Music therapy research II: Research methods suitable for music therapy

The Arts in Psychotherapy, Vol. 20, pp. 117-13 1, 1993 Printed in the USA. All rights reserved.

0197-4556193 $6.00 + .OO Copyright 0 1993 Pergamon Press Ltd.

MUSIC THERAPY RESEARCH II: RESEARCH METHODS SUITABLE FOR

MUSIC THERAPY

DAVID ALDRIDGE, PhD*

Medical investigations into music therapy are generally poor methodologically. Much valuable data, particularly in the field of music therapy research in psychiatry, are wasted for want of an acceptable methodology. This lack highlights the difficulties in researching the arts therapies, where artists are often coerced into using the language and methods of science.

The axis of judgment of “health-illness” belongs to the world of medicine, and music therapy must not necessarily restrict itself to such a world view. The parameters for music therapy assessment must include those of music itself (Aigen, 1991). That music therapy is intended to have an effect in the context of clinical practice is evident, but the parameters of that effect and the way therapeutic change is described are made from an epistemology different from that of modem scientific medicine. What we are challenged to ask of our therapeutic endeavors is, “What meaningful change occurs for patients and their families, and for the clinicians and therapists involved” and “How can this change be expressed and recognized”? Thus, the ascription of meaning also becomes a central issue in any research methodology applied to understanding health and illness.

Making Sense: The Pursuit of Meaning in Researching Therapeutic Realities

And if you ask me for a recipe for speeding up this process, I would say first that we ought to

accept this dual nature of scientific thought and be willing to value the way in which the two processes work together to give us advances in understanding the world. (Bateson, 1941, p. 67)

Gregory Bateson was a leading thinker in the development of systems theory. He proposed the term “ecology of mind” as a way of thinking about the ecology of ideas that bring about meaning (Bateson, 1972, 1978). What we need in clinical research is to facilitate the emergence of a discipline that seeks to discover what media are available for expressing this ecology of ideas, which we see as a person and with which we engage as a therapist or researcher to dis- cern the meaning of change. These media may be as much artistic as they are scientific, thereby emphasizing the art of healing in parallel with the science of healing.

The function of art is to acquaint persons with something they have not known before (Langer, 1953). It is this acquaintance with the unknown that lies at the heart of illness. For the doctor or therapist, there is the anxiety of facing death and “failure.” This acquaintance with the unknown operates for the subject and researcher, therapist and patient. Con- sciousness becomes not a matter of “I think that,” but a matter of “I can,” not necessarily a spoken word, but a creative act. By working in this way, we can be relieved of the tyranny of words and their imposed structure, and free to work dynamically. This “I can” is the important element of intentional-

*David Aldridge, a research consultant to the medical faculty of Universitlt Witten Herdecke, Germany, is also European Editor of The Arts in Psychotherapy.

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ity, which cannot be measured but can be heard, seen and demonstrated. To work in this way is to consider aesthetics, the essentials of pattern and form as expressed. For a research methodology in the creative arts we cannot always revert to the questionnaire and the standard medical test. What we are challenged to develop is a way of presenting the work of art itself as it appears in the context of therapy.

Art and Science

Research from this standpoint of aesthetics is clearly not science in that it has no generalizable reference. The importance of such work is in its particular subjective and unconventional reference. Both art and science bring an appreciation of form and the expression of meaning. In expressive art, sensory qualities are liberated from their usual meaning. It is important to emphasize expressive forms when we wish to discover the quality of life. Sensual qualities become of vital import to the whole, not to be rated on a scale or filtered through the parameters of a ma- chine, but intrinsic to a gestalt. In this way of researching we are concerned with showing rather than saying.

Meaning

When studying human behavior we must look at the context of which that behavior is part, and the closely related phenomenon of the meaning of that behavior. When we explain meaning we are mapping data on to what are already fundamental elements of our knowledge. However, the ultimate aim of what we are doing is to increase this fundamental knowledge. The question we have to ask is “What are the fundamental elements of knowledge (i.e., the ecology of ideas) that are being used at this time”? Further, the symptoms displayed by the patient also exist. These represent another ecology of ideas and are often interpreted from the view of the therapist rather than the patient. However, another way exists-to allow the patient, or the subject of the research, to create a work of art with the therapist. The purpose of creation in this act is to make something known. What is made known can be interpreted on the basis of given fun- damentals, but also exists as a new experience in and for itself.

In our relationships we continually exchange information about unconscious processes. We tell each

other what order of consciousness/unconsciousness attaches to our messages. Art is a form of behavior that perfects communication about how to handle unconscious material. In addition, art has the ability to express that we are dealing with the interface between unconscious and conscious material. Consciousness talks about things or persons and attaches predicates to the specific things or persons that have been mentioned. In unconscious process the emphasis is on the relationship between elements; that is, it is metaphoric. It is concerned with the self-other-self envi- ronment, about patterns of relationship, sometimes called feelings, and is the outward sign of a precise, often hidden, relationship.

Although these processes are difficult to examine verbally or consciously, it is possible to express them artistically and musically. The skill of the artist, or rather the demonstration of his or her skill, becomes a message about those parts of their unconscious, but NOT a message from the unconscious. Our challenge then is always to provide a vehicle for the expression and articulation of that which lies hidden.

The Corrective Nature of Art

Consciousness is necessarily selective and partial about the self. The total mind is an integrated network of propositions, images, processes, neural path- ways-and consciousness is only a sampling of this network.

From a paper originally presented in 1967, Bate- son (1978) wrote:

The point, however, which I am trying to make in this paper is not an attack on medical science but a demonstration of an inevitable fact: that mere purposive rationality unaided by such phenomena as art, religion, dream and the like, is necessarily pathogenic and destructive of life; and that its virulence springs specifically from the circumstance that life depends upon inter- locking circuits of contingency, while consciousness can only see such short arcs of such circuits as human purpose may direct. (p. 118)

Art then poses a question, “What sorts of correction in the direction of wisdom would be achieved by cre- ating or viewing this work of art”? Ironically, a sci- entist of Bateson’s stature found it necessary even some 35 years ago to clarify that he was not attacking medical science. It is tempting to wonder what it is

MUSIC THERAPY RESEARCH

about medical science that is so weak that we must protect it so. Perhaps it only reflects our own hidden desires for certainty.

Pattern and Relationship

Art, from a Batesonian perspective, requires skill and pattern. It is probably an error, Bateson wrote, to think of

. . . . dream, myth and art as being any one matter other than relationship. . . Dream is metaphoric, and is not necessarily about the relata mentioned in the dream. In conventional interpretation, another set of relata, often sexual, is substituted for the set in the dream. There is no a priori reason for supposing that sexual relata are any more primary or basic than any other set. (1978, p. 123)

Rigid focusing upon a single set of relata destroys for the artist the more profound significance of the work. It is about the relationship and not about the identifiable relata. The artwork provides an experience that exposes errors in experience where one pole is chosen rather than another, because poles are mu- tually dependent.

It is important then to consider relationships first, and the relata as defined solely by their relationship. Bateson cited Goethe as setting an example of thinking about relata. A leaf, in this way of thinking, is not a flat green thing but “related in a particular way to the stem (which itself is not a “cylindrical thing”) from which it grows and the secondary stem (or bud) which is formed in the angle between the leaf and the primary stem” (Bateson, 1972, p. 26). We must look for an analogy between living things in the grammar of their structure, the relationship between their parts, as a classification of relationship.

Analogic and Symbolic Language

Works of art do not point out the meaning directly; they demonstrate it by recreating pattern in metaphor- ical shape or form. In this way symptoms are an an- alogical symbolic communication. When symptoms are accepted as a form of expression and part of a living ecology, then there is no pathology. Pathology is the observer’s prejudice. What we see is indicative. This changes the sign applied to behavior from that of “deviant” to “accepted.”

From a modem scientific stance, the body is to be

manipulated according to the processes of classification and normalization. People are observed, classi- fied and analyzed as “cases” in relation to their deviance from a given norm. Disease becomes a cate- gory like any other rather than the unique experience it is. Merleau-Ponty (1968) called this the “second positivity” (i.e., a normal human body against which any particular body can be measured). The dangers of this comparison are that the particular human being is then alienated from his or her body and his or her individuality. Furthermore, the epistemology of this normative process is that of natural science, which emphasizes reason, constancy and predictability. In the face of death and disruption, the imperative of health is to maintain continuity and control. Yet, predictability and control are based on an ideal of con- servatism. It is a philosophical assumption that what is here today will give ground to further instances tomorrow. There is no logical necessity that will safe- guard our passage from past and present to future experiences.

A Descriptive Method

We can encourage people to creatively express the passage of their lives not only as patients in the hospital, but in their daily living at home and at work. It is possible to have a descriptive science of human behavior that can be based upon the aesthetic. In this way we can ask of our research that it expresses what it is to be human, what it is to be well and what it is to fall sick.

The advantage of the creative arts is that they allow us not only to express our pathologies, but they also allow the expression of potential. This tension between what we have become and what we are becom- ing can be reconciled within the context of the aesthetic as a created form. How we document this progress of those who come into our care, or those with whom we choose to journey, may be better expressed in works of art that are realized in the process of living, and that bear the imprint of our sensuality and intuition rather than our rationality and technology.

Methods in music therapy will concentrate on comparing and analyzing expressed form. Thus, we can compare accounts from the medical literature, parameters of musical playing, expressed form as photographs and paintings and drawings, and statements from patients as diaries or journals or videotaped episodes of conversation, to discover corre- spondences between medical description, aesthetic

120 DAVID ALDRIDGE

expressions and patients’ perceptions. This will entail a search for the grammar of underlying structures as the commonality in understanding human beings; that is, that we can classify change according to the relationships between parts, and that these relationships may be based upon particular rules of constitution and regulation.

However, music therapy research cannot be based solely on aesthetic changes. Music therapy is located in the context of the clinical practice of medicine and psychotherapy. Bridges must be built so that clinical change can be recognized by clinical practitioners in medicine and the arts. Single-case studies incorporating elements of both medical assessment and musical assessment can be an effective compromise allowing for both individual treatment initiatives and consider- ation of scientific medicine. Small group trials can then be designed from understandings gleaned in the single-case investigations, which will elicit those parameters that are subject to measure and assessment. LongitudinaI studies, involving compared groups or matched controls, may be feasible at a later stage for comparing chronic problems that are either resistant to change or subject to long-term change.

Any research methods must allow for a follow up period and compare previous clinical changes with those found at follow up. Furthermore, most of the previous research published in the medical literature indicates, albeit indirectly, changes in the quality of life in patients and subsequent changes in depression. Music therapy studies can easily incorporate in assessment methods indicators of life quality changes and changes in depression using well validated clinical measures based on patient report, which would serve as a common preliminary base for clinical comparisons.

Methodological Difficulties in Music Therapy Research

Many practicing creative arts therapists are wary of methodological suggestions from non-arts therapists, because those suggestions are often seen as unsuited to their work. Suggestions from psychologists and medical researchers are often considered as attempts to move the therapists away from the creative- therapeutic experience, which interests them, and im- pose a restrictive alien structure on the research using a language developed from an altogether different epistemology, often manipulating patients as subjects in a way that arts therapists find intolerable.

It is possible to find a way of working that satisfies creative arts therapists, but this takes time (Aldridge, 1990). The advantage of developing a methodology with the therapists themselves is that the results of that work are seen as valid within the working group, and that research itself is used to promote further studies. These studies themselves begin to identify weak- nesses in previous research initiatives so that the therapists include those elements of rigor that are pertinent. Developing research methods in music therapy, for example, is a process of education, the epistemology, agenda and timing of which are negotiated with, and decided by, the therapists. However, when we speak of rigor, it is important to emphasize that the rigor of scientific medicine will appear different to the rigor of social science, as it will to the rigor of aesthetic theory. Some medical scientists, when they speak of human clinical research, fail to see beyond their own methodology, mistaking method for knowledge, and become crippled by their own insecurity at not being able to tolerate ambiguity in ascertaining meaning. We see this reflected in the dilemma of working with two epistemologies-scientific as generalizable reference and a priori conventional, and the aesthetic as individual and a priori unconventional. A tolerance of both the scientific and the aesthetic is called for, with neither demanding predominance over the other, rather that each has something valuable to contribute as a facet of a greater unde~tanding (Aldridge, 1991a).

Creative arts therapists have criticized classical scientific research methods for failing to take into account several important features of arts therapists’ work (Tiipker, 1990). One such feature is that of reliability (i.e., that another researcher can use the same method of music therapy with a group of matched patients and obtain the same result). The reply from the creative arts therapists is that in their mental make up no two people are the same, and the same measure when applied to two or more people can rarely bring the same result. Music therapy is a transpersonal hap- pening and what happens cannot be separated from the person of the therapist. Two therapists can apply the same therapy with quite different results. Simi- larly, in therapeutic art forms-in which patients im- provise music, paint pictures, make movements-no two improvisations, pictures or movements will be wholly the same.

Moreover, it must be borne in mind that, in psy- chotherapeutic and creative arts approaches, people have histories and life stories that are taken into ac-


count and also considered as playing an important part in treatment considerations. It is not possible to re- produce the same situation that occurs in one person in another person. Every therapist must start with the person as he or she is according to their individual biography. Each work produced as art will develop out of this history and contribute to this history. Works of art taken out of the context of the patient (i.e., an individual being with a personal history located within relational and cultural contexts) lose their validity as phenomena.

It is almost im~ssible to seek out objective measures in creative arts therapies when subjective factors play such a predominant role. In the situation of im- provising music, it is impossible to separate out the influences of patient and therapist one from another. The improvisation is mutual. Attempts to objectify the process of therapy disturb the therapy so that it no longer represents that which is to be measured, thus counte~~ding any attempts at objectivity.

Assessment Methods

There is no “gold standard” (i.e., a universally agreed and validated measure) for assessment in music therapy. Because creative music therapy relies upon individual interpretations of each patient, assessment methods have tended to be idiosyncratic, relying upon both the theoretical persuasion of the therapist and his or her experience with a given theory, which becomes a personal interpretation of that theory. Bruscia (1988) has suggested a set of standards for music therapy research emphasizing that assessment attempts to understand a patient’s needs differing from treatment and evaluation in purpose. Treatment intends to produce change. Evaluation documents that change.

Music therapists emphasize that the basis of assessment should be musical parameters taken from their therapeutic epistemology, not those borrowed or imposed by medical science or psychology. Their work is NOT visual and spatial as most medical observations (i.e., the graph, the EEG trace, the meter reading). Their work is aural and temporal. This shift in emphasis between the two major elements of modem scientific thinking is a crucial point. Observe one and the other becomes less precise. Concentrate on physical spatial measures and time factors become elusive; focus on time factors and spatial precision is lacking. Whereas modem medicine provides a spatial understanding, music therapy offers a complementary

balancing understanding of persons as they exist in time.

Generally, we need a research approach that ac- cepts individuals as they are, in performance, and in attempts to discover correlations between what it is that patients expect of the therapeutic endeavor, what therapists expect of the therapeutic endeavor and how those expectations can be made evident when satis- fied. That the work of art-painted, drawn, played or acted-is sufficient in itself is only a partial truth once it is brought into the framework of therapeutic activity. Therapy implies an expected change; that a change has occurred and what has been instrumental in this change is the task of therapeutic research. Such assessments that change has occurred rely upon how varying phenomena are aggregated so that they have meaning. If a variety of descriptions are collected, then some commonality of understanding can be tested out.

Some suggested data sets for comparative research

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Musical playing parameters would be tempo, meter, rhythm, harmony, melody, voice timbre, fluency, articulation, dynamic, responsiveness and adaptability, phrasing and form. Physical parameters would include posture, movement, eye contact and relational proxim- ity, range of movements. Psychological parameters would be mood state, attention, confusion and attitude. Relational playing parameters would be initia- tive taking, potential for exchange within the therapeutic dialogue, avoidance of contact, continuity of the relationship. Journal descriptions by the patient on a daily basis, ~mi-st~ctured for content analysis. Art therapy parameters including drawing, painting and modelling where each “product” is photographed after every session to record changes in form. In addition, it could be possible to include videotapes of the process of modelling/painting/drawing. Body form as a standardized drawing. Medical clinical descriptions of the patient collected on a regular basis.

Concrete proposals for Music Therapy Research

In a companion paper it was suggested that music therapy research could best be achieved by combining

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several sets of data. To make such abstract suggestions concrete, there follow a series of research suggestions based on ideas gleaned from music therapists in clinical practice. When asked, music therapists working in a hospital setting (Aldridge & Verney, 1988) have stated areas of interest they wish to see researched.

and therapist. It is imperative that a form of assessment is developed suitable for assessing the improvised musical playing of adults.

Stage I: The Development of an Assessment Method Suitable for Improvised Music Therapy

Such a form of assessment will not be normative but generalizable; it will simply offer a schema by which musical parameters can be compared both within the patient (i.e., progress and change over time) and between patients. This schema will offer a systematic form of assessment that is consistent and can be communicated to others. Pavlicevic and Trevarthen (1989) have already demonstrated that music therapy assessments can be reliable. Eisler, Szmulker and Dare (1985) have demonstrated that clinical observations of families, previously viewed as descriptive, can be recognized and validated by other clinicians, even when those clinicians come from disparate training backgrounds. The parameters of such improvised playing would be those of music itself and that of communication in the therapeutic relationship.

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A method for assessing the improvised musical playing of adults, which is based upon phenomenology of what is heard in the playing according to the parameters of music therapy. The influence of aesthetics on health care and therapeutic epistemologies; culture, healing and language. A way of describing and expressing the relationship between music and the experience of the body in time and space. The use of music therapy as a treatment for disturbances in movement that appear as neurological phenomena. A study of music therapy in the treatment of Alzheimer’s disease. What can music therapy bring for those who are dying? Such work is related to the improvement of quality of life, and is related to the relationship between the person and his or her body and quality of life. A correlation between a child developmental scale and improvised musical playing.

A Method for Assessing the Improvised Musical Playing of Adults

Although each music therapist has developed an individual way of applying their particular therapy, which is adapted to meet the needs of each patient, the assessment of the music therapy sessions is based upon general musical parameters that are externally valid in the tradition of modem Western music. Music therapy practice also demands that each session is tape recorded and then later indexed according to specific musical parameters and according to parameters of musical relationship. This has been formulated in Nordoff and Robbins music therapy as a rating scale, although the scale itself has not been validated. The scale is criticized by Nordoff and Robbins music therapists as being unsuited for working with adult patients in that it is oriented toward deficits rather than latent possibilities, and does not take into account the more complex nature of the interaction between adult

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Musical playing parameters would be tempo, meter, rhythm, harmony, melody, voice timbre, fluency, articulation, dynamic, responsiveness and adaptability, phrasing and form. Physical parameters would include posture, movement, eye contact and relational proxim- ity . Psychological parameters would be mood state, attention, confusion and attitude. Relational playing parameters would be initia- tive taking within the music, potential for exchange within the musical dialogue, avoidance of musical contact, continuity of the musical relationship. Verbal descriptions by the patient of the session.

Such parameters could be assembled as a map, which is marked by the therapist for absence/presence of factors or by further definite criteria (e.g., phrasing can be subdivided as organized or disorganized, and further subdivided as related to breathing or related to motifs in the instrumental playing). This would require intensive developmental work from experienced therapists to establish the necessary criteria. Such a schema would also contain a section for free com- mentary by the therapist.

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Stage Two: The Validation of a Music Therapy Assessment Method

Videotapes of adult subjects playing in particular ways (i.e., according to clearly defined musical parameters) are recorded. Each videotape will last for 5 minutes. A series of statements are made about these patients according to the assessment method developed above, and a series of control statements at the same level of abstraction are also prepared. Observers (i.e., music therapists from the same background) are shown the videotapes and given a selection of statements from which they are asked to identify the true statements according to the original raters. Correla- tions between clinical raters and true statements/ controls are then calculated. If there is a high inter- relater reliability this experiment can then be repeated using the same videotaped examples and statements, but with music therapists from differing backgrounds. This will encourage an internal validity.

Stage Three: The Assessment of Adult Zmprovised Music Ptaying

This form of assessment can be applied to a broad range of adult therapy situations, including an assessment of improvised musical playing by adults who are nonsymptomatic and not in the context of therapy. Such assessment could be longitudinal and combined with diary techniques and art therapy assessment. Ide- ally, such work would be incorporated into a research project that attempts to understand “health” and “illness” in its expressive form. By analyzing narrative, documentary, musical and pictorial forms, we can develop a strategy for understanding the way in which people construe their own health-maintaining activities.

Stage Four: A Comparison of Music Therapy Change and Clinical Change

Once an assessment method is established, it will be possible to assess changes in the musical playing of patients and compare those with clinical change. This can be initially achieved in terms of single-case studies (Aldridge, 1991~; Barlow & Hersen, 1984; Kaz- din, 1982; Lindberg, 1988; Sandvik, 1988; Schroeder & Wildman, 1988; Sjoden, 1988; Wulff, 1988) and later extended to particular forms of group treatment. Such studies would include the patient groups suggested by the medical literature to benefit from music

therapy (e.g., patients with heart problems and patients with chronic pain) and depend upon carefully defined clinical variables.

Music therapy treatment periods, in single-case studies, could be compared with control periods using music listening or silence. Assessment would incorporate physiological measures, clinical assessment, quality of life, visual analogue scales and patient diaries, as well as music therapy and art therapy assessment. Small group crossover designs with randomized allocation and waiting list controls could be used for a secondary assessment of therapeutic efficacy based on a restricted range of clinical indicators and incorporating a period of clinical follow up when the appropriate criteria for clinical change are identified.

Stage Five: Cross-Cultural Studies

The uses of music as therapy in other world cultures have been ignored in the medical and music therapy literature, although not in the social sciences. It may be timely to consider the role music plays in other cultures as part of healing processes. That healing rituals using music still exist in other cultures is self-evident. Whether or not music is applied to individuals as therapy in other cultures is not so apparent. It should be possible to make a comparison of different cultures and their music healing rituals using pho- tographic/video recordings, musical recordings and detailed observations using the techniques of eth- nomethodology and social anthropology. These would include a study of the instruments used, the musical parameters and systems of explanation brought into the accounts, the underlying epistemology of healing and the types of illnesses that are included.

Devisch and Vervaeck (1986) used such an approach to study an African hospital where attempts were made to establish a meaningful relationship between the inner rhythms of the body, outer rhythms of personal interaction and broader patterns of cultural activity. The Arab tradition, which regards the body as the meeting place of psyche and soma, and lo- cates psychiatric illness within social relationships, gives cultural support to the ideas practiced in such an institution. Other traditions will, no doubt, offer similar opportunities to discover music as the vehicle for healing and encourage interdisciplinary activities among musicologists, music therapists and anthropologists.

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Describing and Expressing the Relationship Between Music and the Experience of the Body in

Time and Space

The performance of improvised music demands an understanding of time. In an earlier paper this concept of time was discussed as kuiros rather than chronos, a lived biological symphonic time rather than a reg- ulated mechanical imposed time (Aldridge, 1989). However, human beings also have physical bodies with substance and perform their daily lives in space. Sacks (1986) described a sixth sense, proprioception, which we have in our bodies and is “that continuous but unconscious sensory flow from the movable parts of our body (muscles, tendon, joints), by which their position and tone and motion is continually monitored and adjusted, but in a way which is hidden from us because it is automatic and unconscious” (p. 42).

Proprioception is indispensable for our sense of self in that we experience our bodies as our own. In certain circumstances, as in neurological damage, there may be situations where we lose that certainty of our own bodies, which leaves our existence in doubt. Such a condition is often expressed by music therapists when they speak of the musical improvised playing of patients with anorexia nervosa. It is also apparent that severely disabled patients, or paralyzed patients, must come to terms with an altered neurological status and live in what is a substantially altered body. A research methodology that concentrates on personal expression may elicit valuable evidence about what it is like to live in such a body and offer possible avenues for therapeutic treatment. If the experience of the body is largely unconscious and automatic, the use of personal forms of artistic expression may be far more valuable for realizing the patient as a whole being rather than relying solely upon ver- balizations of conscious experience. Foucault proposed that when persons are allowed to realize themselves as a work of art, to articulate the unthought, then they are liberated from that in which they are imprisoned (Dreyfus, 1987).

A creative arts study of the body would not reduce bodies to a series of measurements from which levels of pathology could be expressed; rather, each person would be encouraged to express him or herself in a form intended to realize the aesthetic. This would free the persons as patients from the authoritarian practices of a medical science and leave them free to compose themselves as they are. In this way we describe the structures of persons as they are performed according

to musical parameters, not interpreted in the language of psychology or medicine. This is not to discover fixed truths as embodied within a particular rationality, rather to encourage that ceaseless task that is the search for truths as they are individually expressed. This avoids what Dreyfus (1987) described as the “confessional technology” of many modern psycho- therapeutic techniques.

In this way of working we are asking “How is the person as ‘being in the world’ in an existential sense.” The methodology searches for forms that allow persons to show themselves in the world as relationships within that world. This is not so much concerned with the content of the productions, rather the way in which space and time are structured as personal style. A shift of emphasis is made from the experience of illness itself to what purpose that illness serves. Such purposes cannot be measured, but they can be demonstrated. In Merleau-Ponty’s view (1962), pathology occurs when one way of relating to the world becomes the only way of relating to the world. What should be only one of a range of possibilities becomes itself the only possibility (i.e., depression becomes the only emotional available state, pain becomes the only range of perceiving the body). This one-dimensionality of being becomes sedi- mented into the posture and body sets of the patient so that the world is always stuctured in a similar way. New situations, which may call for creativity and flexibility, are responded to with rigidity. In this sense, the world is abandoned in that it loses its temporal sense, and the same issues show up repeatedly. In this sense, we can hear a loss of temporality in the improvised musical playing where the same motifs are continually repeated and the playing is restricted to a narrow range of possibilities. However, rather than classify the patient as deviant, music therapy attempts to meet persons as they express themselves and recover lost possibilities.

The sets of data necessary for such a study would be phenomenological and come from the realms of clinical experience according to the medical descriptions, from music therapy, from art therapy and from patient journals. In the initial phases, the research would be accomplished as single-case designs. In later stages, when data collection is rationalized and a method developed, groups of patients can be compared. Paraplegic patients can also be investigated in terms of range of movements from baseline, during therapy and at follow up. Each session would be videotaped from two set perspectives for the analysis of


range and type of movements against a reference grid, or a computer program could be developed that plot- ted movements from sensors located on the body.

Music Therapy as a Treatment for Disturbances in Movement That Appear as Neurological Phenomena

Writing about Tourette’s syndrome and Parkinson- ism, two neurological problems, Sacks (1986) suggested that,

Complementary to any medicinal, or medical, approach there must also be an ‘existential’ approach: in particular, a sensitive understanding of action, art and play as being in essence healthy and free, and thus antagonistic to crude drives and impulsions, to the ‘blind forces of the subcortex’ from which these patients suffer.

(P. 91)

In the previous paragraphs, an emerging methodology, complementary to medicine, has been described, which attempts to capture such an existential approach. This too could be applied to patients with movement disturbances of neurological origin.

Single-case designs are the ideal medium for such studies as the manifestation of problems is varied from patient to patient. What is yet to be established from successful music therapy with neurological patients is the way in which music therapy itself works. Any preliminary investigations would be wise to establish physiological and neurophysiological grounds for changes in status and correlate with the musical playing, as well as changes in clinical status. These inquiries would incorporate a baseline period where the condition of the patient is stabilized and assessed. Music therapy would then be introduced in the session. Music listening to selected taped known songs and melodies could act as a control treatment period. This would control for musical activity and social contact if instigated by a carer (nurse or family member). The initial treatment periods could be randomized in their delivery. Medical assessments may be made by a physician blind to the treatment. Each patient would be monitored for physiological and neurophysiological changes using appropriate measures (e.g., heart rate, breathing patterns, galvanic skin response and electroencephalograph recordings). All sessions would be videotaped and each videotape analyzed on a series of movement response categories.

What Can Music Therapy Bring For Those Who Are Dying?

What strikes me is the fact that in our society, art has become something which is related only to objects and not to individuals, or to life. That art is something which is specialized or done by experts who are artists. But couldn’t everyone’s life become a work of art? Why should the lamp or the house be an art object, but not our life?

Michel Foucault (Rabinow, 1986, p. 350)

The two study initiatives mentioned above-those of bodily awareness and neurological impairment- are pertinent to working with the dying, and even more so to those with people who have severe neurological impairment as a result of the Acquired Im- mune Deficiency Syndrome (AIDS). As the Human Immunodeficiency Virus (HIV) attacks the central nervous system causing gradual neurological degen- eration and cognitive impairment, music therapy appears to be an ideal tool for maintaining as much functionality as is possible and stimulating other latent neurological possibilities.

Recent work with coma patients has indicated that, despite seemingly hopeless conditions of neurological devastation, music can integrate psychological and physiological processes so that communication can take place (Aldridge, 199 1 b). Even in comatose states there is the ability to communicate. Creative music therapy seems an ideal medium in which to rehearse and stimulate communicational abilities at a time before problems become acute. Furthermore, if seemingly unconscious patients can communicate, we must ask ourselves the question, “Where is the es- sential self located of the patient with whom we communicate?” The patient then ceases to be the sum total of his or her material contents and exists in yet another realm of being. In the later stages of the disease, when patients become confused or cognitively disoriented, the creative arts therapies offer a quali- tatively different means of communication.

Personal identity has been compared to the organization of music (i.e., a form that is continually being improvised in the world). The immune system is the biochemical part of our identity. It is not only a system of reaction, but also a proactive system. Its actions are projected into the future to develop, re- store and maintain our physiological identity based upon the experiences of today and yesterday. Immu- nological reactions are not only effects caused by ag-

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gressive stimuli; they are also meaningful memories of our biochemical make up. The immune system is the major integrative network within our bodies that facilitates our biological adaptation. Our immunological systems are not blind reactors; their major task is to discriminate what constitutes our self, what is our altered self and what is alien or threatening to the composition of that self. When that system is corrupted by a virus, the very foundation of our own biochemical integrity is threatened. This threat must be absorbed into the greater framework of our personal identity. The task of music therapy in this context is to negotiate a new identity, to bring ourselves into a new form, literally a “reformation. ”

For the HIV-infected patient, the task is one of maintaining an identity the source of which is par- tially, and perpetually, self-corrupted (in that the DNA material of some cells is changed). This itself calls for both an acceptance of self and the realization of a creative new self. It also calls for a massive new alignment of bodily immune regulation.

Positive emotions are known to be beneficial for the immune system. It is also possible to go further and say that the qualitative aspects of life-hope, joy, beauty and unconditional love-are also vital in therapy. This is precisely the ground in which the creative arts can hold sway. Patients can explore and express their being in the world that is creative and not limited by their infection.

Significantly for many of these patients, their personal relationships are deteriorating. Either friends die of the same illness, or social pressures urge an increasing isolation. Spontaneous contacts are frowned upon, and the the intimacy of contact is likely to be that of the clinician rather than the friend. Music therapy can offer an opportunity for intimacy within a musical relationship. This is both nonjudg- mental and equal. Once more the patient is encouraged to creatively form a new identity.

Finally, working together in a creative way to en- hance the quality of living can help patients make sense of dying. It is important for the dying, or those with terminal illness, to have approaches used that integrate the physical, psychological, social and spiritual dimensions of their being. In addition, how we care for the sick dying, no matter how they contract- ed their disease, is both a matter of our own personal responsibility and a collective measure of our humanity.

Each patient can be monitored in a longitudinal descriptive study incorporating clinical measures of

health status (including immunological parameters where appropriate), the musical and art therapy parameters described previously in regard to bodily disturbances, a daily journal semi-structured to record personal responses to treatment and to the bodily changes taking place, a recognized quality of life scale, and to other realms of change (i.e., spiritual experiences).

A Study of Music Therapy in the Treatment of Alzheimer’s Disease

We are as unsure of the normal process of cognitive loss in aging as we are of the normal musical playing abilities of adults. The literature suggests that musical activities are preserved while other cognitive functions fail (Crystal, Grober, & Masur, 1989; Da- lessio, 1984; Swartz, Hantz, Crummer, Walton, & Frisina, 1989). Alzheimer’s patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. However, the production of music and the improvisation of music appear to fail in the same way in which language fails. Unfortunately, no established guidelines as to the normal range of improvised music playing of adults is available. Single-case studies of normal elderly adults would provide useful assessment tools by which the musical parameters of improvised playing can be assessed.

Improvised music therapy appears to offer the opportunity to supplement Mental State examinations in areas where those examinations are lacking. First, it is possible to ascertain the fluency of musical production. Second, intentionality, attention to, concentration on and perseverance with the task in hand are important features of producing musical improvisations and are susceptible of being heard in the musical playing. Third, episodic memory can be tested in the ability to repeat short rhythmic and melodic phrases. The inability to build such phrases may be attributed to problems with memory or to a yet unknown factor. This unknown factor is possibly involved with the organization of time structures. If rhythmic structure is an overall context for musical production, and the ground structure for perception, it can be hypothe- sized that it is this overarching structure that begins to fail in Alzheimer’s patients. A loss of rhythmical context would explain why patients are able to produce and persevere with rhythmic and melodic playing when offered an overall structure by the therapist in that, although there is a global failing in cognition,


localized “lower abilities” are retained. The hierar- chy of musical perceptual levels proposed by Swartz (Swartz et al., 1989) may need to be further subdivided into classifications of music reception and music production.

Swartz and his colleagues (p. 154) proposed a series of perceptual levels at which musical disorders take place:

1.

2.

3.

The acoustico-psychological level, which includes changes in intensity, pitch and timbre. The discriminatory level, which includes the discrimination of intervals and chords. The categorical level, which includes the categorical identification of rhythmic patterns and intervals.

4.

5.

The configural level, which includes melody perception, the recognition of motifs and themes, tonal changes, identification of instruments and rhythmic discrimination. The level where musical form is recognized, including complex perceptual and executive functions of harmonic, melodic and rhythmical transformations.

In Alzheimer’s patients it would be expected that while levels (l), (2) and (3) remain unaffected, the complexities of levels (4) and (5), when requiring no naming, may be preserved but are susceptible to deterioration.

Music therapy appears to offer a sensitive assessment tool. It tests those prosodic elements of speech production that are not lexically dependent. Further- more, it can be used to assess those areas of functioning, both receptive and productive, not covered ade- quately by other test instruments (i.e., fluency, perseverance in context, attention, concentration and intentionality). In addition, it provides a form of therapy that may stimulate cognitive activities so that areas subject to progressive failure are maintained.

Case studies suggest that quality of life of Alzhei- mer’s patients is significantly improved with music therapy, accompanied by the overall social benefits of acceptance and sense of belonging gained by commu- nicating with others. Prinsley (1986) recommended music therapy for geriatric care in that it reduces the individual prescription of tranquillizing medication, reduces the use of hypnotics on the hospital ward and helps overall rehabilitation. He recommended that music therapy be based on treatment objectives, the

social goals of interaction and cooperation, psychological goals of mood improvement and self- expression, intellectual goals of the stimulation of speech and organization of mental processes and the physical goals of sensory stimulation and motor integration.

Stage One: Single Case Study of Alzheimer’s Disease

In terms of research, single-case within-subject designs with Alzheimer’s patients appear to be a feasible way to assess individual responses to musical inter- ventions in the clinical realm; comparing changes in cognitive function, changes in Mini Mental State examination, speech production and musical parameters. (These can be extended to include multiple clinical baselines both medical and musical.) Such studies would depend upon careful clinical examinations, Mental State examinations, staging and musical assessments. As has been shown in previous papers, it is possible to discover correlations between medical descriptions and parameters of music therapy (Ald- ridge & Aldridge, 1992; Aldridge & Brandt, 1991).

These inquiries, which may be carried out on an outpatient basis, would incorporate a baseline period where the condition of the patient is stabilized and assessed. Music therapy may then be introduced as the treatment variable for a period of 10 weeks. Music listening to selected taped known songs and melodies could act as a control treatment period for a further 10 weeks. This would control for musical activity and social contact if instigated by a carer (nurse or family member). In a longitudinal study of repeated treatment cycles, comparing several single-case patients, the initial treatment periods may be randomized in their initial delivery. Such studies can never be true reversal designs. It is not possible to revert to an original baseline as there are treatment carry-over effects of maturation. Medical assessments may be made by a physician blind to the treatment.

The advantage of single-case designs is that patients and their families can also be involved in the recognition of treatment targets, and assessment measures incorporated that include information from the family. From previous studies of Alzheimer’s disease it is seen as important to ascertain the previous musical education of the patient and his or her current musical activity.

Dependent variables-hospital anxiety and depression scale (also for quality of life), amount of medi-

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cation, assessment of mood scale, assessment of speech production, Mini-Mental State examination.

Assessment-staging, rating scale of social interaction (ward staff and family/c~er), music therapy assessment, drawing and painting assessment.

As aphasia is also an important feature of dementia, it is feasible to apply a similar study to aphasic patients following cardiovascular accidents using the same criteria of language production and musical parameters, substituting a recognized cognitive function test for the Mini-Mental State examination.

Stage Two: The Development of a Cognitive Functioning Scale Incorparat~r~g Musicat Parameters

A study can be developed to offer a refined form of Mental State examination of cognitive functioning using medical assessments and music improvised playing. Such an examination needs a large population of patients for validation and can be coordinated through an international network of music therapists. Several centers would need to cooperate to provide the necessary panel review required for vaIidation.

Stage Three: A Longitudinal Study of Music Therapy Treatment for Elderly Patients

This study can then be further extended, when clear criteria for clinical influence are recognized, to include a longitudinal comparison study of elderly patients with recognized Alzheimer’s disease, a group of elderly patients with depression but no presence of dementia and a further group of “normal” elderly.

In addition, a comparison study of music therapy with selected groups of patients with dementia can be made. Patients would be randomly allocated to two groups-treatment group and control. Music listening to selected recorded songs would be used as a control for active music therapy. Such a study would require a minimum sample of 86 patients in each group to achieve statistical significance and power. Selection criteria would be those of diagnosis and staging. This can be a multi-center study requiring that the music therapists have a common training background and are prepared in music therapy techniques for working with the elderly. Clinical assessment techniques for assessing change would be the standard Mental State examinations.

A Correlation Between a Child Developmental Scale and Improvised Musical Playing

Modem Nordoff and Robbins improvised music therapy has its origins in working with handicapped children, and particularly with child autism. How- ever, although there is a wealth of case study material in the music therapy literature concerning music therapy with children, there has been no controlled study of Nordoff and Robbins music therapy with handicapped children. A simple crossover design could be used to investigate music therapy as a treatment for handicapped or developmentally delayed children.

Music therapy allows children without language to communicate and has developed a significant place in the treatment of mental handicap in children. A particular communication disorder recognized in children is that of autism, which is characterized, in part, by “an inability to develop normal reciprocal responsive social exchanges and failure to make and maintain love relationships. However, it is known that autism is accompanied by a variety of cognitive deficits and it has been suggested that these may underlie the social deviance and social impairment” (Rutter & Schopler, 1987, p. 2).

Condon also discovered that an autistic child was lost to the world of communication. Many of the be- havioral mannerisms he observed in children ap- peared to be related to a multiple response to sound; there was both an immediate response and a delayed response to a sound event, or “dyssynchrony.” This work resulted in Condon postulating a continuum of degrees of delayed response to sound with autistic- like behavior at the severe end and learning disabili- ties at the milder end. The observed children responded to an immediate actual sound but also ap- peared to respond again to that same sound with a delay “by as much as quarter to a full second” (Con- don, 1975, p. 47). Thaut (1988) also concluded that “The low perfo~ances on complexity and rule ad- herence of such children suggest an inability to orga- nize and retain complex temporal sequences” (p. 567).

In a further study, Atlas and Lapidus (1988) compared the symbolization levels in communicative behavior of children with pervasive developmental disorders. They compared correlations between language, gesture, play and drawing, finding that all four levels were interlinked. As yet no such study exists that links these symbolization levels with those of


music production and parameters of music playing in children.

A Scale of Music Development

It is necessary is to derive a music developmental scale for children that correlates with a child development scale (e.g., the Griffith scale, 1954) and other symbolic activities (i.e., play and drawing) using appropriate scales already established in each modality. This would entail a matching of musical parameters to other expressive behaviors, and can include a comparison of normal child development with developmental problems in childhood associated with communication disorders and retardation linked to mental handicap.

Assessment Criteria

Nordoff and Robbins music rating scales for children (Nordoff & Robbins, 1977),

Griffith child developmental scale (Griffiths, 1954), symbolic play scale from naturalistic observation, structured drawing situation (Atlas & Lapidus, 1988).

The early stages of such a scale development would be a feasibility study. Later stages may include therapists in varying establishments throughout the international network of arts therapists.

In addition, we have little experience of the musical development of children in other countries and continents world-wide. Tsunoda (1983) described the significant hemispheric differences in musical perception in children and adults in Japan. A comparative crosscultural study of child symbolization levels of communication behaviors in children would be of interest in understanding brain plasticity and the effect of culture. A society that has a considerable emphasis on vowel sounds, and a script style that is picto- graphic, as in the Far East, may exhibit quite marked developmental changes in its children.

As yet, there exists no quality of life scale for children with cancer. An extension of the music developmental scale for children would be to discover what quality of life considerations would be necessary for children, and the way in which changes in children health status during cancer treatment are reflected in their musical improvisations.

Parents and Children

The treatment of autistic behavior, mentioned above, is important in the history of applied music

therapy, particularly in the Nordoff and Robbins approach, where seemingly uncommunicative children are encouraged to communicate and, in some cases, brought to speech. In the literature there are hints that such communication disorders are apparent in the families of autistic children. We can hypothesize that the musical restrictions and potentials of children heard in the musical improvisations, if they are indicative of an underlying communicative style, will also be apparent in the musical parameters of the improvised playing of the parents of such children. It would be possible to compare the musical playing of autistic children and their parents/primary carers with that of normal children and their parents/primary carers. Should differences be apparent, then a clinical trial can be designed to test the effectiveness of music therapy for treating children alone, or children with their parents.

Conclusion

The intention of this work has been to devise a way of researching music therapy that generates ideas pertinent to the practitioners of the creative arts therapies, and to cultivate methods that are applicable in context. In this way, research is both accomplished in the everyday practice of music therapy and the results of that research applied by colleagues. Such research also helps refine theory and produces building blocks for further research initiatives. The timing and agenda of this work is dependent upon the music therapists themselves and the resources they can gather.

The time has come to further the debate about methods appropriate to the arts and, in particular, music therapy by implementing clinical studies so that evidence is obtained about which research methods work in practice. This goal will only be achieved by financially supporting specific research projects and employing music therapists with the expectation that some of their working time will be spent in research activities. Complementary to research experience is education. It is imperative that we develop in-service postgraduate courses for practicing music therapists with the specific goal of research training. Such courses would involve developing and teaching meth- odologies appropriate for research, learning to search and review the literature, an introduction to research computing-to include working with text and statistical analysis programs-learning how to write research papers. The examined work would include a

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written examination in two parts: (a) theory-a review of a selected area of literature or a methodology specific to a particular problem, and (b) a clinical research study carried out in practice. This research qualification could be the precursor for doctoral studies or stand alone as a professional qualification.

6. Foster cross-cultural studies of music therapy practice to widen the range of musical understandings and broaden the repertoire of musical styles.

It is imperative that we

1.

2.

3.

4.

5.

encourage research agencies within university centers for the consultation, coordination and analysis of research in music therapy, prefera- bly with connections in other countries. This would encourage professionals from varying institutions to cooperate. Such agencies would coordinate research initiatives in smaller institutions, give advice and support on research methods and help with the analysis of data. To facilitate this coordination it is important to develop a common assessment strategy for music therapy sessions (i.e., a musical improvisation rating scale that could be peer-validated on an international basis-(see 3 below) and serve as a platform for research endeavors. Institute research training courses for practicing music therapists as an in-service postgraduate university diploma. Establish criteria for the establishment of standardized clinical baselines according to music therapy parameters and those of other clinical disciplines, to include other creative arts therapies and medicine. This would appear as an assessment schedule suitable for music therapy with adult patients. Develop and validate rating and assessment scales: (a) a child musical development scale, correlated with other social and symbolic developmental scales; (b) a musical assessment scale, correlated with cognitive rating scales, for the elderly; and (c) further develop life quality scales and health status instruments, sensitive to change relating to various chronic clinical problems in correlation with a standardized music therapy rating scale mentioned above in 3. Develop methods of data acquisition, statistical research, statistical analysis and data presenta- tion suitable for music therapists to use in their daily practice. The development of statistical programs for the monitoring and analysis of time series data would be invaluable and have benefits for other therapeutic approaches.

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Music therapy research II: Research methods suitable for music therapy

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