“The power of music to integrate and cure…is quite fundamental. It is profoundest non-chemical medication”
-Oliver Sacks, M.D., Awakenings
Music therapy is an established health profession using music and musical activities to address physical, psychological, cognitive, social and spiritual needs of individuals of various populations. The primary tool in music therapy is usually music, which if appropriately used becomes a therapeutic medium. Music therapy may be also defined as an interpersonal, planned process that involves a carefully thought-out sequence of steps and procedures. Every chosen technique, musical instrument or tonality has a reason and becomes a clinical intervention. There are many different approaches or schools that may vary in their methods, techniques, concepts or psychological, philosophical framework.
I draw upon the Adult Improvisational Music Therapy of Gillian Stephens Langdon and Creative Music Therapy of Nordoff-Robbins. I am just about to finish a music therapy program at Molloy College as well as an internship in Bronx Psychiatric Center in New York. To acquire the certification from CBMT (Certification Board for Music Therapists) according to the American Music Therapy Association I am obligated to accomplish 1200 hours. Thanks to above mentioned Gillian Stephen Langdon and her support I was able to manage this. Gillian Stephens Langdon is a very well known American music therapist with over 30 years of experience with psychiatric population. She published several professional articles about the topic. I got the rare chance to be her student and learn directly from her.
Adult Improvisational Music Therapy at Bronx Psychiatric Center
The Bronx Psychiatric Center is a long term facility where a large part of the population arrives directly from a prison. Many of the patients do not have any place to go, the clinic thus happens to be their home. One such patient was discharged after about 10 years. He came out of the clinic … passed the main door and stopped … then looked around and said:” I can not …” After so many years, he was not able to be free. He couldn’t take the responsibility of freedom.
The music therapy programs take place in the Rehabilitation center along with art, drama and dance therapy with Gillian Stephens Langdon as the director.
Basic features of Adult Improvisational Music Therapy
Adult Improvisational Music Therapy has four fundamental elements: music (improvisation), words, silence and movement, which freely influence each other during therapy. Especially important is the relationship between words and music, hence improvisational techniques are linked with verbal techniques. The work in therapy may go from music to words, from words to music, from music to music, from words to words. This means that a discussion may follow music, music may follow a discussion and so on. All depends on the music therapist and his sensitivity to feel what words can’t express, but music can and vice versa. It is very important to let a patient express not only verbally or musically, but also allow him a moment of silence to process a difficult moment.
When a client arrives at the clinic a team defines a clinical goal for him. When he enters the rehabilitation program the goals are discussed by the therapists of creative arts again and added or modified depending on client’s needs and the possibilities of the medium (music, art, drama, dance).
At Bronx Psychiatric Center most clients suffer from schizophrenia. One of the recommended treatments for this illness is a combination of medication and therapy. One of the possibilities is indeed music therapy. How I mentioned in the abstract of this article, in contrast to medication, music therapy is able to help in a non-chemical way. Because of the power of music to touch human feelings at all depths letting us feel the connection through music improvisation, it is a very effective way to work with schizophrenic patients. One of the main goals of music therapy is to work with social – emotional skills of the patient. It is very important to break his isolation and help him to express himself. The music therapist starts working on the basic level of communication and attempts to build a meaningful and trustful relationship between him and the patient. One of our friends, the outstanding guitarist of a music band in the clinic, was once preparing for a concert. He was unusually calm. When he was asked by another patient what was going on, he said that he is hearing voices again. The answer of his friend was: “Start to play … they will go away…”. The patients themselves understand how music can help.
Some of the goals of music therapy with schizophrenic patients
To increase self-awareness, self-understanding
To increase interaction with their environment
To improve integration
To increase reality orientation here and now
To improve verbal and nonverbal communication skills
To unblock self-expression
To offer a safe place to express feelings
To expand coping skills
I am working with patients in individual and group settings. A group consists usually of about 4 to 8 patients sitting around a round table with a lot of percussion instruments such us tambourines, maracas, drums etc. A session lasts about and hour and half. The first 50 minutes are dedicated to the therapy and then after a short break follows listening to music (relaxation). The patients have a possibility to bring their own CDs and chose their preferred songs. In the listening part of the session the group also discusses lyrics and dances or sings.
Techniques used with schizophrenic patients
During my internship I learned several techniques that I found very helpful for the work with psychotic patients. I would like to present you some of them.
This technique is used in a group as well as in individual music therapy. It is a short song, easy to remember which is sung at the beginning or at the end of a session. It is usually the same song that helps return to security when the words are toppling, it reminds of the safety of the relationships in the group. It can be sung over and over in numerous ways. The song is sung either by the music therapist or by the whole group. It depends on the goals and patient’s needs. Even though there are many contact songs available, like many music therapists I am usually composing a new contact song for every group or individual. In the contact song, it is good to include the names of the members of the group, tin order to address them directly. One of my patients was originally from China and did not understand English. I composed a song partly in Chinese and partly in English. The goal was to build a bridge between her culture and American culture. This was also the reason why the song was composed partly in pentatonic and partly in diatonic.
While the music therapist is singing the contact song it is very important to relate to the patient. When I sing this song I usually look at the patient, smile at him and welcome him to the group. I demonstrate that I accept him as a member of the group. For many patients it is very difficult to come to the rehabilitation center where music therapy sessions usually take place. With this song I am appreciating their effort to come. After the song is sang for a patient he is supposed to choose another patient to sing the song for. The fact that the music therapist calls their patients by their names and motivates them to interact with each other in the group helps them to orient in reality “here and now” and increases their self-awareness. “I am here now … with these people … they are real … they communicate with me.” It happened to me twice that I started the session without the contact song. Every time someone from the group asked for the song. The contact song becomes an important ritual, that brings safety and structure to the group. For many patients who live their life with hallucinations and paranoid thoughts, the structure of the session is an important element. Many of them need rules to feel safe.
Vocal holding technique
I use this technique mostly in individual music therapy settings. There are many patients who like to improvise on melodic instruments without having any experiences how to play them. One possibility is to accompany the patient’s improvisation by voice. It is very important to carefully listen to the patient and his music. Thus vocalizing works in the same way like instrumental accompaniment. This technique is not just about singing with a patient. It is about interpersonal relationship and about the fact that every one needs sometimes somebody to help or hold his hand. This technique is about holding through the use of music and improvisation.
I had a patient who loved to play the guitar. Because she was never able to make a nice sound she always stopped after a few seconds. “I don’t know … I don’t know ….”, she was repeating while putting the guitar away. When I tried to motive her verbally by saying, “You can do it … don’t give up …”, it never worked. However, when I vocalized with her during her improvisation, the girl kept up playing for about 5 minutes. This technique is about nonverbal communication. I am with the client in a moment he needs me and it is as if I was holding her hand during her first steps before she can go alone.
In the beginning of every session I am asking the patients how they are, how they feel. Very often they start talking about their problems, sorrows, daily worries but also about dreams, wishes or ideas for their future. Patients are not allowed to talk about specifics of their past, because it could traumatize the rest of the group. It is important to direct the discussions in a particular way. However, it is also very important to take their openness with respect. I am always trying to listen to them, help them to identify their emotions and thoughts. One of my patients was in a war and after that he killed his mother in a psychotic attack. He has a tendency to talk about it in a detailed way. In such a case I need to be very attentive and be able to redirect the discussion immediately. After such emotional talks the group is usually very quiet. Then someone takes an instrument and starts playing. The rest of the group then joins in a musical improvisation. In addition to the music therapist, every client in the clinic has his own private psychotherapist. Unfortunately there are too many patients for too few professionals. Because of that the music therapy settings are very often the only place where patients can talk and express themselves.
Creating a song is one of the techniques that suites well after a discussion. The music therapist may motivate the patients to improvise on a particular theme. I may take a guitar, compose an easy melody and ask the patients to give me a few words, ideas around a recent topic or anything that crosses their minds. This I combine with a melody that mirrors the particular moment, feeling or atmosphere. The music therapist participates in the song as well. He should be honest and open. Although the patients are mentally ill, sometime I have a feeling they understand me very well or that they can even see through me. This technique helps to increase verbal and nonverbal communication skills of the patients, supports their self-expression and interaction. The music therapist helps the client to understand that he is not alone and that the music therapy group is the safe place to share.
Assessment and Evaluation
In music therapy it is very difficult to assess. However, for the future of this profession it is very important to prove the effectiveness of techniques and methods. In America, there are many professionals trying to research specific topics in a quantitative or qualitative way. Because of that there is an increasing number of professionals in different fields (psychologist, doctors etc.) who learn about music therapy as an established complementary health profession and accept it.
The main evaluation technique of Adult Improvisational Music Therapy at the Bronx Psychiatric Center is observation. Every music therapist reports monthly the information about the progress of his clients to the team in the clinic. The therapists in the Creative arts department meet weekly to modify goals and strategy of therapy, if needed. Evaluation refers usually to the following areas:
Motor (manipulation with musical instruments etc.)
Emotional (expressivity, creativity etc.)
Cognitive (rational thinking, orientation to time, place, person etc.)
Social (Interpersonal reactions, communication verbal, nonverbal etc.)
Musical (musical ability, range of dynamics, ability to keep the rhythm etc.)
Spiritual (If I am able as a therapist to empathize with the patient)
In conclusion I would like to cite Gillian Stephens Langdon: ”An important element is that of an equal relationship in musical terms. It is not the therapist, a trained musician, playing beautiful music for the client, but both struggling with rhythm and non-rhythm, loud sounds and soft sounds, fast sounds and slow sounds … the music therapist is here to help clients develop their own sounds – sounds that are satisfying to them and work for them in their own world.”