C R E A T IV IT Y A N D CO N S C IO U S N E S S : M U S IC T H E R A P Y IN

IN T E N S IV E C A R E David Aldridge

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a balance he urges us too consider the

. . . h o w e v e r g re at t h e o rg an i c dam ag e . . . t h e re re m ai n s t h e u n di m i n i s h e d po s s i bi l i t y o f re i n t e g rat i o n by art , by c o m m u n i o n , by u n l o c k i n g t h e h u m an s pi ri t ; an d t h i s c an be pre s e n t e d i n w h at at f i rs t s e e m s at f i rs t a h o pe l e s s s t at e o f n e u ro l o g i c al de v as t at i o n p3 7 ( S ac k s , 1 9 8 6 ) .

narrative and symbolic organisation of the patient, such that we consider their possibilities and abilities. In this way what seems to be damaged, ill organised and chaotic becomes composed and fluent. This is the function of the creative arts; through art and play we realise other selves elusive to measurement and fugitive to assessment. Furthermore there is a quality of time which is apparent in arts activities which is intentional and involves the will of the patient where their spirit is set free. When we consider the situation of intensive care, where patients are often damaged, disorganised, intubated, machine - regulated, often unconscious, and unable to communicate; then we must consider a way of

he 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 capacities. As

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introducing

activities

which

will

stimulate

resulting from insufficient communication, sleep and sensory deprivation (Hannich, 1988; Ulrich, 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 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

communion with those patients. In this paper the ground of consciousness is considered. It raises questions patients about who the are and location of the self in with patients who are

comatose, about the nature of communication unconscious challenges medicine to realise the human body as an instrument of knowledge. Some aspects of modern medicine have become increasingly technological. Such is the case of intensive care treatment. Even in what may appear to be hopeless cases, it can save lives (Hannich, 1988) through the application of this modern 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

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ages of 15 and 40 years,

and with severe

of musical organisation. Music therapy is the medium by which a coherent organisation is regained, i.e. linking brain, body and mind. In this perspective the self is more than a corporeal being. As Sacks (Sacks, 1986) writes, the power of music or narrative form is to organize p177. 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 between music eight therapy and contact lasted The twelve minutes.

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 organised as human beings not in a mechanical way but in a musical form; i.e. a harmonic complex of interacting rhythms and melodic contours (Aldridge, 1989a; Aldridge, 1989b; Nordoff & Robbins, 1977). 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

therapist improvised her wordless singing based

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upon the tempo of the patients pulse, and more importantly, the patients breathing pattern. She pitched her singing to a tuning fork. The character of the patients 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 met the family to gain some idea of what the patient was like as a person. 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), head, fine motor movements, to the grabbing of movements of the hand and turning of the eyes opening regaining 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 & Robbins, 1977; Sandman, 1984a; Sandman, 1984b). EEG measurement of brain activity showed former a desynchronization areas. from This theta effect, rhythm, to alpha rhythm or beta rhythm in synchronized

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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 wave of that the relationship between the contraction of the heart and the ascending alpha rhythm (Sandman, 1986) of rhythmic coordination of the brain activity, then it is possible to hypothesize cardiovascular system with cortical rhythmic firings is of primary importance for cognition. What we have is a weaving together of basic primitive human rhythms, which produce an interference pattern which 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, & Hoffman, & Safranek, activity . The ward situation Sleep disturbance is a

Jones, 1984;

Lester,

Brazelton, 1985; Longuet-Higgins, Locsin, 1981; 1982; & Raymond,

1982; Povel, 1984; Rozzano & Koshland,

Steedman, 1977) is a fundamental healing

major

problem

in

intensive care units and metabolic & cycles is

the effect of a (Johnson &

disturbed waking/sleeping rhythm upon other critical Woodland-Hastings, 1986; Moore-Ede, Czeisler, Richardson, 1983; Reinberg & The rhythmic Halberg, of 1971). entrainment

cardiovascular and somatic activities may be the key ground for recovery. This means that we must consider the total behavioural (Engel, 1986) activity of the patient such that

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seemingly independent systems are integrated. The context (i.e. Latin. con textere = weaving together) of this integration is rhythmical involving the co-ordination of the major tidal rhythms of the body and timing mechanisms within the hypothalamus in the brain. As an organizational problem we must look to the way 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 wonder that there are sleep problems when they must respond to constant activity with carers who themselves are physically unsynchronised with the patient. Nursing staff, while synchronised with management needs and hospital routine ,

may need to attend to the sleep/ activity rhythm of the patient. In response to the music therapy some ward staff are astonished that respond to patients can 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 communication 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.

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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 patients, of seemingly upon non-responding machines to dependent

At yet another level, we must consider the fixed chronolological 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 which as yet machines cannot do. Perhaps the key lies in the fact that it is the consciousness of the therapist which stimulates the consciousness of the patient, and this consciousness is not divorced from the living rhythmic reality of our physiology.

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. While the machines themselves are of vital importance, they present data which are independent one from another, and which are often considered in isolation whereas the integration of the systems being measured are the clue to recovery. This is further exacerbated by a scientific epistemology which emphasizes the person only as a material being and which equates mind with brain.

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A period of calm is also recognized as having potential benefit for the patient. What some staff fail to realise is that communication is dependent upon rhythm, not upon volume. We and might space, argue are that further such unconscious by an patients, struggling to orient themselves in time confused atmosphere of continuing loud, disorienting random noise and bright light. 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 behavior even when consciousness appears to be absent. Reflexes do not occur in a vacuum, they are conditional occurring in a context of other behavioural 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 then of how those behaviours can be integrated and where is the seat of such integration. It is quite clear that integration then is an organisational property of the whole organisation in relationship with the environment and not located materially in any cell or any one organ. The environment of the patient includes the vital component of human contact and there is reason to believe that the

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essential

ground

of

this

contact

too

is

creatively realised such that

we, as artist

rhythmical. 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 our contact with such patients at a time of existential crisis points to a fundamental aesthetic of living systems

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 realised 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 intensive monitoring and machine support, particularly in the case of comatose patients, we may ask of ourselves Where is the self of the patient?. Needleman (Needleman, 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

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scientific also

medicine the direct

and human as

instrumentation. body as an

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 communication touches the patient, as singing, then we can also attend to how we speak with the patient in their breathing patterns, and the 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

However, he goes on to say that science has neglected as instrument of knowledge and as a vehicle for sensations ordinary sensory experience, but as subtle as consciousness. He writes ..........it is not simply the intellect which science underestimates, it is the human 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 selfsincerity p169. 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

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those conditions which are the context for healing to take place.

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 Psychotherapy 16, 91-97. Engel, B.T. (1986). An essay on the circulation as behavior. The Behavioral and Brain Sciences 9, 285-318. Gustorff,D. (1990). Lieder ohne Worte. Musiktherapeutische Umschau, 11, 120-126. Hannich, H.J. (1988). berlegen zum Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaft 13, 238-244. Johnson, C., and Woodland-Hastings,J. (1986). The elusive mechanism of the circadian clock. American Scientist 74, 2936. Jones, M., Kidd,G & Wetzel,R (1981). Evidence for rhythmic attention. Journal of Experimental Psychology 7, 1059-1073.

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Kempton, W. (1980). The rhythmic basis of interactional microsynchrony. In M.Key (Ed.), The relationship of verbal and non-verbal communication. . (pp68-75). 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, BM., Hoffman,J. & Brazelton,T. (1985). The rhythmic 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 perception. Psychological Research , 45, 315-337. Reinberg, A., & Halberg,F. (1971). Circadian chronopharmacology. 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, O. (1986). The man who mistook his wife for a hat. London: Pan. Safranek, M., Koshland,G. & Raymond,G. (1982). Effect of auditory rhythm on muscle activity. Physical Therapy, 62, 161-168. Sandman, C. (1984a). Afferent influences on the cortical evoked response. In M.Coles, J.Jennings, & J.Stern (Eds.), Psychophysiological perspectives: Festschrift

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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 Journal of Physiology , 2, , 111-119. Sandman, C. (1986). Circulation as consciousness. The Behavioural 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 recovery from surgery. Science , 224, 420-421.
Acknowledgements: Dr Wilhelm Rimpau for the initiation of this work. Dagmar Gustorff for her pioneering of these skills in difficult conditions. Prof H-J Hannich for his providing the circumstances for the further exploration of this work.

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