4th international conference proceedings - CMTER

CENTER FOR MUSIC THERAPY EDUCATION AND RESEARCH Sri Balaji Vidyapeeth

PROCEEDINGS of 4th INTERNATIONAL CONFERENCE on MUSIC THERAPY: SALUTOGENIC APPROACH TO HEALTH

10.03.2017 Pondicherry

Edited by DR. SUMATHY SUNDAR DR. VELLORE A.R. SRINIVASAN 1

Published by Center for Music Therapy Education and Research, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pondicherry

Editorial Board Patrons Shri. M.K. Rajagopalan, Chairman Prof. Dr. Rajaram Pagadala, Chancellor Editor-in-Chief : Dr. Sumathy Sundar Advisory Board

Executive Editors

Prof. Dr. K.R. Sethuraman

Prof. Dr. A.R. Srinivasan

Prof. Dr. N. Ananthakrishnan

Prof. Dr. B. Sivaprakash Ms. A.N. Uma Members

Dr. S. Srirangaraj Dr. V.R. Hemanth Kumar Dr. Sobana Jaiganesh Mrs. Asha Suresh Babu Ms. Vijay Chitra

Center for Music Therapy Education and Research, Sri Balaji Vidyapeeth

(Deemed to be University, Declared Under Section 3 of the UGC Act 1956) Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkupam, Pondicherry - 607402, India.

Phone : +91 413 2615449 to 58 Extn : 205 Fax : +91 413 2615457 Email : musictherapy@mgmcri.ac.in www.sbvu.ac.in/cmter-center-for-music-therapy-education-and-research

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Organizing Committee Chief Patron Shri. M.K. Rajagopalam, Chairman, SBECPT Patrons Prof. Dr. Rajaram Pagadala, Chancellor, SBV Prof. Dr. KR. Sethuraman, Vice Chancellor, SBV Advisory Board Prof. N. Ananthakrishnan, Dean, Allied Health Sciences Prof. M. Ravishankar, Faculty Dean, Medicine Prof. Usha Carounanidy, Faculy Dean, Dentistry Prof. K. Renuka, Faculty Dean, Nursing Sciences Prof. Nirmal Coumare, Medical Superintendent Mrs. Asha Suresh Babu, GM, Administration Mr. Kannan Aiyer, GM, Finance Organizing Committee Dr. Vellore A R Srinivasan - Orgnanizing Chairman Dr. Sumathy Sundar - Organizing Secretary Mr. Joseph Naresh - Treasurer Members Dr. Sobana Jaiganesh Ms. Bhuvaneswari Ramesh Dr. Selva Balaji Ms. Merlin Joy Dr. A N Uma Ms. Kala Varathan Dr. Prasanya Ms. R. Ambika

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Mr. M. K. RAJAGOPALAN Founder & Chairman, SBECPT

Chairman's Message I am indeed delighted to note that the Centre for Music Therapy Education & Research (CMTER) of Sri Balaji Vidyapeeth is organizing the 4th International Conference on the theme “Music Therapy: Salutogenic approach to Health� on 10th March 2017.

I am sure that these efforts will augument the concept of Wholistic approach to health giving due weightage to the concept of the Alternative Medicine.

I wish the International delegates a pleasant stay and the organising committee best wishes towards the success of the event.

M.K. Rajagopalan Chairman

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Prof. Rajaram Pagadala

MD (ObGyn), DSS (Surg. Onco., Vienna), PhD (Pop. Studies), WHO Dip. (Hlth.Econom. Thailand)

Music Therapy for attaining ‘Quality of Life’

Music has been a source for balancing physical and mental health. Listening to music or playing any music in times of personal crisis, for an individual is comforting. In the past, music has been used for promoting health. Now music is widely used in clinical sciences.

However, it is pity that our colleagues have not shown interest to use music in their professional practices.

Music therapy, must be explored to create a cadre of allied healthcare professionals drawn from various disciplines and thus produce trained musicologists who can play a role to complement in the management of, at least, in managing chronic disease and also in home setup like physiotherapist.

After all clinical evidence showed that Music therapy does good and helps in reducing the period of rehabilitation following disease. Music must be used at least as a supportive and caring method of management in terminally ill to live in comfort.

Music therapy, though ancient and age-old can now be considered as most modern. In the past, it was used to overcome the grief, preserving and enhancing mental and physical health creating a spiritual awakening.

I wish the conference a grand success and hope constructive recommendations will come out of deliberations.

Music therapy must be practiced for attaining “Quality of Life”.

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Prof. K.R. Sethuraman, MD, PGDHE. Vice -Chancellor

Message Personally speaking, having witnessed several individuals undergoing "spiritual possession" (or a trance state) induced by musical chants and rhythmic drumming during the annual festivals in the village temples (Mariamman and Draupathiamman), I am convinced of the power of "culturally appropriate music" to influence thought, mood and action of an individual in the short term. With repeated exposure, perhaps there would be long term consequences too.

There is adequate evidence on the efficacy of Music therapy as a complementary medicine.

In 2009, a Cochrane analysis of 23 clinical trials concluded that music can have a beneficial effect on blood pressure, heart rate, respiration, anxiety, and pain in people with heart disease. The best evidence is perhaps on the efficacy of calming music in anxiety disorders and depression (Harvard Review of Psychiatry, 2011).

Music therapy now plays an accepted role in modern medicine, for all age groups. CMTER of Sri Balaji Vidyapeeth offers PG diploma and Masters-degree in music therapy, offers Music therapy to patients and conducts research projects, including Doctoral research leading to PhD. While it is laudable to get valuable input from the West on the current trends in Music therapy, we need to adapt it to the Eastern ethos and our oriental musical traditions in order for those principles to be culturally relevant and effective.

Salutogenesis (Wellness), as opposed to pathogenesis (disease/illness), was first proposed

by Aaron Antonovsky of Austria. He primarily addressed his peers in health psychology, behavioural medicine, and the sociology of health. The term has been adopted in the medical fields of healthcare and preventive medicine. It has also been adopted by nursing, psychiatry, and healthcare-architecture.

For the last 3 years, SBV has internalised the wellness concept in Yoga and Music therapies. Dr Sumathy Sundar and her team deserve appreciation for putting together an international expert group to share their expertise in this field. I wish the conference the visibility and success it deserves.

Prof KR Sethuraman. MD, PGDHE. Vice Chancellor, Sri Balaji Vidyapeeth.

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Dr. N. Ananthakrishnan, Dean – Research, Postgraduate Studies and Allied Health Sciences (SBV).

Professor of Surgery (MGMCRI) Dt. 25th February, 2017

Message Sri Balaji Vidyapeeth has always played a leading role in promoting complementary medicine and its role in promoting Salutogenesis. Towards this direction, the department of Music Therapy of Sri Balaji Vidyapeeth has been very active and produced many collaborative studies with different departments of this Institute.

Their achievements over a short period of time are a matter of pride to the University.

In this context, the forthcoming International conference on “MUSIC THERAPY: SALUTOGENIC APPROACH TO HEALTH” with leading International Experts highlighting various aspects of Music as a therapeutic tool in the adjunct setting will go a long way in promoting interest in the field thus stimulating many other Universities to follow Sri Balaji Vidyapeeth as an example. Given Government of India interest in complementary and alternative medicines, I am sure, efforts in this direction in our country will be suitably supported.

I wish the conference all success.

Prof. N. Ananthakrishnan

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PROF. DR. VELLORE A.R. SRINIVASAN Registrar, Sri Balaji Vidyapeeth Organizing Chairman, Third International Conference on Music therapy Sri Balaji Vidyapeeth, Pondicherry

Welcome Address Welcome to the 4th International Conference on the theme, Music Therapy: Salutogenic approach to health, hosted by CMTER. CMTER at Sri Balaji Vidyapeeth, Pondicherry has been the leader in this part of the country, with respect to the several facets of music therapy including academics, patient care and research. Our visionary Chairman Sri M.K.Rajagopalan and Vice-Chairman Dr.M.R.Prasanth spare no efforts in realizing such endeavours. The senior and respected functionaries of Sri Balaji Vidyapeeth, namely Chancellor Prof. Rajaram Pagadala, Vice-Chancellor Prof. K.R.Sethuraman and Dean ( Research & Allied Health Sciences) Prof. N.Ananthakrishnan have made it possible, through their yeoman efforts, to host this prestigious conference that boasts of international color and flavour.

As you would all agree, the objective of this endeavour in using music as an intervention is to help realise individual goals within the domain/relationship of the professional who administers music therapy and the person who receives the same. Music therapy and medicine, in recent years have been the recipients of wide attention in the realms of mind body medicine. Salutogenesis is a unique term coined by the well known Professor of Medical Sociology, Aaron Antonovsky. Salutogenesis denotes an approach that essentially focusses on factors that signify human health and well-being, rather than on those factors that cause disease (pathogenesis). This augurs well for music medicine and therapy and hence it is in the fitness of things that salutogenesis occupies the pivotal position in the day long deliberations.

Evidence based Music therapy is the need of the hour as related to the analysis and modulation of physiological and psychological effects/changes. The physiological changes in humans are attributed to the actions of the central nervous system (CNS) which includes brain and spinal cord and the subsequent effects of the CNS on the organs/organ systems, as effected through the autonomic nervous system (ANS). The psychological attributes of an individual are also taken into consideration while actively implementing Music therapy, a facet of the MIND BODY MEDICINE. Genetics also has been given thrust in recent years. For the time being and as far as this conference is concerned, we would concentrate on all these aspects centering around salutogenesis, rather than laying emphasis on pathogenesis.

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Eminent resource persons of international repute have graciously consented to participate in this conference. A hearty welcome to these distinguished persons. It is our great pleasure to welcome our Chief Guest Dr. Gerhard Tucek from the IMC University of Applied Sciences, Krems, Austria to inaugurate the conference and also accord a big and dainty welcome to the internationally acclaimed music therapists- Dr.Helen Odell-Miller, Dr.Felicity Baker, Dr.Jorg Fachner, Dr. Maria Montserrat Gimeno and other resource persons and chairpersons, A big welcome to the avid delegates from India and abroad. Our hearty welcome to the Faculty and student delegates from all over the Globe, Administrators and Management officials of Sri Balaji Vidyapeeth, invited Guests and members from the Mass media. Do enjoy this day long academic and evidence based scientific treat and may we all acquire knowledge, skills and attitude in our own and humble manner that would enable us to practice Music therapy, for the benefit of mankind, by adopting and eulogising salutogenesis.

WELCOME YOU ALL ONCE AGAIN!!!.

Prof. Dr. Vellore A.R. Srinivasan

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Dr. Gerhard Tucek, Head, Josef Ressel Center for Personalized Music Therapy, The IMC University of Applied Sciences, Krems, Austria.

Inaugural Address I bring greetings from Austria and also from the IMC University of Applied Sciences, Krems, Austria to all of you who have assembled here for the 4th International Conference of Music Therapy sponsored and hosted by Sri Balaji Vidyapeeth at Pondicherry. I am honoured that I am given this opportunity to inaugurate this conference and also welcome you here for this event. I think that this is a very good opportunity for all of us to know about the special efforts that are taken by Sri Balaji Vidyapeeth and my colleagues here which will lead to new trends and perspectives of the Asian culture and specifically Indian culture with a broader understanding of music in music therapy. You have a cultural source which is unique in the world with the musical traditions and rituals. Also there is a pioneering work of your university linking the music healing traditions and the 21st century therapeutic ideas taking all the challenges to bridge science and traditions and integrate it in the health care system with the beautiful theme that you have adopted here to introduce music therapy into medical care. This would provide fresh air to the wind of change to the new understandings of music therapy turning away from the strong trends to westernize the idea of music therapy.

In the IMC University of Applied Sciences, Krems, we base our understanding of music in an anthropological approach considering the individual, bio-psycho-social and cultural needs of a patient. What do we have in all cultures in common is the basic need to connect socially (in family, community and the society) although there may be different beliefs and priorities for social connections in different cultures. Similarly, the cultural expressions of human experiences like fear, sorrow, pain, emotions and behavior may be different but the phenomenon of understanding what is common and what is different and how we handle these human experiences through music and making the connections with people is what we do in music therapy. This helps us to understand the anthropological needs in pathological conditions and create a therapeutic relationship which is important in having the desired positive clinical outcomes.

Current neuro-imaging and neuro-anthropological investigations have revealed fresh insights on therapeutic effects of music and here are emerging trends of personalized music therapy services based on new ways of thinking through inter-disciplinary dialogues. I hope that we will have exciting deliberations taking place during this conference which will pave way to understand the music therapy mechanisms/processes and the current trends of development in delivering the music therapy services.

Thank you and I wish you all a happy conference time and enjoy the conference.

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DR. SUMATHY SUNDAR, Ph.D Director, Center For Music Therapy Education And Research Organizing Secretary

Vote of Thanks It is a great privilege and honour to me to have been asked to propose the vote of thanks on this most memorable event of the inaugural function of the 4TH International conference of music therapy. It has been our pleasure to host all the participants of this conference at our university, Sri Balaji Vidyapeeth. I thank all the participants and the other eminent personalities from the academia working in the field of music therapy who have been here with us during this special event.

Our heartfelt thanks to our Chief Patron beloved Chairman Shri M.K. Rajagopalan for sending his greetings to all the conference delegates. It is only because of his passion and generosity that music therapy develops in this part of the country to this dimension and we are ever grateful to him for his unceasing support without which Center for Music Therapy Education and Research cannot exist.

We thank profusely our Chancellor for sending us his greetings and best wishes for the successful conduct of this conference.

We are grateful to our Visionary Vice Chancellor Prof. KR Sethuraman to have delivered the presidential address. Thank you very much for your inspiring presidential address with some special propositions on the salutogenic approach of music therapy based on which the deliberations can take place during the conference.

I have no words to thank our mentor Prof. N Ananthakrishnan, Dean, Research and Allied Health Sciences for his constant encouragement and unconditional support without which CMTER would not have risen to this level. I can only sing to thank him.

We thank profusely our partner Prof. Gerhard Tucek from the IMC University of Applied Sciences, Krems, Austria for being with us today during this special event to inaugurate the conference and also participate in the deliberations of the conference We convey our special thanks to our respected and distinguished guest, Prof. Helen OdellMiller and Prof. Jorg Fachner from Anglia Ruskin University, Cambridge for sharing with us their experience on the topics of their expertise. We are grateful to Prof. Helen Odell-Miller for her exciting key note address.

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I take this opportunity to thank immensely our distinguished international speaker from the University of Melbourne Prof. Felicity Baker who has accepted our invitation graciously and has travelled from Australia to join us here. Our heart-felt thanks to our distinguished speaker from the State University of New York at New Paltz, Associate Professor Maria Montserrat Gimeno and to the other the speakers from the different parts of the globe, colleagues from the university, friends, well wishers, special invitees and the students in the audience who have come here to participate in the proceedings of this exciting conference.

My heart -felt gratitude to Prof. M Ravishankar, Dean of Medical Faculty without whose support, this conference would not have been possible.

I thank the Principals of Indira Gandhi Institute of Dental Sciences and Kasturba Gandhi Nursing College for their constant support and advices which enabled the successful organisation of this conference Our special thanks to Prof. Nirmal Coumere, Medical Superintendent of MGMC &RI for his support towards hosting this conference.

Our very special thanks to the Chairman’s secretariat and General Manager, Administration Mrs. Asha Suresh Babu for providing all possible support and making all the arrangements very meticulously towards hosting this conference.

Our thanks to all the senior faculty and HODs of MGMCRI for their presence and support to make this program a grand success.

I would like to express my sincere thanks to our friends in the media not only for the splendid coverage of today's events but also for their continued support to us all through these years.

An exciting event of this magnitude needs careful planning and execution and I was extremely fortunate to have the most committed organising committee members, my beloved CMTER team and all the volunteers who have been working out of their comfort zone for many days to make this event a great success. My heart-felt thanks to each and every one of you.

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Key Note Address MUSIC THERAPY AND ADULT MENTAL HEALTH IN THE 21ST CENTURY: RESEARCH CLINICAL AND PROFESSIONAL CONSIDERATIONS. Dr Helen Odell-Miller OBE; PhD; is a Professor of Music Therapy, and Director of the Music Therapy Research Centre at Anglia Ruskin University, Cambridge. Her research and clinical work has contributed to establishing music therapy as a profession, over 40 years and specifically to innovating approaches in adult mental health. Helen has published and lectured widely, and has been a keynote speaker at many national and international conferences in Europe, Australia and the USA. She has advised parliament and the government on music therapy, and is an invited member of many Boards, including The Music Therapy Charity, International Council for Research in the Arts Therapies, Cambridgeshire Music, Hills Road Sixth Form College Cambridge (Governor); The Strategy Board of The Council for Allied Health Professions Research (CAPHR). She is affiliated to, and has been a Visiting Examiner and Professor, at The University of Wurzburg, Germany, Aalborg University Denmark; University of Cambridge UK; The Guildhall School of Music and Drama, London UK; and other universities and music therapy centres in Italy, China, Taiwan, Romania and many other countries. She is a Principle Investogator for the international music therapy randmoised controlled research project TIME-A on music therapy and children with autism. She is co-editor and an author for books: Supervision of Music Therapy (Jessica Kingsley 2009)

Forensic Music Therapy (Routledge 2013) and Collaboration and

Assistance in Music Therapy (2017), and has published widely in national and international peer reviewed journals and authored many book chapters. She is a singer, pianist and violinist and a regular member of Cambridge Voices, an a’ cappella choir in the UK. Abstract : Around one in four people in the world suffer from diagnosed mental illness, and many do not seek help but suffer in silence. The World Health Organization lists the major diagnoses within mental health as depression, schizophrenia, dementia, bi polar disorder and developmental disorders including autism on a recent publication. The WHO draws attention to the high percentage of people known to suffer in the world from mental illness: 350 million with depression, 60million with bi-polar disorder, 21 million with schizophrenia and 47.5million with dementia related illness. (World Health Organization 2016). In this paper, I will address the above mental health diagnoses, adding personality disorder, which is often a ‗hidden‘ undiagnosed illness. Although only

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4% of the population are known to suffer from personality disorder, the prevalence of self harm and serious life threatening suicide attempts, often part of the illness, lead to high demands upon medical services and also we know many are hiding symptoms and are undiagnosed.

It is also clear that prevention is key to addressing mental health problems, and mental health wellbeing, and so it is important that health and social care resources are put into early years development, as well as towards the populations actually already diagnosed with mental illness.

Music in everyday life, as described by Ansdell (2014), is important, but music therapists are not necessarily needed for this. What makes music therapy specific is intentionality, (to have therapy), the context, the setting, the trained music therapist, therapeutic goals and outcomes, the relational musical process (not based on the end product), participant intention and expectations.

Music therapy, professionally practiced, is the applied use of music for a specific benefit usually by a qualified music therapist, but -where is a music therapist most needed and what is our role in mental health prevention and treatment? Further, I describe music therapy as ‗the systematic application of music within a therapeutic context for therapeutic purpose, drawing upon live and receptive possibilities of music-this could include free improvisation, structured or unstructured –or sessions draw upon composed or pre-composed music such as through songs or song writing, or receptive techniques involving listening to music.‘ Research is growing, and in some countries, for example Germany UK and Norway, music therapy is included in guidelines for treatment by the relevant government body responsible for assessing health interventions. For example in the UK and Norway, music therapy is in the guidelines for treatment for schizophrenia, and for dementia in the UK the NICE (National Institute for Clinical Excellence) guidelines stress that music and dance related activities are key for people with dementia especially when they can no longer speak. In Australia the well-being agenda for adolescents and young people is embedding music therapy in the community setting.

Music therapy and dementia In two video examples of women with dementia the first shows a woman singing, where she remembers the song, whilst the music therapist accompanies her, and facilitates interaction-going at her pace. The woman also shows a sense of self-pointing to herself in the words ‗you and me‘. The second shows music therapy bringing about the reduction of BPS (Behavioural and Psychological Symptoms).

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Dementia has been prioritized by music therapists, and reasons are particularly related to the qualities of music which can enable dialogue, expression of emotion, interaction, listening, reflection and a shared understanding -long after cognitive skills and the ability to talk declines. Recently a research consortium meeting in Denmark consideredwhy and when is a qualified music therapist needed? Singing for the brain projects are common and do not require the presence of a music therapist, but these events are not targeted to people in the late stages of dementia and it is often impossible for them to access such events. Music is used, and should be, by carers and musicians increasingly in care homes for stimulation and motivation, both active participation and for relaxation. However systematic reviews show that the majority of research projects which measure outcomes delivered by qualified music therapists, focus upon music therapy in care homes, and on reducing ‗behavioural and psychological symptoms‘, and this is where the specific skills of a music therapist are crucial. These problems are often most prevalent in the later stages of dementia and here, musical interaction through improvisation can provide a powerful tool for symptom reduction, as the following case examples show. Hsu et al (2015) confirmed that the use of an individual music therapy framework for dementia intervention described in Ridder et al (2013), and also similar to group intervention in important components as to those described in Odell-Miller (1995) is crucial for this population. Components described in these studies include: Live improvised music using song and structured directed instrumental work to meet identified aims for managing neuropsychiatric symptoms, including movement and walking a) catching attention and creating safe setting b ) regulating arousal level to a point of self regulation c) social communication for psychosocial needs In the excerpt from a music therapy session, a lady can be seen with dementia where improvised music is used to set up an intimate relationship, and in which the therapist adapts moment to moment to the lady‘s needs. She usually makes a constant groaning sound which is distressing to her and others in the care home. Here, the music therapist works with her through rhythm, she begins to dance (although sitting down-look at her feet)—and there is a clinical aim, which relates to her individual needs moment to moment.

There are still questions, in all countries about whether music therapy is an art, a science, allied to medicine, a psychological or sociological treatment or phenomenon. I would argue that the role and identity depends upon the task, and as part of that task,

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the role and professional identity of the music therapist changes according to the setting, the needs of the participants of the therapy. We need to be flexible, whilst maintaining our major skills as therapists and musicians, researchers and teachers.

Also, in some settings, a music therapist can work psychotherapeutically and is trained in most countries to be able to deal with strong and powerful emotions which can be contained and worked with.

The role of the music therapist Let us now consider the role of the music therapist. In one session, we may see ourselves as

composers,

performers,

improvisers,

music

psychotherapists,

philosophers,

magicians, healers, facilitators, assistants, agents and carers. We may be viewed as professionals, volunteers, therapists, psychotherapists, musicians, shamans, groupworkers, community musicians, teachers, music people- the list is endless. Having a sense of the central task is what matters and it is not always easy to hold this in mind with so many competing dynamics. Perhaps our identity and task is clearest when in the room working as a music therapist. Nonetheless, communicating what happened in the room to significant others, funders or relevant institutions, when participants cannot do this on their own, is a challenge but necessary. How to be human and professional –as Allied Health Professionals (AHPs) –is different for each one of us, but an important balance to find.

My next vignettes are about working with adults in different settings and within different music therapy contexts and approaches. Music therapists specialise in working through improvised musical methods, particularly in some countries such as the UK, but this can also include using composed and pre-composed music, and receptive techniques. The power of music to change dynamic, reflect relationships and to arouse emotion is at the heart of why music therapy has become a recognised treatment for people with mental health problems over the last 55 years, culminating in a wealth of research

and

publicised

materials,

discussing

community

music

therapy,

psychoanalytically informed music therapy, interactive music therapy, receptive music therapy,

music

therapy

and

song

writing,

neurologic

music

therapy,

music

psychotherapy, and more.

In

the

improvisational

model,

music

therapy

involves

the

therapist

and

patient/participant making music, or listening together, or one listening to the other, with an emphasis upon what can be learned, changed or alleviated by the process.

Central to this process is the nature of the relationship between therapist and patient, or group members.

Bi polar disorder and schizophrenia

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Interestingly there is less literature and research publication in music therapy for bi polar disorder, than for schizophrenia, but that is because in some culture bi-polar disorder is labeled under psychosis. However, there are specific emerging elements of music for bi polar disorder which are obvious-bi polar disorder, or manic depression is a mood disorder and music can match strong mood changes, the therapist can recognize and reflect these, and also people with bi polar disorder are often able to create high level work when in a manic state such as van Gough, who painted Starry Starry Night whilst in a mental hospital. Also musicians such as Schumann probably had bi polar disorder. Many case examples (as there is hardly any experimental research reported – not

large studies-

by

music

therapists),

show

the

capacity for

interaction,

understanding, a shared musical language and music therapy works along side medication which is usually necessary -and a healthy lifestyle is mentioned as crucial in the NICE guideline to help affect regulation, which music therapy also can address.

In the next example the music therapist is working more as a musician and psychotherapist –a psychoanalytically informed music therapist (Odell-Miller 2001). The therapy process moves between active music making, talking and interpretation is used based on psychoanalytic concepts. This approach was specific to the setting and context, and music therapists need to be flexible and not bound to one theory and practice in the 21st century, where jobs include working across different populations and environments.

Group work is being researched by modern music therapists in the acute psychiatric setting in groups including all diagnoses, and for people who are in acute phases of their illness. Carr (2013) focuses upon the need for structure, for the therapist to work actively and directively in terms of helping provide musical structure in groups, but encouraging patients to take the lead, to use developing confidence in performing and song writing in the group, which leads to recovery. The immediate here and now experience of how people relate to each other is crucial for understanding and improving social relating for patients.

Schizophrenia We know now from the Cochrane review and from research that music therapists have carried out around the world that music therapy can help increase motivation and reduce isolation and help socialization (ie treat the negative symptoms) of schizophrenia, and I undertook research which bears out theses results, looking at the most beneficial approaches for people with schizophrenia. Improvisation using structured and free techniques are found to be effective, and also song writing and group work which engages people in musical interaction, rather than a purely psychoanalytic approach. However in many countries music therapists are informed by psychoanalysis for example using transference and countertransference (Nygaard Pedersen 2007) to

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help deal with the pressures and projections which arise in the therapeutic relationship with people who are psychotically disturbed.

Prison and criminal justice system Channelling aggression is also mentioned repetitively in the literature where aggression and conflict can be expressed through music.

(Pool and Odell-Miller 2011, 2013;

Compton- Dickinson et al 2013, Chen, 2014). Further, Leith (2014) and ComptonDickinson at al (ibid.) focus upon the unique possibilities of music therapy to improve empathy, self -concept and relatedness. Community music therapy and music for health approaches are also reported in the literature (Maguire and Merrick 2013; Benisom and Gilboa 2010; Cox and Gelsthorpe 2008), and relate to the Recovery model. Bands are also common in this field for example ‗The Recovered‘ band (John 2014), and Gold et el (2013). Playing in bands included for groups by choice was included in Gold‘s RCT study Recently, three PhD studies in the forensic field were completed and can be summarized as a) An RCT trial in a prison for men in China (N=200) Outcome: MT reduces anxiety and depression (Chen 2012; 2014). b) A mixed methods study (N=20) in a high secure hospital Outcome MT increases relatedness (men) and shows G-CAMT (Group Cognitive Analytic Music Therapy) as a useful tool (Compton-Dickinson 2013, 2015). c)

A mixed methods study (N=10)

Outcome MT improves self-perception and readiness to engage in rehab.

All these recent studies used live active music making including improvisation. Leith found song –writing emerged as the most effective method, Compton-Dickinson was testing the feasibility of G-CAMT, and Chen asked men to choose each week between previously introduced music imagery, improvisation and song writing. She found no significant different between types of music therapy technique or approach.

Leith‘s (2014) findings include a summary about the type of song –writing indicated as most helpful for her small sample of 10 participants. Features include composed songs using structured predictable harmonic progressions, popular music idioms, where the emotional dynamic builds up during phrases, and sometimes the use of humour. She found that participants used the song-writing process to address in- depth difficult themes from their lives, and that putting these into songs also enabled links to be made to the outside world, including messages to family and friends. Empathy seemed to

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increase for family members for some participants dealing with their significant family member‘s prison life and offenses.

Anger management and management of aggression is another overarching theme emerging from existing music therapy literature from research and clinical examples.

Redirection of anger by changing musical form, or idiom or mood; including the power of musical expression where the trained therapist can accept and engage with anger; are central for this population. Possibilities for reflection, containment and expression of angry feelings musically; with the therapist providing further processing and finding of meaning; in a safe environment, through musical improvisation, are relevant in this field.

Empathy is also outlined by Compton-Dickinson et al (2013) as helped to develop particularly by music therapy interventions.

In summary there are some strong and significant indications that music therapy is beneficial in this field. However specific music therapy quantitative research in the forensic field is sparse in relation to other areas such as for schizophrenia and autism.

More research is needed as reflected in the following ten recommendations for research and future priorities for music therapy in the criminal justice system and forensic fields.

Personality Disorders In the last two decades there has been a change in focus of thinking about people with a diagnosis of personality disorder. Previously, people with personality disorders experienced marginalization by psychiatric services. They were perceived as a group of people hard to treat, who do not readily respond to medication, and for whom at that time there was no body of research directing practitioners towards effective treatments.

More recently this population has been recognized and spoken out about the difficulties they experience and there is a growing body of research and clinical practice in music therapy for this population.

Veronica is a 21-year-old woman diagnosed with a borderline personality disorder. In a music therapy group, she struck a large orchestral gong as part of an improvisation. As she played, the therapist accompanied her by improvising harmonic piano music in response to her playing. This therapeutic incident took place shortly after the death of Veronica‘s mother, with whom she had begun to form a loving relationship, but who she had experienced as un-loving and as someone who had failed to protect her against a man who sexually abused her. (Odell-Miller 2011 (p.34) Overwhelming, angry and raging feelings were expressed in Veronica‘s music therapy session, and she often referred back to that single ‗gong striking‘ as the most therapeutic moment for her in group music therapy. From this point, enabled by the therapist‘s

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verbal interpretations towards further meaning, and through shared music making, she began to find a means of expression and new understanding about relationships in her life. Hitherto she had been unable to do this. She also brought composed songs with hopeful and sometimes depressing suicidal themes to listen to with others in the group in order to help her link her thinking and feeling and to try to find strategies to manage her life.

In some countries, and the UK in particular, attention has more recently been drawn to people with personality disorder, and resources channeled into setting up specialist services specifically for people with the diagnosis. Now, it is easier for people with similar problems to Veronica, to access specialist psychological services, including music therapy.

What is a personality disorder?

People with this diagnosis are often relieved to be diagnosed and to realise that there is some understanding and meaning given to the difficulties they have encountered, such as feeling misunderstood or being over sensitive to others. The main experience of people with this disorder is that their problems are associated with ways of thinking and feeling about others, and themselves, which significantly and adversely affect their functioning in everyday life. They encounter enduring patterns of inner disturbance leading to behaviour and experiences that often deviate from cultural expectations.

Usually personality disorder has an onset in adolescence or early childhood, and the condition is pervasive and inflexible, leading to distress and impairment. More detail is found in American Psychiatric Association (2013) Crucially, music therapy offers something specific especially for people with borderline personality disorder, being flexible to matching and expression of different mood and impulse, and through rhythm, providing possibility for the experience of affect regulation, especially when musical improvisation is used interactively.

As clingy and compliant people, often depressed, anxious and fearful, this group find group work very difficult but music therapy groups potientially enable a new way of relating through hearing, sharing and having to appreciate and co-operate with others in order to make music, composed or improvised. People with obsessive-compulsive personality disorder, tend to be rigid and inflexible in their approach to anything, and musically may be highly accomplished but unable to feel or express emotion through music, or in relationships generally. Music therapy can be both frightening owing to its potential for order and also releasing in the sense that sometimes freedom to improvise simultaneously by creating an aesthetic object (piece of music) with the therapist or group, can help shift patterns. Patients striving for perfection at the expense of their

24

mental health, can, for example, become more able to allow chaos and messy cacophonous music which in turn can enable them to live more full lives. (Pool and Odell-Miller 2011, Odell-Miller 2001).

Arts therapies are mentioned in the UK NICE guidelines generically, rather than music therapy being listed separately, and include art therapy, dance movement therapy, dramatherapy and music therapy, all of which use arts media as the primary mode of communication. Weekly therapy is described as the norm, and group or individual work is listed, with groups of no more than 4-6 recommended. The primary concern is to effect change and growth through the use of the art form in a safe and facilitating environment in the presence of a therapist. Arts therapies can help those who find it hard to express thoughts and feelings verbally.‘ (NICE ibid).

Arts therapies for this population are ‗more concerned with the process of creating something, and the emotional response to this and/or the group dynamics of this. This can be very active (involving the physical characteristics of the art -work and movement), playful, symbolic, metaphorical or lead directly to emotions that need to be understood. Such understanding may be achieved through subsequent discussion, and the use of the art materials when helpful.‘ (NICE 2014).

Patients involved in music therapy can more easily explore feelings that they otherwise find difficult to talk about and begin to turn away from their preoccupations with selfharm.

Group case example borderline personality disorder The emotional processing of music can link thought and feeling, and for people with this condition, music therapy can be useful because making music involves collaboration. It can also allow raw expression of emotion, also important for in a safe therapeutic space.

Listening back to group music therapy examples, the ability to reflect, to play music creatively, with the therapist is important, and the musical structures evolve naturally and through people listening and moderating their pace and meter, including an aesthetic element. Participants report a physicality a self soothing component within music which is hard to describe in words and certainly hard to research scientifically.

Anna is a young mother, with two small children, and attended the music therapy group for two years. Prior to this she spent many years extremely ill, depressed and lacking in self worth, and benefitted from group psychotherapy and individual therapy, and was hospitalised for long periods, and at one point had Electro Convulsive Therapy (ECT).

She has now ended music therapy, has not self -harmed for over three years and is living an independent life. She had an abusive childhood, in that her alcoholic father maltreated both her and her sister. She worked with me on the written material used

25

here, and gave full consent for her story to be used, as long as she did not have to listen carefully to her own musical recordings. This is an example of her degree of low self esteem-she is happy for others to hear her but cannot bear to face herself easily although enjoyed the process of preparation of this material. Our work started when she joined a music therapy group in a specific National Health Service (NHS) for people with personality disorders, which used a multitude of musical ways of looking at relationships particularly that between the inner and outer worlds of members. The rationale that the nature of the group is powerful and forces between group members can be heard in the musical improvisations was crucial to this approach.

Anna often chose bongo drums to help herself think about her mood and affect, and also to connect with others in a way which she said relaxed her as she did not have to always talk. Towards the end of therapy, Anna moved to wanting to work on producing a satisfying piece of music. Music can also focus on aesthetics, which is important in building confidence and self esteem, a facet substantiated through systematic research (Odell-Miller 2007 and 2013). A focus on aesthetics can help develop respect for a healthy unscarred body rather than one cut or burned.

Anna had joined a community choir during her time as an out- patient on the unit, and sometimes she talked longingly about wanting to improve her skills as a singer. At the end of the group therapy, she asked to start singing lessons and was put in touch with an excellent sensitive singing teacher. In two follow up appointments after the ending of group therapy, she brought songs to show me her progress and I accompanied her on the piano, reflecting her movement and journey into her much higher sense of worth and esteem, and towards expanding her performances to solo work within her choir. If readers could hear the musical example of her rendering of a well known song from West Side Story by Leonard Bernstein There‘s a place for us the integrated expressive, dynamically changing, appropriately sometimes holding back style of singing would be evident. It is what I would term an ‗improvised performance‘ using her full resources, but the relationship with the therapist and previous two years of psychoanalytically informed individual work was crucial to the process and outcome for her at the of the treatment. Anna subsequently ceased therapy and managed well in the community, attending the choir regularly but making use of the internalised process of therapy preceding this.

In summary the importance of music-making links to the pathology of personality disorders because music, like the illness, is affect-based. This implies that the music therapist‘s task for people with personality disorders is to help the person understand the meaning of the affect. Free improvisation is very useful in allowing people to be in touch with their difficult emotions and can provide links to meaning and words that

26

might not otherwise have been available as evidenced above through the study findings, clinical experience and the support of a very small body of music therapy literature.

The comparison with the population with schizoprehnia shows in particular a more careful use of music in improvisations, for personality disordered people, whereas those with schizophrenia and schizophrenia-like illness are more likely to disregard collaboration with others, through group music making for example. This can be seen through examining points of synchronicity for endings or beginnings of pieces of music.

Odell-Miller‘s summary of specific ways in which people with personality disorder use music in music therapy. (Odell- Miller 2007) follows:  Music provides a link between emotion and thought  Music is used to heighten understanding of expression of emotion and the meaning of this  Reciprocal roles can be explored musically  Links between memory of abuse and childhood music making can be powerful  Music-making links to the pathology of personality disorders because music, like the illness, is affect-based.  Aesthetic qualities of music are particularly important for this group who are prone to self-harm Odell-Miller 2007 Conclusions In this paper I have considered the different needs, diagnoses and phenomenon which lead to decisions made by music therapists about with approaches and techniques to use for which situation. I hope to have demonstrated that for mental health needs, research and clinical knowledge has advanced and developed so that there is a move to guidance and guidelines as to what works best in which situation, and music therapists are publishing and developing new knowledge showing the crucial benefits and roles for music therapy in the 21st century. More research and practice is needed and we should work together as we are doing regularly at an international level to develop from our current knowledge base.

References American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing Ansdell, G. (2014) How music helps in music therapy and everyday life. Farnham, England: Ashgate.

Benisom, M., & Gilboa, A. (2010). The music of my life: The impact

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of the Musical Presentation on the sense of purpose in life and on self-consciousness. The Arts in Psychotherapy, 37(3), 172-178.

Carr, C.; Odell-Miller, H., Priebe, S. (2013) A Systematic Review of Music Therapy Practice and Outcomes with Acute Adult Psychiatric In-Patients. PLoS ONE Carr, C. (2014) Modelling of intensive group music therapy for acute adult psychiatric inpatients. PhD thesis submitted successfully to Barts and London School of Medicine and Dentistry, Queen Mary University of London Chen, X. (2014). Music therapy for improving mental health problems of offenders in correctional

settings.

PhD

Thesis.

Aalborg

University,

Denmark.

http://vbn.aau.dk/da/publications/music-therapy-for-improving-mental-health-problemsof-offenders-in-correctional-settings(2e5fb025-d14c-4ac5-b57a-ec938ffb284c).html Compton-Dickinson, S.; Odell-Miller, H.; and Adlam, J. (2013) Forensic music therapy.

London Jessica Kingsley ISBN 978-1-84905-252 Compton-Dickinson, S. (2015). A feasibility trial of Group Cognitive Analytic Music Therapy (G-CAMT) in secure hospital settings. PhD Thesis Anglia Ruskin University, UK. http://angliaruskin.openrepository.com/arro/handle/10540/86082 Gold, C., Assmus, J., Hornevik, K., Qvale, L.G., Brown, F.K., Hansen, A. L., Wager, L., and Stige, B. (2013). Music therapy for prisoners: pilot randomized controlled trial and implications for evaluating psychosocial interventions. International Journal of Offender Therapy and Comparative Criminology.

John, D. (2014). ‗The Recovered‘ a band arising from working in an NHS Trust with recovering mental health patients, including those on a medium secure unit. Personal communication.

NICE Guidelines (2014) http://www.nice.org.uk/nicemedia/live/12125/43045/43045.pdf.

P. 115. Accessed 03.01.2014 Geretsegger M, Elefant C, Mossler KA, Gold C. (2014) Music therapy for people with autism spectrum disorder. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD004381. DOI: 10.1002/14651858.CD004381.pub3.

Geretsegger, M.; Holck, U.; Carpente, J.; Elefant, C.; Kim, J. and Gold C. (2015) Common characteristics of improvisational approaches in music therapy for children with autism spectrum disorder: developing treatment guidelines. Journal of music therapy. 52(2):258-81. DOI: 10.1093/jmt/thv005

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Geretsegger, M.; Holck, U.; Gold, C. (2012). Randomised controlled trial of improvisational music therapy‘s effectiveness for children with autism spectrum disorders (TIME-A): study protocol. BMC Pedriatrics 201212:2. DOI: 10.1186/1471 2431-12-2 Hsu, M., Flowerdew R., Parker M., Fachner J., Odell-Miller H. (2015) Individual music therapy for managing neuropsychiatric symptoms for people with dementia and their carers:

a

randomised

controlled

feasibility

study.

BMC

Geriatrics

15:84

doi:10.1186/s12877-015-0082-4Published: 18 July 2015 Leith, H. (2014) Music therapy and the resettlement of women prisoners. PhD Thesis Aalborg

University,

Denmark.http://www.mtphd.aau.dk/organisation/former/helen_leith/ Maguire, A., and Merrick, I. (2013). Walking the line: music therapy in the context of the Recovery approach in a high secure hospital. In S. Compton-Dickinson, H. OdellMiller, and J. Adlam Forensic music therapy: a treatment for men and women in secure hospital settings. (p.90-104). London: Philadelphia Mossler, K.; Chen, X.; Heldal, TO.; Gold, C. (2011) Music therapy for people with schzophrenia and schizophrenia-like disorder. The Cochrane Library. Wiley Online Library.

Odell-Miller, H. (1995) ‗Approaches to music therapy in psychiatry with specific emphasis upon a research project with the elderly mentally ill‘ in T.Wigram, B. Saperston and R. West (eds). The art and science of music therapy. USA: Harwood Academic.

Odell-Miller, H (2001) Music Therapy and Psychoanalysis. In I. Streng and Y Searle, (eds.) Where Analysis Meets the Arts Karnac Books, London. (pp 127-15) Odell-Miller, H. (2007) ‗The practice of music therapy for adults with mental health problems: the relationship between diagnosis and clinical method. PhD Thesis Aalborg University: Denmark.

Odell-Miller, H (2011) The Value of Music Therapy for people with personality disorder Mental Health Practice Volume 14 | Number 10.

Odell-Miller, H. (2014) The development of clinical music therapy in adult mental health practice: music, health and therapy. In V. Bates, A. Bleakley, S. Goodman (eds) Medicine, health and the arts: approaches to the medical humanities. London: Routledge. p.264-280

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Odell-Miller, H (2016) The Future of Music Therapy in Forensic and Criminal Justice Settings. In C. Dileo (ed). Envisioning the future of music therapy. Temple University Publications: USA Odell-Miller, H. (2016) The role, function and identity of music therapists in the 21st century, including new research and thinking from a UK perspective British Journal ofMusicTherapy. Vol. 30(1) 5–12 DOI: 10.1177/1359457516639549 bjm.sagepub.com Pedersen, I. N. (2007). Counter transference in music therapy: A phenomenological study on counter transference used as a clinical concept by music therapists working with musical improvisation in adult psychiatry. Department of Communication, Aalborg University.

Pool, J. and Odell-Miller, H. (2011) Aggression in music therapy and its role in creativity with reference to personality disorder. The Arts in Psychotherapy 38 (2011) 169-177.

Ridder, H.M.O., Stige, B., Qvale, L.G., and Gold, C. (2013) Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Ageing and mental health, 17 (6), 667-678. Doi 10.1080/13607863. 2013. 790926.

World

Health

Organisation

(2016)

Mental

http://www.who.int/mediacentre/factsheets/fs396/en/

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Disorders

Fact

Sheet

Session 1 Professor Felicity Baker is Co-Director of the National Music Therapy Research Unit and Co-Director of the Creative Arts Therapies Research Unit at The University of Melbourne. She is a former Australia Research Council Future Fellow and is currently involved in projects funded by the Australia Research Council and UNESCO. She has published 6 books and over 100 book chapters and research articles, and accumulated more than AUS$1.8Million in research grant funding. She was Head of Music Therapy at The University of Queensland from 2002-2012 before taking up her position at The University of Melbourne. Felicity has a prominent international profile and has co-researchers from the USA, UK, and Europe. She is currently Associate Editor for the Journal of Music Therapy, former editor-in-chief of the Australian Music Therapy Association, and Past President of the Australian Music Therapy Association. Felicity has received many awards including the American Music Therapy Association publication award (2015), an Australian National Teaching Award (2009), and an Australian leadership award (2011).

Facilitating neurological organisation and recovery of speech in people with acquired aphasia through a modified melodic intonation therapy program.

In the rehabilitation setting, the interdisciplinary team works together to provide effective rehabilitation programs for people who have neurological damage, with the ultimate goal being re-integration to the client‘s premorbid lifestyle and community. The primary focus of rehabilitation programs during the initial period post-trauma is addressing functional outcomes, specifically physical (motor), cognitive, communicative, and activities of daily living, due to current understandings that early intervention maximizes functional outcomes (e.g. Mateer & Kerns, 2000). This can and frequently does present a significant challenge for music therapy practitioners who may have to make choices with respect to the overall purpose of the music therapy program, and the approaches used within those programs. I consider addressing the client‘s psychological and emotional adjustment to their acquired disability a necessary component of the rehabilitation process. However, this need is not always acknowledged by the interdisciplinary team who seem more interested in what music therapy can offer with respect to addressing functional outcomes. The presentation will cover foundational concepts of neuroplasticity, music‘s potential to stimulate neuroplastic changes in the brain, and the application of this in addressing aphasia in people with acquired brain injury. A clinical case illustrates how melodic intonation therapy (MIT) (Sparks, Helm, & Albert, 1973), targets functional outcomes while simultaneously responding sensitively to the psychological adjustment of the client.

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References: Baker, F. & Tamplin, J. (2006). Music Therapy in Neurorehabilitation: A Clinician’s Manual. Jessica Kingsley Publishers.

Baker, F. (2000). Modifying melodic intonation therapy programs for adults with severe non-fluent aphasia. Music Therapy Perspectives, 2, 107-111.

Baker, F. (2011). Facilitating neurological reorganization through music therapy: A case example of modified melodic intonation therapy in the treatment of a person with aphasia.

In Anthony Meadows (Ed). Developments in music therapy practice: Case perspectives. (p.281-297). Phoenixville: Barcelona.

Baker, F., Wigram, T. & Gold, C. (2005). The effects of a song-singing programme on the affective speaking intonation of people with traumatic brain injury. Brain Injury, 19, 7, 519–528.

Patel, A.D., Peretz, I., Tramo, M. & Labreque, R. (1998). Processing prosodic and musical patterns: A neuropsychological investigation. Brain and Language, 61, 123-144.

Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., Autti, T., Silvennoinen, H., M., Erkkilä, J., Laine, M., Peretz, I. & Hietanen, M. (2008).

Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain: A Journal of Neurology, 13(3), 866-876.

Sparks, R.W. & Deck, J.W. (1986). Melodic intonation therapy. In R. Chipley (Ed.), Language Intervention Strategies in Adult Aphasia (pp.320-332). Baltimore: Williams & Wilkins.

Sparks, R.W., Helm, N.A. & Albert, M.L. (1973). Melodic intonation therapy for aphasia.

Archives of Neurology, 29, 130-131.

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Session 2

Dr. Gerhard Tucek The IMC University of Applied Sciences, Krems, Austria. completed his studies in Applied Cultural Sciences, Action Research and Social and Cultural Anthropology at the Universities of Klagenfurt and Vienna. At the University of Vienna, he received his "Venia Docendi" for Social and Cultural Anthropology. He is a pioneer in developing music therapy in Austria with the Krems Model of music therapy. He has been a member of the advisory board for the federal law of music therapy at the Austrian Federal Ministry of Health since 2009. He has developed 27 music therapy programs so far in Austria. He teaches regularly in the University of Vienna and the medical university of Vienna. A founding member of the International Association for Music and Medicine and international Music and Art Research Association, Austria He is the Head of Josef Ressel Center for Personalized Music Therapy and the Program Director of Music Therapy in the IMC University of Applied Sciences, Krems, Austria. He serves on the academic board of Chennai School of Music Therapy.

Horizons of personalized music therapy - Researching music therapy processes and relationships (in the clinical fields of Stroke, Hypoxic Brain Damage & Traumatic Brain Injury - TBI)

A.

Abstract and Focuses of the planned Josef Ressel Center (JRC)

Over the last decade, the term ―personalized medicine‖ has become increasingly important in the areas of pharmacogenetics, pharmacogenomics, clinical diagnostics and in particular in chronopharmacology whose subject is the optimum time of administering medication. In other words ―personalized medicine‖ tries to develop optimal therapies primarily based on patient‘s genetics.

The planned JRC takes a humanistic stance and understands the term ―personalization‖ on a more communicative & psychophysiological level.

According to Austrian federal law music therapy is described as “… an interaction between one (or more) therapist(s) with one (or more) patient(s)” MuthG, 2008, 2.

Abschnitt § 6 Abs. 1 (i.d.g.F.)1. In other words the legislator gives importance to human 1

93. Bundesgesetz über die berufsmäßige Ausübung der Musiktherapie (Musiktherapiegesetz – MuthG, 2008, 2. Abschnitt § 6 Abs. 1 (i.d.g.F.).

2 Duncan, Miller, Wampold, Hubble (2011): The heart and soul of change. American Psychological Association.

3

33 effervescence: An experimental anthropological Xygalatas, D. 2014. The biosocial basis of collective

interaction in the context of a therapeutic relation. As a consequence the planned JRC will do research on music therapy and not just on effects of music. Taking into account that the ―effects of (performing or listening) music in the context of a therapeutic relation‖ is very complex, the issue of ―personalisation‖ of therapy is the overall research topic of the application for a Josef Ressel Centre for ―Horizons of personalized music therapy - Researching music therapy processes and relationships (in the clinical fields of Stroke, Hypoxic Brain Damage & Traumatic Brain Injury - TBI)― (hereinafter ―JRC‖).

The idea of structuring music therapy by ―depersonalizing‖ manuals and guidelines gets more and more popular. Nevertheless this has to be seen critical, as this approach does not respond to the complexity of the real bedside situation between patient and therapist. For instance there is the danger to ignore the actual patient‘s needs which are crucial for her / his compliance (Duncan, Miller, Wampold, Hubble 2011)2. However there is no doubt about the necessity of ―good evidence in clinical practice‖, (which goes beyond single case reports) the new approach of the JRC goes towards personalization and therefore combines research on the following two Foci: Focus 1: Research on the psychophysiological disposition of the patient and the therapist and it‘s influence on individual appropriate times of a therapy intervention.

1.

Focus 2: Research on empathy based therapeutic relationship in the light of

selected psychophysiological correlates.

The overall aim of the planned JRC is to develop a model for „personalized therapeutic processes―. We follow the hypothesis, that the daily (subjectively) experienced phenomenon of resonance within a therapeutic process, which can be described on an anthropological level also should have a physiological analogy. As those physiological descriptors we choose EEG and EKG. It is planned to develop routines and procedures For this routines and procedures adapting to the therapeutic processes need to be developed first (years 1 + 2), then testing of specific questions and solutions derived out of y1+2 and indepth-case studies with clients will follow in years 3-5.

Superior goal is the development of a personalized and evidence based music therapy approach in the clinical field of neuro-rehabilitation, which focuses on the power of empathetic human relation which is modulated by musical means. This is of common interest for researchers, therapists and hospital operators.

The main theoretical framework (see: ―Background of the JRC‖) of the planned JRC focuses on investigating resonance phenomenons between patient and therapist on 2

Duncan, Miller, Wampold, Hubble (2011): The heart and soul of change. American Psychological Association.

34

different levels. Therefore we have chosen biometric, psychometric approaches as well as video-data-rating and qualitative approaches which are based on Grounded Theory in order to contextualize events that are in focus of analysis.

The main focus of the planned JRC is not primarily on outcome-research (as it is done in RCTs) but on research of individualized (music) therapeutical processes in order to establish an inner perspective of functioning. That‘s why we will not collect a homogenous group to study a dependent variable with sufficient power.

B.

Aims of the planned JRC:

In Focus 1 (Right moment research) we are looking for a possible link between chronobiological conditions and relational Now-Moments (Stern). We will identify the best possible chronobiological window of the clients to receive therapies.

Relational Data should be authentic and gained as close to practice of Music Therapy as possible. These relational processes are researched within a framework of social neuroscience in order to describe authentic data. This is based on qualitative principles of interaction analysis but applied to physiological data in combination with qualitative behavioral data within an authentic clinical setting.

Ispired by the ideas of the experimental anthropologist Xygalatas (2014)3: ―Rather than taking ―subjects‖ out of context and moving them into sterilized laboratory settings where they become ―objects‖ of experimentation, we attempt to take the laboratory into context by moving it into the field.‖ (see: http://www.malexa.net/).

Focus 2 will research students and health professionals to find out how they gain and deepen their empathetic skills (as evidenced for instance by Oxcitocin-Levels and HRV measurements) in order to „resonate― with their patients.

We expect that in each Focus we will gain relevant new findings, which will develop personalized music therapy as a scientific based discipline further.

Due to the expected large amount of sensitive health data, the development of reliable technical and organisational general framework requirements for safe data collection, processing, transfer and consolidation is an essential condition. This is implemented by ―s-team IT solutions GmbH‖.

A very ambitious goal is the data consolidation on a content based analytical level. For this reason data management and analysis will be done on both levels from year 1–5.

3

Xygalatas, D. 2014. The biosocial basis of collective effervescence: An experimental anthropological study of a fire-walking ritual, Fieldwork in Religion 9(1): 53–67.

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In the course of possible future projects after the planned JRC our findings also might be transferable to other therapeutic disciplines (physio-, ergo- , logo therapy etc.), as suitable therapy times and the objectification of the parameter ―therapeutic relationship― are also relevant for these groups.

C.

Background of the JRC - Anthropological framework and music

therapeutic methods4 Our therapeutic approach has been developed in contexts of concrete clinical practice5 by the designated director of the JRC in cooperation with other colleagues over a period of twenty years.

Additional to music therapeutic core concepts (which are close to other music therapeutic concepts in the field of neuro rehabilitation6) we include anthropological perspectives (Tucek 2006; Tucek et al. 2007; Tucek 2007; Tucek et al. 2009; Tucek 2009; Tucek, 2014; Tucek et al., 2014 Vogl et al. 2015 , Fachner 2007 / 2014), sociological and (Desroche, 1990 ; Elias, 1987 ) psychological perspectives (Rogers , Rosenberg , Peseschkian, 1977 ) chronobiological concepts (Hildebrandt et al., 1998 ). We are oriented toward an individual, bio-psycho-social approach, asking for individual needs of patients and their personal meaning of music therapy.

This approach is reflected in the curricula of our Bachelor- & Master programs at the IMC Krems. These programs were accredited by an independent commission of the Austrian government within the frame of a federal law on music therapy. This legal frame was completed by a professional ethic code, which was elaborated by the Austrian ministry of health in cooperation with the three directors of the Austrian music therapy training programs and representatives of the two Austrian music therapy associations in Oct. 2015.

In our understanding, the complex effect of music therapy can be summarized in three aspects: 

the musical stimulus,

4

This chapter is partially extracted from the following two articles: Steinhoff N, Heine AM, Vogl J, Weiss K, Aschraf A, Hajek P, Schnider P and Tucek G (2015) A pilot study into the effects of music therapy on different areas of the brain of individuals with unresponsive wakefulness syndrome. Front.

Neurosci. 9:291. doi: 10.3389/fnins.2015.00291 and Vogl J, Heine AM, Steinhoff N, Weiss K and Tucek G (2015) Neuroscientific and neuroanthropological perspectives in music therapy research and practice with patients with disorders of consciousness. Front. Neurosci. 9:273. doi: 10.3389/fnins.2015.00273 5 (with patients in an ICU as well as in neurological rehabilitation Phase A – C especially after stroke and TBI) 6 Baumann 2004; Bauman et al. 2007, Zieger 2002.

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

the therapeutic relationship and the



emotional exchange between the patient and therapist.

Within the framework metioned above music therapy tries to find new ways of connecting with the patient and to establish a communication beyond words; i.e., a way of communicating on a very emotional and relational level, which is based on patients' needs and capabilities.

Inspired by theories of embodiment (Csordas, 20027; Storch and Tschacher, 20148), which describe the engagement of culture and individuals through sensual perception and experience, we believe that the meaning of music in therapy develops within the therapeutic session / process as a specific tool of communication between patient and therapist. In contrast to the theories describing communication as an exchange of certain messages between sender and receiver, we assume that the meaning of communication, as well as of music and music therapy, develops in an interaction between humans and their environment. To paraphrase Simon Rattle (2004), “music is not just what it is, but is that what it means to the people.”

To perceive and respond to the personal meaning and individual reactions of patients, the therapist empathically observes the patient and constantly adapts the music and the whole interaction to the reactions of the patient (Eisenberger et al., 2013) 9. This leads to a constant exchange between the patient and the therapist that forms the therapeutic process as well as shapes brain activity.

The foundation of this interaction is the therapeutic relationship. Within this music creates a special kind of frame.

Music itself evokes emotions (Koelsch, 201510), has an impact on the human body, including brain, emotion, and movement, and so lends itself as an appropriate therapeutic medium in this and other fields.

Even though studies show general neurological effects of music as a stimulus, the interand intra-individual meaning of this stimulus is different. Various aspects of listening to or performing music, such as personal preference, experience and the current mood are responsible for the formation of the personal meaning of music. Additionally, emotional auditory stimuli, like listening to one's name or the mother's voice, activate anterior and 7

Csordas, T. J., (2002). Body, Meaning, Healing. New York: Palgrave Macmillan.

Storch, M., Tschacher, W. (2014). Embodied Communication. Kommunikation beginnt im Körper, nicht im Kopf. Verlag Hans Huber.

9 Eisenberger, N., Liebermann, M. D., and Williams, K. D. (2003). Does rejection hurt? An fMRI study of social exclusion. Science 302, 290–292. doi: 10.1126/science.1089134 10 Koelsch, S. (2015). Music-evoked emotions: principles, brain correlates, and implications for therapy. Ann. N. Y. Acad. Sci. 1337, 193–201. doi: 10.1111/nyas.12684 8

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posterior midline cortex in patients with UWS (Laureys et al., 200411; Demertzi et al., 201012). In particular autobiographic memories lead to emotional responses and involve widespread functions of the brain (Svoboda et al., 200613; Cabeza and St. Jacques, 200714; Piolino et al., 200915).

Music therapy uses this knowledge by applying familiar songs, singing names of individuals and using entrained music in therapy to reach the patients more directly and to promote reactions suggestive of awareness (Magee and O‘Kelly, 201516). A study on sensory stimulation revealed that, by inviting responses, we could pass from stimulation (which promotes arousal and attention) to rehabilitation (which promotes and reinforces behavioral responses) (Abbate et al., 201417).

As described above we are using different music therapeutic methods within individualised therapeutic processes. Not only our approach but also other experts in music therapy (Gilbertson & Aldridge 200818) are working in the field of neurologic rehabilitation with live and improvised music as well as with songs. In clinical settings we are using (and also plan to do so within the frame of the JRC) music in a relationoriented therapeutical understanding between patient and therapist.

This approach needs a direct engagement into patient‘s physiologic rhythms, (breathing, muscle tention, Puls, etc.) of the therapist – quite similar to O‘Kelly‘s „Entrained Improvisation― (O‘Kelly et al., 2013)19. Also other well known autors20 (Aldridge,

11

Laureys, S., Faymonville, M. E., De Tiège, X., Peigneux, P., Berré, J., Moonen, G., et al. (2004).

Brain function in the vegetative state. Adv. Exp. Med. Biol. 550, 229–238. doi: 10.1007/978-0-30648526-8_21 12 Demertzi, A., Schnakers, C., Soddu, A., Bruno, M. A., Gosseries, O., Vanhaudenhuyse, A., et al.

(2010). Neural plasticity lessons from disorders of consciousness. Front. Psychol. 1:245. doi: 10.3389/fpsyg.2010.00245 13 Svoboda, E., McKinnon, M. C., and Levine, B. (2006). The functional neuroanatomy of autobiographical memory: a meta analysis. Neuropsychologia 44, 2189–2208. doi: 10.1016/j.neuropsychologia.2006.05.023 14 Cabeza, R., and St Jacques, P. (2007). Functional neuroimaging of autobiographical memory.

Trends Cogn. Sci. 11, 219–227. doi: 10.1016/j.tics.2007.02.005 15 Piolino, P., Desgranges, B., and Eustache, F. (2009). Episodic autobiographical memories over the course of time: cognitive, neuropsychological and neuroimaging findings. Neuropsychologia 47, 2314–2329. doi: 10.1016/j.neuropsychologia.2009.01.020 16 Magee, W. L., and O'Kelly, J. (2015). Music therapy with disorders of consciousness: current evidence and emergent evidence-based practice. Ann. N. Y. Acad. Sci. 1337, 256–262. doi: 10.1111/nyas.12633 17 Abbate, C., Trimarchi, P. D., Basile, I., Mazzucchi, A., and Devalle, G. (2014). Sensory stimulation for patients with disorders of consciousness: from stimulation to rehabilitation. Front. Hum. Neurosci.

8:616. doi: 10.3389/fnhum.2014.00616 18 Gilbertson, S., & Aldridge, D. (2008). Music Therapy and Traumatic Brain Injury - A Light on a Dark Night. London: JKP. 19 O'Kelly, J., James, L., Palaniappan, R., Taborin, J., Fachner, J., & Magee, W. L. (2013).

Neurophysiological and behavioral responses to music therapy in vegetative and minimally conscious states. Front. Hum. Neurosci., 7(884). doi: 10.3389/fnhum.2013.00884 20 Aldridge, D., Gustorff, D., & Hannich, H. J. (1990). Where am I? Music therapy applied to coma patients. [PM_music_special_23_04_03, 14:45, no limits, SKG]. J R Soc Med, 83(6), 345-346.

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Gilbertson, Gustorff & Hannich, Herkenrath, Grün, etc.) are using the tool of improvised music in this field.

Our joice of therapeutic methods (Improvisation, Song, etc.) depend on the patient‘s need at the very therapeutic moment. That is why we plan to do research on the process and not primarily on the methods.

Emotion is a key component of how we experience our environment (Sharon et al., 201321). Emotional stimuli receive privileged access to attention and awareness, and thus are more likely to capture one's attention (Vuilleumer, 200522; Phelps, 200623.

This supports our understanding of music therapy, that by combining musical stimuli, the therapeutic relationship and emotional approach, individual live music therapy encourages multi-sensory, behavioral and physical responses.

As already described music therapy can address the individual needs of patients and offer adjusted stimuli for the support of rehabilitation. We therefore propose that the experience of a therapeutic relationship within music therapy also promotes the connectivity in the neural networks in these patients. Studies found that patients with UWS show emotional processing of auditory and visual information (Coleman et al., 200924; Yu et al.,201325 ).

Interpersonal relationships are a basic need (Insel, 200126; Cozolino 200627. Gustorff and Hannich (2000)28 emphasize that every living individual has the need and ability for perception and interpersonal communication. The therapeutic relationship has to be initiated and maintained actively in every session. Within the therapeutic relationship, we try to connect with the patients by observing their reactions to the performed music and by considering even the smallest physiological changes.

Gilbertson, S., & Aldridge, D. (2008). Music Therapy and Traumatic Brain Injury - A Light on a Dark Night. London: JKP. Herkenrath, A. (2005). Encounter with the conscious being of people in persistent vegetative state. In D. Aldridge (Ed.), Music Therapy in Neurological Rehabilitation (pp. 139-160). London: Jessica Kingsley.

21 Sharon, H., Pasternak, Y., Ben Simon, E., Gruberger, M., Giladi, N., Krimchanski, B. Z., et al.

(2013). Emotional processing of personally familiar faces in the vegetative state. PLoS ONE 8:e74711. doi: 10.1371/journal.pone.0074711 22 Vuilleumier, P. (2005). How brains beware: neural mechanisms of emotional attention. Trends Cogn. Sci. 9, 585–594. doi: 10.1016/j.tics.2005.10.011 23 Phelps, E. A. (2006). Emotion and cognition: insights from studies of the human amygdale. Annu.

Rev. Psychol. 57, 27–53. doi: 10.1146/annurev.psych.56.091103.070234 24 Coleman, M. R., Bekinschtein, T., Monti, M. M., Owen, A. M., and Pickard, J. D. (2009). A multimodal approach to the assessment of patients with disorders of consciousness. Prog. Brain Res. 177, 231–248. doi: 10.1016/S0079-6123(09)17716-6 25 Yu, T., Lang, S., Vogel, D., Markl, A., Müller, F., and Kotchoubey, B. (2013). Patients with unresponsive wakefulness syndrome respond to the pain cries of other people. Neurology 80, 345– 352. doi: 10.1212/WNL.0b013e31827f0846 26 Insel, T. (2001). The neurobiology of attachment. Nat. Rev. Neurosci. 2, 129–136. doi: 10.1038/35053579 27 Cozolino, L. (2006). The Neuroscience of Human Relationships: Attachment and the Developing Social Brain. New York, NY: W.W.Norton & Company Ltd. 28 Gustorff, D., and Hannich, H. J. (2000). Jenseits des Wortes: Musiktherapie mit Komatösen Patienten auf der Intensivstation. Bern: Verlag Hans Huber.

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From an anthropological perspective, the aim of music therapy is to transform the foreign, clinical environment (Umwelt, ―around-world‖) of patients to their contemporaries (Mitwelt, ―with-world‖) (Binswanger,196329; Prinds et al., 201330). By addressing the patient individually and opening up to individual needs and reactions, music therapy is formed not only for the patient but WITH the patient.

The basic aim of music therapy is to encourage the individual resources of the patients and an allostatic regulation (Schulkin, 200431), helping them regain a mental and physical stability. Therefore, music therapy can be activating on the one hand, e.g., by moving the patient's arm hand on an instrument or along with a rhythm. On the other hand, it can encourage balance and relaxation by playing improvisations in e.g., playing to the rhythm of the patient's breath. However, as the needs and meaning of interventions differ from person to person, the central concern is to meet and approach each patient individually.

Amidst a hospital setting with technical apparatus and noise, one always runs the risk of losing sight of the human being. Music therapy tries to build a connection to the patient on an individual, relational level. Being aware of the patient's biography and their new and constantly changing context, the therapist approaches with an inquiring attitude.

It is important for the music therapist to get an understanding of this patient's culture and include it in their therapeutic considerations. In this context, culture is not the idea of ―isolated societies with shared cultural meanings‖ but rather one's own ―local world,‖ as e.g., the environment of the patient and their family. This culture comprises, among others, the patients' relatives, musical preference, ability to play an instrument and personality, and affects all aspects of their experiences (Kleinman and Benson, 200632).

This leads us to the point why anthropology, its core methodology (i.e., ethnography) and its interpersonal, intersubjective nature are important for a music therapist. They help us appreciate and humanly engage with the differentness of a patient and get a deeper understanding of the patient's needs.

Nevertheless, we are aware of the fact that, however confident our interpretations might seem to us, they are always limited by the analytic tools and research methods we use and by the epistemological limits of the concept of intersubjectivity (Willen and Seeman, 201233). We discussed this topic in a recent article in Frontiers of Human Neuroscience (Vogl J, Heine AM, Steinhoff N, Weiss K and Tucek G 201534).

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Binswanger, L. (1963). Being-in-the-world: Selected papers of Binswanger. New York: Basic Books.

Prinds, Ch., Hvidt, NS., Mogensen, O., Buus, N. (2013).Making existential meaning in transition to mothermood – A scoping review. Midwifery. doi: 10.1016/j.midw.2013.06.021.

31 Schulkin, J. (2004). “Introduction,” in Allostasis, Homeostasis, and the Costs of Physiological Adaptation, ed J. Schulkin (New York, NY: Cambridge University Press), 1–16. doi: 10.1017/CBO9781316257081.003.

32 Kleinman, A. and Benson, P. (2006). Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Medicine 3 (10): 1673–76. doi:10.1371/journal.pmed.0030294.

33 Willen, S. S., and Seeman, D. (2012). Introduction: Experience and Inquiétude. Ethos 40 (1): 1–23. doi:10.1111/j.1548-1352.2011.01228.x.

34 Vogl J, Heine AM, Steinhoff N, Weiss K and Tucek G (2015) Neuroscientific and neuroanthropological perspectives in music therapy research and practice with patients with disorders of consciousness. Front. Neurosci. 9:273. doi: 10.3389/fnins.2015.00273.

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Prof. Jorg Fachner has been working in Germany and Finland before he came to the UK to start a position as a Professor of Music, Health and the Brain at Anglia Ruskin University in Cambridge, UK. Starting at the Chair for Qualitative Research in Medicine in Germany in the 1990s he worked at the Faculty for Medicine, University Witten/Herdecke. For his PhD in 2001 he researched neural correlates of consciousness during music listening. Being a musician and connected to the Nordoff/Robbins Music Therapy training offered a profound insight and study of improvisational procedures and thinking. Working with physiologists situated in the same building and faculty sparked his idea to combine neuroscience and music research to understand Music Therapy. Moving to Finland in 2008 he wired 79 depressed clients to an EEG in order study Music Therapy treatment effects on the electrical current flow of the brain. Results were published in high-ranking journals and several streams of data were analysed.

Biomarkers, especially mobile and wireless applications that inform about treatment and the process of doing music therapy are his current focus of research.

IMAGERY AND BRAIN PROCESSING IN RECEPTIVE MUSIC THERAPY SETTINGS Visual and musical imagery Music is present in all cultures, and most people experience moments in which they are moved by music. That is, they have powerful emotional responses to music triggered by a song of their favourite band, a special performance or occasion, a personal memory associated with a particular piece, or images they conjure up during listening. Emotions, like music, are ubiquitous and typically involve a range of different aspects of human behaviour such as physiological changes (e.g., heart rate, skin temperature), motor expressions (e.g., facial expressions, posture), subjective feelings (e.g., being afraid), or action tendencies (e.g., fight / flight reaction).

In a seminal paper, Juslin and Västjfäll (2008) described six psychological mechanisms by which music can induce emotions in the listener: brain stem reflex, evaluative conditioning, emotional contagion, visual imagery, episodic memory, and musical expectancy; the latest version of this framework also includes rhythmic entrainment and aesthetic judgment (Juslin, 2013). While some of these mechanisms have been studied extensively in the context of music and emotion (e.g., musical expectancy: Huron, 2006; Meyer, 1956), others such as visual imagery have so far been largely neglected in spite of the fact that visual imagery plays an important role in music-induced emotions

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(Vuoskoski & Eerola, 2013), with important implications for clinical practice (Karagozoglu, Tekyasar, & Yilmaz, 2013).

Visual imagery refers to a mechanism by which a piece of music, or specific parts thereof, engages the listener in conjuring up internal images that might consist of pictorial representations (e.g. beautiful landscapes, people dancing) or abstract, dynamic representations such as images of going up and down. While visual imagery on its own has been studied widely in psychology (Broggin, Savazzi, & Marzi, 2012; Kolers, 1983) and cognitive neuroscience (Kosslyn et al., 1999), there is little research concerning the relationship of music and visual imagery (Osborne, 1981; Västfjäll, 2002).

That visual imagery is indeed involved in eliciting emotions experienced in response to music has been demonstrated in an experience sampling study in which participants were contacted at random times over the course of two weeks to report whether they had experienced a musical emotion and what its cause had been (Juslin, Liljeström, Västfjäll, Barradas, & Silva, 2008). While emotional contagion was the most commonly reported cause, visual imagery came fourth, followed on rank seven by musical expectancy, a mechanism that has been studied extensively in the past 60 years (Huron & Margulis, 2010). In a more recent study investigating the role of contextual information in music-induced emotions, Vuoskoski and Eerola (2013) found that as many as 80% of their participants reported visual imagery when music was combined with narrative descriptions. These findings are in line with a recently published neuroimaging study; investigating neural correlates of music-induced joy and fear, the authors conclude that visual imagery may play a crucial role in inducing musical emotions, especially for musically-induced fear which led to a higher activation of the visual cortex (Koelsch et al., 2013).

Thus given its prevalence in everyday life, the study of visual imagery as an emotioneliciting mechanism of musical experiences is proportionally underrepresented.

Although a first attempt has been made to study systematically some of the underlying mechanisms of music-induced emotion (Juslin, Harmat, & Eerola, 2013), the authors avoid visual imagery, referring to the difficulty of manipulating it experimentally.

However, recent theoretical and methodological developments (Juslin, 2013) now allow researchers to tackle this this gap in the literature.

Reduced Eye movements during imagery processes Musical imagery research investigates imagination of intervals, melodies and other musical elements in order to compare them to the listening process (Hubbard, 2010).

This may include any imagery of sound and music where there is no physical source, e.g. when conductors study scores or composers compose without piano. Visual imagery

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plays an important role in music-induced emotions, especially when music is combined with narrative descriptions (Eerola & Vuoskoski, 2013). In search of invariants of altered state of consciousness (ASC) Dittrich (1998) described visual restructuring and auditory alterations as core ingredients of an ASC. Listening to music can completely absorb people, cutting off other sensory input, but absorption skills seem to be linked to music preference, imagery, hypnotisability and intensity of emotions evoked (Kreutz, Ott, Teichmann, Osawa, & Vaitl, 2008; Schafer, Fachner, & Smukalla, 2013 ; Snodgrass & Lynn, 1989).

Listening to music has a significant effect on eye movement activity when watching visual stimuli such as a picture or a film clip: people exhibit fewer glances and saccades and they blink more often. This effect is even more pronounced when the music is preferred and the listeners are absorbed, respectively. These results indicate a shift of attention from the outer world (exogenous attention decreases) to the inner world (endogenous attention increases). Attention turns inward, which might be a result of music-induced emotions, memories, associations, or imaginations. Apparently, the listeners‘ vigilance decreases under the influence of music since vigilance has shown to be associated with a higher frequency of fixations (see Lavine, Sibert, Gokturk, & Dickens, 2002; Smith, Hopkins, & Squire, 2006). Similarly, fewer blinks indicate decreasing exogenous attention (Schleicher, Galley, Briest, & Galley, 2008).

Preferred music can intensity the effect on eye movement. Listening to one‘s favorite music can be a very intense experience, which can lead to distraction and detachment from the outer world. Herbert noted that ″music mediates rather than accompanies experiences marked by dissociative and absorbed shifts of consciousness‖ (Herbert, 2011, p. 16). She further concluded that changed perceptual relationships with surroundings contribute to the important function of music to ″intentionally escape preoccupations or unwanted thoughts.″ Reduced eye movement activity could be an expression of a shift of activation of certain brain regions in the course of inward attentional shifts. Dietrich (2003) proposed the concept of hypofrontality to explain functional changes in frontal areas of the brain. The frontal and precentral lobes of the brain constitute the explicit system, the ″active part″ that organizes top-down processing and structures motor activity and output, while the posterior lobes (postcentral, temporal, parietal, and occipital) are the ″receiving parts″— the implicit system of the brain. They are primarily concerned with sensory input and with processing bottom-up information in the implicit system. Dietrich (2003) proposed that the prefrontal cortex, the highest integrating component in a hierarchy of cognitive functions, is deregulated in altered states of consciousness by ceasing to function in a ″normal″ way. This is the hypofrontal (reduced frontal brain activity) state, which can be

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compared to the state of flow, in which effortless information processing seems to take place. It enables the temporary suppression of the analytical and meta-conscious capacities of the explicit system when a person is relaxed and absorbed in the flood of sensory input, allowing the person to see things from a different perspective or to arrive at new creative solutions to problems (Dietrich, 2004). Hypofrontality resulting from intense music experiences may also account for more intense emotions (Kreutz et al., 2008), for pleasure and wellbeing resulting from musical activities (Lamont, 2011) and when listening to music while being under the influence of drugs (J. Fachner, 2011).

A recent study, investigating eye movements of a highly hypnotisable person demonstrated a phenomenon known in hypnosis, the so-called ‗trance-stare‘, which also seems to be ―accompanied by changes in the prefrontal areas of the brain― (Kallio, Hyönä, Revonsuo, Sikka, & Nummenmaa, 2011).

During the ‗hypnotically induced

stare‘ the ―amplitude, velocity and frequency of reflexive saccades were radically suppressed, and the fixation time was increased‖ (Kallio et al 2011). This is in line with the reduction of eye movement observed in our subjects while listening to preferred music increasing absorption significantly. The eye movement pattern observed here, similar to the ‗hypnotically induced stare‘, seem to represent a physiological marker of a music-induced ASC in which attention is absorptive focused inwardly while ‚trancing‘ (Becker, 2004) with music.

Investigating imagery in Music therapy Receptive music therapy focuses on music listening together with a music therapist. One well established approach is Guided Imagery in Music (GIM) in which a therapist accompanies and guides the imagery of a client (Grocke & Wigram, 2007). A typical GIM session comprises an initial discussion of the client‘s concerns, and a focus for the music and imagery experience. The therapist provides a relaxation induction for the client who reclines with eyes closed, while the therapist initiates an altered state of consciousness (ASC) induction. The therapist then chooses a pre-determined music program, or spontaneously chooses music to match the client‘s imagery. As the music plays, the client describes any imagery, feelings, or thoughts (Grocke, 2009), that occur spontaneously while eyes-closed listening to special music programs in an induced ASC (Bonny & Savary, 1973). Commonly, certain passages during the imagery process will have pivotal meaning for the traveller and become a focus in the therapy process (Grocke, 1999). Imagery is diverse including visual, auditory, somatic, direct memories, involuntary and unbidden imagery, images of significant people, places and events from the person‘s history.

But how is spontaneously evoked and guided imagery in connection to music and ASC is processed. What happens in the brain during ASC and imagery processes of pivotal

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moments in GIM? There are a few studies investigating the impact of GIM on brain processing (Hunt, 2011). Lem accompanied GIM travelers and visually compared EEG and acoustic properties (Lem, 1998) indicating that visual imagery occurred to the listeners most frequently during rapid, large-scale releases of musical tension.

In a case study on source localisation of imagery processes the EEG of an experienced GIM traveler was recorded during rest, ASC induction and a GIM listening program (Imagery) (J. Fachner, Ala-Ruona, & Ole Bonde, 2015). EEG data (Power, Asymmetry) was compared (z-scores) against a normative EEG/LORETA database (John, 1989; Thatcher, Biver, & North, 2009) investigating artifact free rest, ASC and pivotal parts (Grocke, 1999) of the music listening preceding verbal response. Verbal responses were analysed separately and GIM EEG data was chosen based on the ratings of an independent GIM therapist.

A difference between rest and ASC induction indicated a state change on lower alpha (810 Hz). Z-scored LORETA Alpha1 power 8+9Hz bins exhibited highest z-score values in cuneus (8Hz) and precuneus (9Hz). Z-Scored LORETA power differences (interindividual rest – ASC) were most prominent in Brodmann Area (BA) 23 (8Hz) and BA 31 (9Hz) indicating involvement of cuneus and posterior cingulate in state changes.

Verbal GIM responses elicited two nodes of interest. During pivotal music listening one node exhibited a high beta anterior left temporal (T5) asymmetry decrease (resembling the ASC induction topography), while z-LORETA current density values increased in BA 37 (Left inferior / Middle temporal lobe on 21-30Hz). On lower Alpha right parietal zscore power values and z-LORETA current density increased in pre-cuneus (resembling the ASC pattern). ASC seem to be of importance for GIM and seems to influence the music listening process. ASC related change indicates connection to visual imagery processing during GIM Music listening. Client‘s responses report a deep relaxation and vivid imagery response and this is reflected in the EEG/LORETA on theta and beta ranges and cuneus area.

Some investigations into receptive music therapy approaches focused on the imagery and brain processes evoked from the droning sounds and vibrations while lying on a body monochord played from the music therapist (J. Fachner & Rittner, 2003; J. Fachner & Rittner, 2011). Studies investigating the specific monochord relaxation response with cancer patients comparing to a verbal muscle relaxation induction showed similar EEG responses in frontal areas (Lee, Bhattacharya, Sohn, & Verres, 2012). A recent RCT aims on comparing monochord relaxation against verbal mindfulness induction in palliative care settings. Findings reported differences in evoked imagery

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and in cardiovascular data indicating a more distinct trophotropic activity compared to mindfulness induction (Warth, Kessler, Hillecke, & Bardenheuer, 2016).

In both music therapies methods, in GIM and in Monochord listening, we can see how music therapy evokes individual imagery and brain processes related to the clients salutogenic capacities evoked and developed in receptive music therapy settings. The imagery evoked enabled change of perspective, coping with severe illnesses.

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Session 3 Dr. Maria Montserrat Gimeno, Ed.D., MT-BC, LCAT is Associate Professor in the music therapy program at the State University of New York at New Paltz. She completed a bachelor's degree in music therapy at Willamette University in Oregon.

Her master's

degree in music therapy and doctorate in counseling psychology are from the University of the Pacific in California. Dr. Gimeno is a licensed creative art therapist and a board certified music therapist in USA and is also trained in the Bonny Method of Guided Imagery and Music.

She presents regularly in national and international

conferences across the globe. Recently, she completed a research study on the use of “Music Imagery Relaxation (MIR)” a technique that she has developed to use with bedridden patients. Dr. Gimeno has taught music therapy courses and presented in the US, Spain, Norway, China, South Korea, Finland, Canada and Austria.

MED-GIM

CLINICAL

RESEARCH

ON

ADAPTATIONS

OF

THE

BONNY METHOD OF GUIDED IMAGERY AND MUSIC (BMGIM) This paper describes Dr. Gimeno‘s research on adaptations of the Bonny Method of Guided Imagery and Music (BMGIM) as well as clinical work done in the hospital setting. Gimeno´s first research study was her Doctoral Dissertation (Gimeno, 2010), which investigated the effects of Music and Imagery to reduce nausea and emesis on patients undergoing chemotherapy treatment. For this study, she used an adaptation of the Bonny Method called ―Short Music Journeys‖ (SMJ). Outcomes indicated a decrease on nausea and emesis overtime. For each week and each type of intervention, the heart rate decreased as indicated by the statistically significant t-values.

Following, Gimeno (2015a) explored the effect of music and imagery to reduce anxiety of post-operative traumatology patients. The Bonny Method adaptation used in this instance is called ―Music Imagery Relaxation‖ (MIR), a technique that she developed.

Results of this study indicated a significant decrease in the level of pain after music and imagery treatment intervention, while anxiety reduction approached significance. In addition, Gimeno‘s clinical experience on adaptations of the Bonny Method include six years of working with women who were experiencing cancer at the Health Alliance of the Hudson Valley in Kingston, NY. At that clinical setting, Gimeno gave weekly Music and Imagery (MI) group support sessions as well as individual sessions.

Currently, Gimeno with her Research Assistant, Haden Minifie, are conducting a research study at Amrita Institute of Medical Sciences (AIMS) at Kochi, Kerala, using the technique MIR as a treatment intervention to evaluate the effects of music and

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imagery to reduce pre-operative anxiety level on Indian woman undergoing breast cancer surgery.

The following paragraphs will introduce the fundaments of the Bonny Method of Guided Imagery and Music (BMGIM), and will give and overview of what Gimeno calls ―MEDGIM‖ which stands for Guided Imagery and Music in the Medical setting. MED-GIM encompasses adaptations of the Bonny Method of GIM to use in the medical setting as well as with populations at risk. These adaptations techniques are examined which include: (a) Short Music Journeys (SMJ); (b) Music and Imagery (MI); and (c) Music Imagery Relaxation (MIR). In addition, music therapy approaches while working with the Indian population are also addressed.

The Bonny Method of Guided Imagery and Music (BMGIM) The Bonny method of Guided Imagery and Music was created by Helen Bonny in the seventies while doing her doctoral dissertation. Helen Bonny had an extraordinary spiritual experience when she was playing the violin as if God had played through her.

She never forgot this experience and later in life she studied music therapy and wrote her Ph.D. dissertation about Guided Imagery and Music (GIM). The Bonny Method of Guided Imagery and Music (BMGIM) is a music-oriented exploration of consciousness. It offers persons the opportunity to integrate mental, emotional, physical and spiritual aspects of well-being, as well as awakening to a greater transcendent identification. It is practiced primarily in psychotherapy and counseling settings. Specifically sequenced classical music programs are used to stimulate and sustain a dynamic unfolding of inner experiences. Facilitators who conduct sessions in this one-to-one modality have backgrounds in the helping professions and are formally trained in The Bonny Method.

The Association for Music and Imagery (AMI) approved the definition of the Bonny Method as a music-assisted integrative therapy, which facilitates explorations of consciousness that can lead to transformation and wholeness. It evolved as a Method through the research and practice of Helen L. Bonny, Ph.D. In its one-on-one application, it is known as The Bonny Method of Guided Imagery and Music (BMGIM) (AMI, 2005).

The structure of a BMGIM session consists of four phases: (1) prelude; (2) induction; (3) music listening and guided dialog; and (4) processing. During the prelude phase, the client is encouraged to verbalize his/her concerns. The practitioner serves to focus the discussion by clarifying, summarizing, and supporting the client´s verbalizations.

During the induction phase of the session, the client is lying on a sofa or in bed and is asked to close the eyes.

The induction includes initial relaxation instructions as a

bridge for the music listening. Immediately after the induction comes the music

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listening phase. This phase lasts for approximately 30-45 minutes. During this time imagery is evoked by the music, and the participant and the practitioner are engaged in a verbal dialog. The last part of the session is the processing phase that consists of encouraging the client to verbally express his/her thoughts, feelings, and emotions regarding the music and imagery experience. The facilitator supports and encourages the client‘s personal process. The session generally lasts for 1.5 hours (Bonny, 1978).

Through this process, clients are given the opportunity to get an introspective insight into their own imagery, helping them to explore problems, issues, and strengths.

MED-GIM Adaptations of the Bonny Method Under the umbrella of MED-GIM, there are three main techniques; Music Imagery Relaxation (MIR), Music and Imagery (MI), and Short Music Journey (SMJ). These adaptations of the Bonny Method have the same session structure which are: prelude, induction, music listening, and postlude. They differ on the duration of the session, the lengths of the music, the music genre, the client positioning, the therapeutic approach and their purpose. In MIR the purpose is to relax the mind and the body, in MI to facilitate self-exploration in a positive and supportive manner, and in SMJ to give a deeper self-exploration in a safe container of a music journey. The three techniques as it is in the Bonny Method of GIM use the client‘s own imagery experience to empower the inner experience. These techniques are humanistic and client centered where the music plays an important psychodynamic role in facilitating the imagery experience.

Its

function is to enhance the imagery and to increase the absorption of imagery experiences to enter a new dimension of awareness. To listen to music in altered states of consciousness provides a new way into spiritual and transpersonal spaces of the mind.

In BMGIM the music used is classical. There is a compilation of musical programs developed by Helen Bonny with a duration between 30-45 minutes. Each program has a specific therapeutic intention and includes several pieces from classical composers. The GIM practitioner chooses the program accordingly with the energy and needs of the client. The SMJ technique also uses music programs but they are shorter in length, 1520 minutes, and in general are not classical. For the MI technique, the music used is generally New Age although client preferences are considered, and for the technique MIR, client preferences are primordial. In some occasions, music chosen by the therapist is used.

The three types of interventions, MIR, MI and SMJ, have different purposes. The MIR technique is given to provide greater calmness to the patient about to face surgery or potentially traumatic procedures. The duration of the MIR session is around 15-20 minutes. The SMJ technique is longer, around 30 minutes, and is given when the patient needs emotional support. SMJ helps the patient to connect to internal resources

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of confidence, possibly unknown by the patient beforehand, through a process that is stimulated by the music.

MI is used more in group settings and facilitates the

exploration of inner resources. Table 1 outlines the differences between MIR, MI, SMJ and the Bonny Method of GIM. MIR is considered less complex in the continuum of the Bonny Method. During the prelude, a therapeutic rapport is developed by facilitating or encouraging a state of mind of well being or enjoyment that is known to the patient. The good experience must be remembered or conjured to create a sense of comfort for the patient. If the patient can reach that state of mind, the session will have been successful. If not, the therapist must be able to provide a narrative to help the patient reach that point. During the prelude, the music therapist tries to draw out key images that will be related to the client‘s experience of comfort.

MI uses supportive inductions, and emphasizes the use of helping the patient to find an inner positive resource to cope with the present stressors. Summer (2002), refers in her study to the importance of giving supportive therapy when clients need to be held to reinforce any positive feeling that might emerge during the session, which allows for increased feelings of safety and good self-esteem.

Table 1 compares elements of BMGIM with SMJ, MI and MIR Elements Purpose

BMGIM

SMJ

MI

MIR

Self-

Self-

Self-

Relaxation

exploration

exploration

exploration

Type of

Re-

Supportive

Supportive

Supportive

therapy

constructive

and

Lying down with

To quiet the mind

re-educative Positioning

Lying down

Lying down or

Sitting on a

with

sitting on a

couch with

eyes closed

couch with eyes closed or

eyes closed or open

eyes closed and open

open Prelude

Preliminary

Preliminary

Preliminary

Creating rapport to

conversation

conversation

conversation

find key words of

finding the

finding the

finding the

the patient‘s

focus for the

focus for the

focus for the

experience of

53

Induction

session

session

session

wellbeing/relaxation

Brief

Brief

Brief

Spoken with music

relaxation;

relaxation;

relaxation;

that contains the

finding an

finding an

finding an

image as the

image as the

image as the

focus

focus with a

focus with a

positive

positive

outcome

outcome

patient‘s experience of wellbeing/relaxation

Music

Dialogue

Dialogue

Drawing a

Music is played at

listening

between

between

mandala

the same time as

patient and

patient and

the induction is

BMGIM

BMGIM

given

practitioner

practitioner

Mostly

Patient

Patient

classical,

preferences:

preferences:

including

new age,

new age,

soundtrack,

soundtrack,

light jazz

light jazz,

classical

classical

Music genre

Helen Bonny programs

Patient preferences

Music length

30-45 minutes

10-15 minutes

10-15 minutes

5-10 minutes

Postlude

Review of

Session is

Session is

No process of

imagery

processed

processed

reflection if the

experiences;

through

through

patient falls sleep;

supportive

supportive

therapy,

therapy,

validating

validating

feelings and

feelings and

reinforcing a

reinforcing a

positive

positive

experience;

experience;

―anchor‖ must

―anchor‖ must

be clear and

be clear and

connected to

connected to

the client

the client

exploration of how the imagery relates to client-stated focus of the session; client draws parallels and meaning from

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when awake, check out how the experience was

imagery

experience

experience

yes

yes/not

Yes

Not

Practitioner

Trained in the

Trained in the

Music

Music Therapist

training

Bonny Method

Bonny Method

Therapist

of GIM

of GIM

Drawing mandala

Conclusion Training in GIM had spread around the globe and evolved into 3 years of postgraduate study that includes a series of personal GIM sessions in addition to training in the selection and use of music during altered states. Therapists also learned to facilitate the imagery and music processes, understand psychodynamic processes, and support transpersonal as well as personal GIM content through intensive seminars and supervised clinical work. Bonny has inspired many people to carry her transformative work to new applications such the adaptations of SMJ, MI, and MIR. References Bonny, H. L. (2002). Music Consciousness: The Evolution of Guided Imagery and Music.

Summer, L (Ed.), (Barcelona Publishers).

Summer, L. (2002). Group music and imagery therapy: emergent receptive techniques in music therapy practice. In Bruscia, K. E. & Grocke, D. E. (Eds), Guided Imagery and Music: The Bonny Method and Beyond, pp. 297-306. Gilsum, NH: Barcelona Publishers.

Gimeno, Maria Montserrat Publications Gimeno, M. M (2016). Music therapy and anxiety in preoperative stress. Annals of SBV, 5(2), 7-47. Retrieved from http://sbvu.ac.in/annals-archive/.

Gimeno, M. M. (2016). The power of imagery in the Bonny method of guided imagery and

music.

Music

Therapy

Today,

12(1),

28-41.

Retrieved

from

http://musictherapytoday.wfmt.info.

Gimeno, M. M. (2016). Supervisión en el Método Bonny de Imagen Guiada y Música (MB or GIM). Departamento de Psiquiatría, Universidad de Murcia.

Gimeno, M. M. (2015a). The effects of music imagery relaxation technique (MIR) in medical setting. International Journal of Pharma and Bio Science, 30-37.

Gimeno, M. M. (2015b). MED-GIM Adaptations of the Bonny method for medical patients: individual sessions. In Moe, T. & Grocke, D. E. (Eds). The Music Imagery -

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Guided Imagery and Music (GIM) Spectrum: A Continuum of Practice. Gilsum, NH: Barcelona Publishers.

Gimeno, MM. (2014). Música e Imagen (MI) fundamentos y aplicación terapéutica: ilustración de caso. Música Terapia y Comunicación Journal, 34, 5-11. Bilbao, Spain.

Gimeno, M. M. (2010). The effect of music and imagery to induce relaxation and reduce nausea and emesis in patients with cancer undergoing chemotherapy treatment. Music and Medicine Journal, 2(3), 174-181.

Gimeno, M. M. (2010). El uso de la música y la imagen en oncologia. En Martí, P. & Mercadal, M. (Eds), Musicotrapia en Medicina Aplicaciones Prácticas. Badalona, SP. Editorial Médica Jims.

Gimeno, M. M. (2008). The effect of music and imagery to induce relaxation and reduce nausea and emesis in cancer patients undergoing chemotherapy treatment. Doctoral Dissertation, University of the Pacific, Stockton, CA. Gimeno, M. M. (2005). Theoretical orientation of The Bonny Method of guided imagery and music (BMGIM). A method of transformation. Aloma Journal, 16, 131-142.

Barcelona, SP: Blanquerna‘s University.

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Session 4 Dr. Sumathy Sundar is the Director of Center for Music Therapy Education and Research. She is the founding Director of Chennai School of Music Therapy and is currently also serving World Federation of Music Therapy as its Chair, Education and Research Commission.

She is one of the founding members of International Association for Music and Medicine and currently serves on the editorial board of “ Music and Medicine”, “Music Therapy Today” and “Journal of Alternative and Complementary Medicine”. She has a wide range of publications from articles to book chapters and podcasts in many International Journals of repute in music therapy. She has served as a scientific committee/board member in many international conferences, organized many international conferences and also presents regularly in several Conferences. Her research interests are in the area of validating/objectifying traditional healing practices and integrating Eastern traditions with Western philosophies of music therapy in patient outcomes.

Dr.C.Adithan is the Director of CIDRF and Professor of Pharmacology at Sri Balaji Vidyapeeth. Before joining here he served as Faculty in Charge Research and Senior Professor and Head of Pharmacology and Clinical Pharmacology Departments at JIPMER, Pondicherry. He was the past President of (1) Indian Pharmacological Society and (2) JIPMER Scientific Research Society. He was also Chief Editor of Indian Journal of Pharmacology for 9 years. He has published 184 research papers. He guided 15 PhD student and many postgraduate medical students. He is Fellow of National Academy of Medical Sciences, International Medical Science Academy and Indian Pharmacological Society. He was an Expert in the selection committee of Shanti Swarup Bhatnagar Prize in the field of Medicine Musicogenetics: A new specialty on horizon?

Sumathy Sundar, Director, Center for Music Therapy Education and Research, SBV Adithan C, Director, Central Inter disciplinary Research Facility, SBV Advances in fields of genetics and molecular biology have changed approach to health and diseases in human beings. Genes are known to affect the health directly by being in causation/predisposing relationship with specific medical condition(s). In addition to direct gene-disease relationship, gene also affect overall medical management of a

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patient by increasing one‘s susceptibility for or resistance to certain drugs and drug interactions, and by increasing or decreasing probabilities of drug tolerance or intolerance – pharmacogenetics has wide applications in practice of medicine. Beyond drugs and diseases, genes start play their role right from formation of an embryo – from synthesis of organ systems, to functioning of organs, to altering thoughts and emotions, to affecting health-related behavior, etc. Concept of medical treatment guided by genetic constitution of a patient seems promising and rational. [1].

Over last a few decades, interest in music therapy has grown globally. Music therapy has found its applications in areas of psychiatry, psychology, neurology, oncology, anesthesiology, intensive care, obstetrics, pediatrics, geriatrics, palliative care, etc [2].

On one side, reciprocal relationship between effects of music on brain and effects of music behavior on brain function seems to hold a strong potential to see music therapy as an important treatment modality in therapeutics in future [3], researches in psychoneuro-endocrino-immunology also point towards irrefutable importance of stress regulation and healthy behaviors in management of many common diseases [4]. As human physiology and pathology are influenced by genes parallelly, we believe that there is a wide scope for research in field of ―musicogenetics‖ – a term coined by us to describe a specialized field of bioscience to study interactions between human genes, music traits, music behavior, and music therapy responses.

Till date, we have studied that roots of musicality is an expression of musical self and that neuroscience and psychobiology have identified the potential of musical expressions to bring about therapeutic change in music therapy [5]. Also studies have indicated a link between the felt quality in musical expression with the psycho-somatic aspects, emotions and thought patterns and the deeper needs of the clients/patients [6].

Researchers have also studied relationship between genes and music traits. Based on research so far, it is rational to think of genetic basis of individual differences in musicality – music perception, music memory, music listening, music production, singing, and music creativity. Genes AVPR1A on chromosome 12q and SLC6A4 on chromosome 17q have been associated with music memory; AVPR1A and SLC6A4 have been also implicated in music perception-music listening and choir perception respectively. Several loci on chromosome 4 are associated with music perception and singing, while certain loci on chromosome 8q have been implicated in music perception and absolute pitch. [7, 8]. Recently, a study by Kanduri et al has shown up-regulation and down-regulation of several genes following listening to music [9]. However, much more research is needed in ―musicogenetics‖ and there is no study in this field that would help to apply knowledge of genetics in field of music therapy.

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As music therapists and researchers, we have tried to identify several unanswered questions and we would like to briefly summarize them as follows: a) Are there genes that predict a therapeutic response or failure to music therapy? If yes, are genes associated with music therapy response same as or different from those associated with music traits? b) Is congenital amusia [8, 10] related to ineffectiveness of music therapy? c) In patients with multi-gene disorders, are there specific genes that would predict high probability of effectiveness of music therapy? d) Can music therapy affect gene expression via epigenetic mechanisms? Of course, these are very basic questions, and further questions are likely to arise when these questions would be answered.

Answers to these questions are likely to reveal links between genetic constitution, a ―personal map‖ of every individual, determinants of musicality and of music therapy; such discoveries would definitely help health care providers and therapists to provide music therapy in a more personalized way and more effectively.

The availability of Next Generation Sequencing and falling cost of genetic analysis and gene expression may help us to investigate and identify the potential responders and non-responders to music therapy. To achieve this objective the effect of different ‗ragas‘ on gene functional analysis is needed.

Musicogenetics appears to be an emerging specialized field that should discover some interesting truths. It is apparent that research in this field requires dedicated and integrated efforts from geneticists, music therapists, psychologists, physicians, and allied health care professionals. Of course, such efforts have a great potential to understand gene-mind-body interactions better, to alter management of several medical conditions, and to influence clinical practice.

References: 1. Chang KL, Weitzel K, Schmidt S. Pharmacogenetics: Using Genetic Information to Guide Drug Therapy. Am Fam Physician 2015; 92(7): 588-94.

2. Kemper KJ, Danhauer SC. Music as Therapy. South Med J 2005; 98(3): 282-8.

3. Thaut MH. The Future of Music in Therapy and Medicine. Annals of the New York Academy of Sciences 2005; 1060(1): 303-8.

4. Lutgendorf SK, Costanzo EF. Psychoneuroimmunology and health psychology: An integrative model. Brain, Behavior, and Immunity 2003; 17(4): 225-32.

5. Perret D. Roots of Musicality: Music Therapy and Personal Development. Jessica Kingsley 2005; 16-22 6. Perret D. Roots of musicality: On neuro-musical thresholds and new evidence for bridges between musical expression and ‗inner growth‘. Music Education Research 2004; 6(3): 327-342. doi: 10.1080/1461380042000281767.

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7. Gingras B, Honing H, Peretz I, Trainor LJ, Fisher SE. Defining the biological bases of individual differences in musicality. Philosophical Transactions of the Royal Society B 2015; 370: 20140092. doi: 10.1098/rstb.2014.0092.

8. Tan TY, McPherson GE, Peretz I, Berkovic SF, Wilson SJ. The genetic basis of music ability. Frontiers in Psychology 2014; 5: 658. doi: 10.3389/fpsyg.2014.00658.

9. Kanduri C, Raijas P, Ahvenainen M, Philips AK, Ukkola-Vuoti L, Lahdesmaki H, Jarvela I. The effect of listening to music on human transcriptome. Peer J 2015; 3: e380. doi: 10.7717/peerj.830.

10. Peretz I, Hyde KL. What is specific to music processing? Insights from congenital amusia. Trends in cognitive sciences 2003; 7(8): 362-7.

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Session 5 Paper presentations An Overview of a Music Therapy Program With a Focus on Continuation and Evolvement with Former Child Abductees, and Orphans of Uganda's Civil War Haden Minifie, MS, MT-BC CEO, Co-Founder, Director, Sing Out! International This presentation outlines the first community music therapy program designed and conducted by Sing Out! International, a nonprofit, 501(c)(3) organization committed to serving communities worldwide that have been affected by trauma. This six-week program was implemented in March and April of 2016 at Hope North School and Vocational Centre in northern Uganda for former child soldiers, abductees, and orphans of Uganda's civil war. The program was designed to address the following goals: (a) deepen the connection to the community; (b) offer an alternate means of expression; (c) decrease stress response; (d) increase positive coping skills; and (e) improve quality of life. These goals were addressed with the following interventions: (a) group drumming; (b) group singing; (c) improvisation; (d) songwriting; and (e) relaxation with music.

Besides introducing the music therapy program to Hope North, Co-Founders trained six teachers in continuing each of the music therapy classes so as to allow for the program to be adapted to meet the needs of the students, and to ensure the continuation of the program for years to follow. Clinical footage will be included in the presentation.

Keywords: community music therapy, former child soldiers, Uganda For almost thirty years, Joseph Kony and the Lord's Resistance Army (LRA) tormented and pillaged communities throughout northern Uganda. Many children were abducted and forced to become soldiers, faced with the choice to kill or be killed. While the Ugandan army made continuous attempts to gain control over the LRA, support of the LRA from the Sudan and the Democratic Republic of Congo allowed the LRA to stay active (Eichstaedt 2009). Okello Kelo Sam, a former child soldier, founded Hope North School and Vocational Center in northern Uganda after hearing about the loss of his brother in the LRA. He purchased forty acres of land and drove trucks throughout Uganda, rescuing as many children as he could find. Hope North is a boarding and day school that serves as a refuge and safe haven for adolescents who have survived these traumatic experiences (―About,‖ n.d.). Learning about this school and what it offers to its students inspired the beginning of a collaboration to bring music therapy to Hope North.

Haden Minifie and Ashley-Drake Estes, two board-certified music therapists, worked together on a program proposal to lead a music therapy program at Hope North as their master's thesis project. After graduating, they co-founded Sing Out! International, a

61

nonprofit, 501(c)(3) music therapy organization whose mission is ―to promote emotional healing in traumatized communities throughout the world through the power of music and song‖ (―About,‖ 2015), with the idea that ―by creating a calm and nurturing environment for survivors to express and process their experiences using tried and true music therapy practices, communities can heal together and move forward‖ (―About,‖ 2015). Minifie and Estes reached out to Okello Kelo Sam about the possibility of leading its first-ever music therapy program in March and April of 2016 at Hope North, an idea that Sam welcomed for the students. This article will focus on an overview of Sing Out! International's music therapy program, delve more specifically into the program's design for the continuation and evolvement of music therapy at Hope North, and offer some reflections of Minifie's experience of daily life in Uganda.

Music Therapy at Hope North Sing Out! International focused on offering music therapy to (a) increase self-expression; (b) promote emotional healing; (c) offer an alternate means of expression; (d) foster connectedness to the community; (e) decrease stress response; and (f) provide positive coping skills. Minifie and Estes utilized several music therapy techniques, (1) group drumming; (2) group singing; (3) improvisation; (4) songwriting; and (5) relaxation with music to address these goals. Music therapy was worked into the daily curriculum for about one hundred students between the ages of 13 and 21, with each grade level, Senior 1-4 and Vocational, focusing on one of the music therapy techniques.

Incorporating music of Ugandan culture was essential to the program. Preferred music was the focal point for each of the music therapy groups, and provided insight into how music is used in everyday life at Hope North. Traditional, local instruments were used, which helped to create an environment that encouraged natural musical expression, and helped to support the growth of each music therapy group. A range of melodic and percussion instruments were incorporated such as calabash (a percussion instrument made from a large gourd), shakers, various types of drums, a hand-crafted, wooden xylophone, adungus (a traditional Ugandan harp), harmonicas, fiddles, and guitars. It was an incredible experience to be able to see how each music group developed and emerged. The co-founders took note of how students were shy and quiet at the beginning of the program, and then slowly expressed themselves more openly, both verbally and through the music. The co-founders noticed an evolvement in the complexity and intricateness of the themes chosen, a deepening of insight in the discussions of the music, and a lengthening of the discussions as session progressed. Students began to feel more comfortable taking turns leading the group in music-making (i.e., playing faster/slower, changing dynamics, rotating instruments, among others). The growth and

62

depth of each music therapy group propelled the emergence of an idea for an opportunity to have the entire Hope North community share in the experience.

The option to host a school-wide music show was met with much excitement and support. This was an opportunity to showcase some of the music that was created with their peers and to hear a taste of what other groups had been working on in a culmination of this first phase of the program. The music show also provided a way for others in the surrounding community outside of the school to be a part of the experience and share in the music. The show unfolded into an evening of traditional song and dance, shared exuberantly by students, staff, and music therapists.

Continuation and Evolvement of Music Therapy at Hope North One fundamental part of the program was setting up a way for music therapy to continue at Hope North. Minifie and Estes believed in providing a way for the program to thrive and be sustainable after they returned to the United States. Minifie and Estes met with the administration of Hope North at the beginning of the program to see how music therapy would fit into the curriculum. The program was designed to be incorporated into the framework of a student's schedule so that neither teachers nor students would have to arrive earlier or stay later during the week. The music groups of group drumming, group singing, improvisation, and songwriting were worked into the daily schedule so that one forty-minute block was set aside for music therapy for each grade each week. Relaxation with music was an open group that was offered daily to all students every evening of the week, with roughly 60-80 students on average in attendance daily. Setting aside one forty-minute period each week provided a way for peer interaction in a setting other than the classroom and on the football (soccer) field.

Minifie and Estes were inspired by the World Health Organization's 2007 initiative of ―Task Shifting,‖ part of its ―Treat, Train, Retain‖ program originally intended to provide additional aid to people living with HIV/AIDS as a model for the continuation of music therapy. In ―Task Shifting,‖ doctors train nurses, nurses train non-specialized clinicians, who in turn train nurses, who in turn train nursing assistants and community health workers, and who in turn train people living with HIV/AIDS (WHO, 2007). Sing Out! International adopted this approach in order to allow for the evolvement and sustainability of music therapy at Hope North. Six teachers volunteered to continue leading each of the classes, committing to leading one music therapy group for forty minutes each week.

During the first half of the program, Minifie and Estes focused on building rapport and creating a safe and supportive environment for musical expression. During the latter half of the program, the teachers were trained to continue one music group, by observing

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first, and then facilitating. During the final two sessions of the program, teachers took a more active role as facilitators, with Minifie and Estes providing guidance and support.

In addition to training the teachers, Minifie and Estes also provided each teacher with an instruction manual with the structure for each music group. The manuals outline steps for facilitating (not leading) musical expression. For example, the group drumming instruction manual provides a detailed step-by-step process for facilitation, beginning with an invitation of a discussion among the students to choose a theme for each session, encouraging the exploration of that theme within the music (i.e., what does that theme look like, sound like, feel like, musically, etc.), and prompting a discussion of that theme.

Minifie and Estes were also able to keep in touch with students, which was a great way to stay connected with Hope North and to hear about the continuation of music therapy.

Among other comments, students reported, ―this was really meaningful for me and my fellows so I really thank Ashley and Haden for what they have done at Hope North‖ (student, personal communication, May 21, 2016); ―I‘ve got new songs for our class‖ (student, personal communication, May 31, 2016); ―I humbly recommend such a wonderful and life-changing initiative‖ (Hope North teacher, personal communication, July 2, 2016); ―it is very okay [the music classes] and it is becoming part of me every week and in the weekends‖ (student, personal communication, August 13, 2016); and ―I and [name of student] we have organized 13 students for music therapy [music show] tonight. I have also invited friends from various schools within and others from Gulu to enjoy this wonderful day with us right here. After we have performed, [name of teacher] will take up his duty for Music dance as our DJ for tonight. We have organized even the traditional dances‖ (student, personal communication, October 9, 2016). What really stood out to the author from these responses is the role that music therapy plays in their lives, the desire to continue having music therapy, and the motivation to remain connected to the surrounding community by gathering others from neighboring schools and villages to celebrate and share in the experience.

Living at Hope North Minifie and Estes were fortunate to be able to live at the school for six weeks in one of the guest houses, which allowed for them to be able to be a part of daily life at Hope North; in addition to leading the music therapy program, Minifie and Estes taught English several days a week, and were able to take part in the cultural activities of Hope North, many of which involved music-making. Minifie and Estes reflected on their personal process as well, aware of the fact that they are two privileged, white, females who lived for a short time in a third-world country. Reflecting on this experience encouraged a sensitivity for cultural awareness in working within a music therapy

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context with individuals from a vastly different culture, and this in turn has instilled in Minifie a desire to continue to reflect on cultural awareness in her current work.

Conclusion Sing Out! International's program at Hope North allowed for music therapy to be accessible to students, and provided for continuation and evolvement for years to come.

The program sought to address goals that reflected the needs of the students within a safe and supportive environment at Hope North, and provided a plan for longevity.

Training the teachers ensured that each music group would occur each week as part of the curriculum, and the training manuals served as a point of reference, with the main idea being that the program would grow in its continuation of meeting the needs of the students. Minifie is grateful to have been immersed in a rich cultural learning experience during her time at Hope North School. Minifie and Estes plan to lead future programs to address the effects of trauma in communities around the world and in the United States.

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Paper 2 TITLE A STUDY OF THE EFFECT OF ADJUNCTIVE MUSIC LISTENING ON THE OUTCOME OF DEPRESSIVE DISORDERS Dr. Karthik Balakrishnan, Dr. Sumathy Sundar

Dr.

Sivaprakash

B,

Dr.

Sukanto

Sarkar,

Abstract Context Depressive disorders are common & have a major personal/economic & social impact. It is well known that a substantial proportion of patients suffering from depression do not achieve satisfactory clinical remission. Thus, depression is a common reason for the use of complementary therapies such as music. Methods that use music for health-related goals, but do not qualify as ―music therapy‖ may be described as ―music medicine‖, or simply as ―music listening‖. Research has documented evidence of significant improvement in depressive scores due to music listening. However, review of the literature indicates conflicting findings too, as well as heterogeneity with regard to study design & methods. Moreover, there is a significant dearth of published Indian research in this context. Socio-cultural factors are important in the application of music in health care. There is also an urgent need to document the utility of complementary treatment methods that can improve the outcome of depressive disorders & maximize response rates. Thus, there is a need to study the effect of adjunctive music listening on the outcome of depression, in the Indian context.

Objective This study aimed to test the hypothesis that the addition of music listening to standard care influences the outcome of depressive disorders. Various factors that could modify the effect of adjunctive music listening on the outcome of depressive disorders were also studied, such as socio-demographic variables, interest in music, alexithymia, & various illness-related variables.

Methods Study design Quasi-experimental study design (pre-test - post-test, non-equivalent groups design; non- randomized intervention study). The study was conducted over a period of one year in the Department of Psychiatry, in a tertiary care hospital in Puducherry (Pondicherry), India Subjects All consecutive patients, aged 19 to 64 years, with a current depressive disorder (WHO ICD-10 F32, F33, F31.3, and F31.4) were considered for inclusion into the study,

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irrespective of current medication status. Patients with any of the following were excluded: psychosis, substance dependence, cognitive impairment, intellectual disability, or hearing loss. Patients requiring electroconvulsive therapy or cognitive-behavioural therapy were also excluded from the study. Informed consent was sought.

Procedure The study protocol was approved by the institutional ethical committee. Ninety-eight patients were screened with reference to the specified inclusion & exclusion criteria.

Five were excluded from the study, based on exclusion criteria. Ninety-three patients were included, after obtaining informed consent.

Patients were categorized into 3 groups (A, B & C), based on need for hospitalization & access to a suitable digital music playback device with headphones. Patients in Group A received daily sessions of investigator-supervised adjunctive music listening for a duration of 10 sessions (30 min each), in the in-patient unit, followed by 20 sessions of self-administered home-based music listening, along with standard care. Patients in Group B received only home-based music listening (30 sessions), along with standard care. Patients in Group C received standard care alone, without adjunctive music listening. Appropriate / suitable music tracks from various musical genres (Indian classical, Western classical, New Age) were selected and compiled into several playlists.

Subjects in groups A & B listened to a music playlist selected by them, through headphones, while reclining on a couch, in a quiet room, in the evening.

Subjects were rated using the following tools: Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Rating Scale (HAM-A), Schalling-Sifneos Personality Scale for alexithymia (SSPS), Interest in Music Scale (IIM), Clinical Global Impressions Scale: Illness severity (CGI-S) & Clinical Global Impressions Scale: Change / Improvement (CGI-C). Ratings on MADRS & HARS were obtained at baseline, day 10 & day 30. Ratings on IIM & SSPS were done at baseline only. CGI-S was applied at baseline, day 10 & day 30. CGI-C was applied at day 10 & day 30.

3 patients dropped out during the study. Analysis was done on 90 subjects who completed the study.

Results The mean age of the sample was 39 Âą 11.08 years. Age of the study subjects ranged from 19 to 60 yrs. Majority of the subjects in group A were from the middle class. Most of the subjects in groups B & C were from the lower / upper lower class. Majority of subjects in all 3 groups were married.

There was no significant difference between the 3 groups in terms of depression, anxiety & CGI-S scores at baseline. Patients in group A had marginally higher interest in music, & a marginally higher level of alexithymia. Western classical music (JS Bach) was chosen by the largest number of patients, in both groups.

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The overall depression, anxiety & CGI-S scores were lower in all 3 groups at 30th day compared to baseline. Though the fall in depression score over a period of 1 month was highest in group A, no statistically significant difference was noted. However, fall in anxiety scores seemed to be approaching statistical significance (p = 0.053), with the largest fall noted in group A. No significant difference was noted between the experimental groups (A & B), in terms of change in depression scores over one month.

No significant correlation was noted between interest in music and change in depression & anxiety scores, in the experimental groups (A & B). A significant correlation between alexithymia and change in depression was noted only in group B (p = 0.041). No significant association was found between type of music selected & outcome, in the experimental groups (A & B).

One of the objectives of the study was to analyze the predictive effect of sociodemographic variables, clinical variables & alexithymia, on the influence of adjunctive music listening on the outcome of depressive disorders. In patients with a moderate baseline depression score, area of domicile emerged as a significant predictor (p = 0.004). In patients with moderate anxiety level, total duration of illness and current duration of illness emerged as significant predictors (p < 0.001), along with marital status (p = 0.044). In patients with severe anxiety level, total duration of illness & age emerged as significant predictors (p < 0.05).

Conclusion A sequential combination of hospital-based / clinician-supervised adjunctive music listening followed by home-based music listening, resulted in the largest fall in both depression & anxiety scores, over a period of 1 month, in patients with depressive disorders. However, the fall in depression scores were not statistically significant, while the reduction in anxiety scores approached statistical significance. However, these results need to be interpreted with caution, in view of the short follow-up period, which is a limitation of this study. It is conceivable that the results would have been different with a longer study period, such as 3-6 months. It is noteworthy that no significant correlation was noted between interest in music and change in depression & anxiety scores. Interestingly, the type of music selected by many subjects seemed to transcend socio-cultural context. Overall, the results of this study are encouraging. Further research is recommended to study the effect of adjunctive music listening on the outcome of depressive disorders, in the Indian context, with a larger sample & longer follow-up.

Key words: Depressive disorders, adjunctive music listening, anxiety, alexithymia, interest in music

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Paper 3 Title: A STUDY ON THE EFFECT OF MUSIC THERAPY ON THE PAIN PERCEPTION DURING THE LATENT STAGE OF LABOR Bhuvaneswari Ramesh, Tutor, CMTER Sumathy Sundar, Director, CMTER, Sunita Samal, Professor, Department of Obstetrics and Gynecology ABSTRACT During labor, women experience a high level of pain intensity. Although pain is an integral part of labor if it exceeds a womanâ&#x20AC;&#x2DC;s pain tolerance, it may have adverse physiological and psychological consequences both on the woman and her foetus and may inhibit/slow down labor progress.

Aims and objectives The aims and objectives of this study are to observe and study the effects of music therapy on pain perception during the latent stage of labor, to compare the baseline difference of the pre-test pain scores of the music and non-music group utilizing two pain scales (VAS-visual analogue scale and BRS- Behavioural Rating Scale), to compare the difference on the post-test pain scores of the music and non-music group.

Hypothesis There is significant pain relief in the latent stage of labor with music therapy intervention.

Methodology 60 primigravida pregnant women were assigned randomly to control and music therapy group. The pregnant women in the control group were given conventional routine care.

The pain scores and behaviour rating scores were recorded pre-and post for both the groups. The statistical analysis was done with the non-parametric statistical MannWhitney and Wilcoxon tests for the pain scores and T-Test for BRS. Result: The study showed significant increase in the pain scores with the control group who did not receive any music therapy intervention while the increase in pain scores were not significant in the music therapy group. There was significant reduction in the behaviour rating scores of the pregnant women in the music therapy group as compared to control group.

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Conclusion Music therapy can be used during labor pain in the first stage. The ability to cope with the pain was indicated with the reduction of the behavioural rating scores of facial gestures, restlessness, vocalisation in the music therapy group.

Key words: Labor, latent stage, music, music therapy, labor pain, pain perception, VAS, BRS. Paper 4 Title: Effect of live music therapy on psychophysiological parameters of hemodialysis patients: A randomized controlled trial Kala Varadan, Tutor,CMTER, SBV Dr. Sumathy Sundar, Director, CMTER Dr. Hemachandar, Associate Professor, Department of Nephrology, MGMCRIT Abstract: Often times hemodialysis patients experience high levels of stress and anxiety and find it difficult to cope with the treatment process. This study evaluated the effects of live music therapy on the psychophysiological parameters of hemodialysis patients and observed reduction in blood pressure, respiratory rate, heart rate and also anxiety levels.

Description: The aim of the study was to observe effects of live music therapy on systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate (HR), respiratory rate(RR) and state anxiety (SA) in hemodialysis patients. 42 hemodialysis patients were randomly divided into 2 groups of 21 each in experimental and control group. Patients in music group listened to live Veena instrumental music for 30 minutes twice a week for 2 months in 16 sessions while the control group just received standard care. SBP, DBP, HR, RR and SA were recorded before and after the music therapy interventions. State Anxiety levels were recorded using the numerical rating scale pre and post music therapy sessions.

Paired t tests revealed that there was a significant reduction in systolic blood pressure, heart rate and respiratory rate in the music group before and after the live instrumental (Veena) music therapy intervention. Between the groups, independent t tests revealed that the music group had a significant reduction in respiratory rate compared to the control group not receiving music. To conclude, listening to live instrumental (Veena) music may reduce blood pressure, bring down heart rate and also improve breathing.

More studies are needed to confirm these findings.

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