Music therapy

David Aldridge Collected Papers


The Music of the Body:
Music Therapy in Medical Settings
David Aldridge
If w e consider our human biology
in terms of musical form rather than
mechanical construction and our
response to biological challenges
as a repertoire of improvisations,
w e may find that disease restricts
our ability t o improvise new
solutions to challenges-in musical
terms, restricts our ability to play
improvised music.
David Aldridge, Ph.D., is associate professor of
clinical research in the Faculty of Medicine at
the University of Witten Herdecke in Germany,
and the European editor for the journal The Arts
in Psychotherapy. He is the coeditor (with
George Lewith) of a handbook of clinical research
methods for complementary medicine (Hodder
and Stoughton 1992).
ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
ALDRIDGE
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?
I
-Michael Foucault (in Rabinow 1986)
I
The use of music as a healing agent appears
to be common to many cultures. Since David
first played to soothe King Saul, there has
been the recognition that music can bring
relief to the afflicted. That the affliction in
Saul's case is usually presented as depression,
though it might well have been an acute ep-
isode of asthma, only serves to emphasize
both the difficulty of historical interpretation
and the generalness of reports about music as
therapy. An earlier article in Advances, Robert
Omstein and David Sobel's "Coming to Our
Senses" (19891, reminds the reader of the
necessity of enjoying the senses for the pro-
motion of health. This paper goes one step
further and presents the use of music as ther-
apy, as it appears in the medical literature
during the last decade. (References to psy-
chiatric settings have been excluded.)
T h e medical and nursing press contains
a series of overviews about music therapy,
ranging from letters to full-scale articles. The
principle emphasis in this material is on the
soothing ability of music and on the value
of music as an antidote to an overly techno-
logical medical approach (Bailey 1985; Brody
1988; Carlisle 1990; Fischer 1990; Harcourt
1988; Harvey & Rapp 1988; Kartman 1984;
McDermit 1984; Morris 1985; Olivier 1986;
Ornstein & Sobel 1989; Paren t-Bender 1986;
Pouget 1986; Rowden 1984; Stem 1989; Thom-
as 1986; Wein 1987; Ziporyn 1984). Most of
these articles are concerned with what is
called passive music therapy-the playing of
17
1
 ALDRIDGE
Music therapy has been studied as
an aid in treating specific medical
problems, including coronary
care, cancer pain management,
and neurological disorders.
usually prerecorded music to patients-and
they emphasize the necessity of healthy
pleasures like music, fragrance, and beau-
tiful sights in reducing stress and enhancing
well-being.
Music therapy is actually more varied
and more complex. In some methods the pa-
tient is indeed a "passive" listener, and live,
or recorded music, is played at the discretion
of the therapist. But even in this situation,
some therapists challenge the term "passive,"
insisting that listening is an active process.
This is supported, for example, by an ap-
proach that uses imagery stimulated by se-
lected musical passages (Bonny 1978; Bonny
1975; Ornstein & Sobel1989). Other methods
of music therapy consist of or include active
playing of musical instruments and singing,
individually or in groups. Some of these
approaches incorporate musical improvisa-
tion as the key component of the therapeutic
activity.
There is growing evidence to support
the claims of music therapists that music can
contribute to healing, although the research
methodologies used to substantiate such
claims often lack scientific rigor or are uncon-
ventional in their approach. It is important to
emphasize that some music therapists reject
quantitative research outright. They believe
that such methods discount the important
individual and qualitative aspects of their
work as artists working in medical settings,
and seek to find alternative forms of research
suitable to the arts in clinical practice. Some
believe that the study of music therapy
provides an opportunity to develop expres-
sive quality-of-life measures for people with
serious illnesses, measures that are not solely
based on verbal reporting (Aldridge 1989c;
Aldridge 1991a).
-
18 ADVANCES, The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
Readers may be surprised to learn that
music therapy has been studied as an aid
in treating a variety of medical problems,
including coronary care, cancer pain manage-
ment, and neurological disorders. In this
article, we shall move from general consider-
ations to specific observations. We begin with
the general use of music in hospital settings,
and then turn to detailing the use of music
therapy to treat particular problems.
Music Therapy
in General Medicine
For a while after World War I1 music therapy
was intensively used in American hospitals
in the rehabilitation of the wounded, with the
aim of raising their morale and as a relief
from the tedium of hospital life (Schullian &
Schoen 1948).Psychiatrists were quick to see
the benefits of music for enhancing mood and
promoting relaxation in their patients. Since
then some hospitals, in mainland Europe
particularly, have incorporated music therapy
within their practice (Aldridge & Verney
1988; Goloff 1981; Jedlicka & Kocourek 1986;
McCluskey 19831, carrying on a tradition of
European hospital-based research into the use
of music as therapy (Leonidas 1981).
The postwar European initiatives were
concerned with rehabilitation and psychiatry.
However, with the development of the per-
spectives of psychosomatics, and with a
growing tolerance of alternative and comple-
mentary medical initiatives, music therapy in
Europe has been applied to a wide range of
medical problems, including cancer care, the
treatment of patients with severely compro-
mised immune systems, the management of
pain, and the relief of anxiety.
The nursing profession in particular
has promoted the general value of music
therapy, especially in the United States, and,
even when music therapists are not available
(Cook 1981), has championed its use as an
important nursing intervention (Cook 1986;
Fletcher 1986; Frandsen 1989; Frank 1985;
Glynn 1986; Grimm & Pefley 1990; Keegan
1989; Kolkmeier 1989; Marchette, Main &
Redick 1989; Moss 1987; Mullooly, Levin &
2

Feldman 1988; Prinsley 1986; Rice 1989;
Sammons 1984; Updike 1990; Walter 1983). At
the same time little work has been published
about the benefits of music therapy in general
medicine. The overall expectation is that the
recreational, emotional, and physical health
of the patient is improved (Goloff 1981).
Music, t h e H e a r t ,
and Respiration
To explore the specific physiological effects
of music, we begin with the effects of music
on heart rate and blood pressure in healthy
people. If music can influence such physio-
logical parameters in healthy individuals, the
findings would support the possibility that
music can be used therapeutically for patients
who have problems with heart disease or
hypertension. As we consider studies in this
area, we shall be led to examine the different
conceptualizations of time and their possible
relation to health and disease.
The effects of music on the heart and
blood pressure have been a favorite theme
throughout history. We can trace the medical
study of such effects to an early issue of The
Lancet. In 1929, two researchers (Vincent &
Thompson 1929) made an attempt to discover
the effect on blood pressure of listening to
music on the gramophone and radio. Subjects
were divided into "musical," "moderately
musical," and "nonmusical" groups. The cri-
teria for musicality were not defined, except
to mention that the ideal "musical" group
were "interested amateurs of good taste and
emotional susceptibility, who can, and hab-
itually do, enjoy music in a naive manner
without the exercise of too much critical
f.iculty."
People with varying degrees of musical
competence responded differently to volume,
melody, rhythm, pitch, and type of music.
Melody produced the most marked effect.
When the music began, a rapid fall in blood
pressure occurred in the "musical" subjects.
However, during the music, a change in
melody, particularly if the music was soft,
resulted in a rise in blood pressure. Volume
also produced an apparent, although less
ADVANCES, The]ournal of Mind-Body Health Vol. 9,No.l Winter 1993
David Aldridge Collected music therapy papers
ALDRIDGE
If music can influence physiological
conditions like heart rate or blood
pressure in healthy people, then
perhaps i t can be used therapeuti-
cally t o help patients with heart
disease or hypertension.
marked, effect in the least musical groups. In
general, listening to music was accompanied
by a fall in blood pressure when the music
began. However, during the music, blood
pressure rose slightly in correlation with
changes in melody, rhythm, pitch, and vol-
ume, according to the musical susceptibility
of the listener. .
M o r e recently, in 1972, a valuable
paper by Bason and Celler (1972) found that
the human heart rate could be varied over
a certain range by synchronizing the sinus
rhythm-that is, the normal heart rhythm-
with an external auditory stimulus. An au-
dible click was played to the subject at a pre-
cise time in the cardiac cycle. When the click
occurred within a certain range of the cycle,
the heart rate could be increased or decreased
up to 12 percent in a period of 3 minutes or
less. Fluctuations in heart rate caused by
breathing remained, but these tended to be
less when the heart was entrained with the
audible stimulus. When the click was not
within the appropriate range of the cardiac
cycle, no change would occur. Bason's paper
is important for supporting the proposition
often made by music therapists that meeting
the tempo of the patient is the initial key to
therapeutic change.
An extension of this premise, that mu-
sical rhythm is a pacemaker, was investigated
by Haas and her colleagues (Haas, Distenfeld
& Axen 1986). In this study, the researchers
examined the effects of musical rhythm on the
respiratory pattern, a pattern that serves both
metabolic and behavioral functions. Meta-
bolic respiratory pathways are located in the
lower pons and medulla, whereas the behav-
ioral respiratory pathways are located mainly
3
 ALDRIDGE
in the limbic forebrain structures which lead
to vocalization and complex behavior. There
appear to be so-called pattern generators in
the brain and spinal cord capable of synchro-
nizing metabolic and locomotor activity,
thereby reinforcing an underlying uncon-
scious rhythmic relationship between the two.
Because there are metabolic conse-
quences of active music making inseparable
from neural activity, the researchers chose
listening to music as the stimulus condition.
Haas hypothesized that the external musical
activity would have a direct influence as a
pacemaker on respiratory patterns but would
have only minimal effect in itself on metabolic
changes and afferent stimuli-that is, would
not induce any gross motor movements.
Twenty subjects were involved in this
experiment. Four were experienced and
practicing musicians, six had formal musical
training but no longer played a musical in-
strument, and the remaining ten had no
musical training. The subjects first listened
to a metronome set at 60 beats per minute
and tapped to that beat on a microphone after
a baseline period. The subjects were then
randomly presented five stimulus conditions:
four musical excerpts to which they also t a p
ped along, and one period of silence. Respira-
tory data, including respiration frequency and
airflow volume, were collected, along with
heart rate and carbon dioxide released at the
end of the breath, to measure gross metabolic
changes and chemical respiratory drive.
The researchers found no appreciable
changes in heart rate during the experiment
indicating metabolic changes. But they also
found that breathing was coordinated with
the musical rhythm, expressed in the finger
tapping. For nonmusically trained subjects
there was little coordination between breath-
ing and musical rhythm, while for trained
musicians there was a tighter coupling of
breathing and rhythm. The Haas study, then,
suggests that motor activity-finger tapping
here-and respiration can be synchronized
by an external musical rhythm.
This finding fits related findings in
other studies-that muscle activity decreases
when one performs a motor task accompa-
20 ADVANCES,The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
nied by a musical rhythm similar to the
rhythm of the subjects' normal heart rate
(Safranek, Koshland & Raymond 1982); that
respiratory rhythm follows the rhythm of
music within certain limits of variability
(Diserens 1920); and that, perhaps most
intriguingly, there is a relationship between
disturbed functional cardiac a r r h y t h m i a s
with disturbed respiration-and musical
rhythmic ability (Richter & Kayser 1991).
I n the last study, the researchers
Kayser and Richter hypothesized that patients
with cardiac arrhythmias perform worse in
perceiving and producing rhythm than do
healthy controls. Thirty-one patients with
functional cardiac arrhythmias were com-
pared with 31 control subjects. Subjects were
required to mark on a sheet of paper rhythmic
patterns played for them on a tape recorder,
and to tap synchronously with repeating
patterns on the tape recorder. Patients with
dysrhythmias had significantly poorer abil-
ities in musical perception and rhythmic
anticipation than healthy controls. Patients
with a rapidly beating heart (tachycardia)
showed a particularly poor sense of rhythm
perception and synchronization.
Time and the Musical
Expression of Disease
Studies such as this support the hypothesis
that people with disease may perceive, and
respond to, music differently than do healthy
people. It may be that different diseases dif-
ferently affect the responses we have to
music. If we consider our human biology in
terms of musical form rather than mechanical
construction and our response to biological
challenge as a repertoire of improvisations,
we can view disease as a restriction of our
abilities to improvise new solutions to chal-
lenges-in musical terms, a restriction of our
abilities to play improvised music (Aldridge
1989a, Aldridge 1991~).
In regard to heart disease, for example,
it is entirely possible to describe the differ-
ences in Type A and Type B behavior in
musical language, suggesting that the Type
A behavior, said to constitute a risk factor for
4
 ALDRIDGE

Table 1
Musical Elements in Contrasting Characteristics of Type A and B Behavior

Type A Behavior Type B Behavior Musical Components

increased voice volume voice quieter volume

fast speech rate
short response latency
emphatic voice
hard metallic voice
less mutuality
trying to keep control
increased reactivity
increased heart rate
higher cardiovascular
arousal maintained
slower speech rate tempo
longer response latency phrasing
less emphasis expression/articulation
melodic voice timbre
increased mutuality musical relationship
less need for control musical relationship
moderate reactivity responsive
decreased heart rate tempo
cardiovascular arousal dynamic
returns to lower level

The table lists the contrasting characteristics of Type A and B behavior end then identifies the musical
element that one could ascribe to such characteristics. Is the behavioral disturbance of heart disease
something like a disruption of musical patterns? Could music therapy be used to help
regulate such disturbances?

heart disease, may express a repertoire of
body response which is "musically limited."
Table 1 identifies the musical components in
the contrasting traits that distinguish Type A
and B behavior.
The Type A behavior pattern has been
characterized as an expression of the way in
which an individual responds to, and pro-
vokes, environmental demands. Helman
(1987) refers to this view of the cause of heart
disease as a cultural construction that in-
volves the "unique social and symbolic char-
acteristics of Western time." In this view, we
are "the embodiment (both literally and figur-
atively) of the values o f . . . Western society."
The individual is caught in the contradictions
of selfdemand and societal demand, which
for some people may become pathogenic.
At the center of this cultural construc-
tion is the notion of time. The predominant
form of Western time is monochronic. Time
is conceived as an external order imposed on
the individual. Such a view developed from
the need of a modem industrialized society
to have a universal public order by which the
means of production could be coordinated
and the actions of many individuals regu-
lated. In this form, deadlines have to be met,
the passage of time is linear, and its measure-
ment is quantitative. This is time as chronos,
and the concept is contained in the idea of
chronic illness.
However, there is an alternative con-
ccptualization of time that is personal rather
than public. This is time as hiros. It is poly-
chronic, and closer to the emerging biological
understanding of physiological times that are
rhythmically entrained (Johnson 19861, not to
an external clock, but to the person as a whole
organism. In this conceptualization, time is
in a state of flux; it is concerned with flexibil-
ity and the convergence of multiple tasks.
Time is seen as springing from the self. We
may have to consider the idea of heart disease
as a kairotic illness where personal biological
time is out of step with external imposed
time.
Some authors do indeed suggest that
when we try to impose a fusion between
external clock time and personal physiologi-
cal time, our physiology is affected (Dossey
1982, Helman 1987). Helman writes:

ADVANCES, The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993 21

David Aldridge Collected music therapy papers 5

 ALDRIDGE
Western society is unique in trying to
impose a fusion between clock time and
individual physiology-between rates
of bodily movement, speech, gestures,
heartbeat, and respiration-and the
small machine strapped to the wrist or
hung on the wall. "Rush hour," dead-
lines, diaries, appointments, and time-
tables all affect the physiology of modem
[people], and help construct hidher
world view and sense of identity.
In music therapy there are possibilities
to experience these varying aspects of time
as they converge in their seamless reality.
The tension between personal and public
time may be heard when improvised music
is played in music therapy. Apart from stim-
ulating experiences that differentiate and
develop those conceptualizations, music ther-
apy may promote an experience of a timeless
qualitative reality essential in particular to
the recovery of patients with heart disease.
Relieving Anxiety and Stress
in Cardiac Patients
Now we turn to the direct use of music in
coronary care.*
Several authors have investigated the
relationship between heart rate and anxiety
in the settings both of hospital care (Bolwerk
1990; Bonny 1983; Davis-Rollans & Cunning-
ham 1987; Gross & Swartz 1982; Guzzetta
1989; Philip 1989; Wein 1987; Zimmerman,
Pierson & Marker 1988) and of dentistry
(Lehnen 1988).The intent usually has been to
reduce anxiety in chronically ill patients or to
treat anxiety in general (Chetta 1981; Daub &
Kirschner-Hermanns 1988; Fagen 1982; Gross
& Swartz 1982; Heyde & von Langsdorff
*The relationshipbetween listening to music and
changes in respiration has been investigated in
various situations other than coronary care-
with college-student subjects (Formby et al. 19871,
psychotherapy patients (Fried 19901, various
chronic illness groups undergoing group psycho-
therapy (Gross & Swartz 1982), orthopaedic and
abdominal surgery patients (Lehmann, Horrichs
& Hoeckle 1985), chronic lung disease patients
(Tiep et al. 1986), and in a study of mental stress
and exercise (Brody 1988).
22 ADVANCES,The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
1983; Lengdobler & Kiessling 1989; Schmut-
termayer 1983; Standley 1986; Zimmerrnan
et al. 1989).
A hospital situation fraught with anxi-
ety for the patient is the intensive care unit.
For patients who have suffered a heart attack,
and whose heart rhythms are potentially
unstable, the setting of the coronary care unit
is itself likely to be anxiety provoking, an
experience that may reinforce the physiologi-
cal and psychological reactions that initially
led to the cardiac distress of the patient.
Several authors have assessed the use
of tape-recorded music delivered through
headphones to reduce anxiety and so reduce
stress (Updike 1990) in patients in intensive
or coronary care clinics. Bonny has identified
a series of musical selections for tape record-
ings that she believes has sedative effects
(Bonny 1983; Bonny & McCarron 1984; Bon-
ny 1975) and also selections that can induce
relaxation and help the patient engage in
imagery (Bonny 1978),but none of these
assertions has been empirically confirmed.
However, Updike (19901, in an observational
study, supports Bonny's impression that there
is a decreased systolic blood pressure, and a
beneficial mood change from anxiety to
relaxed calm, when sedative music is played.
Davis-~ollans(Davis-Rollans & Cun-
ningham 1987) describes the effect of a 37-
minute tape of selected classical music on the
heart rate and rhythm of 24 coronary care unit
patients. (The selections consisted of the first
movement of Beethoven's Symphony No. 6,
the first and fourth movements of Mozart's
Eine klein Nachtmusik, and Smetana's The
Moldau.) Twelve of the patients had had heart
attacks and another 12 had a chronic heart
condition. Patients were exposed to two ran-
domly varied &?-minuteperiods of continu-
ous monitoring, one period with music
delivered through headphones, the other a
control period without music during which
the background noise of the unit was heard
through the headphones. The heart-attack and
chronic-heart-condition patients showed no
differences. Eight patients reported a signifi-
cant change to a happier emotional state after
listening to the music (a result replicated in
6
 ALDRIDGE

Figure 1
Emotional State of 24 Cardiac Patients Before and After Listening to Music Selections
(12 patients with heart attacks, 12 with chronic heart conditions)

tranquil happy worried sentimental sad both happy, other

satisfied romantic depressed satisfied and
tranquil

The shifts in feelings occurred from listening to music over headphones. There were no significant
differences between the responses of the patients who had heart attacks and the patients who had
chronic heart conditions. No changes in feelings were produced by the control intervention of
listening to the background noise of the coronary care unit over headphones.

Updike's observational study [Updike 1990]),
although there were no significant changes in
specific physiological variables during the
music periods. Relevant here is the argument
bv Cassem and Hackett (1971) that relieving
depression is beneficial to the overall status of
coronary care patients. Figure 1 displays the
various emotional shifts in the patients that
appeared after listening to the music.
A study by Guzzetta (1989) sought to
determine whether relaxation and music were
effective in reducing stress in patients admit-
ted to a coronary care unit with the presump-
tive diagnosis of acute myocardial infarction.
In this experimental study, 80 patients were
randomly assigned to a relaxation, music
therapy, or control group. The relaxation and
music therapy groups participated in three
sessions over a two-day period. The relax-
ation group received a tape-recorded relax-
ation induction. The music therapy group
received the relaxation induction and a 20-
minute musical tape selected from three alter-
native musical styles (soothing classical
music, soothing popular music, and nontradi-
tional music defined as "compositions having
no vocalization or meter, periods of silence,
and an asymmetric rhythm"). Stress was
evaluated by peak (apical) heart rates, periph-
eral temperatures (low in cardiac patients),
cardiac complications, and qualitative data.
T h e data revealed that lower apical
heart rates and raised peripheral tempera-
tures occurred more often in the relaxation
and music therapy groups than in the control
group. The incidence of cardiac complications
was also lower in the intervention groups.
Finally, most intervention subjects believed
that such therapy was helpful. Thus, both
relaxation and music therapy were found to
be effective modalities of reducing stress in
these patients, with the combination of relax-
ation and music listening more effective than
relaxation alone. It should be noted further
that apical heart rates were lowered in re-
sponse to music over a series of sessions, thus
supporting the argument that the effect of
music therapy on physiological parameters
occurs over time, and is therefore adaptive.

ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993

David Aldridge Collected music therapy papers 7

 ALDRIDGE

The positive finding of this study is in
contrast to the failure of Zimmerman and
colleagues (Zimmennan, Pierson & Marker
1988) to find an influence of music on heart
rate, peripheral temperature, blood pressure,
or anxiety. However, Zimmerrnan's study
allowed for only one intervention of music.
Zimmennan examined the effects of
listening to relaxation-type music and focused
on self-reported anxiety and on selected phys- , In the study by Bason and Celler (1972), the
iologic indices of relaxation in patients with
suspected myocardial infarction. Seventy-five , matching the heart rates of their subjects with
patients were randomly assigned to one of
two experimental groups-one group listened
to taped music over headphones, the other to ' rate, the music should match the individual
"white noisef'*-or to a control group. The
Spielberger State Anxiety Inventory (Spiel-
berger 1983) was administered before and
after each testing session, and blood pressure,
heart rate, and digital skin temperatures were
measured at baseline and at 10-minute inter-
vals for the 30-minute session. The study
revealed no significant difference among the
three groups in state anxiety scores or phys-
iologic parameters. Analyses were then con-
ducted of the combined experimental groups
and showed that significant improvement
occurred in all of the physiologic parameters.
This finding reinforces the benefit of rest and
careful monitoring of patients in the coronary
care unit, but adds little to the understanding
of music interventions.
Bolwerk (1990) set out to relieve the
state anxiety of patients in a myocardial in-
farction ward using recorded classical music
(Bach's Largo, Beethoven's Largo, Debussy's
Prelude to the Afternoon of a Faun). Forty adults
were randomly assigned to two equal groups,
one of which listened to relaxing music
during the first four days of hospitalization,
the other of which received no music. There
was no controlled "silent condition." While
there was a significant reduction in state anxi- I
ety in the treatment group, state anxiety also
fell comparably in the control group. The
"White noise" or "synthetic silence" is an attempt
to block out environmental noise. In this case it was
a tape recording of sea sounds, which themselves
reasons for this overall reduction in anxiety
may have been that after four days the
I
situation had become less acute, the setting
had become more familiar, and the fact that
, by then a diagnosis had been confirmed.
In all these studies patients listened to
, music (or other sounds), and in thiscontext it
is relevant to recall the different possibilities
suggested by earlier-noted studies in which
people in effect become the music makers.
researchers influenced heart rate by first
a musical rhythm. This finding suggests that
in studies on the influences of music on heart
patient. Matching also makes psychological
sense, since different people have varied reac-
tions to the same music. Further, because
improvised music necessarily "meets" the
tempo of the patient, it may be that such
playing will have a larger impact than does
"passive" listening to music.
The finding of Haas and colleagues
(19861, that listening coupled with tapping
synchronizes respiration pattern with music
rhythm, additionally suggests that active
music playing can be used to influence
physiological parameters and that this syn-
chronization can easily be developed (Ald-
ridge 1989a).
Cancer Therapy, Pain
Management,
and Hospice Care
Cancer and chronic pain can require com-
plex coordinated resources that are not only
medical but also psychological, social, and
communal (Aldridge 1988; Coyle 1987; Fagen
, 1982; Frampton 1986; Frampton 1989; Gilbert
1977; Heyde & von Langsdorff 1983; Walter
1983). Hospice care in the United States and
England has similarly attempted to meet the
need for the varied palliative and supportive
services that provide physical, psychological,
and spiritual care for dying persons and their
families (Aldridge 1988; Coyle 1987; Framp-
l

were rhythmic (Philip 1989; Zimmennan 1989). ton 1986; Heyde & von Langsdorff 1983; Jacob

24 ADVANCES, The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993

. . ---

David Aldridge Collected music therapy papers 8


1986). In all these settings, supportive services
are based upon an interdisciplinary team of
health care professionals and volunteers.
Music therapy is sometimes included
in such services.
In the Supportive Care Program of the
Pain Service to the Neurology Department
of Sloan-Kettering Cancer Center, New York,
a music therapist was part of the supportive
team along with a psychiatrist, nurse-clini-
aan, neuro-oncologist, chaplain, and social
worker (Bailey 1983; Coyle 1987). Music
therapy was used to promote relaxation, to
reduce anxiety, to supplement other pain
control methods, and to enhance commu-
nication between patient and family (Bailey
1983,1984,1985). Depression was a common
feature of the patients in the program, and
music therapy was thought to relieve this
state and enhance the patient's quality of life. ,
A better researched phenomenon is
the use of music to control chronic cancer
pain, in studies that usually favor tape-
recorded interventions rather than the ele-
ment of live performance. Combinations of
pharmacological and nonpharmacological
pain management are acceptable in modem
medicine (McCaffery 1990), with nonphar-
macological interventions generally being
used as a form of distraction.
This is the approach of a study by
Zimmerman and colleagues (Zimmerman,
Pozehl, Duncan & Schmitz 1989) who inves-
tigated whether playing self-selected taped
music combined with suggestions of relax-
ation, affected patients suffering with chronic
pain. The study sought to determine from
self-reports whether the music provided
additional relief to patients receiving pain
medication. In both the experimental and the
control groups, the blood level of analgesic
was controlled. Music was found to decrease
the overall level of the pain experience as
reported by patients randomly assigned to the l
music treatment group. Furthermore, there
was a significant reduction in the sensory, as
well as the affective, component of the pain as
measured by the McGill Pain Questionnaire
(Melzack 1975)-that is, not only was suffer-
ing as an emotional experience reduced, the
ADVANCES, The Journal of Mind-Body Health Vol. 9, N o 1 Winter 1993
- -.- . - - - - -
David Aldridge Collected music therapy papers
ALDRIDGE
In a study of chronic pain, patients
playing self-selected tape-recorded
music reported not only a reduction
in the emotional experience of
suffering but also a reduction in
the actual sensation of pain.
actual physical sensation of pain, according to
the patients, was also reduced. This would
appear to confound the common belief that
music therapy primarily induces qualitative
emotional experiences and to support the
contention that music therapy can have a
direct influence upon sensory parameters.
In addition to reducing pain, particu-
larly in pain clinics (Godley 1987; Locsin 1981;
I
Wolfe 19781, music has been offered during
chemotherapy as a form of relaxation and
distraction (Kammrath 1989) to bring overall
1 relief (Kerkvliet 1990) and to reduce nausea
and vomiting (Frank 1985). Using taped
music and guided imagery in combination
with pharmacological antiemetics, Frank
(1985) found that state anxiety was signifi-
cantly reduced, resulting in less vomiting
, even though the experience of nausea re-
I
mained the same. Although Frank's study
was not controlled, leading to the possibility
8 that the reduced anxiety may have been due
to the natural fall in anxiety levels at the end
1 of a chemotherapy treatment, the study
1 consisted of patients who had previously
, experienced chemotherapy and who were
1 conditioned to experience nausea or vomiting
1 in conjunction with chemotherapy. That the
subjects of the study felt relief and vomited
less is an encouraging sign in the use of music
1 therapy in minimizing the distressing effects
1 of chemotherapy.
In the control of pain, time to listen,
,l separated from the surrounding influence of
' I the hospital unit by the use of headphones,
may itself be an important intervention. This
may be the underlying import of a study by
1
l
Rider (1985) who found that perceived pain
1 was reduced in a hospital situation in re-
. . 25
9
 ALDRIDGE
Music appears t o be a key in helping
patients w i t h seemingly hopeless
neurological devastation regain
their "lost" language capabilities.
sponse to classical music delivered through
headphones. It could be concluded from
his work that isolation from environmental
sounds, canceling out external noise, has a
positive benefit for the patient regardless of
inner content, whether the alternative is
music, relaxation induction, or silence.
Neurological Problems
Neurological diseases often result in physical
and/or mental impairment, and in many
cases their abrupt appearance are traumatic
for the patient and his or her family (Jochims
1990). Music appears to be a key in recovering
former capabilities, language capabilities
especially, in what at first can seem like
hopeless neurological devastation (Aldridge
1991b; Jones 1990; Sacks 1986).
For some patients with brain damage
following head trauma, the problem may be
the temporary loss of speech (aphasia). Music
therapy can play a valuable role helping a
person regain his or her speech (Lucia 1987).
Melodic Intonation Therapy has been devel-
oped to fulfil1 such a rehabilitative role
(Naeser & Helm-Estabrooks 1985; 0'Boyle &
Sanford 1988).This therapy involves embed-
ding short propositional sentences into sim-
ple, often repeated, melody patterns to which
patients tap their fingers. Changes of inflec-
tion, pitch, and rhythm in the melodies are
selected to parallel what would be the natural
speech prosody of the chosen sentence.
The therapy stimulates articulation,
fluency, and the shaping procedures of lan-
guage, all of which are akin to musical
phrasing, and this encourages the singing of
familiar songs. Singing within a context of
communication motivates a patient to com-
municate and thus promotes, it is hypoth-
esized, the act of intentional verbal behavior.
26 ADVANCES, Thie Journal of Mind-Body Health Vol. 9,No.1 Winter 1993
David Aldridge Collected music therapy papers
I In infants the ability to reciprocate the com-
munication of another person is an important
I
element in communicative competence (Mur-
ray & Trevarthen 1986; Street & Cappella
19891and is vital in acquiring speech (Glenn
& Cunningham 1984). Music therapy strate-
1 gies for neurologically damaged adults
I
attempt to utilize the same processes of re-
ciprocation with the expectation that they
will stimulate those brain functions that sup-
port, precede, and extend functional speech
I
recovery, for these brain functions are essen-
tially musical and rely upon brain plasticity.
Combined with the ability to enhance
word retrieval, music can be used to improve
breath capacity, encourage respiration-phon-
ation patterns, correct articulation errors
caused by inappropriate rhythm or speed,
and prepare the patient for articulatory move-
ments. In this sense music offers a sense of
time which is not chronological, which is not
accessible to measurement, and which is vital
in the coordination of human communication
(Aldridge 1989a; Aldridge 1991~).
Jacome (1984) tells of a stroke patient
who was dysfluent and had difficulty finding
words. Yet, he writes, the patient
frequently whistled instead of attempting
to answer with phonemes.. . he spon-
taneously sang Spanish songs without
prompting with excellent pitch, melody,
rhythm, lyrics, and emotional intonation.
He could tap, hum, whistle, and sing
along. . . . Emotional intonation of speech
[prosody], spontaneous facial emotional
expression, gesturing, and pantomirnia
were exaggerated.
From this case study Jacome goes on
to recommend that singing and musicality
in aphasics be tested by clinicians, which
Morgan recommended in a case of aphasia
1 following stroke (Morgan & Tilluckdharry
1982)
l Evidence of the possible global strategy
1 of music processing in the brain-the possi-
bility that both brain hemispheres are in-
volved in this processing-is found in the
clinical literature. For example, in reporting
i
I on two cases of aphasia, Morgan and ~ i l l u c k i
, dharry (1982) describe spontaneous singing
by the patients as a welcome release from the
1 helplessness of being a patient. The authors
-. . . .. .-.--
10

hypothesized that singing was a means to
communicate thoughts externally which
could not be articulated vocally in speech.
Although the "newer aspect" of speech was
lost in the damage of the dominant hemi-
sphere for language, the older function of
music was retained, possibly because music is
a function distributed over both hemispheres.
Berman (1981) suggests that recovery
from aphasia is not a matter of new learning
by the nondominant hemisphere but a taking
over of responsibility for language by that
hemisphere. The nondominant hemisphere
may be a "reserve" of functions available in
case of regional failure, indicating an overall
brain plasticity (Naeser & Helm-Estabrooks
1985).Similarly, language functions may
shift across hemispheres with multilinguals
as compared with monolinguals (Karanth
& Rangamani 1988), or as a result of learning
and cultural exposure where music and lan-
guage share common properties (Tsunoda
1983).
That singing is an activity correlated
with certain creative productive aspects of
language may be an important point in this
context. An example is the case of a 2-year-old
boy of above-average intelligence who expe-
rienced seizures, manifested by tic-like
turning movements of the head (Herskowitz,
Rosman & Geschwind 1984). He induced
seizures, consistently, by his own singing but
not by listening to or imagining music, and
also induced them by his recitation and by
his use of silly or witty language such as pun-
ning. (Seizure activity as registered on an
electroencephalogram correlated with clinical
attacks and was present in both temporo-
central regions, especially on the right side.)
Aphasia is also found in elderly stroke
patients, and music therapy, as reported in
case studies, has been used effectively in
combination with speech therapy to restore
speech (Lehmann & Kirchner 1986).
Gustorff and colleagues (Aldridge,
Gustorff & Hannich 1990) describe the appli-
cation of creative music therapy to coma
patients who were otherwise unresponsive.
By matching her singing with the breathing
patterns of the patient, Gustorff stimulated
ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
ALDRIDGE
The responsiveness t o music of
patients w i t h Alzheimer's disease
is a remarkable phenomenon.
changes in consciousness which are both
measurable on a coma rating scale and appar-
ent to the eye of the clinician.
Problems of the Elderly
The psychosocial rehabilitation of older per-
sons is one of the main problems in health
policy (Haag 1985).About onequarter of the
over 65-year-olds face psychic problems, and
are without adequate treatment and rehabili-
tative care. The development of ambulatory,
community-based services as well as inten-
sive support for existing self-help efforts are
clearly necessary. Music therapy has been
suggested as a valuable part of a combined
treatment for the elderly (Dcllmann-Jenkins,
Papalia Finlay & Hennon 1984; Fenton &
McRae 1989; Gilchrist & Calucy 1983; Gross
& Swartz 1982; Lehmann & Kirchner 1986;
Morris 1986; Prinsley 1986; Rcnner 1986).
Music and Dementia in the Elderly
At the age of 56 Maurice Ravel, the composer,
began to complain of increased fatigue and
lassitude. His condition deteriorated progres-
sively (Henson 1988);and he lost the ability
to remember names, to speak spontaneously,
and to write. While his mind, he reports, was
full of musical ideas, he could not set them
down (Dalessio 1984). Eventually his intel-
lectual functions and speech deteriorated
until he could no longer recognize his
music. In other words, he showed many of
the features now associated with the condi-
tion known as Alzheimer's disease.
The responsiveness of patients with
Alzheimer's disease to music is a remarkable
phenomenon (Swartz et al. 1989). Despite the
language deterioration of such patients musi-
cal abilities appear to be preserved. Beatty
and colleagues describe a woman who had
severe aphasia, memory dysfunction, and
27
11
 ALDRIDGE
apraxia (an inability to perform intentional
movements), yet was able to read an unfamil-
iar song and perform on the xylophone,
which to her was an unconventional instru-
ment (Beatty et al. 1988).
In a case study Aldridge and Brandt
(1991a) suggest that music therapy is an im-
portant diagnostic tool in recognizing cogni-
tive and motor impairment in the elderly,
and a useful therapeutic adjunct in patient
care. Even though the patient they describe
may have been suffering from a pseudode-
mentia, the discussion further articulates the
value of using music therapy for the treat-
ment of the elderly, demented or depressed.
Table 2, which draws on this discussion,
compares the medical assessment of Alzhei-
mer's disease with an assessment based on
music therapy.
Certainly the anecdotal evidence sug-
gests that the quality of life of Alzheimer's
patients is significantly improved with music
therapy (Tyson 19891, accompanied by the
overall social benefits of acceptance and sense
of belonging gained by communicating with
others (Morris 1986). Prinsley (1986) recom-
mends music therapy for geriatric care, main-
taining that it reduces the use of tranquilizing
medication and reduces the use of hypnotics
on the hospital ward and helps overall reha-
bilitation. He recommends that music therapy
aim at specific treatment objectives: the social
goals of interaction and cooperation; the
psychological goals of mood improvement
and self-expression; the intellectual goals of
the stimulation of speech and organization of
mental processes; and the physical goals of
sensory stimulation and motor integration.
Such approaches also emphasize the benefit
of music programs for the professional carers
(Kartman 1984)and the families (Tyson 1989)
of elderly patients.
Assorted Findings
and Possibilities
A full examination of the possible use of
music therapy would cover a variety of only
partially explored areas. The following seem
to be the most important:
28 ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
Breathing Training
Fried (1990) presents a general overview of
the use of music in breathing training and
relaxation. Breathing training in itself is be-
lieved to have a physical benefit for anxious
patients by enabling them to increase tidal
volume-the amount of air moved in a single
breath-without excessive loss of carbon
dioxide (hypocapnia). Typically, anxious pa-
tients have relatively rapid shallow chest
breathing and may hyperventilate.
Music and breathing have been used
to induce alternate states of consciousness,
and Fried's paper correlates the characteris-
tics of consciousness and the role of music in
altering those states, reinforcing the findings
of McLellan (19881, who identifies the quali-
ties of music which can be used to invoke
calm and inner peace.
Nursing approaches have also utilized
the anxiety-relieving effect of music in com-
bination with massage and breathing exer-
cises to relax patients, and to facilitate post-
operative recovery (Keegan 1989).
Anesthesia
The ability of music to induce calm and well-
being has also been used in general anesthe-
sia (Keegan 1989; McCluskey 1983). Patients
express their pleasure at awakening to music
in the operating suite, the music having been
played "openly" before the beginning of the
operation, and then through earphones
during the operation (Bonny & McCarron
1984).
In certain instances, it appears that
surgical patients are aware of the music being
played during an operation. In a study by
Lehmann and colleagues (Lehmann, Homchs
& Hoeckle 19851, patients undergoing elective
orthopaedic or lower abdominal surgery were
given either a placebo infusion (.9 percent
sodium chloride) or the analgesic tramadol in
a randomized and double-blind manner, to
evaluate the efficacy of tramadol as one com-
ponent of balanced anesthesia. Postoperative
analgesic requirement and awareness of
intraoperative events-tape-recorded music
offered via earphones-were further used to
12

Table 2
Comparison of Medical and Musical Assessments of Alzheirner's Disease
Medical Elements of Assessment
continuing observation of mental
and functional status
testing of verbal skills, including
speech fluency
cortical disorder testing: visuo-spatial skills
and ability to perform complex motor tasks
(including grip and right/left coordination)
testing for progressive memory
disintegration
motivation to complete tests, to achieve set
goals and persevere in set tasks
"intention" difficult to assess;
but considered important
concentration and attention span
flexibility in task switching
mini-mental state score influenced
by educational status
insensitive to small changes
ability to interpret surroundings
assess the effects of tramadol. Although
anesthesia proved to be quite comparable in
both groups, striking differences occurred
with respect to intraoperative awareness:
while patients receiving placebo proved to be
amnesic, 65 percent of tramadol patients were
aware of intraoperative music.
The ability to hear music during an
operation is also reported by Bonny (Bonny
& McCarron 1984).
ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
ALDRIDGE
Musical Elements of Assessment
continuing observation of mental
and functional status
testing of musical skills, including
rhythm, melody, harmony, dynamic,
phrasing, articulation
cortical disorder testing: visuo-spatial
skills and ability to perform complex
motor tasks (including grip and right/left
coordination)
testing for progressive memory
disintegration
motivation to sustain playing improvised
music, to achieve musical goals and
persevere in maintaining musical form
"intention" a feature of improvised
musical playing
concentration on improvised playing
and attention to the instruments
flexibility in musical (including
instrumental) changes
ability to play improvised music
influenced by previous musical training
sensitive to small changes
ability to interpret musical context and
assessment of communication in the
therapeutic relationship
Musical Hallucinations
l
Hallucinations may occur in any of our
senses, and auditory hallucinations take
various forms-as voices, cries, noises, and,
1 rarely, music. However, the appearance of
1 musical hallucinations, often in elderly
patients, has generated interest in the medical
literature (Aizenberg, Schwartz & Modai
1 1986; Berries 1990; Fenton & McRae 1989;
29
13
 ALDRIDGE
How music therapy can be i n c o v o -
rated into medical practice requires
extensive research studies. Unfortu-
nately, music therapists and their
medical colleagues have created
something of an impasse whereby
each side demands a style of re-
search unacceptable t o the other.
Gilchrist & Kalucy 1983; Hammere, McQuil-
len & Cohen 1983; McLoughlin 1990; Patel,
Keshavan & Martin 1987; Wengel, Burke &
Holemon 1989). When such hallucinations do
occur they are described as highly organized
vocal or instrumental music. In contrast, the
ringing or other noises in the ears known as
tinnitus is characterized by unformed sounds
which sometimes may possess musical
qualities (Wengel, Burke & Holemon 1989).
T o some, case histories of patients with
musical hallucinations suggest an underlying
psychiatric disorder (Aizenberg, Schwartz &
Modai 1986; Wengel, Burke & Holemon 1989).
The hallucinations may be exacerbated by
dementia occurring with brain deterioration
(Gilchrist & Kalucy 1983). Fenton and McRae
(1989) maintain that patients with musical
hallucinations and hearing loss become anxi-
ous and depressed. Fenton challenges the
association of musical hallucination with
psychosis and previous mental illness. His
explanation points to the degeneration of
the aural end-organ whereby sensory input,
which ordinarily suppresses much nonessen-
tial information, fails to inhibit information
from other perception-bearing circuits. Other
investigators argue for a central brain dys-
function as evidenced by measures of brain
function (Gilchrist & Kalucy 1983).
In a study of 46 subjects with musical
hallucinations (Berrios 19901, the hallucina-
tions were far more common in females.
(The attribution of hallucinations to women
in particular should be regarded with a
degree of caution. As compared to men, out-
30 ADVANCES, The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
of-the-ordinary experiences of women are
more often labeled pathologically.) Age, deaf-
ness, and brain disease affecting the nondom-
inant hemisphere played an important role in
the development of hallucinations; on the
other hand, psychiatric illness and personality
factors were found to be unimportant. For
these patients, the application of music ther-
apy to raise the ambient noise level, to orga-
nize aural sensory input by giving it a musi-
cal sense and thereby countering sensory
deprivation, and to stimulate and motivate
the patient seems a reasonable approach.
Immune Effects
Work referring to the influence of music ther-
apy on immunological parameters is slim.
Lee (19911, who has written of the necessity
for working with HIV and AIDS patients,
emphasizes the value of music therapy. How-
ever, Lee fails to be clear about clinical objec-
tives. There remains the possibility that
immunological parameters may be influenced
by creatively improvising music. Research
on this possibility should aim at linking
musical analyses with clinical information
about immune reactions such that therapeutic
correlations could be attempted (Aldridge
1991b&c; Aldridge & Brandt 1991b; Aldridge,
Brandt & Wohler 1989) and the results could
be related to the current initiatives being
made in psychoneuroimmunology.
Conclusion
Music has the power to stimulate and to calm,
to soothe and to inspire. Playing music un-
doubtedly benefits people. The elderly are
stimulated, the depressed are encouraged,
and the tired are invigorated. How music
therapy can be incorporated into medical
practice requires extensive research studies.
Unfortunately, music therapists and their
medical colleagues have created something
of an impasse whereby each side demands a
style of research unacceptable to the other.
We can hope that in our general search for
methods suitable for researching the human
condition (Aldridge 1991a1, we can find ways
14

Table 3
Comparison of Medical and Musical Assessments of Bowel Disease
Medical Elements of Assessment
separation of self and "nonself"
lack of gut motility
increasingly introverted
- -
restricted in relationships
rigid
--
difficulty expressing feelings
appears to be coping well with life in the
face of internal turmoil
dependent
intractable to change
of working together in the future that will
generate some flexibility in clinical research.
As we have seen, some recent ap-
proaches have shown that the two vocabu-
laries of medicine and music have areas of
commonality (Aldridge 1989a, 1991b&c;
Aldridge & Brandt 1991a&b; Aldridge, Brandt
& Wohler 1989). One example of such com-
monality was illustrated earlier in Table 2,
which compares the medical and musical
assessments of Alzheimer's disease. Table 3,
which compares the medical and musical
assessments of bowel disease, provides
another example.
Gregory Bateson (1972) has reminded
us of the need for the arts to accompany the
science of modem medicine:
The point which I am trying to make in
this paper is not an attack on medical
science but a demonstration of an
inevitable fact: that merely purposive
rationality unaided by such phenomena
ADVANCES. The loumal of Mind-Body Health Vol. 9, No. l
David Aldridge Collected music therapy papers
ALDRIDGE
Musical Elements of Assessment
not tuned to oneself, uncoordinated
lack of rhythmic flexibility, unresponsive
to tempo changes, lack of rhythmical
phrasing
quiet playing with no personal contact
within the playing
difficult to contact in the musical
relationship
repetitive playing, returning to the same
tempo and rhythmic pattern, unrespon-
sive to tempo changes
intolerant of particular harmonies
appears to be going along with the music
but an underlying chaotic structure
no initiatives within the music; dependent
upon the therapist
difficult to treat, requiring many sessions
as art, religion, dream and the like, is
necessarily pathogenic and destructive
of life; and that its virulence springs
specifically from the circumstances that
life depends upon interlocking circuits
of contingency, while consciousness can
only sec such short arcs of such circuits
as human purpose may direct.
What we may have to consider is that
the human being is composed not as a ma-
chine but rather as a piece of music which is
improvised in the moment (Aldridge 1989b).
From such a perspective we may search for
common themes among groups of individuals
and identify particular repertoires of healthy
I
activities, but each person will have his or her
own song. For those of us who are doctors,
our task is to encourage our patients in the
l
articulation of their individual singing. Per-
haps in the future we will be encouraged to
1
l understand how each one of us as a person
1 can become our own work of art.
Winter 1993 31
15
 ALDRIDGE
REFERENCES:
Aizenberg, D., B. Schwartz & T. Modai. 1986. 'Musical
Hallucinations, Acquired Deafness, and Depression."
Journal of Nervous and Mental Disorders. 174:309-11.
Aldridge, D. 1988. "Families, Cancer and Dying.''
]ournal of the Institute of Religion and Medicine. 3:312-322.
Aldridge, D. 1989a. "Music, Communication and
Medicine: Discussion Paper." Journal of the Royal Society
of Medicine. 82:743-746.
Aldridge, D. 1989b. "A Phenomenological Comparison
of the Organization of Music and the Self." The Arts in
Psychotherapy. 16:91-97.
Aldridge, D. 1989c. "Research Strategies in a Hospital
Setting." Complementary Medical Research. 3:20-24.
Aldridge, D. 1991a. "Anesthetics and the Individual in
the Practice of Medical Research: A Discussion Paper."
Journal of the Royal Society of Medicine. 84:147-150.
Aldridge, D. 1991b. "Creativity and Consciousness:
Music Therapy in Intensive Care." The Arts in Psycho-
therapy. 18:359-362.
Ald ridge, D. 1991c. "Physiological Change, Communi-
cation, and the Playing of Improvised Music: Some
Proposals for Research." The Arts in Psychotherapy.
18:59-64.
Aldridge, D. & G. Brandt. 1991a. "Music Therapy and
Alzheimefs Disease." Journal of Bntish Music Therapy.
5(2):28-63.
Aldridge, D. & G . Brandt. 1991b. "Music Therapy and
Inflammatory Bowel Disease." The Arts in Psycho-
therapy. 18:113-121.
Aldridge, D., G. Brandt & D. Wohler. 1989. 'Towards a
Common Language Among the Creative Art Thera-
pies." The Arts in Psychotherapy. 17:189-195.
Aldridge, D., D. Gustorff & H. Hannich. 1990. 'Where
Am I? Music Therapy Applied to Coma Patients
[editorial]." Journal of the Royal Society of Medicine.
83:345-346.
Aldridge, D. & R. Verney. 1988. "Research in a Hospital
Setting." Holistic Health. 18:9-10.
Bailey, L. 1984. "The Use of Songs with Cancer Patients
and Their Families." Music Therapy. 415-7.
Bailey, L. 1985. "Music's Soothing Charms." American
Journal of Nursing. 85:1280.
Bailey, L.M. 1983. 'The Effects of Live Music Versus
Tape-Recorded Music on Hospitalised Cancer
Patients." Music Therapy. 3:17-28.
Bason, B. & B. Celler. 1972. "Control of the Heart Rate
by External Stimuli." Nature. 4:279-280.
Bateson, G. 1972. Steps to an Ecology of Mind. New York:
Ballantine.
ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
Beatty, W., K. Zavadil, R. Bailly & et al. 1988. "Pre-
served Musical Skills in a Severely Demented Patient."
International Journal of Clinical Neuropsychology.
10:158-164.
Berman, 1.1981. "Musical Functioning, Speech
Lateralization and the Amusias." South African Medical
Journal. 59:78-81.
Berrios, G. 1990. "Musical Hallucinations. A Historical
and Clinical Study." British Journal of Psychiatry.
156:188-194.
Bolwerk, C. 1990. "Effects of Relaxing Music on State
Therapy in Myocardial Infarction Patients." Critical
Care Nurse Quarterly. 13:63-72.
Bonny, H. 1978. GlM Monograph U2. The Role of Taped
Music Programs in the GIM Process. Baltimore: ICM
Press.
Bonny, H. 1983. "Music Listening for Intensive
Coronary Care Units: A Pilot Project." Music Therapy.
3:4-16.
Bonny, H. & N. McCarron. 1984. "Music as an Adjunct
to Anesthesia in Operative Procedures." Journal of the
American Association of Nurse Anesthetists. Feb:55-57.
Bonny, H. 1975. "Music and Consciousness." Journal of
Music Therapy. 12:121-135.
Brody, R. 1988. "Which Music Helps Your Muscles."
American Health. 7:80-84.
Carlisle, D. 1990. "Art and Health. A Creative
Approach to Patient Care. The Soothing Arts." Nursing
Times. 86:27-30.
Cassem, N. & T. Hackett. 1971. "Psychiatric Consulta-
tion in a Coronary Care Unit." Annals of Internal
Medicine. 75:9.
Chetta, H. 1981. 'The Effect of Music and Desensitiza-
tion on Preoperative Anxiety in Children." Journal of
Music Therapy. 18:74-87.
Cook, J. 1986. "Music as an Intervention in the
Oncology Setting." Cancer Nursing. 9:23-28.
Cook, J.D. 1981. 'The Therapeutic Use of Music."
Nursing Forum. 20:252-266.
Coyle, N. 1987. "A Model of Continuity of Care for
Cancer Patients with Chronic Pain." Medical Clinics of
North America. 71:259-270.
Dalessio, D. 1984. "Maurice Favel and Alzheimefs
Disease. The Journal of the American Medical Association.
252:3412-3413.
Daub, D. & R. Kirschner-Hermanns. 1988. "Reduction
of Preoperative Anxiety. A Study Comparing Music,
Thalomonal and No Premedication." Anaestetist.
37:594-597.
Davis-Rollans, C. & S. Cunningham. 1987. "Physiologic
Responses of Coronary Care Patients to Selected
Music." Heart-Lung. 16:370-378.
... ,
16

Dellmann-Jenkins,M. D.Papalia Finlay, & C. Hennon.
1984. "Continuing Education in Later Adulthood:
Implications for Program Development for Elderly
Guest Students." InternationalJournal of Aging &Human
Development. 20:93-102.
Diserens, C.M. 1920. "Reaction to Musical Stimuli."
Psychological Bulletin. 20:173-199.
Dossey, L 1982.Space, Time and Medicine. Boulder, CO:
Shambala.
Fagen, T.S. 1982."Music Therapy in the Treatment of
Anxiety and Fear in Terminal Pediatric Patients." Music
Therepy. 213-23.
Fenton. G. & D.McRae. 1989."Musical Hallucinations
in a Deaf Elderly Woman." British Journal of Psychiaty.
155:401-403.
F i h e r , M. 1990."Music as Therapy." Nursing Times.
66:3W 1.
Fletcher, V. 1986.'The Mobile Accident Team: When
the Music Stopped." Nursing Times. 8230-32.
Fonnby, C, R Thomas, W.J. Brown & J.J. Halsey. 1987.
T h e Effectsof Continuous Phonation of 133xenon-
Inhalation Air Curves (Of the Kind Used in Deriving
Regional Cerebral Blood Flow)." Brain and Language.
31:346-363.
Frarnpton, D.1986. "Restoring Creativity to the Dying
Patient." British Medical Journal of Clinical Research.
293:1593-1595.
Frarnpton, D. 1989."Arts Activities in United Kingdom
Hospices. A Report." Journal of Palliative Care. 5:25-32.
Frandscn, J. 1989. "Nursing Approaches in Local
Anwthcsia for Ophthalmic Surgery." Jovrnal of
Ophthalmic Nursing & Technology. 8:135-138.
Frank. J. 1985."The Effects of Music Therapy and
Guided Visual Imagery on Chemotherapy Induced
Nausea and Vomiting." Oncology Nursing Forum. 12:47-
52.
Fried. R. 1990."Integrating Music in Breathing Training
and Relaxation: I. Background, Rationale, and Relevant
Elements." Biofredback-Self-Regulator. 15:161-169.
Gilbert, J. 1977."Music Therapy Perspectives on Death
and Dying." Journal of Music Therapy. 14:165-171.
Cilchr~st,P. & R. Kalucy. 1983."Musical Hallucinations
in the Elderly: A Variation on the Theme." Australian
and New Zealand Journal of Psychiatry. 17:286-287.
Glenn, S. & C. Cunningham. 1984."Nursery Rhymes
and Early Language Acquisition by Mentally Handi-
capped Children." Exceptional Child. 51:72-74.
Glynn, N. 1986.'The Therapy of Music." Journal of
Ccrontolo{;ical Nursing. 125-10.
GodIvy, C. 1987.'The Use of Music Therapy in Pain
Clinics." Music Therapy Perspectives. 4:24-27.
Goloff, M. 1981. 'The Responses of Hospitalised
ADVANCES, The Journal of Mind-Body Health Vol. 9,No. 1 Winter 1993
David Aldridge Collected music therapy papers
ALDRIDGE
Medical Patients to Music Therapy." Music Therapy.
1:51-56.
Grimm, D. & P. Pefley. 1990."Opening Doors for the
Child Inside'." Journal of Pediatric Nursing. 16:368-369.
Gross, J.L. & R. Swartz. 1982."The Effects of Music
Therapy on Anxiety in Chronically 111 Patients."
Music Therapy. 243-52.
Guzzetta, C. 1989."Effects of Relaxation and Music
Therapy on Patients in a Coronary Care Unit with
Presumptive Acute Myocardial Infarction." Heart Lung.
18:609-616.
Haag, G. 1985. "Psychosocial Rehabilitation in
Advanced Age." Rehabilitation-Stuttg. 24:6-8.
Haas, F., S. Distenfeld & K. h e n . 1986."Effects of
Perceived Musical Rhythm on Respiratory Pattern."
Journal of Applied Physiology. 61:1185-91.
Hammeke, T., M. McQuillen & B. Cohen. 1983.
'Musical Hallucinations Associated with Acquired
Deafness." Journal of Neurology, Neurosurgery, and
Psychiatry. 46:570-572.
Harcourt,L. 1988."Music for Health." h1wZealand
Nursing Journal.81:24-26.
Harvey, A. & L. Rapp. 1968."Music Soothes the
Troubled Soul." AD-Nurse. 3:19-22.
Helman, C. 1987."Heart Disease and the Cultural
Construction of Time: The Type A Behaviour Pattern
as a Western Culture-Bound Syndrome." Social Science
and Medicine. 25:969-979.
Henson, R. 1988. "Maurice Ravel's Illness: A Tragedy of
Lost Creativity." British Medical Journal of Clinical
Research. 296:1585-1588.
Herskowitz, J,, N. Rosman & N., Geschwind. 1984.
"Seizures Induced by Singing and Recitation. A Unique
Form of Reflex Epilepsy in Childhood." Archives of
Neurology. 41:1102-1103.
Heyde, W. & P. von Langsdorff. 1983."Rehabilitation
of Cancer Patients Including Creative Therapies."
Rehabilitation Stuttg. 22:25-27.
Jacob, S. 1986. "Soothing the Ragged Edge of Pain.
Bring on the Music." American Journal of Nursing.
86:1034.
Jacome, D. 1984."Aphasia with Elation, Hypermusia,
Musiophilia and Compulsive Whistling." Journal of
Neurology, Neurosurgery and Psychiatry. 47308-310.
Jochims, S. 1990."Coping with Illness in the Early
Phase of Severe Neurologic Diseases. A Contribution
of Music Therapy to Psychological Management in
Selected Neurologic Disease Pictures." Psychotherapy
and Psychosomatic Medical Psychology. 40:115-122.
Johnson, C. & J. Woodland-Hastings. 1986. 'The
Elusive Mechanism of the Circadian Clock." American
Scientist. 74:29-36.
33
17
 ALDRIDGE
Jones, C. 1990. "Spark of Life." Geriatric Nursing of New
York. 1 I:l94-196.
Kamrnrath, L. 1989."Music Therapy during Chemo-
therapy. Report on the Beginning of a study."
Krakenpflege-Frankfurt. 43:282-283.
Karanth, P. & G. Rangamani. 1988."Crossed Aphasia
in Multilinguals." Brain-Long. 341 69-180.
Kartman, L. 1984. "Music Hath Charms." journal of
Gerontological Nursing. 10:20-24.
Keegan, L. 1989."Holistic Nursing." Journal of Post
Anesthesia Nursing. 4:17-21.
Kerkvliet, G. 1990."Music Therapy May Help Control
Cancer Pain." Journal of the National Cancer Institute.
82:350-352.
Keshavan, M., E. Kahn & j. Brar. 1988."Musical
Hallucinations Following Removal of a Right Frontal
Meningiorna." Journal of Neurology, Neurosurgery and
Psychiat y. 51:1235-1236.
Kolkmeier, L. 1989."Clinical Application of Relaxation,
Imagery, and Music in Contemporary Nursing." J-Adv-
Med-Surg-Nun. 1 :73-80.
Lee, C. 1991."Foreword: Endings." Journal of British
Music Therapy. 5:3-4.
Lehmann, K., G. Homchs & W. Hoecklc. 1 9 s . "The
Significance of Tramadol as an lntraoperative
Analygesic. A Randomized Double-Blind Study in
Comparison with Placebo." Anaesthesist. 34:ll-19.
Lehmann, W. & D. Kirchner. 1986."Initial Experiences
in the Combined Treatment of Aphasia Patients
Following Cerebrovascular Insult by Spcvch Therapists
and Music Therapists." ZeitschnftAltmfcrsthung. 41:123-
128.
Lehnen, R. 1988. "Does Music dunng Dental Treatment
Have an Influence on Heart and Circulation Param-
eters?" Zahnar-tl-Prax. 39:297-300.
Lengdobler, H. & W.Kiessling. 1989."Group Music
Therapy in Multiple Sclerosis: Initial Report of
Experience." Psychotherapy & Psychosomatic Medical
Psychology. 39:369-373.
Leonidas, 1.1981."Healing Power of Chants." New York
State journal of Medicine. 81:966-968.
Locsin, R. 1981."The Effect of Music on the Pain of
Selected Post-Operative Patients." journal of Advanced
Nursing. 6:19-25.
Lucia, C.M. 1987.'Toward Developing a Model of
Music Therapy Intervention in the Rehabilitation of
Head Trauma Patients." Music Therapy Perspectives.
4:34-39.
Marchette, L., R. Main & E. Rcdick. 1989."Pain
Reduction during Neona tal Circumcision." Pediatn'c
Nursing. 15:207-208,210.
McCaffery, M. 1990."Nursing Approaches to
Nonpharmacological Pain Control." International
34 ADVANCES, The Journal of Mind-Body Health Vol. 9,No. 1 Winter 1993
David Aldridge Collected music therapy papers
Journal of Nursing Studies. 221-5.
McCluskey, F. 1983."Music in the Operating Suite."
National Association of Theatre Nurses. 20:33-40.
McDermit, R. 1984."Music Therapy: Let's Tune In."
Dimensions in Health Service. 61:33-34.
McLellan, R. 1988.The Healing Forces of Music. New
York: Amity House.
McLoughlin, 1. 1990."Musical Hallucinations." British
Journal of Psychiatry. 156:452.
Melzack, R. 1975. "The McGill Pain Questionnaire:
Major Properties and Scoring Methods." Pain. 1:227-
299.
Morgan, 0. & R. Tilluckdharry. 1982. "Presentation of
Singing Function in Severe Aphasia." West Indian
Medical Journal. 31:159-161.
Morris, K. 1985. "Music Therapy." Nursing Times. 81:18.
Morris, M. 1986."Music and Movement for the
Elderly." Nursing Times. 824-45.
Moss, V. 1987. 'The Effect of Music on Anxiety in the
Surgical Patient." Perioper-Nurs-Q. 3:9-16.
Mullooly, V., R. Levin & H. Feldman. 1988. "Music for
Postoperative Pain and Anxiety." Journal of New York
State Nurses Association. 19:4-7.
Murray, L. & C. Trevarthen. 1986.'The Infant's Role
in Mother-Infant Communications." Journal of Child
Language. 13:15-29.
Naeser, M. & N. Helm-Estabrooks. 1985."CT Scan
Lesion Localization and Response to Melodic Intona-
tion Therapy with Nonfluent Aphasia Cases." Cortex.
21:203-223.
O'Boyle, M. & M. Sanford. 1988."Hemispheric
Asymmetry in the Matching of Melodies to Rhythm
Sequences Tapped in the Right and Left Palms."
Cortex. 24:211-221.
Olivier, L. 1986."Education in Music Therapy."
Soins-Psychiatr. 6637-38.
Ornstein, R. & D. Sobel. 1989."Coming to Our Senses."
Advances. 6:49-56.
Parent-Bender, D. 1986."La Therapie Par La Musique."
Canadian Nurse. 82:26-28.
Patel, I.I., M. Keshavan & S. Martin. 1987. "A Case of
Charles Bonnet Syndrome with Musical Hallucina-
tions." Canadian Journal of Psychiatry. 32:303-304.
Philip, Y. 1989."Effects of Music on Patient Anxiety
in Coronary Care Units [Letter]." Heart-Lung. 18:322.
Pouget, R. 1986. 'What Is Music Therapy?" Soins-
Psychiatr. 66:s-8.
Prinsley, D. 1986."Music Therapy in Geriatric Care."
Australian Nurses Journal. 15:48-49.
Rabinow, P. 1986.The Foucault Reader. London:
Penguin.
18

Renner, M. 1986. "Means for the Activation of the
Elderly. Music for Fun." Krankenpf-Soins-Infirm.
79:85-86.
Rice, T. 1989. "Music in Hospitals: 'It Seemed Like
Heaven'." Nursing Standard. 4:18-19.
Richter, R. & M. Kayser. 1991. "Rhythmic Abilities in
Patients with Functional Cardiac Arrythmias." 7th
Meeting of the European Society for Chronobiology.
Marburg May 30-June 2.
Rider, M.S. 1985. "Entertainment Mechanisms Are
Involved in Pain Reduction, Muscle Relaxation, and
Music-Mediated Imagery." Journal of Music Therapy.
22:183-192.
Rowden, R. 1984. "Music Pulled Them Through."
Nurs-Mirror. 159:32-34.
Sacks, 0.1986. The Man Who Mistook His Wifefor a Hat.
London: Pan.
Safranek, M., G. Koshland, & G. Raymond. 1982. "Effect
of Auditory Rhythm on Muscle Activity." Physical
Therapy. 62:161-168.
Sarnrnons, L. 1984. "The Use of Music by Women
during Childbirth." Journal of Nurse Midwifery.
29:266-270.
Schmuttermayer, R. 1983. "Possibilities for Inclusion of
Group Music Therapeutic Methods in the Treatment of
Psychotic Patients." Psychiatr-Neurol-Med-Psychol-Leip:.
35:49-53.
Schullian, D. & M. Schoen. 1948. Music and Medicine.
New York: Henry Schuman.
Spielberger, C. 1983.Manual for State Trait Anxiety
Inventory. Palo Alto, CA: Consulting Psychologists
Press, Inc.
Standley, ).M. 1986. "Music Research in Medical/
Dental Treatment: Meta Analysis and Clinical
Applications." journal of Music Therapy. 23:56-122.
Stem, R. 1989. "Many Ways to Grow: Creative Art
Therapies." Pediatric Annals. 18:645, 649-52.
Street, R.J. & J. Cappella. 1989. "Social and Linguistic
Factors Influencing Adaptation in Children's Speech."
Journalof Psycholinguist Research. 18:497-519.
ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993
David Aldridge Collected music therapy papers
ALDRIDGE
Swartz, K., E. Hantz, G. Crummer, J. Walton & R.
Frisina. 1989. "Does the Melody Linger On? Music
Cognition in Alzheimer's Disease." Seminars in
Neurology. 9:152-158.
Thornas, E. 1986. "Music Therapy." South African
Medical Journal. 70:717-718.
Tiep, B., M. Bums, D. Kao, R. Madison & J. Herrera.
1986. "Pursed Lips Breathing Training Using Ear
Oximetry." Chest. 90:218-221.
Tsunoda, T. 1983. "The Difference in the Cerebral
Processing Mechanism for Musical Sounds Between
Japanese and Non-Japanese and Its Relation to Mother
Tongue." In Musik in der Medizin. Edited by R Spintge
and R. Droh. Berlin: Springer Verlag.
Tyson, J. 1989. "Meeting the Needs of Dementia." Nurs
Elder. 1:18-19.
Updike, P. 1990. "Music Therapy Results for ICU
Patients." Dimension in Critical Care Nursing. 9:39-45.
Vincent, S. & J. Thornpson. 1929. "The Effects of Music
on theHuman Blood Pressure." The Lancet. 1:534-537.
Walter, B. 1983. "A Little Music Why the Dying Aren't
Allowed to Die." Nursing Life. 3:52-57.
Wein, B. 1987. "Body and Soul Music." American Health.
6:66-75.
Wengel, S., W. Burke & D. Holemon. 1989. 'Musical
Hallucinations. The Sounds of Silence?" Journal of the
American Geriatric Society. 37:163-166.
Wolfe, D. 1978. "Pain Rehabilitation and Music
Therapy." Journal of Music Therapy. 15:162-178.
Zirnmerman, L. M. Pierson & J. Marker. 1988. "Effects
of Music on Patient Anxiety in Coronary Care Units.''
Heart-Lung. 17:560-566.
Zimmerman, L., B. Pozehl, K. Duncan & R Schmitz.
1989. "Effects of Music in Patients Who Had Chronic
Cancer Pain." Western Journal of Nursing Resfirch.
11:298-309.
Ziporyn, R. 1984. "Music Therapy Accompanies
Medical Care." The Journal of the American Medical
Association. 252:986-987.
35
19
The Arts in Psychotherapy, Vol. 18 pp. 59-64. Pergamon Press plc, 1991. Printed in the U.S.A.

PHYSIOLOGICAL CHANGE, COMMUNICATION, AND THE PLAYING OF

IMPROVISED MUSIC: SOME PROPOSALS FOR RESEARCH

DAVID ALDRIDGE, PhD*

Arms, hands, or legs do not behave;
it is the total person who behaves
(Condon, 1975, p. 45)
In our music therapy research (Aldridge, 1988b;
Aldridge & Verney (1988) one of the areas we have
considered is what happens when people improvise
music together. Our intention is to be able to demon-
strate to ourselves and other practitioners the influ-
ence we believe music therapy has on the body of the
patient. We hope to demonstrate, in our later inves-
tigations, the mutual relationship of physical changes
in the therapist and patient during the process of
improvising music together.
In trying to demonstrate this change we have
looked for a simple physiological indicator. From a
preliminary review of the literature about communi-
cation, suitable indicators emerged from the studies of
cardiovascular change. The principal measures in
such work were those concerned with changes in
blood pressure and heart rate. Heart rate was chosen
because it was a relatively easy parameter to observe
and measure. Perhaps more significantly, it was a
parameter acceptable to medical science with whom
we, as a therapeutic discipline, are attempting to
promote a dialogue.
An earlier paper (Aldridge, 1988a) mentioned the
important factors associated with both biological form
and musical form- time, phrasing, pitch, rhythm,
and melodic contour. Similar considerations apply for
studies of communication. The basic preverbal fun-
damentals of human communication are called supra-
segmentals-these are time, phrasing, rhythm, pitch,
and voice tone (which would more accurately be
called timbre). It is these qualities that are considered
by music therapists when they assess tape-recorded
sessions of improvised music therapy.
The literature that first alerted us to these factors
concerned chronic heart disease and Type A behavior
(Dielman et al., 1987; Dimsdale, Stem, & Dillon,
1988; Friedmann, Thomas, Kulick-Ciuffo, Lynch, &
Suginohara, 1982; Linden, 1987; Lynch, Long,
Thomas, Malinow, & Katchor, 1981; Smith & Rhode-
wait, 1986). Heart disease patients were described in
terms that owed as much to a musical basis as they did
to a physiological process. Loud, fast speech using a
limited range of voice timbre, and speech patterns that
interrupted the responses of a partner, appeared to
reflect qualities music therapists heard in their de-
scriptions of patients when they creatively improvised
music (see Table 1). Although these qualitative de-
scriptions may only be regarded as noise in the formal
terms of grammar, they provide the essential expres-
sive context for communication.
It seemed important to compare apparently similar
statements from two different theoretical backgrounds
to see if there was any commonality between them.
As heart disease is such an important problem in both
mortality and morbidity throughout the Western world,
it made sense to propose h o w a discipline like
improvised music therapy could offer a tool for both
assessment and treatment.
The medium of improvised music offers possibil-
ities for extremely varied communication and has a

*David Aldridge is research consultant to the Musiktherapie Abteilung, Universitat Witten Herdecke, Beckweg 4, D 5804 Herdecke (Ruhr),
West Germany.

David Aldridge Collected music therapy papers 20

 DAVID ALDRIDGE

Table 1
Speech characteristics, physiological changes, and musical components

Type A behavior Type B behavior

increased voice volume voice quieter volume

fast speech rate slower speech rate tempo
short response latency longer response latency phrasing
emphatic voice less emphasis articulation
hardlmetallic voice melodic voice timbre
accelerated end of sentences
less mutuality increased mutuality relationship
try to keep control
increased reactivity
increased heart rate decreased heart rate
high cardiovascular arousal situational arousal
which is maintained returns to low level quickly
increased heart rate decreased heart rate

cognitive processing attention to the environment

more thoughts and words better performance of
recognition/perceptual tasks

subtlety beyond that of interview techniques that are
confounded by verbal content. In addition, in impro-
vised playing there is both the possibility of hearing
what may be pathological in terms of restriction and
inflexibility under challenge, and that which indicates
positive possibilities for growth and change. This is
accomplished by an essential feature of the therapy of
performance. The patient is an active participant, not
a passive recipient, in the process of assessment or
therapy.
Time
A central, albeit contentious, area of coronary
heart disease research has been that of Type A
behavior pattern, which is characterized by the way in
which an individual responds to, and provokes, envi-
ronmental demands. Helman (1987) refers to this
view of the cause of heart disease as a cultural
construction that involves the "unique social and
symbolic characteristics of Western time" (p. 969).
In this view we are "the embodiment (both literally
and figuratively) of the values of that society . . ."
(p. 971). The individual is caught in the contradic-
tions of self-demand and societal demand, which for
some people may become pathogenic.
At the center of this cultural construction (Helman,
1985) is the notion of time. The predominant form of
Western time is monochronic. This form is conceived
as an external order imposed on the individual. It
developed from the need of a modem industrialized
society to have a universal public order by which the
means of production could be coordinated and the
actions of many individuals regulated. In this form,
deadlines have to be met, the passage of time is
linear, and its measurement is quantitative. This is
time as chronos.
However, there is an alternative conceptualization
of time that is personal rather than public. This is time
as kairos. It is polychronic, and closer to the emerg-
ing biological understanding of physiological times
that are rhythmically entrained (Johnson & Wood-
land-Hastings, 1986), not to an external clock, but to
the person as a whole organism. In this conceptual-
ization, time is in a state of flux; it is concerned with
flexibility and the convergence of multiple tasks.
Time is seen as springing from the self.
Apart from these notions, there is also the quali-
tatively different time encountered in ritual, in prayer,
and contemplation, during sex, or while dancing.
Most are aware of the difference between an hour
spent in the company of a lover, which seems like

David Aldridge Collected music therapy papers 21

 PHYSIOLOGICAL CHANGE, COMMUNICATION, AND PLAYING OF IMPROVISED MUSIC
minutes, and an hour spent in an administrative
meeting, which can seem like days.
Some authors (Dossey, 1982; Helman, 1987) sug-
gest that when we try to impose a fusion between
external clock time and personal physiological time
our physiology is affected.
. . . Western society is unique in trying to impose a
fusion between clock time and individual physiol-
ogy-between rates of bodily movement, speech,
gestures, heartbeat and respiration-and the small
machine strapped to the wrist or hung on the wall.
'Rush hours,' deadlines, diaries, appointments and
timetables all affect the physiology of modem man,
and help construct his world view and sense of
identity. (Helman, 1987, p. 974)
There may then be a tension between private and
public time resulting in stress and anxiety.
In music there are possibilities to experience these
varying aspects of time as they converge in their
seamless reality. The tension between personal and
public time may be heard in improvised music and,
apart from promoting experiences that differentiate
and develop those conceptualizations, an experience
of a timeless qualitative reality can also be promoted.
When illness is categorized in Western medicine
the time concepts of acute and chronic are used. The
presence of chronic illness is causing many problems
for the delivery of health services throughout modem
society and promoting a debate about the way in
which such illness can be tackled in the latter part of
the twentieth century. However, it may be that
conceptualizations of illness to acute and chronic
dimension of a linear reality are limiting, and it may
be necessary to consider a concept of kairotic illness.
This illness may entail a personal attempt to maintain
identity in the face of imposed environmental con-
straints and would be similar to the way in which
family therapists talk about personal solutions to a
problem located within an ecology of family mem-
bers, cultural constraint, and individual development
(Aldridge, 1988c; Bloch, 1987). These concepts of
time (development) and space (relationship) are fun-
damental to our culture whether it be in terms of
science or art.
Cardiovascular Change and Communication
Lynch (Friedmann et al., 1982; Lynch et al., 1981)
carefully explored the relationship between human
David Aldridge Collected music therapy papers
61
communication, principally talking, and elevations in
blood pressure and heart rate. Reading out loud or
talking to another person produced rapid and signifi-
cant rises in heart rate. From this work he suggested
that certain hypertensive individuals experience diffi-
culties with communication, and that individual ele-
vations in blood pressure may be manifested symptoms
of difficulties with communication.
These communicational difficulties were then re-
lated to the personality traits attributed, albeit conten-
tiously, to Type A individuals with coronary heart
disease. Patients classified as Type A had been
observed to speak fast, loud, have a tendency to
interrupt, and use emphatic gestures. Friedman et al.,
(1982) proposed that tempo and volume were impor-
tant characteristics of communication. Although tempo
and volume were correlated with cardiovascular change,
this correlation was not dependent on the affective
content of conversation and, therefore, independent
of cognitive processes. This finding is important for
music therapists in the Nordoff-Robbins (1977) tradi-
tion who state that there is physical change during the
process of music therapy and that it is not necessary to
use only a psychotherapeutic model for change in
music therapy.
The recommendations of this earlv research for
patients with hypertension were to modify speech rate
and volume using breathing techniques, and to control
communication style. If cardiovascular response is a
process out of the range of conscious awareness, then
presumably cognitive approaches are likely to be only
partial. Music therapy, with its intrinsic factors of
tempo and volume a s direct performance, may be
better suited to changing communicational style than
the so-called talking-therapies.
A feature of assessing Type A behavior and
physiological reactivity has been some form of assess-
ment using an interview (Dimsdale, Stem, & Dillon,
1988). Unfortunately, these interviews have pre-
sented a rather negative picture of the Type A person
as competitive, hard driving, ambitious, impatient,
and often hostile. Yet, within these descriptions there
are other categories of classification that are con-
cerned with elements of speech stylistics. These
speech stylistics are easier to objectify and are less
like personal value judgments. For our research
purposes they are also translatable into musical terms.
Some researchers (Dielman et al., 1987; Linden,
1987; Siegman, Feldstein, Tomasso, Ringel, & Lat-
ing, 1987) recognize the following characteristics for
assessing global Type A behavior:
22
 DAVID ALDRIDGE
voice volume,
speed of speaking,
accelerated speech at the end of statements,
 duration of silent pauses,
 duration of subject's responses,
 interruptiveand non-interruptivesimultaneous speech,
response latency (the amount of time between the
time the question is asked and the subject's an-
swer), and
voice timbre.
These researchers also go on to assess interaction
patterns with the interviewer that they see as hostility
and verbal competitiveness. Verbal competitiveness
is "a tendency to take control of the interview away
from the interviewer by interrupting, asking for un-
necessary qualifications, or raising the voice to drown
out the interviewer's interruptions" (Dielman et al.,
1987, p. 459).
These stylistic qualities and interactions can be
observed in musical improvisation, and without the
need for negative connotations of hostility. In the
context of a spoken interview it is important to
remember that the content of some of the questions
may indeed be hostile or challenging. A further
difficulty is that although speech rate and volume can
be measured, hostility, impatience, and competition
can only be assessed subjectively with poor interrater
reliability.
Speech variables have been significantly correlated
with coronary difficulties. These are:
 voice volume,
voice emphasis,
 speed of speaking,
short response latency (Dielman et al., 1987),
voice volume,
frequency of non-interruptive and interruptive si-
multaneous speech (Siegman et al., 1987).
These variables need not be discovered in a provoc-
ative or challenging manner (Siegman et al., 1987).
Short response latency and accelerated speech are also
expressions of anxiety.
Music therapy can also offer a context for cornmu-
nication. It is not provocative in a hostile sense, and
has the possibility to promote all the elements inher-
ent in speech stylistics without the confounding aspect
of affective components. These variables can be heard
in a way that is not solely voice dependent. Commu-
nication is not only concerned with the use of the
David Aldridge Collected music therapy papers
voice; it also includes those gestures and movements
that accompany vocal behavior. Condon (1975) calls
these coordinated sounds and movements the quanta
of behavior or "linguistics-kinesics. "
In the playing of improvised music may be seen
how the person moves and also hear how the patient
communicates nonverbally. It is this musico-kinesic
behavior that contributes to the assessment of how a
person plays. A central feature of this assessment i$
the elusive quality of intentionality. The movement of
the body provides an indicator of whether the patient
is playing with the therapist and intends to play the
instrument, or that the patient is just going along with
the music. These kinesic considerations are also an
important indicator of self-synchrony within the per-
son-either as bilateral synchrony (right and left hand
playing together), or at the level of hearing and
responding to what is heard.
Music therapy, in the improvised sense used here,
is also dependent on the relationship between the
patient and the therapist-an interactional synchrony.
It may be that a vital aspect of communication, which
is missed by some researchers, is not the ability to
produce sound but the ability to listen and respond
appropriately to sound. Smith and Rhodewalt (1986)
consider this circular process of listening and re-
sponding. They suggest an interactional understand-
ing where people with Type A behavior not only
respond in a certain way but also provoke situations
that will allow them to respond in a characteristic
fashion.
Heart Rate and Attention
While some researchers were studying the impli-
cations of heart rate and communication, others were
studying the relationship between a process like
attention, which is classically attributed to the brain,
and emotion, which is related to the body. This
mind-body unity debate heralded an era of interest in
holistic medicine.
Sandman (1984a,b) began investigating the rela-
tionship between physiological responses and stress-
ful, neutral, or pleasant stimuli. In particular he was
interested in the apparent relationship between atten-
tion and emotion where attentional style could influ-
ence physiological responses to affective stimuli. His
work was based on the premise that the viscera, the
muscles, the heart, and the endocrine system provided
peripheral information to the brain and provided a
context wherein perceptions gained meaning.
23
 PHYSIOLOGICAL CHANGE, COMMUNICATION, AND PLAYING OF IMPROVISED MUSIC
In this approach there appeared to be two general
categories of attentional styles. One, field-indepen-
dent subjects, appeared to use bodily information
more readily than others and made accurate percep-
tual judgments about the environment even though
presented with distracting perceptual information.
Such subjects appeared to have a broad and differen-
tiated range of physiological responses to various
stimuli. For these subjects there was a concordance
between how they said they felt and how they
responded physiologically. The other, field-depen-
dent subjects, tended to base their perceptual judg-
ments on distracting external information, and used
this external information to assess their own state.
When reacting to stimuli they were less emotionally
complex; rather than exhibiting a range of qualita-
tively different reactions they responded with differ-
ent levels of arousal.
The implications for music therapy from these
preliminary findings are that we may also hear such
field dependent or independent characteristics in the
musical playing of the patient. For example, some
patients may have an extensive repertoire of playing
styles and be able to play both rhythmically and
melodically while listening to themselves and to the
therapist in the overall context of the music. Yet
others may have a limited range of playing styles and,
in response to changes in the music, may only change
particular musical parameters (i.e., play louder or
faster).
We speculate that repertoires of coping responses
can be heard musically, and these reflect quantitative,
differentiated physiological responses. It is this link
that we wish to demonstrate in our physiological
experiments. Note that these observed patterns are
considered either musically or physiologically. We
are not necessarily invoking any descriptions of
psychological state.
Sandman was to develop his work further. He was
interested in the pronounced, and paradoxical, de-
crease in heart rate of field-independent subjects in
response to stressful information. He began to dem-
onstrate that a learned heart rate deceleration could
bring about an improved attention to the environment.
Thus, he argued, by controlling heart rate, attention
could also be influenced.
Awareness of the environment was partially regu-
lated by interactions of the brain and the heart. When
heart rate was low, subjects perceived stimuli signif-
icantly better than when heart rate was high. This
David Aldridge Collected music therapy papers
63
view was also supported by indications that when
heart rate decelerated, there was an increased blood
flow to the brain. There appeared to be "a fortuitous
or purposeful synchronization between physiological
systems" Sandman, 1984b, p. 118), and it appeared
that the hemispheres of the brain were "tuned"
(Sandman, 1984a; Walker & Sandman, 1979; Walker
& Sandman, 1982) by the cardiovascular system.
These findings challenged the classical view that
intellectual abilities were the sole province of the
brain and promoted further investigations of links
between both mind and body where the cardiovascu-
lar system influences the brain and behavior. In some
patients "an inviolable relationship exists between the
brain and the cardiovascular system that may be a
biological marker for psychiatric state" (Sandman,
1984a, p. 255).
These researchers speculate that the heart has an
influence on consciousness or awareness. The impact
of heart rate is dynamic and fluctuates between
suppressing and liberating the left and right sides of
the brain. When heart rate increases, it is indicative of
cognitive processing and a rejection of the environ-
ment; when heart rate decreases, there is a switch to
environmental attention. The cardiovascular system
reflects a person's intention to receive information. If
this is so, music therapy is a sensitive tool for
discerning the physiological state of a person as a
whole. This tool is not fragmented by introducing a
measuring instrument between researcher and subject
that limits responses to a narrow mechanical range.
We anticipate that we can hear how changes in the
improvised musical playing are reflected in changes
in the heart rate of the patient. Hypotheses about a
patient listening only to him or herself and not
listening to another may be heard in their fast, or
accelerating, heart rate.
If, as is also inferred in this literature, intellectual
abilities are not solely begun and terminated in the
brain but are whole body phenomena, then the active
playing of the patient in music therapy is most
important. The patient is involved physically in this
therapy, is not expected to sit still and answer a
questionnaire, or remain stationary while being mon-
itored. He or she is asked to play. This improvised
playing encourages the use of soma and psyche. To
play rhythmically is a whole-person activity. To play
rhythmically with another person is an extension of
this activity that includes vital components of rela-
tionship.
24
 DAVID ALDRIDGE
Conclusion
In creative music therapy lies the possibility to
hear in a dynamic way the individual as a whole self
as well as in relationship with another person. We can
hear the person coming into being as he or she creates
a relationship in time. In addition music therapy offers
individuals a chance to concretely experience the self
in time, to literally hear their own self coming into
being. If human survival is concerned with a reper-
toire of flexible coping responses to both external and
internal demands, then in the playing of improvised
music may be heard the creative way in which a
person meets those demands. It could be that illness is
a state where there is: (a) a restriction in the ability of
the person as a whole to improvise creatively (i.e.,
develop new solutions to problems), or (b) a limited
repertoire of coping responses.
By promoting creative coping responses we may
be establishing the possibilities for renewed health.
These are based on the creative qualities of the whole
person that promote autonomy. This catalyzation of
self-healing properties is a central feature of the art of
medicine that can work in concert with the science of
medicine.
The videotape-recorded material of music therapy
and experimental session is the rudimentary vehicle
for research development. Such recordings are rich in
visual and aural data. Not only can those acts that are
quantifiable be counted, but those phenomena that are
not amenable to counting but are qualitatively essen-
tial to health can also be experienced and described.
We may discover in this work that, in terms of
biofeedback, the playing of improvised music offers
the subject an experience richer and more immediate
than the filtering of physiological parameters through
an external machine. In this way the person remains
the supreme and sensitive instrument of his or her
own understanding both literally and figuratively. The
next stage for formulating research studies is to
observe and record the correlations between the heart
rates of subjects and the musical changes that occur
when they are playing improvised music. From these
observations it should be possible to develop a means
of demonstrating physiological change in the context
of a musical relationship, and then go on to observe
particular patient populations to investigate links
between improvised playing, physiological parame-
ters, and ill health.
References
Aldridge, D. (1988a). Music as identity: A contribution to the
David Aldridge Collected music therapy papers
assessment of personal health. Proceedings of the First Znter-
national Conference of Cerebral Dominance. Munchen.
Aldridge, D. (1988b). Research in a hospital setting. Holistic
Health, 18, 9-10.
Aldridge, D. (1988~).Treating self-mutilatory behaviour: A social
strategy. Family Systems Medicine, 6, 5-19.
Aldridge, D., & Verney, R. (1988). Creative music therapy in a
hospital setting: A preliminary research design. British Journal
of Music Therapy, 2, 1 4 1 7 .
Bloch, D. (1987). Familyldiseaseltreatment systems: A co-evolu-
tionary model. Family Systems Medicine, 5 , 277-292.
Condon, W. (1975). Multiple response to sound in dysfunctional
children. Journal of Autism and Childhood Schizophrenia, 5 ,
37-56.
Dielman, T., Butchart, A., Moss, G., Harrison, R., Harlan, W., &
Horvath, W. (1987). Psychometric properties of component
and global measures of structured interview assessed Type A
behavior in a population sample. Psychosomatic Medicine, 49,
458-469.
Dimsdale, J., Stem, M., & Dillon, E. (1988). The stress interview
as a tool for examining physiological reactivity. Psychosomatic
Medicine, 50, 64-71.
Dossey, L. (1982). Space, time and medicine. London: Shambala.
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.
Helman, C. (1985). Psyche, soma and society: The social construc-
tion of psychosomatic disorders. Culture, Medicine and Psy-
chiatry, 9, 1-26.
Helman, C. (1987). Heart disease and the cultural construction of
time: The type A behaviour pattern as a western culture-bound
syndrome. Social Science and Medicine, 25, 969-979.
Johnson, C., & Woodland-Hastings, J. (1986). The elusive mech-
anism of the circadian clock. American Scientist, 74, 29-36.
Linden, W. (1987). A microanalysis of autonomic activity during
human speech. Psychosomatic Medicine, 49, 562-578.
Lynch, J., Long, M., Thomas, S., Malinow, K., & Katchor, A.
(1981). The effects of talking on the blood pressure of hyper-
tensive and normotensive individuals. Psychosomatic Medi-
cine, 43, 25-33.
Nordoff, P,, & Robbins, C. (1977). Creative music therapy. New
York: John Day.
Sandman, C. (1984a). Afferent influences on the cortical evoked
response. In M. Coles, J. Jennings, J. Stem (Eds.), Psycho-
physiological Perspectives: Festschrift for Beatrice and John
Lacey. Stroudberg PA: Hutchinson & Ross.
Sandman, C. (1984b). Augmentation of the auditory event related
potentials of the brain during diastole. International Journal of
Psychophysiology, 2, 111-1 19.
Siegman, A., Feldstein, S., Tomasso, C., Ringel, N., & Lating, J.
(1987). Expressive vocal behavior and the severity of coronary
heart disease. Psychosomatic Medicine, 49, 545-561.
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, 229-25 1.
Walker, B., & Sandman, C. (1979). Human visual evoked re-
sponses are related to heart rate. Journal of Comparative and
Physiological Psychology, 4, 7 17-729.
Walker, B., & Sandman, C. (1982). Visual evoked potentials
change as heart rate and carotid pressure change. Psychophys-
iology, 19, 520-527.
25
The A r t s in P.syclior/~er(~pv.
Vol. 16 pp. 91-97. *" I'c~-g:imon Press plc.
A PHENOMENOLOGICAL COMPARISON OF THE ORGANIZATION OF MUSIC
This paper is concerned with an understanding
of musical perception and how it is linked with
the identity of the whole person. An extension of
the understanding is the notion of being as it is
characterized by the tradition of phenomcnologi-
cal philosophy, which looks toward "being in the
world" as a unified experience.
This phenomenological approach sees a corrc-
lation between music form and biological form.
By regarding the identity of a person as a musical
form that is continually being composed in the
world, a surface appears on which to project our
understanding of a person as a physiological and
psychological whole being. The thrust of this
endeavor is to view people as "symphonic"
rather than "mechanic." By considering how
persons come into the world as whole creative
beings one can speculate on their potential for
health and well-being.
The Perception of Music
As Dennis Fry (1971, p. 1) wrote,
In the case of music there is also continuously
interaction between the physical character of the
musical stimulus and its physiological and psycho-
logical effects so that a more thorough study of
music would demand at least the combining of a
physical, physiological and psychological ap-
proach. Modern science has relatively little infor-
mation about the links between physics, physiology
and psychology and is certainly not in a position to
specify how the effects are related in music, but
*David Aldridge is research consultant to the
David Aldridge
1989. Printed in the U.S.A. 0197-4556189 $3.00 + .OO
AND THE SELF
DAVID ALDRIDGE, PhD*
most scientists would recognize here a gap in sci-
entific knowledge and would not want to deny the
fact of a connection.
The problem in understanding the perception
of music is inherent too in understanding per-
sonal health. Health is complex, yet how is one
to make a unified sense of the complexity that
avoids fragmentation and reduction? Furthcr-
more, how can one begin to understand qualita-
tive aspects of personal life as they are expressed
in terms of hope, joy, and beauty, which com-
plement increasingly sophisticated quantitative
knowledge of the human body?
Although there have been many attempts to
describe the process underlying the perception of
music there has been little success in presenting
any satisfactory explanation. The perception is
not limited solely by the acuity of the ear
(Longuet-Higgins, 1979) and all that impinges on
the listener, but is achieved in combination with
the conceptual structure imposed by the listener.
In this way the knowledge of the phenomenon is
intimately linked with the phenomenon itself.
Both the knower and the known are part of the
same process. Perception in this sense is an
holistic strategy.
Much scientific research into the perception of
music has concentrated on those aspects that can
be measured quantitatively. In this way nature is
organized according to the concepts that are im-
posed on it. This is the analytic mode of con-
sciousness that is predominantly a product of the
Musikthcrapicablcilnng, Univcrsitiits Witten Herdecke, D5084 West Germany.
1
91
Collected music therapy papers 26
92 DAVID ALDRIDGE
verbal intellectual mind (Burtoft , 1980) where
phenomena are represented by number, and var-
iables in equations are represented by quantities.
This paper attempts to dcmonstnite the need
for a phenomenological understanding tliat is
isomorphic with the medium of music itself. An
holistic consciousness that is qualitative, non-
verbal, and participatory appears in the very
phenomenon of music. What is more, Hie cle-
ment of participation by the knower spciiks di-
rectly to the aspect of music as performiincc, ; i n
aspect that is sadly neglected by many reseiirc11-
ers who reduce research into the perception of
music to a restricted range of received sounds.
Heidegger (1962) emphasized the intuitive
element in the comprehension of phenomena.
When music is heard, the phenomenon becomes
its own explanation. It is that which shows itself
in itself. Perhaps one can begin to understand
people as they come into the world, as music,
i.e., composed as a whole.
The explanatory idea of a Frame of Reference
is a common theme among a number of writers
referring to musical perception and brain func-
tion (Longuet-Higgins, 1979; Safranek, Kosh-
land, & Raymond, 1982; Steedman, 1977;
Walker, 1979). Walker suggests an "Ursatz" (the
essential underlying principle) to music thiitis aii
all-embracing thought unifying the music and giv-
ing a musical structure accessible to analysis.
However, he also states that this musical struc-
ture is ultimately unknowable (i.e., beyond
analysis). In this explanation lies the perennial
difficulty of seeking a unifying explanation by an
analysis into parts. Somehow that which is intui-
tively sought is lost in the process of description.
What results is a statement that what is sought is
unknowable, rather than a questioning of the ana-
lytic method of knowing. This situation also pre-
vails in the understanding of personal health.
According to the philosophy of empiricism,
knowledge of the world is gleaned through expe-
rience. This knowledge comes through the
senses. However, there is more to this sensory
knowledge than meets the ear. There is always a
nonsensory factor involved-that of cognitive
perception, the dimension of the mind. This
cognitive perception is a process ol' organizittion
where meaning is imposed upon wh.11 is 1ie;iri.I. I n
this way a seemingly nieaningless ground ol'
sound is given meaning. To perceive tlien is lo
David Aldridge Collected music therapy papers
give meaning to what is heard, an act of identity.
However the nonsensory process of cognition is
transparent, or rather silent, and appears as if
hearing were solely a sensory experience. The
process of discovery in science is also one of the
perception of meaning. What appears to be em-
pirical is indeed cognitive.
If the ohenomenon of music is considered as a
unified whole the question arises whether this
unity is imposed on the senses by the mind, or
whether it is the phenomenon itself that is a
whole. To a great extent organizational frame-
works are imposed on experience; hence there
are descri~tionsthat call for a framework of
reference in the perception of rhythm and of
melody. However, there is a danger of being
blinded to this imposed organization and thus to
believe that this is the way the phenomenon
really is.
Once an attempt is made to synthetically re-
produce the act of n~usical perception the
framework analogy is seen as limited. Lon-
guet-Higgins' (1979, 1982) careful and inspiring
work demonstrates the utility of a frame of refer-
ence approach using tempo and meter for the
perception of rhythm. This approach fails, as he
remarks, when it is understood how a particular
choice of phrasing affects the rhythm. Further-
more, the perception of atonal and arhythmic
music are still mysteries to analytical methods.
Yet one can hear and play arhythmically and
atonally.
However, there is an approach to understand-
ing phenomena as unified wholes. The roots of
this approach are in the work of Goethe's scien-
tific consciousness and the work of Franz Bren-
tano (Bortol't, 1986). Both of these men were to
be influential in the development of phenome-
nology. Goethe perceived the wholeness of the
phenomena not as imposed by the mind but by a
conscious act of experience. This experience
could not be reduced to an intellectual construc-
tion in terms of the way the phenomena are or-
ganized. Bortoft uses the following example to
explain this change of consciousness:
. . . if we watch a bird flying across the sky and
put our attention into seeing flying, instead of
sccing a bird which flies (implying a separation
between an entity 'bird' and an action 'flying'
which it performs), we can experience this in the
27
 MUSIC AND T H E S E L F 93

mode of dynamical simultaneity as one whole primacy of the word in speech, and to understand
event. By plunging into seeingjlyit~gwe find that speech in terms of phrasing, rhythm, pitch, and
our attention expands to experience this moment melody, a different consciousness emerges. This
as one whole which is its own present moment. consciousness reflects a different range of logics
(P. 31) to the predicatory logic of language. Here are
dynamic, movement, interval, and time-the very
In this phenomenological approach sounds are essences of music and of biological function.
heard as sensory information and as a unified
I f consideration is given to what constitutes
experience, which is music as consciousness.
people as identity attention may be better di-
How then can personal health be perceived as ;I
rected to how they are composed not only in
unified experience? qiiii~i~i~i-dvc terms of bones and blood, but how
Iliey are composed as musical beings in regard to
Language as Music
relationship patterns, rhythms, and melodic con-
Whether or not music is a language is ;I riin- tours. This may reflect the original biblical notion
ning debate through the literallire I-dnliiig lo I he tlml in the beginning was "logos" (i.e., order). In
perception of music. Morley (1981) iusis1.s lli:il music lies the phenomenon of a person coming
.
music is a form of conin~unic;itioii ;in;iloi:oiis
. Io into order. It may perhaps be that when a sense
speech in that it has cadences :incl piincti~;i~iot~. ol' l liat order is lost a person experiences a loss of
Perhaps the restructuring of the primicy of l:in, 11:illh.
guage over music to suggest Ihiil lii~igii;igeis ; I
form of music may be more enlightening. I t could Hemispheric Processing
be that speech is analogous to music and lhiil I he
In support of the above argument, the realm of
musical components of speech are ;ibilicittecl in
cerebral processing and music perception may
favor of the literal content. ;ilso be examined. Although language processing
Most in academic life rarely question Hie pri-
may be dominant in one hemisphere of the brain,
macy of the word. As a form of conimunicu~ion
music processing involves an holistic under-
the word appears to be central to endeavor
standing of the interaction of both cerebral
whether written o r spoken. Underlying this con-
hemispheres (Altenmullcr, 1986; Brust, 1980;
cern with language is an analytical conscious-
Gates & Bradshaw, 1977).
ness. A subject-predicate gramnitir is used that
In attempting to understand the perception of
gives a structure to language. This very struc-
music there have been a number of investigations
ture, in turn, structures consciousness. l l is ;I
feature common to Western culture; in the be- into the hemispheric strategies involved. Much
ginning was "the word." To write that creittion ol' the literature considering musical perception
concentrates on the significance of hemispheric
beean with the "word" hides the fact thal the
.a
dominance. Gates and Bradshaw (1977) conclude
author is a writer whose consciousness is struc-
that cerebral hemispheres are concerned with
tured by the medium used.
music perception and that no laterality differ-
It might profitably be asked "How would a
cnces are apparent. Other authors (Wagner &
musician communicate this primal understanding
of consciousness? What is 'in the beginning' for a Hannon, 1981) suggest that two processing func-
musician?" In communicating in a different way tions develop with training where left and right
hemispheres are simultaneously involved, and
perhaps communication with a different con-
sciousness may take place. This understanding that musical stimuli are capable of eliciting both
may also explain the difficulty ofwriting and talk- right and left ear superiority (Kellar & Bever,
1980). Similarly, when people listen to and per-
ing about health using a verbal analytic language
form music they utilize differing hemispheric
when there is concern with a realm of bchavior
processing strategies.
necessitating an holistic mode of consciousness.
Perhaps an expression of health is something that
could better be sung or played.
To move from a position that advocates the Evidence of the global strategy of music pro-

David Aldridge Collected music therapy papers 28

cessing in the brain is found in the clinic;il literii-
ture. In two cases of aphasia (Moigan A 'I il-
luckdharry, 1982) singing was M-CII ;is ;I wclconu-
release from the helplessness ofheiiq; i i p;itii.~i~t.
The authors hypothesized thal singing w;is ; I
means to communicate thoughts externally. Al-
though the "newer aspect" of speech was losi,
the older function of music was rcl;iincd,
possibly because music is a function di~trihi~teil
over both hemispheres.
Berman (1981) suggests that recovery from
aphasia is not a matter OS new learning by tin-
nondominant hemisphere but a taking over of re-
sponsibility for language by that henlisphere. The
nondominant hemisphere may be a reserve of
functions in case of regional failure. A less de-
fensive alternative explanation is that the strat-
egies underlying musical proccss are those same
strategies underlying biological process and (lie
maintenance of the identity of the organism.
Rhythm
Rhythm is the key to the integrativc process
underlying both musical perception and physi-
ological coherence. Barfeld's ( 1978) approach
suggests that when n~usicalform as tonal shape
meets the rhythm of breathing there is the niusi-
cal experience. External auditory activity is
mediated by internal perceptual shaping in the
context of a personal rhythm. It is interesting to
speculate here on the meaning of context, not as
a container but as coiz textere, which is a weaving
together. One pattern is then woven against an-
other to produce an interference pattern, the
basis for matter. Sound is woven together witli'
rhythm.
When considering communication, rhythm is
fundamental to organization. Before any consid-
eration of content one must connect rhythmically
with another person and establish some com-
monality. This connection of rhythms is seen as
the phenomenon of entrainment, which occurs in
the circadian rhythms of temperature and sleep.
Should they lose entrainment, then jet lag takes
place. Scientists observing such phenomena
often attempt to find an underlying mechanism
for entrainment (Johnson & Woodland-Hastings,
1986), a master clock ils it were. However, when
moving from a mechanical perspective a musical
analogy for coordinating rhythm might be more
appropriate.
David Aldridge Collected music therapy papers
The rhythms and pulses that entrain the
rhythmic patterns of the human body are non-
material. The senses-hearing, smell, taste,
sight, touch-in addition to balancing and mov-
ing are integrated as a musical form. It is rhythm
that provides the ground of being, and a rhythm
of which being is generally unaware and that is
perhaps the gestalt of identity.
Dossey (1982) writes of disorders of time being
particularly prevalent in modern society. This
may be rephrased as disorders of disrupted
rhythm. The work of Safranek et al. (1982)
demonstrates that subjects use a preferred per-
sonal tempo in the performance of a motor task.
This personal tempo is reflected as a functional
reflex in the muscle. However, by introducing a
n~usicalrhythm while a musical task is being per-
formed, which is different from that of the per-
sonal tempo of the subject, then a different re-
sponse is invoked in the subject. The authors see
this as a "volitional response." Control over
seemingly involuntary movements can be
achieved by meeting the personal tempo of a sub-
ject and thcn changing to a slower, even beat.
Meeting this tempo has been a central strategy in
hypnotherapy. The existence and role of a per-
sonal tempo are refined even further in creative
music therapy (Nordoff & Robbins, 1977). It may
be inferred thcn that people become aware of the
ground of their being not in verbal logic, but in a
logic analogous to the ground of their own func-
tioning (i.e., music). In this sense insight is had
about a person. not in a restricted verbal intellec-
tual sense, but as being- in the world.
The frame of reference approach mentioned
e;irlier is used indirectly by Povel (1984) to
understand rhythm. Tones in sequence are seen
as having a dual function. They are characterized
by pitch, volume, timbre, and duration. They
also mark points in time. These tones then
produce both structure in time and of time. When
tones are used in sequence only as temporal con-
cepts they can be thought of as providing a tem-
poral grid, which is a time scale on which the
tone sequences can be mapped for duration and
location. It might profitably be asked what the
isomorphic events in terms of physiology are that
would meet such a dual function. There may be
regular sequential pulses of metabolic, cardiac,
o r respiratory activity within the body that also
have qualities of pitch, timbre, and duration.
What is important in these descriptions of musi-
29
 MUSIC A N 1) '1'1-l l< S171 , I T
cal perception is the emphasis on conlexl where
there are different levels of ;itlcntion ocenri i i i f ;
sin~ultaneously against a bachgromnl Iciiipoi ; I I
structure (Jones, Kidd, & Wct/x'I, 1981; Iiukl.
Boltz, & Jones, 1984).
Recent research in cardiology has eniph.isi/.cd
the relationship between changes in bre;itliii~g
patterns, personal tempo, and hypertension. The
work of Lynch and his associates (I~iieilniiinn,
Thomas, Kulick-Ciuffo, Lynch, & Suginoh;ira,
1982; Lynch, Long, Thomas, Malinov, &
Katcher, 1981) has highlighted the link, between
hypertension and fast speaking. A feature of type
A behavior in patients with hypertension is that
their blood pressure, which is alre;idy high,
shows an increase when they comniunic;ite.
Such patients are seen to have diffici11tie-i in
communication. They often appear disconnected
from their feelings and have an underlying sense
of hopelessness regal ding their ; h i l i t y lo corn-
municate effectively. When people do not expect
to communicate effectively their blood pressure
rises. Because they do not expect to be under-
stood they do not listen. By not listening they
miss the chance to lower their blood pressure.
Attention to the environment (i.e., listening) is
seen as promoting a deceleration in heart late
and a decrease in blood pressurc. Yet, attention
to the self is seen as promoting heart rale
(Sandman, 1984; Walker & Sandman, 1979,
1982). Changes then in tempo, and the promotion
of listening o r sounding, will have implications
for cardiac and respiratory activity. Lynch et al.
(1981) suggest therapeutic activities to proniote a
reduction in hypertension utilizing slow and deep
breathing. Playing improvised music as pure
communication, with its absence of verbal con-
tent and its primary component of rhythmic ac-
tivity related to personal tempo and volitional re-
sponsc (Safranek et al., 1982), may be the ideal
medium for achieving such change.
It is important to introduce a word of caution
here. The motor act of communicating is not the
cause of the elevated blood pressure. Blood
pressure is elevated whenever communication
takes place. The elevation points to a process
beyond the motor act, which is intent, a feature
also evident in change of muscle activity (Safran-
ek et al., 1982). This switch from physiology
being proactive rather than merely reactive is a
significant feature of modern physiological rc-
search (Walker & Sandman, 1979, 1982).
David Aldridge Collected music therapy papers
95
Kliylhin too plays a role in the perception of
iiirlnily. The perceptions of speech and music are
(01~iiidabletasks of pattern perception. The lis-
I C I I V I hiis to extract meaning from lengthy se-
qiirin..cs of rapidly changing elements distributed
in I ime (Morrongiello, Trehub, Thorpe, &
I'oililupo, 1985).
Temporal predictability is important for track-
ing melody lines (Jones et al., 1981; Kidd et al.,
1984). Kidd et al. also refer to melody as having a
sinicture in time and that a regular rhythm
acilitates the detection of a musical interval and
its subsequent integration into a cognitive repre-
scnt;ition of the serial structure of the musical
ptitt ern. Adults identify familiar melodies on the
basis of relational information about intervals be-
twccn toncs rather than the absolute information
ol"p;irlicular tones. In the recognition of unfamil-
iar melodies, less precise information is gathered
iihoul the tone itself. The primary concern is with
successive frequency changes o r melodic con-
tour. The rhythmical context prepares the lis-
tener in advance for the onset of certain musical
intervals and therefore a structure from which to
discern, or predict, change.
'Die implication of this work is that change,
whether it be melody o r rhythm, is dependent on
a global rhythmic strategy. To extend this un-
derstanding to biological processes, it can be hy-
pothesized that differences in contour (melody)
(as in the release of hormones, fluctuations in
temperature) and changes in rhythm are detected
in reference to a global rhythmic context of the
body. This global context may be regulated by
the heart or breathing patterns, or may be an
emergent property of the varying rhythmic pat-
terns of the body. Disruption in this overall
global strategy will influence a person's ability to
detect new or changed nontemporal information
(Cuddy, Cohen, & Miller, 1979; Jones e t al.,
l98 1 ; Kidd et al., 1984). One may not be aware of
certain changes and become either out of tune o r
out of time.
Conclusion
The perception of music requires an holistic
strategy where the play of patterned frequencies
is recognized within a matrix of time. People may
be described in similar terms as beings in the
world who are patterned frequencies in time.
30
 A phenomenological approach presses the sci-
entist to understand phenomena as dircct cxpcri-
ences before being translated into thoughts and
feelings. The practice of creative music therapy
adopts such a position. A person is invited to
improvise music creatively with a therapist. It
may be inferred from this playing that one is
hearing a person directly in the world as a dircct
expression of those patterned frequencies in a
matrix of time. Rather than subject a person to
measurement, to be reduced to what is quantifi-
able, he or she may be experienced directly. This
experience requires no verbal translation as in
psychotherapy. What can be heard is the person
being in the world. An extension of such im-
provised playing as an expression of the whole
person is that tendencies to play in differing ways
may be heard. There may bc limitations in
rhythm, melody, or musical structure. By chiil-
lenging personal tempo one may he;ir the extent
of his o r her intent.
If musical form and biologic;il lonn are
isomorphic, improvised music nii~yiilso pix~vitlc
an holistic strategy for thc ;isscssniei~t01" Iie;il~li
and well-being. Feinstein ( 1900) st rcssivl I lir ini-.
portance of clinical logic i n tlic ili;i^ini,sis 01'
cancer, and the iniportancc 01' iillowin~i,~ l i rpii
tient to speak: "The complexity ol' I I I ~ I I Ii ~ ~ c n ~ i i s r ? ; rapid speech on blood pressure. I'syclio.so~~~iitic
the difficulty of studying hiimi~iidisciise, Iml i 1 l . s ~
enables a diseased man 10 I i i l k . 11is ilcscriplion 01'
symptoms gives crucial iiilbi~n~iilioii;ilionl IIn-
diseased structures under iiivcstij~:a~ioii"(p.
Speech itself is limiting both in conleiit ;nul in
form. The creative playing ol' improvised music
offers an holistic form of assessment tliul is rclii-
tional, noninvasive, and nonvcrlx;i, ;ind l l i i i l
allows the identity of the patient to be revealed
and experienced in the world. This context
allows the expression of tendencies that have po-
tential~for those states called health and illness.
If music is an earlier form of communication
than language, and the processing strategies lor
the perception of music are distributcd over both
hemispheres, it is possible to infer that this holis-
tic strategy is closer in developmental terms to
physiological processes and autonomic activity
than language. There is an emerging tolerance
and even acceptance of the inllucncc of 1:mgii;tge
on physiology. However, there is a more subtle
and more precise medium with potcntials lbr
representation and influence (i.e., the playing of
David Aldridge Collected music therapy papers
music). Music is the ideal medium to discover
how people are composed and how they come
into the world as whole beings both to create and
sustain identity. Not only can such personal ex-
pression be recorded for analysis, it can be heard
and experienced directly as a whole.
References
Altenmuller, E. (1986). Brain correlates of cerebral music
processing in Ihe human. European Archive's q / ' P s y c l ~ i -
airy. 23.5, 342-354.
Btirteld, 0. (1978). The case for t i ~ ~ ~ l i r o p o s o p hLondon:
y.
Rudolf Steiner Press.
Bcrnian, 1. W. (1981). Musical functioning, speech lateraliza-
lion and the amusias. South Afkican Medical Journal, 59,
78-8 1.
llortoft, H. ( 1986). Goethe's scientific consciousness. Insti-
tute for Cultural Research (Monograph Series No. 22).
Tunbridge Wells, England.
B ~ L I J. , (1980). Music and language: Musical alexia and
s ~C.
agraphia. Briiiii, 103, 367-392.
Cuddy. L. L., Cohen, A. J., & Miller, J. (1979). Melody
recognition: the experimental application of musical rules.
Cuiiiulidii Journal of'Psychology, 33, 148- 157.
I
l k i s s c y . L. ( 1982). Spiicc, l i n (~I I I ~inccliriiir. Boulder, CO:
Shanibliaki.
'cinstein, A. R. (1966). Symptoms as an index of biological
tic1i:ivior in human cancer. Nature. 209. 241-245.
Ii'icdni;~nn,E., Thomas, S. A . , Kulick-CiutTo, D., Lynch, J .
.l,& Suginoliiira, M. (1982). The cl'l'ects of normal and
Modicinc,
4-1, 545-553.
I'ry, 0. ( 1971). Sonic (:/fic~.so f music. Institute for Cultural
Kcsearch (Monograph Series No. 9). Tunbridgc Wells,
lingland.
-!8I.").
liiiles, A., & Bradshaw, J. (1977). The role of the cerebral
hcniisphcrcs in mu5ic. Brain ond Lang~iai".~,4. 403-43 1.
l-lcidcgger, M. (1962). Being u ~ i dtime. London: SCM Press.
.lohnson, C. H., & Woodland-Hastings, J. (1986). The elusive
rnechanisni of the circadian clock. American Scienti.sl 74.
29-36.
Joncs, M. R., Kidd, G., & Wetzel, R. (1981). Evidence for
rhythmic attention. Journal ofE,vperi~rienliilPsychology,
7. 1059-1073.
Kclliir, L. A., & Bever, T. G. (1980). Hemispheric asymmet-
rics in the perception of musical intervals as a function of
musical expcricncc. Brain mid L t i i i f i i d ~ i ' 10, , 2438.
Kidd, G . , Boltz, M,, & Jones, M. R. (1984). Some effects of
rhythmic content on melody recognition. Amrriciin Jour-
mil o f ' l ' s y r l i o l o ~ y ,97, 153-173.
Longuet-Higgins, H . C. (1979). The perception of music.
s the Royal Society qf London, 205, 307-
I ' r ~ c c r d i ~ i f of
322.
Longuet-Higgins, 1-1. C. (1982). The perception of musical
rhythms. fJcrwpfion, / I , 115-128.
Lynch, .l. J., Long, J. M., Thomas, S. A., Malinov, K. L., &
Katchcr, A. H. (1981). The effects of talking on the blood
pressure of hypertensive and normotensive individuals.
Psyclioso~~iulic Medicine, 43, 25-53.
31
 MUSIC AND THE SELF
Morgan, 0. S., & Tilluckdharry, R. (1982). Presentation of
singing function in severe aphasia. West Indian Medical
Journal, 31, 159-161.
Morley, J. B. (l98 1). Music and neurology. Clinical am1 Ex-
' periine~ztulNeurology, 17, 15-25.
Morrongiello, B., Trehub, S. E., Thorpe, L. A., & Podilupo,
S. (1985). Children's perception of melodies: The role o l
contour, frequency and rate of presentation. Journal of'
Experimental Child P.sycliolof~,40, 279-292.
Nordoff, P., & Robbins, C. (1977). Crcutivc music tlu-nipy.
Individualized treatment / o r tlie luinciicapped cliilcl. New
York: John Day.
Povel, D. J. (1984). A theoretical framework Ibr rhythni pcr-
ception. Psycholofical Rfsecircli, 45, 315-337.
Safranek, M. G., Koshland, G . F., & Raymond, G . (1982).
Effect of auditory rhythm on muscle activity. l'l~y,\icul
TIti-rapy, 62, 16 1- 168.
David Aldridge Collected music therapy papers
Sandman, C. A. (1984). Afferent influences on the cortical
evoked response. In M. Coles, J. R. Jennings, & J. A.
Stern (Eds.), Psycliological perspectives (Festschrift for
Beatrice and John Lacey). Stroudberg, PA: Hutchinson &
Ross.
Steedman, M. J . (1977). The perception of musical rhythm
;ind metre. Perception, 6, 555-569.
Wiigncr, M . T., & Haniton, R. (1981). Hemispheric asym-
m e t r i c ~ in faculty and student musicians and non-
musicians duriny melody recognition tasks. Brain and
, 379-388.
L t ~ t ~ g u a g e13,
Walker, A. (1979). Music and the unconscious. British Medi-
cul Jmirnul, 2 , 164 1-1643.
Walker, B. B., & Sandman, C. A. (1979). Human visual
evoked responses are related to heart rate. Journal of
Comparative rind I'liysiolofficul Psychology, 93, 7 17-729.
Walker, B. B., & Sandman, C. A. (1982). Visual evoked po-
tcntiiils change ;is heart rate and carotid pressure change.
Psyrliopliysiolo~y,19, 520-526.
32

Music, communication and medicine: discussion paper
D Aldridge RID Medical Faculty, Uniuersitat Witten Herdecke, Beckweg 4 D-5804 Herdeke (Ruhr), FRG
Keywords: music therapy; physiology; communication; child development; rhythm entrainment
'The body of the speaker dances i n time with his speech.
Further, the body of the listener dances i n rhythm with that
of the speaker!'
(Condon and Ogston, p 338)
In our work as a department of music therapy within
the faculty of medicine in a West German teaching
hospital we have begun to explore links between the
playing of improvized music as therapy and the
practice of medicine. Music therapists work with
physicians within the hospital as complementary
practitioners. We have attempted to develop a
common language by which patients are described.
This language calls upon the art of medicine as much
as it does upon the science of medicine. Our contention
is that human beings have a personal identity which
is musical1. When we search for a metaphor which
informs the way we describe ourselves then we can
say that we are symphonic, rather than mechanic,
beings.
The main argument of this paper is that musical
components are the fundamentals of communication;
and that rhythm, in particular, is the musical
aspect of communication fundamental to the way
in which we relate to ourselves and to others.
Communication in this sense is not solely restricted
to the transmission of information, but is also
concerned with the establishment and management
of relationships2.
If this argument is true then music is a powerful
and subtle medium of communication which is
isomorphic with the process of living3y4 and music
therapy can be a powerful therapeutic medium for
promoting communication.
The focus for understanding communication is how
the human being can maintain a coherent identity in
a personal and interpersonal milieu. This continually
maintained coherence is a creative act. None of us as
human beings are islands isolated in the universe. We
are organisms which act and interact with the
environment. We experience the world and attempt
to influence it. Communication is the process by which
we interact with our environment which includes the
interpersonal milieux of our friends, colleagues and
lovers. It is the medium by which we negotiate our
self image in those relationships and integrate
ourselves with others.
Dialogue and exchange of information, the regulation
of interpersonal distance and personal boundary,
the mutual expression of human emotion and the
sharing of ideas are based upon communication.
These are located within a matrix of time which is
not static. Sequence, order and phrasing, the funda-
mentals of musical form are vital elements in
maintaining coherence whether in physiological
systems, personal development or interpersonal
relationships.
David Aldridge Collected music therapy papers
Journal of the Royal Society of Medicine Volume 82 December 1989 743
Physiology and communication
At the molecular level the immune system and nervous
system communicate with each other. Psychological
stress and social stress influences the immune system,
sometimes adversely. The relationship between neuro-
endocrine and immune systems is one of mutual
comm~nication~,~. Our bodies are engaged in a con-
tinuing communicative process out of the range of
conscious awareness. These communications are vital
for life. We can, as Rossi5 says
'. . . conceptualize a fairly complete channel of information
transduction between mind a s it is experientially encoded
in the limbic-hypothalamic system filter, and the autonomic
endocrine, immune, and neuropeptide systems that transmit
their "messenger" molecules to the organs and tissues and
to the cellular, genetic, and ultimately molecular levels'.
(P 52)
In this approach mind and body are united within a
rhythmic context of communication which enables
healing to take place. At the core of this work is the
idea that the suprachiasmatic nucleus of the hypo-
thalamus is a regulator of the ultradian (within a
day) rhythms7 responsible for autonomic system
regulation and cerebral dominance5.When the normal
periodicity of these rhythms is disturbed by stress then
psychosomatic reactions may occur. The restoration of
an integrated rhythmic hypothalamic response should
be an important factor in the process of healing. It
is feasible then that music therapy is an ideal medium
for promoting such integration and regulation through
rhythm.
Synchrony, rhythm and communication
'Curative chronobiotics may be visualized for disease such
as certain emotional disorders or rheumatoid arthritis - if,
and only if, rhythm alternation can be recognized to be
etiologically significant" (p 487).
For communicationto occur there has to be an element
of predictability by which events are structured. This
communication occurs within a matrix of time and is
manifested as particular rhythms. These may be the
circadian rhythms (literally about a day) of temper-
ature and sleep in humans, the shorter ultradian
(within a day) rhythms of autonomic system regulation
and metabolic processes, or the shorter periodicities
of respiration, peristalsis and heart rate7-9.These are
the regulatory mechanisms by which self synchrony
is maintained as a process of internal communication.
The work of C ~ n d o n ~ O clearly
- ~ ~ shows the inte-
gration in terms of verbal behaviour, including
silence, and bodily gestures. There is a self syn- o141~076818gl
c o n o u s organization to h and movement which 120743-041~02~0010
is essentially rhythmic. Rhythm provides the means Q1989
by which behaviour is organized. The Royal
However, Condon12goes on to write that as human Society of
beings we also communicate with other people. This Medicine
33
 744 Journal of the Royal Society of Medicine Volume 82 December 1989
he calls 'interactional' synchrony. We are active
participants in communication. When we listen we
move synchronously with the articulatory structure
of the speaker's speech. As the speaker moves with
his own speech, then so does the listener too. What
is 'sent' and 'received' are inseparable in the ordered
context of communication. This gives additional
support to the idea, to which some music therapists
refer, when they say that therapist and patient are
'united in the music'. In Condon's words12
'But what flows through them is a similar order; so that what has
is sent and what is received are understood and shared by
both speaker and listener. What all aspects of this process
have in common is the propagation and reception of order.
There is no "between" i n the continuum of order.' (p 56).
As rhythms are entrained, or synchronized, within
the individual, then the listener will entrain with the
emergent rhythmic structure of the speaker, singer
or player. By watching the movement of the listeners
body as well as by observing the way in which the
listener plays it is possible to glean some ideas about
their perceptual involvement.
Phrasing
A central feature of both musical and biological form
is phrasing. When we speak in dialogues then we
must know when a phrase is ending, and how to begin
another. This occurs in speech by accented differences
in a rhythmic context. When we listen we give a
continuous feedback by small motions and gestures
of our heads and bodies, and vocalizations. When a
phrase is coming to an end there is an increase or
change in such activity13.
Interactional synchrony between people, and the co-
ordination of phrasing in communication, cannot be
explained as reaction or as a reflex response to sound
or movement. Synchronization is achieved by a shared
interaction in a rhythmic context known to both
participants. The basis of such mutual knowledge is
both physiological, in that we share common
physiologies, and cultural14. The forces which bind
us together, which are the essence of our mutuality,
are musical.
Non-verbal communication and relationship
As the preceding paragraphs suggest, communication
occurs in a context of relationship. Peggy Perm2writes
that 'All emotions are an indication of how someone else
is to behave' (p 17). All too often when we consider
communication in the context of therapy we concentrate
on the semantic bases of communication when it is the
relational aspects of the interaction which are primary.
Language and non-verbal behaviours are powerful
organizers of personal and social actions2J4. In
studying communication the role of verbal behaviour
is often over-emphasized, and the role of non-verbal
behaviour neglected. This places a n emphasis on the
'what' of communication (ie the content of communi-
cation)rather than the 'how' of communication (ie the
regulation of that communication). The non-verbal
aspects of communication indicate how the content
is to be received. Watzlawick et al. l5 call this process
'metacommunication'; a communication about a
communication. For example; the comment 'Oh, very
interesting' can have quite a different meaning
according to the tone of voice and gesture used to
David
deliverAldridge
it. Collected music therapy
Sometimes information which is too powerful or
--------- L _ l _ _ . Â ¥ _ __-..__-L L - ---__---:--^.-.3
alone, or words themselves seem inadequate. The
communication of passions, love, ecstasy or anger are
rarely dependent solely on words. At such times
vocalizations and gestures are far more subtle and
'meaningful' than words.
Child development and rhythmic interaction
The development of language and socialization
in the infant depends upon learning the rhythmic
structure of synchronization13.From birth the infant
the genetic basis of an individually entrained
physiology, ie a self synchronicity. The infant has its
own time as 'kairos'. Yet, the process of socialization,
and the use of language depends upon entraining
those rhythms with those of another, ie an inter-
actional synchrony as 'chronos'. This interactional
synchrony could reflect those neural timing mech-
anisms which form the ground of communication
where interactional cycles of attention and affect
are entrained with homeostatic mechanisms in the
nervous system16.
Lester et aZ.17 investigated the synchronization of
neonatal movement and the speech sounds of the adult
talking to the baby. They argued that the ability of
the infant to attend to social stimuli was related to
the infant's capacity for self regulation. Cycles of
rhythmic interaction between infants and mothers,
they argued, reflected an increasing ability by the infant
to organize cognitive and affective experience within
the rhythmic structure provided by the parent.
However, this was not a one-sided phenomenon.
Infants produce forms of expression and gesture that are
not imitations of maternal behaviour18J9.Both baby
and mother learn each others rhythmic structure and
modify their own behaviour to fit that structure.
Arousal, affect and attention are learned within the
rhythm of a relationship.
This is the method employed in music therapy. The
rhythmic structure of the patient is discovered by
the therapist, and the patient is then met within that
rhythmic structure.
Stern et al.20studied the non-verbal behaviour of
mothers and infants. They found two parallel modes
of communication.
One form of communication was that of CO-action.
In this form both mother and infant vocalize together.
These authors suggest that coactional vocalizing is
an early pattern of behaviour which is structurally
and functionally similar to mutual gaze, posture
sharing and rhythm sharing. It occurs during the
highest levels of arousal and is indicative of emotional
tone. In adults CO-active vocalizing occurs in situations
of interpersonal arousal such as intense anger,
sadness, joy or lovemaking.
The contrasting form is that of alternation. This mode
of communicationis that found in conversationwhere
speaker and listener alternately exchange roles. It is
a dialogic pattern and valuable for the exchange of
symbolic information. This alternative mode is
valuable for the acquisition of language. It allows
information to be sent by one person while being
processed by the other. However, it is a separate
pattern to that of CO-action.
CO-actionemphasizes the event of communication it-
self, rather than the content of the communication.
Simultaneous vocalization promotes mutual experi-
ence andpapers
may be essential to the process of bonding and34
feeling of relatedness. These two structurally different
L J- c---rt ..-rt --.....A.+ .¥: +Lrt-1rt.rl-nrv .c ¥;.......rt. :---id -.. --in

Communication and pathology
If musical elements are essential to communication,
then the improvized musical playing of people may
make manifest both underlying pathology and possi-
bilities for growth and change.
Condon and Ogston1Âcompared normal and path-
ological behaviour between patients and therapists
using the medium of film. Human interaction was
filmed. The films were then viewed repeatedly one
frame a t a time, and analysed. Each frame was
numbered and sequences of frames analysed according
to speech and vocalization correlated with body
movements. The authors call this the study of
'linguistics-kinesics'1Â (p 38).
When the same authors studied a chronic schizo-
phrenic patient they found that there was a noticeable
lack of head movements and rigidity of posture in the
patient compared to the relatively free head movement
of normal speakers. The expressive qualities of
speech and movement were severely restricted. A self-
dysynchrony also appeared in the schizophrenic
patient where body movements appeared to be
laterally separate.
In the micro-analysis of films of depressed patients
by Condon1Â prosodic features of pitch, stress,
phrasing and timbre were found which seemed
indicative of underlying pathology;
'A marked laxity of articulatory movements characterizedthe
speech of these patients. With its sparing use of pitch and
accent, their voice had a dead listless quality: changes of pitch
covered a narrow tonal range and were predominantly step-
wise rather than gliding; hovering tones appeared at the end
of sentences, . . .intonations tended to occur in the same stereo-
typed patterns; and emphatic accents were either rare or
absent entirely. Their speech gave an impression of being slow
and halting because of the frequent appearance of hesitation
pauses interrupting the flow of their phrases' (p 344).
It is evident from this description that these are also
musical qualities, and if the improvized playing of a
depressed patient was heard then a music therapist
would be making similar comments.
Fraser et aLZ1showed similar discriminating lin-
guistic profiles of schizophrenic and manic patients.
There was a continuum of linguistic degeneration
across the psychotic spectrum. In an experimental
control group 'normal' subjects produced fluent,
complex and error free utterances. Schizophrenic
patients produced dysfluent, simple and error ridden
speech.
Interestingly, when these patients improved clinically
sentences became more tightly constructed and pitch
widened in range and became more melodically
varied. Again clinical improvement can be heard in
the musical (prosodic or suprasegmental) aspects of
speech style.
Condonl1continued to develop this diagnostic work
further studying the integration of body motion and
speech across many dimensions, particularly in the
field of autistic-like behaviour. His frame by frame
filmed micro-analysis of patients with various syn-
dromes like petit mal, Huntington's chorea, autism,
stuttering, parkinsonism and aphasia, led him to
believe that there may be some relationship between
their problems and an underlying dysfunction in sound
processing. Many of the behavioural mannerisms he
observed in children appeared to be related to a
multiple response to sound; there was both a n
immediate response and a delayed response to a sound
David or
event, Aldridge
'dyssynchrony'. Collected music therapy
Journal of the Royal Society of Medicine Volume 82 December 1989 745
This work resulted in Condon postulating a con-
tinuum of degrees of delayed response to sound with
autistic-like behaviour at the severe end and learning
disabilities a t the milder end. (While not evident as
a motor abnormality during conversation, these
children had difTiculty with reading and mathematics).
The observed children responded to an immediate
actual sound but also appeared to respond again to
that same sound with a delay 'by as much as % to a
full second'll (p 47).
He gives the example of a 2% year old child
throwing a block on a table. The block lands on the
table and the child picks up another such block. The
childs' hands suddenly move in a jerky and seemingly
bizarre manner. Microanalysis of the film revealed
that the child's body moved synchronously with the
sound of the brick hitting the table. At a later time,
16 film frames, the jerky hand movements occurred.
These hand movements were isomorphic with the
sound and movements which occurred 16 film frames
earlier. (There were 24 film frames per second). By
delaying the film sound to coincide with the move-
ment the child was seen to move in precise synchrony.
It was possible to see and hear the occurrence of a
sound on film and predict the occurrence of a bodily
movement 16 frames later without any sound
occurring at that time.
In children with a delayed response to sound
their behaviour appeared to be dominated by that
delay. Furthermore, these children often lacked
a co-ordination between hearing a sound and
visually locating that sound. These children were
literally out of time with the sensory structure of their
world.
The entrainment of vision and sound gives an
important spatial location in the world. To com-
municate we need to be entrained both within
ourselves and with our environment. A delay in sound
processing can lead to estrangement from the world
and personal incoherence.
Discussion
The basic elements of human communication are
musical. Physiological, psychological and social activity
occur in a context of time which is dynamic and the
structure of which is musical. At a fundamental level
human activity is organized as a hierarchy of
rhythmic entrainment; within the individual as self-
synchrony, and within relationships as interactional
synchrony.
When the breakdown of this synchronous be-
haviour occurs then pathology is evident. The
restriction of musical aspects of communication,pitch,
stress, articulation, timbre and fluency, appear to
be indicative of psychopathology. An improvement
in these qualities appears to be evident in a
return to health and the maintenance of a coherent
identity.
It is possible to hypothesize that improvized music
therapyzz is a powerful tool for promoting
communication in terms of personal and interpersonal
integration. Alternative creative dialogues may be
encouraged within the person such that they are not
estranged within themselves, or estranged from
others. Furthermore, clinicians, no matter in which
discipline they have their origins, may be advised to
attend to the musical components of communication.
In this way the arts, as well as science, may inform
papers
the practice of medicine. 35
746 Journal of the Royal Society of Medicine Volume 82 December 1989
References
1 Aldridge D. A phenomenonlogical comparison of the
organization of music and the self. Arts in Psychotherapy
1989;16:(in press)
2 Penn P. Coalitions and binding interactions in families
with chronic illness. Fam Systems Med 1983;1:16-26
3 Aldridge D. The development of a research strategy
for music therapists in a hospital setting. Arts in
Psychotherapy 1989;16:(in press)
4 Aldridge D. Physiological change, communication and
the playing of improvised music. Arts in Psychotherapy
1989;16:(in press)
5 Rossi EL. From mind to molecule: A state-dependent
memory, learning and behavior theory of mind-body
healing. Advances 1987;4:46-60
6 Tee DE. Another look a t the interaction of psyche and
soma. Complementary Med Res 1987;2:1-2
7 Moore-Ede MC, Czeisler CA, Richardson GS.Circadian
timekeeping in health and disease. N Engl J Med
1983;309:469-79
8 Reinberg A, Halberg F. Circadian chronopharmacology.
Ann Rev Pharmacol1971;11:455-92
9 Johnson C, Woodland-Hastings J. The elusive mechanism
of the circadian clock. Am Sci 1986;74:29-36
10 Condon WS, Ogston WD. Sound film analysis of normal
and pathological behavior patterns. J Nerv Ment Dis
1966;14:338-47
11 Condon W. Multiple response to sound in dysfunctional
children. JAutism Childhood Schizophrenia1975;5:37-56
12 Condon W. The relation of interactional synchrony to
cognitive and emotional processes. In: Key MR, ed. The
David Aldridge Collected music therapy papers
relationship of verbal and non-verbal communication.
The Hague: Mouton, 1980:49-65
Kempton W. The rhythmic basis of interactional
microsynchrony. In: Key MR. ed. The relationship of
verbal and non-verbal communication. The Hague:
Mouton, 1980:68-75
Key MR. The relationship of verbal and non-verbal
communication. The Hague: Mouton, 1980
Watzlawick P, Beavin JH, Jackson DD. Pragmatics of
human communication. New York: WW Norton, 1967
Linden W. A microanalysis of autonomic activity during
human speech. Psychosom Med 1987;49:562-78
Lester BM, Hoffman J , Brazelton TB. The rhythmic
structure of mother-infant interaction i n term and pro-
term infants. Child Dev 1985;56:15-27
Murray L, Trevarthen C. The infant's role in
mother-infant communications. J Child Long 1986;
1315-29
Trevarthen C. Facial expressions of emotion in mother-
infant interaction. Human Neurobiol 1985;4:4-21
S t e m DN, Jaffe J, Bebbe B, Bennett SL. Vocalizing in
unison and in alternation: two modes of communication
within the mother infant dyad. Ann NY Acad Sci
1975;263:89-100
Fraser WI, King K, Thomas P, Kendell RE. The
diagnosis of schizophrenia by language analysis. Br J
Pyschiatry 1986;148:275-8
Nordoff P, Bobbins C. Creative music therapy. New York:
John Day, 1977
(Accepted 25 May 1989)
36
The Arts in Psychotherapy, Vol. 18, pp. 359-362. Pergamon Press plc, 1991. Printed in the U.S.A. 0197-4556191 $3.00 + .00

REFLECTIONS

CREATIVITY AND CONSCIOUSNESS:

MUSIC THERAPY IN INTENSIVE CARE

DAVID ALDRIDGE, PhD*

' . . however great the organic damage . . . there
remains the undiminished possibility of reintegration
by art, by communion, by blocking the human spirit;
and this can be presented in what at first seems at first
a hopeless state of neurological devastation."
(Sacks, 1986, p. 37)
The neurologist Oliver Sacks reminds us of the
necessary balance we must bring to our work with
patients in the field of medicine. All too often we are
concerned with testing the patient for deficits, for
measuring and for assessing problem-solving capaci-
ties. As a balance he urges us to consider the narrative
and symbolic organization of the patients, so that we
consider their possibilities and abilities. In this way
what seems to be damaged, ill-organized, and chaotic
becomes composed and fluent. This is the function of
the creative arts; through art and play we realize other
selves elusive to measurement and fugitive to assess-
ment. Furthermore, there is a quality of time that is
apparent in arts activities that is "intentional7' and
involves the will of the patients where their spirits are
set free. When we consider the situation of intensive
care, where patients are often damaged, disorganized,
intubated, machine-regulated, often unconscious, and
unable to communicate, then we must consider a way
of introducing activities that will stimulate commun-
ion with those patients.
In this paper the ground of consciousness is con-
sidered. It raises questions about the location of the
self in patients who are comatose, about the nature of
communication with patients who are unconscious,
and challenges medicine to realize the human body as
an instrument of knowledge.
Some aspects of modem medicine have become
increasingly technological. Such is the case of inten-
sive care treatment. Even in what may appear to be
hopeless cases, it can save lives (Hannich, 1988)
through the application of this modem technology.
However, albeit in the context of undoubted success,
intensive care treatment has fallen into disrepute.
Patients are seen to suffer from a wide range of
problems resulting from insufficient communication,
sleep and sensory deprivation (Hannich, 1988; Ul-
rich, 1984), and lack of empathy between patient and
medical staff. Many activities in an intensive care
situation appear to be between the unit staff and the
essential machines (i.e., subjects and objects). To a
certain extent, patients become a part of this object
world. Improvised music therapy can be a useful
adjunctive therapy in such situations both for the
patient and the staff.
The Music Therapy Sessions
At the suggestion of a hospital neurologist, a music
therapist began working with patients in intensive

*David Aldridge is a research consultant to the medical faculty of Universit'at Witten Herdecke, Germany.
He thanks Dr. Wilhelm Rimpau for the initiation of this work, Dagmar Gustorff for her pioneering of these skills in difficult conditions,
and Professor H.J. Hannich for his providing the circumstances for the further exploration of this work.

359

David Aldridge Collected music therapy papers 37

360 DAVID ALDRIDGE
care (Gustorff, 1990). To investigate this approach
further, the work was monitored in the intensive
treatment unit of a large university clinic. Five
patients, between the ages of 15 and 40 years, and
with severe coma (a Glasgow Coma Scale score
between 4 and 7) were treated. All the patients had
been involved in some sort of accident, had sustained
brain damage, and most had undergone neurosurgery.
The form of music therapy used here was based on
the principle that we are organized as human beings
not in a mechanical way but in a musical form (i.e.,
a harmonic complex of interacting rhythms and me-
lodic contours) (Aldridge, 1989a, 1989b; Nordoff &
Robbins, 1977). To maintain our coherence as beings
in the world we must creatively improvise our iden-
tity. Rather than search for a master clock that
coordinates us chronobiologically, we argue that we
are better served by the non-mechanistic concept of
musical organization. Music therapy is the medium
by which a coherent organization is regained (i.e.,
linking brain, body, and mind). In this perspective,
the self is more than a corporeal being. As Sacks
(1986) wrote, "the power of music or narrative form
is to organize" (p. 177). What music and narrative
structure organizes is the recognition of relationships
between elements, not in an intellectual way, but
direct and unmediated. With coma patients we see
signs of activity, albeit often machine supported, but
totally disorganized. The person exists, sometimes in
what is described as a vegetative state, but hardly
''lives. "
Each music therapy contact lasted between eight
and twelve minutes. The therapist improvised her
wordless singing based on the tempo of the patient's
pulse and, more importantly, the patient's breathing
pattern. She pitched her singing to a tuning fork. The
character of the patient's breathing determined the
nature of the singing. The singing was clearly phrased
so that when any reaction was seen the phrase could
be repeated.
Before the first session the music therapist met the
family to gain some idea of what the patient was like.
On contacting the comatose patient, she said who she
was, that she would sing for the patient in the tempo
of his or her pulse and the rhythm of breathing. The
unit staff were asked to be quiet during this period and
not to carry out any invasive procedures for ten
minutes after the contact.
There was a range of reactions from a change in
breathing (it became slower and deeper), fine motor
David Aldridge Collected music therapy papers
movements, grabbing movements of the hand, and
turning of the head, eyes opening to the regaining of
consciousness. When the therapist first began to sing
there was a slowing down of the heart rate. Then the
heart rate rose rapidly and sustained an elevated level
until the end of the contact. This may have indicated
an attempt at orientation and cognitive processing
within the communicational context (Nordoff & Rob-
bins, 1977; Sandman, 1984a, 1984b). Electroenceph-
alogram (EEG) measurement of brain activity showed
a desynchronization from theta rhythm, to alpha
rhythm or beta rhythm in former synchronized areas.
This effect, indicating arousal and perceptual activity,
fades out after the music therapy stops.
If we consider that cells firing with a cardiac
rhythm have been recorded in the medullary area of
the brain, and that there is a synchronous relationship
between the contraction of the heart and the "ascend-
ing" wave of alpha rhythm (Sandman, 1986) of brain
activity, then it is possible to hypothesize that the
rhythmic coordination of the cardiovascular system
with cortical rhythmic firings is of primary impor-
tance for cognition. What we have is a weaving
together of basic primitive human rhythms, which
produce an interference pattern that itself may be that
of cognition. It is proposed here that the rhythmic
coordination of basic functions in the human body
(Jones, Kidd, & Wetzel, 1981; Kempton, 1980;
Kidd, Boltz, & Jones, 1984; Lester, Hoffman, &
Brazelton, 1985;Longuet-Higgins, 1982; Povel, 1984;
Rozzano & Locsin, 1981; Safranek, Koshland, &
Raymond, 1982; Steedman, 1977) is a fundamental
healing activity.
The Ward Situation
Sleep disturbance is a major problem in intensive
care units and the effect of a disturbed waking1
sleeping rhythm upon other metabolic cycles is criti-
cal (Johnson & Woodland-Hastings, 1986; Moore-
Ede, Czeisler, & Richardson, 1983; Reinberg &
Halberg, 1971). The rhythmic entrainment of cardio-
vascular and somatic activities may be the key ground
for recovery. This means that we must consider the
total "behavioral" (Engel, 1986) activity of the
patient so that seemingly independent systems are
integrated. The context (i.e., Latin, con textere =
weaving together) of this integration is rhythmical
involving the coordination of the major tidal rhythms
of the body and timing mechanisms within the hypo-
thalamus in the brain.
38
 MUSIC THERAPY IN INTENSIVE CARE
As an organizational problem, we must look to the
ways in which staff are employed in work shifts. It
can occur that patients throughout 24 hours are
constantly in contact with nursing staff who are in
their own activity cycle, no matter what time of day or
night. For rhythmically disoriented patients, no won-
der that there are sleep problems when they must
respond to constant activity with caregivers who
themselves are physically unsynchronized with the
patient. Nursing staff, although synchronized with
management needs and hospital routine, may need to
attend to the sleeplactivity rhythm of the patient.
In response to the music therapy, some ward staff
are astonished that patients can respond to quiet
singing. This highlights a difficulty of noisy, busy,
often brightly lit units. All communication is made
above a high level of machine noise. Furthermore,
commands to an "unconscious" patient are made by
shouting formal injunctions (i.e., "Show me your
tongue," "Tell me your name," "Open your eyes").
Few attempts are made at normal human communi-
cation with a patient who cannot speak or with whom
staff can not have any psychological contact. It is as
if these patients were isolated in a landscape of noise,
and deprived of human contact.
A benefit of music therapy is that the staff are
made aware of the quality and intensity of the human
contact. In the intensive care unit environment of
seemingly non-responding patients, dependent on
machines to maintain vital functions and anxiety
provoking in terms of possible patient death, then it is
a human reaction to withdraw personal contact and
interact with the machines. Although the machines
themselves are of vital importance, they present data
that are independent one from another, and that are
often considered in isolation, whereas the integration
of the systems being measured is the clue to recovery.
This is further exacerbated by a scientific epistemol-
ogy that emphasizes the person only as a material
being and that equates mind with brain.
At yet another level, we must consider the fixed
chronological pulses of machines. If human activity is
based on pulse, the nature of those pulses is that they
are variable within a range of reactivity. Those pulses
are lively and accommodate other pulses to form
interacting rhythms. This is not so with machines;
they are fixed in their range. Therefore, what is a
variable in human activity (the tempo of varying
pulses) becomes a constant in these patients. The task
then is to introduce coordinated variety with the
intention to heal, something that as yet machines
David Aldridge Collected music therapy papers
361
cannot do. Perhaps the key lies in the fact that it is the
consciousness of the therapist that stimulates the
consciousness of the patient, and this consciousness is
not divorced from the living rhythmic reality of our
physiology.
A period of calm is also recognized as having
potential benefit for the patient. What some staff fail
to realize is that communication is dependent on
rhythm, not on volume. We might argue that such
unconscious patients, struggling to orient themselves
in time and space, are further confused by an atmo-
sphere of continuing loud, disorienting random noise,
and bright light. For patients seeking to orient them-
selves, the basic rhythmic context of their own
breathing may provide the focus for that orientation.
This raises the problem of intentionality in human
behavior even when consciousness appears to be
absent. Reflexes do not occur in a vacuum; they are
conditional occurring in a context of other behavioral
activity. If bodily systems are proactive, as well as
reactive, then purposive behavior and consciousness
may require the context of human communication to
function. It is also vital that staff in such situations do
not confuse "not acting" on the behalf of the patient
with "not perceiving. "
We can further speculate that the various body
rhythms have become disassociated in comatose states
and following major surgery. The question remains of
how those behaviors can be integrated and where the
seat of such integration is. It is quite clear that
integration is an organizational property of the whole
organization in relationship with the environment and
not located in any cell or any one organ. The
environment of the patient includes the vital compo-
nent of human contact and there is reason to believe
that the essential ground of this contact too is rhyth-
mical.
Communication, Contact, and Consciousness
Improvised singing appears to offer a number of
possible benefits for working in intensive care both in
terms of human contact and promoting perceptual
responses. Human contact as communication is a
creative art form. Although what we know from
machines is valuable, there are other important subtle
forms of knowledge that are best gleaned through
personal contact with the patient. Mindell (1989) took
the courageous step of attempting process-oriented
psychology with comatose patients, accompanying
them on their great symbolic journey. The drama of
39
362 DAVID ALDRIDGE
our contact with such patients at a time of existential
crisis points to a fundamental aesthetic of living
systems creatively realized so that we, as artist
therapists, can go beyond the confines of a soulless
technology. This is not to deny that technology and its
benefits, simply to remind us of our human intention
as it is realized in art, play, drama, music.
What we may also need to consider in future is not
how to observe more, but how to question the quality
of what we are observing and the premises on which
this observation is based. In such situations of inten-
sive monitoring and machine support, particularly in
the case of comatose patients, we may ask of our-
selves, "Where is the self of the patient?" Needle-
man (1988) reminds us that the power of scientific
thought has been to organize our perceptions in such
a manner that we can survive in the world. Hence the
value of scientific medicine and instrumentation.
However, he goes on to say that science has also
neglected the human body as an instrument of knowl-
edge and as a vehicle for sensations as direct as
ordinary sensory experience, but as subtle as con-
sciousness. He writes ". . . it is not simply the
intellect which science underestimates, it is the hu-
man body as an instrument of knowledge-the human
body as a vehicle for sensations as direct as ordinary
sensory experience, but far more subtle and requiring
for their reception a specific degree of collected
attention and self-sincerity" (p. 169).
The question still remains for us as clinicians and
scientists when faced with a patient in coma or a
persistent vegetative state, "Where is the person and
how can I reach him or her?" and then for ourselves
as fellow human beings, "Where am I?" What part of
the therapist is contacting the unconscious patient?
Could it be that if the musical form of our communi-
cation touches our patients, as singing, we can also
attend to how we speak with the patients in their
breathing patterns, and then attend to them with the
very form of our own bodies.
This ability to communicate with unconscious
patients raises further the ethical issues of decisions
about terminating life support when the brain and the
person are no longer seen as one and the same entity
(Mindell, 1989). When patients are not responding it
may be that we are not providing them with the
human conditions in which, and with which, they can
respond. We as therapists are those conditions that are
the context for healing to take place.
David Aldridge Collected music therapy papers
References
Aldridge, D. (1989a). Music, communication and medicine.
Journal of the Royal Society of Medicine, 82, 743-745.
Aldridge, D. (1989b). A phenomenological comparison of the
organization of music and the self. The Arts in Psychother-
apy, 16, 91-97.
Engel, B.T. (1986). An essay on the circulation as behavior. The
Behavioral and Brain Sciences, 9 , 285-3 18.
Gustorff, D. (1990). Lieder ohne Worte. Musiktherapeutische
Umschau, 11, 120-126.
Hannich, H.J. (1988). Uberlegen zum Handlungsprimat in der
Intensivmedizin. Medizin Mensch Gesellschaft, 13, 238-244.
Johnson, C., & Woodland-Hastings, J. (1986). The elusive mech-
anism of the circadian clock. American Scientist, 74, 29-36.
Jones, M,, Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic
attention. Journal of Eqerirnental Psychology, 7 , 1059-1073.
Kempton, W. (1980). The rhythmic basis of interactional mi-
crosynchrony. In M. Key (Ed.), The relationship of verbal and
non-verbal communication (pp. 68-75). The Hague: Mouton.
Kidd, G., Boltz, M,,& Jones, M. (1984). Some effects of
rhythmic content on melody recognition. American Journal of
Psychology, 97, 153-173.
Lester, B. M., Hoffman, J., & Brazelton, T. (1985). The rhyth-
mic structure of mother-infant interaction in term and proterm
infants. Child Development, 56, 15-27.
Longuet-Higgins, H. (1982). The perception of musical rhythms.
Perception, 11, 115-128.
Mindell, A. (1989). Coma: Key to awakening. Boston: Shambala.
Moore-Ede, M. C., Czeisler, C. A., & Richardson. G. S.
(1983). Circadian timekeeping in health and disease. New
England Journal of Medicine, 309, 469-479.
Needleman, J. (1988). A sense of the cosmos. New York: Arkana.
Nordoff, P., & Robbins, C. (1977). Creative music therapy. New
York: John Day.
Povel, D. (1984). A theoretical framework for rhythm percep-
tion. Psychological Research, 45, 315-337.
Reinberg, A., & Halberg, F. (1971). Circadian chronopharma-
cology. Annual Review of Pharmacology, 11, 455-492.
Rozzano, G., & Locsin, R. (1981). The effect of music on the
pain of selected post operative patients. Journal of Advanced
Nursing, 6 , 19-25.
Sacks, 0. (1986). The man who mistook his wife for a hat. Lon-
don: Pan.
Safranek, M., Koshland, G. & Raymond, G. (1982). Effect of
auditory rhythm on music activity. Physical Therapy, 62,
161-168.
Sandman, C. (1984a). Afferent influences on the cortical evoked
response. In M. Coles, J. Jennings, & J. Stem (Eds.), Psy-
chophysiological perspectives: Festschrift for Beatrice and
John Lacey. Stroudberg, PA: Hutchinson & Ross.
Sandman, C. (1984b). Augmentation of the auditory event related
to potentials of the brain during diastole. International Jour-
nal of Physiology, 2, 111-1 19.
Sandman, C. (1986). Circulation as consciousness. The Behav-
ioural and Brain Sciences, 9, 303-304.
Steedman, M. (1977). The perception of musical rhythm and
metre. Perception, 6 , 555-569.
Ulrich, R. (1984). View through a window may influence recov-
ery from surgery. Science, 224, 420421.
40

Where am I?
Music therapy applied to coma patients
Intensive care treatment is a highly technological
branch of medicine. Even in what may appear
to be hopeless cases, i t can save lives1 through
the application of this modern technology. How-
ever, albeit in the context of undoubted success,
intensive care treatment has fallen into disre-
pute. Patients are seen to suffer from a wide
range of problems resulting from insufficient com-
munication, sleep and sensory deprivation2s3 and
lack of empathy between patient and medical staff.
Many activities in an intensive care situation appear
to be between the unit staff and the essential
machines, ie subjects and objects. To a certain extent
patients become a part of this object world. We propose
that improvised music therapy can be a useful
adjunctive therapy in such situations both for the
patient and the staff.
In these situations of intensive monitoring and
machine support, particularly in the case of comatose
patients, we may ask of ourselves 'Where is the self
of the patient?'. Needleman4 reminds us that the
power of scientific thought has been to organize our
perceptions i n such a manner that we can survive in
the world. Hence the value of scientific medicine and
instrumentation. However, he goes on to say that
science has also neglected the human body as an
instrument of knowledge and a s a vehicle for sen-
sations as direct as ordinary sensory experience, but
a s subtle as consciousness.
At the suggestion of a hospital neurologist a music
therapist began working with coma patients. To
investigate this approach further the work was
monitored i n an intensive treatment unit. Five
patients, between the ages of 15 and 40 years, and
with severe coma (a Glasgow Coma Scale score
between 4 and 7) were treated. All the patients had
been involved in some sort of accident, had sustained
brain damage and most had undergone neurosurgery.
The form of music therapy used here is based on the
principle that we are organized as human beings not
in a mechanical way but i n a musical form; ie a
harmonic complex of interacting rhythms and melodic
contour^^-^. To maintain our coherence as beings in
the world then we must creatively improvise our
identity. Rather than search for a master clock which
coordinates us chronobiologically, we argue that we
are better served by the non-mechanistic concept of
musical organization. Music therapy is the medium
by which a coherent organization is regained, ie
linking brain, body and mind. In this perspective the
self is more than a corporeal being.
Each music therapy contact lasted between 8 and
12 min. The therapist improvised her wordless singing
based upon the tempo of the patient's pulse, and more
importantly, the patient's breathing pattern. She
pitched her singing to a tuning fork. The character of
the patient's breathing determined the nature of the
singing. The singing was clearly phrased so that when
any reaction was seen then the phrase could be repeated.
Before the first session the music therapist had met
the family to gain some idea of what the patient was
like a s a person. On contacting the comatose patient
she would say who she was, that she would sing for
David
the Aldridge
patient Collected
in the tempo of his or her pulse music therapy
and the
Journal of the Royal Society of Medicine Volume 83 June 1990 345
rhythm of breathing. The unit staff were asked to be
quiet during this period and not to carry out any
invasive procedures for 10 min after the contact.
There were a range of reactions from a change in
breathing (it became slower and deeper), fine motor
movements, grabbing movements of the hand and
turning of the head, eyes opening to the regaining of
consciousness. When the therapist first began to sing
there was a slowing down of the heart rate. Then the
heart rate rose rapidly and sustained an elevated level
until the end of the contact. This may indicate a n
attempt at orientation and cognitive processing within
the communicational c o n t e ~ t ~EEG* ~ . measurement
showed a desynchronization from theta rhythm, to
alpha rhythm or beta rhythm in former synchronized
areas. This effect, indicating arousal and perceptual
activity, faded out after the music therapy stopped.
Some of the ward staff were astonished that a patient
could respond to such quiet singing. This highlights
a difficulty of noisy units such as these. All communi-
cation is made above a high level of machine noise.
Furthermore commands to an 'unconscious'. patient
are made by shouting formal injunctions, ie 'Show me
your tongue', 'Tell me your name', 'Open your eyes'.
Few attempts are made a t normal human communi-
cation with a patient who cannot speak or with whom
staff can have any psychological contact. It is as if
these patients were isolated in a landscape of noise,
and deprived of human contact. !
A benefit of the music therapy was that the staff
were made aware of the quality and intensity of the
human contact. In the intensive care unit environ-
ment of seemingly non-responding patients, depen-
dent upon machines to maintain vital functions and
anxiety provoking in terms of possible patient death,
then it is a human reaction to withdraw personal
contact and interact with the machines. This is
further exacerbated by a scientific epistemology which
emphasizes the person only as a material being and
which equates mind with brain.
A period of calm was also recognized as having
potential benefit for the patient. What some staff fail
to realize is that communication is dependent upon
rhythm, not upon volume. We might argue that such
unconscious patients, struggling to orient themselves
in time and space, are further confused by an
atmosphere of continuing loud and disorienting ran-
dom noise. For patients seeking to orient themselves
then the basic rhythmic context of their own breathing
may provide the focus for that orientation. This raises
the problem of intentionality in human behaviour,
even when consciousness appears to be absent. It is
also vital that staff in such situations do not confuse
'not acting' with 'not perceiving'.
We can speculate that the various body rhythms
have become disassociated in such comatose states.
The question remains then of how those behaviours
can be integrated and where is the seat of such
integration.
Improvised singing appears to offer a number of
possible benefits for working with coma patients in
terms of human contact and promoting perceptual
responses. Human contact through singing, rather
than speaking, also suggests that the fundamentals o141~0768190,
of human communication are musical in form. In this Mo3542802.,,,,o
way we have the a r t of medicine within the science a lgoo
of medicine. Perhaps the skills of human communi- ~h~ ~~~~l
cation may become part of medical and nursing Society of
papers
education5, 41
particularly in the context of intensive Medicine
346 Journal of the Royal Society of Medicine Volume 83 June 1990
care. Although what we know from machines is
valuable, there are other important subtle forms of
knowledge that are best gleaned through personal
contact with the patient.
The question still remains for us as clinicians and
scientists when faced with a patient in coma, or a
persistent vegetative state, 'Where is the person and
how can I reach her?, and then for ourselves as fellow
human beings, 'Where am I?' This raises further the
ethical issues of decisions about terminating life
support when the brain and the person are no longer
seen as one and the same entitylO.
D Aldridge
Medical Faculty,
Universitat Witten Herdecke
Beckwig 4,D5804 Herdecke, FRG
D Gustorff
Znstitut fur Musiktherapie, Medical Faculty,
Universitat Witten Herdecke
H J Hannich
Wilhelms-Universitat Klinic fur Aniisthesiologie
und operatiu Intensivmedizin
Albert-Schweitzer-Strasse 33, D4400 Miinster, FRG
AIDS afterthought
Barts students are no different from most final year
medics in the need to choose a destination for the
elective period. This need occasionally encompasses
a desire to journey to a warm and exotic part of the
world yet a t the same time is concerned with gaining
some medical experience. It is surprisingly difficult
to combine these two intentions especially since hot
climates are often associated with many outdoor
temptations which can divert thought away from
study and learning.
My elective months were spent in Sydney,
Australia, a choice governed by my previous special
studies in HIV and AIDS. This interest began in 1985
when I joined St Mary's hospital for one year to study
'Infection and Immunity'. From that time, the subject
of AIDS and the management of the immuno-
compromised patient began to appear more frequently
in medical journals. The neuropsychiatric compli-
cations of HIV infection were of particular interest
since they demonstrated links between the immune
system, opportunistic infection and psychological
symptoms in patients who practised diverse lifestyles.
The extent to which the AIDS epidemic will domi-
nate current medical practice in the UK is still
unclear.
My concern was to use my particular academic
knowledge to support the clinical experience obtained
on elective. However, I had not had any direct
personal involvement in the management of HIV
infection and for that reason alone was keen
to spend some time attached to a unit where
Davidwas
there Aldridge Collected
a possibility of some teaching, music therapy
not only
References
1 Hannich H. Uberlegen m m Handlungsprimat in der
Intensivmedizin. Medizin Mensch Gesellschaft
1988;13:238-44
2 Wilson L. Intensive care delirium. Arch Intern fed
1972;130:225-6
3 Ulrich R. View through a window may influence
recovery from surgery. Science 1984;224:420-1
4 Needleman J. A sense of the cosmos. New York:Arkana,
1988
5 Aldridge D. A phenomenological comparison of the
organization of music and the self. Arts in Psychotherapy
1989;16:91-7
6 Aldridge D. Music, communication and medicine. J R
Soc Med 1989;82:743-6
7 NordoffP, Robbins C. Creative music therapy. New York,
John Day, 1977
8 Sandman C . Afferent influences on the cortical evoked
response. In: Coles M, Jennings JR,Stern JA eds.
Psychological perspectives (festscrift for Beatrice and
John Lacey). Stroudberg, PA: Hutchinson and Ross,
1984
9 Sandman C. Augmentation of the auditory event related
to potentials of the brain during diastole. Znt J
Physiology 1984;2:111-19
10 Mindell A. Coma: key to awakening. Boston: Shambala,
1989
regarding HIV infection, but also of general medicine
in preparation for Finals. Fortunately, a gynae-
cologist friend of my parents had trained in Sydney
and introduced me to a consultant immunologist
there, Professor Ronal Penny. Thus I came to
spend my elective a t St Vincent's Hospital, Sydney.
I was extremely fortunate in being funded by
the Guildchrist Foundation, the Clothworkers Trust
and my Medical College, all in the City of London.
It was interesting that none of the London-based
AIDS organizations were able to provide any assis-
tance despite my protocol covering the very serious
negative social aspect of neuropsychiatric compli-
cations of HIV infection.
The public image of the AIDS victim has been the
infected homosexual or drug addict. Sydney, with its
large population of both these sources of patients, also
has people from every walk of life professing beliefs
and carrying out behaviour that, as in all cosmo-
politan society, has no norm. AIDS is making
its grim inroad, indifferent to stereotyping. During
my time in Sydney, I saw many aspects of inpatient,
outpatient, community and laboratory care of HIV
infection. It is a sad game of numbers that the
Australian population is not much more than a
quarter that of the UK, but contains as many recorded
cases of AIDS. The field of neuropsychiatric compli-
cations was too vast for deep investigation in
the limited time of the elective period. My work
covered a broad overview of the illness and gave me
a deep understanding of compassion. 0141-07681901
'AIDS patients? Did you wear a mask. I hope 060M6~021~02
you wore rubber gloves!' This was the reaction Q lggo
of several of my fellow students on my return l-he~~~~l
to London. I must say that, to an extent, these Society of
papers
intimations of fear and caution echoed my own 42 Medicine

Music Therapy and
Intensive Care
Keywords: MUSIC, COMA, INTENSIVE
CARE
Patients in intensive care often suffer
through insufficient communication,
inadequate sleep, sensory deprivation"2
and lack of empathy between patient
and medical staff. Many activities in in-
tensive care appear to be simply be-
tween unit staff and objects, and to a
certain extent patients become a part of
this object world. We propose that im-
provised music therapy can prove valu-
able in this context both for the patient
a i d the staff.
At the suggestion of a hospital
neurologist a music therapist began
working with patients in intensive care.
Five patients, between the ages of 15
and 40 years, and with severe coma (a
Glasgow Coma Scale score between 4
and 7*) were treated. All had been in-
volved in some sort of trauma and had
sustained brain damage, and four had
undergone neurosur@ry. Music ther-
apy is based on the principle that we are
organized as human beings not in a
mechanical, chronobiological way but in
a musical fashion i.e. a harmonic com-
plex of interacting rhythms and melodic
contour^."^"' To maintain our coherence
as beings it seems we must creatively
maintain our identity. Music therapy is
the medium by which coherent organiz-
ation is regained, linking brain, body
and mind. In this perspective the self is
more than simply a corporeal being.
Each music therapy contact lasts be-
tween eight and twelve minutes. The
therapist~mprovisesher wordless sing-
ing based upon the tempo of the
patient's pulse, and more importantly,
the patient's breathing pattern, pitching
her singing to a tuning fork. The charac-
ter of the patient's breathing determines
the nature of the singing which is clearly
phrased so that when any reaction is
seen the phrase can be repeated.
Before the first session the music
movements, grasping movements of the
hand, turning of the head and eye opcn-
ing. When the therapist first begins to
sing heart rate slows. Then it rises
rapidly and sustains an elevated level
until the end of the contact. This may
indicate an attempt at orientation and
cognitive processing.6" The EEG shows
a desynchronization from theta rhythm,
to alpha rhythm or beta rhythm in for-
mer synchronized areas. This effect, in-
dicating arousal and perceptual activity,
fades out after the music therapy stops.
Neurones linked to cardiac rhythm
have been identified in the medulla and
there is a synchronous relationship be-
twccn the contraction of the heart and
the 'ascending' wave of the EEG alpha
rhythm.' It is possible that the rhythmic
co-ordination of the cardiovascular sys-
tem with cortical rhythmic firing is of
primary importance for cognition.
Furthermore, sleep disturbance is a
major problem in intensive care units
and the effect of a disturbed waking1
sleeping rhythm upon other metabolic
cycles may be critical. The rhythmic en-
trainment of cardiovascular and somatic
activities may be a key clement in recov-
ery. This means that we must consider
the total 'behavio~ral'~ activity of the
patient including rhythmical inte-
gration of independent systems with
major tidal rhythms of the body.
A patient's response to quiet singing
highlights a difficulty of noisy, busy,
often brightly lit units where communi-
cation is hindered by continuous back-
ground noise. Shouted commands to an
unconscious patient include formal in-
junctions, i.e. "Show me your tongue",
"Tell me your name", "Open your
eyes". There may be few attempts made
at normal h u m a n communication
where the patient cannot speak or
where there is restricted physiological
access. It is as if he were isolated in a
landscape of noise, and deprived of hu-
man contact.
One benefit of music therapy is t o
remind the staff of the imnortance
' of the
quality and intensity of human contact.
Whilst life support and monitoring de-
vices are essential they encourage a
This raises the problem of intention in
human behaviour even when con-
sciousness appears to be absent. It is
also vital that staff do not confuse "not
responding" with "not receiving".
We can further speculate that the
various body rhythms become dis-
associated in comatose states and fol-
lowing major surgery. The question re-
mains then of how rhythms can be
integrated and where is the seat of such
integration. It is very likely that it is a
property of the whole organism. The
environment of the patient includes the
vital component of human contact and
there is reason to believe that the essen-
tial basis of this contact too is rhythmi-
Improvised singing appears to offer
a number of possible benefits for inten-
sive care both in terms of human contact
and promoting perceptual responses.
Better responses to singing, rather than
speaking, suggests that the fundamen-
tals of human communication are musi-
cal in form. In this way we have the art of
m e d i c i n e w i t h i n t h e science of
medicine.
1. Wilson L. Intrnsivr ciiri* ik-lirium. A r h w tifhitfrwl h<rili-
c h r 1972; 130: 225-h.
2. Ulrich R. View 111rtiui;h<i wiiulunv in.iy i n f l ~ n ~ i irfoivery
i~t~
from surgrry. Srii-iirr 1QM.224: 420-1.
3. Aldndge D. A plienon~.'ii~~Iugit'al annparistin of the orpni?.-
ationof music.ind tin-self An'. in Piyhllit'riily I'W*; ll>.'ll-
7.
!+c also Yingling CD, liosobuchi V, llarrington M (1990) I'.KX
asa prcilirtor of rortm'ry from coma. laurel 336: 873and Siwtr
R (1990) Effectsof auditory stimuli on comatose pitients wilt
head injury. Heart 1111d l.un{ I t : 37.3-H.-Kilitur

therapist meets the family to gain some
idea of what the patient is like as a
person. O n meeting the comatose
patient she introduces herself and tells
him she will sing in the tempo of his or
her pulse and rhythm of breathing. The
Unit staff are asked to be quiet during
this period and to avoid invasive pro-
cedures for ten minutes after the con-
tact. There is a range of reactions
including a change in breathing (it be-
comes slower and deeper), fine motor
"Normal score 15, worst score 3
mechanistic approach which sees the
patient simply as a biological complex.
A period of calm may also benefit the
patient. What some staff may fail to
recognize is that communication de-
pends on rhythm, not simply upon vol-
u m e . Such unconscious patients,
struggling to orient themselves in time
and space, are further confused by an
environment of continuing loud, disori-
entating random noise and bright light.
For these patients the basic rhythmic
context of their own breathing may pro-
vide the required focus for orientation.

INTENSIVE & CRITICAL CARE DIGEST Vol. 10 No. 1 MARCH 1991

David Aldridge Collected music therapy papers 43

 Journal of the Royal Society of Medicine Volume 86 February 1993

Music and Alzheimer's disease -assessment

and therapy: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Universitat Witten Herdecke,

Beckweg 4, D-5804Herdecke BRD, Germany

Keywords: dementia; Alzheimer's disease; music psychology; music therapy; mental state examination

Dementia is an important source of chronic disability Ravel, the composer, began to complain of increased
leading to both spiralling health care expenditure fatigue and lassitude. Following a traffic accident his
among the elderly and a progressive disturbance of condition deteriorated progressively. He lost the ability
life quality for the patient and his or her family. Withto remember names, to speak spontaneously and to
write. Although he could understand speech he was no
anticipated increases in the population of the elderly in
Europe, then it is timely to find treatment initiatives longer capable of the coordination required to lead a
in the Western world which will ameliorate the impact major orchestra. While his mind, he reports, was full of
of this problem. Music therapy while not offering a musical ideas, he could not set them down. Eventually
cure for such a disease may be in a position to offer his intellectual functions deteriorated until he could
amelioration of the impact of the disease and provide no longer recognize his own music. Even in a composer
a valuable adjunct to diagnosis. of his standing, with what we may guess was a
progressive dementing illness, his active music-making
The diagnosis of Alzheimer's disease is prone to error
and authors differ as to the difficulty of making a capabilities deteriorated, albeit after speech failed.
precise diagnosis. In the early stages of the disease the However, the responsiveness of patients with
symptoms are difficult to distinguish from those of Alzheimer's disease to music is a remarkable pheno-
normal aging, a process which itself is poorly under- menon. While language deterioration is a feature of
stood. A second source of error in diagnosing cognitive deficit, musical abilities appear to be
Alzheimer's disease is that it is masked by other preserved. This may be because the fundamentals of
conditions. Principle among these conditions is that language itself are musical, and are prior to semantic
of depression which itself can cause cognitive and and lexical functions in language development.
behavioural disorders. Although language processing may be dominant in
Clearly Alzheimer's disease causes distress for the one hemisphere of the brain, music production
patient. The loss of memory and the accompanying loss involves an understanding of the interaction of both
of language, before the onset of motor impairment, cerebral hemispheres. In attempting to understand
means that the daily lives of patients are disturbed. the perception of music there have been a number
Communication, the fabric of social contact, is inter- of investigations into the hemispheric strategies
rupted and disordered. The threat of progressive involved. Much of the literature considering musical
deterioration and behavioural disturbance has ramifi- perception concentrates on the significance of hemi-
cations not only for the patients themselves, but also spheric dominance. Gates and Bradshaw2 conclude
their families who must take some of the social that cerebral hemispheres are concerned with music
responsibility for the care of the patient, and the perception and that no laterality differences are
emotional burden of seeing a loved one becoming apparent. Other authors suggest that two processing
confused and isolated. functions develop with training where left and right
A brief cognitive test, the Mini-Mental State hemispheres are simultaneously involved, and that
Examination (MMSE), has been developed to screen musical stimuli are capable of eliciting both right and
and monitor the progression of Alzheimer's disease. left ear superiority. Similarly, when people listen to
As a clinical instrument it is widely used and well and perform music they utilize differing hemispheric
validated in practice. As a bed-side test the MMSE processing strategies.
is widely used for testing cognition and is useful Evidence of the global strategy of music processing
as a predictive tool for cognitive impairment and in the brain is found in the clinical literature. In two
semantic memory without being contaminated by cases of aphasia3 singing was seen as a welcome
motor and sensory deficits. The items which the release from the helplessness and a means to
MMSE fails to discriminate (minor language deficits), communicate thoughts externally. Berman4 suggests
or neglects to assess (fluency and intentionality) may that recovery from aphasia is not a matter of new
be elicited in the playing of improvised music. A learning by the non-dominant hemisphere but a
dynamic musical assessment of patient behaviour, taking over of responsibility for language by that
linked with the motor co-ordination and intent hemisphere. The non-dominant hemisphere may be
required for the playing of musical instruments used a reserve of functions in case of regional failure.
in music therapy, and the necessary element of Little is known about the loss of musical and
interpersonal communication,may provide a sensitive language abilities in cases of global cortical damage.
complementary tool for assessment1. Any discussion is necessarily limited to hypothesiz-
ing as there are no established baselines for musical
Music and dementia performance in the adult population. Aphasia, which
Late in adult life, at the age of 56 years, and after is a feature of cognitive deterioration, is a complicated
David Aldridge
completing Collected
two major concertos for the music therapy
piano Maurice papers While syntactical functions may remain
phenomenon. 44
 94 Journal of the Royal Society of Medicine Volume 86 February 1993

Table 1. Features of medical assessment and musical assessment

Medical elements of assessment Musical elements of assessment Examples of improvised playing

Continuing observation of Continuing observation of mental ¥Improvisationusing rhythmic instruments

mental and functional status and functional status (drum and cymbal) singly or in combination,
Â¥improvisationusing melodic instruments
Â¥singin and playing folk songs with harmonic
accompaniment

Testing of verbal skills, Testing of musical skills; rhythm, ¥playin tuned percussion (metallophone,
including element of speech melody, harmony, dynamic, xylophone, chime bars) demanding precise
fluency phrasing, articulation movements

Cortical disorder testing; visuo-
spatial skills and ability to
perform complex motor tasks
(including grip and right left
co-ordination).
Cortical disorder testing; visuo-
spatial skills and ability to
perform complex motor tasks
(including grip and right left
co-ordination).
Â¥alternat playing of cymbal and drum using a
beater in each hand
Â¥co-ordinate playing of cymbal and drum using
a beater in each hand
Â¥co-ordinate playing of tuned percussion

Testing for progressive memory Testing for progressive memory ¥th playing of short rhythmic and melodic
disintegration disintegration phrases within the session, and in successive
sessions

Motivation to complete tests, to Motivation to sustain playing ¥th playing of a rhythmic pattern deteriorates
achieve set goals and persevere improvised music, to achieve when unaccompanied by the therapist, as does
in set tasks musical goals and persevere in the ability to complete a known melody,
maintaining musical form although tempo remains
'Intention' difficult to assess; 'Intention' a feature of improvised ¥th patient exhibits the intention to play the
but considered important musical playing piano from the onset of therapy and maintains
this intent throughout the course of treatment

Concentration and attention Concentration on the improvised ¥th patient loses concentration when playing,
span playing and attention to the with qualitative losses in the musical playing
instruments and lack of precision in the beating of
rhythmical instruments

Flexibility in task switching Flexibility in musical (including ¥initiall the musical playing is limited to a
instrumental) changes tempo of 120 bpm and a characteristic pattern
but this is responsive to change

Mini-mental state score Ability to play improvised music malthough the patient has a musical
influenced by educational status influenced by previous musical background this is only of help when she
training perceives the musical playing, it is little
influence in the improvised playing

Insensitive to small changes Sensitive to small changes ¥musicachanges in tempo, dynamic, timbre
and articulation which a t first are missing are
gradually developed

Ability to interpret Ability to interpret musical ¥th patient develops the ability to play in a
surroundings context and assessment of musical dialogue with the therapist
communication i n the demanding both a refined musical perception
therapeutic relationship and the ability of musical production

longer, it is the lexical and semantic functions of The patient often spontaneously sang without error
naming and reference which begin to fail in the early in pitch, melody, rhythm and lyrics, and spent long
stages. Phrasing and grammatical structures remain periods of time listening to music. Beatty6 describes
giving an impression of normal speech, yet content a woman who had severe impairments in terms of
becomes increasingly incoherent. These progressive aphasia, memory dysfunction and apraxia yet was
failings appear to be located within the context of able to sight read an unfamiliar song and perform on
semantic and episodic memory loss illustrated by the the xylophone which to her was an unconventional
inability to remember a simple story when tested. instrument. Like Ravel, she no longer recalled the
Musicality and singing are rarely tested as features name of the music she was playing.
of cognitive deterioration, yet preservation of these Swartz and his colleagues7 propose a series of
abilities in aphasics has been linked to eventual perceptual levels at which musical disorders take
recovery, and could be significant indicators of hier- place:
archical changes in cognitive functioning. Jacome5 (i) the acoustico-psychologicallevel, which includes
found that a musically naive patient with transcortical changes in intensity, pitch and timbre.
mixed aphasia exhibited repetitive, spontaneous (ii) the discriminatory level, which includes the
David Aldridge
whistling and whistling in response Collected music therapy papers of intervals and chords.
to questions. discrimination 45

(iii) the categorical level which includes the categorical
identification of rhythmic patterns and intervals.
(iv) the configural level, which includes melody
perception, the recognition of motifs and themes, tonal
changes, identification of instruments, and rhythmic
discrimination.
(v) 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 (i), (ii) and (iii) remain unaffected, the
complexities of levels (iv) and (v), when requiring no
naming, may be preserved but are susceptible to
deterioration.
It is perhaps important to point out that these
disorders are not themselves musical, they are dis-
orders of audition. Only when disorders of musical
production take place can we begin to suggest that
a musical disorder is present. Improvised musical
playing is in a n unique position to demonstrate this
hypothetical link between perception and production.
Descriptions of musical perception emphasize the
importance of context where different levels of
attention occurring simultaneously against a back-
ground temporal structure. Musical improvisation
with a therapist, which emphasizes attention to the
environment utilizing changes in tempo and volitional
response, without regard for lexical content, may be
an ideal medium for treatment initiatives with
Alzheimer's patients. The playing of simple rhythmic
patterns and melodic phrases by the therapist, and
the expectation that the patient will copy those
patterns or phrases, is similar to the element of
'registration' in the mental state examination.
While improvised musical playing is a useful tool
for the assessment of musical abilities, it is also used
within a therapeutic context. In this way assessment
and therapy are interlinked; assessment providing the
criteria from which to identify therapeutic goals and
develop therapeutic strategies.
If we are unsure as to the normal process of cog-
nitive loss in aging, we are even more in the dark
as to the normal musical playing abilities of adults.
The literature suggests that musical activities are pre-
served while other cognitive functions fail. Alzheimer
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 appears 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.
Improvised music therapy in our experience appears
to offer the opportunity to supplement mental state
examinations in areas where those examinations are
lacking (Table 1). 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 susceptible to 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 a n overall context for musical
production, and the ground structure for perception1,
itDavid
can beAldridge
hypothesized that it is thisCollected music therapy
overarching
Journal of the Royal Society of Medicine Volume 86 February 1993 95
structure which begins to fail in Alzheimer 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, and would suggest a global
failing in cognition while localized lower abilities are
retained.
Music therapy appears to offer a sensitive assessment
tool. It tests those prosodic elements of speech produc-
tion which are not lexically dependent. Furthermore,
it can be used to assess those areas of functioning,
both receptive and productive, not covered adequately
by other test instruments; ie fluency, perseverance in
context, attention, concentration and intentionality.
In addition it provides a form of therapy which may
stimulate cognitive activities such that areas subject
to progressive failure are maintained. Certainly the
anecdotal evidence suggests that quality of life of
Alzheimer patients is significantly improved with
music therapy accompanied by the overall social
benefits of acceptance and sense of belonging gained
by communicating with others. Prinsley recommends
music therapy for geriatric care i n that it reduces the
individual prescription of tranquilizing medication,
reduces the use of hypnotics on the hospital ward and
helps overall rehabilitation. He recommends that
music therapy be based on treatment objectives; the
social goals of interaction co-operation; psychological
goals of mood improvement and self-expression; intel-
lectual goals of the stimulation of speech and
organization of mental processes; and the physical
goals of sensory stimulation and motor integration8.
The understanding of musical production may well
offer a clue to the ground structure of language and
communication in general. It is research in this realm
of perception which is urgent not only for the under-
standing of Alzheimer's patients but in the general
context of cognitive deficit and brain behaviour.
Acknowledgment: The author would like to thank the music
therapist Gudrun Aldridge for access to the audio-tape
recording of her clinical work, and her clinical insights into
working with the elderly.
References
1 Aldridge D. Music, communication and medicine: dis-
cussion paper. J R Soc Med 1989;82:743-6
2 Gates A, Bradshaw J. The role of the cerebral hemi-
spheres in music. Brain Lung 1977;4:403-31
3 Morgan 0, Tilluckdharry R. Presentation of singing
function in severe aphasia. West Indian Med J 1982;
31:159-61
4 Berman I. Musical functioning, speech lateralization and
the amusias. S Afi Med J 1981;59:78-81
5 Jacome D. Aphasia with elation, hypermusia, musicophilia
and compulsive whistling. J Neurol Neurosurg Psychiatry
1984;47:308-10
6 Beatty WW, Zavadil KD, Bailly RC, et aL Preserved
musical skills in a severely demented patient. Znt J Clin
Neuropsychol 1988;10:158-64
7 Swartz K, Hantz E, Crummer G, Walton J, Frisina R. Does
the melody linger on? Music cognition in Alzheimer's
disease. Semin Neurol 1989;9:152-8
8 Prinsley D. Music therapy in geriatric care. Aust Nurses
J 1986;15(9):48-9
An extended list of references can be obtained from
the author.
(Acceptedpapers
30 December 1991) 46
Journal of Clinical Gempsychologv, Vol. 4, No. l, 1998

Music Therapy and the Treatment of Alzheimer's

Disease
David ,41dridge1

Ahheimer patients, despite aphasia and memory loss, continue to sing old songs and
to dance to past tunes when given the chance. Quality of life expectations become
paramount in any management strategy, and music therapy appears to play an impor-
tant role in enhancing the ability to actively take part in daily life. Improvised music.
therapy appears to offer the opportunity to supplement mental state examinations in
areas where those examinations are lacking. It is possible to ascertain the fluency of
musical production, perseverance with the task in hand, and episodic memory. The
inability to build phrases may be attributed to problems with memory or to an yet
unknown factor. This unknown factor is possibly involved with the organization of time
structures. Thus, music therapy offers an assessment tool sensitive to small changes.
Certainly, the anecdotal evidence suggests that quality of life of Ahheimers patients is
significantly improved with music therapy accompanied by the overall social benefits
of acceptance and sense of belonging gained by communicating with others.
KEY WORDS: rhythm; phrasing; intentionality; quality-of-life; music-therapy; memory.

INTRODUCTION

At the age of 56, the composer Maurice Ravel began to complain of increased
fatigue and lassitude. Following a traffic accident, his condition deteriorated pro-
gressively (Henson, 1988). He lost the ability to remember names, to speak spon-
taneously, and to write (Dalessio, 1984). Although he could understand speech, he
was no longer capable of the coordination required to lead a major orchestra. While
his mind, he reports, was full of musical ideas, he could not set them down (Dales-
sio, 1984). Eventually, his intellectual functions and speech deteriorated until he
could no longer recognize his own music. We would speculate now that he had
been suffering from Alzheimer's disease.
In this paper; the value of music for the sufferers of Alzheimer's disease will
be discussed. In particular, there will be a focus on music as therapy.
'~edizinische Fakultat, Universitat Witten Herdecke, Alfred Herrhausen Stra. 50, 58448 Witten,
Germany.

David Aldridge . therapy papers

Collected music 47

Job Title: JCG1 Article: M0 Makeup: MTW/Nov. 23, 1997

Kevboardino: MTW/Nov. 23. 1997 Last Revision: MTWINov. 23. 1997
18 Aldridge

MUSIC AS THERAPY
There are two principal ways of doing music therapy: "active music therapy"
which requires that the patient, or a group of patients play musical instruments, or
sing, with the therapist; and, "passive music therapy" whereby the patient, or a
group of patients, listen to the therapist who plays live, or recorded, music to them.
In active music therapy, the music is often improvised to suit the individual patient.
In passive music therapy, the music is often chosen to suit particular patients.
Within each of these two main approaches, there are varying schools throughout
the Western world, some based on the work of particular teachers, and some are
more eclectic and based on psychotherapeutic approaches. Music therapy has been
reviewed in the medical and nursing press and the principle emphasis is on the
soothing ability of music and the necessity of music as an antidote to an overly
technological medical approach. Most of these articles are concerned with passive
music therapy and the playing of pre-recorded music to patients emphasizing the
necessity of healthy pleasures like music, fragrance, and beautiful sights for the
reduction of stress and the enhancement of well-being. The overall expectation is
that the recreational, emotional, and physical health of the patient is improved
(Aldridge, 1993b).
After the Second World War, however, music therapy was intensively developed
in American hospitals (Schullian and Schoen, 1948). Since then, some hospitals,
particularly in mainland Europe, have incorporated music therapy carrying on a
tradition of European hospital-based research and practice (Aldridge, 1990;
Aldridge, Brandt, and Wohler, 1989). In recent years, there has been a move to
develop an academic tradition of research that attempts to begin a clinical dialogue
with other practitioners through research practice (Aldridge, 1989, 1991a,b, 1993a;
Aldridge, Gustorff, and Hannich, 1990).

MUSIC, COGNITION AND LANGUAGE

As in Ravel's demise above, the responsiveness of patients with Alzheimer's

disease to music is a remarkable phenomenon (Swartz, Hantz, Crummer, Walton,
and Frisina, 1989). While language deterioration is a feature of cognitive deficit,
musical abilities appear to be preserved. This may be because the fundamentals of
language, as we have seen in previous chapters, are musical, and prior to semantic
and lexical functions in language development.
Although language processing may be dominant in one hemisphere of the brain,
music production involves an understanding of the interaction of both cerebral hemi-
spheres (Altenmuller, 1986; Brust, 1980; Gates and Bradshaw, 1977). In attempting
to understand the perception of music, there have been a number of investigations
into the hemispheric strategies involved. Much of the literature considering musical
perception concentrates on the significance of hemispheric dominance. Gates and
Bradshaw (1977J'conclude that cerebral hemispheres are concerned with music per-
ception and that no laterality differences are apparent. Other investigators (Wagner
and Hannon, 1981) suggest that two processing functions develop with training where

David Aldridge Collected music therapy papers 48

Job Title: JCGI Article: È8 Makeup: MTWNov. 23, 1997

Kevboardina: MTW/Nov. 23. 1997 Last Revision: MTWNov. 23. 1997
Music Therapy and Treatment of Alzheimer's Disease 19

left and right hemispheres are simultaneously involved, and that musical stimuli are
capable of eliciting both right and left ear superiority (Kellar and Bever, 1980). Simi-
larly, when people listen to and perform music, they utilize differing hemispheric
processing strategies.
Evidence of the global strategy of music processing in the brain is found in
the clinical literature. In two cases of aphasia (Morgan and Tilluckdhany, 1982),
singing was seen as a welcome release from the helplessness of being a patient.
The authors hypothesized that singing was a means to communicate thoughts ex-
ternally. Although the "newer aspect" speech was lost, the older function of music
was retained possibly because music is a function distributed over both hemispheres.
Berman (1981) suggests that recovery from aphasia is not a matter of new learning
by the nondominant hemisphere but a taking over of responsibility for language by
that hemisphere. The nondominant hemisphere may be a reserve of functions in
case of regional failure.
Little is known about the loss of musical and language abilities in cases of
global cortical damage, although the quality of response to music in the final stages
of dementia is worth noting (Norberg, Melin, and Asplund, 1986). Any discussion
is necessarily limited to hypothesizing as there are no established baselines for mu-
sical performance in the adult population (Swartz et al., 1989). Aphasia, which is
a feature of cognitive deterioration, is a complicated phenomenon. While syntactical
functions may remain longer, it is the lexical and semantic functions of naming and
reference which begin to fail in the early stages. Phrasing and grammatical struc-
tures remain giving an impression of normal speech, yet content becomes increas-
ingly incoherent. These progressive failings appear to be located within the context
of semantic and episodic memory loss illustrated by the inability to remember a
simple story when tested (Bayles et aL, 1989).
Musicality and singing are rarely tested as features of cognitive deterioration,
yet preservation of these abilities in aphasics has been linked to eventual recovery
(Jacome, 1984; Morgan and Tilluckdhany, 1982), and could be significant indica-
tors of hierarchical changes in cognitive functioning. Jacome (1984) found that a
musically naive patient with transcortical mixed aphasia exhibited repetitive, spon-
taneous whistling and whistling in response to questions. The patient often spon-
taneously sang without error in pitch, melody, rhythm, and lyrics, and spent long
periods of time listening to music. Beatty et al. (1988) describe a woman who had
severe impairments in terms of aphasia, memory dysfunction, and apraxia; yet, she
was able to sight read an unfamiliar song and perform on the xylophone which
to her was an unconventional instrument. Like Ravel (Dalessio, 1984), an elderly
musician who could play from memory (Crystal, Grober, and Masur, 1989) no
longer recalled the name of the composer, she no longer recalled the name of
the music she was playing.
Swartz et aL (1989) propose a series of perceptual levels at which musical dis-
orders take place: (1) the acoustico-psychological level, which includes changes in
intensity, pitch, and timbre; (2) the discriminatory level, which includes the dis-
crimination of intervals and chords; (3) the categorical level, which includes the
categorical identification of rhythmic patterns and intervals; (4) the configural level,
which includes melody perception, the recognition of motifs and themes, tonal

David Aldridge Collected music therapy papers 49

Job Title: JCG1 Article: È8 Makeup: MTWNOV.23, 1997

Kevboardino: MTWNov. 23. 1997 Last Revision: MTWNov. 23. 1997
 20 Aldridge

changes, identification of instruments, and rhythmic discrimination; (5) the level

where musical form is recognized, including complex perceptual and executive func-
tions of harmonic, melodic, and rhythmical transformation.
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.
It is perhaps important to point out that these disorders are not themselves
musical, they are disorders of audition. Only when disorders of musical production
take place can we begin to suggest that a musical disorder is present. Improvised
musical playing is in an unique position to demonstrate this hypothetical link be-
tween perception and production. Rhythm is the key to the integrative process un-
derlying both musical perception and physiological coherence. When considering
communication, rhythm is also fundamental to the organization and coordination
of internal processes, and externally between persons (Aldridge, 1989). Rhythm of-
fers a frame of reference for perception (Povel, 1984).
Rhythm too plays a role in the perception of melody. The perceptions of
speech and music are formidable tasks of pattern perception. The listener has to
extract meaning from lengthy sequences of rapidly changing elements distributed
in time (Morrongiello, Ti-ehub, Thorpe, and Capodilupo, 1985). amporal predict-
ability is important for tracking melody lines (Jones, Kidd, and Wetzel, 1981; Kidd,
Boltz, and Jones, 1984). Kidd et a i (1984) also refer to melody as having a structure
in time and that a regular rhythm facilitates the detection of a musical interval and
its subsequent integration into a cognitive representation of the serial structure of
the musical pattern. Adults identify familiar melodies on the basis of relational in-
formation about intervals between tones rather than the absolute information of
particular tones. In the recognition of unfamiliar melodies, less precise information
is gathered about the tone itself. The primary concern is with successive frequency
changes or melodic contour. The rhythmical context prepares the listener in ad-
vance for the onset of certain musical intervals and therefore a structure from which
to discern, or predict, change. One may not be aware of certain changes and become
either out of tune or out of time; such a loss of rhythmical structure, which appears
outwardly as confusion, may be a hidden factor in the understanding of Alzheimer's
disease.
What is important in these descriptions of musical perception is the emphasis
on context where there are different levels of attention occurring simultaneously
against a background temporal structure (Jones et al., 1981; Kidd et a i , 1984). Mu-
sical improvisation with a therapist, which emphasizes attention to the environment
(Sandman, 1984; Walker and Sandman, 1979; Walker and Sandman, 1982) utilizing
changes in tempo and volitional response (Safranek, Koshland, and Raymond,
1982), without regard for lexical content, may be an ideal medium for treatment
initiatives with Alzheimer's patients. The playing of simple rhythmic patterns and
melodic phrases by the therapist, and the expectation that the patient will copy
those patterns or-phrases, is similar to the element of "registration" in the mental
state examination.
While improvised musical playing is a useful tool for the assessment of musical
abilities, it is also used within a therapeutic context. In this way, assessment and

David Aldridge Collected music therapy papers 50

Job Title: JCG1 Article: M0 Makeup: MTWNov. 23, 1997

Kevboardino: MTWNov. 23. 1997 Last Revision: MTWNov. 23. 1997
 Music Therapy and Treatment of AJzheimer's Disease 21

therapy are interlinked; assessment providing the criteria from which to identify
therapeutic goals and develop therapeutic strategies.

MUSIC THERAPY AND THE ELDERLY

Much of the published work concerning music therapy with the elderly is con-
cerned with group activity (Bryant, 1991; Christie, 1992; Olderog Millard and Smith,
1989) and is generally used to expand socialization and communication skills, with
the intention of reducing problems of social isolation and withdrawal, to encourage
participants to interact purposefully with others, assist in expressing and commu-
nicating feelings and ideas, and to stimulate cognitive processes, thereby sharpening
problem-solving skills. Additional goals also focus on sensory and muscular stimu-
lation and gross and fine motor skill development (Segal, 1990).
Clair (1990a,b) has worked extensively with tlie elderly and found music ther-
apy a valuable tool for working in groups to promote communicating, watching
others, singing, interacting with an instrument, and sitting. Her main conclusions
are that although the group members deteriorated markedly in cognitive, physical,
and social capacities over an observation period of 15 months, they continued to
participate in music activities. During the 30-minute sessions, group members con-
sistently sat in chairs without physical restraints for the duration of each session
and interacted with others regardless of their deterioration. This was the only time
in the week when they interacted with others (Clair and Bernstein, 1990b). Indeed
for one 66-year-old man, it is the sensory stimulation of music therapy that brought
him out of his isolation such that he could participate with others, even if for a
short while (Clair, 1992).
Wandering, confusion and agitation are associated problems common to elderly
patients living in hostels or special accommodations for Alzheimers' patients. A
music therapist (Cloutier, 1993) has tested singing with the an 81-year-old woman
to see if it helped her to remain seated. After 20 singing sessions, the therapist
read to the woman to compare the degree of attentiveness. While music therapy
and reading sessions redirected the subject from wandering, the total time she sat
for the music therapy sessions was double that of the reading sessions (214.3 min
vs. 99.1 min), and the time spent seated in the music therapy was more consistent
than the sporadic episodes when she was being read to. When agitation occurs in
such elderly women, then individualized music therapy appears to have a signifi-
cantly calming effect (Gerdner and Swanson, 1993). In terms of reducing repetitive
behavior, musical activity also reduces disruptive vocalizations (Casby and Holm,
1994).
The above conclusions are supported by Groene (1993). Thirty residents (aged
60-91 years) of a special Alzheimer's unit,'who exhibited wandering behavior, were
randomly assigned to either mostly music attention or mostly reading attention
groups where they received one-to-one attention. Those receiving music therapy
remained seated longer than those in the reading sessions.
One of the central problem of the elderly is the loss of independence and
self-esteem, and Palmer (1977, 1983, 1989) describes a program of music therapy

David Aldridge Collected music therapy papers 51

Job Title: JCGl Article: M0 Makeup: M W o v . 23, 1997

Kevboardino: MTWINOV. 23. 1997 Last Revision: MTWiNov. 23. 1997
 at a geriatric home designed to rebuild self-concept. For the 380 residents, ranging
from those who were totally functional to those who needed total care, a program
was adapted to the capacities and needs of individual patients. Marching and danc-
ing increased the ability of some patients to walk well; and for the nonambulatory,
kicking and stamping to music improved circulation and increased tolerance and
strength. Sing-along sessions were used to encourage memory recall and promoted
social interaction and appropriate social behavior (Palmer, 1983, 1989). It was such
social behavior that Pollack and Namazi (1992) report as being accessible to im-
provement through group music therapy activities. It is the partcipative element,
that appears to be valuable for communication, and the intention to participate
that is at the core of the music therapy activity which we will see in the following
section.
Music therapy has also been used to focus on memory recall for songs and
the spoken word (Prickett and Moore, 1991). In ten elderly patients, whose diag-
nosis was probably Alzheimer's disease, words to songs were recalled dramatically
better than spoken words or spoken information. Although long-familiar songs were
recalled with greater accuracy than a newly presented song, most patients attempted
to sing, hum, or keep time while the therapist sang. However, Smith (1991) suggests
that it is factors such as tempo, length of seconds per word, and total number of
words that might be more closely associated with lyric recall than the relative fa-
miliarity of the song selection.
In a further study of the effects of three treatment approaches (musically cued
reminiscence, verbally cued reminiscence, and music alone) on the cognitive func-
tioning of 12 female nursing home residents with Alzheimer's Disease, changes in
cognitive functioning were assessed by the differences between pre- and postsession
treatment scores on the Mini-Mental State Examination. Comparisons were made
for total scores and subscores for orientation, attention, and language. Musically
cued and verbally cued reminiscence significantly increased language subsection
scores and musical activity alone significantly increased total scores (Smith, 1986).
Prinsley (1986) recommends music therapy for geriatric care as it reduces the
individual prescription of tranquilizing medication, reduces the use of hypnotics on
the hospital ward, and helps overall rehabilitation. He recommends that music ther-
apy be based on treatment objectives, the social goals of interaction 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. Such goals as stimulation of
the individual, promoting involvement in social activity, identifying specific indi-
vidualized behavioral targets, and emphasizing the maintenance of specific memory
functions is repeated throughout the music therapy literature (Prange, 1990; Smith,
S., 1990, 1991). Similarly, Smith, D. S. (1990) recommends behavioral interventions
targeted at the more common behavioral problems (e.g., disorientation, age-related
changes in social activity, sleep disturbances) of institutionalized elderly persons.
In a study of mu& therapy in two nursing homes, life satisfaction and self-esteem
were significantly improved in the home where the residents participated in the
musical activities in comparison with a matched control group that had no music
therapy (VanderArk, Newman, and Bell, 1983).

David Aldridge Collected music therapy papers 52

Job Title: JCG1 Article: M 0 Makeup: MTWNov. 23, 1997

Kevboardino: MTWNov. 23. 1997 Last Revision: MTWNov. 23. 1997
Music Therapy and Treatment of Alzheimer's Disease 23

MUSIC THERAPY WITH AN ALZHEIMER'S PATIENT- A CASE STUDY

In improvised music therapy, the music therapist plays the piano improvising
with the patient who uses a range of instruments and voice. This work often begins
with an explanatory session using rhythmic instruments, in particular the drum and
cymbal; progressing to the use of rhythmic/melodic instruments such as the chime
bars, glockenspiel or xylophone; developing into work with melodic instruments (in-
cluding the piano); and the voice. An emphasis is placed on a series of musical
,improvisations during each session, and music is the vehicle for the therapy. Each
session is audiotape-recorded, with the consent of the patient, and later analyzed
andindexed as to the musical content. No musical training is required of the patient
although it is essential to discover the musical background of the patient. They are
asked about to which music they like to listen, and perhaps more importantly, to
which music did they dance when they were younger.
A 55-year-old female patient came to outpatient treatment at a general hospital
for ten weekly sessions. Each session lasted 40 minutes. Her son drove her to each
session as she was unable to find her way alone using public transport. Her sister
had died with Alzheimer's disease and the family were concerned that she too was
repeating her sister's demise. Her memory had begun to fail and she became in-
creasingly disturbed. The patient was referred initially to the hospital when she,
and her son, became aware of her own deteriorating condition. At home, she was
experiencing difficulties in finding items of clothing and other things necessary for
everyday life. She could not cook for herself anymore and was unable to write her
own name. While wanting to speak, she experienced difficulty in finding words. She
also appeared to be depressed, and in the light of her sister's death, and her own
knowledge regarding her current predicament, it seemed reasonable to make this
assumption. As she had previously played the piano for family and friends, although
without any formal training, music therapy appeared to have potential as an inter-
vention adjuvant to her medical treatment.
In all ten sessions, she demonstrated her ability to play a singular ordered
rhythmic pattern in 414 time using two sticks on a drum. However, a feature of her
rhythmical playing was that in nearly all the sessions, the patient would let control
of the rhythmic pattern slip such that it became progressively imprecise, losing both
its form and liveliness. The initial impulse of her rhythmical playing, which was
clear and precise, gradually deteriorated as she lost concentration and ability to
persevere with the task in hand. However, when the therapist offered an overall
musical structure during the course of the improvisation, by playing herself a known
piece of music, then the patient could regain her precision of rhythm.
In the rhythmical playing on drum and cymbal, the therapist attempted to de-
velop the patient's attention span through the use of short repeated musical patterns
and changes in key, volume and tempo. She hoped that through changes in the
sound to steer the patient to maintaining a stable musical form. This technique
helped the to maintain a rhythmical pattern and brought her to the stage
which she could express herself stronger musically. The therapist also searched for
other ways to develop variety in rhythm by moving away rom the repetitive pattern
played by this patient.

David Aldridge Collected music therapy papers 53

Job Title: JCG1 Article: #80 Makeup: MTWiNov. 23, 1997

Kevboardina: MTW/Nov. 23. 1997 Last Revision: MTWiNov. 23. 1997
 A change in the patient's ability to improvise was shown when the patient rec-
ognized, and could repeat rhythmical patterns in a musical dialogue and thereby
brought into a musical context. In the last session of therapy, the patient was able
to change her playing in this way such that she could express more strongly by
bringing into line her thoughtful and expressive playing. It was this ability to become
rhythmically flexible when brought into the form of a dialogue that is a fundamental
feature of encouraging communicational competence.
From the first session of therapy, the patient made it quite clear her own intent
to sit at the piano and play whatever melodies she chose and to find the appropriate
accompaniments. This wish and the corresponding willpower to achieve this end,
was shown in all the sessions. It was possible to use this impetus to play as a source
for improvisation. She laughed with joy at the success of playing and often asked
to repeat a successful accomplishment. Lapses and slips in her rhythmical playing
could be carried by the intent and expression with which she played. While her
overall intention to play was preserved, her attention to that playing, the concen-
tration necessary for musical production and the perseverance required for com-
pleting a sequence of phrases progressively failed and was dependent on the overall
musical structure offered by the therapist.
At the end of the treatment period, she was able to cook for herself and could
find her own things about the house. The psychiatrist responsible for her therapeutic
management reported an overall improvement in her interest in what was going
on around her, and in particular that she maintained attention to visitors and con-
versations. The patient regained the ability to sign her name, although she could
only write slowly. While wanting to speak, she still experienced difficulty in finding
words.
It appears that music therapy had a beneficial effect on the quality of life for
this patient, and that some of the therapeutic effect may have been brought about
by handling the depression associated with her failing cognitive abilities and the
forebodings of a future reflecting her sister's fate. While the patient came to the
sessions with the intention of playing, her ability to take initiatives was impaired,
mirroring the state of her home life where she wanted to look after herself, yet
was unable to take initiatives. This stimulus to take initiatives in the music was
seen as an important feature of the music therapy by the therapist and appears to
have a correlate in the way in which the patient began to take initiatives in her
daily life.
Active music-making promotes interaction between the persons involved,
thereby promoting initiatives in communication. Furthermore, the implications for
the maintenance of memory by actively making music is significant. As Crystal et
al. (1989) found in an 82-year-old musician with Alzheimer's disease, there was a
preserved ability to: (1) play previously learned piano compositions from memory,
although the man was unable to identify the composer or titles of each work, and
(2) learn the new skill of mirror reading while being unable to recall or recognize
new information.'This woman could remember some old songs, but also learned
new melodies arid retained them from session to session.
A contraindication for music therapy with such patients who are aware of their
problems is that the awareness of further cognitive abilities as experienced in the

David Aldridge Collected music therapy papers 54

Job Title: JCGI Article: It80 Makeup: MTWNov. 23, 1997

Kevboardino: MTWINov. 23. 1997 Last Revision: MTWNov. 23. 1997
Music Therapy and Treatment of Alzheimer's Disease 25

"fable I. Features of Medical and Musical Assessment

Medical elements of assessment
Continuing observation of mental and
functional status
Testing of verbal skills, including element of
speech fluency
Musical elements of assessment
Continuing observation of mental and
functional status
Testing of musical skills; rhythm, melody,
harmony, dynamic, phrasing, articulation

Cortical disorder testing; visuospatial skills Cortical disorder testing; visuospatial skills
and ability to perform complex motor tasks and ability to perform complex motor tasks
(including grip and right left coordination). (including grip and right left coordination).
Testing for progressive memory disintegration Testing for progressive memory disintegration

Motivation to complete tests, to achieve set
goals and persevere in tests
"Intention" difficult to assess; but considered
important
Concentration and attention span
Motivation to. sustain playing improvised
music, to achieve musical goals and
persevere in maintaining musical form
"Intention" a feature of improvised musical
playing
Concentration on the improvised playing and
attention to the instruments

Flexibility in task switching Flexibility in musical (including instrumental)

Mini-mental state score influenced by
educational status
Insensitive to small changes
Ability to interpret surroundings
changes
Ability to play improvised music influenced
by previous musical training
Sensitive to small changes
Ability to interpret musical context and
assessment of communication in the
therapeutic relationship

playing may exacerbate any underlying depression and demotivate the patient to
continue. For this patient, she was painfully aware that she could no longer find
the harmonies with her left had required for the accompaniment of her favorite
songs. This too was another sign of her failing cognitive ability. However, what
appeared to be of value from the music therapy sessions (as can be seen in Tables
I and 11) is that active musical playing provides a basis from which assessments of
varying competencies can be made. Not only is it possible to discern a variety of
motor abilities and cognitive competencies, including episodic memory, there is the
further advantage of assessing intentionality and perseverance throughout episodes
of playing and the session itself. This form of assessment is not based on a verbal
competence; and furthermore, the patient is not aware that she is being tested.

CONCLUSION

Alzheimer patients, despite aphasia and memory loss, continue to sing old
songs and to dance to past tunes when given the chance. Indeed, fun and enter-

David Aldridge Collected music therapy papers 55

JobTitle: JCQ1 Article: Ã ˆ 8 Makeup: MTWNov. 23, 1997

Kevboardina: MTWNov. 23. 1997 Last Revision: MTWNov. 23. 1997
 Table 11. Musical Elements of Assessment and Examples of Improvised Playing
Musical elements of assessment Examples of improvised playing
0 Testing of musical skills; rhythm, melody, Improvisations using rhythmic instruments
harmony, dynamic, phrasing, articulation (drum and cymbal) singly or in combination
0 Improvisations using melodic instruments

Singing and playing folk songs with harmonic

accompaniment

0 Cortical disorder testing; visuospatial skills Playing tuned percussion (metallophone,

Cortical disorder testing; ability to perform
complex motor tasks (including grip and right
left coordination)
xylophone, chime bars) demanding precise
movements
Alternate playing of cymbal and drum using a
beater in each hand
Coordinated playing of cymbal and drum using
a beater in each hand
Coordinated playing of tuned percussion

0 Testing for progressive memoxy disintegration
Motivation to sustain playing improvised
music, to achieve musical goals and persevere
in maintaining musical form
"Intention" a feature of improvised musical
playing
0 The playing of short rhythmic and melodic
phrases within the session, and in successive
sessions
The playing of a rhythmic pattern deteriorates
when unaccompanied by the therapist, as does
the ability to complete a known melody,
although tempo remains
The patient exhibits the intention to play the
piano from the onset of therapy and maintains
this intent throughout the course of treatment

Concentration on the improvised playing and
attention to the instruments
Flexibility in musical (including instrumental)
changes
Ability to play improvised music influenced
by previous musical training
The patient loses concentration when playing,
with qualitative loss in the musical playing and
lack of precision in the beating of rhythmical
instruments
Initially the musical playing is limited to a
tempo of 120 Bp and a characteristic pattern
but this is responsive to change
Although the patient has a musical
background this is only of help when she
perceives the musical playing, it is little
influence in the improvised playing

Sensitive to small changes Musical changes in tempo, dynamic, timbre,

and articulation which at first are missing are
gradually developed

Ability to interpret musical context and The patient develops the ability to play in a
relationship musical dialogue with the therapist demanding
both a refined musical perception and the
ability of musical production

David Aldridge Collected music therapy papers 56

Job Title: JCG1 Article: È8 Makeup: MTW/Nw. 23, 1997

Kevboardlna: MTWNov. 23. 1997 Last Revision: MTW/Nov. 23. 1997
 Music Therapy and Treatment of Alzheimer's Disease 27

tainment are all part and parcel of daily living for the elderly living in special ac-
commodation (Glassman, 1983; Jonas, 1991; Kartman, 1990; Smith, 1992). Quality
of life expectations become paramount in any management strategy, and music ther-
apy appears to play and important role in enhancing the ability to actively take
part in daily life (Lipe, 1991; Rosling and Kitchen, 1992). However, the production
of music, and the improvisation of music, appears to fail in the same way in which
language fails.
Improvised music therapy appears to offer the opportunity to supplement men-
tal state examinations in areas where those examinations are lacking. First, it is
possible to ascertain the fluency of musical production. Second, intentionality, at-
tention to, concentration on, and perseverance with the task in hand are important
features of producing musical improvisations and susceptible to 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 an as-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 hypothesized that it is this overarching structure which begins to fail in
Alzheimers 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. Such a hypothesis would tie in with the musical
hierarchy proposed by ~wartz'(l989), and would suggest a global failing in cognition
while localized lower abilities are retained. However, the hierarchy of musical per-
ceptual levels proposed by Swartz may need to be further subdivided into classifi-
cations of music reception and music production.
Music therapy offers an assessment tool sensitive to small changes (see Tables
I and 11). It tests those prosodic elements of speech production which are not lexi-
cally dependent; that is, rhythm, melody, harmony, dynamic, phrasing, articulation.
Furthermore, it can be used to assess those areas of functioning, both receptive
and productive, not covered adequately by other test instruments (i.e., fluency, per-
severance in context, attention, concentration, and intentionality). In addition, it
provides a form of therapy which may stimulate cognitive activities such that areas
subject to progressive failure, as in progressive memory disintegration, are main-
tained. There is a possibility to promote both visuo-spatial skills needed in playing
instruments and the concentration needed to maintain that playing over a period
of time. The playing of instruments apart from its therapeutic value is enables an
assessment of grip strength and right-left coordination.
Certainly, the anecdotal evidence suggests that quality of life of Alzheimers
patients is significantly improved with music therapy (McCloskey, 1985, 1990; Tyson,
1989) accompanied by the overall social benefits of acceptance and sense of be-
longing gained by communicating with others (Morris, 1986; Segal, 1990).
Unfortunately, most of the literature concerning cognition and musical per-
ception is based.On audition and not musical production. Like other authors, we
suggest that the production of music, as is the production of language, a complex
global phenomenon as yet poorly understood. The understanding of musical pro-
duction may well offer a clue to the ground structure of language and communi-

David Aldridge Collected music therapy papers 57

Job Title: JCGI Article: #80 Makeup: MTWNov. 23, 1997

Kevboardina: MTWINov. 23. 1997 Last Revision: MTWINov. 23. 1997
 28 Aldridge

cation in general. It is research in this realm of perception which is urgent not only
for the understanding of Alzheimers patients but in the general context of cognitive
deficit and brain behavior. It may be as Berman (1981) suggests, that the nondomi-
nant hemisphere is a reserve of functions in case of regional failure and this func-
tionality can be stimulated to delay the progression of degenerative disease. We
may need to address in future research the coordinating role of rhythm in human
cognition and consciousness whether it be in persons who are losing cognitive abili-
ties, or in persons who are attempting to gain cognitive abilities.

REFERENCES
Aldridge, D. (1989). Music, communication and medicine: Discussion paper. /. Roy. Soc. Med 82(12):
743-746.
Aldridge, D. (1990). The development of a research strategy for music therapists in a hospital setting.
Arts Psychother. 117: 231-237.
Aldridge, D. (1991a). Aesthetics and the individual in the practice of medical research: A discussion
paper. J. Roy. Soc. Med. 84: 147-150.
Aldridge, D. (1991b). Creativity and consciousness: Music therapy in intensive care. Arts Psychother.
18(4): 359-362.
Aldridge, D. (1993a). Music and Alzheimers' disease-assessment and therapy: A discussion paper.
/. Roy. Soc. Med 86: 93-95.
Aldridge, D. (1993b). The music of the body: Music therapy in medical settings. Advances 19(1): 17-35.
Aldridge, D., Brandt, G., and Wohler, D. (1989). towards a common language among the creative art
therapies. Arts Psychother. 17: 189-195.
Aldridge, D., Gustorff, D., and Hannich, H. (1990). Where am I? Music therapy applied to coma patients
(editorial). L Roy. Soc. Med 83(6): 345-345.
Altenmuller, E. (1986). Brain correlates of cerebral music processing. Eur. Arch. Psychiat. 235: 342-354.
Bayles, K A., Boone, D. R., Ibmoeda, C. K, et a t , (1989). Differentiating Alzheimer's patients from
the normal elderly and stroke patients with aphasia. L Speech Hear. Disord. 54: 74-87.
Beatty, W W, Zavadil, K D., Bailly, R. C. et at (1988). Reserved musical skills in a severely demented
patient. Int. J. Clin. Neumpsychot 10: 158-164.
Berman, I. (1981). Musical functioning, speech lateralization and the amusias. South African Med. 3. 59:
78-81
.-
Brust, J. (1980). Music and language: Musical alexia and agraphia. Brain 103: 367-392.
Bryant, W (1991). Creative group work with confused elderly people: A development of sensory inte-
gration therapy. Brit. J. Occup. Ther. 54(5): 187-192.
Casby, J. A., and Holm, M. B. (1994). The effect of music on repetitive disruptive vocalizations of
persons with dementia. Am. Occup. Ther. 48(10): 883-889.
Christie, M. E. (1992). Music therapy applications in a skilled and intermediate care nursing home
facility: A clinical study. Act. Adapt. Aging 16(4): 69-87.
Clair, A. (1992). Music therapy for a severely regressed person with a probable diagnosis of Alzheimer's
Disease. In Bruscia, K (ed.), Case Studies in Music Therapy, Barcelona Publishers, Phoenixville, PA
Clair, A. A. (1990). The need for supervision to manage behavior in the elderly care home resident
and the implications for music therapy practice. Music Ther. Perspect. 8: 72-75.
Clair, A. A., and Bernstein, B. (1990a). A comparison of singing, vibrotactile and nonvibrotactile in-
strumental playing responses in severely regressed persons with dementia of the Alzheimer's type.
J. Music Thm 27(3): 119-125.
Clair, A. A., and Bernstein, B. (1990b). A preliminary study of music therapy programming for severely
regressed persons with Alzheimer's-type dementia. J. Appl. Gerontol. 9(3): 299-311.
Crystal, H., Grober, E., and Masur, D. (1989). Reservation of musical memory in Alzheimer's disease.
J. Neuml. Neuqsury. Psych& 52(12): 1415-1416.
Dalessio, D. (1984). Maurice Ravel and Alzheimer's disease. JAMA 252(24): 3412-3413.
Fitzgerald Cloutier, M. L (1993). The use of music therapy to decrease wandering: An alternative to
restraints. Music Ther. Perspect. ll(1): 32-36.
Gates, A., and Bradshaw, J. (1977). The role of the cerebral hemispheres in music. Brain Lung. 4:
403-431.

David Aldridge Collected music therapy papers 58

Job Title: JCG1 Article: È8 Makeup: MTW/Nov. 23, 1997

Kevboardino: MTWiNov. 23. 1997 Last Revision: MTWiNov. 23. 1997
 Music Therapy and Treatment of Alzheimer's Disease 29

Gerdner, L. A., and Swanson, E. A. (1993). Effects of individualized music on confused and agitated
elderly patients. Arch. Rychiatr. Nursing 7(5): 284-291.
Glassman, L. A (1983). The talent show: Meeting the needs of the healthy elderly. Music The% 3(1):
82-93.
.-
Groene, R. W (1993). Effectiveness of music therapy: Intervention with individuals having Senile De-
mentia of the Alzheimer's type. 1. Music The% 30(3): 138-157.
Henson, R. (1988). Maurice Ravel's illness: A tragedy of lost creativity. Brit. Med. Clin. Res. 296(6636):
1585-1588.
Jacome, D. (1984). Aphasia with elation, hypermusia, musicophilia and compulsive whistling. J. Neurol.
Neumswg. Psychiat. 47(3): 308-310.
Jonas, J. L (1991). Preferences of elderly music listeners residing in nursing homes for art music, tra-
ditional jazz, popular music of today, and country music. L Music Ther. 28(3): 149-160.
Jones, M,, Kidd, G., and Wetzel, R. (1981). Evidence for rhythmic attention. 1. Exp. Psychol. 7: 1059-1073.
Kartman, L L (1990). Fun and entertainment: One aspect of making meaningful music for the elderly.
Act. Adapt. Aging 14(4): 39-44.
Kellar, L, and Bever, T (1980). Hemispheric asymmetries in the perception of musical intervals as a
function of musical experience. Brain Lang. 10: 24-38.
Kidd, G., Boltz, M., and Jones, M. (1984). Some effects of rhythmic context on melody recognition.
Am. J. PsychoL 97(2): 153-173.
Lipe, A W (1991). Using music therapy to enhance the quality of life in a client with Alzheimer's
dementia: A case study. Music The%Perspect. 9: 102-105.
~ h ~ l o s kL e ~J., (1985). Music and the frail elderly. Act. Adapt. Aging 7(2): 73-75.
McCloskey, L J. (1990). The silent heart sings. Special issue: Counseling and therapy for eiders. Gen-
erations 14(1): 63-65.
Morgan and Tilluckdharry, R (1982). Presentation of singing function in severe aphasia. West Indian
Med. J. 31: 159-161.
Morris, M. (1986). Music and movement for the elderly. Nursing Times 82(8): 44-45.
Morrongiello, B., Trehub, S., Thorpe, L, and Capodilupo, S. (1985). Children's perception of melodies:
The role of contour, frequency, and rate of presentation. J. Exp. Child Psychol. 40(2): 279-292.
Norberg, A, Melin, E., and Asplund, K (1986). Reactions to music, touch and object presentation in
the final stage of dementia. An exploratory study. Int. Nursing Stud. 23(4): 315-323.
Olderog Millard, K A, and Smith, J. M. (1989). The influence of group singing therapy on the behavior
of Alzheimer's disease patients. J. Music The%26(2); 58-70.
Palmer, M. (1989). Music therapy in gerontology: A review and a projection. National Association for
Music Therapy California Symposium on Clinical Practices (1987, Costa Mesa, California). Music
T!ier. Perspect. 6: 52-56.
Palmer, M. D. (1977). Music therapy in a comprehensive program of treatment and rehabilitation for
the geriatric resident. J. Music Thm l4(4): 190-197.
Palmer, M. D. (1983). Music therapy in a comprehensive program of treatment and rehabilitation for
the geriatric resident. Act& Adapt. Aging 3(3): 53-59.
Pollack, N. J., and Namazi, K H. (1992). The effect of music participation on the social behavior of
Alzheimer's disease patients. J. Music The%29(1): 54-67.
Povel, D. (1984). A theoretical framework for rhythm perception. Psychol. Res. 45: 315-337.
Prange, F! (1990). Categories of music therapy at Judson Retirement Community. Music The%Perspect.
8: 88-89.
Prickett, C. A, and Moore, R S. (1991). The use of music to aid memory of Alzheimer's patients.
J. Music T l m 28(2): 101-110.
Prinsley, D. (1986). Music therapy in geriatric care. Aust. Nurses J. 15(9): 48-49.
Rosling, L. K, and Kitchen, J. (1992). Music and drawing with institutionalized elderly. Miniconference
in Music and Geriatrics (1990, Coquitlam, Canada). Act. Adapt. Aging 17(2): 27-38.
Safranek, M., Koshland, G., and Raymond, G. (1982). Effect of auditory rhythm on muscle activity.
Phys. The%62: 161-168.
Sandman, C. (1984). Afferent influences on the cortical evoked response. In Coles, M., Jennings, L,
and Stern, J. (eds.). Psychological Perspectives (Festschrift for Beatrice and John Lacey), Hutchinson
and Ross, Stroudberg, PA
Schullian, D., and Schoen, M. (1948). Music and Medicine, Henry Schuman, New York.
Segal, R. (1990). Helping older mentally retarded persons expand their socialization skills through the
use of expressive therapies. Special Issue: Activities with developmentally disabled elderly and older
adults. Activ., Adapt. Aging 15(1-2): 99-109.
Smith, B. B. (1992). Treatment of dementia: Healing through cultural arts. Pride Inst. 1. Long Term
Home Health Care ll(3): 37-45.

David Aldridge Collected music therapy papers 59

Job Title: JCG1 Article: U80 Makeup: MTW/Nov. 23, 1997

Kevboardina: MTW/Nov. 23. 1997 Last Revision: MTW/Nov. 23. 1997
Smith, D. S. (1990). Therapeutic treatment effectiveness as documented in the gerontology literature:
Implications for music therapy. Music Thez Perspect. 8: 36-40.
Smith, D. S. (1991). A comparison of group performance and song familiarity on cued recall tasks with
older adults. L Music Ther. 28(1): 2-13.
Smith, G. H. (1986). A comparison of the effects of three treatment interventions on cognitive Func-
tioning of Alzheimer patients. Music Ther. 6a(l): 41-56.
Smith, S. (1990). The unique power of music therapy benefits Atzheimer's patients. Activ.,Adapt. Aging
14(4): 59-63.
Summer, L (1981). Guided imagery and music with the elderly. Music Ther. l(1): 39-42.
Swartz, K.. Hantz, E., Crummer, G., Wilton, J., and Frisina, R (1989). Does the melody linger on?
Music cognition in Alzheimer's disease. Semin. Neural. 9(2): 152-158.
Tyson, J. (1989). Meeting the needs of dementia Nws. Elder l(5): 18-19.
VanderArk, S., Newman, I., and Bell, S. (1983). The effects of music participation on quality of life of
the elderly. Music Ther. 3(1): 71-81.
Wagner, M., and Hannon, R (1981). Hemispheric asymmetries in faculty and student musicians and
nonmusicians during melody recognition tasks. Brain Long. 13: 379-388.
Walker. B., and Sandman, C. (1979). Human visual evoked responses are related to heart rate. L Comp.
PhysioL Psychol. 93: 717-729.
Walker, B., and Sandman, C. (1982). Visual evoked potentials change as heart rate and carotid pressure
change. Psychophysiology 19: 520-527.

David Aldridge Collected music therapy papers 60

Job Title: JCGIArticle: M 0 Makeup: MTW/Nw. 23, 1997

Kevboardina: MTW/Nov. 23. 1997 Last Revision: MTW/Nov. 23. 1997
The Arts in Psychotherapy. Vol. 19, pp. 243-255, 1992
Printed in the USA. All rights reserved.
TWO EPISTEMOLOGIES: MUSIC THERAPY AND MEDICINE IN THE
TREATMENT OF DEMENTIA
DAVID ALDRIDGE, PhD and GUDRUN ALDRIDGE, Dipl, MT*
In earlier papers it has been suggested that it is
possible for music therapists, creative arts therapists
and medical practitioners to work together so that they
may negotiate a common language (Aldridge &
Brandt, 1991; Aldridge, Brandt, & Wohler, 1989).
This paper extends that debate further into another
clinical realm, that of dementia in the elderly.
Dementia is an important source of chronic dis-
ability leading to both spiralling health care expendi-
ture among the elderly and a progressive disturbance
of life quality for the patient and his or her family. In
the United States the cost of institutional care for
patients with dementia is estimated at over $25 billion
a year (Steg, 1990). If 4% to 5% of the US elderly
population suffer from dementia, then it can be esti-
mated that 1.25% of the adult population are suffering
with the problems of severe dementia. Other esti-
mates of the same population suggest that 15% of
those over the age of 65 will have moderate to severe
dementia with projections to 45% by the age of 90
years (Odenheimer, 1989). Current estimates are that
over 60% of those cases of dementia result from Alz-
heimer's disease (Kalayam & Shamoian, 1990).
Dementing illnesses, or acquired cognitive disor-
ders, have been recognized for centuries, but little
progress was made in specific diagnoses until the evo-
lution of the nosologic approach to disease and early
clinical descriptions of neurosyphilis and Hunting-
ton's chorea in the 1800s. Such descriptions were
further supported by concurrent understandings that
suggested the influence of the brain on behavior. The
*David Aldridge, a frequent contributor, is a research consultant to the medical faculty of Universitat Witten Herdecke, Germany and
European Editor of The Arts in Psychotherapy.
Gudrun Aldridge is a music therapist.
David Aldridge Collected music therapy papers
0197-4556192 $5.00 + .OO
Copyright 0 1992 Pergamon Press Ltd.
first histopathological characterizations of cognitive
disorders were made possible by developments in the
optical microscope. Thus, Alzheimer (1907) was able
to see the neuronal degeneration and senile plaques in
the brain of a 55-year-old woman with progressive
memory impairment and identify the disease that to-
day bears his name.
Although cognitive impairment is evident from be-
havior, and neurohistopathology can recognize neu-
ronal degeneration, the diagnosis of Alzheimer's dis-
ease is prone to error, and authors differ as to the
difficulty of making a precise diagnosis (Odenheimer,
1989; Steg, 1990). In the early stages of the disease
the symptoms are difficult to distinguish from those of
normal aging, a process that itself is poorly under-
stood. To date, there exist no normative established
values of what is cognitive impairment or memory
loss, or what neurochemical and neurophysiological
changes accompany normal aging. It is, therefore,
extremely difficult to establish criteria for determin-
ing abnormal changes from a normal population
and the researcherlclinician must in part rely upon
within-the-subject designs to indicate progressive
deterioration.
A second source of error in diagnosing Alzhei-
mer's disease is that it is masked by other conditions
(see Table 1). Principal among these conditions is that
of depression, which itself can cause cognitive and
behavioral disorders. In addition, it is estimated that
20% to 30% of patients with Alzheimer's disease will
have an accompanying depression (Kalayam & Sha-
61
244 ALDRIDGE AND ALDRIDGE
Table 1
Differential Diagnosis of Alzheimer's Disease
Differential Diagnosis
Multi-infarct dementia and other forms of cerebrovascular
disease
Parkinson's disease
Progressive supranuclear palsy
Huntington's disease
Central nervous system infection
Subdural haematoma
Normal pressure hydrocephalus
Multiple sclerosis
Seizure disorder
Brain tumor
Cerebral trauma
Metabolic disturbance
Nutritional deficiency
Psychiatric disorder
Substance abuse or overmedication
Taken from Steg, R. 1990, Determining the cause of dementia.
Nebraska Medical Journal, 75 (4). 59-63. Reprinted with permis-
sion.
moian, 1990) thereby compounding diagnostic prob-
lems further.
Clinical Descriptions of Dementia
The clinical syndrome of dementia is characterized
by an acquired decline of cognitive function that is
represented by memory and language impairment.
Whereas the term dementia itself is used widely
throughout the medical literature, and in common us-
age, to describe cognitive impairment, it is generally
applied to two conditions: dementia of the Alzhei-
mer's type (DAT) and multi-infarct dementia.
The course of Alzheimer's disease is one of pro-
gressive deterioration associated with degenerative
changes in the brain. Such deterioration is presented
in a clinical picture of episodic changes and a pattern
of particular cognitive failings that are variable
(Drachman, O'Donnell, Lew, & Swearer, 1990).
Mental status testing is one of the primary forms of
assessing these cognitive failings, which include short
and long-term memory changes, impairment of ab-
stract thinking and judgment, disorders of language
(aphasia), and difficulty in finding the names of
words (anomia), the loss of ability to interpret what is
heard, said and felt (agnosia), and an inability to carry
out motor activities, such as manipulating a pen or
toothbrush, despite intact motor function (apraxia).
David Aldridge Collected music therapy papers
When such clinical findings are present, then a prob-
able diagnosis can be made; a more definite diagnosis
depends upon tissue diagnosis (see Table 2).
Although dementia of the Alzheimer's type begins
after the age of 40, and is considered to be a disease
of the elderly, the influence of age on prognosis is not
as significant as the initial degree of severity of the
problem when recognized (Drachman et al., 1990).
Disease severity, as assessed by intellectual function,
appears to be the most consistent predictor of the
subsequent course of the disease, particularly when
accompanied by a combination of wandering and fall-
ing, and behavioral problems (Walsh, Welch, & Lar-
son, 1990). However, the rates of decline between
subgroups of patients are variable and a patient's rate
of progression in one year may bear little relationship
to future rate of decline (Salmon, Thai, Butters, &
Heindel, 1990). Some authors (Cooper, Mungas, &
Weiler, 1990) suggest that an as yet unproven factor,
other than declining cognitive ability, may also play a
part in the associated abnormal behaviors of anger,
agitation, personality change, wandering, insomnia
and depression, which occur in later stages of the
disease.
Clearly, Alzheimer's disease causes distress for
the patient. The loss of memory and the accompany-
ing loss of language, before the onset of motor im-
pairment, means that the daily lives of patients are
disturbed. Communication, the fabric of social con-
tact, is interrupted and disordered. The threat of pro-
gressive deterioration and behavioral disturbance has
ramifications not only for the patients themselves, but
also their families, who must take some of the social
responsibility for care of the patients and bear the
Table 2
Diagnostic Evaluation of Dementia
Diagnostic Categories
Complete medical history
Mental status examination
Complete physical and neurological investigation (including
investigation for infection of central nervous system if
suspected)
Complete blood count and blood chemistry tests (including
vitamin B 12 levels)
Thyroid function tests
Serology for syphilis
Computerized tomography (CT) or magnetic resonance imaging
(MRI), electroencephalography (EEG), or positive emission
tomography (PET) scanning
62
 TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA
emotional burden of seeing a loved one becoming
confused and isolated.
Finally, it must also be borne in mind that the
elderly depressed can exhibit a pseudodementia
(Caine, 1981) whereby Alzheimer's is mimicked (see
Table 3). Such patients recover and show no sign of
residual intellectual impairment.
Assessment of Dementia
A brief cognitive test, the Mini-Mental State Ex-
amination (Folstein, Folstein, & McHugh, 1975), has
been developed to screen and monitor the progression
of Alzheimer's disease. The test itself is intended for
the clinician to assess functions of different areas of
the brain, and is based upon questions and activities
(see Table 4). As a clinical instrument it is widely
used and well validated in practice (Babikian, Wolfe,
Linn, Knoefel, & Albert, 1990; Beatty & Goodkin,
1990; Eustache, Cox, Brandt, Lechevalier, & Pons,
1990; Faustman, Moses, & Csemansky, 1990; Gag-
non, Letenneur, Dartigues, Commenges, Orgogozo,
Gateau, Alperovitch, Decamps, & Salamon, 1990;
Jairath & Campbell, 1990; Summers, DeBoynton,
Marsh, & Majovski, 1990; Zillmer, Fowler, Gutnick,
& Becker, 1990). A bedside test, the MMSE is
widely used for testing cognition and is useful as a
predictive tool for cognitive impairment and semantic
memory (Eustache et al., 1990) without being con-
taminated by motor and sensory deficits (Beatty &
Goodkin, 1990; Jairath & Campbell, 1990).
Elderly patients scoring below 24 points out of a
Table 3
Features Differentiating Pseudodementia From Dementia
Pseudodementia
Onset can be dated with some precision
Symptoms of short duration before medical help is sought
History of previous psychiatric dysfunction
Patients usually complain much of cognitive loss
Patients make little effort to perform even simple tasks
Behavior often incongruent with severity of cognitive
impairment
Nocturnal accentuation of dysfunction uncommon
"Don't know" answers typical
Marked variability in performance on tasks of similar
difficulty
After Caine (1981). Mental status changes with aging. Seminars in Neurology, I ( l ) , 39, Thieme Medical Publishers. Reprinted with
permission.
David Aldridge Collected music therapy papers
245
possible total score of 30 are considered demented.
However, this scoring has been questioned on the
grounds of its cut-off point of 24 as the lower limit,
particularly for early dementia (Galasko, Klauber,
Hofstetter, Salmon, Lasker, & Thai, 1990); and, that
it is influenced by education (Gagnon et al., 1990).
Poorly educated subjects with less than eight years of
education may score below 24 without being
demented.
Further criticisms of the Mini-Mental State Exam-
ination (MMSE) have been that it is not sensitive
enough to mild deficits, but it could be augmented by
the addition of a word fluency task and an improve-
ment in the attention-concentration item (Galasko et
al., 1990). In addition, the MMSE seriously under-
estimates cognitive impairment in psychiatric patients
(Faustman, Moses, & Csemansky, 1990). An impor-
tant feature neglected by the MMSE is that of "in-
tention" or executive control (Odenheimer, 1989),
which refers to the ability of the patient to persevere
with a set task, to reach a set goal or to change tasks.
The items the MMSE fails to discriminate (minor
language deficits), or neglects to assess (fluency and
intentionality), however, may be elicited in the play-
ing of improvised music. A dynamic musical assess-
ment of patient behavior, linked with the motor co-
ordination and intent required for the playing of mu-
sical instruments used in music therapy, and the
necessary element of interpersonal communication,
may provide a sensitive complementary tool for as-
sessment (Aldridge, 1989a) (see Table 5). This would
not make music therapy a diagnostic tool. It would
not be possible to say that patients played in a partic-
Dementia
Onset can be dated only within broad limits
Symptoms can be of long duration before medical help is
sought
History of previous psychiatric dysfunction unusual
Patients usually complain little of cognitive loss
Patients struggle to perform tasks
Behavior usually compatible with severity of cognitive
impairment
Nocturnal accentuation of dysfunction common
Near-miss answers frequent
Consistently poor performance on tasks of similar difficulty
63
246 ALDRIDGE AND ALDRIDGE

Table 4
Mini-Mental State Examination

Item Component Score

Orientation for time year, season, month, date and day 5

Orientation for place state, county, city, building and floor
Registration Subject repeats "rose," "ball" and "key"
Attention for calculation Serial subtraction of 7 from 100 or spell "world" backward
Recall "Rose," "ball" and "key"
Naming Pencil and watch
Repetition No ifs, ands, or buts 1
Three stage verbal command Take a piece of paper in your right hand, fold it in half, and put it on the floor 3
Written command Close your eyes 1
Writing A spontaneous sentence 1
Construction Two interlocking pentagons
Total

Taken from Galasko, D., Klauber, M , , Hofstetter, C . , Salmon, D., Lasker, B. & Thai, L. (1990). The Mini-Mental State Examination in
the early diagnosis of Alzheimer's disease. Archives of Neurology 47 (l), 49-52.

ular way before they had the disease, or that their
particular performance was a consequence of the dis-
ease, but it would provide a useful tool for assessing
current ability. From this platform of current ability,
linking musical assessment to medical diagnosis, it
would be possible to recognize a broad spectrum of
therapeutic changes, including improvements or de-
terioration~,which would not be confined to verbal
abilities alone.
Table 5
Features of Medical and Musical Assessment
Music and Dementia
Late in adult life, at the age of 56, and after com-
pleting two major concertos for the piano, Maurice
Ravel, the composer, began to complain of increased
fatigue and lassitude. Following a traffic accident, his
condition deteriorated progressively (Henson, 1988).
He lost the ability to remember names, to speak spon-
taneously, and to write (Dalessio, 1984). Although he

Medical Elements of Assessment Musical Elements of Assessment

continuing observation of mental and functional status
testing of verbal skills, including element of speech fluency
cortical disorder testing; visuo-spatial skills and ability to
perform complex motor tasks (including grip and right left
coordination)
testing for progressive memory disintegration
motivation to complete tests, to achieve set goals and
persevere in set tasks
"intention" difficult to assess, but considered important
concentration and attention span
flexibility in task switching
mini-mental state score influenced by educational status
insensitive to small changes
ability to interpret surroundings
continuing observation of mental and functional status
testing of musical skills; rhythm, melody, harmony,
dynamic, phrasing, articulation
cortical disorder testing; visuo-spatial skills and ability to
perform complex motor tasks (including grip and right left
coordination)
testing for progressive memory disintegration
motivation to sustain playing improvised music, to achieve
musical goals and persevere in maintaining musical form
"intention" a feature of improvised musical playing
concentration on the improvised playing and attention to the
instruments
flexibility in musical (including instrumental) changes
ability to play improvised music influenced by previous
musical training
sensitive to small changes
ability to interpret musical context and assessment of
communication in the therapeutic relationship

David Aldridge Collected music therapy papers 64

 TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA
could understand speech, he was no longer capable of
the coordination required to lead a major orchestra.
Whereas his mind, he reported, was full of musical
ideas, he could not set them down (Dalessio, 1984).
Eventually his intellectual functions and speech dete-
riorated until he could no longer recognize his own
music.
However, the responsiveness of patients with Alz-
heimer's disease to music is a remarkable phenome-
non (Swartz, Hantz, Crummer, Walton, & Frisina,
1989). Although language deterioration is a feature of
cognitive deficit, musical abilities appear to be pre-
served. This may be because the fundamentals of lan-
guage itself are musical and are prior to semantic and
lexical functions in language development (Aldridge,
1989a; 1989b; 1991b).
Although language processing may be dominant in
one hemisphere of the brain, music production in-
volves an understanding of the interaction of both
cerebral hemispheres (Altenmiiller, 1986; Brust,
1980; Gates & Bradshaw, 1977). In attempting to
understand the perception of music there have been a
number of investigations into the hemispheric strate-
gies involved. Much of the literature considering mu-
sical perception concentrates on the significance of
hemispheric dominance. Gates and Bradshaw (1977)
concluded that cerebral hemispheres are concerned
with music perception and that no laterality differ-
ences are apparent. Other authors (Wagner & Han-
non, 1981) suggested that two processing functions
develop with training where left and right hemi-
spheres are simultaneously involved, and that musical
stimuli are capable of eliciting both right and left ear
superiority (Kellar & Bever, 1980). Similarly, when
people listen to and perform music they utilize differ-
ing hemispheric processing strategies.
Evidence of the global strategy of music process-
ing in the brain is found in the clinical literature. In
two cases of aphasia (Morgan & Tilluckdharry,
1982), singing was seen as a welcome release from
the helplessness of being a patient. The authors hy-
pothesized that singing was a means to communicate
thoughts externally. Although the "newer aspect" of
' speech was lost, the older function of music was re-
tained, possibly because music is a function distrib-
uted over both hemispheres. Berman (1981) sug-
gested that recovery from aphasia is not a matter of
new learning by the nondominant hemisphere but a
taking over of responsibility for language by that
hemisphere. The nondominant hemisphere may be a
reserve of functions in case of regional failure.
David Aldridge Collected music therapy papers
Little is known about the loss of musical and lan-
guage abilities in cases of global cortical damage.
Any discussion is necessarily limited to hypothesizing
as there are no established baselines for musical per-
formance in the adult population (Swartz et al.,
1989). Aphasia, which is a feature of cognitive dete-
rioration, is a complicated phenomenon. Although
syntactical functions may remain longer, it is the lex-
ical and semantic functions of naming and reference
that begin to fail in the early stages. Phrasing and
grammatical structures remain, giving an impression
of normal speech, yet content becomes increasingly
incoherent. These progressive failings appear to be
located within the context of semantic and episodic
memory loss illustrated by the inability to remember
a simple story when tested (Bayles, Boone, Tomoeda,
Slauson & Kaszniak, 1989).
Musicality and singing are rarely tested as features
of cognitive deterioration, yet preservation of these
abilities in aphasics has been linked to eventual re-
covery (Jacome, 1984; Morgan & Tilluckdharry,
1982), and could be significant indicators of hierar-
chical changes in cognitive functioning. Jacome
(1984) found that a musically naive patient with
transcortical mixed aphasia exhibited repetitive, spon-
taneous whistling, and whistling in response to ques-
tions. The patient often spontaneously sang without
error in pitch, melody, rhythm and lyrics, and spent
long periods of time listening to music. Beatty (Be-
atty, Zavadil & Bailly, 1988) described a woman who
had severe impairments in terms of aphasia, memory
dysfunction and apraxia yet was able to sight-read an
unfamiliar song and perform on the xylophone, which
to her was an unconventional instrument. Like Ravel
(Dalessio, 1984), and an elderly musician who could
play from memory (Crystal, Grober, & Masur, 1989)
but no longer recalled the name of the composer, she
no longer recalled the name of the music she was
playing.
Swartz and his colleagues (Swartz et al., 1989, p.
154) proposed a series of perceptual levels at which
musical disorders take place:
(a) the acoustico-psychological level, which in-
cludes changes in intensity, pitch and timbre;
(b) the discriminatory level, which includes the
discrimination of intervals and chords;
(c) the categorical level, which includes the cate-
gorical identification of rhythmic patterns and
intervals;
(d) the configural level, which includes melody
65
248 ALDRIDGE AND ALDRIDGE
perception, the recognition of motifs and
themes, tonal changes, identification of instru-
ments, and rhythmic discrimination;
(e) 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 (a), (h) and (c) remain unaffected, the
complexities of levels (d) and (e), when requiring no
naming, may be preserved but are susceptible to
deterioration.
It is perhaps important to point out that these dis-
orders are not themselves musical; they are disorders
of audition. Only when disorders of musical produc-
tion take place can we begin to suggest that a musical
disorder is present. Improvised musical playing is in
a unique position to demonstrate this hypothetical link
between perception and production.
Rhythm is the key to the integrative process un-
derlying both musical perception and physiological
coherence. Barfeld's (1978) approach suggested that
when musical form as tonal shape meets the rhythm of
breathing there is the musical experience. External
auditory activity is mediated by internal perceptual
shaping in the context of a personal rhythm. When
considering communication, rhythm is also funda-
mental to the organization and coordination of inter-
nal processes, and externally between persons (Ald-
ridge, 1989a).
Rhythm offers a frame of reference for perception
(Povel, 1984). Musical tones played in sequence are
seen as having a dual function. They are characterized
by pitch, volume, timbre and duration. They also
mark points in time. These tones then produce both
structure in time and of time. When tones are used in
sequence only as temporal concepts they can be
thought of as providing a temporal grid, which is a
time scale on which the tone sequences can be
mapped for duration and location. It might profitably
be asked what the isomorphic events in terms of phys-
iology are that would meet such a dual function.
There may be regular sequential pulses of metabolic,
cardiac, or respiratory activity within the body that
also have qualities of pitch, timbre and duration.
Rhythm too plays a role in the perception of mel-
ody. The perceptions of speech and music are formi-
dable tasks of pattern perception. The listener has to
extract meaning from lengthy sequences of rapidly
changing elements distributed by time (Morrongiello,
David Aldridge Collected music therapy papers
Trehub, Thorpe, & Podilupo, 1985). Temporal pre-
dictability is important for tracking melody lines
(Jones, Kidd, & Wetzel, l98 1; Kidd, Boltz, & Jones,
1984). Kidd et al. also refer to melody as having a
structure in time and that a regular rhythm facilitates
the detection of a musical interval and its subsequent
integration into a cognitive representation of the serial
structure of the musical pattern. Adults identify fa-
miliar melodies on the basis of relational information
about intervals between tones rather than the absolute
information of particular tones. In the recognition of
unfamiliar melodies, less precise information is gath-
ered about the tone itself. The primary concern is with
successive frequency changes or melodic contour.
The rhythmical context prepares the listener in ad-
vance for the onset of certain musical intervals and
therefore a structure from which to discern, or pre-
dict, change. One may not be aware of certain
changes and become either out of tune or out of time;
such a loss of rhythmical structure, which appears
outwardly as confusion, may be a hidden factoiin the
understanding of Alzheimer's disease.
What is important in these descriptions of musical
perception is the emphasis on context where there are
different levels of attention occurring simultaneously
against a background temporal structure (Jones, Kidd,
& Wetzel, 1981; Kidd, Boltz, & Jones, 1984). Mu-
sical improvisation with a therapist, which empha-
sizes attention to the environment (Sandman, 1984;
Walker & Sandman, 1979, 1982) utilizing changes
in tempo and volitional response (Safranek, Kosh-
land, & Raymond, 1982), without regard for lexical
content, may be an ideal medium for treatment initi-
atives with Alzheimer's patients. The playing of sim-
ple rhythmic patterns and melodic phrases by the ther-
apist, and the expectation that the patient will copy
those patterns or phrases, is similar to the element of
"registration" in the mental state examination.
Although improvised musical playing is a useful
tool for the assessment of musical abilities, it is also
used within a therapeutic context. In this way, assess-
ment and therapy are interlinked, assessment provid-
ing the criteria from which to identify therapeutic
goals and develop therapeutic strategies.
Music Therapy With an Alzheimer's Patient
Nordoff-Robbins music therapy is based upon the
improvisation of music between therapist and patient
(Nordoff & Robbins, 1977). The music therapist
plays the piano, improvising with the patient who
uses a range of instruments. his work often begins
66
 TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA
with an exploratory session using rhythmic instru-
ments, in particular the drum and cymbal, progressing
to the use of rhythmiclmelodic instruments such as the
chime bars, glockenspiel or xylophone, developing
into work with melodic instruments (including the
piano) and the voice. In this way of working, the
emphasis is on a series of musical improvisations dur-
ing each session, and music is the vehicle for the
therapy. Each session is audiotaped, with the consent
of the patient, and later analyzed and indexed as to
musical content.
In the case example below, music therapy is used
as one modality of a comprehensive treatment pack-
age. The patient is seen on an outpatient basis for 10
weekly sessions. Each session lasts for 40 minutes.
She is unable to find her way on public transport and
is brought to the hospital by her son.
Frau X was a 55-year-old woman who came to the
hospital for treatment. Her sister, now dead, had Alz-
heimer's disease, and the family was concerned that
she was repeating her sister's demise as her memory
became increasingly disturbed. She began playing the
piano for family, friends and acquaintances at the age
of 40, although without any formal studies. Given this
interest, music therapy appeared to have potential as
an intervention adjuvant to medical treatment.
Initially the patient was referred to the hospital
when she and her son became aware of her deterio-
rating condition, although the disease was in its early
stages. At home she was experiencing difficulties in
finding clothing and other things necessary for every-
day life. She could not cook for herself anymore and
was unable to write her own signature. When wanting
to speak, she experienced difficulty in finding words.
It may be assumed, given the family background, and
her own understanding of her failings, that the cog-
nitive problems were exacerbated by depression and
likely to be a pseudodementia.
Rhythmic Playing
In all 10 sessions Frau X demonstrated her ability
to play, without the influence of her music therapist,
a singular ordered rhythmic pattern in 414 time using
two sticks on a single drum. This rhythmical pattern
appeared in various forms and can be portrayed as
seen in Example 1.
A feature of her rhythmical playing was that in
nearly all the sessions, during the progress of an im-
provisation, the patient would let control of the rhyth-
mic pattern slip so that it became progressively im-
David Aldridge Collected music therapy papers
249
Example l . Rhythmic playing by the patient on a drum using a
beater in her right hand.
precise, losing both its form and liveliness. The initial
impulse of her rhythmical playing, which was clear
and precise, gradually deteriorated as she lost concen-
tration and ability to persevere with the task in hand.
However, when the therapist offered an overall mu-
sical structure during the course of the improvisation,
the patient could regain her precision of rhythm. As
suggested earlier, to sustain perception an overall
rhythmical structure is necessary, and it is this musi-
cal gestalt (i.e., the ability to provide an overall or-
ganizing structure of time) that fails in Alzheimer's
disease.
The patient reacted quickly to changes in time and
different rhythmic forms, and incorporated these
within her playing. Significantly, she reacted fluently
in her playing to changes from 414 time to 314 time,
often remarking " . . . now it's a waltz. . . ." With
typical well-known rhythmical forms (e.g., the Ha-
baner rhythm) in combination with characteristic me-
lodic phrases, she laughed, breathed deeply, and
played with intent.
These rhythmical improvisations, using different
drums and cymbals, were played in later sessions on
two instruments together. The patient had no diffi-
culty in controlling and maintaining her grip of the
beaters. Similarly, she showed no difficulty in coor-
dinating parallel or alternate-handed playing on a sin-
gle instrument although she played mostly with a
quick tempo (120 beats per minute). However, the
introduction of two instruments brought a major dif-
ficulty for the patient. She stood disoriented before
the instruments, unable to integrate them both in the
playing. It was only with instructions and direction
from the therapist that the patient was able to coordi-
nate right-left playing on two instruments, and
changes in the pattern of the playing were also diffi-
cult to realize (see Examples 2 and 3).
What did remain throughout the improvisations
was the inherent musical ability of the patient, in
terms of tempo (ritardando, accelerando, rubato) and
Example 2 . Dialogic playing on the drum.
67
 ALDRIDGE AND ALDRIDGE
Example 3. A change in the pattern of playing.
dynamic (loud and soft), which she expressed when-
ever she had the opportunity. This would also accord
with Swartz et al. series of perceptual levels at which
musical disorders take place (i.e., levels-(a) the
acoustico-psychological level, (b) the discriminatory
level, which includes the discrimination of intervals
and chords, and (c) the categorical level, which in-
cludes the categorical identification of rhythmic pat-
terns and intervals).
Melodic Playing
Melody is a natural expression of motion that
arises and decays from moment to moment. In this
motion, the size of the intervals provides an enormous
melodic tension that itself has a dynamic power. The
experience of melody is itself an experience of form.
As a melody begins, there is the possibility to grasp a
sense of the immediacy of the whole form and prepare
for the aesthetic pleasure of deviations from what is
expected. This element of tension between the ex-
pected and the unpredictable has been at the heart of
musical composition for the last 200 years. In addi-
tion, it is melody that leads the music from the rhyth-
mical world of feeling into the cognitive world of
imagination.
When Frau X played, her melodies were always
lively. She knew many folk songs from earlier times
and was able to sing them alone. After only a few
notes played by the therapist on the piano, she could
associate those notes with a well-known tune. How-
ever, when the patient tried to play a complete melody
on the piano, or other melody instrument alone, it
proved impossible. Although beginning spontane-
ously and fluently, she had difficulty in completing a
known melody.
Melody instruments, like the metallophone and the
xylophone, which were previously unknown to the
patient, remained forever strange to her. At the intro-
duction of a new melody she would often seek a mel-
ody known to her rather than face the insecurity of
improvisation. When the therapist sat opposite her
and showed her which notes to play she then was able
to follow the therapist's finger movements. When
presented with a limited range of tones, she also had
David Aldridge Collected music therapy papers
difficulty in playing them, which may have been com-
pounded by visuo-spatial difficulties (e.g., it is easier
to strike the surface of a drum than the limited precise
surfaces of adjacent chime bars).
Harmonic Playing
At the beginning of the very first session after en-
tering the therapy room, Frau X set her eyes on the
piano and began to play spontaneously "Happy is the
Gypsy Life." She easily accompanied this song har-
monically with triads and thirds. The second song she
attempted to play proved more difficult as she failed
to find the subdominant, whereupon she broke off
from the playing and remarked ". . . that always
catches me out." This pattern of spontaneously strik-
ing up a melody, and then breaking off when the
harmony failed, was to be repeated whenever she
tried other songs like "Happy Birthday" and "Horch
was kommt von drauBen rein." She showed a fine
musical sensitivity for the appropriate harmony,
which she could not always play. In the playing of the
drum, her musical sensitivity in her reactions to the
contrasting sound qualities of major and minor was
reduced, but overall she had a pronounced perception
of this harmonic realm of music. As in tests of lan-
guage functioning, the production of music is im-
paired while perceptual abilities remain.
Changes in the Musical Playing of the Patient
In the rhythmical playing on drum and cymbal, the
therapist attempted to increase the patient's attention
span through the use of short repeated musical pat-
terns and changes in key, volume and tempo, hoping
that the patient would maintain a stable musical form.
This technique helped the patient to maintain a rhyth-
mical pattern and brought her to the stage where she
could express herself stronger musically. Above the
emphasis of the basic beat in the music, the therapist
searched for other ways to respond to and develop a
variety in rhythmical patterns by moving away from
the repetitive pattern played by the patient. In a quick
tempo the patient was able to maintain a basic beat for
a certain time. As soon as the tempo changed and
became slower, or the music varied with the intro-
duction of a semiquaver, the stable element of the
music was disturbed and took on a superficial
character.
A further change in the improvising was shown
when the patient recognized, and could repeat, rhyth-
68
 TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA
mica1 patterns, which were frequently realized as a
musical dialogue and brought into a musical context.
In the last session of therapy, the patient was able to
change her playing in this way so that she could ex-
press more strongly by bringing into line her thought-
ful and expressive playing (see Example 4).
A crucial point in the music was when she chose to
play for a bar on the cymbal. Although after a while
she trusted herself to play without help on two instru-
ments, she could not come to grips with a new per-
sonal initiative on these instruments. This was also
reflected in her continuing difficulty with what were
initially strange instruments, like the temple blocks.
She also expressed her insecurity about how to pro-
ceed and needed instructions.
The patient displayed few changes in her dynamic
playing. She reacted to dynamic contrasts and transi-
tions, but powerful forte playing was only achieved in
the last session. At times her playing had a uniform
quality of attack, which gave it a mechanistic and
immovable character. It was not possible for her to
build a freely improvised melody from a selection of
tones. It was as if she was a prisoner of the search for
melodies of known fixed songs; therefore, the thera-
pist chose the free form of improvising on rhythm
instruments.
Intentional Playing
From the first session of therapy the patient made
quite clear her intent to sit at the piano and play what-
ever melodies she chose and to find the appropriate
accompaniments. This wish, and the corresponding
willpower to achieve this end, was shown in all the
sessions. It was possible to use this impetus to play as
a source for improvisation. In the sixth session, Frau
X improvised a rhythmical piece in 414 time, which
the therapist then transformed with a melodic phrase.
At the end of the phrase the patient laughed with joy
at the success of her playing and asked to play it
again. The original lapses and slips in the form of the
rhythmical playing could be carried by the intent and
expression with which she played. Although her over-
all intention to play was preserved, her attention to
that playing, the concentration necessary for musical
Example 4. Change in the form of the patient's playing.
David Aldridge Collected music therapy papers
25 1
production and the perseverance required for complet-
ing a sequence of phrases progressively failed and
was dependent on the overall musical structure of-
fered by the therapist.
Clinical Changes
At the end of the treatment period, which also used
homeopathic medicine, she was able to cook for her-
self and find her own things about the house. The
psychiatrist responsible for her therapeutic manage-
ment reported an overall improvement in her interest
in what was going on around her, and, in particular,
that she maintained attention to visitors and conver-
sations. The patient regained the ability to write her
name, although she could only write slowly. While
wanting to speak, she still experienced difficulty in
finding words. The medical practitioner with overall
responsibility for the patient used no validated clinical
assessment procedure for mental state examination.
It appears that music therapy had a beneficial ef-
fect on the quality of life for this patient, and that
some of the therapeutic effect may have been brought
about by handling the depression. Indeed, it may be
that the patient was suffering from a pseudodementia
confounded by her own anxiety and depression re-
garding the demise of her sister. Although the patient
came to the sessions with the intention of playing
music, her ability to take initiatives was impaired.
This situation reflected the state of her home life,
where she wanted to look after herself, yet was unable
to take initiatives. This stimulus to take initiatives was
seen as an important feature of the music therapy by
the therapist, and appears to have a correlation in the
way the patient began to take initiatives in her daily
life. Active music making also promotes interaction
between the persons involved, thereby promoting in-
itiatives in communication that the patient also en-
joyed, particularly when she accomplished playing a
complete improvisation.
A contraindication for music therapy with patients
who are aware of their problems is that the awareness
of further cognitive abilities as experienced in the
playing may exacerbate any underlying depression
and demotivate the patient to continue.
Conclusion
If we are unsure of the normal process of cognitive
loss in aging, we are even more in the dark as to the
normal improvised musical playing abilities of the
69
252 ALDRIDGE AND ALDRIDGE
elderly. Any further activities will depend upon some
baseline assessment of musical improvising ability.
The literature suggests that musical activities are pre-
served while other cognitive functions fail. Alzheimer
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 that language fails. Unfortunately, no es-
tablished guidelines for the normal range of impro-
vised music playing of adults is available.
Improvised music therapy appears to offer the op-
portunity to supplement mental state examinations in
areas where those examinations are lacking (see Table
6), although such a hypothetical claim awaits further
investigation. First, it is possible to ascertain the flu-
ency of musical production. Second, intentionality,
attention to, concentration on and perseverance with
the task in hand are important features of producing
musical improvisations and susceptible to 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 in-
volved 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 hypothesized that it is this overarching struc-
ture 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 me-
lodic playing when offered an overall structure by the
therapist. Such a hypothesis would tie in with the
musical hierarchy proposed by S w a m (Swartz et al.,
1989, p. 154) and would suggest a global failing in
cognition while localized lower abilities are retained.
However, the hierarchy of musical perceptual levels
proposed by Swartz may need to be further subdi-
vided into classifications of music reception and mu-
sic production.
Music therapy also appears to offer a sensitive as-
sessment tool. It tests those prosodic elements of
speech production that are not lexically dependent.
Furthermore, it can be used to assess those areas of
functioning, both receptive and productive, not cov-
ered adequately by other test instruments (i.e., flu-
ency, perseverance in context, attention, concentra-
tion and intentionality). In addition, it provides a form
of therapy that may stimulate cognitive activities so
that areas subject to progressive failure are main-
David Aldridge Collected music therapy papers
tained. Certainly the anecdotal evidence suggests that
quality of life of Alzheimer's patients is significantly
improved with music therapy (Tyson, 1989), accom-
panied by the overall social benefits of acceptance and
sense of belonging gained by communicating with
others (Morris, 1986). Prinsley recommended music
therapy for geriatric care in that it reduces the indi-
vidual prescription of tranquilizing medication, re-
duces 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 cooperation, psychological
goals of mood improvement and self-expression, in-
tellectual goals of the stimulation of speech and or-
ganization of mental processes, and the physical goals
of sensory stimulation and motor integration (Prins-
ley, 1986).
In further research, single-case within-subject de-
signs with Alzheimer's patients appear to be a feasible
way forward to assess individual responses to musical
interventions in the clinical realm. (These can be ex-
tended to include multiple baselines.) Such studies
would depend upon careful clinical examinations,
mental state examinations and musical assessments.
Unfortunately, most of the literature concerning
cognition and musical perception is based upon audi-
tion and not musical production. The production of
music, as is the production of language, is a complex
global phenomenon as yet poorly understood. The
understanding of musical production may well offer a
clue to the ground structure of language and commu-
nication in general. It is research in this realm of
perception that is urgent not only for the understand-
ing of Alzheimer's patients, but in the general context
of cognitive deficit and brain behavior. It may be, as
Berman ( 1 98 1) suggested, that the nondominant
hemisphere is a reserve of functions in case of re-
gional failure, and this functionality can be stimulated
to delay the progression of degenerative disease. Fur-
thermore, it is important to point out that when the
overall rhythmic pattern failed for the patient de-
scribed above, the patient was able to maintain her
beating in tempo. A similar situation may apply to
coma patients who cannot coordinate basic life pulses
within a rhythmic context and thereby regain con-
sciousness (Aldridge, 1991a; Aldridge, Gustorff, &
Hannich, 1990). We may need to address in future
research the coordinating role of rhythm in human
cognition and consciousness, whether it be in persons
who are losing cognitive abilities or in persons who
are attempting to gain cognitive abilities.
70
 TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA

Table 6
Comparative Elements of Two Therapeutic Epistemologies: Medicine and Music Therapy in the Treatment of Patients With
Dementia

Medical Elements of Assessment Musical Elements of Assessment Music Therapy Examples

continuing observation of mental and
functional status
testing of verbal skills, including
element of speech fluency
cortical disorder testing; visuospatial
skills and ability to perform complex
motor tasks (including grip and right
left coordination).
testing for progressive memory
disintegration
continuing observation of mental and
functional status
testing of musical skills; rhythm, melody,
harmony, dynamic, phrasing, articulation
cortical disorder testing; visuospatial
skills and ability to perform complex
motor tasks (including grip and right left
coordination).
testing for progressive memory
disintegration
improvisations using rhythmic instruments
(drum and cymbal) singly or in combination
improvisations using melodic instruments
singing and playing folk songs with harmonic
accompaniment
playing tuned percussion (metallophone,
xylophone, chime bars) demanding precise
movements
alternate playing of cymbal and drum using a
beater in each hand
coordinated playing of cymbal and drum
using a beater in each hand
coordinated playing of tuned percussion
the playing of short rhythmic and melodic
phrases within the session, and in successive

motivation to complete tests, to

achieve set goals and persevere in set
- motivation to sustain playing improvised
tasks
"intention" difficult to assess, but
considered important
concentration and attention span
flexibility in task switching
mini-mental state score influenced by
educational status
insensitive to small changes
ability to interpret surroundings
music, to achieve musical goals and
persevere in maintaining musical form
"intention" a feature of improvised
musical playing
concentration on the improvised playing
and attention to the instruments
flexibility in musical (including
instrumental) changes
ability to play improvised music
influenced by previous musical training
sensitive to small changes
ability to interpret musical context and
assessment of communication in the
therapeutic relationship
sessions
the playing of a rhythmic pattern deteriorates
when unaccompanied by the therapist, as
does the ability to complete a known melody,
although tempo remains
the patient exhibits the intention to play the
piano from the onset of therapy and
maintains this intent throughout the course of
treatment
the patient loses concentration when playing,
with qualitative loss in the musical playing
and lack of precision in the beating of
rhythmical instruments
initially the musical playing is limited to a
tempo of 120 bpm and a characteristic
pattern but this is responsive to change
although the patient has a musical
background this is only of help when she
perceives the musical playing, it is little
influence in the improvised playing
musical changes in tempo, dynamic, timbre
and articulation, which at first are missing,
are gradually developed
the patient develops the ability to play in a
musical dialogue with the therapist
demanding both a refined musical perception
and the ability of musical production

We had set out to negotiate a common language
between practitioners, and this was achieved. Al-
though the clinical benefits of music therapy for pa-
tients with dementia or pseudodementia remain spec-
ulative, a common language to discuss and compare
therapeutic changes has been developed, which is the
first step in a continuing program of research dia-
logues. The next step is for other therapists to attempt
correlations with their elderly patients to see if our
hypotheses stand up to practical clinical investigation.

David Aldridge Collected music therapy papers 71

254 ALDRIDGE AND ALDRIDGE
Our experiences suggest that it is important to con-
sider a period of active assessment separate from ther-
apy, and that assessment must also incorporate
time for orientation to the music therapy setting,
the relationship, the instruments and the activity of
improvising.
References
Aldridge, D. (1989a). Music, communication and medicine: Dis-
cussion paper. Journal of the Royal Society of Medicine, 82
(12), 743-746.
Aldridge, D. (1989b). A phenomenological comparison of the or-
ganization of music and the self. The Arts in Psychotherapy,
16, 91-97.
Aldridge, D. (1991a). Creativity and consciousness. The Arts in
Psychotherapy, 18 (4), 359-362.
Aldridge, D. (199 1b). Physiological change, communication, and
the playing of improvised music: Some proposals for research.
The Arts in Psychotherapy, 18 (l), 59-64.
Aldridge, D., & Brandt, G. (1991). Music therapy and inflamma-
tory bowel disease. The Arts in Psychotherapy, 18 (2), 1 13-
121.
Aldridge, D., Brandt, G., & Wohler, D. (1989). Towards a com-
mon language among the creative art therapies. The Arts in
Psychotherapy, 17, 189-195.
Aldridge, D., Gustorff, D., & Hannich, H. (1990). Where am I?
Music therapy applied to coma patients [editorial]. Journal of
the Royal Society of Medicine, 83 (6), 345-346.
Altenmiiller, E. (1986). Brain correlates of cerebral music process-
ing. European Archives of Psychiatry, 235, 342-354.
Alzheimer, A. (1907). Uber eine einartige Erkrankung der Him-
rinde. Allgemeine Zeitschrijt fur Psychiatric und Psychisch-
Gerichtliche Medizin, 64. 146-148.
Babikian, V., Wolfe, N., Linn, R., Knoefel, J., & Albert, M.
(1990). Cognitive changes in patients with multiple cerebral
infarcts. Stroke, 21 (7), 1013-1018.
Barfeld, 0 . (1978). The case for anthroposophy. London: Rudolf
Steiner Press.
Bayles, K. A., Boone, D. R., Tomoeda, C. K., Slauson, T. J., &
Kaszniak, A. W. (1989). Differentiating Alzheimer's patients
from the normal elderly and stroke patients with aphasia. Jour-
nal of Speech and Hearing Disorders, 54, 74-87.
Beatty, W., & Goodkin, D. (1990). Screening for cognitive im-
pairment in multiple sclerosis. An evaluation of the Mini-
Mental State Examination. Archives ofNeurology, 47 (3), 297-
301. - Kidd, G . , Boltz, M , , & Jones, M. (1984). Some effects of rhyth-
Beatty, W. W., Zavadil, K. D., & Bailly, R. C. (1988). Preserved
musical skills in a severely demented patient. International
Journal of Clinical Neuropsychology, 10, 158-164.
Berman, I. (1981). Musical functioning, speech lateralization and
the amusias. South African Medical Journal, 59, 78-81.
Bmst, J. (1980). Music and language: Musical alexia and agraphia.
Brain, 103, 367-392.
Caine, E. (1981). Mental status changes with aging. Seminars in
Neurology. 1 (l), 36-42.
Cooper, J., Mungas, D., & Weiler, P. (1990). Relation of cogni-
tive status and abnormal behaviors in Alzheimer's disease.
Journal of the American Geriatrics Society, 38 (g), 867-870.
Crystal, H., Groher, E., & Masur, D. (1989). Preservation of
David Aldridge Collected music therapy papers
musical memory in Alzheimer's disease. Journal of Neurology,
Neurosurgery and Psychiatry, 52 (12), 1415-1416.
Dalessio, D. (1984). Maurice Ravel and Alzheimer's disease.
Journal of the American Medical Association, 252 (24), 3412-
3413.
Drachman, D., O'Donnell, B., Lew, R., & Swearer, J. (1990).
The prognosis in Alzheimer's disease. Archives of Neurology,
47, 851-856.
Eustache, F., Cox, C . , Brandt, J., Lechevalier, B., & Pons, L.
(1990). Word-association responses and severity of dementia in
Alzheimer disease. Psychological Reports, 66 (3 Pt 2), 1315-
1322.
Faustman, W., Moses, J. J., & Csemansky, J. (1990). Limitations
of the Mini-Mental State Examination in predicting neuropsy-
chological functioning in a psychiatric sample. Acta Psychiat-
rica Scandinavica, 81 (2), 126-131.
Folstein, M. F . , Folstein, S. E., & McHugh, P. (1975). Mini-
Mental State: A practical guide for grading the cognitive state
of patients for the clinician. Journal of Psychiatric Research,
12, 189-198.
Gagnon, M,, Letenneur, L., Dartigues, J., Commenges, D., Or-
gogozo, J . , Barberger Gateau, P,, Alperovitch, A., Decamps,
A., & Salamon, R. (1990). Validity of the Mini-Mental State
Examination as a screening instrument for cognitive impair-
ment and dementia in French elderly community residents.
Neuroepidemiology, 9 (3), 143-1 50.
Galasko, D., Klauber, M., Hofstetter, C., Salmon, D., Lasker, B.,
& Thai, L. (1990). The Mini-Mental State Examination in the
early diagnosis of Alzheimer's disease. Archives of Neurology,
47 ( l ) , 49-52.
Gates, A., & Bradshaw, J . (1977). The role of the cerebral hemi-
spheres in music. Brain and Language, 4 , 403431.
Henson, R. (1988). Maurice Ravel's illness: A tragedy of lost
creativity. British Medical Journal of Clinical Research, 296
(6636), 1585-1588.
Jacome, D. (1984). Aphasia with elation, hypermusia, musico-
philia and compulsive whistling. Journal of Neurology, Neu-
rosurgery and Psychiatry, 47 (3), 308-310.
Jairath, N., & Campbell, H. (1990). Two mental status assessment
methods: An evaluation. Journal of Ophthalmic Nursing Tech-
nology, 9 (3), 102-105.
Jones, M,, Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic
attention. Journal of Experimental Psychology, 7 , 1059-1073.
Kalayam, B., & Shamoian, C. (1990). Geriatric psychiatry: An
update. Journal of Clinical Psychiatry, 51 (S), 177-1 83.
Kellar, L., & Bever, T. (1980). Hemispheric asymmetries in the
perception of musical intervals as a function of musical expe-
rience. Brain and Language, 10, 24-38.
mic content on melody recognition. American Journal of Psy-
chology, 97, 153-173.
Morgan, O . , & Tilluckdharry, R. (1982). Presentation of singing
function in severe aphasia. West Indian Medical Journal, 31,
159-161.
Morris, M. (1986). Music and movement for the elderly. Nursing
Times, 82 (g), 44-45.
Morrongiello, B., Trehub, S . , Thorpe, L., & Podilupo, S. (1985).
Children's perception of melodies: The role of contour, fre-
quency and rate of presentation. Journal of Experimental Child
Psychology. 40, 279-292.
Nordoff, P., & Robbins, C. (1977). Creative music therapy. New
York: John Day.
72
 TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA
Odenheimer, G. (1989). Acquired cognitive disorders of the elder-
ly. Medical Clinics of North America. 72 (6), 1373-141 1.
Povel, D. (1984). A theoretical framework for rhythm perception.
Psychological Research, 45, 315-337.
Prinsley, D. (1986). Music therapy in geriatric care. Australian
Nurses Journal, 15 (9), 48-49.
Safranek, M., Koshland, G . , & Raymond, G . (1982). Effect of
auditory rhythm on muscle activity. Physical Therapy, 62,
161-168.
Salmon, D., Thai, L., Butters, N., & Heindel, W. (1990). Lon-
gitudinal evaluation of dementia of the Alzheimer type: A com-
parison of 3 standardized mental status examinations. Neurol-
ogy, 40 (g), 1225-1230.
Sandman, C. (1984). Afferent influences on the cortical evoked
response. In M. Coles, L. Jennings, & J. Stein (Eds.), Psycho-
logical perspectives (Festschrift for Beatrice and John Lacey).
Stroudberg, PA: Hutchinson & Ross.
Steg, R. (1990). Determining the cause of dementia. Nebraska
Medical Journal, 75 (4), 59-63.
Summers, W., DeBoynton, V., Marsh, G., & Majovski, L.
(1990). Comparison of seven psychometric instruments used
for evaluation of treatment effect in Alzheimer's dementia.
Neuroepidemiology, 9 (4), 193-207.
David Aldridge Collected music therapy papers
Swartz, K., Hantz, E., Cmmmer, G., Walton, J., & Frisina, R.
(1989). Does the melody linger on? Music cognition in Alz-
heimer's disease. Seminars in Neurology, 9 (2), 152-158.
Tyson, J. (1989). Meeting the needs of dementia. Nursing Elderly,
1 ( 5 ) , 18-19.
Wagner, M., & Hannon, R. (1981). Hemispheric asymmetries in
faculty and student musicians and nonmusicians during melody
recognition tasks. Brain and Language, 13, 379-388.
Walker, B., & Sandman, C. (1979). Human visual evoked re-
sponses are related to heart rate. Journal of Comparative and
Physiological Psychology, 93, 7 17-729.
Walker. B., & Sandman, C. (1982). Visual evoked potentials
change as heart rate and carotid pressure change. Psychophys-
iology, 19, 520-527.
Walsh, J., Welch, H., & Larson, E. (1990). Survival of outpatients
with Alzheimer-type dementia. Annals of Internal Medicine,
113 (6), 429-434.
Zillmer, E., Fowler, P,, Gutnick, H., & Becker, E. (1990). Com-
parison of two cognitive bedside screening instruments in nurs-
ing home residents: A factor analytic study. Journal of Geron-
tology, 45 (2), 69-74.
73
 International Tinnitus Journal, Vol. 11, No. 2, 163–169 (2005)

Auditive Stimulation Therapy as an Intervention

in Subacute and Chronic Tinnitus:
A Prospective Observational Study
Martin Kusatz,1 Thomas Ostermann,2 and David Aldridge3
1 Tinnitus
Therapy Center, Krefeld and Dusseldorf; 2 Department of Medical Theory and
Complementary Medicine and 2,3 Faculty of Medicine, University of Witten Herdecke, Germany

Abstract: Tinnitus is a noise, a ringing, or a roaring sound in the affected ear and is becoming
an increasingly serious problem for health care systems. Integrative treatment concepts are
currently regarded as promising therapeutic approaches for managing tinnitus. The aim of this
study was to present the results of auditive stimulation therapy, a program of music therapy
developed specifically for tinnitus treatment. We collected data on outpatient treatment results
from 155 tinnitus patients and evaluated them in a prospective observational study with three
defined times of measurement (start, end, and 6 months after the end of treatment). Apart from
anamnestic data and subjective evaluation of treatment, the major outcome parameter was the
score of the tinnitus questionnaire. To evaluate effectiveness of the therapy, we calculated ef-
fect sizes (according to Cohen). Fifty-one percent of the patients were male, and the mean pa-
tient age was 49 years. Of the 155 patients, 137 (88%) were capable of gainful employment,
which means that they fell in the age range between 18 and 65 years. The duration of tinnitus
was more than 6 months for 80% of patients, and 43% had been suffering from tinnitus for
more than 3 years. In general, all subscales of the tinnitus questionnaire showed highly signif-
icant changes (t-test, p  .01) between the measurement points “start of therapy” and “end of
therapy,” whereas no significant difference was found between the measurement points “end
of therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at a
level recorded at the end of the therapy; we did not observe a reduction to the level prior to
treatment. The values for the effect sizes mostly ranged between medium ( 0.5) and high
( 0.8). Closer investigations indicated that a combination of music therapy and psycho-
logical training rendered the best effect sizes. This study demonstrated that music therapy
is an effective integrated treatment approach and offers a way to make progress in tinnitus
treatment.
Key Words: effectiveness; music therapy; outcome research; tinnitus

T
he term tinnitus is derived from the Latin tinnire
(“ringing”) and is defined as the perception of
sound in the absence of any appropriate exter-
nal stimulation. A basic difference separates objective
and subjective tinnitus. The term objective tinnitus is
used for ear sounds based on genuine physical vibra-
tions-oscillations that may be perceived by others or
even measured [1]. This type of tinnitus is rather rare,
whereas subjective tinnitus is far more frequent. In
Reprint requests: Prof. Dr. David Aldridge
such cases, only the person afflicted perceives the
sounds. These may occur as rustling, whistling, whir-
ring, ringing, or droning sounds. High-frequency sounds
are perceived far more often than are low-frequency
sounds [2], and a hearing impairment is detectable in
more than 50% of all cases.
The incidence of patients experiencing tinnitus in
Germany and the Western world is approximately 10%.
Some 1–2% of the population is severely disturbed by
tinnitus, which may disrupt everyday activities and
sleep [3]. If the symptoms continue for 6 months, we
consider the condition to be chronic, the degree of
which differs considerably from person to person and

163
David Aldridge Collected music therapy papers 74
International Tinnitus Journal, Vol. 11, No. 2, 2005
affects patients in different ways [4]. A decompensated
tinnitus is accompanied in most cases by other com-
plaints (e.g., depression, anxiety, impaired sleep and
concentration, sensitivity to noises, and the like) [5–7];
consequently, intervention is required. Several treat-
ments of chronic tinnitus have been proposed and im-
plemented [8]. Among complementary therapies, home-
opathy and acupuncture are proposed [9–11]. Although
several case studies reported efficacy of these treat-
ments, the empirical support in well-controlled studies
is still weak [12,13].
Today, such integrative therapy concepts as cogni-
tive-behavioral treatment compiled from counseling,
relaxation therapy, music therapy, and pharmacological
preparations (lidocaine, neurotransmitters) are regarded
as promising therapeutic approaches for managing tin-
nitus [7]. In particular, music therapy offers the chance
of a global treatment approach for tinnitus patients
[14]. Harmony, for instance, as a connecting link be-
tween rhythm and melody also has a social function.
Rhythm may also influence biological parameters via
tempo accentuation and meter [15]. These components
form the theoretical background for auditive stimula-
tion therapy (AST), the music therapy (MT) program
evaluated in this study.
THERAPY
AST is a complex program of MT originally employed
in the treatment of chronic pain and developed specifi-
cally for tinnitus treatment. It consists of a total of 10
therapy sessions and employs specifically developed
receptive music programs in combination with an edu-
cation program. Musical self-control (MSC) training is
a music program designed on the basis of music psy-
chology and MT, the effectiveness of which was dem-
onstrated in a clinical study [16]. The objective of MSC
training is to improve patients’ control of ear sounds
and to relieve their feelings of helplessness. Ringing in
the ear or strange sounds bring about alterations in per-
ception. If we encourage the ability of selective hear-
ing, we can promote some sounds in the hierarchy of
perception and ignore other sounds or regulate them
until they become hardly perceptible. Such training im-
proves (i.e., lowers) the level of sensitivity to sounds.
Finally, the objective of AST is to bring about a
change in sound perception that induces relaxation, re-
duces anxiety, and stimulates changes in unfavorable
behavior patterns, thus improving the emotional state.
The education program is aimed at alterations on a cog-
nitive level.
The outpatient therapy (duration, 2 weeks) with
AST consisted of a total of 38 hours of therapy (20-hr
psychological training, 10-hr MT [AST], 8-hr kinesi-
164
David Aldridge Collected music therapy papers
Kusatz et al.
Figure 1. Complete 2-week program of auditive stimulation
therapy (AST) as a function of hours of therapy per day. (A 
admission; PT  psychological therapy; MO  motor therapy.)
therapy) and also included counseling by ear, nose, and
throat experts, orthopedists, and dentists. Figure 1 shows
the complete 2-week program of AST with its different
modules.
METHODS
At the Tinnitus Therapie Zentrum Krefeld (Germany),
we performed an observational study on a multimodal
treatment concept (Krefelder-Modell) being applied on
an outpatient basis for subacute and chronic tinnitus
over a projected period of 2 years. Data on treatment
were collected and evaluated in a prospective observa-
tional study using several standardized questionnaires
immediately before and after therapy and at follow-up
after 6 months. Apart from anamnestic data, the ques-
tionnaires asked for a subjective evaluation of treat-
ment results. The tinnitus questionnaire designed by
Goebel and Hiller [17], now the recommended standard
tool throughout Germany, was used at all times for
measurement. Included in the evaluation were only
those questionnaires in which more than 90% of the
questions were answered properly.
We included a total of 155 patients in this evalua-
tion. Sufficient follow-up documentation for assess-
ment was available for 111 patients (71.6%). Figure 2
shows the questionnaire instruments used and the pa-
tient flow in this study.
For an evaluation of the efficiency and sustained
success of the therapy, we applied the t-test to show
significant differences of tinnitus questionnaire scales
after therapy. We carried out subgroup analysis of out-
come measures according to the degree of tinnitus se-
verity. Therefore, the tinnitus questionnaire results were
grouped in the following clinically relevant groups:
minor tinnitus (0–30 points); medium tinnitus (31–46
points); serious tinnitus (47–59 points); and very serious
tinnitus (60–84 points).
As the treatment concept presented in this study
(Krefelder-Modell) is a multimodal concept, the differ-
75
Auditive Stimulation Therapy in Tinnitus
Figure 2. Patients and questionnaire instruments. (AST  auditive stimulation therapy.)
ent elements of treatment can be compared to achieve
more detailed results on the efficiency of the MT train-
ing program (AST). Kinesitherapy having received a
distinctly lower rating by patients, only the two treat-
ment elements rated as most successful were compared
with respect to their effectiveness: psychological train-
ing (PT) and music therapy (MT).
To evaluate effectiveness of the therapy and to ren-
der the results comparable with each other and also
with other treatment facilities in the health care sector,
we calculated effect sizes according to Cohen [18] and
corrected according to McGaw and Glass [19].
PATIENTS
One hundred thirty-seven patients (88.38%) were of
wage-earning age (i.e., between 18 and 65 years). Table
1 shows that the duration of tinnitus was longer than
6 months for 80% of patients. A total of 43.3% had
been suffering from tinnitus for more than 3 years; 33.5%
of those interviewed reported that tinnitus developed
gradually. Every second patient (50.3%) said tinnitus
set in suddenly; 16.1% did not answer this question;
76.8% said tinnitus occurred continuously; and 21.3%
reported that tinnitus occurred with interruption. Three
patients (1.9%) had no comment. Almost all patients
(94.8%) reported times at which tinnitus was particu-
larly intense. In contrast, only 75.5% said that at times
tinnitus was barely perceptible.
Patients were also asked how often they resorted to
seeking assistance through the health care system over
6 months before treatment, and they had the option of
David Aldridge Collected music therapy papers
International Tinnitus Journal, Vol. 11, No. 2, 2005
several possible answers. Seventy-four patients answer-
ing this question (47.74%) reported 111 individual con-
sultations (main consultation with ear, nose, and throat
specialists), which means an average of 1.5 consulta-
tions per patient approximately. Before treatment, pa-
tients were also asked about previous treatment; 137
patients reported a total of 304 instances (i.e., an aver-
age of 2.2 treatments per patient). The major treatments
were infusions (78.8%).
RESULTS
The total score of the tinnitus questionnaire (Tinnitus
Fragebogen [TF]) at the different measurement points
is shown in Figure 2. The follow-up sample with regard
to the TF total score did not differ significantly from
that of the general population, which has been demon-
strated [16]. Therefore, Figure 3 shows the mean scale
values of the tinnitus questionnaire before and after out-
patient tinnitus therapy (n  146) and also at follow-up
after 6 months (n  106).
In general, all subscales showed highly significant
changes (t-test, p  .01) between the measurement
points “start of therapy” and “end of therapy,” whereas
we found no significant difference between the mea-
surement points “end of therapy” and “follow-up.” At
follow-up, the values of the subscales were stabilized at
a level recorded at the end of the therapy; we did not
observe a reduction to the level before treatment. Ap-
proximately 80% of the patients with a disease severity
of medium to very serious at least moved to a clinically
improved stage (e.g., from very serious to serious). The
165
76
International Tinnitus Journal, Vol. 11, No. 2, 2005 Kusatz et al.

Table 1. Sociodemographic and Anamnestic Data

Characteristic Male Female Total

Gender 51% 49% 100%

Age
Mean 48.9 yr 48.7 yr 48.8 yr
Standard deviation 12.1 yr 15.5 yr 13.9 yr
Median 52 yr 50 yr 51.5 yr
Marital status
Single 16% 17% 17%
Married or established partner 74% 64% 69%
Divorced or living separated 10% 9% 10%
Widowed — 9% 5%
Graduation
Secondary school 55% 43% 49%
Secondary modern school 25% 29% 27%
High school, A-levels 7% 18% 13%
University or college 13% 9% 11%
Profession
Laborer 33% 13% 23%
Clerk 40% 48% 44%
Self-employed 4% 3% 3%
Unemployed 24% 37% 30%
Duration of tinnitus
6 mo 20% 20% 20%
6–12 mo 16% 16% 16%
1–3 yr 20% 22% 21%
3–5 yr 14% 10% 12%
5 yr 30% 32% 31%
Loudness, ear-ringing: 0 (not at all) to 10 (maximum)
Mean (95% CI) 6.5 (6.0–7.0) 5.5 (4.9–6.1) 6.1 (5.7–6.5)
Standard deviation 2.2 2.8 2.5
Median 6 5.5 6
Disruption, ear-ringing: 0 (not at all) to 10 (maximum)
Mean (95% CI) 7.0 (6.4–7.6) 6.4 (5.7–7.1) 6.7 (6.3–7.1)
Standard deviation 2.6 3.0 2.8
Median 7 6 7
Restrictions, ear-ringing: 0 (not at all) to 10 (maximum)
Mean (95% CI) 5.8 (5.1–6.5) 4.5 (3.8–5.2) 5.2 (4.7–5.7)
Standard deviation 3.0 3.2 3.2
Median 6 4 5

details of this transition process will, however, be the

Figure 3. Total score on the tinnitus questionnaire (TF) at the
different measurement points, according to degree of disease
severity.
subject of a following evaluation using Marcov-chains
methods.
We determined the values of effect sizes for individ-
ual subscales and for the total score. The values for the
effect sizes were all in the range of medium ( 0.5) to
high ( 0.8), with the exception of the scale somatic
disorders, and are illustrated in Figure 4.
In a comparison of the individual therapies, AST
was responsible for a surprisingly high percentage of
the positive total result and clearly was preferred by pa-
tients, despite the fact that psychological training was
twice as long (20 therapy session hours as compared to
10 for MT). For further analysis of these findings, we

166
David Aldridge Collected music therapy papers 77
Auditive Stimulation Therapy in Tinnitus
Figure 4. Changes (on the tinnitus questionnaire) of scale
values in effect sizes. (E  emotional distress; C  cognitive
distress; I  intrusiveness; A  hearing problems; SI  sleep-
ing problems; SO  somatic complaints.)
calculated effect sizes at measurement times and re-
lated to the patients’ subjective evaluation. Figure 5
illustrates the calculation of effect sizes.
A combination of MT and PT renders the best thera-
peutic effect. MT alone ranked in second place, and PT
was third. The combination of MT-PT comprises the
partial therapies MT and PT, and this suggests that the
share of MT in this result is higher than that of PT. In
addition, MT shows excellent effect sizes over longer
periods, a clear indication of the quality of the concept
of AST as to contents and didactic implementation. The
results appear to confirm in particular the intention of
enabling patients to continue independently with MT
and to make autonomous use of receptive music pro-
grams. The most expressive results in this context cer-
tainly are those of the follow-up, as the data from these
particular patients are available for all measurement
times. In retrospect, they were able to come to a conclu-
sive evaluation for themselves.
In answer to the question of whether the therapy
Figure 5. Changes in effect sizes (total, n  143; follow-up,
n  105) depending on patients’ preferred therapy. (MT 
subgroup of patients favoring music therapeutic elements;
MTPT  subgroup of patients who were indecisive between
music therapy and psychotherapy; PT  subgroup of pa-
tients favoring psychotherapeutic elements.)
David Aldridge Collected music therapy papers
International Tinnitus Journal, Vol. 11, No. 2, 2005
helped them to cope better with ringing in the ear, 40%
of patients described the success as excellent, 29% as
good, and 16.8% as satisfactory. At a follow-up 6 months
after the end of the therapy, the question was whether
any ear ringing was still perceivable; 3.2% of patients
reported none at all; 30.8% had a temporary absence of
ear ringing; some two-thirds of patients continued to
perceive noises during the 6 months after the therapy
ended, but these had noise that had been clearly reduced.
In summary, 52.3% indicated further positive changes
after the therapy was concluded.
CONCLUSION
An analysis of the tinnitus problem, particularly from a
traditional perspective, suggests a general confusion
among most experts, although many scientists have ex-
plored the problem. A great variety of models and treat-
ment approaches are available, the effectiveness of which
is still inconclusive. The standard therapies in Germany
include medication to improve blood circulation or,
with increasing frequency, infusions as part of a hospi-
talization period, with disproportionate side effects as
compared to the severity of the complaints [20].
In this study, we were able to demonstrate that the
multimodal concept achieves highly significant changes.
The calculation of effect size, according to the tinnitus
questionnaire results, illustrates that the most signifi-
cant effect sizes occurred in the area of psychological
stress and total score changes. In comparison with ef-
fect sizes of other studies with hospitalized patients and
outpatients summarized in a meta-analysis by Schilter
[21], the advantages of this treatment concept become
evident. With an overall effect size of 0.63 from pre-
therapy to follow-up, other multimodal therapeutic
strategies range far behind the results of the therapeutic
approach described in this study. Medical treatments
(e.g., tocainide, lidocaine, carbamazepine) or other rem-
edies have effect sizes in the same magnitude; however,
these therapies have side effects, such as tremor, vertigo,
giddiness, and nausea [21]. Therefore, our nonpharma-
cological intervention achieves the high effect sizes of
the drug-based therapies without their concomitant side
effects. The Krefelder-Modell treatment concept alone
uses an MT training program embedded within a com-
plex treatment approach, indicating that the advantage—
compared to other treatment forms—is principally the
influence of the specific MT intervention.
If we assume that tinnitus is not a disease but a
symptom of an underlying process, singular symptom–
oriented approaches will fail [2]. Sixty-one percent of
patients state that professional medical help was not
of much use—a shockingly high figure in view of the
numerous medical interventions. Much suggests a holistic
167
78
International Tinnitus Journal, Vol. 11, No. 2, 2005
treatment approach, in which ringing in the ear is viewed
as a sign of particularly high stress. The question of
whether the symptom is of a somatic or a psychosomatic
nature seems to be of no importance in the treatment
of subacute and chronic tinnitus. An analysis not only of
the biological but of the psychological and social needs
of patients [22] provides a more comprehensive insight
into and understanding of their situation. MT AST is
seen as salient to their problems among patients and as
highly effective, perhaps because we are not making a
direct, singular psychological intervention but an inter-
vention in the same modality as that in which the symp-
tom is experienced. By accommodating sound control
within an ecology of other sounds, itself within a stress-
reduction context, we are offering a form of self-control
that is adapted to a personal environment [23–25]. On
this extended basis of our knowledge about hearing, we
should be able to develop for affected patients coping
strategies that address the causes of the problem directly
and thus render the symptom superfluous.
Our follow-up interview of patients after 6 months
showed a high degree of sustained therapeutic success.
Furthermore, these interviews provide important feed-
back for therapists and show longer-term positive treat-
ment results, specifically in the areas of well-being and
reintegration of patients in their family environment, as
amply demonstrated in our study. We hear frequently
that therapy success in most cases becomes evident
over time. If a reorientation in terms of perception takes
place, the consequences of this reorientation, as thera-
peutic effects, are best seen in follow-up assessments.
The subjective symptom of tinnitus is a phenome-
non that the unaffected cannot easily understand, as de-
fining a cause is difficult in most cases. Hearing of
sounds that are normally located externally is suddenly
directed internally and, therefore, is difficult for others
to imagine. The affected individual suffers from a per-
sonal noise problem that is inaudible to others; conse-
quently, others lack understanding. Musicians, how-
ever, understand this concept as part of their daily
practice [26]. “Only inner anticipatory hearing makes
musical interpretation possible. This phenomenon is
most obvious in Ludwig van Beethoven who composed
without being able to hear. Accordingly, listening must
also be seen as an internal process of perception” [14].
Neugebauer reminded us that a sensory stimulation
must not necessarily result in a conscious perception,
nor must a sensory experience necessarily be caused by
a physical stimulus. The specific way in which music
therapists or musicians hear may indeed be helpful or
suitable in understanding tinnitus patients and also in
explaining—taking a composer as an example—how
such experiences of internal hearing may also be ob-
served in different settings in which they are absolutely
168
David Aldridge Collected music therapy papers
Kusatz et al.
normal and by no means pathological. Aldridge [25]
suggested that the purpose of MT is that patients are en-
abled to generate expressive potentials that reveal new
possibilities for becoming healthy. In the context of ear
ringing, MT might help to create a context of meanings
that integrates the sounds or noises into the music and
thus removes them from conscious perception, which
would clearly promote recovery. Sounds no longer per-
ceived as disturbing, once brought under control, are
perceived as musical.
This study demonstrates that MT is an effective
treatment approach and offers a way to make progress
in tinnitus treatment. Music has an esthetic aspect; it is
part of our cultural heritage. How we integrate sounds
into our daily life and how they become perceived as
noise or music is a complex activity involving the phys-
iological, the psychological, and the social. A therapeu-
tic intervention that incorporates these understandings
appears to offer considerable benefits, not as a cure but
as a healthy adaptation.
REFERENCES
1. Feldmann H. Pathophysiologie des Tinnitus. In H Feld-
mann (ed), Tinnitus. Stuttgart: Thieme, 1992:33–70.
2. Pilgramm M, Rychlik R, Lebisch H, et al. Tinnitus in der
Bundesrepublik. HNO Aktuell 7:261–265, 1999.
3. Rosanowski F, Hoppe U, Kollner V, et al. Interdiscipli-
nary management of chronic tinnitus: II. Versicherungs-
medizin 53(2):60–66, 2001.
4. Wilhelm T, Ruh S, Bock K, Lenarz T. Standardisierung
und Qualitätssicherung am Beispiel Tinnitus. Laryn-
gorhinootologie 74:300–306, 1995.
5. Duckro PN, Pollard CA, Bray HD, Scheiter L. Compre-
hensive behavioural management of complex tinnitus: A
case Illustration. Biofeedback Self-Reg 9(4):459–469, 1984.
6. Goebel G, Keeser W, Fichter M, Rief W. Neue Aspekte
des komplexen chronischen Tinnitus: II. Die verlorene
Stille: Auswirkungen und psychotherapeutische Möglich-
keiten beim komplexen chronischen Tinnitus. Psychother
Psychosom Med Psychol 41:123–133, 1991.
7. Goebel G. Studien zur Wirksamkeit psychologischer
Therapien beim chronischen Tinnitus. In G Goebel (ed),
Ohrgeräusche–psychosomatische Aspekte des komplexen
chronischen Tinnitus. München: Quintessenz, 1992:87–102.
8. Kröner-Herwig B. Psychologische Behandlung des chro-
nischen Tinnitus. Weinheim: Psychologie Verlags Union,
1997.
9. Park J, White AR, Ernst E. Efficacy of acupuncture as a
treatment for tinnitus: A systematic review. Arch Oto-
laryngol Head Neck Surg 126(4):489–492, 2000.
10. Simpson JJ, Donaldson I, Davies WE. Use of homeopathy
in the treatment of tinnitus. Br J Audiol 32(4):227–233,
1998.
11. Weihmayr T. Managing tinnitus with natural healing. When
79
Auditive Stimulation Therapy in Tinnitus
it whistles and rings in the ear. Natural Healing Series: 18.
Tinnitus. Fortschr Med 116(10):48–49, 1998.
12. Biesinger E. Die Behandlung von Ohrgeräuschen. Stutt-
gart: Georg Thieme Verlag, 1999.
13. Ernst E. Complementary and alternative medicine in the
practice of otolaryngology. Curr Opin Otolaryngol Head
Neck Surg 8(3):211–216, 2000.
14. Neugebauer L. Schöpferische Musiktherapie bei Patienten
mit chronischem Tinnitus. In D Aldridge (ed), Kairos III:
Beiträge zur Musiktherapie in der Medizin. Göttingen:
Hans Huber Verlag, 1999:42–50.
15. Mosonyi D. Psychologie der Musik. Darmstadt: Tonos-
Edition, 1975.
16. Kusatz M. Auditive Stimulation Therapy AST—Intervention
in Subacute and Chronic Tinnitus. Hanover: Proceedings of
the Fifth Triennial Conference of the ESCOM, 2003:45–49.
17. Goebel G, Hiller W. Qualitatsmanagement in der Thera-
pie des chronischen Tinnitus. Otorhinolaryngologia-
Nova 10(6):260–268, 2000.
18. Cohen J. Statistical Power Analysis for the Behavioral
Sciences. Hillsdale, NJ: Erlbaum, 1988.
David Aldridge Collected music therapy papers
International Tinnitus Journal, Vol. 11, No. 2, 2005
19. McGaw B, Glass GV. Choice of metric for effect size in
meta analysis. Am Educ Res J 17:325–337, 1980.
20. Bork K. Juchreiz nach Hydroxiethystärke: Auch bei
Intensivepatienten häufig. Arznei-telegramm. 31(6):53,
2000.
21. Schilter B. Metaanalyse zur Effektivität medikamentöser
und psychologischer Therapien bei chronischem subjek-
tivem Tinnitus. Frankfurt: VAS-Verlag, 2000.
22. Aldridge D. Leben als Jazz. In D Aldridge (ed), Kairos II,
Beiträge zur Musiktherapie. Göttingen: Verlag Hans Hu-
ber 1998:5–6.
23. Aldridge D, Gustdorff D, Neugebauer L. A preliminary
study of creative music therapy in the treatment of chil-
dren with developmental delay. Complementary Ther
Med 3:197–205, 1995.
24. Aldridge D. Music Therapy Research and Practice in
Medicine. London: Jessica Kingsley, 1996.
25. Aldridge D. Musiktherapie in der Medizin. Göttingen:
Verlag Hans Huber, 1999.
26. Neugebauer L. Das Pfeifen nervt nicht mehr so. Musik-
therapeutische Umschau 4:326–335, 2001.
169
80
The Arts in Psychotherapy, Vol. 18, pp. 113-121. 0 Pergamon Press plc, 1991. Printed in the U.S.A.
MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE
DAVID ALDRIDGE. PhD and GUDRUN BRANDT, Dipl. MT*
This paper presents two comparative views of
inflammatory bowel disease. One is from the general
medical literature; the other is that of a music therapist
who has played extensively with patients who have
the disease. The music therapist was unaware of the
medical descriptions of the disease when she made
her descriptions of the musical improvised playing of
such patients. It is apparent from both sets of descrip-
tions that they have elements in common such that a
dialogue can occur between medical practitioners and
arts therapists. Some implications for the treatment of
patients with inflammatory bowel disease are also
discussed.
Inflammatory Bowel Disease
Inflammatory bowel disease is a term that refers to
a collection of diseases affecting the bowel. These
diseases are characterized by the presence of chronic
inflammation of the gastrointestinal tract that cannot
be ascribed to any specific cause. The most common
of these maladies are ulcerative colitis and Crohn's
disease. Both have a common insidious onset result-
ing in chronic symptoms that may include severe
episodic diarrhea, colicky abdominal pain, weight
loss, nausea and vomiting, and pus, blood or mucus
in the stool.
Although there are common symptoms in inflam-
matory bowel disease, Crohn's is distinguished from
others because it generally affects the terminal ileum
and the right colon, sometimes the whole bowel
(Calkins & Mendeloff, 1986), but rarely the entire
digestive tract although it can affect any part of the
alimentary canal (Strober & James, 1986). Ulcerative
*David Aldridge is a research consultant to the medical faculty of Universitat Witten Herdecke, West Germany. Gudrun Brandt is a music
therapist.
David Aldridge Collected music therapy papers
0197-4556191 $3.00 + .00
colitis always affects the rectum and sometimes the
entire colon.
These are not generally highly fatal diseases, but
they are important for public health concerns in that
their incidence is early in life, therapy often involves
surgery, there is a risk of developing intestinal cancer
in later life, and there are enormous social costs
involved in chronic illness (Sanderson, 1986). These
ailments cause great personal embarrassment and
discomfort for the patient, often resulting in a re-
stricted lifestyle and a miserable existence (Robert-
son, Ray, Diamond & Edwards, 1989). Any therapeutic
endeavors must attend to enhancing the life quality of
the patient.
Epidemiological Factors
The etiology and pathogenesis of both ulcerative
colitis and Crohn's have not yet been clarified.
Diagnosis is difficult. A significant time may elapse
between the onset of first symptoms and a definite
diagnosis. As the diseases share similar symptoms,
diagnosis is problematic (Bruce, 1986; Shivananda et
al., 1987). The incidence of ulcerative colitis appears
to be more frequent in modem Western society and is
increasing (Calkins & Mendeloff, 1986).
The primary age ranges for the incidence of
inflammatory bowel in both sexes are between 15 to
25 years and between 55 to 60 years (Calkins &
Mendeloff, 1986; Shivananda et al., 1987). Children
under six years of age appear to be resistant to the
development of Crohn's; between the ages of 6 to 10
years ulcerative colitis, but not Crohn's, occurs with
increasing frequency.
81
1 14 ALDRIDGE AND BRANDT
There is an increased frequency of inflammatory
bowel in families of patients who suffer from it, with
a mixture of both Crohn's and ulcerative colitis. This
has suggested that there may be a genetic basis for the
disease (Sanderson, 1986; Strober & James, 1986)
although this genetic base remains as yet undiscov-
ered. Such diseases may be inherited as behaviors that
are learned in family contexts and passed on from
generation to generation.
Diet
Because of the nature of the malady, dietary intake
has been considered one of the most important envi-
ronmental exposure factors of the digestive system.
Among patients with Crohn's, one possible causative
factor is increased sugar consumption. Dietary fiber,
increased milk products, carbohydrate, protein, and
total calorie consumption have also been implicated
(Persson & Hellers, 1987).
The studies have proved to be problematic because
dietary exposure may have occurred many years prior
to the diagnosis, or the prolonged onset of the disease
may lead to the alteration of dietary practice. For
example, patients may increase their consumption of
refined sugar in an attempt to compensate for loss of
energy or loss of weight as a consequence of the
disease.
Liquid elemental diets developed for the space
programs in the United States have been used for the
treatment of Crohn's. Although the efficacy of such
a diet is not known (Sanderson, 1986), the results are
shown to be as helpful as high dose steroids for the
remission of small bowel Crohn's in children. Chil-
dren treated in this way experience an acceleration of
growth.
The use of nutritional supplements may have a
small role to play in helping extremely sick children
to obtain some calories, but this approach is seen as
beneficial only in the short term (Clark, 1986).
Patient enthusiasm for the diet wanes in the long term
because it is unpalatable. Bruce (1986) also com-
mented that an elemental diet worsens the difficulties
of young people with the disease by placing them in
a regressed position that allows the mother to exercise
absolute control as she did when they were infants.
What is lacking in dietary studies is a perspective
that it is not necessarilv the content of the food that is
important but the way it is eaten, the situation in
which it is eaten, and the conditions in which it is
David Aldridge Collected music therapy papers
digested. The preparation of food, the way it is eaten,
and the way that waste products are disposed of are
also closely patterned by culture. The offer of food
and its acceptance are also of great symbolic value
(Helman, 1985; Kleinman, 1978).
Zmmunological Factors
As it has been difficult to establish an infectious
cause for inflammatory bowel disease. some research-
ers have sought an immunological basis (Kett, Rog-
num & Brandzaeg, 1987; Strober & James, 1986;
Trabucchi, Mukenge, Barrati, Colombo & Fregoni,
1986; Van Spreuuwel, Lindeman & Meijer, 1986).
Crohn's disease begins as the product of an underly-
ing inflammatory process. The presence of increased
numbers of macrophages and mast cells appears to be
an important feature. The specific physiologic func-
tion of mast cells remains unknown, but they are
known to contain inflammatory mediators, such as
histamine, and may play a role in allergic reactions.
Although a pathogen has not been found, somehow
natients become sensitive to the constituents of their
own gut flora, which has widespread negative effects
on the entire immune system. Patients react nega-
tively to their own body, a rejection of a part of their
very own self.
Modem researchers have taken the old idea that
emotions influence the health status of people and
have developed the sciences of psychoneuroimmunol-
ogy - the study of the effects of psychological
factors on the immune system (Baker, 1987; Blalock
& Smith, 1985), and of neuroimmodulation - the
study of the mechanisms whereby the nervous system
modulates the activity of the immune system (Baker,
1987; Stein, Keller & Schleifer, 1985; Trabucchi et
al.. 1986). Emotions influence health status as distur-
bances to the immune system by specific interactions
between the nervous system, immune and endocrine
systems. This suble combination of physiological
mechanisms is designed to recognize and deal with
nonself or altered material. What is self and nonself
are crucial decisions isomorphic with the physiology
and psychology of the persons and the family with
whom they dwell.
Chronic stress has also been shown to alter the
immune system (Baker, 1987; Patterson, 1988; Stein
et al., 1985) and thereby recovery. Immunological
descriptions of inflammatory bowel disease also sug-
gest a similar process, a transient infection provoking
82
 MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE
an immune response that is exacerbated by psycho-
logical factors. Strikingly, patients with bowel dis-
ease often attribute the onset of their disease to a
stressful event (Robertson et al., 1989). This is
literally a gut reaction to a significant life event.
Psychological Factors
There is a long history u i associating somatic
symptoms and emotional disturbance. If inflamma-
tory bowel disease is, as some researchers believe, a
motility disorder of the gut, then that motility is
sensitive to the emotional state of the person. Highly
anxious patients may produce symptoms at times of
emotional distress (Lask, 1986).
Although psychiatric illness and psychopathology
are not more prevalent in patients with inflammatory
bowel disease (Clouse & Alpers, 1986), there does
appear to be some evidence of depression in patients
with Crohn's (Tarter, Switala, Carra & Edwards,
1987) but this appears to occur only in those with
persistent disease activity (Robertson et al., 1989).
High levels of neuroticism (a score of more than 12 on
the Eysenck Personality Inventory) are associated
with these patients and they become more introverted
as the disease progresses (Robertson et al., 1989).
The search for causative psychological factors has
been in vain principally because of the insidious onset
of the disease. Although most researchers accept that
psychological difficulties are sequelae of the disease
and that stress and emotional difficulties exacerbate
it, no factors appear to be causative. Traditionally,
ulcerative colitis has been regarded as a psychoso-
matic illness. Psychoanalysis has taken the view that
such illness has its origins in the mental mechanisms
used to cope with the emotions. From this perspec-
tive, the disease represents a reaction to a real or
threatened loss of the mother, or someone else on
whom the patient is dependent. Ulcerative colitis
patients are seen as rigid, controlling, and dependent.
Recent psychoanalytic approaches have observed that
inflammatory bowel disease patients have a tendency
to somatize their problems, and that they have diffi-
culty in expressing emotions verbally (Bruce, 1986;
Stanwyck & Arnson, 1986). This state is termed
"alexithymia." To spare themselves emotional pain,
these patients project those problems into bodily
functioning. Hence, the situation in which some
patients with bowel disease appear to be coping well
with difficult life situations.
David Aldridge Collected music therapy papers
115
There appears to be a clearer link in children
between abdominal pain and emotional upset (Bruce,
1986). Abdominal pain is common in children, and
the gut appears to mirror the emotions better than any
other body system. Furthermore, clinicians working
with children with bowel disease remark that abdom-
inal pain appears to be a common occurrence in the
repertoire of distress management in the families of
those children (Bruce, 1986; Lask, 1986). There
appears to be a vicious circle where the physical
symptoms of the disease lead to stress and behavioral
problems. These problems then provoke physical
symptoms and aggravate pre-existing organic pathol-
ogy. The children and the family are affected. If the
family cannot cope, and there is a family repertoire of
distress management by an escalation of physical
symptoms, then the symptoms of the children are
exacerbated further.
Lifestyle Factors and the Patient's View
Patients with inflammatory bowel disease have
been described in the literature in a negative and
limited way. They are seen as dependent, restricted in
their relationships, sexually and emotionally inade-
quate, depressed, isolated, demanding, angry, and
lacking in self-confidence (Joachim & Milne, 1987).
A lack of self-confidence is hardly surprising given
that there is such a negative perception of their
patients by practitioners, combined with the difficul-
ties of the disease itself. A number of researchers
have attempted to present patients' views of the
problem. As both a nurse and a sufferer, Neufeldt
(1987) wrote that the most difficult part of the disease
is its unpredictability, and that the symptoms them-
selves frequently cause depression. The bouts of
nausea, vomiting, and diarrhea lead to loss of sleep,
listlessness, and nutritional deficiencies. This combi-
nation of embarrassing symptoms, and the random-
ness of onset of those symptoms, is socially disruptive
for the working life and home life of the patient.
Joachim and Milne (1987) investigated the impact
of inflammatory bowel disease on the lifestyle of
patients. These patients said that, overall, their dis-
ease greatly decreased their satisfaction with life. Yet,
paradoxically, they reported minimal influence on a
day to day basis. This appears to represent the
observation frequently made by clinicians that these
patients appear unwilling to complain about specific
problems, or they deny that problems exist in the face
83
 ALDRIDGE AND BRANDT
of evident personal and relational turmoil.
In an attempt to understand the relationships be-
tween biological, psychological, and social phenom-
ena, Helman (1985) examined the self-perceptions
and explanatory models of patients with ulcerative
colitis. He found that most patients had a multi-causal
holistic model of their disorder. Tension, anger,
frustration, stress and uncertainty were seen as attack-
ing the body and were separate from the self. Simi-
larly, when their own personalities were seen as
contributory to the chronicity of their condition, that
personality was seen as separate from the self. These
causal attributes, he argued, are learned from various
medical encounters and are part of the culture. This
notion of nonself was also applied to organs of the
body. Weakness in an organ could be hereditary,
constitutional, or acquired. Somehow the weak organ
was separate from the self, but responsive to interac-
tions with other people. The disease or organ then
becomes a public interface between the self and the
environment and is responsive to outside forces sep-
arate from the inside self.
In Helman's view (1985), the image a person has
of the disease is a natural symbol whereby the
physiological process of the disease is understood:
. . . the symbol organizes both social and emotion-
al experiences, and helps define certain emotions,
thoughts, personality traits, and parts of the body as
either 'self or 'non-self'. Defining some of these as
'non-self' can bring the patient's self image closer to
the normative order of contemporary life - to social
values of independence, fitness, youthfulness, con-
tentment and social success and control the bodily
functions and emotions. (p. 15)
Not only does this image that persons have affect
their physiological state, this image may also affect
the way that they perceive, and are perceived by,
members of their family (Aldridge, 1990~).
Family Perspective
A family systems perspective of bowel disorder
emphasizes that the functions of the gut, the patient,
the family, and the treatment system evolve together
(Bloch, 1987; Stierlin, 1989). In this view, the
process of chronic illness begins by a random dis-
equilibrating event. This could be a transient infection
or a stressful life situation. Pain ensues. This event
occurs in the context of a relationship. The patient has
David Aldridge Collected music therapy papers
a family, and the event is given meaning by the
patient and the family. We know that some viruses do
not kill the host cell, but transform it so that it has an
altered function, particularly in terms of immunocom-
petence (Bloch, 1987).
A similar situation occurs in the family context
where a disease event is handled in a particular way
(Aldridge, 1990~).Experiences surrounding gut pain
are organized around a set of beliefs about what the
cause of the pain is, what it means, and how it is to be
handled (i .e., a repertoire of distress management).
Not only do the patient and the family of the patient
share similar meanings about an illness, and what
counts as disease, they also share a similar immune
context. In this way, a random event such as an
infection may find that its host is not only the patient
but the immunocompetence and beliefs of the family
milieu.
Approaches to Treatment
It appears that inflammatory bowel disease is best
approached from an holistic perspective that inte-
grates different understandings. Although surgical
interventions will still be necessary, it is important to
remember that the sequelae of surgery are not only
physical. Surgery can be traumatic, leaving the pa-
tient with a sense of anger, resentment, feeling both
anxious and depressed, and having to adapt to a new
lifestyle. These psychological and social consequences
may best be handled by a team approach that includes
people who comprehend the day to day living situa-
tion of patients within their relational setting.
Lask (1986) and Bruce (1986), in their work with
children, approach their treatment from such a family
systems perspective and recommend the use of a
physician, surgeon, psychologist, social worker, nurse,
and stoma therapist. Stress management techniques
can be used to reduce anxiety and communication
skills, whereas psychotherapeutic activities can be
used to control excessive worry (Freyberger, Kiins-
beck, Lempa, Wellman & Avenarius, 1985; Milne et
al., 1986; Svedlund, Sjodin, Ottosson, & Dotevall,
1983).
A feature common to many reports about the
treatment of inflammatory bowel disease is that it is
intractable to therapeutic endeavors. Furthermore, the
patients themselves are described quite negatively,
which may be in part because of their inability to
communicate in verbal terms about their emotional
84
 MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE
distress. What is often ignored is that the communi-
cation medium for these patients is essentially non-
verbal. Symptoms are the forms of communication
that symbolize the distress of these patients. For
practitioners dependent primarily on forms of com-
munication that are predominantly verbal there is a
disparity between modes of communication.
Implications for Music Therapy
There are no psychological factors that are neces-
sary or sufficient to cause intestinal disease in suscep-
tible individuals. However, it is clear that there are
certain psychological or social factors that can either
influence the course of the disease or provide a
context for the disease to develop. The presence of
beliefs about self and nonself appear to befundamen-
tal in these patients, linking immunocompetence,
individual psychology, and familial status.
Although psychological factors may not be causal,
they are important for recovery. Therapeutic endeav-
ors may be better directed to actively stimulating the
immunocompetence of the patient. If the mind does
influence the immune system, there is a battery of
therapeutic interventions available. As the main mode
of communication about distress for patients with the
bowel disorder is nonverbal, then nonverbal therapies
appear to be an esstential part of a coordinated
therapeutic approach.
Music therapy stimulates positive emotions, en-
hances coping responses, is isomorphic with the form
of physiological systems (Aldridge, 1989, 1990b, in
press b) and appears to be an ideal therapeutic
medium. The motility of the gut is rhythmic and it
seems reasonable that music therapy could restore, or
promote, rhythmic flexibility. Similarly, the pro-
cesses of the immune system too are rhythmic in their
ultradian cycle. Music may provide the substrate for
entraining various physiological sub-systems. Essen-
tially music can "tune" the communicational context
that unites the central and peripheral nervous systems
and the immune system.
It has been shown that positive experiences, such
as laughter when incorporated into a coping style,
have a beneficial influence on the immune system
(Dillon & Baker, 1985). If this is true of laughter, we
may expect that the greater range of positive experi-
ences available in creatively playing music, if incor-
porated as a coping style, will have a healing effect
via the immune system. Note that the word "incor-
David Aldridge Collected music therapy papers
porated" literally means taken into the body. It may
also be necessary for clinicians from other disciplines
to communicate with their patients nonverbally if
symptomatology is the currency of communication
(Aldridge, 1990b).
Finally, we must attend to the symbolic aspects of
the disease for these patients so that they are no longer
separated from the self that feeds them. In this sense,
the playing of improvised music gives the disease
itself an objective appearance as a played reality.
Patients are then offered a chance to change in the
W
concrete sensual realm of their own existence.
The Musical Playing of Patients With Bowel
Disease
Our task has been to build bridges between the
W
work of medical practitioners and creative arts thera-
pists (Aldridge, in press a, 1990a; Aldridge, Brandt
& Wohler, 1990). One way to promote a dialogue
between practitioners is to compare differing realms
of description. In the following sections we compare
the features of the improvised musical playing of
patients with the features we find in the medical
literature.
Fourteen adult patients with ulcerative colitis, and
12 adult patients with Crohn's disease were seen over
a period of two years. The average number of weekly
sessions was seven per patient and each therapeutic
contact lasted for half an hour. It must be ernohasized
that this research is descriptive and in the first stages
of exploration. The significant factor is not the
number of patients but the characteristics of playing
of those (i.e., playing with more patients
would have yielded no more characteristics) and how
those characteristics compare with descriptions from
another discioline - medicine. All the sessions are
recorded on audiotape and later indexed.
The method of therapy used is one of creative
musical improvisation initiated by Nordoff and Rob-
bins (1977) but adapted later at the University of
Witten Herdecke for working adult patients. The
music therapist plays the piano improvising with the
patient, who uses a range of instruments. This work
often begins with an exploratory session using rhyth-
mic instruments, in particular the drum and cymbal,
progressing to the use of rhythmiclmelodic instru-
ments such as the chime bars, glockenspiel, or
xylophone, developing into work with melodic instru-
ments (including the piano), and the voice. In this
85
118 ALDRIDGE AND BRANDT
way of working, the emphasis is on musical impro-
visation and music as the vehicle for the therapy.
Ulcerative Colitis
A prominent feature of the way these patients play
is that they appear to have no personal connection
with what they are playing. They appear to play with
a distance from what they are playing. This distance
is evident in their posture. When they are strong
enough to stand, their posture is often such that both
feet are not firmly on the ground (i.e., their legs are
crossed). The drumsticks are held loosely in the hands
with the inner wrist uppermost, and they play from
the wrists without involving the whole body. This
seemingly uncommitted posture makes it difficult to
play a clear beat on the drum. When the drum is
beaten, the beats are loose. The patient allows the
beater to fall and rebound rather than make a directed
intended beating movement. A characteristic of the
drum playing is that these patients play with alternate
hands (right, left, right, left) and they seem to have
difficulty in coordinated playing using both hands
together.
Rhythmic playing. This lack of coordination is
reflected in patients' rhythmic playing, which has a
limited range and often occurs as typical rhythmic
patterns:
J JJ J JJ J J7 J JY J l2 continuously; or
J n J J J n J J J ~7 J continuously
This rhythmic playing does not follow the natural
accenting, but is syncopated. Often the playing is on
the upbeat before the bar starts, and begins with a
small drum roll giving the music a military air. The
playing itself goes on and on without any rhythmic
phrasing. This lack of flexibility is reflected in the
tempo of the musical playing where the patients
constantly attempt to return to a fast tempo.
Harmony. Generally, there is an intolerance by the
patient for strong harmonies in the piano playing of
the therapist and contact becomes lost, particularly
when diminished minor, fifth, or augmented chords
are played. This intolerance is indicative of an emo-
tional distance between the patients and the music
particularly when there is an increase in musical
tension. For example, they stop playing before a
musical climax is achieved.
Melody. In the construction of melodies, these
David Aldridge Collected music therapy papers
patients are flexible and full of imagination. How-
ever, this has a mechanical quality as if the playing
were an intellectual exercise and never really gripped
the patient internally. Although able to construct and
copy melodies, there is an inability to sustain a
melody. This gives the impression that the same
music could go on and on repetitively without any
direction to it, and without the patients taking any
initiatives, as if they were passive participants in an
unrelenting process. This also appears to be a suitable
description for the process of chronic disease.
Crohn's Disease
These patients appear very stiff in their upper body
movements. They too have difficulties in coordina-
tion and mostly alternate between left and right
handed playing on the drum.
Rhythmic playing. Because of the coordination
difficulties, these patients' playing often sounds like a
gallop. Similarly the rhythmic structure is disordered
and gives the impression of going on and on without
end. As with ulcerative colitis patients, there seems to
be no means of initiating an end to this repetitive
music and consequently they appear to avoid coming
into contact with the music. This is also reflected in
their inability to respond to tempo changes, giving the
musical playing a quality of immovability.
Harmony. When using specific harmonies, notably
the sixth and diminished chords, their response is one
of vulnerability. Sometimes they cry; sometimes they
stop playing altogether, walking away from the in-
struments, or they continue to play indifferently and
mechanically with even less contact to the music.
Melody. The melodic playing on the xylophone or
glockenspiel is rhythmically quick, unsustained, and
has no internal logic. The intervals between tones are
chaotic (i.e., wide then narrow). This melodic play-
ing, similar to that of the colitis patients, is generally
quiet. There is an overall feeling of emotional dis-
tance in their playing and they give the impression
that they are totally at the mercy of the situation.
Overall, Crohn's and ulcerative colitis patients
have a similar lack of dynamic to their playing, which
is limited and rigid - a feature that is reflected in the
activity of their gut.
Process of Therapy
Generally, these diseased patients require many
sessions before any improvement is apparent. The
86
 MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE
Table 1
Comparative elements of two therapeutic epistemologies
descriptive elements from
the medical literature
0 separation of self and nonself
lack of gut motility
increasingly introverted
restricted in their relationships
rigid
difficulty expressing feelings
 appear to be coping well with life in the face of internal
turmoil
0 dependent
intractable to change
coordination problems finally disappear and there is
more stability and control of the hands. The rhythmic
playing becomes more definitive and there is an
apparent form to the phrasing and tempo. Overall,
there is less rigidity in the playing and the patients
appear to sense the bigger musical form in which they
are playing. However, what remains is the impression
that they never really come to grips with the music
and that they still play with an empty passivity as if
they were not tuned to their own bodies. Finally, the
musical give and take in the therapeutic relationship is
difficult and they appear isolated from their musical
partner, the therapist.
Conclusion
There are correlations between findings in the
literature that describe patients with inflammatory
bowel disease and their musical playing (see Table 1).
Although the patients say that they have fun playing,
there remains an underlying intractable emotional
distance within the playing and within the therapeutic
relationship. Any therapeutic endeavors with these
patients must take into account their personal and
relational difficulties, which suggests that an early
psychotherapeutic contact be made in the process of
treatment. This reinforces the idea of a team approach
to chronic problems and emphasizes the value of the
art therapies both for providing relief and for their
David Aldridge Collected music therapy papers
elements of the musical playing
not tuned to themselves, uncoordinated
lack of rhythmic flexibility, unresponsive to tempo changes
and lack of rhythmical phrasing
 quiet playing with no personal contact within the playing
difficult to contact in the musical relationship
repetitive playing returning to the same tempo and
rhythmic pattern, unresponsive to tempo changes
intolerant of particular harmonies
appear to be going along with the music but an underlying
chaotic structure
no initiatives within the music and dependent on the
therapist
0 difficult to treat requiring many sessions
impact on life quality in the face of a disease
intractable to modem medicine.
Furthermore, the apparent correlation between de-
scriptive elements found in the literature and in the
work of the music therapist, initially blind to the
content of the medical literature, suggests that a
common language between practitioners is not such a
fanciful idea. A common language is achievable in
reality if confined initially to simple observations at
the level of description or usage (Aldridge et al.,
1990). Although the two perspectives share common
descriptions, the creative arts have the possibility not
only for the description of pathology but to play with
what is seen as a limitation, and use it as a possibility
for change.
Recommendations for Further Research
Apart from securing a basis for clinical discussion,
these descriptions are the basis for futher research.
They provide the concepts from which hypotheses can
be generated (Aldridge, 1988, 1990a). It should be
possible for music therapists from other institutions
and backgrounds to play with patients suffering from
inflammatory bowel disease and discern similar char-
acteristics of playing. Similar findings, or the rejec-
tion of what we have found, will be a significant
move in establishing a clincal validity for music
therapy concepts.
87
120 ALDRIDGE AND BRANDT
Eisler, Szmulker and Dare (1985) found that clin-
ical descriptions were not subjective and could be
used by family therapists of differing schools to
discriminate between differing family styles of behav-
ior recorded on videotape. It should be within the
compass of music therapists from other schools to
discern whether or not there are similar characteristics
in the playing of these patients recorded on audiotape.
It may also be possible for other creative arts thera-
pists to find comparative elements that show similar-
ity with these descriptions.
The playing characteristics of this group of patients
need to be compared with the playing characteristics
of another group of patients with a differing chronic
problem (i.e., chronic heart disease, chronic depres-
sion, osteoarthritis) to determine the characteristics
common to chronicity as distinct from those of the
particular diseases. In addition, this work would be
strengthened by establishing the musical playing char-
acteristics of a group of healthy adults.
It seems a given that psychological factors influ-
ence the immune system. We can hypothesize that the
creative arts therapies also increase the immunocom-
petence of our patients. Further cooperative research
between clinicians and practicing therapists that dem-
onstrate this link will enhance the status of the
creative arts therapies and provide the physical evi-
dence to support our therapeutic intuitions. The time
has come when music therapists and other creative
arts therapists must work together for mutual benefit.
This work will enhance the service they offer their
patients.
References
Aldridge, D. (1988). The single case in clinical research. In S.
Hoskyns (Ed.), Proceedings of the Fourth Music Therapy
Research Conference (pp. 3-10). London: City University.
Aldridge, D. (1989). A phenomenological comparison of the
organization of music and the self. The Arts in Psychotherapy,
16(2), 91-97.
Aldridge, D. (1990a). The development of a research strategy for
music therapists in a hospital setting. The Arts in Psychother-
apy, 17(3), 231-237.
Aldridge, D. (1990b). Music, communication and medicine. Jour-
nal of the Royal Society of Medicine, 82, 743-746.
Aldridge, D. (1990~).Making and taking health care decisions.
Journal of the Royal Society of Medicine, 83, 720-723.
Aldridge, D. (in press, a). Aesthetics and the individual in the
practice of medical research: A discussion paper. Journal of the
Royal Society of Medicine.
Aldridge, D. (in press, b). Physiological change, communication
and the playing of improvised music: Some proposals for
research. The Arts in Psychotherapy.
Aldridge, D., Brandt, G., & Wohler, D. (1990). Toward a
David Aldridge Collected music therapy papers
common language among the creative art therapies. The Arts in
Psychotherapy, 17(3), 189-195.
Baker, G.H. (1987). Invited reivew: Psychological factors and
immunity. Journal of Psychosomatic Research, 31, 1-10.
Blalock, J.E., & Smith, E.M. (1985). The immune system: Our
mobile brain? Immunology Today, 6, 115-1 17.
Bloch, D. (1987). Family 'disease' treatment systems: A co-
evolutionary model. Family Systems Medicine, 5, 277-292.
Bruce, T. (1986). Emotional sequelae of chronic inflammatory
bowel disease in children and adolescents. Clinical Gastro-
enterology, 15, 89-104.
Calkins, B.M., & Mendeloff, A.I. (1986). Epidemiology of
inflammatory bowel disease. Epidemiological Reviews, 8, 60-
91.
Clark, M.L. (1986). The role of nutrition in inflammatory bowel
disease: An overview. Gut, 72 (Sl), 72-75.
Clouse, R.E., & Alpers, D.H. (1986). The relationship of psychi-
atric disorder to gastrointestinal illness. Annual Review of
Medicine, 37, 283-295.
Dillon, K.M., & Baker, K.H. (1985). Positive emotional states and
enhancement of the immune system. International Journal of
Psychiatry, 15, 13-17.
Eisler, I., Szmulker, G., & Dare, C. (1985). Systematic observa-
tion and clinical insight - Are they compatible?An experiment
in recognizing family interactions. Psychological Medicine, 15,
173-188.
Freybexger, H., Kunsbeck, H.J., Lempa, W., Wellmann, W., &
Avenarius, H.J. (1985). Psychotherapeutic interventions in
alexythmic patients with special regard to ulcerative colitis and
Crohn patients. Psychotherapeutic Psychosomatics, 44.72-81.
Helman, C. (1985). Psyche, soma and society: The social constmc-
tion of psychosomatic disorders. Culture, Medicine and Psy-
chiatry, 9, 1-26.
Joachim, G., & Milne, B. (1987). Inflammatory bowel disease:
Effects on lifestyle. Journal of Advanced Nursing, 12, 483-
487.
Kett, K., Rognum, T.O., & Brandzaeg, P. (1987). Mucosal
subclass distribution of immunoglobulin G-producing cells is
different in ulcerative colitis and Crohn's disease of the colon.
Gastroenterology, 93, 9 19-924.
Kleinman, A. (1978). Culture, illness and care. Annals of Internal
Medicine, 88. 251-258.
Lask, B. (1986). Psychological aspects of inflammatory bowel
disease. Wiener klinische Wochenscrift, 29, 544Ñ547
Milne, B., Joachim, G., & Niehardt, J. (1986). A stress manage-
ment programme for inflammatory bowel disease patients.
Journal of Advanced Nursing, 11, 561-567.
Neufeldt, J. (1987). Helping the IBD patient cope with the
unpredictable. Nursing, 17, 4 7 4 9 .
Nordoff, P,, & Robbins, C. (1977). Creative music therapy. New
York: John Day.
Patterson, J.M. (1988). Families experiencing stress. Family Sys-
tems Medicine, 6, 202-237.
Persson, P.G., & Hellers, G. (1987). Crohn's disease and ulcer-
ative colitis: A review of dietary studies. Scandinavian Journal
of Gastroenterology, 22, 385-389.
Robertson, D., Ray, J., Diamond, I., & Edwards, J. (1989).
Personality profile and mood state of patients with inflamma-
tory bowel disease. Gut, 30(5), 623-626.
Sanderson, I.R. (1986). Chronic inflammatory bowel disease.
Clinical Gastroenterology, 15, 71-87.
Shivananda, S., Pena, A.S., Nap, M,, Weterman, I.T., Mayberry,
J.F., Ruitenberg, E.J., & Hoedemaeker, P.J. (1987). Epide-
88
 MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE

miology of Crohn's disease in Regio Lieden, the Netherlands. Lancet, 2 , 589-591.

Gastroenterology, 93, 966-974.
Stanwyck, D., & Arnson, C. (1986). Is personality related to
illness? Advances, 3, 4-15.
Stein, M,,Keller, S., & Schleifer, S. (1985). Stress and neuroim-
modulation: The role of depression and neuroendocrine func-
tion. Journal of Immunology, 135, 827-833.
Stierlin, H. (1989). The psychosomatic dimension: Relational
aspects. Family Systems Medicine, 7(3), 254-263.
Strober, W., & James, S.P. (1986). The immunologic basis of
inflammatory bowel disease. Journal of Clinical Immunology,
6 , 415-432.
Svedlund, J., Sjodin, I., Ottosson, J.O., & Dotevall, G. (1983).
Controlled study of psychotherapy in irritable bowel syndrome.
Tarter, R.E., Switala, J., Carra, J., & Edwards, K. (1987).
Inflammatory bowel disease: Psychiatric status of patients
before and after disease onset. International Journal of Psychi-
atry, 17. 173-181.
Trabucchi, E., Mukenge, S., Barrati, C., Colombo, R., & Fre-
goni, F.W. (1986). Differential diagnosis of Crohn's disease of
the colon from ulcerative colitis: Ultrastructure study with the
scanning electron microscope. International Journal of Tissue
Reactions, 8, 79-84.
Van Spreuuwel, J.P., Lindeman, J., & Meijer, C.J. (1986).
Quantitative analysis of immunoglobulin-containing cells in
gastrointestinal pathology. The International Academy of Ana-
lytical and Quantitative Cytology and Histology, 8, 314-320.

David Aldridge Collected music therapy papers 89


Pergamon
A PRELIMINARY STUDY OF CREATIVE MUSIC THERAPY IN THE
TREATMENT OF CHILDREN WITH DEVELOPMENTAL DELAY
DAVID ALDRIDGE, PhD, DR. RER. MED. DAGMAR GUSTORFF and
DR. RER. MED. LUTZ NEUGEBAUER*
This paper has two main purposes. The first is an
attempt to demonstrate that creative music therapy is
a viable therapeutic form for developmentally-
delayed children, and in doing so elucidate what it is
in the therapy that is valuable. For referring patients,
paediatricians and payers (possible funding agencies
and third-party medical insurers) alike, we need to
present evidence that the work that we are engaged in
has a value that makes sense to them. Although we, as
therapists and researcher, are convinced of the value
of our own work according to our criteria, we too are
seeking ways to understand how what we do is effec-
tive. The process of looking at clinical practice,
sometimes from a different perspective, gives the pos-
sibility to gain a valuable insight into what we are
doing, to promote that work in other settings and to
broaden the basis of our teaching.
The second purpose is to present an integrated ap-
proach to music therapy research that combines both
a quantitative approach, as shown by measuring
changes, and a qualitative approach, as argued from
the interpretation of empirical data. Although this sec-
ond purpose may seem rather unorthodox, the reason
underlying it is that we hope to show that in music
therapy research we can creatively adapt techniques
and forms of argumentation to suit our needs and that
we do not have to take a polarized stance either for or
against qualitative or quantitative methods. Indeed, to
maintain an ideological position is to fall into the trap
of methodolatry on one hand or scientism on the
'David Aldridge is Professor for Clinical Research Methods at the University of Witten Herdecke, Germany.
Dagmar Gustorff and Lutz Neugebauer are CO-Directors of the Institute for Music Therapy at the University of Witten Herdecke
David Aldridge Collected music therapy papers
The Arts in Psychotherapy. Vol. 22, No. 3. pp. 189-205, 1995
Copyright 0 1995 Elsevier Science Ltd
Printed in the USA. All rights reserved
0197-4556195 $9.50 + .00
other. Research methods are simply tools for struc-
turing our thinking and gathering the evidence that we
will use to support our arguments. In some ways we
are rehearsing a debate that has already been compre-
hensively argued in both the fields of nursing (Dzurec
& Abraham, 1986, 1993) and social psychology
(Shadish & Fuller, 1994). By relating both sets of
information it may be possible to generate insights not
available from the two types of information separately
(Heyink & Tymstra, 1993).
The overall aim of our research then is to present
our work with children suffering from a variety of
developmental challenges and propose that by using a
particular form of assessment available to other music
therapists we can see quantitatively that a beneficial
change occurs. The reason for that change, we will
argue, is attributable to specific qualities of creative
music therapy.
The music therapy approach taken here is based
upon that of Nordoff and Robbins (1977) improvised
music therapy, which has its origins in working with
handicapped children. However, although there is a
wealth of case study material in the music therapy
literature concerning music therapy with children and
a considerable literature suggesting the value of music
therapy for child development (Wilson & Roehmann,
1987), there have been few controlled studies of Nor-
doff and Robbins music therapy with handicapped
children.
An important feature of childhood development is
90
190 ALDRIDGE, GUSTORFF AND NEUGEBAUER
the acquisition of speech and the ability to communi-
cate meaningfully with another person. Music therapy
encourages children without language to communi-
cate and has developed a significant place in the treat-
ment of mental handicap in children. How such com-
munication is achieved, and how in some instances it
leads to speech, are as yet unknown. Indeed, the very
ability to develop and achieve speech in normal chil-
dren is a miracle of daily living that continues to
baffle linguists and psychologists. Although this pa-
per makes no attempt to solve the riddle of how
speech is brought about, we will attempt to demon-
strate how music therapy helps developmentally-chal-
lenged children progress toward a richer communica-
tive life.
Developmental delay can be the consequence of
various difficulties, physical, mental or social (Peter-
son & Schick, 1993). Children who are developmen-
tally challenged experience the same emotional con-
flicts and difficulties as normal children; however,
they are also more likely to experience rejection when
they fail to meet standards of expectation associated
with their chronological age. This rejection can lead
to behavioral disturbances. The successful social in-
tegration of children with developmental delay relies
upon a sensitive and adaptable social environment, as
does the sequence of development itself. If the envi-
ronment is both modified to meet the needs of the
children and to enhance communication possibilities
according to their potential, then we may expect
fewer behavioral problems. Children who are devel-
opmentally delayed face the same developmental
tasks and challenges and have the same needs to be
loved, stimulated and educated, as normal children.
What they face is a progression that may be slower
and perhaps limits their future capabilities. Our ther-
apeutic task is to respond to abilities and potentials so
that those limitations themselves are minimized. If
both environment and the individual are important for
developmental change, the therapist provides, albeit
temporarily, an environment in which individual
change can occur.
Child Development and Challenges to Theory
Child development itself is subject to various theo-
ries and is a continuing source of active academic
debate. All children are now conceived of as very
active constructive thinkers and learners, rather than
passive copiers of what is given to them (Case, 1993;
Lewis, 1993). Children select and transform what is
David Aldridge Collected music therapy papers
meaningful for them from the context within which
they find themselves. What. is selected and trans-
formed is in pan in accordance with their cognitive
abilities, yet these abilities are not separate from other
related developmental processes. Each child may dif-
fer in his or her development. Furthermore, children
not only take from the environment, they too give out
signals that modify their environment. Infants give
clues to their mothers about how they expect them to
react. Improvised creative music therapy, with its
emphasis on activity within a dynamic personal re-
lationship, may play a role in encouraging develop-
ment particularly when it focuses on communicative
abilities.
The idea that children change in regular stages that
are governed by their biology and that they become
progressively better in a linear evolutionary develop-
ment is being challenged (Florian, 1994; Ross, Fri-
man & Christophersen, 1993; Spieker & Bensley,
1994; Wagner, Torgesen & Rashotte, 1994). Morss
(1992) called for an interpretative, as opposed to a
causal-explanatory, approach to human experience
and proposed that studies of infancy are often studies
of scientists studying infancy, and, like Sipiora
(1993), found that the infant under study is often ab-
sent. Sipiora criticized Piaget for skewing the natural
choice of questions answerable only by children to
those of an adult consciousness. Pure observation
cannot always distinguish children from their beliefs
and it is the inner life of the children, what they wish
to communicate, that should be the focus of our at-
tention (Florian, 1994; Wagner, Torgesen & Rash-
otte, 1994). Siege1 (1993) reminded us that this de-
bate is not entirely new and, interestingly for the cre-
ative arts therapies, that nonverbal tasks are the best
means of representing the thinking of very young chil-
dren. She also emphasized that Piagetian develop-
mental stages are not supported empirically and what
may seem to be an orderly sequence of acquisition
may indeed be an artefact of the way in which tasks
are structured. The outcome of this debate is that in
understanding children we are encouraged to study
processes not products, that those processes when re-
lated to assessment will always occur in a dialogue
between child and therapist.
If we return briefly to the secondary purpose of this
paper, we can propose that a qualitative method of
research will be necessary to look at this process of
developmental change as it occurs between therapist
and child, and a quantitative method can help us to
identify specific changes
91
 CHILDREN WITH DEVELOPMENTAL DELAY
The above challenge to Piagetian orthodoxy is
based partly on a questioning of the orthodoxy of the
spoken word as being primary (Siegel, 1993). Some
authors are concentrating on how children perform in
the world, which is a "world-of-others," as the prin-
cipal focus for attention. Play is seen as a mental act
including unconscious fantasies and wishes, a physi-
cal act that is observable and a necessary awareness
that what is being enacted is "play." Play, when
defined by its functions, facilitates the libidinization
of the body and is an area of importance bridging the
realms of the personal and the social (Mash, 1993).
For Vygotsky (1978), this intermediary realm, the
distance between what children can do on their own
and what they can do with the help of an adult, is
referred to as the proximal zone. It is such a "zone"
that we find in creative music therapy. Musical activ-
ity is based upon what the child can do in musical
play, but the potential of what the child can do further
is based upon what child and therapist are capable of
together. Furthermore, with an emphasis on the ac-
tivity of musical playing within the context of a per-
sonal relationship, the libidinization of the body is
achieved as a communicative act.
In our work we emphasize the role of the therapist
as encouraging and providing the context in which
musical communication takes place. The therapeutic
relationship is a relationship that mirrors the primary
relationship of learning to communicate in which de-
velopment emerges. Vandenberg (199 l ) reminded us
that looking, hearing, smelling, sucking and grasping
are some of the early reflexes for assimilating objects
and the basis from which cognitive development
emerges. At birth, children are most responsive to the
human voice through hearing. It is this orientation to
the social world of others that is of such importance.
The special relationship with others is something that
is "elaborated from those primitive forms of attune-
ment" (p. 1282). This is a reflection of the position
taken by Stem (Neef, 1993) that the infant has a core
self that is in a relationship with the core self of the
other, and this relationship forms a crucial axis of
development. The symbolic world of the child is im-
bued with the relationship with the caregiver and oth-
ers of significance. Our proposal is that such a rela-
tionship is essentially "musical. "
Aldridge (1989) has emphasized the importance of
rhythmic interaction for the development of language
and socialization in the infant. From birth the infant
has the genetic basis of an individually entrained
physiology (i.e., a self-synchronicity). The infant has
David Aldridge Collected music therapy papers
191
its own time, yet the process of socialization and the
use of language depend upon entraining those
rhythms with those of another. Cycles of rhythmic
interaction between infants and mothers reflect an in-
creasing ability by the infant to organize cognitive and
affective experience within the rhythmic structure
provided by the parent. This organization, however,
is not a one-sided phenomenon. Infants produce
forms of expression and gesture that are not imita-
tions of maternal behavior. Both baby and mother
learn each other's rhythmic structure and modify their
own behavior to fit that structure. Arousal, affect
and attention are learned within the rhythm of a
relationship.
The competence of infants is not solely a quality
inherent within the individual. Individuals are located
in particular environments, those of their significant
relationships. Gaussen (1985) criticized maturational
models of child assessment in that they do not take
into account the variability and individual differences
of the developmental processes. Assessment methods
rely on how the child responds and moves; they tell
little about what the child knows and responds to.
Such a criticism echoes that of the authors above who
wish to know more of the inner life of the child, a
life that is not solely dependent upon intact motor
responses.
Nevertheless, communication is dependent upon
motor coordination, and motor responses, as we shall
read below, are important indicators that a child is
developing. For the parent, rather than the theoreti-
cian and psychologist, the pragmatics of understand-
ing the child are based upon what that child can do.
Furthermore, communication is also dependent upon
doing. What that "doing" means is important, but
achieving that "doing" and coordinating with another
person are primary. Hence the value of nonverbal
therapies and the establishment of a communicative
relationship before the complexities of lexical mean-
ing are necessary.
Motor Development: Gesture and Communication
The development of children demands many inte-
grated skills. One important skill is to control motor
activity, that is, to be able to draw and write, handle
a knife and fork, play with a ball and run. Children
who do not master such activities are often labelled as
clumsy, whereupon they meet with disapproval from
their peers and often family members. On reaching
play-school or school age these children find them-
92
192 ALDRIDGE, GUSTORFF AND NEUGEBAUER

selves facing ridicule. Such ridicule may then lead to children at their stage of understanding in that gesture
a lack of self-esteem and confidence, which is further maps the phenomena closely. Indeed gestures in a
exacerbated by social withdrawal (Winemiller & communication dialogue are preverbal and do not
Mitchell, 1994). Once such children find they cannot need the extra abstract and lexical dimension of
perform "properly" they give up trying. The conse- speech. It is such gestural activities that are actively
quences of such personal and social handicap as clum- utilized in the repertoire of play songs used in the
siness or perceptual-motor dysfunction remain into Nordoff and Robbins approach.
adult life. Active music therapy then would seem to be a
There are three main processes assumed to be nec- relevant therapy form as it concentrates on, and fos-
essary for the performance of motor skills: kinesthe- ters, the use of purposive coordinated movements that
sis, muscle control and timing (Laszlo & Sainsbury, occur in a context of time and relationship, offering a
1993). Kinesthesis is the sense that conveys informa- form for communication without words.
tion about the position and movement of the body and
limbs. This sixth sense, referred to by Sacks as
Developing Children and Music Therapy
"proprioception," is a sense we have in our bodies
and is Twelve patients were assessed, selected and ran-
domly allocated into two groups of six children (see
that continuous but unconscious sensory flow Figure 1). Each child was to receive individual music
from the movable parts of our body (muscles, therapy. This formed a treatment group and an initial
tendon, joints), by which their position and tone non-treatment group to serve as a waiting-list control.
and motion is continually monitored and ad- The non-treatment group received music therapy after
justed, but in a way which is hidden from us waiting for three months, while the previously treated
because it is automatic and unconscious. children had a break from therapy. Our intention was
(Sacks, 1986, p. 42) to stay as close to the clinical practice of music ther-
apy as possible. This intention influenced the timing
Proprioception is indispensable for our sense of of the treatment stages in that a course of music ther-
self in that we experience our bodies as our own. apy treatment takes about three months followed by a
Muscle control refers to the way in which movement three-month pause. Similarly, we could only ever
is directed and controlled spatially. These movements take on six new patients in one treatment period. All
must also be coordinated and this involves timing. the subjects of this study would receive music ther-
Laszlo (Laszlo & Sainbury, 1993), however, argued
that kinesthesis is the overarching factor that unites
both direction and timing in the control of posture, in
error detection and in memorizing movements. In-
deed, the coordinating of action involves the whole
body and, von Hofsten (1993) asserted, can only be
understood as a purposive dynamic future-oriented
interaction between the organism and the external
world. Actions originate not from reflexes, but from
spontaneously produced, purposeful controlled move-
ments (i.e., actions develop through action). Yet this
action must be structured and thisstructure is that of
time. Active music therapy would seem to be an ideal
medium for encouraging purposeful controlled move-
ment in a time structure that is formed yet flexible.
Gestures also help us understand what a child
means and at what stage of understanding a child is in
(Alibali & Goldin-Meadow , 1993; Goldin-Meadow ,
Alibali & Church, 1993). Gesture is spontaneous and
often idiosyncratic, whereas speech conforms to an
established form. Some expressive events may be bet- Figure I . Allocation of children to treatment groups and study
ter encoded in communications as gestures for some design.

David Aldridge Collected music therapy papers 93

 CHILDREN WITH DEVELOPMENTAL DELAY
apy, and the maximum treatment delay after intake
would be for three months.
Entrance criteria were that the children should be
4-6.5 years in chronological age with a developmen-
tal age of 1S-3.5 years and that the selected children
had no previous experience of music therapy. Chil-
dren were excluded from the study if they had a phys-
ical problem that was degenerative, if they were cur-
rently receiving psychopharmaceutical treatment or if
they were currently attending another form of creative
art therapy. Playschool or kindergarten attendance
was not interrupted.
The use of waiting list controls and alternating
treatment periods met our ethical demands for the
treatment of children in terms of clinical research in
that both procedures mirrored our normal practice.
Furthermore, the study was clearly explained to all
the participating parents and caregivers of the chil-
dren, who were assured that refusal to take part in the
study would not disqualify their childrenfor treat-
ment. Similarly, all participants were asked to give
permission for the use of the data as part of a research
project and for possible publication.
Referrals were from a local paediatrician who as-
sessed the children before treatment began (at intake).
We had previously set the criteria for the clinical as-
sessment of developmental change (see below). A
medical student, trained in the assessment of children,
saw the children and their caregivers every three
months to assess any clinical changes according to the
medical criteria (Tests 1 , 2 , 3 , and 4 after intake). She
was initially "blind" as to whether the children were
in the treatment or non-treatment group.
The main assessments were developmental accord-
ing to psychological and functional criteria (the Grif-
fith's test, see below), and musical according to the
Nordoff and Robbins rating scales. Music therapy
sessions were recorded on audiotape and later indexed
according to music therapy criteria.
Our main hypothesis was that there would be
greater developmental changes in the music therapy
treatment group, in the first session of the treatment
period, compared with the no-treatment group. Our
secondary hypothesis was that by the end of the two
treatment sessions both groups would have changed
equally.
The Griffiths Scale and the Nordoff and Robbins
Rating Scale F ,
Ruth Griffiths, as a psychologist, spent a great deal
of time observing babies and small children. From
David Aldridge Collected music therapy papers
193
these observations she developed a series of scales
that could be used to gain insight into areas of leam-
ing in young children. The function of these scales
was not to say categorically what the reason may be
for a child's slowness to learn, rather to diagnose
those areas of a child's capability and to provide a
profile of capabilities from which the child may re-
spond to treatment. This emphasis on the positive
potential of the scales was attractive initially for our
work as it reflected, and had features complementary
with, the approach of Nordoff and Robbins music
therapy (see Table 1) in focusing on the inherent po-
tential~of the child rather than concentrating on the
known pathologies. Reading her book (Griffiths,
1954), which was written 4 0 years ago, is a fascinat-
ing insight into the rigor of a scientist who clearly has
a love for children, and how that rigor can be applied
in the assessment of behavior. Sometimes creative
arts therapists criticize science for seemingly leaving
out the individual and thereby losing any relevance
for treatment. With Griffiths, however, there is a con-
stant reminder that these scales were crafted from a
devotion to the lot of those children who were in need
so that we, as carers of those children, could better
our own observations to meet their needs.
There are six subscales that have equal degrees of
difficulty. Each subscale tests a different avenue of
learning with the intention of discovering true poten-
tialities in the handicapped child (Griffiths, 19701
1984, pp. 171-172). Once such potentials are recog-
nized, help can be brought as early as possible when
needed. Indeed, the tests are intended to educate the
carers and the educators about the needs of the child.
Although the central plank of the work is to provide a
differential diagnosis of mental status (see Figure 2),
that diagnosis is clearly linked with potentials for
treatment.
Attempts were made by Nordoff and Robbins as
early as 1964 to develop rating scales for individual
music therapy (Weaver & Clum, 1993). However,
these evaluative scales proved to be difficult to com-
pose and adequately meet the complexity of musical
responses. Two years later, scales for evaluating au-
tistic children in the day center were adapted for
music therapy use and evolved as Scale 1. Child-
Therapists Relationship in Musical Activity and Scale
11. Musical Communicativeness.
Scale I evaluates the relationship between child
and therapist as it develops from what may be total
obliviousness, through limited response to a stability
and confidence in the mutuality of playing music to-
gether. It must be stressed that it is in the musical
94
 ALDRIDGE, GUSTORFF AND NEUGEBAUER
Table l
A comparison of contents of the Griffiths Scales and the Nordoff and Robbins Rating Scales
Griffiths' Subscales
A: Locomotor Development
pushes with feet, lifts head, kicks vigorously, begins to
crawl, climbs, can walk on tiptoe, catches a ball. hops and
skips.
B: Personal-Social Scale
responds to being held, smiles, resists adult taking a toy
away, anticipatory movements, plays "pat-a-cake," plays
with other children, has a special friend.
C: Hearing and Speech
most intellectual of the scales, indicative of hearing
problems; startled by sounds, vocalization other than
crying, searches for sound visually, listens to music*,
listens to conversations. rings bell, likes rhymes and
jingles, enjoys s t o r y - b k , develops words and speech,
names objects, defines by use, comprehends sentences.
D: Hand and Eye Co-ordination
(observe the hands of the child)
follows visually moving objects, uses hands for
exploration, points with fingers, likes holding toys, plays
with bricks, scribbles freely, builds a tower, folds paper,
copies shapes, draws recognizable figures and objects.
E: Performance Tests
measures skill in manipulation, speed of working and
precision with an awareness of the child's eagerness and
persistence; searches for a toy under a cup, manipulates
cubes and boxes, opens screw-topped jars, makes
patterns.***
F: Practical Reasoning
recognition of differences in size and categorizing as
"bigger," this scale measures the ability to reason in
"embryo." Any child before he or she can express ideas
verbally can look, listen, think and learn the foundations
of knowledge and the way in which the mind works in
apprehension of the environment.
*There is an overall neglect of musical ability.
**Moves from pathology to ability, yet lacks the neutrality of the Griffiths' scales which assess all stages as milestoneslpotentials
***There is, however, no mention of musical patterns.
tAfter Item 6 the Nordoff and Robbins scales converge.
activity that the relationship is developed, and the
vocabulary used to evaluate the performance of the
child is mainly musical. Whereas Nordoff and Rob-
bins stress that the evaluation is of the relationship
itself, the language itself places emphasis on evaluat-
David Aldridge Collected music therapy papers
Nordoff and Robbins Rating Scales
Scale 11: Musical Communicativeness
musical communication is realized through 3 modes of activity;
instrumental, vocal and bodily movement.
Scale I: Child Therapists Relationship in Musical Activity
Item 1-3. Child appears oblivious to the therapists, fleeting signs of
awareness, awareness of the situation leads to rejection.
Item 6: Child comes to the session with obvious pleasure and
establishes a consistently recurring positive response to the therapy
situation.
Scales I and 11: Musical Communicativenesst
Ranges from uncommunicative, non-responsive beating which is
disordered, impulsive or haphazard or compulsive beating of
inflexible tempo or pattern**; leading to child beats with some
musical organization, and recognizes salient components of the
music, rhythm or melody or harmony. Child finds musical activity
meaningful and satisfying.
Child communicates with others and communicates his understanding
of musical objectives.
The child comes to the session with obvious satisfaction and pleasure,
and enjoys being active in the music.
Scale 11: Musical Communicativeness
Musical communication is realized through 3 modes of activity;
instmmental, vocal and bodily movement.
Scale 11: Musical Communicativeness
His beating shows an awakening recognition and some anticipation of
salient components of the music; rhythmic pattern, melodic rhythm,
change of dynamics, phrase structure.
Scales I and 11: Musical Communicativeness~
He adopts and sustains the mode(s) of musical response available to
him, shows purposeful involvement with the musical activity. The
child's interest centers strongly upon particular musical activities
which he finds meaningful and satisfying. He pursues these activities
with purposefulness.
ing the child (i.e., we would not expect that the ther-
apist is totally oblivious of the child).
Scale I1 attempts to evaluate both the state of mu-
sical communication in the session and, "provides an
index to the personality development of a child
95
 CHILDREN WITH DEVELOPMENTAL DELAY
ievereiy retarded childv Severe hearing loss
A = locomolor development
B = personal-social relationship
C = hearing and speech
Figure 2. Examples of Griffith's profiles for varying groups of children.
through assessing the character and consistency of the
musical communicativeness he manifests'' (Nordoff
& Robbins, 1977, p. 193). The scale includes three
modes of activity-instmmental, vocal and body
movement, which provide an aggregate rating on l 0
levels of communication ranging from "no commu-
nicative response" through active participation to an
intelligent musical commitment. Both scales are
rather rough and ready and have never really been
validated in clinical practice. Indeed, after level 6,
both scales converge and could be conceivably col-
lapsed into one scale. However, the scales do provide
an available clinical guide to practice and evaluation.
Results
A clinical trial, even with limited numbers, is an
exercise in good will, good planning and good for-
tune. Although planning to treat 12 children, we
"lost" 4 children in the study, lost in the sense that 4
children could not be included in the end results for a
variety of reasons. One boy during the first sessions
of music therapy was discovered to be profoundly
deaf rather than being mentally handicapped and de-
velopmentally delayed, which meant that he had to be
fitted with hearing aids. T h i ~
finding seems to point to
music therapy assessment as a valuable diagnostic
method for developmenta!ly delayed children simply
because it brings attention to active hearing in an
almost naturalized setting. One other child had been
abused by a member of her family and it was not
David Aldridge Collected music therapy papers
' M n ' s syndrome Slow child Average ability chi!d
D = hand and eye cocxdination
E = performance tests
F = practical reasoning
possible to continue the full program of treatment and
assessment. Two children came from families of eth-
nic minorities and it was both difficult to get them to
music therapy sessions and to maintain the continuity
of follow-up.
By the end of the study there were two unbalanced
groups, similar in chronological age, but different in
mental age despite the random allocation. We see in
Figure 3, which illustrates the Griffiths subscale
scores for the children in both groups, in comparison
with Figure 2, that the children range from what is
considered to be severely delayed to the "slow"
child. Five, out of the eight children, failed to score
on the practical reasoning scale (Subscale F). Sub-
scale F is heavily dependent upon speech and repre-
sents the general language deficits in these children.
However, we see by the final assessment sessions,
Figure 4, that all the children have developed some
capacity for practical reasoning. Indeed all the chil-
dren improve, as would be expected. Children de-
velop with or without music therapy. But the rate at
which they develop and how this is possibly influ-
enced by music therapy is the subject of this study.
We see in Figure 5 that the changes in the Griffiths
scores do indeed differ according to which group the
children are in. During the same period of time from
intake, the first treatment group (A) changes more
than the children who are on the waiting list (mea-
sured at Test l). When the waiting list group is treated
and then tested (at Test 21, and the children who were
treated take a rest, the newly treated children start to
96
 Group A
im

lm

80

E 60
6
m
L

g
CJ
40

20

0
Kathlean David Sophie Zena ' Tomrny

Group B
7
lrn A B C D E F

l A B C D E F

Salty Suzie

A = locomotor development D = hand and eye coardination

B = personal-social relationship E = performance tests
C = hearing and s p c h F = practical reasoning

NOW lhal four of lhe children in Gmup A. and one chiid in Gmup B, do not score on the practical reasonong scale

Figure 3 . Griffiths Quotient intake profiles.

catch up in their development. Such differences can
be demonstrated at a level of statistical significance
(at Test l df = l , F = 7.072, P = 0,045) and
support our initial hypotheses that music therapy will
bring about an initial change. Although it appears
clear that music therapy does make a difference to the
development of these children, it does not immedi-
ately tell us why music therapy helps or what indeed is
changing specifically. It makes sense here to look at
the individual subscale changes of the Griffiths scale.
When we look at the subscale changes (see Table
21, there are significant differences between the
groups. First, there is a continuing significant differ-
ence on the hearing and speech subscale and the sta-
tistic points to a significantly changing ability to list&
and communicate. The personal-social interaction
subscale (B) also proves to be the significant differ-
entiator at Tests l and Tests 3. After Test 3, the

David Aldridge Collected music therapy papers 97

 CHILDREN WITH DEVELOPMENTAL DELAY

Group A

'T----

Kathleen David Sophie Zena Tornrny

A = locomotor development D = hand and eye coardination

B = personal-social relationsh~p E = pcrfomance tests
C = hearing and speech F = practical reasoning

Figure 4 . Griffiths Quotient final assessment profiles.

children in Group A have received two treatment pe-
riods of music therapy. It must be noted here that
Tests 2, 3 and 4 are all made after children have been
treated at least once with music therapy. Music ther-
apy seems to have an effect on personal relationship,
emphasizing the positive benefits of active listening
and performing, and this in turn sets the context for
developmental change. Howevtx, the groups also dif-
fer initially on hand-eye coordination (subscale D),
and this is not surprising given that the playing of
musical instruments demands such manipulative and
perceptive skill.
Although focused listening in a personal-social re-
lationship sets the scene for music therapy and pro-
vides the context in which change can occur, a further
investigation of the data reveals an important variable
related to hand-eye coordination that is correlated
with significant clinical changes when the children are
tested. Subscale D, which measures hand and eye
coordination and is taken to be demonstrative of non-
verbal communication (Muenzenmaier, Meyer & Fer-
ber, 19931, is significantly correlated with change
throughout the series of test times. At Test l (Pearson
r 0.915, Bonfen-oni p 0.001) and Test 2 (Pearson r

David Aldridge Collected music therapy papers 98

 ALDRIDGE, GUSTORFF AND NEUGEBAUER

Q
no music therapy

A
with music therapy

no music therapy

no music therapy

with music therapy

with music therapy

no music therapy

- l
Group A Group B

n e s e changes are lhe mean changes from when the children were measured at inlake; lhaf
is, lhe inlake is the baseline, zero. The test scores, l ,2,3 and 4 are the mean changes in the
Griffilhs quotienls for each group at three months, six months, nine monlhs and one year
fouowing the inital measurement at intake. Note at test 4 in Group B lhere appears to he a
regression in the changes.

Figure 5. Group differences in Griffiths test score means changes from intake.

0.903, Bonferroni p 0.002), hand-eye coordination is
correlated with the hearing and speech scale change,
scale C. A change occurs on both scales of nonverbal
communication and potential verbal communication.
Furthermore, at Test 3, hand-eye coordination is cor-
related with changes in the performance tests, scale E
(Pearson r 0.902, Bonferroni p 0.033), and later at
Test 4, hand-eye coordination is correlated with
changes in practical reasoning (Pearson r 0.933, Bon-
ferroni p 0.010). The active element of musical play-
ing, which demands the skills of hand and eye coor-
dination and listening, appears to play a significant
role in developmental changes.
Case Vignettes
Although it may be unorthodox to include clinical
case studies alongside statistical reasoning, we be-
lieve that a time has come when we can have the
freedom to add some variety to the way in which our
work is presented. There are no statutes that say case
vignettes are banned from such work and, as most of
us know from reading the work of other clinicians,

David Aldridge Collected music therapy papers 99

 CHILDREN WITH DEVELOPMENTAL DELAY

Table 2
Effect of treatment group on subscale scores

Subscale Test time SS DF MS F P

A: locomotor development Test l

error
Test 2
error
Test 3
error
Test 4
error
B: personal-social Test 1
error
Test 2
error
Test 3
error
Test 4
error
C: hearing and speech Test l
error
Test 2
error
Test 3
error
Test 4
error
D: hand-eye co-ordination Test l
error
Test 2
error
Test 3
error
Test 4
error
E: performance tests Test 1
error
Test 2
error
Test 3
error
Test 4
error
F: practical reasoning Test 1
error
Test 2
error
Test 3
error
l Test 4

error

Univariate F tests: *significant p < 0.05; **significant p < 0.01

David Aldridge Collected music therapy papers 100

 ALDRIDGE, GUSTORFF AND NEUGEBAUER
what we often really need to know is how the statis-
tical relevance comes to have any clinical relevance.
In these two examples we see that although clear de-
velopmental changes accessible to assessment take
place, it is the qualitative subtleties of personal mean-
ing that play an important role for the parents. In
the first study, a clear quantitative change takes
place in the Griffiths test score (see Figure 7). In the
second example, although no clear objective change
occurs in the test scores over time (see Figure 6), the
parents see important qualitative changes that they
perceive as improvements.
Dora
Dora, the child of a mentally handicapped mother
and a socially disturbed father, was adopted at birth.
While experiencing feeding difficulties she put on
weight. She was developmentally delayed, hyperac-
tive and often uncontrollable. As a baby she received
physiotherapy because she started to walk late and, at
the time therapy began, was still in diapers. Her major
problem was presented as episodes of agitation and
restlessness after which she appeared to have lost
much of what she had previously learned. Following
such episodes she said that she would fall or her head
would fall off. An electroencephalogram showed no
obvious signs of pathology. Socially she was distant
from other children and adults, was extremely anx-
ious in the presence of others and protected her eyes
with her arms clamped to the sides of her head. She
would not listen to others or make eye contact. Some-
times her voice had a strange "fairy-tale" character.
She had been seen by a child psychiatrist.
At the beginning of the music therapy Dora cried a
lot and had t o be held in the arms of the CO-therapist
throughout the session. When he tried to put her down
she cried even louder. Eventually she responded to
the musical structure offered to her and, although
making no eye contact with the therapist at the piano,
rang a small bell with her finger. Gaining in confi-
dence, while remaining in the arms of the co-
therapist, she played the cymbal continuously. When
asked if she had finished playing, she replied clearly
that she had. Eventually, in the fourth session, she
had confidence to play a drum alone. Now there was
no crying and she looked confidently at the therapist.
The therapist had composed a special "Good-bye
song" for her and she sang, too! By the tenth session,
her musical playing was formed and she played a
crescendo alone.
David Aldridge Collected music therapy papers
At first Dora told her adoptive mother that she
would not come to music therapy, but, after the first
few sessions, appeared to come gladly. At home she
displayed both sympathy for others and sadness. That
she herself could be emotional was an important ex-
perience for her mother. Similarly, Dora made it clear
she was happy to see her mother and said that she
loved her. Although previously distant, she now cud-
dled others and was happy to be cuddled. After two
music therapy sessions Dora began to sleep well, and
sleep alone, which was a great benefit for the parents.
When she had an episode of agitation she said that she
no longer needed to be held and could manage alone.
Instead of using single words, she combined words
together as phrases and could say "I," "we" and
"you" in the proper context.
After the second treatment block, she became dry
during the day. The table in her bedroom, once used
for changing her diapers, became a desk. Although
not being particularly comfortable at the kindergarten,
she started to make friends.
Sophie
Sophie was a much wanted child, as her mother
had previously miscarried twice. Although being able
to sit alone at four months, she failed to crawl and
failed to pull herself up to stand. There appeared to be
no organic cause for such delay. The physiotherapist
found that Sophie had difficulties with both her fine
and coarse motor control. Although able to hear nor-
mally, she failed to speak. Sophie also played alone
and was not interested in distractions. After a virus
infection and a fever of up to 42 degrees centigrade
when she was unconscious for a short time, she be-
came very anxious. An electroencephalogram showed
no obvious signs of irregularity.
In the first session Sophie clung to her mother and
was carried into the therapy room by the CO-therapist,
on whose arm she remained. Her hands shook, she
whimpered and was very anxious. She played a small
bell and a chime bar so quietly that they could hardly
be heard.
In the second session she was also very withdrawn
and came crying into the room. However, with the
support of the CO-therapistshe played single tones on
the piano, sat on the CO-therapist's lap and played
separately both drum and cymbal.
By the fourth session she was able to come into the
therapy room alone and, after a while, came to the
piano where she played single unrelated tones, which
101
 CHILDREN WITH DEVELOPMENTAL DELAY 20 1

at times accidentally met the music played for her by
the therapist. Sophie was very insecure in the musical
pauses and immediately retreated from rhythmical im-
pulses. However, in the fifth session she played more
often in relationship to the music, using both hands to
beat the drum in parallel and alternately. She was
surer in the therapeutic relationship and made consid-
erably more effort to play, even when it was manually
difficult for her.
After this treatment period Sophie's mother de-
scribed her as being much freer in daily life. For
example, she investigated alone the family's newly
acquired caravan. When travelling on the local bus,
she greeted the child next to whom she sat. When the
door bell rang, she opened the door. When she
wanted to play with her mother she would find the
toys herself, a reverse of the previous situation. She
showed more initiative. Furthermore, although speak-
ing in a general babble, she could remember words
and situations. If misunderstood, she would become
annoyed and show it.
In the next treatment period her playing on
drum and cymbal at first remained impulsive. But,
by the seventh session she came happy and expec-
tant directly to the piano where she played with more
security.
A significant change came about in the eighth ses-
sion where she was constantly active and the musical
aspects of her playing were more recognizable. She
could accompany, and play, changing tempi, decide
between loud and soft playing, repeat musical motifs
and brought some continuity to her playing that was
no longer spoiled by small distractions. Her acciden-
tal changes were supported in the music so that they
became parts of the musical whole, and she worked
hard to maintain the musical relationship.
In the following ninth session Sophie's playing
sounded ambivalent and not so related as in the pre-
vious week. She seemed withdrawn and unsure in
what she did. However, by the next session she was
restored to her previous level of progress and was able
to express herself in diverse musical activities. With
help, she was able to play the drum with parallel and
alternative arm movements and by the final session

Intake Test1 Test? Test3 Test4

Kathleen

 David

A Sophie

+ Zena

X Tomrny

With No With No
MT MT MT MT
These changes are the individual changes in the overall Griffiths test score from when the
children were measured at intake. The intake score for each child is now the baseline, zero
for indicating further comparative changes from the original scores. The test scores, 1.2.3
and 4 are the changes in the Griffiths quotients for each child at three months, six months,
nine months @ o n e year following the inital measurement at intake. With MT = the
children had music therapy treatment before this test and after the last test. No MT = the
children had no music therapy prior to this test and after the previous test.

Figure 6. Changes in the Griffiths test scores for treatment group A from intake to final assessment

David Aldridge Collected music therapy papers 102

202 ALDRIDGE, GUSTORFF AND NEUGEBAUER

had many developed musical improvisational possi-
bilities at her disposal.
Sophie's mother described her daughter as being
much more capable of playing with her brother, and
both able to dress herself and put on her shoes. Al-
though she was defiant when asked to repeat a word,
for instance, she babbled more and often repeated the
first syllable of a word that she had heard. Sophie was
more independent. On visiting a friend of her moth-
er's, Sophie had gone to the refrigerator to fetch a
drink when no one had understood that she was
thirsty. She had become much more aware, and ap-
peared to be surprised by her own capabilities. The
consequences were that she became braver and more
energetic in taking new things on, would play with
others and sit next to her brother or her parents. On
going to bed, she took her teddy bear with her along
with other cuddly toys. For her mother it was a per-
sonal breakthrough when Sophie allowed her hair to
be cut and styled and agreed to wear a slide in her
hair.
Although the individual developmental profiles of
both the above children can be seen in Figures 6 and
7, it is important to emphasize here the role of paren-
tal observation. When therapeutic change occurs, the
primary arena for expression of that change is not
solely in the therapy room. What parents are expect-
ing is that children will be different at home. These
changes are often subtle and too varied for a standard-
ized questionnaire. Therefore, the personal interview
with the parents is of equal importance for under-
standing changes in children. How we weave subjec-
tive and objective results together is the creative na-
ture of our inquiry, and we can do this once we have
established the criteria, fpr the way in which our data
are collected.
Discussion
Children will develop. Some develop slower than
others, and for an even smaller minority that devel-
opment is delayed through a variety of causes. We
argue, like others before us, that music therapy can
facilitate development and enhance its rate in those

Intake Test1 Test2 Test3

Suzie

No With No With
MT MT MT MT
These changes are the individual changes in the overall Griffiths test score from when the
children were measured at intake. The intake score for each child is now the baseline, zero
for indicating further comparative changes from the original scores. The test scores, 1.2.3
and 4 are the changes in the Griffiths quotients for each child at three months. six months,
nine months and one year following the inital measurement at intake. With MT = the
children had music therapy treatment before this test and after the last test. No MT = the
children had no music therapy prior to this test and after the previous test.

Figure 7. Changes in the Griffiths test scores for treatment group B from intake to final assessment.

David Aldridge Collected music therapy papers 103

 CHILDREN WITH DEVELOPMENTAL DELAY
children whose development is in some way im-
paired. When we speak of developmental change we
are in the main speaking about the ability to commu-
nicate either nonverbally or verbally. Indeed, the par-
ents of the children treated in this study had an ex-
pectation that what they and their children did to-
gether would make some sense to them, that their
children could communicate needs, desires and emo-
tions, and that they, too, the parents and caregivers,
could communicate their feelings to the children. That
Sophie could show both sadness and happiness were
considered to be important for her mother. That she
could also cuddle was a significant milestone in the
emotional relationship of child and mother.
In this study we have gone some way to fulfilling
our first purpose in demonstrating that developmental
change can be perceived according to standardized
testing in the context of clinical research. The Grif-
fiths test is acceptable to us and to referrers in that
it is based upon a broad base of clinical observa-
tions and makes sense when applied to the lives of
the children being assessed. Like music therapy it-
self, the emphasis is on eliciting the potential of the
children.
We can say that children, when they partake in
improvised creative music therapy, achieve signifi-
cant developmental milestones in comparison with
those children who are not treated. Later, when a
comparison group of children is treated, they too rap-
idly achieve developmental goals. It must be men-
tioned here that at no stage in the study was music
therapy targeted to specific developmental achieve-
ments or aimed at particular behavioral activities.
What we were interested in was what developmental
changes took place, rather than trying to manipulate
children so that targeted changes occurred. The rea-
son for not specifying behavioral goals is that creative
music therapy is not based on such a behavioral plan
of identifying specific clinical aims that would detract
from the essential aim of making music together. As
all the children were so completely different, as is the
nature of developmental delay, the same target vari-
able could not apply to all the children. Furthermore,
as this was a preliminary study, we could not know
what we were to focus on before we had made the
study. However, there is a paradox inherent in cre-
ative music therapy in that we emphasize the musical
activity as paramount in therapy, yet it is the be-
havioral changes that we champion as therapeutic
success.
Our initial purpose was also to discover what it is
David Aldridge Collected music therapy papers
203
in the activity of making music that is important.
Clearly, the activity of listening, in a structured mu-
sical improvisational context, without the lexical de-
mands of language, is a platform for communicational
improvement. The building blocks of language,
rhythm, articulation, sequencing (Alien, Barone &
Kuhn, 1993), pitch, timbre (Annett, 1993) and turn-
taking (Blampied & France, 1993) are musical in
nature. Focused listening to another person, we
would argue, is also a prerequisite of effective mutual
communication and dialogue. Furthermore, musical
dialogue in the music therapy relationship seems to
bring about an improvement in the ability to form
and maintain personal social relationships in other
contexts.
Hand and eye coordination, which is dependent on
a wider body awareness, appears to be the third vital
component in developmental change. That hand
movement plays such an important role is also sup-
ported by the literature emphasizing the role of non-
verbal communication and gesture in the subtle as-
pects of emotional expression (Barrett, 1993), the ac-
quisition of language (Millard et al., 1993) and in
cognitive development (Alibali & Goldin-Meadow,
1993; Goldin-Meadow, Alibali & Church, 1993). The
active playing of a drum demands that the child listen
to the therapist who in turn is listening to and playing
for him or her. This act entails the physical coordi-
nation of a musical intention within the context of a
relationship. We would argue that this unity of the
cognitive, gestural, emotional and relational is the
strength of active music therapy for developmentally
challenged children.
In addition, the importance of the visual system in
generating speech is necessary to bear in mind.
Shuren , Geldmacher and Heilman ( 1993) proposed
that there is a visual semantic system storing codes for
concrete words and picture names and a verbal system
for conceptual knowledge of a more abstract type.
Both systems work together, yet the second is more
dependent upon internal stimuli or self-generated di-
alogues. The activation of hand and eye together in
this study, visual-semantic and gestural, may have
had an influence on the speech-related practical-
reasoning sub-scale F, which all children exhibited by
the end of the study.
The proximal zone, where child and therapist play
together, awakening a potential and extending the
possibilities of the child, appears to be an important
concept for music therapy and is critical in achieving
new creative possibilities in the therapeutic relation-
104
 ALDRIDGE, GUSTORFF AND NEUGEBAUER
ship. Although the musical therapeutic relationship is
the domain of this zone, the means of achieving this
relationship is in the encouragement of active listen-
ing. Yet, such listening is also related to performing.
The intention to communicate is brought into a struc-
ture so that communication can be achieved as per-
formance. In this case the structure is musical, has
the advantage of flexibility and is built upon the ca-
pabilities of the individual child. His or her own ca-
pabilities, no matter how limited, are brought into the
mutual realm of musical relationship with the thera-
pist and therefore are open to variety and, thereby,
development.
The caregivers of the children in this study said
that a benefit of music therapy was that they could
enjoy their children and what the children did began
to make more sense. If through this "making sense"
a child achieves independence by the expression of
needs, desires and wishes, and the ability to act ac-
cordingly, then we have gone some small way in our
study to demonstrate a benefit of creative music ther-
apy. Listening and performing in the musical relation-
ship, that is, action and purposeful movement in a
relational context, appear to be the building blocks of
developmental change and of relevance for cognitive
change. That these factors are pre-verbal, and not
language dependent, would argue for the importance
of creative arts therapies in the treatment of develop-
mentally delayed infants.
Our secondary purpose was to find a suitable re-
search approach integrating quantitative and qualita-
tive methods. We have used empirical data that can be
analyzed statistically, but, as in all statistical meth-
ods, the analysis must be applied and interpreted. By
using multivariate techniques, we have chosen to in-
vestigate the relationship between variables as shown
by our data. The relationship between variables, al-
though suggested as significant by the analysis, must
be interpreted as clinically significant by the re-
searcher and further validated by the clinicians. As
Dzurec and Abraham (1986) remarked:
In other words, for the researcher using multi-
variate analysis, as for the researcher using phe-
nomenology, meaning is not inherent in data as
they are analysed, but is implied by the re-
searchers view of reality and the construction of
reality to be conveyed in a given situation.
Hence attribution of meaning to objective data
collected using either multivariate analysis or
phenomenology is a subjective task. (p. 61)
David Aldridge Collected music therapy papers
The above work needs to be validated with a larger
population of children and is best considered as a
pointer in a general direction rather than as a conclu-
sive statement. We found the clinical controlled trial
to be a rather clumsy approach for our purposes. Even
a small number of children are radically different in
their capabilities. The treatment approach could not,
in practice, be blinded from the assessor in the first
phase as parents would ask her when their child would
eventually get to music therapy. What did emerge was
the importance of a reliable assessment instrument
such as the Griffiths profile that could be systemati-
cally applied over longer treatment, and no treatment,
periods. Longitudinal single case designs would ap-
pear to be appropriate for further studies. Ideally, we
would have also used a child musical development
scale if one had been available. The Nordoff and Rob-
bins scales are not reliable instruments for compara-
tive research, but they d o provide a guide to individ-
ual assessment. For future researchers, it is important
to repeat that the interview with the parents or care-
givers is of equal value in that subtle individual and
relational changes are reported that would otherwise
escape the attention of a questionnaire or formal as-
sessment instrument. A qualitative study would em-
phasize in the future the relationship between the mu-
sical processes of change and the various changes as
they occur in the life of the child at home. We would
want to ascertain that patterns of communication oc-
curring in the music therapy sessions could indeed be
transferred to other situations with siblings or caregiv-
ers.
Although we can make generalizations from the
above work, it is important for music therapists as
researchers to stay in contact with the single child.
This does not invalidate group research methods. As
we see here, the comparison of groups has alerted us
to significant changes. Hopefully, future research will
reflect the creative tensions between generalizibility
and specificity-what we can say about music therapy
with children in general and what happens to the in-
dividual child in the process of therapy. Quantita-
tively, we have assessed changes through the collec-
tion of data according to a particular instrument, the
Griffiths test. Qualitatively, we have interpreted those
data to develop inferences from what is observed.
References
Aldridge, D. (1989). Music, communication and medicine: Dis-
cussion paper. Journal of the Royal Society of Medicine.
82(12), 743-6.
105
 CHILDREN WITH DEVELOPMENTAL DELAY
Alibali, M., & Goldin-Meadow, S. (1993). Gesture-speech mis-
match and mechanisms of learning: What the hands reveal
about a child's state of mind. Cognitive Psvchologv. 25. 468-
523.
Alien, K. D., Barone, V. J., & Kuhn, B. R. (1993). A behavioral
prescription for promoting applied behavior analysis within pe-
diatrics. Journal of Applied Behavior Analysis, 26(4), 493-
502.
Annett, M. (1993). Biological asymmetry and handedness. Inter-
national Journal of Behavioral Development. 16(4), 629-630.
Barren, K. ( 1993). The development of non-verbal communication
of emotion: A functionalist perspective. Journal of Non-Verbal
Behavior. 17(3), 145- 169.
Blampied, N. M., & France, K. G. (1993). A behavioral model of
infant sleep disturbance. Journal of Applied Behavior Analysis,
26(4), 4 7 7 4 9 2 .
Case, R. (1993). Theories of learning and theories of development.
Educational Psychologist. 28(3), 219^233.
Dzurec, L., & Abraham, I. (1986). Analogy between phenome-
nology and multivariate statistical analysis. In P. Chinn (Ed.),
Nursing research methodology: Issues and implementation.
Gaithersburg, MD: Aspen.
Dzurec, L., & Abraham, I. (1993). The nature of inquiry: Linking
quantitative and qualitative research. Advances in Nursing Sci-
ence, 1 6 ( \ ) , 73-79.
Florian, J. E. (1994). Stripes do not a zebra make, or do they?
Conceptual and perceptual information in inductive inference.
Developmental Psycholog\. 30( l), 88- 101.
Gaussen, T. (1985). Beyond the milestone model-A systems
framework of infant assessment procedures. Child Care.
Health and Development. I I . 131- 150.
Goldin-Meadow, S., Alibali, M., & Church, R. (1993). Transi-
tions in concept acquisition: Using the hand to read the mind.
Psychological Review, 100(2), 279-297.
Griffiths, R. (1954). The abilities of babies. London: University of
London Press.
Griffiths, R. (1 984). The abilities of young children. High Wy-
combe: ARICD. (original work published 1970)
Heyink, J., & Tymstra, T. (1993). The function of qualitative
research. Social Indicators Research. 29. 29 1-305.
Laszlo, J. l., & Sainsbury, K. M.(1993). Perceptual-motor devel-
opment and prevention of clumsiness. Psychological Re-
searchÑPsychologisch Forschung, 55(2), 167- 174.
Lewis, J. M. (1993). Childhood play in normality, pathology, and
therapy. American Journal of Orthopsvchiatp, 63(1), 6- 15.
Mash, E. J. (1993). Rochester symposium on developmental psy-
chopathology (vol 3)-Models and integrations. Canadian
Journal of Behavioural Science-Revue Canadienne Des Sci-
ences du Comportement. 25(4), 628-632.
Millard, T., Wacker, D. P., Cooper, L. J., Harding, J . , Drew, J . ,
Plagmann, L. A., Asmus, J . , Mccomas, J., & Jensenkovalan,
P. (1993). A brief component analysis of potential treatment
packages in an outpatient clinic setting with young children.
Journal of Applied Behavior Analvsis. 26(4), 475-476.
David Aldridge Collected music therapy papers
Morss, J . (1992). Making W ~ V ~ S - D ~ C O ~ Sand
I Ndevelopmen-
CI~O~
tal psychology. Theoretical Psychology, 2(4), 445465.
Muenzenmaier, K., Meyer, I., & Ferber, J. (1993). Childhood
abuse and neglect-Reply. Hospital and Community Psychia-
try. 44(12), ll93-ll94.
Neef, N. A. (1993). Introduction. Journal of Applied Behavior
Analysis, 26(4), 4 19.
Nordoff, P., & Robbins, C. (1977). Creative music therapy. New
York: John Day.
Peterson, L.. & Schick, B. (1993). Empirically derived injury pre-
vention rules. Journal of Applied Behavior Analysis, 26(4),
45 1-460.
Ross, L. V., Friman, P. C., & Christophersen, E. R. (1993). An
appointment-keeping improvement package for outpatient pe-
diatrics-Systematic replication and component analysis. Jour-
nal of Applied Behavior Analysis, 26(4), 4 6 1 4 6 7 .
Sacks, 0. (1986). The man who mistook his wife for a hat. London:
Pan.
Shadish, W., & Fuller, S. (1994). The social psychology of sci-
ence. London: Guilford Press.
Shuren, J., Geldmacher, D., & Heilman, K. (1993). Nonoptic
aphasia: Aphasia with preserved confrontation naming in Alz-
heimer's disease. Neurology. 43. 1900- 1907.
Siegel, L. S. (1993). Amazing new discovery-Piaget was wrong.
Canadian Psvcholo~v-Psychologie Canadienne, 34(3), 239-
245.
Sipiora, M. (1993). Repression in the child's conception of the
worl&A phenomenological reading of Piaget. Philosophical
Psychology, 6(2), 167- 180.
Spieker, S. J., & Bensley, L. (1994). Roles of living arrangements
and grandmother social support in adolescent mothering and
infant attachment. Developmental Psychology. 30(\), 102-1 11.
Vandenberg, B. (1991). Is epistemology enough? An existential
consideration of development. American Psychologist, 46(12),
1278-1286.
von Hofsten, C. (1993). Prospective control: A basic aspect of
action development. Human Development. 36, 253-270.
Vygotsky, L. (1978). Mind in society. Cambridge, MA: Harvard
University Press.
Wagner, R. K., Torgesen, J. K., & Rashotte, C. A. (1994). De-
velopment of reading-related phonological processing abili-
ties-New evidence of bidirectional causality from a latent
variable longitudinal study. Developmental Psychology, 30( 1),
73-87.
Weaver, T . L., & Clum, G. A. (1993). Early family environments
and traumatic experiences associated with borderline personal-
ity disorder. Journal of Consulting and Clinical Psychology,
6/(6), 1068-1075.
Wilson, F., & Roehmann, F. (1987). Music and child develop-
mem. St. Louis, MO: MMB Music.
Winemiller, D. R., & Mitchell, M. E. (1994). Development of a
coding system for marital problem solving efficacy. Behaviour
Research and Therapy. 32( l). 159-164.
106
 Music and Medicine
2(1) 41-47
Psychometric Results of the Music Therapy ª The Author(s) 2010
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
Scale (MAKS) for Measuring Expression and DOI: 10.1177/1943862109356927
http://mmd.sagepub.com
Communication

Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG), Dipl.
Psychologist,1 Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist,2
Kirstin Goth, Dr. phil. nat., Dipl. Psychologist,3
Fritz Poustka, Prof. Dr. med., Professor emeritus,3 and
David Aldridge, PhD, FRSM4

Abstract
The Music Therapy Rating Scale (MAKS), originally developed in 1996, was evaluated again in 2009 using a sample of 62 children
from a psychiatric unit and from different primary schools, with measures at three different time points during therapy process.
The scale is intended as an objective rating of a client’s musical behavior. The evaluation of the scale was to determine any possible
ambiguity or weakness in the discriminatory power of the scale items. After excluding such items, the results show high reliability
(a > .75) and good objectivity with trained raters (r > .70) for the two main scales and a significant sensitivity to change.

Keywords
musical communication, musical expression, music therapy, rating scale MAKS

There has been an urgent need for evaluation in music therapy
over the past years, and specific assessment instruments for
music therapy are still missing, especially for patients who can-
not be evaluated by verbal tests (Aldridge, 1996; Tischler,
2000). It is important in clinical practice that we describe in
detail the patient’s mental state and psychic structure. There-
fore, we need to identify specific criteria for the assessment
of a client’s musical expression. The question remains as to
how we interpret what we hear in a musical context in terms
of both relationship and expression and the implications of this
interpretation for therapy.
Music Therapy Rating Scales
Music therapy rating scales already exist in the literature (for an
overview, see Phan Quoc, 2007; Sabatella, 2004). Many of
them, however, are neither specific to music therapy nor vali-
dated. In Germany, semantic differentials are often used for
describing improvised music during music therapy interven-
tion. These differentials are bipolar adjective lists with scales
divided into five or seven intervals to rate a subjective impres-
sion of what is heard. They were used by music therapy
researchers in the 1990s due to a shortage of specific scales for
music therapy (Burrer, 1992; Inselmann & Mann, 2000; Pechr,
1996; Steinberg & Raith, 1985; Steinberg, Raith, Rossnagel, &
Eben, 1985; Vanger, Oerter, Otto, Schmidt, & Czogalik, 1995;
Zahler, 2002).
As specific music therapy rating scales, Bruscia’s Improvi-
sation Assessment Profiles are often used in music therapy
research in English-speaking countries (Bruscia, 2001), but
these have yet to be validated. Maler’s (1989) scale is partly
validated but is very complicated in applying ratings and is
no longer implemented. The Nordoff/Robbins rating scales
(Nordoff, Robbins, Fraknoi, & Ruttenberg, 1980a, 1980b),
used primarily with children with disabilities, are now under
evaluation. Schumacher’s Assessment of the Quality of Rela-
tionship (Schumacher, 1999; Schumacher & Calvet, 2007;
Schumacher & Calvet-Kruppa, 1999) is currently being evalu-
ated for its application to people with mental disorders
other than autism. Pavlicevic’s Music Interaction Rating scale
(Pavlicevic, 1991, 2007), describing the patient’s level of con-
tact during musical improvisation in music therapy, has been
validated for use with psychiatric patients. The challenge of
1
Freies Musikzentrum, Munich, Germany
2
University of Würzburg, Würzburg, Germany
3
Goethe University, Frankfurt am Main, Germany
4
Nordoff-Robbins-Zentrum, Witten, Germany (nordoff_robbins@mac.com)
Corresponding Author:
Dorothee von Moreau, Institut für Musiktherapie, Freies Musikzentrum,
Munich, Germany
Email: dvmoreau@web.de

David Aldridge Collected music therapy papers 107 41

42 Music and Medicine 2(1)

Table 1. The Music Therapy Rating Scale (MAKS): Expression and For scoring purposes, all items were divided into seven lev-
Communication Subscales els. Each level was operationalized, creating precise descrip-
MAKS tions to avoid ambiguity (of some items; see Table 2).
This scale was validated in 1996 by an initial evaluation pro-
Expression scale: Communication scale: cess with 52 raters on the basis of 10 video scenes of different
rating improvised solo rating improvised duo playing adolescent patients in a psychiatric clinic (Moreau, 1996,
playing (14 items) with the therapist (13 items) 2003). Scores allowed significant differentiation between cli-
(Dealing with the instrument) (Engagement) ents with various psychiatric disorders (p < .001). The results
Range of melody (TR) Autonomy (AT) for objectivity (mean interrater correlation: Kendall’s tau ¼
Initiative (IN) Inner participation (BT) .4 for the Expression scale and .3 for the Communication scale)
(Form/musical figure) (Formal aspects) needed to be improved, but the retest results suggested that a
Form (FG) Need of space (RA) training of the raters may slightly improve the score for
Structure (ST) Length of playing intervals (DA)
objectivity.
Variation (VR) Logic structure (LA)
(Vitality/dynamics of expression) (Regarding the other) The experiences of Plum (Plum, Lodemann, Bender,
Suspense/tension (SP) Reference (BZ) Finkbeiner, & Gastpar, 2002) and Isermann (2001), testing the
Power (SK) Intensity of contact (KI) practicability of the scale in a clinical context with adults with
Vitality (LB) Contact behavior (KV) schizophrenia, encouraged us to revise the scale and to reeval-
Flow (SF) Variability in acting (VV) uate it in a clinical setting.
Dynamics (DY) Dominance (DO)
(Quality of expression) (Quality of expression)
Sound quality (KQ) Quality of flow (DQ) Aim and Hypotheses
Quality of expression (AU) Quality of affects (AQ)
The main task of the actual study was to evaluate the MAKS
Clarity of emotions (EA) Quality of play (SQ)
Resonance/involvement (EL) again with trained raters, according to the general psychometric
criteria of objectivity and reliability and to establish its useful-
Hypothetical categories are in brackets. ness, clinical applicability, and relevance.

1. Testing reliability shows to what extent the scales are free

measuring the music therapy outcome with young and adoles-
cent psychiatric patients, however, has not been addressed.
A question remains about whether scales, conceptually
based on developmental psychology, are appropriate for chil-
dren without developmental disabilities or severe psychiatric
disorders, but who are, nevertheless, unstable in both emotional
expression and social interaction. We identified the need for a
music therapy rating scale specifically for measuring musical
behavior on more than one dimension in order to depict the cli-
ent’s behavior that included dissent, inconsistency, and
ambivalence. A rigorous scale could then be used for the initial
assessment process and for a final assessment at the end of ther-
apy, making it a useful tool for an evaluation of therapy out-
come. While we have diagnostic scales, we have no rating
scales for assessing therapeutic change.
of measurement error. The a priori criterion for accepting
reliability according to psychometric standards (see Bortz
& Döring, 2006) was set at a Cronbach’s alpha greater than
.75.
2. The objectivity of a scale shows to what extent the raters
agree in their judgment. The a priori criterion for accepting
objectivity according to psychometric standards was set at
a Pearson’s interrater correlation greater than .7.
3. Sensitivity to change shows to what extent the scale will
detect the development of the client’s musical expression
or communication skills throughout the duration of ther-
apy. The a priori criterion for accepting the hypothesis was
significance (tested by MANOVA with the factors Psycho-
pathology and Time of Measurement), p < .05, for the
within-subject factor Time.

Development of the Scale and First Results of Validation
Development of the Music Therapy Rating Scale (MAKS)
began in 1994 with a survey of music therapy experts (Moreau,
1996). In a process of item testing and reduction, the scale has
been modified in clinical practice for several years. For the
final version, the MAKS was composed of two subscales. One,
the Expression scale, is 14 items for rating a client’s improvi-
sational musical performance in a solo playing. The second, the
Communication scale, is 13 items for rating a client’s improvi-
sational musical performance in duo playing with the therapist
(for an overview of the scale’s categories see Table 1).
Methodological Design
Procedures
For the rating of the children’s musical behavior, we produced
video recordings of each child in a standardized assessment
session of about 15 minutes at three measurement points in
time (t1 ¼ at the beginning, t2 ¼ in the middle, and t3 ¼ at the
end of music therapy treatment or music workshop). In each
assessment session, the child was asked to play by hand a large
African drum alone, and then in a second episode to play it
together with the therapist. During the duo play, the therapist
was instructed to answer the child’s offering on contact with

42 David Aldridge Collected music therapy papers 108

Moreau et al. 43

Table 2. Music Therapy Rating Scale (MAKS) Item Examples: Expression and Communication Subscales

Expression scale: Initiative (frequency of the client’s own ideas)

No initiative (only plays Very low-level initiative Low-level Normal High-level Very high-level Extreme-level initia-
when requested and/or (reproduces only familiar initiative initiative initiative initiative (more tive (cannot restrain
offered assistance) musical patterns) (1-2 ideas) (2-3 ideas) (3-4 ideas) than 4 ideas) him- or herself)

Communication scale: Dominance (level the client places him- or herself under or above the therapist)
Strongly subordinate Moderately A little Equal A little Moderately Strongly dominating
(does not play or falls subordinate subordinate dominating dominating (overwhelming)
silent) (conformist) (partly (decisive, (influential)
conformist) inviting)

empathy and to stay cautious neither to force nor to push the Distribution of main diagnoses
child’s reactions more than necessary. From the videos of each 30
assessment session, the therapist chose a representative scene
of solo playing of 20 to 30 seconds for the rating of musical 25
expression and a representative scene of duo playing with the
therapist of 30 to 40 seconds for the rating of musical commu-
nication. The therapist decided which part of the video was typ- 20
ical or representative of the child’s behavior at that time of
treatment. Finally, we had six video episodes for each partici- 15
pant, containing one solo and one duo scene from each time
segment (t1, t2, t3). These video scenes from all children were
assembled in random sequence and recorded on CDs for rating 10
by three independent observers who had been trained in using
the MAKS. These raters, three music therapy colleagues from 5
different music therapy training backgrounds and with 3 to 5
years’ music therapy experience with children, watched the
videos and scored the musical behavior of the children using 0
F90 F91 F92 F93 F94 F98 F84 F44 healthy
the MAKS.
Figure 1. Main diagnoses (International Classification of Diseases,
Instruments Version 10) of the children’s sample.

For the evaluation of the children’s improvisational solo and

of 3 to 4 months. We selected only boys and only those children
duo play, we used the Expression and Communication scales
without impaired intelligence to assure that the groups were
of the MAKS, as described above. In addition, the children’s
homogeneous in gender and cognitive ability—although the
parents filled out a personality questionnaire, the Junior
children differed in age (see Table 3).
Temperament and Character Inventory (JTCI 7-11 R; Goth,
Neither group differed in creativity (ANOVA p ¼ .958, tested
Cloninger, & Schmeck, 2003; Goth & Schmeck, 2008). The
by JTCI 7-11 R), but they differed significantly in all other cate-
personal nurse at the hospital or the parents, for the nonclinical
gories of temperament and character (ANOVA p < .010, tested
group, filled out a short psychopathology questionnaire, the
by JTCI 7-11 R). We found significant differences in the SDQ
Strengths and Difficulties Questionnaire (SDQ; Goodman,
total score (w2 test p ¼ .025), in the categories prosocial behavior
2001; German translation, Woerner et al., 2002).
(w2 test p ¼ .000) and problems with peers (w2 test p ¼ .008).
However, to our surprise, there were aspects of psychopathology
Participants in both groups. Some healthy controls displayed severe or minor
Thirty-eight inpatients from a university hospital for child and social and emotional problems. The clinical group was poorer in
adolescent psychiatry attended group music therapy sessions both psychosocial adaptation and social skills.
over a period of 4 weeks to 10 months, depending on the length
of their hospital stay. Most of the patients had a main diagnosis
Results
of hyperkinetic disorder, F90, according to the International
Classification of Diseases, Version 10 (ICD-10), and most had Reliability
multiple diagnoses (see Figure 1).
In addition, 24 healthy children from different primary The results for scale reliability were taken from the data of the
schools attended a music workshop of 10 sessions over a period 62 children’s first assessments (t1) at the beginning of therapy.

David Aldridge Collected music therapy papers 109 43

44 Music and Medicine 2(1)

Table 3. Characterization of the Clinical Sample criterion (marked by the black line; see Figure 2) in one of the
contexts (initial study in 1996, after training situation, and
Inpatient participants Control participants
(n ¼ 38) (n ¼ 24) actual study)—except those items that were already mentioned
in case of reliability: FG (form), ST (structure), and EA (clarity
Age (years, months) 9, 9 (+1, 7) 8, 1 (+1, 5) of emotions). In the Communication scale, we identified the
Sex Male Male items KI (intensity of contact) and DQ (dynamic quality) as not
The intelligence score (IQ) in the clinical group was taken from axis III of the showing sufficient psychometric properties.
International Classification of Diseases, Version 10 (Remschmidt et al., For the total score analysis of the Expression scale and the
2002). In the healthy group, IQ was controlled by school. Communication scale, we used only those items with sufficient
discriminatory power and that loaded on a stable factor in the
Table 4. Reliability of the Expression (A) and Communication (K) factor analysis. Based on this selection criteria, the total score
Subscales for Each Rater (G, C, B) of the Expression scale, (without items FG ¼ form, ST ¼ struc-
ture, EA ¼ clarity of emotions) showed an interrater correlation
G C B
of r ¼ .9, and the total score of Communication scale (without
Expression scale items RA ¼ need of space, DA ¼ length of playing intervals,
A: alpha .80 .72 .75 BZ ¼ extent of extraverted or introverted orientation or refer-
(rit) FG (.23) FG (–.20) FG (.11) ence) was r ¼ .7.
ST (–.16) ST (–.01) ST (–.22)
EA (.15) EA (.21)
A: alpha* .88 .83 .83 Sensitivity for Change
A: rit-range* .39-.74 .36-.74 .27-.81 (KQ) We tested sensitivity for change by MANOVA analysis with
Communication scale
K: alpha .85 .76 .81
the factors Psychopathology (SDQ total score) and Time of
(rit) DA (.01) DA (.03) DA (.11) Measurement (t1, t2, t3). For this analysis, we took the MAKS
BZ (.08) BZ (.13) BZ (–.02) Expression total score and the MAKS Communication total
K: alpha* .88 .78 .84 score (all items of each scale except the weak items, as
K: rit-range* .34-.85 .21-.64 (KV) .23-.72 (LA) described above). The analysis of the solo plays showed
For the subscales, alpha and rit ¼ results for all items; alpha* and rit-range* ¼
significant changes over time in musical expression (within-
results with reduced items. FG ¼ form; ST ¼ structure; EA ¼ clarity of emo- subject factor time: p ¼ .023). Analyzing the duo plays, we had
tions; DA ¼ length of the play the client takes compared to the therapist; BZ ¼ even stronger effects of significant changes in musical commu-
reference or extent of extraverted or introverted orientation. nication (within-subject factor time: p ¼ .001). We can con-
clude that the MAKS is sensitive to discrete changes in
musical expression and communication.
We analyzed the ratings of each single observer separately to
get an idea of the stability of these results. A first analysis on
all items of the Expression scale and all items of the Commu- Discussion
nication scale showed a Cronbach’s alpha coefficient greater After excluding the weak items for all total score analyses, the
than .70, but the corrected item total correlations of some items total scores of the Expression scale and the total scores of the
were below the criterion of .3 (see Table 4). Communication scale present sufficient objectivity and relia-
As these items (FG ¼ form; ST ¼ structure; EA ¼ clarity of
bility. The results on the level of item with different training
emotions; DA ¼ length of the play the client takes compared to
conditions suggest that good training is absolutely necessary
the therapist; and BZ ¼ reference or extent of extraverted or
for using the scale.
introverted orientation) also had low objectivity scores, they were
The items of form (FG) and structure (ST) did not show
removed for a new analysis (in Table 4, see alpha* and rit- sufficient interrater, nor corrected total item correlations.
range*). The results then fulfilled the criterion alpha of greater These items are ambiguous in operationalization, difficult
than .75, and the range of the corrected item total correlation was to rate, and do not contribute to explaining musical expres-
improved too. sion skills. Other items like length of the play the client
takes compared to the therapist (DA) and the extent of
extraverted or introverted orientation (BZ) need better train-
Objectivity ing. Children in a psychiatric setting often change their
The scale’s objectivity was measured by the interrater correla- orientation while playing with an adult person and hardly
tion of all three raters (Pearson’s coefficient) for each single show stable patterns.
item to detect nonobjective items. We took the data of all chil- The items clarity of emotions (EA) or intensity of contact
dren and all assessment sessions. These results were compared (KI) can be removed from the scale. Ratings of intensity of
to the results gained in the first evaluation process (Moreau, contact or clarity of emotions do not depend on observable
1996), and the results gained immediately after the rater train- behavior but on the rater’s personal impression. The scale has
ing. Almost all items of the Expression scale fulfilled the limitations when asked to portray the quality of various

44 David Aldridge Collected music therapy papers 110

Moreau et al. 45

0.7

0
TR IN FG ST VR SP SK LB SF DY KQ AU EA EL

0.7

0
AT BT RA DA LA BZ KI KV VV DO DQ AQ SQ

actual study training initial study

Figure 2. Objectivity (Pearson’s correlation coefficient ¼ y-axis) of the items (x-axis) of the Expression scale (Figure 2a) and the
Communication scale (Figure 2b).

emotions or the intensity of contact between persons. On the
other hand, the item inner participation (BT), operationalized
by attention, is easier to observe.
The MAKS is a rating scale constructed by music therapy
experts specifically for evaluating music therapy. The accurate
description of each interval of the items allows a detailed
reflection of a client’s musical behavior. Therefore, the MAKS
is more precise than semantic differential tests and presents a
wider field of musical expression or communication skills as
the scales examine more than one aspect of behavior. Inconsis-
tent, or contradictory behavior of the client may be portrayed
comparing the solo- and the duo-playing conditions and also
comparing different aspects of musical expression, for exam-
ple, tension (SP) and loudness (SK), or tension (SP) and move-
ment (LB).
during music therapy. As an interval scaled rating instru-
ment, the scale allows strong statistical methods for data
analysis. When the week items are eliminated, the scale ful-
fills the necessary psychometric standards of reliability and
objectivity when it is used by well-trained raters. It is sen-
sitive to change and can portray a child’s development dur-
ing therapy.
For further research, we have to determine group-specific
characteristic profiles with regard to diagnosis, age, and/or gen-
der to be able to give a clear diagnostic statement related to a
patient’s MAKS profile.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.

Conclusion Funding
The MAKS is a scale constructed specifically to evaluate We would like to thank Andreas-Tobias-Kind-Stiftung, Hamburg,
the musical expression and communication skills that occur Germany, for financial support for this study.

David Aldridge Collected music therapy papers 111 45

46
References
Aldridge, D. (1996). Music therapy research and practice in medi-
cine: From out of the silence. London: Jessica Kingsley.
Bortz, J., & Döring, N. (2006). Forschungsmethoden und Evaluation
für Human- und Sozialwissenschaftler [Research methods and eva-
luation for human and social scientists]. Heidelberg, Germany:
Springer.
Bruscia, K. E. (2001, March 02). Response to the forum discussion of
‘‘IAP’s’’ on the Nordic Journal Web site, http://www.hisf.no/njmt/
forumiaplist.html
Burrer, S. (1992). Musiktherapeutishe Einzelfallforschung: Rating
von 20 Improvisationsausschnitten aus einer musiktherapeutischen
Behandlung [Single case research of a music therapy process: Rat-
ing of 20 scenes of musical improvisation from music therapy].
Unpublished thesis, Fachhochschule Heidelberg.
Goodman, R. (2001). Psychometric properties of the Strengths and
Difficulties Questionnaire. Journal of the American Academy of
Child and Adolescent Psychiatry, 40, 1337-1345.
Goth, K., Cloninger, C. R., & Schmeck, K. (2003). Das Junior Tem-
perament und Charakter Inventar für das Grundschulalter—JTCI
7-11 [The Junior Temperament and Character Inventory for chil-
dren of elementary schools—JTCI 7-11]. University Clinic for
Psychiatry and Psychotherapy with children and adolescents, Uni-
versity of Frankfurt, Frankfurt am Main, Germany.
Goth, K., & Schmeck, K. (2008). Das Junior Temperament und Char-
akter Inventar: Eine Inventarfamilie zur Erfassung der Persoen-
lichkeit vom Kindergarten- bis zum Jugendalter nach Cloningers
biopsychosozialem Persönlichkeitsmodell [The Junior Tempera-
ment und Character Inventory: An inventory system for rating the
personality from nursery school up to youth according to Clonin-
ger’s Biopsychosocial Model of Personality]. Göttingen, German:
Hogrefe.
Inselmann, U., & Mann, S. (2000). Emotionales Erleben, Ausdruck
und Kommunikation in Musikimprovisationen. Eine qualitativ-
quantitative Einzelfallstudie [Emotional experience, expression
and communication in musical improvisations: A qualitative-
quantitative single case study]. Psychotherapie, Psychosomatik,
Medizinische Psychologie, 50, 193-198.
Isermann, H. (2001). Einzelfalluntersuchung einer Gruppenmu-
siktherapie mit schizophrenen Patienten [A case study of group
music therapy with schizophrenic patients]. Unpublished thesis,
Hochschule Enschede.
Maler, T. (1989). Klinische Musiktherapie. Ausdrucksdynamik,
Ratingskalen und wissenschaftliche Begleitforschung im Lue-
becker Musiktherapie-Modell [Clinical music therapy: Dynamics
of expression, rating scales and scientific research within the Lue-
beck music therapy model]. Hamburg, Germany: Dr.R.Kraemer.
Moreau, D. v. (1996). Entwicklung und Evaluation eines Beschreibungs-
systems (MAKS) zum Ausdrucks- und Kommunikationsverhalten in
der Musiktherapie [Development and evaluation of a rating system
(MAKS) on expression and social behavior in music therapy].
Unpublished thesis, University of Würzburg, Würzburg, Germany.
Moreau, D. v. (2003). MAKS: A scale for measurement of expressive
and musical behavior. Music Therapy Today, 4(4). Retrieved July
25, 2003, from http://www.musictherapyworld.net
46 David Aldridge Collected music therapy papers
Music and Medicine 2(1)
Nordoff, P., Robbins, C., Fraknoi, J., & Ruttenberg, B. (1980a).
Ratingskalen für improvisatorische Einzel-Musiktherapie. Teil I
[Rating Scales for Improvisational Individual Music Therapy: Part
I]. Musiktherapeutische Umschau, 1, 99-121.
Nordoff, P., Robbins, C., Fraknoi, J., & Ruttenberg, B. (1980b).
Ratingskalen für improvisatorische Einzel-Musiktherapie. Teil II
[Rating Scales for Improvisational Individual Music Therapy: Part
II]. Musiktherapeutische Umschau, 1, 185-202.
Pavlicevic, M. (1991). Music in communication: Improvisation in music
therapy. Unpublished dissertation, University of Edinburgh, Scotland.
Pavlicevic, M. (2007). The Music Interaction Rating Scale (schizo-
phrenia) (MIR(S)): Microanalysis of co-improvisation in music
therapy with adults suffering from chronic schizophrenia. In T.
Wosch & T. Wigram (Eds.), Microanalysis in music therapy:
Methods, techniques and applications for clinicians, researchers,
educators and students (pp. 174-185). London: Jessica Kingsley.
Pechr, M. (1996). Musikalische und psychologische Parameter in
experimenteller Therapiemusik—Depressive und Normalgesunde
im Vergleich zweier Messinstrumente [Musical and psychological
parameters in experimental therapy music—A comparison of
depressive and healthy persons using two instruments of measure-
ment]. Musiktherapeutische Umschau, 17, 115-128.
Phan, Quoc, E. (2007). Forschungsansaetze zur Operationalisierung
von emotionalem Ausdruck und Interaktion in der musikthera-
peutischen Improvisation [Research approaches to the operatio-
nalising of emotional expression and interaction in music
therapy improvisation]. Musiktherapeutische Umschau, 28,
351-361.
Plum, F. J., Lodemann, E., Bender, S., Finkbeiner, T., & Gastpar, M.
(2002). Gruppenmusiktherapie mit schizophrenen Patienten.
Entwicklung des Kontaktverhaltens, des improvisatorischen Spie-
lausdrucks und der Psychopathologie [Group music therapy with schi-
zophrenic patients: Development of social behavior, improvisational
expression and psychopathology]. Nervenheilkunde, 10, 522-528.
Remschmidt, H., Schmidt, M., & Poustka, F. (2002). Multiaxiales
Klassifikationsschema für psychische Störungen des Kindes- und
Jugendalters nach ICD-10 der WHO [Multiaxial Classification
Chart for Psychic Disorders of Children and Young Adults accord-
ing to ICD-10 of WHO]. Bern, Switzerland: Huber.
Sabatella, P. E. (2004). Assessment and evaluation in music therapy.
An overview from literature and clinical practice. music therapy
today. Music Therapy Today, 5(1). Retrieved February 6, 2006,
from http://www.musictherapyworld.net
Schumacher, K. (1999a). Musiktherapie und Saeuglingsforschung
[Music therapy and infant research]. Frankfurt am Main,
Germany: Peter Lang.
Schumacher, K., & Calvet, C. (2007). The ‘‘AQR-instrument’’
(Assessment of the Quality of Relationship)—An observation
instrument to assess the quality of a relationship. In T. Wosch &
T. Wigram (Eds.), Microanalysis in music therapy: Methods, tech-
niques and applications for clinicians, researchers, educators and
students (pp. 79-91). London: Jessica Kingsley.
Schumacher, K., & Calvet-Kruppa, C. (1999b). The AQR: An analysis
system to evaluate the quality of relationship during music therapy.
Nordic Journal of Music Therapy, 8, 180-192.
112
Moreau et al.
Steinberg, R., & Raith, L. (1985). Music psychopathology II: Assess-
ment of musical expression. Psychopathology, 18, 265-273.
Steinberg, R., Raith, L., Rossnagel, G., & Eben, E. (1985). Music
psychopathology III: Musical expression and psychiatric disease.
Psychopathology, 18, 274-285.
Tischler, B. (2000). Ist Musiktherapie empirisch begruendbar? [Is
music therapy empirically reasonable?] Musiktherapeutische
Umschau, 21, 312-323.
Vanger, P., Oerter, U., Otto, H., Schmidt, S., & Czogalik, D. (1995).
The musical expression of the separation conflict during music
therapy: A single case study of a Crohn’s disease patient. Art in
Psychotherapy, 22, 147-154.
Woerner, W., Becker, A., Friedrich, C., Klasen, H., Goodman, R.,
& Rothenberger, A. (2002). Normative data and evaluation of
the German parent-rated Strengths and Difficulties Question-
naire (SDQ): Results of a representative field study. Zeitschrift
fu¨r Kinder- und Jugendpsychiatrie und Psychotherapie, 30,
105-112.
Zahler, E. (2002). Frei improvisierte Musik in der Musiktherapie als
Medium fuer Ausdruck und Kommunikation von Emotionen. Eine
musikpsychologische Studie zur musiktherapeutischen Grundla-
genforschung [Free improvised music in music therapy as a
medium for expression and communication of emotions: A music
psychology study for music therapy basic research]. Unpublished
thesis, University of Vienna, Austria.
David Aldridge Collected music therapy papers
47
Bios
Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG),
Dipl. Psychologist, is a psychological psychotherapist with clinical
practice at the University Clinic of Child and Adolescent Psychiatry
and Psychotherapy in Würzburg and Frankfurt am Main, Germany,
and chairperson of the postgraduate music therapy training BWM at
the Freies Musikzentrum in Munich, Germany.
Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist, is a professor at the
Institute for Psychology, University of Würzburg, Würzburg,
Germany.
Kirstin Goth, Dr. phil. nat., Dipl. Psychologist, is a psychologist in
the Department of Psychiatry, Psychosomatics and Psychotherapy for
Children and Young Adults at Goethe University, Frankfurt am Main,
Germany.
Fritz Poustka, Prof. Dr. med., professor emeritus, Clinic for Psychia-
try, Psychosomatics and Psychotherapy for Children and Young
Adults at Goethe University, Frankfurt am Main, Germany.
David Aldridge, PhD, FRSM, is codirector of Nordoff-Robbins-
Zentrum, Witten, Germany.
113 47
J Autism Dev Disord (2007) 37:1264–1271
DOI 10.1007/s10803-006-0272-1
ORIGINAL PAPER
Use of Songs to Promote Independence in Morning Greeting
Routines For Young Children With Autism
Petra Kern Æ Mark Wolery Æ David Aldridge
Published online: 22 November 2006

Springer Science+Business Media, LLC 2006
Abstract This study evaluated the effects of individ-
ually composed songs on the independent behaviors of
two young children with autism during the morning
greeting/entry routine into their inclusive classrooms.
A music therapist composed a song for each child
related to the steps of the morning greeting routine and
taught the children’s teachers to sing the songs during
the routine. The effects were evaluated using a single
subject withdrawal design. The results indicate that the
songs, with modifications for one child, assisted the
children in entering the classroom, greeting the teacher
and/or peers and engaging in play. For one child, the
number of peers who greeted him was also measured,
and increased when the song was used.
Keywords Music Therapy Æ Child Care Program Æ
Inclusion Æ Autism Æ Transitioning Æ Collaborative
Consultation
P. Kern
Frank Porter Graham Child Development Institute,
University of North Carolina at Chapel Hill,
Chapel Hill, USA
M. Wolery
Department of Special Education,
Vanderbilt University, Nashville, USA
D. Aldridge
Chair of Qualitative Research in Medicine,
University of Witten-Herdecke, Witten, Germany
P. Kern (&)
School of Music, University of Windsor,
401 Sunset Avenue, Windsor, ON, N9B 3P4, Canada
e-mail: PetraKern@prodigy.net
123
David Aldridge Collected music therapy papers
Introduction
Providing early intervention services to young children
with autism spectrum disorders is supported by sub-
stantial research and program evaluation data (Dawson
& Osterling, 1997; National Research Council, 2001).
Some of this research argues for providing services in
inclusive classes in community-based programs (Strain,
McGee, & Kohler, 2001). However, for children with
autism to benefit from such placements, attention must
be given to their individualized learning needs (Strain
et al., 2001).
Children in early childhood classes experience
multiple transitions each day between activities and
routines as well as to and from the classroom. Exam-
ples are initial arrival at the classroom, engaging in
play, moving from one area of the classroom to
another, going outdoors and coming back from out-
doors, moving to a snack area, and going to a cot for
naptime (Alger, 1984; Baker, 1992). Young children
often spend large amounts of time in these classroom
transitions (Carta, Greenwood, & Robinson, 1987).
For many young children with and without autism, the
initial transition into a classroom each day can result in
crying, clinging to the caregiver, and active avoidance
of the class. Their parents and other caregivers may be
uncertain about how to respond to these behaviors
(Alger, 1984). These behaviors also may result in
similar reactions from classmates and avoidance of the
entering child (Osborn & Osborn, 1981).
Transitions, including the initial daily transition into
the class, may be difficult for young children with
autism (Dawson & Osterling, 1997; Mesibov, Adams,
& Klinger, 1997). In addition, they may lack an
understanding of symbolic gestures such as waving
114
J Autism Dev Disord (2007) 37:1264–1271
hello or good-bye or at least may engage in these
greeting behaviors less than age mates (Hobson & Lee,
1998). Recommended strategies for promoting suc-
cessful transitions of children with autism include using
(1) structure and predictable routines (Marcus, Scho-
pler, & Lord, 2001; Trillingsgaard, 1999), (2) visual
cues (Bryan & Gast, 2000; Schmit, Alper, Raschke, &
Ryndak, 2000), and (3) songs (Baker, 1992; Furman,
2001; Gottschewski, 2001; Williams, 1996).
Songs are a common occurrence in early childhood
classes and are used by a wide range of professionals for
skill promotion, entertainment, and expression of
emotions (Enoch, 2001; Furman, 2001; Humpal, 1998).
In music therapy, ‘‘hello’’ and ‘‘good-bye’’ songs are
used frequently to establish predictable routines and
structure, provide undivided attention, and communi-
cate a welcome (Bailey, 1984; Nordoff & Robbins,
1995). Using songs to promote successful transitions is
recommended for young children with autism (Furman,
2002; Humpal & Wolf, 2003; Snell, 2002), but no pre-
vious study evaluated greeting and good-bye songs on
the performance of young children with autism during
the morning arrival time.
Studies on interest in music and relative strength of
musical abilities in some children with autism
(Applebaum, Egel, Koegel, & Imhoff, 1979; Thaut,
1987, 1988) and the effectiveness of music therapy
interventions (Bunday, 1995; Kostka, 1993; Wimpory,
Chadwick, & Nash, 1995) suggest music therapy is a
viable treatment option for individuals with autism.
For instance, songs have been used to supplement the
use of social stories to support social interaction in
children with autism (Brownell, 2002; Pasiali, 2004).
Key recommendations for educating young children
with autism (e.g., individualization, structure and pre-
dictability, emphasis on strengths and individual needs)
can be incorporated in music therapy protocols or are
part of the nature of music itself (American Music
Therapy Association (AMTA), 2002). Although not
studied systematically, music therapy can include
embedding music therapy principles and strategies into
ongoing routines of children’s days using a collabora-
tive and consultative model of service delivery
(Furman, 2001, 2002; Snell, 2002).
The purpose of this study was to evaluate the effects
of individually composed greeting songs implemented
by classroom teachers on the independent performance
of two young children with autism during the morning
greeting routine. Three research questions were asked:
(1) Does the use of an individually composed song,
sung by teachers, increase appropriate independent
performance during the morning arrival routine of
young children with autism; (2) Can classroom teachers
David Aldridge Collected music therapy papers
1265
apply the principles important to music therapy in a
particular routine, and (3) Does use of the song
increase interactions between the child with autism and
his peers?
Method
Participants
Two boys, Phillip and Ben, with autism participated in
the study. Phillip was a 3 year 5 month-old African
American, and Ben was a 3 year 2 month-old Euro-
pean American. Licensed psychologists who were not
involved in the study used the DSM-IV criteria
(American Psychiatric Association, 2000) when estab-
lishing their diagnoses. On the Childhood Autism
Rating Scale (Schopler, Reichler, & Renner, 1988),
both boys were placed in the mild to moderate range.
Prior to the study, Phillip and Ben had been enrolled
for 10 months in an inclusive community-based child
care program affiliated with an university. They were
selected for the study on the request of their parents
and classroom teachers and therapists.
Both boys had limited speech, and the Picture
Exchange Communication System (PECS) (Bondy &
Frost, 1994) was being used. Ben was beginning to use
a few functional words. Phillip and Ben showed limited
social interactions with peers, played primarily when
supported by adults, and engaged in stereotypic
behaviors. Both children exhibited difficulties with
transitions, although objects were used successfully
with some transitions other than the morning arrival
transition. The morning arrival transition was prob-
lematic for both boys. Phillip would refuse to enter the
classroom, scream, or lie on the floor. Ben would hold
on to his caregiver, cry, and ignore efforts of the
teachers to welcome him. Phillip and Ben were inter-
ested in and responded well to music. They preferred
listening to selected musical pieces, and participated in
classroom musical activities.
Other participants included the target children’s
classmates with parental consent (n = 13), the target
children’s respective caregivers (n = 2), and classroom
teachers (n = 5). The class size of Phillip’s class was
seven children (including him) ages 2 to 3 years and
included both males and females from different ethnic
groups. Five of his classmates were developing typi-
cally, and one had disabilities. Ben’s class had eight
children (including him) ages 3 to 4 years and
included both males and females from different ethnic
groups. Five of the children were developing typically
and two had disabilities. All adults in the classroom
123
115
1266
participated based on their schedules, which included
staggered start times to cover the entire child care
day. They had diverse educational backgrounds,
ranging from high school diploma to Baccalaureate
degree with certification in early childhood education.
Their teaching experience ranged from 1 to 4 years.
Phillip and Ben’s caregivers (a mother and nanny,
respectively) participated in the study on a daily basis
by bringing them to their classrooms and participating
in the greeting time procedures. The teachers and
caregivers did not have prior experience with music
therapy interventions.
Setting
The inclusive university-affiliated child care program in
which the study occurred held accreditation from the
National Association for the Education of Young
Children (NAEYC) and the State’s highest quality
ranking for child care programs. The classrooms
followed the recommended practice guidelines of
NAEYC (Bredekamp & Copple, 1997) and the Divi-
sion for Early Childhood (Sandall, McLean, & Smith,
2000). Specialists such as music therapists, occupa-
tional therapists, speech language pathologists, physi-
cal therapists or special educators worked with the
individual child or a group of children in the ongoing
classroom routines or as a consultant to the classroom
teachers (McWilliam, 1996). Cubbies for children to
place their personal items were located in the hall
outside each classroom.
The study occurred during the morning greeting
routine. In the mornings, children arrived individually
over a 1.5 h period. The usual routine was for each
child, and his/her parent, to place personal items in the
child’s cubby and then enter the classroom together.
All children would be greeted by, and greet, the tea-
cher and peers, then engage in play. The classroom
curriculum allowed free play during the morning arri-
val time. Children engaged in different play areas by
themselves or with each other. The parents signed the
child in and had a brief conversation with the teacher
before saying ‘‘good-bye’’ to the child and leaving the
classroom.
Materials
Before the study, the teachers used a laminated picture
(10 · 10 cm) communication symbol (Mayer-Johnson,
1992) showing a waving stick figure and the word
‘‘Hello’’ printed on the top using 18 pitch letters and
the Arial font. This symbol was used in the study to
assist the target participants in greeting classroom
123
David Aldridge Collected music therapy papers
J Autism Dev Disord (2007) 37:1264–1271
teachers and peers, regardless of their language and
communication skills when entering the classroom in
the morning.
The first author composed a greeting song unique to
each target participant.1 The music was composed to
match each child’s personality with the lyrics convey-
ing the demands of the desired five-step morning
greeting routine (see below). To emphasis the
detachment from the caregiver, step four, which
reflected the ‘‘good-bye’’ part, differed musically in
melody and mood from the other steps. All other steps
followed the same melody, but used different lyrics.
Some of the lyrics were flexible to allow the children
to choose different peers and describe the daily
weather condition. A practice CD containing the song
and the song transcriptions were given to the teachers
and caregivers during a staff/caregiver training session.
The intention of the songs for both children was to
ease the transition from home to school, to increase
their independent performance (i.e., independent
functioning) during the five-step morning greeting
routine, and to support their interaction with peers
(i.e, engaging in greeting peers).
Design
Single subject research designs were used. For Phillip,
an A-B-A-B withdrawal design (Aldridge, 2005;
Tawney & Gast, 1984) was used. The baseline con-
dition (A) consisted of the existing greeting routine,
and the treatment (B) involved using the song during
the greeting routine. For Ben, a modification of this
design was used; specifically, an A-B-C-A-C design.
The baseline (A) was the existing greeting routine,
the treatment (B) was the use of the song during the
greeting routine, and the C condition was a modifi-
cation of the song. Staff/caregiver training activities
occurred prior to baseline measures.
Baseline Condition (A)
In the baseline condition, the child and caregiver
entered the center, placed the child’s belonging in his
cubby in the hallway, and picked up the picture
symbol showing the stick figure waving ‘‘Hello,’’
which was attached with Velcro to the child’s cubby.
They then entered the classroom, and a classroom
teacher initiated the greeting routine, which was
similar to that used with classmates. Five steps were
followed: (1) the target child enters the classroom
1
Interested readers can contact the first author to get a music
score.
116
J Autism Dev Disord (2007) 37:1264–1271
independently; (2) the target child greets a person
(teacher or peer) in the classroom verbally and/or
hands over the picture symbol; (3) the target child
greets a second person (teacher or peer) in the
classroom verbally and/or hands over the picture
symbol; (4) the target child says/waves ‘‘good-bye’’ to
the caregiver, who leaves the classroom; and (5) the
target child engages in appropriate play with a toy or
material found in the classroom. A system of least
prompts (Wolery, Ault, & Doyle, 1992) was used to
assist the target child in responding independently to
each step of the greeting routine and ensure the child
completed each step of the routine.
Staff/Caregiver Training Activities
Initially, the first author consulted with the caregivers
and teachers to identify realistic intervention goals and
acceptable procedures for use in the greeting routine.
Before baseline measures, she composed and recorded
the individual songs, and gave them to the caregivers
and teachers. During a circle time in the children’s
classrooms, the first author led the children and
teachers in learning and singing the songs. She also
gave precise instructions to the teachers and caregivers
about how to approach and assist the target children in
greeting and interacting with peers musically. The
teachers were encouraged to include all peers who
would come forward voluntarily to greet the target
child in the greeting routine during all phases (baseline,
intervention, and reversal). Staff training ended after
2 weeks when the teachers and respective caregiver
sang the song correctly and indicated that they were
comfortable with the procedures.
Intervention (B)
In the intervention condition, the procedures used in
the baseline were continued. The only change was the
use of each child’s greeting song. The songs had lyrics
matching each of the five steps of the greeting routine.
The teacher began singing the song as the child entered
the classroom, and sang the lyrics for each step as it
was occurring.
Modified Intervention (C)
For Ben, the number of independently completed steps
did not change substantially with the introduction of
the song. Based on an analysis of the situation, we
concluded Ben began to cry when separating from his
caregiver and this interfered with independent perfor-
mance of the steps. Thus, the fourth step (saying
David Aldridge Collected music therapy papers
1267
‘‘good-bye’’) was eliminated, and his caregiver left the
classroom as Ben entered it. Other procedures
remained the same.
Response Definitions and Measurement
Two adult behaviors and five child behaviors were
measured through direct observation using event
recording. Data were collected during morning arrival
time, when the teachers and peers were present. The
observation started when the target child and his
caregiver entered the classroom. The observation
ended when the target child picked up a toy/material in
the classroom, even if he had not said ‘‘hello’’ or
‘‘good-bye.’’ Data collection sessions lasted between 2
and 10 min. Phillip was observed for a total of 28 ses-
sions across 2 months. Data collection for Ben was
initiated 5 months later, and occurred in 31 sessions
over 3 months.
The adult behaviors were: Prompting was defined as
a teacher or caregiver assisting the child in performing
a step in the routine. This assistance was either verbal
(e.g., ‘‘Say, Hello’’) or physical (e.g., the adult put her
hand on the child to help in the exchange of the pic-
ture). No adult prompt was defined as the teacher or
caregiver not giving a prompt for a step of the greeting
routine.
The child behaviors for each step of the routine
were as follows. Independent response was defined as
the child performing the behavior required in each
step of the routine without any adult assistance.
Prompted response was defined as the child perform-
ing the step of a routine but receiving adult prompt to
do so. No response was defined as the child not
responding, even when prompted. Error was defined
as the child either not following the sequence of the
routine or engaging in an appropriate behavior not
prescribed by the routine, and Inappropriate response
was defined as the child engaging in problematic
behavior (i.e., tantrums). These categories were coded
for each of the five steps of the morning greeting
routine. An additional category was added for Ben to
identify the number of classmates with and without
disabilities who greeted him independently during the
routine. This category was added because of informal
observations with Phillip indicating peer greeting
behavior changed during the course of the interven-
tion. The number of peers greeting independently was
defined as peers receiving the ‘‘Hello’’ symbol from
Ben without verbal or physical prompting from an
adult. Some observations were videotaped with a
Panasonic AG-195 Camcorder and analyzed immedi-
ately afterwards.
123
117
1268 J Autism Dev Disord (2007) 37:1264–1271

Observer Training and Interobserver Agreement Phillip’s performance steadily moved toward indepen-
dence. After 10 sessions in intervention, Phillip’s per-
Before the baseline condition, a music therapist (first formance appeared consistent, as evidenced by three
author), a special educator and a research assistant consecutive sessions with four independent steps at the
observed and recorded the behaviors of teachers and same level; thus, the intervention was withdrawn.
children in the morning greeting routine. Training was Phillip’s performance immediately decreased and by
concluded when inter-observer agreement was at 80% the second day of the second baseline condition, his
for three consecutive observations. During the study, performance returned to the initial baseline levels with
inter-observer agreement checks occurred in a mean of two independent steps (again entering the classroom
22% of the observations for each condition and child. and finding a toy to play with). After three days, the
The percentage of agreement was calculated using the song intervention was re-introduced. Immediately,
point-by-point method (Tawney & Gast, 1984). The Phillip’s performance increased. After four sessions,
number of agreements were divided by the number of Phillip’s performance was equal to his performance at
agreements plus disagreements with the quotient the end of the initial intervention condition. His per-
multiplied by 100. Overall, inter-observer agreement formance remained steady at this level until the ninth
ranged from 75 to 100%, with a mean of 94%. session of intervention where Phillip performed all of
the steps of the routine independently.

Results Ben

Phillip In the initial baseline condition, Ben’s performance was

stable as shown in Fig. 2. In the majority of the sessions,
During the initial baseline condition, Phillip’s perfor- he had one independent step completed, entering the
mance was stable as shown in Fig. 1. In all sessions classroom independently. On session four of the first
except the fourth, Philip completed two steps of the baseline condition, Ben did three independent steps.
routine independently. In the fourth session, he did not With the introduction of the song intervention, Ben’s
do any step independently. The steps he did indepen- performance was variable. Ben responded in the
dently were entering the classroom and finding a toy majority of sessions with one independent response, as
with which to play. With the introduction of the song in the baseline condition. In four of 12 mornings, Ben
intervention, Phillip’s performance initially dropped to completed more than one of the steps independently.
one step independently (entering the classroom), but Given the lack of substantial change in his performance,
after two days of song intervention, Phillip’s perfor- the ‘‘good-bye’’ step was eliminated and the caregiver
mance was back at baseline level. By the forth day of left the classroom as he entered (Condition C). This
intervention, Phillip’s performance was above baseline produced an abrupt and sharp increase in the number of
level and by the sixth session, Phillip’s performance steps completed independently. He consistently had
was consistently higher than the baseline level. The three of four steps done independently. After five ses-
trend during the intervention condition indicates sions of stable performance, the intervention was

Baseline Intervention Baseline Intervention

Number of Independent Responses

5
Baseline Intervention Modified Baseline Modified
Number of Independent Responses

Intervention Intervention
5
4

4
3
3
2
2

1
1

0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Sessions Sessions

Fig. 1 Number of independent responses performed by Phillip Fig. 2 Number of independent responses performed by Ben
during the morning greeting routine in baseline and intervention during the morning greeting routine in baseline, intervention,
sessions and modified intervention sessions

123
David Aldridge Collected music therapy papers 118
J Autism Dev Disord (2007) 37:1264–1271
withdrawn. An immediate decrease in his independent
behavior occurred. With the re-introduction of the
intervention, the data resulted in an abrupt and sharp
increase in the number of independent steps. Ben
completed all four steps independently. This high level
of performance was stable during the last condition.
The number of peers who greeted Ben without adult
prompting are shown in Fig. 3. During the initial
baseline condition, no peers greeted Ben during the
greeting routine. With the use of the song intervention,
two peers greeted him independently on 9 of 12 days,
and four, three, and one peer greeted him on the
remaining days. With the modified intervention, two
peers greeted him on three of five days, but on one day
no peers greeted him and on the other day, one peer
greeted him. The removal of the song in the second
baseline resulted in more variable data. Two peers
greeted him independently on two of five days; on the
second day, three peers greeted him, but on the last
two days, one peer greeted him. The reintroduction of
the modified intervention resulted in two peers greet-
ing him on three of four days, with one peer greeting
him on the first day of the condition. Thus, initiation of
the song intervention resulted in an increase in the
number of peers greeting Ben, but withdrawal of the
song in the second baseline did not result in data pat-
terns similar to the first baseline. Neither the modifi-
cation of the intervention nor the withdrawal of the
song intervention returned the peers’ behavior to
baseline conditions, with the exception of one day.
Discussion
This study evaluated the effects of embedding a music
therapy intervention (using original greeting songs) in
the morning arrival routine on the independent func-
tioning of two young boys with autism. It also examined
5 Baseline
Number of Peers Greeting Ben
4 outcomes, but future research should examine this
3 difficulty with this step such as the lack of under-
2
1 staff development activities and ongoing collaborative
0
0 2 4 6
Fig. 3 Number of peers greeting Ben during the morning
greeting routine in baseline, intervention, and modified inter-
vention sessions
David Aldridge
1269
whether teachers could implement the songs in the
context of that routine after receiving consultation and
training from a music therapist; and, finally, whether use
of the songs influenced classmates’ greetings to one
target child. As shown, the data support the use of
individualized songs implemented in this manner to
facilitate independent entry into classrooms. As such, it
adds to the literature on how to include young children
with autism in inclusive classrooms (Strain et al., 2001).
In this study, individualized greeting songs matching the
participants’ personality (based on the music therapist’s
judgments) and the demands of the morning greeting
routine were effective in facilitating a smooth transition
from home to the child care program. These findings
support the recommendation to use songs to ease
transitioning for individuals with autism (Baker, 1992;
Furman, 2001; Gottschewski, 2001).
These effects occurred, with the teacher rather than
the music therapist implementing the songs in the
morning greeting routine. The teachers did not use
songs for this purpose prior to this study, did not know
the songs until they were taught by the music thera-
pists, and did not have formal musical training or
experience with music therapy interventions. In addi-
tion, the training time was relatively short. This study
replicates and extends earlier studies showing that
classroom teachers can embed intervention strategies
successfully into ongoing routines, when training and
monitoring were provided (Kemmis & Dunn, 1996;
Venn et al., 1993). However, despite their success,
teachers were challenged with parts of the musical
characteristics of the songs. For example, in both cases
the teachers did not implement the change in music
indicating the good-bye part of the songs (step four of
the greeting routine). Interestingly, and perhaps coin-
cidentally, it was exactly this part that distressed both
target children. This raises the question if the imple-
mentation of the change in music signaling the ‘‘good-
bye’’ part would have changed the target children’s
performance during this step. No data are available to
Intervention Modified Baseline Modified
suggest the change in the music would produce positive
Intervention Intervention
possibility. Other explanations exist for the children’s
standing of conventional gestures and the fact that it
signaled the caregiver leaving. Clearly, high quality
consultation seem to be critical components for
8 10 12 14 16 18 20 22 24 26 28 30 32 appropriate and successful implementation of teacher-
Sessions mediated interventions using music therapy principles.
In this study, maintaining teacher’s comfort level,
motivation, and monitoring of the teachers’ use of the
procedures were needed.
123
Collected music therapy papers 119
1270
The use of the songs also potentially had positive
effects on peers’ greeting behavior and interaction
toward the target children. This was noted informally
for Phillip and then measured formally for Ben. Peers
volunteered in singing and greeting the target children
during their morning arrival time, or participated by
giving their input to the song (e.g., statements about
the weather condition) while engaging in other activi-
ties. The song intervention seemed to pique the inter-
est of peers and evoke a positive view toward Ben. This
change seemed to be affected by the intervention alone
and was not contingent on Ben’s performance. That is,
the greeting song motivated the peers to interact with
Ben, but his performance did not change until after the
peers had regularly greeted him. However, the number
of peers greeting him did not return to the levels of the
initial baseline during the second baseline condition.
The teachers, parents of the target children, and
parents of other classmates reported the intervention
was effective and valuable. The mother of one of
Phillip’s peers said that before the intervention her
child was intimidated by Phillip’s inappropriate
behavior at greeting time. With the implementation of
the song, this classmate ran to school hoping to arrive
before Phillip so he could participate in Phillip’s
greeting song. Phillip’s mother reported she was very
pleased by the success of the intervention and
requested further songs for other challenging situa-
tions. Ben’s caregiver said: ‘‘I think this was perfect for
Ben. He had a hard time leaving me in the mornings,
but with the help of the Good Morning Song the
transition became much easier for Ben.’’ After evalu-
ating the song intervention with Phillip’s classroom
teacher, she came to the following conclusion: ‘‘Tran-
sitions into the classroom were stressful for the chil-
dren, parents, and teachers. The Hello Song allowed us
to implement a simple intervention each day. The song
is great, and helped all of us tremendously.’’ These
comments, the teachers willingness to use the song
intervention within daily classroom routines, and the
request for new songs addressing other challenging
behaviors (i.e., waiting and hand washing) is some
evidence of the social validity of the procedures and
effects.
This study has several limitations; for example, only
two participants were studied because of their need for
intervention during the morning arrival time. Replica-
tion of this study for additional participants is recom-
mended. Further, for Ben, a modification was needed
before the song was successful. Thus, it is unclear
whether the modified intervention would have been
effective if Ben had not experienced the original inter-
vention. Also, the music therapist composed original
123
David Aldridge Collected music therapy papers
J Autism Dev Disord (2007) 37:1264–1271
songs for each child; thus, these data do not indicate
whether a teacher, without assistance from a music
therapist, could adapt a pre-composed song (referred to
as the ‘‘Piggybacking’’ technique) and produce similar
results. Another limitation concerns the lack of mainte-
nance and generalization data.
This study suggests future studies should focus on
the effects of songs in other challenging routines for
young children in inclusive classes. Similarly, studies
focusing on using songs to promote other skills (e.g.,
social and communicative abilities) should be imple-
mented. Finally, systematic studies of the effects of
songs designed for young children with autism should
contain measures of the effects on their peers. Do such
songs change the behaviors and attitudes of peers
toward their classmates who have autism?
Acknowledgement This study is a part of a series of single case
studies investigating embedded music therapy interventions for
the inclusion of young children with autism spectrum disorders in
a community-based, university-affiliated Family and Child Care
Program. The authors wish to acknowledge Dr. Ann N. Garfinkle
for her contributions to the study. Gratitude also goes to the
children and families, teachers and colleagues for their partici-
pation, dedication, and collaboration in this study.
References
Aldridge, D. (Ed.) (2005). Case study designs in music therapy.
London, England; Bristol, PA: Jessica Kingsley Publishers.
Alger, H. A. (1984). Transitions: Alternatives to manipulative
management technique. Young Children, 39(6), 16–25.
Applebaum, E., Egel, A. L., Koegel, R. L., & Imhoff, B. (1979).
Measuring musical abilities of autistic children. Journal of
Autism and Developmental Disorders, 9, 279–285.
American Association of Music Therapy (AMTA) (2002). Music
therapy and individuals with diagnosis on the autism spec-
trum. Retrieved February 12, 2005 from the Internet: http://
www.musictherapy.org/factsheets/autism.html.
American Psychiatry Association (APA) (2000). Diagnostic and
statistical manual of mental disorders (4th ed.), Text Revi-
sion. Washington, DC: Author.
Baker, B. S. (1992). The use of music with autistic children.
Journal of Psychosocial Nursing Mental Health Service,
20(4), 31–34.
Bailey, L. M. (1984). The use of songs in music therapy with
cancer patients and their families. Journal of Music Therapy,
4, 5–17.
Bredekamp, S., & Copple, C. (Eds.). (1997). Developmentally
appropriate practice in early childhood programs (Rev. ed.).
Washington, DC: National Association for the Education of
Young Children.
Brownell, M. K. (2002). Musically adapted social stories to
modify behaviors in students with autism: Four case studies.
Journal of Music Therapy, 39, 117–144.
Bryan, L. C., & Gast, D. L. (2000). Teaching on-task and on-
schedule behaviors to high-functioning children with autism
via picture activity schedules. Journal of Autism Develop-
ment Disorder, 30, 553–567.
120
J Autism Dev Disord (2007) 37:1264–1271
Bondy, A. S., & Frost, L. A. (1994). The picture exchange
communication system. Focus on Autism, 9, 1–19.
Bunday, E. M. (1995). The effects of signed and spoken words
taught with music on sign and speech imitation by children
with autism. Journal of Music Therapy, 32, 189–202.
Carta, J. J., Greenwood, C. R., & Robinson, S. (1987). Appli-
cation of an eco-behavioral approach to the evaluation of
early intervention programs. In R. Prinz (Ed.), Advances in
the behavioral assessment of children and families (Vol. 3,
pp. 123–155). Greenwich, CT: JAI Press.
Dawson, G., & Osterling, J. (1997). Early intervention in autism.
In M. J. Guralnick (Ed.), The effectiveness of early inter-
vention (pp. 307–326). Baltimore: Paul H. Brookes.
Enoch, A. (2001). Let’s do it again. All Together Now! (ATN),
7(1), 5–7.
Furman, A. (2001). Young children with autism spectrum dis-
order. Early Childhood Connections, 7(2), 43–49.
Furman, A. (2002). Music therapy for learners in a community
early education public school. In B. L. Wilson (Ed.), Models
of music therapy interventions in school settings (2nd ed.,
pp. 369–388). Silver Spring, MD: The American Music
Therapy Association, Inc.
Gottschewski, K. (2001). Autismus aus der Innenperspektive und
Musiktherapie [Autism from an inside-out perspective and
music therapy]. In D. Aldridge (Ed.), Kairos V: Musikther-
apie mit Kindern: Beitraege zur Musiktherapie in der Medi-
zin (pp. 40–57). Bern; Goettingen; Toronto; Seattle: Verlag
Hans Huber.
Hobson, R. P., & Lee, A. (1998). Hello and goodbye: A study of
social engagement in autism. Journal of Autism and Devel-
opmental Disorders, 28, 117–127.
Humpal, M. E. (1998). Information sharing: Song repertoire of
young children. Music Therapy Perspectives, 19, 37–38.
Humpal, M. E., & Wolf, J. (2003). Music in the inclusive envi-
ronment. Young Children, 58, 103–107.
Kemmis, B. L., & Dunn, W. (1996). Collaborative consultation:
The efficacy of remedial and compensatory interventions in
school context. The American Journal of Occupational
Therapy, 59, 709–717.
Kostka, M. J. (1993). A comparison of selected behaviors of
students with autism in special education and regular music
classes. Music Therapy Perspectives, 11, 57–60.
Mayer-Johnson, R. (1992). The picture communication symbols.
Solana Beach, CA: Mayer-Johnson, Co.
Marcus, L., Schopler, E., & Lord, C. (2001). TEACCH Services
for preschool children. In J. S. Handelman & S. L. Harris
(Eds.), Preschool education programs for children with
autism (2nd ed., pp. 215–232). Austin, TX: Pro-Ed.
McWilliam, R. A. (Ed.) (1996). Rethinking pull-out services in
early intervention: A professional resource. Baltimore, MD:
Paul H. Brookes.
Mesibov, G. B., Adams, L., & Klinger, L. (1997). Autism:
Understanding the disorder. NY: Plenum Press.
National Research Council (2001). Educating children with aut-
ism. Committee on educational interventions for children
David Aldridge Collected music therapy papers
1271
with autism. Division of Behavioral and Social Science and
Education. Washington, DC: National Academy Press.
Nordoff, P., & Robbins, C. (1995). Greetings and goodbyes: A
Nordoff-Robbins collection for the classroom use. Bryn
Mawr, PA: Theodore Presser.
Osborn, K., & Osborn, D. (1981). Discipline and classroom
management. Athens, GA: Education Association.
Pasiali, V. (2004). The use of prescriptive therapeutic songs in a
home-based environment to promote social skills acquisi-
tion by children with autism: Three case studies. Music
Therapy Perspectives, 22(1), 11–20.
Sandall, S., McLean, M. E., & Smith, B. J. (2000). DEC: Rec-
ommended practices in early intervention/early childhood
special education. Longmont, CO: Sopris West.
Schmit, J., Alper, S., Raschke, D., & Ryndak, D. (2000). Effects
of using a photographic cueing package during routine
school transitions with a child who has autism. Mental
Retardation 38, 131–137.
Schopler, E., Reichler, R., & Renner, B. (1988). The Childhood
Autism Rating Scale (CARS). Los Angeles, CA: Western
Psychological.
Snell, A. M. (2002). Music therapy for learners with autism in a
public school setting. In B. L. Wilson (Ed.), Models of music
therapy interventions in school settings (2nd ed., pp. 211–275).
Silver Spring, MD: The American Music Therapy Associa-
tion.
Strain, P. S., McGee, G. G., & Kohler, F. W. (2001). Inclusion of
children with autism in early intervention environments. In
M. J. Guralnick (Ed), Early childhood inclusion: Focus on
change (pp. 337–363). Baltimore: Paul Brookes.
Tawney, J. W., & Gast, D. L. (1984). Single subject research in
special education. Columbus: Merrill.
Thaut, M. H. (1987). Visual versus auditory (musical) stimulus
preferences in autistic children: A pilot study. Journal of
Autism and Developmental Disorders, 17, 425–432.
Thaut, M. H. (1988). Measuring musical responsiveness in
autistic children: A comparative analysis of improvised
musical tone sequences of autistic, normal and mentally
retarded individuals. Journal of Autism and Developmental
Disorders, 18, 561–571.
Trillingsgaard, A. (1999). The script model in relation to autism.
European Children Adolescence Psychiatry, 8(1), 45–49.
Venn, M. L., Wolery, M., Werts, M. G., Morris, A., DeCesare,
L. D., & Cuffs, M. S. (1993). Embedding instruction in art
activities to teach preschoolers with disabilities to imitate
their peers. Early Childhood Research Quarterly, 8, 277–294.
Williams, D. (1996). Autism: An inside-out approach. London,
Bristol, PA: Jessica Kingsley.
Wimpory, D., Chadwick, P., & Nash, S. (1995). Brief report:
Musical Interaction Therapy for children with autism: An
evaluative case study with two-year follow-up. Journal of
Autism and Developmental Disorders, 25(5), 541–552.
Wolery, M., Ault, M. J., & Doyle, P. M. (1992). Teaching students
with moderate and severe disabilities: Use of response
prompting strategies. White Plains, NY: Longman.
123
121
 The Arts in Psychotherapy, Vol. 20, pp. 285-297, 1993
Printed in the USA. All rights reserved.
HOPE, MEANING AND THE CREATIVE ARTS THERAPIES IN THE
TREATMENT OF AIDS
DAVID ALDRIDGE, PhD*
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 (in Rabinow, 1986, p. 350)
The general proposal of this paper is that the cre-
ative arts therapies have a significant role to play in
the treatment of AIDS patients. Not only do they offer
an existential form of therapy that accepts patients as
they are and affords them an opportunity to define
themselves as they wish to be, they are primarily
concerned with aesthetic issues of form and existen-
tial notions of potential rather than concepts of pa-
thology. That the persons are infected with a virus
recalcitrant to medical initiatives is a given and is
inarguable. What the persons will become and how a
personal future is defined, a future admittedly re-
stricted and often tragically curtailed, are matters for
joint therapeutic endeavor between therapists and pa-
tients and are not accessible to a normative medical
science (Aldridge, 199la).
The end stage of our therapeutic endeavor is that
the patients will die. This raises important questions
about the nature and goals of therapy, with important
implications for establishing the criteria for measuring
or assessing the efficacy of our therapeutic endeavors.
Many of the considerations we need to make, partic-
ularly with the dying, are not amenable to operational
*David Aldridge is Associate Professor of clinical research methodology in the medical faculty of Universitat Witten Herdecke, Germany,
and European Editor of The Arts in Psychotherapy.
285
David Aldridge Collected music therapy papers
0197-4556193 $6.00 + .OO
Copyright 0 1993 Pergamon Press Ltd.
definition and thereby elusive to measurement (Feifel,
1990). However, they are amenable to artistic expres-
sion in that they can be written as poetry, acted as
drama, moved as dance, drawn, sculpted and painted
as art, told as stories and played as music.
Creative arts therapies (music therapy, art therapy,
dance therapy, drama therapy and poetry therapy)
have been developed for use in predominantly psy-
chotherapy settings. Some creative arts therapists
have developed the work with the dying in hospice
settings (Dessloch, Maiworm, Florin, & Schulze,
1992; Frampton, 1989) and Lee (199 1) has developed
the use of music therapy both with cancer patients in
the hospice setting and with AIDS patients.
The following sets out some considerations that we
may wish to incorporate into our treatment and re-
search initiatives. As the treatment of AIDS patients
occurs predominantly in a medical setting, it is nec-
essary to present some of the medical understandings
of the problem in the first part of this paper. Those
medical understandings, however, are partial. Medi-
cine is a restricted set of practices from the repertoire
of our possible healing strategies. What we also need
are understandings gained from existential psychol-
ogy and the creative arts themselves. Such under-
standing~will be attempted in the latter part of this
paper.
AIDS Definition
AIDS (Acquired Immunodeficiency Syndrome) is
clinically complex. The process begins with infection
122
 286 DAVID ALDRIDGE
through the bloodstream with the Human Immunode-
ficiency Virus (HIV). Initially there are no obvious
symptoms. However, after about 4 weeks flu-like
symptoms may occur, indicating an immune reaction.
This reaction is the body's normal way of removing
infections. What then occurs is the most dangerous
part of the viral activity that makes HIV so intractable
to treatment. The immune system is in part composed
of "helper cells." It is these cells that act as a host to
the virus which then changes their structure. Every
time an immune reaction occurs in the body the virus
is replicated. What was formerly "helping" is now
"infecting. " However, it must be stressed that not all
HIV-infected patients will undergo this process of se-
roconversion (i.e., changed immune status).
The stage is set for the development of AIDS, the
development of which varies from individual to indi-
vidual. As the immune system deteriorates there are
increasing possibilities for opportunistic infections. It
is often these infections from which the patient even-
tually dies. As a condition, AIDS was characterized
by the following symptoms: (a) common infections,
like pneumonia, to which the body has no immunity,
(b) the development of malignancies like rare skin
cancers and (c) neurological disorders sometimes
leading to dementia. However, a new AIDS definition
has been proposed by The Centers for Disease Control
in the United States regardless of symptomatic ex-
pression to include those people who are seropositive
for HIV and have a particular white blood cell count
(CD4 T-lymphocyte) of less than 200Ipl (Editorial,
1992; Nelson, 1992). The result of such a decision for
research is that it will be easier to define cases. In
practice such a decision means that the incidence of
AIDS will rise sharply. Recently new AIDS indica-
tors of the disease have been recognized as pulmonary
tuberculosis, recurrent bacterial pneumonia and inva-
sive cervical cancer. The inclusion of pulmonary tu-
berculosis has "more to do with efforts to control
tuberculosis among HIV-infected populations than its
value as an indicator of severe immunodeficiency"
(Editorial, 1992 p. 1200; Nelson, 1992). We see here
that even in the apparently simple process of case
definition, considerations of social control are raised,
echoing the stigmatization of tuberculosis patients in
the earlier part of this century.
Immunity, Life Events and Social Context
AIDS is how the immune system reacts between
viral infection and the development of AIDS and is
David Aldridge Collected music therapy papers
dependent upon the individual. However, the social
and psychological conditions in which the infected
persons live are also contributing factors to the devel-
opment of AIDS. As we are now becoming increas-
ingly aware of the influence of lifestyle upon immune
capabilities (Ader, 1987; Darko, 1986; Solomon,
1987), it is in this arena of contact that we may be best
able to offer therapeutic help. An already weakened
system is further weakened by the threat of a lingering
death, social isolation and condemnation. The contact
between arts therapists and patient is the opposite to
that of isolation in that it offers the patient the chance
to be a partner in a creative process that is without
stigmatization.
There is a considerable bodv of work on the rela-
tionship between life events and psychological disor-
der, which has been extended to working with AIDS
patients (Atkins & Amenta, 1991; Blaney et al.,
1991; Dew, Ragni, & Nimorwicz, 1991; Ross, 1990).
In a study to determine the extent to which stigmati-
zation influences mental health in 80 homosexual
men, there were significant associations between life
events and mental health. Events related to AIDS had
the highest correlations (Ross, 1990). Ross suggested
that the impact of life events may be amplified by
stigmatization and that degree of life change is asso-
ciated closely with psychological dysfunction. He
concluded that life events, which are related to both
stigmatization and related emotional distress, are sig-
nificant predictors of psychological dysfunction.
For every patient living with the diagnosis of AIDS
or a positive HIV test result this means a turning point
in his or her life. It is existential uncertainty and un-
predictability that lie at the root of post diagnostic
problems. Although the need for early treatment is
evident, this also means a personal exposure to social
scrutiny. AIDS is seen as threatening, as is no other
current disease. This is in part exacerbated by infor-
mation campaigns. Once the diagnosis is made, the
whole texture of social life and intimate relationships
changes radically. Any future perspective on life is
inhibited by the possibility of repetitive stays in hos-
pital and a deteriorating physical and mental status.
Physical problems go hand in hand with emotional
problems, and these occur in a context of personal
relationships. The consideration of physical, emo-
tional and relational problems together is sometimes
known as the biopsychosocial model (Engel, 1977;
Sadler & Hulgus, 1990). Using such a model, Wolf et
al. (1991) evaluated 29 symptomatic and asymptom-
atic HIV-infected homosexual/bisexual men between
123
 CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS
18 and 45 years old in the areas of psychiatric1
psychosocial, neuropsychological, family and irnrnu-
nological functioning. The outcome measures were
mood disturbance, psychological distress and white
blood cell count (CD4). The most significant other
family member, as selected by each subject, com-
pleted family measures. The subjects experienced
psychological distress and neuropsychological prob-
lems. Coping was related to enhanced mood as was
perceived social support, which was also related to
lower psychological distress. Higher levels of neuro-
psychological functioning (verbal memory, visual
memory, motor speed and visual-motor sequencing)
were associated with enhanced psychosocial function-
ing andlor immunological status. The authors con-
cluded that it is important then to make longitudinal
studies using a multidimensional approach in which
HIV-infected persons and their most significant other
family members are evaluated.
The suicide rate in persons with AIDS is signifi-
cantly higher than in the general population (Cohen,
1990; Grant & Hampton Atkinson, 1990). Grant
(Grant & Hampton Atkinson, 1990) remarked that
although some subgroups of HIV-positive individuals
(e.g., military samples) may be at heightened risk for
suicide, systematic studies showing an increased risk
for suicide are lacking. Schneider considered suicidal
ideation among relatively asymptomatic HIV-positive
gay men as a cognitive coping strategy that may al-
leviate emotional distress (Schneider, Taylor, Ham-
men, Kemeny, & Dudley, 1991). Certainly the pic-
ture is complex. Risk factors for suicide in the general
population include hopelessness, impulsivity, sub-
stance abuse disorder, recent illness, recent hospital-
ization, depression, living alone and inexpressible
grief. These factors are present in particular AIDS
patients who are depressed, lonely and isolated and at
high risk for suicide. Marital break-up or a failing
relationship that eventually ceases is a significant fea-
ture leading to such loneliness. As Blaney remarked
(Blaney et al., 1991), the lack of social support is a
strong predictor of psychological distress and is im-
plicated in the control of chronic disease. Suicidal
behavior may be the end stage of a process of increas-
ing psychological distress related to both failing
health status, because of increasing symptoms, and
increasing isolation.
Help-Seeking
In a longitudinal survey of help-seeking and psy-
chological distress among San Francisco gay men
David Aldridge Collected music therapy papers
287
(Hays, Catania, McCusick, & Coates, 1990), those
men reported high levels of anxiety, depression and
help-seeking from their social networks. High per-
centages of AIDS-diagnosed men sought help from all
sources (peers, professionals, family), whereas non-
diagnosed men were more likely to seek help from
peers. Regardless of the men's HIV status, peers were
perceived to be the most helpful source. Family mem-
bers were less likely sought and were perceived as
least helpful. However, in other studies, family and
friends appear to play an important, if sometimes am-
biguous, role in caregiving. The psychological burden
of the families and health workers involved in their
treatment of AIDS patients is probably greater than
that of any other medical condition (Maj, 1991).
In a study by Atkins and Amenta (1991), family
adaptation to AIDS and to other terminal illnesses
was compared by measuring the number of stress-
ful events experienced by the family after diagnosis
and role flexibility in response to medical stressors.
Families of AIDS patients had significantly more
stress, more rules prohibiting emotional expression,
lower trust levels and more illness anxiety than other
families.
In young children with AIDS, with the exception
of transfusion-infected children, there is necessarily
the presence of an infected adult, usually the mother.
The problem in such a situation is not that of a child
with a fatal illness but that of an entire family. In a
study of 30 natural caregivers (mostly mothers but
also fathers, aunts and grandmothers), most of the
caregivers were economically disadvantaged and
needed help in coping with stress and their life situ-
ation (Reidy, Taggart, & Asselin, 1991). Their need
to confide in others was frequently not met although
they responded well to medical care, support and
advice.
Social and Ethical Aspects
Few diseases since syphilis in the 19th century and
tuberculosis in the early part of this century have
raised the ethical, scientific and economic questions
that AIDS has. The moral responsibility of the ther-
apist to offer unconditional care for the patient has
been threatened. The scientific principles of placebo
trials and safe drug testing procedures have been con-
sistently challenged by the community of AIDS ac-
tivists (Faden & Kass, 1990), and the cost of health
care provision for European and American health care
systems is potentially crippling. Furthermore, the dis-
124
 288 DAVID ALDRIDGE
ease has struck our modem society at its most vulner-
able point in raising the issue of how we care for the
sick, the poor and those we label as deviant (Acker-
man, 1989; Ribble, 1989). Not only are patients in-
fected with a recalcitrant virus, they are often infected
by our attitudes of intolerance and condemnation
(Johnston, 1988).
As some of those persons contracting the AIDS
virus are likely to belong to groups that are socially
vulnerable-homosexual men and women, the urban
poor of ethnic minorities and drug users-the chal-
lenge of offering treatment is one that reaches into the
ethical resources of our healing communities. It is
precisely the source of contracting AIDS that causes
many of the ethical problems. At a time when appar-
ently choice of sexual orientation was becoming a
matter of personal preference rather than solely gen-
ital dominance, and the tolerance of homosexual and
lesbian activity was increasing, the AIDS virus served
once more to condemn groups of people to the state of
potential deviancy (Faden & Kass, 1990).
Fear of contagion, coupled with prejudices about
lifestyle, are undoubtedly strong factors of influence
in the way that some caregivers treat their patients. A
wide range of emotional reactions by the caregiver
may occur from refusal to provide care, resulting in
rejection, to a total immersion in the infected person's
needs, leading to burnout. Because irrational fears
and attitudes play an important role in conditioning
these reactions, education alone for the caregivers
may not be sufficient to change behavior. Counselling
sessions and mutual support groups are often the most
appropriate contexts where fears and concerns can
receive an individually tailored response, and where
formal and informal caregivers can be helped to man-
age stress.
In contrast to other terminal illnesses, patients can
often clearly say where, when and under what cir-
cumstances they contracted the disease. It is these
circumstances that form the axis of judgment about
the illness~eitherinnocently infected victims or ir-
responsible deviants. The conditions governing the
attribution of the status sick (Parsons, 1951) are that
the sick: (a) do not form groups, (b) recover within a
prescribed time, and (c) are not causally responsible
for their own demise. The last two of these conditions
are violated by patients infected with the HIV virus.
Furthermore, the AIDS activists who encourage suf-
ferers to form groups and advocate for changes in
treatment and support on their own behalf are threat-
ening a longstanding social requirement that the sick
David Aldridge Collected music therapy papers
remain divided and powerless. Furthermore, as a pro-
portion of the AIDS-infected population is drug users,
the very virus is associated with an already socially
stigmatized group. As Ribble (1989) pointed out, a
nurse may feel a strong empathy for the sexually-
infected partner of an intravenous drug user, yet sig-
nificantly less empathy for the infected drug user.
Maintaining Integrity and Hope
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, restore and maintain our physio-
logical identity based upon the experiences of today
and yesterday. Immunological reactions are not only
effects caused by aggressive stimuli; they are also
meaningful memories of our physiological makeup.
The immune system is the major integrative network
within our bodies that facilitates our biological adap-
tation (Wiedermann & Wiedermann, 1988).
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. Yet, it is possible to go further and say that
the qualitative aspects of life-hope, joy, beauty and
unconditional love-are also vital and beneficial in
therapy. This is precisely the ground in which the
creative arts can have their own being. Patients can
explore and express their being in the world, which
is creative and not limited by their infection. From
such a perspective we might expect that, although
physical parameters may fluctuate or deteriorate, life-
quality measures or existential indicators would show
improvement.
A significant existential beneficial factor in en-
hancing the quality of life is hope. Hope has been
identified as a multifaceted phenomenon that is a
valuable human response even in the face of a severe
reduction in life expectation. Herth's (1990) study
explored the meaning of hope and identified strategies
that were used to foster hope in a sample of 30 ter-
minally-ill adults. Cross-sectional data were collected
on 20 of the subjects and longitudinal data were col-
lected on 10 of the subjects in order to provide a
clearer understanding of the hoping process during the
125
 CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS
dying trajectory. Hope was defined by Herth as an
"inner power directed toward enrichment of 'be-
ing'. " With the exception of those diagnosed with
AIDS, overall hope levels among subjects were high
and were found to remain stable over time. Seven
hope-fostering categories (interpersonal connected-
ness, attainable aims, spiritual base, personal attri-
butes, light-heartedness, uplifting memories and af-
firmation of worth) and three hope-hindering catego-
ries (abandonment and isolation, uncontrollable pain
and discomfort, devaluation of personhood) were
identified.
Hope, like prayer (Saudia, Kinney, Brown, &
Young, 1991), is a coping strategy used by those
confronted with a chronic illness, which involves an
expectation that goes beyond visible facts and can be
seen as a motivating force to achieve inner goals.
These goals change. Although a distant future of life
expectancy no longer exists for AIDS patients, life
aims can be redefined and refocused. With the pro-
gression of physical deterioration, the future becomes
less defined in time but in the meaning attached to
life events in relationship to meaningful others. In
later stages there is a shift toward less concrete
goals and a refocusing on the self to include the
inner peace and serenity necessary for dying (Herth,
1990). Music therapy, for example, with its ability to
offer an experience of time that is qualitatively rich
and not chronologically determined, is a valuable
intervention.
The arts therapies, with their potential for bringing
form out of chaos, should offer hope in situations of
seeming hopelessness and are, therefore, a means of
transcendence. This idea of transcendence, the ability
to extend the self beyond the immediate context to
achieve new perspectives, is seen as important in the
last phases of life where dying patients are encour-
aged to maintain a sense of well-being in the face of
imminent biological and social loss (see Figure 1).
Implications for Treatment
For many AIDS patients, personal relationships
are deteriorating. Either friends die of the same illness
or social pressures urge an increasing isolation. Spon-
taneous contacts are frowned upon and the intimacy
of contact is likely to be that of the clinician rather
than the friend. Creative arts therapies can offer an
opportunity for intimacy within a creative relation-
ship. This is both nonjudgmental and equal. Once
David Aldridge Collected music therapy papers
more the patient is encouraged to creatively form a
new identity.
Working with a therapist in a creative way to en-
hance the quality of living can help patients make
sense of dying (Aldridge, 1987b). It is important for
the dying, or those with terminal illness, that ap-
proaches be used that integrate the physical, psycho-
logical, social and spiritual dimensions of their being
(Con, 1993; Feifel, 1990; Gary, 1992; Herth, 1990).
The intensification of the inner life through artistic
activity helps provide a refuge from the emptiness of
existence in a threatened future, but also provides a
platform from which the next existential spring can be
made. Having AIDS changes the experience of time.
Many of those who have the disease are young. Sud-
denly they are faced with a provisional and uncertain
existence. Without a goal it is difficult to live for the
future. To do something positive, to create, to play, is
to take life seriously. The creative act is to take the
opportunity to live. The creative act gives us the pos-
sibility to realize something of value in the world.
Whereas passive appreciation of art and beauty en-
hances our aesthetic appreciation, the act of creation
offers a way forward into the future. For those who
are suffering, the creative act, no matter how small,
offers the chance to achieve something concretely
(Frankl, 1963). By painting, singing, dancing, acting
or making music together we can bring the emotion of
suffering into the world in a concrete form. Suffering
made external as expression and brought into form by
art gives the individual the chance to grapple with the
meaning of that suffering and thereby bring about
change. To quote Frankl (1963):
Whenever one is confronted with an inescap-
able, unavoidable situation, whenever one has
to face a fate that cannot be changed, such as an
inoperable cancer, just then is one given a last
chance to activate the highest value, to fulfil the
deepest meaning, the meaning of suffering. For
what matters above all is the attitude we take
toward suffering, the attitude in which we take
our suffering upon ourselves. (p. 178)
The meaning of life is discovered in concrete acts
of creation that are aesthetic. What is internal is ex-
pressed externally as form. By bringing onto paper, or
forming as sound, by moving the body in a sequence
of dance or creating a narrative with dramatic intent,
the individual takes responsibility for answering the
126
 DAVID ALDRIDGE
Coping with physical changes
Coping with personal changes
Coping with relationship changes
Coping with spiritual changes
Figure l. Coping requirements and changes associated with terminal illness. It must be emphasized that these changes have ramifications at
differing levels. Personal changes have implications for an intimate relationship within the family and throughout the social environment
(Aldridge, 1987b, p. 214).
questions life asks. These questions of meaning are
answered in what we do, that is, concrete activities
performed for individual destinies. Thus, the creative
act retains its individuality and cannot be prescriptive.
Furthermore, such an act is aesthetic; it brings into
form, making coherent and manifest what is unintel-
David Aldridge Collected music therapy papers
Anticipation of pain
Management of pain
Management of the physical consequences of illness (nausea,
incontmence)and change m physical appearance
Management of the physical consequences of treatment
Loss of hope, fitness and identity
Anxiety and depression about the future
Loss of role in family and in employment
Frustration and helplessness
Resolution of conflict
Change in parental roles
Anxiety about the future welfare (emotional and financial)
Anticipated hospital contacts and treatment
Anticipated loss of a family member or partner
Planning the future
Social isolation
Changes in family boundary, and of family and marital
emotional distance
Negotiation of dependendindependence
Saying 'good-bye' and talking about dying
Handling the above personal and physical changes within the
context of an intimate relationship
Changes in, and loss of, sexual activity
Feelings of loss, alienation and abandonment
Understanding suffering
Accepting dependency
Handling anger and frustration
Forgiving others
Discovering peace
Discussing death
Grieving
Planning the funeral
Discovering hope and the value of living
ligible and hidden (Arnheim, 1992). As Langer
(1953) wrote, "The function of art is to acquaint the
beholder with something he has not known before"
(p. 22). Each situation is unique and needs a creative
response. In this sense, the creative act is one similar
to play, which lies between the most personal, inti-
127
 CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS 29 1

mate and subjective sphere and the external world of
objects (Winnicott, 1951) in that it bridges the inter-
nal world of the individual with the external world of
the therapeutic relationship (Robbins, 1992).
The art form presents the whole intelligible form as
an intuitive recognition of inner knowledge projected
as outer form-subjective is made objective but in the
terms of the subject and thereby unconventional. In
artistic expression we have the possibility of making
perceptible an inner experience. Music, drama and
visual art are concerned, not with the stimulation of
feeling, but the expression of feeling. It may be more
accurate to say here that feelings are not necessarily
an emotional state, but more an expression of what
the person knows as inner life (Aldridge, 1989).
Our treatment initiatives should also be made early
in the patient's illness, soon after diagnosis, so that a
relationship is made with the patient and with the
carers (See Figure 2). The therapeutic relationship
offers intimacy at a time when often the individual is
threatened with isolation and rejection. We can help
our patients discover their own sense of meaning by
their living out their lives in individual creative acts
within the context of the therapeutic relationship.
Robbins (1992) referred to such situations as "cre-
ative holding environments" (p. 178). What we need
are time and the opportunity to maintain long-term
stability in the relationship, although the physical
consequences of the disease continually remind us of
the precariousness of corporeal existence. It is this
very balance between the temporal aspects of the
body and the existential act of living in that body that
is at the crux of the therapeutic act.
Research Suggestions
Because of the nature of the disease and its indi-
vidual progression it will be necessary to formulate
research designs that follow individual patients over
time (see Figure 3). Such designs are longitudinal.
There have been calls elsewhere for such longitudinal
designs, combining scientific and artistic intellectual
rigor, which follow individual patients as they chart
their course through the depths and shallows of their
illness (Aldridge, 199la). In any such study it is also
necessary to consider a recurring theme heard from
varying perspectives. This theme concerns the neces-
sity to include the views of the partners, or immediate
family, of patients in any long-term therapeutic initi-
atives (Wolf et al., 1991).
To carry out such long-term research, which fol-
lows the course of an illness, it is necessary to de-
velop a core team of practitioners and researchers who
will remain with a project for its duration. The estab-
lishment of such a team is dependent upon adequate
research funding, sufficient academic support and
personal supervision for the personnel to sustain in-
terest in a field of work notorious for the toll it takes
on the professionals involved. As research interviews
and therapeutic practice can be emotionally demand-
ing, it is imperative to implement adequate supervi-
sion, a feature accepted in therapy but often neglected
in research.
As the field of practice is changing rapidly, it is
important to maintain a review of the current litera-
ture. There are a number of databases that provide
background information about the field of AIDS re-

start early after diagnosis

consider creative arts therapies as diagnostic tool
develop a stable team, encourage long-term stability
include the caregivers or partner in the therapy plan
establish a support group for the professional caregiving team
promote teamwork and identify common aims
be ready for changes in physical status of the patient
integrate the physical, psychological, social and spiritual
be aware of the existential anxiety of working with AIDS patients; death, contagion,
sexuality and disempowerment

Figure 2. Treatment recommendations.

David Aldridge Collected music therapy papers 128

 DAVID ALDRIDGE

promote prospective longitudinal studies

develop a stable core research team, academic and clinical
establish ethical guidelines for the use of collected information
install procedure for continuing current literature review
gather data from patients and their partnerdfamilies
consider creative arts therapies as diagnostic tool
identify appropriate health measures; life quality scales, hope index, diary recordings
establish art and music archive of patient creations
distinguish parameters for discerning treatment costs
propose specific hypotheses for doctoral studies

Figure 3 . Research recommendations.

search and that will furnish the research team with
valuable insights from other practitioners.
With neurological problems a feature of HIV in-
fection, it should be possible to explore the contribu-
tion the arts therapies can make to the detection of
behavioral and functional changes. Creative arts ther-
apies appear to offer sensitive assessment tools. They
can be used to assess those areas of functioning, both
receptive and productive, not covered adequately by
other test instruments (i.e., fine motor behavior, per-
severance in context, attention, concentration and in-
tentionality). In addition, they provide forms of ther-
apy that may stimulate cognitive activities so that be-
haviors subject to progressive failure are maintained
(Aldridge & Aldridge, 1992).
Buckwalter (Buckwalter, Cusack, Kruckeberg, &
Shoemaker, 1991) described the outcomes of a study
involving family members of communication-
impaired long-term care residents in a collaborative
nursingtspeech language pathology intervention de-
signed to increase the residents' communication abil-
ity. Family members provided memorabilia and arti-
facts or produced audio or videotapes for use in con-
junction with a speech therapy program. Findings
revealed that, despite a minimal improvement in
speech ability, there was a dramatic increase in family
members' satisfaction. As peers, partners or family
play an important role in the process of therapy and
are susceptible to considerable distress too, we must
include assessments of their perceptions of therapeu-
tic change.
Quality of life has become accepted in the assess-
ment of cancer treatment programs. If the HIV virus
is endemic to populations and there is no cure for
AIDS, our research endeavors must include some ap-
praisal of life quality (Catalan, 1990). To this end, the
use of established life-quality scales alongside indi-
vidual assessment protocols will provide therapists
with feedback about the impact of their work on the
everchanging life of the patient.
There are varying life-quality scales in existence
that have been tested for reliability and validity
(Aaronson, 1989; Bowling, 1991; Clark & Fallow-
field, 1986; Gold, 1986; Oleske, Heinze, & Otte,
1990; Porter, 1986; Spitzer, 1987). The Hospital
Anxiety and Depression scale was developed from
clinical experience as a brief rating instrument to de-
tect the extent of mood disorders as distinguished
from the physical illness of the patient. Zigmond and
Snaith (1983) purposefully excluded all items relat-
ing to physical disorder, retaining only items relating
to psychic symptoms that are valuable with AIDS
patients whose physical condition may deteriorate but
psychological condition improve. As a scale in daily
use, it has proved to be reliable, easily understood by
patients and easy to administer and evaluate by clini-
cians (Clark & Fallowfield, 1986). Because the Hos-
pital Anxiety and Depression scale is a self-report
questionnaire, the patient gives an account of his or
her own perception of life quality. The generally ac-
cepted, but cruder, Karnofsky Performance Scale
(Karnofsky, Abelmann, & Craver, 1948), while
weighted toward the physical dimensions of life qual-
ity, is physician rated and considered to be flawed in
that there are discrepancies between what doctors per-
ceive and what patients perceive.

David Aldridge Collected music therapy papers 129

 CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS
It is important to understand when using such
scales that "quality of life" has a multiplicity of
meanings and, therefore, to some therapists the scales
may seem naive and limited. Those researchers who
have developed the scales know themselves that such
limitations exist. Rather than develop an unwieldy
global package, some researchers have concentrated
on specific items gleaned from a factor analysis of
many previously posed questions with an eye to de-
veloping a refined clinical instrument.
In addition to the quality of life, the fostering of
hope is seen as a valuable activity in patient care
(Herth, 1990, 1991). Herth's Hope Index is a useful
screening tool that assesses hope over time and vali-
dates nursing diagnoses of hopefulness and hopeless-
ness. Hope is a complex concept with many dimen-
sions, yet it is possible, using such a scale, to assess
the way in which patients view their future.
The message from all of this is to select the re-
quired test from a number of suggestions according to
the particular research question being asked that is
appropriate to clinical practice. Clinical scales are
generally designed as a guide for practice and are easy
to administer. Research instruments are often com-
prehensive in scope, time-consuming to administer
(occasionally requiring training) and evaluate and rich
in material. Using previously validated questionnaires
builds bridges between small initiatives and a greater
body of knowledge, helping the researcher to see the
value of his or her work.
Although a research approach in itself, the patient
diary (Murray, 1985) is an important part of an eval-
uative index. The patient diary is rather a catch-all
term in that some researchers will collect daily data
according to specific rating scales as above. These
could be more appropriately termed calendar meth-
ods. An extension of daily rating and subjective com-
mentary would appropriately be called a diary. The
detailed daily recording of patient commentaries in-
volving introspective accounts may be likened to a
journal and is the least formal, in experimental terms,
of the three approaches mentioned here (Aldridge,
1991c, 1992).
In diary studies, the principal collector of data is
the patient. One of the tasks of research scientists
working in the field of clinical practice is to discover
what happens in the context of the patient's daily life
and to make some attempt to discover how his or her
problem impinges upon his or her daily routine. Sim-
ilarly, it is important to discover who in the family of
that person is involved at the time of onset of the
David Aldridge Collected music therapy papers
293
symptoms and in the management of those symptoms.
The use of subjects making their own assessments of
symptomatology offers a nonintrusive means of gath-
ering data. Perhaps as significantly, the diary also
offers the patient a neutral stance whereby the symp-
toms are assessed methodically and in accordance
with a particular framework designed to be ultimately
beneficial.
The use of diaries has several advantages. First,
there is the opportunity to provide a daily scoring that
eliminates recall error and in general produces con-
sistent reporting. Second, there is a comprehensive
view of the person's health and the relational context
of that health status vis a vis other family members.
Third, symptoms are treated as episodes rather than
solely static events. Fourth, diffuse conditions are in-
cluded that may not be disabling or necessitate inter-
vention but that contribute to the profile of the pa-
tient's symptomatology. Finally, diaries provide an
opportunity to see the way in which problems develop
over time and the way in which treatment initiatives
can influence such developments. When studying
complex chronic problems, the contextual informa-
tion over time also illustrates how psychological or
social factors enhance or complicate the clinical pic-
ture. There is no reason why the recorded data should
only be concerned with symptomatic change. A jour-
nal could include poems, drawings and descriptions
of dreams.
A benefit of using calendar and diary methods is
also one of the drawbacks. The data are rich and
varied but these cause problems for analysis; there can
be too much data. Furthermore, patients can become
sensitized to their own problems and hence concen-
trate more and more on those problems. This is a
confounding factor for single-case research designs in
general where the research process itself becomes a
treatment variable. However, for discovering what a
patient considers to be important about the treatment
process, diary methods are very useful. In the case of
AIDS patients, feedback, throughout a long therapy
process involving various therapeutic initiatives, is a
valuable feature.
The above measures are concerned with the health
status of the patient from a particular medical orien-
tation, albeit broad in its incorporation of psychical,
emotional, psychological, relational and social di-
mensions. What is clearly missing is the collection of
material from the creative arts activities.
A standard method for active music therapy is to
make an audio or video recording of the therapy ses-
130
 DAVID ALDRIDGE
sion and then index this recording after the session.
Such material is then available for assessment accord-
ing to given criteria and for evaluation for validation
by peers. Similarly, graphic (Niederreiter, 1990;
Oliveri, 1991) and plastic material produced in the
studio can be saved to show a progression during the
course of the therapy. This work can also be photo-
graphed when each item is completed or at stages
during the course of creation. With new advances in
computer technology, it is possible to develop photo-
graphs as prints and to commit the same images for
archiving electronically on a compact disc. Such im-
ages then can be saved in a database, displayed later
on a monitor screen and incorporated into research
documents. By saving images over time, it is possible
to gain an overview of recurring elements, variations
and changes in composition and form.
Although it is difficult enough for music therapists
to agree on an established language for research, there
are grounds to believe that active cooperation is pos-
sible among creative arts therapeutic disciplines (Al-
dridge, Brandt, & Wohler, 1990). It is important that
a research structure be established so that creative arts
therapists meet regularly to discuss their work and, in
doing so, develop a common language. Our experi-
ence is that changes in form, whether sculpted,
painted, drawn or played, occur concurrently. The
task we face is to correlate such changes in the cre-
ative therapies with changes according to other mea-
sures of health outcome. Furthermore, we need to
establish our expectations of patients in their first
therapy sessions. We know little about how adults
spontaneously create in various media (i.e., sing,
move, draw or paint) particularly when they are pre-
viously untutored and unpracticed.
With the extended costs of health care for the
AIDS patient playing a significant role in health-care
delivery, when medical insurance support is likely to
be exhausted or, for the poor, nonexistent (Faden &
Kass, 1990), the financial burden of health care is
going to fall onto the shoulders of the wider commu-
nity. Any new initiatives will need to establish the
cost of treatment over time. Although the creative arts
therapies are labor intensive and time consuming, the
potential savings in using fewer expensive pharma-
ceutical products, lesser long-term use of medical fa-
cilities and possibly extended survival rates are valu-
able (Krupnick & Pincus, 1992). The estimates of
such costs will depend upon developing methodolo-
gies that include clinical outcome measures (e.g., the
above-mentioned quality of life scales), functional
David Aldridge Collected music therapy papers
outcome measures (e.g., the ability to care for the
family, number of days lost from work) and the costs
of health-care utilization. To do this we need to es-
tablish the routine inclusion of cost data in our studies
and establish clinical outcome criteria that make sense
for the patients, clinicians and therapists involved and
the policymakers responsible for third-party methods
of reimbursement (Aldridge, 1990).
McCormick, Inui, Deyo, and Wood (1991) ob-
served that AIDS has become a chronic disease and
the demand for long-term care has increased. The
authors studied a cohort of hospitalized persons with
AIDS to determine the proportion and characteristics
of 120 AIDS patients who could appropriately be
cared for in long-term care facilities with skilled nurs-
ing on the medical wards of five Seattle tertiary care
hospitals. The appropriateness for long-term care was
determined by the patients' physicians, nurses and
social workers according to four admission criteria:
(a) impaired activities of daily living, (b) diagnosis of
central nervous system illness or poor cognition, (c)
living alone and (d) weight loss. One-third of hospi-
talized persons with AIDS were considered appropri-
ate for care in long-term settings, accounting for one-
third of the days AIDS patients currently spend in
hospitals. These patients can be identified early in
hospital stays using a simple clinical index based on
the criteria above.
In formulating such a research proposal it is ap-
parent that the suggestions are general. We must de-
velop specific research studies, but as yet have limited
experience. The research tradition in the creative arts
therapies is limited. Music therapy, in particular, has
no established research methodology, although there
is a body of research material in the music therapy and
medical press (Aldridge, 1993a, 1993b). There are,
however, research methods and clinical outcome
measures that can be utilized from other spheres of
practice. A priority must be to get started doing re-
search as a series of longitudinal pilot studies.
Cautions About Practice and Research
The creative arts can be used as adjuvant therapies
complementary to medical initiatives in palliative
care. In modem scientific medicine, people are trans-
formed into the subjects of research. They are classi-
fied into disease groupings. This subjectification, and
the conditional requirement that they remain passive
to keep the status "sick" not "deviant," is chal-
131
 CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS
lenged by AIDS patients. In contrast, the creative
therapies expect patients to be active self-defining
agents. The requirement is that the patients are moral
(i.e., actively partaking and self-defining) when they
are sick and suffering, not that they be subjected to
our morality and definition (i.e., passive and judged).
Foucault challenged us to find a new truth that is
creative and performed free from the politics of med-
ical authority (Rawlinson, 1987). It is this freedom of
truth and practice that we must encourage with our
AIDS patients. The therapist and the patient can chal-
lenge the notions that we must always be able to do
something and that everything humanly significant is
subject to measurement.
At the center of the AIDS debate is a massive
existential anxiety that patients and we as therapists
face. This anxiety is based upon the confrontation
with death, the fear of contagion, the challenge to our
sexual orientation, the exercise of power over another
and the reality of poverty in a material world. Death,
the inevitable end process of living, so often ignored,
comes into the foreground, and thereby the normal
expectation of medical endeavor, that the patient will
recover to a state of normative health, is challenged.
Contagion, the fear of being invaded, is ever present.
Despite our knowledge of the transmission of the vi-
rus, our fears of contagion have little to do with such
rationality. For example, in talking with general prac-
titioners and oncologists about working with cancer
patients, the difficulty for the doctors was the fear of
"catching cancer," an irrational fear in a purportedly
rational scientific enterprise (Aldridge, 1987a).
Sexuality, which we learn to express and which we
take for granted as part of our identity, is seen as a
matter of choice and preference not as solely dictated
by our genetic makeup. The notion of "sex" makes it
possible to group together in an artificial unity ana-
tomical elements, biological functions, conducts, sen-
sations and pleasures suitable to the scrutiny of mod-
em scientific medicine (Dreyfus, 1987).
Foucault (1988, 1989) described such a tendency,
to normalize all aspects of human behavior and bring
them under medical control, as bio-power. The effect
of this power on the patient is that he or she responds
in the same way to every situation as if the possible
responses had become reduced to one form. For
Foucault, the therapeutic act is to bring about a
change in such structuring, to give the life of the
patient the stability and the uniqueness of a work of
art, as we read in the introductory quotation to this
paper.
David Aldridge Collected music therapy papers
295
We know too that patients are socially vulnerable
and that their caregivers, particularly in the face of
children with AIDS, are disadvantaged. Poverty is a
challenge to us all in that no matter what therapeutic
skills we bring to bear and no matter how we strive for
our own empowerment, we are continually faced with
the blight of material neglect. How we care for the
poor, the sick and the dying, no matter how they
contracted their disease, is both a matter of our own
personal responsibility and a collective measure of
our humanity (Aldridge, 1991b) .
Conclusion
The creative arts therapies, with their emphases on
personal contact and the value of the patient as a
creative productive human being, have a significant
role to play in the fostering of hope in the individual.
Hope involves feelings and thoughts and necessitates
action (i.e., it is dynamic and susceptible to human
influence). Stimulating the awareness of living in the
face of dying is a feature of the hospice movement
where being becomes more important than having.
The opportunity, offered by the creative arts activi-
ties, for the patient to be remade anew in the moment,
to assert an identity that is aesthetic in the context of
another person, separate yet not abandoned, is an ac-
tivity invested with that vital quality of hope and true
to the quotation at the beginning of this paper. For the
therapist, hope is a replacement for therapeutic nihil-
ism enabling us to offer constructive effort and sound
expectations (Menninger, 1959).
Any therapeutic tasks must concentrate on the res-
toration of hope, accommodating feelings of loss, iso-
lation and abandonment, understanding suffering,
forgiving others, accepting dependency while remain-
ing independent and making sense of dying. Creative
arts therapies can be powerful tools in this process of
change, which can be accommodated within an over-
all rubric of quality of life. Although quality of life
scales exist for the general clinical population of
cancer patients, they fall short of meeting the re-
quirements for individual patients. Expectations of
life quality differ. Furthermore, the elusive life qual-
ities inherent in creative activities-joy, release,
satisfaction, simply being-are not readily suscepti-
ble to rating scales. We can, however, hear them
when they are played, see them when they are painted
or danced and feel them when they are expressed
dramaturgically.
132
 296 DAVID ALDRIDGE
Creative arts therapies appear to open up a unique
possibility to take an initiative in coping with disease
or to find a level to cope with near death. It is this
opening up of the possibilities that is at the core of
existential therapies (Dreyfus, 1987). Rather than pa-
tients living in the realm of pathology alone, they are
encouraged to find the realm of their own creative
being. If the progress of this disease, AIDS, is an
increasing personal isolation, then the therapeutic re-
lationship is an important one for maintaining inter-
personal contact, a contact that is morally nonjudg-
mental, where the ground of that contact is aesthetic
and expressive, not scientific and repressive. Further-
more, the therapeutic question is not "What am I?, ' '
a question that lies in the realm of categorization and
cognition, but "How am I?," which is one of being.
Finally, in our treatment initiatives and research
projects it is necessary to care for the caregivers, who
will include the family, friends or partner of the pa-
tient. We must also bear in mind the psychological
burden on health workers themselves. Although
working with couples and families may be alien to
some individual therapeutic directions, the over-
whelming burden of care and suffering of daily living
lies outside of the clinic. When clinical care is nec-
essary, we are also best guided to attend to ourselves
and colleagues, too, as we accompany our patients on
the long journey that awaits us all. Social disruption,
isolation, conflict and neglect are the doors to the
house of despair. Creative &S therapies must respond
to those who enter that house, but at a social level
where we must be the architects of change. People
will die. It is what we contribute to the quality of their
living that is of importance.
References
Aaronson, N. (1989). Quality of life assessment in clinical trials:
Methodologic issues. Controlled Clinical Trials, 10(4 Suppl.),
195s-208s.
Ackerman, F. (1989). Family-systems therapy with a man with
AIDS-Related Complex. Family Systems Medicine, 7(3), 292-
304.
Ader, R. (1987). Brain, behavior and immunity. Brain, Behavior
and Immunity, l , 1-6.
Aldridge, D. (1987a). A team approach to terminal care: Personal
implications for patients and practitioners. Journal of the Royal
College of General Practitioners, 37, 364.
Aldridge, D. (1987b). One body: A guide to healing in the church.
London: S:P:C:K.
Aldridge, D. (1989). A phenomenological comparison of the or-
ganization of music and the self. The Arts in Psychotherapy,
16, 91-97.
David Aldridge Collected music therapy papers
Aldridge, D. (1990). The delivery of health care alternatives. Jour-
nal of the Royal Society of Medicine, 83, 179-182.
Aldridge, D. (1991a). Aesthetics and the individual in the practice
of medical research: A discussion paper. Journal of the Royal
Society of Medicine, 84, 147-150.
Aldridge, D. (1991b). Healing and medicine. Journal of the Royal
Society of Medicine, 84, 5 16-51 8.
Aldridge, D. (1991~).Single case research designs for the clini-
cian. Journal of the Royal Society of Medicine, 84, 249-252.
Aldridge, D. (1992). The needs of individual patients in clinical
research. Advances, 8(4), 58-65.
Aldridge, D. (1993a). Music therapy research I: A review of music
therapy research as presented in the medical literature. The Arts
in Psychotherapy, 20, 11-35.
Aldridge, D. (1993b). Music therapy 11: Research methods suitable
for music therapy. The Arts in Psychotherapy, 20, 117-131.
Aldridge, D., & Aldridge, G. (1992). Two epistemologies: Music
therapy and medicine in the treatment of dementia. The Arts in
Psychotherapy, 19, 243-255.
Aldridge, D., Brandt, G., & Wohler, D. (1990). Toward a com-
mon language in the arts therapies. The Arts in Psychotherapy,
17. 189-195.
Amheim, R. (1992). Why aesthetics is needed. The Arts in Psy-
chotherapy, 19, 149-151.
Atkins, R., & Amenta, M. (1991). Family adaptation to AIDS: A
comparative study. Hospital Journal, 7(1-2), 71-83.
Blaney, N., Goodkin, K., Morgan, R., Feaster, D., Millon, C.,
Szapocznik, J., & Eisdorfer, C. (1991). A stress-moderator
model of distress in early HIV-1 infection: Concurrent analysis
of life events, hardiness and social support. Journal of Psycho-
somatic Research, 35(2-3), 297-305.
Bowling, A. (1991). Measuring health: A review of the quality of
life assessment scales. Buckingham: Open University Press.
Buckwalter, K. C., Cusack, D., Kruckeberg, T., & Shoemaker,
A. (1991). Family involvement with communication-impaired
residents in long-term care settings. Appl. Nurs. Res., 4(2),
77-84.
Catalan, J. (1990). Psychosocial and neuropsychiatric aspects of
HIV infection: Review of their extent and implications for psy-
chiatry. Journal of Psychosomatic Research, 22(3), 237-248.
Clark, A., & Fallowfield, L. (1986). Quality of life measurements
in patients with malignant disease: A review. Journal of the
Royal Society of Medicine, 79, 165-169.
Cohen, M. (1990). Biopsychosocial approach to the human immu-
nodeficiency virus epidemic. A clinician's primer. General
Hospital Psychiatry, 12(2), 98-123.
Con, C. (1993). Coping with dying: Lessons that we should and
should not learn from the work of Elisabeth Kiibler-Ross.
Death Studies, 17, 69-83.
Darko, D. (1986). A brief tour of psychoneuroimmunology. An-
nals of Allergy, 57(4), 233-238.
Dessloch, A., Maiworm, M,, Florin, I., & Schulze, C. (1992).
Hospital care versus home-bound hospice care-Quality of life
in patient with terminal cancer. Psychotherapie, Psychosoma-
tik, Medizinische Psychologie, 42(12), 424-429.
Dew, M,,Ragni, M., & Nimorwicz, P. (1991). Correlates of psy-
chiatric distress among wives of hemophilic men with and with-
out HIV infection. American Journal of Psychiatry, 148(8),
1016-1022.
Dreyfus, H. (1987). Foucault's critique of psychiatric medicine.
The Journal of Medicine and Philosophy, 12, 31 1-333.
133
 CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS
Editorial (1992). Changing case-definition for AIDS. The Lancet,
340, 1199-1200.
Engel, G. (1977). The need for a new medical model: A challenge
for biomedicine. Science, 196, 129-136.
Faden, R., & Kass, N. (1990). AIDS will pose moral dilemmas
well into 1990s. Kennedy Institute of Ethics Newsletter, 4(3),
1-2.
Feifel, H. (1990). Psychology and death. Meaningful rediscovery.
American Psychologist, 45(4), 537-543.
Foucault, M. (1988). The use ofpleasure: The history of sexuality.
London: Peregrine.
Foucault, M. (1989). The birth of the clinic. London: Routledge.
Frampton, D. (1989). Arts activities in United Kingdom hospices.
A report. Journal of Palliative Care, 5(4), 25-32.
Frankl, V. (1963). Man's search for meaning. New York: Wash-
ington Square Press.
Gary, G. A. (1992). Facing terminal illness in children with AIDS.
Developing a philosophy of care for patients, families, and
caregivers. Home Health Nurse, 10(2), 40-43.
Gold, J. (1986). Quality of life measurements in patients with
malignant disease. Journal of the Royal Society of Medicine,
79, 622.
Grant, I., & Hampton Atkinson, J . (1990). Neurogenic and psy-
chogenic behavioral correlates of HIV infection. In B. Wake-
man (Ed.), Immunologic mechanisms in neurologic and psy-
chiatric disease (pp. 291-304). New York: Raven Press.
Hays, R., Catania, J., McKusick, L., & Coates, T. (1990). Help-
seeking for AIDS-related concerns: A comparison of gay men
with various HIV diagnoses. American Journal of Community
Psychology, 18, 743-755.
Herth, K. (1990). Fostering hope in terminally-ill people. Journal
of Advanced Nursing, 15, 1250-1259.
Herth, K. (1991). Development and refinement of an instrument to
measure hope. Scholarly Inquiry for Nursing Practice: An In-
ternational Journal, 5(1), 39-5 1.
Johnston, M. (1988). AIDS related psychosocial issues for the
patient and physician. Journal of the American Osteopathy As-
sociation, 88(2), 234-238.
Karnofsky, D., Abelmann, W . , & Craver, L. (1948). The use of
nitrogen mustards in the palliative treatment of carcinoma.
Cancer, I, 634-656.
Krupnick, J., & Pincus, H. (1992). The cost effectiveness of psy-
chotherapy. American Journal of Psychiatry, 149, 1295-1 305.
Langer, S. (1953). Feeling and form: A theory of art. London:
Routledge and Kegan Paul.
Lee, C. (1991). Foreword: Endings. Journal of British Music Ther-
apy, 5, 3 4 .
Maj, M. (1991). Psychological problems of families and health
workers dealing with people infected with human immunode-
ficiency virus. 1. Acta Psychiatrica Scandinavica, 83(3), 161-
168.
McCormick, W., Inui, T., Deyo, R., & Wood, R. (1991). Long-
term care needs of hospitalized persons with AIDS: A prospec-
tive cohort study. Journal of General Internal Medicine, 6(1),
27-34.
Menninger, K. (1959). Hope. The American Journal ofPsychiatry,
116(12), 481491.
Murray, J. (1985). The use of health care diaries in the field of
psychiatric illness in general practice. Psychological Medicine,
15, 827-840.
David Aldridge Collected music therapy papers
297
Nelson, H. (1992). USA: New AIDS definition. The Lancet, 340,
1151.
Niederreiter, L. (1990). Kreatives Gestalten: Kunsttherapie mit
HIV-infizierten. Miinchener Medizinische Wochenschriji, 41,
supplement without page numbers.
Oleske, D., Heinze, S., & Otte, D. (1990). The diary as a means
of understanding the quality of life of persons with cancer re-
ceiving home nursing care. Cancer Nursing, 13(3), 158-1 66.
Oliveri, G . (199 1). Malen als Versuch der Krankheitsbewaltigung.
Ammerkungen zu den Bildem eines HIV-Infizierten. Psycho-
sozial, 14(4), 4 3 4 7 .
Parsons, T. (1951). The social system. New York: Free Press.
Porter, R. (1986). Psychotherapy research: Physiological measures
and intrapsychic events. Journal of the Royal Society of Med-
icine, 76, 257-261.
Rabinow, P. (1986). The Foucault reader. London: Penguin.
Rawlinson, M. (1987). Foucault's strategy: Knowledge, power,
and the specificity of truth. The Journal of Philosophy and
Medicine. 12. 371-395.
Reidy, M., Taggart, M. E., & Asselin, L. (1991). Psychosocial
needs expressed by the natural caregivers of HIV infected chil-
dren. Aids Care, 3(3), 331-343.
Ribble, D. (1989). Psychosocial support groups for people with
HIV infection and AIDS. Holistic Nursing Practice, 3(4), 52-
62.
Robbins, A. (1992). The play of psychotherapeutic artistry and
psychoaesthetics. The Arts in Psychotherapy, 19, 177-186.
Ross, M. (1990). The relationship between life events and mental
health in homosexual men. Journal of Clinical Psychology,
46(4), 4 0 2 4 11.
Sadler, J., & Hulgus, Y. (1990). Knowing, valuing, acting: Clues
to revising the biopsychosocial model. Comprehensive Psychi-
atry, 31(3), 185-195.
Saudia, T. L., Kinney, M. R., Brown, K. C., & Young, W. L.
(1991). Health locus of control and helpfulness of prayer. Heart
Lung, 20(1), 60-65.
Schneider, S., Taylor, S., Hammen, C., Kemeny, M,, & Dudley,
J. (1991). Factor influencing suicide intent in gay and bisexual
suicide ideators: Differing models for men with and without
human immunodeficiency virus. Journal of Personal and So-
cial Psychology. 61(5), 776-788.
Solomon, G. (1987). Psychoneuroimmunology: Interactions be-
tween central nervous system and immune system. Journal of
Neuroscience Research, 18, 1-9.
Spitzer, W. (1987). State of the science 1986: Quality of life and
functional status as target variables for research. Journal of
Chronic Diseases, 6, 4 6 5 4 7 1.
Wiedermann, C., & Wiedermann, M. (1988). Psychoimmunology:
Systems medicine at the molecular level. Family Systems Med-
icine, 6(1), 94-106.
Wimicott, D. (1951). Transitional objects and transitional phe-
nomena. In D. Winnicott (Ed.), Collected papers (pp. 229-
242). New York: Basic Books.
Wolf, T., Dralle, P,, Morse, E., Simon, P., Balson, P., Gaumer,
R., & Williams, M. (1991). A biopsychosocial examination of
symptomatic and asymptomatic HIV-infected patients. Interna-
tional Journal of Psychiatry in Medicine, 21(3), 263-279.
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and
depression scale. Acta Psychiatrica Scandanavica, 67, 361-
370.
134
 Complementary Therapies in Medicine (2005) 13, 25-33

4 Functionality or aesthetics?
5 A pilot study of music therapy in the treatment
6 of multiple sclerosis patients夽
7 D. Aldridge a, ∗, W. Schmid b, M. Kaeder c, C. Schmidt a, T. Ostermann d

8
a Chair for Qualitative Research in Medicine, University of Witten Herdecke, Alfred-Herrhausen-Str. 50,
D-58448, Germany
F

10
b Institute for Music Therapy, Faculty of Medicine, University of Witten Herdecke, Germany

11
c Gemeinschaftskrankenhaus, Herdecke, Germany
OO

12
d Department of Medical Theory and Complementary Medicine, Faculty of Medicine,

13 University of Witten Herdecke, Germany

KEYWORDS Summary
Music therapy; Introduction: Neuro-degenerative diseases are, and will remain, an enormous public
PR

Matched control group; health problem. Interventions that could delay disease onset even modestly will have
Self-acceptance; a major public health impact. The aim of this study is to see which components of
Self-esteem;
the illness are responsive to change when treated with music therapy in contrast to
a group of patients receiving standard medical treatment alone.
Depression;
Material and methods: Twenty multiple sclerosis patients (14 female, 6 male) were
Anxiety;
involved in the study, their ages ranging from 29 to 47 years. Ten participants formed
Functional scores; the therapy group, and 10 the matched control group matched by age, gender and
D

Aesthetic the standard neurological classification scheme Expanded Disability Status Scale
(EDSS). Exclusion criteria were pregnancy and mental disorders requiring medica-
tion. Patients in the therapy group received three blocks of music therapy in single
TE

sessions over the course of the one-year project (8—10 sessions, respectively). Mea-
surements were taken before therapy began (U1), and subsequently every three
months (U2—U4) and within a 6-month follow-up without music therapy (U5) af-
ter the last consultation. Test battery included indicators of clinical depression and
anxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale), a
EC

self-acceptance scale (SESA) and a life quality assessment (Hamburg Quality of Life
Questionnaire in Multiple Sclerosis). In addition, data were collected on cognitive
(MSFC) and functional (EDSS) parameters.
Results: There was no significant difference between the music-therapy treatment
group and the control group. However, the effect size statistics comparing both
RR

groups show a medium effect size on the scales measuring self-esteem (d, 0.5423),
depression HAD-D (d, 0.63) and anxiety HAD-A (d, 0.63). Significant improvements

夽 This project was supported by Schering gmbH.

CO

* Corresponding author. Tel.: +49 2302 926 780; fax: +49 2302 926 783.
E-mail address: davida@uni-wh.de (D. Aldridge).

1 0965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.
2 doi:10.1016/j.ctim.2005.01.004
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 135
 2 D. Aldridge et al.

were found for the therapy group over time (U1—U4) in the scale values of self-
esteem, depression and anxiety. In the follow-up, scale values for fatigue, anxiety
and self-esteem worsen within the group treated with music therapy.
Discussion: A therapeutic concept for multiple sclerosis, which includes music therapy,
brings an improvement in mood, fatigue and self-acceptance. When music therapy is
removed, then scale scores worsen and this appears to intimate that msuic therapy
has an influence.
© 2005 Elsevier Ltd. All rights reserved.

14 Introduction sures by which therapeutics are evaluated, and 58

adopt a pragmatic approach to living as well as pos- 59

15 Neuro-degenerative diseases are, and will remain, sible in the context of a chronic condition.10 60

16 an enormous public health problem. Interventions Although complementary and alternative 61

17 that could delay disease onset even modestly will medicine approaches are being asked for by 62

18 have a major public health impact. These diseases patients suffering with multiple sclerosis, only 63

19 are disabling to the sufferers, there is a loss of nor- a limited number of studies have explored arts 64

20 mal motor functioning, a change in mood, and a and music therapy recently. O’Callaghan,11 for 65

21 gradual loss of cognitive abilities1,2 including audi- example, encourages patients to write songs using 66

22 tory problems3 and memory changes,4 and sensory expressive elements related to positive feelings 67
F

23 processing.5 These multifarious problems worsen for other people, memories of relationships and 68

24 during the course and stages of the disease.1 expressions of the adverse experiences resulting 69
OO

25 Furthermore, the patient does not suffer alone; from living with the illnesses. 70

26 these losses have an impact upon family and social In a controlled pilot study Wiens et al.12 demon- 71

27 life. strated a potential strengthening effect of music 72

28 Multiple sclerosis is the most frequent in- therapy—–with a focus on breathing and speech—– 73

29 flammable disease of the central nervous system on the respiratory musculature of multiple sclerosis 74

among young adults. It is an autoimmune disease patients. Respiratory muscle weakness is character-
PR

30 75

31 with additional genetic and environmental factors6 istic of individuals with advanced multiple sclerosis 76

32 and considered to be one disease in the general and can result in repeated infections of the lung. 77

33 class of neurodegenerative diseases. Disease pro- Based on experiences with a music-therapy 78

34 gression differs considerably from patient to pa- group of 225 hospital inpatients with multiple scle- 79

35 tient, so that while we may talk about stages of rosis who participated in a 6-week group music- 80

the diseases there is no typical multiple sclerosis therapy program,13 music therapy appeared to of-
D

36 81

37 patient but rather a heterogeneous group of pa- fer psychological support, relieve anxiety and de- 82

38 tients where generalizations do not really apply.7 pression and possibly help with the difficult process 83

As there are no curative therapeutic interventions, of coping with the disease individually.
TE

39 84

40 we are reliant upon a palliative intervention. Magee,14—17 also makes use of well-known, pre- 85

41 While medical approaches will undoubtedly fo- composed songs and spontaneous improvisation on 86

42 cus on a functional strategy for treatment, we can- instruments and their attitudes change from a “dis- 87

43 not ignore that these diseases have implications abled self-concept” to a more ‘‘able self-concept’’. 88
EC

44 for the performance and appearance of the person In a further study,18 the authors showed improve- 89

45 in everyday life. Therefore, we need therapeutic ments in mood state following music therapy, al- 90

46 approaches that include aesthetic performance as though depression was not directly affected. 91

47 well as functional performance.8 Studies into factors governing the quality of life 92

48 Multiple sclerosis patients show increasing inter- for multiple sclerosis patients are interesting in this 93
RR

49 est in complementary and alternative therapies.9 context. They reveal that patients and their physi- 94

50 One reason is their general disappointment with cians have different perspectives. Physicians deter- 95

51 conventional medicine, since causal treatment is mine quality of life mainly with physical and func- 96

52 not possible; another is a wish to play a more ac- tional parameters, while patients themselves see 97

53 tive role in coping with the disease and a demand psychosocial well-being, emotional stability and 98

for a wider range of therapies to meet psychosocial ways to cope with multiple sclerosis-induced stress
CO

54 99

55 needs as well. Patients say that by using a com- as the most important factors.19 High levels of de- 100

56 plementary medical approach then they take per- pression and anxiety are associated with people 101

57 sonal responsibility for health, reframe the mea- with MS who seek complementary approaches, al- 102
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 136
 Functionality or aesthetics? 3

103 though this may be an underlying factor of chronic encounter and experience. Individual themes and 156

104 illness.20 musical developments emerged for each individual 157

105 The aim of this study is to see which components patient; some wanted to sing and dance, others 158

106 of the illness are responsive to change when treated wanted to be sung to, and others wanted to play an 159

107 with music therapy in contrast to a group of patients instrument or brought their own instruments with 160
108
receiving standard medical treatment alone. them. There were no expectations of previous mu- 161

sical education. The patients wanted recordings of 162

their sessions and their individual selections were 163

109 Patients recorded onto compact discs. They played them to 164

their partners or friends or just listened to some 165

110 Twenty multiple sclerosis patients (14 female, 6 pieces and remembered the condition and feelings 166

111 male) were involved in the study, their ages rang- of the situation. 167

112 ing from 29 to 47 years, with episodic, secondary There was a high degree of willingness on the 168

113 chronic and primary chronic progression and an av- part of all patients to take part in the study, so that 169

114 erage disease duration of 11 years. all rounds of interviews were completed, and 85% 170

115 Ten participants formed the therapy group, and of all music-therapy sessions took place. 171

116 10 the control group. The groups were comparable

117 in the standard neurological classification scheme
118 Expanded Disability Status Scale (EDSS).21 The EDSS Methods 172
119 of both groups was 2.6 on average, which means
that the participants were between normal func-
F

120
A matched control trial was implemented using 173
121 tions (score: 0) and disability that precludes full a battery of indices before therapy began (U1), 174
daily activities (score: 5.5).
OO

122
and subsequently every three months (U2—U4) and 175
123 Exclusion criteria were pregnancy and mental within a 6-month follow-up without music therapy 176
124 disorders requiring medication. (U5) after the last consultation. 177
125 All participants were informed of the content The test battery included the following instru- 178
126 and details of the study and gave their written con- ments. 179
127 sent to publish the material, especially the video
PR

128 sequences from the music-therapy sessions. The

129 Ethical Committee of University of Witten Herdecke Indicators of clinical depression and anxiety 180

130 examined the protection of data privacy and the (Beck Depression Inventory and Hospital 181

131 ethical aspects. Anxiety and Depression Scale) 182

132 Patients were matched by the researcher ad-

133 ministering the trial for age, gender, stage of dis- The Beck Depression Inventory (BDI) is an estab- 183

ease and the standard neurological classification lished and reliable questionnaire for assessing the
D

134 184

135 scheme EDSS. The basis for the recruitment pop- severity of depression and offers an instrument 185

136 ulation was from patients coming for their regular suitable to compare this study with other clini- 186
TE

137 check-ups to the general hospital. A patient was cal studies.23 Patients with multiple sclerosis are 187

138 allocated to the treatment group. The next con- considered to be impaired in identifying emotional 188

139 secutive patient, if matching the previous patient, states from prosodic cues,24 so it makes sense to 189

140 would be allocated to the control group. If not, use such an inventory. 190

that patient would be allocated to the treatment The Hospital Anxiety and Depression Scale (HAD)
EC

141 191

142 group until the treatment group was complete. Sub- is a self-administered, bidimensional instrument 192

143 sequently, 10 matching control patients were allo- developed to screen for clinically significant de- 193

144 cated. pression and anxiety in medical populations (Zig- 194

145 The patients in the therapy group received three mond, 1983, p. 657). Somatic items are excluded 195

blocks of music therapy in single sessions over to avoid the confounding effect of physical illness.
RR

146 196

147 the course of the project (8—10 sessions, respec- While it is recognised that patients with multi- 197

148 tively). Patients in the matched control group ple sclerosis have a high lifetime risk for major 198

149 were promised music therapy after the waiting depression, less is known about affective insta- 199

150 period. bility and how symptoms like irritability, sadness 200

151 The music-therapy approach used for this study and tearfulness affect a subject’s overall degree of 201
CO

152 is based on the Nordoff Robbins approach.22 Both psychological distress.25 Clinically significant anx- 202

153 patient and therapist are active. Music-making on iety, either with or without depression, was en- 203

154 instruments, or singing, and the music itself that dorsed by 25% of patients, three times the rate for 204

155 emerges, all are potential possibilities for activity, depression.26

UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 137
 4 D. Aldridge et al.

205 Scale for self-acceptance (SESA) Results 256

206 The Scale for the Evaluation of Self-Acceptance Fig. 1 shows the development of the outcome- 257

207 (SESA) is a 35-question scale translated from an measures in the course of time with therapy from 258

208 original scale that assesses the acceptance of U1 to U4 and up to U5 in the follow-up. At the start 259

209 self and others.27 Social support, and coping be- of the study (U1) there was no significant differ- 260

210 haviours, are important for persons afflicted with ence between therapy group and control group on 261

211 multiple sclerosis. A healthy conception of oneself the varying scale measures. 262

212 is central to coping effectively with the day-to-day Significant improvements were found within the 263

213 stresses of modern living. The onset of any neuro- therapy group over time (U1—U4) in the scale 264

214 logical disease, with either actual visible deficits or values of SESA (p = 0.012) for depression (BDI, 265

215 potential future disability, threatens the integrity p = 0.036; HADS-D, p = 0.035) and anxiety (HADS-D 266

216 of that concept.28 subscale anxiety, p = 0.13). Significant differences 267

were found for the control group in regard to the 268

subscale anxiety (HADS-A, p = 0.031), while the val-

217 Hamburg Quality of Life Questionnaire in 269

ues for depression and self-acceptance did not show

Multiple Sclerosis
270

any significant differences over time (U1—U4). No

218
271

differences were found for the functional and phys- 272

219 The Hamburg Quality of Life Questionnaire in Multi- iological values (MSFC, EDSS) and quality of life 273
220 ple Sclerosis (HAQUAMS) is a disease-specific qual- (HAQUAMS). The latter is probably because the 274
ity of life instrument for MS. There are 38 items
F

221
HAQUAMs quality of life is mainly assessed from 275
222 about physical, psychological and social functions statements of physical well-being and mobility thus 276
and questions about symptoms, progression of the reflecting scores on the functional scales. How-
OO

223
277
224 disease and general impairment.29 ever, there was no significant difference in the 278
225 People suffering with multiple sclerosis identify improvement from U1 to U4 between the music- 279
226 depression and social function as important compo- therapy treatment group and the control group (see 280
227 nents of quality of life (Somerset, 2003, p. 608) and Table 1), although effect size statistics comparing 281
228 including preferences for health states and treat- both groups show a medium effect size on the scales 282
PR

229 ment alternatives in the decision to initiate treat- measuring self-esteem (d, 0.5423), depression HAD- 283
230 ment for individual patients is seen as an important D (d, 0.63) and anxiety HAD-A (d, 0.63). In the 284
231 treatment consideration.30 follow-up, scale values for fatigue, anxiety and self- 285
232 In addition, data were collected on cognitive esteem worsen within the group treated with music 286
233 (MSFC) and functional (EDSS) parameters. The EDSS therapy. 287
234 describes the state of disability of an MS-patient The use of p-values and effect size are used as 288
and ranges from 0 (normal) to 10 (death due to
D

235
guides in this study as to what may be interesting as 289
236 MS). It is a classification scheme that insures all hypotheses for further studies, or if further studies 290
237 participants in clinical trials are in the same class, are warranted. They are intended as exploratory
TE

291
238 type or phase of MS.21 It is also used by neurolo- statistics rather than confirmatory. This is a pilot 292
239 gists to follow the progression of MS disability and study and there are considerable limitations both 293
240 evaluate treatment results. Because of its strong in terms of the sample size and a bias in terms of 294
241 emphasis on ambulation, the EDSS is insensitive matching in that there was no random allocation to 295
to changes in other neurological functions and to the treatment group.
EC

242
296
243 cognitive dysfunction in MS. The Multiple Sclerosis Considering the correlations between the scale 297
244 Functional Composite (MSFC) is a multidimensional scores differences between T1 and T4, we found 298
245 instrument to assess disability of MS-patients. It correlations between the HAD depression index and 299
246 has three parts, testing the function of legs and self-acceptance, and depression on the BDI and HAD 300
walking-ability, the functions of arms and hands and anxiety and depression (see Table 2). We could,
RR

247
301
248 the cognitive functions.31 The IFSS is a scale that therefore, reduce our battery of tests to the Hospi- 302
249 assesses incapacity and fatigue. tal Anxiety and Depression scale in any future trial. 303

250 For an evaluation of the efficiency and sustained

251 success of music therapy, Wilcoxon-test statistics of
252 outcome-measures differences from U1 to U4 be- Discussion 304
CO

253 tween the groups were applied to show significant

254 differences. Additionally, effect-sizes were calcu- This study tried to identify factors to be influ- 305

255 lated according to Cohen18 and corrected according enced with a music therapeutic approach in treat- 306

to McGaw and Glass19 . ing patients with multiple sclerosis. Music therapy 307
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 138
Functionality or aesthetics? 5

F
OO
D PR
TE
EC
RR

Figure 1 Outcome measures over time. U1—U4: treatment phase, U5: follow-up. Dashed line: control-group, full-line:
music-therapy group. BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-
D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg
CO

Quality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability, MSFC: Multiple Sclerosis
Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC: Multiple Sclerosis Functional Composite.
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 139
 6 D. Aldridge et al.

Table 1 Wilcoxon signed rank test comparing therapy and matched control group.
Music-therapy group, Control group, median Wilcoxon signed rank test,
median [25%ile, 75%ile] [25%ile, 75%ile] p significance (two-tailed)
EDSS 2.3 [1.4; 3.5] 2.5 [1.5; 3.6] 0.76
MSFC 0.23 [−0.21; 0.47] 0.14 [−0.45; 0.34] 0.61
IFFS 34.0 [24.3; 45.0] 22.5 [12.8; 47.5] 0.22
SESA 115 [79; 125] 110 [99; 128] 0.59
BDI 13.0 [6.5; 19.0] 7.0 [3.0; 20.0] 0.33
HADS-A 9.0 [4.8; 11.8] 8.0 [3.75;13.25] 0.54
HADS-D 5.5 [3.8; 7.0] 6.0 [1.5; 9.5] 0.84
HAQUAMS 2.3 [2.1; 2.5] 2.0 [1.8; 2.4] 0.07

Difference between intake and end of treatment scores

(Wilcoxon signed rank test)
EDSS MSFC IFSS SESA BDI HADS-A HADS-D HAQUAMS
z −.303 −.507 −1.224 −.533 −.972 −.613 −.205 −1.837
Asymptotic significance .762 .612 .221 .594 .331 .540 .837 .066
(two-tailed)
BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-D: Hospital Anxiety and Depression
Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis,
F

EDSS describes the state of disability MSFC: Multiple Sclerosis Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC:
Multiple Sclerosis Functional Composite.
OO

308 can be considered as a part of a treatment strat- there is no cure. This frequently life-long process 326

309 egy for two reasons. One, it offers a means to for patients starting when multiple sclerosis is di- 327

310 improve communicative performance.18 Second, it agnosed obviously demands a range of therapeutic 328

311 promotes the presentation of a self that may be possibilities which must also consider and encour- 329
PR

312 considered as handicapped or degenerating but can age a patient’s creative abilities.33 What we need 330

313 be performed as satisfying and whole—–and that is to establish is which of the varying parameters is 331

314 a matter of aesthetics.8,32 We know from the lim- subject to influence by music therapy, which was 332

315 ited, principally anecdotal, music-therapy litera- the aim of this study. 333

316 ture that there are potential benefits from music In this study various outcome-parameters were 334

317 therapy in terms of enhancing mood and improving evaluated for their possible appropriateness for 335
D

318 self-identity. showing effects of music therapy. These were both 336

319 While there are numerous projects aimed at find- functional and affective. We included many param- 337

320 ing medical relief for suffering and the treatment eters because although the clinicians involved knew 338
TE

321 of disease, we are reminded that disease-related that something positive was happening, there was 339

322 problems influence patient’s mental behaviour and no clear indication of what this was and how to mea- 340

323 this has ramifications for relationships. A major sure it. Through this study we now have an idea of 341

324 confrontation for those offering treatment, as it is what changes and from this basis can develop hy- 342

for the patient, is that the problem worsens and potheses for a controlled study.
EC

325 343

Table 2 Correlation of the differences in scales between T1 and T4.

SESA BDI HAD-A HAD-D HAQUAMS
RR

**
SESA −0.37 (0.11) −0.33 (0.15) −0.61 (0.04) 0.03 (0.89)
BDI 0.57** (0.01) 0.49* (0.03) 0.13 (0.59)
HAD-A 0.41 (0.07) 0.12 (0.62)
HAD-D 0.01 (0.96)
Levels of significance are printed in parentheses. BDI: Beck Depression Inventory, HAD-AS: Hospital Anxiety and Depression
CO

Scale—–anxiety, HAD-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS:
Hamburg Quality of Life Questionnaire in Multiple Sclerosis.
∗∗ Correlation is significant at the level 0.01 (two-tailed).
∗ Correlation is significant at the level 0.05 (two-tailed).
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 140
 Functionality or aesthetics? 7

344 Positive changes are shown in patients’ de- recognition of their abilities rather than patholo- 400

345 pressed mood, which are also reflected in the gies, and a possibility for them to exercise their 401

346 self-acceptance scale. Given that patients with own agency. 402

347 a chronic disease are also stigmatised,34 and

348 this spoiled identity is further exacerbated by
349 the concept of degeneration,35 then any inter- Qualitative considerations 403

350 vention that improves mood and enhances self-

351 acceptance is valuable in mitigating stigma. We In a final interview, 9 out of 10 music-therapy par- 404

352 know from the anecdotal literature that music ther- ticipants in the study described how important it 405

353 apy is important for establishing and recreating self was to become personally active in their treat- 406

354 identity.15,32,36 Perhaps we should not simply con- ment. All 10 participants reported an immediate 407

355 sider these diseases as neurodegenerative but as improvement in their well-being during sessions. In 408

356 dialogue-degenerative diseases, where there is a eight participants, this improved state continued 409

357 breakdown in dialogue between the sufferer and for some time and was confirmed by partners or 410

358 the community. friends. This is also confirmed by improvements in 411

359 There were no recognizable changes in motor the self-acceptance and depression scales but not 412

360 and functional abilities. The form of creative mu- by quality of life scores. Differences over time in 413

361 sic therapy used here is efficacious for promoting the depression scores and self-acceptance scores 414

362 a positive self-identity and relieving the emotional are highly correlated with each other that may re- 415

363 burden on a patient but not for improving functional flect their common conceptual background. Seven 416

abilities. participants described an enhanced perception of

F

364 417

365 Improvements in patients of the therapy group themselves with an increasing self-confidence over 418

with regard to relieving anxiety and depression, and the course of the therapy. They were increasingly
OO

366 419

367 above all with regard to improved self-acceptance, able to let themselves be surprised by the music as 420

368 are a consequence of the qualitative changes it emerged and by their own previously undiscov- 421

369 brought about in music-therapy encounters. The ered musical skills. Music and music therapy are ex- 422

370 change in the subscale anxiety of the HADS-D in perienced by patients as ‘‘something moving’’ that 423

371 both groups may be an indication that regular shifts negative thoughts about the disease into the 424
PR

372 professional patient care helps reduce depression background and offers a means of expression for 425

373 in multiple sclerosis sufferers. Standard therapeu- feelings of security, freedom and pleasure.38 One 426

374 tic practice is that patients only attend for con- participant relates how she met a friend in the Uni- 427

375 tact with a practitioner or treatment when there versity that she had not seen in a long time, af- 428

376 is a flare up in symptoms. Being recruited into ter treatment. They talked for a while and it was 429

377 a trial and being regularly assessed is also per- only on parting that she told her friend that she has 430

haps an important variable for therapeutic con- multiple sclerosis. This was a shift in her percep-
D

378 431

379 tact. tion of herself as first and foremost ‘‘a sick per- 432

380 There is a worsening of the music-therapy group son’’ to a normal person with other priorities in 433
TE

381 scale scores at follow-up when music-therapy treat- life. 434

382 ment is withdrawn, particularly with regard to self- What is evident from this study is that in assess- 435

383 esteem. This may be argued as evidence of the ing music therapy in terms of meeting patients’ 436

384 temporary effect of music therapy or that music needs then we cannot simply take a functional 437

therapy does indeed have an effect and we see approach alone. Multiple sclerosis patients have
EC

385 438

386 how the patient responds when the therapy is with- a variety of needs, some of these are psychoso- 439

387 drawn. cial and some of these are also aesthetic. An aes- 440

388 The importance of therapeutic contact is re- thetic therapy offers the opportunity to experi- 441

389 flected in a qualitative analysis of the data. Two ence the self not as solely degenerative but also 442

hundred and twenty-six music-therapy sessions as creative. This is a major turn around in self-
RR

390 443

391 were documented on video and evaluated with the understanding and is reflected in both self-esteem 444

392 help of episodes and generation of categories.37 and an improvement in mood. We are not denying 445

393 What emerged from the qualitative aspects of that these patients have a degenerative disease, 446

394 the study were parameters concerning contact be- simply that these patients are not themselves de- 447

395 tween therapist and patient, coping with the sit- generate. In the face of pathology, even in sick- 448
CO

396 uation, the sharing of musical roles, and an abil- ness, we have the potential to be active creative 449

397 ity to structure time and the possibility to initi- agents. Music therapy emphases creative dialogue 450

398 ate changes in play. These factors reflect the needs as an remedy in the face of a dialogic degenerative 451

399 of these patients for a deeper personal contact, a disease.35 452

UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 141
 8 D. Aldridge et al.

453 We have used effect sizes here, although mod- 16. Magee W. ‘‘Singing my life, playing myself’’: music therapy 515

454 est, to provide a platform for other studies that will in the treatment of chronic neurological illness. In: Wigram 516

T, Backer JDe, editors. Clinical applications of music ther-

455 no doubt improve on what we have attempted. This 517

apy in developmental disability, paediatrics and neurology. 518

456 exploratory study has indicated the potential ben- London and Philadelphia: Jessica Kingsley Publishers; 1999. 519
457 efits of music therapy as an aesthetic intervention p. 201—23. 520

458 concerned with the performance of self in everyday 17. Magee W. Identity in clinical music therapy: shifting self- 521

459 life. At some stage we will also need to consider contsructs through the therapeutic process. In: Miell D, 522
460 editor. Musical identities. Oxford: Oxford University Press;
multi centre trials. 523

2002. p. 179—97. 524

18. Magee W, Davidson J. The effect of music therapy on mood 525

states in neurological patients: a pilot study. J Music Ther
References
526
461
2002;39(1):20—9. 527

19. Rothwell PM, Dowell, Mc Z, Wong CK, Dorman PJ. Doc- 528

462 1. Amato MP, Zipoli V. Cognitive dysfunction in multiple scle- tors and patients donı̌t agree: cross sectional study of pa- 529

463 rosis: current approaches to clinical management. Expert tients’ and doctors’ perceptions and assessments of dis- 530

464 Rev Neurotherapeut 2002;2(5):731—42. ability in multiple sclerosis. Br Med J 1997;314:1580— 531

465 2. Mahler M, Benson D. Cognitive dysfunction in multiple scle- 3. 532

466 rosis: a subcortical dementia? In: Rao S, editor. Neurobe- 20. Sparber A, Wootton JC. Surveys of complementary and 533

467 havioural aspects of multiple sclerosis. Oxford: Oxford Uni- alternative medicine: part V. Use of alternative and 534

468 versity Press; 1990. complementary therapies for psychiatric and neuro- 535

469 3. Armstrong C. Selective versus sustained attention: a con- logic diseases. J Altern Complement Med 2002;8(1):93— 536

470 tinuous performance test revisited. Clin Neuropsychol 6. 537

471 1997;11(1):18—33. 21. Kurtzke JF. Rating neurologic impairment in multiple scle- 538
F

472 4. Johnson SK, Deluca J, Diamond BJ, Natelson BH. Se- rosis: an Expanded Disability Status Scale (EDSS). Neurology 539

473 lective impairment of auditory processing in chronic fa- 1983;33:1444—52. 540

474 tigue syndrome: a comparison with multiple sclerosis 22. Nordoff P, Robbins C. Creative music therapy. New York: 541
OO

475 and healthy controls. Percept Mot Skills 1996;83(1):51— John Day; 1977. 542

476 62. 23. Aikens JE, Reinecke MA, Pliskin NH, Fischer JS, Wiebe 543

477 5. Schurmann M, BasarEroglu C, Basar E. A possible role of JS, McCracken LM, et al. Assessing depressive symptoms 544

478 evoked alpha in primary sensory processing: common prop- in multiple sclerosis: is it necessary to omit items from 545

479 erties of cat intracranial recordings and human EEG and the original Beck Depression Inventory? J Behav Med 546

480 MEG. Int J Psychophysiol 1997;26(1—3):149—70. 1999;22(2):127—42. 547

6. Gold R, Rieckmann R. Pathogenese und Therapie der Mul- 24. Beatty WW, Orbelo DM, Sorocco KH, Ross ED. Comprehen- 548
PR

481

482 tiplen Sklerose. Bremen: UNI-MED Verlag Bremen; 2000. sion of affective prosody in multiple sclerosis. Mult Scler 549

483 7. Evers KJ, Karnilowicz W. Patient attitude as a function 2003;9(2):148—53. 550

484 of disease state in multiple sclerosis. Social Sci Med 25. Feinstein A, Feinstein K. Depression associated with multi- 551

485 1996;43(8):S1245—51. ple sclerosis. Looking beyond diagnosis to symptom expres- 552

486 8. Aldridge D. Aesthetics and the individual in the practice sion. J Affect Disord 2001;66(2/3):193—8. 553

487 of medical research: a discussion paper. J R Soc Med 26. Feinstein A, O’Connor P, Gray T, Feinstein K. The effects of 554

488 1991;84:147—50. anxiety on psychiatric morbidity in patients with multiple 555

D

489 9. Alcock G, Chambers B, Christopheson J, Heiser D, Groet- sclerosis. Mult Scler 1999;5(5):323—6. 556

490 zinger D. Complementary and alternative therapies for mul- 27. Berger EM. The relationship between expressed acceptance 557

491 tiple sclerosis. In: Halper J, editor. Advanced concepts in of self and expressed acceptance of others. J Abnorm Psy- 558
TE

492 multiple sclerosis nursing care. New York: Demos Medical chol 1952;47:778—82. 559

493 Publishing; 2001. p. 239—66. 28. Jiwa TI. Multiple sclerosis and self esteem. Axone 560

494 10. Thorne S, Paterson B, Russell C, Schultz A. Comple- 1995;16(4):87—90. 561

495 mentary/alternative medicine in chronic illness as in- 29. Gold SM, Heesen C, Schulz H, Schulz K-H. Disease specific 562

496 formed self-care decision making. Int J Nurs Stud quality of life instruments in multiple sclerosis: validation 563

497 2002;39(7):671—83. of the Hamburg Quality of Life Questionnaire in Multiple 564

EC

498 11. O’Callaghan C. Lyrical themes in songs written by palliative Sclerosis (HAQUAMS). Mult Scler 2001;7:119—30. 565

499 care patients. J Music Ther 1996;33(2):74—92. 30. Prosser LA, Kuntz KM, Bar-Or A, Weinstein MC. Patient and 566

500 12. Wiens ME, Reimer MA, Guyn HL. Music therapy as a treat- community preferences for treatments and health states in 567

501 ment method for improving respiratory muscle strength in multiple sclerosis. Mult Scler 2003;9(3):311—9. 568

502 patients with advanced multiple sclerosis: a pilot study. Re- 31. Fischer JS, Rudick RA, Cutter GR, Reingold SC. For the Na- 569

503 habil Nurs 1999;24(2):74—80. tional MS Society Clinical Outcomes Assessment Task Force 570
RR

504 13. Lengdobler H, Kiessling WR. Group music therapy in multi- (1999). The multiple sclerosis composite measure (MSFC): 571

505 ple sclerosis: first report. Psychotherapie, Psychosomatik, an integrated approach to MS clinical outcomes assessment. 572

506 Medizinische Psychologie 1989;39(9/10):369—73. Mult Scler 1999;5:244—50. 573

507 14. Magee W. A comparative study of familiar pre-composed 32. Aldridge D. Music therapy research and practice in 574

508 music and unfamiliar improvised music in clinical music medicine. London: Jessica Kingsley; 1996. 575

509 therapy with adults with multiple sclerosis. London: Royal 33. Kriz J. Grundkonzepte der Psychotherapie. Weinheim: Psy- 576
CO

510 Hospital for Neuro-disability; 1998. chologie Verlags Union; 1994. 577

511 15. Magee W. Music therapy in chronic degenerative illness: re- 34. Goffman E. Stigma. Notes on the management of a spoiled 578

512 flecting the dynamic sense of self. In: Aldridge D, editor. identity. Englewood Cliffs, NJ: Prentice-Hall; 1963. 579

513 Music therapy in palliative care: new voices. London: Jes- 35. Aldridge D. The creative arts therapies in the treatment of 580

514 sica Kingsley; 1999. p. 82—94. neurodegenerative illness. In: Trias G, editor. Music therapy 581
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 142
 Functionality or aesthetics? 9

582 and art therapy in neurodegenerative diseases. Barcelona: therapy traces. Music Ther Today (online). Available at 587
583 la Caixa; 2003. p. 37—46. http://musictherapyworld.net; 2002, December. 588
584 36. Aldridge D. A phenomenological comparison of the organi- 38. Schmid W. Music therapy with people suffering from multi- 589
585 zation of music and the self. Arts Psychother 1989;16:91—7. ple sclerosis. In: Trias G, editor. Music therapy and art ther- 590
586 37. Aldridge D, Aldridge G. Therapeutic narrative analysis: a apy in neurodegenrative diseases. Barcelona: Fundación 591
methodological proposal for the interpretation of music ‘‘la Caixa’’; 2003. 592

593
F
OO
D PR
TE
EC
RR
CO
UN

YCTIM 751 1—9

David Aldridge Collected music therapy papers 143
22; lournal of the Royal Society of Medicine Volume 80 April 1987
Clinical assessment of acupuncture in asthma therapy:
discussion paper
D Aldridge P ~ D P C Pietroni FRCGP MRCP Department of General Practice, St Mary's Hospital Medical
School, London
Keywords: acupuncture, asthma, complementary therapy, controlled trials
This paper is concerned with reviewing the use
of acupuncture for the relief of chronic bronchial
asthma, for it is our intention to embark upon a con-
trolled clinical trial of acupuncture therapy in the
context of general medical practice. A secondary
property of this paper is a discussion of clinical trial
methodology as applied to a complementary therapy.
Acupuncture
Acupuncture is a therapy which has gained some
recognition both within the realms of popular prac-
tice and, perhaps more importantly, within the realm
of medical practice. The practice of acupuncture is a
collection of procedures which include the insertion
of needles at specific points of the body for both
the relief of pain and the treatment of disease, with
moxibustion and cupping.
Traditional descriptions of acupuncture are con-
cerned with the flow of vital energy, called ch'i,
along fixed paths called meridians. These are linked
together with each other and the organs of the body.
Flow of energy along these paths has a circadian
rhythm, so that at times and season it may vary.
Energy in this context has a bipolar character; it can
be positive called 'yang', and negative called 'yin'.
The energy within the body, ch'i, reflects both the
vitality of the universe and society l.
For a body to be healthy in this system of descrip-
tion, the flow of ch'i in the meridians is normal and
balanced. Essentially the process is one of maintain-
ing balance, i.e. becoming healthy or losing health.
Diagnosis, too, is seen as a process and takes into
account many factors. It includes a patient history of
changes in behaviour, appetite and emotions. The
state of the skin, eyes, breath and tongue are noted
for colour, consistency and odour. There are also
special techniques for the evaluation of the flow of
energy in the 12 meridians, electrical measure-
ments of skin resistance, and the palpation of skin
subcutaneous tissue.
Although the mode of action of acupuncture is not
known precisely, there are a number of suggestions
which propose that the mechanism is linked with the
secretion of endorphins2. Yu and Lee3 suggest that
acupuncture relieves that part of the bronchocon-
striction which does not arise from the constriction
of smooth muscle as a result of chemical mediators.
The effect of acupuncture in asthma is mediated
through modification of the reflex component of
0141-0768/87/
04022203,~0200/0
bronchoconstriction. Other writers invoke the prox-
@ 1987
imity of the central nervous system projections of the
The Royal acupuncture simulation site and the pain path as the
Society of rationale for the selection of treatment loci, humoral-
Medicine biochemcal mechanisms, neuromechanisms, and the
David Aldridge Collected music therapy papers
bioelectric mechanism1.It has been pointed out, how-
ever, that these descriptions are made by 'scientific
apologists'1.
It is more likely that acupuncture represents many
phenomena and that a primary difficulty, as discussed
later, lies in a treatment modality that is under-
pinned by an Oriental philosophy being subjected
to an explanation by the differing theoretical
understanding of modern Western medicine.
Asthma
Asthma is a condition characterized by symptoms
which are present over long periods of a patients' life.
The number of people with asthma in the United
Kingdom is estimated to be about two million - a
number too great for the hospital services to provide
continuing care. Although the condition is often mild
and readily treated, for those persons with a chronic
condition the illness is composed of recurrent crises
and debilitation. Gregg4estimates that the incidence
of asthma in the population is increasing, and in a
form that is frequently more severe than in the past.
The general practitioner is in a position to identify
the incidence of asthma, to be involved in preventive
measures and to offer early treatment. Many persons
seen in hospital outpatient departments could be
managed just as easily in the context of the general
practitioner clinic5.
Asthma is often refractory to pharmacotherapy,
the side effects of which can be distressing. A low-risk
form of treatment such as acupuncture could consti-
tute an advancement in the management of asthma6,
particularly if used in the context of general medical
practice which utilizes elements of patient education
and a self-care perspective.
Clinical controlled trials of asthma
A literature search was carried out using the Medline
database through St Mary's Hospital Medical School
library. The criteria for the search were English
language papers on 'asthma therapy' and 'acupunc-
ture' published in the past ten years. Eight
studies were discovered having a controlled trial
methodology which used either a 'placebo' or 'no
treatment' control group3v612.
Although these trials ostensibly used a controlled
trial methodology, there were many inconsistencies.
First, most of the trials had few subjects; the largest
trial had 111subjects but the rest had no more than
25. Second, there was a large disparity in the age
ranges; in one trial the ages ranged from 6 to 71 years.
Third, the clinical entities were wide-ranging.
The predominant conclusion of the controlled
trials was that at best acupuncture resulted in only
144

modest improvement in the 'objective' assessment of
airways impedance. These objective measures were
mainly concerned with expiratory flow rates, airway
conductance and thoracic gas volume. A greater
perception of symptom relief was made subjectively
by the patients using self-report measures and diary
techniques, a point that will be discussed further
later in the paper.
Clinical evaluations
Two t r i a l ~ were
~ ~ , essentially
~ ~ evaluations by
clinicians of clinical practice. A range of symptoms
associated with asthma were covered, the treatment
approach being varied according to the presenting
symptoms. The number of treatment sessions was not
standardized but varied according to the symptoms
and symptomatic improvement.
The criteria for improvement were subjective and
included the assessments of both practitioner and
patient. Cioppa13 found that 67% of the patients
improved with acupuncture treatment. The conclu-
sions of this research were that acupuncture appears
to: (a) relieve muscle spasm; (b) be useful in subacute
onditions; (c) be something other than hypnosis; (d)
Kacilitate manipulation; (e) have an immediate effect;
(/) give complete remission - not only palliation - in
many cases; (g) give a sense of well being; (h) be a
valuable adjunct to standard practice. Fuller14 also
considered acupuncture to be effective in treating
chronic asthma and recommended its use.
The remaining papers were a collection of miscel-
laneous reports and letters about the clinical appli-
cation of acupuncture, the relationship to general
medical practice, and replies to letters15z1.
Hossrizzdescribed the use of acupuncture massage
for the relief of asthma in children. This entails a
number of techniques using pressure a t acupuncture
sites, friction and manipulation. Hossri also used
hypnosis in combination with these techniques.
Acupressure, the substitute of digital pressure for
needling at specific sites, has been used in medi-
cine and dentistry both for the relief of pain and
tensionz3- 2 5 .
R'iscussion
here is a disparity between the claims of acupunc-
turists as to positive clinical benefit, and the findings
of the clinical trials research, which demonstrates
little 'objective' change but does emphasize 'subjec-
tive' change. Such difficulties bedevil the assessment
of alternative or complementary therapies, particu-
larly since there is a confusion between different
levels of measurement - i.e. between that which is
measurable in terms of quantity such as gas volume,
and that which cannot be readily subjected to such
quantification such as 'feeling better'.
A more serious critique concerns the controlled
trial methodology itself. The trials studied here failed
to provide a sample size with sufficient power to make
any valid conclusions from the statisticsz6.Further-
more, the trials really did not investigate 'acupunc-
ture'. The process of standardizing the treatment
approach removed from the practice itself that which
is the essence of the treatment. By restricting need-
ling sites to specific loci, limiting the number of treat-
ment sessions and abdicating the use of traditional
diagnostic practices, the trials were really reduced to
testing the insertion of needles a t particular points. It
is therefore not surprising that needling as 'acupunc-
David Aldridge Collected music therapy papers
Journal of the Royal Society of Medicine Volume 80 April 1987 223
ture' in these trials differed from needling as a
'placebo' or 'sham' acupuncture. What the trials
failed to do was realize that even though methodology
can be applied, if it is applied without understanding
simply as a formula then no significant findings
emerge. To do this abdicates both responsibility
in science and real discovery. Science is not
methodology;methodology serves science.
How can we as scientists say that we have sub-
jected a practice to adequate investigation when we
remove from the process that which is essential?
When applied rigidly, clinical trials remove the inter-
action between the subject and the researcher. It is
this very interaction which is at the very heart of
clinical practice, and which cannot be removed no
matter how impersonal we may wish to be. The separ-
ation of the disease from the person loses those very
qualities which we need to understand. Diseases may
be treated as aggregates and submitted to statistical
analysis, but it is individual persons in whom those
diseases are located and who confront us in our
surgeries.
Another feature of the clinical trial methodology
was that asthma was seen as a homogeneous clinical
entity. There was no consideration that the symp-
toms were located within persons who perceived
their symptoms differentially, or that asthma in a
6-year-old is qualitatively different from that in a
71-year-old.
Asthma appears to be tractable to acupuncture
when treated by committed clinicians who use tradi-
tional techniques. The clinical trials have not
investigated acupuncture as a treatment modality,
but 'needling techniques'. The challenge for clini-
cians and researchers is to examine rigorously the
practical effects of acupuncture treatment but from a
perspective which involves the whole person and the
totality of the treatment process.
The way forward
It is our intention to carry out a pilot study of acupuc-
ture treatment and education classes in the manage-
ment of chronic asthma. Our referrals will be taken
from hospital outpatients where the patients will be
assessed by an external researcher, who will also
carry out the post-trial blind assessment. Of 150
patients who will be recruited to the study, 50 will be
randomly allocated to an acupuncture treatment;
another 50 oatients will be allocated to education
classes; and the third group of 50 patients will be
offered continuing general practitioner contact only.
All groups will be asked to complete a diary for the
eight-week treatment period, and a t a later follow-up
period.
The acupuncture treatment method will be deter-
mined by the acupuncturist. There-willbe no definite
fixed number of treatment sessions, but it is antici-
pated that the acupuncturist will attempt to keep
within the eight-week timescale. The acupuncture
sites will not be controlled, and it is expected that the
acupuncturist will use a traditional pulse diagnosis.
The data collected will cover a broad spectrum of
information concerned both with the symptoms and
illness behaviour, as follows:
(1) impact of asthma upon health (using the
Nottingham Health P r ~ f i l e ~ and ' * ~ life
~ style data
(Social Problem Q~estionnaire*~), and locus of
control30;
145
224 Journal of the Royal Society of Medicine Volume 80 April 1987
(2) diary recording of events3133,asthma attacks,
use of medication/bronchodilator, night-time disturb-
ance, time off work, crisis consultations, GP home
visits and scores for wheeze, breathlessness, chest
tightness and cough;
(3) qualitative measures of practitioner, patient and
family satisfaction;
(4) knowledge and skills of patient about the
management of asthma;
(5) peak expiratory flow.
The education classes will consist of direct teach-
ing about allergens and triggers of asthma (physical,
psychological and relational); the correct use of
medication, where appropriate, and the broncho-
dilator; and what asthma is in terms of airway
impedance. Building on this basis there will be an
opportunity for each person to identify through the
diaries their own particular triggers.
A number of complementary strategies will be
introduced, including dietary understandings, speci-
fic breathing technique, the use of relaxation tech-
niques and stress management. It is anticipated that
the people involved in this project will be able to
personalize these strategies according to their own
lifestyles and the contexts in which they become
symptomatic.
This pilot study will attempt to meet our earlier
criticisms of controlled trials. Acupuncture will not
be restricted solely to needling, and a range of data
will be collected which will include the physical, the
psychological, the relational and the familial.
Acknowledgment: This research is funded by the Wates
Foundation.
References
Millman BS. Acupuncture: Context and critique. Ann
Rev Med 1977;28:223-34
Guillemin R, Vargo T, Rossier J. Beta endorphin and
adrenicorticotrophin are secreted concomitantly by
the pituitary gland. Science 1977;197:1367
Yu DYC, Lee SP. Effect of acupuncture on bronchial
asthma. d i n Sci Molec Med 1976;51:503-9
Gregg I . The quality of asthma in general practice - a
challenge for the future. Family Practice 1985;2:94-100
Arnold AG, Lane DJ, Zapata E. Acute severe asthma:
Factors that influence hospital referral by the general
practitioner and self referral by the patient. Br J Dis
Chest 1983;77:51-9
Dias PLR, Subramanian S, Lionel NDW. Effects of
acupuncture in bronchial asthma: a preliminary com-
munication. J R Soc Med 1982;75:245-8
Shao JM, Ding YD. Clinical observation of 111 cases
of asthma treated by acupuncture and moxibustion.
Journal of Traditional Chinese Medicine 1985;5:23-5
Christensen PA, Laurensen LC, Taudorf E, Sorensen
SC, Weeke B. Acupuncture and bronchial asthma.
Allergy 1984;39:379-85
Berger D, Nolte D. Acupuncture in bronchial
asthma: body plethysmographic measurements of acute
bronchospamolytic effects. Comparative Medicine East
and West 1977;5:265-9
David Aldridge Collected music therapy papers
10 Tashkin DP, Bresler DE, Kroenig, RJ, Kerschner H,
Katz RL, Coulson A. Comparison of real and simulated
acupuncture and isoprotenerol in metacholine-induced
asthma. Ann Allergy 1977;39:379-87
11 Tashkin DP, Kroenig RJ, Bresler DE, Simmons M,
Coulson AH, Kerschnar H. A control trial of real and
simulated acupuncture in the management of chronic
asthma. J Allergy Clin Immunol1985;76:855-64
12 Takishima T, Mue S, Tamura G, Ishihara T, Watanabe
K. The bronchodilating effect of acupuncture in
patients with acute asthma. Ann Allergy 1982;48:44-9
13 Cioppa FJ. Clinical evaluation of acupuncture in 129
patients. Diseases of the Nervous System 1976;37:639-43
14 Fuller JA. Acupuncture. Med JAust 1974;ii:340-l
15 Alien M. Activity generated endorphins: a review of
their role in sports science. Can J Appl Sport Sci
1983;8:115-33
16 Rebuck AS. The outpatient management of asthma.
Ann Allergy 1985;55:507-10
17 Donnelly WJ, Spyykerboer JE, Thong YH. Are patients
who use alternative medicine dissatisfied with orthodox
medicine? Med JAust 1985;142:53941
18 Bodner G, Topilsky M, Greif J.Pneumothorax as a com-
plication of acupuncture in the treatment of bronchial
asthma. Ann Allergy 1983;51:401-3
19 Hayhoe S. Effects of acupuncture in bronchial asthma
J R Soc Med 1982;75:917
20 Marcus P. Effects of acupuncture in bronchial asthma.
(I
J R Soc Med 1982;75:670
21 Rosenthal RR, Wang KP, Norman PS. All that is
asthma does not wheeze. N Engl J Med 1975;292:372
22 Hossri CM. The treatment of asthma in children
through acupuncture massage. Journal of the American
Society of Psychosomatic and Dental Medicine 1976;
23:3-16
23 Weaver T. Acupressure: An overview of theory and
application. Nurse Practitioner 1985;10:38-42
24 Kurland D. Treatment of headache pain with auto-
acupressure. Diseases of the Nervous System 1976;
37:127-9
25 Penzer V. Acupressure in dental practice: Magic a t the
tips of your fingers. Journal of the Massachusetts Dental
Society 1985;34:71-5
26 Lewith GT, Machin D. On the evaluation of the clinical
effects of acupuncture. Pain 1983;16:111-27
27 Hunt SM, McEwen J , McKenna SP. Measuring health
status: a new tool for clinicians. J R Coil Gen Prac
1985;35:185-8
28 Hunt SM, McEwen J , McKenna SP. Social inequaliti
and perceived health. EffectiveHealthCare 1985;2:1514
29 Corney R, Clare AW. The construction, development
and testing of a self report questionnaire to identify
social problems - a pilot study. Psychol Med 1985;
15:637-49
30 Lefcourt HM. Locus of control. New Jersey: Lawrence
Erlbaum, 1982
31 Barry DMJ, Marshal1 TH, Rothwell RPG. Asthma and
diaryltreatment cards. NZ Med J 1985;98:556
32 Freer CB. Self care: a health diary study. Med Care
1980;18:853-61
33 Murray J. The use of health diaries in the field of
psychiatric illness in general practice. Psychol Med
1985:15:82740
(Accepted 9 September 1986)
146