The Arts in Psychotherapy, Vol. 17 pp. 231-237. 0 Pergamon Press plc, 1990. Printed in the U.S.A. 0197-4556190 $3.00 + .OO

THE DEVELOPMENT OF A RESEARCH STRATEGY FOR MUSIC THERAPISTS

IN A HOSPITAL SETTING

DAVID ALDRIDGE, PhD*

This is a report of preliminary research in the medical faculty at the University of Witten/Herdecke from January 1987 until September 1987. The aim of the initial project was to establish specific research strategies for music therapists in a hospital setting. The work is a practical reflection of the approach recommended by McNiff (1987), which suggests that we must pursue research and scholarship to serve both clinical practice and higher education.

The intention of the researcher in the project is to devise a way of researching into the phenomena of a particular creative arts therapeutic approach (music therapy) in a way that generates exciting ideas perti- nent to the practitioners (in this case music therapists) and their colleagues, and that is applicable to the institutional context (the hospital). This way of work- ing while meeting specific needs also considers the ecological niche in which those needs reside, i.e., the particular research interventions are designed to “fit” into the broader setting (the hospital community) in which they are applied. Such a fit is made not only on the practical grounds of clinical practice and patient access, but also in terms of philosophy (Aldridge 1988).

I am proposing that there is such a phenomenon as an ecology of ideas. When we consider the healing process we must incorporate the many activities that contribute to our health. Bateson (1972) comments:

. .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 cir-

cumstance that life depends upon interlocking cir- cuits of contingency, while consciousness can only see such short arcs of such circuits as human purpose may direct. (p 146)

Orthodox and complementary medical practitio- ners are currently seeking ways of carrying out research that addresses the needs of clinicians and considers the whole person. This project keeps such clinical and holistic perspectives in mind. This work is also happening at a time when other research commentators in the creative arts (Bunt & Hoskyns 1987; Clarke & Hoskyns, 1987; McNiff 1987) are advocating broad research perspectives that include qualitative and quantitative data.

The Setting

The university hospital at Witten Herdecke is a large district general hospital serving the immediate community. It has inpatient and outpatient facilities. The underlying philosophy of the hospital is anthro- posophical and based on the teachings of Rudolf Steiner (1971).

Anthroposophical medicine is an extension of orthodox medical practice. Its basic tenets are:

l Each person is a unique individual and treatment decisions must recognize this individuality.

l Scientific, artistic, and spiritual insights, which recognize the whole person, need to be applied

*David Aldridge is research consultant to the Musictherapie Abteilung Universitlt Witten Herdecke, West Germany.

231

232 DAVID ALDRIDGE

together in our therapeutic endeavors.

l Life has meaning and purpose. If these qualities are lost then there is a deterioration of health.

l Illness may provide opportunities for positive change and new balance in a person’s life.

Creative music therapy (Nordoff & Robbins, 1977) has been an important part of therapeutic approaches since the hospital began. As a discipline it has always been part of the medical faculty and enjoyed the cooperation of medical practitioners. For a researcher it is an ideal virgin environment to formulate research strategies. There is no established way of researching. The only stipulation is that the methodology main- tains the integrity of music therapy and does not attempt to impose a restrictive methodology on the practice. Nordoff-Robbins’ Creative Music Therapy is an approach that, as the name suggests, actively involves the patient in making music creatively. The therapist encourages the patient to improvise music using percussion and tuned percussion instruments by singing with the patient, and by encouraging the patient to play with the therapist at the piano. No attempt is made to interpret the music psychothera- peutically. The process of creatively improvising music, and the development of a musical relationship between therapist and patient, are seen as the vehicles of therapy.

It is also important to emphasize that the visual arts and eurhythmy are also practiced within this hospital. Health is an activity that occurs within an environ- ment of creativity.

Method

The general methodological approach is that of ethology or clinical anthropology (Aldridge & Pietroni, 1987a) where initial careful observations are used as a platform on which to build further endeavors.

The work “strategy’ ’ in the title of this paper is deliberate. Strategy indicates a general approach to the research campaign in the hospital setting and is a statement of intent. More detailed and particular research designs come at a later date. In these later designs it is possible to state particular research

criteria of patient selection, variable definition, ex- perimental control, instrumental measures, and meth- ods of analysis.

In the preliminary stages I met the five hospital music therapy staff collectively, and then singly each month for six months. I also went out into the hospital and interviewed those senior medical practitioners who were known to be interested in music therapy either because they were regular referrers to the music therapists or because they professed an interest in music therapy. These interviews were then written up as an internal paper and submitted departmentally as well as to those previously interviewed. All practitio- ners involved were then invited to a common meeting and asked for their comments about the work so far. This meant that the work stayed close to the com- ments of the practitioners directly or peripherally involved.

From these early discussions it was possible to see what common areas of interest were available to build on. This paper is a report of the results of those discussions.

Areas of Research

Three areas are recommended for the research in the music therapy department (see Table 1). These emerged from the discussions with the doctors and therapists in the hospital who were asked directly what they wanted to see from the music therapy department and how much they were willing to cooperate, and from extensive talks with the music therapists.

A significant feature in developing research ideas was to get music therapists to present their taped work to the researcher, and to say what questions were raised by that work. All the discussions focused on clinical practice, not idealized abstractions about research.

The general intent of this work is to develop a common structure for single case designs (Aldridge, 1988b) such that individual analysis and comparative analysis can be made. Music therapists in the hospital work with individuals, and are referred a series of individuals with similar problems by physicians. For example, particular therapists are referred patients who have chronic bowel disease (Aldridge & Brandt, 1989a), cardiovascular disease (Aldridge & Brandt.

MUSIC THERAPY RESEARCH IN A HOSPITAL SETTING 233

Table 1

Proposed Research Structure

year

OfE

Physiological

work establish

physiological

criteria of change

in therapist; patient

interaction

Clinical

studies

single case

studies, develop

methods and

working

~~ationships

Theoretical work

literature

reviews,

theory development

s~posium

Publications

case studies

and

position papers

yeaI% continue work, continue work, coilect case

two identify refine hypotheses, examples from

and clinical problems. look for long recorded work

three refine term changes

hypotheses develop prepare clinical

theory aad outcomes papers

prepare research define report and further proposals techniques

None of these areas of work are exclusive, but each part wiH inform the other. For the sake of practicality, and to avoid confusion it may help to think of three areas: physiological work. t~achin~/theo~ work and the clinical case studies. Not al1 therapists will want to concentrate on all three areas. The clinical case study work and the physiotogica~ work will provide a framework for more refined and formal research studies. These studies will inform and he informed by the developing theory. This approach gives the work both conceptual and practicaf coherence. Knowledge gained in this way has meaning for the practitioners and retains the integrity of therapeutic practice, which is enlivened by the rigor of a naturalistic science.

1989b), AIDS, cancer, anorexia nervosa, and neuro- logical disorders.

The initial session for therapy is one of assess- ment, and a common format for assessment is being negotiated between music therapists to allow compar- ison between single case studies. These therapists can also compare their assessments and notes of the therapeutic process with notes made by other thera- pists of the same patient. The observations made during the investigations of physiological changes correlating heart rate changes with musical changes can be discussed with therapists working with patients with cardiovascular disease.

The three areas for future research are as follows.

Physiological

The aim of this area is to discover the physiolog- ical implications of improvising music with a thera- pist. As the music therapy department shares its accommodation with the department of physioIogy

there are opportunities for continuing dialogues. The questions to be asked are:

What changes occur during the process of playing music together- (a) in the individuals concerned, and (b) in the interaction between patient and ther- apist‘? What are the i~lp~icat~ons of those changes- (a) for the patient, and (b) for the course of the therapy?

There has been a limited amount of work on the influence of receptive music on physiological param- eters. However, there also has been little work on the interaction between therapist and patient playing mu- sic together. This investigation of mutual influence in therapy is potentially of great benefit in understanding therapist/patient interaction in contexts other than music therapy.

The initial part of this program will monitor the

234 DAVID ALDRIDGE

heart rate of the patient and the heart rate of the therapist, and the playing of the therapist on the piano and the playing of the patient on a drum. These will be recorded in real time onto a videotape recording of the session. It will be possible to see observed changes in the therapeutic interaction on the videotape and correlated changes in the other parameters. Each interaction will occur in a variety of contexts: rest, playing a composed work, and creative improvised playing. In some ways this is an attempt to monitor the physiology of creative dialogues, a feature many of us try to include in our clinical practice.

The reasons for choosing heart rate were then (a) it is a relatively easy parameter to measure and observe, (b) it indicates important aspects of listening and the activity of communication (Friedmann, Thomas, Kuliek- Cioffo, Lynch, & Sugimohara, 1982; Lynch, Long, Thomas, Malinkow & Katchor, 1981; Smith &Rhode- Walt, 1986; Walker & Sandman, 1982), and (c) it is a parameter acceptable to medical scientists in the wider community with whom we are attempting to promote a dialogue. It also has an immediate rele- vance for patients suffering with heart disease.

Theoretical

This work will focus on the taped work of the therapy sessions. Nordoff & Robbins music therapists always audiotape their work and have a system for indexing their tapes. This careful observation, which is accessible to another clinician/researcher, is a significant feature of any research approach and emphasizes the rigor of the therapists.

The questions to be asked are:

1. 2.

3.

4.

5. 6. 7.

8.

How do music therapists talk about their work? What are the questions they ask of their own therapeutic endeavor? How can the adult work be documented in an acceptable way? Can some terms be defined in a way that can form a common vocabulary for talking about music therapy with our peers and colleagues? How does the therapy work? What happens during the course of therapy? What is the relationship between the music and the patient as a whole person? Can a patient’s state of health or illness be heard in the way in which he or she improvises music; and if so, how can this be demonstrated?

These questions are concerned with internal va- lidity .

Clinical

This work will concentrate on understanding clin- ical outcomes and questions of therapeutic changes. It will be carried out within the context of the hospital wards and in cooperation with interested doctors and therapists.

The questions to be asked are:

1.

2.

3.

4.

5.

6.

What changes during the process of therapy in terms of the patient’s problem? How is this change recognized by the music therapist? How can this change be communicated to other professional practitioners? What is evidence of therapeutic change for the patient? What are the clinical criteria of the referring practitioners in terms of patient referral, thera- peutic change, and clinical prognosis? How can observed changes be documented and correlated with those of other practitioners and family members?

These questions are concerned with external va- lidity .

It is important to note that in this approach the process of therapy and outcome are not separate activities. It is convenient to consider them as sepa- rate but this does not happen in clinical practice. Similarly, clinician and researcher work together, not separately (Aldridge & Pietroni, 1987a, 1987b; Lin- coln & Guba, 1985; Pietroni & Aldridge, 1987).

Examples of this clinical work currently being carried out are for the treatment of chronic bowel disorders and psychiatric problems. The clinical progress of the patient is carefully recorded and the comments and assessments of the cooperating practitioners com- pared. For instance, we are finding that therapeutic change as recognized by the psychiatrist is also represented in changes in the playing of improvised music and in the way in which the patient paints.

Implications for Practice

We have developed a way of working that satisfies the members of the music therapy department and

MUSIC THERAPY RESEARCH IN A HOSPITAL SETTING 235

their various needs. Research solutions have not been imposed on the therapists; they have been developed wirh the therapists. The three areas of research- clinical, experimental and theoretical are all interre- lated, yet separate. While maintaining a picture of the whole research endeavor it is possible to implement particular strategies appropriate to the level of inves- tigation. A holistic strategy does not mean that everything must be all lumped together in an infinite series of multiple variables-rather that each part is understood in relationship to other parts and to the whole.

By following a program that is flexible, different clinicians are allowed to follow their own interests. Some therapists, for instance, are more interested in the physiological experiments whereas others are more concerned with theoretical issues about health indices and well being.

Methodological Development

Each of the previous areas has its own detailed protocol, which again is being refined in another round of practical investigation. In this way the comments of the therapists are constantly sought and incorporated into the research strategies.

Although the development of an appropriate meth- odology takes time initially, it is satisfying in the long run. A benefit of working in this way is that the therapists are intimately involved with the research, which is seen as applicable in practice and as belong- ing to the therapists. The traditional split between research and clinical practice is avoided. In this context the researcher is a facilitator and guide, and the therapist as clinician actively engages in the research process (i.e., therapist as researcher). My argument is that when methodology meets the needs of the therapists and is based on their epistemology, research endeavors are likely to be completed.

The development of research methodology is not pursued as an activity separate from the epistemology that underlies the therapeutic activity. Rather than impose an alien methodology on music therapy it has been a policy within the department to develop rigorous methods that are isomorphic with the under- lying premises of music therapy. Many of the pub- lished research studies about music and music therapy from the United States so far have been from a standpoint of music psychology. In general they have been reductionist, and, in particular, cerebral (Clarke

& Hoskyns, 1987). Although concentrating on the mechanics of perception, they have neglected the questions of music as an artistic activity, the relation- ship between music and healing processes within the body, the implications of music for health, and the interrelationship among body, mind, and spirit. Sim- ilarly, there has been no investigation of the relation- ship between therapist and patient.

By applying rigid methodologies without due re- gard for the nature of the therapy itself and the persons involved, those studies have been unscien- tific. They have lacked internal validity. Methodol- ogy is intended to serve science. Science is not the servant of methodology (Pietroni & Aldridge, 1987). By restricting our questions to those that can only be answered by orthodox methodologies, we ignore the possibility of finding the very answers we seek.

Clinical Dialogues

By pursuing a research policy that involves a variety of creative arts therapists and medical practi- tioners, the work of the department is linked to other practitioners within the hospital. The advantage for research and clinical practice is that a many-sided picture of the patient is composed. Furthermore, continuing clinical dialogues are encouraged between practitioners.

Academic Life

In reviewing the literature, writing papers, and talking about theoretical issues, the academic life of the department is enlivened. The staff is encouraged to read articles outside the usual range of reading, and new material is introduced.

There are also benefits for the students in the music therapy department and the medical school. By con- centrating on clinical case studies and individual instruction, it is possible to add an extra experiential dimension to their teaching whereby knowledge and experience are placed into new or challenging rela- tionships.

Single case study designs (Barlow, Herson & Jackson, 1973) are a particularly effective way of teaching students. It allows them to follow their own interests under expert supervision. They are respon- sible for their own learning, but this is guided by a tutor. By following single case study designs, it is possible to prepare material for the production of case

236 DAVID ALDRIDGE

studies and theses for examination. For the staff it means that papers can be prepared

for publication based on their own clinical practice but within the framework of a formal research instru- ment. In time this will build a repertoire of case studies all based on a similar format.

Research in Context

There are several reasons why the research project within the department of music therapy developed so well, and these are related to the hospital setting.

Own Interest

The idea of carrying out a research program was not imposed; it came out of an interest shown by the music therapists themselves and their desire to grow as a department. The fact that all the music therapists in the department are trained in the Nordoff-Robbins approach has enabled a consistency of approach.

Timing and Validity

The time was right for the development of re- search. As a department, the music therapists were aware that there was a need to develop academically. Similarly, the music therapy staff was looking to formulate research methods that could be validated internally on their own terms as clinicians, yet would satisfy external criteria of validity. In our early discussions we considered the audiences for our work: (a) the broader audience of the professional culture, (b) the smaller audience of our music therapy peers, and (c) ourselves. In addition, the hospital and medical faculties were actively seeking new research endeavors.

Rejlexive

The music therapists were already questioning their own work relative to theory building, clinical efficacy, and therapeutic process. The research has always attempted to stay close to those questions and to relate each part of the work to the whole.

Having an overview has maintained a necessary cohesion between differing ideas and interests. Each person does not have to know what every other person is doing in detail. This allows for academic independence. However, all the parts relate to a commonality of interest that promotes cohesion and

gives meaning and structure to all the research en- deavors. To work in this way means that staff members can be both independent and interdepen- dent. By maintaining a commonality of purpose, different members can follow their own interests without feeling disloyal to their colleagues.

Hospital Ethos

The whole ethos of the hospital community is one of a cooperative culture of like-minded people. The art therapies, eurythmy, and music therapy are rec- ognized by the medical staff as having a legitimate place within the whole therapeutic approach. This integration-clinically, theoretically, and methodo- logically-is worthy of its own research study. When art and medicine meet in such a setting it is possible to begin dialogues between practitioners from differ- ing clinical backgrounds where beauty, inspiration, and the deepest longings of the human spirit are seen as essential for health.

Holistic Approach

The commonality of background at the hospital, which is founded in anthroposophy, maintains a cohesive framework at times of dissent. When super- ficial disagreement occurs, there is recourse to a deeper unity both at an epistemological level and in the tradition of working. In a health setting where the author has worked recently, where the talk was of holistic medicine and multidisciplinary practice, su- perficial disagreement led to the exposure of deep fundamentally opposed medical epistemologies and professional differences. The academic tradition at Herdecke, which remains true to its holistic approach yet is responsive to change, encourages a true scien- tific endeavor where both imagination and rigor work together.

Perhaps the most important feature of working at Herdecke is the acceptance of differing levels of understanding of particular phenomena. Orthodox medicine, although making many advances, still has severe limitations in understanding the human being as a whole person. By refusing to accept simplistic and reductionist solutions, Herdecke is preparing a way for the future of medical science understandings. It is only in the field of applied clinical research methodologies that grapple with complexity that the difficult area of chronic illness will be tackled in the

MUSIC THERAPY RESEARCH IN A HOSPITAL SETTING 237

later part of the twentieth century. However, as Lynch (1977) says in his book about the medical conse- quences of loneliness:

Examining the nature of living together, understand- ing the nature of human dialogue, and blending a scientific understanding of human companionship within a philosophical framework that will allow us to appreciate its complexity will not be an easy matter. (p. 231)

It is my contention that music is this dialogue.

External Influence

A tradition of anthroposophy and the secure un- derpinning of practice with epistemology were further enhanced by the ready acceptance of people from outside the hospital to bring in new ideas. Academic tolerance is surely the mark of an intellectual climate in which ideas can grow. At Herdecke there was this readiness to consider a broad spectrum of ideas as Steiner (1971) himself advocated. This did not mean an uncritical acceptance, but it did mean a willingness to listen in good faith.

Conclusion

There is no one paradigm for scientific research. When we consider creative arts therapies we must consider both art and science. This dichotomy is of our own making. No such split exists either in music, painting, or dancing, or in our own health for that matter. When we enforce the split we run the risk of losing creativity and the essential properties of healing.

It is my intention to develop methods that sensi- tively articulate what is pertinent to the experience of playing music together and the implications for the health of a person. By listening to various colleagues it is possible to begin to attempt to answer their questions using their criteria. Our overriding empha- sis is to constantly return to the music as it is used creatively in clinical practice to test out our emerging hypotheses.

Our methodological approach of commitment to mutual dialogue in research reflects the approach of creative arts therapists to their work and anthroposo- phists to medicine. I hope that as a community of scientists and artists, linked by our common fraternity as practitioners, we can extend these dialogues to

other practitioners, whatever their disciplines and training.

References

Aldridge, D. (1988a). Treating self-mutilating behavior: A social strategy. Family Systems Medicine, 6, 5-19.

Aldridge, D. (1988b). Single case research designs. Complemen- tary Medical Research, 3. 37-46.

Aldridge, D., & Brandt, Cl. (1989a). Music therapy and the treatment of chronic bowel disease (in preparation).

Aldridge, D., & Brandt, G. (1989b). Music therapy and the treatment of cardiovascular disorders (in preparation).

Aldridge, D., & Pietroni, P. (1987a). Research trials in general practice: Towards a focus on clinical practice. Family Practice, 4, 311-315.

Aldridge, D., & Pietroni, P. C. (1987b). The clinical assessment of acupuncture for asthma therapy. Journal of the Royal Society of Medicine, 80, 222-224.

Barlow, H., Hersen, M., & Jackson, M. (1973). Single case experimental designs. Archives of General Psychiatry, 29, 319-325.

Bateson, Cl. (1972). Steps to an ecology of mind. New York: Ballantine.

Bunt, L. Cl., & Hoskyns, S. L. (1987). A perspective on music therapy research in Great Britain. Journal of British Music Therapy, I, 34.

Clarke, E., & Hoskyns, S. L. (1987, February 21). Starting research in music therapy. Proceedings of the Third Music Therapy Day Conference, City University, London.

Friedmann, E., Thomas, S., Kulick-Ciuffo, D., Lynch, J., & Suginohara, M. (1982). The effects of normal and rapid speech on blood pressure. Psychosomatic Medicine, 44, 545-553.

Lincoln, S. Y., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills: Sage.

Lynch, J.J. (1977). The broken heart: The medical consequences of loneliness, New York: Basic Books.

Lynch, J., Long, M., Thomas, S., Malinkow, K., & Katchor, A. (1981). The effects of talking on the blood pressure of hyper- tensive and normotensive individuals. Psychosomatic Medi- cine, 43, 25-33.

McNiff, S. (1987).Research and scholarship in the creative arts therapies. The Arts in Psychotherapy, 14, 285-292.

Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day.

Pietroni, P. C., & Aldridge, D. (1987). Summary of discussion on British Medical Association report. Holistic Medicine, 2, 95- 102.

Sandman, C. (1984). Afferent influences on the cortical evoked response. In Psychophysiological perspectives: Festschrifr for Beatrice and John Lucey. M. Coles, J. Lennings, & J. Stem, (Eds.). Stroudberg PA: Hutchinson & Ross.

Smith, T. W., & Rhodewalt, F. (1986). States, traits and pro- cesses: A transactional alternative to the individual difference assumptions in Type A behavior and physiological reactivity, Journal of Research in Personality, 20, 7 11-129.

Steiner, R. (1971). Theosophy. New York: Anthroposophic Press, Walker, B., & Sandman, C. (1982). Visual evoked potentials

change as heart rate and carotid pressure change. Psychophys- iology, 19, 520-527.