The Arts in Psychotherapy, Vol. 18, PP. 359-362. e Pergamon Press plc, 1991. Printed in the U.S.A. 0197-4556/91 $3.00 + .OO

REFLECTIONS

CREATIVITY AND CONSCIOUSNESS:

MUSIC THERAPY IN INTENSIVE CARE

DAVID ALDRIDGE, PhD*

“

* . . however great the organic damage . . . there remains the undiminished possibility of reintegration by art, by communion, by blocking the human spirit; and this can be presented in what at first seems at first a hopeless state of neurological devastation.”

(Sacks, 1986, p. 37)

The neurologist Oliver Sacks reminds us of the necessary balance we must bring to our work with patients in the field of medicine. All too often we are concerned with testing the patient for deficits, for measuring and for assessing problem-solving capaci- ties. As a balance he urges us to consider the narrative and symbolic organization of the patients, so that we consider their possibilities and abilities. In this way what seems to be damaged, ill-organized, and chaotic becomes composed and fluent. This is the function of the creative arts; through art and play we realize other selves elusive to measurement and fugitive to assess- ment. Furthermore, there is a quality of time that is apparent in arts activities that is “intentional” and involves the will of the patients where their spirits are set free. When we consider the situation of intensive care, where patients are often damaged, disorganized, intubated, machine-regulated, often unconscious, and unable to communicate, then we must consider a way of introducing activities that will stimulate commun- ion with those patients.

In this paper the ground of consciousness is con-

sidered. It raises questions about the location of the self in patients who are comatose, about the nature of communication with patients who are unconscious, and challenges medicine to realize the human body as an instrument of knowledge.

Some aspects of modem medicine have become increasingly technological. Such is the case of inten- sive care treatment. Even in what may appear to be hopeless cases, it can save lives (Hannich, 1988) through the application of this modem technology. However, albeit in the context of undoubted success, intensive care treatment has fallen into disrepute. Patients are seen to suffer from a wide range of problems resulting from insufficient communication, sleep and sensory deprivation (Hannich, 1988; Ul- rich, 1984), and lack of empathy between patient and medical staff. Many activities in an intensive care situation appear to be between the unit staff and the essential machines (i.e., subjects and objects). To a certain extent, patients become a part of this object world. Improvised music therapy can be a useful adjunctive therapy in such situations both for the patient and the staff.

The Music Therapy Sessions

At the suggestion of a hospital neurologist, a music therapist began working with patients in intensive

*David Alctridge is a research consultant to the medical faculty of Universit;?t Witten Herdecke, Germany. He thanks Dr. Wilhelm Rimpau for the initiation of this work, Dagmar Gustorff for her pioneering of these skills in difficult conditions, and Professor H.J. Hannich for his providing the circumstances for the further exploration of this work.

359

360 DAVID ALDRIDGE

care (Gustorff, 1990). To investigate this approach further, the work was monitored in the intensive treatment unit of a large university clinic. Five patients, between the ages of 15 and 40 years, and with severe coma (a Glasgow Coma Scale score between 4 and 7) were treated. All the patients had been involved in some sort of accident, had sustained brain damage, and most had undergone neurosurgery.

The form of music therapy used here was based on the principle that we are organized as human beings not in a mechanical way but in a musical form (i.e., a harmonic complex of interacting rhythms and me- lodic contours) (Aldridge, 1989a, 1989b; Nordoff & Robbins, 1977). To maintain our coherence as beings in the world we must creatively improvise our iden- tity. Rather than search for a master clock that coordinates us chronobiologically, we argue that we are better served by the non-mechanistic concept of musical organization. Music therapy is the medium by which a coherent organization is regained (i.e., linking brain, body, and mind). In this perspective, the self is more than a corporeal being. As Sacks (1986) wrote, “the power of music or narrative form is to organize” (p. 177). What music and narrative structure organizes is the recognition of relationships between elements, not in an intellectual way, but direct and unmediated. With coma patients we see signs of activity, albeit often machine supported, but totally disorganized. The person exists, sometimes in what is described as a vegetative state, but hardly “lives.”

Each music therapy contact lasted between eight and twelve minutes. The therapist improvised her wordless singing based on the tempo of the patient’s pulse and, more importantly, the patient’s breathing pattern. She pitched her singing to a tuning fork. The character of the patient’s breathing determined the nature of the singing. The singing was clearly phrased so that when any reaction was seen the phrase could be repeated.

Before the first session the music therapist met the family to gain some idea of what the patient was like. On contacting the comatose patient, she said who she was, that she would sing for the patient in the tempo of his or her pulse and the rhythm of breathing. The unit staff were asked to be quiet during this period and not to carry out any invasive procedures for ten minutes after the contact.

There was a range of reactions from a change in breathing (it became slower and deeper), fine motor

movements, grabbing movements of the hand, and turning of the head, eyes opening to the regaining of consciousness. When the therapist first began to sing there was a slowing down of the heart rate. Then the heart rate rose rapidly and sustained an elevated level until the end of the contact. This may have indicated an attempt at orientation and cognitive processing within the communicational context (Nordoff & Rob- bins, 1977; Sandman, 1984a, 1984b). Electroenceph- alogram (EEG) measurement of brain activity showed a desynchronization from theta rhythm, to alpha rhythm or beta rhythm in former synchronized areas. This effect, indicating arousal and perceptual activity, fades out after the music therapy stops.

If we consider that cells firing with a cardiac rhythm have been recorded in the medullary area of the brain, and that there is a synchronous relationship between the contraction of the heart and the “ascend- ing” wave of alpha rhythm (Sandman, 1986) of brain activity, then it is possible to hypothesize that the rhythmic coordination of the cardiovascular system with cortical rhythmic firings is of primary impor- tance for cognition. What we have is a weaving together of basic primitive human rhythms, which produce an interference pattern that itself may be that of cognition. It is proposed here that the rhythmic coordination of basic functions in the human body (Jones, Kidd, & Wetzel, 1981; Kempton, 1980; Kidd, Boltz, & Jones, 1984; Lester, Hoffman, & Brazelton, 1985; Longuet-Higgins, 1982; Povel, 1984; Rozzano & Locsin, 1981; Safranek, Koshland, & Raymond, 1982; Steedman, 1977) is a fundamental healing activity.

The Ward Situation

Sleep disturbance is a major problem in intensive care units and the effect of a disturbed waking/ sleeping rhythm upon other metabolic cycles is criti- cal (Johnson & Woodland-Hastings, 1986; Moore- Ede, Czeisler, & Richardson, 1983; Reinberg & Halberg, 197 1). The rhythmic entrainment of cardio- vascular and somatic activities may be the key ground for recovery. This means that we must consider the total “behavioral’ ’ (Engel, 1986) activity of the patient so that seemingly independent systems are integrated. The context (i.e., Latin, con texrere = weaving together) of this integration is rhythmical involving the coordination of the major tidal rhythms of the body and timing mechanisms within the hypo- thalamus in the brain.

MUSIC THERAPY IN INTENSIVE CARE

As an organizational problem, we must look to the ways in which staff are employed in work shifts. It can occur that patients throughout 24 hours are constantly in contact with nursing staff who are in their own activity cycle, no matter what time of day or night. For rhythmically disoriented patients, no won- der that there are sleep problems when they must respond to constant activity with caregivers who themselves are physically unsynchronized with the patient. Nursing staff, although synchronized with management needs and hospital routine, may need to attend to the sleep/activity rhythm of the patient.

In response to the music therapy, some ward staff are astonished that patients can respond to quiet singing. This highlights a difficulty of noisy, busy, often brightly lit units. All communication is made above a high level of machine noise. Furthermore, commands to an “unconscious” patient are made by shouting formal injunctions (i.e., “Show me your tongue, ” “Tell me your name,” “Open your eyes”). Few attempts are made at normal human communi- cation with a patient who cannot speak or with whom staff can not have any psychological contact. It is as if these patients were isolated in a landscape of noise, and deprived of human contact.

A benefit of music therapy is that the staff are made aware of the quality and intensity of the human contact. In the intensive care unit environment of seemingly non-responding patients, dependent on machines to maintain vital functions and anxiety provoking in terms of possible patient death, then it is a human reaction to withdraw personal contact and interact with the machines. Although the machines themselves are of vital importance, they present data that are independent one from another, and that are often considered in isolation, whereas the integration of the systems being measured is the clue to recovery. This is further exacerbated by a scientific epistemol- ogy that emphasizes the person only as a material being and that equates mind with brain.

At yet another level, we must consider the fixed chronological pulses of machines. If human activity is based on pulse, the nature of those pulses is that they are variable within a range of reactivity. Those pulses are lively and accommodate other pulses to form interacting rhythms. This is not so with machines; they are fixed in their range. Therefore, what is a variable in human activity (the tempo of varying pulses) becomes a constant in these patients. The task then is to introduce coordinated variety with the intention to heal, something that as yet machines

cannot do. Perhaps the key lies in the fact that it is the consciousness of the therapist that stimulates the consciousness of the patient, and this consciousness is not divorced from the living rhythmic reality of our physiology.

A period of calm is also recognized as having potential benefit for the patient. What some staff fail to realize is that communication is dependent on rhythm, not on volume. We might argue that such unconscious patients, struggling to orient themselves in time and space, are further confused by an atmo- sphere of continuing loud, disorienting random noise, and bright light. For patients seeking to orient them- selves, the basic rhythmic context of their own breathing may provide the focus for that orientation. This raises the problem of intentional@ in human behavior even when consciousness appears to be absent. Reflexes do not occur in a vacuum; they are conditional occurring in a context of other behavioral activity. If bodily systems are proactive, as well as reactive, then purposive behavior and consciousness may require the context of human communication to function. It is also vital that staff in such situations do not confuse “not acting” on the behalf of the patient with “not perceiving.”

We can further speculate that the various body rhythms have become disassociated in comatose states and following major surgery. The question remains of how those behaviors can be integrated and where the seat of such integration is. It is quite clear that integration is an organizational property of the whole organization in relationship with the environment and not located in any cell or any one organ. The environment of the patient includes the vital compo- nent of human contact and there is reason to believe that the essential ground of this contact too is rhyth- lllkd.

Communication, Contact, and Consciousness

Improvised singing appears to offer a number of possible benefits for working in intensive care both in terms of human contact and promoting perceptual responses. Human contact as communication is a creative art form. Although what we know from machines is valuable, there are other important subtle forms of knowledge that are best gleaned through personal contact with the patient. Mindell(l989) took the courageous step of attempting process-oriented psychology with comatose patients, accompanying them on their great symbolic journey. The drama of

DAVID ALDRIDGE

our contact with such patients at a time of existential crisis points to a fundamental aesthetic of living systems creatively realized so that we, as artist therapists, can go beyond the confines of a soulless technology. This is not to deny that technology and its benefits, simply to remind us of our human intention as it is realized in art, play, drama, music.

What we may also need to consider in future is not how to observe more, but how to question the quality of what we are observing and the premises on which this observation is based. In such situations of inten- sive monitoring and machine support, particularly in the case of comatose patients, we may ask of our- selves, “Where is the self of the patient?” Needle- man (1988) reminds us that the power of scientific thought has been to organize our perceptions in such a manner that we can survive in the world. Hence the value of scientific medicine and instrumentation. However, he goes on to say that science has also neglected the human body as an instrument of knowl- edge and as a vehicle for sensations as direct as ordinary sensory experience, but as subtle as con- sciousness. He writes “. . . it is not simply the intellect which science underestimates, if is the hu- man body as an instrument of knowledge-the human body as a vehicle for sensations as direct as ordinary sensory experience, but far more subtle and requiring for their reception a specific degree of collected attention and self-sincerity” (p. 169).

The question still remains for us as clinicians and scientists when faced with a patient in coma or a persistent vegetative state, “Where is the person and how can I reach him or her?” and then for ourselves as fellow human beings, “Where am I?” What part of the therapist is contacting the unconscious patient? Could it be that if the musical form of our communi- cation touches our patients, as singing, we can also attend to how we speak with the patients in their breathing patterns, and then attend to them with the very form of our own bodies.

This ability to communicate with unconscious patients raises further the ethical issues of decisions about terminating life support when the brain and the person are no longer seen as one and the same entity (Mindell, 1989). When patients are not responding it may be that we are not providing them with the human conditions in which, and with which, they can respond. We as therapists are those conditions that are the context for healing to take place.

References

Aldridge, D. (1989a). Music, communication and medicine. Journal of the Royal Society of Medicine, 82, 743-745.

Aldridge, D. (1989b). A phenomenological comparison of the organization of music and the self. The Arts in Psychother- apy, 16, 91-97.

Engel, B.T. (1986). An essay on the circulation as behavior. The Behavioral and Brain Sciences, 9, 285-318.

Gustorff, D. (1990). Lieder ohne Worte. Musiktherapeutische Umschau, 11, 120-126.

Hannich, H.J. (1988). Oberlegen zum Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaf, 13, 238-244.

Johnson, C., & Woodland-Hastings, J. (1986). The elusive mech- anism of the circadian clock. American Scientist, 74, 29-36.

Jones, M., Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic attention. Journal of Experimental Psychalogy, 7, 1059-1073.

Kempton, W. (1980). The rhythmic basis of interactional mi- crosynchrony. In M. Key (Ed.), The relationship afverbal and no&e&l ~ommunicatian (pp. 68-75). The Hague: Mouton.

Kidd. G.. Boltz. M., 8c Jones, M. (1984). Some effects of rhythmic content on melody recognition. American Journal of Psychology, 97, 153-173.

Lester, B. M., Hoffman, J., & Brazelton, T. (1985). The rhyth- mic structure of mother-infant interaction in term and proterm infants. Child Development, 56, 15-27.

Longuet-Higgins, H. (1982). The perception of musical rhythms. Perception, 11, 115-128.

Mindell, A. (1989). Coma: Key to awakening. Boston: Shambala. Moore-Ede, M. C., Czeisler, C. A., & Richardson, G. S.

(1983). Circadian timekeeping in health and disease. New England Journal of Medicine, 309, 469479.

Needleman, J. (1988). A sense of the cosmos. New York: Arkana. Nordoff, P., & Robbins, C. (1977). Creative music therapy. New

York: John Day. Povel, D. (1984). A theoretical framework for rhythm percep-

tion. Psychological Research, 45, 3 15-337. Reinberg, A., & Halberg, F. (1971). Circadian chronopharma-

cology. Annual Review of Pharmacology, II, 455-492. Rozzano, G., & Locsin, R. (1981). The effect of music on the

pain of selected post operative patients. Journal of Advanced Nursing, 6, 19-25.

Sacks, 0. (1986). The man who mistook his wife for a hat. Lon- don: Pan.

Safranek, M., Kosbland, G. & Raymond, G. (1982). Effect of auditory rhythm on music activity. Physical Therapy, 62, 161-168.

Sandman, C. (1984a). Afferent influences on the cortical evoked response. In M. Coles, J. Jennings, & J. Stem (Ed%), Psy- chophysiological perspectives: Festschrif for Beatrice and John Lacey. Stroudberg, PA: Hutchinson & Ross.

Sandman, C. (1984b). Augmentation of the auditory event related to potentials of the brain during diastole. Znternational Jour- nal of Physiology, 2, 11 l-l 19.

Sandman, C. (1986). Circulation as consciousness. The Behav- ioural and Brain Sciences, 9, 303-304.

Steedman, M. (1977). The perception of musical rhythm and metre. Perception, 6, 555-569.

Ulrich, R. (1984). View through a window may infhtence recov- ery from surgery. Science, 224, 420-421.