Catégorie : ÂM NHẠC ĐIỀU TRỊ HỌC

Son Vi Nguyen,M.D:MUSIC THERAPY FOR THE MENTALLY ILL

MUSIC THERAPY FOR THE MENTALLY ILL

Dr. SON VI NGUYEN

by Son Vi Nguyen,M.D.

From his very early time, man has learnt that there is an extremely close relationship between him and the universe.

In fact, man is not only a creature of the Earth, he is an integral part of an unified system which, in spite of its extreme diversity, still presents itself with extreme harmony and uniformity. Through his senses, man has been able to communicate with nature in a very intimate way. With his eyes, he came to appreciate the different aspects of his world, to fear its power and to admire its beauty. But man has never been a passive witness of nature, his relationship with the universe is a very dynamic one. Not only he perceives it as a reality, but he is able to assess it, interpret it according to his own perspective, recognize the laws that command it and represents it in the most creative and emotional way.

It is due to this esthetic experience and this need for esthetic expression that our ancestors, the prehistoric man has left behind a treasure of drawings that still grace many rocks and caves of the world. But the world is not only a reality to man through visual representation, man has come to realize that nature is filled with extreme diverse sounds.

There are the sounds of the winds, of thunder, of waves breaking on the rocks, of the rains in a stormy night; and also there are also the joyful singing of birds calling for a new day to come.

The story went that there was a weary hunter who, on an unsuccessful day, was on his way to his cave, his mood was grim, his morale low, he sat by a brook and in awhile discovered wonderful sounds, that was the brook singing its way through the rocks, then the crickets, the bullfrogs, and some unknown birds just joined in chorus. Before he realized what was happening, the jungle had vibrated to these enchanting sounds, our man’s stomach was still empty but his mood was better. There was in himself something that was relaxing, something that was encouraging. He remembered he had heard. this wonderful hymn of nature somewhere, in better times. Someone has said that the history of music therapy began with Athanasius Kircher and his « Musurgia Universalis,

Ars Magna Consoni et Dissoni » published in 1650. I dare say that the beginning of music therapy had its origin from time immemorial when our ancestors like this unlucky hunter found consolation and appeasement from the wonderful music of nature.Of course, the isolated sound of thunder, of a rock splashing on water are not music, all they could do is, perhaps, to cause a startle, but a series of thunders, the ticking sound of drops of water on a pond, the rhythmic sounds of the bullfrogs or all of those sounds combined can have a special influence on our mind and mood. Thus, isolated sounds are not music, but a succession of sounds or groups of sounds occurring at certain intervals can create what we call rhythm, a combination of sounds or a succession of sounds constitutes what are known as harmony and melody.

Rhythm, harmony and melody are the key characteristics of music. But if one considers the music of all cultures, it is rhythm that stands out fundamentally. Without rhythm, there is no music. And not only man has learnt to appreciate rhythm in nature whether it is from his heart beats or produced by successive waves coming on the beach, but also he has been able to create his own rhythm, his own music. He has learnt that the benevolent influence of music doesn’t come only from experiencing it, but also from being able to express it, create it.

The history of man is the history of discovery leading to better creativity which in turn favors further discoveries. It is this process that has helped man discover the multitude qualities of music and from this position, develop creativity of the broadest magnitude, and benefit the most from his own creation. From the minute that man discovers music, its beauty and its benevolent influence, man and music have become inseparable, in as much as music and therapy have gone hand in

Page two

Music Therapy hand throughout man’s history. It is no surprise that lullabies are strikingly alike the world over. And the world over, the role of lullabies is to put an infant to sleep, they do this through their universal characteristics which include a regular, monotonous, metronomous rocking rhythm even though the tempo may vary. Man’s love for music seemed to be relentless and universal, music is with him whenever and wherever there is an occasion to commemorate, to celebrate or to grieve. Music goes with man in war, in prayer, in time of joy or desperation. Music honors God and the mortals in life and in death. Music conveys power to the medicine man, helps folk stories endure with time, music invigorates the sick and elevates the desperate, music is the pride of the rich and the friend of the poor. Music is one of the best means of communication transcending culture thanks to its primitive but powerful nature. It is no surprise to find that many of the most illustrious thinkers are also strong advocates of music. Plato attributes such an importance to music that he believed by changing a musical mode, the whole foundation of a state could be at stake. He believes that music is the medicine of the soul, thus when the soul has lost its harmony, rhythm and melody can bring it back to order. Plato believes that music should not be considered as a vulgar means of entertainment but as an ennobling educational tools. Aristotle shared most of Plato’s views, but his system of thinking seems to be more comprehensive, he attributes to music three functions: It is a source of recreation and pleasure,it is suited to the intellectual use of leisure,and it is a powerful ethical force in the molding of character. Aristotle also believes in the « cathartic » role of music in the same way as Freud’s psychoanalysis. Since music has the power to elicit the feeling of joy, sorrow, anger, courage etc…, it can help the subject relate to his own feelings and from there ventilate his conflictual feelings and find a resolution to his emotional conflicts. Music contains in itself imitations of character, reproduced by different modes: the Lydian is decorous and educative,the Phrygian is violently exciting and emotional,the Dorian is more composed and manly.Since Aristotle believes in a close interaction between body and mind, he also thinks that music, by influencing the mind has also an effect on the body. Because of the importance that the Greeks and Romans attributed to music, one can understand why Apollo who is the God of’ music, is also the God of poetry, prophecy and medicine. Homer also praised the qualities of music as the guardian of virtue, it has helped Penelope and Clytemnestra preserve their chastity during the absence of their husbands. The philosopher Seneca, Rome’s most prominent Stoic, was also a strong advocate of music, he believes that « Whoever has no knowledge of music, knows other things to no purpose ».Among the most widely recognized values of music are its psychotherapeutic values. Amphion and Orpheus, through their soothing tunes becalmed the rage of wild beasts and caused rocks and stones, mountains and forest to yield to their will. Achilles appeased his fury at Agamemnon with the sweet sounds of the lyre.

Pythagoras used music to help his disciples resolve their emotional conflicts, he used the principle of « contraria contrariis curantur » (opposites are healed by opposites). Thus, the Phrygian mode would make an anxious man more irritable, but a soft and soothing mode would have the effect of

Page three

Music Therapycalming down the same person. Pythagoras also combined music, poetry, dance to help preserve a healthy emotional stability; his ideas, interestingly are very close to the concepts of music therapy of our time.Descartes in his « Compendium musices » defines the nature and the role of music in a cryptical way: « The object of this art is sound, the end: to delight, and move various affections in us. » His views were shared by many later generations of musicians such as Roger North and have served as the foundation of the principles of music therapy as we see them today. As mentioned above, music has been used for therapeutic purposes, both mentally and physically from time immemorial. But we have to wait until this century for music therapy to gain its official place in the hospitals, particularly mental hospitals and to become a well structured entity widely recognized. In the United States, Music therapy has been used to certain degree during World War I in helping with the readjustment of wounded servicemen. Until 1942, musicians were assigned to small units and a band is provided for each regiment. But things changed during the years 1942-1943, at which time music seemed to be discouraged and only divisions and Armies had their band, soldiers were not allowed to take musical instruments overseas. But shortly, the higher authorities started realizing that there is one thing that the medical staff cannot completely achieve: keep up the morale of the wounded. It was recognized that music was among the appropriate answers. So finally the Army’s Reconditioning Program was launched and music therapy had a more important role in military hospitals. The American National Red Cross has also used music as an important part of its recreational activities in service hospitals, The USO-Camp shows also included music in their program for American hospitals overseas. The American Federation of Music Clubs and the Civilian Defense Volunteer Offices have both provided military and civilian hospitals with musical programs. One of the main founders of music therapy in civilian hospitals, particularly mental hospitals, was Willem Van de Wall, a professional harpist, who, after World War I joined the Pennsylvania Bureau of Mental Health, he organized at Allentown, Pa., one of the first formal music therapy program in the United States. His book « Music in Hospitals » has become a classic in the field of music therapy. By the end of World War II, 192 hospitals had some sort of music therapy program, and today more than 2500 music therapists are working in hospitals. More research has been done in the field of music therapy as far as back in the 1930’s when it was demonstrated that music increases metabolism, increases or decreases muscular energy, accelerates respiration or decreases its regularity. It has significant effects on pulse and blood pressure, lowers the threshold for sensory stimuli, and has remarkable impact on internal secretions.Music, in the context of music therapy, is not a form of entertainment, but it has been structured in a way to ensure its therapeutic potentials and eliminate any possible adverse effect. It is worth mentioning that in music therapy, the word music implies four different designations: 1/ the music itself; 2/ listening to music; 3/ having the music in the environment; 4/ the making of music. According to William Sears, music therapy works according to a process and construct that depend on different properties inherent to music that are delineated in the following classification:

page fourMusic TherapyA.

Experience within structure 1. Music demands time-ordered behavior. a/ Music demands reality-ordered behavior b/ Music demands immediately and continuously objectified behavior 2. Music permits ability-ordered behavior a/ Music permits ordering of behavior according to physical respons levels b/ Music permits ordering of behavior according to psychologica response levels 3. Music evokes affectively ordered behavior 4. Music provokes sensory-elaborated behavior a/ Music demands increased sensory discrimination b Music may elicit associations usage and extra-musical ideas and associationsB. Experience in self-organization1. Music provides for self-expression2. Music provides compensatory endeavors for the handicapped individuals3. Music provides opportunities for socially acceptable reward and non reward .4. Music provides for enhancement of pride in self a/ Music provides for successful experience b/ Music provides for feeling needed by others c/ Music provides for enhancement of esteem by others.C. Experience in relating to others 1. Music provides means by which self-expression is socially acceptable 2. Music provides opportunity for individual choice of response in groups 3. Music provides opportunities for acceptance of responsibilities and others a/ Music provides for developing self directed behavior b/ Music provides for developing other-directed behavior 4. Music enhances verbal and non-verbal social interaction and communication 5. Music provides for experiencing cooperation and competition in socially acceptable forms 6. Music provides entertainment and recreation necessary to the general therapeutic environment 7. Music provides for learning realistic social skills and personal behavior patterns acceptable in institutional and community peer groups »On a psychoanalytic point of view, music is a primitive preverbal form of communication that is more likely to elicit more primitive emotions. Its rhythm and its fluidity often evoke the sounds of the waves, an immensity that dominates the world, that is why music can cause a regression to an infantile stage where the subject feels in control, omnipotent; music helps the child to sublimate his aggressive impulses at an emotiona1 level rather than at a higher cognitive level. On the other hand, Van de Wall believes that music causes in man a series reactions that are both physical and emotional in nature. 1. The sensory-motor reactionIt has been observed that under the influence of music, mainly from its rhythm, the

Page five

Music Therapy subject would start to kick his legs or rock his body or clap his hands to the rhythm of the tune, this muscular reaction is automatic in nature and if the subject wants to restraint it, he has to provide extra effort to get control over this automatic muscular reaction. Thus the respiratory and cardio-vascular changes are directly related to this bodily reaction. Van de Wall sees a practical application in this phenomenon: « when the soldiers are tired during long marches and scouts come to the end of a difficult hike, a spirited song or the strains of a snappy band will release new energies and keep them going with renewed spirit »2. The mental responsesWhen a subject listens to a piece of music, certain feelings either pleasant (joy and satisfaction) or unpleasant (anger or sorrow) are elicited. This emotional response is largely subjective and indicative of a tendency to ego-centricity, but when the subject makes an effort to analyze, to understand the music he is listening to, the reaction is more objective, more music-oriented. This observation can have an application in helping very withdrawn people to project themselves more in the objective world. Because listening to music is an esthetic experience, the music-centered subject would try to catch the meaning of the music, the level of success of the performer. He would be involved in an intellectual activity that can pull him out of a state of inertia caused say, by a severe depression or state of regression. Listening to music also entails an associational response. The state of mind, the environment, the situation in which one listens to a piece of music are going to be associated with this piece of music for quite a while. Thus if we are in good spirit when listening to a piece of music, then later on when we hear the same piece of music, it is likely that we would experience pleasurable feelings. This phenomenon has been called « spreading of an affect », it explains why we can react so differently to a same piece of music and this needs to be taken into consideration when devising any music therapy program.As described above, music can be a powerful psychotherapeutic instrument even though it operates at a more primitive level. Ira Altshuler thinks that it is precisely because of this primitive level of functioning that music would work in situations that would be otherwise impossible to influence. In people whose » higher brain functions are impaired and cause them to be inattentive, distractible, confused, depressed, hallucinated, music reaching them first emotionally at a thalamic level (the thalamic response will cause the patient to tap his foot, sway his body or nod his head) will be able to reach the higher cortical level through the thalamic connections. Altshuler points out that many points (other than the ones mentioned above) need to be taken into consideration when organizing a music therapy program:Establishing contact Clinical experiences have shown that certain type of music are used to reach certain type of state of mood. Thus gay music would not influence a depressed patient who would respond initially better to soft music. This is known as the « iso » (equal) principle. It is only after the patient has been « captured » by the matching tempo, that we can switch to an opposite tempo to obtain the therapeutic effect that is sought after. But the « iso » criteria is not only based on the mood, it is also based on religious, ethnic or cultural background. 2. Order of presentationHere, music is assessed based on rhythm, melody, harmony, mood and pictorial

Page six

Music Therapyassociation and considered in this order when presented to the patient. Rhythm is first offered, because it is the most primitive and powerful factor, melody and particularly harmony interest more cerebellar functions, and pictorial association is the realm of higher cortical functions. Organizing a music therapy program must start with the concept that this service must be part of the multidisciplinary treatment team. The music therapy department must work in harmony with the medical staff, nursing staff, social workers and the activity therapy in harmony with the medical staff, nursing staff, social workers and the activity therapy department. It must develop a program where patients can be helped at a group level. This would need a lot of input from the rest of the treatment team, as much as the department would be a consultant to the team. The music therapy program must set up its treatment goals, the type of patients who can be helped, those objectives need certain level of flexibility in order to deal with a patient population that is indeed complex. It must decide on the type of instrument used, the nature and level of participation of the patients, its time schedule and coordination of activities with other departments. The choice of the musician staff is also important. Even though Mersenne in his « Les preludes de l’Harmonie Universelle » believed that certain types of character are more suitable to the composer or the practical musician, we believe that any good musician could do the job provided he/she knows the nature and objectives of the job and is willing and able to work with his patients and other staff. We will address later the technical questions of what type of patients could be helped by music therapy and how they could be helped. In summary, after more than half a century being officially introduced in hospitals, music therapy has assessed itself as a powerful element of the treatment program, particularly for psychiatric patients. The author of this paper has a personal experience about it: for a non specialist to write about such topic is not much fun, soft music in the background has helped him get through this ordeal.

Son Vi Nguyen, M.D.Houston, summer 1987

Dr. Nguyen is former Assistant Professor of Psychiatry at : – The University of Texas School of Medicine, Department of Psychiatry and Behavioral Sciences at Houston- Texas Tech University- The Texas College of Osteopathic Medicine

He was also former Medical Director of several Private Psychiatric Hospitals:- The Psychiatric Pavilion- Cedar Creek Hospital- Quest Residential Treatment Center- Golden Phoenix Geriatric Hospital.