Music Therapy Today, Vol. 12, No. 1

Music Therapy Today

WFMT online journal Volume 12, No. 1

2016 WFMT. All rights reserved ISSN: 1610-191X

MusictherapyToday, Volume 12, No. 1, 2016

suggested citation of this publication

author a. a., author B. B., & author C. C. (2016).

Title of article. Music Therapy Today 12(1), pp-pp.

Retrieved from http://musictherapytoday.wfmt.info

MusictherapyToday, Volume 12, No. 1, 2016

Music therapy perspectives 2016 edition editor

Melissa Mercadal-Brotons, ph.D., Mt-Bc, sMtae

Business Manager

amy clements-cortés, ph.D., rp, Mt-Bc, Mta, FaMi

editorial Board

anita Gadberry, ph.D., Mt-Bc Joy allen, ph.D., Mt-Bc Kana Okazaki-sakaue, Da, Mt-Bc, NrMt, araM Katrina MacFerran, ph.D., rMt Michael silverman, ph.D., Mt-Bc Nancy Jackson, ph.D., Mt-Bc patricia L. sabbatella, ph.D., eMtr-supervisor, Mtae-spain sooji Kim, ph.D., Mt-Bc, KcMt sumathy sundar, ph.D Giorgios tsiris, ph.D. candidate, MMt-Nr, Ba (hons) renato sampaio, ph.D. candidate, Mt helen Oosthutzen, MMus (Music therapy)

translations

Melissa Mercadal-Brotons, phD, Mt-Bc, sMtae

Graphic Design

editorial Médica Jims, s. L.

published by

World Federation of Music therapy (WFMt) www.wfmt.info Music therapy today issN 1610-191X

MusictherapyToday, Volume 12, No. 1, 2016

cONteNts CeleBRaTiNg ShaRiNg ouR KNowledge ..... 5 Amy Clements-Cortés MoViNg oN! ..... 7 Melissa Mercadal-Brotons

MuSiC TheRapy iN TuRKey: CuRRiCuluM aNd ReSouRCe deVelopMeNT ThRough pRofeSSioNal CollaBoRaTioN(wfMT) ..... 8 Burcin Ucaner, Annie Heiderscheit MuSiC TheRapy foR ChildReN iN ZiMBaBwe: aN iNTRoduCToRy expeRieNCe ..... 21 Grace Chiundiza

The poweR of iMageRy iN The BoNNy MeThod of guided iMageRy aNd MuSiC ..... 28 María Montserrat Gimeno how To deVelop The CoMpeTeNCy of CliNiCal iMpRoViSaTioN ..... 42 Sung-yong Shim

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MuSiC TheRapy aNd high ReSTiNg heaRT RaTe: uNdeRlyiNg MeChaNiSMS aNd pRaCTiCal ModelS ..... 54 Wolfgang Mastnak

MuSiC TheRapy haNdBooK. ediTed By BaRBaRa l. wheeleR BooK ReView ..... 79 Melissa Mercadal-Brotons eRRaTa ..... 83

MusictherapyToDAy, Volume 12, No. 1, 2016

celebrating sharing our Knowledge

amy clements-cortes, phD, rp, Mt-Bc, Mta, FaMi; president, WFMt I am pleased to write an introduction to the fall 2016 edition of Music Therapy Today (MTT). The WFMT is an organization that seeks to advance the discipline of music therapy as an art as well as a science; and one of the avenues we are able to share knowledge is through MTT. There are numerous academic journals from which we as therapists can learn from our peers not only in our professional discipline, but from many others such as: social workers, nurses, psychotherapists, musicians and more. What is special about MTT is that it is a journal that seeks to include scholarly writing from music therapists and pre-professionals from the 8 global regions of the WFMT.

In this issue you will find articles that discuss the development of music therapy in Turkey, stress management, clinical improvisation, community music therapy, guided imagery and music and heart rate. It is quite a diverse and informative collection, exemplifying our multifaceted and unique profession. Music therapy has the potential to benefit individuals across the lifespan, and our work has an impact on the global stage of healthcare.

In addition to the 5 papers you will find an informative book review on a text that many in

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our discipline will find informative and instructive. A special thank you to all authors in this edition.

The WFMT journal is a peer reviewed publication made possible through the exceptional editor in chief and chair of the WFMT Publication commission: Dr. Melissa Mercadal-Brotons; and the committed MTT editorial review board comprised of reviewers from around the world. I want to thank Dr. Mercadal-Brotons for her devotion and hard work in preparing this latest edition. I am confident you will enjoy this edition and that it inspires you to consider submitting an article for publication in future editions. It is truly an honour for me to serve as the WFMT President as we work our way towards the World Congress of Music Therapy in 2017. The Congress proceedings will be published in a special edition of MTT in Spring 2017, and authors are already working on their submissions. I am so excited to continue to build, celebrate and share our music therapy work through MTT. Warm Regards from Canada.

MusictherapyToDAy, Volume 12, No. 1, 2016

about the author

amy clements-cortes, phD, rp, Mta, Mt-Bc, FaMi Amy Clements-Cortes is Assistant Professor, Music and Health Research Collaboratory, University of Toronto; Senior Music Therapist/Practice Advisor, Baycrest; Instructor and Supervisor, Wilfrid Laurier University and Registered Psychotherapist. She is the President of the World Federation of Music Therapy (WFMT), Managing Editor of the Music and Medicine journal and serves on the editorial review board of the Journal of Music Therapy, Music Therapy Perspectives and Voices.

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MuSiCThErAPyToDAY, Volume 12, No. 1, 2016

Moving on!

Melissa Mercadal-Brotons, PhD, MT-BC, SMTAE Chair Publications Commission, WFMT It is a real pleasure to write this introductory note to the 2016 edition of Music Therapy Today. This issue includes articles from various regions of the world and addresses also a variety of topics, all relevant to the music therapy profession. All together it is a good rendition of what the World Federation of Music Therapy is and represents: «An international nonprofit organization bringing together music therapy associations and individuals interested in developing and promoting music therapy globally through the exchange of information, collaboration among professionals, and actions» (http://www.wfmt.info/). Music Therapy Today is one of the potent resources of the WFMT with the mission to move on towards meeting this objective.

The articles you will find in this issue illustrate the multifaceted aspects of the music therapy profession. Subjects such as the development of music therapy in countries where its presence is still limited, music therapy methods such as improvisation or guided imagery and music, and applications of

music therapy in settings such as stress management, cardiovascular rehabilitation and community contexts are focuses addressed in this issue of Music Therapy Today. You will also find an exhaustive book review, which is a unique contribution to our discipline, and certainly an invaluable resource for our profession.

I want to express my gratitude to my colleague Dr. Catherine Clancy for her support and assistance in the final revisions of the papers included in this issue.

I hope this publication contributes to strengthen the presence and recognition of music therapy throughout the globe as it enhances the quality of life for people with disadvantages and needs.

Sincerely.

About the Author

Melissa Mercadal-Brotons, PhD, MT-BC, SMTAE Melissa Mercadal-Brotons is the Director of the Music TherapyMaster Program, Escola Superior de Música de Catalunya (ESMUC), and Coordinator of Research and Master Programs at ESMUC. She is the Chair of the Publications Commission of the World Federation of Music Therapy (WFMT) and the Spanish Delegate of the European Music Therapy Confederation (EMTC).

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MusictherapyToday, Volume 12, No. 1, 2016

Music therapy in turkey: curriculum and resource Development through professional collaboration

Burcin ucaner, ph.D Gazi university Department of Musicology, Department head president of Music therapy association ankara, turkey annie heiderscheit, ph.D., Mt-Bc, LMFt past president, World Federation of Music therapy Fellow, association of Music and imagery assistant professor, Director of Music therapy augsburg college, Minneapolis, MN Correspondence can be directed to annie Heiderscheit at: heidersc@augsburg.edu

abstract

Music therapy continues to develop as a profession around the world. This article outlines the emergence and development of music therapy as a profession in Turkey. The rich history and tradition of music in healing in Turkish culture is highlighted, along with its influence and impact on the profession’s development. Key events that have influenced this development are discussed. Governmental and educational factors are identified and explored, as well as the curriculums developed that work within current certifying structures. Challenges innate in the development process are reviewed, as well as how these have been addressed.

Key words: music therapy, development, history, curriculum, Turkey.

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Resumen

La musicoterapia continúa desarrollándose como profesión en todo el mundo. Este artículo describe el comienzo y el desarrollo de la musicoterapia como profesión en Turquía. Se destaca la riqueza en la historia y tradición de la música en la curación en la cultura turca, junto con su influencia e impacto en el desarrollo de la profesión identificándose los eventos clave que lo han influido. También se identifican y exploran los factores gubernamentales y educativos, así como los currículos desarrollados que funcionan dentro de las estructuras actuales.

Se repasan los desafíos innatos en el proceso de desarrollo, así cómo se han abordado.

Palabras clave: musicoterapia, desarrollo, historia, currículum, Turquía.

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introduction

Music therapy continues to develop as a profession throughout the world. a recent article

by Gadberry, Kavaliova-Moussi, Lotter, Milford and Mukherjee (2015) highlighted the development of the profession in four areas of the world including australia and New Zealand, South africa, Eastern Mediterranean and India. The authors explored what has influenced and impacted the development of music therapy, such as indigenous cultures’ use of music in rituals, healing ceremonies and social integration. additionally, they discuss how music has been utilized in various cultural traditions, religious and spiritual functions. The authors also identify challenges in the developmental process of music therapy in each respective country, as well as the challenges encountered. These challenges included cultural inheritance, accreditation, and recognition and acceptance of this new profession. While developmental processes are unique to each area and culture, there is value in sharing and learning from these differing experiences.

The present article focuses on the development of music therapy in Turkey, which possesses a rich history and tradition in the use of music in healing practices throughout many centuries. The authors will explore the deep history and the events and processes that have worked to foster the development of the profession. The recognition of the music therapy as an accredited healthcare professional in the country was a requirement, and this process will be reviewed. Resources needed and utilized throughout the process will be discussed. additionally, the authors detail how they developed a curriculum within the framework of current health ministry structures in order to offer training opportunities within the country. Curriculum plans are presented that include pathways for po-

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tential students with differing backgrounds, such as medicine or music.

This next section will focus on exploring the long history of the role music played over the centuries in health and healing practices in the country and how this has impacted and influenced the development of the profession to date. history of Music in healing in turkey

In Central asia, shamans used music for healing practices. Musicians performed live music to the patients two or three times a week.

This music was based on maqams, which are musical modes or scales with a set of melodic formulas that guide the improvisation or composition (Harris, 2008). Maqams were chosen based on the patient’s disease, their horoscope, and time of the day the music would be played (morning, mid-morning, noon, evening, etc.) (Kılıç, 2007). In Seljuk (985/1038-1157) and ottoman Empire eras (1299-1922), Houses of Healing (sifahane) were established where music was utilized in healing practices. Health institutions and hospitals were generally and commonly called darüşşifa/şifahane (gate of health) during the Seljuk period, other names such as bimarhane (home of the sick), maristan (place of the sick), darülmerza, darüttıb (gate of medicine), darüşsıhha (gate of health), şifahiyye (place of health) and darülafiye were also utilized in various times and in different parts of the country. Darüşşifas (şifahane) were usually located in large campuses called külliyes, which included a madrassa (Islamic religious school), a mosque and a bathhouse (Songur & Saygın, 2014, p.200). darüşşifas were generally built by funds that came from the members of the ruling family (Kılıç, 2007, p.33). Serving as hospitals, darüşşifas, provided free healthcare for Muslim or nonmuslim women, children, men, civilians, sol-

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diers, passengers, merchants and homeless, etc., (i.e. for everyone) (Bayraktaroglu, 2014, p.145). While the caravanserais and inns had a 3-day lodging limit during the Seljuk times, there was no limit at the darüşşifas for the sick and foreigners who had no other place to stay (Songur & Saygın, 2014, p.200). Expenses of these health centers were covered by specially instituted foundations which were granted lands, shops, and other trading establishments and were managed by the ruling family and the wealthiest of the community.

The same organizational structure and services provided at these health centers continued during the ottoman times (1299-1922).

Hospitals constructed during the ottoman times were built as part of the larger külliyes, which provided greater access to health services and also meant patients were less isolated. (Bayraktaroglu, 2014, p.146). Infrastructures necessary and required for musical treatments and applications were included in the design of hospitals and health centers, as well as acoustics considerations (Bayraktaroglu, 2014, p.146; yücel, 2016, p.53). It is known that experienced musicians gave concerts at darüşşifas twice a week. during these concerts, the musicians made appropriate use of maqams and played so that patients became relaxed. as auxiliary therapy, fine scented flowers were presented to the patients and the sounds of birds and water were also included (Kılıç 2012, p.33). Some of the Houses of Healing are still in existence today, including Sultan Bayezid II Kulliye of Edirne, Gevher Nesibe Medical Museum in Kayseri and Divrigi Great Mosque and Hospital.

Gevher Nesibe Health Center, one of the şifahanes of the Seljuk times, was built in 1206 by the Seljuk Sultan Giyaseddin Keyhüusrev I, in memory of his brother Sultan Kilicarslan II’s daughter, Gevher Nesibe, (yücel, 2016). as the patients were being treated at the şifa-

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hanes, students studying medicine also received their education and training in these settings. In addition there was a department specifically for treating patients with mental disorders (Kılıç, 2012) which included 18 rooms, with a rudimentary speaker system. It is believed that this system allowed patients to listen to music and sounds of water which would help them to relax (yücel, 2016). Since 1982, this şifahane is now a medical history museum.

Sultan Mehmed the Conquerer (1432 - 1481) built the Enderun Hospital inside Topkapi Palace between 1461 and 1478. Baron J. B. Tavernier, a Parisian who visited İstanbul in the 17th century, writes that musicians played music for patients at the Enderun Hospital on traditional Turkish instruments such as the ney, santur, çenk and miskal. The music lasted from morning until the evening and sometimes as late as midnight (Bayraktaroglu, 2014).

Evliya Çelebi (1611-1682), one of the prominent travelers of the 17th century, visited Edirne darüşşifa in 1652 and wrote in his travelogue that 10 musicians performed music for the patients 3 times a week. He also stated that music was performed not only for mental patients but also for other patients at the facility (Şengü, 2014, p.110). There are many writers who include references about the music performed in Şifahanes, such as El Kindi (796-874), Ebu Bekir Er Razi (854-932), al-Fârâbi (870–950), Feytullah Şirvani (891/1486), avicenna (980–1037), Suuri Hasan Efendi (?1693), Hızır ağa (1710/1760), Gevrekzade Hafız Hasan Efendi (1727-1801), Mehmed Hafid Efendi (?-1811) and Hasim Bey (1815-1868) mentioned the effects of scales (altınölçek, 2013, p.60., Çoban, 2005, p.43).

El-Kindi, one of the earlier philosophers of Islam, utilized the relationship between breathing and sound in his medical studies, brin-

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ging together the effect on human soul and body. El-Kindi, in his «Kitab-ul Musavvitad», touches upon what kind of sounds initiate or dissipate different types of feelings. In his «Risâle fi Hubr Sınâati’t-Te’lif», he writes about sounds that are good to the human ear and suggests harmonious melodies have a positive effect on people (Turabi, 1996, p.19).

Ebu Bekir Er Razi sang, played the oud and was interested in poetry, literature, and music.

However, when he was nearly 20 years old, he refrained from music saying that «it was not appropriate for people to do music after they are old enough to grow a beard and moustache» and diverted his time to alchemy, chemistry, medicine, and philosophy (Karaman, 2004, p.106). Farabi (870 - 950), who was a physician, musician, and a philosopher, in his «El Musiki», «El-Kelam fi’l Musiki», «Kitabü fi İhsasi’l-İka» ve »El-Musiki’l Kebir» defined which maqam acted on people’s souls at various times throughout the day. He also wrote about instruments and musicians (Öztürk & Erseven, 2009, p.11., altınölçek, 2013, p.57). When Farabi wrote about the impact of maqams on people, he wrote, «Rast maqam makes people joyful, Rahavi maqam makes them think of infinity, Kucek maqam makes them sad» (yücel, 2014, p.56).

İbn-i Sina (980-1037), a physician and philosopher, became well-known as a result of his work titled, «El-Kanun fi’t-Tıb» (Law of Medicine) which was considered a main reference for about 700 years and was used in European universities until the middle of the 17th century (aydın, 2014, p.71). He also wrote about mathematics, astronomy, physics, chemistry, poetry, and music. In his «Kitabü’ş Şifa», «Kitabü’n Necat» ve «danişname», he wrote about the effect of music on people (Öztürk & Erseven, 2009). In one of his writings he states: «one of the best and effective ways of therapy is to increase the patients’

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mental and spiritual strengths, to encourage them to fight against the illness, to make their surroundings enjoyable, to make them listen to the best music, and to stay in touch with the people they love» (Öztürk & Erseven, 2009, p.13). according to İbn-i Sina, sounds that are arranged in a harmonious way have a deep impact on the human soul.

Şuuri Hasan Efendi (?-1693) was a physician and poet who lived during the ottoman times. The second part of his book Tediü’l Emzice, which is thought to have been written in 1677, includes topics on music and healing.

Here he describes the relationship between maqams and various illnesses and recommends specific maqams for their treatment.

He suggests that the science of music is related to the science of medicine, much like it is related to other sciences. He suggests pulse rates are in synchrony with specific maqams and related to the rhythms of other maqams (Turabi, 2011, p.153).

Gevrekzade Hafız Hasan Efendi (1727-1801) worked as the chief physician at ottoman court during Selim III’s reign. In his Emraz-I Ruhaniyye, Nagamat-I Musikiyye ile Tedavi, he wrote how important music was as therapy for mental patients and how effective it was (ak, 1997). In Neticetü’l Fikriyye and Tedbir-I Veladetü’l-Bikriyye, he wrote about how specific maqams could be used to treat different child diseases. For example, he wrote, «the Rast maqam was used against high fever and paralysis, Uşşak maqam was good for foot aches» (altınölçek, 2013, p.66). In another work titled er-Risaletü’l-Musikiyye Mine’d -devai’r Ruhaniye, he made a long list of maqams and the various diseases each could treat (altınölçek, 2013) Hasim Bey (1815-1868) was born in İstanbul. during Mahmud II’s reign, he studied in Enderun with the most important figures of

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Turkish Music of the time. He conducted the Palace Turkish Music orchestra and later was appointed as the head of muezzin (yalçın, 2014, p.2054). In his «Ta’dilü’l Emzice», he stated, «a physician who did not know methods of music could not be successful at diagnosis and treatment» (ak, 1997, p.48). In his writings he also presents tables of maqams that are effective at different times of day and, using an illustration of a human body, shows which maqams affected each part of the body, depending on a person’s horoscope (ak, 1997).

There are inconsistencies between the effects of scales mentioned in these books. For example, al-Farabi claimed that the Buzurg scale had a frightening effect on people while Gevrekzade Hasan Efendi mentioned its healing effects on fear-related illnesses (ozturk et al., 2009, p.16). according to al-Farabi, the hicaz scale gives feelings of modesty, while Gevrekzade Hasan Efendi emphasized its aphrodisiac effects.

Şifahanes either lost their functionality, or were destroyed or closed due to WWI, the demise of the ottoman Empire, and lack of financial support from foundations. For about 150 years until the present day, the use of music in healing at the şifahanes fell into oblivion. Books which were written during the Seljuk and ottoman times regarding the effects of maqams were eventually translated into Turkish (they were originally mostly written in arabic). In these translations, the musical applications described in these books were referred to as music therapy. This naming error has continued to be utilized for the last 20 years.

Currently, there is a growing interest in music therapy in Turkey. This strong interest has arisen through the work of various professionals ranging from academics in music, medi-

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cal professionals, as well as organizations striving to engage in a global music therapy community. The lack of a defined profession and clearly delineated training for music therapy creates ambiguity regarding who can practice this discipline and what can be referred to as music therapy. This growing interest has lead to music therapy training programs being established in Turkey, and the definition of the requirements and credentials necessary to practice as a music therapist in Turkey. However, the development of the profession would also benefit from experiences gained by students in music therapy overseas.

Development of Music therapy in turkey

When I (Burcin) was a college student, I watched a television news program about music therapy as it was practiced in the United States. I was impressed, and this fostered my curiosity about the profession. I then began to research music therapy, but at that time I was not able to access any information in Turkey, where training was unavailable. after graduating from college, I attended a music education symposium in which a Turkish scholar talked about experiences at a Nordoff-Robbins Music Therapy Center. This presentation reignited my interest.

despite the lack of awareness and understanding of music therapy in Turkey, I still wanted to learn more and work in this field. For this reason, I attended the World Music Therapy Congress held in argentina in 2008 and then the International Society for Music Education (ISME) Commission Pre Conference Seminar on Special Music Education and Music Therapy in 2010. Then, in 2012 I attended music therapy sessions at the ISME conference in Greece. all of these helped me to develop an understanding about the training and practice of music therapy around the world. Ho-

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wever, I still did not have a comprehensive understanding of the profession or the training required to become a music therapist.

When I decided to go to the United States, I sent emails to more than 15 music therapy departments there, of which only two responded. one reply was from dr. annie Heiderscheit, director of Music Therapy at augsburg College in Minneapolis, Minnesota, who was very encouraging and embracing. It was clear she was interested in supporting and helping me learn more about this field.

My (annie’s) experience and involvement serving in various leadership roles with the World Federation of Music Therapy (WFMT) not only fostered my interest in learning about the development of music therapy in different countries, but also provided me with numerous opportunities to travel and learn about the development of music therapy in many countries. These experiences helped me to recognize and understand that the development of the profession is not only influenced but also impacted by numerous factors unique to each country. These include historical practices of music in healing, cultural practices, values, beliefs, governmental bodies, and healthcare ministries.

our next step involved completing the necessary paperwork for me (Burcin) to apply to be a visiting scholar at augsburg College. during my stay at augsburg, I participated in undergraduate equivalency and graduate music therapy courses. Throughout these three months, I engaged in the following courses: Introduction to Music Therapy, Music Therapy Methods I (focused on receptive and recreative methods), Music Therapy Methods II (focused on creative and improvisational methods) and Psychological Foundations of Music. I also took the following graduate level music therapy courses: Music, Neurology and

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Physiology, Music Therapy Research I and II and weekly music therapy practicum supervision sessions. Engaging in these courses provided me a greater understanding of music therapy as a profession, music therapy in clinical practice, methods utilized in music therapy practice and the role of music in the therapeutic process. developing this knowledge regarding these aspects of music therapy was also vital to help me understand the information necessary for music therapy training. This provided the basis from which the two of us worked on developing a curriculum to be offered in Turkey.

during this time, I was also able to observe several board certified music therapists (MTBC) facilitating sessions in a variety of clinical settings including a children’s hospital, long term and memory care, a hospice, and a Parkinson’s day program. I spent time each week observing annie in clinical practice at the University of Minnesota Masonic Children’s Hospital. Here I was able to observe music therapy with children on the pediatric intensive, cardiovascular intensive care and medical/surgical units. Through these academic and clinical experiences, I developed a more comprehensive understanding of music therapy. This has allowed me to return to Turkey with a deeper understanding of the profession, practice and training of music therapy.

It is important to recognize the current and limited practice of music therapy in Turkey. To date, there is only one board certified music therapist practicing in Turkey. danny Lundmark, MT-BC completed a bachelor’s degree in music therapy at Berklee College of Music in Boston, Massachusetts and maintains a clinical practice in Istanbul. There are several Turkish students completing their training in music therapy in Finland (University of Jyväskylä), France (atelier de Musicothérapie de

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Bourgogne, dijon), Italy (Centro Italiano Studi arte-Terapia, Naples) and Spain ( Escola Superior de Musica de Catalunya, Barcelona).

Lastly, there is a clinician, who completed her graduate studies in Lesley University. She practices music therapy in the United States and returns frequently to Turkey to offer workshops on music therapy and expressive arts therapies.

When I returned to Turkey following my time at augsburg, there was an even greater interest in music therapy. Students and scholars from many fields such as medicine, nursing, physiotherapy, psychology, and music, wanted to meet with me and talk about music therapy.

I was asked many questions such as, «How are music therapists trained in the United States?», «Where do music therapists work?» and «How is music therapy practiced?» However, since many of these individuals were interested in working in this field, the most common questions were, «Where can I receive music therapy training?» and «When will music therapy training be available in Turkey?» There was also interest in the press and media. I was interviewed on several radio programs as well as on Turkey's official television channel, TRT. These interviews provided many opportunities to talk about music therapy and this has extended public interest further.

The growing interest warranted developing a curriculum for music therapy training. There were many people among health and music professionals who wanted to have music therapy training. developing a new curriculum in a health-related profession often requires working within established frameworks and guidelines of governing healthcare agencies.

This was the case in Turkey. In order to begin the process, it was necessary to determine the organizations that would need to approve the curriculum and the accompanying guidelines.

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In Turkey, the Ministry of Health oversees the curriculums of healthcare related professions.

In 2013, the Ministry of Health established The department of Traditional and Complementary Medicine as an entity within the Ministry. This new department oversees fifteen practices including: acupuncture, hypnosis, apitherapy, phytotherapy, leech therapy, cupping, reflexology, ozone therapy, homeopathy, chiropractic care, osteopathy, mesotherapy, music therapy, prolotherapy and maggot therapy. This would mean that any curriculum for music therapy would need to meet the requirements, guidelines and be approved by the department of Traditional and Complementary Medicine.

another significant development was the establishment of the Music Therapy association in 2014. Many professionals from various fields are interested in music therapy and in supporting the development of the profession in Turkey. However, there are differing perceptions about music therapy in Turkey due to various practices. academic studies often address the history of music in healing in Turkey.

Scholars and healthcare professionals in Turkey identify practices such as having patients listen to music, performing music for patients, or the use of music in special education and orff practices as music therapy. While music therapy is not defined and not yet a recognized profession, the label of music therapy is utilized to identify a variety of music based practices. The use of music in healing is regarded as non-threatening, safe, efficient and cost effective (Ucaner, 2016). all of these factors support the need for the development of a music therapy training curriculum, not only to provide a foundation for the profession, but also to define who can practice as a music therapist in Turkey.

Government approval and accreditation

Traditional and Complementary Medicine

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Practices By-Law was published in the official Gazette No. 29158 and entered into effect on october 27, 2014. This By-Law includes the definition of music therapy, criteria for becoming a certified practitioner, situations congruent for music therapy practices, music therapy centers and devices and materials that equip music therapy centers. according to the By-Law, certified practitioners are determined as follows: certified doctors, health professionals under the supervision of certified doctors and assistant practitioners who have at least a bachelor degree in a music-related field and have completed a certified music therapy education. In other words, music therapists can only work under the supervision of a certified doctor or dentist.

The ‘Music Therapy application Centre’, is a place in which music therapy is provided. It can be established within the scope of training and research hospital or research centers within the faculty of medicine or dentistry. The centers can work under the supervision of a certified doctor who has a related certificate approved by the Ministry of Health or under the supervision of a dentist.

The Ministry of Health then issued Certified Music Therapy Education Standards on July 13, 2016. Universities must comply with the standards issued in order to get approval from the Ministry of Health if they want to offer Certified Music Therapy Education. The aim of the Music Therapy Education is to help health and music professionals to develop essential skills for music therapy practice. Health and music professionals are eligible to obtain music therapy training. doctors, dentists and graduates of music-related fields with at least doctoral degree or proficiency in music are eligible to complete the certified music therapy education. The instructors of all courses must have at least a bachelor degree or official proof of work expe-

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rience in the fields related to the courses that they will teach.

Developing a curriculum

The development of the certified music therapy education curriculum needed to fit within the structure that existed then and was recognized by the Turkey Ministry of Health.

The Traditional and Complementary Medicine Practices By-Law, approved in 2014, provided the structure within which to develop a music therapy curriculum. other traditional and complementary modality trainings under the umbrella of this by-law comprised a set of courses that totaled a maximum of 400 hours. Therefore, in order to have a curriculum included within this bylaw, the structure delineated by the Ministry of Health has to be followed.

during dr. Ucaner’s time at augsburg College, we worked collaboratively to develop the appropriate curriculum that would address the educational needs of the various individuals interested in the certified music therapy education. For example we needed to address the musical development of physicians, as well as the clinical, physiological, psychological and sociological knowledge of musicians.

The 400-hour curriculum follows:

• Introduction to the profession of music therapy (20 hours) • Introduction to music therapy clinical practice (20 hours) • Psychological and sociological foundations of music (20 hours) • Music Therapy Methods I (30 hours) • Music Therapy Methods II (30 hours) • Music Therapy Clinical Practice I (35 hours) • Music Therapy Clinical Practice II (35 hours) • Music Therapy Clinical Practice III (35 hours) • Music Therapy Group Experience (30 hours) • Clinical Practice Practicum (65 hours)

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In addition to the 320 hours of music therapy coursework, individuals already certified as a healthcare professional, would need to complete the following music coursework:

• Music Theory (20 hours) • aural Skills (20 hours) • Music History (20 hours) • Repetory/Chamber/Instrument (20 hours)

Individuals with a degree in music, would need to complete the following coursework in addition to the 320 hours of music therapy coursework: • anatomy and Physiology (20 hours) • Neurology (20 hours) • Psychology (20 hours) • abnormal Psychology (20 hours)

The combination of courses in addition to the 80 hours of music or sciences reached the 400 hours required by the Ministry of Health.

The 400-hour curriculum plan was presented unsuccessfully to the Ministry of Health. The committee claimed the program was too long, and they accepted only the part of the curriculum that defined the baseline must be met in order to grant a certificate in music therapy. Institutions are permitted to offer a longer curriculum if they wish, like the 400hour curriculum we developed.

The approved Certified Music Therapy Education curriculum is composed of 235 hours that includes theoretical and applied training.

The theoretical component includes in-class training and the applied training involves experience in a clinical setting. For example, in Clinical Music Therapy Practice I, 4 hours of the course are theoretical training and 16 hours are applied training, while Collective (Group) Music Performance is all applied training. The courses in the curriculum include the following:

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• Introduction to Music Therapy and Clinical Terminology (20 theoretical hours) • Physiology (30 hours: 25 theoretical and 5 applied) • Music Theory and Music Reading (25 hours: (9 theoretical and 16 applied) • Collective (Group) Music Performance (20 applied hours) • Psychological and Sociological Foundations of Music (30 theoretical hours) • Music Therapy Methods (25 theoretical hours) • Clinical Music Therapy Practice I (20 hours: 4 theoretical and 16 applied) • Clinical Music Therapy Practice II (20 hours: 4 theoretical and 16 applied) • Clinical Music Therapy Practice III (20 hours: 4 theoretical and 16 applied) • Clinical Music Therapy Practice IV (25 hours: 9 theoretical and 16 applied)

The physiology course is not required for doctors, dentists, nurses and physiologists due their pre-existing knowledge and expertise in this area. additionally, music theory, reading music and Collective (Group) music performance are not required courses for graduates in music-related fields. Therefore, health professionals will have 205 hours of training in total including 105 hours of theoretical and 100 hours of applied training. Music professionals will have 185 hours of training in total including 121 hours of theoretical and 64 hours of applied training.

People who are both health and music professionals will have 160 hours of training in total including 96 hours of theoretical and 64 hours of applied training. Following the successful completion of the courses, trainees must pass a theoretical exam in order to be granted their certified music therapy education certificate. assessment criteria for certification

Exams of each course will be given by the lecturer responsible for the course.

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Students who score 70% and above in the theoretical exam are considered to have successfully completed the course. Students who score below 70% can take the exam two more times.

If a student does not successfully pass the exam following these three attempts, he or she is required to re-apply for a certified music therapy education program. The student’s final grade is calculated from the average between their theoretical and applied exam scores. Successful students are awarded a Music Therapy Certificate which is registered by the Ministry of Health and valid for 7 years. at the end of this period, the certificate holders must fulfill one of the following to renew their certificate:

• Experience as a music therapist for at least 1 year • Publication of at least 2 scientific papers • Presentation of papers in at least at three congresses/symposiums • attendance of at least three congresses/ symposiums • Completion of a theoretical, multiple choice exam

The questions on the exam will be chosen from topics within the music therapy training program and the recent advances in the field.

The questions will be prepared by the practitioners of music therapy certificate training program and under the coordination of the Ministry of Health's Music Therapy Unit.

certification and reaccreditation

People who have overseas music therapy training can apply to the Ministry of Health for accreditation of their training and certification. Qualified applicants must take and successfully complete theoretical and applied exams. Successful participants score 70% or above in theoretical exam. a provisional article was added to the certi-

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fied music therapy education standards. according to this article, people will be awarded a special one-time ‘Music Therapy accreditation Certificate’ without being required to take the theoretical and applied exams if they fulfill one of the following :

• Publications of at least two scientific papers in a national/international indexed journal, • Publication of at least one book or one chapter in a book related to the field, • Completion of a Master level study with thesis in related field, • Experience as researcher or manager of a project supported by a university or TUBITaK (The Scientific and Technological Research Council of Turkey) • Supervision of a thesis in a related field

The applications will be assessed and reviewed by a commission that is established within the scope of Ministry of Health.

It is essential to pay attention to current structures and regulations, and work within the established accreditation frameworks, when developing an education and training curriculum for certification and re-accreditation processes. However, materials and resources are also needed to teach individuals how to practice music therapy. This is a challenge when music therapy is in a developing stage and there is no music therapy literature published in Turkish. Nevertheless, it also creates an opportunity. Textbooks and research literature are needed in order to teach the courses, and individuals are needed to begin to translate current available literature into the Turkish language. This requires collaborative efforts to determine appropriate texts and develop a plan for translation and publication.

Developing resources

one step in the process of developing the re-

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sources involved the authors’ discussing what seminal text(s) would be most helpful in teaching the music therapy courses in the curriculum. We determined the book, Defining Music Therapy by Kenneth Bruscia (2014) would be the initial book to translate and integrate into the curriculum. during dr.

Ucaner’s visit to augsburg College, dr. Bruscia (Barcelona Publishers) consented to the translation into Turkish of his book. Several publishers in Turkey were contacted to explore their interest in publishing the text, despite the fact that music therapy was still unrecognized by the institutions. as a result, to date, two music therapy texts have been translated and published in Turkish. These include Defining Music Therapy by Kenneth Bruscia and Principles of Music Therapy by Gerard ducourneau. These texts are a vital resource for a music therapy curriculum, as they allow students in Turkey to learn about music therapy in their own language.

In addition to developing textbooks, there has been increased interest in offering symposiums on the use of music in healing and music therapy in Turkey. Within the past year, The International Music Therapy Symposium was organized by the association of art Psychotherapy in Istanbul, april 27-29, 2016, and another International Music Therapy Symposium was held in Kutahya, May 28-30, 2016, within the scope of Hisarli ahmet Symposium VII. during the Hisarli ahment symposium 56 papers, 11 concerts, one photograph exhibition, one painting exhibition, one panel presentation, 6 workshops, and one interview were presented.

The papers covered topics on the use of music in health and healing in Turkish history, literature surveys, defining music therapy, music therapy methods in clinical practice and the use of music in medicine, psychotherapy, education, and special education. Two academics from the United Sta-

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tes and Brazil presented their papers via Skype. Summaries of the symposium papers were published in Turkish as a book.

This publication provides another additional resource for the profession and for education and training purposes. Currently, a major publisher in the United States is planning to publish a book of selected papers presented at the symposium.

conclusion

The development of music therapy in Turkey is still in its early stages. However, there has been a significant amount of work and effort to support the establishment of music therapy as a profession and a curriculum has been designed for the training of qualified professionals. Interest in music therapy is increasing in Turkey and is contributing to a greater understanding of music therapy as a profession and in clinical practice. This growing interest has prompted professionals to seek out conferences, events and experiences and make contact with program directors in the United States and other countries in order to develop their knowledge and broaden their understanding of music therapy.

In order to begin developing a curriculum that could be offered in Turkey, it was important to adhere to government guidelines. approval was achieved by the Ministry of Health through the Traditional and Complementary Medicine Practices By-Law in 2014, which provided a structure and pathway for a music therapy certificate.

The development of music therapy in Turkey has been a collaborative process. It has required interest from within the country, willingness to understand music therapy, initiative to seek opportunities to gain knowledge and the commitment of colleagues to work together to develop a curriculum designed

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within the structures of the governing and certifying bodies. It is the authors’ hope that this article provides insight for expanding and anchoring the profession of music therapy in other parts of the world. as we work together, we can foster the development of music therapy worldwide. references

ak, a. (1997). Avrupa ve Türk-İslam Medeniyetinde Müzikle Tedavi. Konya: Öz Eğitim Basım ve yayıncılık. altınölçek, H. (2013). Müzikle Tedavi. Istanbul: Kitabevi yayınları. aydın, K. (2014). İbn-i Sina. Türk Dünyası Bilgeler Zirvesi: Gönül Sultanları Buluşması (s.

71-76). Eskişehir: Türk dünyası Kültür Başkenti ajansı.

Bayraktaroğlu, N. (2014). Selçuklularda Şİfahaneler ve Gevher Nesibe Tıp Merkesi. Sürekli Tıp Eğitimi Dergisi, 144-147.

Bruscia, K. (2014). Defining Music Therapy.

Chicago: Barcelona Publishers. Çoban, a. (2005). Müzikterapi. Istanbul: Timaş yayınları.

Gadberry, a., Kavaliova-Moussi, a., Lotter, C., Milford, J., & Mukherjee, B. (2015). Music Therapy development around The World.

Music Therapy Today, 15-24.

Harris, R. (2008). The Making of a Musical Canon in Chinese Central asia: The Uyghur Twelve Muqam. ashgate Publishing, Ltd. Kılıç, a. (2007). Kayseri Gevher Nesibe Şifahanei ve Tıp Medresesi. Istanbul: Medicalpark Hastanesi Kültür Hizmetleri yayınları.

Kılıç, a. (2012). Istanbul Şifahaneleri. Istanbul: Istanbul Büyükşehir Belediyesi yayınları.

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Karaman, H. (2004). Bir Biyografi denemesi: Ebu Bekir er-Razi. Çorum İlahiyat Fakültesi Dergisi, 101-128. Öztürk, L., Erseven, H., & atik, F. (2009). Makamdan Şifaya. Istanbul: Türkiye İş Bankası Kültür yayınları. Şengül, E. (2014). Müzikle Tedavinin Merkezi Edirne Sultan II.Beyazid Darüşşifası.

Edirne: Edirne Valiliği Kültür yayınları Songur, H., & Saygın, T. (2014). Şifahabeden Hastaneye. Süleyman Demirel Üniversitesi Sosyal Bilimler Enstitüsü Dergisi, 199-121.

Songur, H., & Saygın, T. (2014). Şifahanden Hastaneye . Süleyman Demirel Üniversitesi Sosyal Bilimler Enstitüsü Dergisi, 199-212.

Turabi, a. H. (2011). Hekim Şuuri Hasan Efendi ve Ta’dilü’l-Emzice adlı Eserinde Müzikle Tedavi Bölümü. Marmara Üniversitesi İlahiyat Fakültesi Dergisi, 153-166.

Ucaner, B. (2016). Perception of Music Therapy in Turkey. VII. International Hisarlı Ahmet Symposium-Music Therapy. Kütahya. www.saglik.gov.tr. (2016, 07 13). http://saglik.gov.tr: http://saglik.gov.tr/GETaT/dosya/ 1-104153/h/muzik-terapi.pdf adresinden alındı yücel, H. (2014). Türk İslam Medeniyetlerinde Müzikle Tedavi yöntemlerinin Uygulandığı Şifahaneler: amasya darüşşifası. TURANSAM Uluslararası Bilimsel Hakemli Dergisi, 52-62. yalçın, G. (2014). Haşim Bey Mecmuası Edvar Bölümünün Kaynakları. Turkish Studies, 2053-2074.

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about the author

Burcin ucaner She received her bachelor’s degree from Erciyes University at Musical Sciences department of College of Fine arts in 2001.

She received her master’s and Phd degrees in 2007 and 2011, respectively,from Music Education department at Gazi University College of Education. She founded the Music Therapy association in Turkey of which she is currently the president. She serves as the department head at Musicology department at Gazi University’s Turkish Music State Conservatory in ankara.

She is also enrolled in a master’s degree program at Complementary Master of Music Psychology and Music Therapy at Centro ItalianoStudi arte-Terapia in Naples, Italy.

about the author

annie heiderscheit annie Heiderscheit, Ph.d., MT-BC, LMFT is the director of music therapy at augsburg College in Minneapolis, Minnesota, where she oversees the undergraduate and graduate music therapy programs. She is currently the Past President of the World Federation of Music Therapy and serves as the Communication Chair for the International association of Music and Medicine.

She is a senior music therapist at the University of Minnesota Masonic Children’s Hospital, maintaining and active clinical and private practice, as well as an active research practice.

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Music therapy for children in Zimbabwe: an introductory experience Grace chiundiza rMt Graduate diploma in Music Therapy; BA Creative Arts (Music)

abstract

Resumen

This paper presents an initial project conducted in Zimbabwe in order to gauge the feasibility of promoting music therapy to a broader community. It discusses the challenges facing the children from a small Shona speaking community in Harare, Zimbabwe, and the possible benefits of music therapy for them.

It also reflects on issues such as difficulty accessing the participants, and methods and techniques used in this project, which resulted in positive outcomes.

Este artículo presenta un proyecto inicial realizado en Zimbabwe con el fin de evaluar la viabilidad de promover la musicoterapia en una comunidad más amplia. Se analizan los desafíos que enfrentan los niños de una pequeña comunidad de habla Shona en Harare, Zimbabwe, y los posibles beneficios de la musicoterapia para ellos. También reflexiona sobre temas como la dificultad para acceder a los participantes, y los métodos y técnicas utilizados en este proyecto, que conllevaronresultados positivos.

Background

The targeted children were from the outskirts of Harare, which is in Mashonaland Province.

Traditional children’s songs, in Zezuru dialect, were used in the program.

Zimbabwe has a population of about 15 million people, and has 16 official languages.

The country is divided into provinces, of which one is Mashonaland where the dominant language is Shona. There are several dialect groups in Shona: In the North are the Korekore, in the Central part are Zezuru, in the East are Manyika, South are Ndau and in the Great Zimbabwe ruins are Kalanga. With the colonization of Zimbabwe and subsequent missionary influence, there was a crusade against African cultures which supplanted them with European and Christian doctrines.

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The children from the small Shona speaking community in Zimbabwe live with various challenges: firstly, their families may face economic difficulties due to the lack of regular income; secondly, they have an inadequate transport system, poorly-resourced schools, and few playgrounds. The cause of these challenges lies in a crisis of identity.

Traditionally, the Zimbabwean identity was composed of many diverse cultures. There

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were two major circumstances in Zimbabwean history that I interpret as main contributors to the identity crisis. First, the country was under colonial rule for many years, which overpowered the multiple cultural differences to a great extent, and replaced them with one language, and a single style of dress, food, and music1. Second, as a result of the transition from colonization to self-rule, most of the farmland was reallocated to indigenous farmers. due to this reallocation, small communities arose where the workers were no longer gainfully employed; which means that many communities of displaced workers have supplanted the traditional communities in Zimbabwe today.

These displaced communities appear to have been forgotten, and for this reason, although a child may live about 20 kilometers away from Harare, the distance can lead to isolation. The most significant problem with this isolation is a lack of good mental health and emotional wellbeing.

Table 1 lists some of the existing challenges for children in the Harare community and the possible target areas to be addressed in Music Therapy.

the Music therapy project

one of the main objectives of this Music Therapy project was to build self-conďŹ dence in the children. Michel and Martin (2007), state that performing in front of others improves self-esteem, group cohesion and self-control.

Making music together, with a common goal, was used to promote positive changes in the children’s behaviour, giving them hope, and allowing them to feel that they were not alone in their struggle. Making music together is also known to build motivation, creativity, coherence, listening, and a sense of belonging.

Not only are the children learning new skills and songs; they are learning to share resources. Although the children may have lost their identity, through music therapy they can build their self-esteem and self-expression.

Gaining access to the community

The challenges facing the children came to the attention of one of the churches in Harare. The Glad Tidings Fellowship interacts with several communities in the outskirts of Harare in various ways. The Fellowship assisted in gaining access to one of these small

TABLE 1. existing challenges and Musictherapy target areas

challenges for children

possible advantages of Music therapy

Lack of opportunity

Making music with others

Loss of identity/music identity

Revival of traditional play songs/ music resources

Poverty and suffering

Lack of good mental health and emotional well being

Motivation/ Building hope through Songwriting development of awareness of self/improvement of self-esteem

1. I myself have undergone a change in my own personal and cultural identity due to colonial rule; my traditional songs, style of dress, and way of life were considered primitive

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communities to carry out this project with a few of their children. The Church showed interest in the potential benefits that music therapy could provide to help enhance the children’s self-esteem and socialization, and suggested that their volunteers should be involved. The volunteers helped approach parents and then assisted the music therapist for the duration of the project. Gaining access to the children through the Church speeded the process of building trust and openness.

Another concern was about where to source musical instruments, but fortunately reasonably priced, hand made instruments were available in Harare.

Method and Outcomes

Music therapy sessions were conducted with a group of 13 children living in a small community about 20 kilometers away from the capital city of Harare in a function center donated for the project. The function center was ideal as it allowed separation between participants and non-participating children.

In addition, the center had other facilities such as toilets and provided shelter from the rain, sun and cold. Resources for the project included hand made percussion instruments such as drums (ngoma), shakers (hosho), leg rattles (magavhu), wood clappers (makwa), and tambourines.

According to Bruscia (1998), some of the effective methods for helping participants in music therapy are «singing, playing an instrument, improvisation, and composition». This project therefore used singing, playing an instrument, improvisation, composition, and performing for others as the main techniques in the music therapy sessions.

Having trained and worked in a western environment, the music therapist had to adapt

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her style in order to make the project relevant. It was felt that it would be beneficial to work with the children with what was already known to them and therefore what would come naturally, in order for them to benefit from the music therapy program.

Childhood memories were a source of inspiration and reflection, with images of enjoying the traditional Shona children’s songs, remembering my parents moving from the rural area to the city, and not knowing any of our neighbours as they had moved from other areas as well. It was during the night time under the moonlight when children in the neighbourhood gathered to play and sing traditional songs. This was a way of socialization and getting to meet and make friends.

Mutema (2003) in his research paper on indigenous knowledge systems affirms the importance of Shona traditional children’s songs to socialization. Additionally, «it was this socialization which made it possible for children to adapt to their natural and social events» (p. 61). The traditional songs not only fostered socialization, but also promoted a sense of belonging and ownership. other Shona traditional children’s song methods were also used, such as call and response (kushaura nekutsinhira), improvisation (kuita zvinoenderana nezviripo), rhythm (mutinhimira), and songwriting (kunyora nziyo).

A list of the Shona traditional children’s songs was put together, some from the music therapist’s childhood memories, and others sourced from Nyota and Mapara (2008) (Pote Pote, Zangariyana) and Mutema (2013) (Du Du Muduri). The Shona traditional children’s songs were chosen because they tend to be considered primitive and old fashioned and thus go out of use.

The music therapy sessions consisted of a greeting (hello song) at the beginning of the

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session, and a goodbye song at the end. The traditional children’s song, Du du mu duri was adopted as the greeting song. Duri is a Shona word for mortar where grain is pounded to make maize (mealie) meal. Mealie meal is used for making a staple food enjoyed by most Zimbabweans called sadza. on the first day, the greeting song was used to get to know the children’s names. The children stood in a circle; the therapist sang, «Du du mu duri» and the children responded with, «katswe». Then the therapist went around the circle calling each child by name, for example, «Chipo mu duri» and the children responding with «katswe». When the child’s name was called he or she joined hands with the one already called as a sign of togetherness. Establishing relationships is a fundamental element for the success of any group activity. According to Hanser (1999), «relationship building should be part and parcel for the success of any therapeutic program» (p. 61). Therefore, in the days that followed, a different child led the greeting song each time. The children became more comfortable joining hands; some were swinging their joined hands as they sang, building their relationships in a non-confronting way.

The song is like a metaphor - when each grain is poured into the mortar it goes in as an individual grain, but when the grain is pounded it becomes mealie meal, and the mealie meal is used to cook something enjoyable. The grain may lose its individuality but at the same time it becomes a part of something good. When people are together, good and great things can be achieved. The children got to know each other’s names and some of those who were shy and timid loosened up.

Moreover, the children had an opportunity to lead, and this set out the mood of the session. They also had the opportunity to make choices as to what instrument they wanted to play and take on turns in leading the group.

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The goodbye song was created with the same format and melody style of a traditional children’s song. The children sat in rows facing each other. The boys call out to the girls «Vasikana Woye» (hey girls); the girls respond by singing back to the boys «Vakomana Woye» (hey boys); the boys call back «Mutambo wedu waperera pano» (our activity has now come to an end), and the girls respond back the same phrase. Then, they all played their instruments and sang repeating «Mutambo wedu waperera pano» (our activity has now ended). The goodbye song embraced all the methods and techniques; such as call and response, improvisation with voice and instrument, rhythm and performance. Additionally, the sound of different instruments created a lively atmosphere.

singing: Kuimba

The one significant style of singing which can be used in any setting in a Zimbabwe Shona context, for example church worship, funerals, choirs - is the call and response (kushaura nekutsinhira). Most of the Shona traditional children’s songs are made up of call and response, such as the greeting and the goodbye songs mentioned earlier. Call and response is an open way of interacting in song. one sings a phrase and the rest of the group responds, and anyone in the group can add a phrase or a vocal sound. The children were also encouraged to play call and response using percussion instruments. one thing that was evident with this activity was that everyone participated with vigor and adapted well to the songs.

They were also taught the Spiritual «He’s Got the Whole World in His Hands», which was accompanied on the guitar and sung a few times before they joined in. The song became popular as it was requested on the coming days. The musical activities and learning a new song made them feel good about themselves and it gave them personal joy and a sense of achievement.

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improvisation: Kuita zvinoenderana nezviripo.

Improvising, using the voice and/or percussion instruments, is part of Shona culture.

First, this was demonstrated by playing a simple steady beat on a percussion instrument, and then one child was asked to play his or her percussion instrument along with the therapist, using a different pattern. Second, the other children were invited to play their instruments with their own particular pattern. Finally, the children were asked to practice improvising with different percussion instruments such as maracas, drums, tambourines, leg rattlers, and wood clappers. The children were encouraged to watch and listen to each other to see that their individual pattern fitted with the others.

The activity was kept as simple as possible so that they would not be overwhelmed.

Then the children were guided to include singing with the playing; with the emphasis on listening and observing each other. The improvisation activity was a learning tool that came naturally to them. Additionally, the children not only observed improvisation but they also played and sang by ear.

Wigram (2004) explains that «playing or singing by ear» helps «develop the ability to listen and imitate rather than to read music» (p. 24). Playing and singing by ear and observation are skills that can be enhanced in the children so that they are not lost, as learning to play and sing by ear is traditional in Shona culture. Most of the children’s songs have been passed on by word of mouth. The children also learned multitasking; that is, singing and playing an instrument at the same time. The improvisation activity gave the children an opportunity to be creative, to have meaningful interaction with one another, and gave them a sense of achievement.

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rhythm: Mutinhimira

When it comes to rhythm, African people become alive. Rhythm resonated very powerfully with the children as it is embedded in the Shona culture. For example, babies are sung lullabies and rocked in rhythm (mutinhimira) forwards and backwards, to help them sleep.

The children in the therapy sessions were guided to play rhythm with percussion instruments. A rhythm was presented and the children were asked to copy it. Each child had a turn to play a rhythm and the others would then repeat it. Some of their rhythms were gentle while others were fast and complex!

The rhythm exercise helped the children learn to lead and the others to follow. They acquired self-control and appreciated each other as they listened, observed, and imitated others. No one was better than the other and everyone contributed equally. The activity enhanced coherence and a sense of togetherness. songwriting: Kunyora nziyo

Songwriting was something the children had not done before. Ideas for a song were suggested using the name of their community and they were asked to create sentences with words that described their community using each letter of the name. Suddenly the words and sentences began to flow and were then arranged so that they became meaningful.

The music therapist helped with the melody of the song. derrington (2005) states that «songwriting increases confidence and independence... The production of a song can provide a real sense of achievement» (p.71).

Songwriting as a way of self-expression was beneficial for the children as it enabled them to think critically, solve problems, and work

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together. Social interaction and creativity was enhanced; everyone’s contribution demonstrated these qualities. Songwriting improved their self-esteem, and was a valuable exercise for the children’s self-expression and sense of achievement, which could enhance their future possibilities.

performance: Fefedzo

The last day of the program the parents of the children were invited to their performance. Some children from the more centralized part of Harare were also invited to attend to provide an audience for the participants of the program. The Glad Tidings Fellowship Church was instrumental in gathering other children in the audience. There were over 200 children altogether. The participants performed well and with great enthusiasm and the audience loved it. Their self-esteem was enhanced and their skills at self-expression had started to develop. The words of the song they wrote, about how beautiful their area was with trees and birds, expressed their hopes for the future. It was

such a joy to see that music had helped the children express themselves in such a profound way. some additional Observations

on the first day of the program the children did not know each other very well, but as soon as the music making began, the interaction was spontaneous and this continued long after they finished playing music. The musical activities gave them personal joy and made them feel good about themselves.

Songwriting gave them confidence and a sense of achievement. Playing instruments and singing together built coherence and creativity. They talked about the enjoyment and achievements to the other children who were not part of the project. Improvements in behaviour, self-expression and self-esteem were observed. A lot of interest was generated amongst the non-attendees, who too wanted to attend.

Table 2 below includes a third column, which summarizes the outcomes or the program.

TABLE 1. existing challenges, Music therapy target areas and Outcomes.

challenges for children

possible advantages of Music therapy

Lack of opportunity

Making music with others

Poverty and suffering

Motivation/ Building hope through Songwriting

Loss of identity/ music identity

Revival of traditional play songs/music resources

Lack of good mental health development of awareand emotional ness of self/improvement well-being of self-esteem

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Observed Outcomes

Enhanced sense of belonging / creativity and improved self-confidence Improved self-esteem, improved decision- making skills, self- expression and confidence

Enhanced sense of self, enjoyment and meaningful interaction / personal joy Increased sense of self / self-awareness and improved mental functioning

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conclusion

I would like to conclude this paper with a short quote from Petronella Chigara, the Church’s coordinator of volunteers two months after the project finished: «We have begun to see some improvements with the issues we had highlighted. The children still recall the songs.

As a result of the positive feedback, we would like to have the program run more frequently». It is now intended that the program be extended to other communities and areas in Zimbabwe and Africa.

references

Bruscia, K. E. (1998). Defining music therapy.

Phoenixville, PA: Barcelona Publishers.

Crowe, B.J., & Colwell, C. (Eds.) (2007). Effective clinical practice in music therapy: Music therapy for children and adolescents, and adults with mental disorders. Silver Spring, Md: American Music Therapy Association.

derrington, P. (2005). Teenagers and songwriting: Supporting students in a mainstream secondary school . In F. Baker, & T. Wigram (Eds.), Songwriting: methods, techniques and clinical applications for music therapy clinicians, educators and students (pp. 6890). Philadelphia: Jessica Kingsley Publishers, London.

Hanser, S.B. (1999). The new music therapist’s handbook (2nd ed.). Boston, MA: Berklee Press.

Mutema, F. (2013). Shona traditional children’s games and songs as a form of indigenous knowledge: An endangered genre.

Journal of Humanities And Social Sciences (IoSR-JHSS), 15(3), 60-63.

Nyota, S., & Mapara J. (2008). Shona traditional children’s games and play: Songs as indigenous ways of knowing. The Journal of Pan African Studies, 2 (4), 198.

Wigram, T. (2004). Improvisation: Methods and techniques for music therapy clinicians, educators and students. London: Jessica Kingsley Publishers.

about the author

Grace chiundiza, GradDip Music therapy; Ba creative arts (Music) Grace Chiundiza is a Registered Music Therapist. Music therapy work for Grace began at Alzheimer’s Australia and Macquarie Psychiatric Hospital in Sydney. She is pioneering music therapy in her home country Zimbabwe. She is the author of the book «Musical Woman: My Road to Music Therapy» that relates to her personal journey of realizing her goal of becoming a professional music therapist. Grace has her own music therapy private practice called ‘Grace Wellness Networks’ in Sydney where she works with adults and children with developmental, physical and learning disabilities. She is also a singer and songwriter, performing cultural and transcultural songs.

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MusIctherapyToday, Volume 12, No. 1, 2016

the power of Imagery in the Bonny Method of Guided Imagery and Music

Maria Montserrat Gimeno, edD, Mt-Bc, Lcat Fellow, association for Music and Imagery abstract

This case study reports the self-experiences of Elena, a client who attended a series of sessions of the Bonny Method of Guided Imagery and Music (BMGIM) over a 10-week period.

The power of imagery is reflected in Elena’s drawings, which also reveal her personal process. Elena began BMGIM sessions after having moved to the United States from her hometown in South america. This move appears to have been the precipitator of her presenting problems, which were also related to her past personal history. Elena grew up in a family with an alcoholic father who died when she was young. Soon after, she experienced a separation from her mother who moved to the United States. Through the sessions, Elena was able to be in touch with her inner self, becoming more aware of who she was, developing independence within her family dynamics and recovering from symptoms of Persistent depressive disorder.

Keywords: Bonny Method, guided imagery and music, mandala drawings, Persistent depressive disorder

Introduction

The Bonny Method is a method of individual music therapy in which the client reports images as they occur while listening to classical

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Resumen

Este estudio de caso describe las auto-experiencias de Elena, una paciente que asistió a una serie de sesiones de el Método Bonny de Imágen Guiada y Música (BMGIM) durante un período de 10 semanas. El poder de la imagen se refleja en los dibujos de Elena, que también revelaron su proceso personal. Elena comenzó las sesiones de BMGIM después de haberse trasladado a los Estados Unidos desde su ciudad natal en Sudamérica. Este hecho parecía ser lo que precipitó los problemas que presentaba, que también estaban relacionados con su historia personal pasada. Elena creció en una familia con un padre alcohólico que perdió a una edad temprana. Después de su muerte vivió una separación de su madre que se trasladó a los Estados Unidos. A lo largo de las sesiones, Elena pudo estar en contacto con su ser interior, ser más consciente de quién era, desarrollar la independencia dentro de su dinámica familiar y recuperarse de los síntomas del Trastorno Depresivo Persistente.

Palabras clave: Método Bonny, imagen guiada y música, dibujos de mandalas, Trastorno Depresivo Persistente

music in an altered state of conciousness. Helen Bonny developed the method in the early 1970s and called it Guided Imagery and Music. The Bonny Method of Guided Imagery and Music is a music-assisted integrative the-

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rapy that facilitates explorations of consciousness, which can lead to transformation and wholeness (Clark, 2002).

a Bonny Method session is divided into four phases: (1) the prelude, during which the practitioner’s goals are to understand the present problems and build rapport with the client (Bonny, 1978a). The contents of the interaction serve as a guide for the practitioner to choose appropriate music for the session and an appropriate intention for the client to consider; (2) the induction, which prepares the client for music listening and is the bridge between the outer and inner life of the listener/traveler. a brief relaxation is fostered during the induction; (3) the musical journey, during which the music selection is played. The task of the practitioner is to be attentive to both the imagery and the music, and to assist the client in allowing the imagery to emerge through a non-directive dialogue (Bonny, 1978a); and (4) the postlude, during which the session is integrated as the client draws parallels and meaning from imagery (Bonny, 1978b).

The practitioner facilitates the generation of images by encouraging and supporting the listener in his/her experience. In addition to generating images, music also provides structure, emotional support, and dynamic movement to the images. Imagery, in this context, is defined as «any feelings, thoughts, physical sensations, memories, fantasies, or experiences stimulated by music» (Summer, 1985, p.

85).

Individuals become more involved in imagery experiences while listening to music, as it provides structure and can become a «projective screen» that encourages involvement (Goldberg, 1998). Music, which is essentially ordered auditory information, is thought to help organize the mind that attends to it and thus

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reduce psychic entropy, the disorder we experience when random information interferes with goals (Short, 1991). Siegel (1986) found that «emotions and imagery are transmitted through the central nervous system (CNS) and interact to influence healing» (p.158).

Imagery allows patients to tap into a powerful resource: the power of the mind to take an active role.

Goldberg (2002) suggested that the emotional elements of music, such as instrumental timbre, vocal color, dynamics of pitch, intensity and harmony, may act directly on the autonomic nervous system (aNS) to evoke an emotional response. In addition, she stated that emotion and image are bound together, and one may lead to the other when the latter is beyond conscious awareness. a focus on physiological sensations, evoked by music during GIM sessions, often leads to overt emotion or emotionally laden images. Music directly affects the aNS, according to achterberg (1985).

Many researchers have developed clinical applications of imagery in treatment (danahauer, Marler, Rutherford, Lovato, asbury, McQuellon, and Miller, 2006; Sahler, Hunter, and Liesveld, 2003). danahauer et al. (2006) reported the benefits of listening to music selections and guided imagery to decrease anxiety and pain for women undergoing a colposcopy procedure. In contrast to material directed by the practitioner, Siegel (1986) suggested that «imagery spontaneously produced by the client may be the most useful treatment, and cites the artwork of patients with cancer as an example of spontaneous image-related material» (p.156). Within healthcare theory and practice, there is an increasing awareness that the state of one’s mind has a significant effect on the body (Sahler et al., 2003). The Bonny Method of GIM is one music therapy technique in which

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music is used to generate images. Nolan (1983) described an assaultive patient in the prison system who presented with anger management issues. The patient described vivid images and related to them during the GIM sessions. The images were significant to his struggle with losing his grandmother and to his negative feelings about past relationships.

GIM provided means for the client, who was in denial, to break through his resistance and gain a greater understanding of himself. Through GIM, he was able to access his inner world and experience a release of intense emotions (Nolan, 1983).

In a randomized controlled study of eight nonclinical participants, McKinney, antoni, Kumar, Tims, and McCabe (1997) found that participants had significantly lower levels of depressed mood following a series of six weekly GIM sessions. In a study on the absorption and control of mental imagery, Burns (2000) states that «understanding music’s impact on imagery can assist clinicians utilizing music and imagery interventions» (p35). In addition, Rusell (1992) found that the combination of music and imagery was a healthy and helpful coping strategy for college students experiencing stress.

This Bonny Method uses specifically programmed classical music to stimulate and support a dynamic unfolding of inner experiences in service of physical, psychological, and spiritual wholeness (Bonny, 1978c). a fundamental assumption of GIM is that music and imagery can be a powerful means of self-exploration leading to the discovery of unconscious material. The interaction between listener, music, and guide is what makes GIM unique. originally used with individuals seeking relief from depression, life transitions, and personal growth, The Bonny Method has since shown its clinical effectiveness. Recent medical outcomes have demonstrated the healing effects

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of BMGIM in cases of head injuries, cancer, aIdS, rheumatoid arthritis, and other psychoneuroimmunological disorders (Burns, 2001; Bonde, 2005; Gimeno, 2010; Goldberg, et al., 1988; Jacobi, et al., 2001-2002).

In a GIM session, a common technique is to have a client create a mandala as a way to process the imagery experienced during the listening phase. Essentially, in its traditional form, a mandala is artwork contained within a circle. Pickett (1996-97) stated that the use of carefully chosen western classical music paired with mandala creation might offer a window into what lies beneath conscious thoughts. In clinical settings, music and mandalas have been used to address therapeutic goals, including but not limited to the following: to promote receptivity, to stimulate or relax a person, to evoke affective states and experiences, to evoke imagery and fantasies, and to stimulate peak and spiritual experiences. In non clinical settings, these art forms have been used for self-exploration, to foster self-awareness, to reduce stress, to stimulate creativity, for spiritual practice, and for training or supervision purposes (Bruscia, 2002; Bush, 1995; Marshall, 2003; Merritt, 1996).

Hearns (2009-10) used GIM combined with mandala drawings and interpretations to help a client confront a history of domestic abuse. operating from the premise that the mandala images are «a product of who we are at the moment» (Hearns, 2009-10, p. 57), Hearns and her client discussed the metaphors presented in the images, advancing toward the goal of her client’s self-discovery. Körlin (20078) also used mandalas as a means of recording images induced through Music Breathing (MB), an adaptation of the Bonny Method. Körlin’s patient, who was suffering from PTSd, gained insights into his condition through the mandalas in a manner similar to Hearns’s patient. of these two studies, drawn from a much larger pool of studies mixing mandala

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and GIM methodologies, Hearns’s process of using mandala drawing in conjunction with music and imagery most closely resembles that of Elena’s case study.

client: elena Background Information

Elena is a 38-year-old South american woman who recently immigrated to the United States (USa). She began participating in BMGIM sessions after being referred to the practitioner by a friend who used to attend Sunday church meetings regularly with Elena. during the initial interview, she reported feeling low and having no desire to do things. Elena expressed her difficulties adjusting to the culture, especially since her knowledge of English was limited. In sessions, Elena mostly spoke Spanish. Her husband was more fluent in English, while Elena’s mother, María, who was living with her, did not speak English at all. Elena was the mother of two daughters, aged nine and seven, and a son, aged five

Elena’s parents were present in her life as a child, but not her three siblings who were already married when she was born. She stated having memories of her father, alcoholic, being drunk and becoming emotionally and physically abusive. during this time, Elena relied on her mother’s protection, but reported feeling unsupported and abandoned by her as a child. Elena’s father died when she was young, and her mother, María, then traveled to USa to be with her oldest son who was living there. When María left, Elena went to live with her older sister in her hometown.

She reported how difficult this time was for her, and how much she missed her mother.

María would periodically return to her hometown for a short visit to be with the rest of her family. at the age of 37 Elena moved to the USa with her three children and her husband. Following Elena, Maria also moved to

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the USa permanently and settled in Elena’s home.

Elena felt responsible for taking care of her mother and, as she missed her while growing up and felt abandoned as a child, perhaps Elena was also searching for maternal attention. She said that the responsibility of taking care of her aging mother was overwhelming, as she was trying to please her all the time. additionally, Elena appeared to lack a sense of self-identity, as she focused on pleasing others more than taking care of herself. She also stated feeling alone and groundless as her husband was away from home most of the day, busy with work and school schedules.

Elena was able to find social support through the congregation at her church, which she attended weekly.

Elena had not been evaluated by a psychiatrist, nor was she on any antidepressant medication. Nevertheless, her presenting concerns fit well with the symptoms of Persistent depressive disorder such as feeling low and alone, and experiencing low self-esteem, discouragement, and poor concentration. These problems had been persistent for less than a year and might therefore be considered as an adjustment reaction to her immigration to the United States. It appeared, however, that her difficulties adjusting to the new culture precipitated other issues from Elena’s childhood. Her difficulties can be interpreted as a grief reaction, given the nature of her relationship with her deceased father, although he died long ago. Moreover, the nature of her relationship with her mother, which was difficult from an early age, also led to frequent bouts of sadness and loneliness.

Elena said that she tended to withdraw from peers. during sessions she used self-defeating statements that revealed a lack of self-confidence and low self-esteem. Her mood appea-

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red depressed, and she often reported feeling frustrated. The practitioner assessed the core of her depressed mood as related to fusion with her mother’s personality. The main goal addressed in the GIM sessions was to develop Elena’s self-identity and independence. Elena wanted to live her life as an individual without constant demands from her mother and family members. The problem she presented in her treatment was that she was showing behavior and feelings that were not genuine. She wanted to be authentic in her life and to identify herself separately from the person she was pretending to be.

Elena underwent a series of 10 BMGIM sessions. during this time, she was able to connect with her inner self and gain insights into her life. The sessions were based on the reflective mode, which can be understood as the patient’s response to the music as it reflects her internal processes (Bonny, 2002).

Elena’s receptivity to the music allowed it to lead her. Her experiences with the music suggested unresolved conflicts that she was facing internally, stemming from past relationships and early trauma. The music evoked the flow of images and emotions throughout the sessions. In each session, the induction connected Elena’s personal reflection with her previous mandala drawings. She drew a mandala after each musical journey. all of her drawings contained concrete imagery that reflected her internal process in the music experience. Most of her drawings depicted scenes in nature. The mandalas provided access to unconscious issues in a creative and non-verbal manner. all music selections used in this study are complete musical programs from Helen Bonny’s collection that were compiled by the author during her training in the Therapeutic art Institute. The type of inductions given followed a continuum from the previous session. during the prelude, the client considered the most prominent image and

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how it reflected where she was at the present moment. The following section chronicles Elena’s musical journeys and describes the mandalas to which these 10 journeys gave rise. elena’s therapeutic process Session One

Music Program: Imagery This was Elena’s first session. The prelude provided a safe container for her to disclose personal information, family and clinical history. Because it was Elena’s first experience with BMGIM sessions, the practitioner selected the Imagery program for a general exploration. an instruction of exploring a path was given during the prelude to facilitate image development while the music was playing. during the music, Elena imagined herself safely at the shore of a lake in her native country.

Elena used to visit this lake as a child and endorsed feelings of homesickness. In the music, she felt safe as she traveled to the lake. although she was alone, she was able to feel relaxed, absorbing the memories of the nature surrounding this place.

FIGURE 1. Mis pasos (My steps) during the postlude, Elena processed the contents of her mandala drawing, which repre-

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sented a lake in her hometown in South america. She reported feeling both peaceful and homesick while processing her drawing (see figure 1). She used to go to this lake when in South america enjoying nature. Elena revealed that she did not feel at peace in her daily life and remarked that her husband was frequently absent at work or at the school. Elena started feeling alone and experiencing great pressure about raising three young children without much support from her spouse. as Elena reflected on her inner resources, she was reassured by her sense of peace during the musical journey. She realized that she could transfer this inner resource of peace to her daily life even if her husband was absent.

This experience empowered Elena to access the inner peace already existing in her heart.

The practitioner validated her feelings and encouraged Elena to increase her awareness by reconnecting with this inner space when she needed to cope with her feelings.

Session Two

Music Program: Caring during the musical journey, Elena described her first image to the practitioner as a field of flowers. as she was looking at this field, one of the flowers caught her attention. The flower was pink, fragile, and bending toward the sun.

Elena said that the flower was weak and needed a trestle to support it. as she moved in the imagery, she noticed and described weeds around the solitary flower. She said that these weeds were denying the solitary flower the power to grow. Later, she explained how changing the soil and adding more flowers would give support to the lone, pink, fragile flower. after taking care of the weak flower, Elena noticed how it became strong and powerful, able to stand on its own with minimal support.

The mandala shown in figure 2 is called Crecimiento (Growth). as perceived by the prac-

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FIGURE 2. Crecimiento (Growth)

titioner, the position of the sun in this mandala is closer to the ground, as opposed to the typical position of the sun high in the sky.

In addition, the bent-over of flowers drawn at the bottom of the mandala is bending over toward the sun. during the postlude, Elena reflected on the symbolism her drawing displayed. She explained that the bent-over flowers represented the lack of support she was facing in her life. Elena commented that she was feeling alone and expressed that everything was going in the wrong direction.

as open discussion developed, Elena’s body language conveyed that she was sad and tired. These feelings were explored as being related to the lack of support from her husband in the home environment and the demands from her mother and children. Elena reported that she felt the need to be alone and, at the same time, to be more engaged with her husband. She stated that she wanted to be open and share her feelings with him more.

as Elena identified herself as the solitary flower, she reflected on the obstacles in her family relationships that were obstructing her inner «beauty» and «growth». although she did not know what to do about it, she was able to disclose the reason for her unhappiness. Her perceptions of other people prevented her from being herself. Elena connec-

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ted the metaphor that the lone, fragile, pink flower was she, and it allowed her to understand that, with personal care and support, she would grow strong like the flower. at this point, Elena reached the insight of the importance of taking care of her own needs first, and agreed that the strong flower was a symbol that helped her increase self-actualization and self-expression during times of vulnerability.

Session Three

Music Program: Peak Experience during the prelude, Elena reported experiencing feelings of guilt and frustration while dealing with conflicts at home pertaining to her mother and sister. This was the first time that she expressed concerns about them. She explained that she wanted to set boundaries to avoid being abused by relatives. during the induction, she was invited by the practitioner to bring back the image of the garden and to focus on the strong flower. during the music, she saw herself with a helper in the garden.

She reported that this person helped her to «embellish» it. She provided details about how she invited her family to experience the beauty of the garden, but only her mother and husband were present. She reported that the family disappeared from the garden, and she found herself in front of a mirror. She des-

FIGURE 3. Claridad (clarity)

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cribed that she saw a body with no face and said, «I am missing an important part of my body; I am missing half of me». She expressed the need to get closer to the mirror to find herself. She began to see the whole body, yet the face was unclear. Elena stated, «I can’t find my true identity, I do not feel this is me».

She started shaking her head and finally saw her face in the mirror.

Following the music, Elena drew her body as she had seen it in the mirror (see Figure 3). as perceived by the practitioner, the mandala depicts how Elena’s body is connected with her emotions. The mouth is closed, which may symbolize a lack of communication. In addition, the face on the drawing appears to be very sad. Moreover, arms and legs have been omitted from the drawing. The mandala suggests Elena’s feelings of being powerless.

as she reflected upon the drawing of her body, Elena noticed that her closed mouth appeared powerless. She realized and reported that she takes on the burden of others and this upsets her. She said that she wanted to find clarity and to communicate her thoughts and feelings with others better. as Elena processed the session, she recognized a starting point in which to distinguish herself from others.

Session Four

Music Program: Transitions In this fourth session, Elena said that she felt content, as she was seeing some progress in her interactions with her husband, who was more involved in the home. She reported becoming more aware of keeping in touch with herself. In this session’s imagery, she saw herself locked into a room. She wanted to take the initiative to open the door. This effort produced tears, as she said that she was unsure of the dangers or risks beyond the room. She

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said, «I feel unable to talk... I feel sad». Her tears during the session indicated her awareness of her personal needs, but she expressed guilt for needing something for herself. She explained that the white door without a handle symbolized her desire not to take action, but rather to wait for someone else to open the door for her. She realized that she had to take responsibility for the changes that would give her resolution. She reported that she was starting to open up in her awareness of who she really was.

The mandala Elena drew during the postlude shows a door starting to open, indicating that something was about to happen (see figure 4). Her drawing portrayed an inaccessible white door that has no knob or handle, and it looks hard to move.

state what her thoughts and needs were. although she was becoming more self-aware, she was struggling to remain present through the trials she was facing. Elena was encouraged to stay connected to her own process, as struggle is a significant aspect of change and personal growth.

Session Five

Music Program: Relationships When Elena started the fifth session, she was trying to convey many thoughts about what had occurred in her family relations over the week, as well as trying to manage or avoid the guilt that she reported feeling in the past.

Through the induction, the practitioner encouraged her to be in touch with her feelings of frustration. during her musical journey, Elena reported seeing a bird at the base of a tree facing the world and observing other birds flying. The bird was in the process of taking the initiative to fly, but was fearful. The bird began to explore the area of the tree for small details of plants and insects. Elena stated, «Things and people are not the same as I am . . . I do not belong there». She described seeing flowers growing, and the environment became warmer to her.

FIGURE 4. Comunicación (communication) during this session, Elena started doing more of her personal work and seeing some changes. She still reported fears that other people would not accept her. She was afraid of what would happen when she said the truth to the external world. «I need to let them know what my needs are. I need to express myself more» she said. She reported that she needed to express herself more freely and openly.

Elena was still in the process of being able to

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FIGURE 5. Sobreponerse (to Get Over something)

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In the mandala she drew during the postlude (see figure 5), there is a small bird standing beneath a tree. It may be interpreted that Elena was staying still on the ground. one can see that she is not standing on the roots, but close to the trunk of the tree. There is the question of whether the meaning of the roots signifies her past with her mother or with the family, and the possibility of not being her own person. Elena displayed some insights with regard to the meaning of her imagery and she identified herself as the bird facing the world. She became aware that she could make the decision to stay alone or to move.

Elena reported that the experience brought her confidence and readiness for her own flight or exploration. She was ready to take action instead of hiding in her room, as she had done in the past.

Session Six

Music Program: Nurturing during the Prelude, Elena reported finding herself fighting against her emotions and sometimes acting in a way that she disliked. She explained that she was angry with her mother for telling her what to do and how to behave. She stated that it was important to her to be able to express her thoughts. In her imagery during the musical journey, Elena described seeing the bird from her previous trip climbing the tree. The bird was following a light as it was climbing at its own pace.

The mandala Elena drew is shown in figure 6. according to the practitioner’s interpretation, the bird that was possibly frightened in the previous mandala is now climbing the tree, and might be alone without fear. Elena might be moving along and making progress.

In the postlude, she reported that she identified herself with the bird; she said that she

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FIGURE 6. Progreso (progress) knew she was alone, and she felt no fear about moving on. She related feeling that her solitude was a source of comfort, telling her that she was progressing. at the same time Elena explained that she was fighting against many emotions. The practitioner gave support encouraging her to stay in this moment of tension, bringing awareness to express what needed to be expressed in her real life.

Session Seven

Music Program: Positive Affect In the prelude, Elena reported that during the weekend she went with family members to Los angeles on a trip. She told the story about one financially successful brother who was causing her distress. That brother was dominant in family decisions. She said that it was sometimes difficult to control her emotions of frustration in the dynamics with this brother. She was becoming more aware of the challenges posed by her family; although, she was still blaming herself for the conflicts. as the music listening began, Elena described seeing a path that became clearer as she got into a lightened area. She saw herself walking ahead, noticing that no one was telling her what to do. In her imagery Elena encountered

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dark places on her path, but she did not hesitate to keep moving to find the «open spaces». She said, «I am not alone; there is energy behind me. Some people are waiting for me to take the first step».

Session Eight

Music Program: Caring In this session, Elena began to examine painful issues that she experienced as a child being abused by her father, who was alcoholic. She reported feeling abandoned by her mother who was not always protecting her.

Elena explained that she was struggling at home in the effort to communicate effectively with her family and to understand her own value in the home. In her imagery during the music listening, she described being at home looking out of an open window. .

FIGURE 7. Disfrutar (enjoy) Elena called the mandala shown in figure 7 «Enjoy». In the perception of the practitioner, this is a positive mandala; although, there is still a railing between her and the scene. She could be expressing her confidence, as she drew herself outside on her own. In the postlude, Elena shared her realization of being a leader during her imagery in pursuit of a goal, and reflected on the recognition that she needed to keep up the journey and be the leader of her own life.

She also described a bridge that appeared before a river or a lake where she paused to enjoy. She stated feeling secure and safe without disappointment. The title of her mandala «Enjoy» reflected her power to face challenges, to be able to overcome risk, to make her own decisions, and to enjoy the end results of her efforts. The practitioner encouraged Elena to be fully attentive to the present moment, so that she might allow herself to be the leader of her path finding joy in these inner spaces.

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FIGURE 8. Mi Refugio (My refuge) after the music, Elena drew an open window (see figure 8). This suggested that she felt safe at home, a refuge to which she could return. Nature could be a source of peace for her. during the postlude, as she described looking at her drawing, she said «I am in my home, this is my refuge, I am safe and tranquil». This session brought her to a crossroads in her personal process. She expressed a mix of bliss in this realization and conflict with her desire for independence. Elena said that she was facing the challenges, creating space for the heart to see itself as lovable, and feeling ready to make essential life-style adjustments.

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Session Nine

Music Program: Creativity 1 during the prelude, Elena reported her difficulties as she was trying to be herself. She expressed the frustration and experience of a lack of understanding from her close family members. In her imagery during the music listening, she described going from a dark place to an open space with a sun rising. While in darkness, Elena was silent and afraid to be alone in that space. over time, however, she reported being able to accept her fear and began to cry. Upon crying, the darkness split in two, transforming into a sunrise.

FIGURE 9. Mi Jardín (My Garden) The mandala she drew after the music is shown in figure 9 and shows two gardens.

The gardens are symmetrical, leaning in toward one another, but separated from each other by a red space. The flowers in the gardens are purple. These gardens mirror the darkness Elena experienced previously, which was also split into two.

In the discussion of the mandala drawing, Elena noticed that the two gardens could represent her in balance with the outside world.

She said that she was able to see these two worlds separately. Elena became aware of the

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identity separation that was happening despite the emotional turmoil that she was experiencing. She commented on having encountered all of these feelings and aspects of the heart that were hidden. Elena was seeking to resonate with her innermost being and reality.

In the drawing, the flowers on both sides of the garden are settled and separated. The two sides suggested to Elena that she was able to differentiate herself from others.

Session Ten

Music Program: Peak Experience This was the final session, and Elena went over all her mandalas to analyze and integrate what she had learned over the process.

She expressed her awareness of her inner process and how she was able to take control of her problems. Instead of reacting with avoidance, she said that she was seeing the connections in the mandalas with her process of growth. She reflected upon being able to separate herself from the outside world and to see who she was as an individual. during the music listening, Elena noticed that she was in a large, luxurious home with a large window. There was a party in that mansion and she described being a stranger in the house, keeping herself separated from the group. Elena explained that there were many people in the room, all rather isolated individuals who were not talking together, and the place became awkward to her. Unexpectedly, she felt «invited» to join in and become part of the group. She said that she would have liked to meet the partygoers, but at the same time she didn’t feel comfortable to do so. She realized that she didn’t have to be there and went to the garden outside. as she went outside, she reported feeling regret, low self-esteem, and guilt for having left the room. Elena then said that she wanted to return to the party, and she made the decision to go back and get involved with the people in the party.

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FIGURE 10. Vida Propia (Own Life) Her mandala depicted the party (see figure 10). There are at least eight people in the drawing, some of whom are sitting on a couch, others are standing and interacting in a warmly lit room with big windows and a plant. In this drawing, Elena represented herself with other people for the first time. She is not looking out the window, but rather doing something as she is participating in life. during the postlude, she expressed new insights about her ability to be connected with life and to communicate with other people.

In her conscious mind, she felt that the external world was not controlling her anymore.

Significantly, Elena stated that she wanted to continue to engage with life and follow her «own path», allowing her world to come into existence in a new way.

conclusion

The ten GIM sessions supported Elena in significant ways, as she began to make important decisions about the relationships in her life. Initially, feelings of helplessness, dependency, and guilt were frequent, but these diminished over the course of the sessions. The changes in her imagery represent her journey to a stronger sense of identity. She grew in self-worth and confidence, following her in-

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tuition, which was based on her own needs and desires. Reflecting upon her drawings was significant, as Elena could identify the symbolism in them and how they were related to her personal process. Elena was able to be in touch with her weaknesses as well as her strengths. during closure, she reviewed with the practitioner the sequence of mandalas that she had drawn during the sessions.

Elena was able to relate, with great insight, with the progression of her personal journey that was reflected in her drawings. She reported having developed an individual sense of self, as well as a sense of security in trusting a deeper awareness within her consciousness. Specifically, the mandala drawings helped Elena to become aware of her personal process.

In the current study, the drawing and postlude discussion are equally important to the therapeutic process. The mandala concretizes the client’s subconscious state. as in Elena’s case, the prompt to draw does not always produce drawings that depict the musical journey. This would suggest that the mandalas grant the client and facilitator deeper access to the client’s internal state. When the facilitator questions the client about the drawings his or her interpretation evolves from the client’s response. In other words, mandala work is a two-part, client-driven process, which would fail to deliver results if either party were omitted.

Based on results from this and past studies, the researcher would recommend using mandalas in GIM therapy in all cases, excepting those involving a patient unwilling or unable to draw. When the client is disinterested in drawing, other means of concretizing the subconscious may be utilized. Writing, for example, is one effective means of processing a musical journey and may be used instead of mandalas to ground the patient.

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The results of this case study attest to the effectiveness of using a series of GIM sessions to enhance several aspects of the self. Elena’s mandala drawings were a representation of the unconscious mind that gave her valuable information, thus allowing her to believe in her inner self. These experiences were very powerful to her. Implications in the field of GIM are significant, since this case study illustrates how drawings can enhance selfawareness and empower access to inner strengths. references

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Bonny, H. L. (1978a). GIM monograph #1: Facilitating GIM sessions. Baltimore, Md: ICM Publications.

Bonny, H. L. (1978b). GIM monograph #2: The role of taped music programs in the GIM process. Baltimore, Md: ICM Publications.

Bonny, H. L. (1978c). GIM monograph #3, Past, Present and Future Implications. Baltimore: ICM Publications.

Bonny, H. L. (2002). The state of the art in music therapy. In Summer, L. (Ed.), Music Consciousness: The Evolution of Guided Imagery and Music (pp. 156-17). Gilsum, NH: Barcelona Publishers.

Bruscia, K. E. (2002). The boundaries of guided imagery and music and the Bonny Method. In Bruscia, K. E. & Grocke, d. E. (Eds), Guided Imagery and Music: The Bonny Method and Beyond (pp. 37-61). Gilsum, NH: Barcelona Publishers.

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Bush, C. (1995). Healing imagery and music: Pathways to the inner self. Portland, oR: Rudra Press.

Burns, d. S. (2000). The effect of classical music on the absorption and control of mental Imagery. Journal of the Association for Music and Imagery, 7, 34–42.

Burns, d. S. (2001). The effect of the Bonny Method of guided imagery and music on the mood and life quality of cancer patients. The Journal of Music Therapy, 38(1), 51-65.

Clark, M. F. (2002). Evolution of the Bonny method of guided imagery and music (BMGIM). In Bruscia, K. E. & Grocke, d. E. (Eds), Guided Imagery and Music: The Bonny Method and beyond (pp. 5–35). Gilsum, NH: Barcelona Publishers. danahauer, S. C., Marler, B., Rutherford, C. a., Lovato, J. F., asbury, d. y., McQuellon, R. P., & Miller, B. E., (2006). Music or guided imagery for women undergoing colposcopy: a randomized controlled study of effects on anxiety, perceived pain and patient satisfaction. Journal of Lower Genital Tract Disease, 11(1), 29–45.

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.

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Goldberg, F. S. (2002). a holographic field theory model of the Bonny Method of guided imagery and music (BMGIM)). In Bruscia, K. E. & Grocke, d. E. (Eds), Guided Imagery

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and Music: The Bonny Method and Beyond (pp. 359-377). Gilsum, NH: Barcelona Publishers.

Hearns, M. (2009-10). Journey beyond abuse: healing through music and imagery. Journal of the Association for Music and Imagery, 12, 47-59.

Jacobi, E. M., & Eisemberg, G. M. (20012002). The efficacy of guided imagery and music (GIM) in the treatment of rheumatoid arthritis. Journal of the Association for Music and Imagery, 8, 57-73.

Korlin, d. (2007-8). Music breathing: Breath grounding and modulation of the Bonny method of guided imagery and music.

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McKinney, C., antoni, M., Kunmar, M., Tims, F., & McCabe, P. (1997). Effects of guided imagery and music (GIM) therapy on mood and cortisol in healthy adults. Health Psychology, 16, 390-400.

Merritt, S. (1996). Mind, music and imagery: Unlocking the treasures of your mind.

Santa Rosa, Ca: aslan.

Nolan, P. (1983). Insight therapy: Guided imagery and music in a forensic psychiatric setting. Music Therapy, 3, 43-51.

Pickett, E. (1996-97). Guided Imagery and Music in head trauma rehabilitation. Journal of the Association for Music and Imagery, 5, 51–60.

Russell, L. a. (1992). Comparisons of cognitive, music, and imagery techniques on anxiety reduction with university students.

Journal of College Students Development, 33, 516-523.

Sahler, o. J., Hunter, B. C., & Liesveld, J. L. (2003). The effects of using music therapy with relaxation imagery in the management of patients undergoing bone marrow transplantation: a pilot feasibility study. Alternative Therapies in Health Medicine, 9(6), 70-74.

Short, a. (1991). The role of Guided Imagery and Music in diagnosing physical illness or trauma. Music Therapy, 1, 22–24.

Siegel, B. (1986). Imsges in disease and healing. In Siegel, B. (Ed.), Love, medicine and miracles (pp. 157-160). New york, Ny: Harper & Row. Summer, L. (1985). Imagery and music. Journal of Mental Imagery, 9, 83-90.

about the author

Maria Montserrat Gimeno Maria Montserrat Gimeno, Phd, MT-BC, LCaT, FaMI is an associate Professor in the Music Therapy Program at the State University of New york at New Paltz. dr. Gimeno is well respected nationally and internationally for her research on the use of Music and Imagery in medical settings. Recently, she completed a research study on the use of Music Imagery Relaxation (MIR) a technique that she developed to use with bedridden patients.

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how to Develop the competency of clinical Improvisation sung-yong shim, phD

Abstract

Throughout many years of music therapy practice and teaching, clinical improvisa-tion has been a vital therapeutic intervention tool for Dr. Sung-yong Shim as a music therapist.

This article is intended to share not only strategies, but also approaches with regard to how to be proficient in clinical improvisation in music therapy settings. The value of this article is to provide personal information about all the steps (a to Z) in clinical improvisation and also propose strategies to improve competency in clinical improvisation.

Keywords: Clinical improvisation, music therapy, training.

Background

During the course of my music therapy education at undergraduate and graduate level, there was a large amount of study dedicated to music, psychology and clinical theory. I also learned the skillful use of music and its elements for therapeutic purposes in order to meet client needs and enhance their experience. Both in education and then in clinical practice, I first concentrated on strengthening my ability to move freely between theoretical knowledge, the act of music-making, and problem-solving skills in the context of a clinical

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Resumen

A lo largo de muchos años de práctica y docencia musicoterapia, la improvisación clínica ha sido una herramienta de intervención terapéutica vital para el Dr. Sung-yong Shim como musicoterapeuta. Este artículo tiene como objetivo compartir no sólo las estrategias, sino también los enfoques con respecto a cómo llegar a ser competentes en la improvisación clínica en el contexto de la musicoterapia. El valor de este artículo es que proporciona información personal sobre todos los pasos (A a Z) en la improvisación clínica y también propone estrategias para mejorar la competencia en la improvisación clínica.

Palabras clave: Improvisación clínica, musicoterapia, formación.

or educational setting with a wide client base.

Second, I focused on gaining the capacity for advanced clinical improvisation and skillful use of music for working with clients. Last, I looked for opportunities to understand, integrate, and apply information relating to the practice of music therapy.

What Music Therapy Approach do I use in my clinical practice?

I contend that there is not one, but many forms of therapy to which clients will respond.

By combining certain aspects of diverse pro-

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fessions, music therapy can be successful in meeting a client’s needs; this fact has produced various approaches to music therapy. among these diverse approaches, I personally have sought a music-centered and client-centered approach which integrates theoretical aspects with both musical and humanistic clinical techniques. as a therapist, I have been impressed and influenced by humanistic psychology as well as client-centered therapy integrated with music-centered therapy. I endeavor to use each of these approaches together to be able to understand my clients on a personal, psychological, and musical basis.

In addition, I have been influenced by aesthetic Music Therapy (aeMT)*1 since my undergraduate studies in music therapy at WLU (Wilfrid Laurier University). I found new respect and passion for clinical improvisation through the music therapy models, particularly in my graduate studies.

What is my personal motivation for using clinical improvisation?

I would say that for me, improvisation has been a diary for everyday life since I was a child. For instance, I have improvised music using piano on a regular basis and uploaded almost one thousand pieces on my music diary home-page (www.youtube.com/trenchant06). Furthermore, learning how to use musical improvisation clinically as a therapeutic tool has been a wonderful opportunity to experience musical interaction between my clients and myself. It has been an ongoing and pleasant experience. My experience in music and music therapy so far has led me to this brief personal definition of clinical improvisation:

Clinical improvisation is the music produced spontaneously and applied therapeutically within a clinical setting between a music therapist and client(s). Clinical improvisation is one of the most effective mediums for communicating with client(s) in music therapy.

I believe that the musical interaction that improvisation can naturally generate not only establishes a musical rapport, but also an interpersonal one. During improvisation with clients, the music becomes unified and a great feeling arises which is inexplicably transcendent. I have been intrigued and inspired by this aspect of clinical improvisation which, for me, has been one of the most efficient methods of interacting with clients.

What is my professional motivation to feel so strongly about clinical improvisation?

In music therapy, there are diverse therapeutic interventions used as tools in order to meet the client’s needs. among them, there is one that has been significantly emphasized, regardless of different approaches, as a valuable therapeutic tool in music therapy: clinical improvisation. Despite the wide recognition of this approach as a central and effective tool, most music therapists, including music therapy students, struggle with the ambiguous characteristics of clinical improvisation. Wigram (2004) mentioned that defining the concept of improvisation is a big challenge due to the many varied understandings of what is meant by improvisation, and the different levels at which this is understood.

Music therapists and music therapy students are concerned by how to master such a po-

1. aesthetic Music Therapy (aeMT) is one of the music therapy models developed by Colin andrew Lee. according to Lee (2003), aeMT holds a viewpoint that considers music therapy from a musicological and compositional perspective as stated in this definition: «aeMT can be defined as an improvisational approach that views musical dialogue as its core. Interpretation of this process comes from an understanding of musical structure and how that structure is balanced with the clinical relationship between client and therapist. The therapist must therefore be a clinical musician». (p.2)

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werful therapeutic skill - the ability to support, match, follow, lead and produce rich and sophisticated music in order to meet client(s) needs. Most music therapists and music therapy students struggle to establish confidence and proficiency in order to produce effective and smooth communication, musically and clinically, for clients in clinical improvisation. It is the ambiguity of clinical improvisation which impedes its ability to find the milestone in a difficult situation that is experienced in music therapy practice.

What are the historical roots of improvisation?

Improvisation has been used by musicians in music history for a long time, and has developed from the Baroque period to now. Dupré (as translated in Fenstermaker, 1973) contends that improvisation holds an important place in the musical arts and has been practiced by many great composers for centuries.

Solomon (1986) describes the basic concept of improvisation as the discovery and invention of original music spontaneously, while performing it, without preconceived formulation, scoring, or context.

Dean (1989) contends that improvisation is the simultaneous conception and production of sound in performance. With regard to improvisation in the context of performance, Jourdain (2002) notes that «as performance, improvisation can be a marvel – a conjunction of physical technique, musical understanding, and creative flare» (p. 176). Improvisation is identified as a music of self-definition and interpreted as taking part in a musical performance, whether as a performer or as a listener, to explore, to affirm, to celebrate one’s identity (Small, Durant, & Prevost, 1984).

Dean also presents some answers as to why some people are interested in improvisation,

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leading them to a desire for self-improvement. He believes that people strive to achieve competency in improvisation to gain personal fulfillment, self-development, and the creation of originality in music, and, in addition, to communicate with others such as other musicians and the audience.

among various understandings of improvisation like those above, there seem to be two common elements which emerge from people’s interest: spontaneity and interaction.

Spontaneous action or performance is a key aspect of improvisation, as people are fascinated by «free» performance without a framework of rules. Interaction (or communication) also plays an important role in improvisation when people share their joy in being involved with such a creative act. Communicating with others in such a personal and meaningful way in the intangible and boundless world which in music is fascinating. In an effort to better understand this communication it is often helpful to liken it to other forms of communication, and such comparisons are often fruitful. For instance, improvisation is often compared to conversation or dialogue. Jourdain (2002) paradoxically explains the relationship between conversation and improvisation as «the conversationalist draws upon a well-organized hierarchy of knowledge about the world, the pianist upon a well-organized hierarchy of musical ideas» (p. 174).

Just as conversation needs the «well-organized hierarchy of knowledge», the information of a language, and the physical ability to verbally communicate, improvisation requires the musical ideas, an access to the musical language, and the physical ability to express oneself using musical instruments.

Perhaps the concept of mutual interaction occurring in musical performance, whether consciously or unconsciously and intentio-

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nally or unintentionally, may be attractive to people. The interactive character of improvisation may be applied to clinical improvisation in music therapy as an effective tool for communicating with clients therapeutically.

What is the value of improvisation in Music Therapy?

Tony Wigram (2004) made a clear and concise definition of clinical improvisation as «the use of musical improvisation in an environment of trust and support established to meet the needs of clients» (p. 37). Wigram, Pedersen and Bonde (2002) define clinical improvisation in a glossary and lexicon of music therapy as: «Generally, the use of musical improvisation with a specific therapeutic purpose in an environment facilitating response and interaction. a musical relationship is gradually built through shared repertoire and exchange of musical expressions. The theoretical basis is that the spontaneously produced sounds created within a musical framework represent aspects of personality at conscious or unconscious levels» (p.

316).

Rogers (as cited in Bunt & Hoskyns, 2002) presents an explicit description of the value of clinical improvisation in music therapy as «music therapy involves the use of free clinical improvisation through which the therapist examines the relationship between herself and the client, seeking to understand, reflect, and interpret (either musically and verbally) therapeutic issues (p.104)». It is held that the interaction and relationship with the client are vital parts of clinical improvisation beyond the concept of using music as the intervention tool. Lee (2003) raises the importance of the relationship in improvisation in music therapy. When the mu-

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sic therapist and client are able to create a shared musical space between them in the improvisation, both players can express themselves and create a highly intimate and dynamic interactive relationship. Pavlicevic (2000) addresses a possible goal of clinical improvisation while emphasizing relationship and communication with clients in the musical interaction.

In general, the therapist needs to enable the client to express him or herself through the music and both players need to share a reciprocity of intention while improvising.

Etkin (1999) explains the interactive and interpersonal relationship with a client in clinical improvisation as «Music in the form of ‘clinical improvisation’ is used to establish a relationship with the client, provide a means of communication and self-expression, and effect change and the realization of potential» (p. 63). This relationship is crucial and central to a music therapy session. Words are not necessarily needed to establish the relationship since music is fundamentally the language that can stimulate people’s emotion without words. Through the language of music as a medium, a music therapist strives to meet client needs in clinical improvisation. In addition, Bruscia (1996) explains that music can also be used as the assistant or substitute tool of language, enabling the client to express feelings which are otherwise difficult to express verbally. The improvisations are based either on an instrumental theme (rhythm, melody, etc.) or on a vocal theme (idea, emotion, task, etc) related to the client’s mental, emotional and physical state. Music is linked with emotions (feelings) through musical interaction in clinical improvisation and it is related to the use of music for a therapeutic purpose. Davis, Gfeller and Thaut (1999) discuss the asset of expressing feeling in music as «less threatening or alternative way to

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share emotions. Music as an outlet for expressing emotions has enormous potential as a therapeutic tool for clients with emotional upsets» (p. 50).

What has clinical improvisation taught me?

For me, it has been a tremendously meaningful and fruitful process to get to know more about clinical improvisation through study from both theoretical and practical perspectives in the course of my music therapy journey so far.

Throughout the entire process, I have been able to think about clinical improvisation in a variety of dimensions. Now I personally feel that clinical improvisation has become a specialized area of my music therapy practice. also, I feel I have matured into a better practitioner, researcher, teacher and clinical musician in music therapy.

I would like to speak concisely about I have learned in the process of reflecting on and practicing clinical improvisation as a practitioner, researcher and clinical musician.

As a practitioner

1. I have been able to understand the current role of clinical improvisation as viewed by other practitioners theoretically and practically in music therapy.

2. I have been able to learn more about my own progress and where I stand in the learning process of clinical improvisation.

3. I have been able to gain knowledge about the current education system including its approach to music therapy, administration and teachers/supervisors. I have learned about the tremendous influence the education system has over music therapy students and music therapists in their learning process.

4. I have been able to confirm that clinical improvisation is a powerful, intriguing and challenging therapeutic tool by witnessing each participant’s philosophy,

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belief, concern, and proficiency in clinical improvisation.

As a researcher

1. I have been able to understand the necessity of conducting not only quantitative, but also qualitative research in music therapy in order to establish music therapy as an efficacious health care profession.

2. I have been able to become familiar with the possible research framework in music therapy, including research designing, research paradigms, models, reasonings, etc.

3. I have been given diverse opportunities for in-depth/clinical consideration of balancing between art and science.

4. I have become a competent researcher in dealing both with numerical and non-numerical data including musical data.

As a clinical musician

1. I have been able to gain concrete and practical information regarding how others in music therapy perform clinical improvisation artistically and clinically.

2. I have been able to find out why music therapists and music therapy students need to dedicate their time and effort to be able to transcribe their work into musical notation. We definitely need to know how we communicate and interact with our clients musically, clinically and visually so that we can communicate our findings, aiming for a more evidenced-based music therapy profession.

3. I have been able to witness ‘live’ references as well as gain knowledge of other’s «biology» of clinical improvisation.

4. I have been able to discern the optimum boundary between artistic and clinical playing by studying the struggles, concerns, endeavors, and techniques of others in clinical improvisation.

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What would be my recommendations to music therapists regarding clinical improvisation?

In clinical improvisation, the ability of a skilled and sensitive music therapist must be considered an essential component since it can be connected directly to both musical and clinical intervention in music therapy. Since clinical improvisation is a central, if not an essential, part of the practice of music therapy, regardless of what approach is sought, the ability to improvise is therefore considered exceedingly important. Improvisation is an intriguing, challenging and difficult skill for music therapists to possess.

What makes a music therapist feel challenged to attain proficiency in doing clinical improvisation? This is exactly one of the major issues that I keep hoping to examine through my ongoing reflection process. I believe that there are two main reasons which cause clinical improvisation to be a difficult skill to master. one is the intrinsic fact of the mind-set of humanity toward people who need help. a music therapist, as a health care professional, must have the responsibility of providing health care through a skillful use of music.

In order to clarify the humanistic mind-set that I mentioned above, I would like to mention a few terms that I think meaningful and crucial for a therapist: altruism, devotion, and empathy. I believe that people, particularly those who work with others as therapists, must possess a profound concern for the happiness and welfare of other people; moreover, they should also be able to dedicate their time and energy based on a feeling of love, affection and admiration. Bruscia (1998) describes the necessity for empathy as follows: «Empathy is essential in the therapistclient relationship; in fact, it is the basis for all the interventions that a therapist uses to help

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the client» (p. 61). I always remind myself of these words and believe that one must be profoundly aware of their meaning in order to work for and with people who need help.

The second explanation with regard to the question of why music therapists feel that they should improve their improvisation skills is the extrinsic reason as follows. The musical competency acquired by dedicated efforts, studying and practicing, can be applied to a therapeutic purpose through its use; the more musically competent a therapist, the more successful their techniques will be.

Jourdain (2002) points out the musical improvisation skills of a performer: “The quality of the performance depends on the depth and flexibility of the hierarchy, and upon the performer’s ability to exploit the hierarchy quickly, in real time” (p.174). Nordoff and Robbins (as cited in Wigram, Pedersen & Bonde, 2002) offer a significant perspective on how music can be used in music therapy.

«The improvisational style must be free from musical conventions, and flexible. Intervals are important and represent different feelings, when used in melody. Triads and chords can be used in special ways – for example, the tonic triad to indicate stability, while inverted triads represent dynamic movement. Improvised music should also include musical archetypes, such as organum, exotic scales (Japanese, Middle Eastern), Spanish idioms and modal frame works (p. 127)».

Clinical improvisation is highly complex, as it contains two different aspects – not only a humanistic mind-set, but a high level of musicianship. Every music therapist’s actual ability to perform clinical improvisation is quite different from that of others. Some demonstrate a high level of proficiency while others do not. Indeed, it is acknowledged that many music therapists seem to be intimidated by

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the creative process which deals with converting something intangible into something tangible, while trying to meet what clients need. In addition, clinical listening, interpreting, and reacting from both aesthetic and therapeutic perspectives are also considered important components necessary for mastering clinical improvisation.

What is my personal approach to clinical improvisation?

During clinical improvisation, I believe that a music therapist can provide a «bridge» to a client to escape from his or her inner world which they may experience as a struggle or somehow overwhelming. The music therapist can enable (through musical and sometimes verbal support) the client to express his or her own feelings through improvisation. The musical structure and context of the improvisation may support the client to make him or her feel more safe and free. appropriately, my clients have been given the opportunities to express themselves emotionally and physically on diverse musical instruments while being musically supported; they are also encouraged to vocalize freely during the improvisations.

at times, I have been questioned regarding the probable scenario of doing clinical improvisation. In other words music therapy students and music therapists have questions regarding the possible steps from the beginning to the end of clinical improvisation.

Whenever I was asked about these steps, I thought that it would be very helpful if someone could provide the theoretical steps of how to begin, progress, and end clinical improvisation. I propose the following outline of steps based on my professional experience and reflection:

1. Wait and let client initiate playing (ClientCenteredness).

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2. Figure out what tone the client produces and respond through colouring the tone using your main instrument.

3. after colouring the tone, choose promptly and intuitively what idioms, genres and rhythms might be suitable in order to meet the client’s music.

4. Concrete form (e.g. a-B-a, Rondo, a-B-C etc.) – when returning to the a theme, the client may realize the similarity.

5. If the client stops playing, don’t panic!

Use musical «questions» by producing melodic lines (phrase) on your instrument. Without words, the melodic lines can contain certain metaphorical or poetic meaning (e.g. are you oK? Why have you stopped playing? ) These can also be replaced by vocalization using certain techniques such as «recitative» as was discussed previously.

6. Transpose when client appears to be «bored» or when you feel stuck with one theme or its simplicity – client may recognize the change.

7. Use vocal improvisation as a catalyst while improvising instrumentally at any given time.

8. When developing the theme you initiated, it would be beneficial for you to use variation form due to its similarity, familiarity, or likeness to the original theme.

9. To pause your playing is a good technique to use when the clients attention needs to be drawn during clinical improvisation.

10. Remember the ‘a’ theme, including its key, and get ready to produce a cadence no matter who ends the playing between you and client.

11. If the client attempts to play more after you produce the cadence, you may be able to present a «Coda» in order to respond accordingly while playing.

The significance of clinical listening has been discussed previously. In addition, I would like

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to note that watching a client clinically is also important in doing clinical improvisation. If a music therapist can utilize his or her eyes in accordance with their ears, the therapist may be able to respond more diversely and dynamically while capturing client movement, facial expression, or verbalization. That is to say, clinical observation can prove as effective a means as clinical listening when a music therapist aims to meet the client for therapeutic purpose. In addition, I would like to suggest that a music therapist should be constantly aware of the difference between an aesthetic view of musical playing and that of playing music for a therapeutic purpose in clinical improvisation. Maintaining an appropriate balance between these two perspectives is the key to success in meeting what a client needs in clinical improvisation.

What would you recommend to broaden skills in clinical improvisation?

I would like to introduce a list of effective methods of practice to increase competency in clinical improvisation. This is my personal method of becoming familiar with clinical improvisation:

1. Listen to diverse music every day if possible (not only classical music, but also Jazz, Rock, Hip-hop, Reggae, cultural music, etc.).

2. Get to know and memorize more repertoires - e.g. idioms, rhythms (particularly, syncopations or off-beats), genres, scales, modes, harmonic progressions, etc.

3. Make harmony using vocalization when you listen to familiar songs from radio, CD, TV, etc.

4. aim to develop perfect pitch – it is very helpful to produce a similar tone to what the client presents in clinical improvisation.

5. Make harmony and improvise using your main instrument when you listen to familiar songs.

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6. Regular practice (the most important thing) – keep a musical diary while improvising about what you have learned from your everyday life- be familiar with improvisation in daily life.

7. Spend extra time and study harmony, counterpoint, and variation.

8. Practice transposition of each musical idiom you know.

9. analyze your favorite songs or pieces harmonically and make chord progressions to go along with them. Use the chord progressions to communicate with the client and meet client’s music, a method I have found to work very well.

10. Prepare melodic phrase for musical question – e.g. it works when clients stop playing instruments.

When our effort and time are dedicated enough, all of the methods introduced above will become integrated into our own techniques.

Subsequently, the techniques will become embedded into our repertoire as well as our clinical sense. We are then able to treat our clients with a sense of clinical rigor in accordance with a good level of musicianship. I would also like to list «strategies» which I have found successful through my clinical work as well as supervisory work with my supervisee in doing clinical improvisation. Items are listed in random order as they arose from diverse situations.

1. a music therapist should be able to use a large variety of techniques no matter what his or her main instrument may be.

This will increase the musicality during improvisation and decrease the monotony currently experienced by some practitioners. It is also a good idea to develop some ostinatos that will support client music. Playing melodies alone may be too overbearing and might take the focus away from the client’s contributions.

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2. It is not necessary to answer client questions each time they are posed. It is more effective to re-direct the client towards the music in order to maintain its importance and its role as the focus of the session.

3. There should be clear form within the clinical improvisations. Each section should have its themes in order to create a sense of continuity.

4. It would be beneficial for music therapists to develop an activity based on seventh chords in the key of C major for guitar.

This will significantly increase the harmonic possibilities when improvising with clients. It will also serve to establish boundaries with them concerning the use of the guitar while being engaged with the activity 5. It is important to remember that the music therapist is not a regular performer and should always be acutely aware of the client’s music, state, pathology etc. In order to counteract the possibility of becoming unaware of the client or ignoring him or her, it is advisable to keep the eyes open.

6. It is also important not to lead the client’s music by swaying or otherwise moving to the beat as this may impede their ability to create the music that they wish to create. Remember that there are always other ways to interact with the client including eye contact, smiling etc. We do not have to limit ourselves to musical communication only.

7. a music therapist needs to have a clear theme when playing an instrument with a client. This way, when the therapist returns to that theme, it will clearly indicate the improvisation’s structural form. This consistency is fundamentally important and gives the improvisation its much needed structure.

8. although syncopation is a powerful tool, it is basically more important to start in

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unison with the client in order to establish consistency. When the client is comfortable with the meter and beat, it will then be possible to develop the client’s music as well as syncopation.

9. a music therapist must dedicate his or her effort in order to develop clinical improvisation competency with any instrument he or she would like to use and apply it to their clinical work. The therapist, needless to say, will only get better if he or she practices.

10. It is true that the music created during the session is a direct reflection of the therapeutic relationship. It is also true that a music therapist’s confusion and inability will directly influence the client’s ability to express him or herself and feel free during their sessions together.

11. Take what the client gives you musically and embrace it with chords. Chords to a note are like a parent’s arms to a baby; they provide context as well as support and help the session to progress.

12. Use more technique during the session.

This will increase the quality of the music and peak client interest.

13. In order to keep the session interesting, use the themes/idioms/scales that your client responds to, but on a variety of other instruments.

14. Work to increase eye contact with the client. at times, a client may enter his or her own musical world where he or she is not aware of the collaborative improvisation between the client and music therapist. Maintaining eye contact helps to ground the client in that collaborative relationship and keep them centered on their feelings and the production of music.

15. Develop techniques that work to capture his or her attention (one idea is the use of rhythm exchanges). adding layers and innovative techniques to the music works towards maintaining client attention.

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16. aim towards developing an even deeper level of interaction and social awareness.

This can include awareness of music, body language, facial expression, and verbal dialogue if possible.

17. If a music therapist loses the client’s attention, it may be effective to play full, rich chords on the instrument. The therapist must be sure to leave ample space in order to give the client the opportunity to play freely within the structure the therapist creates using the chords.

18. Use diverse chords for the hello/goodbye songs instead of C major. I would also insert more space in the hello/goodbye song which will invite the client to play within the structure created.

19. It would be beneficial for a music therapist if he or she can develop skills using seventh chords and be competent using them in the activities including improvisation; the chords will frame the client’s contributions musically. This will give the client the opportunity to act as a «Soloist» and explore different techniques on the guitar or piano within a safe musical structure.

20. Boring music may occur when a music therapist stays with something that works and is comfortable, not challenging and exciting.

21. Music therapists must ensure that there is therapeutic work being accomplished during clinical improvisation; although recreational improvisation has therapeutic value, it is not exactly therapy. The therapist must be careful that improvisation with clients remains challenging and purposeful.

22. a music therapist must be able to utilize what the client verbalizes in order to take it to the next level and create a song.

There is no purpose in merely repeating the words/phrases back to the client.

Give the client’s words a context, as a mu-

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sic therapist gives client’s music a larger context.

23. Plan the session, but be open to musical spontaneity. Think of themes on the spot and develop them. The music therapist’s resources inform his or her intuition and experience only when he or she strives hard to study and incorporate them.

24. am I aware of what I’m doing at every moment during the session? It is conscious or instinctual? Has it become innate? Has it become part of my intuition?

Cultivate awareness of these questions at all times.

25. Interacting with others is inevitably an exchange, and it establishes a relationship. aim to encourage the client to listen to the therapist’s music (i.e. during rhythm exchanges) to increase client’s interpersonal awareness.

26. Try not to disrupt the music when the client asks a question or makes a statement. Instead, keep the musical flow by either singing or rhythmically repeating the client’s words.

27. a music therapist must work on having smoother links between his or her respective sections. The flow of the session is good, but the therapist must work on developing the flow within the improvisations.

28. one exercise that a music therapist could use in order to develop the skill of maintaining flow is following a visual «map» that is a pre-composed piece. By following the flow of the music (intro, theme, development, climax, theme) this could indeed improve his or her improvisational skills.

29. Develop «container» music to support client’s contributions while framing the tones which the client presents. This could include whole note, simple rhythms, full chords, etc.

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30. Pausing is a strong way of regaining the client’s attention if they enter their own musical world.

31. Is it really necessary to say hello and goodbye 16 times to the client? Consideration is needed.

32. always have a rationale behind any task including clinical improvisation in a music therapy session.

What topics should be considered in future research in the area of clinical improvisation?

For future research endeavors, I would like to suggest a probable research topic regarding the analysis of clinical improvisation to anyone, including myself. It would be an interesting study if I were to ask participants to improvise in response to musical statements provided, and then interview each participant to subsequently ask why they have responded as they did. That is to say, the research would aim to learn more about clinical judgment in clinical improvisation. In addition, I am looking forward to having an opportunity to investigate my clinical work from clinical improvisation sessions so that I will be able to present my insight and my own clinical judgment as well as clinical musicianship through this possible study in the future.

I do understand that clinical improvisation is just one of the powerful therapeutic tools in music therapy. I have neither idealized this therapeutic tool as the only technique, nor ignored other therapeutic techniques in music therapy. Rather, my aim has been to anatomize this powerful tool more specifically for readers who may need a «blueprint», «manual», or «textbook» with regard to clinical improvisation.

all of the contents presented in this article

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may already be known to readers. However, I rest assured that this article will exhibit concrete and integrated information through presenting the theoretical and practical information for readers in their learning process.

I’d like to dedicate this paper to those who strive hard to be competent and struggle with mastering clinical improvisation.

references

Bunt, L. & Hoskyns, S. (2002). The handbook of music therapy. London: Brunner-Routledge.

Bruscia, K. E. (1996). authenticity issues in qualitative research. In M. Langenberg, K. aigen, & J. Frommer (Ed.), Qualitative music therapy research: Beginning dialogues (pp.

81-107). Gilsum, NH: Barcelona Publishers.

Bruscia, K. E. (1998). Defining music therapy (Ed.). Gilsum, NH: Barcelona Publishers.

Davis, W. B., Gfeller, K. E., Thaut, M. H. (1999).

An introduction to music therapy: Theory and practice (2nd ed.). New york: McGrawHill.

Dean, R. (1989). Creative improvisation. MK: open University Press.

Dupré M. (1925) Traite d’improvisation a l’orgue (J. Fenstermaker, Trans.). Paris: Leduc. (original work published in 1925) Etkin, P. (1999). The use of creative improvisation and psychodynamic insights in music therapy with an abused child. London: Jessica Kingsley Publishers.

Jourdain, R. (2002). Music, The brain, and ecstasy: How music captures our imagination. New york: Quill.

Lee, C. a. (2003). The architecture of aesthetic music therapy. NH: Barcelona Publishers Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New york: The John Day Company.

Pavlicevic, M. (2000). Improvisation in music therapy: Human communication in sound.

Journal of Music Therapy, 37. 277.

Small, C., Durant, a., & Prevost, E. (1984). Im-

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provisation; History, directions, practice.

London: Calouste Gulbenkian Foundation.

Solomon, L. (1986). Improvisation II: Perspectives in new music, 24, 224-35.

Wigram, T. (2004). Improvisation: Methods and techniques for music therapy clinicians, educators and students. London: Jessica Kingsley Publishers Ltd.

Wigram, T., Pedersen, I. N., Bonde, L. o. (2002).

A comprehensive guide to music therapy; Theory, clinical practice, research and training. London: Jessica Kingsley Publishers Ltd.

About the Author

sung-yong shim Sung-yong Shim, PhD, completed his ďŹ rst bachelor of music composition and education in Korea. after graduation, he went to Canada to study music therapy and completed honours bachelor of music therapy and master of music therapy at Wilfrid Laurier University (WLU), Waterloo, ontario. He has worked with a variety of clientele from the young to the elderly in music therapy. He is also a special educator as he received his PhD in special education from Seoul National University (SNU). He has taught not only music therapy, but also special education including counseling with exceptional children. Currently, he is lecturing at a few universities including SNU in Seoul, Korea.

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MusictherapyToday, Volume 12, No. 1, 2016

Music therapy and high resting heart rate:

underlying Mechanisms and practical Models

Wolfgang Mastnak, shanghai conservatory of Music, Department of Music therapy (p. r. china) austrian heart association

abstract

High resting heart rate (RHR) is considered a cardiovascular and early death risk factor. despite medical evidence of music therapeutic influence on regulatory cardiac mechanisms, underlying mechanisms still remain unclear. This study aims at clarification of functional connections between music and changes in heart rate and identification of psycho-neuro-cardiac mechanisms for improved application of music in heart patients.

Findings emphasise the distinct interplay between cortical (typically psychological) and subcortical (more physiologically determined) processes with decisive implications for cardio music therapy.

on the basis of neuroscientific findings a novel functional audio-cardiac theory is constructed, highlighting: a) Continuous ramification of sound data processing modalities along the auditory pathway up to highest neo-cortical complexity and subsequent re-convergence towards clear-cut cardiac responses; b) essential multifunctional information integrating areas (e.g. insular cortex) and subordinate specialised modules constituting music-related cardiac control systems; c) associative brain areas receiving both cognitive-emotional and physiological information (e.g. amygdala) mirroring the dualistic, psychosomatic features of neuro-cardiac music therapy; d) qualitative sound-transformations in the

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Resumen

Un elevado ritmo cardíaco en reposo (RHR) se considera un alto riesgo de muerte cardiovascular. A pesar de la evidencia médica de la influencia de la musicoterapia sobre los mecanismos cardíacos regulatorios, el papel de estos mecanismos aún no es conocido. Este estudio se propone poner en claro las conexiones funcionales entre la música y los cambios en el ritmo cardíaco e identificar los mecanismos psico-neuro-cardíacos para mejorar la aplicación de la música en pacientes cardíacos. Los conocimientos enfatizan las distintas interacciones entre los procesos corticales (típicamente psicológicos) y los subcorticales (mayormente fisiológicos ) con implicaciones decisivas para la musicoterapia en cardiología.

Basándose en hallazgos neurocientíficos se ha formulado una nueva teoría funcional audiocardíaca, que pone de relieve: a) La continua ramificación a lo largo de la vía auditiva de los distintos estímulos sonoros hasta las zonas más complejas del neocortex y el conocimiento de las respuestas cardíacas subsecuentes; b) Multifuncional información esencial abarcando áreas (por ejemplo: el córtex) y módulos especiales subordinados que constituyen sistemas de control de los efectos de la música sobre el corazón; c) Áreas asociadas del cerebro que reciben a la vez informaciones cognitivo-emocio-

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organ of Corti (physical into neural information) and the auditory cortex (neural into psychological information). These findings lead to four main suggestions for music therapeutic application: a) Complementary primary cardiovascular prevention; b) under cardiologic guidance possible reduction of medication; c) control of psychological problems following pathological heart events; and d) enhancement of self-efficacy and selfconfidence in health-related contexts. Three practical models and their clinical indications are discussed: musical treatment of primary elevated RHR; conditioned heart problems and behavioural music therapy; and sound balancing in heart-related dysbalanced personalities.

Key words: cardiac music therapy, functional music neuroanatomy, high resting heart rate.

nales y fisiológicas ( por ejemplo: la amígdala) reflejando las características dualísticas y psicosomáticas de la musicoterapia neuro-cardíaca; d) Transformaciones cualitativas debidas al sonido en el órgano de Corti (información física transformada en neurológica) y en el córtex auditivo (información neurológica transformada en física). Estos hallazgos conducen a las cuatro principales sugerencias para la aplicación terapéutica de la música: a) Prevención cardiovascular complementaria; b) Posible reducción de la medicación bajo control cardíaco; c) Control de los problemas psicológicos consecuencia de trastornos cardíacos; y d) Mejora de la autoeficiencia y de la autoconciencia en contextos relacionados con la salud. Se analizan tres modelos prácticos y sus aspectos clínicos: tratamiento musical en casos de valores elevados de RHR; problemas cardíacos condicionados y musicoterapia conductual; y efecto equilibrante del sonido en personalidades con desequilibrios relacionados con cardiopatías.

Palabras clave: musicoterapia cardíaca, neuroanatomía de la música funcional, ritmo cardíaco en reposo elevado. introduction: Music therapy for cardiologic indications

There is no doubt that music therapy has gained a certain position in cardiology. Though it seems that classical medical domains are about to enhance acceptance of arts-related methods, in cardiology three destabilising issues become evident:

1. The role of music therapy is often narrowed down to a supportive factor to prevent psychological co-morbidities or to improve treatment conditions in a psychological way.

2. There is low medical confidence in distinct physiological efficacy of music therapy, especially with regard to distinct medical indications.

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3. Music therapy in medical contexts is sometimes glorified as a comprehensive method for most complex medical purposes. Neither respecting differential diagnostics nor reflecting underlying physiological mechanisms obstruct full clinical compatibility and acceptance.

Música é remédio para o coração is a promising title that easily arouses suspicion in cardiologic circles: «Music has been of beneficial effect on patients of pain... acting on the autonomic nervous system by reducing heart rate, blood pressure and pain postoperatively, and having a positive effect after acute myocardial infarction. Music reduces anxiety and pain following open-heart surgery in adults ...»

(Todres, 2006, p. 166).

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In 2008 German media, such as Focus Online from 12th of November 2008, praised music as a miraculous treatment for the heart and blood vessels. Though such exaggerations are rather detrimental for the clinical acceptance of music therapy, the studies these media referred to are of high clinical quality. Carried out under the guidance of Professor Michael Miller, director of the Center for Preventive Cardiology / University of Maryland Medical Center, they point to significant musical influences on the cardiovascular system (Miller, Mangano, Beach, Kop, & Vogel, 2010). «The objective was to evaluate the extent to which music may affect endothelial function. In previous research, a link between music and physiologic parameters such as heart rate and blood pressure has been observed ... music that evoked joy was associated with increases in mean upper arm FMd [flow-mediated dilatation]... whereas reductions in FMd were observed after listening to music that elicited anxiety... Self-selected joyful music was associated with increased FMd to a magnitude previously observed with aerobic activity or statin therapy». These are striking results which point to music as a highly efficient means for cardiovascular prevention and therapy. In the context of our studies three aspects of Miller’s studies are of crucial importance and lead to further considerations:

1. Music and physiological response. Music therapy can be used for primarily physiological purposes. Still we have to investigate whether these are monocausal or multidimensional. With other words: Music influences what kind of physiological spectrum?

2. dualistic principles of influence. Physiological effects of music depend on emotional factors. Together with contradictory research outcomes (Sleight, 2013) these results call for clarification. In our article we suggest dualistic cortical-subcortical mechanisms explaining psychological and physiologic

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components of cardiac responses to auditory stimuli.

3. Underlying cerebral mechanisms. Most clinical investigations follow empirical designs and paradigms of evidence based medicine.

Focusing exclusively on input-outcome-measurements they do not explain underlying physiological or cerebral mechanisms. That, however, is a main aim of this contribution which supports the theory of auditory stimulation for cardiac regulation (Valenti, Guida, Frizzo, Cardoso, Vanderlei, & de abreu, 2012).

Promoting studies on underlying mechanisms of music therapeutic effects will most probably help to optimise music therapeutic plans and designs, and will enhance compatibility with conventional healthcare disciplines. Evidence based medicine and randomised controlled trials (RCTs) have to be complemented by investigations explaining mechanisms underlying the evident surface.

It is obvious that music affects the psyche and the mood. In cardiology applications of music for stress and anxiety reduction in coronary heart disease patients are well elaborated (Bradt, & dileo, 2009). This fact opens a wide range of music therapeutic possibilities in cardiology: for pain and anxiety reduction in cardiac surgical patients (Bauer et al., 2011; Voss, Good, yates, Baun, Thompson, & Hertzog, 2004) and in the context of angiographic interventions (Buffum, Sasso, Sands, Lanier, yellen, & Hayes, 2006; Chang, Peng, Wang, & Lai, 2011), in cardiac postoperative care of children (Hatem, Lira, & Mattos, 2006) and in cardiac rehabilitation (Mandel, Hanser, Secic, & davis, 2007).

Nevertheless, at the moment music therapy gets more essentially involved in primary cardiologic treatment, underlying mechanisms have to be more clearly identified. Pharma-

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cological and musical treatment are based on different mechanisms. drugs cannot provide rhythmic stimulation of neural units while music follows complexly mediated ways to interact with neuroendocrine processes. Future interdisciplinary work has to identify and harmonise various physiological gates to cardiac regulation: chemical substances, auditory stimuli, electric stimulation etc. For interdisciplinary treatment that includes music therapeutic intervention not only as an optional add-on means, an enlarged and more comprehensive system of physiological understanding is needed. Philosophy of medicine discusses the fact that conventional Western physiology shows features of reductionism. It is very likely that progress in music therapeutic research will also influence medical thinking and paradigms. reduction of high rhr: clinical and healthcare related Motivations

Formally the importance of high resting heart rate (RHR) is mirrored by the fact that it represents one of the risk factors of the international aCS Risk Model (Eagle et al., 2004). Medical studies clearly point out the cardiologic relevance of elevated heart rates and claim clinical recognition: «despite current guidelines that do not still recognize HR as a cardiovascular risk factor, it appears that physicians should pay more attention to it in clinical practice since high HR is warning about an increased risk» (Barrios, Escobar, Bertomeu, Murga, de Pablo, & asín, 2009, p. 292).

Elevated RHR is not only a health threatening moment in cardiovascular patients. a recent prospective cohort study from Norway (Nauman, Janszky, Vatten, & Wisløff, 2011) showed that among men and women without known cardiovascular disease, an increase in RHR over a 10-year period was associated with in-

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creased risk of death from IHd [ischemic heart disease] and also for all-cause mortality.

Still there is this old cardiologic problem, whether high resting heart rates have to be considered a risk marker or a risk factor (Gosse, 1998). This issue characterises the discussion about that phenomenon and its clinical implications (Escobar & Barrios, 2008). Though pathological mechanisms are still not clearly understood, there are strong arguments for high RHR as a direct cardiovascular threat (Fox et al., 2007, p. 823): «Recent large epidemiologic studies have confirmed ... resting HR to be an independent predictor of cardiovascular and all-cause mortality in men and women with and without diagnosed cardiovascular disease. Clinical trial data suggest that HR reduction itself is an important mechanism of benefit of beta-blockers and other heart-rate lowering drugs used after acute myocardial infarction, in chronic heart failure, and in stable angina pectoris». as music is able to exert a regulating influence on heart rates as well as on blood pressure, we postulate music therapy as an efficient, physiologically mild and psychologically supportive constituent of future RHR treatment. Various newer studies (Barrios, Escobar, Bertomeu, Murga, de Pablo, & asín, 2009) highlight the importance of reducing elevated RHR, specific cardio music therapy is about to gain in importance.

For our further cardio music therapeutic considerations we accept Borer’s (2008, p. F2) argument that heart rate ... «is evolving from its demonstrated status as a risk marker of mortality and morbidity in various populations, to become a risk factor in patients with established coronary artery disease ... The relationships between resting heart rate and the development of coronary artery disease, as well as all-cause and cardiovascular mortality, were found to be strong, graded and in-

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dependent of other factors such as blood pressure and physical activity. The ongoing BEaUTIFUL and SHIFT trials will assess the therapeutic value of pure heart rate reduction in populations with coronary artery disease with and without failure ... thus providing the necessary evidence to support risk factor status for heart rate in this population».

This issue is of high relevance in pathophysiology and interdisciplinary cardio-music-therapeutic research. Together with clinical evidence for positive music therapeutic effects in individuals with elevated resting heart rate, the findings of the Norwegian study and the fact that heart rate reduction is the cornerstone of the treatment of angina (diaz, Bourassa, Guertin, & Tardif, 2005) delimit music therapeutic domains within preventive and rehabilitative medicine.

From a preventive-medical viewpoint music therapy is considered a possible means for heart rate regulation, while in long-term cardiac rehabilitation it additionally helps to reduce the quantity of daily pills as well as a patient’s psychologically devastating selfimage of being fully dependent on pharmacological treatment. Nevertheless, even though some studies such as the previously mentioned (Miller et al., 2010) emphasise extremely high cardio-protective potentials of music, we do not recommend isolated music therapeutic interventions to reduce elevated resting heart rate. In this context we suggest a clear identification of the patient’s pathological parameters and holistic individual treatments. Thus psycho-physiologic causes have to be identified. Especially referring to newer sports cardiological studies both for individuals with cardiovascular risk factors (Vanhees et al., 2012a) and with cardiovascular disease (Vanhees et al, 2012b) additional sports cardiologically controlled physical activity has to be taken into consideration. a connection between RHR and physical fit-

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ness is also mirrored by the interdependency of RHR and Vo2peak (Nauman, aspens, Nilsen, Vatten, & Wisløff, 2012). Interdisciplinary research combining these fields is needed. scientific Motivation: «evidence Based» is not enough

Psychologically oriented music therapy refers more to systemic theories, while medical music therapy is widely based on empirical studies and RCTs. This trend and the history of philosophy of science are closely interrelated.

Psychological schools of thought mostly tended to follow phenomenological or constructivist paradigms, while evidence based medicine created standards such as double-blind studies or RCTs highlighting objective outcomes and statistical significance.

While similarities with classical psychological features, e.g. in the case of analytic Music Therapy or GIM, seem to fit to the nature of music therapy, RCTs in music therapy cause serious methodological problems. on the one side there is no musical placebo – an idea that would contradict itself – . on the other side we have to take into account that therapeutic effects of music on the one hand and of drugs on the other depend on totally different mechanisms. This issue relates essentially to the dualism of (virtual) aesthetic and physiological natures of an auditory stimulus and to the fact that from a physiological point of view music originates at qualitative transformations of sound waves into neural information by the hair cells of the organ of Corti. In contrast to these mechanisms pharmacodynamics are intertwined with biochemical metabolic processes of very different nature. Scientific paradigms which work perfectly for pharmacological studies in humans do not necessarily apply to music therapeutic issues.

In addition to these problems, evidence ba-

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sed studies and randomised controlled designs show analogies to the classical black box of early behavioural psychology. While during that time avoidance of any hypothetic construction of inner-psychological processes represented the explicit scientific credo, the cognitive revolution made clear that this obsolete paradigm had ignored the complex human nature and had to be replaced by more appropriate models (Miller, 2003). Stimulusresponse-studies are of high scientific value.

But they do not explain underlying psychological mechanisms. These have been hypothesised by cognitive models and step by step verified. Similarly conventional RCTs yield important results and facilitate therapeutic decisions. But they do not explain underlying mechanisms. our neuroscientific investigations on the neural modes of information processing between the musical stimulus of the inner ear and the control of heart activities by cardiac nuclei of the brain stem are intended to contribute to a deeper understanding of underlying mechanisms of music therapy in individuals with elevated resting heart rate. In general we suggest critical estimations of the value of exclusively quantitative empirical studies in music therapy on the one hand and the strengthening of neuroscientific approaches on the other. empirical and psychosomatic Motivation: Musical and cardiac rhythms are intertwined

Beyond the cultural-anthropological evidence that music has the power to influence the heart beat, scientific investigations go back to the 1970s. Kneutgen (1970) reports the effect of a lullaby on respiratory synchronisation and a decrease of the heart rate. Harrer (1982) refers to the observed connection of heart-rate acceleration and increased musical tempi, and Frank (1982) describes a stunning integral ratio (1:1, 1:2, 2:3) between musical

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rhythms and heart rate. These findings are compatible with our rhythm-response-categorisation of heart patients: The synchronisation- and the slow-down-types. on the basis of various studies we can assume that rhythmic aspects are the major determinants of physiological responses to music (Gomez, & danuser, 2007). Nevertheless, we must not ignore other factors such as the timbre or the volume which seem to exert a distinct influence on the blood pressure.

Newer controlled studies are about to verify the influence of musical rhythms on the heart rate, focussing especially on beats per minute, heart rate variability, and cardiovascular rhythms such as Mayer waves: «Music emphasis and rhythmic phrases are tracked consistently by physiological variables. autonomic responses are synchronized with music, which might therefore convey emotions through autonomic arousal during crescendos or rhythmic phrases» (Bernardi et al., 2009, p. 3171).

This study supports the hypothesis of a non arbitrary interrelation between musical input and physiological reaction, but does not discuss underlying neural mechanisms which represent the main issue of our considerations.

In opposition to our findings which point to a dualistic influence on cardiac reactions to music, the quoted study emphasises that physiological responses do not depend on aesthetic preferences. This standpoint was confirmed in a newer follow-up publication by Sleight (2013, p. 99): «We found that contrary to many beliefs, the effect of a style of music was similar in all subjects, whatever their individual music taste. We also found that this effect appeared to operate at a sub-conscious level through the autonomic nervous system». a recent study on music-induced heart rate responses using biofeedback methods has important implications for music therapeutic practice. Comparing effects of listening to

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pre-recorded music, sonification biofeedback of the heart rate, and an algorithmically modulated musical feedback signal conveying the subject’s heart rate showed (Bergstrom, Seinfeld, arroyo-Palacios, Slater, & Sanchez-Vives, 2014) «that using musical biofeedback allowed participants to modulate their state of physiological arousal at least equally well as sonification feedback, and much better than just listening to music, as reflected in their heart rate measurements, controlling for respiration-rate». This study involves implicitly the interconnection of musical stimulus, complex sensory self-awareness, and physiological responses, which correlates with our theories. Neuroscientific theories emphasise the multitude of heterogeneous types of physiological reactions to sensory stimuli. These, however, can decisively depend on a patient’s idiosyncratic quality of listening. This aspect has not been investigated previously in a cardiac rhythmological context. In clinical practice we found significantly different heart-rate responses to music between individuals who listened in a more analytical way and those who felt a perfect inner identity with the musical gestalt. This moment is mirrored by a connection between the limbic system and the insular cortex as we will describe below and entails consequences for music therapeutic practice.

The traditional polarity between active and receptive music therapy also relates to issues concerning the heart rate. Recent studies show that music structures determine heart rate variability of singers, particularly focusing on the coupling of heart rate variability (HRV) to respiration (Vickhoff et al., 2013). Based on neuropsychological considerations, it is very likely that the crucial question is not, whether receptive or active music therapy is more effective, but how therapeutic processes depend on the subjective identity between music and the self.

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Though there are strong scientific arguments for a functional connection between musical rhythms and dynamic heart activities, other studies reject this hypothesis stating that there was no evidence for a direct influence of music on heart rates. a clearly designed Turkish study (amaral et al., 2014) «aimed to evaluate the acute effects of classical baroque and heavy metal music of different intensities on cardiac autonomic regulation ...

The subjects were exposed to three equivalent sound levels (60-70 dB, 70-80 dB and 8090 dB) ... auditory stimulation with heavy metal music did not influence HRV indices in the time and frequency domains in the three equivalent sound level ranges. The same was observed with classical baroque musical auditory stimulation with the three equivalent sound level ranges. The conclusion was that musical auditory stimulation of different intensities did not influence cardiac regulation in men». The results of this study resemble those of recent investigations (amaral et al., 2014) «which aimed to investigate acute cardiac response and heart rate variability (HRV) when listening to differing forms of music ...».

With the result that «music with different tempos does not influence cardiac autonomic regulation in men». These outcomes are obviously contradictory to findings quoted above. assuming that all these data are scientifically reliable, the striking heterogeneity of musical influence on heart rates poses crucial questions for cardiac music therapy. one important aspect relates to different acculturation and the problem of cultural sensitivity in music therapy. another essential aspect involves different aesthetic attitudes as well as modalities of listening and experiencing music. These decisive differences correlate with complex neural music processing systems causing very heterogeneous modes to respond to music in a psychosomatic way. Both studies which state music-heartconnections and those which deny them usually claim further investigations. Espe-

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cially those highlighting a distinct connection between musical and cardiac rhythms emphasise the urgent importance of neuroscientific analyses (Valenti, Frizzo, Cardoso, Vanderlei, & abreu, 2012, p. 955) «In this study, we described the relationship between musical and auditory stimulation and heart rate variability ... Musical auditory stimulation influences heart rate variability through a neural mechanism that is not well understood».

This is precisely what our present study tries to contribute to: a deeper and more adequate understanding of underlying neural mechanisms of the relationship between music and heart rhythms. underlying Neural Mechanisms: research Modes and Novel theory

due to the dominance of evidence based medicine and RCTs, the characteristics and values of interdisciplinary research for discovery of functional neural mechanisms should be shortly outlined: similar to behavioural psychological research before the cognitive revolution evidence based medical and therapeutic research refers mostly to the investigation of input-outcome-relationships in specific populations. In this context «input» refers in general to behaviours (e.g. smoking), psychosomatic states (e.g. stress hormone levels), and interventions (e.g. analytic music therapy). «outcomes» usually concern visible conditions (e.g. infarction or death) or psychological respectively physiological correlates (e.g.

RHR). Nevertheless, similar to the black box in classical behavioural research, underlying mechanisms are not regarded and thus remain undiscovered. This disadvantage has led to the cognitive revolution and the rejection of the black-box paradigm: a deeper interest in the human mind required the at-

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tempt to look «inside». as thoughts and emotions are not directly accessible, forming hypotheses and constructing models became necessary.

Similarities to our issues become evident: we cannot directly observe the nature of music processing in the nervous system. Nevertheless, to gradually approach underlying mechanisms helps us to understand music therapeutic effects and to optimise clinical designs. This type of research comprises five steps:

1. Neuroanatomy. Identifying various pathways, neural relays, afferent and efferent links, etc., neuro-anatomy creates a sort of roadmap of the brain. dissection of the dead human brain, animal studies, and comparative neurobiology yield relevant data.

2. Functional neuroanatomy. analysis of mental, behavioural, and somatic sequelae, in vivo brain tests (e.g. fMRI, EEG) and animal studies lead to the identification of functional units in the brain.

3. Comparative biology. anthropological and comparative evolutionary studies help us to estimate to what extent results from animal models can be applied to humans, e.g. how to infer from the brainstem of a rat to functions of the human analogue.

4. Functional construction. Integration of these data results in the construction of theoretical models which have to be compatible with in-vivo observations. The possibility of erroneous or inadequately biased observations or research designs and outcomes has to be taken into consideration.

5. Evaluation and proof. There is mostly no direct verification or falsification of such theories. We rather tend to evaluate the theory’s pragmatic value in clinical practice as well as its compatibility with new scientific findings in a continuous process.

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our theory which is designed to explain neural and neuro-psychological mechanisms that are triggered through cardiac music therapy is based on this sort of research.

Neuro cardiac Mechanisms

The scientific kernel of this article concerns to neural and neuro-psychological interrelationships between music and heart rates, referring both to basic research in cardio-neurosciences and music therapeutic implications, particularly for chronic tachycardia and patients with elevated resting heart rate. In this context we highlight three crucial structures: a) efferent, «non-auditory» projections from the auditory pathway; b) central nervous auditory-data-processing and complex interactive neural networks; and c) psycho-vegetative influences on functional cardiac areas of the brain stem.

Nevertheless, these structures and systems must not be understood as isolated units, but rather as overlapping and interactive modules. Functional units such as the cochlear nuclei, efferent ramifications such as from the inferior colliculus, and zones of qualitative information transformation such as the organ of Corti, play decisive roles for music induced psycho-vegetative processes.

analysing processes with regard to the whole functional system we discovered a certain complexification of data processing on the way from the organ of Corti to cortical interactivities and a certain subsequent homogenisation of information towards the cardiac centres of the brain stem. Complementary points concern following characteristic principles:

1. Physiological functions follow rather standardised mechanisms (e.g. the way of trans-

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forming the sound wave into neural patterns in the organ of Corti).

2. Neuronal encodings of sound-wave-information are conducted via main neural paths (e.g. lateral lemniscus) and specific ramifications with distinct functions in auditory-neural-circuitries (e.g. arising from the medial geniculate body of the thalamus) towards the cortex.

3. Higher processing of auditory data and the cognitive construction of music as a psychological phenomenon is based on extremely complex and differently nuanced central nervous interactivities of functional modules. This area of highest affective, creative, and aesthetic heterogeneity is also considered responsible for different musicheart-responses in individuals.

4. Neural generalisation of these information processing outcomes and –referring to vegetative responses– convergence towards new qualities of physiological triggers that follow again rather standardised biological mechanisms (figure 1). auditory pathway, collaterals and ramifications

The way from transforming the sound wave into neural patterns in the organ of Corti along the vestibulocochlear nerve to the cochlear nuclei and further via the lateral lemniscus, the inferior colliculi, the medial geniculate body and the acoustic radiation to the auditory cortex is well known and scientific results are accessible without problems (oertel, Fay, & Popper, 2002). Particularly the scientific standard of studies on functional microstructures in the organ of Corti (Nam, 2014) is highly advanced, the tonotopic organisation of the auditory pathway comprising neural tracts, nuclei, and cortical structures are well described. In this context, tonotopy refers to the spatial arrangement of where sounds of

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cortical areas of higher auditory data processing: • Cognitive construction of music • aesthetic experience & emotional nuances • Complex associations (e.g. with biographical data, sensory body awareness etc.)

High inter-individual heterogeneity & qualitative nuances.

– auditory pathway and ramifications towards neuro-physiological circuitries.

– Complex loops and regulatory modules.

– High range of variations.

– Reintegration of processed musical data and homogenisation of psycho-vegetative triggers.

– Converging decrease of complexity & variations.

organ of Corti: sound wave → neural pattern.

Standardised physiological mechanisms.

Brainstem: Cardiac nuclei.

Standardised physiological mechanisms.

FIGURE 1. auditory neural patterns serve mutually interacting autonomic and psychological systems. integral outcomes trigger cardiac regulation centres. different frequency are processed in specific auditory units. Tones close to each other in terms of frequency are represented in topological neighbouring regions.

While classical neuroanatomy knows the cochlear nucleus just as the first relay station in the auditory system, splitting into ipsi- and contralateral paths, contemporary studies discovered this zone as a functional unit charged with first sound-data-processing tasks.

While already former investigations revealed the tonotopic organisation of the cochlear nucleus (Bourk, Mielcarz, & Norris, 1981) and thus prepared the way towards a deeper

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comprehension of its role in pitch-processing, recent studies describe different neural reactions to stimulation, namely the primary-like, chopper, and onset response patterns (Liu, Wang, Xiao, & Zhou, 2014) showing aspects of rhythmic sound-data processing in the cochlear nucleus. Such findings are crucial for investigations on connections between music and heart rates, emphasising that influences are not performed in an analogous way, but depend on complex central nervous constructions.

Recently especially top-down processes from the cortex to subcortical structures have been

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discussed in the context of regulatory circuitries of neural sound-processing. These findings are of high importance for cardiac music therapeutic issues, particularly as they make sure that higher sound-data-processing reorganises via specific retro-loops the quasi neural raw material of the sound (Markovitz, Tang, & Lim, 2013). descending projections from the cortex to subcortical structures are critical for auditory plasticity, including the ability of central neurons to adjust their frequency tuning to relevant and meaningful stimuli. It is very likely that these processes not only apply to pitch-depending structures, but also to rhythmical ones, particularly as tones necessarily include data about the duration of a sound. In this context, descending projections from the auditory cortex to the inferior colliculus (Winer, Chernock, Larue, & Cheung, 2002) are of striking importance for our considerations.

Such top-down retro-loops as well as recently found collateral projections within the auditory pathway, play an important role for various purposes of cerebral sound processing (Schofield, Mellott, & Motts, 2014). «The prominence of the collateral projections suggests that the same information is delivered to both the IC [inferior colliculus] and the MGN [medial geniculate nucleus], or perhaps that a common signal is being delivered as a preparatory indicator or temporal reference point».

That means that basic auditory data processing must not be understood as a strictly hierarchical bottom-up process as it was described by traditional theories. Quick, but just rudimentarily processed bottom-up information and slower, intelligently processed musical information with top-down components are intertwined. In contrast to aesthetic features of music, the word «quick» refers to vital functions of auditory stimuli, as they are, for instance, needed for instinctive defence reactions (Schofield, Mellott, & Motts, 2014).

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The-se direct projections could provide the thalamus with some of the earliest (i.e. fastest) information regarding acoustic stimuli.

Based on these neurophysiological facts, we intuit a neuroscientific explanation for the very heterogeneous physiological responses to acoustic stimuli. These neuro-psychological models correlate highly with phenomenological observations and clinical findings: musical impacts on physiological rhythms may be modulated by psychological dispositions and modes of musical perception and aesthetic experience. This requires individual pre-checks in cardiac music therapeutic practice. Nevertheless, in opposition to the well examined tonotopic organisation, there is a huge lack of studies focusing on rhythm- and accent-related processes within the auditory pathway as well as specific efferent projections from the auditory pathway carrying rhythmic information. Referring to holistic modes of psychophysical data processing in humans, recent studies using quantum physical theories for the explanation of transitions between matter and mind (Mastnak, 2013) allow deductions for qualitative interdependencies between biological processes and aesthetic experiences. inferior colliculus, Music-induced Movements and cardiac Nuclei

Though the inferior colliculus (IC) is mainly known as the auditory pathway’s relay station linking the cochlear nucleus and the medial geniculate body, functional investigations discuss its fundamental role for integrating sounds, filtering and selectivity (Gittelman, Li, & Pollak, 2009) as well as for frequency recognition and pitch discrimination (Egorova, & Ehret, 2008; Ehret, & Merzenich, 1988). Inhibition plays an important role in such IC processes (Pollak, Xie, Gittelman, andoni, & Li,

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2011). Nevertheless, additional afferent and efferent projections are relatively seldom considered of therapeutic importance. Referring to connections with heart rhythms, afferent somatosensory information to the inferior colliculus could be influential via stimulated body -movement and perceived identity with musical rhythms (aitkin, dickhaus, Schult, & Zimmermann, 1978). Speculations are made about the role of the external nucleus of IC in descending auditory input to the spinal cord and in the comparison of auditory and cutaneous information during sound-evoked coordinated body movements. additionally, efferent links to ventrocaudal pontine nuclei of the reticular system and interrelations with facial motor processes which include also fright reactions (Steidl, Faerman, Li, & yeomans, 2004) might play a certain role.

The facial motor-expressive system, however, is connected to the ambiguous and solitary nuclei and thus to cardiac rhythm control.

This hypothetical connection has probably not been mentioned before. Still, we assume that this functional structure exerts a certain influence on interconnecting mechanisms between music and heart rhythm. This might contribute to the explanation of cerebral regulating mechanisms in cases which do not show subjective and aesthetic dependencies of music and heart rate correlations.

Linking neuro-behavioural studies revealing that activation of neurons in the superior and inferior colliculi evoke increases in cardiovascular and respiratory activity (Ligaya et al., 2012) with findings explaining the IC role in sound-processing points clearly to our research topic: the crucial role of the inferior colliculus in modulating music induced cardiac responses.

Though scientific results in this domain are still quite rare, subcortical mechanisms seem

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to be of general high importance for cardiac music therapy.

Medial Geniculate Body and psycho-physiological Dualistic Determination

Though the medial geniculate body of the thalamus is frequently just regarded as a direct relay linking the inferior colliculus and the auditory cortex, there are additional efferent projections of importance for our theories. Emotionally negative labelling of music is closely related to activities between the auditory cortex and the amygdala, encoding both the acoustic features of a stimulus and its valence (Kumar, von Kriegstein, Friston, & Griffiths, 2012). at the same time the medial geniculate body projects into the amygdala playing a crucial role in fear conditioning circuits (Clugnet, & Ledoux, 1990). as psychovegetative conditioning is interrelated with acquired chronic elevated RHR, these mechanisms clearly concern our research topic. This issue refers also to music therapeutic deconditioning as described in example two at the end of this article.

Together with the fact that the amygdala receives sound-information from both the medial geniculate body and the auditory cortex, the well known role the amygdala plays for triggering the heart rate (yang, Simmons, Matthews, Tapert, Bischoff-Grethe, ... & Paulus, 2007) is enriched by a new aspect of importance for cardiac music therapy: Sound shape, musical gestalt and music-associated emotions influence via the amygdala cardiac rhythms.

Cerebral data processing centres receiving projections from both cortical and sub-cortical areas are here supposed to play an outstanding role for overlapping processes integrating

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psychological and somatic factors. Such dualistic determinism is considered to be decisive for literally all psychosomatic processes, including elevated resting heart rate and heart rate variability. Participating in both modes, music can be assumed to be a strong regulating means in psychosomatic therapy. auditory cortex, Neural Networks and regulative systems

The auditory cortex (Poeppel, overath, opper, & Fay, 2012) is a complex system transforming music encoding neural patterns into auditory sensation and musical experience.

Functional units specialising in cognitive and emotional processes generate the complex individual feature of musical awareness and responses, associating auditory sensation with personality, biographic memory, socio-communicative interpretation, and vegetative processes. Complex interplays between information processing and systemic networking are decisive for regulative medical functions. In the context of interdependencies between music and heart rhythms, three crucial modulators and mechanisms are identified:

1. Music psychological characteristics: aesthetic preference, biographical connotation, musical habits and conditioned traits, experienced identity with music, etc; 2. Music and psycho-vegetative integration: Insular cortex, limbic system, etc; 3. Musical rhythm and beat: neuro-cognitive construction of musical time features in the temporal lobe, particularly by specified functional units differentiating beats (ventral) and rhythm (Liégois-Chauvel, Peretz, Babaï, Laguitton, & Chauvel, 1998).

Body movement and the experience of musical beat and rhythm are closely interrelated.

Central nervous mechanisms synchronising

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sensory and motor processes are important for behavioural co-ordination and psychosomatic balance. This also relates to the experience of an individual identity between music and the self.

discussing music induced regulation of heart rhythms, these complex processes have to be taken into consideration. Connections between the dorsal pre-motor cortex and the posterior part of the superior gyrus of the temporal lobe have to be understood as central functional modules (Chen, Zatorre & Penhune, 2006). This study yields good arguments for the assumption of the following hypothesised functional sequence: rhythm processing (temporal lobe) → pre-motor processes → cardiac brain stem nuclei → heart rate regulation. Still further research is required. insular cortex

In this study the insular cortex is considered the essential cortical module processing data for musical influences on cardiac functions. anatomically we have to emphasise that the insular cortex receives projections from the auditory cortex as well as from the medial geniculate body (Rodgers, Benison, Klein, & Barth, 2008). This refers to what we call principles of psycho-vegetative dualistic determinism. Nevertheless, the insular cortex is not only a relay station. Being an evolutionarily old cortical area, it represents a powerful organ dedicated to multi-sensory neural integration and important higher functions in sound and rhythm processing (Herdener, Lehmann, Esposito, di Salle, Federspiel, Bach, ... & Seifritz, 2009; Rodgers, Benison, Klein, & Barth, 2008).

Clinical observations identify cortical traumata such as acute cortical stroke or partial seizures as possible genesis of pathological

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changes of heart rates. additionally, animal studies show significant effects of phasic insular cortex stimulation on heart rate chances (oppenheimer & Cechetto, 1990), and emphasise its profuse autonomic and limbic connectivity. Further studies show cardiovascular effects of human insular cortex stimulation, highlighting lateralisation (oppenheimer, Gelb, Girvin, & Hachinski, 1992). «on stimulation of the left insular cortex, bradycardia and depressor responses were more frequently produced ... The converse applied for the right insular cortex». Subsequent studies confirm this connection (oppenheimer, 2006). Recent evidence implicates several cortical structures, especially the insula, in cardiac rate and rhythm control. These results are compatible with our hypothesis of the insular cortex as the probably most essential module in music induced RHR-regulation. solitary Nucleus

For decades the solitary nucleus has been considered one of the cardiac brain stem kernels performing heart rate regulating functions (Healy, Jew, Black, & Williams, 1981). The baroreceptor reflex loop which mediates bradycardia is sensitive to impulses from catecholamine axons entering the intermediate NTSm [nucleus tractus solitarius medialis].

Recent studies support psychosomatic interpretations of these mechanisms, emphasising involved oxytocin processes which may be related to psychosocial functions (Higa, Mori, Viana, Morris, & Michelini, 2002). oxytocin terminals in the solitary vagal complex modulate reflex control of the heart, acting to facilitate vagal outflow and the slowdown of the heart.

Concerning music as a possible heart rate regulator, the role of the solitary nucleus within

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homeostatic systems has to be newly discussed (Bailey, Hermes, andresen, & aicher, 2006). Cranial visceral afferents activate central pathways that mediate systemic homeostatic processes. afferent information arrives in the brainstem nucleus of the solitary tract (NTS) and is relayed to other CNS sites for integration into autonomic responses and complex behaviors. ambiguous Nucleus

Clinical as well as animal studies confirm regulating functions of the ambiguous nucleus on blood pressure and heart rate (Wang, Irnaten, Neff, Venkatesan, Evans, Loewy, ... & Mendelowitz, 2001). Recent studies reveal synchronising functions of GaBaergic and cardioinhibitory parasympathetic neurons in the ambiguous nucleus (Frank & Mendelowitz, 2012). Though distinct relevance of such findings for our purposes are still unclear, in a wider systemic coherence they suggest deeper neuroscientific and biochemical investigations in cardiac music therapy.

Though we do not assume a direct connection between the auditory cortex and the ambiguous nucleus, we suggest the hypothesis of important indirect links via the neural motor system which refers also to autonomous neural loops as well as to features of aesthetic awareness. crucial structures and Modes of cardiac Music influence

This study suggests five main functional principles characterising components of the entire system of music induced heart rate control:

1. Collaterals from basic to high auditory areas.

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Skipping step by step processing facilitates quick startle reactions and refers to early steps of anthropologic evolution (figure 2).

Higher auditory data processing centres.

Higher auditory data processing centres.

Lower auditory data processing centres.

Lower auditory data processing centres.

2. Retro-projections from higher levels of auditory «intelligence» to lower ones modulate the acoustic «raw material» and play an important role for sound selection. Such top-down-processes represent crucial constituents of regulatory circuitries (figure 3).

3. Efferent projections from the auditory pathway to non-auditory neural centres create subordinate modules for special functions within the music-heart-system (figure 4).

4. dualistic projections from both neocortical areas (awareness) and subcortical structures to the same functional modules play a decisive role for autonomous and aesthetic influences on cardiac reactions (figure 5).

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Non-auditory cerebral centre.

auditory pathway.

FIGURE 2. Bottom-up collaterals skipping intersecting centres of auditory data processing.

FIGURE 3. retro-projections from levels of higher auditory intelligence to lower levels creating regulatory circuitries.

FIGURE 4. efferent projections from the auditory pathway to non-auditory centres creating subordinate modules of the music-heart-system.

5. Integration areas, particularly the insular cortex, represent the functional cores for the transition of musical patterns into cardiac responses.

Together with these functional principles, it is possible to explain heterogeneous effects

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Highest cognitive neocortical structures & processes (aesthetic awareness).

Subcortical structures & functions (submental procedures).

associative, integrating and stimulus-response according areas (e.g. insular cortex).

FIGURE 5. Dualistic projections from higher cognitive cortical areas and subcortical areas to associative and integrating units coordinate auditory stimuli, aesthetic processes and neural cardiac triggers. of music on heart rates as well as contradictions between studies which focus exclusively on musical input and cardiac response, but not on underlying neuro-psychological mechanisms. Especially with regard to cardiac music therapeutic practice, we identify:

1. dominating subcortical structures and pathways triggering cardiac control centres. Widest exclusion of aesthetic processes is compatible with studies emphasising the independence of musical heart rate influence from individual music preferences.

2. Mainly subcortical structures trigger cardiac responses. aesthetic influences play rather marginal roles, but may obstruct processes through the experience of aversive sounds.

3. Interacting cortical and subcortical processes may lead to the awareness of holistic identity with music comprising mental and somatic aspects. Synchronisation of physiological rhythms are experienced as natural.

4. dominating cortical processes influence somatic processes mainly through emotional and mental impacts. Similar to the previous case, inter-individually highly hetero-

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geneous aesthetic, cognitive, and emotional conditions play a decisive role for physiological responses.

The more we ascend along the path of auditory data processing towards psychological processes, the more we face inter-individual diversity. While processes in the organ of Corti or the cochlear nuclei show high interindividual similarity, musical preferences mirror the heterogeneity of the world of music.

The more we leave the zones of highest music processing and approach somatic responses, such as cardiac triggers is the brain stem, the more processes converge again towards high inter-individual comparability. This «doublepyramidal» principle has to be considered a crucial model in cardiac music therapy. three clinical issues and Music therapeutic approaches

The following three clinical examples should demonstrate the wide field of application of cardio music therapy and the explanatory potential of the cardio-neuropsychologic model above.

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Primary Elevated Resting Heart Rate: A Music Therapeutic Case Report

Mr L is physically relatively fit and shows good cognitive abilities. He has slight tendencies to obsessive-compulsive thinking, vague anxieties, though no phobic or panic disorder, feels easily guilty, and has problems to enjoy leisure time. He is driven by the idea that he has to fulfil various tasks, just relaxing is for him rather a waste of time and a certain sin against life.

Mr L has a relatively high resting heart rate and a slightly elevated blood pressure, but does not take cardiac drugs. Still, he fears cardiovascular problems and is terrified by the idea to suffer a cerebral stroke. There are phases in his life where he does a lot of sports, not at least for health reasons, but he has big problems to relax and to overcome the inner feeling of being driven.

In the context of a preventive and rehabilitative heart support group, he decides to try to control blood pressure and heart rate by music. a music therapist asks about experiences with music, relaxing responses, preferences etc. Mr L mentions that slow pieces by J. S. Bach exert a calming influence both on his mind and his body. and he tells about an experience some decades ago, where he heard, just by chance, the recording of the aria No. 39 «Erbarme dich, mein Gott» from the St Matthew Passion. He was literally mesmerised, forgot everything around himself and felt an enormous calmness in his soul. He cannot remember having experienced a similarly deep calmness again. a test setting is arranged. after measuring Mr L’s heart rate and blood pressure he listens to a Cd recording of this aria. Blood pressure and heart rate go down, though Mr L cannot be classified as a synchronization type. Though

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his breath frequency and the musical beat are numerically correlated, music and heart rate do not exhibit integer ratio synchronisation.

In addition to these physiological data, Mr L speaks again about a certain calmness, though not as deep as the first time.

Mr L begins to apply music at home, 2 times a day: measuring blood pressure and heart rate, listening to this aria two times in a row, again measuring blood pressure and heart rate. Results are similar to the first test, but Mr L is not satisfied with the setting. He dislikes the second measuring of blood pressure which destroys his calm feelings. In addition to that, he fears that frequent application harms the miraculous flair of Bach’s music.

He begins to investigate the psychological and cardiac influence of other pieces of music, such as Sarabandes by Bach, slow movements from Mozart’s piano concertos and pieces from Mendelssohn’s and Händel’s oratorios. additionally to listening, he develops, mostly through self-experience, a form of synchronised breathing, slow movements which look like conducting or Tai Chi, and a sort of «inversion of gaze». He has the impression that he can also invert his ear and experience the music like sounding inside the body, so that the auditory and visual sense are directed towards «inner spaces».

In addition to a decrease of his resting pulse, he appreciates these sessions at home for particularly three reasons: a) he begins to enjoy the feeling of calmness and to be able to forget the time; b) he discovers a certain creativity of expressive movements, he feels astonishingly in balance, harmonising music, body expression, and mood; c) he likes the inner images which emerge, somehow like in a dream, but in a more conscious way. These visual sensations relate on the one side to his biography, he realises them as «films from the past», on the other side they are of symbo-

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lic value and give him enigmas to solve (which he likes). Sometimes they are just aesthetically wonderful. Though Mr L is quite active in his life, as a person, he feels alone. during these «rituals of listening», however, he feels in a deep relation with the universe and secure.

Conditioned Elevated Resting Heart Rates: A Behavioural Music-Therapeutic Method

Music therapy comprises a huge amount of various methods and concepts and concerns very heterogeneous issues and clinical aims (aigen, 2014). one music therapeutic approach goes back to the theoretical roots of behavioural therapies, including principles of conditioning and a self-concept that depends on one’s behavioural repertoire and characteristics.

Based on anthropologically old mechanisms, threatening experiences and horrifying situations trigger high heart rates. Pathogenic conditions can lead to chronification, often called «conditioned tachycardia». In the case of high heart rates we have to refer to interdisciplinary differential diagnostics, especially taking into consideration:

1. Physiological disorders of the cardiac nervous system.

2. a weak physical respectively heart condition is frequently associated with elevated resting heart rates.

3. Subconscious or repressed threats leading to specific cardiac conversion syndromes.

4. Generalising traumatic experiences causing permanent stress and stress-related signs.

5. Conditioning processes in the sense of behavioural psychology establish permanent elevated resting heart rates.

Particularly in the case of conditioned elevated RHR, behavioural medical intervention or

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specific behavioural therapeutic treatment is a good method of choice. depending on the patient’s personality and mode of psychosomatic responses to auditory stimuli, music can become a highly efficient means for curative deconditioning. Crucial points in music therapy are:

1. Use of aesthetically or biographically positively labelled musical stimuli.

2. Creating a high sensory body-awareness.

3. according to the law of contiguity, establishment of a sensed unity of music, heart activity, and inner calmness.

4. Training frequencies according to behavioural psychological and medical guidelines (in general regularly at the beginning and intermittent during the phase of consolidation).

5. development of the ability of imaginative musical stimuli for bio-rhythmical regulation.

To avoid diagnostic errors and cardiac threats, regular evaluation of therapeutic outcomes and close collaboration with a cardiologist is recommended. according to our dualistic theory, deconditioning processes may be based on a rather beat-controlled physiological mechanism or on an affective cognition-rhythm-related form of music processing.

Heart Rates and Dysbalanced or Decomposed Personalities: A Model of SOUND WORK

Sound Work (Mastnak, 2000) was developed on the basis of psychiatric and psychosomatic case analyses in order to create a pragmatically efficient music therapeutic system. Four main pathologically relevant features were identified:

1. traumata and symbolizations. Highly negative experiences in former life phases

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creating pathological behaviour or traumasymbolising psychosomatic phenomena.

2. somatisations. Psychological problems leading to somatic symptoms, often also involving specific psychosomatic reinforcement loops.

3. holistic Balance. Psychosomatic processes becoming desynchronised. The patient feels broken, torn apart, depersonalised, etc.

4. energetic Derailment. Energies cannot be controlled or break down or are pathologically fixed on isolated processes.

These characteristics led to the development of four corresponding methodological fields:

1. sound coping (trauma and symbolisation).

2. sound Focusing (somatisation and psychosomatic circuitries).

3. sound Balancing (re-adjustment of a well balanced self).

4. sound energising (regulation of energy and availability of energy).

Sound Work is a vocal and body oriented method for application in groups and working with four main constituting elements: voice – body – group – space.

Feelings of falling apart, of losing the integrity of one’s body and mind, of a sort of psychosomatic decomposition and being bio-rhythmically derailed belongs to the symptoms of many psychiatric and psychosomatic troubles, such as panic attacks, personality disorders, and schizophrenia. Though not representing their characterising symptoms and main pathological criteria, they are painful, irritating, and horrifying for the patient. In addition to that, they may not only be considered as visible expression of a disease but also as an interacting agent, a dynamic part in a psychosomatic circuitry, a pathological loop that tends to stabilise and consolidate the disorder’s nature.

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Sound Balancing is based on the therapeutic assumption that voice-body-work on psychosomatic harmonisation may exert a curative regulatory influence on distinct dysbalanced conditions. In our case, these include also cardiac rhythmological issues. The presented voice-body-therapeutic example not only relates to elevated RHR but also to various psy-chosomatically triggered abnormities of cardiac rhythms. Individual and group therapy are combined. individual therapy

In a preparatory phase the patient tries: a) to touch the radial and carotid pulse; b) to feel the impulse of the heart beat on the body (e.g. when sitting on one’s legs, body upright and relaxed, the aorta pulse usually causes rhythmic movements of the upper body); c) to feel the heart rate like an internal rhythm.

Being able to sense the pulse, the patient tries to synchronise his/her respiratory rate by integer ratios respecting also the perceived shape of the pulse wave and gestalt of respiratory cycles. Not only the single accent or peak is important, not only the mere frequency matters. Usually pulse and breathing follow different shapes which can be interpreted as different «melodic» curves. additionally, the patient begins to create movements and vocal expressions that fit rhythmically to pulse and breathing. The shapes of the body movement and the vocal expressions, their inner tensions and dynamics (e.g. rubato) may resemble the shape of the pulse wave or the breathing. Nevertheless, they also can develop totally different forms. Musical metres, beats, and pulses, however, must be identical and perfectly synchronised. The patient tries to intensify the aesthetic connection between bio-rhythms, body-voice-rhythms and the inner sense of rhythm. a main target is not to «perform», but to «be within» this «sympho-

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nic» process. In a deep psychosomatic state of synchronised somatic, motor, and musical rhythms, heart beats usually become controllable and can decrease. often, however, heart rates are decreased automatically.

Group therapy

Group therapeutic processes are based on preconditions that have been acquired in the individual setting und comprise: a) a group feeling of different tempi and their bio-rhythmical impacts and reactivity; b) the group experience of a «common heart beat» similar to archaic rituals; c) rhythmically synchronised communication and non-verbal empathy; d) creative vocal and body-expressive processes which are based on body oriented and bio-rhythmic identity; e) experience of social inclusion and safety through synchronised musical and somatic rhythms; f) space for creative expression of psychological issues.

Both in individual and group therapy, multiple aspects of re-balancing play a decisive role.

Bio-rhythmic, emotional, socio-communicative, empathetic, and holistic balance are of crucial importance. cONcLusiON

Music therapy can be regarded as an efficient and psychosomatically relatively safe intervention in individuals with high resting heart rate. In pathological cases, it is the duty of the cardiologist to decide the role of music therapy as an add-on therapy, a complementary therapeutic application, or even an alternative to pharmacological treatment. The decision involves issues of individual cardiac responsiveness to music. The corresponding patient typology depends crucially on cortical

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and subcortical mechanisms linking the auditory pathway and cardiac regulatory processes.

While the application of chemical medication usually requires a discussion of possible side effects and physiological interactions, in music therapy we have to take multifaceted effects into consideration. It is mainly the responsibility of music therapists to identify and to assess psychological co-effects of music, such as the reduction of anxieties or the alleviation of symptoms of low mood. The involvement of psycho-physiological feedback loops, such as e.g. those referring to pain control or vegetative processes, has to be taken into clinical consideration. This requires close collaboration between physicians and music therapists.

In addition to the results from music therapeutic evidence based medical investigations, which provide guidelines for intervention, studies on neuropsychological mechanisms linking auditory stimulation and heart activities help to identify individual responses to music therapy. It seems that closer interdisciplinary collaboration between empirical, neuropsychological, and aesthetical music therapeutic research would result in more advanced applications of music therapy in cardiology. reFereNces

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amaral, J.a., Nogueira, a.M., Roque, a.L., Guida, H.L., de abeu, Raimundo, R.d., ... & Valenti, V.E. (2014). Cardiac autonomic regulation during exposure to auditory stimulation with classical baroque or heavy metal music of different intensities. Türk Kardiyoloji Derneği Arşivi, 42(2), 139-146. doi: 10.5543/tkda.2014.39000 Bailey, T.W., Hermes, S.M., andresen, M.C., & aicher, S.a. (2006). Cranial visceral afferent pathways through the nucleus of the solitary tract to caudal ventrolateral medulla or paraventricular hypothalamus: targetspecific synaptic reliability and convergence patterns. Journal of Neuroscience, 26(46), 11893-11902. doi: 10. 1523/JNEURoSCI.2044-06.2006 Barrios, V., Escobar, C., Bertomeu, V., Murga, N., de Pablo, C., & asín, E. (2009). High heart rate: more than a risk factor. Lessons from a clinical practice survey. International Journal of Cardiology, 137(3), 292-294. doi: 10.1016/j.ijcard. 2008.05.045 Bauer, B.a., Cutshall, S.a., anderson, P.G., Prinsen, S.K., Wentworth, L.J., olney, T.J., ... & Bauer, B.a. (2011). Effect of the combination of music and nature sounds on pain and anxiety in cardiac surgical patients: a randomized study. Alternative Therapies in Health and Medicine, 17(4), 16-23.

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1002/14651858.Cd006577 Buffum, M.d., Sasso, C., Sands, L.P., Lanier, E., yellen, M., & Hayes, a. (2006). a music intervention to reduce anxiety before vascular angiogra- phy procedures. Journal of Vascular Nursing, 24(3), 68-73. doi: 10.

1016/j.jvn.2006. 04.001 Chang, H.K., Peng, T.C., Wang, J.H., & Lai, H.L. (2011). Psychophysiological responses to sedative music in patients awaiting cardiac catheterization examination: a randomized controlled trial. Journal of Cardiovascular Nursing, 26(5); E11-18. doi: 10.1097/JCN. 0b013e 3181fb711b Chen, J.L., Zatorre, R.J., & Penhune, V.B. (2006).

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dif, J.C. (2005). Long-term prognostic value of resting heart rate in patients with suspected or proven coronary artery disease.

European Heart Journal, 26(10), 967-974. doi: 10.1093/eurheartj/ehi190 Eagle, K.a., Lim, M.J., dabbous, o.H., Pieper, K.S., Goldberg, R.J., Van de Werf, F., ... & Fox, K.a. (2004). a validated prediction model for all forms of acute coronary syndromes: Estimating the risk of 6-month postdischarge death in an international registry. JAMA, 291(22), 2727-2733. doi: 10.1001/jama.291.22.2727 Egorova, M., & Ehret, G. (2008). Tonotopy and inhibition in the midbrain inferior colliculus shape spectral resolution of sounds in neural critical bands. European Journal of Neuroscience, 28(4), 675-692. doi: 10.1111/j.

1460-9568.2008. 06376x Ehret, G., & Merzenich, M.M. (1988). Complex sound analysis (frequency resolution, filtering and spectral integration) by single units of the inferior colliculus of the cat. Brain Research, 472(2),139-163. doi: 10.1016/01650173(88) 90018-5 Escobar, C., & Barrios, V. (2008). High resting heart rate: a cardiovascular risk factor or a marker of risk? European Heart Journal, 29(2), 2823-2824. doi: 10.1093/eurheartj/ ehn447 Fox, K., Borer, J.S., Camm, a.J., danchin, N., Ferrari, R., Lopez-Sendon, J.L., ... & Tendera, M. (2007). Resting heart rate in cardiovascular disease. Journal of the American College of Cardiology, 50(9), 823-830. doi: 10.1016/j.jacc.2007.04.079 Frank, J.G., & Mendelowitz d. (2012). Synaptic and intrinsic activation of GaBaergic neurons in the cardiorespiratory brainstem network. PLoS One, 7, e36459. doi: 10.1371/ journal.pone. 0036459 Frank, C. (1982). Musical rhythms as possible synchronizer of biological rhythms? [original title: Musikrhythmen als möglicher Synchronisator für biologische Rhythmen?]

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Mechanisms underlying directional selectivity for frequency-modulated sweeps in the inferior colli- culus revealed by in vivo whole-cell recordings. Journal of Neuroscience, 29(41),13030-13041. doi: 10.1523/ JNEURoSCI.2477-09.2009 Gomez, P., & danuser, B. (2007). Relationships between musical structure and psychophysiological measures and emotion. Emotion, 7(2), 377- 387. doi: 10.1037/1528-3542.7.

2.377 Gosse, P. (1998). Heart rate: risk factor, risk marker. Annales de Cardiologie et d’Angéiologie, 47(6), 438-439.

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Hatem, T.P., Lira, P.I., & Mattos, S.S. (2006). The therapeutic effects of music in children following cardiac surgery. Jornal de pediatria (Rio), 82(3), 186-192 Healy, d.P., Jew, J.y., Black, a.C., & Williams, T.H. (1981). Bradycardia following injection of 6-hydroxydopamine into the intermediate portion of nucleus tractus solitarius medialis. Brain Research, 206(2), 415-420. doi: 10.1016/0006-8993(81)90541-2 Herdener, M., Lehmann, C., Esposito, F., di Salle, F., Federspiel, a., Bach, d.R., ... & Seifritz, E. (2009). Brain responses to auditory and visual stimulus offset: shared representations of temporal ed-ges. Human Brain Mapping, 30(3), 725-733. doi: 10.1002/ hbm.20539 Higa, K.T., Mori, E., Viana, F.F., Morris, M., & Michelini, L.C. (2002). Baroreflex control of heart rate by oxytocin in the solitary-vagal

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complex. American Journal of Physiology.

Regulatory, Integrative and Comparative Physiology, 282(2), R537-R545. doi: 10.1152 /ajpregu.00806.2000 Iigaya, K., Müller-Ribeiro, F.C., Horiuchi, J., Mcdowall, L.M., Nalivaiko, E., Fontes, M.a., & dampney, R.a. (2012). Synchronized activation of sympathetic vasomotor, cardiac, and respiratory outputs by neurons in the midbrain colliculi. American Journal of Physiology. Regulatory, Integrative and Comparative Physiology, 303(6), R599R610. doi: 10.1152/ ajpregu.00205. 2012 Kneutgen, J. a. (1970). a musical form and its biological function: about the effect of lullabies [original title: Eine Musikform und ihre biologische Funktion: Über die Wirkungsweise der Wiegenlieder]. Zeitschrift für experimentelle und angewandte Psychologie, 17, 245-265.

Kumar, S., von Kriegstein, K., Friston, K., & Griffiths, T.d. (2012). Features versus feelings: dissociable representations of the acoustic features and valence of aversive sounds.

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2012 Liégois-Chauvel, C., Peretz, I., Babaï, M., Laguitton, V., & Chauvel, P. (1998). Contribution of different cortical areas in the temporal lobes to music processing. Brain, 121(Pt 10), 1853-1867. doi: 10.1093/brain/121.

10.1853 Liu, J., Wang, C., Xiao, Z., & Zhou, L. (2014).

Changes of response patterns to excitatory stimuli of different intensities: a modelbased study of cochlear nucleus neurons.

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03.01 Mandel, S.E., Hanser, S.B., Secic, M., & davis, B.a. (2007). Effects of music therapy on health-related outcomes in cardiac rehabilitation: a randomized controlled trial. Journal

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of Music Therapy, 44(3), 176-197. doi: 10.1093/jmt/ 44.3.176 Markovitz, C.d., Tang, T.T., & Lim, H.H. (2013).

Tonotopic and localized pathways from primary auditory cortex to the central nucleus of the inferior colliculus. Frontiers in Neural Circuits, 7, 77. doi: 10.3389/fncir.2013.

00077 Mastnak, W. (2000): Sound Work. Therapy with Voice and Body. [original title: Sound Work. Therapie mit Stimme und Körper].

Musik-, Tanz- und Kunsttherapie, 11(3), 119 -125. doi: 10. 1026//0933-6885.11. 3.119 Mastnak, W. (2013). Subatomic consciousness and music therapy: From quantum physical hypotheses to psychosomatic effects of music. [original title: Subatomare Bewusstheit und Musik- therapie. Quantenphysikalische Hypothesen zur psychosomatischen Wirkung von Musik]. Musik-, Tanzund Kunsttherapie, 24(4), 174-187. doi: 10.1026/0933-6885/ a000145 Miller, G.a. (2003). The cognitive revolution: a historical perspective. Trends in Cognitive Science, 7(3), 141-144. doi: 10.1016/ S1364 -6613(03) 00029-9 Miller, M., Mangano, C.C., Beach, V., Kop, W.J., & Vogel, R.a. (2010). divergent effects of joyful and anxiety-provoking music on endothelial vasoreactivity. Psychosomatic Medicine, 72(4), 354-356. doi: 10.1097/PSy. 0b013e3181da7968 Nam, J.H. (2014). Microstructures in the organ of Corti help outer hair cells form travelling waves along the cochlear coil. Biophysical Journal, 106(11), 2426-2433. doi: 10.1016/ j.bpj. 2014. 04.018 Nauman, J., aspens, S.T., Nilsen, T.I., Vatten, L.J., & Wisløff, U. (2012). a prospective population study of resting heart rate and peak oxygen uptake (the HUNT Study, Norway). PLoS One, 7, e45021. doi: 10.1371/ journal.pone.0045021 Nauman, J., Janszky, I., Vatten, L.J., & Wisløff, U. (2011). Temporal changes in resting

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heart rate and deaths from ischemic heart disease. JAMA, 306 (23), 2579-2587. doi: 10.1001/jama.2011. 1826 oertel, d., Fay, R.R., & Popper, a.N. (Eds) (2002).

Integrative functions in the mammalian auditory pathway. New york: Springer. oppenheimer, S. (2006). Cerebrogenic cardiac arrhythmias: cortical lateralization and clinical significance. Clinical Autonomic Research, 16(1), 6-11. doi: 10.1007/s10286-0060276-0 oppenheimer, S.M., & Cechetto, d.F. (1990).

Cardiac chronotropic organization of the rat insular cortex. Brain Research, 533(1), 6672. doi: 10. 1016/0006-8993(90)91796-J oppenheimer, S.M., Gelb, a., Girvin, J.P., & Hachinski, V.C. (1992). Cardiovascular effects of human insular cortex stimulation. Neurology, 42(9), 1727-1732. doi: 10.1212/ WNL.42.9. 1727 Poeppel, d., overath, T., opper, a., & Fay, R.R. (Eds) (2012). The human auditory cortex.

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(2014). Subcollicular projections to the auditory thalamus and collateral projections to the inferior colliculus. Frontiers in Neuroanatomy, 8, 70. doi: 10.3389/fnana.

2014. 00070 Sleight, P. (2013). Cardiovascular effects of music by entraining cardiovascular autonomic rhythms music therapy update: tailored to each person, or does one size fit all?

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03.020 Todres, I.d. (2006): Música é remédio para o coração [Music is medicine for the heart].

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2013.00334 Voss, J.a., Good, M., yates, B., Baun, M.M., Thompson, a., & Hertzog, M. (2004). Sedative music reduces anxiety and pain during

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chair rest after open-heart surgery. Pain, 112(1-2), 197-203. doi: 10.1016/j.pain. 2004.

08.020 Wang, J., Irnaten, M., Ne, R.a., Venkatesan, P., Evans, C., Loewy, a.d., ... & Mendelowitz, d. (2001). Synaptic and neurotransmitter activation of cardiac vagal neurons in the nucleus ambiguus. Annals of the New York Academy of Sciences, 940, 237-246. doi: 10.1111/j.1749-6632.2001. tb03680.x Winer, J.a., Chernock, M.L., Larue, d.T., & Cheung, S.W. (2002). descending projec-

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1016/j.neulet.2007. 09.039

about the author

Wolfgang Mastnak Wolfgang Mastnak is professor of music therapy at the Shanghai Conservatory of Music. He is president of the austrian Heart association for long-term cardiac rehabilitation and holds the chair of music education at the University of Music and Performing arts in Munich / Germany. He is member of the New york academy of Sciences and the European academy of Sciences and arts.

Mastnak started his music therapeutic career as head of the music therapeutic division of the neuro-psychiatric polyclinics in Salzburg / austria. at this time he began to develop Sound Work as a voice-body-oriented music therapeutic group method. Today Mastnak specialises in psychiatric and cardiac music therapy, music therapeutic methodology and meta-theories. dealing with ethno music therapy and cultural sensitivity in music therapy he focuses mainly on Eastern asia and Europe. a further main topic of his research concerns music in preventive medicine and health promotion as well as intersections of music education and therapy.

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Music therapy handbook edited by Barbara L. Wheeler

the Guildford Press, New york, Ny isBN 978-1-4625-1803-6 (507 pages)

reviewer: Melissa Mercadal-Brotons, PhD, Mt-Bc, sMtae Professor and Director of the Music therapy Master’s Program, escola superior de Música de catalunya (esMuc), Barcelona, spain.

«Music therapy handbook», is a comprehensive book that covers a broad variety of topics related to the contemporary field of Music Therapy, which can be of interest to a wide audience. This new volume has been edited

by Dr. Barbara Wheeler, Professor Emerita at Montclair State University, and very active in presenting and teaching in the United States as well as internationally. In addition, she is a widely published author, and offers here a comprehensive text, which ranges from basic fundamental concepts on which the profession is built, to emerging clinical approaches written by expert contributors who represent a variety of countries and regions served by the World Federation of Music Therapy (WFMT).

Music Therapy Handbook unfolds in three parts: overview and issues, orientations and approaches, and clinical applications. The third part includes three sections: music therapy for children and adolescents, music therapy for adults, and medical music therapy.

Each of the parts is preceded by a short overview and summary of its content.

In Part 1: Overview and issues, Dr. Wheeler introduces the field of music therapy starting with a definition of the discipline and comparing it to other uses of music in health and community settings. The chapter also includes the specific populations and work con-

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texts where this treatment modality is applied, some information about the training needed to become a professional of the field, and the importance of research and its dissemination for the development of the profession. In Chapter 2, Drs. William Davis and Susan Hadley address the history of music therapy from an international perspective, beginning with the uses of music for healing in ancient times up to the establishment of the profession in the 1950’s and the current status of the field. «Aesthetic foundations of Music Therapy: Music and Emotion» (Chapter 3) explores the topic of emotions in music therapy. Dr. Hiller delves into the relationship between emotions and music making and how involvement in active music facilitates the expression of emotions. In Chapter 4, «Music therapy and the brain», Dr. Tomaino discusses how music is processed in the brain and its connections to the rest of the neurological system. Dr. Kim and Dr. WhiteheadPleaux address several cultural issues in Chapter 5 («Music therapy and cultural diversity») as they relate to the practice of music therapy and stress the importance of music therapists’ cultural awareness as our society becomes more diverse and heterogeneous.

Chapter 6 «Ethics in Music Therapy» observes and analyzes several ethical issues as they relate to the practice of music therapy, such as confidentiality, multiple relationships, and social media. Debbie Bates includes several case

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examples to illustrate these issues, which help the reader to think broadly about the challenge these may present. Dr. Lipe develops the topic of «Music Therapy Assessment», a crucial component of the music therapy process, in chapter 7. She examines several issues related to assessment, and reviews several types of assessment and their psychometric properties. Chapter 8, entitled «Music Therapy Research», by Dr. Burns and Dr. Meadows, emphasizes the importance of research in the music therapy field and the connections between research findings and clinical applications. The chapter also includes an overview of research methods used in music therapy including quantitative, qualitative and mixed methods. Dr. Baker discusses «Evidence-Based Practice in Music Therapy» (EBP) in chapter 9, in which she defines EBP, and what is accepted as evidence in music therapy. She also talks about the contribution of qualitative research to the field and the insight this brings regarding what patients value from their experience in music therapy. Part I ends with Chapter 10 in which Dr. Gardstrom and Dr. Sorel review the different «Music Therapy Methods» (receptive, compositional, improvisational, and re-creative) and some of their variations and applications illustrated with case examples with a variety of populations.

Part ii, «Orientations and approaches» includes 10 chapters each of which focus on a different approach and/or philosophical orientation of music therapy. Each chapter starts with a brief definition and explanation of the approach, followed by a review of the historical and theoretical foundations of the approach, and case examples to illustrate music therapy applications of each approach in clinical contexts. Chapters 11 («Psychodynamic approaches» written by Dr. Connie Isenberg), 12 («Humanistic approaches» by Dr. Bryan Adams), and 13 («Cognitive-Behavioral ap-

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proaches» by Dr. Suzanne Hanser) address specific psychotherapeutic orientations, which provide bases for Music Therapy practice. Dr. Cynthia Briggs tackles «Developmental approaches» in Chapter 14, in which she discusses how models of human developmental in music can guide music therapy practice.

Chapters 15-20 present specific music therapy approaches started and developed by music therapists. «Creative Music Therapy» (perhaps better known as Nordoff-Robbins Music Therapy) is the topic of Chapter 15, presented by music therapists Nina Guerrero, David Marcus and Dr. Alan Turry. Improvisation and the concept of the musical child are two of the key elements of this approach.

Madelaine Ventre and Dr. Cathy H. McKinney share their knowledge and expertise in the «Bonny Method of Guided Imagery and Music» in Chapter 16, also known as GIM (Guided Imagery and Music). Music listening, classical music, and altered states of consciousness are central elements of this approach. In Chapter 17, music psychotherapist Benedikte B. Scheiby focuses on «Analytical Music Therapy». Improvisation is the main method of this approach, and several adaptations are also presented. «Neurologic Music Therapy» (NMT) is the topic of Chapter 18, presented by Dr. Corene P. Hurt-Thaut and neurologic music therapist Sarah B. Johnson.

The standardized clinical techniques presented in this chapter are all research-based and this model follows a transformational design to guide the clinical practice of the NMT professional in order to select the best technique according to the client’s needs and therapeutic objectives. Dr. Brynjulf Stige describes «Community Music Therapy» (CoMT) in Chapter 19. The emphasis of this approach is the practice of music therapy outside traditional settings, mainly in the context of the community. It involves a participatory, ecological, and sometimes activist focus to promote social

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change, health and wellbeing. Chapter 20 («Music Therapy in Expressive Arts») concludes this second part of the book. Margareta Wärja presents a multimodal approach (Music-centered expressive arts therapy), stressing the body-mind connection, in which music therapy is combined with other artistic modalities such as visual arts, dance/movement, drama, music, photo/filmmaking, writing, and literary art for therapeutic purposes.

Some professional music therapists define themselves as eclectic since they incorporate aspects of the different music therapy approaches described in this part. However, there are others that subscribe to a particular approach and are aligned with a specific model or philosophical orientation. Part II of the book is a good representation of what music therapists base their work on and how models and philosophical orientations influence music therapists’ daily clinical work.

Part iii «Clinical Applications» is divided in three sections. All chapters follow the same structure beginning with an introduction and presentation of the terminology specific to the topic in question. It is followed by a definition of the specific population and the challenges it presents. The focus of the following section includes music therapy targeted areas and examples of specific interventions from the authors’ clinical evidence-based experience. The chapters conclude with a section on applications of other disciplines, with examples on how other professionals can be integrated in the music therapy sessions or how they can apply some of the music resources while under the supervision of music therapists. Each chapter is also completed with a summary.

section a focuses on Music Therapy with children and adolescents including chapters 2126: Music Therapy for Developmental Issues in Early Childhood (presented by Marcia

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Humpal), Music Therapy for Children with Intellectual Disabilities (co-authored by Beth MacLaughlin and Ruthlee Figlure Adler), Music Therapy for Children with Autism Spectrum Disorder (co-authored by Dr. John A. Carpente and Dr. A. Blythe LaGasse), Music Therapy for Children with Speech and Language Disorders (presented by Dr. Kathleen M. Howland), Music Therapy for Children with Sensory Deficits (co-authored by Greta E. Gillmeister and Paige A. Robbins Elwafi), and Music Therapy in the Schools (by Dr. Katrina Skewes McFerran).

section B concentrates on Music Therapy for adults and includes chapters 27-32 covering the topics of Music Therapy for Adults with Mental Illness (written by Gillian Stephens Langdon), Music Therapy with Addiction Treatments (presented by Dr. Kathleen M. Murphy), Music Therapy for older Adults (coauthored by Dr. Hanne Mette Ridder and Dr. Barbara L. Wheeler), Music Therapy for Women Survivors of Domestic Violence (co-authored by Dr. Elizabeth york and Dr. Sandra L. Curtis), Music Therapy for Survivors of Traumatic Events (presented by Ronald M. Borczon), and Music Therapy for Grief and Loss (written by Dr. Robert E. Krout).

section c is totally devoted to Medical Music Therapy including Chapters 33-35. Music Therapy in the Neonatal Intensive Care Unit is co-authored by Dr. Helen Shoemark and Dr. Deanna Hanson-Abromeit. Dr. Joanne Loewy presents the chapter Medical Music Therapy for Children. Medical Music Therapy for Adults is co-authored y Dr. Carol Shultis and Lisa Gallagher. This section concludes with the chapters Music Therapy for Adults with Traumatic Brain Injury or other Neurological Disorders (by Dr. Jeanette Tamplin), and Music Therapy at the End of Life, co-authored by Dr. Clare o’Callaghan, Lucy Forrest, and yun Wen.

MusictheraPyToDAy, Volume 12, No. 1, 2016

A wonderful reference book which ranges from the theoretical foundations on which the field of music therapy is based to a broad variety of clinical applications with clear examples that illustrate what music therapists actually do with a wide range of populations and ages. This is a significant contribution to the music therapy literature, and is highly recommended to music therapy educators, stu-

dents, clinicians and allied health care professionals. All of the chapters offer unique and valuable information that is applicable to many global contexts, and which are informed by distinguished authors who weave research results, personal and professional experiences into their writing with great clinical examples that bring music therapy to life.

about the author

Melissa Mercadal-Brotons, PhD, Mt-Bc, sMtae Melissa Mercadal-Brotons is the Director of the Music TherapyMaster Program, Escola Superior de Música de Catalunya (ESMUC), and Coordinator of Research and Master Programs at ESMUC. She is the Chair of the Publications Commission of the World Federation of Music Therapy (WFMT) and the Spanish Delegate of the European Music Therapy Confederation (EMTC).

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ERRATA: Dr. Petra Kern’s bio for the article Advancing the World Federation of Music Therapy (WFMT) organization: Strategic planning process (authors: Annie Heiderscheit, Ph.D., MT-BC, LMFT, Petra Kern, Ph.D., MT-BC, MTA, DMtG, Amy Clements-Cortes, PhD, RP, MT-BC, MTA,Anita L. Gadberry, Ph.D., MT-BC,Jeanette Milford, MMusThrpy, GDipAppPsych, and Jen Spivey, MA, MS, MT-BC) published in the 30th Anniversary Edition of Music Therapy Today (Vol. 11, N. 2) should read as follows: Petra Kern Petra Kern, Ph.D., MT-BC, MTA, DMtG, owner of Music Therapy Consulting, online professor at the University of Louisville, and Editor-in-Chief of Imagine is former WFMT President and recipient of WFMT’s first Service Award. During the strategic planning process, she provided a historical perspective to predict and determine the future of WFMT.

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Graphic design by:

EDITORIAL MÉDICA JIMS, S. L. Sant Eudald, 4bis, b.1; 08023 Barcelona (Spain) jims@es.inter.net www.jimsmedica. com

We publish music therapy books in Spanish Publicamos libros de musicoterapia en español

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