Music therapy and inflammatory bowel disease

The Arfs in Psychotherapy. Vol. 18, pp. 113-121. 0 Pergamon Press plc, 1991. Printed m the U.S.A. 0197-4556191 $3.00 + .OO

MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE

DAVID ALDRIDGE, PhD and GUDRUN BRANDT, Dipl. MT*

This paper presents two comparative views of inflammatory bowel disease. One is from the general medical literature; the other is that of a music therapist who has played extensively with patients who have the disease. The music therapist was unaware of the medical descriptions of the disease when she made her descriptions of the musical improvised playing of such patients. It is apparent from both sets of descriptions that they have elements in common such that a dialogue can occur between medical practitioners and arts therapists. Some implications for the treatment of patients with inflammatory bowel disease are also discussed.

Inflammatory Bowel Disease

Inflammatory bowel disease is a term that refers to a collection of diseases affecting the bowel. These diseases are characterized by the presence of chronic inflammation of the gastrointestinal tract that cannot be ascribed to any specific cause. The most common of these maladies are ulcerative colitis and Crohn’s disease. Both have a common insidious onset resulting in chronic symptoms that may include severe episodic diarrhea, colicky abdominal pain, weight loss, nausea and vomiting, and pus, blood or mucus in the stool.

Although there are common symptoms in inflammatory bowel disease, Crohn’s is distinguished from others because it generally affects the terminal ileum and the right colon, sometimes the whole bowel (Call&s & Mendeloff, 1986), but rarely the entire digestive tract although it can affect any part of the alimentary canal (Strober & James, 1986). Ulcerative

colitis always affects the rectum and sometimes the entire colon.

These are not generally highly fatal diseases, but they are important for public health concerns in that their incidence is early in life, therapy often involves surgery, there is a risk of developing intestinal cancer in later life, and there are enormous social costs involved in chronic illness (Sanderson, 1986). These ailments cause great personal embarrassment and discomfort for the patient, often resulting in a restricted lifestyle and a miserable existence (Robert- son, Ray, Diamond&Edwards, 1989). Any therapeutic endeavors must attend to enhancing the life quality of the patient.

Epidemiological Factors

The etiology and pathogenesis of both ulcerative colitis and Crohn’s have not yet been clarified. Diagnosis is difficult. A significant time may elapse between the onset of first symptoms and a definite diagnosis. As the diseases share similar symptoms, diagnosis is problematic (Bruce, 1986; Shivananda et al., 1987). The incidence of ulcerative colitis appears to be more frequent in modem Western society and is increasing (Calkins & Mendeloff, 1986).

The primary age ranges for the incidence of inflammatory bowel in both sexes are between 15 to 25 years and between 55 to 60 years (Calkins & Mendeloff, 1986; Shivananda et al., 1987). Children under six years of age appear to be resistant to the development of Crohn’s; between the ages of 6 to 10 years ulcerative colitis, but not Crohn’s, occurs with increasing frequency.

*David Aldridge is a research consultant to the medical faculty of Universitat Witten Herdecke, West Germany. Gudrun Brandt is a music therapist.

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114 ALDRIDGE AND BRANDT

There is an increased frequency of inflammatory bowel in families of patients who suffer from it, with a mixture of both Crohn’s and ulcerative colitis. This has suggested that there may be a genetic basis for the disease (Sanderson. 1986; Strober & James, 1986) although this genetic base remains as yet undiscov- ered. Such diseases may be inherited as behaviors that are learned in family contexts and passed on from generation to generation.

Diet

Because of the nature of the malady, dietary intake has been considered one of the most important envi- ronmental exposure factors of the digestive system. Among patients with Crohn’s, one possible causative factor is increased sugar consumption. Dietary fiber. increased milk products. carbohydrate, protein, and total calorie consumption have also been implicated (Persson & Hellers, 1987).

The studies have proved to be problematic because dietary exposure may have occurred many years prior to the diagnosis, or the prolonged onset of the disease may lead to the alteration of dietary practice. For example, patients may increase their consumption of refined sugar in an attempt to compensate for loss of energy or loss of weight as a consequence of the disease.

Liquid elemental diets developed for the space programs in the United States have been used for the treatment of Crohn’s. Although the efficacy of such a diet is not known (Sanderson, 1986), the results are shown to be as helpful as high dose steroids for the remission of small bowel Crohn’s in children. Chil- dren treated in this way experience an acceleration of growth.

The use of nutritional supplements may have a small role to play in helping extremely sick children to obtain some calories, but this approach is seen as beneficial only in the short term (Clark, 1986). Patient enthusiasm for the diet wanes in the long term because it is unpalatable. Bruce (1986) also com- mented that an elemental diet worsens the difficulties of young people with the disease by placing them in a regressed position that allows the mother to exercise absolute control as she did when they were infants.

What is lacking in dietary studies is a perspective that it is not necessarily the content of the food that is important but the way it is eaten, the situation in which it is eaten, and the conditions in which it is

digested. The preparation of food, the way it is eaten, and the way that waste products are disposed of are also closely patterned by culture. The offer of food and its acceptance are also of great symbolic value (Helman, 1985; Kleinman, 1978).

Immunological Factors

As it has been difficult to establish an infectious cause for inflammatory bowel disease. some researchers have sought an immunological basis (Kett, Rog- num & Brandzaeg, 1987; Strober & James, 1986: Trabucchi. Mukenge, Barrati, Colombo & Fregoni, 1986; Van Spreuuwel, Lindeman & Meijer, 1986). Crohn’s disease begins as the product of an underlying inflammatory process. The presence of increased numbers of macrophages and mast cells appears to be an important feature. The specific physiologic function of mast cells remains unknown, but they are known to contain inflammatory mediators, such as histamine, and may play a role in allergic reactions. Although a pathogen has not been found, somehow patients become sensitive to the constituents of their own gut flora, which has widespread negative effects on the entire immune system. Patients react negatively to their own body, a rejection of a part of their very own self.

Modem researchers have taken the old idea that emotions influence the health status of people and have developed the sciences of psychoneuroimmunol- ogy - the study of the effects of psychological factors on the immune system (Baker, 1987; Blalock & Smith, 1985), and of neuroimmodulation - the study of the mechanisms whereby the nervous system modulates the activity of the immune system (Baker, 1987; Stein, Keller & Schleifer, 1985: Trabucchi et al., 1986). Emotions influence health status as distur- bances to the immune system by specific interactions between the nervous system, immune and endocrine systems. This suble combination of physiological mechanisms is designed to recognize and deal with nonself or altered material. What is self and nonself are crucial decisions isomorphic with the physiology and psychology of the persons and the family with whom they dwell.

Chronic stress has also been shown to alter the immune system (Baker, 1987; Patterson, 1988; Stein et al., 1985) and thereby recovery. Immunological descriptions of inflammatory bowel disease also sug- gest a similar process, a transient infection provoking

MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE 115

an immune response that is exacerbated by psychological factors. Strikingly, patients with bowel disease often attribute the onset of their disease to a stressful event (Robertson et al., 1989). This is literally a gut reaction to a significant life event.

Psychological Factors

There is a long history of associating somatic symptoms and emotional disturbance. If inflammatory bowel disease is, as some researchers believe, a motility disorder of the gut, then that motility is sensitive to the emotional state of the person. Highly anxious patients may produce symptoms at times of emotional distress (Lask, 1986).

Although psychiatric illness and psychopathology are not more prevalent in patients with inflammatory bowel disease (Clouse & Alpers, 1986), there does appear to be some evidence of depression in patients with Crohn’s (Tarter, Switala, Carra & Edwards, 1987) but this appears to occur only in those with persistent disease activity (Robertson et al., 1989). High levels of neuroticism (a score of more than 12 on the Eysenck Personality Inventory) are associated with these patients and they become more introverted as the disease progresses (Robertson et al., 1989).

The search for causative psychological factors has been in vain principally because of the insidious onset of the disease. Although most researchers accept that psychological difficulties are sequelae of the disease and that stress and emotional difficulties exacerbate it, no factors appear to be causative. Traditionally, ulcerative colitis has been regarded as a psychosomatic illness. Psychoanalysis has taken the view that such illness has its origins in the mental mechanisms used to cope with the emotions. From this perspective, the disease represents a reaction to a real or threatened loss of the mother, or someone else on whom the patient is dependent. Ulcerative colitis patients are seen as rigid, controlling, and dependent. Recent psychoanalytic approaches have observed that inflammatory bowel disease patients have a tendency to somatize their problems, and that they have difficulty in expressing emotions verbally (Bruce, 1986; Stanwyck & Arnson, 1986). This state is termed “alexithymia.” To spare themselves emotional pain, these patients project those problems into bodily functioning. Hence, the situation in which some patients with bowel disease appear to be coping well with difficult life situations.

There appears to be a clearer link in children between abdominal pain and emotional upset (Bruce, 1986). Abdominal pain is common in children, and the gut appears to mirror the emotions better than any other body system. Furthermore, clinicians working with children with bowel disease remark that abdominal pain appears to be a common occurrence in the repertoire of distress management in the families of those children (Bruce, 1986; Lask, 1986). There appears to be a vicious circle where the physical symptoms of the disease lead to stress and behavioral problems. These problems then provoke physical symptoms and aggravate pre-existing organic pathology. The children and the family are affected. If the family cannot cope, and there is a family repertoire of distress management by an escalation of physical symptoms, then the symptoms of the children are exacerbated further.

Lifestyle Factors and the Patient’s View

Patients with inflammatory bowel disease have been described in the literature in a negative and limited way. They are seen as dependent, restricted in their relationships, sexually and emotionally inade- quate, depressed, isolated, demanding, angry, and lacking in self-confidence (Joachim & Milne, 1987). A lack of self-confidence is hardly surprising given that there is such a negative perception of their patients by practitioners, combined with the difficulties of the disease itself. A number of researchers have attempted to present patients’ views of the problem. As both a nurse and a sufferer, Neufeldt (1987) wrote that the most difficult part of the disease is its unpredictability, and that the symptoms themselves frequently cause depression. The bouts of nausea, vomiting, and diarrhea lead to loss of sleep, listlessness, and nutritional deficiencies. This combination of embarrassing symptoms, and the random- ness of onset of those symptoms, is socially disruptive for the working life and home life of the patient.

Joachim and Milne (1987) investigated the impact of inflammatory bowel disease on the lifestyle of patients. These patients said that, overall, their disease greatly decreased their satisfaction with life. Yet, paradoxically, they reported minimal influence on a day to day basis. This appears to represent the observation frequently made by clinicians that these patients appear unwilling to complain about specific problems, or they deny that problems exist in the face


of evident personal and relational turmoil. In an attempt to understand the relationships be-

tween biological, psychological, and social phenom- ena, Helman (1985) examined the self-perceptions and explanatory models of patients with ulcerative colitis. He found that most patients had a multi-causal holistic model of their disorder. Tension, anger, frustration, stress and uncertainty were seen as attack- ing the body and were separate from the self. Simi- larly, when their own personalities were seen as contributory to the chronicity of their condition, that personality was seen as separate from the self. These causal attributes, he argued, are learned from various medical encounters and are part of the culture. This notion of nonself was also applied to organs of the body. Weakness in an organ could be hereditary, constitutional, or acquired. Somehow the weak organ was separate from the self, but responsive to interactions with other people. The disease or organ then becomes a public interface between the self and the environment and is responsive to outside forces separate from the inside self.

In Helman’s view (1985), the image a person has of the disease is a natural symbol whereby the physiological process of the disease is understood:

. . . the symbol organizes both social and emotional experiences, and helps define certain emotions. thoughts, personality traits, and parts of the body as either ‘self’ or ‘non-self’. Defining some of these as ‘non-self’ can bring the patient’s self image closer to the normative order of contemporary life - to social values of independence, fitness, youthfulness, con- tentment and social success and control the bodily functions and emotions. (p. 1.5)

Not only does this image that persons have affect their physiological state, this image may also affect the way that they perceive, and are perceived by, members of their family (Aldridge, 1990~).

Family Perspective

A family systems perspective of bowel disorder emphasizes that the functions of the gut, the patient, the family, and the treatment system evolve together (Bloch, 1987; Stierlin, 1989). In this view, the process of chronic illness begins by a random dis- equilibrating event. This could be a transient infection or a stressful life situation. Pain ensues. This event occurs in the context of a relationship. The patient has

a family, and the event is given meaning by the patient and the family. We know that some viruses do not kill the host cell, but transform it so that it has an altered function, particularly in terms of immunocompetence (Bloch, 1987).

A similar situation occurs in the family context where a disease event is handled in a particular way (Aldridge, 1990~). Experiences surrounding gut pain are organized around a set of beliefs about what the cause of the pain is, what it means, and how it is to be handled (i.e., a repertoire of distress management). Not only do the patient and the family of the patient share similar meanings about an illness, and what counts as disease, they also share a similar immune context. In this way, a random event such as an infection may find that its host is not only the patient but the immunocompetence and beliefs of the family milieu.

Approaches to Treatment

It appears that inflammatory bowel disease is best approached from an holistic perspective that inte- grates different understandings. Although surgical interventions will still be necessary, it is important to remember that the sequelae of surgery are not only physical. Surgery can be traumatic, leaving the patient with a sense of anger, resentment, feeling both anxious and depressed, and having to adapt to a new lifestyle. These psychological and social consequences may best be handled by a team approach that includes people who comprehend the day to day living situation of patients within their relational setting.

Lask (1986) and Bruce (1986), in their work with children, approach their treatment from such a family systems perspective and recommend the use of a physician, surgeon, psychologist, social worker, nurse, and stoma therapist. Stress management techniques can be used to reduce anxiety and communication skills, whereas psychotherapeutic activities can be used to control excessive worry (Freyberger, Ktins- beck, Lempa, Wellman & Avenarius, 1985; Milne et al., 1986; Svedlund, Sjodin, Ottosson, & Dotevall, 1983).

A feature common to many reports about the treatment of inflammatory bowel disease is that it is intractable to therapeutic endeavors. Furthermore, the patients themselves are described quite negatively, which may be in part because of their inability to communicate in verbal terms about their emotional


distress. What is often ignored is that the communication medium for these patients is essentially nonverbal. Symptoms are the forms of communication that symbolize the distress of these patients. For practitioners dependent primarily on forms of communication that are predominantly verbal there is a disparity between modes of communication.

Implications for Music Therapy

There are no psychological factors that are necessary or sufficient to cause intestinal disease in suscep- tible individuals. However, it is clear that there are certain psychological or social factors that can either influence the course of the disease or provide a context for the disease to develop. The presence of beliefs about self and nonself appear to be fundamen- tal in these patients, linking immunocompetence, individual psychology, and familial status.

Although psychological factors may not be causal, they are important for recovery. Therapeutic endeavors may be better directed to actively stimulating the immunocompetence of the patient. If the mind does influence the immune system, there is a battery of therapeutic interventions available. As the main mode of communication about distress for patients with the bowel disorder is nonverbal, then nonverbal therapies appear to be an esstential part of a coordinated therapeutic approach.

Music therapy stimulates positive emotions, en- hances coping responses, is isomorphic with the form of physiological systems (Aldridge, 1989, 1990b, in press b) and appears to be an ideal therapeutic medium. The motility of the gut is rhythmic and it seems reasonable that music therapy could restore, or promote, rhythmic flexibility. Similarly, the pro- cesses of the immune system too are rhythmic in their ultradian cycle. Music may provide the substrate for entraining various physiological sub-systems. Essen- tially music can “tune” the communicational context that unites the central and peripheral nervous systems and the immune system.

It has been shown that positive experiences, such as laughter when incorporated into a coping style, have a beneficial influence on the immune system (Dillon & Baker, 1985). If this is true of laughter, we may expect that the greater range of positive experiences available in creatively playing music, if incorporated as a coping style, will have a healing effect via the immune system. Note that the word “incor-

porated” literally means taken into the body. It may also be necessary for clinicians from other disciplines to communicate with their patients nonverbally if symptomatology is the currency of communication (Aldridge, 1990b).

Finally, we must attend to the symbolic aspects of the disease for these patients so that they are no longer separated from the self that feeds them. In this sense, the playing of improvised music gives the disease itself an objective appearance as a played reality. Patients are then offered a chance to change in the concrete sensual realm of their own existence.

The Musical Playing of Patients With Bowel Disease

Our task has been to build bridges between the work of medical practitioners and creative arts therapists (Aldridge, in press a, 1990a; Aldridge, Brandt & Wohler, 1990). One way to promote a dialogue between practitioners is to compare differing realms of description. In the following sections we compare the features of the improvised musical playing of patients with the features we find in the medical literature.

Fourteen adult patients with ulcerative colitis, and 12 adult patients with Crohn’s disease were seen over a period of two years. The average number of weekly sessions was seven per patient and each therapeutic contact lasted for half an hour. It must be emphasized that this research is descriptive and in the first stages of exploration. The significant factor is not the number of patients but the characteristics of playing of those patients (i.e., playing with more patients would have yielded no more characteristics) and how those characteristics compare with descriptions from another discipline - medicine. All the sessions are recorded on audiotape and later indexed.

The method of therapy used is one of creative musical improvisation initiated by Nordoff and Rob- bins (1977) but adapted later at the University of Witten Herdecke for working adult patients. The music therapist plays the piano improvising with the patient, who uses a range of instruments. This work often begins with an exploratory session using rhythmic instruments, in particular the drum and cymbal, progressing to the use of rhythmic/melodic instruments such as the chime bars, glockenspiel, or xylophone, developing into work with melodic instruments (including the piano), and the voice. In this


way of working, the emphasis is on musical improvisation and music as the vehicle for the therapy.

Ulcerative Colitis

A prominent feature of the way these patients play is that they appear to have no personal connection with what they are playing. They appear to play with a distance from what they are playing. This distance is evident in their posture. When they are strong enough to stand, their posture is often such that both feet are not firmly on the ground (i.e.. their legs are crossed). The drumsticks are held loosely in the hands with the inner wrist uppermost, and they play from the wrists without involving the whole body. This seemingly uncommitted posture makes it difficult to play a clear beat on the drum. When the drum is beaten, the beats are loose. The patient allows the beater to fall and rebound rather than make a directed intended beating movement. A characteristic of the drum playing is that these patients play with alternate hands (right, left, right, left) and they seem to have difficulty in coordinated playing using both hands together.

Rhythmic playing. This lack of coordination is reflected in patients’ rhythmic playing. which has a limited range and often occurs as typical rhythmic patterns:

J ~7 J Jl J XJ J fl J fj continuously; or

JJTJJJLIJJJJTJ continuously

This rhythmic playing does not follow the natural accenting, but is syncopated. Often the playing is on the upbeat before the bar starts, and begins with a small drum roll giving the music a military air. The playing itself goes on and on without any rhythmic phrasing. This lack of flexibility is reflected in the tempo of the musical playing where the patients constantly attempt to return to a fast tempo.

Harmony. Generally, there is an intolerance by the patient for strong harmonies in the piano playing of the therapist and contact becomes lost, particularly when diminished minor, fifth, or augmented chords are played. This intolerance is indicative of an emotional distance between the patients and the music particularly when there is an increase in musical tension. For example, they stop playing before a musical climax is achieved.

Melody. In the construction of melodies, these

patients are flexible and full of imagination. How- ever, this has a mechanical quality as if the playing were an intellectual exercise and never really gripped the patient internally. Although able to construct and copy melodies, there is an inability to sustain a melody. This gives the impression that the same music could go on and on repetitively without any direction to it, and without the patients taking any initiatives, as if they were passive participants in an unrelenting process. This also appears to be a suitable description for the process of chronic disease.

Crohrl ‘s Disease

These patients appear very stiff in their upper body movements. They too have difficulties in coordination and mostly alternate between left and right handed playing on the drum.

Rhythmic playing. Because of the coordination difficulties, these patients’ playing often sounds like a gallop. Similarly the rhythmic structure is disordered and gives the impression of going on and on without end. As with ulcerative colitis patients, there seems to be no means of initiating an end to this repetitive music and consequently they appear to avoid coming into contact with the music. This is also reflected in their inability to respond to tempo changes, giving the musical playing a quality of immovability.

Harmony. When using specific harmonies, notably the sixth and diminished chords, their response is one of vulnerability. Sometimes they cry; sometimes they stop playing altogether, walking away from the instruments, or they continue to play indifferently and mechanically with even less contact to the music.

Melody. The melodic playing on the xylophone or glockenspiel is rhythmically quick, unsustained, and has no internal logic. The intervals between tones are chaotic (i.e., wide then narrow). This melodic playing, similar to that of the colitis patients, is generally quiet. There is an overall feeling of emotional distance in their playing and they give the impression that they are totally at the mercy of the situation.

Overall, Crohn’s and ulcerative colitis patients have a similar lack of dynamic to their playing, which is limited and rigid - a feature that is reflected in the activity of their gut.

Process of Therapy

Generally, these diseased patients require many sessions before any improvement is apparent. The

MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE 119

Table 1

Comparative elements of two therapeutic epistemologies

descriptive elements from the medical literature

elements of the musical playing

l separation of self and nonself l lack of gut motility

l increasingly introverted 0 restricted in their relationships

l rigid

l difficulty expressing feelings 0 appear to be coping well with life in the face of internal

turmoil

0 dependent

l Intractable to change

0 not tuned to themselves, uncoordinated

0 lack of rhythmic flexibility, unresponsive to tempo changes

and lack of rhythmical phrasing

l quret playing with no personal contact within the playing

l difficult to contact in the musical relationship

l repetttive playing returnmg to the same tempo and

rhythmtc pattern, unresponsive to tempo changes

l intolerant of particular harmomes

0 appear to be going along with the music but an underlying

chaotic structure

0 no initiatives wtthm the music and dependent on the therapist

0 difficult to treat requiring many sesstons

coordination problems finally disappear and there is more stability and control of the hands. The rhythmic playing becomes more definitive and there is an apparent form to the phrasing and tempo. Overall, there is less rigidity in the playing and the patients appear to sense the bigger musical form in which they are playing. However, what remains is the impression that they never really come to grips with the music and that they still play with an empty passivity as if they were not tuned to their own bodies. Finally, the musical give and take in the therapeutic relationship is difficult and they appear isolated from their musical partner, the therapist.

Conclusion

There are correlations between findings in the literature that describe patients with inflammatory bowel disease and their musical playing (see Table 1). Although the patients say that they have fun playing, there remains an underlying intractable emotional distance within the playing and within the therapeutic relationship. Any therapeutic endeavors with these patients must take into account their personal and relational difficulties, which suggests that an early psychotherapeutic contact be made in the process of treatment. This reinforces the idea of a team approach to chronic problems and emphasizes the value of the art therapies both for providing relief and for their

impact on life quality in the face of a disease intractable to modem medicine.

Furthermore, the apparent correlation between descriptive elements found in the literature and in the work of the music therapist, initially blind to the content of the medical literature, suggests that a common language between practitioners is not such a fanciful idea. A common language is achievable in reality if confined initially to simple observations at the level of description or usage (Aldridge et al., 1990). Although the two perspectives share common descriptions, the creative arts have the possibility not only for the description of pathology but to play with what is seen as a limitation, and use it as a possibility for change.

Recommendations for Further Research

Apart from securing a basis for clinical discussion, these descriptions are the basis for futher research. They provide the concepts from which hypotheses can be generated (Aldridge, 1988, 1990a). It should be possible for music therapists from other institutions and backgrounds to play with patients suffering from inflammatory bowel disease and discern similar characteristics of playing. Similar findings, or the rejection of what we have found, will be a significant move in establishing a clincal validity for music therapy concepts.


Eisler, Szmulker and Dare (1985) found that clinical descriptions were not subjective and could be used by family therapists of differing schools to discriminate between differing family styles of behav- ior recorded on videotape. It should be within the compass of music therapists from other schools to discern whether or not there are similar characteristics in the playing of these patients recorded on audiotape. It may also be possible for other creative arts therapists to find comparative elements that show similar- ity with these descriptions.

The playing characteristics of this group of patients need to be compared with the playing characteristics of another groun of natients with a differing chronic

common language among the creative art therapies. The Arts in Psychotherapy, 17(3), 189-195.

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It seems a given that psychological factors influence the immune system. We can hypothesize that the

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Music therapy and inflammatory bowel disease

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