Music Therapy Today, Vol. 1, No. 1

2000 vol. 1

EDITORIAL BOARD: Publisher/Editor in Chief: Prof. Dr. D. Aldridge Editor: Dr. Jörg Fachner, joergf@uni-wh.de Managing editor: Christina Wagner, cwagner@uni-wh.de Book review editor Annemiek Vink, a.c.vink@capitolonline.nl Odds and ends, themes and trends Tom Doch , t.doch@t-online.de International contacts Petra Kern, PETRAKERN@prodigy.net Scientific Advisory Board Prof. Dr. Jaako Erkkilä, University of Jyväskulä, Finland Dr. Hanne Mette Ridder, University of Aalborg, Denmark Dr. Gudrun Aldridge, University Witten/Herdecke, Germany Marcos Vidret, University of Buenos Aires, Argentinia Dr. Cochavit Elefant, Bar Ilan University Israel Prof. Dr. Cheryl Dileo. Temple University in Philadelphia, USA Prof. Dr. Marlene Dobkin de Rios, University of California, Irvine, USA Dr. Alenka Barber-Kersovan , University of Hamburg, Germany Prof. Dr. Tia DeNora, University of Exeter, UK Dr. Patricia L. Sabbatella, University of Cadiz, Spain

Table of Contents

Volume I, Issue 1 (November 2000) (“Music Therapy Today� formerly published as Research and Practice News at www.musictherapyworld.net)

Enhancing Communication Skills of Girls with Rett Syndrome through Music Therapy Cochavit Elefant Singing in Individual Music Therapy with Elderly Persons suffering from Dementia Hanne Mette Ridder Musical Acts of Love in the case of severely ill and dying children and their families Trygve Aasgaard

Volume I, Issue 1 (November 2000)

Aspects of music therapy on the psychiatric ward for adults at the Herdecke Community Hospital Peter Hoffmann

Music Therapy Today Sample Issue 2000 - 2003

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MT Practice News: Research Showcase

Editor, David Aldridge

davida@uni-wh.de

Research news is a magazine for sharing research news.

This month’s practitioner is Cochavit Elefant. You can contact her at P.O.Box 1323 Kfar Saba, Israel 44221 E-mail: elefant@netvision.net.il Cochavit is a PhD student at Aalborg University with Trygve Aasgaard, the practitioner of the month in "Practice News"

research showcase: Cochavit Elefant Research Project: Enhancing Communication Skills of Girls with Rett Syndrome through Music Therapy

Background: Girls with Rett syndrome, although quite impaired, show a strong desire to communicate. This is evident by their eye gaze, facial expression and body gestures. They are unable to do so due to the lack of expressive language and the inability to functionally use their hands. Their interest to communicate with others made me pursue their desire through research in music therapy.

Aim: The aim of this study is to investigate if girls with Rett Syndrome will enhance their communication skills when provided the opportunity to make choices between songs . The research focuses on: 1) intentionality in the girls' choice making, 2) song preferences, 3) emotional responses to songs, 4) vocalization & 5) body gestures.

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A multiple baseline, single subject design is used in this study. In this time series design, seven girls with Rett syndrome is viewed as a single case unit in which the experimental comparison is within the individual girl. This type of research which has a rigorous methodology, maintains the flexibility in the therapeutic process of the clinical work. Seven girls with Rett syndrome received individual choice making of songs during music therapy. Once the girl made two consecutive choices of the same song, it was sung to her by the music therapist accompanied by the guitar. The research lasted eight months and was videotaped throughout the sessions. Data of the girls' choice making, song preference and other communicative and emotional responses were collected and analyzed by viewing the video materials.

Results to date: All seven girls show a distinct process in their ability to learn. They show clear intentionality in choosing songs and have preferences between certain songs. Some features such as body rocking and hand wringing vary with the music. Emotional responses and vocalization is being analyzed at this time and seems to be in response to the content of the music. For example, if the music has an element of surprise, most of the girls will respond by laughing, smiling or vocalizing during the exact moment of surprise. Currently I am analyzing qualitatively the music of their most and least favorite songs.

Bibliography related to the research: ●

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Aldridge, D. (1996).Music Therapy Research and Practice in Medicine: From Out of the Silence. London: Jessica Kingley: Barlow, D.H. & Hersen, M. (1984). Single Case Experimental Designs. Massachusetts: Simon and Schuster.

Hagberg, B. (1993). Rett Syndrome: Clinical and Biological Aspects. London: Mac Keith.

Hill, S.A. (1997). The Relevance and Value of Music Therapy for Children with Rett Syndrome. British Journal of Special Education, 24 (3), 124-128.

Kerr, A., & Stephenson, J.B.P. (1986). A Study of the Natural History of Rett Syndrome in 23 Girls. American Journal of Medical Genetics, 24 (suppl. 1), 77-83.

Kratochwill, T.R. (1992). Single-Case Research Design and Analysis. New Jersey: Lawrence Erlbaum Association, Inc. Lindberg, B. (1991). Understanding Rett Syndrome. New York: Hogrefe & Huber.

Sigafoos, J., Laurie, S. & Pennell, D. (1995). Prelimenary Assessment of Choisce Making Among Children with Rett Syndrome. Journal of the Association for Persons with Severe Handicaps, 20, 175-184.

Trevarthen, C. & Burford, B. (1997). Evoking Communication in Rett Syndrome: Comparison with Conversations and Games in Mother - Infant Interaction. European Child and Adolescent Psychiatry, 6 (Suppl. 1), 1-5.

Wesecky, A. (1986). Music Therapy for Children with Rett Syndrome. American Journal of Medical Genetics, 24 (suppl. 1), 253-257.

Wigram, T. (1993). "Assessment and Treatment of a Girl with Rett Syndrome" in K. Bruscia: Case Studies in Music Therapy. N.H. USA: Barcelona Publication.

Wigram, T. (1995). The Art & Science of Music Therapy: A Handbook. Chur, Switzerland: Harwood Academic Publishers GmbH.

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Editor, David Aldridge

davida@uni-wh.de

Spring 2001

Research news is a magazine for sharing research news.

This month’s practitioner is Hanne Mette Ridder. You can contact her at: hm@musikterapi.org

research showcase: Hanne Mette Ridder Research Project: Singing in Individual Music Therapy with Elderly Persons suffering from Dementia

Background: To forget your keys, the name of your neighbour, where you put your glasses, or even forgetting your password, is annoying, - but well, it happens to all of us. But when you forget where you live, fail to recognise a close friend, forget what things around you are called, even your own name, then you have a serious problem!

If a person is confused for more that 6 months, and this is not caused by another illness, if that same person suffers from amnesia and one or more cognitive dysfunctions, then that person is likely to be suffering from dementia. Nearly 100 different diseases can lead to dementia.

Alzheimer's Disease is probably the most well known of the dementias, and together with a type of dementia caused by several small strokes in the brain, it covers most of the dementia cases. To get old does not mean that you forget things and that you cannot perform difficult intellectual tasks!

Dementia is a disease and is not caused by age. But the older a person gets, the more the risk of getting a dementia disease increases. In Denmark 2% of the population suffers from dementia, and as the number of old people increases, this percentage is predicted to increase.

In general persons with dementia, among other symptoms, suffer from aphasia and amnesia. This file:///D|/resnews/rn_sho02.htm (1 of 6) [3/10/03 3:47:17 PM]

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makes verbal communication very difficult, sometimes confusing and occasionally anxiety provoking.

Singing together seems to be a way of communicating without confronting the various deficits a person constantly faces. As a music therapist, when singing a song with a person, I do not demand things from that person. I do not expect an answer. Singing is a secure way of being together, inviting the person to take part. Constant demands are being made on dementia sufferers throughout the day. When you lose your memory, your history, your identity, your ability to solve problems and answer questions, the reality around you becomes strange and exacting.

In several studies it is documented that singing is a valuable source to increase quality of live with this population.

Singing is a viable source of stimulation and interaction, an alternative method of communication, reduces agitation and promotes engagement in an activity, as well as interaction with another human being (for background material see Aldridge, D 2000 "Music therapy and dementia care" Jessica Kingsley Publishers, London http://www.jkp.com/catalogue/mus/ald_mus_dem.html

Clinical Technique: In the individual music therapy setting singing familiar songs are chosen as a non-verbal form of expression and as a way to â—? â—? â—?

contain and express inner feelings, interact with another person stimulate reminiscence and a feeling of identity in a safe and secure relation

In order to create a secure, calm and agreeable situation the structure and the surroundings of the setting is recognizable and familiar. Songs are song acapella in order to relate to a single musical source.

Research Method: This is an exploratory case study approach. I have made systematic observations of 6 residents, diagnosed with a primary degenerative dementia or a vascular dementia, living in a gerontopsychological unit. Data collection has been based on video recording, heart rate measurements, day-to-day questionnaires, case description and music therapist's log.

Video recorder was placed in a corner of the room focusing on sofa (or sofa and door in some occasions) where participant and music therapist mostly would be seated, and in this way avoiding having a third person to handle the camera in the room.

Heart rate measurements were done with equipment, which is designed for athletes and allow ambulating.

Staff on day duty, and staff on evening duty filled out day-to-day questionnaires. Questionnaires sought information about daily routines, state of health, and an observation of behaviour (based on file:///D|/resnews/rn_sho02.htm (2 of 6) [3/10/03 3:47:17 PM]

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a modification of CMAI: Cohen-Mansfield Agitation Inventory -(Cohen-Mansfield 1996)) In order to describe the participants a MMSE and CMAI was carried out.

(MMSE: Mini-Mental State Examination. Scores in cognitive functioning from 0 - 30. see (Aldridge 1996)) Procedure: Each participant was observed for 6 weeks. In the second to the fourth week participants took part in a daily music therapy session 5 days a week, all together 20 individual music therapy sessions.

The following scheme shows the procedure with each participant: Week 1

Week 2

Week 3

Week 4

Week 5

Individual m.t. sessions

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Video recording

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Week 6

Heart beat Measurements

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Questionnaires

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Participants: Sex: 2 males and 4 females.

Age. 73-84 years. Average age: 80 Diagnoses: Dementia of Alz's type (case studies A and B), vasculardementia (case studies C and D), Dementia vascular/frontal (case study E), and Dementia of Pick's type (case study F).

Stages of dementia: stages 4-5 (Sandman, PO: stages from 1 to 6) MMSE scores: 0-5 CMAI: all participants have scores in the groups: physical aggressive and physical non-aggressive.

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Marital status: two participants are married. Four are widows/widowers.

Inclusion criteria: ● ● ● ● ● ●

diagnosis of primary degenerative dementia or vascular dementia no source of cognitive impairment or communication impairment other than dementia no history of psychiatric illness or drug/alcohol dependency no individual music therapy in last 2½ years consent of participant's relatives expression of agitation as defined by Cohen-Mansfield

Hypotheses: My hypotheses in this research project are: ● ● ●

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that singing has an influence on persons with dementia that this influence can be defined upon communicative characteristics that persons with dementia in an advanced stage communicate musically, and that this musical communication can be recognised by a system of communicative signs that music therapy has an influence on aspects in residential daily life for the person with dementia

Analysis: I completed data collection end of November 2000 and will now start analysing the material.

Parameters describing responses and interaction in the music therapy sessions will be developed based on the video material. Heart rate data and part of the questionnaires will be displayed graphically, and correlation to responses and interaction will be analysed.

This is a research in progress, and some of the data already tells me, that participants profit from the music therapy sessions.

First of all I want to document this through case descriptions supported and documented with different types of data material.

On the video recordings it seems to be clear that 5 out of 6 (5/6) participants shows a direct reaction to the songs. - A reaction that is visually recognizable and can be described by different parameters. They react to the songs in the music therapy sessions by humming/singing (3/6), singing with text (2/6), reacting on the meaning of the songs e.g. by laughter or comments (3/6), expressing feelings of sorrow/nostalgia (often when song is recognized in the beginning of verse or refrain), tapping the beat (4/6), recognizing phrases (4-5/6), etc.

These responses to the music are documented via the video material. Raw analyses of the sessions with help of the recordings and the time counter already tells me in which sessions and to which songs participants make responses. These data will first of all be displayed graphically with spreadsheets to make an overview. From this material examples can easily be pointed out for close file:///D|/resnews/rn_sho02.htm (4 of 6) [3/10/03 3:47:17 PM]

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analyses. External assessors will randomly pick out sessions from the 60 hours video material to control my analyses, which are made upon defined parameters. There must be agreement between our analyses.

There might be a possibility to make these analyses with help of computer software?

Heart rate data is very easy to handle as numbers are already in the computer. The gap between the pulse rate when resting and when moving around and being physically active can give a picture of how much a participant is ambulating during the session. Heart rate data might also, when compared with other information!!, give a picture of inner (emotional) activity. Interim analyses of heart rate data pre and post sessions (which were carried through in 3 different periods of the year) seem to show a tendency with all 6 participants towards a reduction in average heart beat pr. Min. On results like this there will be made statistics to see if there is any significance.

Questionnaires first of all give information about routines, events and incidents in the daily life that might have an impact on the single session. Is there important information about health? Did the person sleep exceptional long that morning? Were there many visitors the evening before? - Maybe a birthday?

In addition to this the questionnaires gives an overview of behaviour during the day. Questions are posed in a way that answers can be displayed graphically, and this might show some tendencies about behavioural changes in daily life. Data is based on subjective valuation of behaviour made from different staff members knowing the participant well. This is just a smaller part of the project and does not intend to fulfil the demands of a controlled, outcome study concerning a behavioural analyse, but it might support the observation of changes registred in the case description.

Biography: Ph.D.-student at Aalborg University, Institute for Music and Music Therapy. Completed music therapy education in 1989 and worked with music in Bukoba (Tanzania), with teenagers in special education in Tolne (Denmark), with children with different handicaps in Paderborn (Germany) and since January 1995 (until March 2000) as a music therapist at the gerontopsychological unit at the nursing home "Caritas" in Skejby (Denmark). Comments are welcome on: hm@musikterapi.org Supervision by:

1. Inge Nygaard Pedersen, associate professor at the institute for music and music therapy in Aalborg, music therapist, head of the music therapy clinic at Aalborg Psychiatric Hospital.

2. David Aldridge, Chair of Qualitative Research at the Faculty of Medicine at the University of Witten-Herdecke, Germany.

Bibliography: ●

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Aldridge, D. (1996). Music Therapy Research and Practice in Medicine. From out of the Silence. London, JKP. Aldridge, D., Ed. (2000). Music Therapy in Dementia Care. London, JKP. Bright, R. (1997). Music Therapy and the Dementias. Improving the Quality of Life.

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Washington, MMB. Brotons, M. (2000). An Overview of the Music Therapy literature Relating to Elderly People.

Music Therapy in Dementia Care. D. Aldridge. London, JKP. Clair, A. A. (1996). "The Effect of Singing on Alert Responses in Persons with Late Stage Dementia." Journal of Music Therapy 33(4): 234-247.

Cohen-Mansfield (1996). "Behaviour and mood evaluations: assessment of agitation."

International psychogeriatrics 8: 233-245.

Fitzgerals-Cloutier, M. L. (1993). "The use of music therapy to decrease wandering: an alternative to restraints." Music Therapy Perspectives 11: 32-36.

Friis, S. (1987). Musik i ældreplejen. København, Munksgaard.

Kitwood, T. (1997). "The Experience of Dementia." Aging & Mental Health 1(1): 13-22.

Malloch, S. (1999). "Mothers and infants and communicative musicality." Musicæ Scientiæ special issue 1999-2000: 29-54.

Millard, K. s., J (1989). "The Influence of Group singing Therapy on the Behavior of AD Patients." Journal of Music Therapy 26(2): 58-70.

Sacks, O., Ed. (1998). Music and the Brain. Clinical Applications of Music in Neurologic Rehabilitation. USA, MMB. Tomaino, C., Ed. (1998). Clinical Applications of Music in Neurologic Rehabilitation. USA, MMB. Trevarthen, C. (1999). "Musicality and the intrinsic motive pulse: evidence from human psychobiology and infant communication." Musicæ Scientiæ special issue 1999-2000: 155199.

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MT Practice News: Research Showcase

Editor, David Aldridge

davida@uni-wh.de

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Trygve Aasgaard.

practice showcase: Musical Acts of Love in the care of severely ill and dying children and their families

Trygve Aasgaard, MA, is Music Therapist at The National Hospital of Norway, Assistant Professor at Oslo University College, Faculty of Nursing and Lecturer in Palliative Music Therapy at The Norwegian State Academy of Music.

He is presently PhD candidate at Aalborg University, Denmark, conducting a research project about the life-histories of songs made by children with cancer.

Abstract: It is an interdisciplinary responsibility for hospital and hospice staff to provide an environment where love "to" the patient and "from" the patient can be made visible. Music and love have many close connections. The first part of this paper describes and discusses examples where the music therapist, in collaboration with nurses, hospital teachers, medical staff and relatives assists seriously ill young patients to express love and thankfulness. Secondly it describes how parents of dying children can be assisted by the music therapist to say farewell. The final part of the paper focuses on "pleasure" and "joy" as important (underestimated?) therapeutic goals in palliative music therapy and -care.

Introduction There seems to be an endless variety of how man perceives relationships between "music" and "love". We are loving music. We are expressing love through music. In the history of human

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mankind and in many religions, music is often understood as some kind of spiritual matter, being "heavenly", "divine", "the speech of angles", or "a gift of God". So music makes us start loving; and it can perhaps even make us more loveable persons. But music also influences our hormones, our instincts, and our wishes to make love. Music is thus body and soul. That’s why music therapists are continuously concerned with music's numerous possible influences on our bodies as well as of our thoughts, emotions, self concept and relationships with other people. When the topic is "love"‌or "hate"‌we will easily find musical equivalents.

However, considering music therapy practice in the context of love is more complicated. Music therapy is a profession. The music therapist's relation to his clients/patients or even to his "job" is not automatically more characterised by any love-aspects than doctors' or nurses' or, for that sake, a lawyer's or an economist's professional relationships. If we are uncritically applying the numerous general music-love allegories in the practical music therapy contexts (and unfortunately that happens far too often), we are easily falling into the pitfalls of sentimentality or ending up with "mere words". This problem becomes evident in descriptions and assessments of the uses of musical means in palliative care and particularly so in contexts with young patients. more...

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MT Practice News: Research Showcase

Editor, David Aldridge

davida@uni-wh.de

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Trygve Aasgaard.

practice showcase: Musical Acts of Love (Page II) in the care of severely ill and dying children and their families

One practical side of the expression of love is doing “good things” to the person being loved. When living in the proximity of death or possible life threatening disease, we are seemingly more aware of small acts of love than during normal times when we are preoccupied with numerous minor (?) problems. I believe I have seen this time and time again in families where one member gets cancer, in paediatric cancer wards and in hospice outpatient and inpatient settings. “Acts of love” have some common characteristics: They are not specifically goal directed more than hopefully being appreciated by the receiver. They are not thought of as necessarily bringing any permanent practical "results". On the contrary these acts are, first of all, expressions . . . sometimes carefully worked out, sometimes improvised. This paper deals with how a music therapist can assist patients and relatives in the processes of “making love become audible” in the child cancer ward.

Brian’s dreams "Brian" is 14 years old. Since he was six he has been in and out of hospital because of his Acute Myeloid Leukaemia (AML). He has gross learning difficulties and attends a special school when he is "at home"; he is living with his uncle and aunt.

Writing and maths are really not Brian's cups of tea. His social life has been also been disrupted many times because of his illness, hospitalisation and periods of isolation. Now he is in hospital again . . . fatigued and frequently feeling unwell.

Teachers, doctors and nurses knowing Brian well experience that his self-confidence is seemingly rather low at the time. Nevertheless: He has started to look at the girls, a rumour also claims that he has fallen in love!

Brian has heard songs made by younger hospitalised patients. Nice songs, but dealing with rather childish themes, Brian states. At the hospital school he learns to use a PC, and one day Brian has actually written his very first, very own song-text: "LOVE". Grammatical errors are being corrected. And one afternoon the music therapist, assisted by Brian, makes a melody to the text. A nurse informs that Brian file:///D|/pracnews/pn_sho01a.htm (1 of 3) [3/10/03 4:09:39 PM]

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has said (with a smile on his mouth) numerous times that day: "I dread what will happen when Trygve comes". He does not have much strength today; he is bedridden and is receiving a dose of chemotherapy intravenously, but he is eagerly following me conducting the compositional process. Brian chooses the rhythm and speed of the melody and says he wants it to be in “heavy rock style”, otherwise he has no melodic suggestions. “Love” is written out nicely, and some days later it is being performed during the weekly "Musical Hour" in the entrance hall of the paediatric department. The music therapists plays the piano and patients, relatives and staff are singing, clapping hands or drumming: Love is nice girls and tough boys, loving each other, and attending the same school.

"How old are you? Can you say you love me"?

Then they move together, and that is cosy. (translation from Norwegian by T.Aa )

Big applause! Brian has watched the performance from the sideline. He does not sing or say a word himself, but he is blushing and smiling. During the following weeks “Love” can be heard at many occasions in the paediatric department. Brian seems to be particularly pleased that he has participated in the making of a real poptune and not just a children’s song.

A soon fifteen year old boy has made “his” own song. It is nothing peculiar about that. The theme of the text is probably the most common you can think of. What may be interesting is to consider the creation and life of this song with the paediatric cancer ward and Brian’s social situation as contexts: a very sick youth in a very restricted social environment where “normality” becomes a luxury. However, when this song is being performed, Brian is seemingly not primarily a patient with a life threatening disease. For some moments he appeares to be in the centre of attention just as a normal and creative teenager. * Staff nurse comments: [This song] was an expression of what Brian thought of as positive in his life. There were so many other aspects that were negative. [One value] in life is actually worth living for . . . and that's love, ok? Surely this has kept him afloat and given him the courage to live. * Enrolled nurse comments: […] "move together, and that is cosy" […] He had a really good time after having moved to his aunt and uncle […] They often used that expression, "cosy". […] And Brian had a tremendous need of love". * Hospital teacher comments: “He was incredibly proud. He grew ‘several feet’ when you made music to his text . . . there were so many other things he did not master at the time”.

Is this account of Brian’s first song in hospital (later he made more) telling something about the music therapist as a catalyst for the patient’s thankfulness, hope, joy and love? Brian never sung himself, at least not for other people. When the music therapist, nursing staff etc. were performing Love, the song had a certain representative function of the patient’s wishes or dreams and need for expression. Both the artistic process and product were testimonies of genuine aspects of health in this youngster even if he was seriously ill at the same time. Numerous limitations of action, an increasingly reduced strength and many unpleasant symptoms now marked Brian's life situation. He was temporarily not able to do very much on his own. But Brian seemingly liked very much to hear (other people sing) his song. Not very different from a nurse assisting or taking over the patient’s

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self-care during illness and infirmity, the music therapist “represented" Brian, supporting some of his healthy and creative, but lesser known sides.

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Editor, David Aldridge

davida@uni-wh.de

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Trygve Aasgaard.

practice showcase: Musical Acts of Love (Page III) in the care of severely ill and dying children and their families

The music therapist as a messenger For eight months Mary’s best friend in hospital has been her primary nurse, Dagny.

Mary (8) has experienced a particularly tough time since she was diagnosed as having Acute Myeloid Leukaemia: Persistent emesis, local infections needing surgical interventions, numerous unpleasant and frightening blood tests, pain not easily alleviated by opiates, and months of isolation. Now she has been transferred to another university hospital. Mary shall receive bone marrow from her little brother.

She says she is missing her primary nurse who is presently not allowed to visit her because of the strict isolation regime Mary must live under.

Mary is becoming increasingly pain ridden and sick. However, the day before the planned transplantation her general condition seemingly eases a little (according to the father). While she is alone in her new isolate for some few minutes she writes two texts, “Friends" and “I’m bored”. The next morning the father hands the two sheets of paper to the music therapist. Mary has made short texts before and she has improvised songs together with her mother, a hospital teacher and with the music therapist. But this is the first time Mary has written texts originally intended to be sung. “Friends" is a short, funny text with end rhymes. It commences by frankly stating that “Dagny (the nurse) and I are friends”. The next song is longer and actually telling a little story: I’M BORED How are you?

Here I am, and I’m bored.

My primary nurse comes to me.

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she is helping me.

Her name is Dagny, and we are friends and make many things together.

But when I’m feeling sorry, she comforts me, and we play together.

And in the evening she comes to me, and then I fall asleep. (translation from Norwegian by T.Aa.)

One week later Mary asks for the music therapist. The two songs has been preliminary recorded with me singing and playing the piano. The rhythmical texts has not been altered, the melodies come easily. I am also talking to Mary on the cassette, explaining her how I have been dealing with the texts. If she wants to alter the melodies or make completely new melodies, it’s just fine. Mary listens to the recorded songs. She is looking concentrated and is continuously smiling. Then she asks if I can bring the cassette with the two songs to Dagny, if possible already today; the melodies suit the songs ok. Some hours later I am able to deliver the cassette to Mary’s former primary nurse at the other hospital. I can see that she is really touched by this gift from her friend in the "far away" isolation room.

Mary does what she finds naturally in her situation, she makes songs about something really important in her life at the time. She is thinking of and missing a beloved person. An isolated hospital patient's repertoire of possible choices of actions is understandably very much restricted. In this case we see that "making and giving away a song" is something Mary can create and conduct from her sick room. We do not know exactly why Mary wants to have the songs handed over to the primary nurse as soon as possible. Perhaps does she primarily want to make nurse Dagny happy and give her “a gift; perhaps will she tell she misses the comfort and company of her primarily nurse. *Mary’s mother comments: “This is actually a love song to the nurse. This is one way of confirming the warm relationship they have had for a long time”. *Hospital teacher comments: “ Mary seemingly experienced the text and the music as a symbiosis. The one could not be without the other”. The song […] shows us the importance of having a companion that can be trusted 1000% while in hospital . . . and even if one have to change hospital for a while.

Music can be understood as a non-verbal language or more correctly as a variety of communicative elements. A song communicates through both textual and musical channels. (Each time a song is played or heard, it is actually a “new” song, because the non musical song-contexts, the human

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mind included, always change or develop.) “I’m bored”, addressed to nurse Dagny, is seemingly containing a significant textual message. What the composed music/ the performed music possibly did to the text will not be discussed here. People knowing the texts beforehand and then listening to the song might perceive the verbal content as being amplified, underlined, distorted or destroyed by the music. Perhaps the music added one or more dimensions to the plain text? Mary preferred merry melodies. I therefore composed something I hoped would be perceived as optimistic, even if the title and the start of the text was “boring”. It is also likely that making a tape increased the song's potentials for being performed or "used". And surely the music therapist was a most willing and happy messenger . . .

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Editor, David Aldridge

davida@uni-wh.de

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Trygve Aasgaard.

practice showcase: Musical Acts of Love (Page IV) in the care of severely ill and dying children and their families

When there is not much more to do When the music therapist enters the room of a child who is soon going to die, he painfully realises the many limitations of his profession. Music cannot prolong anyone’s life; the music therapist is no Orpheus “who subjugated Hades by his entreaties”, through singing and playing his lyre. Death is often not beautiful at all. When children die, it is always tragic and meaningless, although death can also be perceived as a release from a “meaningless” life situation marked by persistent pain or decay.

“Peter” There is no more noise from the infusion pump. Most technical devises have been removed from Peter’s bedside. Curative or life-prolonging therapies have come to an end. During the last days all strength has seemingly left the little patient. The four year old boy is lying on his side, with closed eyes; his tummy is large, his limbs are very thin. I have placed myself quite close to Peter, improvising very quietly on a pentatonic lyre. The mother is also in the room. Her tears are running. No words are spoken by any of us.

After a time Peter opens one eye and looks at me. I am surprised; he is perhaps less unconscious than I have been thinking. Familiar with Peter’s musical preferences, I whisper to him: “Shall we sing ‘Hocus-pocus’ ” ? I believe he is nodding. . . Then, as softly as I can, I start singing about the Jack in the box. Peter interrupts me: “The blanket, the blanket”! I have forgotten to cover his head with a blanket. (In this song the child that is chosen to be the Jack in the box is “hidden” under some kind of cover. The song ends with the words “come forward!”. The “Jack in the box” emerges suddenly, and all bystanders are of course highly surprised.) I cover Peters head halfway with his sheet, sing the song with a brittle lyre accompaniment and remove the sheet most carefully at the end. Peter smiles for a second, but shortly file:///D|/pracnews/pn_sho01c.htm (1 of 4) [3/10/03 4:09:57 PM]

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after he closes his eyes again. He dies the next morning.

“Tommy” “Tommy’s” parents are divorced, but now they have come together to stay with their three year old son in the paediatric oncology ward. We all know that Tommy will not live for many more days. One morning the mother, the father and another relative sing a hymn for Tommy who apparently is sleeping peacefully. A common interest of the parents has been choir activities, and now they are singing the upper parts from a four voice arrangement. Eventually I join them, singing the bass part. It is impossible for me to see if the boy perceives or reacts to our music. “There is so little we can do now, but Tommy has always appreciated listening to us singing for him”, the mother says.

After the aunt has left, I ask the parents if they think I could assist them in some way.

The father tells me that Tommy’s favourite song at night time is “Who can sail without wind?”. It had been nice if I could find or make a version for three voices. A couple of hours later I have found what the father asked for in a music library. During the afternoon the three of us sing the beautiful and sad Swedish song for Tommy again and again. After I have left the ward, the parents continue to sing throughout the evening. Tommy dies early next morning. His father says later that he is fairly sure that his boy could hear the singing and that he made some sort of approval when asked if they should sing the song once more. . .

“Magnus” Half a year ago Magnus’s brain tumour was seemingly completely removed by surgery and radiation. He started school as a normal six year old kid, but after a month he became continually dizzy and unsteady. An operation revealed a new tumour near the brain stem, unfortunately inaccessible for any curative treatment.

Radiation therapy might prolong life somewhat, but Magnus’ future prospects were rather gloomy. The mother tells me that the family has been in a state of shock since the last operation. “We are not able to do much ourselves for Magnus now, but we are most grateful for anyone who can ‘give’ Magnus something now“.

The handsome boy has trouble to keep both eyes open, his face is almost expressionless. Magnus is awake but tired. I have brought a lyre and I play some, probably well known, phrases on a treble recorder. He looks at me. I show him how to touch the stings, and Magnus actually manages to play gently while I sing some lines about the two of us starting up a rock band. Magnus smiles (the mother says this was the first time he smiled since many days). As far as I can see, he mentally drops out after our improvisation, but he nods when I propose we shall record our next session. I leave the pentatonic lyre at the bedside. Magnus’ mother might want to play a little on it.

Three days later I meet the mother again. Magnus is away for an X-ray. He has recently suffered many periods of restlessness, possibly because of a gradually increased pressure on the brain stem. Once when Magnus was shivering, his mother started to pluck the strings of the lyre, and Magnus very soon quietened down. Since this occasion Magnus asked her to play the lyre at several times. One night he woke up and told his parents that he just had been thinking over what kind file:///D|/pracnews/pn_sho01c.htm (2 of 4) [3/10/03 4:09:57 PM]

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of song would be most fun to sing during “the recording with Trygve” in a day or two.

Magnus’ state of consciousness deteriorates rapidly, almost hour by hour, and soon he is out of reach from ordinary communication. No recording, no more fun! He is sleeping day and night. One morning, however, I find a message at the bedside table to me from the mother. She has written on a paper serviette: “Magnus wants to hear ‘Children of the Rainbow’ today. Thanks!”. A nurse is sitting at the bedside reading aloud from one of Magnus’ books. And when she has finished the story, anyone coming in the vicinity of Magnus’ room will hear the sounds from a keyboard and the voices of a music therapist and a student singing about “ a sky with stars as long as you can see”.

I believe we can consider the examples above as interplays of loveable acts between patients, parents and music therapist. We can still discuss “healing consequences” even when a prolongation of life is out of reach. David Aldridge, one of the world’s leading scholars on music therapy research, claims that: “Healing is done at a variety of levels, not just for the individual, but within an ecology of relationships […] Music therapy is not a form of treatment in the medical sense - it is, however, a form of accompaniment” (Aldridge, 1999:24).

Who is "giving" and who is "receiving" are probably less interesting questions than to search out which meanings can be related to these acts or events. When Tommy is nodding or Peter and Magnus are smiling for the last times in their lives, we are witnessing a child’s precious gifts to his parents. But the playing or singing in the sick-room can just as well be understood as a loveable act towards a child. The music therapist is privileged to be able to work "within" such moments that can be highly emotional, moments often remembered for a long time. The parents of Peter, Tommy and Magnus expressed later that the musical events during the last days meant something valuable to them. A more accurate investigation reveals that the “meaningfulness” is not related to only one circumstance. Tommy’s mother said that the musical elements in the sick room were good for the despaired parents themselves, and that being musically active made them feel they did, at least, something for their dying child. They knew he liked the song they were singing. Magnus’ mother told me that she was convinced that the music “had a positive influence” on him. We observed he had some moments with fun; and according to the mother he became more relaxed by the music (or by the musical activity). Our planned small, but unfinished, project also made him look forward to something nice: a dream about a song. Playing Magnus’ favourite song for him, although he was unconscious, was another way of expressing love and honour to a now totally helpless boy. The “Children of the Rainbow” was also sung in his funeral. I could see that Peter’s mourning parents were relieved and grateful by experiencing their son take part in playing, even on his last day of life.

They invited the music therapist to perform songs Peter had liked at the funeral in their local village some 500 kilometres away from the hospital.

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Through The Norwegian Childhood Cancer Parent Organisation I have met and listened to many parents who have lost a child through cancer. In their accounts of the last period of their children’s lives, the acts of creativity, the playing, their enjoyment of music or simply humorous events (!) are often included. I do not doubt that the stories are true. Aspects like those being mentioned here give us a more complete picture of the lost child underlining it's humanness, childishness . . . and not the least: the child’s preserved healthy sides . . . in the middle of sickness and process of death. To tell the story of the child can still be an act of love from the parents.

When people are approaching death, in some way or another, the feeling of loneliness can be overwhelming. Singing together certainly helps many experiences they are not alone. Singing together is a strong demonstration of being together. At the deathbed of a beloved person the singing together means being active participants. The musical activity can soothe as well as support the mourners and it can promote more or less collective deep and meaningful life experiences.

But is there perhaps something in the described musical examples that cannot be reduced to “function”? Is it a legitimate reason for bringing music to these children by simply stating “because music is music”? I believe people in general (cross-culturally) have a wordless primary understanding of music as being one of the most specific human attributes. This may be one explanation why music is taken as granted when so many are confirming existentially important moments in their lives, from baptism to funeral.

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MT Practice News: Research Showcase

Editor, David Aldridge

davida@uni-wh.de

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Trygve Aasgaard.

practice showcase: Musical Acts of Love (Page V) in the care of severely ill and dying children and their families

Conclusion We have been looking into some of the processes where the music therapist assists patients and relatives “making love become audible” in the child cancer ward. The examples chosen have dealt with fairly basic interactions and few complicated procedures or techniques. The author realises that these descriptions could just as well have been interpreted through quite different kinds of glasses: psycho-dynamically, within a coping perspective etc. I will not completely disagree with someone claiming that the concept of “love” is so vague and has so many sides, that it really does not indicate a clear direction of the therapeutic process if used as a general goal. On the other side I believe that it might be prolific if we, from time to time, reflect on what this much used and misused concept means and how aspects of love appear in our professional practice as well as in our private lives.

The Oxford Textbook of Palliative Medicine (Doyle, Hanks and Macdonald, 1993) is an 845 page standard text on how terminally ill people shall be treated (including sections dealing with music therapy to adults and children). In the subject index we find many entries on “loss”, but nothing on “love”, lots about pain and pain reducing therapies but nothing about “pleasure” or “joy”. Simply aiming at providing pleasure, fun, a loveable environment, or supporting the patient’s healthy sides are seemingly not always highly ranked therapeutic goals. But that does not mean such actions or aims are non existent in today’s practice, they rather belong to the realms of "silent knowledge" and “silent actions” amongst health workers and members of the creative therapy professions. The loveable moments in the care of very sick or dying patients are frequently experienced, sometimes being thought of and talked about, but seldom a topic regarded as sufficiently important for systematic exploration and reflection. And true enough: It is not easy to measure, quantify and grade either love (except reproduction) or musical experiences. But this fact does not reduce the significance of love and music in our lives on earth.

References file:///D|/pracnews/pn_sho01d.htm (1 of 2) [3/10/03 4:10:08 PM]

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Aasgaard, T. (1999) Music Environmental Therapy in Hospice and Paediatric Oncology Wards. In Aldridge, D. (Ed) Palliative Music Therapy, London : Jessica Kingsley Publishers, 29-42 Aldridge, D. (1996) Music Therapy Research and Practice in Medicine: from out of the Silence. London : Jessica Kingsley Publishers Doyle, D., Hanks, G. W. C. , Macdonald, N. (1993) Introduction. In (Ed.) Doyle, D., Hanks, G.W. C., Macdonald, N. Oxford Textbook of Palliative Medicine. Oxford: Oxford University Press

Trygve Aasgaard, MA, is Music Therapist at The National Hospital of Norway, Assistant Professor at Oslo University College, Faculty of Nursing and Lecturer in Palliative Music Therapy at The Norwegian State Academy of Music. He is presently PhD candidate at Aalborg University, Denmark, conducting a research project about the life-histories of songs made by children with cancer.

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Editor, David Aldridge

davida@uni-wh.de

Winter 2001

This article is also available in german. Click here for the german version, please.

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Peter Hoffmann. You can contact him at: peterh@uni-wh.de

practice showcase: Aspects of music therapy on the psychiatric ward for adults at the Herdecke Community Hospital

The department The psychiatric department for adults at the Herdecke Community Hospital (http://www.gemeinschaftskrankenhaus.de) is a relatively small psychiatric unit with a total of 34 beds. It comprises three wards: a psychiatric and a psychotherapeutic ward, and a closed ward (or open, as may be required) with eight beds. The department has a psychiatric outpatient ward and also a day care unit affiliated to the hospital with 20 beds, to which in-patients may also be referred.

Music therapy forms part of a very wide range of different treatment approaches within an anthroposophical context.

The department offers ● ● ● ● ● ●

psychotherapy drug therapy (including anthroposophical drug therapy) art therapies (painting, sculpturing, music therapy) eurythmics and drama therapy handicraft therapy workgroups (fairy tales, cooking, weaving)

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various sports acitivites behavioral and psychoeducative therapies individual care a social service unit.

The treatment concept is geared to the individual's needs and possibilities, comprises single and group therapies and takes a patient's social context into account wherever possible. The department provides a support group for family members.

Clients/Patients Clients/patients on this ward, irrespective of individual diagnosis, suffer mainly from the following symptoms: ● ● ● ● ● ● ● ● ● ● ●

fear a high degree of insecurity contact / relationship disorders, differentiation problems perceptional disorders emotional limitations, altered sensation reduced impulse changed perception of environment and/or reality impaired activity impaired mental processes and speech capability changed body perception vegetative symptoms (palpitation, vertigo etc.)

The individual diagnosis may be: anxiety and cumpulsive neuroses depression addiction and personality disorders psychoses.

Music therapy The type of music therapy employed in Herdecke is based on the Nordoff/Robbins creative music therapy (Aldridge 1997-2001, Ansdell 1994, Nordoff/Robbins 1986). In musical encounters we seek to discover the individual patient's music and to make it ring out. The idea is to help patients to find their individual expression in music-making, and to open up ways to develop their perception and performance, a performance which may be impaired, restricted or insufficiently developed due to personality disorders or disease. The individual patient may thus discover or recover his/her own potential for feeling, perceiving and acting.

Music is a meeting place, allows nearness and deep-felt encounters. It is performed by therapist and patient alike, whereby the therapist accompanies and encourages the patient's music-making on the basis of the potential and response inherent in musical dialogue.

Music therapy is a form of treatment in its own right, and understood and employed as a therapy complemeting others.

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Encounter and dialogue in improvised music A short musical example may serve to highlight some ideas on "aspects of encounter - ways towards dialogue" which I consider of particular importance.

A 28-year-old patient - without previous musical experience - has chosen a metallophone. She starts to play a melody which I take up on the piano.

Immediately, a form of joint music-making has emerged which I feel to be characterized by contact and moments of encounter.

Ex. 1 Without giving more details on the patient, I continue with a more general description of the situation: Both participants do not know what to expect before they start to play. They experience a state of "insecurity". This state of "not knowing" - as to what will happen and what the other person is going to offer - requires an attitude of listening, of searching for and approaching what is to follow. The "metallophone" starts, and sets up a melodious gesture. The "piano" tries to take up the gesture and is again taken up by the "metallophone" after some time. Individual activities on each instrument combine to form a joint activity, not only in sequence but also simultaneously. A musical form emerges which is performed by both and taken up by both. Both persons take up and perform, in synchronization.

A joint activity performed like this allows for co-movement, co-sensation, following the activity of the other. Such a co-movement - with its mental and physical dimensions - offers an opportunity for empathy, for a sympathetic perception of the other person. Such empathy may only emerge from an effort for encounter. This applies likewise to the spoken word, to music or other therapeutic media.

In such a relationship, the therapist is challenged not only to understand rationally but also to make himself available as a person with his sensory perceptions and emotions. The psychiatrist SchmidDegenhardt described this as "..not so much scientific method but rather practical human work" (Schmid-Degenhard 1994). The most essential requirement for a therapist is a listening attitude in order to perceive what the client does, or wants to do, and to be able to offer what the client needs.

This is easier said than done. To achieve and maintain a listening attitude is an essential requirement and also a great challenge. In contact with clients or patients, the listening process must not be ended prematurely ("now I know what this is about") by a quick, rational classification.

On the other hand, a listening, open and active perception of a patient may also hold a certain risk: to be led by a patient to a point which the therapist had never intended - or believed possible - to reach. A patient may thus become the guide of his own therapist, may have "guidance competence", according to the psychiatrist Klaus DĂśrner (DĂśrner 2000). As a musician, I should say he is the conductor of our joint music-making.

The obvious significance of the encounter concerns the quality of the relation between client/patient and therapist. However, the encounter involves a further dimension, that is the "encounter" of a patient with himself through - or rather in - the music performed by him, and through the emerging dialogue. A patient may perceive his own limitations and potentials in this encounter, his individual characteristics are reflected in the music and the partner in dialogue, as well as opportunities for development. A patient/client may address his own modes of acting or perceiving in the musicmaking, may develop a new or different view of himself. This emerges in the course of a process which is truly artistic, i.e. undergoing various stages of coping with the musical material. In most cases, the first step (a) is an unconscious, ‚naive' testing of the unknown instrument, followed by (b) actively exploring what is possible. In perceiving and discovering qualities emerging from the

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material in the process of exploring (c), the music-making patient then enters into a dialogue with the material (d). This last step is characteristed by activities like perceiving and performing, giving and taking in a figurative sense, and resembles a dialogue. Ideally, the music performed by the therapist offers the basis for such a process, leaving room for the experimental "dialogue" of a patient with the instrument, leaving room to discover the music and one's own nature and potential in this process. My concern is to point out that in inviting a patient/client to make music, we must be generally aware of these different paths towards dialogue, although they are closely related to each other: the "encounter" of a patient/client with himself, with the music, and with the therapist.

Patient cases Several cases which are narratives of various encounters with patients may serve to describe practical music therapy in my field of work. In all cases, the basic attitude of striving for encounter is certainly audible. Consequently, I shall focus on music therapy and deliberately neglect other aspects of treatment and care which are of clinical significance.

(For reasons of data protection, it is not possible to publish all cases presented at the conference including the pertinent audio illustrations. The names of the patients described below have been changed.)

Herr Becan Herr Becan is 31 years old. A few years ago, he came to Germany to work in the gastronomy sector, until his illness became evident two years ago. Our first meeting: I do not know much about him. His outward appearance suggests southern/mediterranean origins; short black hair; rather short built. He is very slow, appears fearful. I have no idea how advanced his German is, since he practically does not speak, and wonder if he understands me at all. The staff on the ward face the same problem: Herr Becan is isolated, without contacts, almost mutistic. Diagnosis on admittance: Herr Becan suffers from paranoid hallucinatory pychosis, with delusions, hearing of voices, forced thinking, delusion of being influenced. Prior to admission, he was almost stuporous.

In the music therapy room, Herr Becan is unable to choose between instruments. However, as soon as I give him a drumstick and ask him to play he immediately starts a musical activity.

The following example is taken from our third session. Herr Becan plays the drum with a drumstick, producing "unclear rhythmic shapes" which are difficult to follow. I try to accompany his music, to make contact, which is audibly hard for me.

Example 2 For moments, he atunes his activity to the piano music, something like a communicative intention emerges for short instants and then is lost again. The example shows a relation in imitation and subsequently an exact orientation in tempo.

In accompanying him, I learn that although my playing must be geared to taking up his movements, he himself may only find orientation if I disengage from his playing. My musical activity shows an engagement with his music and a disengagement via musical motifs taken from his playing. There is a continuous alternation between taking up, offering etc.

In my efforts to accompany his activities, to follow him, to listen, I experience individual qualities of expression and performance, qualities which alternate between structured and unstructured, oriented and unoriented, between relationship and "separate world", between isolation and sporadic

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contact.

The music thus allows sensory perception of something which expresses his actual condition. The first music therapy session shows that it is possible to make contact for short moments. Music seems to reach him in his isolation, to offer him ways to feel and to develop expression and contact.

In the following sessions, Herr Becan learns how to direct and orient his activities better. He is more and more able to take up elements of the music offered, our play now involves frequent imitation.

His music is mainly geared to my playing, he seems to be unable to add something of his own. I take into account that he needs my stimuli for structure and orientation. Some very simple songs emerge in our sessions which we sing together. An improvisation in our tenth session becomes a song with a small improvised part. Herr Becan is unable to sing the song with confidence but gains orientation from the reliable form and the repetitions offered. The improvised part contains imitations which allow for another direct, although "copying" relationship.

From then on, something like a sense of form emerges very tentatively. Herr Becan appears to perceive musical forms more clearly and take them up more intensively. He is able to anticipate some song elements, develops a limited capacity to pre-listen, to form perspective and direction.

The time element in his activity, momentary at first, gradually gains in volume and roundedness.

The following example from the twelfth session may serve to illustrate this development.

Herr Becan and I sing, improvising clearly structured phrases of a folk-music type.

Herr Becan follows the melody of the phrase with his voice and shows that he is developing a sense of musical form. It becomes quite obvious that in order to do so he needs the musical offer of contact. He performs "in the shadow" of my stimulus.

In the course of the example, we hear repeated imitation situations where I can now accompany him on the piano.

After 4 months, Herr Becan is released on probation, at first on a day-to-day basis, and then referred to the day care unit.

Contact in musical encounters helped him to develop orientation and structure for his activities, to gain some degree of confidence in perceiving, performing and shaping the relationship. He was able to make contact - albeit short and tentative. He lost some of his rigidity, as could be felt mainly in his singing.

The staff on the ward reported similar observations on different levels: in his general activities, he shows more structure and orientation, in contacts, he is more flexible, but frequently still taciturn and withdrawn.

Herr Ehrlich After prolonged hospitalization, Herr Ehrlich is referred to music therapy sessions as an outpatient.

He is in his late thirties and for many years has been suffering from schizzo-affective psychosis with frequent depressions. Herr Ehrlich loves music, often listens to music and plays the mouth-organ.

At the time of our first meeting, his medical caregivers believe him to have difficulties in every-day life to accept social responsibilities and structures and often to harbour unrealistic ideas. He is termed unreliable in social relations and his ability to commit himself is doubted.

In music therapy, which I start without any knowledge of this diagnosis, I meet a person who immediately takes up musical activity and is able to experience and benefit from its expressive and performative potential. His play shows a high degree of expressive intensity, flexibility, fine perception for mutuality, openness for contact and engagement.

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In the following example (consisting of three excerpts from an improvisation) Herr Ehrlich has chosen a melodica and starts to play; at first he experiments with the instrument. Subsequently, a peaceful music develops which becomes rather lively and then again tranquil. This music makes evident that Herr Ehrlich has a high level of attention, marked sensitivity and an active willingness to enter into a mutual relationship, and also that music releases creativity: for him, music obviously is an area where he may experience and enjoy his personal identity in a very comprehensive sense.

Examples 3, 4, 5 This example suggests that different therapists may have differing and even contradictory perceptions of one and the same patient. In a clinical setting, exchange between therapists and care-givers is of great importance, also dialogue with the patient himself in order to review assessments and evaluations and place them in the appropriate context.

Conclusion Let me come back to the attitude of "striving for encounter" mentioned at the beginning, which I called the basis for empathy, accompaniment and understanding. The examples demonstrate that this attitude may be combined with very different types of behaviour and musical techniques, in accordance with the specific situation and the requirements of the individual patient: cautious accompaniment, active joining in, advancing, offering, imitating, contrasting, opposing etc. But in each case, the music therapist must listen carefully in order to perceive and encourage a patient's potential. A story I recently heard from the psychiatrist Klaus Dörner (Dörner 2000) underlines the intended, empowering meaning of listening for the therapeutic encounter: A woman told her therapist she was afraid to allow anybody to help her.

He asked for the reason, and she answered: "Because I am afraid that somebody might wish to help me."

"What is it you want?" he asked.

"That somebody listens to me until I have found a way how to help myself."

References: ●

●

●

● ●

Aldridge, D. Hg. (1997-2001 ) Kairos I-V. Beiträge zur Musiktherapie in der Medizin. Bern, Huber.

Ansdell, G. (1994): Music for Life. Creative Music Therapy with Adult Clients. London, Kingsley.

Dörner, K. (2000) in einem Vortrag zum Thema: "Das Leiden am medizinischen Krankheitsmodell der (Gemeinde-) Psychiatrie" während des Forum-Reha (Brennpunkte in der Psychiatrie) am 4.-6.5. 2000 in Hamburg Nordoff, P.; Robbins, Cl. (1986) Schöpferische Musiktherapie. Stuttgart, Fischer.

Schmid-Degenhard, M. (1994). Betroffensein und Verstehen in der Begegnung mit dem psychotischen Menschen. Schweizer Archiv für Neurologie und Psychiatrie, 145, (6), 25-28.

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Editor, David Aldridge

davida@uni-wh.de

Winter 2001

Dieser Artikel ist auch in Englisch verfügbar. Für die englische Version bitte hier klicken.

Practice news is a magazine for sharing news about clinical practice and teaching.

This month’s practitioner is Peter Hoffmann. You can contact him at: peterh@uni-wh.de

practice showcase: Aspekte zur Musiktherapie in der erwachsenenpsychiatrischen Abteilung des Gemeinschaftskrankenhaus Herdecke

Die Abteilung Die erwachsenenpsychiatrische Abteilung des Gemeinschaftskrankeinhauses in Herdecke (http://www.gemeinschaftskrankenhaus.de) ist mit insgesamt 34 Betten eine vergleichsweise kleine psychiatrische Abteilung. Sie ist unterteilt in drei Stationen, einer psychiatrischen, einer psychotherapeutischen, eine fakultativ zu schließenden mit acht Betten. Es gibt eine psychiatrische Institutsambulanz ebenso eine dem Krankenhaus angeschlossene Tagesklinik mit 20 Betten, in die auch Patienten aus dem stationären Kontext überwiesen werden können. Die Musiktherapie ist eingebettet in ein Behandlungskonzept mit einem sehr breiten Spektrum, das von anthroposophischen Impulsen und Konzepten für die Behandlung gekennzeichnet ist: Es gibt: ● ●

● ●

Gesprächstherapie (in der Regel tiefenspsychologisch fundiert) medikamentöse Therapie (einschließlich anthroposophisch erweiterter medikamentöser Therapie ) künstlerische Therapien (wie Mal-, Plastizier- undMusiktherapie) Eurythmie und Dramatherapie

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Werktherapie Märchen-, Koch- und Webgruppen unterschiedliche Sportangebote verhaltenstherapeutische und psychoedukative Verfahren individuelle Bezugspflege einen Sozialdienst.

Das Behandlungskonzept ist stark am Einzelnen und seinen Bedürfnissen und Möglichkeiten orientiert, beinhaltet gleichermaßen Gruppen- wie Einzelangebote und ist bestrebt, das familiäre Umfeld aufzunehmen. Im Stationskontext wird eine Angehörigengruppe angeboten.

Die Klienten/Patienten Die Klienten/Patienten dieser Abteilung werden in ihrem Sein diagnoseübergreifend vor allem durch folgende Leidenssymptome geprägt (Auswahl) : ● ● ● ● ● ● ● ● ● ● ●

Angst hohe Selbstverunsicherung Kontakt- Beziehungsstörungen, Abgrenzungsprobleme Wahrnehmungsstörungen Gefühlseinschränkungen, Veränderungen des Erlebens Antriebsstörungen Veränderungen des Welt- Realitätsbezuges Beeinträchtigungen des Handelns Denkbeeinträchtigungen, Sprachbeeinträchtigung veränderte Körperwahrnehmung vegetative Symptome (Herzrasen, Schwindel etc.)

Dahinter verstecken' sich im Einzelfall ganz unterschiedliche Diagnosestellungen: Angst- und Zwangserkrankungen Depressionen Sucht- und Persönlichkeitsstörungen, Psychosen.

Die Musiktherapie Die in Herdecke angewandte Musiktherapie basiert auf dem Ansatz der Schöpferischen Musiktherapie nach Nordoff/Robbins (Aldridge1997-2001, Ansdell 1994, Nordoff/ Robbins 1986). In einer musikalischen Begegnung mit dem einzelnen Patienten ist angestrebt, seine Musik zu suchen und zum Erklingen zu bringen. Damit ist gemeint: dem einzelnen Patienten im musikalischen Handeln zu seinem individuellen Ausdruck zu verhelfen, Wege zur Entfaltung von Wahrnehmungsund Gestaltungsmöglichkeiten zu eröffnen. Gestaltungsmöglichkeiten, die durch die individuelle Persönlichkeits- oder Krankheitsentwicklung eingeengt, verdeckt sind oder nur unzureichend entwickelt wurden. Dem Einzelnen können darüber lebendige Möglichkeiten seines Seins (wieder) verfügbar werden: im Erleben, im Wahrnehmen und im Handeln.

Die Musik ist Begegnungsfeld, sie ermöglicht Nähe und tiefe Begegnung. Sie wird vom Therapeuten wie Patienten gleichermaßen gestaltet, wobei der Therapeut das Spiel des Patienten file:///D|/pracnews/pn_sho02.htm (2 of 7) [3/10/03 4:10:23 PM]

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begleitet und unterstützt. Er orientiert sich dabei an dem, was ihm an Potential im dialogischen Miteinander entgegenkommt.

Musiktherapie ist als eigenständiges Verfahren in den Behandlungskontext integriert und wird als Ergänzung zu den anderen Verfahren verstanden und eingesetzt.

Begegnung und Dialog in der improvisierten Musik An einem kleinen Musikbeispiel möchte ich einige mir wichtige, übergeordnete Aspekte zum Motto "Aspekte der Begegnung -Wege zum Dialog" deutlich machen.

Eine 28 jährige Patientin - ohne musikalische Vorerfahrung - hat sich ein Metallophon ausgesucht. Sie beginnt auf diesem Instrument einen melodischen Bogen zu spielen, den ich am Klavier aufgreife. Es ergibt sich unmittelbar eine gemeinsame Musik, die nach meinem Empfinden von Kontakt und Augenblicken der Begegnung geprägt ist.

Bsp. 1 (mp3, 537 kb) Ohne auf die Patientin im Speziellen weiter einzugehen, möchte ich die Situation übergeordnet genauer beschreiben: Beide Beteiligten wissen - bevor sie zu spielen anfangen - nicht, was kommen wird. Sie befinden sich in einem Zustand der 'Ungewißheit'. Dieser Zustand des 'Nicht-Wissens' - in Bezug darauf, was sich ereignen wird und was der jeweils andere im gemeinsamen Spiel anbietet - verlangt nach einer Haltung des Hörens, des Suchens und des Begegnens für das Folgende.

'Das Metallophon' beginnt, setzt eine melodische Geste in den Raum. 'Das Klavier' versucht die Geste aufzugreifen, zu begleiten, - darauf bezieht sich nach einiger Zeit wiederum 'das Metallophon'. Aus den Aktivitäten der Einzelnen an ihren Instrumenten entsteht etwas Gemeinsames, nicht nur im Nacheinander, sondern auch in der Gleichzeitigkeit. Es entsteht eine musikalische Form, an deren Gestaltung beide Personen teilhaben, auf die sich beide wiederum beziehen. Beide Personen beziehen sich und gestalten gleichermaßen, und zwar zeitgleich, synchron.

Ein Miteinander, das so gestaltet ist, ermöglicht Mitbewegung, Mitempfindung, ein Mitvollziehen des Handelns des anderen. In solchem Mitbewegen - das seelische wie körperliche Dimensionen hat liegt die Möglichkeit zu einem einfühlenden Erkennen, zu einem einfühlenden Verstehen des anderen. Ein solches einfühlendes Verstehen kann nur möglich werden aus einem Streben nach Begegnung. Das gilt für das Wort, für die Musik oder andere Medien in der Therapie gleichermaßen.

In einer solchen Beziehung ist der therapeutisch Tätige nicht nur als rational Verstehender gefragt, sondern gefordert , sich mit seinen Sinnen und seinen Empfindungen als Person dem anderen zur Verfügung zu stellen. Und das ist - wie der Psychiater Schmidt-Degenhardt sagt - "...weniger wissenschaftliche Methode als mitmenschliche Praxis" (Schmid-Degenhard 1994). Wichtig dazu ist eine hörende, lauschende Haltung, um aufgreifen zu können, was der andere tut, was er tun möchte und um anbieten zu können, was er zur Verwirklichung dessen benötigt.

Das ist leichter gesagt, als tatsächlich getan. Es ist eine große Herausforderung wie eine Notwendigkeit, eine hörende Haltung zu pflegen und zu bewahren. Dies meint im Kontakt mit Klienten oder Patienten, das Hören nicht vorschnell - vor-weg-nehmend - durch ein "Jetzt weiß ich, wo es lang geht" oder durch eine schnelle, rationale Kategorisierung zu beenden. Eine lauschende, file:///D|/pracnews/pn_sho02.htm (3 of 7) [3/10/03 4:10:23 PM]

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offene, aktive Wahrnehmung für den Patienten birgt andererseits auch eine 'Gefahr': nämlich die, dass man von einem Patienten dahin geführt wird, wohin man selbst nie beabsichtigt hätte zu gehen (oder es auch nicht für möglich gehalten hätte zu gelangen). In diesem Sinne ist der Patient der Führer des Therapeuten. Er hat - wie der Psychiater Klaus Dörner sagt - "Führungskompetenz" (Dörner 2000). Als Musiker würde ich sagen: er ist der Dirigent unserer gemeinsamen Musik.

Die zunächst naheliegende Bedeutung der Begegnung betrifft die Beziehungsqualität zwischen Klient/Patient und Therapeut. Damit verbunden ist jedoch eine andere Dimension der Begegnung, nämlich die 'Begegnung' des Patienten mit sich selber durch die oder besser in der von ihm gestalteten Musik und durch den Dialog mit dem Gegenüber. Eigene Begrenzungen wie Möglichkeiten werden im Miteinander erlebbar, die Eigenheiten der Person werden durch die Musik und durch das Gegenüber gespiegelt, der eigene Entwicklungsraum wird spürbar. Es kann möglich werden, dass der Patient/Klient seinen Handlungs- und Erlebnisweisen im Spiel gegenüber treten kann, sich zu ihnen in ein neues oder anderes Verhältnis bringen kann. Dies entsteht in einem Prozeß, der im eigentlichen Sinne ein künstlerischer Prozeß ist. Nämlich im Durchlaufen verschiedener Stufen der Auseinandersetzung mit dem musikalischen Material. Meist steht dabei im Anfang (a) das unbewußte, 'naive' Ausprobieren des noch unbekannten Instrumentes, dem (b) ein aktives Erforschen von Möglichkeiten folgen kann. Mit (c) der Wahrnehmung und Entdeckung von Qualitäten, die beim Erforschen aus dem Material entgegen treten, bringt sich der Musizierende dann (d) in ein Gespräch mit dem Material. Diese letzte Stufe ist von Aktivitäten wie Wahrnehmen und Gestalten, von Geben und Nehmen im übertragenen Sinne gekennzeichnet und hat dialogische Qualitäten. Die vom Therapeuten gestaltete Musik bietet für diesen Prozeß im Idealfall die Grundlage. Sie läßt Raum für das entdeckende 'Gespräch' des Patienten mit dem Instrument, sie läßt Raum, die Musik zu entdecken und sich und seine Möglichkeiten darin kennenzulernen. Mein Anliegen ist, darauf hinzuweisen, dass wir bei der Einladung zum musikalischen Spiel an den Patienten/Klienten diese unterschiedlichen Felder der Dialogfindung im weitesten Sinne im Bewußtsein haben müssen, wenngleich sie eng miteinander verwoben sind: die ‚Begegnung' des Patienten/Klienten mit sich selber, mit der Musik, mit dem Therapeuten.

Fallbeispiele Mit einigen Beispielen, die unterschiedliche Geschichten von Begegnungen mit Patienten erzählen, möchte ich die Praxis der Musiktherapie in meinem Arbeitsfeld vorstellen. Bei allen Fallbeispielen ist das Streben nach Begegnung als grundsätzliche Haltung sicher hörbar. Ich stelle dabei die Musiktherapie in den Mittelpunkt und vernachlässige damit bewußt andere, für den klinischen Verlauf wesentliche Aspekte der Behandlung und Begleitung.

(Aus Datenschutzgründen können an dieser Stelle nicht alle, der in der Tagung vorgestellten Fallbeispiele und der dazugehörige Audioillustrationen veröffentlicht werden. Die Namen der folgenden Patienten sind verändert).

Herr Becan Herr Becan ist 31 Jahre alt. Vor einigen Jahren kam er aus dem Ausland mit seiner Familie nach Deutschland and arbeitete in der Gastronomie, bis vor zwei Jahren seine Erkrankung begann. Zu unserer ersten Begegnung: Ich weiß nicht viel von ihm. Er hat ein südländisches Äußeres, schwarze kurzgeschnittene Haare, ist relativ klein. Er ist sehr verlangsamt, wirkt sehr ängstlich. Ich weiß nicht, wie gut sein Deutsch ist, da er so gut wie nicht spricht. Ich frage mich, ob er mich

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überhaupt versteht. Die Kollegen auf der Station stellen sich die gleiche Frage: Herr Becan ist isoliert, ohne Kontakt, nahezu mutistisch. Gespräche sind so gut wie unmöglich. Sein Verhalten ist durch Verharren gekennzeichnet. Zum Aufnahmegrund: Herr Becan leidet an einer paranoid halluzinatorischen Psychose, mit wahnhaftem Erleben, Stimmenhören, Gedankeneingebung, Fremdbeeinflussungserleben. Vor seiner Aufnahme war er nahezu stuporös.

Im Musiktherapieraum ist Herr Becan nicht in der Lage Instrumente zu wählen. Allerdings nimmt er unmittelbar eine musikalische Aktivität auf, als ich ihm einen Trommelstock gebe und ihn auffordere auf einer Trommel zu spielen.

Das folgende Beispiel ist aus der dritten Sitzung. Herr Becan spielt auf einer Trommel mit einem Schlegel. Es entstehen schwer mitvollziehbare "unklare rhythmische Gestalten" . Ich versuche, was Herr Becan macht musikalisch zu begleiten, Kontakt herzustellen, was mir hörbar schwer fällt.

Bsp. 2 (mp3, 466 kb) An der Klaviermusik ordnet sich für Momente seine Aktivität, zum Teil blitzt etwas wie eine kommunikative Absicht auf, dann verliert sich dies wieder. Im Beispiel kommt es zu einem Bezug in der Imitation, daraus folgend zu einer genauen Orientierung im Tempo.

Ich bemerke im Spiel mit Herrn Becan, im Begleiten seiner Aktivität, dass mein Spiel sich zwar an einem Aufnehmen seiner Spielbewegungen orientieren muß, sich für ihn eine Orientierung allerdings erst durch ein Lösen meinerseits von seinem Spiel ergibt. Mein musikalisches Handeln ist stark geprägt von einem Eintauchen in seine Musik und einem Lösen daraus mit musikalischen Motiven, die sich aus seinem Spiel ergeben. Es entsteht ein steter Wechsel von Aufnehmen, Anbieten usw..

Im Versuch, seine Aktivitäten zu begleiten, im Versuch mich mitzubewegen, mich einzuhören, erlebe ich individuelle Ausdrucks- und Gestaltungsqualitäten. Qualitäten, die zwischen Strukturlosigkeit und Strukturierungsversuchen, zwischen Orientierungslosigkeit und anlehnender Orientierung, zwischen Bezugnahme und 'eigener Welt', zwischen Isolation und sporadischem Kontakt hin und her schwanken.

Damit wird in der Musik etwas sinnlich erlebbar, was Ausdruck der momentanen Befindlichkeit von Herrn Becan ist. In der Musiktherapie der ersten Sitzungen zeigt sich, daß es für kurze Momente möglich ist Kontakt zu finden. Die Musik scheint ihn in seiner Isolation zu erreichen. Sie gibt ihm selbst Möglichkeit zum Erleben und zur Entwicklung von Ausdruck und Kontakt.

Im weiteren Verlauf der Musiktherapie kommt es dazu, daß Herr Becan seine Aktivitäten stärker führen und ausrichten kann. Immer mehr kann er auch Elemente der angebotenen Musik aufgreifen, regelmäßig ergeben sich in unserem Spiel nun Imitationssituationen.

Sein Spiel ist meist stark anlehnend, orientierend an mein Spiel, etwas 'Eigenes' hineinzubringen, scheint ihm nicht möglich. Ich richte mich danach, dass er zu seiner Strukturierung und Orientierung meine Angebote braucht. Im Verlauf entwickeln sich nun ganz einfache Lieder, die wir gemeinsam singen. So entsteht aus einer Improvisation in der zehnten Sitzung ein Lied mit einem kleinen Improvisationsteil. Herr Becan kann das Lied nicht verläßlich singen, aber durch die verläßliche Form und die angebotenen Wiederholungen gewinnt er Orientierung. Im Improvisationsteil ergeben sich Imitationen, die wiederum eine direkte, wenn auch 'kopierende' Bezugnahme ermöglichen.

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Ganz zaghaft entwickelt sich im Verlauf nachfolgend so etwas wie ein Formgefühl. Herr Becan scheint die musikalische Formen deutlicher wahrnehmen zu können und intensiver mittragen zu können. Verläufe von Liedern kann er teilweise nun auch antizipieren. Es entsteht ein labiles Vorhören. Perspektiven und Richtungsbildung im Handeln entstehen ansatzhaft. Die zeitliche Gestalt seiner Aktivität, anfangs eher rein momenthaft auf den Augenblick bezogen, erhält etwas mehr 'Raum' und Bogen.

Das folgende Beispiel aus der zwölften Sitzung illustriert das.

Herr Becan und ich singen improvisierend über eine klare Phrasenstruktur in einem sehr volkstümlichen Charakter. Herr Becan vollzieht den Spannungsbogen der gesungenen Phrase stimmlich mit. Darin wird deutlich, daß er ein Gefühl für die musikalische Form erhält. Genauso deutlich ist, dass er dafür das musikalische Angebot im Kontakt braucht. Er gestaltet 'im Schatten' meiner Angebote. Im Verlauf des Beipiels kommt es wieder zu einer Imitationssituation, in der ich ihn nun mit dem Klavier imitieren kann.

Herr Becan wird nach 4 Monaten zunächst tageweise zur Belastungerprobung nach Hause entlassen, dann in die Tagesklinik.

In der Musik konnte er durch den Kontakt in der Begegnung Orientierung, Strukturierung für sein Handeln entwickeln, er gewann etwas an Sicherheit im Wahrnehmen, Handeln und der Gestaltung der Beziehung. Er konnte, wenn auch zaghaft und kurz, Kontakt von sich aus in Gegenseitigkeit gestalten. Er gewann ein wenig an Schwingungsfähigkeit, dies war besonders beim Singen erlebbar.

Auf anderen Ebenen im Stationsalltag war Vergleichbares zu beobachten: Auf der Handlungsebene allgemein ist er in allem strukurierter, orientierter. Im Kontakt schwingungsfähiger, aber nach wie vor oft einsilbig und zurückgezogen.

Herr Ehrlich Herr Ehrlich kommt nach längerem stationären Aufenthalt ambulant zur Musiktherapie. Er ist Ende dreißig und schon seit vielen Jahren an einer schizzo-affektiven Psychose erkrankt, in deren Verlauf er immer wieder in Depressionen fällt. Herr Ehrlich mag Musik sehr gerne, er hört viel Musik und spielt selbst Mundharmonika.

In der Zeit als wir uns begegnen, fällt es ihm nach Aussage der ärztlichen Betreuer im Alltag u.a. schwer, Verbindlichkeiten und Strukturen im Sozialen einzuhalten, er sei mit seinen Ideen oft unrealistisch, versponnen. Er wird als beziehungslabil bezeichnet und es entsteht die Frage, wie sehr er überhaupt Beziehungen verbindlich gestalten kann.

In der Musiktherapie, die ich ohne Kenntnisnahme dieser ärztlichen Einschätzung beginne, erlebe ich einen Menschen, der unmittelbar in musikalische Aktivität gehen kann und die gestalterischen und ausdrucksbezogenen Möglichkeiten darin unmittelbar für sich erleben und nutzen kann. Sein Spiel ist geprägt von hoher Ausdrucksintensität, Flexibilität, einer feinen Wahrnehmung für Gegenseitigkeit im musikalische Spiel, hoher Kontaktbereitschaft und Verbindlichkeit darin.

Im folgenden Beispiel (das aus drei Ausschnitten einer Improvisation besteht) hat sich Herr Ehrlich eine Melodica ausgesucht und beginnt zu spielen, zunächst ausprobierend, er macht sich mit Spielmöglichkeiten bekannt. Im Verlaufe entwickelt sich eine zunächst ruhige, dann ziemlich lebendige Musik, die wiederum in einen file:///D|/pracnews/pn_sho02.htm (6 of 7) [3/10/03 4:10:23 PM]

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ruhigen Teil mündet. In der Musik ist erlebbar, dass Herr Ehrlich eine hohe Aufmerksamkeit, eine ausgeprägte Sensibilität und eine aktive Bereitschaft für ein Miteinander in der Beziehung hat. Und, dass Musik schöpferische Möglichkeiten freisetzt: Für Herrn Ehrlich ist Musik offensichtlich ein Feld, in dem er seine persönliche Identität in ganz umfassendem Sinne erleben und ausleben kann.

Bsp. 3,4,5 (mp3, 1062 kb) Dieses Fallbeispiel deutet an, wie unterschiedlich, gar gegensätzlich die Wahrnehmungen von einem Patienten durch die Therapeuten sein können. Im klinischen Zusammenhang ist hier der Dialog zwischen den Betreuern und Behandlern gefordert, besonders auch der Dialog mit dem Patienten selber, um Einschätzungen und Bewertungen jeweiliger Verläufe hinterfragen und entsprechend einordnen zu können.

Zum Schluß Ich möchte zurückkommen auf die am Anfang erwähnte Haltung des 'Strebens nach Begegnung', die ich als Grundlage für Einfühlung, Mitvollzug und Verständnis bezeichnet habe. Aus den Beispielen ist deutlich geworden, dass diese Haltung mit ganz unterschiedlichem Verhalten und musikalischen Techniken in der jeweiligen konkreten Situation verbunden ist, je nachdem, was die Begegnung mit dem einzelnen Patienten erfordert, was der einzelne Patient fordert. Dies kann ein zurückhaltendes Begleiten, ein aktives Mitgehen, ein ‚Vorgehen', ein Anbieten, ein Imitieren, ein Kontrastieren, ein Gegenüberstellen u.a. sein. Immer geht es dabei aber um ein Wahrnehmen und Unterstützen der Potenziale des Anderen aus dem Hören heraus. Die abschließende Geschichte, die ich kürzlich von dem Psychiater Klaus Dörner (Dörner 2000) hörte, weist auf die gemeinte, ermöglichende Bedeutung des Hörens für die therapeutische Begegnung: Eine Frau sagt ihrem Therapeuten, sie habe Angst sich helfen zu lassen.

Auf seine Frage nach dem "Warum" sagt sie : "Weil ich Angst habe , daß mir jemand helfen will."

"Was wünscht Du Dir?" fragt er.

"Das mir jemand zuhört, solange bis ich gefunden habe, wie ich mir helfen kann."

Literatur: ●

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Aldridge, D. Hg. (1997-2001 ) Kairos I-V. Beiträge zur Musiktherapie in der Medizin. Bern, Huber.

Ansdell, G. (1994): Music for Life. Creative Music Therapy with Adult Clients. London, Kingsley.

Dörner, K. (2000) in einem Vortrag zum Thema: "Das Leiden am medizinischen Krankheitsmodell der (Gemeinde-) Psychiatrie" während des Forum-Reha (Brennpunkte in der Psychiatrie) am 4.-6.5. 2000 in Hamburg Nordoff, P.; Robbins, Cl. (1986) Schöpferische Musiktherapie. Stuttgart, Fischer.

Schmid-Degenhard, M. (1994). Betroffensein und Verstehen in der Begegnung mit dem psychotischen Menschen. Schweizer Archiv für Neurologie und Psychiatrie, 145, (6), 25-28.

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