"Rhythm is there in the cycles of the seasons, in the migrations of the birds and animals, in the fruiting and withering of plants, and in the birth, maturation and death of ourselves. Mickey Hart
Miracle of modern marvels is the advent of Music Therapy, known to have been utilized as a formally recognized therapeutic modality as early as the 18th century. Of course, music has been used as a palliative measure for hundreds, perhaps even thousands of years but Music Therapy as a specifically defined and credentialed form of treatment is a relatively novel phenomenon. Simply defined, Music Therapy is the process of using music-based interventions to accomplish individual goals ranging from mitigating the severity of symptoms in those suffering from Schizophrenia and Bi-polar disorder, to simple relaxation and stress reduction (see also other articles found in the articles section of the JamPlay site!). But what is truly remarkable is some of work being done with those suffering from extreme pain as well as those who are in their last days on his great big blue marble that we like to call “Earth.”
I was recently blessed with the opportunity to interview one of my colleagues in the counseling industry, a woman by the name of Tine Sample B.M., a licensed Music Therapist in Windsor Colorado and an individual who has had considerable experience working with those dealing with chronic pain disorders as well as those in hospice care. Tina is also a musician herself (naturally), plays guitar and piano as well as sings, and incorporates all of her musicality into her counseling in various ways as you will soon see. The following is an excerpt from a fairly lengthy interview and for the sake of confidentiality, any client names used have been changed. After a brief discussion, Tina and I began our interview with the topic of songwriting:
ML “So how is it that you utilize songwriting with your clients, Tina?”
Tina “Well, the process begins with a discussion, much like you would hear in many counseling circles...clients eventually talk about issues that are important to them, like 'I never really told my husband how I really felt' about some particular issue, then we begin the song with their words.”
ML “So you use their feelings, words and emotions as a jumping off point for the song?”
ML “And do they give you the music or contribute in any way to the actual writing of the chords and melodies and so forth?”
Tina “No, not usually. They're usually the lyricists and I help them to compose the music as we go...also, many of them are in extreme pain and are sometimes even lapsing in and out of consciousness.”
ML “Wow, that must be very intense and difficult work at times.”
Tina “Yes, it is but extremely rewarding as well.”
ML “I can imagine, what other words, emotions, issues come up and are worked into song form?”
Tina “Spirituality and religion are very common... for example, some clients are curious 'am I going to go to heaven' so the topic of the song begins with their fears, thoughts and ideas about heaven and why they believe they may or may not be admitted when the time comes.”
ML “And what do you do if they're saying nothing at all, or are unable to speak?”
Tina “Then I play instrumental or cathartic music and then hopefully draw them out with a discussion of what words/phrases are powerful to them, and what it means to them.”
ML “I see, how do you know what kind of music to bring to each client, I mean, you obviously have to be careful to not bring inappropriate music, if you know what I mean?”
Tina “Yes, I make sure to match the kind of music that each client would be most likely to benefit from, so somebody who has Western decor in their room will likely benefit from Country and Western music...I tailor make the intervention to what I think they would like and benefit from.”
ML “I bet that's difficult with some of the clients.”
Tina “Yes, sometimes you just have to guess, and frankly sometimes it doesn't matter what kind of music they like, but rather that I'm there and there is music, any music...”
ML “Do you have any stories where that type of situation took place?”
Tina “Yes, there was one situation where I was asked to come into a room and play some music for a man who had an elevated heart rate and respiration, and wasn't expected to live. What's interesting about this type of music therapy is that you match the rate of the music you're playing with their heart rate, then gradually slow it down. His wife was there as well and she asked me to sing 'Jesus loves me' so I played some chords and sang. She then asked me to sing 'Amazing Grace', which I did. The wife and husband both had tears in their eyes and it was an incredibly powerful moment for us all. He looked up at me with tears in his eyes and although he couldn't speak, he looked more grateful than anybody I had ever seen in my life.”
ML "That's an amazing story Tina and I can imagine it was very very moving for you...and from a clinicians perspective I'm curious, how do you know when a particular intervention is effective, I mean, how do you know that you helped to reduce his heart rate and respiratory rate?"
Tina “We watched the readouts of his vital signs, the music seemed to be helping him relax and slowed both his heart rate as well as his breathing.”
ML “That's remarkable and certainly a testament to the power of music as well as the power of the mind!”
Tina “Yes Mark, absolutely. There was another case where I was working with a woman in her 60's let's call her 'Clara'....she had been diagnosed with Esophageal cancer and wasn't expected to live beyond a couple of months. We worked on songwriting, collaboratively, on issues like family and her kids, what she could have done differently in her life etc. We wrote a song together entitled “I'm on My Way Home,” meaning to her going away to the afterlife and I added the rhythm guitar for it. The song and our interaction measurably changed her affect, her mood and decreased her depression and her feelings of hopelessness. The next time I saw her she told me that she was going home. I responded by asking her 'are you ready?' She said 'No, Tina, I mean I'm really going home! Hospice had seen such a drastic change in her both physically as well as mentally that they released her.”
ML “That's absolutely amazing Tina.”
Tina “Yes it truly was. She was one of my favorite clients.”
ML “Do you use music therapy interventions with groups of clients?”
Tina “Yes, I work with groups of anywhere between 5 to 15 people, with various different types of presenting problems including Schizophrenics and other fairly serious types of disorders. One schizophrenic woman used song to help reduce the effects of her auditory hallucinations.”
ML “You mean she heard voices?”
Tina “Yes, and singing helped to distract her and reduce the power of her hallucinations.”
ML “How do you get the members of the group to interact and how is that therapeutic for them?”
Tina “I bring a box of instruments including Claviers, Tambourines, bells and other percussive instruments and everybody picks an instrument and plays together.”
ML “Sounds like you might end up with pandemonium there (laughs)?”
Tina “Well, sometimes but usually it's the other way around where they're reticent to play. We also do an exercise that I call 'mirroring' where pairs of two clients will play instruments across from each other and mirror the others' emotions, affect. It can really help to calm clients although sometimes the clients don't know what to do and just sit there looking at each other.”
ML “What effect does that seem to have on the clients?”
Tina “It seems to really have a calming affect in general although you never know for sure. But what I've witnessed overall is a sort of chanting effect where one client will calm the other and themselves at the same time. Kind of what you might see in a drum circle.”
ML “I see...can you talk a little more about work you've done with Music Therapy and pain management?”
Tina “Yes, I remember working with a woman in her 50's, we'll call her Tanya. She suffered from extreme pain, a sleep disorder as well as multiple brain tumors. I played musical pieces with prominent string sections and instructed her to breathe in through her nose and out of her mouth. This is the opposite technique from breathing techniques in yoga where they instruct you to breathe in and out of the nose. Breathing out of the mouth can help to reduce heat in the body and help to achieve relaxation...Tanya began to fall asleep and I talked to her very softly using guided imagery. She told me she wouldn't be there next time and she was terrified. We talked at length about her fears and pain and she was finally able to sleep.”
ML “That's a great story Tina and certainly more evidence of the positive effects of music on suffering people.”
Tina “Yes, I see new examples of it every day in my work...”
Due to the lengthy nature of the interview, I summarized the highlights and most interesting portions of our discussion for your perusal. Tina had numerous other stories concerning the miraculous power of music therapy and individuals who were able to gain some solace and relief from their symptoms simply by listening, or interacting on some level with music.Music Therapy and Pain Management
The Medical industry often delineates between two types of pain: fast and slow. Fast pain corresponds to acute forms which are usually shorter in duration and easier to locate, in terms of their origins. This variety of pain often responds well to medication and can be locate and centralized to one area. Slow pain, on the other hand, is synonymous with chronic pain which tends to be long term and is sometimes difficult to define and treat. In fact, many physicians are unable to locate the exact origins of many individual's chronic pain making it even more elusive and difficult to contend with. Neuropathic pain or Neuralgia is an example of a disorder which can cause chronic pain, and although it is often caused by nerve damage, it can also be difficult to locate the exact cause and location of the source of the pain itself making it extremely difficult to treat.
Chronic pain is also closely linked with pain tolerance and can be affected by one's mental attitude from moment to moment as well as other extraneous factors such as age, gender (women are said to have a higher tolerance to pain when compared to their male counterparts and this tolerance may be due, in part, to increases in estrogen during menstrual cycles, see http://www.med.umich.edu/opm/newspage/2003/painbrain.htm) and cultural factors as well. It's important to mention at this point in the discussion that many medical professionals (and philosophers as well) consider pain to be perceptual in nature, and subsequently controllable with the mind. In fact, because the brain contains no nociceptive tissue (tissue containing pain-transmitting neurons), the brain itself is not capable of experiencing pain rendering the expression “head-ache” a misnomer. Rather, pain is perceived primarily in the thalamus and can be mitigated and controlled by the sufferer.
Because of the subjective nature of pain, it is also highly prone to mitigation and even extinguishing when the sufferer is exposed to certain stimuli. Music is a powerful stimuli and research has shown that exposure to various types of music actually causes physical changes in the brain including chemical changes that are measurable. One of these changes is a quantifiable increase in the amount of endorphins (literally endogenous-opiates) in the brain which, like artificially administered opiates, has the effect of reducing the perception of pain.
A study published in 2006 in the Journal of Advanced Nursing (JAN) examined the effects of Music based therapy on pain, depression and disability, as well as feelings of power and control, in a group of 60 African American and Caucasian patients suffering from chronic pain. Some of the subjects were exposed to music while others (control group) were not. The study showed statistically significant evidence that those exposed to music did indeed experience a reduction in pain and depression, as well as an increase in their perception of personal power. Researchers concluded based on their findings that nurses treating those suffering from chronic pain can benefit from an insight into Music-based therapies, in order that they may teach their patients to utilize music as an enhancement to traditional analgesic medications.Music and Post-Surgical Recovery
Music and Music therapy has been found to reduce the levels of pain experienced by people in various states of recovery, but it has also been documented as an important element in post-surgery recovery as well. Many health care facilities over rely on the use of traditional medications, creating unwanted chemical dependencies in their patients which often fall short of the mark in terms of optimal care for the individual patient at hand.
The phenomenon known as “pseudoaddiction” comes into play here and can be defined as the abnormal behavior that arises as a result of receiving insufficient, or inadequate medications for the treatment of his or her pain. In a post-surgery scenario, patients often experience unimaginable levels of pain during recovery. Larger and larger doses of pain killers are prescribed, including the use of the powerful narcotic drug known as Dilaudid (Hydromorphone Hydrochloride). Dilaudid has some horrific side affects including involuntary muscle tremors, rapid or slowing heart rate, nausea, weakness, constipation, terrifying nightmares and on and on. In addition to the dizzying array of possible side affects is the larger-than-life possibility of addiction to the narcotic and the very real possibility that the drug will lose its ability to quell pain over time. Doctors and hospital staff constantly adjust patient's medications to contend with the possibilities of either over medicating and causing unnecessary side affects and possible chemical dependency, or under medicating and creating other problems. These conditions can lead to pseudoaddiction which progresses through three phases:
1) Inadequate prescription of medications to meet pain needs of the patient.
2) Escalation of demands by the patient coupled with behavioral changes to convince others of the severity of pain.
3) Crisis of mistrust between patient and hospital team.
From this point the patient-health care team relationship falls apart creating additional stress on the patient and presenting possibilities for difficulties in recovery.
Adding additional interventions such as Music therapy to the post-surgical environment can help to alleviate pain while reducing the need for debilitating narcotic medications. Take USC University Hospital in Los Angeles, for example where Doctor/Musician Peter Crookes leads a troupe of classical musicians who perform once a month for the patients. Crookes belongs to a group of volunteer musicians who call themselves “Music Heals” and who hold fast to the notion that the healing qualities of music are invaluable as a supplement to medications. “Studies show music can help people recovering from pain and reduce the need for post-op medications” says Crookes who works by day as a Bariatric surgery but moonlights as a violinist. Crookes as well as others support the notion that although the use of narcotics is integral to the recovery process, other more holistic methods of treatment can be used as well that help to relax the individual and speed up the recovery process. http://the-brain-and-music.blogspot.com/2009/07/music-releases-endorphins-in-brain.htmlMusic Therapy and Hospice Care
Therapist Tina Sample showed us that Music Therapy can help to mitigate some of the symptoms suffered by those in long term and hospice care, giving them hope and and helping them to perhaps gain some valuable perspective about life and passing. In addition, many studies are showing the value of music therapy in a hospice setting in terms of mitigating and alleviating pain, increasing physical comfort, increasing overall energy, reducing anxiety as well as the amount of time spent in treatment and improving the overall quality of life. Needs treated by music therapists fall into 5 basic categories.
1) Social - Including isolation, loneliness, boredom and the need to make meaningful contact with significant others.
2) Emotional - Including depression, anxiety, anger, fear and frustration. This is a particularly important category due to the fact that patients who are agitated or extremely anxious are more difficult to treat and are more likely to experience difficulties in the other categories.
3) Cognitive - Including neurological impairments, disorientation and confusion.
4) Physical - Including pain which is frequently of the chronic variety, shortness of breath, muscle spasms and cramping.
5) Spiritual - Including the experience of losing spiritual connection and/or spiritually-based rituals. Many of these patients have strong emotions relative to losing their connection with their churches and those associated with their church.
The Social category listed above has another important dimension as well in terms of working with the families of the infirm. Dealing with losing a cherished loved one can be incredibly traumatic for the surviving family members and music can help to ease some of the grief that they are experiencing. Also, music can be a powerful social element when played in a group which compels participation from different family members, even those who are often more shy and reserved. Old songs and melodies from years past are compelling sources of emotion and nostalgia that often have the effect of drawing people together and providing a sense of unity. This unity in and of itself can be therapeutic for both the families as well as the patients.Tempis Fugit
Some may tout the value of the presence of nurses and doctors as adequate and cling to the notion that attention from hospital staff alone should be therapeutic enough to rehabilitate and deal with patient's needs. Truth be told, most hospital staff are too busy to provide the quality of care necessary to truly make a qualitative difference in their patient's lives. In a study done with 80 patients in hospice care, an evaluation was done looking at each person's length of life while either receiving music Therapy or not during their stay. 40 of the patients received Musical interventions while the other 40 did not. The data showed a significant difference in life span (while in Hospice) for those who received Music Therapy. Further analysis showed that the Music Therapists involved in the study paid more visits to the patients than either the nurses or the social workers, and spent more time with them in general. This study pointed out the unappealing fact that nurses in hospice often only deal with their patient's physical needs, while social workers only contend with case management issues. Music Therapists are far more likely to address more personal needs of dying patients such as the emotional, social, cognitive and spiritual that are equally, if not more important than the physical. Further, studies like this one highlight the fact that many facilities are understaffed and under budgeted to deal with the complex needs of our aging and infirm population.Money Makes the World go Around, Sadly
Strong empirical research supporting the value of music based therapy is essential in order that insurance companies as well as Medicaid and Medicare provide the necessary funding for Music Therapy. Government agencies and other funding sources that provide reimbursement for palliative care seek accurate and insightful data to ensure that the services provided meet the needs of the patients and families. Consequently, further studies need to be implemented showing the importance and value of music to the treatment of those suffering from pain disorders or other debilitating ailments.
Since 1994, Medicare has recognized Music Therapy as a reimbursable service under the benefits for Partial Hospitalization Programs (PHP). This type of therapy falls under the category of "activity therapy" although certain parameters do apply that therapists must adhere to in order to gain reimbursement for their services. The interventions cannot be simply recreational or diversionary in nature and must be specifically geared towards each patient's treatment plan. As long as therapists meet individualized goals, Medicare supports the use of Musically based interventions with their patient's and provides funding for services.Conclusion
Fortunately, individuals like Music Therapist Tina Sample as well as other pioneers in the field are showing us the value of Music Therapy when working with our suffering population. More than ever, we have a need to think outside of the box, away from antiquated practices that we have continued to use simply because it's so much easier and profitable to drug our infirm and aging people than to deal with their needs. We need more interventions that are more personalized, more creative and more musical.