Case Examples of Music Therapy for Medical Conditions [1 ed.] 9781937440299

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Case Examples of Music Therapy for Medical Conditions Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Medical Conditions Copyright © 2012 by Barcelona Publishers All rights reserved. No part of this e-book may be reproduced and/or distributed in any form whatsoever. E-ISBN: 978-1-937440-29-9 Distributed throughout the world by: Barcelona Publishers 4 White Brook Road Gilsum NH 03448 Tel: 603-357-0236 Fax: 603-357-2073 Website: www.barcelonapublishers.com SAN 298-6299 Cover illustration and design: © 2012 Frank McShane

Table of Contents CASE ONE Music Therapy at Childbirth Dianne Allison CASE TWO Facilitating Neurological Reorganization through Music Therapy: A Case of Modified Melodic Intonation Therapy in the Treatment of a Person with Aphasia Felicity Baker CASE THREE Embracing Life with AIDS: Psychotherapy through Guided Imagery and Music (GIM) Kenneth E. Bruscia CASE FOUR Music Therapy for Children in Hospital Care: A Stress and Coping Framework for Practice Jane Edwards Jeanette Kennelly CASE FIVE Healing an Inflamed Body: The Bonny Method of GIM in Treating Rheumatoid Arthritis Denise Grocke CASE SIX Medical Music Therapy with Premature Infants: Family-Centered Services Miriam Hillmer Olivia Swedberg Jayne M. Standley CASE SEVEN Rehabilitation Following a Colloid Cyst using Music, Movement and the Creative Arts: A Case Study of a Young Man Roberta S. Kagin CASE EIGHT The Quiet Soldier: Pain and Sickle-Cell Anemia Joanne V. Loewy CASE NINE Singing My Way through It: Facing the Cancer, the Darkness, and the Fear Maria Logis

Alan Turry CASE TEN The Use of Latin Music, Puppetry, and Visualization in Reducing the Physical and Emotional Pain of a Child with Severe Burns Rebecca Loveszy CASE ELEVEN Reclaiming a Positive Identity: Music Therapy in the Aftermath of a Stroke Nancy McMaster CASE TWELVE Dealing With Physical Illness: Guided Imagery and Music and the Search for Self Ann Newel CASE THIRTEEN When Life Begins Too Early: Music Therapy in a Newborn Intensive Care Unit Monika Nöcker-Ribaupierre

Introduction Kenneth E. Bruscia Case examples provide very unique and valuable insights into how different forms of therapy are practiced, as well as how clients respond to those therapies. This e-book describes various ways that music therapy has been used to help individuals with medical conditions. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform all those affected by medical conditions about the potential benefits of music therapy. About Music Therapy (Based on Bruscia, 1993) Definition and Applications In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants. Music therapy is used with individuals of all ages and with a variety of conditions, including psychiatric disorders, medical problems, physical handicaps, sensory impairments, developmental disabilities, substance abuse, communication disorders, interpersonal problems, and aging. It is also used for self-development purposes, such as improving learning, building self-esteem, reducing stress, supporting physical exercise, and facilitating a host of other health-related activities. Given its wide applications, music therapists may be found in general hospitals, psychiatric facilities, schools, prisons, community centers, training institutes, private practices, and universities. Basic Premises The thing that makes music therapy different from every other form of therapy is its reliance on music as the primary medium for promoting the client’s health. Every session involves the client in a music experience of some kind. The main ones are listening to, recreating, improvising, and composing music. These will be described in more detail in the next few paragraphs; however, it is important to explain immediately that clients do not have to be musicians to participate in or benefit from music therapy. In fact, because most clients have not had previous musical training, the music activities and experiences used in therapy sessions are always designed to take advantage of the innate tendencies of all human beings to make and appreciate music at their own developmental levels. Of course, in clinical situations, music therapists may encounter clients who have physical or mental impairments that interfere with

one or more of these basic musical potentials. Therefore, care is always taken to adapt music therapy experiences to the unique musical capabilities and preferences of each client. Music therapists also screen clients who may have adverse psychological or psychophysiological reactions to participation in music. Four Basic Music Experiences Used in Therapy To understand how music therapy works, it is necessary to examine the unique nature of each of the four types of music experience—listening to, recreating, improvising, and composing. In those therapy sessions that involve listening, the client takes in and reacts to live or recorded music in the style preferred by the client. The client may respond through activities such as relaxation or meditation, structured or free movement, perceptual tasks, freeassociation, story-telling, imaging, reminiscing, drawing, and so forth. Music listening experiences are used with clients who need to be activated, soothed, or further developed— either physically, emotionally, intellectually, and/or spiritually—as these are the kinds of responses that music listening elicits. In those therapy sessions that involve re-creating music, the client sings or plays precomposed music. This may include learning how to produce sounds, imitating musical phrases, learning how to sing, learning to read notation, participating in group sing-along’s, performing a song or piece, participating in a musical show or drama, and so forth. Re-creative experiences are most appropriate for clients who need to develop sensorimotor skills, learn adaptive behaviors, maintain reality orientation, master different role behaviors, identify with the feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, the therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually the therapist simplifies the process by engaging the client in aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or

relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for individuals with medical conditions, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them. This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made to present an accurate and unbiased account of the therapy process to the extent possible, and theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a

question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with an individual with medical conditions, the truth value of the case is of vital interest. That leads to the second scientific question: Can the information learned in this case be applied to other cases? Or even more rigorously, can the findings of this case be generalized to similar or matched cases? Here too, readers who are directly affected by medical conditions are as interested in this question as scientists and researchers. Their interest is in whether individuals with medical conditions in their own lives can derive the same benefits of music therapy as the client in this case did. Scientists or researchers can also glean other very important information from case studies. Because clinical cases provide rich descriptions of the therapy process, they usually provide myriad ideas for what needs to be studied scientifically. By describing what seemed to work and or not work for a particular client, a clinical case reveals to the researcher which clinical protocols and therapeutic outcomes warrant further research, while also suggesting specific hypotheses that might be tested. Moreover, because events unfold naturally in a clinical case as they do in real life, and because variables cannot be controlled as in laboratory research, the clinical case gives very important information on what specific variables must be considered when doing research, not only the most likely independent and dependent variables that are likely to be related, but also what extraneous variables need to be controlled. Of course, a research case can provide the same insights, to some degree, as a clinical case; they too offer valuable information on potential independent, dependent, and extraneous variables to consider. The greatest advantage of the research case is not only that it provides objective evidence of what works or doesn’t work in therapy, but also because it can reveal the “effect size” of the therapeutic change. That is, a single-case research study can show how big an effect the independent variable had on the dependent variable, or the extent to which the treatment protocol was effective in inducing therapeutic change in the client. Though this effect and its size cannot be generalized, careful replication of research cases and meta-analysis can begin to build a case for the establishment of clinical cause-effect relationships. Reading from a Personal Perspective By their very nature, case examples invite the reader to identify with one or more characters involved in the case, and then move from identifying with one character to identifying with another. The characters may include the client, the therapist, other clients, loved ones, and so forth. Identifying with people involved in the case not only helps the reader to understand first-hand what each character is experiencing, but also gives the reader an opportunity to compare how the character reacted with how the reader would react. Here are some examples: 1) Identifying with the client: What must the client be thinking or feeling about the therapist, music, other clients, or loved one? If I were the client, would I think or feel the same? What does this client need and want from those involved in the therapy process, and would I need or want the same? These same questions can be posed for every client involved in the case.

2) Identifying with the therapist: What must the therapist be thinking or feeling about the client, the music, the other clients, or the client’s loved one? Would I think or feel the same? What kind of person would I be if I were working with this client? What is the therapist trying to do, and would I try to do the same? 3) Identifying with loved ones: What must the loved one be thinking or feeling about the client, the therapist, the music, and other clients? If I were a loved one, would I think or feel the same? What does this person need or want, and would I need or want the same? Does this person believe that music therapy will help, and would I? How does the loved one feel about the therapist, and how he or she is relating to the client? Does the therapist know what he or she is doing? The fascinating thing about taking an empathic position is that once one successfully steps into one character’s shoes, and becomes sensitive to who he or she is, an endless number of additional empathic positions arise, and one’s entire personal reaction to the case becomes enlivened. Reading from a Clinical Perspective A clinical perspective is concerned primarily with methodological questions that are most often posed by other clinicians. Clinicians want to know what does and does not work when working with a client in music therapy. Practically speaking then, they are most interested in the following kinds of questions: 1) Based on this case, what should I be looking for in clients? What client needs and resources do I have to address more in my own work? How can I assess these facets of the client in music therapy? 2) Based on this case, what kind of therapist-client relationship is best for this kind of client, and what is the best way of forming such a relationship? 3) What is the role of music in working with this clientele? What types of music experiences are most therapeutically relevant and effective? What styles of music are most appropriate? 4) Based on this case, what are the best ways of responding to the client when he or she is acting out, abreacting, resisting, or not progressing? 5) Based on this case, what clinical criteria should be used in evaluating the client’s therapeutic progress? Other Writings on Medical Conditions The case examples in this e-book were taken exclusively from various books published by Barcelona Publishers. Thus, these cases, though typical, may not comprise a representative sample of all clinical practices in music therapy for individuals with medical conditions. Additional case examples have been written, which further elaborate how these individuals with can derive therapeutic benefits from music. Here is a list of other published case examples of music therapy in medical treatment.

Aldridge, G. (1996). ‘A Walk through Paris’: The Development of Melodic Expression in Music Therapy with a Breast-Cancer Patient. The Arts in Psychotherapy, 23(3), 207–223. Andersson, K., Björk, O., Ericsson, B., Forssberg, H., Hammarlund, I., Jennische, M., & Von Wendt, L. (2006). Music therapy for Children with Sequelae After CNS Tumour: A CaseControl Study. Developmental Medicine & Child Neurology, 4823. Bonde, L. O. (2005). “Finding a New Place...” Metaphor and Narrative in One Cancer Survivor’s BMGIM Therapy. Nordic Journal of Music Therapy, 14(2), 137-154. Bonde, L. O. (2005). “Finding a New Place...”: Metaphor and Narrative in One Cancer Survivor’s BMGIM Therapy... Bonny Method of Guided Imagery and Music. Nordic Journal of Music Therapy, 14(2), 137–154 Bonde, L. O. (2007). Imagery, Metaphor and Perceived Outcome in Six Cancer Survivors’ BMGIM Therapy. In A. Meadows (Ed.), Qualitative Inquiries in Music Therapy: A Monograph Series (pp. 132-164). Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (1991). Embracing Life with AIDS: Psychotherapy through Guided Imagery and Music (GIM). In K. E. Bruscia (Ed.), Case Studies in Music Therapy (pp. 581-602). Phoenixville, PA: Barcelona Publishers Bruscia, K. E. (1995). Images of AIDS. In C. A. Lee (Ed.), Lonely Waters: Proceedings of the International Conference, Music Therapy in Palliative Care, Oxford 1994 (pp. 119-124). Oxford: Sobell Publications. Colwell, C. M. (1997). Music as Distraction and Relaxation to Reduce Chronic Pain and Narcotic Ingestion: A Case Study. Music Therapy Perspectives, 15(1), 24–31 Davis, K. (1998). “To Never Surrender:” Music Therapy in the Fight against Multiple Sclerosis. Canadian Journal of Music Therapy, 6 (1), pp. 20–34. Dawes, S. (1985). Case study: Advanced Stage Huntington’s Disease. Eleventh National Conference of the Australian Music Therapy Association, Inc. “Growing Together with Music”, 87-92. Dawes, S. (1985). Case study: Advanced Stage Huntington’s Disease. Eleventh National Conference of the Australian Music Therapy Association, Inc. “Growing Together with Music”, pp. 87–92. Edwards, J. (1995). “You are singing beautifully:” Music Therapy and the Debridement Bath. The Arts in Psychotherapy, 22 (1), 53–55 Glassman, L. R. (1991). Music Therapy and Bibliotherapy in the Rehabilitation of Traumatic Brain Injury: A Case Study. The Arts in Psychotherapy, 18(2), 149–156. Goldberg, F. S., Hoss, T. M., & Chesna, T. (1988). Music and Imagery as Psychotherapy with a Brain Damaged Patient: A Case Study. Music Therapy Perspectives, 5, 41–45. Gundling, D. H. (1998). Musical Massage Sound Therapy: A Chronic Pain Syndrome Case Study. Music Therapy Perspectives, 16(1), 48–49 Jackson, M. (1995). Music Therapy for Living: A Case Study on a Woman with Breast Cancer. Canadian Journal of Music Therapy, 3(1), 19–33. Langenberg, M., Frommer, J., & Tress, W. (1995). From Isolation to Bonding: A Music Therapy Case Study of a Patient with Chronic Migraines. The Arts in Psychotherapy, 22(2), 87– 101. Lee, C. (1996). Music at the Edge: The Music Therapy Experiences of a Musician with AIDS. London, UK: Routledge.

Lee, K. V. (2010). An Autoethnography: Music Therapy after Laser Eye Surgery. Qualitative Inquiry, 16(4), 244-248. Mandel, S. (1988). Music therapy: A Personal Peri-Surgical Experience. Music Therapy Perspectives, 5, 109-110. Mandel, S. (1991). Music therapy: A Repeated Personal Perisurgical Experience. Music Therapy Perspectives, 9, 111. Niu, N., Perez, M., Katz, J. (2011). Singing Intervention for Preoperative Hypertension Prior to Total Joint Replacement: A Case Report. Arthritis Care and Research, 63 (4), 630–632. Pickett, E. (1987). Fibroid Tumors and Response to Guided Imagery and Music: Two Case Studies. Imagination, Cognition and Personality, 7(2), 165–176. Ridder, H., & Aldridge, D. (2005). Individual Music Therapy with Persons with Frontotemporal Dementia: Singing Dialogue. Nordic Journal of Music Therapy, 14(2), 91-106. Rojo, N., Amengual, J., Juncadella, M., Rubio, F., Camara, E., Marco-Pallares, J., & ... RodriguezFornells, A. (2011). Music-Supported Therapy Induces Plasticity in the Sensorimotor Cortex in Chronic Stroke: A Single-Case Study Using Multimodal Imaging (fMRI-TMS). Brain Injury, 25(7/8), 787-793. Stevens, K. M. (1992). My Room––Not Theirs! A Case Study of Music during Childbirth. Australian College of Midwives Incorporated Journal, 5(3), 27–30 Stewart, A. (2000). Case Studies: Music Therapy in the NICU. In J. V. Loewy, & J. V. Loewy (Eds.), Music Therapy in the Neonatal Intensive Care Unit. (pp. 111–120). New York, NY: The Louis & Lucille Armstrong Music Therapy Program. Vanger, P., Oerter, U., Otto, H., & Schmidt, S. (1995). The Musical Expression of the Separation Conflict during Music Therapy: A Single Case Study of a Crohn’s Disease Patient. The Arts in Psychotherapy, 22(2), 147–154. Williams, K. (2003). A Child with Burn Injury in a Paediatric Hospital: A Music Therapy Case Study. Annual Journal of the New Zealand Society for Music Therapy, 30–47. Zelazny, C. M. (2001). Therapeutic Instrumental Music Playing in Hand Rehabilitation for Older Adults with Osteoarthritis: Four Case Studies. Journal of Music Therapy, 38, 97–113. Reference for Introduction Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Medical Conditions

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE ONE Music Therapy at Childbirth Dianne Allison Abstract This case study presents the application of music therapy in the antenatal, labour, delivery and postnatal phases of birthing by a 30-year-old primipara woman and her husband. The study outlines the antenatal preparation of music for their labour, and describes the musical, non-musical and medical events of the labour and delivery. Postnatal follow-up through questionnaire and discussion with the couple is presented along with the conclusions as to the effectiveness of music therapy assisted labour with them. Background Information The subjects of this case study were a 30-year-old woman, Annie, and her 39-year-old husband, Rob, expecting their first child. Prior to her confinement, Annie was a clerk in the Accounts division of a National Communications Company, and Rob worked as a labourer for a Metropolitan Water Board. Their employment indicated them to be middle-income earners. Annie and Rob were first made aware of the opportunity to use programmed music at 22 weeks gestation, when their obstetrician gave them a questionnaire designed by the author (hereafter called the therapist) as part of her post-graduate research project on the use of music in pain management during labor. The questionnaire sought information regarding the couple’s intention to use music and/or a support person in addition to the male partner, as well as their general expectations for the labour and delivery of the child. At this stage, Annie and Rob were given no details concerning the programmed music other than anecdotal information from their obstetrician. Their responses to the questionnaire indicated that they intended to use their own music rather than programmed music, and that they were not taking a second support person into the labour. Their expectations were for “active labour if possible in birthing unit but pain relief if necessary.” Their preferred methods of pain relief were music, nitrous oxide (gas mask) and massage. They took the option to withhold their names from the therapist but did give the obstetrician’s name. The therapist was introduced to Annie and Rob at their antenatal class, when Annie was at 33 weeks gestation. During the class, the therapist discussed pain management in labour and briefly explained details about previous research findings on the use of music in labour. She also outlined the present research project. By the end of the class session, Annie and Rob changed their minds, deciding to utilize the programmed music being offered. After contacting the therapist, they arranged a private meeting with her.

Music Therapy Assessment The first consultation was held at the therapist’s home, a requisite of the research design, when Annie was at 35 weeks gestation. She appeared to be carrying the fetus quite low in utero and, as a result was more comfortable seated on the edge of the couch for most of the 90-minute consultation. Rob, on the other hand sank into the couch next to Annie and appeared very relaxed, resting one foot on the other knee. They were both dressed casually; Annie was in a maternity dress/T-shirt, her hair short and neat; Rob was in shorts, T-shirt and thongs with long shoulder-length hair. They were both relaxed but excited about the imminent birth of their first child. The consultation was kept informal so as to engender in Annie and Rob a sense of trust in the therapist’s professional advice regarding their music for labour, and to enable the therapist to gain an impression of their musical tastes and preferences through discussion about their life experiences. It was also essential to establish a rapport which was both appropriate and conducive to the therapist’s attendance at the birth, should Annie and Rob so agree. Annie’s pregnancy had been planned and free of worry. She enjoyed excellent health, with Rob commenting that her health had been better during pregnancy than when not pregnant. (Annie was susceptible to headaches but had experienced none since becoming pregnant). An ultrasound was performed at 17 weeks gestation in order to determine an estimated due date for the birth, which was set at February, 1991. An obstetric visit at 30 weeks queried fetal growth with the suggestion that fetal size was “small for date.” Hospitalization was suggested at 32-34 weeks if no increase in size was detected, however, an Ultra-Sound at 36 weeks revealed fetal development to be within normal limits. This episode worried Annie and Rob, but they firmly believed the fetus to be healthy because Annie’s health and weight gain had been normal. Annie’s and Rob’s musical tastes and experiences were quite different. Annie had received formal piano lessons from her mother who was a music teacher; whilst Rob had received no formal music education as such. Neither of them actively pursued music as a leisure time activity, however both enjoyed listening to music. Annie’s preferences were for classical instrumental and middle-of-the-road vocal music such as Elton John, Bette Midler and Lionel Ritchie. Rob, however enjoyed heavy rock music such as the Rolling Stones and The Who, explaining that the discrepancy in their preferred style was more likely to be a function of their age difference of 9 years rather than differences in their personalities. Rob was happy to have any of Annie’s preferred music, assuming (quite correctly) that heavy rock music would have a limited role to play in their labour. Following a detailed explanation by the therapist about music in labour, a music programme was designed to Annie and Rob’s specifications. They had brought the required audio-cassettes for recording by the therapist with a “starter” tape being given to them at the conclusion of this first consultation. The author’s impression of this couple at the conclusion of the first consultation was that Rob was easy-going and satisfied that whatever music Annie chose was best for her and their baby in labour. He was positive toward the suggestion of the therapist’s attendance at the

birth, understanding that active birth may require maximum energy and effort from himself. To this end, he felt a second support who could focus on the music and its function in labour would likely benefit himself, and in turn Annie. Annie was also relaxed about the labour. Her expectations of the labour and birth were “Looking forward to the birth - hoping for a natural birth if possible.” She was slightly hesitant about the therapist’s attendance at the birth. This was seen by the therapist, and later verified by Annie as an embodiment of “fear of the unknown” and fear of losing control in front of a stranger. This was not uncommon in primipara women. It was hoped that continued contact with Annie and reassurance and support by the therapist would alleviate this hesitancy. Method The design of this empirical case study was influenced by three main sources: four American projects researching the same area; the therapist’s personal birth experiences; and a six-month pilot project conducted by the therapist prior to commencement of the research project. Clark (1981), Codding (1982), Hanser, Larson and O’Connell (1983) and Winokur (1984) investigated the effectiveness of music in reducing pain, fear, and/or anxiety responses of women during childbirth. The present research follows a similar design to Winokur’s with the use of individualized music programmes for women and their partners in the third trimester of pregnancy. Similarly, couples using these programmes were prepared by the therapist for their use during labour and delivery, with the therapist attending forty percent of these births. This preparation was done in conjunction with the antenatal classes offered by the hospital where delivery was planned. Antenatal preparation and the actual approach and procedure of labour and delivery in Australia differs greatly from that in the U.S.A., where childbirth classes are usually Lamaze-based. The levels of breathing for stages of labour (i.e. shallow breathing, panting, etc.) have been all but phased out of Australian antenatal preparation, as has the notion of “coaching” women in labour. Similar to both is the aim to educate a woman and her partner in lay terms about the theories, physiology and psychology of childbirth with strategies for coping during labour. However, the greatest difference between the antenatal preparations is that women in Australia are being taught and encouraged to labour instinctively, trusting the process of labour coupled with the knowledge they have acquired from classes. The woman establishes her own natural breathing patterns in accordance with the stage of labour. Women will use different breathing patterns instinctively in labour without necessarily being made aware of them. Rather than “coaching” the woman, partners now take a nondirective, supportive role, trusting the process and supporting the here-and-now of the woman’s labour experience. These differences are subtle but significant. The research project used only primipara women. The four reasons are as follows. First, fear of the unknown and the shock of the intensity of contractions once labour is established can have negative effects on a labour and, hence, outcome. If a woman and her partner are not adequately prepared for the psychological and physical impact of labour, there may be a greater need for analgesic and/or anaesthetic pain relief. It is important to note that anaesthetic pain relief through an epidural greatly increases the likelihood of a forceps delivery

and episiotomy, as effective bearing down on the fetus is made difficult by numbed pelvic and abdominal muscles. Second, if physical and psychological trauma to both mother and child during childbirth can be avoided or at least minimized, the mother has a better chance of bonding and coping with a new routine, decreased amount of sleep and the learning of parentcrafts such as breastfeeding, nappy changing and bathing. Third, a multipara woman will generally already have networked and acquired a support system of at least one other mother within her own community, whereas a primipara woman invariably must begin this networking at the same time as learning to cope with a major change of lifestyle. Continuity of care by the music therapist from the antenatal and labour and delivery period into the postnatal period can assist the assimilation back into the home and wider community. Finally, multipara women often labour differently with the benefit of experience and hindsight, and as a result can have significantly reduced length of labour and, hence outcome. A pilot project and the therapist’s second childbirth, which took place 6 and 8 months prior to the commencement of the project, also helped to refine the design of the present treatment and research. The purpose of the pilot project was manifold: to test the incidence of active and drug-free labour, as experienced by the therapist, but in primipara women; to refine the recording of music; to determine preferred music styles of women; to refine a personalized clinical approach when attending a labour; and to determine whether specific types of music were more effective at given times in labour. The pilot project was conducted over six months and was offered to primipara women delivering at the small private hospital at which the research was to be based. The therapist attended five births for experience but prepared music for seven women and discussed its use (no tapes given) with another thirteen. The refined results of this pilot project were employed in designing the methodology for Annie and Rob. The Tapes Annie and Rob provided eight blank 90-minute audiocassettes (TDK-D90), for the therapist to make the recordings. Ninety-minute cassettes were used because experience had shown that cassettes shorter in length did not allow optimum process to be achieved with the music; cassettes longer than 90 minutes in length often compromised the quality of the music. Each tape was designed for a specific purpose, and was to be used during the weeks prior to delivery or during labour itself, as Annie and Rob deemed appropriate. Table 1, which appears at the end of this paper, gives details on the eight tapes comprising the individualized music programme for Annie and Rob. The cassettes were distributed to Annie either by mail or were picked up by her personally. Contact was maintained via telephone. Tapes numbers 6 and 7 were given to Annie and Rob at the final consultation. The Hospital, Midwives and Obstetrician Annie and Rob had booked a Family Birthing Unit (FBU) at a 100-bed private hospital 15 minutes drive from their home. The hospital, which had a reputation as being progressive for its

encouragement of active labour with minimal intervention, offered two FBUs with bedroom, lounge, kitchenette and bathroom (one with a spa and shower). The decor was in co-ordinated pastel colours with the impression of a comfortable and spacious motel unit. Medical and resuscitation equipment was stored behind floor-to-ceiling pastel curtains at the head of the bed. Lighting was controlled by dimmer light switches and vertical blinds in each of the three rooms. The lounge offered a couch and two armchairs as well as a dining table, chairs and television. Fluids (water, juice, tea, coffee, ice) and snacks were stored within the kitchenette for immediate access. One midwife was allocated per labouring woman to allow for continuity of care over an eight hour shift, and to decrease the number of people entering the room thus potentially affecting the labour process. Observations (blood pressure, pulse and fetal heart rate) were monitored hourly in early stages of labour and half hourly once labour was established and progressing. Internal examinations were generally performed only when either dilatation was suspected to be complete or when there were contraindications, e.g., non-progressive labour, fetal distress (as detected via Fetal Heart Monitor or a show of meconium stained fluid), examination of position of fetus especially if in abnormal position, maternal distress and the likes. Annie’s obstetrician showed a positive and keen interest in the use of programmed music during delivery. Final Consultation The therapist met with Annie and Rob at their home at 39.5 weeks to complete antenatal preparation for using the music programme during labour and delivery. Annie returned two cassettes for minor alteration (i.e. changing two songs on Tapes 4 and 7). Other than this Annie had enjoyed all of the cassettes, and had listened regularly to the “Support Relaxation” and “Pelvic Rocking - Vocal” cassettes. Annie and Rob were excited and psychologically prepared to give birth and meet their baby. The baby’s head had engaged in Annie’s pelvis and was lying in normal cephalic position. Medical observations by Annie’s obstetrician indicated that a normal labour was anticipated and imminent. At the end of the consultation, Annie appeared to be more positive toward the therapist’s attendance at the birth. However, the final decision was to be made once labour was established. The two revised tapes were to be returned to Annie 3 days later. Two and a half days after the therapist left them, Annie went into labour (39.5 weeks). Treatment Process At Home 0200 Spontaneous rupture of membranes (SROM) occurs. Annie and Rob are excited; Rob is slightly anxious. Contractions increase from 15 minutes apart and mild to 3-4 minutes apart and moderate. Annie sleeps till 0700.

0845 Therapist is notified. Annie and Rob listen to “Pelvic Rocking-Instrumental” and “Contemporary Instrumental” until leaving home for hospital. 1045 Annie and Rob go to hospital. Therapist is asked to attend. Contractions are 3-4 minutes apart and moderate. Annie is distressed with side effects of onset of labour (i.e., shaking, vomiting, diarrhea). Amniotic fluid begins draining. Annie and Rob are unsure of what tape to play in the car. At Hospital 1105 Annie is admitted to hospital, walks to Family Birthing Unit, and goes into warm bath which provides immediate relief. No music is played. 1205 Therapist arrives. Contractions are 3 minutes apart and moderate. Annie sits in bath with heels together and knees apart while Rob rubs her back. Annie feels relaxed in the bath and was conscious of different positions to facilitate the progress of labour. Annie listens to “Contemporary Instrumental” as she is coping well and relaxed. This tape was also helpful to her for visualization in early established labour. 1225 Annie is talking between contractions, and inhales/exhales slowly during contractions. The therapist chooses “Pelvic Rocking - Vocal” as Annie has no signs of tiring and had energy. She felt peaceful and positive and wanted to maintain her general mood. 1230 Mucous plug from base of cervix came free while in the bath. New mid-wife comes on duty and introduces herself. 1243 There is a sudden increase in intensity of contractions, 2-3 minutes apart. Annie switches to “Flute/Harp tape.” The nature of her contractions and mood changes. Vocal music is no longer suitable, as Annie needs something soothing and relaxing. Annie is managing the pain well so the therapist decides to save the “Support” tape for the next acceleration (speed/intensity) of contractions. 1255 Fetal Heart checked (recorded by therapist). 1305 Contractions are 2 minutes apart and strong. Annie has slight urge to push with contractions. Internal examination by Doctor showed cervix to be 8 cms dilated but with a thick anterior lip. Due to the lip, Annie was requested by Doctor not to push as damage to the cervix and moulding of fetal skull would likely result. Urges to push become stronger. Rob and Annie were surprised and pleased that 80% of dilatation had been completed. “Support” tape is chosen, as Annie requires all the assistance and support possible to control her natural urges to push. Music needed to offer her maximum relaxation to decrease any panic or anxiety and to help her rest/sleep between contractions. Volume of music is increased considerably by therapist so as to aggressively draw as much attention away from her pushing urges. Annie nodded her head in rhythm to three regularly sequenced beats in one particular piece of music. She was so relaxed that her head lowered closer to the bathwater with each repeat of these beats. 1330 Annie and Rob are alone in bathroom. Mood was peaceful and Annie was wellcontrolled, using “Support” tape and prayer to control the urge to push.

1355 Contractions are 2 minutes apart with stronger urges to push on alternate contractions. Fetal Heart rate is taken (recorded). Volume of the music is decreased on “Support” tape as Annie is controlling urges well. 1415 Contractions are further apart (3-4 minutes). Annie tries different positions in bath to encourage contractions but pressure to push increases with the change. She resumes sitting with heels together and knees apart. Annie is tiring and sleeping between contractions. She is shaking with the cold. “Pelvic Rocking Instrumental” tape is used to encourage gentle movement and to increase alertness. Annie feels disappointed and unsure as to why contractions slowed down. Volume of music is decreased to provide quiet background, and to give Annie the option to use the music actively or just relax to it. 1450 Volume of music is decreased further so as to allow maximum relaxation while still offering support to move if desired. 1501 Annie is very relaxed, slow, and sleepy in bath. “Support” tape is used to encourage Annie to rest and get her sleep between contractions. 1505 Therapist asks Annie if music was suitable. After putting the “Pelvic-Rocking Instrumental” tape on it seemed a little too slow for the present mood. Annie requested “Contemporary Instrumental” after considering the question for about 15 seconds. Annie, Rob and therapist agreed this tape was more appropriate at this time. 1540 Contractions are 5 minutes apart but 2.5 minutes in duration (1 minute moderate pain/1 minute strong pain/30 seconds easing off). The labour appears to have slowed down considerably with contractions seemingly less effective. Annie is aware of slower pace. 1555 Annie gets out of bath to encourage movement, and thus contractions. Doctor arrives. Annie is comfortable standing with her back to Rob and swaying slightly to music. 1605 Annie gets onto bed. Internal examination by Doctor reveals cervix to be fully dilated and effaced. Mood of the room changes with Annie sitting on side of bed and rocking vigorously to music. Midwife asks which position will be used for delivery. Annie is full of renewed energy as she is able to push with her urges and becomes ready for delivery of their child. As Annie sits on the Birthing Stool ready for pushing stage of labour she says to therapist, “This is Van Morrison, isn’t it?......the ‘Pelvic-Rocking’ tape.” Rob sat on a normal sized chair behind Annie on the birthing stool, supporting Annie under her armpits. With each contraction and push she would grasp Rob’s fingers. Annie whispered to Rob, “I don’t think I can do this.” The therapist positioned a mirror in front of Annie so that she and Rob could witness the progress of their baby’s journey. “Pelvic Rocking - Vocal” is used as it matches Annie’s energy level without being overly loud and imposing. Annie speaks with the doctor, midwife, therapist and Rob between contractions. Thus, vocal music was appropriate. 1617 Annie is pushing effectively with each contraction. Doctor is lying on floor next to therapist at Annie’s feet, observing progress. Annie and Rob rock side-to-side with the music between contractions. Doctor alludes to the music frequently.

1635 1650

1654 1745

“Support” tape is used for delivery, as it was the most familiar to Annie and would, therefore be easier to attach to and focus on. Also, if so needed, as the head came onto view she is requested not to push, Annie would have a point of focus for restraining the urge. Rob changes positions with therapist so as to assist doctor with delivery of their baby. The therapist now sits behind Annie, allowing her to squeeze her fingers and push back onto her during contractions. Hindwaters of amniotic fluid break as head of baby crowns the perineum. Annie is asked not to push in order to allow perineal stretching. Therapist reminds Annie to focus on the rhythm of the music, which, at that time was appropriately matched to the shallow breathing required by Annie. The doctor encourages small pushes so as to minimize trauma to the perineal and vaginal area. Again, the music has moderately short phrasing which was suited to such short and regular pushing. Delivery of a live baby girl. The therapist places “Post-Natal” tape on 3 minutes after delivery. The last 20 minutes of labour and the delivery are recorded by therapist and continued postnatally until cassette is full. The therapist departs the birthing unit, having spoken to Annie and Rob about their immediate thoughts on the experience. Rob states repeatedly that he felt the music was what made the difference to both him and Annie. Annie felt that the music and the prayer together were the effective methods for restraining the urges to push. Both were surprised and very pleased at Annie’s ability and strength to complete the labour without drugs for pain relief. The mood was one of pride and elation. Evaluation

More formal evaluation as to the effectiveness of music in pain management consisted of giving Annie a Post-Natal Questionnaire and interviewing the couple. The Post-Natal Questionnaire, completed at Day 3 after the birth revealed the following: 1) Annie described the degree of discomfort or pain experienced during labour and delivery as intense. This was level 6 on a 7 point scale which included: None, Very Mild, Mild, Strong, Very Strong, Intense and Extremely Intense. 2) When asked to rank order the effectiveness of various techniques she used in pain relief and management, Annie placed the music first and prayer second. 3) Annie stated that she felt that music was helpful to her during labour. The manner in which music was helpful was that it was a “means of relaxation, distraction for myself and Rob.” 4) On a scale of 1-10, Annie rated her childbirth experience as “8” with regard to expectations and satisfaction. The three words Annie used to describe her feelings about her first childbirth experience were “peaceful, relaxed, and beautiful.” 5) Annie stated that in retrospect she would “try to stay more relaxed in early stages at home and during internal examinations” for a future labour and delivery experience.

The interview with Annie and Rob postnatally focused on their labour and childbirth experience and how music was or was not incorporated into that experience. The interview took place on Day 7 after the birth, when they were both tired but still happy with the events surrounding the birth of their daughter. Annie said she was most aware of the “Support” tape during her labour. She felt that the tapes which she preferred i.e. “Support,” “Contemporary Instrumental” and “Harp and Flute” were the ones she could focus on more readily. On the whole, Annie felt that the music gave her a focus. “I knew the music was there for me - it kept coming to me.” Annie felt that she was more conscious of the music in hospital than at home, and at no time did the music or therapist irritate her. Annie felt that suggestions by the therapist as to management of contractions and discomfort were helpful (e.g. breathing/visualizing the music, and focusing on the music at strategic times). Postnatally Annie still listened to all of her tapes, especially her “Support” tape which assisted with feeding and settling of the baby. Rob admitted to usually being a “bundle of nerves” with anything new, but he firmly believed the music helped him and Annie to relax. He was conscious of the music most of the time, but particularly when the “Support” and “Contemporary Instrumental” tapes were played. Annie and Rob both agreed that they would use music in a subsequent labour. Discussion and Conclusions The results of the present case study support showed music to be an effective means of pain management for Annie and Rob. Music and prayer were the two techniques used by Annie to control the pain, with music being rated as the most effective of the two. According to a Victorian Birthing Services Review in 1988, 29% of women (multipara and primipara combined) used no drugs or TENS units in their labour. Annie was one of those women. There are many factors which can affect how a woman labours. One of the greatest influences is her physical and psychological approach to her pregnancy and childbirth experience. It cannot be understated that in their relaxed, flexible but committed approach to their childbirth preparation, Annie and Rob improved their chances of having the active, drugfree labour they had hoped for. The format of this case study may be noticeably different from ones detailing music therapy with a disabled client. Annie and Rob in effect set their own aims for their childbirth experience, that is, active labour to facilitate the birth of their child and drug-free labour so as to minimize any trauma on Annie and the child during the labour process. Because their aim was achieved, Annie and Rob naturally attributed some of that success to the programmed music. It is difficult to determine whether Annie would have managed her labour as positively without the music. Two main factors contributed to the effectiveness of the music with Annie, which may not be present with other women. First, Annie already believed in the role of music, and had fully intended to use it during labour and delivery; hence, she expected the music to have a positive effect. Second, she used music as an integral part of her psychological preparation antenatally. Thus, an experimental test of the effectiveness of music would have to control for at least two variables: expectations regarding the effectiveness of music, and the use of music in antenatal preparation.

Another issue is that obstetric research is such that no one labour can be reconstructed or re-experienced. Hence, the events and outcome of a labour such as Annie and Rob’s must be accepted as an entire unit—which is quite difficult to match with other couples for experimental purposes. From a clinical point of view, the most important points of discussion seem to be the role and appropriateness of the therapist and the music programme. Aside from all the positive comments, Annie did not fault any choices of music or professional decisions made by the therapist. She stated that at no time did the therapist or music irritate her during the labour. An interesting question, however, is whether music could have been used to greater advantage at various points in the labour, and if so, when. As obstetricians will verify, hindsight is one of the most important aspects for learning about labour. Hindsight would benefit every primipara woman. However, hindsight of a previous labour is a luxury available only to multipara women—as well as obstetricians, midwives, and assisting therapists. For this therapist, hindsight brought forth two insights. Firstly, without a doubt, Annie needed the therapist to be present earlier in the labour. The therapist would have used the “Support” and “Flute/Harp” tapes at home in order to calm Annie and to minimize the side effects of the labour (i.e. vomiting and diarrhea, which were causing her anxiety). The second insight is more of a question with regard to the labour itself. For the final three hours of her labour Annie, due to incomplete cervical dilatation and effacement, had to suppress natural urges to push her baby down the birth canal and thus give birth. By suppressing that urge, Annie was actually causing contractions to regress (i.e. denying her natural urges). The contractions then became further apart. It is difficult to argue which type of music if any could have assisted Annie more effectively at this point. The fact that the therapist tried both active (“Pelvic Rocking-Instrumental”) and relaxing (“Support”) music as well as asking Annie which music she preferred at the time (“Contemporary Instrumental”) meant that every opportunity was given to maximize the music’s potential. Obstetric procedure and outcome have many permutations and combinations and can be discussed ad infinitum. What is clear from this case study, is that Music Therapy-Assisted Labour was an effective pain management technique for Annie and Rob, and that it holds equal promise for other couples who are committed to a similar approach to the birthing process. Glossary Active labour: Taking various positions and moving, usually in a vertical fashion, to facilitate the labour process Anterior lip: Occurs when front of cervix is not thinned evenly, causing partial obstruction of the birth canal. Cervix: Neck of the womb. Contractions: Tightening and releasing of abdominal and lower back muscles which draw up the sides of the cervix, causing it to open; can be described as mild, moderate, or strong according to their effectiveness. Dilatation: Spreading or widening of the cervix, which must reach 10 cms before a vaginal birth can occur.

Epidural: Place in the lower spine where a plastic catheter is inserted in order to inject anaesthetic for pain relief. Episiotomy: Surgical enlargement of perineum via incision. Hindwaters: Amniotic fluid which sits behind the fetal head. Meconium: The first bowel movement of a fetus or neonate, which is usually black, like thick oil. Mucous Plug: A mass of mucous which seals the cervix during pregnancy, and breaks loose before or during labour. Multipara: Woman expecting her second or subsequent child. Perineum: Skin area between the anus and genitals. Primapara: Woman expecting her first child, having no previous labour. Small for Dates: Fetus is suspected to be abnormally small for its gestation. Spontaneous Rupture of Membranes (SROMS): The amniotic fluid surrounding the fetus in utero bursts. TENS: Transcutaneous Electrical Nerve Stimulation: Two or four electrodes are strategically placed on the lower spine with a hand-held battery pack, and small shocks are administered to block pain messages to brain. References Clark, M. (1980). An evaluation of music therapy-assisted labor. Unpublished master’s thesis. University of Kansas. Codding, P. (1982). An exploration of uses of music in the birthing process. Unpublished master’s thesis. Florida State University. Hanser, S., Larson, S., and O’Connell, A. (1983). The effect of music on relaxation of expectant mothers during labor. Journal of Music Therapy, 20 (2), 50-58. Health Department of Victoria (1990). Having a Baby in Victoria: Final Report of the Ministerial Review of Birthing Services in Victoria. Melbourne: Author. Winokur, M. (1984). The use of music as an audio-analgesia during childbirth. Unpublished master’s thesis. Florida State University.

Table 1 INDIVIDUALIZED MUSIC-BIRTHING PROGRAMME FOR ANNIE AND ROB Tape 1: Support - Relaxation Style: Instrumental music from Baroque and Classical periods. Examples: Mascagni’s “Intermezzo” from “Cavalleria Rusticana” Gluck’s “Gavotte” from “Iphigenia in Aulis” Haydn’s “Serenade” Rachmaninoff’s” 18th Variation” from “Rhapsody on a Theme of Paganini” Antenatal: Listen at least once per day from 36th week onwards to relax, and to develop an association of this music with relaxation. Use as focus while relaxing. Labour: Listen when help, support or comfort is needed, and particularly when contractions increase in length of intensity. Tape 2: Pelvic Rocking - Instrumental Style: Instrumental music from Classical Period. Examples: Williams’ “Fantasia on Greensleeves” Dvorak’s slow movement from “New World Symphony” Mozart’s “Menuet” from “Don Giovanni” Poncielli’s “Dance of the Hours” Antenatal: Listen to when active (e.g., driving, cooking, moving around). Learn to associate music with relaxing movement and activity. Labour: Use during active, later stages of labour (i.e., when nonverbal but still active). Tape 3: Support - Background 1 Style: Flute and Harp Pieces from Classical and Baroque periods. Examples: Wagenseil’s “Harp Concerto in G Major - Andante” Mozart’s “Concerto for Flute, Harp and Orchestra in C Major” Antenatal: Use as background music for relaxed activities, in addition to Tape 1. Labour: Same as Tape 1. Tape 4: Pelvic Rocking - Vocal Style: Popular vocal with strong movement implied in rhythm. Examples: Van Morrison: “Have I Told You Lately?” Chris DeBurgh: “Lady in Red” Louis Armstrong: “What a Wonderful World” Elton John: “I Need You to Turn To” Simply Red: “If You Don’t Know Me By Know” Antenatal: Same as Tape 2. Labour: Same as Tape 2.

Tape 5: Post-Natal Style: Annie’s favourite popular songs. Examples: Dan Fogelberg: “Longer” Harry Chapin: “I Let Time Go Lightly” Phil Collins: “Father to Son” Amy Grant: “Father’s Eyes Chris DeBurgh: “For Rosanna” Antenatal: To encourage singing to baby in utero and for breathing. Labour: To stimulate hormones if labour is slow to progress and to encourage deep breathing and body vibration. Postnatal: To affirm birth of baby. Tape 6 Support - Background 2 Style: Contemporary instrumental: Sound tracks and New Age. Examples: Fresh Aire: “Embers” Enya: “Watermark” Sky: “Hello” Mark Knopfler: “Irish Love from ‘Cal’” Antenatal: Use as background music for whatever is desired (e.g., entertaining, housework, etc.). Labour: Use as alternate to support tapes, mainly for relaxing. Tape 7: Early First Stage Style: Popular vocal. Examples: Van Morrison: “Bright Side of The Road” Wet Wet Wet: “Broke Away” Dire Straits: “Brothers in Arms” Eagles: “Best of My Love” Antenatal: For times of increased physical activity or exercise. Labour: Limited use during early labour. Tape 8: Blank Labour: During final 15 minutes of labour, record fetal heartbeat (via Sonicaid or Monitor) and conversations; record moment of birth, first sounds of baby, and conversations immediately after birth.

CASE ONE Facilitating Neurological Reorganization through Music Therapy: A Case Example of Modified Melodic Intonation Therapy in the Treatment of a Person with Aphasia Felicity Baker Introduction In the rehabilitation setting in Australia, the interdisciplinary team works together to provide effective rehabilitation programs for people who have neurological damage, with the ultimate goal being re-integration to the client’s premorbid lifestyle and community. The primary focus of rehabilitation programs during the initial period post-trauma is addressing functional outcomes, specifically physical (motor), cognitive, communicative, and activities of daily living, due to current understandings that early intervention maximizes functional outcomes (e.g., Mateer & Kerns, 2000). This can, and frequently does, present a significant challenge for music therapy practitioners who may have to make choices with respect to the overall purpose of the music therapy program and the approaches used within those programs. I consider addressing the client’s psychological and emotional adjustment to his/her acquired disability a necessary component of the rehabilitation process. However, this need is not always acknowledged by the interdisciplinary team who seem more interested in what music therapy can offer with respect to addressing functional outcomes. The clinical case presented here illustrates how music therapy interventions, specifically melodic intonation therapy (MIT) (Sparks, Helm, & Albert, 1973), target functional outcomes while simultaneously responding sensitively to the psychological adjustment of the client. Foundational Concepts The Clinical Context Working in a neurorehabilitation setting involves working together with the clients, interdisciplinary team members and family members to reduce the severity of the acquired impairment. The clients I worked with were adults (usually young adults aged 18-35 years) and were almost exclusively traumatically brain-injured as a result of a road traffic accident. Dependent upon the severity of the injury, and their phase of recovery, these clients may be in a coma, requiring a high level of care (completely dependent for all functional activities of daily living), semi-independent (living within the hospital but in units containing their own kitchenette and laundry), or integrated into the community and returning to the hospital as outpatients. Client progress can be rapid (some clients may only be in hospital for weeks), steady (hospitalized from 3-6 months), or slow (more than 6 months and sometimes years after the acquired brain injury). Therefore, the work of the music therapist is wide ranging and requires the experience to work with minimally responsive clients as well as highly independent

clients, all of whom vary in their recovery pace. The clients’ needs and therapy approaches selected are influenced by these factors. Regardless of the severity of injury and their phase of recovery, clients often present with a combination of physical, communication, cognitive and emotional impairments (Baker & Tamplin, 2006). Physical impairments may range from limited range of movement, decreased coordination of movement, dyspraxia (impaired sequencing of movement), reduced muscle strength and endurance, poor trunk control, hemispheric neglect or perseveration. Cognitive and behavioral impairments typically range from poor concentration, poor abstract thinking, poor on-going memory or poor frustration tolerance, to disinhibited behaviors. Importantly, and often neglected, clients have extensive emotional adjustment needs – loss of independence, loss of role, loss of self-concept, loss of physical appearance, feelings of guilt and self-blame, feelings of anger toward others, and feelings of anger with hospitalization and the therapeutic process. When addressing the client’s therapy needs, it is important for the clinician to be aware that each physical, cognitive, communicative, behavioral and emotional adjustment impacts all other areas of the client’s therapeutic outcomes. So, a holistic approach within a functional framework is required. Of particular relevance to this chapter, clients with neurological damage may display a range of communication impairments, including aphasia (of various forms), dyspraxia, dysphasia and dysphonia. Broca’s aphasia is a communication disorder caused by damage to the Broca’s area of the brain in the posterior–inferior frontal gyrus of the left hemisphere. It is classified as one of the expressive aphasias and is characterized by non-fluent, effortful, slow, halting and uneven speech (Helms-Estabrooks, 1992). Clients will commonly have limited word output, with short phrases and sentences. They will misarticulate or distort sounds, their speech may be agrammatical, they may have impaired naming of objects, and they may not be able to repeat back words or sentences if modeled first by another person. However, their comprehension of language may be relatively intact with only slight impairments. Neuroplasticity and Rehabilitative Potentials Music therapy’s effectiveness in neurorehabilitation is not itself a new concept. In fact, clinicians have published work in neurorehabilitation since the 1950’s (e.g., Claeys, Miller, Dallow-Rampersad & Kollar, 1989; Cohen, 1988; Fields, 1954; Lucia, 1987). However, recent knowledge acquired in neuroscience and clinical neuromusicology have allowed music therapy clinicians to reflect upon their approaches and refine them accordingly (e.g., Baker et al., 2005; Kim & Koh, 2005; Magee, 2007; Särkämö et al., 2008; Schaulag et al., 2008; Tamplin & Grocke, 2008; Wheeler et al., 2003). Perhaps the most important concept informing my work is that of neuroplasticity. Neuroplasticity is the term used to describe the process that the brain undergoes during recovering from injury. What is known now is that the brain is not structurally static, but capable of self modification and reorganization (Kolb 2004; Kolb & Gibb, 1999; Mateer & Kerns, 2000). This means that if one part of the brain that was responsible for performing a certain behavior has been damaged, there is the potential for the brain to reorganize itself and another part of the brain will “take on” the responsibility for that function.

An important finding in neuroscience is that neuroplasticity doesn’t just happen on its own. It is dependent upon the client being engaged in experiences that encourage the use of the behavior that is lost or impaired. And we know this because studies that have scanned the brains of people from certain professions show that their neuronal morphology differs slightly to those not engaged in such activities (Patel, 2008). For example, when compared with the general population, secretaries and appliance repairman develop advanced finger dexterity over sustained periods of use (Kolb & Gibb, 1999). Brain scans showed differences in trunk and finger neurones in their brains when compared with other people. Relevant for music therapy practice, the same types of observations have been noted when people engage in making music. For example, the digit fingers in the left hands of string players show increased cortical representation when compared with the left thumb, yet no such differences were found in the cortical representation of the right hand (Elbert et. al., 1995). These findings show that the more frequently a skill is performed or practiced, the more the neural connections are strengthened and thus, the more likely the client will be able to perform that skill again, with more accuracy, for longer duration, and/or with greater efficiency. There is mounting evidence that early intensive therapeutic intervention (2-3 times per week minimum), as opposed to less often (e.g., once per week) increases the chances for maximum cortical reorganization (neuroplasticity) (e.g., Mateer & Kerns, 2000). Mateer and Kerns (2000) and Nudo (2007) also provide evidence that varied approaches to developing a skill are more effective than pure repetition because they encourage multiple neural connections that increase the chances of developing and strengthening neuroactivity. In relation to my own practice as a music therapist, I therefore tend to work with clients intensively and engage varied activities to promote neural connectivity and facilitate the neuroplastic process. The potential for music-based interventions to facilitate recovery of speech and language is supported by music and imaging studies that show how neuronal networks responsible for music processing are widely distributed throughout the brain (e.g., Patel et al., 1998 Sergent et al., 1992; Zatorre et al., 1992; 1996). Further, many of these music processing sites are in areas of the brain that are adjacent to, or overlap with, the areas of the brain involved in language and speech functioning, and are therefore relevant and influential in my understanding of my work with clients with communication disorders, including that of aphasia. To illustrate just a few: • • •

engagement in speech and music activates some of the same areas of the primary auditory regions of the brain (Zatorre et. al., 1992) listening to music (scales and auditory imagery for sounds) and words activate the same areas of the secondary auditory regions (Falk, 2000; Sergent et. al., 1992; Zatorre et. al., 1996), and Broca’s area (known to be involved in the motor activity related to language) is also activated when playing music (Sergent et. al., 1992) and when musicians are engaged in a rhythmic task (Patel et al., 1998).

Given this knowledge, music-based interventions have a strong potential to stimulate neuronal changes by encouraging the areas of the brain responsible for music to take over

responsibility for the speech skills that were previously controlled by the now neurologically adjacent and overlapping damaged areas of the brain. What we hope will happen during music therapy is that existing neural pathways will be strengthened, and that new neural pathways connecting undamaged areas of the brain will be created. Melodic Intonation Therapy As described in the previous section, because music is processed through varied areas of the brain, particularly those that overlap with areas of speech, and because repetition/active participation in music making can alter the brain’s neuronal morphology, music-based techniques that engage unimpaired areas of the brain responsible for music making are well suited to assist with the rehabilitation of speech. Originally developed by Sparks, Helm & Albert (1973), Melodic Intonation Therapy (MIT) is a technique developed to facilitate the production of language in people with mild to moderate non-fluent aphasia. The approach described in this chapter is a modified version of MIT (referred to here as MMIT) which was adapted to assist those with severe non-fluent aphasia regain some verbal communication. Readers wanting more information about traditional MIT and the differences between MIT and the approach presented here are encouraged to read Baker (2000). MMIT is a structured intervention whereby phrases or short sentences are set to music. These phrases are repeatedly sung to the client with the intention being that he/she will learn to sing them, internalize them, and eventually say them in a functional setting. My approach incorporates four components – preparing material for use in the sessions, implementing the intervention with the client, providing homework and practice tasks for the client, and then assessing and regularly reassessing client progress. These components are described in more detail in the case study below. The Therapeutic Process The Client At the time I met Tara, she was a 32-year-old woman who had been struck by a car four months earlier. Born and raised in the Philippines, she was on vacation in Australia, visiting her sister, while recuperating from the loss of her first child (who, at age eight, had recently died of a brain tumor). She also had a younger child, aged six, who was in the Philippines and living with her estranged husband. At the time of her accident, Tara was employed with an international company and spoke English fluently. The accident left Tara with severe head injuries. On admission to emergency care, she was unconscious, intubated, and remained so for two months. Brain scans indicated Tara had sustained severe damage to the left hemisphere of her brain. Right hemispheric damage was also sustained. Several interventions were performed during the first few months postaccident, including two craniotomies. Once medically stable, Tara was transferred to a specialist traumatic brain injury rehabilitation hospital. Assessment of Client

Three months post-injury, Tara regained consciousness, and prior to her referral to music therapy, completed a range of functional skills assessments including an assessment of her speech and language skills. Tests indicated speech difficulties including severe right hemiparesis affecting her right facial muscles, severe non-fluent aphasia (Broca’s), and dyspraxia (a motor planning problem). Tara demonstrated that she had retained English verbal comprehension. Tara began participating in active rehabilitation programs which were comprised of physiotherapy, occupational therapy, speech pathology and counseling. During speech pathology, various interventions were implemented to promote verbal output, and despite Tara’s high level of motivation, she was unresponsive. A book of compics (pictorial communication system) was created for Tara so she could communicate her basic needs and wants while speech therapy continued. A month later (four months post-injury), a staff member at the hospital witnessed Tara singing the words to a Beatles’ song playing on the radio and had reported to the speech pathologist that Tara was singing the words to the song with clarity. It was at this point that Tara was referred to music therapy. On assessment, it was ascertained that Tara regularly participated in karaoke singing while in the Philippines. She had a beautiful sounding and controlled singing voice, and had a large repertoire of Western “pop” songs. She was a particular fan of Mariah Carey. Most importantly, she sang the words of familiar songs with remarkably accurate articulation. Her music skills appeared to be unaffected by her injury and this suggested that the areas of the brain responsible for music production were not damaged. Initial Music Therapy Program After consultation with the speech pathologist, and in keeping with the view that regular therapy is necessary in the early phase of rehabilitation, it was recommended that Tara receive five half-hour sessions of music therapy each week in addition to the four one-hour sessions of speech pathology she was already receiving. The music therapy sessions focused on singing popular love songs that Tara knew well, which aimed at 1) providing Tara with an opportunity to use her voice in an enjoyable activity that was guaranteed to be successful, and 2) practicing articulating words clearly (to support the work being done in speech pathology). The speech pathology program focused on conducting intensive drills aimed at improving Tara’s verbal output. In spite of the intensive efforts of both speech pathologist and myself, after two months, Tara was unable to produce simple consonant and vowel combinations even when paired with gestural cues, pictures of mouth shapes, or modeling. While only brain imaging could prove this, it might suggest that there was extensive damage to certain areas responsible for speech, reducing her responsiveness to traditional speech approaches in areas that were not adjacent to the areas activated by the music-based approaches. Introducing Melodic Intonation Therapy Because Tara continued to sing beautifully, with motivation and clear articulation, discussion between the speech pathologist and myself led us to try Melodic Intonation Therapy.

Here, it was actually the speech pathologist who implemented the program over the following three months, while I continued to provide Tara with opportunities to sing in order to maintain her clarity of articulation. Integral to the therapeutic process with Tara was the need to simultaneously address her psycho-emotional needs and processes. Here, the singing and ensuing therapeutic relationship that we developed allowed Tara to express issues that could potentially lead to low therapy motivation. By singing songs that were either enjoyable or meaningful, Tara was able to express her frustration, anger or grief around her acquired disability and the loss of her daughter. For example, she would frequently arrive for music therapy distressed, and due to her language impairments, was unable to verbally articulate what was going on for her. Instead, we perused songbooks together and I would play the keyboard to accompany her singing. Singing released different emotions at different times – sadness (tears), tension (relaxed body) and happiness (smiling, laughing) – in ways that allowed her to work through her grief and loss. Modifying MIT: A Ten Week Trial Despite intensive efforts by the speech pathologist and myself, Tara remained unable to generate words independently outside of a singing context. Not deterred by her lack of progress, the speech pathologist and I were convinced that because Tara could sing, music would be key to any success she would have in speech therapy. We needed to rethink what we were doing and vary our approach. I suggested we make best use of the intact music skills Tara was displaying and introduce a modified version of MIT, which we would trial over ten weeks. Step 1: Preparing the Musical Phrases. The speech pathologist first selected ten common words (herein called “keywords:” e.g., door, chair, bed, book), each of which were placed at the end of a phrase. For example, for the keywords coffee, bed, chair and door, the phrases could be constructed as “I want a cup of coffee, go to bed, sit on a chair, knock at the door.” My clinical experience has shown that clients are more likely to recall the final word of the phrase than other words in the phrase (Baker & Tamplin, 2006). Once I had constructed these phrases, I then set them to music. I created a melody for each phrase using a limited pitch range (usually no greater than a Major 6th) and composed at a register that aligned with Tara’s vocal range. It was important that she was presented with “singable” melodies, otherwise she may have felt uncomfortable singing, and this may have limited her participation and therefore negatively affect outcomes. I constructed the melodies so they could be joined together to form a song. However, I was careful to ensure that each phrase had an individual melody distinct from the others in the set and did not resemble the sound of any other song phrase that Tara was likely to know. For example, creating a song phrase that used the melodic line from the opening phrase of “happy birthday” may confuse Tara, resulting in her singing the words of “happy birthday” instead of the target phrase. Another feature of the phrases I composed for Tara was that they were composed around a central harmonic structure. I found creating a set of phrases in this way provided maximum potential for the client to internalize the phrases. Figure 1 provides an example of some of the phrases that I used in Tara’s program.

Step 2: Introducing the Phrases in the Session. When commencing MMIT in a typical session with Tara, I first started by singing the musical phrases to her a number of times while accompanying my singing on the keyboard. I sang the words of the phrases with very clear articulation. After several repetitions, I invited Tara to join in and “sing along” with me. Tara enjoyed this and joined in enthusiastically. Her articulation improved quite dramatically from the frequent incorrect sounds (caused by her co-morbid dyspraxia), and over the course of a couple of minutes, I noticed she was becoming more confident in her singing – singing louder and less tentatively, giving the impression she was aware of her improving performance. Following intensive daily practice of these phrases over four weeks, I gradually withdrew my participation and encouraged Tara to sing the phrases unaided. My role at this point was to assist her in becoming more independent in her singing. When her singing began to break down or she lost the melody, I would prompt her by choosing one of the following options: Return to singing in unison with her. Sing the phrase that immediately preceded the “target phrase” to cue Tara. Sing the first word/s of the target phrase, leaving Tara to complete the phrase. It was important for me to recognize that Tara’s performance varied substantially from session to session as she began to internalize the phrases. More consistency in the generation of specific phrases occurred over time. To promote Tara’s independence in melodic recall, I encouraged Tara to sing her favorite songs at intermittent points throughout the session. This provided Tara with the often needed “break” from the hard work of therapy. Importantly, it also provided a distraction from the melodies to ensure that Tara would not perseverate on the “practiced” phrases. Perseveration is common in brain injured people. Tara enjoyed the singing but was always anxious to return to the practicing of the phrases. I explained to her that the singing of songs has therapeutic benefit: i.e. that it is like a test to see if she can recall the MMIT melodies once another tune was going around in her head. Once she understood this, she was able to enjoy the singing more. Step 3: Moving Towards Independence. The final step in the MMIT process was to encourage Tara to use the target words in normal conversation. To achieve this, I asked Tara questions to test her independent word generation. For example, it is hoped that she would generate the word “soap” in response to the question “What do you wash yourself with in the shower?” Or “cappuccino” in response to the question “What are you going to order at the

café?” At times this was quite a frustrating step for Tara, as her performance was initially inconsistent. However, with support from me, and continual practice, Tara managed to improve her output. Within two months, Tara had internalized the melodic phrases as a strategy, and was able to generate the ten words when cued. This relatively slow progress can be understood in terms of the neurological reorganization taking place in the brain. Initially, we are trying to encourage the use of certain neural pathways that have not been used in this way before. It takes time for the brain to adjust to this new way of doing things. Neurological research referred to earlier indicated that the more frequently a pathway is activated as a consequence of engaging in a task (like singing), the stronger the connection will become. This suggests that over time, we would expect that Tara would improve in this domain should she continue to engage in the program. Tara’s Rapid Progress Tara’s slow but steady progress was so encouraging that the therapy team recommended increasing her music therapy program to four hours per week. At this time, the speech pathologist and I introduced new target words. Tara indicated that she wanted to be able to call her family members by their names, so this was the focus of the next phase in her program. She was very motivated by this task – the words had more personal meaning for her – and so she often arrived at the music therapy office asking whether she could have more sessions. To address her request for more therapy, I introduced a homework program for her to implement between sessions. This program involved her playing an audio recording of all the melodic phrases so she could sing along with the recording. This approach aligns with the modern views of rehabilitation which indicate that during the initial phase of recovery, frequent sessions (even if they are short in length) are needed to maximize recovery. This self-initiated practice resulted in Tara learning new words at a faster pace. I monitored Tara’s progress regularly to determine how many phrases she was able to independently generate and how many still required musical prompts. I did this by beginning each session with a recap of what had been addressed in previous sessions without providing any music (cues). Another important feature of Tara’s program was that while I may have introduced new material, I would often revisit and reassess previous material to ensure she was maintaining her ability to self-generate the phrases rehearsed earlier. The next stage in Tara’s MMIT program was to introduce functional words suggested by the occupational therapist. These targeted words included personal hygiene items such as soap, lipstick, makeup, brush and the names of clothing items such as shoes, shirt and jumper. This enhanced her activities of daily living by enabling Tara to name the various items she was manipulating or wearing. Within six months of commencing MMIT, Tara was learning one or two new words each week and was able to independently generate 25 of the 32 words that she had been introduced to. Of the remaining seven, she was able to recall six of these when musical cues were provided by the therapist. Tara is Reintegrated into the Community

The four-times weekly MMIT program continued until Tara’s discharge to a shared community house 12 months after initially commencing MMIT (18 months post-injury). At that time, Tara’s music therapy program was reduced to one outpatient session per week. She was also discharged from speech therapy. Tara continued to utilize the audio recorded program to practice between each session. On commencement of her community living program, the occupational therapist requested that I teach Tara to verbalize words and/or phrases that would assist her in communicating with others in the community. Phrases that were added to the program included “I want a 2-hour ticket, zone 1 and 2” (referring to a transit ticket), “I want to take money out of my account,” “I want a taxi to Saint Albans,” “I want to make an appointment” and “Where are the toilets?” As part of her rehabilitation program, Tara and I would have music therapy sessions in the community. We visited a bank, a doctor’s surgery, a coffee shop and a toyshop, and Tara practiced independently using these phrases so she could perform her banking needs, make doctor’s appointments and have a cappuccino. My role was to facilitate this process, be a back-up person, prompt her to use her musical cues should she have problems generating words, and assess her independence in the community. Tara was initially motivated to use her language within the community but found it difficult when members of the public were impatient with her. My support was crucial in maintaining her motivation to keep trying. Perhaps the most significant moment for Tara was when she managed to communicate with the bank teller her request to withdraw money from her account. I witnessed the first time that she was able to achieve this task independently. She gained so much confidence from this one event – it was moving to witness Figure 2 illustrates the changes over the course of the MMIT program in terms of the number of phrases in the program, the number Tara could recall independently, and the number she could recall when given musical prompts. The figure shows that Tara’s progress was initially slow, but over time, her progress accelerated, particularly in relation to how many words/phrases she could independently generate.

This might suggest that neural pathways were connecting and strengthening at a more rapid rate, with each connection increasing the probability that Tara’s brain would reactivate the pathway on a subsequent occasion. On final assessment, after 30 months using MMIT both as an inpatient and then as an outpatient, Tara had acquired a functional language of 148 words/phrases, of which she was able to initiate 124 of these independently and the remaining 24 were recalled following musical cues. She was able to express her immediate needs, feelings and interests. Without the modifications made to the traditional MIT program, Tara may not have been able to use verbal language at all. Conclusion The case study of Tara indicates the value that MMIT can have in assisting a person with neurological damage to regain some speech function. Although a speech pathologist would normally implement an MIT program, the necessity to create phrases with predictable but individual melodic and rhythmic structures indicates the need for a music therapist’s input into the MMIT program. It suggests that the musical centers of the brain, when activated, facilitated a neuronal reorganization that allowed Tara’s brain to access language again. Further, consideration for Tara’s emotional well-being and the support that can be offered through

music therapy was instrumental in maintaining Tara’s motivation for therapy, a reward for her hard work, and an outlet to explore her feelings associated with receiving the traumatic brain injury. References Baker, F. & Tamplin, J. (2006). Music Therapy in Neurorehabilitation: A Clinician’s Manual. London: Jessica Kingsley Publishers. Baker, F. (2000). Modifying melodic intonation therapy programs for adults with severe nonfluent aphasia. Music Therapy Perspectives, 18(2), 107-111. Baker, F., Wigram, T. & Gold, C. (2005). The effects of a song-singing programme on the affective speaking intonation of people with traumatic brain injury. Brain Injury, 19(7), 519–528. Claeys, M. S., Miller, A. C., Dallow-Rampersad, R. & Kollar, M. (1989). The role of music therapy in the rehabilitation of traumatically brain injury clients. Music Therapy Perspectives, 6, 71-76. Cohen, N. (1988). The use of superimposed rhythms to decrease the rate of speech in a brain damaged adolescent. Journal of Music Therapy, 25(2), 85-93. Elbert, T., Pantev, C., Wienbruch, C., Rockstroh, B. & Taub, E. (1995). Increased cortical representation of the fingers of the left hand in string players, Science, 270, 305–307. Falk, D. (2000). Hominid brain evolution in music. In N.L. Wallin, B. Merker, and S. Brown (Eds.), The Origins of Music (pp. 197– 216). Cambridge, MA: Massachusetts Institute of Technology. Fields, B. (1954). Music as an adjunct in the treatment of brain-damaged patients. American Journal of Physical Medicine, 33, 273-283. Helms-Estabrooks, N. (1992). Aphasia Diagnostic Profiles. Austin Tx: Pro-Ed. Kim, S. J. & Koh, l. (2005). The effects of music on pain perception of stroke patients during upper extremity joint exercises. Journal of Music Therapy, 42, 1, 81-92. Kolb, B. (2004). Mechamisms for cortical plasticity after neuronal injury. In J. Ponsford (Ed.), Cognitive and Behavioral Rehabilitation: From Neurobiology to Clinical Practice. New york: Guilford Press. Lucia, C. M. (1987). Towards developing a model of music therapy intervention in the rehabilitation of head injured clients. Music Therapy Perspectives, 4, 34-37. Magee, W. (2007). Development of a music therapy assessment tool for patients in low awareness states. NeuroRehabilitation, 22(4), 319-324. Mateer, C. A. & Kerns, K. A. (2000). Capitalizing on neuroplasticity. Brain and Cognition, 41(1), 106-109. Nudo, R. (2003). Adaptive plasticity in motor cortex: Implications for rehabilitation after brain injury. Journal of Rehabilitation Medicine, 35(suppl. 41), 7-11. Patel, A. D. (2008). Music, Language, and the Brain. New York: Oxford University Press. Patel, A., Peretz, I., Tramo, M. & Labreque, R. (1998). Processing prosodic and musical patterns: A neuropsychological investigation. Brain and Language, 61, 123-144. Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., Autti, T., Silvennoinen, H. M., Erkkilä, J., Laine, M., Peretz, I. & Hietanen, M. (2008). Music

listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain: A Journal of Neurology, 13(3), 866-876. Schlaug, G., Marchina, S. & Norton, A. (2008). From singing to speaking: Why singing may lead to recovery of expressive language function in patients with Broca’s aphasia. Music Perception, 25(4), 315-323. Sergent, J., Zuck, E., Terriah, S. & Macdonald, B. (1992). Distributed neural network underlying musical sight-reading and keyboard performance. Science, 25, 106-109. Sparks, R.W. & Deck, J.W. (1986). Melodic intonation therapy. In R. Chipley (Ed.), Language Intervention Strategies in Adult Aphasia (pp. 320-332). Baltimore: Williams & Wilkins. Sparks, R.W., Helm, N.A. & Albert, M.L. (1973). Melodic intonation therapy for aphasia. Archives of Neurology, 29, 130-131. Tamplin, J. & Grocke, D. (2008). A music therapy treatment protocol for acquired dysarthria rehabilitation. Music Therapy Perspectives, 26(1), 23-29. Wheeler, B., Shiflett, S. & Nayak, S. (2003). Effects of number of sessions and group or individual music therapy on the mood and behavior of people who have had strokes or traumatic brain injuries. Nordic Journal of Music Therapy, 12(2), 139-151. Zatorre, R.J., Evans, A.C., Meyer, E. & Gjedde, A. (1992). Lateralisation of phonetic pitch discrimination in speech processing. Science, 256, 846-849. Zatorre, R.J., Halpern, A. R, Perry, D.W., Meyer, E. & Evans, A.C. (1996). Hearing in the mind’s ear: a PET investigation of musical imagery and perception. Journal of Cognitive Neuroscience, 8(1), 29-46. I wish to thank the editor of Music Therapy Perspectives who kindly gave permission for me to include some previously published material (Baker, 2000).

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE THREE

Embracing Life with AIDS: Psychotherapy through Guided Imagery and Music (GIM) Kenneth E. Bruscia Abstract This case describes individual psychotherapy with Matt, a 26-year old man recently infected with the AIDS virus. In the eleven sessions, Guided Imagery and Music (GIM) was used as the main technique within a psychodynamic orientation. Through an intense process of imagery transformation, Matt gained insight into how traumatic events from his past prevented him from coping with the emotional challenges of living with AIDS. Ultimately, this led him to confront one of the most important questions of his life: Shall I live dead, or shall I die living? Background Information At the time we met, Matt was 26-years-old, and had been diagnosed as HIV positive just a few months earlier. I remember our first meeting quite vividly. When he shook my hand, I could feel him trembling. He was tall and gaunt, and had dark circles around his eyes. He looked scared and worried, and smoked one cigarette after another. When he smiled, he had to visibly work the muscles in his face. Sometimes I caught him looking at me to see if I was looking at him. Matt complained of dizziness, tremors, nausea and fever, for which he was taking several different medications—in addition to AZT (an anti-viral drug for AIDS) and Xanax (a drug to control anxiety). He talked about his symptoms and medication needs in a very serious way, almost as if he needed me to know how much he was suffering, or how sick he was. Perhaps he was trying to tell me how much help he needed. I felt uneasy because, in fact, I was wondering if he really needed to take so many things, especially since many of his symptoms can be sideeffects of Xanax (Schatzberg & Cole, 1986). I was also worried that he might be relying on drugs to fix (or numb) everything in his body and thereby relinquishing responsibility for his health to doctors and medicine. Matt had stopped working, and in the last few months, had also stopped going out altogether. He was “petrified” of passing out on the street from dizzy spells, or having a fullblown anxiety attack with other people around. Apparently, he spent most of his time at home watching television, trying to distract himself from his ruminations and fears. Matt told me that he had contracted AIDS through his work as a hemodialysis technician in a nearby hospital. He said that on several occasions he had stuck himself with an infected needle. As he told me these things, the tone of his voice became quite emphatic, even clipped. It sounded like he did not want me to assume that he had been promiscuous or that he used

drugs. It upset me that he might worry about such a thing, so I tried not to change my facial expression or body language. I wondered if he had already experienced blame from others. I thought of all the people I know who justify their detachment from AIDS or their negligence of those who have it by simply saying, “They deserve it!” On the other hand, he himself may have feelings of guilt and shame. Maybe he feels he deserves it. As Matt continued, I had to change my body position to let go of some of the tension building. Matt has been in a love relationship with the same man for six years. They live together, and Matt feels their relationship is quite strong. John is ten years older, and has a Ph.D. His results were negative on the HIV test. Right now they are having serious financial problems because John has just lost a high-paying job as a hospital administrator. To make matters worse, Matt’s current insurance company refuses to cover his medical expenses. Matt changed jobs (and insurance companies) before being diagnosed, and now neither company will take financial responsibility. Matt has also been refused Social Security benefits and welfare. Understandably, his face was filled with anger and frustration. Matt then shifted the conversation to his family. He has already told them all about his situation: that he is gay and that he is infected with the virus. I was relieved, for this is not always the case: many men like Matt face AIDS alone, without the support they need from loved ones. Matt is very close with his two sisters, and talked at great length about them and their children. Then becoming rather terse, Matt described his mother as a “dominating bitch,” and said he has an ongoing battle with her. He then described his father as passive and uninvolved, and said no more. I then asked him what he would like to accomplish in our work together. Matt replied: I get these terrible images... I can see myself dead... It feels like I am falling backward into a deep black hole... I live in constant anxiety, dreading the minute that they will come back... When they don’t go way, I go into complete panic... Sometimes I imagine John sitting beside me, and that helps to calm me... After the images go away, I get very depressed... I can’t live like this. I was moved by what he said, realizing more each moment how desperate his cry for help was. I also realized that his trembling was more than a body symptom: his whole being was shaking. I began to explain how Guided Imagery and Music (GIM) works: that after helping him to get relaxed and focused, I would put on a specially designed tape of music that would stimulate his imagination; that while listening, he might have body sensations, visions, feelings, memories, fantasies, or any variety of internal experiences; that while he was imaging, we would have an ongoing dialogue which I would transcribe for later reference; and that I would be with him throughout, helping him to explore his inner world in whatever way he wished. We talked about the possibility of his fearful image coming up, and that eventually he may need to confront it. Matt felt willing to take those risks, if someone was at his side. Moving into Imagery

Treatment Process

After preparing the space and making both of us as comfortable as possible (Matt lying on a floor mat, and me sitting beside him), I asked Matt to close his eyes and to start breathing deeply. I then led him through a relaxation induction that I created based on our previous discussions. It involved having Matt imagine a ball of light moving through his body and making each part feel “strong” and “alive.” I took this approach for several reasons. First, I was worried that closing his eyes and experiencing the darkness would trigger his fearful image of falling back into a black hole. Thus, focusing him on a light would help him to illuminate or move away from the darkness. Second, Matt expressed such fear over “falling dead,” that I felt that he needed to perceive himself as strong (in control) and alive in order to relax more fully. Third, I purposely used a “see-feel” sequence in the induction (i.e., see the light, feel strong and alive), because in our previous discussions he had described his experiences in this way (i.e., seeing himself dead then immediately feeling himself falling backward). Following how someone sequences their sensory channels to process their experience helps to build rapport while also facilitating inductions to an altered state of consciousness (Grinder & Bandler, 1981). I selected a GIM tape program that is commonly used for a first session. It consists of six musical selections (which are cited in italics below), lasting a total of 42 minutes. As each piece is quite different in instrumentation, mood and style, the tape has the potential to evoke many different imagery processes (visions, memories, fantasies, feelings); and since each piece is relatively short, the tape also allows the imager to move in and out of each image or process as desired. By encouraging the imager to explore different areas and layers of the imagination, the tape is useful for clinical assessment. The Imagery Preview Often GIM sessions present different chapters in the person’s life, with the first session giving a preview of the entire story about to unfold. This was particularly true with Matt. Images from his first session set the stage, painted the scenery, and introduced the main characters of his life story. In the ten weekly sessions that followed, these same images returned, transformed, generated new stories, and clarified themselves continuously—as if they were speaking to Matt’s psyche with insight and loving persistence. Matt’s began his story alone—stranded on an island. The opening sections of Ravel’s ballet, “Daphnis and Chloe” set the scene. {Note to the reader: The italicized sections below are taken from session transcripts. Brackets have been used to enclose my interventions or observations, and titles of the music being heard. Ellipses have been used to indicate silence, passage of time, or irrelevant segments of the transcript.} I am walking along a deserted beach...alone and stranded... I can see a huge rock ahead, blocking the shoreline...[Allegretto from Brahms’ First Symphony begins]... I want to walk around it and get to the other side... but I don’t know how... [Take a good look around]... [The “Gianicolo” from Respighi’s “Pines of Rome” begins]... Gulls are hovering over the edge of the rock, way out in the water... I can’t get around it in the water... I have to walk inland...I’m climbing around the rock... I see a cave that looks like a big black hole in the ground...

[How do you feel?]...lam scared... But I’m OK—there are iron gates blocking the entrance... I am walking past the cave entrance... I see an old dead tree that has fallen to the ground... Its roots are all sticking up... Its trunk has been burned and there is a hole in it... [The “Sirenes “from Debussy’s “Nocturnes” is playing]... It’s getting dark and starting to rain... I don’t think I can get around this rock... It seems senseless to go on in the dark... I better go back to the beach... I’m walking back... [How are you feeling?]... Really frustrated... and anxious. I want to get off this island, but for some reason, I can’t... [Tschesnekoffs “Salvation is Created” begins almost inaudibly] I’m back on the beach... [How does it look now?] Over the water, where the gulls were, I can see people dressed in black, floating and hovering in the air... [Notice anything else?]...I’m looking all around... Oh, my God... Two men are coming to rescue me in a boat... I can’t see their faces, but one is dressed in red and the other in blue... They’re taking me to their boat... They don’t have faces... [Pachelbel ‘s “Canon in D” begins]...I’m getting in... we’re leaving... I’m looking back at the beach... I see a small child that we’ve left behind... and a huge black bird is perched on the hill behind him, looking down... We are reaching the mainland... The blackbird has followed us here, and is hovering over us... I’m going home now, where I can be safe. As the tape ended, I helped Matt to return to waking consciousness. In our discussion of the imaging experience afterwards, I encouraged him to react to whatever affected him most, while also focusing him on aspects of the experience that I felt were significant to his therapeutic process. This session gave an incredibly accurate preview of Matt’s process. In the next seven sessions, he weaved in and out of the main images in this session, and each time, the images transformed or moved his life story along. What follows is a description of how Matt worked through these central images (i.e., the black bird, the rain and the house, the island cave, and the abandoned child), and as a result was resurrected to a life with AIDS. The Black Bird The black bird was a key image in the first session—one that had already begun some kind of active transformation process—from a gull, to hovering people dressed in black, to a huge blackbird with a foreboding and ominous presence. Matt felt threatened by the bird, yet he did not voice his fears, neither during nor after the imaging—as if it was too much for him at the time. Matt was also unable to identify what kind of bird it was. I allowed my own feelings to enter my awareness: I did not trust it with the child. I did not like it hovering and following—like a vulture insidiously waiting to devour a carcass. I was afraid of it. Before the second session, I went through the transcript I had taken of Matt’s imagery, and discovered that the bird appeared when Matt was confronted with an obstacle, when he felt powerless to escape, and when he left the child behind. My inquiry made me feel like I had begun to hover over the bird hovering over Matt, and I wondered why I felt it was important to do this. Does Matt need to be protected, or do I need to reassure myself that (like any good

therapist) I could protect or rescue him? Will my rational understanding of the image somehow make it go away? Did I need protection from it? The bird did not re-appear in Matt’s imagery for several sessions, however it did arise quite prominently in his mandala drawings. In the first, he drew the bird quite representationally, flying beneath the sun. In subsequent portrayals, it changed positions and shapes. In the next drawing, it was so big that it created an eclipse of the sun; in another it was a large ground mass (like a black hole); and in the next, it turned into shadowy human figures on the edges of the mandala, with their backs towards the viewer. Then, in the fourth session, the bird presented itself again in Matt’s imagery. Bach’s “Passacaglia and Fugue in C Minor” set the stage. Matt was walking along a path with the blueman and redman, when the bird appears and starts to follow them. As the melody in the bass repeats over and over, the bird circles and hovers around them, getting closer and closer with each increment in volume. The fugue begins, and relentlessly piles layers of fear and frustration on top of one another as the three men watch the bird hovering over them, arguing among themselves. A terrifying climax is inevitable, and as the chords crescendo to a crashing close, the blueman overcome by anger, shoots the bird to the ground. A long silence ensues before Bach’s “Come Sweet Death” begins—the music is now slow and desolate, and Matt sighs deeply, showing great consternation in his face, despite the relief evident in the rest of his body. When asked, he explains that he feels confused about why the blueman, who is his model of goodness, has killed the bird—rather than the redman (who Matt believes has an evil side). In the next piece (Bach’s “Sarabande” from the “Partita in B Minor”), Matt questions the blueman, who refuses to explain himself other than to say: “One day you will understand.” Matt’s frustration with this evasiveness builds during Bach’s “Little Fugue in G Minor” until all three men decide to leave. As they do, Matt has to pass by the dying bird. As he does, the bird tries to communicate to him, but is barely audible. Matt refuses to listen, and supported by the strong bass notes in the fugue, steps over it quickly, in contempt and disgust. In the final fortissimo chord of the fugue, a black snake sneaks away in the grass. The slow movement of Brahms’ “Violin Concerto” begins, and as the violin plays long, tender melodies over a soft orchestral accompaniment, Matt shares how he feels about the redman and blueman. Despite their differences, he loves and accepts them both. Then a wonderful transformation takes place during Bach’s “Double Violin Concerto.” Matt takes the blueman and redman by the hands and pulls them into himself, as if to unite them and to reincorporate them into his own being. As he does this, the three merge to form a large green swirl. This integration takes place as the two violins (blueman and redman) play with orchestra (Matt) in perfect, harmonic counterpoint, each part barely distinguishable in timbre but clearly different in contribution. Afterwards, Matt and I talked about what a relief it was to be rid of the bird. Matt felt like he had been successful in overcoming a menace that had tortured him for a long time. We talked about what menaces in Matt’s life this bird might have represented, and how good it felt to triumph over them. We talked about the need to be strong to conquer the menaces of life, including AIDS. We also discussed how uniting the redman and blueman felt like he was literally “pulling himself together.” I was silently skeptical because of the black snake that appeared—I suspected that it was yet another transformation of the bird. The next week, Matt drew a mandala that had a

huge black phallus penetrating the lower left part of the circle. In my thinking, the bird had transformed yet again, but I said nothing to Matt. He believed that the bird had really gone away, and in fact, it did not appear in his images for several sessions. Then, another mandala appeared with many black spots evenly scattered throughout the space. I could not help relate it to the previous drawing. It looked like the black phallus had exploded, and germinated enough spots to completely occupy the territory. The spots looked like sperm—the black sperm of the bird (or snake). Since AIDS can be transmitted through sperm, I further imagined that, in Matt’s psyche, the bird was the carrier of AIDS, the 20th century black plague, and the black messenger of death. In the fourth session, the bird re-appeared. Matt was sitting under a tree, as the Adagio from Marcello’s Oboe Concerto edged him into feelings. The tree was alive, and its roots were in the ground, but it was very sad and lonely. Its branches were drooping downward, and there was a large hole in the trunk. It sounded like the tree he saw in the first session—before it had been uprooted from the ground. I wondered if Matt had gone back to an earlier time in childhood. He had. I am wearing blue pants and a red shirt... an outfit I had when I was 8-years-old... The blackbird is back... It’s perched on top of the tree... [The Adagio of Rodrigo’s Concerto de Aranjuez begins]. The tree is trying to shake it off...but it can’t. It’s starting to rain... My throat is tickling... [Matt’s body begins to writhe, and his voice gets constricted]. I am stuck on the ground... I feel caught... paralyzed... My arms and legs are so heavy I can’t move... I am trying desperately to move... but I can’t....[long silence during orchestra version of Bach’s Prelude in Eflat Minor]... [What’s happening now?]...I am down at the stream... washing myself... The bird has gone away. Matt’s images came to a close peacefully, with the Romanze from Dvorak’s Czech Suite—as if nothing had happened. I was shocked. What had transpired in those few moments of silence? Since it was not possible to pursue the matter within the imagery, I waited until Matt had regained consciousness, and then asked how he freed himself from the ground. Staring straight into my eyes with a stone face, Matt answered: “Sheer rage!” I noticed that he was trembling again. No more was said. Strangely enough, the bird never reappeared in Matt’s imagery. I took this as a sign that the full story, without symbolic or fictional characters, was ready to unfold. Often, images and symbols provide us with safe ways of dealing with very disturbing material, things that we repress and do not allow into consciousness. The bird had been very important to Matt because, as we shall see, it allowed him to work through very painful material in a gradual and ambiguous way, just as dreams do. The elusive nature of the image and its lack of reality as a “figment of his imagination” allowed Matt to deny or distort its true meaning at the earlier stages; however, every time it recurred, the bird further redefined itself, and in so doing began to gradually debunk each denial and distortion, until Matt was willing and able to admit and integrate into his consciousness what really transpired in that image and what the bird really signified. This did not happen until a few sessions later. Several other recurring images had to develop sufficiently until Matt would be ready to recount the life events that he was trying so desperately to forget and confront at the same time.

The Rain and the House Images of rain storms appeared in several of the early sessions. Rain is so ambiguous! It cleanses, muddies, and fertilizes. It can bring relief from a drought, or it can flood the landscape. It can pour down from black clouds or fall gently from grey skies, and when the sun follows, it can bring rainbows and pots of gold. It comes from above, as if the good and bad of it are sent to us from the heavens by God (Cirlot, 1971). When Matt encountered rain, it was “stormy weather,” and he frequently sought refuge in a house. On the first occasion, Matt was walking along a country road, and passed by a white house that belonged to an elderly couple. Sometime later Matt saw black swirls in the sky, and fearing that a storm was coming, ran back to the house for protection. Upon his return, he found that the windows and doors had been boarded up. Unable to go inside, Matt stood on the porch and waited until the dark clouds and rain had passed. I remember this image so vividly. In my mind’s eye, the house looked like the faces of his parents: with their eyes, ears and mouths completely covered. It was as if Matt were seeking the safety of his home, wanting to take refuge in the laps of his parents (the porch), but they had gone off somewhere and left him behind, at least in spirit. Their eyes had blinders on and they were unable to see the storm; their ears had been plugged, and they could not hear Matt’s call for help; and most disturbing, their doors were closed, as if they were no longer willing or able to give him refuge from the storm. The image of Matt standing on the porch reminded me of the child who had been left behind on the island, unprotected from the bird. Each time Matt saw a house in subsequent sessions, there was danger lurking. In the third session, he escaped another storm by running onto the same porch with his lover; in the fifth session, he passed a house before entering the island cave which had frightened him earlier. Again it was raining. The Island Cave Matt went to the same island in three of the initial five sessions. Islands are often isolated places where people go to withdraw (very much like Matt’s apartment). They are also places of refuge from the ocean—or the deep, threatening waters of the unconscious (Jung, 1954). I felt that this was particularly relevant to Matt. He seemed to be struggling with whether he should allow certain material to emerge or to suppress it. Every time he went to the island he encountered some kind of threat, but then would leave before confronting it. His images on the island were full of fantasy and symbolism, with very few real-life people or events, suggesting that he could only deal with these images if their true meaning was disguised in some way. His repeated returns gave me the sense that he had some unfinished business to clear up there before he could leave it once and for all. After the bird had been slain, Matt gained greater confidence in confronting images that frightened him. In the seventh session, he returned to the island and proceeded directly to the cave. This time Matt was accompanied by a man dressed in green (the swirl that merged the redman and blueman into Matt). It’s too dark to go in... I’m lighting a torch... We’re inside... We‘re walking on a bridge over a huge cavern. At the bottom are deep craters... filled with bubbling black tar. I’m real

uncomfortable inhere... (What do you want to do?) I’m going to solve this once and for all... We’re going back outside, to climb the hill over the roof of the cave. [With determination and a bit of anger in his voice, Matt says to the greenman]: “Let’s dig a hole in the ground, and let sunlight into this f—king cave once and for all.” We are digging... We’ve reached through the roof of the cave. I can see down into the cave. I want to go back inside now, and see what’s inside. We’re back where the hole in the roof is... I can see rays of sunlight coming down... There are tons of green powder everywhere... We are putting it in buckets and throwing it over the bridge... It’s cooling down the tar... kind of deactivating it... We’ve won a battle. Afterwards, Matt was quite proud of himself. I told him how much I admired his courage and determination. He saw this session as a triumph over the big black hole that frightened him so, and therein his fear of death. I cautioned him that this image could still return, but that the important thing was that he had created his own “antidote” for it. We also explored what the greenman and the green powder might represent in terms of resources within himself. Matt concluded: “I have to care enough to do something about my problems.” For me, this was one of those split-level discussions therapists sometimes have. Outwardly, I was focused on helping Matt relate his experience and images to his life. Inwardly, I was focused on what implications these images had within the therapeutic process. I was struck with Matt’s boldness in letting the sunlight flood the cave, and illuminate its contents. Was Matt readying himself to let the painful material into the light of day? What would emerge from the cave? I agreed with Matt that the greenman was a part of himself—that part that wanted to help him—not only to pull himself together, but also to help bring something from his unconscious into the light. But I also realized that the greenman was an image of me as therapist. In Matt’s positive transference towards me, he was beginning to see that I cared, and that through me, perhaps he could care and do something about himself. If there was a negative transference, Matt’s concluding statement could have been a warning to me: “You have to care enough before I can do something about my problems.” Paradoxically, it is always scary for a therapist to gain this kind of trust or hope, even though it is a primary goal. I could not help think of all the greenmen in my life. I hoped that, for Matt’s sake, I could be like the best of them—not the many that had let me down. I realized that this was a countertransference reaction that needed to be examined closely at another time; meanwhile, I had to refocus myself on Matt’s needs in the here-and-now. I often find that significant sessions such as this mark off stages within the therapeutic process, and that a review of what has been accomplished to date is very helpful in consolidating and integrating material that has been brought into consciousness. After we had finished discussing the specific details of the imagery in this session, I asked Matt if we could spend some time going over earlier sessions. To guide our discussion, we put all of his session transcripts and mandala drawings in chronological order, and then proceeded week by week. I asked him to summarize what each session and drawing meant in a few words, as I took notes. Upon finishing, we turned the individual statements into a brief narrative: All of my troubles appear when I am alone—marooned on an island. I let the bird do his thing, as evil as it is, and I will face obstacle after obstacle until the nicest part of me reaches the breaking point. Before I do, I am consumed by fear, and I

feel paralyzed to do anything about things, but then I become enraged and this gives me the power I need. There are different parts of me that take over at different times. The most frightening thing is when I stop caring and give up. If I really care—if I really want to live—then I can find the courage to work out my problems. Maybe the courage comes from rage over what life has brought me. As a result of this review, Matt and I both felt good about his progress. After the session, I realized that there was still one recurring image that Matt had not explored—the house. The Abandoned Child In the eighth session, the tar bubbled up and the full story of Matt’s life was brought to light. It was a horrible tale of childhood—one that had made it necessary for him to create his images of the bird, the rain, the house, the island, and the cave. Matt and I had decided to begin the session with a house as a focus or starting image. To prepare him, I asked him to concentrate on taking in-breaths that brought him inner strength, and releasing out-breaths that brought calmness. I then asked him to return to his favorite house from childhood. Matt began: I am playing in the back yard... where I lived when I was six... I have on red pants and a blue shirt... Mom is calling me to go inside... Everyone has been packing... We’re moving... Mom and Dad are leaving to take the last truckload... They have left me behind with Bruce, a friend of theirs... He’s picking me up... I’m getting real nervous... He’s holding me too tight.. [Matt’s body tightens up so much that his trembling stops; his face reddens as if he cannot breathe] I wish he’d stop... Stop I...He’s getting on top of me... crushing me... I can’t move... I can’t breathe... I can’t even scream. He had been raped. I remember crying—realizing that he could not do so—not then, and for some reason, not now either. I also remember holding back the tears. Matt needed more than tears, he also needed someone strong who could support his rage, and help him survive this ordeal. As soon as the rape scene ended, Matt’s images were flooded with memories of violence and blood, all episodes that actually took place later in his life. He recalled: breaking the neighbor boy’s arm with his bare hands (age 8); cleaning up the blood after his grandfather had a lung hemorrhage (age 12); being beaten by his pimp (age 15); killing a squirrel who had been hit by a car (age 18); and being struck by a car himself (age 21). Afterwards, we talked very little. I said I was sorry for what Bruce had done to him. He said he still felt ashamed, because Bruce continued to rape him for several years. Apparently, his parents were completely oblivious. He admitted that most of the time, he controlled his anger over what had happened to him, but that occasionally it surfaced. When the session ended, I remember hating to say good-bye. I did not want our parting to feel like another abandonment. All I could think of was how he had been left alone that day in the empty house, and that later, he would be alone again in his apartment. He assured me he would be “fine.”

As I drove home that night, Matt’s images flooded my consciousness, coming together in streams: The hovering bird had descended upon an unsuspecting child who had been left behind, a child who was wearing red and blue. Then, while being held down and unable to move, the phallus was inserted. The rains came in storms of dirty sperm, and the house stood empty with no one to protect him. The family tree had been uprooted, and if it was to turn green again, someone would have to care. Matt was the island, alone then and now, for his secret would always set him apart. Yet he was surrounded by oceans of feelings that could flood him at any time. As with the cave, a part of him had fallen into a black hole and died, and the remains had been locked there with iron gates. In the aftermath came blood—blood that would be shed as sacrifice, blood that caused shame, and ultimately, blood that would become infected as a final punishment. Resurrected: To Live or Die? After this, Matt’s images were quite different. None of the previous images recurred. The bird, the rain, the house, the island, and the cave had all given full voice to the horrors of his past life. The grief and rage of the child he had left behind were now in his awareness. Matt’s life story had been told; it was up to date. The irony of releasing the past is that, despite the relief that comes, the person is plummeted into the realities of the present—which for Matt, were as ugly as those in the past. The fact that he had AIDS came to the forefront of his consciousness, bringing increased anxiety. His symptoms seemed to worsen, and he became even more of a recluse. He took no consolation in the news from the doctor that his blood count was better than ever, and he ruminated over the progression of the disease. He seemed more frightened than ever, and his trembling was more pronounced. Even his imaging, which had been so easy and productive, was beginning to falter. Though this seemed like Matt’s bleakest hour, his imagery said otherwise. In the next (and final) three sessions, he had tremendously healing images—all related to the death and resurrection of Christ: Matt forgave his father for abandoning him and healed their relationship through a cross; his side was pierced with a harpoon, and he tried to wash it clean with water; and as he walked through the cemetery, Easter lilies bloomed over each grave. Then came the turning point: I am standing over my own grave...It’s open, and I’m looking down at my body... 1 feel a man’s presence behind me. I can only see his face. He’s beautiful. His hands are on my shoulders now, and he is telling me to be strong...in a very fatherly and loving way... I feel love towards him, but I am afraid... He is telling me to go back into my body...to get into my body and live...But I ‘m afraid... how strange... I wonder if I am afraid of living or dying... He is repeating it again: “Go back into your body, and live!”... I feel unsteady... like I’m falling back... I can’t stand it anymore... I have to come out! Suddenly (midway into the tape), Matt’s eyes opened and he rose up, like he had just awakened from a terrible dream. Then, with seemingly no rhyme or reason, he blurted:

It’s all so clear to me now: Dizziness is not being held up... Nausea is what I get instead of crying... The knot in my stomach is when I lose myself... Trembling is not having anything to hold onto... This was the first time I saw Matt lose control of his emotions. And unlike anything that he had ever done before, he asked if I would hold him. I sat next to him, and as I put my arm around him, he rested his head on my chest and cried—very much like a child who needed to cry in the safety of his parent’s embrace. I rocked him until his crying and trembling subsided, and then he said something I will never forget: “Living is more like falling into a black hole than dying is.” I was reminded of what Laing (1967) said about the human dread of nothingness: “We are afraid to approach the fathomless and bottomless groundlessness of everything. “There’s nothing to be afraid of [is both] the ultimate reassurance and the ultimate terror” (p. 20). The relevance of an existentialist such as Laing made me realize that Matt had moved from an early life (or psychosexual) crisis to a full-blown existential (cognitive) one. The Truth Sets Him Free A few days later, Matt called me at home, and said that he needed to talk. After hemming around for several minutes, he told me that he had not been completely honest with me. For a long time, he had been abusing alcohol and his medications, and could not bring himself to tell me. I could hear in his voice how difficult this admission was for him, and despite my own feelings of shock, I tried to reassure him that his telling me was a significant turning point. I then asked him: “Why are you telling me now? What makes this secret so difficult for you to keep any longer?” In his reply, Matt’s progress and the value of our work together was revealed: “Before it didn’t make any difference. In the last session, I realized that I have been more dead than alive for a long time. If I’m going to try to live, I better do something about this now, before it’s too late.” Matt checked into an in-patient unit of a local hospital for detoxification and treatment, where he stayed for nearly two months. After being discharged, he began regular follow-up treatment with his psychiatrist, and joined a weekly support group for alcoholics who are HIV infected. Several months later, I called Matt. From what he said, it sounded as though he was back on the road of the living, taking full responsibility for himself. Before we ended our conversation, Matt thanked me and said: “You really helped me to take a look at myself, and to begin embracing the life I still have to live.” Discussion and Conclusions

Psychotherapy with Matt involved five dynamic elements: the imagery, the music, the mandalas, my personal perspectives, and our relationship as client and therapist. The roles of each are described below. Role of Imagery As implied throughout the case, imagery probably played the most significant role in Matt’s treatment. Because they carry symbolic meanings and are by nature ambiguous, images provided Matt with the distance he needed to eventually integrate very threatening material into his awareness. As containers of feelings and the energy attached to them, images also helped Matt to acknowledge his despair, powerlessness and rage which had been buried deep inside since his childhood trauma. Early in his work, Matt himself realized that his imagery provided symbolic vehicles for working through inner struggles. As we made progress, he also realized that transformations in his imagery provided symbolic representations of real interior changes taking place in his psyche. Matt once commented that when new images appeared, it gave him an opportunity to discuss things about himself that he had never shared with anyone. Somehow his imaginary world brought forth reality, and presented it in terms that he could talk about with as much distance as he needed. Images also bring time and timelessness into perspective. Because they are not limited to one time zone, they often reveal the links between different time periods. Thus, the stories that unfolded with each image allowed Matt to see the continuity of his own past, present, and future. Time made sense; sequels from the past became cycles of the present. The evil that the bird perpetrated on him in the past had planted the seeds of shame and guilt, which formed the basis of his present reaction to his AIDS diagnosis, which in turn spread the bird’s blackness into an eclipse of his future. Matt realized he had given up on life a long time ago, and that rage was one of the few things left—even if it was suppressed. Finally, images also instruct and inform the psyche by bringing forth the wisdom that already lies within the person. Matt’s images helped him to find meaning in himself and to create meaning for his life. Perhaps, this newly discovered possibility—to find and make meaning out of the meaningless—had more significance for Matt than anything. His past was filled with pain and sorrow—which he suffered for no good reason; his present was filled with anxiety and fear, because of a disease that struck him—for no good reason; and now his life would prematurely come to an end—again for no good reason. What does it all mean? What is life really all about? Is it worth it? These are questions that haunted Matt. In terms of process, imagery first served as an uncovering technique—one well-suited for exploring secrets of the unconscious and past. But as Matt progressed in therapy, the past was uncovered, the experiences of the wounded child were revisited, and his unconscious scars were revealed. This allowed the images to move forward in time, and to focus Matt on current issues, and how these issues were residues from the past. At this point, Matt was ready to face the existential conflict that he was experiencing as a person living with AIDS: to live dead or die living.

Throughout this case, and in my discussion of the role of imagery, I have given a great deal of attention to the symbolic meaning and significance of Matt’s imagery. I have done this, not because I believe that images always need to be interpreted, nor because this is common practice in GIM, for neither generalization is true. I have emphasized interpretation for several reasons peculiar to Matt’s case. First, imagery was the main arena for action and change within Matt’s therapeutic process. His progress was inextricably linked to and expressed within his images and transformations therein; it did not depend upon verbal interactions or our relationship, though these elements played important supporting roles. Second, Matt’s images were primarily of the symbolic or metaphoric type: he did not often have purely sensory or affective types of images, or images that contained real-life people and places. Third, according to Wilber (1986), different pathologies characterize different developmental stages in the life span, and consequently call for different psychotherapeutic techniques and orientations. I believe that Matt was in the stage of personal development which is characterized by problems originating from the repression of unconscious conflicts from childhood. Unconscious material does not present itself to the psyche in a logical or direct way: rather it relies upon symbolism and ambiguity to make its entry into consciousness more acceptable. Thus, much of our work was geared toward gradually translating the symbolic language of Matt’s unconscious into acceptable and decipherable terms, thereby moving him from pathologies steeped in the past to realities of the present. Role of Music The significance of music in Matt’s case is quite basic: without it, his imagery (which was so central to his process) would not have been as rich, productive, or transformative. Matt was very susceptible to the various elements of music and to changes therein, and his images always related directly to what was happening in the music. In fact, Matt’s images were so closely related to the music that I sometimes wondered whether they were dependent upon it. I find that when a person’s imagery is “music-dependent,” there are two potential problems in guiding, both of which I considered at various times in working with Matt. First, it gave me too much control over his images. I did not want to manipulate his process by selecting and changing the music in ways that would push his imaging in a particular direction. Second, it gave him an opportunity to resist the process. Sometimes, as he would approach an important experience within the imagery and the music changed, Matt would move away from the image to accommodate the music, thus avoiding something difficult or unpleasant that he may have been ready to confront. Other imagers are more “music-independent” and forge ahead with the imagery process they are undergoing, regardless of shifts or even drastic changes in the music. Ironically, Matt did not respond to music very emotionally. When Matt had intense feelings, they arose from the images, which in turn were supported or amplified by the music— not vice-versa. I might even say that Matt resisted the emotional force of the music, and did not allow it to trigger any cathartic releases. In contrast, the music helped me to stay emotionally involved and attuned to Matt’s images. As suggested earlier, I often felt that I had to model the feeling responses that Matt denied himself.

Last but not least, the music helped to take Matt into deeper levels of consciousness, while also providing him with the supportive matrix he needed to do so. The Mandalas Matt thoroughly enjoyed drawing mandalas. From a therapeutic point of view, I found that they helped Matt in several ways. First, they helped him to contain threatening feelings aroused by the music and the imagery. Putting the images, shapes or colors into the confines of the circle provided boundaries for all the material that was escaping from his psyche; it also gave him the means by which he could exercise some control over the emotions attached to the material. Being a recognizable, archetypal form, the circle also afforded him some intellectual control over its contents, for after he was finished, he could take a good look at how everything fit together, and in doing so, he could see the “whole” of it. From my point of view, the mandalas provided a framework or context for understanding Matt’s imagery. And related to this, they helped me to recognize symbolic equivalents in his unconscious material. For example, he used black for several things in the mandalas which related directly to the black bird and its equivalents in the imagery (e.g., eclipse, dark clouds, phallus, seeds, black hole, snake, cave, grave, Bruce, etc.). These equivalences in the mandalas and images bring together seemingly unrelated unconscious material, and reveal symbolic themes or underlying processes operating in the psyche. For example, all of the black images or symbols used by Matt were either evil forces that penetrate (phallus, seeds, snake, Bruce) or empty spaces that are penetrated (black hole, cave, grave). Going one step further, the theme of penetration can be further understood by examining equivalences in the qualities and activities associated to it in the mandalas and imagery. Matt associated penetration to sexual exploitation, fertilization, infection, and burial. Personal Perspectives Throughout this case, I have kept the reader informed of my own personal thoughts and reactions to Matt and his imagery processes. I have even shared my projections, interpretations, and countertransference issues. I have done so because these personal perspectives are central to the way I work. For me, psychotherapy, regardless of mode and technique, is a process of travelling between three experiential spaces: the client’s world, my own personal world, and my world as therapist. I see the process as “lending” myself to the client—but not only myself as therapist, but also my personal self. Without going into every one of these spaces, psychotherapy is impossible: I cannot be fully present or empathic to the client without entering his/her world— however to do so, I must leave my own world as person or therapist to do so; I cannot react to the client authentically if I do not leave his/her world and return to my own personal world; and I cannot intervene therapeutically if I do not monitor my travels to both other worlds by seeking the expertise and skill found in my world as therapist. Of course, central to the ability to move between these worlds is the ability to have both fluid and firm boundaries, depending on what is required. A therapist must be able to leave him/herself, but also return at will.

These world travels are required regardless of method, technique or theoretical orientation: for who I am as person and therapist, and how I feel as person and therapist ultimately determine how I will use music, imagery, mandalas, verbal discussions, etc. Without me being fully human as both person and therapist, these are mere artefacts of therapy. From an existential point of view, I can experience these worlds on three levels: (1) directly (i.e., through spontaneous and unmediated apprehension through the senses); (2) perceptively (i.e., through perceptual or affective classification of the experience, such as hot/cold, sad/happy, etc.); and (3) reflectively (i.e., through thoughtful analysis of relationships between experiences and worlds). Thus, depending on which world and level of experience is relevant to the moment, I may experience any of the following: THE CLIENT’S WORLD: Directly, perceptively or reflectively; MY WORLD AS PERSON: Directly, perceptively or reflectively; MYWORLD AS THERAPIST: Directly, perceptively or reflectively. Of course, it is important to also acknowledge that the client has similar options as to which world and level of experience s/he will enter at any point in time. Client-Therapist Relationship Matt and I had what I considered a very positive relationship. At the most basic level, I liked him and he liked me. We enjoyed being with one another, and we were rarely at a loss of words. We also laughed a lot. From a psychodynamic point of view, Matt had an essentially positive transference towards me through most of our work together. This was extremely important, and not always easy, given Matt’s past experiences with men in my same age bracket. He resented his father for being weak, blind, and not protecting him from Bruce; and he hated Bruce for the unforgiveable crime of raping him. With this in mind, I had to be strong, reliable, present, kind, and nonsexual. I also took note of what he resented in his mother: she tried to dominate Matt in every way; yet because of her own oblivion, had no control over what Bruce was doing to him. I was careful therefore not to be directive, oblivious, or useless! I felt that it was important to avoid inviting or working through these negative transference issues with Matt because time was limited, and I felt that he desperately needed a positive male or father image. I was also certain that he could not meet the emotional challenges he had to face in our work together without unequivocal trust in me and the support that I would provide. As for negative aspects of the transference, certainly Matt’s concealments could be seen in this light. He had concealed his childhood “shames” from his own father until he was an adult, and similarly, he had hidden his adult “shames” from me until he was ready to terminate therapy. Ultimately, I suspect that the abruptness of our termination also had its origins in negative issues that were out of my awareness and therefore left unresolved. I have often wondered whether he “abandoned” me to punish his own father for abandoning him. Unfinished Business

Matt’s termination was timely yet premature. I missed the opportunity for us to achieve some kind of closure in our work. Given his decision to enter a residential treatment program, it was impossible for us to continue working together until after his discharge; and by that time, we were both in very different circumstances. Had we continued, I feel that our work would have focused on two areas: dependency and the expression of feelings. My approach to his dependency issues would have been existential, emphasizing the importance of personal freedom, will, choice, and responsibility— this in contrast to a psychoanalytic approach focusing on dependency relationships and deficiencies in holding environments of the past. If a negative transference was present, I would stress the need to be “authentic” in our own here-and-now relationship rather than stuck in someone else’s from the past. Improvisational therapy would have been the method of choice, as it can explore these kinds of issues so directly, and especially within the context of authentic interpersonal relationships (Bruscia, 1987). Matt did not express his feelings very freely. Even in the most intense GIM sessions, it was difficult for him to cry, lose his composure, or even raise his voice; yet it was quite obvious that he had very intense feelings that were suppressed. Here again, my approach would have been improvisational. I believe that Matt first needs to “sound” his feelings out with full use of his body, before he would be ready to release them fully in non-musical ways. Once Matt became freer with musical self-expression, we could have resumed receptive methods of cathartic release, such as GIM. Postscript Matt’s case has truly been a source of wonderment to me: How indomitable must the human spirit be—that Matt has survived the ravages of so many rainstorms! How powerful must images be—that they healed Matt’s deepest wounds and resurrected his life! What a gift of life music is—that it goes in and out of our deepest and most intimate spaces with such ease—resonating, soothing, and understanding the very fiber of our being. And how human a therapist has to be—to realize that it is not in our knowing or doing that we can help someone like Matt to move along his life path—but in our accepting and loving wherever he is. Glossary HIV Positive: Presence of the Human Immunodeficiency Virus (or retrovirus) in the blood, causing an excessive increase in immune suppressor cells and a corresponding decrease in immune helper cells. AIDS: Acquired Immune Deficiency Syndrome. Guided Imagery and Music (GIM): Originated by Helen Bonny (1978), GIM is a method of psychotherapy, healing and self-actualization which involves spontaneous imaging to music in a relaxed state, while dialoguing with a guide. The practice of GIM requires special training. Mandala: A drawing enclosed in large part within a circle.

Transference: Reactions client have towards therapists wherein the client relates the therapist as if the therapist were a significant person in the client’s life, usually his/her parents. In a positive transference, the client projects positive feelings about the associated significant person onto the therapist/associated significant person; in a negative transference, the client projects negative feelings. Countertransference: Traditionally, the therapist’s reaction to the client’s transference. The author’s definition is: any conscious or unconscious reactions of therapists to clients which have their origins in the therapist’s own personality or life experience. A positive countertransference takes place when the therapist uses these personal reactions to the therapeutic advantage of the client; a negative one takes place when the therapist is unaware of personal reactions towards the client, and because of this, puts the client at risk and endangers the therapeutic process. References Bonny, H. (1978). Facilitating GIM Sessions. Salina, KS: Bonny Foundation. Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C Thomas Publishers. Cirlot, J. (1971). Dictionary of Symbols. (Second Edition). Translated from Spanish by Jack Sage. New York: Philosophical Library. Grinder, J., and Bandler, R. (1981). Trance-formations. Moab, Utah: Real People Press. Jung, G. (1954). The Practice of Psychotherapy. (Collected Works: Volume 16). New York: Pantheon Books. Laing, R. (1967). The Politics of Experience. New York: Pantheon Books. Schatzberg, A., & Cole, J. (1986). Manual of Clinical Psychepharmacology. Washington, DC: American Psychiatric Press. Wilber, K. (1986). The Spectrum of Psychopathology. Treatment Modalities. In K. Wilber, J. Engler, and D. Brown (Eds.), Transformations of Consciousness. Boston: New Science Library - Shambhala.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE FOUR Music Therapy for Children in Hospital Care: A Stress and Coping Framework for Practice Jane Edwards Jeanette Kennelly Introduction The experience of illness and/or injury and subsequent hospitalization is inevitably stressful. A range of theoretical perspectives inform and support therapeutic interventions with children and their families to manage stress following hospitalization. Crisis theory (Schaeffer & Moos, 1998) explains unexpected stress-inducing events as propelling individuals into turbulent and overwhelming cognitive and emotional experiences that challenge the resources available for maintaining equilibrium, or what is known as “coping.” For children and their families, coping with their experiences of illness and/or injury leading to hospitalization can be additionally challenged by the developmental needs of the child. Offering support requires attention to children’s perception of events, including attending to their comprehension of, and participation in, ongoing medical treatment. This chapter describes a stress and coping framework that provides support to techniques used in music therapy services in a children’s hospital. The authors present an outline of their approach, using case material to illustrate the application and integration of a framework incorporating theoretical constructs about stress, coping and adjustment within clinical practice. Foundational Concepts Stress Management and Enhanced Coping for Hospitalised Children Approaches from the psychological literature concerning stress and coping (for example, Lazarus & Folkman, 1999; Aldwin, 2007) have been adapted to provide a theoretical foundation in music therapy work with children facing the challenge of treatment for injury or illness (Edwards, 1999b). Other music therapists have also noted the usefulness of theories of stress and coping in work with hospitalized children and their families (Daveson, 1999; Robb, 2003). The stress and coping literature has provided us with a theoretical perspective with which to conceptualize children’s responses within an overarching framework. Consequently, we were able to design and implement effective ways to offer help through music therapy.

As the child responds to the stress of his/her hospitalization, his/her capacity to adjust to the psychological and other demands can begin to manifest. Sometimes difficulties are demonstrated through such behaviors as not speaking, only speaking to particular people, refusing play opportunities, avoiding eating and drinking, mobilizing at a lower level than their ability, and being withdrawn or looking sad. It has been proposed that “successful adjustment is achieved when the child demonstrates skills in communication, play and perception consistent with skill levels prior to the injury, and when the child demonstrates verbalizations, interactions and other social skills as appropriate to chronological age and temperament” (Edwards, 1998, p. 22). Four primary foundational concepts have informed this framework for practice: Theories of stress, coping and adjustment Transactional models of stress Developmental theories Family-centered care In everyday clinical work it would be unusual for a practitioner to distinguish between these constructs in describing his/her thinking about interactions with patients, or in justifying the use of particular techniques. These constructs are learned, integrated and become useful as needed to elaborate experiences of the patients and their families, and are especially applicable when work is difficult or interactions are highly charged in some way. These concepts overlap and intertwine significantly and are produced discretely here to show the authors’ applications within music therapy practice. Stress, Coping and Adjustment One of the foundational concepts within this framework is the management of stress to attain equilibrium through effective coping. Managing stress can be described as a process of undertaking the tasks of coping. In a hospital environment, these tasks have been described as: Dealing with pain and symptoms Dealing with the hospital environment and treatment procedures Developing and maintaining positive relationships with medical, nursing, and allied health staff Maintaining emotional equilibrium Preserving a positive self-image, including maintaining competence and mastery Sustaining relationships with friends, family and using these relationships as a means of support and information Preparing for an uncertain future (adapted from Moos & Schaeffer, 1984) Supporting the processes required to accomplish these tasks requires the therapist to attend sensitively to complex interactions between family members, the staff and the patient. The music therapist navigates a vast and challenging psychological terrain that is often encountered in the ward environment through observing and interpreting verbal and nonverbal behaviors of the various family members and staff. Transactional Model of Stress

In the cognitive stress, appraisal and coping model proposed by Lazarus and Folkman (1991), psychological stress is defined as “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1991 p. 21). The individual’s interpretation of the meaning or perceived threat of the experience, termed “appraisal,” is a main contributing factor in a stress response. Using this model in practice can include, for example, attention to the ways in which the individual perceives the events that have occurred, and whether there are any aspects of this interpretation that may require external mediation, such as blaming or guilt responses (Lazarus & Folk-man, 1991. The transactional approach to stress modelling (Aldwin, 2007) represents a shift from what has been described as reductionism, or the scientific linear causal model, to an approach that emphasizes relationships and interactions between variables that are understood as multifaceted and non-linear. In a transactional approach, the investigation of human experience is pursued with a range of potential and perceived complexities kept in mind (Aldwin, 2007). That is, the idea that the same event is experienced the same way by every person is relinquished, and a new theory of the relationship between the individual’s prior experiences, current perspectives and context is proposed. Within a transactional approach, three dimensions of the stress experience have been identified: The strain experienced, which has emotional and physiological dimensions The stressor, including the type of stress and its temporal dimensions, and The transaction between these dimensions, including the person’s cognitive appraisal of the stress and the perceived intensity of the stress that contribute to his/her responses (Aldwin, 2007) That is, “the person, the situation and coping mutually affect each other in a process that evolves over time” (Aldwin, 2007 p. 99). For the child in hospital, a range of issues in relation to the “situation” (point 2, above) impact on the child’s coping, along with the coping of those who are caring for him/her. For example, a parent who seems highly stressed by their child’s admission for a simple procedure may have previously been to the hospital with another child in more challenging health circumstances. Their presenting anxiety may stem from this history of their hospital experiences. The distance the rest of the family lives from the hospital, the supports available to that parent (for example, paid leave availability from their work), may all impact the experience of hospitalization, and the perception of threat and stress, apart from the immediate and/or ongoing medical needs of the child. It brings to mind the story we were told at our hospital of a boy of six years of age admitted for appendicitis. The surgeon attended him at bedside and told him the details of the operation he would undertake to remove his appendix. The boy listened attentively. However, when the surgeon took a pen out of his pocket to write some notes, the boy showed signs of distress. It seemed he understood the operation was to take place then and there. This story shows that even caring practitioners, who follow good practices for giving information to their young patients, sometimes miss the perception of the facts by the listener.

The clinical team, including the music therapist, listen respectfully to the meaning of the events experienced by the children with whom they work, and try not to predict what a child will understand, or how they will deal with information or events. The starting point is providing children with a place to tell the story of their fears, their experiences, what they like about hospital, and what they miss from outside the hospital. It is proposed that this helps the child integrate the experience of hospitalization and to make sense of his/her injury or illness in his/her own way. At the same time, the therapist and the patient engage in mutual learning about the patient’s circumstances and wishes. Developmental Theory Children’s development is multi-faceted, involving cognitive, psychosocial, physical and moral dimensions of process and change from birth through early adulthood. While the development and capacities of any child are individual and unique, many theorists and practitioners in music therapy use developmental stage theories as well as theories and philosophy about identity, rights and family to provide a broad base for practice and writing in a range of fields related to understanding and working with children’s needs (see Loewy, 1997; 2000). Stage models can also assist in understanding children’s ability to manage and understand pain experiences (Edwards, 2005a; Gaffney, McGrath & Dick, 2003) and have been used to develop successful and effective assessment tools (Loewy, 2000). Family Centered Care At the hospital where the music therapy work described here was conducted, a family centered approach was embraced. Families were considered the main support available to children in managing their psychological adjustment to treatments and medical care. In addition, children were understood to benefit from strong attachment bonds with the family, and these bonds were considered vulnerable to damage through the possible physical and emotional separation that could occur when children were not able to cope with their experiences (see Jolley & Shields, 2009). The music therapists worked with family members, where ‘family’ was considered to be the people with whom the child shared strong affectionate bonds of love and care, and the people on whom the child was dependent for their daily care needs. The therapists worked with the family as a whole as well as with individuals within the family, as needed. Stress and Coping Responses Supported through Music Therapy In the following case description, the reader is directed to the integration of aspects of this conceptual framework within the material presented. Some commentary following the case elaborates on how using a stress and coping framework helped in providing an effective therapeutic presence for this patient. However, we have also found this framework useful for other pediatric treatment arenas, including rehabilitation (Edwards & Kennelly, 2004; Kennelly & Brien-Elliott, 2001), intensive care (Kennelly & Edwards, 1997), and in general considerations of children’s experience of hospitalization (Edwards, 2005c; Kennelly & Brien-Elliott, 2002). The Client Beni was eight years old at the time of his admission to the burns unit of a children’s hospital. He was brought to the hospital following an accident that had caused 30% full thickness burns1 to his back, posterior, arms, lower abdomen and thighs. His parents

accompanied him to hospital and resided in a motel near the hospital during Beni’s recovery. Although Beni was able to converse a little in English, he mainly spoke in his own community language. Hospital staff described him as being quiet, withdrawn and unresponsive, and only communicating with his parents. He demonstrated little interest or engagement when medical and nursing staff approached and would not join in any play activities initiated by therapy staff. Beni was referred to music therapy by the clinical nurse consultant of the unit, Kerrie, one week after his admission. Kerrie expressed concerns about his adjustment to hospital and his injuries, observing that he did not engage verbally with staff and that this lack of ability or desire to do so may impact his treatment and the healing of his injuries. She also felt that giving Beni and his family opportunities to interact with staff during treatment procedures would assist Beni in his ability to self-express and potentially feel less isolated in this hospital environment. Assessment In the first assessment session, Jeanette went to Beni’s room to find him alone, lying in bed. In this initial period of interaction Jeanette sought to determine what kinds of music Beni was interested in, whether music therapy was indicated, and if so, the ways in which it would be possible to communicate together. At the start of this first session, Beni was very quiet and still. While Jeanette improvised a song about the teddy bear above his bed, Beni smiled and nodded when asked if the bear was his. Soon after, his parents arrived and Beni no longer acknowledged Jeanette’s presence. He seemed to visibly withdraw and now looked toward the window on his right-hand side. Jeanette turned her attention to Beni’s parents and discovered that his father played guitar in a band and had written his own songs. These songs discussed the customs, religious beliefs and practices, and the way of life in their community. Beni’s parents both enjoyed singing, and they described Beni as sharing their love of music, especially instrumental playing. Toward the end of the session, Jeanette offered Beni’s father the guitar, and, together with his partner, they sang two of their own community songs. They told Jeanette the titles were “Black Magic Man” and “Home Sweet Home.” Previously, when Beni had been offered instruments, he had refused to play them. Now, together with his parents, he took the tambor and played with them using a syncopated ostinato pattern, smiling all the time. After this session, Beni’s music therapy goals were refined to focus on extending his available resources in coping with his burn injuries, hospitalization and treatment. The objectives included providing opportunities for self-expression, support during treatment procedures and increased interaction between family members. Based upon this family interaction, it became clear that Beni’s music therapy sessions would now begin by including his family in the recollection of familiar song material so as to provide a safe, known and supportive environment for music therapy to take place. Sessions centered around singing familiar Aboriginal songs from Beni’s community, along with prominent Aboriginal bands. Improvisational experiences on tuned and untuned percussion instruments were also incorporated into sessions. These sessions took place before, during and after medical procedures, including his debridement baths2, and also prior to and after surgery. The Therapeutic Process

Beni’s music therapy program consisted of a total of 14 sessions that can be divided into three stages: “Turning Away” (session 1), “Songs of Place” (Sessions 2-12) and “I Want to go Outside/Goodbye” (Sessions 13-14). The therapeutic relationship between Beni and Jeanette changed as trust and greater interaction developed, supporting his adjustment to hospital and decreasing his stress and anxiety. Turning Away During the initial stage of Beni’s program, the burns team dealt with a range of concerns that included promoting opportunities for Beni to communicate his experience of treatment, but which also related to a fear for his survival. Beni was about to undertake an intensive period of medical treatment that included numerous skin graft operations. Grafting requires ongoing debridements and many dressing changes, events that were potentially painful and distressing for Beni. Staff were concerned that because Beni and his family were isolated from their home environment, this perceived lack of family support could impact Beni’s ability to cope with these procedures and his overall recovery. It was therefore important that opportunities were made available to provide Beni and his family to get the emotional and physical support they required. In this first session, Beni’s parents looked upset and concerned for their son. After some discussion between Jeanette and his parents about their family and home environment, Jeanette was introduced to one of Beni’s favorite songs - a song sung in his native language. Jeanette invited Beni’s father to take her guitar and play and sing the song for them. The father seemed reluctant but, with encouragement, eventually sang and played the song using a quiet tone. As the song was played, Beni began to smile, and he soon joined in singing with his father. Beni also sang quietly and continued to watch his parents engage with Jeanette. Beni’s mother soon joined in with this singing and also played along using a tambor. By the end of the session, Jeanette and his parents were singing and smiling. Beni was even beginning to play the tambor with his mother’s assistance. This song helped Beni form a connection between hospital and home. The therapeutic rapport initiated in this first session was possible because of this familiar song. The alliance of trust and support that began through the connection between the music therapist and Beni’s parents also facilitated the potential that was later realized. Through the choice of familiar song material recreated by a family member, music therapy was able to alleviate tension and anxiety for Beni. This session also provided opportunities for a means of communication, not only between Beni and Jeanette but also between Beni and other hospital staff as the program continued. Nursing, medical and allied health staff soon became familiar with Beni’s songs and often encouraged Beni and his family to sing and talk of their home environment when Jeanette was not present. Music therapy assisted in increasing socialization between the family members and hospital staff and also assisted in normalizing the hospital environment for Beni and his family; and perhaps even for hospital staff themselves. These staff would often comment on the lovely sounds coming from Beni’s room and the positive impact this music made on the hospital environment.

Songs of Place During this stage (sessions 2–12,) Beni expressed a range of feelings and emotions relating to his hospitalization, his injuries and his isolation from home. Sessions now took place in a variety of settings, including the bathroom during debridements. Support was provided to assist pain management, using music as relaxation and distraction during debridement procedures. During these sessions, Beni would often request the songs “Black Magic Man” and “Home Sweet Home” and two songs that Jeanette wrote that were purposely based on similar chordal progressions from his two well-known songs. Whenever injections were administered or dressings applied or removed, these were the songs that Beni requested. They were always played softly and calmly with an arpeggiated guitar pattern. Vocals were also sung softly, with ‘oohs’ and ‘ahs’ added instead of the lyrics, to promote a comforting, supportive environment. These sessions were often quite long, commencing in Beni’s individual hospital room, moving to the bathroom for his debridement bath, to the table in the bathroom for his dressings to be changed and finally back to his room where he often fell asleep. Music therapy remained a constant for Beni through these treatment stages. Music engaged him in different ways depending on his needs at the time. Jeanette would always invite Beni to take the lead in deciding which songs and instruments to use next. The time spent in the bathroom felt intense for Jeanette - not only due to the warm temperature of the bathroom (which is standard in burn care debridement), but also the intrusive nature of the procedure (Beni was semi-nude and in a bath) and the stress of anticipating Beni’s distress when he experienced pain or distress. During the debridements, Beni would watch Jeanette and listen to the music she played. This was usually guitar accompaniment and unaccompanied vocal improvisations. He would communicate with Jeanette using smiles and head nods/shakes to communicate his musical wishes. During one session, following the debridement when dressings were being reapplied, Beni appeared tired and looked as though he would fall asleep. Jeanette asked the nurse present if she should stay. The nurse replied, “it doesn’t matter.” As Jeanette softly said goodbye to Beni, he opened his eyes and called out, asking her to stay. The session continued until all dressings were completed and when Beni, assisted by his father, walked back to his hospital bed. He continued with the music therapy session in his room, engaging actively in instrumental improvisation with Jeanette using tambors, maracas and castanets. Many of the sessions in this second stage of Beni’s programme continued in this way. Jeanette would present him with a variety of instruments and together or with his parents present, would actively engage in creative musical play. It was not until Session 5 that Beni verbally spoke to Jeanette, asking to use a drum for an improvisation. During this session, Beni continued to dialogue with Jeanette, speaking of his home environment and reminiscing on past events that involved music making with his family. He requested the electronic keyboard and began experimenting with different rhythmic accompaniments and timbres. He seemed much more engaged and interactive now and eager to experiment with music and demonstrate his skills to Jeanette, his family and hospital staff.

During debridements, nursing staff started to comment on a more ‘relaxed’ Beni, who interacted more easily whenever the music therapist was present. Together with medical staff, they reported an increase in interactions with Beni during these procedures and were pleased that Beni attempted to communicate with them in English. Staff made positive and encouraging comments about Beni’s drumming and told his parents how much they enjoyed listening to their community songs. As therapy continued, recorded music and videos of a popular Australian Aboriginal band was provided for Beni. One of these songs, “Freedom,” became his favorite, and he often requested this song to be played and sung over and over. The song spoke of feeling alone and wanting things to happen in the world by being free. At the end of the song Beni would smile, laugh and play a loud sound on the tambor. He was able to express himself and his needs through this song - a desire to be free and away from the hospital environment. Music therapy also provided other opportunities for Beni to express his feelings. In a session where he received an injection, Beni placed the sticker he had received as a reward for the procedure on the tambor and loudly struck the instrument several times. He would then ask the music therapist to play ‘his song’ - Beni’s song, which the music therapist had improvised on guitar. Beni would then relax back into his bed and accompany the music therapist with his tambor, using a syncopated rhythm. Whenever he felt tired, he requested quiet and peaceful music – this often occurred after debridement when he was often exhausted after the traumatic experience. Throughout this stage, the therapeutic process grew and matured into a trusting, safe and secure relationship where Beni felt he could be supported and understood. The music acted as the connection between home and hospital and assisted in alleviating the stress and anxiety that Beni had initially experienced upon his admission to hospital. I Want to Go Outside/Goodbye The final sessions (sessions 13–14) centered around preparation for Beni’s discharge and return home. Beni began song-writing with Jeanette, creating lyrics about seeing his friends again and riding his bike. He also wrote about leaving hospital and how he would feel about arriving back home. During these sessions, Beni would take Jeanette’s hand and show her the guitar chords that he wanted her to play. This interaction also demonstrated the close and trusting relationship that had developed between them. One of the final sessions involved Beni, his parents and Jeanette singing and playing instruments outside the playroom in the burns unit. Other patients, their families and hospital staff gathered around to watch and listen. Beni sang loudly and confidently and smiled from ear to ear as he shared his music with others around him. As the songs ended, everyone applauded. Jeanette left the final session as hospital staff continued to sing and play instruments with Beni and his parents, talking with him about his music and home life. Music Therapy: Making a Difference in a Child’s Experience of Hospital Prior to music therapy intervention, Beni was described as a withdrawn and frightened child who only communicated with his parents and preferred to speak his native language. The

music therapy program, conducted over 14 sessions, provided Beni with opportunities to improve his self-expression, to feel safe and supported and to cope effectively with treatment procedures. In the final stages of the work, Beni was interacting with others outside of his immediate family and was demonstrating enjoyment through mastery, playing music for others. In considering the experiences of a child who is far from home, both geographically and culturally, the music therapist must be sensitive to the circumstances he/she encounters with the child and his/her family members. It is important to find ways to cope with one’s countertransference in the situation where a child is minimally responsive or seems afraid. The urge to embrace or engage the child must be resisted in order to be available as the child needs, rather than smother one’s own anxieties about being a good enough therapist by overwhelming the child with either affection or enthusiasm (see also Edwards, 1999a). It is important to wait until the child is ready to use the potential opportunities provided in music therapy. A family-centered approach considers that the family are a primary resource for the patient’s coping and adjustment. In this case, Jeanette’s ability to encourage and communicate with Beni’s parents resulted in them sharing important musical material that became an aural lynch pin for Beni’s feelings of connection between the challenges of hospital and the safety and security of home. Conclusion The music therapy literature attests that music can be a successful way to start a supportive dialogue with a young person experiencing a crisis (Daveson & Kennelly, 2000; Edwards, 1995; Ledger, 2001; Robb, 2003). In order to provide a therapeutic service through music therapy to patients receiving care in hospital, we used concepts from the following four theoretical areas: Theories of stress, coping and adjustment Transactional models of stress Developmental theories Family centered care With constructs from these theoretical approaches in mind, we were able to promote the necessary psychological support, mastery of effective coping skills, and family integration to improve Beni’s hospital experience, making an otherwise difficult time more manageable. In order to do this effectively, his developmental level had to be acknowledged, including the psychological, emotional and physical dimensions of his life stage. This, in conjunction with consideration of his needs for independence/dependence and support, and his capacity to cope with difficult circumstances, allowed the therapeutic process to unfold. We developed this way of thinking about patients through collaboration and dialogue around our clinical experiences. This in turn has led us to expand our theoretical understanding of stress and coping for children in hospital and their families. We hope that this work, and the resultant evolving framework, will continue to be a support to patients and their families in the

most trying of circumstances, and in so doing, they may gain positive experiences from being offered, and engaging in, music therapy. References Aldwin, C. (2007). Stress, Coping and Development: A Integrative Perspective (2nd ed.). London: Guilford Press. Daveson, B. & Kennelly, J. (2000). Music therapy in palliative care for hospitalised children and adolescents. Journal of Palliative Care, 16, 35-38. Daveson, B. (1999). A model of response: Coping mechanisms and music therapy techniques during debridement. Music Therapy Perspectives, 17(2), 92-98. Edwards, J. (1995). “You are singing beautifully”: Music therapy and the debridement bath. The Arts in Psychotherapy, 22(1), 53-55. Edwards, J. (1998). Music therapy for children with severe burn injury. Music Therapy Perspectives, 16, 20-25. Edwards, J. (1999a). Music therapy with children hospitalised for severe injury or illness. British Journal of Music Therapy, 13, 21-27 Edwards, J. (1999b). Anxiety management in pediatric music therapy. In Cheryl Dileo (Ed.), Music Therapy and Medicine: Theoretical and Clinical Applications. Silver Spring, MD: American Music Therapy Association. Edwards, J. (2005a). Developing music therapy approaches to pain management in hospitalized children. In C. Dileo and J. Loewy (Eds.). Music Therapy at End of Life (pp. 57-64). Cherry Hill, NJ: Jeffrey Books. Edwards, J. (2005b). The role of the music therapist in working with hospitalized children: A reflection on the development of a music therapy program in a children’s hospital. Music Therapy Perspectives, 23(1), 36-44. Edwards, J. (2005c). The contribution of music therapy to the process of therapeutic change for people receiving hospital care. Chapter 9 in Carole-Lynne Le Navenec & Laurel Bridges (Eds.). Creating Connections between Nursing Care and Creative Arts Therapies. Springfield: Charles C Thomas. Edwards, J. & Kennelly, J. (2004). Music therapy in paediatric rehabilitation: The application of modified Grounded Theory to identify techniques used by a music therapist. Nordic Journal of Music Therapy, 13, 112-126. Gaffney, A., McGrath, P.J. & Dick, B. (2003). Measuring pain in children: Developmental and instrument issues. In N. Schechter, B. Berde and M. Yaster (Eds.) Pain in Infants, Children and Adolescents (2nd ed.) (pp. 128-141). Philadelphia: Lippincott, Williams & Wilkins. Jolley, J. & Shields, L. (2009). The evolution of family–centered care. Journal of Pediatric Nursing, 24, 164-170. Kennelly, J. & Brien-Elliott, K. (2002). Music therapy for children in hospital. Educating Young Children: Learning & Teaching in the Early Childhood Years, 8, (3), 37-40. Kennelly, J. & Brien-Elliott, K. (2001). The role of music therapy in paediatric rehabilitation. Paediatric Rehabilitation, 4(3), 137-143. Kennelly, J. & Edwards, J. (1997). Providing music therapy to the unconscious child in the paediatric intensive care unit. The Australian Journal of Music Therapy, 8, 18-29.

Lazarus, R. & Folkman, S. (1991). The concept of coping. In A. Monat & R. Lazarus (Eds.) Stress and Coping: An Anthology (3rd Ed.(Ed.) Loewy, J. V. (Ed.) (1997). Music Therapy and Pediatric Pain. New York: Sachnote Press. Loewy, J. V. (2000). Music psychotherapy assessment. Music Therapy Perspectives, 18(1), 47-58. Moos, R. H. & Schaefer, J.A. (1984) The crisis of physical illness: An overview and conceptual approach. In R. Moos (Ed.) Coping with Physical Illness: New Perspectives. New York: Plenum Press. Robb, S. L. (2003). Designing music therapy interventions for hospitalized children and adolescents using a contextual support model of music therapy. Music Therapy Perspectives, 21, 27-40. Schaefer, J. A. & Moos, R. M. (1998). The context for posttraumatic growth: Life crises, individual and social resources, and coping. In G. Tedeschi, C. Park & L. Calhoun (Eds.), Posttraumatic Growth: Positive Changes in the Aftermath of Crisis (pp. 99-125). New Jersey: Lawrence Erlbaum Associates.

____________________________________ Full thickness burns involve damage and destruction to all layers of the skin and require surgical treatment, including skin grafts, to restore the skin. 2 In the debridement bath, skin is cleaned gently with sponges to remove dead skin so as to promote healing, minimize infection and to reduce scarring. See Edward 1

Taken from: Hadley, S. (Ed.) (2003). Psychodynamic Music Therapy: Case Studies. Gilsum NH: Barcelona Publishers.

CASE FIVE Healing an Inflamed Body: The Bonny Method of GIM in Treating Rheumatoid Arthritis Denise Grocke Abstract This chapter will describe the psychodynamic features of the Bonny Method of Guided Imagery and Music (GIM) therapy with a forty-three-year-old woman who, at the start of GIM therapy, had a fifteen-year history of rheumatoid arthritis (RA). The psychodynamic aspect of the study is based on the concept of physical illness as a manifestation of unresolved issues in the client’s life, and that the symptoms of the illness depict the client’s psychoemotional needs. The case study will illustrate how GIM sessions over five years allowed the client to relive events from childhood, and to express emotions relative to those events. The client’s imagery was symbolic of the manifestation of the illness and she frequently had imagery relating to her blood stream, joints, and cells, and learned quickly that she could enter the imagery of the body as a means of engaging the precipitating cause of the irritation. The issue of counter transference will be discussed with respect to two significant sessions in which the client was in extraordinary pain. The countertransference issue was whether the choice of music (which exacerbated the pain) made her condition worse, or whether the pain she was suffering was a necessary process of working through the disease. Introduction The Bonny Method of GIM is a specialized area of therapy in which clients listen to prerecorded classical music in a deeply relaxed state and in which visual imagery, changes in mood, and physiological effects in the body are experienced. GIM was developed by Dr. Helen Bonny, a music therapist at the Baltimore Psychiatric Institute, USA, in the 1970s. The method is based on the principles of psychodynamic therapy, where unresolved psychological issues in the client are brought to the surface and may be resolved. In GIM, the clients’ issues are represented in symbolic form in the visual images, feeling states, and body responses. The music programs used in GIM were designed by Bonny, and each incorporates selections from the classical music repertoire. The music contour of the program is designed to have a beginning piece which stimulates imagery, a middle selection to deepen the experience emotionally, and a final selection which returns the client to a nonaltered state of consciousness. A section of a large music work (e.g., a symphony or concerto) may be programmed alongside a work of another composer or another stylistic period. The choice of

music for each program is made according to the potential for inducing imagery and deepening emotion. A GIM session lasts approximately two hours. There is a period of discussion (of approximately fifteen minutes) in which the client and therapist decide together on a focus issue for the session. The client moves to a relaxation mat and reclines with eyes closed. The therapist provides a relaxation induction which is individually tailored to the client’s energy level and to the focus issue for the session. A focus image is given to stimulate the commencement of the imagery process, and the music program is chosen (by the therapist). As the music plays, sequences of images unfold, and these are verbalized by the client. The therapist makes interventions which are designed to bring the client closer to the image, and to notice any feelings or emotions which are associated with the images. The therapist also takes a transcript of the imagery sequence. At the end of the music, the therapist helps the client bring the imagery to a close, and a reorientation to the nonaltered state of consciousness is given. The client processes the meaningfulness of the imagery in relation to their daily life issues. This processing is done through verbal discussion or through free drawing or mandala drawings. Only one study has been done on the efficacy of GIM in treating patients with RA (Jacobi, 1994; Jacobi & Eisenberg, 1996). Twenty-seven patients with RA received ten individual sessions of GIM, and data were collected on medical measures (including walking speed, joint count, and perception of pain intensity), and general psychological status (including mood, symptoms of distress/anxiety, and “ways of coping”). Statistically significant results were found for lower levels of psychological distress and subjective experience of pain. Statistically significant differences were also found for walking speed and joint count. There were no statistically significant results, however, in disease status, and it was argued that a longer period of treatment with GIM may be indicated for changes to occur in disease indicators. In working with clients who have physical illness, Short (1990, 1991) noted that images emerging during GIM sessions may be physical markers of the illness. She found further that the marker could be useful in diagnosis. The image may be directly similar to the diseased body part, or may be an image of the fight against disease. Background Information Sandra referred herself to GIM at the age of forty-three. She came from a large family of eight children and was the third daughter. She had married in her early twenties and given birth to three children. Her husband was frequently relocated by the company he worked for, so that Sandra lived in various houses throughout the marriage. After one such relocation, she was diagnosed with rheumatoid arthritis (RA). The psychodynamic features of this disease are fascinating. One of the group of autoimmune diseases, RA affects women more than men in a ratio of 3:1, with the age of onset being between twenty to fifty years. The etiology of RA is unknown, but there is evidence of genetic predisposition to the disease (Akil & Amos, 1999, p. 40). The onset of the disease is thought to take place when an antigenic stimulus activates the components of the immune system. The antigen is picked up by a cell of the body, activating the secretion of antibodies. The antibody then binds to the antigen. Once the immune system has detected foreign antigens, this is communicated to other systems within the body, thus complicating a vicious cycle — the body detects the antigen, produces antibodies, and these

may be deposited in tissues, joints or blood vessels causing inflammation (Morrow, Nelson, Watts, & Isenberg, 1998). In essence, the body “turns upon itself.” In the acute stage, symptoms include painful joints, accompanied by a low level fever, fatigue, weight loss, and anemia. In the advanced stage there may be severe muscle wasting and deformity of joints and loss of movement resulting from contractures. In the acute phase, rest and analgesics are required for the pain and immobilization of the joints. A wide range of medications is used, particularly anti-inflammatory drugs and gold salts (Collins Concise Medical Dictionary, 1986, p. 326), and these are potentially toxic. A condition associated with RA is Sjögren’s syndrome, a key symptom of which is dry, gritty eyes, which may appear to be inflamed (redness), although vision is normal. The progression of RA is one of “flare-ups” and periods of remission. It is interesting to note that symptoms of RA disappear during pregnancy, but flare up after childbirth, indicating that hormones may play a major role. Since there is no cure for the disease, patients frequently turn to complementary medicine for relief of pain through diet, gentle exercise, and other forms of treatment. Naparstek (1995) uses Guided Imagery (without music) in treating patients with a range of conditions. In relation to RA she comments: “Generally speaking rheumatoid arthritis erodes the bone at the joint and swells the soft tissue surrounding it.... Corrective envisaging includes ‘filling in’ the bone at the eaten-away points...” (p. 60). The key symptoms of RA lend themselves to symbolic interpretation. Inflammation suggests heat, fire, and anger, and the term “flare-up” suggests a spontaneous rapid increase in these symptoms. The “dry, gritty eyes” of Sjögren’s syndrome suggest the need for fluid to flush out the residual grit, and this fluid can be found in tears. Interestingly, at the start of GIM therapy Sandra was wearing plugs in her tear ducts in order to keep her eyes moistened. From a psychodynamic point of view, the eyes could be better lubricated by naturally formed tears. In the process of GIM therapy it is common for therapists to look for symbolic associations between the symptoms of disease and the psychoemotional needs of the client. For Sandra, it appeared that her therapeutic needs might include an exploration of feeling inflamed (angry) and expression of tears (possibly of grief or hurt) that would moisten her eyes. In addition, the concept of flare-ups suggested that her symptoms and her progression in therapy might wax and wane, particularly her experience of pain, stiffness, and fatigue. And it was probable that, as GIM therapy progressed and unresolved issues came to consciousness, those symptoms might be exacerbated before they were ameliorated. Sandra responded extremely well to the Bonny Method of GIM. Initially she had monthly sessions, but these increased in frequency during times when she was dealing with an issue from childhood, or an issue evident in her current life situation. She had always enjoyed music, had been involved in musicals as a child, and loved to sing. She also played the guitar. She recalled childhood experiences where she had felt overlooked in the large family — her mother was constantly busy with many children and the needs of an aging grandmother and a busy farming business. From early childhood, Sandra had learned to be the peacemaker in the house, repressing her real feelings in favor of keeping the peace. Several of her siblings, however, were very vocal in making their needs known, so that Sandra developed a fear of speaking up in the presence of strong, authoritarian men and women. She was a qualified

nurse, and often had found it difficult to assert herself in the presence of authoritarian charge nurses and medical doctors. This nexus of issues was evident in the symptoms of her illness. Her difficulty in expressing anger, and in asserting herself, had led to the development of an illness in which the joints and tissues were periodically inflamed and painful. As a peacemaker, her tears of grief and disappointments from childhood had been blocked, and this was manifested in the plugs in her tear ducts which were necessary to keep the moisture inside her eyes. In GIM sessions, Sandra would often have imagery associated with water. In her early sessions she had the opportunity to swim in water, sometimes naked, and other times supported by key people in her life. She had imagery of significant animals, particularly a black snake. One of her most reliable sources of strength, however, was the image of a school friend, an Aboriginal girl whose name was Miriam. Miriam frequently appeared as a welcome face with a “huge smile.” Treatment In order to explain the elements of psychodynamic therapy with Sandra, three GIM sessions using the same music program will be discussed. In Sessions 38, 45, and 57, the program entitled Body Program (Bonny, 1987) was used. The Body Program comprises music mostly written during the twentieth century, including: Shostakovich: Allegretto, from the String Quartette #3 Shostakovich: Allegretto, from the String Quartette #8 Nielsen: Andante un poco tranquillo (excerpt), Symphony #5 Vierne: The Chimes of Westminster (a solo work for organ) Beethoven: Largo, from the Piano Concerto #3 Prokofiev: Larghetto, from the Classical Symphony The prominent features of the Shostakovitch selections are dissonant harmonies, short, angular melodies, and dancelike tempi. The music programs often chosen for Sandra in previous sessions had featured consonant harmonies and music with lyrical melodies, and so the decision to use more dissonant, angular music was a significant one. In Session 38, Sandra had presented for the session describing a flare-up of her arthritis. A measure of the activity of the illness is the erythrocyte sedimentation rate (ESR). The normal range is 4-19mm; Sandra’s level was 80. She described two issues that she felt contributed to this: her work environment, where she was required to take on more demands, and ongoing health problems with one of her children. She complained of pain in her head, shoulders, and neck, and that the sensation of the pain was “nagging.” As I mentally considered the range of music programs available, the Body Program seemed to best fit the sensation of “nagging,” and so I chose this music for the session. I asked Sandra to designate a color for the “nagging pain,” and she chose “dull dark blue.” I suggested she breathe this color through her body as a means of strengthening her awareness of her body. I then started the music. As soon as the music began, Sandra’s face changed. Her brow became furrowed, and her face was distorted with pain. She began to report what was happening in the imagery:

“someone has a paintbrush, painting my joints with blue” When I asked how that felt for her, she said, “Slapdash, a bit rough, grating.” I asked if she could see who was doing the painting. She said, “It’s a big hand, a man’s hand.” I asked if she had something to say to him. She replied, “You don’t understand how painful it is, I need something smoother, the bristle is too rough, it’s making the pain worse instead of better, it’s really irritating.” In the Bonny Method of GIM the therapist may change the music if it seems inappropriate to the client’s experience. In this session I was ambivalent about what to do. Sandra’s imagery suggested she wanted something smoother. Her words “you don’t understand how painful it is” I took to be directed to me, and my countertransference was activated. On the one hand, I felt I had made her pain worse. By choosing the “wrong” music I was inflicting greater pain on Sandra, rather than lessening it. On the other hand, the pain she described was a “nagging” pain, and the Shostakovich was a good match to the quality of the pain. In addition, I felt somatic changes within my own body — my heart rate had increased, and I felt stiff throughout my chest as I wrestled with what to do. My inner voices also clouded the decision: “This was a terrible choice of music,” and “I’m causing her pain.” Finally, I changed the music to a different program in which the music of Vaughan-Williams was gentle, calming, and consonant. The imagery then changed to images of her as a child with her hair in two long plaits. She ascended a castle staircase and was taken into a room where the young girl was gently massaged. Something was burning up inside her, like a fever, and the girl in the imagery began to cry. Sandra then recalled that her mother had said that when she (the mother) died, Sandra would be the one to ensure that the family stayed together. Sandra felt this was too big a responsibility, and that it was not fair for her to carry that responsibility. At the end of the music, and once Sandra had returned to a nonaltered state of conscious, she began to talk about the session. I commented that I noticed that the music at the beginning had made the pain worse, and apologized to her for exacerbating the pain. But Sandra commented that the music had forced her to feel the extent of the pain, and that it had opened up the insight into taking on the responsibility of keeping the peace. On reflection, I was uncertain whether Sandra’s reassurance was to placate my concern or whether it had been as helpful as she described. In my notes of reflection after the session I had written, “Had I taken on the role of peacekeeper, and placator in the session by changing the music?” Bruscia (1998, p. 76) has written about the aspect of choosing music in GIM as a point at which the therapist’s countertransference can be activated. When Sandra described the “nagging pain,” my choice for the music was influenced by my own experience of “nagging pain.” Thus, when she stated “you don’t know how painful it is” I felt responsible for causing the exacerbation of the pain and therefore decided to change the music to something more gentle. Some weeks passed, and in Session 45 Sandra presented with low energy. She had resigned from her demanding job and was preparing to start a new business from home. She was physically tired; however, she stated that her tiredness was also due to the domineering women at her workplace, who had in part influenced Sandra’s decision to resign from the job. As Sandra settled on to the mat, she spoke of an image of two domineering women pushing her in the back, and this was irritating her. As I considered all of the music programs available for the session, I again felt the Body Program best matched the irritation of being pushed in the back. As the first of the Shostakovich selections began, Sandra had an image of

witch’s hands — they were long, thin, and pointy. Sandra was irritated by the witch and wanted to be rid of her. This could only happen if she confronted the witch. During the Shostakovich piece, Sandra started to develop a body shape the same as the witch — her breasts became matronly, her bottom developed a wiggle, and she developed an authoritarian “strut.” “When I am sweet and docile, she walks all over me. I want to be her equal, meet her where she is at. I want her out of my body” Sandra reported. “She is like the music — powerful, with an authoritarian look. I don’t have to feel her power over me, I have to get rid of her, she’s not going to attack my back any more. The energy is coming out of my hands — I’m challenging her to a fight.” At this point I offered Sandra a high-density foam pillow to pound. This type of physical intervention can be helpful for clients in GIM in order to release pent-up emotion. After Sandra had pounded as much as she needed, I asked how her hands felt. I was concerned that the physical pounding may have hurt her arthritic hands. She commented that her hands were “relieved,” they had been “niggling and frustrated” and the pounding had done them good. In this session, I did not experience any of the ambivalence felt in Session 38. Sandra seemed to be empowered by the music and I did not take on any imagery experiences at a countertransference level. In Session 57, Sandra had presented with problems with her eyes. She had new plugs inserted in the tear ducts. Her eyes felt irritated and sore, and she had a visual image of a black zigzag across her eyes. The back of her head felt heavy, with a dull ache. Since Sandra had worked well with the Body Program in Session 45, I chose it again. Initially, she stated that the music corresponded with her head, and she was irritated “everywhere.” Her eyes were gritty and sandy, like sandpaper. It was like being in a dark room “not knowing where things are.” Small darting animals appeared, and then birds like magpies started pecking at her. While she was experiencing this imagery, she was “ducking” her head on the cushion, as if to protect herself from the attacking birds. At this point in the session I felt the same feelings of doubt that had emerged for me in Session 38. This music exacerbated her pain, but I thought it could also give her clarity about being “pecked” if she could explore the imagery further. Was the music I chose helping or causing more pain? If she was in greater pain, should I intervene by changing the music? Yes or no? Before I could act on this dilemma, Sandra’s imagery quickened — the magpies took on the faces of three domineering women in her life: They were “so quick, say things so quick, they go through you, so irritating right through my body, everywhere, my arms, head, shoulders, and eyes. I try to open my eyes slowly, to mesmerize the magpies, but the eyes are too irritated to open.” My counter-transference was enacted again — perhaps I was one of the domineering women, in choosing this music for her. Perhaps not opening her eyes was a form of resistance? I had written “resistance” (with a query sign [?]) in the margin of the paper used to transcribe the session. The music changed to the Nielsen selection of the Body Program and Miriam, her Aboriginal childhood friend, appeared in the imagery. “She’ll bathe my eyes with healing waters — the waters are cool on my eyes that feel SO hot. Miriam’s eyes are so beautiful, and she puts her fingers over my eyes, saying I should also put my own hands there. I can feel my own strength coming into my eyes.”

During the Beethoven selection (the slow movement of the Piano Concerto #3), Sandra commented, “All the meanness I felt toward them, but not saying, was in my body. It’s all out now, I don’t want to feel mean, I don’t want to feel irritated by them, I don’t want to fight fire with fire. I want to see them clearly, hear them clearly, then say back to them what I want to say. I’ve been scared of people all my life.” And later in the Beethoven: “There are electric charges going through my body, I am becoming more alive.” Miriam appeared once more in the imagery, saying, “You have your own strength.” By not changing the music in this session I allowed Sandra to bring about her own resolution to the irritating magpies. Her resolution was to invoke the image of Miriam, the Aboriginal girl, who healed the burning of Sandra’s eyes. Miriam could be seen as an archetypal figure, or as a projection of Sandra’s feminine identity. The important point, however, was that I did not act as peacemaker (as I had in Session 38) by changing the music to something more gentle. Instead she enacted her own inner strength to resolve the unpleasant imagery. Discussion Part of the process of the Bonny Method of GIM involves the client bringing to the surface images and associated feelings that have been repressed or unresolved in the unconscious. The music plays an integral part in bringing these memories to the surface so that they can be resolved in the imagery. The choice of music is therefore pivotal. Some aspects of the GIM session involve input from the client — in deciding on the focus issue for the session, in the imagery that comes forth, and in processing the meaning of the imagery at the end of the session. The one major decision in which they have little or no influence is the choice of music. Clients may infrequently request gentle music, or strong music, but they do not choose the program. This decision therefore depends on the therapist’s knowledge of the music, and an informed calculation of how well the music of the entire program (of 30-45 minutes) will relate to the issue brought by the client to the session. Should the music be inappropriate it is possible to change to another selection of music, or another program altogether, but such changes themselves involve a therapeutic decision made by the therapist. Countertransference may be operating as the therapist makes these choices. Priestley (1994) discusses different types of countertransference, including e-countertransference, in which the therapist “becomes aware of the sympathetic resonance of some of the patient’s feelings through his own emotional and/or somatic awareness” (p. 87). This was certainly my experience in all three sessions mentioned above. However, Summer (1998) has stated that “in all music therapy techniques there is a triadic, not dyadic relationship” (p. 433). That is, there is potential for the client to have transference to both the therapist and the music. Within the Bonny Method of GIM, Summer argues that transference may be a “pure music transference,” when “the music serves the essential therapeutic function” (p. 434). The client’s transference may also be split between the primary music stimulus, and the verbal interventions of the therapist. In Session 38, for example, Sandra’s experience of “someone has a paintbrush, painting my joints with blue” was influenced by my subsequent intervention — “How does that feel for you?” Although we argue that GIM therapists do not direct the imagery per se, the direction inherent in this intervention is to focus Sandra’s attention on her feelings about being painted, rather than, for example, the

size of the paintbrush, or who might be holding it. Each intervention of the therapist, therefore, has a propensity for countertransference. Likewise, when Sandra reported the feeling was “slapdash, a bit rough, grating,” my intervention was to ask if she could see who was doing the painting. “It’s a big hand, a man’s hand” prompted me to ask if she had something to say to him. And this intervention evoked the response “you don’t understand how painful it is, I need something smoother, the bristle is too rough, it’s making the pain worse instead of better, it’s really irritating.” From a psychodynamic perspective, both transference and counter-transference are operating interactively. Sandra’s transference is operating toward the music, but influenced by my interventions. My countertransference was operating toward Sandra’s exacerbated pain, and also to the music. Therapeutic Gains Each of the three sessions described above were pivotal sessions for Sandra. In each case, the sessions following unearthed memories of a significant event that needed to be reexperienced from her adult perspective in order to gain insight into the meaning of the event. After Session 38, when her ESR count was 80, Sandra telephoned for an extra session. The precipitating cause was the ongoing illness of one of her daughters. In this session, I used the program entitled Mostly Bach, a program comprising works of Bach orchestrated by Stokowski. Typically, this music program is used for sessions requiring strong music, to match an issue of similar content. Sandra’s imagery covered a range of hurtful events from her life — she recalled memories of the daughter (currently sick) as a baby; that soon after the birth her husband had been transferred by the company he worked for to a new location, and Sandra packed up the old house and moved once again into a new home. She recalled being overwhelmed by the physical work involved. In addition, her husband was working late into the night to acquaint himself with the new job. It was at this point that she received the diagnosis of arthritis. She was placed on medication, but one of the side effects was lockjaw. She recalled the terrifying feelings of not being able to move her mouth, or speak, and feeling a lack of control over the situation. The session following Session 45 also unearthed significant and traumatic memories. She recalled being a very small child, and being unnoticed by everyone around her. She had a profound feeling of not being wanted, or not belonging. She recalled slinking out of the family house and not being noticed, and she experienced grief over her father’s illness and subsequent death, recalling vivid images of him dying in hospital, an ashen gray color. Imagery Related to the Body After Session 45, Sandra began to use imagery to explore within her physical body. In Session 54 she arrived for her session describing her body as very tense and sore. During the relaxation induction she chose the color “electric blue” to illustrate the feeling within her body, and she imaged a gentle blue color to take into her body to relieve the pain and soreness. To the music of Vaughan-Williams (Fantasia on a Theme of Thomas Tallis), she found herself underwater. Initially she was weighed down with heavy armor, and instead of removing the

armor (her defense), she decided to leave it on and journey inside her body to find the answers. At first, she explored her heart, which was a brown-red color, then she found tentacles growing in her body — in her bones, muscles, joints, and the cells. As she looked closely at the tentacles they transformed into vines of ivy, twisting through her body, like poison ivy. I asked her to look to the roots of the ivy vine. She found herself inside a house, as a small child, aged seven. Her energy had been “zapped.” The girl was crying “burning tears” and the tears began to burn down the ivy. Later the armor fell off her body. In subsequent sessions, Sandra recalled hurtful events from her childhood, growing up in a household with seven other children and the challenge to be seen and heard. She recalled crying herself to sleep at night. She also recalled hurtful events at school where she was singled out for ridicule. In Session 56, a masculine figure appeared in her imagery with the same color hair and eyes as Sandra. She named him David. In Jungian theory this image represents the internalized masculine. But one week later she suffered a flare-up of the arthritis in her spine, sufficient to put her to bed for a period of four weeks. In the next GIM session she experienced quite grotesque imagery — a black spider with red stripes appeared, but the legs of the spider transformed into tentacles of burning hot coal. A red lump started to get bigger and bigger, ready to explode. An image of her domineering sister appeared. She was holding a thorn and was pressing the thorn into the lump. As Sandra screamed at the woman — “Don’t do this anymore” — the pain subsided. The spider reappeared with the message “speak the truth.” At this point in Sandra’s therapy there were visible signs of change. She had her hair cut short, and she felt she was becoming more assertive with her domineering sister. In Session 71, she re-experienced the onset of lockjaw, in which the jaw was rigid, unable to move. She was terrified by the sensation of having no control over her mouth. In Session 72, Sandra’s imagery returned to an exploration within her body. She was experiencing pain in her sternum, and as she imaged the pain, she found the ribs on either side of the sternum involved in a fight. The sternum was “caught in the middle.” This image was the catalyst for exploring further childhood memories where she was caught in the middle, and she would shut herself away from the family when others were arguing. In the ensuing months Sandra was faced with two significant losses — the death of her mother (which was expected) and the death of her youngest daughter (as a result of an accident, and unexpected). At a time when she expected her RA to reappear, it did not. Over several sessions, Sandra was able to mourn, and in one session found a place within her heart to rest. She imaged a seat where she could sit within her own heart and grieve for her loved ones. Her heart featured again in Session 84. The music program “Peak Experience” was used during the session, and during Wagner’s Prelude to Act 1 of Lohengrin, Sandra’s heart began to expand. Her heart became so enlarged that her body could fit inside it. A red and gold glow, like the sanctuary light in a church, filled the heart, and she felt enormous energy radiating from it. Sandra called this image of the heart the “core” of herself, and from this session on she frequently entered her heart to sit on the seat and rest there. In one session (98), she maintained a dialogue between her mind, body, and spirit, recognizing the “wise woman” within her and the “anxious woman” who disturbed the harmony of the mind-body-spirit connection. She felt she was beginning to recognize the different aspects of herself, and this was helpful when faced with stresses and demands.

After a break over the Christmas holiday period, Sandra commented that she had not experienced a flare-up for more than a year, and that she was no longer taking medication. We were fascinated that there had been no flare-up given the traumatic year she had experienced with the death of her mother and her daughter. It was as if the profound grief had brought the mind, body, and spirit together, and in that deep connection the RA had gone into remission. Most recently, Sandra has changed her focus of work, choosing to conduct grief counseling through her local church. She continues to be free of symptoms of RA, and has been off medication for three years. She believes that the Bonny Method of GIM completely changed her life. Summary In this case study, the Bonny Method of GIM was effective in many ways. It helped Sandra to confront the acute pain of arthritis, and via the imagery to find the root cause of the inflammation. This process of exploration, however, initially exacerbated the pain, and once this had occurred several times, I became more aware of her capacity for engaging the imagery and invoking images to help herself. Because the pain was heightened, Sandra was able to see clearly some of the childhood issues that had caused her to develop a pattern of repressing emotion, hiding from conflicts, and hiding disappointments and grief. Later GIM sessions allowed her not only to explore the very core of her body, but to find a sanctuary deep within her own heart where she could sit and rest. This sanctuary became an essential inner place during the profound grief she suffered over the loss of her mother and her beloved youngest daughter. That she is currently free of symptoms and medication is testimony to the capacity of the Bonny Method of GIM in bringing about life-changing transformation. References Akil, M., & Amos, R. S. (1999). “Rheumatoid Arthritis: Clinical Features and Diagnosis” (Chapter 10). In M. L. Snaith (ed.), ABC of Rheumatology. Second edition. London: BMJ. Bruscia, K. (1998). “Signs of countertransference.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Collins Concise Medical Dictionary. (1986). London: Collins. Jacobi, E. (1994). The Efficacy of the Bonny Method of Guided Imagery and Music as Experiential Therapy in the Primary Care of Persons with Rheumatoid Arthritis. Unpublished doctoral dissertation. Union Institute. Cincinnati, OH. Jacobi, E., & Eisenberg, G. (1996). GIM in Medicine: Enhancing the Quality of Life in Rheumatoid Arthritis. Presentation to the AMI Conference, Vancouver, BC, Canada. Morrow, J., Nelson, L., Watts, R., & Isenberg, D. (1998). Autoimmune Rheumatic Disease. Second edition. Oxford: Oxford University Press. Naparstek, B. (1995). Staying Well with Guided Imagery. London: Thorsons. Priestley, M. (1994). Analytical Music Therapy. Phoenixville, PA: Barcelona Publishers. Short, A. (1990). “Physical Illness in the Process of Guided Imagery and Music,” Australian Journal of Music Therapy, 1, 9-14.

Short, A. (1991). “The Role of Guided imagery and Music in Diagnosing Physical Illness or Trauma,” Music Therapy, 10 (1), 22-45. Summer, L. (1998). “The Pure Music Transference in Guided Imagery and Music.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE SIX Medical Music Therapy with Premature Infants: Family-Centered Services Miriam Hillmer Olivia Swedberg Jayne M. Standley Introduction Research on the effects of music listening with neonates has shown numerous benefits, including increased weight gain, decreased length of hospital stay, and improved oxygen saturation levels (Caine, 1991; Collins & Kuck, 1991; Standley & Moore, 1995). Training parents of premature infants in the use of music therapy techniques with their child has shown benefits for both infants and parents (Cevasco, 2006; Whipple, 2000). A family-centered approach to medical music therapy was used in this case study, wherein music listening was used to enhance parent-infant bonding and promote infant development. This clinical work took place in the Neonatal Intensive Care Unit (NICU) at a regional medical center in the Southeastern United States. Parents of an infant born prematurely were trained to use recorded music in their infant’s isolette while the infant was an inpatient in the NICU. The parents indicated strengthened perceptions of bonding with their child and increased understanding of their infant’s responses. The infant showed positive responses to the music intervention, including improved vital signs, as reported by parent feedback. Foundational Concepts Medical music therapy involves the use of evidence-based music therapy practices to help meet the physical and/or psychosocial needs of patients receiving medical treatment (Gfeller, 1999). Physical needs may include pain reduction, sensory integration, and muscular functioning. Psychosocial needs may include normalization of the environment, anxiety reduction, and provision of emotional support that assists an individual in coping with their current situation (Gfeller, 1999). Protocols for medical music therapy treatment are based on findings from this growing body of medical music therapy research. Just as medical treatment is based on evidence-based standards of care with predictable outcomes for specific diagnoses, medical music therapy is grounded in research (Standley & Walworth, 2005). Results from music therapy research in the Neonatal Intensive Care Unit (NICU) have shown positive benefits of medical music therapy with premature infants. A meta-analysis (Standley, 2002) showed an overall effect size of .83 for music interventions with premature

infants. Standley (2003) describes five music therapy interventions that research shows are beneficial for premature infants: i.

ii. iii. iv. v.

Sustained music, live or recorded, provided individually -increases respiratory regularity and oxygen saturation (Collins & Kuck, 1991; Standley & Moore, 1995; Cassidy & Standley, 1995) and decreases distressed behaviors (Coleman, Pratt, Stoddard, Gerstmann, & Abel, 1997; Flowers, McCain, & Hilker, 1999). Music to reinforce non-nutritive sucking using the Pacifier Activated Lullaby device increases sucking endurance (Standley, 2000; Standley, 2003) and reduces pain perception (Whipple, 2004). Music and multimodal stimulation - increases tolerance to stimulation and decreases length of stay (Standley, 1998). Infant stimulation - facilitates alertness and responses to others in infants close to discharge (Ilari, 2003; Standley, Walworth, & Nguyen, 2009; Tims, 1978; Trehub & Trainor, 1993). Parent counseling - promotes parent/infant bonding and trains parents in the use of music with their child (Whipple, 2000; Cevasco, 2006).

Music therapists working in the NICU must be familiar with best-practices in NICU music therapy so they can convey these practices to the parents. Because of the fragility of premature infants, specialized training in NICU music therapy is recommended for qualified music therapists seeking to practice in the NICU. Standley (2003) provides a summary, based on the results of numerous studies, of guidelines for music use in the NICU: • • • • • • • • • •

less than 70 dB on a C scale maximum of four hours per day music sung by the mother, another female, or children is preferable singing should be a cappella or with a single accompanying instrument the character of the music should be soothing, constant, and relatively unchanging light rhythmic emphasis, constant rhythm constant volume melodies in the higher vocal ranges, which are heard best by infants a variety of musical selections should be used so as not to cause habituation or fatigue most lullabies meet the above criteria and are thus appropriate for premature infants (Standley, 2003).

While music therapy has long been used in medical treatment and is becoming part of standard care in many NICUs, it has evolved as the practice of medicine has grown and changed. Recent studies promote a family-centered approach to medical care, which has shown beneficial outcomes for patients and their families (Henneman & Cardin, 2002; Kardia, et al., 2003). While traditional medical care has focused on the diagnosis and treatment of illness, family-centered care takes into account not only how the patient’s psychosocial state impacts their physical health, but also the needs of the family who form the patient’s support system.

Because medical music therapy addresses psychosocial needs in addition to physical needs, this focus on family-centered care is not a new phenomenon for music therapists working in medical settings; indeed, the family-centered approach is easily incorporated in the medical music therapy model, in which the music therapist works with the patient and his/her family to help strengthen the patient’s support system. The benefits of using a family-centered approach to medical treatment have been documented in the NICU (Harrison, 1993; Cisneros Moore, et al., 2003). Having a pre-term infant can be stressful for parents, more so than having a full-term infant (Bremond et al., 1993). This early stressful experience can be detrimental to the formation of parent-infant attachment (Feldman & Eidelman, 2006; Forcada-Geux et al., 2006; Minde, et al., 1983). Parentinfant attachment has a great impact on child development (Crawford, 1982). Receiving appropriate support can help mediate the effects of a stressful experience on parents of preterm infants (Lawhon, 2002; Brisch, et al., 2003). Training in uses of music with premature infants is a successful form of support for parents (Whipple, 2000; Lai, et al., 2006; Maguire, et al., 2007). Henneman and Cardin (2002) recently published guidelines for family-centered critical care, broken into ten steps, which can provide foundation for the provision of family-centered care in the NICU. Step one is to understand the meaning of family-centered care, defined by the authors as “a philosophical approach to care that recognizes the needs of patients’ family members as well as the important role that family members play during a patient’s illness” (p. 12). Step two is to know the needs of the family. Step three involves integrating familycentered values into hospital standards and policies, leading to step four, using hospital resources to provide family-centered care, and step five, creating tools to help families. Step six cautions healthcare professionals not to confuse family issues with security and confidentiality issues and step seven reminds them to be consistent with patients’ families. Step eight, making family-centered care a multidisciplinary group endeavor, will help with the implementation of step nine, which recognizes the need for ongoing attention and support for a family-centered approach. The authors’ final advice in step ten is to be patient and recognize that implementing a new approach successfully will take time. When utilizing a family-centered approach to medical music therapy in the NICU, it is also important that the music therapist provide nonjudgmental understanding and acceptance of decisions made by parents regarding treatment or the withholding of treatment (Standley, 2003). This case study utilized two of the NICU music therapy interventions described by Standley (2003): 1) individually provided periods of sustained music, and 2) parent counseling. These interventions were implemented by a NICU-MT using a family-centered approach. The protocols that were followed were based on the body of music therapy research with premature infants. The Clients This case example focuses on the use of parent training in the use of recorded music placed in the isolette/crib. Of particular importance were parent perceptions of their child’s progress and feelings of bonding with their infant. The clients were parents of an infant in the High-Risk NICU. As is often found in parents with infants in the NICU, these clients experienced

a high level of stress related to the condition of their child. The baby was born at 26 gestational weeks and had a birth weight of around 1.5 pounds. The young gestational age and small size of the infant initially restricted the amount of contact the parents were able to have with their baby. For several weeks they were limited to interacting with their infant through an isolette and were not able to hold their little one. The baby was born at such a young age that the mother commented during the first meeting with the music therapist that the infant had not yet developed the ability to cry. With conditions this serious, care was out of the parent’s hands and, as a result, they missed out on an essential bonding period. The opportunity for the clients to provide music for their infant was seen as a possible way to promote bonding between parent and child. The clients were offered parent training in playing recorded music for their baby once the infant was identified, in a weekly interdisciplinary meeting, as a possible candidate for services. This music therapy referral was based on gestational age and medical stability of the infant. Per hospital protocol for sound stimulation and current research literature (Standley, 2000; Standley, 2002; Standley, 2003), music therapy was not offered to the parents until the infant was 30 weeks corrected gestational age. Assessment In the NICU setting, it is important for both the infant and family needs to be assessed and addressed. The infant requires medical attention with the music intervention serving as an adjunct to treatment. The music therapist assesses the infant’s appropriateness for music interventions on an ongoing basis. This includes understanding the infant’s current medical condition, ability to tolerate auditory, tactile, visual, and vestibular stimulation, and positive reactions to music interventions. Families often require emotional support, and music-based interventions provide this. The music therapist assesses family needs through conversation with medical staff and the family as well as through observation of family interactions with both the infant and medical staff. In this case study, the clients’ needs were assessed during the music therapist’s initial phone conversation and subsequent meeting in which training on playing recorded music took place. The family had heard about music therapy services prior to being contacted and had inquired about receiving these services for their child. They were pleased to find out that receiving training from a music therapist enabled them to have a more active role with their infant and that the benefits of music listening for neonates were supported by research. In assessing the clients, the music therapist paid particular attention to how both parents interacted with their infant, any concerns verbalized, their level of involvement with the standard care of their infant, and their level of passiveness or aggressiveness in interacting with the music therapist. The infant’s ability to tolerate the auditory stimulation as well as positive signs was also assessed throughout the training session. Upon our first meeting, the clients appeared anxious about the condition of their child as evidenced by their frequent questions and uncertainty of how to respond to statements relating to their baby’s current condition. For instance, prior to training, the parents were asked to fill out a form assessing their feelings of closeness and bonding with their infant. For many of the statements on the questionnaire, parents asked for clarification, wrote explanations to their answers, or left the statement blank. The music therapist attempted to ease the client’s concerns by assuring them there was no ‘right’ answer to the questionnaire, no ‘wrong’

questions to ask, and that they would receive further information on how to read their child’s response to the music. It was determined that family centered music therapy, in the form of parent training, would be beneficial for the client and support a more active parenting role. The Therapeutic Process The therapeutic process in the NICU is different with each individual client, depending on the level of family involvement and the overall family dynamics. It begins while the therapist is assessing the infant and family needs and continues once an appropriate course of action is determined. The music therapist has many researched treatment options at their disposal including multimodal stimulation, music listening, the Pacifier Activated Lullaby device, and parent training in therapeutic music techniques (Caine, 1991; Cassidy & Standley, 1995; Cevasco, 2006; Standley, 1998; Standley, 2000; Whipple, 2000). It is important that therapeutic interventions utilize a family centered approach whenever possible. As was mentioned earlier, Henneman & Cardin (2002) outline several steps to successfully implementing family centered care. Steps that are applicable for the music therapist in the NICU setting include: •

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Step One – Understanding what family centered care is: The music therapist must understand that this approach to treatment recognizes the needs of the family, that these needs affect the patient, and understand this interplay. Specifically in the NICU, this includes understanding that the use of music strategies promoting parent education or bonding can have a direct impact on the infant. Step Two – Knowing the needs of the family: The family typically has three needs: 1) for information, 2) for reassurance, and 3) to be with the patient. NICU music therapy interventions can address all three needs if the music therapist communicates with the family about treatment and facilitates interaction between parent and infant. Step Three – Integrating into standards and policies: The music therapist must make it standard practice to contact the family of infants in the NICU when services have been referred. This provides the opportunity for the therapist to provide information, address parental concerns/assess parental needs, and offer family centered services as appropriate. This practice should also be written into departmental policies. Step Four – Creating tools to help: The music therapist can offer information and packets to families to use as resources. Handouts highlighting the benefits of music, listing appropriate types of music, outlining steps to treatment, and listing music therapy contact information. Step Five – Making family centered care a multidisciplinary group endeavor: As a part of the clinical team in the NICU, the music therapist should be in close contact with staff from other disciplines (i.e., speech and/or occupational therapy, patient education, and nursing) who are providing treatment and/or are in contact with the patient and family. There should be open communication regarding family and patient needs between the music therapist and these individuals. This can take place

in the form of interdisciplinary meetings, one on one interactions between the music therapist and specific staff members, or both. When implemented correctly, these steps to family centered care aid parents in coping with their infant’s hospitalization by addressing their concerns and needs. This, in turn, facilitates a healthier emotional state, creating a better environment for parents to make critical decisions regarding their child. However, even with family centered care, whatever the needs of the family, the needs of the patient come first. Medical staff must always be consulted before implementing any music therapy intervention with neonates. Throughout the therapeutic process and regardless of the type of intervention, the music therapist is constantly monitoring three things: 1) the infant’s response to music interventions; 2) the infant’s medical progress and; 3) the changing needs of the parents. The infant constantly provides feedback as to how the intervention is being tolerated. Medical staff and therapists continually keep a watchful eye on vital signs (heart rate, respiratory rate, and oxygen saturation level), subtle distress signs, and signs of pleasure. Some of this feedback is obvious to the observer, such as crying, smiling, or a large change in the infant’s vital signs. Conversely, some infant responses are more subtle and require careful observation, such as thrusting of the tongue or orienting toward a stimulus. For the music therapist, these signs, whether positive or negative, guide the therapeutic process. A sign of distress causes the therapist to pull back and allow the infant to return to its previous state. A positive sign indicates tolerance of the stimuli, is noted by the therapist, and as appropriate, further stimuli is introduced. The current medical state of the infant is extremely important when providing any type of therapy. Placement of tubes, time of last feeding, and recent procedures are just a few of the issues the therapist should be aware of before starting a therapeutic intervention. Answers to these questions will determine whether music therapy is appropriate at the current time and, if appropriate, whether adaptations need to be made due to the infant’s medical condition. The parent’s needs may change over time and the needs of one parent may be different from his/her partner/spouse. For instance, some parents are overwhelmed initially and cannot process all of the information they receive about their infant. They may initially reject attempts from medical staff to provide help and support, whereas later they may become empowered at the thought of caring for their infant and may seek as much information and support as possible. The infant’s current condition and various other factors such as individual coping styles and support from extended family and community are variables that may affect the needs of the parents. The music therapist must be sensitive to this and offer information, reassurance, and facilitate opportunities for bonding, where appropriate. The therapeutic process in this case example illustrates how music therapists provided family centered care while constantly monitoring infant responses, infant medical condition, and parental needs. The music therapist began treatment once parent training in recorded music was determined to be the appropriate therapeutic intervention for the clients. The parent training consisted of several steps: Parents selected a CD from the ‘approved music’ list to be placed in a provided CD player. This was a list of approved CDs available for the clients to use while

the infant was in the hospital and was categorized depending on the age of the baby. The music therapist explained what was taken into consideration when compiling the list, including limited instrumentation, slow, even tempo, few voices, and lack of sudden musical changes. It was explained that the benefits of these musical qualities fostered soothing, predictable stimulation for infants. The clients were given a copy of this list to use as a future reference in selecting appropriate music for their infant (see Appendix 1 for a list of appropriate CDs). The importance of obtaining nurse permission prior to playing music was stressed. The nurse in charge of the infant at the time of each intervention was the authority on his/her current medical condition and appropriateness for music listening at the time. Especially earlier on, as the infant’s medical condition was more severe, the clients understood that the nurse had the child’s best interest in mind in approving or declining the playing of recorded music on a particular day. As the infant aged, graduated to the intermediate nursery, and became more medically stable, the medical staff granted the clients a larger role in determining the appropriate time to play music. This was evidenced in feedback forms filled out by the clients, indicating a more independent role as the infant grew and developed. Equipment was cleaned in accordance with hospital infection control procedures and the importance of such procedures was explained. Such precautions included cleaning with hospital-grade cleaners prior to each use and dedicating equipment to the individual patient. With antibiotic-resistant strands of viruses and bacteria fast becoming a problem in communities and hospitals, precautions to reduce the spread of germs are extremely important. This is especially true for a susceptible population such as premature infants. The parents were receptive and appreciative of the precautions taken to protect their loved one. The music therapist explained the set-up and position of the equipment in the infant’s bed. Correct placement included the speakers at the foot of the bed facing the infant. One speaker was placed by each foot to allow for equal stimulation across both hemispheres of the brain (Standley, 2003). Appropriate volume level was discussed to avoid levels exceeding 70 db (scale C). All CD players were marked by the music therapist with an appropriate maximum volume level (less than 70db on scale C). This marking was based on tests with a decibel meter in an empty isolette. Because different recordings produce different decibel blends, clients were informed that volume levels may need to be lowered, but should never be increased above the marked level. Music was started by the music therapist and continued through the rest of the training session. Positive signs and ways to identify these signs were discussed. These included, but were not limited to: smiling, cooing, stable vital signs or positive change in vital signs, head orientation toward the music and opening eyes. Subtle signs of overstimulation, ways to identify these signs and appropriate parental response were discussed. These included, but were not limited to: crying, halt hand, finger splay, tongue protrusion, hiccup, grimace,

spitting/vomiting and struggling movement. Clients were taught that if these signs continued for more than 15 seconds, the music should be stopped until the behavior ceases and the patient returns to his/her baseline behavior. The music therapist demonstrated this during the training session. Other distress signs, ways to identify these and appropriate parental response were discussed. These included oxygen saturation level below 86%, heart rate less than 100 beats per minute, or heart rate greater than 200 beats per minute. Clients were told to halt the music immediately if these physiological changes occurred and to wait until the infant returned to baseline. The music therapist demonstrated this during the training session. Clients were given an information sheet listing all distress signs and ways to respond to these. This allowed for independence by reassuring them that they did not have to memorize everything discussed but would have the information in writing to which they could refer. The music therapist walked parents through completion of the ‘Music Form’ and where to place this when completed. This form was completed by the clients every time music was played. It asked for clients to rate their perceptions of the music’s effect on their infant. Completed forms provided feedback to the music therapist regarding the parent’s and infant’s changing needs, along with the effectiveness of the training intervention. Instructions were given regarding maximum duration and frequency of music playing: 30 minutes at a time was recommended for each child, not exceeding three times per day. Music listening should be alternated with at least 30 minutes of silence. These guidelines were included in the previously mentioned information sheet. Research in the use of recorded music with premature infants shows benefits from listening to music for up to four hours a day, but adverse effects exceeding this amount (Baily, et al., 2005). Therefore, a conservative time limit was given in order to avoid the possibility of exceeding four hours of sound stimulation in a 24-hour period. The music therapist remained with the clients to answer any questions and contact information was provided for any future questions. As the training took place the music therapist made note of the client’s reaction to the information provided. This involved paying attention to how they were able to identify positive signs from their infant or signs of overstimulation, types of questions asked, whether they seemed more or less anxious as a result of parent training, and the overall comfort level in administering the recorded music. By the end of the training, the clients appeared more relaxed and assured of themselves as they started to take over the role of music provider with a better understanding of how to interpret their infant’s responses. From this one-time meeting, the parents were given a positive means of interacting with their child. The music therapist determined that the clients were ready to provide music for their infant independently with the music therapist available for any questions or concerns. The frequency of music, infant responses, and parent perceptions were monitored through the use of ‘music record forms’ (Appendix 2) that the clients filled out during each music session.

Throughout their time in the NICU, the clients rated their perceptions of bonding with their infant utilizing a 5-point Likert scale. This helped assess the effectiveness of familycentered music therapy interventions on the clients’ feelings of involvement and comfort in caring for their loved one. The first assessment was taken prior to any intervention from the music therapist. Responses indicated overall uncertainty on the part of the clients. They rated their feelings of anxiety and fear that their interactions may harm the infant as ‘high.’ They gave a rating of ‘low’ to their feelings of being able to calm their loved one and understanding the infant responses. They were neutral about their perceptions of bonding with their child. Finally, they were unable to answer questions relating to feeling helpful to their baby, understanding their parenting role, perceptions of whether their infant was jittery, and knowing how to nurture their infant. Each follow-up assessment, taken throughout the infant’s time in the NICU and post discharge, indicated that the clients gained more confidence in interacting with their child and feelings of bonding. Specifically, the clients demonstrated a positive change in response to the question ‘I feel bonding with my infant’ and ‘I know how to calm my baby.’ In fact, responses to the question about calming the infant changed from ‘strongly disagree’ prior to music therapy intervention to ‘strongly agree’ by the time the infant was discharged. The clients also demonstrated a positive change in their response to the question ‘I feel my interactions may harm my baby’ moving from ‘agree’ initially to ‘strongly disagree.’ The music record form also offered insight into the clients’ perception of the effectiveness of the music intervention. The clients filled out ten separate forms indicating that they provided nine independent music listening sessions for their infant following the parent training session with the music therapist. Responses during the first and second sessions indicated a neutral response by the clients regarding their perceptions of the music’s benefits for their infant. These questions specifically asked about the music’s effect in calming and nurturing the infant, as well as improving vital signs, environment, and quality of life. Following the first two sessions, the clients always marked a positive response to these questions, suggesting a shift in perception and an increase in confidence. However, the one question that asked about the music’s benefits on the infant’s development was left blank on every form. This suggests that the parents lacked knowledge regarding music’s researched benefits on infant development. As the infant moved from the high risk NICU to the intermediate NICU and became more medically stable, the parents became even more independent in their administration of music. With medical staff permission, they brought their own CD player and made decisions regarding music’s appropriateness at the time. This suggests an understanding of their child’s current state, responses, and a confidence in providing the stimulus. This was a far cry from the music therapist’s initial meeting with the clients where uncertainty prevailed. Through the information and support provided by the music therapist and medical staff, the clients were given an opportunity to take on a pro-active parenting role, have meaningful interactions with their child and bond during a critical period. The baby was discharged at approximately 39 weeks corrected gestational age. The music therapist followed up with the clients one week post discharge to address any further needs and assess continued perceptions of bonding. Summary

When working in the NICU, the music therapist fulfills several roles. The most important is as an advocate for the patient in offering complimentary therapeutic interventions to soothe and promote optimal development in a stressful environment. This involves close contact and a healthy working relationship with various medical staff. Also important is for the music therapist to address family needs because this will have a direct impact on the long-term health of the patient. Family-centered care supports all of these roles and fosters an environment of healing. All music therapy interventions, from multimodal stimulation (Standley, 1998) to parent training (Cevasco, 2006; Whipple, 2000), to the use of the Pacifier Activated Lullaby device (Standley, 2000), work with the family-centered model of care by focusing treatment on the specific needs of the patient, involving family, and engaging in constant consultations with medical staff. This case example is one illustration of the success of family-centered care through the use of parent training in playing recorded music. First, the infant’s specific needs were identified at a multidisciplinary meeting. Next, the clients were consulted regarding possible music therapy interventions and an assessment of the client’s needs was conducted by the music therapist. Given the infant’s age and medical needs, as well as the client’s desire for an increased role in care, reservation in interactions, and uncertainty in understanding their child’s responses, parent training in playing recorded music was deemed the most appropriate intervention. The clients were presented with information regarding the benefits of music for their child, signs of pleasure or overstimulation, and steps for offering music stimulation. The music therapist monitored the client’s feelings of bonding with their infant as well as their perceptions of the music’s benefit. Overall, the results suggest the effectiveness of the music therapy parent training intervention and continued follow-up. The clients’ confidence in their role as parents, feelings of bonding, and understanding of their child’s responses grew throughout the process. In addition, the feeling that the music was a positive intervention that benefited the infant, strengthened. However, the clients remained unsure about the music’s benefits on their child’s development. While they could physically see if the music positively affected the infant’s current state, they did not show an understanding of its potential longterm benefit. This highlights an area to be stressed both in initial training with the clients as well as in follow-up interactions. The music therapist should stress research supporting the effectiveness of music interventions on child development, putting this information into terms that are easy for parents to understand. There is a rich amount of this type of literature both in the NICU setting and beyond (Tims, 1978; Ilari, 2003; Standley, et al., 2009). Articles or information sheets can be provided to the clients for continued reference, as well as more discussion of how the music may directly benefit their child (i.e. weight gain, neural development, etc.). This addition would further support family centered care, augment the therapeutic experience, and make a stressful situation for parents and infants in the NICU more manageable. References

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