academics and evidence based research also dons great relevance. CMTER has taken cognizance of these avenues. Eminent resource persons of international repute have consented to conduct this conference. A hearty welcome to these distinguished persons. A big welcome to the avid delegates from India and abroad. Do enjoy this academic treat and may we all acquire knowledge, skills and attitude to practice Music therapy, for the benefit of the mankind.
Prof. Dr. Vellore A.R. Srinivasan 9
World Federation
of Music Therapy
Dr. Amy Clements-Cortes, President, World Federation of Music Therapy
Presidential address As the current President of the World Federation of Music Therapy (WFMT) it is my distinct privilege to be invited to open the 2nd International Conference on Music Therapy themed: “Current Trends in Music Therapy Clinical Practices, Training and Research� presented by the Mahatma Gandhi Medical College and Research Institute, in Pondicherry, India. I want to thank Dr Sumathy Sundar and the Mahatma Gandhi Medical College for inviting me and for the special honour of inaugurating this conference. While I am physically not able to be with you today I am sending warm wishes for this conference from my home in Woodbridge, Ontario, Canada. As the President of the WFMT, I am fortunate to see how music therapy is advancing around the globe through my constant contact with the WFMT council, therapists, educators, researchers and organizations in the 8 WFMT regions. While music therapy is a young profession, relatively speaking, it is a steadily growing discipline that is becoming more and more recognized as not only an art but a science. According to the World Federation of Music Therapy, in 2012 there were approximately 14, 623 music therapists working around the globe. From a historical viewpoint, there have been 3 phases in the global development of music therapy. Phase one was the development of the profession stemming from World War II, and work with War Veterans primarily in the United States, and Canada, as well as parts of Europe. The second phase has been further expansion in Europe, Japan, New Zealand, Australia and Latin America and these areas are continuing to strengthen their music therapy outreach. The third phase which we are in at present is the emergence of training for music therapists in places such as India, China and Africa. I want to commend the Mahatma Gandhi Centre for helping to pioneer the continued development and growth of music therapy in India as an allied health care as well as academic discipline. Through the groundbreaking efforts of Sri BalajiVidyapeeth, the Center for Music Therapy Education and Research, now offers a 1 year Post Graduate Diploma in music therapy, and in the near future the first Masters of Science degree in Medical Music Therapy. The understanding that music therapy is not only an art but a science appears to be a driving factor behind this institution embracing and implementing the Masters of Science in music therapy in a medical facility. What is advanced in the design of the training programs here is the interdisciplinary team of educators at the College, and the interaction with the departments of nephrology, pediatrics, psychiatry, surgery, dermatology and community services. This unique Masters will put India on the global stage as a country that recognizes the importance of housing a music therapy program in a medical facility. 10
There are a number of trends in clinical practice, training and research depending on where a person resides in the world. One global overarching trend in music therapy training and clinical music therapy provision involves music therapists increasingly seeking out advanced degrees, in addition to acquiring specializations within the field of music therapy, such as Guided Imagery and Music (FAMI), and Neurologic Music Therapy (NMT). It is highly likely that in the near future an undergraduate degree from a University will no longer be sufficient training to qualify a person to practice as a music therapist. This is more likely in areas where training programs have been in existence the longest, and where clinicians have established a stable ground for the profession through their organizations and training programs. It is encouraging to see India and theMahatma Gandhi Medical College being proactive and implementing a M.Sc. in Medical Music Therapy in music therapy in the near future to meet such training needs as expressed by students and therapists. As I become more familiar with the development of music therapy in India it is encouraging to see that each year there are an increasing number of ongoing and completed research projects coming out of the Mahatma Gandhi College, as well as publications that add to the literature on music therapy. The result of this work is that the profile of music therapy in India is elevated.For example, in 2014 there were 5 publications. I want to make note of one significant one, which is the authoring of a book chapter written by Dr. Sumathy Sundar titled “Music therapy education in India: Developmental perspectives.” Featured In Karen Goodman's edited book titled “International perspectives in music therapy education and training: Adapting to a changing world”. This book has an extensive readership by not only music therapy educators and supervisors but also allied health care professionals, and is a resource educators are looking to help them develop, revise and create music therapy programs. Due to Dr. Sundar's chapter, her contribution and the training examples in India are part of their considerations. I want to note for you today that India is well represented on the global stage in several ways. Dr. Sumathy Sundar, is the Chair of the Education and Training Commission for the WFMT, and serves on the editorial review board of several prominent journals including: Music Therapy Today, Journal of Music Therapy and Music and Medicine. Dr. Baishali Mukherjee serves the WFMT as the Regional Liaison for South East Asia, and Bhuvaneswari Ramesh, is a tutor in the WFMT Assembly of student delegates. Quite remarkable to have such representation from a country with few therapists at present. India's strong presence will only continue to grow with the hard work of such individuals and through events such as this conference. It is my dream that one day soon there will be education equivalencies and standards of clinical practice that extend beyond an individual country to facilitate music therapists being able to work in more than their home country and to bring a variety of cultures and world views to our clients. The WFMT is working hard to assess clinical training in all our 8 regions. The WFMT Commission on Education and Training, headed by Chair, Dr. Sumathy Sundar promotes dissemination of knowledge regarding contemporary guidelines for the standards of the education and training of music therapists around the world. The aim of this commission is to provide a forum for communication that will serve to better inform music therapy educators about existing training practices and will encourage crosscultural discussions regarding educational standards. This Commission also aims to 11
develop educational resources for music therapy educators to further enhance education/training practices and to deepen understanding regarding cultural considerations and training programs worldwide. I encourage you to visit our website for further details.While the WFMT has a broad audience to disseminate learnings, findings and assessments on education and training, it is at events such as this that the actual discussions and work are initiated and the work plans can unroll to support continued global development. As it is the 30th Anniversary of the WFMT, I also am pleased to invite you to be a part of our celebrations. There are a number of ways to do so, including: contributing to the WFMT Treasured Memories project, the 30th Anniversary song contest, by submitting a paper to the folk music project or music examples to our library of International music, or by submitting a formal paper to the WFMT peer reviewed Music Therapy today journal. Students can also get involved in the Assembly of Student Delegates and we have an International Internship Registry to assist students who want to obtain their clinical skills in other destinations than their home countries I do hope that this conference will provide a platform for the sharing of best teaching and clinical practices, including a keynote address given by Dr. Gerhard Tucek, from Krems, Austria. It is an opportunity for dialogue among allied health care professionals, students, researchers, music therapists and educators sharing their work and thoughts with a focus on stimulating and advancing the growth of music therapy in India. I wish everyone a wonderful learning opportunity and hope that our paths cross again in the near future.
12
DR. SUMATHY SUNDAR Head, Center For Music Therapy Education And Research Organizing Secretary
Vote of Thanks It is a great pleasure and honour to me to have been asked to propose the vote of thanks on this most memorable event of the inaugural function of the 2nd International conference on music therapy. At the outset, I am grateful to our Chief Guest Dr. Amy Clements-Cortes, President World Federation of Music Therapy from Canada for her gracious acceptance to inaugurate the conference online and deliver the Presidential address. Thank you very much for your inspiring inaugural address. I convey our special thanks to our respected and distinguished guest, Prof. Dr. Gerhard Tucek from the IMC University of Applied Sciences, Krems, Austria for delivering the key note address and share with us his expertise and experience on the subject. Our heartfelt thanks to our beloved Chairman Shri M.K. Rajagopalan for releasing the conference proceedings. I take this opportunity to thank immensely all our distinguished speakers from India and abroad who have accepted our invitation and have travelled from different parts of the country and the globe, colleagues from the university, friends, well wishers, special invitees and the students in the audience who have come here to participate in the proceedings of this exciting conference. I would like to express my sincere thanks to our friends in the media not only for the splendid coverage of today's events but also for their continued support to us all through these years. My heart -felt gratitude to the Chief Patron, our beloved Chairman Shri M.K. Rajagopalan, our patrons Chancellor, Hon. Prof. Rajaram Pagadala, Vice-Chancellor, Hon. Prof. KR Sethuraman, Dean, Research and PG Studies and Allied Health Sciences and our mentor Prof. N Ananthakrishnan and Dean of Medical Faculty Prof. M Ravishankar without whose passion and unconditional support, this conference would not have been possible. Further, I thank our IT department for their complete support to have this tech conference involving online inaugurations and video presentations. An exciting event of this magnitude needs meticulous planning and execution and I was extremely fortunate to have the most committed organising committee members, my CMTER team and all the volunteers who have been working out of their comfort zone for many days to make this event a great success. My heart felt thanks to each and every one of you. 13
2ND INTERNATIONAL CONFERENCE on “CURRENT TRENDS IN MUSIC THERAPY EDUCATION, CLINICAL PRACTICE AND RESEARCH” 23.06.2015 Scientific Program Registration : 8.00 a.m. - 9.00 a.m.
Inauguration : 9.00 a.m. - 9.30 a.m.
Session I
9.30 a.m. to 10.00 a.m.
Key note Address Music Therapy in Neurological Rehabilitation: Evidence Based Practice and Research Prof. Dr. Gerhard Tucek, Program Director, Department of Music Therapy, Head of Research and Vice Head, IMC University of Applied Sciences, Krems, Austria Tea Break: 10.00 a.m. to 10.30 a.m. Session II
10.30 a.m. to 11.30 a.m.
Session Chair: Dr. Vellore A R Srinivasan CMTER Model of Music Therapy Dr. Sumathy Sundar, Consultant and Head, CMTER The Effects of Music Imagery Relaxation in Medical Settings Dr. Maria Montserrat Gimeno, Fellow of Music and Imagery, Assistant Professor of Music Therapy, State University of New York (SUNY) at New Paltz, USA Music Therapy as a Community Service for Hospitals: Community Music Therapy from Hospitals Dr. Lucy Bolger (Australia) Course Tutor, The Music Therapy Trust, New Delhi
Session III
11.30 a.m. to 12.15 p.m.
Session Chair: Dr. Sumathy Sundar The Limbic System as a Seat of Emotions: Indian Classical Music as Modulators of Emotions The Need for Evidence-Based Research Dr. Vellore A R Srinivasan, Professor, Department of Biochemistry, MGMC&RI and adjunct faculty, CMTER Musical Interaction to facilitate Communication Skills in Children with Autism Dr. Baishali Mukherjee, Faculty and Research Associate, Chennai School of Music Therapy, Bangalore Effect of Music Therapy on Immunology Dr. Parin Parmar, Pediatric Allergist and Asthmologist, Music Therapy Consultant, Rajkot, Gujarat
Poster session: 12.30 p.m. to 1.00 p.m.
Lunch: 1.00 p.m. to 2.00 p.m. 14
Session IV
2.00 pm to 2.30 pm
Special Lecture Music Therapy Clinical Experiences – Where Everything Comes Together Dr.Gene Ann Behrens, Professor of Music, Director of Music Therapy Program, Elizabeth Town College, Pennsylvania, US
Session V
2.30 pm to 3.15 pm
Chair: Dr. B. Amirtha Ganesh The 'Aha!'Moment: Experiments and Experiences of Composing for Music Therapy Arnab B Chowdhury, Founder & Director, Ninad, Pondicherry Specific Requirements and Adaptability of Musical Instruments for Therapeutic Settings Aurelio C Hammer, Founder & Director, Svaram Musical Instruments and Research Center, Pondicherry.
Tea Break: 3.15 p.m. to 3.30 p.m. Panel Discussion
3.30 p.m. to 4.15 p.m.
What is the Scope of Music Therapy in this Millennium? Dr. Gerhard Tucek, Dr. Sumathy Sundar, Dr. Vellore A R Srinivasan, Dr. Maria Montserrat Gimeno, Dr. Lucy Bolger, Dr. Baishali Mukherjee, Dr. Parin Parmar, Arnab Chowdhury, Aurelio C Hammer Moderator: Prof. S. Easwaran, Head, Department of Psychiatry Valedictory Address
4.15 p.m. - 4.30 p.m.
National Anthem
15
Prof. Dr. Gerhard Tucek completed his studies in Applied Cultural Sciences, Action Research and Social and Cultural Anthropology at the Universities of Klagenfurt and Vienna. At the University of Vienna, he received his "Venia Docendi" for Social and Cultural Anthropology. He is a pioneer in developing music therapy in Austria with the Krems Model of music therapy. He has been a member of the advisory board for the federal law of music therapy at the Austrian Federal Ministry of Health since 2009. He has developed 27 music therapy programs so far in Austria. He teaches regularly in the University of Vienna and the medical university of Vienna. A founding member of the International Association for Music and Medicine and international Music and Art Research Association, Austria. He is the Program director of music therapy, Head of research unit and Vice Head of Department of Health Sciences in the IMC University of Applied Sciences, Krems, Austria. He serves on the academic board of Chennai School of Music Therapy.
Key Note Address
MUSIC THERAPY IN NEUROLOGICAL REHABILITATION: EVIDENCE-BASED PRACTICE AND RESEARCH
I
t is a great pleasure and honour to me to have been asked to present the key note speech in this 2nd International Conference on Music Therapy and I thank Sri Balaji Vidyapeeth, Mahatma Gandhi Medical College and Research Institute and Dr. Sumathy Sundar, Head of Center for Music Therapy Education and Research for giving me this opportunity. It is heartening to note that in a country known so well for its long and rich traditions and cultural diversity, music therapy is also being developed as a part medical curriculum in this university bringing to forefront the importance of science behind using music as a therapeutic tool in health care services. I congratulate the University for having made commendable efforts in advancing this profession and academic discipline by way of offering professional training programs, introducing patient care and community music therapy services on a routine basis and engaging in diverse research activities. Noting also that the ease with which the music therapy services are so naturally carried out in collaboration with the interdisciplinary team of doctors, nurses and the other allied health care professionals, I am sure that in the years to come, we can witness a very rapid development in the understanding of music therapy as a very valued tool in modern health care delivery system in your country. Our understanding in IMC University of Applied Sciences is that health is not only a perfect physiological state, but also a social construction. We are aware that we always act in the cultural frame work in our roles as a patient, therapist, student etc... but humans - at any point of time - are more than the roles that they are referred to. We also realise as music therapists, the necessity of personal growth apart from developing methodical skills and work in and with an interdisciplinary team in the department of music therapy of 15 parttime professors, 4 musicians, 3 professors with rehabilitation integrating an interdisciplinary approach in understanding the music therapy process. 16
One of the very important and major advances made in the recent times in understanding the therapeutic effects of music is the neuro-scientific research relating to the cerebral processes relating to music medicine and music therapy studies. Music listening and music making are complex, multi sensory experiences get processed in multiple centers in the brain. Magnetic and functional magnetic resonance tomography (MRT, fMRT) brain mapping, positron emission tomography (PET) as well as magnetic encephalography (MEG) and other techniques are used to explore focal brain activities before, during and after musical exposures. These researches indicate that besides the auditory cortex, music increases activity in frontal, temporal, parietal and sub cortical regions (Brown et al., 2015; Koelsch, 2009; Altenmüller and Schlaug, 2013). Thus, music has a wide range of effects on emotion (Vuilleumier and Trost, 2015: Blood and Zatorre, 2001; Boso et al, 2006; Koelsch, 2006, 2009, 2015; Koelsch and Jentschke, 2010; Pereira et al 2011), cognitive functions such as attention and memory (Baird and Samson, 2015; Castro et al., 2015; Särkämo et al., 2008), motor functions (Schaefer and Overy, 2015; Levitin and Tirolovas, 2009; Koelsch, 2009; Limb 2006)and mood (Zattore, 2015; Radstaak et al., 2015; Särkämo et al., 2008). This neuro-science knowledge helps us to understand the physiological effects of musical elements and also theoretical foundations of music therapy but music therapy process is much more complex and to understand this, mere neuro-science knowledge is not enough but dialoguing on music therapy and neuro-science with interdisciplinary perspectives are important while working in a neurological rehabilitation set up. There are three important elements influence working as a music therapist in neurological rehabilitation settings. 1) musical stimuli 2) therapeutic relationship and 3) the emotional exchange which takes place between the therapist and the patient. Also the aesthetic experience, sensory perception and the cultural anthropological perspectives in interpreting the meaningful experience and performance of patient and therapist, regulating effects of listening to music and making music (both perceptive and active), singing and moving and experiences of joy and harmony which re-establishes inner psychological and physiological structures are the broader approaches needed to understand the complex process of music therapy outcome research. The images of the brain do not comprise these meanings of music therapy to the patients and the impact on their daily life. Although neuroscience is a valuable complement to music therapy research, especially with patients with disorders of consciousness, it is an illusion that everything can be seen in the brain. We have to be aware that music therapy is much more than listening to music and interpret the neuro scientific outcome carefully with an integrated and broader approach. Our comprehension of music therapy (Tucek, 2014; Tucek et al., 2014) derives from an anthropological perspective. We are oriented towards an individual, bio-psycho-social approach, asking for individual needs of patients and their individual meaning of music therapy. As Simon Rattle (2004) said analogously, “music is not just what it is, but is that what it means to the people.” To perceive and respond to the personal meaning and individual reactions of patients, the therapist observes the patient empathically and constantly adapts the music and the whole interaction to the reactions of the patient (Eisenberg et al., 2003).This leads to a constant exchange between the patient and the therapist and forms the therapeutic process as well as the brain activation. 17
The foundation of this interaction is the therapeutic relationship. From early childhood, experiences of bonding and attachment enhance the growth and connectivity in the neural network (Schore, 1994), whereas social isolation increases the risk for morbidity and mortality (Cacioppo und Hawkley 2003) and the potential for aggression.(Eisenberg et al., 2003).Thus, interpersonal relationships are a basic need (Cozolino, 2006; Insel, 2001). Gustorff and Hannich (2008) emphasize that every living individual has the need and ability for perception and interpersonal communication. A recent study conducted from the music therapy department of the University of Applied Sciences Krems, Austria indicated that it is important to see patients with Unresponsive Wakefulness Syndrome (UWS) from a holistic perspective as social individuals as they cannot perceive environment. The therapeutic relationship has to be initiated and maintained actively in every session. Within the therapeutic relationship we try to connect with the patients by observing their reactions to the performed music and by considering even the smallest physiological changes. Live music therapy can address the individual needs of patients and offer adjusted stimuli for the support of rehabilitation. Thus the experience of a therapeutic relationship within music therapy also promotes the connectivity in the neural networks in these patients. (Steinhoff, N et al. 2015) Also, combining anthropological methods like the ethnographic investigation with neuroscientific quantitative data collection and behavioural measures can provide further understanding of what is really happening within music therapeutic interventions. Especially ethnographic insights can help us with the interpretation of research results and inspire us to ask novel questions. The fact, that an observed and described phenomenon is difficult to confirm, does not provide sufficient evidence against its genuineness or importance, but we need to develop more powerful methods with which to study such phenomenon and to make them comprehensible and valuable for a music therapist in daily clinical practice. Disorders of consciousness bare many unanswered questions, which are increased by the inability of the patients to communicate their own perceptions and views. However, considering not only snap-reading methods but a broader view of the patients environment, could help us gain more knowledge on music therapy and approach to the patient directly. (Vogl, Julia et al, 2015) To achieve this, an intense self-reflecting process of the therapist and researcher is required. Considering a neuro-anthropological perspective from the beginning of a music therapy training program encourages this broader view in future therapists and researchers and may help lead us towards a deeper comprehension of our work with a patient. (Vogl, Julia et al. 2015) Summing up, music therapy practice can be advanced by neuroscience opening up to individual real-life settings and starting to comprise all elements of music therapy, because its benefit may lie exactly in its complexity. Music therapy must be viewed with a multisensory, emotional, physical and social approach and therefore involves many neurological functions. If we want to meet the individual needs of the patients, music therapy should not be standardized. Therefore, it is crucial to have research methods within the frame, in which the investigation of individual music therapy takes place. Opening up to this complexity requires new ways of thinking which can be enhanced by an interdisciplinary dialogue. Especially in music therapy, whose theory and methods are 18
based on the combined knowledge of various disciplines, a dialogue with neuroscience can support the evidence for our practical work and provide insight into deeper processes in our patients. Hence, the dialogue between music therapy and neuroscience is seen as an important, fruitful advantage for both disciplines. (Steinhoff, N et al 2015)
References: Altenmüller E and Schlaug G.(2015). Apollo's gift: new aspects of neurologic music therapy. Prog Brain Res. 217:237-52. doi: 10.1016/bs.pbr.2014.11.029. Baird A and Samson S.(2015). 10.1016/bs.pbr.2014.11.028.
Music and dementia. Prog Brain Res. 217:207-35. doi:
Brown S, Martinez MJ and Parsons LM. (2004). Passive music listening spontaneously engages limbic and paralimbic systems. Neuro report. 15;15(13):2033-7. Brown RM, Zatorre RJ and Penhune VB.(2015). Expert music performance: cognitive, neural, and developmental bases. Prog Brain Res. 217:57-86. doi: 10.1016/bs.pbr.2014.11.021. Blood AJ and Zatorre RJ.(2001). Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc Natl Acad Sci U S A. 98(20):11818-23. Boso M, Politi P, Barale F and Enzo E. (2006). Neurophysiology and neurobiology of the musical experience. Funct Neurol. 21(4):187-91 Cacioppo JT, Hawkley LC. Social isolation and health, with an emphasis on underlying mechanisms. Perspect Biol Med. 2003 Summer;46(3 Suppl):S39-52. Castor M, Tillmann B, Luauté J, Corneyllie A, Dailler F, André-Obadia N and Perrin F. (2015). Boosting cognition with music in patients with disorders of consciousness. Neurorehabil Neural Repair. . pii: 1545968314565464. Cohn, S. (2004). Increasing resolution, intensifying ambiguity: an ethnographic account of seeing life in brain scans. Econ. Soc. 33 (1), 52-76. Cozolino L. (2006). The neuroscience of human relationships: Attachment and the Developing Social Brain. New York: W.W.Norton & Company Ltd. Domínguez D., J. F., Lewis,E.D., Turner, R. and Egan, G.F.. (2009). The Brain in Culture and Culture in the Brain: A Review of Core Issues in Neuroanthropology. Progress in Brain Research. Vol. 178. Elsevier. doi:10.1016/S0079-6123(09)17804-4. Eisenberger N, Liebermann MD, Williams KD. Does rejection hurt? An fMRI study of social exclusion. (2003) Science 302: 290-292. Gustorff, D, Hannich, H.J. (2000). Jenseits des Wortes: Musiktherapie mit komatösen Patienten auf der Intensivstation. Bern: Huber. Insel, T. The neurobiology of attachment. Nature Reviews Neuroscience (2001). 2: 129–136. doi:10.1038/35053579 Koelsch S. (2015). Music-evoked emotions: principles, brain correlates, and implications for therapy. Ann N Y Acad Sci. 1337(1):193-201. doi: 10.1111/nyas.12684. Koelsch S. (2012). Brain & Music. West Sussex: Wiley-Blackwell Koelsch S. A neuroscientific perspective on music therapy. (2009). Ann N Y Acad Sci. 1169:374-84. doi: 10.1111/j.1749-6632.2009.04592.x Koelsch S, Jentschke S. (2010). Differences in electric brain responses to melodies and chords. Cogn 19
Neurosci. 22(10):2251-62. doi: 10.1162/jocn.2009.21338 Koelsch S.(2006). Significance of Broca's area and ventral premotor cortex for music-syntactic processing. Cortex. 42(4):518-20. Levitin DJ, Tirovolas AK. (2009). Current advances in the cognitive neuroscience of music. (2009). Ann N Y Acad Sci. 1156:211-31. doi: 10.1111/j.1749-6632.2009.04417.x. Limb CJ. (2006). Structural and functional neural correlates of music perception. Anat Rec A Discov Mol Cell Evol Biol. 288(4):435-46. Nettleton, S., Kitzinger, J. and Kitzinger, C.(2014). Social Science & Medicine A Diagnostic Illusory ? The Case of Distinguishing between ' Vegetative ' and ' Minimally Conscious ' States.Social Science & Medicine 116. Elsevier Ltd: 134–41. doi:10.1016/j.socscimed.2014.06.036. Pereira CS, Teixeira J, Figueiredo P, Xavier J, Castro SL and Brattico E. (2011). Music and emotions in the brain: familiarity matters. PLoS One. 2011;6(11):e27241. doi: 10.1371/journal.pone.0027241. Epub. Rattle, S (2004). Interview in the movie “Rhythm is it” Särkämö T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M and Autti T. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain. 131(Pt 3):866-76. doi: 10.1093/brain/awn013. Schaefer RS and Overy K.(2015). Motor responses to a steady beat. Ann N Y Acad Sci. 1337(1):40-4. doi: 10.1111/nyas.12717 Schore AN.(1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Erlbaum. Steinhoff N. (2012). Reorientation Syndrome after Traumatic Brain Injury. Mechanism: Access and Solutions to This Underestimated Problem After Traumatic Brain Injury. Coping with Blast-Related Traumatic Brain Injury in Returning Troops, Series NATO Science for Peace and Security Series - E: Human and Societal Dynamics, Vol. 86.187 – 191, doi 10.3233/978-1-60750-797-0-187. Steinhoff, N; Heine, A; Vogl, J. Weiss, K; Aschraf, A Hajek, P; Schnider, P; Tucek, G (2015). Effects of music therapy on different areas of the brain of individuals with unresponsive wakefulness syndrome. In: Frontiers in Human Neuroscience (submitted) Tucek G. (2014). Der Wandel von einer altorientalischen Musiktherapie zur Ethno-Musiktherapie sowie zum, Kremser Studienkonzept“. In: Stegemann, T. & Fitzthum, E. (Hrsg.). Wiener Ringvorlesung Musiktherapie. Grundlagen und Anwendungsfelder – ein Kurzlehrbuch. Wiener Beiträge zur Musiktherapie (Bd. 11). Wien: Praesens. Tucek, G.; Zoderer, I.; Simon,P.; Sobotka, M.; Wenzel, C. (2014).Grundideen des „Kremser Modells der Musiktherapie“ im Spiegel der Feldpartitur, in: Videotranskription in der Qualitativen Sozialforschung. Multidisziplinäre Annäherungen an einen komplexen Datentypus. Hrsg: Moritz, Christine, (VS-Verlag) Wiesbaden Zatorre RJ. (2015). Musical pleasure and reward: mechanisms and dysfunctions. Ann N Y Acad Sci. 1337(1):202-11. doi: 10.1111/nyas.12677 Vogl, J.; Heine, A.; Steinhoff, N.; Weiss, K.; Tucek, G. (2015). Neuroscientific and neuroanthropological perspectives in music therapy research and practice with patients with disorders of consciousness. In: Frontiers in Human Neuroscience (submitted)
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Dr. Sumathy Sundar is a clinical music therapist, researcher and educator in India. She is the founderDirector of Chennai School of Music Therapy, Chennai and presently serves as consultant and Head of Center for Music Therapy Education and Research, a unit of Mahatma Gandhi Medical College and Research Institute, Pondicherry. She holds a Ph.D. in music therapy interventions in cancer care and has master's degree both in Indian music and also in applied psychology. She currently serves the World Federation of Music Therapy as its Chair, Education and Training Commission. A founding member of the International Association of Music and Medicine, she presently serves its board of directors as a member. She is on the editorial board of the international Journals "Music and Medicine" and "Music Therapy Today".
CMTER MODEL OF MUSIC THERAPY
Abstract The aim of this paper is to discuss in detail the profile of the three tiered hospital based music therapy program from the Center for Music Therapy Education and Research (CMTER), a unit of Mahatma Gandhi Medical College, Sri Balaji Vidyapeeth developed in a pioneering effort by Sri Balaji Vidyapeeth. The training, practice and research models are presented. Under the training model, the course content, therapeutic approaches adopted, teaching strategies, clinical training methods are discussed. Under the practice model, the referral system and the patient care straegies are discussed and under the research model, how research opportunities are created for both the faculty and the students through collaborative network are presented and discussed I. Training Model The unique aspect of this one year post graduate diploma program is that the training is offered as a part of medical curriculum from a health sciences university from the Center for Music Therapy Education and Research (CMTER), a unit of Mahatma Gandhi Medical College and Research Institute. The center is engaged in developing music therapy in all the three spheres of clinical practice, education and research under one roof. Currently, if offers a one year Post Graduate Diploma in Music Therapy training program. This is the only university-based professional music therapy training program offered from a medical college in India. This hospital based one year training program is slowly being replaced by a two years Masters degree in Medical Music Therapy from the next academic year. This training program in India was developed by me in the hospital attached to the medical college to see how it develops, meets and balances the expectations of the university, the teachers as well as the students. Our understanding of music therapy is that it is both the art and science of healing and by science; it is meant to be both the medical and social science considering the therapeutic relationship component in the music therapy process. 21
The medical model is influenced by the mind body medicine principles. The mind, a product of the brain influences physical health through three main brain-body information transfer system namely, the autonomic nervous system (ANS), neuro endocrine pathways and neuro immune pathways and the health behaviour pathways.1 Music therapy being a mind body medicine, the therapeutic musical dialoguing outcome during music therapy process depends on how brain transfers musical information to the ANS, endocrine, immune pathways and health behaviour pathways influencing physical health. (fig 1 and fig.2). This neuro-scientific approach helps us to understand the physiological, endocrine and immune responses. But considering health to be a complete state of physiological, psychological and social well being and that the musical experiences could be understood in a better manner through a biopsychosocial approach, music therapy could be learnt from an integrated perspective of multi-disciplinary concepts. The learning that unlike a pill effect, musical experiences have to be appropriately selected considering the individual needs which are based in culture and context to have positive therapeutic outcome comes through Integrated medical, psychological and cultural approaches. This forms the basis for the course content of the ongoing training program culminating in a Post Graduate Diploma in Music Therapy. The training distinguishes between music medicine and music therapy approaches and the aspiring health care professionals/allied health care professionals learn to integrate music/music therapy in their work. The course content also distinguishes clearly between healing and music therapy practices and trains the music therapists to use healing practices within the global understanding of music therapy frame work.
Fig1. Brain-Body Information Transfer System in Mind Body Medicine
Figure 2
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Music Therapy as a Mind - Body Therapy
MUSIC THERAPY
a) COURSE CONTENT Theoretical and practical content of training in two semesters of 250 hours of theory classes and 250 hours of practicum clinical training were planned. There are 4 modules each semester with one module marked for clinical training in each semester. The course content is described in detail as below. SEMESTER 1 Music Therapy Foundations UNIT 1: Introduction to different elements of music like melody, rhythm, pitch, tone, microtones, ornamentations, Timbre, Tempo, Voice and language with reference to Indian music, different genres of Indian music, repertoire for music therapy, History of music therapy in India, Healing practices and distinction between traditional healing practice and music therapy, Spirituality in Indian music Unit 2: Introduction to what is health and well being, conceptual framework for music, health and well being, Bio medical and biopsychosocial approach to treatment of disease, Music as a biopsychosocial approach for restoring and improving health, Understanding what is music therapy and the misconceptions, where music therapists work, scope of 23
music therapy applications, different methods of listening, playing musical instruments, improvisation and recreating participatory experiences and the broad range of responses to these different methods in clinical applications UNIT 3: Introduction to International approaches of music therapy (psychodynamic, behavioural music medicine and humanistic) and music therapy techniques used broadly within different methods like receptive music listening experiences, playing musical instruments and Improvisation and the scientific perspectives of using these techniques to bring a relatively permanent change in the individual and improving the Quality of life. UNIT 4: Music Therapy Process – different stages of music therapy process, how relation between music and health assessed. UNIT 5: Traditional healing practices, Time theory of Ragas, Chrono biological implications, principle of entrainment on how music can be used as an external pacemaker to entrain the biological rhythms Clinical Foundations UNIT 1: Human body as an integrated whole. Homeostasis and biological rhythms in various systems of human body. Their interdependent, harmonious and rhythmic working relationships in health and breakdown of these natural mechanisms in rhythm and harmony causing disease. Endogenous and Exagenous Rhythms, Circadian, Infradian and Ultradian rhythms UNIT 2: Introduction to physiology of cardiovascular and respiratory systems. regulatory effects of music therapy – recent researches and resources in music and medicine area. UNIT 3: Autonomous responses to music, studying how brain processes music and major computational centres for music Activation of sympathetic and para sympathetic nervous system and Role of Limbic system in processing music. UNIT 4: Introduction to endocrine and immunological systems. Important aspects related to research in these areas in music therapy, Stress: Psycho-neuro-endocrine and immune correlates. UNIT 5: how singing and improvising can stimulate brain plasticity, brain mechanisms related to music supported training in motor and language areas, EEG studies in music therapy. UNIT 6:Music Therapy as a mind body medicine, brain information transformation system and how this information is passed on to autonomous, endocrine and immune pathways to influence health related outcomes. Psychological Foundations UNIT 1: General psychological concepts like motivation, learning, perception and cognition; emotions and its relation to music therapy practice and research and understanding human behaviour and factors influencing human behaviour UNIT 2: Understanding human development across life span through Psychological theories behind music therapy practice and research, its need and application in modern health care, principles and mechanisms of psychoanalytic and psychodynamic theories 24
UNIT 3 Behavioural and humanistic theories and approaches in music therapy practice UNIT4: Introduction to childhood and adolescent disorders: Attention deficit and hyperactive disorder, conduct and separation anxiety disorders, oppositional defiant disorder, autistic spectrum disorder and childhood depression Developing Musicianship and Musical Competencies UNIT 1: Developing repertoire for clinical use in hospitals. UNIT 2: Developing sensitivities to different aspects of music through understanding different structures of music and its effect on people around - form, timbre, rhythm, raga, tempo and laya UNIT 3: Learning techniques with different forms of relaxation training through music, guided imagery, unguided imagery, raga mala paintings (imagery) song writing and lyric discussion. UNIT 4: Improvisational (raga and rhythmic) techniques by role playing in classes in both vocal and instrumental tuned and un-tuned, group and individual drumming Unit 5: Learning to assess the musical profile of the patient in factors 1)musical interests, 2)listening pattern, 3)musical training, 4) responses to musical experiences and 5) musicality levels UNIT 6: Submission of structured music therapy session activities as per assignments given to them (5 in number) to conduct music therapy sessions in the classroom environment on the basis of their learning
SEMESTER II Music Therapy Clinical Applications UNIT 1: medico functional music for clinical application in pain management in hospitals, Pain theories (Gate control and neomatrix theories) and role of music, MT techniques and clinical benefits UNIT 2: Role of music in enhancing quality of life of geriatric citizens and in the management of various biological, psychological and cognitive aspects of aging. UNIT 3: Music Therapy in Neurological rehabilitation. MT implications in cognitive, communicative, sensory motor and socio emotional impairment. UNIT 4: Music Therapy for childhood disorders, children with special needs like learning disabilities, autistic spectrum disorder and other developmental delays UNIT 5: Use of music for managing stress, cardiovascular disorders and respiratory disorders Assessments and Documentation UNIT 1: What is assessment in music therapy and how assessment is ongoing in music therapy sessions and assessments in different stages of music therapy process UNIT 2: Assessing physiological measures, observation of behavior, performance of task, 25
using self rating scales and psychological methods. UNIT 3: case reports, how to conduct interviews and record narratives in case studies UNIT 4: Documentation which are specific to music therapy in recording the changes with respect to engaging, motivating and promoting creativity and self confidence in patients. UNIT 5: Audio and video documentation Interdisciplinary Understanding and Applications of Music Therapy UNIT 1: Music Therapy and psychopathology in ADHD, anxiety disorders and mood disorders UNIT 2: Working alongside medical professionals in an interdisciplinary settings, areas for referral by other health care professionals UNIT 3: Music Medicine approaches. Practice and research areas. UNIT 4:Introduction to Psychosomatics and psychoneuroendocrine research relating to Music Therapy. UNIT 5: Use of music in pediatric wards and neonates and infants. theories and techniques Practical/Clinical Training UNIT 1: Clinical placements in departments of cardiology and pulmonary rehabilitation to work with clinicians with referral areas recommended by them. Music Therapy techniques to reduce heart rate, respiratory rate, blood pressure and other psychological and psychosocial parameters UNIT 2 : Music therapy areas to work with children with special needs. Community outreach placements to learn to create templates for MT assessment and work in collaboration with the other therapists on learning disabilities, autistic spectrum disorder and other childhood disorders. UNIT 3 : Clinical placement in department of psychiatry and antenatal and labor wards and Department of surgery and dermatology to identify music therapy goals and objectives and work both in in-patient and out-patient service areas. UNIT 4: Group music therapy for geriatric individuals adults and transgender community: Music therapy techniques for adults in class room/ geriatric community placement centers. Outreach placements in a transgender community center to work with transgender community in groups. UNIT 5: Submission of 5 single case reports/studies of different conditions B) TEACHING STRATEGIES The innovative teaching approach provides a structured and interactive learning environment through didactic and active experiential approaches through a multimedia platform, classroom role play, interactions with patients, and analysis of actual clinical problems. The teaching faculty include professionals drawn from various clinical and paraclinical specialities such as music therapy, musicology, psychology, psychiatry, microbiology, physiology, biochemistry etc. The teaching strategies are to train the students to have a strong theoretical background and also develop clinical skills. Becoming 26
skilled music therapists is the primary learning outcome for the students. The teaching strategies are adapted to train students to begin their entry-level clinical practice by honing their clinical and music therapy skills and enhancing their personality in physical, psychological and spiritual dimensions. The students become reflective, and become sensitive to the aesthetic and therapeutic qualities of music. In addition, they develop a commitment to the subject of music and its therapeutic use. C) CLINICAL TRAINING The students while doing their internship training, engage themselves in in-patient and out-patient music therapy services initially through real-time observation and then followed by supervised clinical experiences. Students work along bedside in clinical departments in the areas which are not limited to: pre operative and post operative wards, antenatal and postnatal wards, pediatric and dermatology departments either giving single exposure music therapy/music listening services or multiple exposure music listening/music therapy services depending on the individual/group needs identified in collaboration with the attending physician, surgeon, psychologist, psychiatrist or the nurse who is referring the patient for music therapy services. Problem areas/patient needs in each clinical department are also generally identified and clinicians are trained to give appropriate referrals for music therapy services which the students administer under supervision. Also, as a part of the curriculum, CMTER facilitates community-based music therapy learning experiences to the students through pre existing collaborations that the hospital has with external agencies. The students learn to transfer their skills and competencies in community settings and also learn to provide community services. The collaboration of the university and hospital with the community service agencies not only help the students but also the agencies. Currently, the students enrolled for the one year program with CMTER work with the transgender community, school for children with special needs and also an old age home compulsorily for about 6 hours per week. II) PRACTICE MODEL Music therapy at CMTER consists of a team of 3 faculties and four internship trainees offering clinical services both to inpatient as well as outpatients with a wide range of medical conditions. CMTER runs the first out-patient department services in the country from a hospital on all the days between 9.30 am to 1.00 pm. The goal of music therapy services is to support patients with emotional difficulties, communication deficiencies, alleviate anxiety, de-stress, reduce pain perception, improve mood and sleep quality and reduce length of hospital stay. The services are given individually and also in groups depending on the needs. We have a well equipped music therapy room wherein music therapy consultations are provided on referrals from health care/allied health care professionals. (Table 1). For outpatient services, referrals are provided based on a basic checklist provided to the clinicians from the music therapy centre identifying the general problem areas and also a referral sheet fulfilling certain criteria for recommending music therapy services. There are inpatient services given in routine to the patients undergoing haemodialysis procedures, children receiving immunization injection procedures, during procedures like endoscopy and colonoscopy, antenatal wards, pre-operative and post operative wards
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III) RESEARCH OPPORTUNITIES The students of the medical college, dental college and nursing college within the campus have opportunities to engage in music medicine and music therapy research projects in collaboration with CMTER and with the Central Inter-Disciplinary Research Facility (CIDRF) of SBV. Clinical faculty get engaged in research projects under the co-guidance of CMTER faculty and CMTER faculty and students do research projects with the coguidance of faculty of various clinical departments. There were five publications from CMTER last year, four clinical projects were completed this year and have just been sent for publication to peer reviewed journals.
References 1. Sivaprakash, B. (2013). (Ed) Mind and Medicine. Newsletter. Department of Psychiatry. Mahatma Gandhi Medical College. Pondicherry. Volume 1 Issue 1 July-Sep 2013 2. Sundar, Sumathy. (2014). Understanding Music Therapy: Clearing Misconceptions. Annals of Sri Balaji Vidyapeeth. Jun.2014;3(1) 3. Sundar, Sumathy (2014). Referral areas for Music Therapy Services in Hospitals. "The Harmony" Bulletin. June 2014. Center for Music Therapy Education and Research
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Dr. Maria Montserrat Gimeno is Assistant Professor in the music therapy program at the State University of New York at New Paltz. She completed a bachelor's degree in music therapy at Willamette University in Oregon. Her master's degree in music therapy and doctorate in counseling psychology are from the University of the Pacific in California. Dr. Gimeno is a licensed creative art therapist and a board certified music therapist in USA and is also trained in the Bonny Method of Guided Imagery and Music. She presents regularly in national and international conferences across the globe. Recently, she completed a research study on the use of “Music Imagery Relaxation (MIR)� a technique that she has developed to use with bedridden patients. Dr. Gimeno has taught music therapy courses and presented in the US, Spain, Norway, China, South Korea, Finland, Canada and Austria.
THE EFFECTS OF MUSIC IMAGERY RELAXATION IN MEDICAL SETTING Abstract: This presentation reports a pilot study completed at the Health Alliance of the Hudson Valley (HAHV) in Kingston, NY. It includes patients recovering from orthopedic surgery who received music therapy treatment within 36 hours post-surgery. This study followed a randomized controlled trial design; 31 patients were assigned to either the control or the experimental group. The experimental group received music and imagery therapy treatment while the control group did not. The technique used is called Music/Imagery Induced Relaxation (MIR), an adaptation of the Bonny Method, which uses the patient's experience of wellbeing to induce relaxation while the patient listens to preferred music. A statistical analysis of the data was conducted using a Repeated Measures t-test. Independent variables included the music used in each session, which varied according to client preferences and imagery. Dependent variables included level of pain and anxiety as well as physiological measures of heart rate and blood pressure. Results indicated a significant decrease in the level of pain after music therapy treatment, while anxiety reduction approached significance. Statistical significance was found for systolic blood pressure from pre to post session, while diastolic blood pressure approached significance following the music treatment. After the session, each client responded to a satisfaction survey, and the results show that all participants had a positive experience. The music therapy treatment indicates that music and guided imagery improved outcomes, whereas receiving no music therapy treatment did not improve any of these outcomes. Keywords: music, imagery, guided, relaxation, Bonny Method adaptation, medical Introduction Anxiety and pain are perhaps the most frequent and pressing psycho-physiological problems that patients present after surgery. The stresses of being in a hospital and the unfamiliarity of the setting can cause patients to experience anxiety. In addition, the uncertainty about the outcome of the surgery combined with a pending recovery period can leave anyone feeling anxious and insecure (Johnston, 1980). Anxiety is a natural response 30
to a perceived threat or danger. For the purpose of this study, surgery is the perceived threat. Although surgery is beneficial and often times necessary, patients tend to feel nervous about the procedure itself. Anxiety causes many physiological symptoms, e.g. tightness in the chest, difficulty breathing, sweating; as well as emotional distress, e.g. feeling tense and nervous (Frey & Odle, 2006). These symptoms can actually slow down the recovery process. Research has shown that patients with lower anxiety levels can recover faster from medical procedures (Madson & Silverman, 2010). The use of alternative treatments, such as music therapy, can help reduce anxiety levels without the use of medication (On Kei, Yuet, Moon, & Wai, 2005). Several studies have shown the positive effects of music and relaxation as a treatment to reduce pain and anxiety (Good, Ahn, Cong, & Stanton-Hicks, 2005; Madson & Silverman, 2010; Li, Zhou, Yan, Wang, & Zhang, 2012). Each study was executed to see the responses of patients to music before and after a medical procedure, and each showed significant reduction in pain and anxiety levels in the treatment group (Good et al., 2005; Madson & Silverman, 2010; Li et al., 2012). One method of music therapy, called the Bonny Method of Guided Imagery and Music (BMGIM), has proven to be very successful in reducing anxiety levels (Beebe & Wyatt, 2009). The BMGIM is a music therapy technique that was developed by Helen Bonny in the early 1970's at the Maryland Psychiatric Research Center (Bonny & Savary, 1973). Goldberg (1995) stated that this technique is considered unique in music therapy because it uses music to create an altered state of consciousness in order to further the patient's own understanding of him/herself (as cited by Beebe & Wyatt, 2009). It consists of four phases: (a) preliminary discussion; (b) induction; (c) music-listening period, and (d) post-session integration. The session generally lasts for 1.5 hours (Bonny, 1978). Through this process, clients are given the opportunity to get an introspective look into their own imagery, helping them to explore problems, issues, and strengths. Through this inner-personal exploration, clients can confront and conquer the root of their anxiety, resulting in a higher state of relaxation (Ventre, 2002). Several authors have reported adaptations of the BMGIM since Helen Bonny first developed it. The literature suggests variations, such as duration of the music, selection of the music, and bodily position during the music listening (Gimeno, 2010; Goldberg, 1998; Picket, 1996-1997; Short, 1991; Summer, 2002; West 1994). Goldberg (1994) recommended the use of music with a narrow range to allow a very brief imagery experience without the dynamic unfolding that is characteristic of a standard session. Blake (1994) suggested a short duration of music (no longer than 10 minutes) in a new age or classical style. She also recommended having the client in a sitting position rather than lying down on a couch, as is the case of a regular BMGIM session. Summer (2002) referred in her study to the importance of giving supportive therapy when clients need to be held to reinforce any positive feeling that might emerge during the session. In the same study, she encourages the use of task-oriented inductions as opposed to one induction that encourages exploration. She cites examples where the direction is to create a safe place or to provide a relaxing image that holds the client in a calm and positive feeling. Summer (2002) states that an induction should clearly present a self-affirming image rather than a conflictive one. A positive image allows for increased feelings of safety and good self-esteem. In the current study, the investigator is looking at an adaptation of BMGIM called Music Imagery Relaxation (MIR). MIR is a shorter session, generally 30 minutes, and the imagery goal is to relax the body and mind. It uses the concept of music and imagery in 31
order to give patients the tools to reflect inwardly and conjure up positive images, promoting relaxation and decreasing anxiety (Gimeno, 2015). The purpose of this study was to take an in-depth look at whether MIR could reduce pain and anxiety of patients who had received orthopedic surgery. The aims of the study were that patients in the experimental group receiving MIR treatment would have a larger reduction of pain and anxiety than the ones in the control group. Additionally, the psychological measures of heart rate and blood pressure would be reduced after the music therapy treatment. Indeed, music therapy researchers identify music therapy uses in the alleviation of pain and anxiety as perhaps the most effective use of music therapy in the field (Bernatzky, Presch, Anderson, & Panksepp, 2011). Methodology This study was conducted at the HAHV in Kingston, NY. The participants were patients who had had orthopedic surgery, which included hip and knee replacement. A total of 31 Caucasian patients participated in this pilot study. Participants were randomly assigned to either the experimental or the control group. The criteria for inclusion was as follows: the patient must (a) undergo orthopedic surgery including knee or hip replacement; (b) be between 18-75 years of age; (c) be able to read and understand English and/or Spanish; (d) have no history of acute psychiatric illness; and (e) have adequate mental/cognitive functioning. Recruitment This study was addressed to English as well as Spanish speaking patients. However, only English speaking Caucasian patients were available. Prospective participants were informed of the study at a meeting that was held on Mondays to inform patients about their upcoming orthopedic surgery. The researcher took the last five minutes of this meeting to inform the patients about the study and the criteria for inclusion. Patients who volunteered to participate and met the criteria signed a consent form at this meeting, while others signed it at a later time, after they made the decision. Research Design This study followed a randomized controlled trial design with an experimental and a control group. The experimental group received music and imagery treatment while the control group received standard care only. There were four dependent variables collected both before and after the MIR treatment intervention. The statistical analysis used in this study was completed using Repeated Measures t-tests for the dependent variables of pain, anxiety, heart rate and blood pressure, to determine whether there was a statistical significance before and after music and imagery treatment for the experimental group. For the control group, the same time frame was used to take measurements to test for statistical significance. Experimental treatment conditions were guided imagery and music. Participants received one session of MIR within 36 hours after a hip or knee replacement. Participants responded to a satisfaction survey once the session ended.
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Table 1 Repeated Measures Design: Two groups, Random Selection, Pre-test, Post-test
Group Pre-test Treatment Post-test End of X Experimental group = E (R) O1 X O2 SS ______________________________________________________________________________ Control group = C (R) O1 O2 ______________________________________________________________________________ Symbol SS = Satisfaction Survey Variables Studied Independent variables were music and imagery. The music used within each treatment session consisted of the participants' preferred music. The length of each musical selection varied between eight and ten minutes. The imagery used was based on what the participant reported during the prelude phase regarding a memory of experiencing well-being. Dependent variables were the level of pain and anxiety, and physiological measures of heart rate and blood pressure. Procedure Demographic information on the participants was collected, which included gender, age, ethnicity, primary language (spoken/written), and type of orthopedic surgery. In addition, pre- and post-tests on levels of pain and anxiety, as well as physiological measures of heart rate and blood pressure were taken. At the end of the music therapy treatment, every participant responded to a satisfaction survey. Each participant in the experimental group received one MIR session within 36 hours after surgery. The purpose of the MIR technique was to induce relaxation, helping the participant to be in touch with a positive inner experience through music and imagery while in an Altered State of Consciousness (ASC). The session lasted for approximately 30-40 minutes. The MIR treatment consisted of four phases: (1) The first phase is called Prelude. During this time, a therapeutic rapport was developed by discussing an experience of well-being that was known to the participant. (2) The second phase is called Induction. During this time, the researcher provided a brief relaxation exercise in transitioning to the ASC. (3) The third phase is called Music Listening. During this time, the participant was engaged in listening to eight to ten minutes of preferred music while the researcher was verbalizing a script elaborated from the participant's reported experience of well-being. At this stage all the senses were utilized to intensify the imagery, making it as vivid as possible for the participant to revisit the experience. (4) This last phase is called Process, which involved the processing of the experience they just had (Gimeno, 2015). Data Collection The data collected included: (1) the level of anxiety pre and post-treatment measured using a Visual Analog Scale (VAS) with anchors from 0-100 millimeters; (2) physiological 33
measures of heart rate (HR), and blood pressure (BP) which were recorded by the nurse in charge using a portable monitor pre and post-treatment. At the end of the session, the participants in the experimental group received an envelope containing a satisfaction survey that consisted of five questions, and completed their surveys at their convenience within the next hour. Participants in the control group received a complimentary session of MIR after all data was collected. Results The sample for this study included 15 men and 16 women with a mean age of 65 years (4475). Results from the experimental group indicated that heart rate showed a significant improvement following music and imagery treatment (p=0.01). In regards to blood pressure, the systolic showed a significant improvement following music and imagery treatment (p=0.03), while the diastolic showed improvement that approached significance (p=0.06). The VAS for pain showed a significant improvement following music and imagery treatment (p=0.01), while anxiety showed improvement that approached significance (p=0.06). In the control group, heart rate significantly worsened following no treatment (p=0.01). No other measure showed statistically significant change. In conclusion, MIR treatment improved outcomes, whereas standard treatment alone did not improve any outcomes. Table 2 Mean scores, standard deviation and p value for the dependent variables in both groups Experimental Group Pre-test Mean (SD)
Experimental Group Post-test Mean (SD)
p
Control Group Pre-test Mean (SD)
84.38 (16.4)
76.13 (11.3)
0.01
73.94 (11.2)
77.8 (11.1)
0.01
127.25 (17.9)
121.19 (11.5)
0.03
127.69 (21.5)
129.13 (18.8)
0.65
65.31 (9.3)
60.19 (7.5)
0.06
66.88 (12.9)
70.19 (11.6)
0.33
Visual Analog Scale _P
4.44 (2.7)
1.88 (2.1)
0.01
3.88 (2.2)
3.63 (2.6)
0.56
Visual Analog Scale _A
7.38 (11.7)
1.38 (2.0)
0.06
2.75 (3.2)
3.00 (3.1)
0.10
Factor HeartRate Systolic Blood Pressure Diastolic Blood Pressure
Control Group Post-test Mean (SD)
p
Descriptive Analyses on Perception of Patients' Benefits The following results pertain to the participants' perceptions of the benefits of MIR treatment. When observing the percentages of the surveys, it is noted that all participants (100%) reported positively to the five questions listed: (1) do you feel that the music with imagery session was helpful in promoting relaxation? Y/N; (2) do you feel less anxious after the session? Y/N; (3) was your imagery pleasant while listening to the music? Y/N; (4) did you like the choice of music? Y/N; (5) would you like to have another session of this type? Y/N. Discussion Results of this study showed statistical significance and validated the benefits of the MIR technique to induce relaxation. This was a mixed method study wherein both the 34
quantitative and qualitative measures show the success of this technique. This is the first time that this technique has been tested, and the results are promising. It would be interesting to do experiments using this technique on larger pools of participants, patients with different diagnoses, different demographics and cultures, and so on. I think that this technique can also be successfully applied in other settings outside of hospitals, and am interested in the possibility of using this technique with children, which would involve figuring out the best adaptations of the treatment to use depending on the various stages of childhood development. Two components of this study seem to be important to its success in distracting patients from their pain and anxiety: (1) the use of preferred music, no matter what type of music the patient requested; and (2) revisiting an experience that was enjoyable for the patient, and at the same time deeply personal and poignant. Allowed to choose whatever music they preferred, even if it wasn't what we would typically consider music to induce relaxation, patients were more easily able to connect to the treatment on a very personal level. And in doing so, participants were able to revisit remembered experiences that they owned personally. For example, there was a case of a patient who chose rock and roll music. Some may think that this type of music would not relax someone. But this patient depicted a memory of a time in which he was on a camping trip with his granddaughters, listening to this music in the background, and roasting marshmallows over the fire. The effects of this music in this case helped him to really connect with this experience to revisit it. Previous research supports the idea that the way we think affects our physiological body responses, our mood, and our experience of pain and anxiety (Frey & Odle, 2006). We can see these same dynamics in the current study, where a positive memory impacts the body's physiological responses and the patient's experience of pain and anxiety. Further research needs to be done to find out exactly what in the brain is being activated and/or altered when music is used to induce a positive memory, as opposed to the memory being experienced without music. A comparison may be able to be drawn between this topic and the recovery of patients with traumatic brain injuries, where we see the brain creating new pathways and healing damaged ones in order to recover from the injury (Archibald, Hutton, Clarke, Mosimann, & Burn, 2013). This finding has led to the possibility of exploiting this connection in order to strengthen new connections for no longer functioning pathways. The experience of being in a hospital, especially with life threatening ailments, can be extremely traumatic to a patient, affecting the brain's function. Worries in regards to medical diagnosis and prognostic, ruminating on negative thoughts, in an environment that is unfamiliar, uncomfortable, and removed from all of the things that the patient associates with the positive memories of his/her life, can be seen as injuring the brain. Can music play an important role in helping to heal the worries of the mind? The current study shows that the use of listening to preferred music in and ASC paired with a script of a personal wellbeing experience, has the ability to quickly and effectively switch patients out of their negative feelings and into a vivid, positive memory. This experiment is well supported by The Gate Control theory of pain, developed by Ronald Melzack and Patrick Wall in 1965. The theory asserts that non-painful sensory input, known as “non-noxious stimuli,” can “close the gates” to painful input, impeding the 35
sensation of pain from entering into a person's consciousness via the central nervous system (Mendell, 2015). In the case of this study, we can consider the components of MIR, the preferred music and the story script, the non-noxious stimuli that prevent pain from being experienced. It would be of interest to do research in collaboration with other disciplines, such as neuropsychology, exploring how music actually alters the brain function during experiences such as MIR. I am also curious to see if a patient, given a recording of preferred music and a personal script, can be trained at home to cope with pain and anxiety. Furthermore, music therapy research has shown the benefits of intervention for relaxation in a hospital setting. For example, the study by Good et al., (2005) shows that teaching music and relaxation techniques to patients helps to decrease their pain after intestinal surgery. But there is no research in my awareness that shows the patient's own, personal imagery, with preferred music, having such effects. This personal ownership of imagery is at the core of the Bonny Method of GIM. MIR is an adaptation of the Bonny Method, and shares this core with it. To conclude, this experiment offers some valuable results for best practices and music therapy research protocols.
References Archibald, N. K., Hutton, S. B., Clarke, M.P., Mosimann, U. P., & Burn, D. J. (2013). Visual exploration in parkinson's disease and parkinson's disease dementia. Brain: A Journal of Neurology, 739-750. doi: http://dx.doi.org/10.1093/brain/awt005 Beebe, L. H. & Wyatt, T. H. (2009). Guided imagery & music: Using the bonny method to evoke emotion & access the unconscious. Journal of Psychosocial Nursing & Mental Health Services, 47(1), 29-33. Retrieved from http://search.proquest.com/docview/225534887?accountid=12761 Bonny, H. (1978). Facilitating GIM sessions: GIM Monograph#1. Baltimore: ICM Books. Bonny, H. L., & Savary, L. M. (1973). Music and your mind: listening with a new consciousness. New York, NY: Harper & Row. Retrieved from Blake, R. (1994). The Bonny Method of guided imagery and music (GIM) in the treatment of post-traumatic stress disorder (PTSD) with adults in psychiatric settings. Music Therapy Perspectives, 12, 125-129. Frey, R. J., & Odle, T. G. (2006). Anxiety. In The Gale encyclopedia of medicine (3 ed., Vol. 1, pp. 357-362). Detroit, MI: Retrieved from http://ehis.ebscohost.com Good, M., Anderson, G., Ahn, S., Cong, X., & Stanton-Hicks, M. (2005). Relaxation and music reduce pain following intestinal surgery. Research In Nursing & Health, 28(3), 480-251. Johnston, M. (1980). Anxiety in surgical patients. Psychological Medicine, 10(1), 145-152. doi: http://dx.doi.org/10.1017/S0033291700039684 Li, X., Zhou, K., Yan, H., Wang, D., & Zhang, Y. (2012). Effects of music therapy on anxiety of patients with breast cancer after radical mastectomy: a randomized clinical trial. Journal of Advanced Nursing, 68(5), 1145-1155. doi:10.1111/j.1365-2648.2011.05848.x Madson, A., & Silverman, M. (2010). The effect of music therapy on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients. Journal Of Music Therapy, 47(3), 220-232. 36
Mendell, L. (2015). Constructing and deconstructing the gate theory of pain. PAINÂŽ, 155(2), 210216. Retrieved May 4, 2015, from http://www.sciencedirect.com/science/article/pii/S0304395913006581# On Kei Angela, L., Yuet Foon Loretta, C., Moon Fai, C., & Wai Ming, C. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal Of Clinical Nursing, 14(5), 609-620. doi:10.1111/j.13652702.2004.01103.x Ventre, M. (2002). The individual form of the Bonny Method of Guided Imagery and Music (BMGIM). In K. E. Bruscia & D. E. Grocke (Eds.), Guided imagery and music: the Bonny Method and beyond (pp. 29-35). Gilsum, NH: Barcelona Publishers. Bonde, L. O. (2005). The Bonny method of guided imagery and music (BMGIM) with cancer survivors. A psychosocial study with focus on the influence of BMGIM on mood and quality of life. Aalborg: Institute for Musik of Musikterapi, Aalborg Universitet Bruscia, K.E. & Grocke, D. E. (2002). Guided imagery and music: The Bonny Method and Beyond. (Barcelona Publishers). Gimeno, M. M. (2010). The effect of music and imagery to induce relaxation and reduce nausea and emesis in patients with cancer undergoing chemotherapy treatment. Music and Medicine Journal, 2(3), 174-181. Goldberg, F. S. (1998). Images of emotion: the role of emotion in guided imagery and music. Journal of the Association for Music and Imagery, 1, 5-15. Goldberg, F. S. (1994). The Bonny Method of guided imagery and music (GIM) as individual and group treatment in a short-term acute psychiatric hospital. Journal of the Association for Music and Imagery 3, 18-31. Pickett, E. (1996-97). Guided imagery and music in head trauma rehabilitation. Journal of the Association for Music and Imagery, 5, 51-60. Short, A. (1991). The role of guided imagery and music in diagnosing physical illness or trauma. Music Therapy, 1, 22-48. Summer, L. (2002). Group music and imagery therapy: emergent receptive techniques in music therapy practice. In Bruscia, K. E. & Grocke, D. E. (Eds), Guided Imagery and Music: The Bonny Method and Beyond, pp. 297-306. Gilsum, NH: Barcelona Publishers. West, T. (1994). Psychological issues in hospice music therapy. Music Therapy Perspectives, 12, 125-129. Wigle, J.R., & Kasayka, R.E. (1999). Guided imagery and music with medical patients. In Dileo, Ch. (Eds), Music Therapy & Medicine: Theoretical and Clinical Applications, pp. 23-30. American Music Therapy Association, Inc. Silver Spring, MD.
37
Dr. Lucy Bolger is the current course tutor for the Music Therapy Trust's Postgraduate Diploma in Music Therapy, based in Delhi, India. She has recently completed her PhD at the University of Melbourne, where she examined the process of collaboration in participatory music projects with marginalised adolescents. Alongside 10 years of music therapy practice with people at all stages of life, Lucy has been involved in music therapy research in community and school settings. She is committed to fostering flourishing musical cultures to promote health and wellbeing.
In
particular, Lucy's work focuses on collaboration, sustainability and participatory practice in music therapy with marginalised communities and individuals, both in the Australian and international development contexts.
MUSIC THERAPY AS A COMMUNITY SERVICE FOR HOSPITALS: COMMUNITY MUSIC THERAPY FROM HOSPITALS
G
lobally, there is an expanding understanding of the role of health services and treatment to include health promotion and prevention as well and critical curative measures. This is reflective of the WHO definition of health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity� (WHO, 1986). Healthcare is increasingly perceived as a continuum from acute care through to health promotion and wellness (O'Grady and McFerran, 2007). In this construct, the ultimate aim of health services is to facilitate patient's transition towards the healthy end of the healthcare continuum, and maximise the possibility for people to maintain this healthy status – in other words, to minimise the possibility of relapse or recurrence. This understanding of health care emphasises the importance of cultural context and community in supporting health and recovery. Since the turn of the century, the impact of context on patients' potential for health and recovery from illness has received increasing attention in health care (Rolvsjord, 2004). Cultural understandings of health and illness, as well as access and availability of support and services, impact on patients' potential to maintain their health after illness or disability, and will influence their attitude and approach to medical treatment and health services. Additionally, in the current health and medical landscape, there is a growing emphasis on patient engagement to maximise recovery and reduce the possibility of re-admission (Rolvsjord, 2010). The result is a growing ecological, participatory orientation to patient care. This ecological understanding takes into account the community context in which health services are operating, and engages with different levels of the social system surrounding patients. In a practical sense, this represents a need for stronger links between hospital and community centres and services. As the primary hub of health care service provision, hospitals are vital as a base to connect outwards with communities and engage patients in their own recovery. 38
Globally in the music therapy profession, ecological and participatory thinking is gaining increasing prominence in the theoretical discourse (Pavlicevic&Ansdell, 2004; Stige et al, 2010 Stige&Aaro, 2012). Ecological and participatory practice and research is articulated not only in community-based music therapy services, but also in medical settings: in acute hospitals (O'Brien, 2006, 2014;Shoemark; 2009;Kildea, 2007), inrehabilitation (Wood, Verney&Aitkenson, 2004); and in mental health care (Hense, 2015; Cheong-Clinch, 2011Solli&Rolvsjord, 2015; Rolvsjord, 2010). Such music therapy studies describe a dual emphasis. In addition to addressing core medical issues of patients, this work includes supporting patients to transition through services: from in-patient, to outpatient, to community services. Additionally, in acute medical settings, music therapists describe a whole-community understanding of the hospital environment. As such, they identify music therapy's role as contributing to the wider ecology of the hospital, not just the individual treatment of each patient. In addition, a growing emphasis on working together with families and carers in medical music therapy contexts is emerging (Shoemark&Dearn, 2008; Magill, 2009). Why is this ecological approach to medical services important? Treating the immediate medical needs of patients is critical. It will always be primary to the practice of music therapists and health professionals working in medical settings. This is as it should be. However, there is potential benefit in also thinking beyond immediate treatment and adopting a long-term view of patients' prognosis. Once patients leave the hospital, it can be difficult to maintain motivation and capacity to independently adhere to recovery protocols. This may result in impaired recovery and potential readmission. Facilitating patients' transition back to community may support ongoing recovery and maximise the best use of limited financial, human and practical resources of hospitals. Music therapy is in the strong position to support this transition, as it is an intervention that can be implemented flexibly at all stages of the health care continuum (O'Grady &McFerran, 2007). There is a wide and growing evidence base for music therapy in medical settings, including a series of meta-analyses that highlight both areas of impact and areas for further research. In addition to quantitative studies investigating outcomes of music therapy, important qualitative case studies examine music therapy processes and patient experiences in medical settings. Both of these types of evidence offer critical information that can be used to inform India's music therapy profession as it develops. Of course, indigenous Indian music therapy research is also needed, and this is a growing area as the discipline continues to develop. Existing music therapy theory and evidence from around the world offers an excellent basis, but must be also investigated in the light of the Indian context. We cannot assume that methods and approaches from overseas can simply be imported without consideration of India's unique social and cultural health milieu. In this paper I describe the way an ecological approach to music therapy is currently being implemented in a large private hospital in Delhi. I examine this program and early outcomes in consideration of the Indian context, and use this to consider the relevance of ecological music therapy models in hospital settings in India. Introducing the hospital context: VIMHANS The music therapy program that is the focus of this paper has been developing over the past 39
two years, and continues to develop and expand. The program is based at VIMHANS, a private hospital in Delhi with a primary focus on neurology and mental health treatment and rehabilitation. The hospital provides both acute in-patienttreatment and ongoing outpatient services focused on recovery and rehabilitation. In addition, VIMHANS runs a variety of outreach community services with external partner organisations. Through these levels of service, the hospital has developed its own ecology that extend beyond treatment rooms and into the wider social context impacting on patients. VIMHANS employs a wide treatment team including doctors and surgeons, nurses and care staff, psychologists and social workers, allied health professionals and complementary therapists. Staff work in cooperation to address the needs of patients. Music therapists are employed as part of this team. VIMHANS takes a progressive, holistic approach to care, where emphasis is placed on treating the whole patient, rather than just the illness. There is an underlying understanding thatit is necessary to both treat of the underlying pathology and support the patient to engage and develop the healthy aspects of their life in order to optimise health for people with neurological disorders and mental health challenges. This is important in areas such as neurology and mental health where illness or disability is rarely eradicated completely and ongoing support and management is often necessary. The premise for this dual focus for treatment is the notion that the healthy aspects of a patient's life can serve as protective factors to support ongoing rehabilitation and recovery towards health and wellbeing. This emphasis not just on treating illness but promoting health is reflected in the overall culture at VIMHANS. The hospital as a whole serves as hub where a sense of community isencouraged and intentionally fostered as part of patient treatment. Music therapy at VIMHANS The music therapy program at VIMHANS is a collaboration between The Music Therapy Trust (TMTT) and VIMHANS hospital. Currently, VIMHANS employs two qualified music therapists to deliver clinical services within their hospital programs. In addition, music therapy students are engaged in student placements at VIMHANS, and TMTT provides advocacy and training workshops in music therapy for health care staff and students at VIMHANS. Since the program began two years ago, music therapy services have expanded from 8hours to 17 hours per week. The program has expanded its focus from individual sessions in neurorehabilitation to a combination of group and individual sessions in in-patient, outpatient and outreach programs across the gamut of hospital clinical areas. Current services outlined in more detail in Table 1 below. This increase in hours and broader ecological approach to service delivery has allowed the music therapy program to increase its caseload from 8 patients per week to approximately 50 patients per week. This is significant in a country where there is a very large population in need of services and very few qualified music therapists to deliver this work. The program is evaluated in an ongoing way using patient and staff report to ensure satisfaction in meeting the goals of the program. Some initial research has been undertaken in targeted clinical areas and results are currently being collated. Further 40
targeted research is projected, but is currently under development as the program continues to develop. Service In-patient
Out-patient
Outreach
Common diagnoses of referred patients Neurology: - Coma - Stroke - ABI Mental health: - Schizophrenia - Bipolar - Anxiety - Depression - Substance abuse
Clinical services provided Groups and individual sessions - on hospital ward - in MT room
Neurology: - Stroke - ABI Child and adolescent mental health: - Autism Chronic mental illness - Schizophrenia - Bipolar - Anxiety - Depression
Group and individual sessions - in outpatient clinic - in group therapy room - in MT room
Aged care: - Older adults MT workshops - Health care students - Health care professionals
General goals for treatment -
-
-
Group sessions at shared elder home Hospitalbased workshops
-
-
Motivation to participate in recovery Engagement Reality orientation Emotional expression Functional recovery: vocal and motor Sensory stimulation
Self-esteem and identity Independence Sense of purpose Emotional expression Child development
healthy aging use of music as a resource for health capacity building
TABLE 1: Summary of ongoing music therapy services at VIMHANS. Overview based on 6monthly program evaluations. The ecological approach to services at VIMHANS allows music therapists to focus on different goals at different stages of recovery, and to support patients as they transition through different hospital services. Therefore the music therapy program at VIMHANS is working at different levels of the hospital community – from bedside work in wards to the outpatient clinic to the wider community. The program also working across the health-care continuum, from acute medical crisis to recovery and rehabilitation through to health promotion and wellbeing. Different aspects of the music therapy program have different aims and objectives based on the needs of patients at different stages of illness and recovery. Consistent with many music therapy services around the world, a treatment focus is more prominent in acute services (Baker and Tamplin, 2006;Magee & O'Kelly, 2015; O'Kelly et al, 2014), while in recovery and health promotion services the music therapist is often 41
focused on building the patients' resources for health through music (Batt-Rawden, DeNora& Ruud, 2005, Ruud, 2010;DeNora , 2007). In addition to specific patient outcomes, this ecological approach to music therapy has helped to foster a musical culture across the hospital at VIMHANS. This musical presence supports to development of VIMHANS as a community hub for health services, as music is able to connect staff, patients and families across the hospital. Although this is perhaps a secondary outcome of the program, it has important implications in the Indian context. India is a communal society that often connects through music. Music at VIMHANS can offer patients and families a tangible and familiar medium to engage with hospital services.
In addition, one of the key challenges facing people with mental health challenges or disability in India is stigmatisation. Music therapy connects with the healthy aspects of patients, and this is important in fostering hope, as well as helping to 'normalise' the hospital experience for both patients and their loved ones. This can support people to remain engaged in their treatment as it can create links to the outside world beyond medical treatment, even while being conducted in a hospital. This familiar, social feature of music can be beneficial in addressing a second cultural challenge for Indian health services: Fatalism. Recovery and rehabilitation is long journey that requires ongoing commitment from patients. A fatalistic approach to disability and illness is not compatible with this ongoing commitment, and health care professionals often report that people will often abandon rehab and seek out spiritual options instead. While spirituality can be a supportive resource for health, it needs to be in conjunction with health services to maximise recovery. Music therapy can address spiritual needs of patients musically, whilst keeping them engaged in their medical treatment. The music therapy program at VIMHANS developed spontaneously from a traditional 1:1 treatment model to a broader ecological approach, in response to the needs of the hospital. Reflection on the current development of this program suggests that music therapy using this ecological approach can add value to medical services at both an individual patient level, as well as at a broader hospital community level. In addition, this program suggests that an ecological approach to music therapy Indian hospitals can not only address core health concerns of patients, but also address some challenges for health services that are specific to the Indian context. In particular, the challenge of delivering music therapy to a large population, and cultural challenges of stigmatisation and fatalism that can be a barrier to prolonged engagement in with hospital services. Further research to investigate these areas may help to further articulateimportant aspects of the unique contribution that music therapy can make in hospital settings in India. Resources Baker &Tamplin (2006).Music Therapy Methods in Neurorehabilitation: A Clinician's Manual, London: Jessica Kingsley Batt-Rawden, K. B., DeNora, T., & Ruud, E. (2005). Music listening and empowerment in health promotion: A study of the role and significance of music in everyday life of the long-term ill. Nordic Journal of Music Therapy, 14(2), 120-136. 42
DeNora, T. (2007). Health and music in everyday life--a theory of practice.Psyke& Logos, 28(1), 271-287. Hense, C (2015) Forming the Youth Music Action Group, Voices: A World Forum for Music Therapy, 15 (1), https://voices.no/index.php/voices/article/view/810 Kildea, C. (2007). In your own time: A collaboration between music therapy in a large pediatric hospital and a metropolitan symphony orchestra. Voices: A World Forum for Music Therapy, 7(2). Retrieved from https://voices.no/index.php/voices/article/view/495/402 Magee & O'Kelly (2015) Music therapy with disorders of consciousness: Current evidence and emergent evidence-based practice, Annals of the New York Academy of Sciences, 1337, pp256272 Magill, L. (2009). Caregiver empowerment and music therapy: Through the eyes of bereaved caregivers of advanced cancer patients. Journal of Palliative Care, 25(1), 68-75. O'Brien, E. (2006). Opera therapy: Creating and performing a new work with cancer patients and professional singers. Nordic Journal of Music Therapy, 15(1), 82-96. O'Grady , L., &McFerran, K. (2007). Uniting the work of community musicians and music therapists through the health-care continuum: A grounded theory analysis. Australian Journal of Music Therapy, 18, 62-86. O'Kelly et al (2014) Music therapy advances in neuro-disability – innovations in research and practice: Summary report and reflections on a two-day international conference.Voices: A World Forum for Music Therapy, 14(1), https://voices.no/index.php/voices/article/view/742/637 Pavlicevic, M., &Ansdell, G. (2004).Community Music Therapy. London: Jessica Kingsley Publishers. Rolvsjord, R. (2004). Therapy as empowerment: Clinical and political implications of empowerment philosophy in mental health practices of music therapy. Nordic Journal of Music Therapy, 13(2), 99-111. Rolvsjord, R. (2010). Resource-oriented music therapy in mental health care. New Hampshire: Barcelona Publishers. Ruud, E. (2010).Music therapy: A perspective from the humanities. New Hampshire: Barcelona Publishers. Shoemark, H., &Dearn, T. (2008). Keeping parents at the centre of family centred music therapy with hospitalised infants. Australian Journal of Music Therapy, 19, 2-24. Shoemark, H. (2009). Sweet melodies: Combining the talents and knowledge of music therapy and elite musicianship. Voices: A World Forum for Music Therapy, 9(2). Retrieved from https://voices.no/index.php/voices/article/view/347/271 Solli, H. &Rolvsjord, R (2015).“The opposite of treatment”: A qualitative study of how patients diagnosed with psychosis experience music therapy,Nordic Journal of Music Therapy, 24:1, 67-92 Stige, B., Ansdell, G., Elefant, C., &Pavlicevic, M. (2010). Where music helps. Community Music Therapy in action and reflection. Surrey: Ashgate. Stige, B., &Aarø, L. E. (2012). Invitation to Community Music Therapy. New York: Routledge. WHO (1986).Ottawa charter for health promotion. Geneva: World Health Organization. Wood, S., Verney, R., & Atkinson, J. (2004). From therapy to community: Making music in neurological rehabilitation. In M. Pavlicevic& G. Ansdell (Eds.), Community Music Therapy (pp. 48-62). London: Jessica Kingsley Publishers. 43
Dr. Vellore A.R. Srinivasan has a doctoral degree in Medical Biochemistry. His Medical Biochemistry PG degree was obtained
from CMC Vellore in 1987 which earned him the credit
"first" in Madras
University. A co- inventor of a patent in medicine, he is also a performing Classical vocalist, percussionist and composer. He has been featured on several TV channels including CNNIBN. He is currently Professor, Department of Biochemistry, Mahatma Gandhi Medical College and Research Institute, Pondicherry and also an adjunct faculty, Center for Music Therapy Education and Research.
THE LIMBIC SYSTEM AS THE SEAT OF EMOTIONS: INDIAN CLASSICAL RAGAS (Musical modes) AS MODULATORS OF EMOTIONS - The need for evidence based studies Abstract: Musical modes or ragas in indian classical music have been in vogue since the days of Ayurvedic medicine. These musical modes were used in ancient Indian music as modulators of emotions. The putative role of these musical modes needs to be confirmed by carrying out evidence based research as only a few studies are available the world over. This is the need of the hour. Introduction: The human brain is a fascinating organ which complies with the phrase “ known and yet unknown�. As we trace the concepts of evolution , we arrive at the fact that the brain has acquired three significant components that progressively had appeared and eventually became superimposed. The primitive component comprises of the structures of the brain stem-medulla, pons and cerebellum. The ancient nuclei, namely globus pallidus and the olfactory bulb are other structures. These structures are believed to have originated from the reptiles . The ancient mammalian brain,
Fig. 1 THE LIMBIC SYSTEM 44
also known as paleopallium or “ intermediate� essentially comprises of the limbic system. The limbic system corresponds to the brain of lower animals. On the contrary, the highly evolved structures of the brain comprise of the hemispheres that signify a recent type of cortex, namely neocortex. These represent the brain of the superior mammals, including primates and human beings. These definitions signify the phylogenesis or evolution of human brain. Despite the fact that the structures are anatomically well connected, each of them retain certain special characteristics. The limbic system is the seat of human emotions (Fig.1). Several nuclei of gray matter (neurons) constitute the limbic lobe (derived from the Latin word "limbus" that denotes circle / ring). The limbic lobe borders around the brain stem and hence its name. Emotions and feelings, such as wrath, disgust, fright, passion, love, hate, joy and melancholy originate in the limbic system (Fig.2). This system also takes care of a few aspects of personal identity/ idiosyncrasy and memory. This is a vantage point for music therapy, since modulation of emotions and feelings, intrinsically coupled to the memory largely contribute to the well – being of an individual.
Fig.2 The components of the limbic system
Emotions are a conglomerate of the limbic system : The neuroanatomist James Papez delineated the fact that emotion is not a function of any specific brain center, but essentially of a circuit that involves primarily the four basic structures, interconnected through several complex nervous bundles : the hypothalamus and its mamillary bodies, the anterior thalamic nucleus, the cingulate gyrus and the hippocampus (Fig. 2). The Papez circuit acts in a physiologically harmonious manner, which is synonymous with the central functions of emotion and its characteristic expressions. Presently, newer structures have been acceded to the circuit which includes the prefrontal area, the parahippocampal gyrus and also subcortical groupings such as the amygdala, the medial thalamic nucleus, the septal area, basal nuclei and a few portions of the brainstem ( Table 1).
45
Table 1 system
Emotions: Culmination of Structure- Function interrelationship in the Limbic
Functions
Remarks
Amygdala
Controls major affective activities
Involved in fear, rage, anxiety, aggression
Hippocampus
Emotions linked to long term Allows comparison of a danger memory with past experiences
Structure
Connect various pathways of limbic system
Fornix and Varied emotions parahippocampus Thalamus
Relays sensory and motor Regulation of consciousness, sleep, alertness signals, besides fostering changed reactivity to emotions
Hypothalamus
Lateral part involved in Involved in the differential pleasure and rage; median part expression of emotions related to aversion
Cingulate gyrus
Pain and reaction to aggression
Associated with pleasant memories and anxiety
Brainstem
Maintenance of sleep awake cycle
Secretes norepinephrine; acts as alerting guard
Ventral teg mental Secretes dopamine and is area involved inpleasure
Decrease in dopamine action is implicated in addiction
When the physical symptoms of a particular emotion appear, there is a threat that it may return to the limbic centers, through the hypothalamus and precisely in this regard, music therapy can be so strong so as to generate a situation that is synonymous with the decrease in anxiety. The hypothalamus also regulates the functioning of the autonomic nervous system which regulates pulse, blood pressure arousal etc., in response to emotional circumstances. Why music therapy? The use of musical interventions to facilitate individual goals within the limits of a therapeutic relationship is the core of music therapy. When a music therapist explores the various facets of music, he/she would certainly take into consideration the physiological, emotional, social, ethical and spiritual tenets, before administering therapy to the clients. Human emotions form a major component that must be taken cognisance of 46
while administering music therapy, in this era of personalised medicine. Though the effect of musical modes in the Indian classical music, on the human brain has been perceived since several years, objectivisation continues to be a major lacuna. We admit that the Indian classical rAgAs ( rAgs) are presently being used the world over, but seldom documented. This is mainly attributed to the lack of evidence based research. This needs to be addressed immediately. What are ragas? : rAg or rAga denotes a musical mode in the Indian classical music genre. Each rAga has an ascending scale known as ArOha(na) and a descending scale referred to as avarOha(na). Basically, there are two functional genres or styles, namely Carnatic style that is popular in South India and Hindustani style that is in vogue in North India. There are 72 main rAgas in the Carnatic style known as Melakarta ragas and hundreds of rAgas are created out of them by indulging in permutations and combinations ( janya rAgas). rAgas may have all the seven swarAs or notes (sampoorna) or may be pentatonic (audava) meaning musical modes of five notes or hexatonic (sHAdava)—six musical notes etc. The Hindustani musical modes are known as rAg and there are basically ten thAts from which originate scores of rAgs. In any rAg, it is important to understand the concept of vadi and samvadi, meaning the most important musical note and the second most important one respectively. For exploring the full potentials of the musical modes as therapeutic agents , this key point must be borne in mind. Role of music in therapy: Music maintains the emotional, physiological and psychological well being of an individual. Since time immemorial music in India has been used in therapy. The tone,timbre, beats,tempo and arrangement of the musical notes ( swarA) in a musical mode ( rAg) tend to stimulate or calm down the structures of the limbic system. The ancient Indian system of Medicine , namely Ayurveda recommended music for therapeutic purpose. Ayurveda states that the rAg (rAga) produces a soothing effect on the mind and body by acting on muscles, nerves and chakras. The chakras or vantage points are present in the human body that mediate/ modulate subtle nuances in mind and body ultimately creating a state of equipoise and upholding health. The present day equivalent is MIND BODY MEDICINE. Music therapy is presently administered as an adjuvant and comes under Complementary and Alternative Medicine (CAM). (Classical Indian) musical modes as putative therapeutic agents : Based on the intrinsic capacity of the musical mode, specific emotions are believed to originate that ultimately determine the therapeutic effect of the rAg ( raga) concerned. The putative role of Indian classical ragas are depicted in Table 2. A demonstration on the musical modes ( carnatic genre) would be featured during the conference.
47
Table 2: The putative effect of ( Indian Classical ) musical modes ( rAgAs) as modulators of emotions
Emotion ( as Name and Nature of the musical linked to the mode in the carnatic genre
Sl.No.
Rasa (as structures of described the Limbic conventionally) system ) 1.
Shanta
Peace, serenity
Yedukulakambhoji,Madhyamavati, Surutti)
2.
Veera
Courage
Atana,Hamsanandi
3.
Karuna
Compassion
Sahana, Mukhari
4.
Rowdra
Anger
Chalanata,Pantuvarali
5.
Shringara
Love
Behag, Khamas, Kharaharapriya
6.
Bheebatsa
Disgust
Ahiri,Mayamalavagaula
7.
Hasya
Joy,happiness Kuntalavarali, Janaranjani
8.
Adbhutha
wonder
Bilahari, Kedaragaula, Anandabhairavi
9.
Bhaya
Fear
Revati, Chakravakam
(Indian classical) musical modes in therapy: The need for evidence based research The National Library of Medicine,USA (NLM) through its database PUBMED provides more than 20 million citations for evidence based research in biomedicine. Unfortunately, hardly a handful of references are available with respect to the use of Indian classical music in therapy and more importantly that pertaining to the role of musical modes as effectors of emotions. Music is endowed with the exceptional ability of evoking strong emotions and also plays a pivotal role in affecting the moods of individuals. Functional neuroimaging and lesion studies provide the information that music-evoked emotions can modulate activity in virtually all limbic and paralimbic brain structures. It may please be noted that these cardinal structures of the brain are involved in the initiation, generation, detection, maintenance, regulation and culmination of emotions that have an enormous value for the individual concerned. It is quite clear that certain music-evoked emotions involve the nucleus of evolutionarily adaptive neuroaffective mechanisms. As an extension of this statement, it must be noted that these structures are related to emotional disorders. A comprehensive profile of music-evoked emotions based on the musical modes in Indian Classical music and their neural correlates/ attributes would go a long way in advocating the systematic and rational use of Indian classical music in therapy.
48
Though the earliest Indian treatise in Sanskrit, rAga chikitsa makes references to the curative potentials of musical modes in Indian classical music, greater thrust on evidence based medicine has to be laid in the present context. It must however be said that evidence based research in music therapy is being carried out in a few Indian centres including the National Brain Research Centre, Haryana, India. But, more studies
pertaining to the objectivisation of music therapy in the Indian context need to be undertaken. For instance, Guided Imagery and Music (GIM) is a popular technique developed by the renowned music therapist Helen Bonny. Here in, listening to music is used as a path to invoke emotions, pictures, and symbols from the patient. This could act as a nexus to the exploration and expression of feelings. GIM can be tried with reference to the use of Indian musical modes ( rAgAs) in therapy. According to Juslin and Vastfjall, in addition to cognitive appraisals , there are other mechanisms to study music and emotions :o
brain stem reflexes
o
conditioning (i.e., a particular music is associated with a positive or negative emotion)
o
contagion (i.e., listener perceives the emotional expression of music, and then “mimics� this expression internally)
o
visual imagery (i.e., images evoked by music act as probable cues to an emotion)
o
episodic memory (i.e., a piece is associated with a particular event, which, in turn, is associated with an emotion) and
o
expectancies that are fulfilled or denied (i.e., emotion is induced in a listener because a specific feature of the music violates, delays, or confirms the listener's expectations about the continuation of the music)
o
While studying the effect of Indian classical music on emotions, the above facets should be mandatorily included to generate evidence based research.
IT IS CONCLUDED THAT CLASSICAL INDIAN MUSIC HAS IMMENSE POTENTIALS AS MOOD STABILISERS AND EFFECTORS/MODULATORS OF EMOTIONS. MORE RESEARCH ON EVIDENCE BASED MODALITIES IS THE NEED OF THE HOUR, *Prof. Vellore A.R.Srinivasan is also a Carnatic ( Indian classical ) vocalist, percussionist and composer 49
Dr. Baishali Mukherjee is a psychologist and music therapist working with children with special needs since last 10 years. She is a faculty of Chennai School of Music Therapy and was trained in music therapy as part of her Ph.D. degree in the University of Strathclyde, UK. She was a lecturer in the Department of Psychology in the West Bengal State University. She has diplomas in Indian classical music and classical dances ( Bharathanatyam and Odyssey). She currently serves World Federation of Music Therapy as its regional liaison for South East Asia.
MUSICAL INTERACTION TO FACILITATE COMMUNICATION SKILLS IN CHILDREN WITH AUTISM
M
usic is a powerful and universal medium for communication and therapeutic interaction is proved by the findings of cross-cultural musical research and by the success of music therapy with a wide variety of patients. Studies of motherinfant communication have led to a new approach to research and assessment of communication in musical forms. Young children express themselves in musical ways through facial, vocal, or non- vocal movements, and the musicality of communication between a mother and her infant builds a well-coordinated cooperative relationship before the infants have any language. Studies have shown that parents' intuitive behavior supports infant's innate communicative capacities and motives (Papousek and Bornstein, 1992; Papousek and Papousek, 1987; Stern et al., 1985). Research on how infants stimulate intuitive behavior in parents suggests that “we are born like this and that the sympathy arises from an inborn rhythmic coherence of body movement and modulation of affective expressions� (Trevarthen and Malloch, 2000). Literature on Music Therapy with Children with Autism Hobson (1993) described autism as a failure to engage in patterned intersubjective coordination and exchange with other people. A disturbance in the brain impairs the coherence and flexibility of motivation and consciousness (Trevarthen, 2000). Children with autism lack the motivation to participate in reciprocal, rhythmic and temporal communication with others. In spite of the serious impairment of their intersubjective expression with other persons, the responses of children with autism to certain forms of music and musical stimuli shows that some of the infantile foundations of their innate musicality remain unimpaired. Deeply rooted biological responses to music, when appropriately engaged in musical interaction, can build new experiences of affectiveconative relatedness for the children with autism (Mukherjee, 2008). As autism presents impairment in all aspects of communication, the music therapist aims to develop communication skills and a capacity for social interaction in children with autism (Gold, Wigram and Elefant, 2006). According to Gold, Wigram and Elefant (2006) 50
the central technique of music therapy for children with autism includes both free and structured improvisation, and the use of songs and listening to music. In an improvisational setting the therapist assumes the role of the mother to provide stimulation through music in a way that enables and encourages the child to express himself or herself musically. Considering that every child is musical. The current literature supports the efficacy of improvisational music therapy on intra and interpersonal development in children with autism specifically in the areas of emotional communication, social interaction, self expression, pre-verbal communication, concentration, joint attention, communicative functions, expressive communicative responses- verbal and non verbal, interpersonal engagement and overall improvement in the socio-emotional life of the children (Saperston, 1973; Nordoff and Robbins, 1977; Bruscia, 1987, Bunt 1994, Edgerton, 1994; Wigram, 1995; Robarts, 1998; Plahl, 2000; Holck, 2002; Kim, 2006; Gold, Wigram and Elefant, 2006). Another line of successful research in music therapy with children with autism, Musical Interaction Therapy (MIT) (Wimpory, Chadwick and Nash, 1995), is based on Newson's theory of intersubjective communication in infancy and the social- interactionist perspective of autism (Hobson, 1993; Mundy and Sigman, 1989; Newson, 1987) can be distinguished from the Nordoff- Robbins improvisational music therapy approach (Robarts, 1998). The current study used fundamental techniques of improvised music therapy and musical interaction therapy to communicate and interact with children with autism through Indian music. Aim of the Study: The overall aim of the study was to introduce interactive musical intervention in India for children suffering from autism to enhance and facilitate their communication and interaction skills in the course of individual music therapy sessions. OBJECTIVES OF THE STUDY · To facilitate and enhance interaction and communication skills in children with autism through participation in musical interaction. · To give a descriptive account of children's communicative responses in the context of musical interaction. · Introducing music therapy using the method of improvisation and interaction for children with autism in an Indian context by using Indian music.
METHOD DESIGN OF THE STUDY A case study research design was chosen as best suited to meet the objectives of the study, which required detailed analysis of individual cases to describe each child's communicative responses to music and its progress through the course of musical interaction sessions. Case study design is a flexible design in the qualitative tradition for in depth study with multiple sources of evidence (Robson, 2002). It allows evidences in qualitative, quantitative or mixed data form to enrich the depth of analysis. Yin (1994) stated that the “case study's unique strength is its ability to deal with a full variety of evidence” (p. 8). A case study is more an investigative strategy than a specific method of experimentation to make measurement. 51
METHOD OF DATA COLLECTION Participants in the study Ten children with autism were selected for the study from the Spastic Society of Karnataka, Bangalore, India. There were 2 girls and 8 boys aged between 3 and 7 years. Children with confirmed diagnosis of autistic disorder according to the Diagnostic and Statistical Manual for Mental Disorder', 4th Edition (DSM-IV) and their availability for repeated sessions were selectedfor the study. The diagnosis was previously established by a team of professionals comprising a pediatric neurologist, a developmental pediatrician and a psychiatrist, all with experience in autism. None had previous experience of any musical intervention. All of ten children were first exposed to musical intervention through this study. Setting of the Room A few musical instruments were placed for the child on a mattress on the floor, including drums- one big and one small with drum sticks, a pair of tambourines, a pair of bells, a pair of musical rattles, one pair of 'ghungur' (bells that Indian women tie to the leg for dances), and a xylophone. Pairs of instruments were offered one for the child and one for the researcher with the intention of encouraging interpersonal communication by imitation, turn taking and sharing of interest. Research in joint play settings with children with autism has found that matched pairs of toys facilitate and motivate intersubjectivity between the child and the adult in play (Marwick, 2001; Nadel 2002). All the sessions were recorded and stored as confidential with date, time and name of the child. A video camera was fixed on a tripod in the corner of the room focussed mainly on the child. Presentation of Music Approximately 15 songs (Bengali lullabies, South Indian lullabies, Indian modern songs, tunes of Ragas and tunes of English nursery rhymes) were selected to sing for musical interaction with children. Songs were first presented with no instrumental accompaniments. Songs were presented in an interactive manner in individual session following simple strategies established to aid communication by musical interaction therapy (Wimpory, Chadwick and Nash, 1995) and improvised music therapy (Bruscia, 1987). ANALYSIS All ten cases were analyzed individually and the conclusion was drawn on the basis of common features and changes that took place in the process of therapy. The present research adapted an integrative approach to the evaluation of progress in communication skills through the sessions of music therapy that combines quantitative approach by showing measurement of changes with qualitative approach by drawing direct interpretation from the empirical data. By relating both sets of information, qualitative and quantitative, it may be possible to generate insights not available from the two types of information separately (Heyink and Tymstra, 1993). All the sessions in the study were videotaped. Videos were subjected to analysis by repeated 52
observation, each case being analyzed separately. A detailed category system has been created to evaluate the musical interaction sessions based on those developed for assessing and evaluating improvisational music therapy (Nordoff and Robbins, 1977; Bruscia, 1987) and for microanalysis of mother- infant communication (Trevarthen and Marwick, 1982). The category system was divided into four main categories with sub-categories in each to capture the child's awareness and receptivity in the therapy setting; the child's mood and emotion and how it is expressed in musical interaction; therapist-child communication and interaction (musical and intersubjective); and the child's musical creation and musical self expression. Child's progress and change across the sessions were evaluated for each category in terms of the occurrence of behavior by a 4 point scale ranged from 'none to a lot' (0, 1, 2, 3). The inter-rater reliability (Cohen's Kappa; K>.75) was checked for each of the categories. After the category system had been tested and its validity and reliability established it was felt by the researcher that the full experience or 'story' of the session that includes the context or cause in relation to interaction and communication, was not being captured. interaction with the researcher through music. Presenting clinical evidence in the form of story or case reports i. e. by describing or narrating exactly what happened in the session is commonly used in music therapy. Each session in the narrative analysis was presented in the form of a narrative, the unit of which was an event termed as 'episode'. Each narrative was consisted of a series of episodes that occurred in the session. The communicative narratives were then described according to the categories and modalities of expression it contained. The communicative narrative in the form of a story described the emotion, intentionality, motivation and interest behind each communicative or interactive act made by the child and the sequences of their occurrence. Then progress of each child or case was ultimately evaluated on the basis of the communicative narrative where the two methods of analysis contributed.The analysis designed for this research provided an integrative approach towards evaluation of communication skills in the context of musical interaction. RESULTS The individual case studies design of this research required to consider each case separately. The findings from both the categorical and narrative analyses were descriptive that included the nature of the problem in each child, communicative features, responses to music, communicative intentions as expressed in musical interaction, forms of communicative responses, emotional expressions in music, self expressions through music, child- therapist relationship and the overall progress made by each and every child. This paper reports only on the progress in communication and interaction skills made by children in the course of musical interaction sessions with the therapist. This section will provide a few examples resulted from categorical and narrative analysis of video and audio recorded sessions from different cases as an evidence of progress in communication and interaction skills. The grouping of cases on the basis of the scores on the category system was found not to be informative as they were too variable. But an improvement in communication and interaction skills in the context through consecutive sessions of musical interaction with the researcher was common for all the children. The scores on different areas of the category system increased gradually. Generally the starting score was found to be lower than the final score achieved by all the children. But the dips and jumps in scores showed 53
that the nature of progress differed between the children. The number of sessions attended by the children also varied. The following example (Fig.1) represents the comparative evaluation of ten sessions of a case (Case 2). This five years old boy with autism showed gradual progress through the sessions, he was non verbal with very poor attention span, lack of communication with parents, teachers and peers in school, and with excessive stereotypic movements and behaviours. His impaired capacities to communicate, to engage with other person and to express his mood, intention and interest to therapist improved in the course of the musical interaction sessions. Session 7 showed a fall in the quality of communication but that followed by a gradual recovery again.
Figure1:Comparative evaluation of sessions by the category system of a case. X axis - The number of sessions from 1- 10 Y axis - The summated scores for the categories
In the same child (Case 2), the nature of progress as analyzed by the category system will be clearer in the following example (Fig.2). The following figure shows few examples from subcategories of the category system that reveal the child's improvement in responses to music and in progress in relationship with the therapist. As well as a decrease in resistance to the therapist, except in session seven which showed high resistance with general fall in overall communicative responses, as reflected by the inverted curvature of the graph (Fig. 2).
Figure2: Comparative evaluation of sessions by the category system of a case. X axis - The number of sessions from 1- 10 Y axis - The summated scores for the categories
A gradual progress followed by a dip and then recovery, this pattern was commonly observed among all ten cases. While in general the interactions showed gradual improvement in successive sessions there were exceptions. It was important to analyze, in these instances, what could have distracted or disturbed the child and caused them to be less involved in interaction. In this context the narrative analysis of episodes from sessions of therapy helped to explain all contextual factors that could enhance, maintain, or disrupt the rhythm and the trend to improvement of a child's performance. At the same time, the narrative account clearly demonstrated that the interactive or communicative power of music was effective in bringing out and counteracting all such life events, which can potentially affect the wellbeing and relationships of a child with autism. The following examples of narrative accounts of two cases will illustrate the approach. 54
Case 2: He was a very fussy boy who used to become anxious and depressed with any change in his family or school circumstance. He showed high resistance to musical instruments in the beginning. Slowly developed preferences, took initiative to bring the instruments back in later session and enjoyed playing and sharing them with the researcher. His dependence on structure in experience was reduced with the increase in musical interaction and intersubjective engagement with the therapist. Case 4: He was a little boy who displayed anxiety when separated from his mother. Frequent changes in mood characterized his behaviour. Intersubjectivity with him developed in the background of a particular musical interaction game, which was repeated in consecutive sessions. In session 9 he was involved throughout in playing the musical game with the therapist and the whole session had potentiality to be considered as an episode. The way a child responded or expressed his or her intentions and emotions in interaction, the modality and patterns of expressions and the reason behind establishing communication and interaction with the researcher through music were captured through narrative analysis of sessions. Categories helped in identifying episodes from sessions. The two forms of analysis- categorical and narrative were found to be integrated and complementary to produce a thorough evaluation of each child's progress and the effects of circumstantial events that were different in each case. The sequence of episodes through the sessions had revealed the change in quality of communication is evident in the following example (Table 1.), a four years old boy (Case 4) with autism who was non verbal with impaired communication and social interaction skills and with high level of separation anxiety was able to form a mutually cooperative relationship by sharing his attention, intention, and emotion in musical play with the therapist while started from a strong rejection and resistance in session one. Table 1. Episodes through the Sessions- reflect the change in quality of interaction. Session Episode Duration Characteristics of the Episode No. No. 1
No Episode of Interaction, showed Resistance and Rejection.
2
E1
1m.
Intention to play music expressed through Negative Behaviour by throwing Tantrums.
3
E1
40 s.
Expressed Anger through Improvisation on a Tambourine
4
E1
1m.20s.
Tantrum to Engagement (with Voice and Movement narrative)
6
E1
1m.
First Showed Interest in Musical Game (with Movement narrative)
7
E1
15s.
8
E1
12s.
Initiating and Giving Cue to Start the Session (with Movement narrative) Vocal Interaction - Intentionality Expressed in Voice (with Voice narrative)
5
No Episode of Interaction
9 10
E1
18m.06s.
The whole session as an Episode- series of interactions, the child was involved throughout.
52s.
Engagement through Music- Interested, Motivated, Involved.
E= Episode, m.= minute, s.= second. 55
The episodes of musical interaction captured through narrative analysis revealed both similarity and individuality among ten cases. The expressive narratives of communication displayed the emotions and intentions of the children during interaction, and their forms of expressions by means of vocalizations and body movements. The emotions expressed by the children in musical interaction were both Subjective and Intersubjective. Happiness and excitement in participation and interaction through music was observed for all the children. Anger in interpersonal interaction was observed in two children and an expression of depression was observed in one child. Three children showed pride in their musical creation. Expressions of sympathy and affection were also observed during interactions with the researcher. As all 10 children were non-verbal, vocalizations were the only forms of vocal response observed, other than crying, screaming, humming and singing for interaction. The data show strong common features in the communicative intentions expressed by all ten children. There were episodes where the children used both vocal and bodily forms of expressions in a coordinated manner to express their intentions or emotions for communication. The children expressed intentions for communication through vocalization, movement, facial expression, posture, proximity, orientation and through the overall behaviour during interaction. The above few examples of descriptive narratives of communication from ten different case showed how the gradual progress in communication and interaction skills was made by children with autism as well as how their intentionality and feelings were expressed in interpersonal relationship through the medium of music. It denotes that in the music the musicality of two persons can meet even for children with autism, which severely impairs the flexibility of emotions, motivations, and relationships. The discussion will explain and compare these qualitative findings in the light of other studies on music therapy with children with autism. DISCUSSION In music therapy case study is the most common way by which therapists present their work. The account of each patient includes musical behaviors, description of musical communicativeness, process of developing client- therapist relationship, life events of the client and the context of music therapy (Wigram, 2002) and all these sources of evidence are related to the therapeutic development and progress (Mukherjee, 2008). The same approach was followed in the present study; each case being analyzed separately with all evidences, gave an overall picture of the trend of progress on communication skills through the sessions of musical interaction by all ten children with autism. Progress was observed for all the participants in all the category areas as well as a positive change in the number and quality of interaction episodes through the sessions was observed. Evidently the musical interaction facilitated communication and helped to draw the children out from their isolation in a stereotypic world, and their attention and interest to music appeared to be an essential factor for developing successful spontaneous communication. The present research attempted to examine how musical interaction enhanced or facilitated communication in these ten children with autism. In the normal process of development of communication, mother and infant both show a motivation to communicate with each other that shows the properties of musicality. A mother either by reflecting or attuning to the infant's emotional states, stimulates the impulses for both self-expression and 56
communicative expression in her infant (Stern, 1999) and this supports the development and growth in infant's mental life. In turn, developments in the infant's motivation and capacity for expressive activity influence the mother's engagement. In this research, through the interactive use of the emotive properties of music children were given opportunity to experience a preverbal level of communication like that in early sympathetic mother-infant communication which encouraged their self and communicative expressions. Accepting the concept that 'music is a fundamental channel of communication' (Hargreaves, MacDonald &Miell, 2005, p. 1) through which emotion, intention and meaning can be shared, the study was aimed to facilitate and enhance mutually satisfying and creative experience between researcher/therapist and these children with debilitating autism by using music as a medium of interaction with them. Music therapy promotes sharing by providing a means for self expression and for communication (Wigram, 2002) for individuals who are normally cut off from social contact. This study developed an original method, based on established principles of improvised music therapy (Bruscia, 1987; Wigram, 2004) and musical interaction therapy (Wimpory et al., 1995; Prevezer, 1998), by using Indian music for interaction with children with autism. Improvisation is at the heart of Indian music and its rich melodic and rhythmic elements fit well with the therapeutic techniques employed for interaction with children (Mukherjee, 2008). Techniques were developed either to express communication to the child or to elicit communicative responses from the child. The intention was to facilitate and enhance the children's undeveloped expressive and receptive impulses so that they would feel motivated to engage with the researcher and to share intentions and emotions growing out of an enjoyable experience of musical interaction (Mukherjee,2008). The children were first introduced to a context where there was no demands for structure in the engagement and they were not expected to behave or respond in any pre determined way. Rather they were encouraged to build, or discover an engagement in their own way (Mukherjee, 2008). The children's voluntary presence in the session was essential from the start and the researcher responded and followed the child musically regardless of the form or modality of expression the child chose, whether by means of music or without music. All non verbal modes of expressions were accepted as 'musical' according to the theory of communicative musicality (Malloch, 1999; Trevarthen and Malloch, 2000) which identifies the musical properties of 'pulse', 'expressive quality' and 'narrative purpose' as fundamental expressive parameters of all non verbal communication. Accordingly techniques adapted from established musical improvisation and musical interaction therapies were employed in a particular way with the intention to help each child to recover innate abilities and motivation for moving in communicative ways that had become hidden under the dark veil of autism. The sharing of musical activities evidently appealed to fundamental expressive impulses in these non-verbal children, and it worked effectively with all of them. The musical elements of their interaction together helped them to become involved in musical dialogues that grew from our shared communicative musicality (Wigram and Elefant, 2007). Similar elements are observed in intuitive movements of human dynamic communication in other relationships notably in the vocal or gestural turn taking exchanges between a mother and her infant, and these are the behaviours cultivated in a musical therapeutic relationship 57
between a client and therapist through creative variation of their co-created music. The method employed in this study for musical interaction with the autistic children assumed with Trevarthen and Malloch (2000, p.14) that “all musics speak to human motives that move the body and express a communicative will.” That “All humans have this music” (Mukherjee, 2008). The methods used in this qualitative study, the results obtained from analysis and conclusions that can be drawn are inevitably subject to practical limitations that need to be taken into account when considering the significance of the study within the wider field of research on therapy for children with autism. The large age range of the children, the different number of sessions for each child, the wide variation of function and diagnosis among the children might have influenced the general significance of the results. But the analysis was designed in a way that evaluated improvement on communication and interaction skills individually for each child. No statistical test was applied to present group results. However, this method of analysis drew attention to the differences and considered the significance of the individuality expressed by each child in musical interaction, accepting the nature of autism as a variable 'spectrum' disorder. The findings from this research show that the communication and interaction skills improved in ten participants with autism through sessions of musical interaction using Indian music. Further investigations are necessary to determine whether this positive effect of musical interaction would generalize to the wider population of autistic children. It is also warranted to investigate further the elements and process involved in musical interaction that was found to facilitate communication in these ten participants. CONCLUSION The results of this study confirmed that the music can be a powerful medium, and that it helped to improve communication skills with ten children with autism. The study demonstrated that the use of music in an improvised and interactive form can be an effective part of an intervention programme for assisting children whose communication is impaired by autism. The analysis procedure developed for this research indicated the importance of context in evaluation of communication skills by integrating categorical and narrative analysis of episodes of interaction. It showed that such a method can be useful for researchers in music therapy to develop a more sensitive method for analysis of communicative behaviours of clients in case study research. The challenge of the study was to introduce a new form of interactive musical intervention for children with autism in India by using Indian music to promote their communication skills. This differs from the receptive music therapy tradition of the country. It was a first systematic attempt in India to expose children with autism to a flexible interactive form of intervention through the medium of music to encourage their spontaneous communication. The study also has clinical and educational value that showed music can be an auxiliary medium for promoting mental health in children with autism.
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REFERENCES: American Psychiatric Association, (2000). Diagnostic and Statistical Manual- IV- Text revision. Washington, DC: American Psychiatric Association. Bruscia, K. E. (1987). Improvisational Models of Music Therapy. Springfield: Charles C. Thomas. Bunt, L. (1994). Music Therapy: An Art Beyond Words, London: Routledge. Edgerton, C. L. (1994).The effect of improvisational music therapy on the communicative behaviours of autistic children.Journal of Music Therapy, Vol. 31 (1), (pp. 31-62). Gold, C., Wigram, T., and Elefant, C. (2006).Music therapy for autistic spectrum disorder. Cochrane Database of Systematic Reviews, Issue 2, Art No: CD004381. DOI: 10.1002/14651858. CD004381. pub2. Heyink, J. &Tymstra, T. (1993). The function of qualitative research. Social Indicators Research, 20, 291- 305. Hobson, R. P. (1993). Autism and the Development of Mind. Hove/ Hillsdale: Laurence Erlbaum Association. Holck, U. (2002). Music therapy for children with communication disorders. In T. Wigram, I. N. Pedersen & L.O. Bonde (Eds.), A Comprehensive Guide to Music Therapy: Theory, Clinical Practice, Research and Training. London and Philadelphia: Jessica Kingsley Publishers. Kim, J. (2006). The Effects of Improvisational Music Therapy on Joint Attention Behaviours in Children with Autistic Spectrum Disorder.PhD Thesis, Aalborg University. Malloch, S. (1999).Mothers and infants and communicative musicality.Rhythms, Musical Narrative, and the Origins of Human Communication, Musicae Scientiae, Special Issue, 1999-2000, 29-57. Marwick, H. (2001) The Joint-Play Intersubjectivity Assessment Method (JPIAM): use with Autistic Spectrum Disorder children and their interactive partners. Project Report, University of Strathclyde, Glasgow. Mukherjee, B. (2008). Musical interaction with children with autistic spectrum disorder in an Indian context, PhD Thesis. University of Strathclyde, Glasgow, United Kingdom. Mundy, P. &Sigman, M. (1989). Specifying the nature of social impairment in autism. In G. Dawson (Ed.), Autism: Nature, Diagnosis and Treatment. New York: Guilford. Nadel, J. (2002). Imitation and imitation recognition: Their functional role in preverbal infants and nonverbal children with autism. In A. Meltzoff& W. Prinz (Eds.) The Imitative Mind: Development, Evolution and Brain Bases, 42-62, Cambridge, MA: Cambridge University Press. Newson, E. (1987).Education, treatment and handling of autistic children.Children and Society, 1(1), 34- 50. Nordoff, K. & Robbins, C. (1977). Creative Music Therapy, New York: John Day Publisher. Papousek, H. & Bornstein, M.H. (1992) Didactic interactions: Intuitive parental support of vocal and verbal development in human infants. In H. Papousek, U. Jurgens and M. Papousek (Eds.) Nonverbal Vocal Communication: Comparative and Developmental aspects. Cambridge: Cambridge University Press/ Paris: Editions de la Maison des Sciences de l' Homme, 209-229. Papousek, H &Papousek, M. (1987). Intuitive parenting: A dialectic counterpart to the infant's integrative competence. In Osofsky, J. D. (Ed.) Handbook of Infant Development,2nd Edition, New York: Wiley. 59
Plahl, C. (2000). Development through Music: Assessment of Music Therapy Treatment. PhD Thesis (1999), Munster: Waxman. Prevezer, W. (1998).Entering into Interaction: Some Facts, Thoughts and Theories about Autism, with a Focus on Practical Strategies for Enabling Communication. Report published at The Elizabeth Newson Centre, 272 Longdale Lane, Ravenshead, Notts NG15 9AH. Robarts, J. (1998). Music Therapy for Children with Autism. In C. Trevarthen, K.Aitken, D. Papoudi and J. Robarts (Eds.) Children with Autism: Diagnosis and Intervention to Meet their Needs, 172- 202, London and Philadelphia: Jessica Kingsley Publishers. Robson, C. (2002). Real World Research, 2nd Edition, Blackwell Publishers. Saperston, B. (1973). The use music in establishing communication with an autistic mentally retarded child. Journal of Music Therapy, Vol. 10, (pp. 184- 188). Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psychoanalysis and Development Psychology. New York: Basic Books. Stern, D. N. (1999). Vitality Contours: The temporal contour of feelings as a basic unit for constructing the infant's social experience. In P. Rochat (Ed.) Early Social Cognition: Understanding Others in the First Months of Life, 67- 80, Mahwah: Erlbaum. Trevarthen, C. (2000). Autism as a neurodevelopmental disorder affecting communication and learning in early childhood: Prenatal origins, post natal course and effective educational support. Prostoglandins, Leucotrines and Essential Fatty Acids, 63 (1/2), 41- 46. Trevarthen, C. &Malloch, S. (2000). The dance of wellbeing: Defining the musical therapeutic effect, Nordic Journal of Music Therapy, 9 (2), 3-17. Trevarthen, C. and Marwick, H. (1982). A method for analyzing mother- infant communication.Extract from 'Cooperative Understanding in Infants'.Unpublished Project report to the Spencer Foundation in Chicago, Edinburgh University. Wigram, T. (1995). A model of assessment and differential diagnosis of handicapped children through the medium of music. In T. Wigram, B. saperston and R. West (Eds.). The Art and Science of Music Therapy: A Handbook, (pp. 181- 193). London: Harwood Academic Publishers. Wigram, T. (2002). Introduction to music therapy. In T. Wigram, I. Pedersen & L. Bonde A. (Eds.) Comprehensive Guide to Music Therapy: Theory, Clinical Practice, Research and Training, 17- 43. London and Philadelphia: Jessica Kingsley Publishers. Wigram, T. (2004). Improvisation: Methods and Techniques for Music Therapy Clinicians, Educators and Students. London and Philadelphia: Jessica Kingsley Publishers. Wigram, T. and Elefant, C. (2007). Therapeutic dialogues in music: Nurturing musicality of communication in children with Autistic Spectrum Disorder and Rett Syndrome. In S. Malloch and C. Trevarthen (Eds.) Communicative Musicality: Narratives of Expressive Gesture and Being Human. Oxford: Oxford University Press. Wimpory, D., Chadwick, P., & Nash, S. (1995). 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. Yin, R. (1994). Case Study Research: Design and Methods, 2nd Edition, Sage Publications.
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Dr. Parin N Parmar, MD, DAA, PGDMT is a Pediatric Allergy-Immunology Consultant and Holistic Nutrition Expert from Rajkot, Gujarat, India. He is also a Research Associate-cum-Faculty at Chennai School of Music Therapy, Chennai. He is a non-professional key-board player and composer, trained under the living legend Shri Kantibhai Sonchhatra since age of 7 years. Apart from nonacademic writing, he has published more than 10 academic articles in various international journals in his young career. His areas of special interest are integrative medicine, traditional music therapy, holistic nutrition, psychoneuroimmunology, and mind-body medicine.
EFFECT OF MUSIC THERAPY ON IMMUNOLOGY
Abstract Therapeutic potential of music has been explored by both modern science and ancient wisdom. As a complementary and alternative medicine, music therapy has wide applications in clinical medicine, ranging from psychiatric, psychosomatic, neurological, immunological, endocrinological, painful and stress-related disorders. With advances in psychoneuroimmunology and psychoneuroendocrinology, the mind-body connections of many physical disorders have been understood, which may explain one of the possible mechanisms how music therapy improves clinical symptoms and quality of life in such patients. A better immune system also ensures maintenance of health and well-being of health individuals. This article aims to review effects of different forms of music and music therapy techniques on various clinical immunological disorders including autoimmunity, allergies and cancers as well as on various laboratory parameters of immune function such as immunoglobulin levels in serum and fluids, cytokines and immune cell functions. Many studies have shown music therapy affecting immunological disorders positively, both subjectively and objectively. There are also many studies suggesting improved laboratory parameters of immune system as effect of exposure to music. A few studies in animals are also encouraging. However, many of them have limitations such as smaller samples, lacunae in methodology, contradictory findings in other studies, etc. Further research into this field would require co-ordinated efforts by music therapists, clinicians and medical researchers, which will help to understand the mechanisms underlying therapeutic effects of music therapy better, to explore more applications of music therapy in health and diseases and to utilize music for therapeutically in a more scientific way. Research in this less-explored field should be encouraged as music therapy offers a harmless treatment option and has potential to reduce medicine requirements in patients with various disorders. Key-words: music, immune system, psychoneuroimmunology, immunoglobulin, cytokines, interleukins, allergic disorders, autoimmune disorders, cancer, stress. 61
Introduction Human immune system is highly complex. Immune system has to play an important role in many of the diseases (Table 1); be it directly or indirectly. To be very simple for understanding, a person is more prone to infections if the immune system is “weak”, develops allergic disorders if the immune system identifies “harmless” particles as “harmful”, develops autoimmune diseases if the immune system mounts an attack against “self/own” particles, develops cancer if the immune system allows uncontrolled growth of a specific type of cells, ... Not to stop here, “behind the curtain” role of the immune system in health and diseases is even greater. Through out the life, immune system is continuously at work. It has a great capability to adapt to situations, to fight with foreign particles (live or dead), to change roles during various phases of life, and to play a part in ageing process and some degenerative disorders also, towards the end of life. It could be almost said that keeping the immune system healthy is synonymous to living healthy. Music has been used for healing since ancient times. Music therapy, in forms of Raga Chikitsa and sound healing, has been described in Ayurveda, the traditional Indian medical system. Modern medical science also supports use of music for therapeutic purpose in different forms, using different techniques, for various conditions, for all the age groups, even for maintaining health. Various mechanisms explaining therapeutic effects of music therapy have been proposed; some of them are related to changes in immune system. This article aims to explore effects of music therapy interventions on various immunological or immune-system-related clinical disorders as well as on laboratory parameters of immune system. Music therapy in clinical disorders Among allergic disorders, music therapy has been most commonly explored and used for asthmatic patients. Music-assisted relaxation techniques and listening to music have 1 shown both subjective and objective improvements in a few studies . Various forms of music-assisted breathing exercises, singing and wind instrument playing (flute, etc) have shown variable benefits, including mild improvement in lung function parameters 2,3. In a 4 recent study, music therapy improved markers of asthma in asthmatic rats . It can be presumed that relaxation techniques reduce stress levels and “active” forms of music therapy improve airway dynamics. A recent systemic review has mentioned various benefits of music therapy in asthmatic patients; however, due to different techniques and 5 methodologies used, it is difficult to make a uniform protocol for use of music in asthma . Both acute and chronic stresses are known to worsen asthma control. It is also important to note that psychological stress is an important trigger for a subset of asthmatic patients where relaxing music therapy could find more applications. Other allergic disorders such as allergic rhinitis, atopic dermatitis, and urticaria are also influenced by stress significantly; effect of music therapy in these disorders should be explored. Oncology is another area where music therapy has been used successfully. Music therapy significantly improves anxiety, fatigue, mood disturbances, depression, pain and quality of life in both adult and pediatric patients with cancer6, 7. Music therapy is a widely utilized 8 coping method among cancer patients and facilitates diagnostic procedures, surgery and 9, 10, and 11 chemotherapy . However, little is known about immunological effects of music 62
therapy in cancer patients. A study by Burns SJ, et al has shown positive effects on both emotions and immune system by receptive music therapy and improvisation in cancer patients12. A case remission of hepatocellular carcinoma possibly by psycho13 14 neuroimmunological intervention has also been reported . Nunez MJ , et al have suggested potential benefit of music therapy in reducing lung metastasis by reducing enhancing effects of stress on development of metastasis in rodents. Emergence of a new discipline – neuroimmunomodulation (NIM) holds promise to explore the field of 15 immunology of cancer and effects of music therapy interventions . Apart from a few studies, use of music therapy in autoimmune disorders is little explored so far. Connection between psychological stress and autoimmunity is known and there is a good possibility that music therapy can be helpful to these patients. Music-mediated imagery has been utilized for patients with arthritis and lupus patients16. Music therapy has shown improved emotional problems and enhanced therapeutic effects of conventional drugs in patients with systemic lupus erythematosus17. Possible role of music therapy in inflammatory bowel diseases such as Crohn's disease and ulcerative colitis also has been 18 suggested . Music therapy has shown to improve depression, anxiety, and self esteem in patients with multiple sclerosis19. Music therapy has also been used in patients undergoing organ transplants or stem cell 20, 21 transplants with some positive effects . Exposure to opera or classical (Mozart) music induced prolonged survival of allogeneic cardiac allografts and generated CD4(+)CD25(+)Foxp3(+) regulatory cells in murine model as compared to New Age music 22. Effects of music therapy on laboratory parameters of immune system As mentioned in beginning of the article, human immune system is very complex. It's the army of the human body and has various types of defensive cells and cellular products; similar to hierarchical structure of army of any country. Major cell types that are involved in an immune response are T lymphocytes (including Helper T cells, Killer T cells, memory T cells, and others), B lymphocytes, neutrophils, monocytes-macrophges, eosinophils, antigen presenting cells, natural killer cells, etc. Various immunoglobulins, cytokines, chemokines, and other cellular products secreted by different cells serve specific immune functions. Therefore, in laboratory, it is very difficult to evaluate the whole immune system. Most of the studies assess effects of music therapy on number of specific cells in blood or levels of cellular products in blood or secretions or both. Quantitative evaluation of these cells or cellular products can indicate status of some aspects of immune system. In normal subjects, group drumming can increase NK cell activity and lymphokineactivated killer cell activity [23]. Recreational music-making has shown significant increased number of lymphocytes, CD4+ T cells, memory T cells, and production of interferon-gamma and interleukin-6 in healthy older individuals [24]. In corporate employees, recreational music-making changes in natural killer (NK) cell activity and gene expression changes in for interferon-gamma and interleukin-10. [25]. Music listening has been shown to reduce interleukin-6 levels [26]. Selection of music is also important as different types of music can induce different types of immunological and neuroendocrine changes [27]. In patients with neurodegenerative diseases, music therapy increases both NK cell numbers and activity [28] as well as decreases plasma interleukin-6 levels [29]. In patients 63
with atopic dermatitis with latex allergy, listening to Mozart has reduced total immunoglobulin E (IgE) and latex-specific IgE levels, with increased Th1 cytokine and decreased Th2 cytokine production; a cytokine pattern which is desirable for allergic patients from therapeutic perspective [30]. Music therapy intervention has also been shown to increase immunoglobulins, the different types of proteins secreted by B lymphocytes that serve the immune function by attaching themselves on the target microbes/particles. Secretory IgA in saliva is frequently measured as an index of mucosal immunity. Listening to music, choral singing, instrument playing and movement music therapy have been shown to increase levels secretory immunoglobulin A (SIgA) in different population [31, 32, 33, 34]. Active participation in music activity in form of playing percussive instruments and singing causes greater increase in SIgA levels as compared to passive listening [33]. Music and the immune system – where is the connection ? With advances in fields of psychoneuroimmunology (PNI) and psychoneuroendocrinology (PNE), the connections between mind and immunity are becoming clearer. Thoughts and emotions have a strong influence on endocrine and immune systems; chronic psychological stress can affect immune system adversely and can play a causative or permissive role in multiple diseases. Production and function of immunologically active cells is adversely affected due to various direct and indirect effects of stress [35]. Stress-reducing effects of music and music therapy are known since long. Apart from relaxing effects, music therapy also affects autonomic nervous system, hypothalamuspituitary-adrenal axis (HPA axis), mood & emotions, and quality of life positively [36]. All of these factors being linked to immune system, music therapy has a great potential for improving immunity and having therapeutic effects in immune-related disorders. Conclusion Music therapy is helpful for many patients with disorders related to immune system. Literature supports both clinical benefits as well as improvement in immunological laboratory parameters with music therapy. However, considering the vast spectrum of diseases involving immune system, the literature is sparse. There is a lot of scope in this field for research and further quality studies may identify even more applications of music therapy in various disorders. Table 1: Diseases related to immune system
Allergic disorders
Immunodeficiencies Autoimmune disorders
Oncologic disorders
Allergic rhinitis, allergic asthma, allergic conjunctivitis, atopic dermatitis, contact dermatitis, urticaria/angioedema, food allergies, anaphylaxis, etc Primary and secondary immunodeficiency disorders Systemic lupus erythematosus, rheumatoid arthritis, Crohn’s disease, ulcerative colitis, multiple sclerosis, myasthenia gravis, autoimmune thyroiditis, diabetes mellitus type 1, autoimmune hepatitis, autoimmune vasculitis, etc Lymphoproliferative disorders (leukemias and lymphomas), various carcinomas 64
References 1. Groller B. Effectiveness of combined relaxation exercises for children with bronchial asthma. Kinderarztl Prax. 1992 Feb; 60(1): 12-6. 2. Lucia R. Effects of playing a musical wind instrument in asthmatic teenagers. J Asthma. 1994; 31(5): 375-85. 3. Janiszewski M, Kronenberger M, Drozd B. Studies on the use of music therapy as a form of breathing exercise in bronchial asthma. Pol Merkur Lekarski. 1996 Jul; 1(1): 32-3. 4. Lu Y, Liu M, Shi S, Jiang H, Yang L, Liu X, et al. Effects of stress in early life on immune functions in rats with asthma and the effects of music therapy. J Asthma. 2010 Jun; 47(5): 526-31. doi: 10.3109/02770901003801964. 5. Sliwka A, Wloch T, Tynor D, Nowobilski R. Do asthmatics benefit from music therapy? A systematic review. Complement Ther Med. 2014 Aug; 22(4): 756-66. doi: 10.1016/j.ctim.2014.07.002.Epub 2014 Jul 8. 6. Archie P, Bruera E, Cohen L. Music-based interventions in palliative cancer care: a review of quantitative studies and neurobiological literature. Supprt Care Cancer 2013; 21: 2609-24. doi: 10.1007/s00520-013-1841-4. 7. Tsai HF, Chen YR, Chung MH, Liao YM, Chi MJ, Chang CC, et al. Effectiveness of music intervention in ameliorating cancer patients' anxiety, depression, pain, and fatigue: a metaanalysis. Cancer Nurs. 2014 Nov-Dec; 37(6): E35-50. doi: 10.1097/NCC.0000000000000116. 8. Zaza C, Sellick SM, Hillier LM. Coping with cancer: what do patients do. Journal of psychosocial oncology. 2005; 23: 55–73. 9. Sabo CE, Michael SR. The influence of personal message with music on anxiety and side effects associated with chemotherapy. Cancer nurs. 1996; 19: 283–289. 10. Haun M, Mainous RO, Looney SW. Effect of music on anxiety of women awaiting breast biopsy. Behavioral medicine (Washington, D.C.) 2001; 27: 127–132. 11. Li X-M, Yan H, Zhou K-N, Dang S-N, Wang D-L, Zhang Y-P. Effects of music therapy on pain among female breast cancer patients after radical mastectomy: results from a randomized controlled trial. Breast cancer research and treatment. 2011; 128: 411–419. 12. Burns SJ, Harbuz MS, Hucklebridge F, Bunt L. A pilot study into therapeutic effects of music therapy at a cancer help center. Altern Ther Health Med. 2001 Jan; 7(1): 48-56. 13. Jozuka H, Jozuka E, Suzuki M, Takeuchi S, Takatsu Y. Psycho-neuro-immunological treatment of hepatocellular carcinoma with major depression – a single case report. Curr Med Res Opin. 2003; 19(1): 59-63. 14. Nunez MJ, Mana P, Linares D, Riveiro MP, Balboa J, Suarez-Quintanilla J, et al. Music, immunity and cancer. Life Sci. 2002 Jul 19; 71(9): 1047-57. 15. Conti A. Oncology in meuroimmunomodulation. What progress has been made? Ann N Y Acad Sci. 2000; 917: 68-83. 16. Rider MS, Kibler VE. Treating arthritis and lupus patients with music-mediated imagery and group psychotherapy. The Arts in Psychotherapy. 1990; 17: 29-33. 17. Sun L, Xiao H, Zeng K, Wang Q, Fang, L, Chen M, et al. (2007). Therapeutic Effect of Receptive Music Therapy for Patients with Systemic Lupus Erythematosus. Journal of Guangzhou University of Traditional Chinese Medicine. 2007; 5: 006. 18. Aldridge D, Brandt G. Music therapy and inflammatory bowel disease. The Arts in Psychotherapy. 1991; 18: 113-21. doi: 10.1016/0197-4556(91)90018-6. 65
19. Schmid W, Aldridge D. Active music therapy in the treatment of multiple sclerosis patients: a matched control study. J Music Ther. 2004; 41(3): 225-40. doi: 10.1093/jmt/41.3.225. 20. Madson AT, Silverman MJ. The effect of music therapy on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients. J Music Ther. 2010 Fall; 47(3): 220-32. 21. Cassileth BR, Vickers AJ, Maqill LA. Music therapy for mood disturbance during hospitalization for autologous stem cell transplantation: a randomized controlled trial. Cancer. 2003 Dec; 98(12): 2723-9. 22. Uchiyama X, Jin M, Zhang Q, Amano A, Watanabe T, Niimi M. Music exposure induced prolongation of cardiac allograft survival and generated regulatory CD4+ cells in mice. Transplant Proc. 2012 May; 44(4): 1076-9. doi: 10.1016/j.transproceed.2012.02.008. 23. Bittman BB, Berk LS, Felten DL, Westengard J, Simonton OC, Pappas J, et al. Composite effects of group drumming music therapy on modulation of neuroendocrine-immune parameters in normal subjects. Altern Ther Health Med. 2001 Jan; 7(1): 38-47. 24. Koyama M, Wachi M, Utsuyama M, Bittman B, Hirokawa K, Kitagawa M. Recreational musicmaking modulates immunological responses and mood states in older adults. J Med Dent Sci. 2009 Jun; 56(2): 79-90. 25. Wachi M, Koyama M, Utsuyama M, Bittman B, Kitagawa M, Hirokawa K. Recreational musicmaking modulates natural killer cell activity, cytokines, and mood states in corporate employees. Med Sci Monit. 2007 Feb; 13(2): CR57-70. 26. Stefano GB, Zhu W, Cadet P, Salamon E, Mantione KJ. Music alters constitutively expressed opiate and cytokine processes in listeners. Med Sci Monit. 2004 Jun; 10(6): MS18-27. Epub 2004 Jun 1. 27. Hirokawa E, Ohira H. The effects of music listening after a stressful task on immune functions, neuroendocrine responses, and emotional states in college students. J Music Ther. 2003 Fall; 40(3): 189-211. 28. Hasegawa Y, Kubota N, Inagaki T, Shinagawa N. [Music therapy induced alterations in natural killer cell count and function.] Nihon Ronen Igakkai Zasshi. 2001 Mar; 38(2): 201-4. 29. Okada K, Kurita A, Takase B, Otsuka T, Kodani E, Kusama Y, et al. Effects of music therapy on autonomic nervous system activity, incidence of heart failure events, and plasma cytokine and catecholamine levels in elderly patients with cerebrovascular disease and dementia. Int Heart J. 2009 Jan; 50(1): 95-110. 30. Kimata H. Listening to Mozart reduces allergic skin wheal responses and in vitro allergen specific IgE production atopic dermatitis patients with latex allergy. Behav Med. 2003 Spring; 29(1): 15-9.
31. Charnetski CJ, Brennan FX Jr, Harrison JF. Effect of music and auditory stimuli on sercretory immunoglobulin A (IgA). Percept Mot Skills. 1998 Dec; 87(3 Pt 2): 1163-70. 32. Kreutz G, Bongard S, Rohrmann S, Hodapp V, Grebe D. Effects of choir singing or listening on secretory immunoglobulin A, cortisol, and emotional state. J Behav Med. 2004 Dec; 27(6): 623-35. 33. Kuhn D. The effects of active and passive participation in musical activity on the immune system as measured by salivary immunoglobulin A (SIgA). J Music Ther. 2002 Spring; 39(1): 30-9. 34. Shimizu N, Umemura T, Hirai T, Tamura T, Sato K, Kusaka Y. Effects of movement music therapy with the Naruko clapper on psychological, physical and physiological indices among elderly females: a randomized control trial. Gerontology. 2013; 59(4): 355-67. doi: 10.1159/000346763. Epub 2013 Apr 23. 35. Cohen S, Rabin BS. Psychologic stress, immunity, and cancer. J Natl Cancer Inst. 1998; 90(1): 34. doi: 10.1093/jnci/90.1.3. 36. Kemper KJ, Danhauer SC. Music as therapy. Southern Medical Journal. 2005; 98(3): 282-8. doi: 10.1097/01.SMJ.00001564773.11986.39. 66
Dr. Gene Ann Behrens is Professor of Music and Director of the Music Therapy Program at Elizabethtown College, in Pennsylvania in the United States. She has taught and supervised students for 17 years and worked as a music therapist for over 40 years in a variety of settings. She obtained her Bachelor of music therapy, Masters in special education, and Doctoral in music therapy and minor in counseling at Michigan State University, Kent State University, and University of Kansas, respectively. Gene has served on committees and executive boards for the American Music Therapy Association, MidAtlantic Region, and Certification Board for Music Therapists. She presently is chair of the Global Crises Intervention Commission for the World Federation of Music Therapy, a member of the Mid-Atlantic Music Therapy research committee, and on the editorial board for Music Therapy Perspectives.
MUSIC THERAPY CLINICAL EXPERIENCES – WHERE EVERYTHING COMES TOGETHER
I
believe that the clinical training experiences, or practicums, within music therapy programs are critical to the development of students' music therapy skills. This sequence of hands-on courses is where everything comes together for the students. Clinical training experiences demand that students integrate a wide range of concepts and skills—such as knowledge about clients, music skills, and music therapy techniques—taught within a variety of classes. In addition, some of these important concepts and skills demand that they are learned and refined across several instructional experiences. These educational requirements highlight some of the challenges for music therapy educators—how to design a curriculum that meets the multidimensional, developmental, and integrated learning needs of students. Multidimensional or interdisciplinary refers to the wide variety of course content that needs to be taught, such as music history and theory; psychology; anatomy and physiology; guitar, keyboard, and vocal skills; and research design, just to name a few. Some content also is developmental as the concepts or skills cannot be taught just once as factual information, but need to be revisited at higher levels of training to fully learn the skills. For content to become meaningful and useful, students also need to learn to integrate key concepts and skills across different courses. The challenge is to incorporate all three approaches, connecting each with the appropriate type of content. These three approaches to learning are the focuses of two curriculum theories, integrated and spiral, which can be used to plan music therapy programs and define the content and sequence of the clinical training experiences. The integrated curriculum theory has been linked to the early concepts of Dewey, Piaget, and Bruner (Vars, 1991) and discussed by several more recent educators such as Fogerty (1991), Jacobs (1989), and Lapp and Flood 67
(1994). Fogerty (1991) suggests that the integration of content exists along a continuum, from fragmented to sequenced to a fully integrated approach.Fragmented courses are taught in isolation of each other; sequenced classes are somewhat integrated in that the content of each course becomes the foundation on which the next course is taught. Courses are considered fully integrated when the interrelationships among common concepts and skills are emphasized. An integrated music therapy curriculum challenges educators and students to identifycommon themesand the interrelationships that exist across a wide range of classes. The spiral curriculum theory was developed by Bruner (1960) and stresses that learning occurs in stages as connections are madeat increasingly more advanced levels of training. Bruner believed he could teach any concept if he presented it at the skill level of a student. According to the theory,early learning of a skill should support and informmore advanced learning.A spiral curriculum supports teaching the music therapy concepts and skillsthat are developmental, first at an introductory level and then bringing the content back again throughout the program while teaching the material at more advancedstages.Both curriculum theories, integrated and spiral, support the growth of life-long learning skills in music therapy students. While it is important that the music therapy curriculum overall reflect the multidimensional, developmental, and integrated learning needs of students, the success of the clinical training component demandsthe involvement of thesethree concepts. The conceptssupport both the sequence of experiences leading up to practicums andthe actual organization of the practicums.To prepare students for their practicum courses,pretraining experiencesneed to:a) include the multidimensional concepts and skills that are critical to success in the clinic, b) challenge students to make connections across the wide variety of content areas, and c) appropriately sequence those skills that are developmental. Theorganization of the practicum courses needs to step students into early introductory experiences that support the eventual development of advanced, integrated skills. In fact, the two curriculum theories, integrative and spiral, are what I used to develop the sequence of classes and clinical training experiences at Elizabethtown College, an undergraduate school in the United States. As a result, I believe the sequence and content of the practicum courses are one of the strengths of our music therapy program. Content and experiencesrelated to success in the clinic were organized across a variety courses such that students would sequentially develop and integrate the concepts and skills. In addition, I includedpre-clinical experiences that step the students into their sequence of practicums.Throughout each semester, there also are several different volunteer experiences in the community that provide additional opportunities for students to interact with clients and rehearse skills and concepts. Applying the two curriculum theories, the sequence of clinical experiences at Elizabethtown Collegeis as follows. The first music therapy courserequiresstudents to observe several different sessions in our on-campus clinic and writeobservational reports. As a part of their secondsemester class, students are assigned to a specific client or groupthat theyobserve throughout the semester; they also sit in on processing, andcontinue to write reports. For their third semester course, students are assigned to a practicum during which they help upper level students as “an extra pair of hands� while also learning to apply class content such as taking data, writing reports, and employing music and non68
music techniques. The students then go on to complete five semesters of supervised clinical course work, each often with a different supervisor and the potential for more learning experiences. Seniors also can volunteer for an additional clinical experience their last two semesters as a part of a Senior Capstone Program. Student grades on the clinical evaluation form, success in internships, higher scores on their board certification exam, ease of obtaining jobs, and the doubling the number of students in the program the last seven years are indicators that suggest the success of the program. In conclusion, I share some comments from a senior student's recent interview: “I think [my experiences at Elizabethtown College] have been really great and it's something I talk a lot about to prospective students…how we progress through the experiences. We are in very early but I don't think it is too early…asyou get a good sequence of experiences [to prepare you]...before you jump in [and lead]. And even when you are in your first practicum, they ease you into it. Then as you get into the higher levels of practicums, you start] the sessions a little bit sooner. It's great that way. And I've loved having a senior [capstone] session.”
References Bruner, J. (1960).The process of education, Cambridge, Massachusetts: Harvard University. Fogarty, R. (1991). Ten ways to integrate curriculum. Educational Leadership, 49(2), 61-65. Jacobs, H. H. (Ed.). (1989). Interdisciplinary curriculum: Design and implementation. Alexandria, VA: Association for Supervision and Curriculum Development. Lapp, D., & Flood, J. (1994). Integrating the curriculum: First steps. Reading Teacher, 47(5), 416-419. Vars, G. F. (1991). Integrated curriculum in historical perspective. Educational Leadership, 49(2), 14-15.
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Arnab B. Chowdhury Third generation from a family of musicians and a holistic education at Sri Aurobindo International Centre of Education (Pondicherry, India), ensured Arnab's prowess for lateral thinking and application. He is trained in Hindustani Classical (tabla) and Western Classical (piano). At XTC Sound Lab (MIT Media Lab, 'Music, Mind and Machine Group', Boston-Bangalore), as computer music researcher delving into music and the cognitive investigations describing it, he composed with Csound and was a member of 'Karaoke-on-Demand Machine' project, ranked among the top 25 inventions from MIT Media Lab. Arnab works with therapists and medical practitioners to compose music that can heal. He has performed as an artist and held workshops for music therapists in India and at the World Congress for Music Therapy, Austria, July 2014. He is founder of Ninad (www.ninad.in).
THE 'AHA!' MOMENT EXPERIMENTS AND EXPERIENCES OF COMPOSING FOR MUSIC THERAPY Abstract Music is composed conversation; between the composer and his circumstances, people around him and primarily, with himself. Music is a multi-sensory experience; it has a motivating effect on the listener and the composer. It is meta-linguistic, meta-religious, cuts across age, geographies and cultures; it helps you bond, quite simply and spontaneously. Music is processed in both sides of the brain. Music is therapy. 'Know Your Rhythm' program is about training even those who are not formally trained in music to have this facility of music conversations. Whether they are paramedics, medical practitioners, therapists, or school children or children with special needs or even the elderly, rhythm seemed to be the best option to train and receive music as therapy precipitating a deep healing experience. The aha! moment marks recovery for the ailing and a fulfilling experience for the composer, care giver and the care receiver through a series of active and receptive experiments in music with a self-evaluation index. Keywords: composing for music therapy; music composition; motif; harmony; laya; the aha! moment; know your rhythm; konnakol; bol; train the therapist; rhythm; Indian Classical; Hindustani; Ccarnatic; rhythmic cueing; vocal percussion; pattern recognition Music as Composed Conversation With a lineage that traces back to Baba Allaudin Khan (Maihar Gharana) - Guru of Pandit Ravi Shankar (sitar), Ustad Ali Akbar Khan (sarod), Pandit Rabin Ghosh (violin, my grand uncle),music was the lens through which my sensory organs discovered the world. The 'conduit' was my father and teacher, Arun Chowdhury (vocalist and disciple of Pandit Rabin Ghosh). At 3 years, my fingers played percussion notes on our dining table. So my 70
father brought me a tabla. One of the lead percussion instruments in Indian Classical music, I played tabla solo and as accompaniment. I am also fortunate to have learnt to play the piano. With the piano, I could fluidly move between percussion and 'Swar' (note). There, at the age of 12, began my conversations between rhythm and melody and other musical paradigms. I began to compose in an intercultural milieu that is Pondicherry! By extension, music composition became my way of conversing with my father and subsequently with collaborators, therapists and patients. And so I learnt well that music is a language that needs no words, no translations. We all are aware, that of all the sense organs, the ear develops the first, while the foetus is still less than 5 months old. So, the listening impulse is embedded in us, humans, quite deeply and since very early. It is then no surprise that “humans are typically vocal learners” (as they grow) “because they learn the articulation in speech and the vocalisation of songs just by listening to them”.1 Music composition … the visual that comes … is a build-up of a wave, wave after wave; and the gentle or harsh breaking sounds of the waves resound within me and mainly the silence of anticipation …. I live close to the sea which itself is a metaphor for a composition in rhythmic continuum. All that I have learned so far, does it offer me a template that I can use as a lens to view structures across music and health domains? Can I easily flit between a sound scape and a visual? Between sound and feeling? Between math and physical sciences? Between the intangible mind and the relatively tangible brain? Is music on its own therapeutic? Or do we need to compose special music for therapy? What aspect of music can we use to intervene? And how do we make this music meaningful and still unite all, across languages and cultures? I draw upon this questioning and learning to explain the particular approach that we have been using for our forays into music therapy projects. Choosing Rhythm We looked at the most efficacious points for intervention and we zeroed in on RHYTHM. Tal, (variously transliterated as "tala", "taal" or "taala") is the Indian system of rhythm. It has been argued that rhythm is fundamental to the creation of any musical system. The Tal system roughly corresponds to metre in Western music. Tal literally means "clap". For our experiment, we considered Rhythm which, when vocalised, seemed to become the bridge between speech and music. Indian Classical music tradition has a system of phonemes. Vocalised rhythm with these phonemes does require specialised training, but it can be learned easily as compared to melody-centric music. This bridge of vocalised rhythm, we found to be a space in itself --- open to creativity, innovation and its possible effects in the field of music therapy. 'Know Your Rhythm' (KYR) is our programme to discover one's rhythm and a sense of musicality.
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The rhythm-centric music exercises of this programme have been drawn from various streams of music: ranging from Hindustani, Carnatic, Western Classical, contemporary, AUM chanting, folk, Binaural to popular films. With special emphasis on Indian vocal percussion systems (‘konnakol', 'bol'), KYR connects music therapeutically with kinesthetics, speech therapy, proprioception,etc. to help the therapists and their target population find their own rhythm (Figure 1). The target
population can range from patients, school children, children with special needs to senior citizens. Rhythm seemed most appropriate: its percussive nature, easy loopability, smooth progression, disrupt-harmonise ability, aural and sensory memory of heartbeats in-utero, rocking movement during infancy, and lullabies, were some of the considerations for choosing Rhythm. Rhythm-driven composition is a fulfilment in motion. From a composer's experience, it can be described as a coming together of forms, structures of music; with such fluidity, fluency that one actually senses the harmony in their movements. The composed piece too reflects the same flow, the same mood. The individual ingredients and their ensemble create an environment or a modality in which healing happens quite spontaneously, for the composer and the listener (Figure 2). 'By modality we mean – the quality or state of being modal – a quality, attribute, or circumstance that denotes mode, mood'1 or manner. With KYR we try to answer questions like 'Is music an effective modality in healthcare?''Does music make a difference in the various issues affecting human beings?''How and Why?'
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Several things became clear during the KYR programme: 1. We needed to focus on training the therapists/paramedical staff. It made demographic sense in a country like India. Ideally, Music Therapy(MT) works best in a 1:1 ratio of therapist:patient. In two of our projects, this ratio ranged - 1:8 to 1:30. 2. Everyone liked music but very few had serious music training. However, they had formal qualifications; they were therapists or health care workers. 3. Access to music was through films, film songs, television, lyrical poems sung by elders in the family and some folk music/songs known to the community 4. There was no way these therapists could find resources like time, space, funds to attend music lessons or look for MT qualification. 5. Mostly women, these therapists doubled, quadrupled as homemakers, mothers, teachers, and working women. 6. It is near impossible to reach out to the needs of patients on a one to one basis (Our immediate patients were children with special needs). We looked at a 'Train the Therapist' model as our best option: Train the existing therapist/caregiver population, who in turn deliver Music Therapy to children with special
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needs and sensitise the child's family to follow a music prescription (Figure 3). That felt good, our medicine was sweet to the ear and could be delivered via a simple mobile phone. As we all have seen, children are fascinated by gadgets!
These projects are works-in-progress. But our vision to have at least one music therapist within each family seems possible, given that India is world's fastest growing market for mobile phones with a fairly large population that seems to succumb to modern diseases and disorders! For KYR, our health care personnel consisted of: -
Teachers (educationists)
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Occupational therapists
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Physiotherapists
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Speech therapists
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Nurses
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Volunteers
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Specially trained parents or family members of children with special needs
The basic KYR module tries to establish 'a phonological loop' for the therapists. Our music repertoire includes specifically composed pieces of music, pieces used by other music therapists during the course of their sessions, popular film songs with lyrics and without lyrics (instrumental). Matriarchs are carriers of musical and cultural heritage including folk music and story songs with values so we drew from their collection of songs and 'humming', known or improvised poems that could be sung, and simple instructions given melodiously. During KYR programme, therapists actively learn and participate by keeping and 'holding' Rhythm. 'In clinical neurology, a rhythm is supposed to be a non-random repetition of a certain wave form that distinguishes itself clearly from the background.'2And during MT Training the therapists learn to 'hold' it purposefully.
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KYR Wellness Experiment
While training the therapists, we selected musical content (songs and instrumental music) that corresponded to the 'Reminiscent Bulge'3 period i.e. the musical content that the trainers listened to during their youth typically between 15-22 years of age. As David Huron4 remarks, 'these content had generated maximum oxytocin back then' and now we use this factto engage the therapist to learn about Rhythm and in turn help them further engage the children/patients. We gauge the reminiscent bulge period of our trainers from their physical age, cultural and sub-cultural heritage and preferences, family value systems, generation gap vis-à-vis their patients. Then we field the musical content from a variety of sources starting from spiritual and religious music, popular film songs to folk songs, over which we have vocal percussion exercises (Figure 4). This is how the song “Kannae Kalaimane” was chosen. This song is a lullaby from the award-winning Tamil film 'Moondram Pirai' where the protagonist is singing to a patient of retrograde amnesia. Vocal percussion – the language of music The Eight Schedule of the Constitution of India lists 22 languages. There are several other recognised languages and several hundred dialects. http://india.gov.in/my-government/constitution-india/constitution-india-full-text So we had a challenge as to which languages to concentrate on. Vocal percussion made sense because it is meta-cultural, meta-religious and well-structured with syllables which makes it a-cultural, reduces hierarchy between trainer and therapist, or caregiver and care receiver. Since this language is new to most therapist and patients, there is an innate fascination to learn a new language which requires more attention span, coordination between vocalisation and auditory senses, imitation, co-pausing, therefore increasing brain or neural plasticity.
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Konnakol is a 'Rhythm-phonetic system. It has its roots in Carnatic music system of South India. Konnakol consists of composition, performance or communication of rhythms through the art of vocal percussion'5. Bol, in Hindustani Music System, performs a similar role. Bol is a mnemonic syllable. It is used to define the tal. The word bol comes from the Hindi verb bolna, which means "to speak or vocalise." From a MT perspective, it is a set of techniques with specific musical, therapeutic, logopedic, psychomotor and pedagogical values. It is especially appropriate to facilitate and improve the faculties of attention, concentration, assimilation, storage and repetition: in this sense it is aimed at the fundamental aspects of the so-called 'operational intelligence'.6 It 'consists in articulating particular syllable-phonemes which have the ability to loosen and strengthen the muscles used in speech, accompanied by clapping and swaying motion of the whole body. It is very useful in working with hyper-active subjects with little ability to remain on task for significant time. Improves the acquisition and practice of mathematical calculation, facilitates the strengthening of brain neuronal synapses favouring the connections between the two hemispheres.'7 During one of our KYR project, we experimented with Bols:Dha and Dhin Readers can try the following experiment (Figure 5):
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Ingredients for Composing Music Instead of using pre-recorded music pieces, composing music gives us more freedom and control to achieve a desired outcome. Within the larger context of Rhythm, our music compositions are based on the following four ingredients: 1.
Motif
2.
Harmony
3.
Laya
4.
The aha! moment
Each ingredient creates its own unique modality. As mentioned earlier, by modality we mean - the quality or state-of-being modal- a quality, attribute, or circumstance that denotes mode, mood, or manner. The four basic ingredients for composing music for music therapy 1.
Motif
Motif can be generically defined as a repeated theme or pattern which gives a work of art its identity. In Indian Classical music, we have two streams: Hindustani and Carnatic, both these make Indian music so rich. Both are based on the Raga, which literally means "colour, hue" and also "beauty, melody" and denote special melodic modes. Ideation wise, within the context of a Raga, Sthayi comes closest to a 'motif'in Hindustani Classical music system –a primary melody section of a Raga to which the performer (vocalist or instrument) returns to after every variation or musical exploration/adventure/excursion. In Carnatic Music System, the term 'motif' lends itself to Pallavi. What is fascinating is the etymological tri-combination of the term Pallavi: pa is derived from padam which means phrase; lla comes from layam which means tempo; 8
vi is from vinyasam which means variation.
In the Western Classical music system, motif can perhaps be defined as a musical fragment or succession of notes that has some special importance in or is characteristic of a composition (Figure 6). When we compose a motif, what state are we in? Are we also likely to produce the same state in the listener/learner/practitioner?
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Modality: Sharing and creativity. A motif helps us share our music with others at specific points and yet maintain our creativity at other times. 2.
Harmony
In Western Classical music, harmony is the use of simultaneous pitches (tones, notes), or chords. The study of harmony involves chords and their construction and chord progressions and the principles of connection that govern them. Harmonisation usually sounds pleasant to the ear when there is a balance between the consonant and dissonant sounds. In simple words, harmonisation occurs when there is a balance between "tense" and "relaxed" moments.9 In our KYR programme, we build and sense harmony with Konnakol. This builds multiple concentration for the therapists: knowing what to vocalise, listening to one's own vocalisation, listening and following other voices and tempo. In addition, when hand gestures are used, they add to the complexity of the harmony, both visual and auditory. When achieved well, harmony creates within the therapist a sense of oneness through diversity (Figure 7). Modality: Polyphony, Collaboration, Entrainment Rhythm and Harmony "Rhythmic patterns cause entrainment --- the tendency for two oscillating bodies to come into phase with each other so that they vibrate together. .... Entrainment produces synergy, which is the working together of two or more things or people to generate an effect greater than their individual capabilities combined. ... Sound and breath produces such synergy. ... in medicine, synergy is the phenomenon whereby the combined action of two things --- for example, drugs and muscles --- is greater than the sum of their individual effects."10 78
1.
Laya (tempo)
We locate Laya in Nature and in our body system. The tempo of a Rhythm can be discerned in musical parlance as very very slow as watching the sunrise or sunset (ati ati vilambit); very slow (ati vilambit) as observed in the gait of an elephant walking; slow (vilambit) as observed in the gait of a chameleon walking on a branch; medium (madhya) in the normal
human heartbeat at around 60-80 BPM; fast (drut) of the human heart during a fightflight situation;(ati drut) during severe convulsions following epilepsy, (ati ati drut) during thunder strikes leading to severe rainstorm. All deviations can be understood within this range and therein is the indicator to choose the appropriate tempo (laya) to achieve therapeutic goals (Figure 8). In the world of medicine, listening to one's Laya has its importance. 'Rhythm is a central order parameter for music and is mostly perceived aurally. In the human body, many processes are organised rhythmically but with the exception of the heartbeat and breathing they do not produce significant mechanical vibration and cannot be listened to. It is therefore an obvious question whether these “silent� rhythms can be made audible, in order to find out what the result sounds like. While continuous sound can be perceived if the frequency is in the range between 30 and 16,000 Hz, rhythm is perceived 79
if a sound event repeats itself with a frequency between approximately 0.5 and 20 Hz. Sound synthesis of physiological rhythms that lie outside has to be transformed into this range.'11 So we asked: Can we understand a diseased body as a 'human being' that is out of rhythm or in disharmony? Can we get back to health by recomposing the Laya? In this experiment (Figure 9) we use Laya and observe behavioural parameters of participants --- therapists and children. For this we created a modality in which the temple elephant is a symbol of sacredness, grandeur, peace and strength. This elephant is a favourite among children of Pondicherry, and they love to feed it bananas. There is a relationship of awe for this huge, but gentle creature. For the grown Ups, this elephant reminds them of nature --- forests, creating moments and spaces of peace and inner security, in an urban locale growing at an alarming pace, distancing itself from rural atmosphere.
With this experiment, we could say that if one listens to oneself, one could perhaps determine one's own 'rhythm of being' as self-therapy. If we take this further, if we can train aspiring therapists to listen to themselves; then, with the law of transitivity the probability of their sensing and expressing the Laya of their patient increases. 1.
Aha!
'The aha! moment refers to the common human experience of suddenly understanding a previously incomprehensible problem or concept or arriving at a solution that has eluded the analytical mind. Psychologists have studied insight using behavioural methods for nearly a century. 80
Recently, the tools of cognitive neuroscience have been applied to this phenomenon. A series of studies have used electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) to study the neural correlates of the “aha! moment� and its antecedents. Although the experience of insight is sudden and can seem disconnected from the immediately preceding thought, these studies show that insight is the culmination of a series of brain states and processes operating at different time scales. Elucidation of these precursors suggests interventional opportunities for the facilitation of insight.'12 For music composition, the aha! moment can arrive as a culmination of a synchronisation of various movements and music structures that produce something that touches the heart and soul. It 'moves' you to tears or smiles spontaneously with a deep sense of happiness (Figure 10). For the discerning music connoisseur, listening to live music performances, in India, we have the aha! moment expressed in linguistic terms. Phrases with hand gestures are used to express deep appreciation by the listener to the performing musician(s) during the performance. In Hindustani Classical music, phrases like 'Wah, Wah! ', 'Kya Baat Hai!' are often uttered with enthusiasm. While in Carnatic Classical concerts, 'Shabash!', 'Besh!' are heard from the audience. This shows that in Indian tradition, we do have a direct correlation between music, the aha! moment and its expression.
During our KYR programme, the aha! moments have come in myriad ways: when the communication between the therapist and the patient is complete; the environment is that of empathy and compassion. There is eye contact from the patient, a smile, some laughter, a sudden breaking into a song, a comprehension or a breakthrough for the patient in a goal achievement- as simple as being able to hold a spoon or being able to eat without spilling, or being able to stand, take a step after an accident/surgery. 81
To sum up, the aha! moment marks recovery, and 'sweet anticipation' of further/progressive recovery (Figure 11). It brightens up our eyes with hope, trust and confidence. Healing occurs and one regains health.
Music does create conditions to maximise the likelihood of the Aha! Moment. Responses to Music are 'animĂŠ', as the French would say, infused with life-energy. 'Music has an intention of influencing positive emotions such as pleasure, happiness, aesthetic sensation, pleasant feeling of excitement, comfortable tranquillity, a sense of unity, a sense of accomplishment etc. as actions.'13 Indian Music system has had a long tradition of understanding and creating music for Health and Wellness. 'Music is Universal. You will never find a culture without Music.'14 Acknowledgements I would like to thank my father and teacher Shri Arun Chowdhury for his creative teachings and insights, my colleague Smt Prarthana Kalaskar for crucial inputs and discussions and my former teachers at Sri Aurobindo International Centre of Education for their observations on Music. Notes 1 Modality.(n.d.)American HeritageÂŽ Dictionary of the English Language, Fifth Edition. (2011). Retrieved May 29 2015 from http://www.thefreedictionary.com/modality 2 'The vocal production must be linked with the perception of the own sound production, since the ear (auditory perception) controls the voice (vocal tract). The interaction of both systems builds a phonological loop.' WilfriedGruhn. 2009. 'The audio-vocal system in song and development', In
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'Music that Works – Contributions of biology, neuropsychology, psychology, sociology, medicine and musicology' R.Haas, V.Brandes, Springer, Austria. 113. 3, 4 David Huron. (2011). A talk at Rice University's Shepherd School of Music as part of the Exploring the Mind Through Music Conference. 05:45 – 16:50.[Video File]. Retrieved from https://www.youtube.com/watch?v=Ydn-eLXU__Q 5 Konnakol (last modified on 17 February 2015) http://en.wikipedia.org/wiki/Konnakol 6, 7 Riccardo Misto.(2014). 'Rhythm-phonetic system – Takadhimi', In Collection of Abstracts.14th World Congress of Music Therapy, Cultural Diversity in Music Therapy Practice, Research and Education.Vienna and Krems, Austria. 39. 8Pallavi (last modified on 1 May 2015) http://en.wikipedia.org/wiki/Pallavi 9 Harmony (last modified on 18 May 2015) http://en.wikipedia.org/wiki/Harmony 10Russill Paul.(2004). The Yoga of Sound - Tapping the Hidden Power of Music and Chant'.New World Library, California, USA.134-35. 11GeroldBaier and Thomas Hermann. (2009). 'Sonification: listen to brain activity, In 'Music that Works – Contributions of biology, neuropsychology, psychology, sociology, medicine and musicology' R.Haas, V.Brandes, Springer, Austria. 17. 12 JohnKounios and Mark Beeman.TheAha! Moment, The Cognitive Neuroscience of Insight. http://cdp.sagepub.com/content/18/4/210 doi: 10.1111/j.1467-8721.2009.01638.x Current Directions in Psychological Science August 2009 vol. 18 no. 4 210-216 13 Aniruddh Patel. Music and the Mind, Health Matters Series.2010, 03:51 – 04:03.UC SD TV P r o g r a m [ V i d e o f i l e ] . R e t r i e v e d f r o m https://www.youtube.com/watch?v=wdyHuWv3fsc 14Izumi Futamata.(2014). Radical Musicism in the Clinical Practice of Music Therapy.In Collection of Abstracts.14th World Congress of Music Therapy, Cultural Diversity in Music Therapy Practice, Research and Education.Vienna and Krems, Austria. 447. References American Heritage® Dictionary of the English Language, Fifth Edition. (2011). Retrieved May 29 2015 from http://www.thefreedictionary.com/modality Baier, G. andHermann, T. (2009). 'Sonification: listen to brain activity, In 'Music that Works – Contributions of biology, neuropsychology, psychology, sociology, medicine and musicology' R.Haas, V.Brandes, Springer, Austria. 17. Futamata, I. (2014). Radical Musicism in the Clinical Practice of Music Therapy, In Collection of Abstracts.14th World Congress of Music Therapy, Cultural Diversity in Music Therapy Practice, Research and Education.Vienna and Krems, Austria. 447. Gruhn, W. (2009). 'The audio-vocal system in song and development', In 'Music that Works – Contributions of biology, neuropsychology, psychology, sociology, medicine and musicology' R.Haas, V.Brandes, Springer, Austria. 113. Harmony (last modified on 18 May 2015) http://en.wikipedia.org/wiki/Harmony Huron, D. (2011). A talk at Rice University's Shepherd School of Music as part of the Exploring the Mind Through Music Conference. 05:45 – 16:50.[Video File]. Retrieved from https://www.youtube.com/watch?v=Ydn-eLXU__Q Konnakol (last modified on 17 February 2015) http://en.wikipedia.org/wiki/Konnakol 83
Kounios, J. and Beeman, M.TheAha! Moment, The Cognitive Neuroscience of Insight. http://cdp.sagepub.com/content/18/4/210 doi: 10.1111/j.1467-8721.2009.01638.x Current Directions in Psychological Science August 2009 vol. 18 no. 4 210-216 Misto, R. (2014). 'Rhythm-phonetic system – Takadhimi',In Collection of Abstracts.14th World Congress of Music Therapy, Cultural Diversity in Music Therapy Practice, Research and Education.Vienna and Krems, Austria. 39. Pallavi (last modified on 1 May 2015) http://en.wikipedia.org/wiki/Pallavi Patel A. (2010).Health Matters Series, Music and the Mind.03:51 – 04:03. UC SD TV Program [Video file]. Retrieved from https://www.youtube.com/watch?v=wdyHuWv3fsc Paul, R. (2004). The Yoga of Sound - Tapping the Hidden Power of Music and Chant.New World Library, California, USA.134-35.
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Aurelio C. Hammer (A. C. Hammer) has spent three decades in the exploration and study of musical instruments, their origin, universality and cultural specific expressions, their significations and application in therapeutic settings. He is the founder and director of SVARAM Musical Instruments & Research in Auroville, Pondicherry, Tamil Nadu. He offers seminars and practices a sound healing modality at Quiet Healing Center on the Coromandal Coast, Tamil Nadu.
SPECIFIC REQUIREMENTS AND ADAPTABILITY OF MUSICAL INSTRUMENTS FOR THERAPEUTIC SETTINGS Abstract With the growing need for music therapy interventions in specialized settings the question of utilisation and adaptability of conventional musical instruments poses some interesting challenges which could lead towards innovative instrument developments. Understanding the uniqueness of instrument archetypes and their specific applications and possibilities can help to define parameters and possibly bring about necessary adaptations to therapeutic use. This article is written from the perspective of an instrument builder with an ethno-musicological background working with sound and vibrational healing modalities. Introduction Even if the role of music for the healing arts dates a long history in many cultures there are only rare cases of musical instruments reserved or specifically created solely for interventions in medical and special-needs educational settings. The musical instruments utilised for this purpose are conventional types and are not differentiated from the ones used in music practice, musical education and performing arts. The therapeutic and clinical context often has very specific requirements and numerous limitations and the study and analysis of long term experience and reflections of music therapists is required to understand if and where musical instruments have to be adapted and changed in construction and ergonomics. The author, also trained in music therapy, opens the discussion for a possible enriching dialogue and interaction between therapists and instrument builders to stimulate adaptions and new instrument creations which can respond to apparent needs in the professional and institutional setting. Description If we take a look at the utilisation of musical instruments in contemporary music therapy it is apparent that in spite of strong cultural-specific forms and expressions, there is a trend 85
towards common, nowadays universally available and easily accessible instruments like the guitar, bowed strings, simple flutes and woodwinds and handy percussions and drums. More sophisticated, traditional or oversize instruments like the family of brass winds, some bass and mechanical instruments or the royal organ - which played such an important role in the coherence, well-being and inspiration of the communal congregation are less appropriate or just not practical to be integrated in the work. The discussion of the effect and specific utility of purely acoustic material or electronic digital instruments with their dependency on electricity is an interesting one, but left aside here as it does need a separate in depth enquiry and study. The differentiation between participatory and purely receptive forms of therapy, individual and group work, special needs education and clinical work or community music making settings brings a diverse range of requirements and demands on musical instruments. The question posed here on the appropriateness and utility of specific musical instruments for the therapeutic work therefore largely depends on the context and situational setting. The cultural background and musical tradition of place and client add unique character and necessitate a variety in the selection of musical instruments. Whereas the personal skill, musical training and proficiency of the therapist in one or more instruments always stands in the foreground and lies at the heart of the actual practice of the profession, the availability of a specifically selected large range of musical instruments supports the versatile range of music therapy interventions. For most students of music therapy in the western cultural context it is a requirement to be proficient in playing the piano as this also goes hand in hand with studying the music theory and practice of the system of musical harmony in its manifold expression. Pianos are stationary instruments due to their size and weight and only the introduction of electronic keyboards opens an opportunity to shift and install the so prominent keyboard instrument in temporary setups. The popularity and easy accessibility of the guitar have made it a very common and universally accepted tool for the craft, art and science of music therapy. Touching upon the novel emerging situation of music therapy in India and its rare appearance in clinical setting immediately the question rises on the right selection and place of traditional musical instruments in the work with the stationary patient. A strong determining factor in that choice is of course given by the personal history and background of the patient and her conditioned taste and liking for specific music. Is it possible and pragmatic to introduce the Veena or Sitar in the clinical set up? What is the special character and gift of a live Tampura or is it rather advisable and justified to use handy electronic devices and playback mechanisms? What is the unique role and outstanding contribution of the immediate human voice - so central in the Indian classical and folk tradition - and its heightened vibration through singing? As mentioned above the importance of the piano as the central instrument of western music in the academic training of a music therapist, the training and practice of the voice in its full capacity of tonal and empathic expression is essential and possibly of foremost importance in the work of the music therapist. It is recorded from numerous instances that the tonal quality of the doctor's voice can often play a bigger role in the curative advance
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than the actual information conveyed. How much more effective is the impact of a thoroughly trained and experienced singing voice of the therapist upon the patient in need. Many well researched works have been published in regard to the role of the human voice and vocal communication and exchange between patient and therapist, but as also the nonverbal dimension of music therapy intervention is one of its specificities in differentiation to conventional, but in commonality with other art-based therapies, we return here to our theme of the role of musical instruments and their limitations, possibilities of adaption and new creations to support and enhance the therapeutic work. To further the point of useful and helpful changes and possible adaptability of musical instruments for the clinical work, here a few examples of successful adaptions having risen out of concrete situations in the work with instrument building. The well-known 'Chalice of Repose' project, initiated by the University of Montana, working with Music Thanalogy and its application of 'Music for the Dying' in geriatric and clinical institutions has found and selected the harp as the ideal instrument for its purpose due to its polyphonic ambient of being able to create musical tapestries, and while subtle, also having a full and encompassing sound with varied dynamic and volume ranges. For the pragmatic reason of portability, weight and size, limitation of space in wards, ICUs, homes etc. the utilization of the standard concert petal harp posed too many challenges and to find solutions to the strong pragmatic restrictions and burden of the music therapist the project cooperated with instrument builders to find the most suitable model amongst the various types of harps which offers all the necessary requirements to be used favourably in the clinical work. This offers now the opportunity for hundreds of music therapy trained harp-players in North America and Australia to assist and positively impact thousands of patients in the difficult end of life transition. The Sound Stone Therapy has been introduced in the university clinic in Tubingen, Germany, and brought satisfying results in the field of geriatrics, working with patients with dementia, Alzheimer and related symptoms. The direct exposure to the strong vibrations emanating from the up to 60 kg heavy instruments through the immediate stimulation of the sense of hearing and touch proofed to bring a calming, deepening as well as invigorating effect, often even in the first therapeutic session. To be able to enhance the experience for the patients of playing the Sound Stones a special shape was developed at SVARAM Musical Instruments in Auroville (near Pondicherry) to create a Therapy Stone which allows both the therapist and the patient to play simultaneously and so generate a direct rapport and the desired impact. This change in instrument design makes it possible to seamlessly transit form a former purely receptive into an interactive contact with the whole range from a contemplative deepening to a stimulating, dynamic non-verbal communication between patient and therapist. Besides these mayor changes in design of musical instruments from our immediate work, a number of alterations as for example in the ergonomics of string instruments and the mallets of bar instruments for easier handling by the patient have been effectively implemented. Also, change of tunings as for example open tunings for the guitar, have been explored and proven very helpful. A variety of unconventional tuning systems, besides the internationally standardized equal tempered chromatic scale have been experimented with interesting results which merely mentioned here, deserve special attention and systematic enquiry beyond the scope of this brief description. 87
Conclusion While in some traditional societies rare musical instruments had been specifically created for ritualistic, therapeutic and healing purposes, contemporary music therapy, according to setting and cultural context, utilises conventional and simplified instruments for its purpose. Some cases of positive adaptability through collaborations with music instrument builders have been exposed to exemplify further possibilities to improve practicalities and enhance the patient - therapist interface and musical communication in spite of limitations of setting and context. A further exploration of design and ergonomic alterations and possible new creations of musical instruments, utilising the vast range of world-music instruments and traditional, ethnic and unconventional tuning systems is steadily unfolding and projected to grow with the inclusion of as rich a traditional music culture as the Indian into the field and practice of music therapy.
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