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SRI BALAJI VIDYAPEETH

DEEMED UNIVERSITY Accredited by NAAC with A Grade

Taking Forward Music Therapy : Shaping The Future

CENTER FOR MUSIC THERAPY EDUCATION AND RESEARCH Sri Balaji Vidyapeeth

Mahatma Gandhi Medical College and Research Institute Campus, Pondicherry

PROCEEDINGS of RD 3 INTERNATIONAL CONFERENCE on "BEST PRACTISED MODELS AND RESEARCH IN MUSIC THERAPY : GLOBAL PERSPECTIVES”

16.02.2016 Pondicherry Edited by DR. SUMATHY SUNDAR DR. VELLORE A.R. SRINIVASAN


SRI BALAJI VIDYAPEETH

DEEMED UNIVERSITY Accredited by NAAC with A Grade

Taking Forward Music Therapy : Shaping The Future

CENTER FOR MUSIC THERAPY EDUCATION AND RESEARCH Vision To contribute to the advancement and establishment of music therapy as an innovative component in the modern and evidence-based practice of medicine.

Mission l To harness the healing effects of music and integrate music

therapy into routine patient care, under the umbrella of complementary and alternative medicine. l To set high standards for music therapy education in a clinical

environment. l To foster high quality scientific research that would facilitate the

evidence-based application of music therapy.


CENTER FOR MUSIC THERAPY EDUCATION AND RESEARCH

Sri Balaji Vidyapeeth Mahatma Gandhi Medical College and Research Institute Campus, Pondicherry

PROCEEDINGS of 3RD INTERNATIONAL CONFERENCE On "BEST PRACTISED MODELS AND RESEARCH IN MUSIC THERAPY : GLOBAL PERSPECTIVES”

16.02.2016 Pondicherry

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

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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 Prof. Dr. K.R. Sethuraman Prof. Dr. N. Ananthakrishnan Prof. Dr. S. Krishnan Executive Editors Prof. Dr. A.R. Srinivasan 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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S.No.

Content

Page No.

1

Chairman's Message - Mr. M. K. Rajagopalan

5

2

Chancellor's Message - Dr. Rajaram Pagadala

6

3

Vice-Chancellor's Message - Dr. K.R. Sethuraman

7

4

Dean's Message - Dr. N. Ananthakrishnan

8

5

Welcome Address - Dr. Vellore A.R. Srinivasan

9

6

Inaugural address - Dr. Suzanne B. Hanser

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7

Vote of Thanks - Dr. Sumathy Sundar

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Scientific Program

14

Key Note Address Music Therapy and Biomarkers of Depression Treatment Dr. Jorg Fachner

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8

9

Current Research Initiatives in Music Therapy Dr. Sumathy Sundar

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10

Principles of Cognitive Behavioral Therapy - How They Provide Support for Trauma-Informed Music Therapy Work Dr. Gene Ann Behrens

33

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Neurologic Music Therapy in Medical Rehabilitation Dr. Anna Bukowska

41

12

Thoughts on Western Therapeutic Practices in Myanmar, Nagaland and Bethlehem - Tsvia Horesh

47  

13

Paper Presentations

58

14

Poster Presentations

61

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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. Y.M. Jayaraj, Pro Vice-Chancellor, SBV 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. S. Ravichandran, Additional Director, MGMCRI Prof. Nirmal Coumare, Medical Superintendent Mrs. Asha Suresh Babu, PS to Chairman 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 Ms. Kala Varathan Dr. Sakthi Devi Dr. Prasanya Ms.M. Sujitha Ms. R. Ambika

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

Date: 20 01 2016

Chairman's Message It is my privilege and honour to welcome you all for the 3rd International Conference in Music Therapy organised by Sri Balaji Vidyapeeth, a health sciences university accredited with "A" grade by the NAAC. Working with a vision of contributing to the advancement and establishment of music therapy as an innovative component in the modern and evidence-based practice of medicine, we have been integrating music therapy services into routine patient care, under the ambit of Complementary and Alternative Medicine since 2010, initiating training in a clinical environment and fostering scientific research that would facilitate the evidence-based application of music therapy integrating the local traditions and healing practices. We are hosting the International conference on music therapy for the third time since 2012 and we are proud of the fact that ours is one among the very few health universities in the country that offers a fully accredited training program in music therapy. Also, the students and the faculty have very good opportunities to gain expert knowledge and engage in relevant research with the state-of-the-art facilities. Also, our programs have started to reach noticeable heights globally. We are also having overseas collaborations with global experts in music therapy who share their experience and expertise with our faculties and students. This conference with the theme "Best Practised Models and Research in Music Therapy" has been conceptualized and planned with an interesting scientific program with high quality evidence-based contributions from both International and National delegates on the subject. I wish all the delegates a good learning experience. I am confident that the conference proceedings which will be published by us will be an excellent compilation of present knowledge and advancements made on the best practised models and research in music therapy, to be used by all who are interested in integrating music therapy and medicine. I take this opportunity to thank you all for joining us today. Also, I wish the organising committee a grand success in their future endeavours. M.K. Rajagopalan Chairma

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

January 27th, 2016

Prof. Rajaram Pagadala Chancellor Music Therapy in 21st Century

Opportunities for introducing Music therapy in clinical practice is enormous. However, physicians are either ignorant or biased for familiarizing Music Therapy as an adjuvant therapy in clinical practice. Though Music Therapy is not a part of conventional medicine, that is mostly Western Medicine, Music Therapy, indeed is, gaining momentum, the world over. Evidence-based research during the past few decades has proved that Music Therapy has a place in restoring health and wellness. In ancient Indian Medicine, Music therapy was used in many types of diseases including mental disorders. There is enough evidence to show that it is time that Music Therapy should find its place in the modern curricula. Therefore, medical academicians must open doors to discuss with 'music masters' and conduct inter disciplinary research to sign in a new page for Music Therapy. A cursory look at the recent research work done show applying Music Therapy in patients with chronic illness, those requiring pain relief in Rahab departments and those in labor rooms does show that it is time Music Therapy be included as a part of the undergraduate curriculum, at least. Today, it is well known that the healthcare costs have sky-rocketed and are prohibitive. Poor are being exploited. Music Therapy in clinical practice can reduce the costs and help restore health quickly. The power of music is ill understood. It has been proved to be beneficial in restoring individual's physical, emotional and social wellbeing. Music Therapy, at least can be enriched with traditional treatment that can assist in the prevention of certain impending conditions like depression, chronic pain, and also perhaps faster recovery after a surgery. Practice of Music Therapy in the 21st century, in my opinion, is certain to stay.

Prof. Rajaram Pagadala

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

Message

Currently, Music Therapy is a well established complementary therapy. A music therapist uses all facets of musical experiences (singing, free improvisation, listening-to or moving-to music etc) to achieve treatment goals and to assist clients improve their health status. Research has shown that Music therapy is effective in improving health in various domains such as, cognitive function, motor skills, emotional development, social skills, and quality of life. Controlled studies combining modern medical practices with music have shown varying results. We need to carefully choose areas where Music therapy is useful without any adverse effects. An example: Music in the Operating Room (OR) is known to have beneficial effects on patients. Specifically, music has been shown to decrease pain, stress, and anxiety, the demand for analgesic and anaesthetic drugs. From a surgeon's point of view, music facilitates achievement of higher speed and accuracy of task performance. This conference on the Best Practice Models in Music Therapy and Research is timely and will shed light on one of the pathways for integrative medical practice, which is the trend in the 21st Century. It is heart-warming to learn that a large number of medical students have registered to attend this event. Dr Sumathy Sundar, the head of Music therapy, and Prof N Ananthakrishnan, the Dean of Faculty of Allied Health Sciences & Research, deserve our appreciation for taking the initiative to organize this international conference. The national and international speakers deserve our appreciation of their willingness to share their expertise and experiences with all of us. Professor K.R. Sethuraman, MD, PGDHE.

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Dr. N. Ananthakrishnan, Dean – Research, Postgraduate Studies and Allied Health Sciences (SBV). Professor of Surgery (MGMCRI) Dt. 01.02.2016 Message

The department of Music Therapy in SBVU is organizing its 3rd International Conference on ―BEST PRACTISED MODELS AND RESEARCH IN MUSIC THERAPY: GLOBAL PERSPECTIVES‖ on 16th February, 2016. Our experiences in this field are still in their very early days. Nevertheless our footsteps in this field are becoming visible worldwide. Seeing the progress that is being made from day-to-day by our department in patient care services and research activities, I am sure that the 3rd International Conference would be a great success in providing a forum for exchange of views of all those interested in this field. It is our fervent hope that the interactions and discussions during the Conference would go a long way in spreading the importance of Music Therapy in the context of modern medical practice. 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 Wonderful greetings to you all!! Welcome to Sri Balaji Vidyapeeth!! We feel delighted to host the Third International Conference on Music Therapy titled BEST PRACTISED MODELS AND RESEARCH IN MUSIC THERAPY : GLOBAL PERSPECTIVES and do emphatically state that we feel immensely delighted in welcoming the distinguished speakers, Resource persons, Delegates, discerning students of Music Therapy from all over the globe and invited guests. The Center For Music Therapy Education and Research (CMTER) at Sri Balaji Vidyapeeth, Pondicherry came into existence, thanks to the yeoman efforts of our visionary Chairman Mr.M.K.Rajagopalan and backed eminently by the stalwarts : Prof. Rajaram Pagadala - the Hon'ble Chancellor, Prof. K.R.Sethuraman -the esteemed ViceChancellor and Prof. N.Ananthakrishnan – the respected Dean of Research & Allied Health Sciences. Evidence-Based Music therapy is the need of the hour and we at CMTER are quite aware of this fact. It is in the fitness of things that the best practised models and research in music therapy, as related to the holistic inclusion of a wide gamut of changes, including physiological and psychological need to be addressed from a global perspective. It is flat that Music therapy and medicine have a competent and major role to play in the modern era and are synonymous with objective adjuvant, in the scenario of modern medicine and therapeutics. Eminent resource persons of international repute have consented to conduct this conference. A hearty welcome to these distinguished persons. A big and special welcome to Prof. Suzanne B Hanser, Chair, Department of Music Therapy at the internationally acclaimed Berklee College of Music , who has graciously consented to inaugurate the conference and deliver the presidential address . Hearty welcome to you all. Do enjoy this academic treat and we sincerely hope and pray that you would have gathered many an important facet at the end of the conference and that you would also partake of sharing ideas during the open forum, at the point of culmination of the conference. Prof. Dr. Vellore A.R. Srinivasan

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Inaugural Address Suzanne B. Hanser, Ed.D., MT-BC is founding chair of the Music Therapy Department at Berklee College of Music. Dr. Hanser is Past President of both the World Federation of Music Therapy and the National Association for Music Therapy. She established the music therapy program at the Leonard P. Zakim Center for Integrated Therapies at Dana-Farber Cancer Institute, and is also a Resident Scholar at the Women's Studies Research Center at Brandeis University. Dr. Hanser is the author of The New Music Therapist's Handbook, and coauthor of Manage Your Stress and Pain, book and CD, with Dr. Susan Mandel. Her upcoming book, Integrative Health through Music Therapy: Accompanying the Journey from Illness to Wellness will be published in April, 2016. In 2006 Dr. Hanser was named by the Boston Globe as one of eleven Bostonians Changing the World. She is the recipient of a National Research Service Award from NIA, the Sage Publications Prize, and the American Music Therapy Association's Lifetime Achievement Award. I send greetings from Boston, Massachusetts. This is Suzanne Hanser. I chair the Music Therapy Department at Berklee College of Music, and I have been honored with this invitation to provide an address and welcome for you in India. I have a special place in my heart for India. I have been fortunate to be there several times, and I have learned from my colleagues,who are music therapists, and my colleagues who are musicians, and I even spent time in an ashram, learning some of the ancient mantras and the many ancient traditions of India. I am so blessed to be here with you virtually. This is a very special opportunity for music therapists to share so many of their ideas with each other and with the world. And thanks to the electronic technology, I am here with you, and certainly here with you in spirit. You know, there is a revolution in healthcare, and I am very excited to be in the United States at a time when finally, ancient wisdom, contemplative traditions, and spirituality, are all being integrated into medical services and healthcare. Finally, there is science to back up the wisdom that the ancient texts so articulately explained to us. And with this evidence, modern medicine in the West is waking up to what you in India have known for at least 5,000 years. Those mantras and ragas – now there's an explanation for how that affects the brain, and isn't that amazing, that Western science and Eastern philosophy can come together to take the best of each to provide even more effective music therapy services? I am so thrilled to be part of Integrative Health, this new revolution in healthcare, and this conference offers an opportunity for us to call upon that Western influence and 12


Eastern wisdom to bridge some of the gaps and develop an understanding of each other's traditions. Of course, this comes together in a holistic way, so we can really use Ayurveda and Ayurvedic medicine, we can use Traditional Chinese Medicine, and the contemplative arts, and put them all together into already established music therapy protocols that have been reviewed through research. Using the best of both worlds, quite literally, is offering such a wealth of wisdom and experience, and new ways of thinking about what health is. For the first time, in a long time, healing is being used in modern medicine. Just that term, ―healing,‖ is transforming the way we think of health. Health is not just physical health: it is wellbeing; it is wellness. And these things can occur even when there is illness and when there is a disease. Wellness and wellbeing – this is what we seek; and in music therapy,we offer individuals ways to cope with their disease, ways to improve their health overall, and live to see optimal health. Living at their greatest potential, using their creativity, and their internal resources, and their powers to heal themselves: this is what music therapy is now doing. I am very proud to be with you today in the way that I can be, on the other side of the world but very much with you, and very much encouraging you to make the most of your time together and share it with the rest of us in the world. Thank you very much 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 3rd

International

conference on 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. At the outset, we are grateful to our Chief Guest Prof. Suzanne Hanser, Chair, Department of Music Therapy, Berklee College of Music, Massachusetts for her gracious acceptance to inaugurate the conference online and deliver the Presidential address. Thank you very much for your inspiring

inaugural address with some special

propositions on Integration of Western Philosophies and Eastern Traditions in music therapy based on which the deliberations can take place during the conference. Our heartfelt thanks to our beloved Chairman Shri M.K. Rajagopalan for releasing the conference proceedings. We convey our special thanks to our respected and distinguished guest, Prof.

Jorg

Fachner, Anglia Ruskin University, Cambridge for delivering the key note address and share with us his expertise and experience on the topic Biomarkers and Music Therapy in the treatment of depression. I take this opportunity to thank immensely all our distinguished international speakers who have accepted our invitation and have travelled from 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.

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My heart -felt gratitude to the Chief Patron, our beloved Chairman Shri M.K. Rajagopalan, our patrons Chancellor, Hon. Prof. Rajaram Pagadala, Vice-Chancellor, Hon. Prof. KR Sethuraman, Pro Vice-Chancellor, Prof. YM Jayaraj, Dean, Research and PG Studies and Allied Health Sciences and CMTER's beloved mentor Prof. N Ananthakrishnan and Dean of Medical Faculty Prof. M Ravishankar without whose passion and unconditional support, this conference would not have been possible. I thank the Principals and all the faculty of our partners Mahatma Gandhi Medical College and Research Institute, 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. Ravichandran, Additional Director and Prof.

Nirmal

Coumere, Medical Superintendent of MGMC &RI for their support towards hosting this conference. Our very special thanks to the Chairman's Secretariat and Mrs. Asha Suresh Babu for providing all possible support and

making all the arrangements very meticulously

towards hosting this conference. I also thank profusely our other sponsors for their generous financial support to the conduct of this conference. 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. Further, I thank our IT department for their support to have this tech conference involving online inaugurations and video presentations. 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. Dr. Sumathy Sundar

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Session - 1 Key Note Address MUSIC THERAPY AND BIOMARKERS OF DEPRESSION TREATMENT 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. Abstract : How can we document change as a function of doing music in a therapeutic setting and how does it work? Biomarkers representing the effectiveness and those representing the music therapy process are related to an accumulation of and a focus on important moments in therapy time. Analysing resting state EEG may inform about group effects, while moments of interest in the improvisational process may reveal synchronization of brain processes. In music therapy it may be an important key to understand where and why change in therapy occurs. We will discuss the promises of biomarkers and neurometrics for music therapy, will draw on results of depression research, on recent work with wireless EEGs and improvisation, music performance, neurofeedback and game applications in psychiatric and neurorehabilitation. Antidepressant reduction or interaction? Activating brain circuits inducing pleasure gives rise to the hope that the right music therapy intervention stirring up the emotions of the individual client at the right time, may reducemedication prescribed for mental health issues, as music can replace the drug's desired effects. For example, in a study with depressed clients comparing treatment with Indian 'relaxation' music or hypnotics, the authors discussed that ―the effects of music could be equivalent to 10 mg of Chlordiazepoxide or 7 mg of Diazepam‖ . 17


Reductions of medication have been demonstrated in medicine employing music, for example, as an adjunct to anaesthetic medication . For instance, sedatives are regularly administered before surgery to reduce a patient's anxiety. However, sedatives often have negative side effects (drowsiness, respiratory depression, etc.), and may interact with anaesthetic agents, prolonging patient recovery and preventing discharge. Therefore, increased attention is being paid to the introduction of music to reduce medication during , and reducing anxiety before

surgery. These few examples may indicate that

there is hope that we can use music as a decrement of medication. The word 'complementary' means 'in addition to' or 'allied to' and is seen as an addition to standard care. For example, research into treating chronic pain with music therapy indicates that ―music therapy is an effective adjuvant intervention for patients suffering from chronic non-malignant pain, doubling the effects of pharmacological treatment‖ . Our ownresearch into the treatment of depression with music therapy indicates that a complementary interaction between improvisational music therapy and antidepressant medication may facilitate standard care– . Clients receiving music therapy and standard care showed significantly decreased depression and anxiety symptoms compared to those receiving only standard care. Personalised medicine On one hand we may strive for a reductionof medication but on the other hand the right medication may support psycho- or music therapy. This is desirable from the stance of personalized medicine . Prescriptions are ideally based on the bio-psycho-social identity of a particular person and not solely on a diagnostic classification. Personalized medicine hopes to address the right medication based on genotypes and biomarkers reflecting the client's biological condition , aiming to administer an individualized combination. While an antidepressant may be adequate for moderate or severe depression, it may not be the right choice for a first episode of mild depression. However, antidepressant prescriptions are on the rise

and once the proposed 'chemical imbalances' are treated with

antidepressants, they ―may reduce sense of self and soul into dopamine, serotonin, neurons, milligrams‖ . A striking example of the dominance of medication in depression treatment is a Finnish study

that explored the treatments offered to people who were retired prematurely

because of depression. The study revealed that 89% of the retired individuals during 1993 to 2004 never received any form of psychosocial treatment. Without a doubt, a better balance between the treatment choices could be achieved. There is convincing evidence that a combination of psychosocial support (such as psychotherapy) and medication is the best treatment,with psychotherapy acting as the initial treatment . Biomarking Music Therapy Treatment 18


A distinction among outcome types in clinical trials is between clinical endpoints and surrogate endpoints or biomarkers. A clinical endpoint may reflect ―how a patient feels or functions, or how long a patient survives‖ . In contrast, a biomarker is an objectively measured indicator of normal or pathological processes. Nevertheless, the process of selecting a measure remains subjective. A biomarker is objective only in the sense that it is not easily influenced by social expectancy bias and similar biases that may be encountered in clinical assessments. That is, ―a measure can only be objective once it is decided which measure to use‖ . How well this indicator reflects a clinical endpoint may vary (p. 118).One of the biomarkers aiming to be a surrogate for predicting and estimating

the

effectiveness

of

a

pharmacological

intervention

in

depression

treatment are EEG measures, as for example Frontal Alpha Asymmetries . This article reflects on its use in an RCT on music therapy and depression. In a randomised controlled trial (RCT), an outcome research method of proving treatment effectiveness, researchers were interested in whether music therapy added to standard care of depression treatment produced different outcomes from standard care only . Here it was important to develop a balance between a flexible and spontaneous practice of responding to the client and a standardisation of a treatment practice. Standardisation meant, for example, using the same musical instruments and a shared reference system created by all therapists taking part in the study, in terms of understanding depression, research and treatment practice and its philosophy . By constructing treatment fidelity, i.e. a consensus of understanding limitations of aims and common techniques employed, for example to be clear that this is a model of a normal treatment and not a normal treatment as such, a baseline to start from was developed and supervised on the way – . The results indicated a significant effect of music therapy added to standard care compared to standard care only. Three of the outcome measures indicated a substantial improvement, i.e. a reduction of depression and anxiety scores and an increase of overall global function - and most clients were not happy that the treatment ended after 20 sessions – . Emotion, depression and frontal brain activity Clients with depression have difficulties in expressing and processing emotion , and, given the frequent comorbidity with anxiety , are more likely to act in a withdrawn and anxious manner in social interaction . A heuristic concept explaining affective disorders links the withdrawal behaviour of depressed clients to increased right frontal activity, i.e., pathological asymmetric frontal processing of emotion . Depressed clients tend to use rumination and expressive suppression as strategies to regulate their emotions instead of actively approaching them . A few studies have demonstrated an immediate effect of pleasurable music listening on frontal processing in depression, i.e., during and after music listening a relatively right19


sided frontal activity of depressed adolescents and depressed mothers shifted towards relatively left-sided activity. These results indicate an immediate influence of music listening on frontal processing in depression. Fachner et al's aim was to find out whether these effects are lasting, and can be observed in an additional resting EEG recording, i.e., one not taken during or directly after listening, as in the study with depressed mothers from Field et al (1998), but after a course of active music therapy . Correlations between anterior EEG, Montgomery-Ă…sberg Depression Rating Scale (MADRS) and the Hospital Anxiety and Depression Scale - Anxiety Subscale (HADS-A), power spectral analysis

(topography,

means,

and

asymmetry)

and

normative

EEG

database

comparisons were explored. Neurometrics Normative EEG comparisons allow to distinct excessive or abnormal EEG patterns against a database of age, gender, and condition-matched controls in order to estimate zscored deviation from normality on measures at baseline and after treatment. The ztransformation is a nonlinear transformation in which each measured value is translated to a deviation from the typical value of a healthy person of the same age. In Case study designs normative EEG databases may help to provide an objectivist measure to estimate a client's brain process before and after a therapy session or sequence (Fachner et al., 2010) or guide neuro-feedback goal setting in music therapy (Miller, 2011). Ideally a client returns to normal processing. Neurologists have used EEG tools for decades, but research asks for generalizability of these biomarkers in the music therapy realm (Fachner et al., 2013; Gold et al., 2013). Brain plasticity, music and language processing in music therapy The results of the EEG study were quite interesting and may shed another light on Felicity's work on vocalisations. Many functions of the brain are bilaterally processed. For example, the left frontal operculum (Broca's area) organizes motor processes of speech production, while the contralateral site may influence the tone of the voice , a function reduced in aprosodic clients after cerebral damage . F. North's three examples show how vocalisation changed and became a tool for musical communication in therapy. In the depression study outlined above, the EEG resting state measures employed, a simple and easy to apply indicator of neuroplasticity, as utilised in Pharmaco-EEG studies , pointed to fronto-temporal changes as a signature of difference between both groups and between the pre and post music therapy treatment . Fronto-temporal areas have broadly been investigated in research on common areas of music and language processing . Emotional modulation of limbic structures, activation of the perception-action mediation in premotor areas, and intentional processes of social cognition in frontal and temporal areas are discussed as possible neuroscientific 20


concomitants of music-therapeutic action

. A study on fronto-temporal lobar

degeneration in 26 patients indicated the importance of fronto-temporal areas for the recognition and processing of emotion in music . Further, increases in the density of grey matter of Broca's area have been found in orchestral musicians , indicating the relevance of musical training for fronto-temporal brain plasticity. At intake the depressed clients perceived emotions in film music excerpts representing sadness and anger differently from normal controls. That is, they detected anger and fear more often than normal controls . Non-verbal expression of emotional content through music creation, and subsequent verbal reflection of its personal meaning, is part of the therapeutic relationship established during music therapy . Considering that about 70% of the therapy sessions were used for verbal reflection and 30% for improvising, fronto-temporal changes may prove that doing music therapy initialised neural reorganisation in areas which were busy with processing music and language in manifold ways, while offering the client a context to experience and embody a playful means of emotional expression supporting reduction of anxiety among and depressive withdrawal from others. Felicity's work shares this offer to the clients: 'an invitation to change'. Prosody and emotion in music therapy treatment Previous music therapy research has encouraged a closer enquiry into music therapy and the enhancement of pre-verbal skills in expressing and communicating emotions . In her three musical excerpts F. North exemplifies how vocalisation and communication link to music and language processing, and how the emotional colour of the voice can change in a musical dialogue. In the depression study, right-hemispheric activity increased after music therapy . Panksepp and Trevarthen discussed the importance of right hemispheric prosody in its connection to emotion processing and communicative musicality and already Patel et al had suggested a shared neural resource for prosody and music. In psychotherapy research speech prosody measures indicated emotional involvement during an interview on childhood memories . Koelsch et al

has stressed

the close connection of semantic and syntactic functions in music and speech processing. Processing of melody is connected to pre-motor speech process activation at a laryngeal level, initiating pre-motoric level movement processes, especially when meaningful and rewarding emotional processes trigger perception-action mediation . Examining patients with lesions in Broca's area, Sammler et al discussed the left Inferior Frontal Gyrus as a functional prerequisite for processing musical syntax. Results with aphasic patients undergoing melodic intonation therapy showed plasticity changes in the fibre tract connecting the superior temporal and inferior frontal lobes and the motor cortex in the right anterior hemisphere . Right hemispheric activity at fronto-lateral sites is also linked to prosodic processing . Williamsen et al. correlated reduced alpha, theta and delta power at F8 demonstrating that aprosodic expressive deficits of a client were 21


―caused by cerebral damage to the right hemisphere region homologous to Broca's area‖ . Taking the fronto-lateral asymmetry changes in Fachner et al's study and the findings on prosodic processing in these regions together, we may look at traces of emotional processing that occurred in music therapy with depressed clients. Outlook Music therapy is increasingly recognized as an area full of applied potential in the field of neuroscientific research . Music therapists are attracted by brain research as some principles applied in therapy, such as the social aspects of music making , seem to be confirmed in neuroscientific research. However, music therapists and neuroscientists recognize the limitations of the tools and paradigms of neuroscientific heuristics, but also their potential to visualize components of a music therapy action mechanism

.

Furthermore, outcome research aims to detect biomarkers and predictors of treatment response

. Biomarkers like neurotransmitters (see below), hormones, cytokines,

lymphocytes, vital signs, and immunoglobulinsindicating music–related changes of psychoneuroimmunological status are seen as promising tools to study stress reduction and wellbeing from a music psychology perspective, that is to say, to use music more systematically, . Brain imaging methods are becoming more sophisticated and provide insights into formerly hidden cerebral processes related to human functioning and pathologies. Studies of the brain aim to show how music plasticizes fibers , sparks neurotransmitter cascades

, and synchronizes body movement

and biological

rhythms .

Interest is growing in the area of flow states, for instance, training musicians to enter a relaxed but highly concentrated state in preparation for an artistic performance in the orchestra. In jazz and rock bands neurofeedback (NFB) methods have been successfully applied in this area

and aim to train the participant to control brainwaves that

represent certain brain states, moods and emotions. However, engaging in NFB and bio– guided music therapy means that people learn to perform according to rules that put the music and the body into a harmonic relationship . References Aina, Y., & Susman, J. L. (2006). Understanding comorbidity with depression and anxiety disorders. The Journal of the American Osteopathic Association, 106(5 Suppl 2), S9-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16738013 Aldridge, D. (1996). Music therapy and research in medicine - from out of the silence. London: Jessica Kingsley Publishers.

22


Alhaj, H., Wisniewski, G., & McAllister-Williams, R. H. (2011). The use of the EEG in measuring therapeutic drug action: focus on depression and antidepressants. J Psychopharmacol, 25(9), 1175-1191. doi:10.1177/0269881110388323 Balzer, H.-U. (2011). Chronobiology - as a foundation for and an approach to a new understanding of the influence of music. In R. Haas & V. Brandes (Eds.), Music that works (pp. 25-83). Berlin: Springer. Baskaran, A., Milev, R., & McIntyre, R. S. (2012). The neurobiology of the EEG biomarker as a predictor of treatment response in depression. Neuropharmacology, 63(4), 507-513. doi:10.1016/j.neuropharm.2012.04.021 Bringman, H., Giesecke, K., ThÜrne, A., & Bringman, S. (2009). Relaxing music as premedication before surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica, 53(6), 759-764. doi:10.1111/j.1399-6576.2009.01969.x Dalla Bella, S., Kraus, N., Overy, K., Pantev, C., Snyder, J. S., Tervaniemi, M., . Lopez, L. (2009). The Neurosciences and Music III : disorders and plasticity (Vol. 1169). Boston, Mass.: Published by Blackwell Pub. on behalf of the New York Academy of Sciences. Davidson, R. J., Marshall, J. R., Tomarken, A. J., & Henriques, J. B. (2000). While a phobic waits: regional brain electrical and autonomic activity in social phobics during anticipation of public speaking. Biol Psychiatry, 47(2), 85-95. doi:10.1016/S00063223(99)00222-X De Gruttola, V. G., Clax, P., DeMets, D. L., Downing, G. J., Ellenberg, S. S., Friedman, L., . . . Zeger, S. L. (2001). Considerations in the evaluation of surrogate endpoints in clinical trials. summary of a National Institutes of Health workshop. Control Clin Trials, 22(5), 485-502. doi:S0197-2456(01)00153-2 [pii] Deshmukh, A. D., Sarvaiya, A. A., Seethalakshmi, R., & Nayak, A. S. (2009). Effect of Indian classical music on quality of sleep in depressed patients: A randomized controlled trial. Nordic Journal of Music Therapy, 18(1), 70-78. doi:10.1080/08098130802697269 Egner, T., & Gruzelier, J. H. (2003). Ecological validity of neurofeedback: modulation of slow wave EEG enhances musical performance. Neuroreport, 14(9), 1221-1224. doi:10.1097/01.wnr.0000081875.45938.d1 Erkkilä, J., Ala-Ruona, E., Punkanen, M., & Fachner, J. (2012). Perspectives on creativity in improvisational, psychodynamic music therapy. In D. Hargreaves, D. Miell, & R. MacDonald (Eds.), Musical Imaginations: multidisciplinary perspectives on creativity, performance and perception (pp. 414-428). Oxford: Oxford University Press. Erkkila, J., Gold, C., Fachner, J., Ala-Ruona, E., Punkanen, M., & Vanhala, M. (2008). The effect of improvisational music therapy on the treatment of depression: protocol for a 23


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[pii]10.1186/1471-244X-8-50 Erkkilä , J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi, M., Gold, C. (2011). Individual music therapy for depression - Randomised Controlled Trial. Br J Psychiatry, 199(2), 132–139. doi:10.1192/bjp.bp.110.085431 Fachner, J. (2014). Communicating change – meaningful moments, situated cognition and music therapy – a reply to North (2014). Psychology of music, 42(6), 791-799. doi:10.1177/0305735614547665 Fachner, J., & Erkkilä , J. (2013). The Finnish research model of a music therapy practice treating depression. Musiktherapeutische Umschau, 34(1), 35–45. Fachner, J., Erkkila, J., & Brabant, O. (2016 in press). On musical identities, social pharmacology and timing in music therapy. In D. Hargreaves, R. MacDonald, & D. Miell (Eds.), Musical Identities. Oxford: Oxford University Press. Fachner, J., Gold, C., & Erkkilä, J. (2013). Music therapy modulates fronto-temporal activity in the rest-EEG in depressed clients. Brain Topography, 26(2), 338-354. doi:10.1007/s10548-012-0254-x Fancourt, D., Ockelford, A., & Belai, A. (2014). The psychoneuroimmunological effects of music: A systematic review and a new model. Brain, Behavior, and Immunity, 36(February), 15-26. doi:10.1016/j.bbi.2013.10.014 Field, T., Martinez, A., Nawrocki, T., Pickens, J., Fox, N. A., & Schanberg, S. (1998). Music shifts frontal EEG in depressed adolescents. Adolescence, 33(129), 109-116. Gold,

C.,

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electroencephalographic frontal alpha asymmetry and frontal midline theta as biomarkers for depression. Scand J Psychol, 54(2), 118-126. doi:10.1111/sjop.12022 Greenberg, R. P., & Goldman, E. D. (2009). Antidepressants, psychotherapy or their combination: Weighing Options for depression treatments. J Contemp Psychother, 39, , 83-91. doi:10.1007/s10879-008-9092-2 Gruzelier, J. (2009). A theory of alpha/theta neurofeedback, creative performance enhancement, long distance functional connectivity and psychological integration. Cogn Process, 10 Suppl 1, S101-109. doi:10.1007/s10339-008-0248-5 Harikumar, R., Raj, M., Paul, A., Harish, K., Sunil Kumar, K., Sandesh, K. Thomas, V. (2006). Listening to music decreases need for sedative medication during colonoscopy: a randomized, controlled trail. Indian Journal of Gastroenterology, 25(1), 3.

24


Henriques, J. B., & Davidson, R. J. (1991). Left frontal hypoactivation in depression. J Abnorm Psychol, 100(4), 535-545. doi:10.1037/0021-843X.100.4.535 Holsboer, F. (2008). How can we realize the promise of personalized antidepressant medicines?

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doi:http://dx.doi.org/10.1038/nrn2453 Honkonen, T. I., Aro, T. A., Isometsa, E. T., Virtanen, E. M., & Katila, H. O. (2007). Quality of treatment and disability compensation in depression: comparison of 2 nationally representative samples with a 10-year interval in Finland. J Clin Psychiatry, 68(12), 1886-1893. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18162019 Hunt, A. (2015). Boundaries and potentials of traditional and alternative neuroscience research methods in music therapy research. . Front. Hum. Neurosci., 9(342). doi:10.3389/fnhum.2015.00342 Jones, N. A., & Field, T. (1999). Massage and music therapies attenuate frontal EEG asymmetry in depressed adolescents. Adolescence, 34(135), 529-534.

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doi:10.1080/02699930903407948 Koelsch, S. (2009). A neuroscientific perspective on music therapy. Ann N Y Acad Sci, 1169, 374-384. doi:10.1111/j.1749-6632.2009.04592.x Koelsch, S. (2012). Brain and music. Oxford Wiley-Blackwell. Koelsch, S., Kasper, E., Sammler, D., Schulze, K., Gunter, T., & Friederici, A. D. (2004). Music, language and meaning: brain signatures of semantic processing. Nat Neurosci, 7(3),

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Leiser, S. C., Dunlop, J., Bowlby, M. R., & Devilbiss, D. M. (2011). Aligning strategies for using EEG as a surrogate biomarker: A review of preclinical and clinical research. Biochem Pharmacol, 81(12), 1408-1421. doi:10.1016/j.bcp.2010.10.002 LÜnnqvist, J. (2009). Stressi ja depressio (Stress and depression). Retrieved from http://www.terveyskirjasto.fi/terveyskirjasto/tk.koti?p_artikkeli=seh00020 Magee , W., & Stewart, L. (2015). The challenges and benefits of a genuine partnership between Music Therapy and Neuroscience: a dialog between scientist and therapist. . Front. Hum. Neurosci., 9(:223). doi:10.3389/fnhum.2015.00223 Menon, V., & Levitin, D. J. (2005). The rewards of music listening: Response and physiological connectivity of the mesolimbic system. Neuroimage, 28(1), 175-184. doi:10.1016/j.neuroimage.2005.05.053 Miller, E. B. (2011). Bio-Guided Music Therapy. London: Jessica Kingsley Publishers. Moneta, M., Penna, M., Loyola, H., Buchheim, A., & Kächele, H. (2008). Measuring emotion in the voice during psychotherapy interventions: Apilot study. Biological Research, 41, 389-395. doi:10.4067/S0716-97602008000400004 Nickel, A. K., Hillecke, T., Argstatter, H., & Bolay, H. V. (2005). Outcome research in music therapy: a step on the long road to an evidence-based treatment. Ann. N.Y. Acad. Sci., 1060, 283-293. doi:10.1196/annals.1360.021 Norris,

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Saletu, B., Anderer, P., & Saletu-Zyhlarz, G. M. (2010). EEG topography and tomography (LORETA) in diagnosis and pharmacotherapy of depression. Clin EEG Neurosci, 41(4), 203-210. doi:10.1177/155005941004100407 Sammler, D., Koelsch, S., & Friederici, A. D. (2011). Are left fronto-temporal brain areas a prerequisite for

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28


Session - 2 Current Research Initiatives in Music Therapy

Dr. Sumathy Sundar is a clinician music therapist, researcher and educationalist in India. She is the founder-director of Chennai School of Music Therapy and currently serves as Director, Center for Music Therapy Education and Research at Sri Balaji Vidyapeeth. She holds a Ph.D. in musical interventions in cancer care and has Master's degree in Indian music and applied psychology. She also currently serves World Federation of Music Therapy as its Chair, Education and Training Commission. A founding member of the International Association of Music and Medicine, she presently serves its board of directors as a member. She is on the editorial board of the International Journals " Music and Medicine and "Music Therapy Today." 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. Abstract: The need for music therapy research in India is diverse. Central to advancing music therapy clinical practice in hospitals is to know the levels of evidence in patient care outcomes through music therapy interventions. More so, as music therapy develops as an interface between modern medicine and Complementary/Alternative Medicine(CAM) under the umbrella of integrative medicine and advances as an innovative component in the modern and evidence-based practice of medicine in the country. In this situation, research initiatives in the form of quantitative experimental designs

are taken up to

find out the benefits of music therapy on patient outcomes which may contribute and facilitate the process of getting the music therapy profession legally certified by the government. Development of Music Therapy in India is complex as many traditional healing practices which use music as a primary medium for healing needs to be integrated in practice and taking up appropriate research is the first step in creating the first level of scientific evidence to ensure meaningful and phased integration of music therapy services in modern medicine according to the governmental health policy guidelines. This article discusses in detail the current research initiatives taken up by the faculty of Center for Music Therapy Education and Research (CMTER), a unit of Sri Balaji Vidyapeeth (SBV) a health sciences university to facilitate the evidence-based 29


application of music therapy. The research thrust areas, various research outcomes, further needs and the directions for future research are also discussed. Introduction : The main thrust of SBV is to strive towards excellence in areas which are also the focus areas of the Government of India and are considered to be at the advancing frontiers of medical science. SBV has set up Center for Music Therapy Education and Research as a part of its AIM-HIGH initiative to integrate music therapy in patient care services and started relevant research in this area bringing this area under integrative medicine.1 Wheeler2 describes different levels and types of music therapy research, and that different levels are appropriate at different points in the development of music therapy in a country. The research may be used to 1) describe a situation 2) identify and examine processes and causal factors 3) provide evidence about outcomes 4) change a situation. What type of research is to be done depends on what is the context and where the research takes place and by whom. Here, the context is music therapy practice and research in hospitals and the type of research conducted in CMTER is more on getting the evidence about outcomes and so randomized control trials are more often used to observe and record the patient outcomes.

Different thrust areas are identified and

research initiatives focus on a) providing evidence about outcomes and b)change the situation to make relatively permanent changes to happen in the patient outcomes. Research Thrust Areas : Five areas have been identified and research clusters were formed in collaboration with the Central Inter-disciplinary Research facility available from the University which operated to encourage faculty and students to work collaboratively and engage in high quality music therapy research. The areas identified were 1) Traditional healing practices 2) Inter-disciplinary collaborations and patient outcomes 3) Community health and well-being 4) Mind Body Medicine 5) Education and professional training. These research clusters were formed to objectify and create evidence for integrating traditional healing practices in clinical practice,

encourage and strengthen evidence by inter-

disciplinary collaborations to improve health related Quality of Life and patient outcomes, to create awareness and serve families and communities with music as a cultural resource and defence for health and foster good quality research on influence of music

on

autonomic

nervous

system,

psychoneuroimmunology

and

psychoneuroendocrinology and lastly to help students and faculty to learn and practice music therapy skills, to prepare them for teaching, take up research opportunities and become global players.3

30


Research Initiatives : In this section, the various research projects taken up by the CMTER faculty are discussed one by one. The primary focus is on objectifying traditional healing practices and integrating them in clinical practice. Explorative studies on Traditional healing practices like chakra activation through music, Explorative studies on Vedic chanting, Mantras and Raga Chikitsa integrating the Indian based time theory of ragas and also Ayurveda. In one of the studies, the effect of chakra activation or balancing of energy levels on body physiology was explored through a single musical manoeuvre of roughly 12 - 15 minutes in controlled conditions with seven healthy adults who were musically trained. The concept of chakras & kundalini energy has been described in Yoga, Ayurveda and other ancient Indian and Eastern traditional medicine systems. Chakras are considered to be part of human energy body. Kundalini is a dormant energy which can be activated using various chakra activation techniques. Various healing methods like yoga, meditation, qigong, music therapy, reiki, acupuncture, etc are believed to work with energy systems of the body as one of several mechanisms.4 Various chakra activation and chakra balancing techniques have been described in ancient literature like certain types of Yogasanas (postures), meditation techniques, musical techniques, etc. Till date, only a few scientific studies have been published which studied the effect of chakras on human physiology and hence this study was taken up.3 The present study examined the effect of a single performance of musical (vocal) technique for chakra activation and its effect on body temperature. The results indicated that a single session of musical (vocal) technique of chakra activation elevated body temperatures in all 7 subjects. Further research is required to study effects of various chakra activation techniques on body temperature and other physiological parameters.5 In another study, A 27 years aged pregnant female with psychiatrist diagnosed major depression for 3 years and history of multiple stressors came for music therapy. The researchers evaluated her tridoshas as per Ayurvedic system. She was treated with receptive music therapy using Indian classical music, with ragas being selected as per Time Theory of Ragas. At end of 20 sessions of receptive music therapy, improvement was seen in all symptoms of depression; her Tridosha evaluation showed more balance (from baseline V-7, P-16, K-3 to V-12, P-14, K-10 at end of treatment) and Caroll Rating Scale for Depression showed improvement from pre-treatment score of 16 to 5.6

31


Fig. 1. Time theory of Ragas with Ayurvedic Principles (Adapted from the Raga Samay Chakra of ITC Sangeet Research Academy) Under collaborative research and patient outcomes, studies were conducted in collaboration with the faculty of various clinical specialities. One of the studies reported the effect of live music therapy in the form of singing along with the use of finger and hand puppets on a total of 100 children coming for routine immunization to pediatric outpatient department. It was a randomized control trial with experiment (n = 50) and control (n = 50) groups. The Modified Behavior Pain Scale (MBPS), 10-point pain levels, and 10-point distress levels were documented by parents. Duration of crying was recorded by investigators. Pre- and postimmunization blood pressures and heart rates of parents holding the children were also measured and recorded by investigators. Independent and paired t tests were used for analysis. All 3 domains of the Modified Behavior Pain Scale and duration of crying showed significant improvement (P < .05) in the experiment group. Pain and distress levels also showed statistically nonsignificant 32


improvement in experiment group. Blood pressure and heart rate of parents showed no difference. Music therapy could be helpful to children, parents, and health care providers by reducing discomfort of the child during pediatric immunization.7 Another randomized control trial of Bhuvana and others observed the effect of relaxing music on systolic blood pressure, diastolic blood pressure and heart rates in 60 hospitalized pre-hypertensive pregnant women in 3rd trimester of pregnancy. Instrumental music was played to the pregnant women three times and observations recorded. experiment group

showed significant reduction in systolic blood pressure,

diastolic blood pressure and heart rate after each session of receptive music therapy. In comparison between experimental and control groups, systolic blood pressure showed significant reduction. No subject experienced any adverse effect. The study concluded that listening to relaxing music can reduce blood pressure and heart rates in hospitalized pre-hypertensive pregnant women during 3rd trimester. The blood pressure lowering effect of relaxing music listening was more significant for systolic blood pressure and receptive music therapy seemed to be safe in pregnant women.8 Sobana and others in their study studied the impact of music therapy in patients posted for upper gastro intestinal endoscopy based on their preferences in the physiological, psychological and behavioural parameters as well as cooperation level to the invasive diagnostic procedure. 60 Subjects of age 30 to50 years posted for upper GI endoscopy were divided into two groups GI&,GII of 30 each. GroupI heard music which they selected through headphones for 20 minutes and Group II calmly rested before the diagnostic procedure. Blood pressure, heart rate, respiratory rate, state anxiety and cooperation levels to the procedure were assessed before and after music intervention. The results indicated reduction in systolic blood Pressure and respiratory rate in the Group I in the post music interventional recording compared to pre music therapy readings. Diastolic pressure did not show significant change whereas heart rate mildly showed an increase. state anxiety scores s markedly reduced in Group I indicating they have calmed down. The cooperation level of the patients with the surgeon during the procedure was substantially better in Group I where 60% were highly cooperative compared to20% of the control group and concluded musical preference of the patients has to be considered to obtain positive responses.9 A 3 arm open labelled randomized control study was conducted by Haarika and others to determine the effectiveness of music and motherâ&#x20AC;&#x2122;s voice on pain reduction in neonates receiving a painful procedure namely venepuncture using Neonatal Pain Agitation Sedation Score (NPASS) pre-validated scale. Divided into music (n=98), motherâ&#x20AC;&#x2122;s voice (n=98) and control (n=96) groups, 292 neonates were analyzed by a block randomized trial and concluded that music and mother's voice (infant directed speech) help in pain reduction in neonates. Music could be better than mother's voice in pain reduction during venepuncture.10 33


In order to explore the effects of music therapy in waiting area of intensive care units, Sundar and others performed live music to the family members of ICU patients who experienced high levels of stress and anxiety.

Weekly 1-hour sessions of live music

therapy consisting of devotional songs and prayers were performed in waiting area of ICU. Responses of 100 first degree relatives of ICU patients were documented using an 8-item questionnaire. 69% and 24% of the subjects rated live music therapy sessions as ―excellent‖ and ―very good‖ respectively; 50% and 35% of relatives of ICU patients reported that they felt ―excellent‖ and ―very good‖ respectively after a single session. 77% of the subjects felt such session was very much needed for them and 92% of the subjects reported that there were high chances that they would recommend such sessions in the hospital in future. Neither investigators nor the live music performers experienced any rejection, opposition or adversity from any of patients, their relatives, doctors, hospital staff and authorities. In this study, they found music therapy to be feasible, acceptable and highly appreciated as well as encouraged by first degree relatives of ICU patients.11 Studies are also taken up in community settings to observe and record the benefits of music therapy. In a study taken up by Divya and others, 80 geriatric individuals living in an old age home were given group singing with various themes like de-stressing and energizing, 2) self expression, 3) Sharing and bonding and 4) managing emotions. In destressing and energizing theme, the researcher collected the favourite songs of the group as a whole and initiated the singing sessions and encouraged all the group participants to sing along clapping the hands and varying the tempos in slow progression. the songs used were Tamil devotional songs and

bhajans.

Most of

In self-expression, each

member of the group chose their most favourite song which they sang while playing simple percussion instruments and also discussed with the group why they liked that particular song. In sharing and bonding, all the participants also learnt the favourite songs of others in the group and sang together in the group and each participant shared their feelings of singing the favourite song of the other participants.

In managing

emotions theme, the group participants sang songs with body percussion and movements using hands giving vent to their emotions. During each session, singing was initiated by the researcher and the subjects were encouraged to sing along and perform simple movements using hands depending on the theme and concluded that music therapy in form of group singing improves GDS scores, PSQI scores and UCLA Loneliness scores in geriatric subjects having mild depression at end of 3 weeks. Group singing activity can offer safe, acceptable and economical intervention for institutionalized geriatric persons. There are also ongoing projects observing and recording the effect of music therapy on the foetus invitro, patients in the operation theatres undergoing surgery under regional anaesthesia, colic babies and pre-operative anxiety levels of patients undergoing dermato-surgery procedures. there is also an MD thesis on the effect of music therapy on patients diagnosed of tinnitus.

34


Research Publications : Around 20 research publications have emanated from CMTER so far in the last three years with 11 publications in the last year in both national and international journals of repute. All the publications have been indexed in pubmed/scopus/google scholar. Conclusion : Substantial research is being carried out at CMTER to create an evidence on the beneficial effects of music on patient outcomes and explorative studies undertaken to test the feasibility of integrating the traditional healing practices. However, all the researches are quantitative experimental design studies. To understand music therapy better, more qualitative case study approach have to be adopted which would educate the relationship component in music therapy, the clinical details and the music therapy process to both the music therapists and also the other health care and allied health care professionals.

35


References: 1.

Sundar S, Sivaprakash, B. Annual Report of Center for Music Therapy Education and Research. 2014. Sri Balaji Vidyapeeth.

2.

Wheeler, Barbara, L. The importance of research in educating about music therapy: Voices: A world forum for Music Therapy, [S.I], v14, n.2, jun.2014.ISSN.1504-1611. Available at <https: Voices.no/index.php/voices/article/view/746/644>. Date accessed: 9.Feb.2016. doi 10.15845/voices/V1412.746

3.

Sundar S. Report to National Assessment and Accreditation Council. Center for Music Therapy Education and Research. Sri Balaji Vidyapeeth. Nov. 2015

4.

McMurray S. Chakra talk: Exploring human energy systems. Holistic Nursing Practice 2005 Mar/Apr; 19(2): 94.

5.

Sundar S, Parmar P. Effect of a Single Musical Chakra Activation Manoeuvre on Body Temperature: A Pilot Study. (Submitted)

6.

Sundar S, Pavitra D, Parmar, P. Indian classical music as receptive music therapy balances Tridoshas and improves clinical depression in a pregnant woman. (Submitted)

7. Sundar S, Ramesh B, Dixit P, Venkatesh S, Das P, Dhandapany G. therapy as an active focus of attention distress

during

paediatric

Life music

for pain and behavioural symptoms of

immunization.

Clinical

Paediatrics.

DOI:

10.1177/0009922815610613 8.

Sumathy S. Bhuvaneswari R. Anandraj R. Effect of Relaxing Music on Blood Pressure and Heart Rate in Hospitalized Pre-hypertensive pregnant women in 3rd trimester of pregnancy: A Randomized control study. Asian J Pharm Clin Res. Vol.8, Issue 5, 2015, 186-188

9.

Sobana, R. Sumathy S, Priyanka, D. A study on the effect of music in reducing the anxiety of patients posted for upper GI endoscopy. Int. J Pharm Bio Sci 2015 April; 6(2): (3) 307-313.

10. Haarika V, Soundararajan P, Sundar S,

The effectiveness of music and mother's

voice on pain reduction during venepuncture in neonates - a randomized control trial. (Submitted) 11. Sundar S, Ramesh B, Varathan K. Live music therapy in the waiting area of intensive care units. Int J Res Med Sci.2016. Volume 4, Issue:3

36


Principles of Cognitive Behavioral Therapy â&#x20AC;&#x201C; How They Provide Support for Trauma-Informed Music Therapy Work

Dr. Gene Ann Behrens is Professor of Music and Director of the Music

Therapy

Program

at

Elizabethtown

College,

in

Pennsylvania in the United States. She has taught and supervised students for 17 years and worked as a music therapist for over 40 years in a variety of settings. She obtained her Bachelor of music therapy, Masters in special education, and Doctoral in music therapy and minor in counseling at Michigan State University, Kent State University, and University of Kansas, respectively. Gene has served on committees and executive boards for the American Music Therapy Association, Mid-Atlantic Region, and Certification Board for Music Therapists. She presently is chair of the Global Crises Intervention Commission for the World Federation of Music Therapy, a member of the Mid-Atlantic Music Therapy research committee, and on the editorial board for Music Therapy Perspectives. Many music therapists would identify themselves as eclecticâ&#x20AC;&#x201D;shifting among the concepts of various best practice approaches to meet the varying needs of their individual clients. Cognitive behavioral therapy is one combined, best practice approach that has the distinction of being well researched (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Since the independent development of cognitive and behavioral approaches during the 1950s and their combined use in the 1980s, it is not surprising that as PTSD was definedin the 1980s, cognitive behavioral strategies were developed to treat trauma (Foa, Keane, Friedman, & Cohen, 2009; Kar, 2011). Recent research on the neurobiology of trauma (Isaacs, 2009; Solomon & Heide, 2005; van der Kolk, 2006, 2014; van der Kolk, McFarlane, Weisaeth, 1996), though, suggests many of the cognitive behavioral methods for trauma that confront and recall events actually re-traumatize clients. Before integrating a traumatic experience, clients need to first unlearn reactive coping skills resulting from changes in their brain chemistry due toatraumatic event and then relearn new higher order processing strategies that help them effectively cope(van der Kolk, 2006, 2014). Despite the potential negative outcomes of some CBT trauma methods, however, many of the underlying principles of CBTcan be used to support a new music therapy framework for trauma treatment based onthe neurobiology of trauma research (Behrens, 2014). Recent researchon the use of CBT with other populations reports its effectiveness withanxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012, p, 427). Despite its frequent use by many health care workers in 2001, Luce reported that few music 37


therapists were embracing this preferred approach to psychiatric care. As its popularity continued to grow, Cassity conducted a Delphi poll in 2007 and reportedthat CBT could be the main psychological approach of music therapists by 2016. With the start of 2016, however, only few music therapists still seem to refer to the concepts of CBTin their treatment descriptions (Hilliard, 2001; Silverman, 2012, 2014, 2015;Markovich& Tatsumi, 2015). Luce (2001) proposed that possibly the principles supporting CBT had become so imbedded within the practice of music therapists that the approach is not directly referenced. Despite the success of some CBT methods for specificdiagnoses, the use of CBT for PTSD began to be questioned by the early 2000s. Researchers and clinicians stated thatonly 25-50% of patients with trauma symptomsreported relief by the end of treatment; some in fact reported leaving treatment as they became worse (Odgen, Pain, & Fischer, 2006; Zayfert, Becker, &Gillock, 2002). A few of the CBT approaches identified for PTSD (Foa, Keane, Friedman, & Cohen, 2009) include exposure therapy, the ―confronting [of] thoughts and safe or low-risk stimuli that are feared or avoided‖ (p. 549); systematic desensitization, the ―pairing of the trauma-related memories and reminders with muscle relaxation to inhibit the fear‖ (p. 549); and cognitive processing therapy, providing ―exposure to the trauma memory via writing a trauma narrative and repeatedly reading it‖ (p. 550). Recent research on the neurobiology of trauma, however, suggests thesetreatment methods, ones that encourage clients to repeatedly confront and discuss their trauma,actually are re-traumatizing clients (van der Kolk, 2014; van der Kolk, McFarlane, Weisaeth, 1996). Researchers continue to confirm that trauma responses occur in the brain and body, and for those diagnosed with PTSD, the reactive neural changes become a pattern of responses that generalize across time(Isaacs, 2009; Solomon & Heide, 2005; van der Kolk, 2006, 2014; van der Kolk, McFarlane, Weisaeth, 1996). In fact, many of the symptoms that were the focus of treatment for years, now can be traced to neurobiological changes in the brain, such as: (a) decreased activity in the left hemisphereis related to difficulty when verbally process trauma; (b) hyperarousal of the right hemispheredecreases ability to interpret and mediate information; (c) high levels of norepinephrine attached to raw sensory-emotional information in the amygdala results in strong memories; (d) reducedlevels of acetylcholinein the basal forebrain limits ability to learn; (e) disruption of the hypothalamus dysregulatesflight-flight responses; (f) lack of mediation from the orbitofrontal cortex reduces ability to regulate emotions, selfawareness, and relationships; and (g) limited integration and top-down processing of raw sensory-emotional information in the hippocampus inhibits ability to connect and recall events (Perry, 2006; Perry & Pollard, 1998; Perry, Pollard, Blakley, & Baker, 1995; van der Kolk, 2014; van der Kolk, McFarlane, Weisaeth, 1996; Ziegler, 2011). Research suggests that treatment, therefore, needs to involve goals that focus on positive neural changes (Ziegler, 2011) and methods that focus on body-oriented, bottom-up, nonverbal 38


to verbal strategies that help unlearn maladaptive and develop adaptive coping skills (van der Kolk, 2014; van der Kolk, McFarlane, Weisaeth, 1996). These important changes need to occur before the reintegration of the trauma event to develop effective coping skills that can prevent re-traumatization during processing. Music therapy is one approach that can address all of the neural goals and treatment methods for a trauma-informed, neurobiological-based treatment (Behrens, 2011). Although limited research exists onthe use of a music therapy approach based on the neurobiology of trauma research, results from studies on music and the brain provide support for the potential success of using music as therapy within a neurobiology framework. Results from studies suggest that: (a) music is processed throughout the brain

(Sergent, 1993; Schlaug, 2009); (b) the left auditory cortex, pitch area-right

auditory cortex, planum temporale, and corpus callosum are larger for musicians (Bermudez & Zatorre, 2005; Lee, Chen & Schlaug, 2003; Schlaug, Jancke, Huang, & Steinmetz, 1994); (c) conductors have increased activity in multisensory areas (Hodges, Hairston, Burdette, 2005); (d) music affects levels of neurotransmitters (dopamine, serotonin) (Evers & Suhr, 2000; Menon & Levitin, 2005); (e) the limbic system is activated by the valence and intensity of music (Hodges & Sebald, 2011); (f) most music tasks require integrated left and right hemispheric processing (Hodges & Sebald, 2011); (g) music is an effective distracter (Bradshaw, Brown, Cepeda, & Pace, 2011); (h) music is an effective reinforcer (Standley, 1996); and (i) music creates some of the strongest procedural memories (Hodges & Sebald, 2011).Music, therefore, has the potential to integrate hemispheric processing; develop higher order thinking; stimulate neural activity across the brain;engage processing in areas related to both positive and negative emotions; provide needed repetition to develop neural pathways; slowly develop expressive skills; and provide distracting, motivating environments that support trust and predictability. Based on the neurobiology of trauma and music-brain research, Behrens (2014) has developed a Music Therapy Trauma-Informed Framework (MTTF) that outlinesfour important components. These four components involve strategies that should be involved in all treatment experiences, key domains that need to be addressed, a treatment sequence that develops adaptive coping skills and avoids re-traumatizing clients, and goals (based on Ziegler, 2011) that focus on positive neuralchanges. The framework was developed to guide music therapists in using music as therapy to support the needs of clients at various stages of trauma treatment without re-traumatizing them. Although the framework was developed independent of all psychological approaches, the importance of the cognitive, emotional, behavioral, and social domains in trauma treatment reflects a potential connection with some of the tenets that support a cognitive behavioral

approach.Judith

Beck

(2011)

identified

one

set

of

ten

tenets

underlyingCBTthat is frequently quoted in the literature. Eight of these principles will

39


be briefly discussed as also key to Behrens’(2014) neurobiological-based,music therapy framework(MTTF) for trauma treatment. First, CBT and MTTF support an individualized conceptualization of and treatment approach for each client that evolves from session to session. In trauma therapy, it is critical to understand that trauma is individualized—not everyone experiencing a similar trauma event responds the same. Some individuals may not be traumatized; some may respond with short-term trauma; and others might develop PTSD. It is, therefore, important to not label someone as traumatized until performing an assessment. Music research also demonstrates the individualized nature of music preference and responses in therapy (Hodges & Sebald, 2011). In addition, the direction for trauma treatment needs to evolve based on the progress of each session. Second, CBT and MTTF seek to provide structure in sessions, therebyestablishing a safe, predictable environment. While safety and predictability are important to all therapeutic approaches, they are crucial in trauma work and also lead to a third CBT principle, the development of a strong therapeutic relationship. Clients with unresolved trauma find it very difficult to develop trust and relationships. In music therapy, the trust and a relationship must develop with both the music and therapist. While the use of rituals, boundaries, and sequences are effective strategies thatallow for greater exploration and creativity, the inherent qualities of music provide for time-ordered and reality-ordered experiences. New research suggests that music may stimulate the release of oxytocin and vasopressin that influence stress and social connections (Legge, 2015). Fourth, CBT and MTTF initially focus treatment in the here-and-now. This principle is essential to trauma work to avoid re-traumatizing clients. Music therapy experiences developed to support Behrens’ (2014) first three treatment steps—the establishment of safety, projective assessment of trauma, and the unlearning of maladaptive and learning of adaptive coping skills—need to focus on the present to avoid referring to the trauma event and re-traumatizing clients. Dealing with day to day events that involve stressorsis key to learning coping strategies thathelp clientsdecrease reactive responses and increase higher order processing. Once clients can effectively modulate hyperactive emotional, cognitive, and behavioral responses, then treatment can begin to help clients reintegrate events, emotions, and responses related to the past traumatic event/s. Fifth, CBT and MTTF are goal-oriented. While not focused on identifying problems as CBTdoes, the Behrens’ Framework (2014) does emphasize the overlapping of two or more neural goals for change while working on each of the five treatment steps. The Framework helps music therapists creatively develop an unlimited number of music therapy experiences that uniquely rehearse several of the five neural goals (Ziegler, 2011) at the same time while also focusing on goals that support needs within the domains and treatment steps. In addition, the previously discussed music-brain research 40


supports the potential of music to initiate positive brain change. Music experiences often involve repetition, and research supports that what gets fired together will get wired together (Perry, Pollard, Blakley, & Baker, 1995). In two other related principles, CBT and MTTF both identifyeducation as important to helping clients to identify, evaluate, and learn to respondto cognitive, emotional, and behavioral responses. Within both approaches, there is an emphasis on identifying what is not working and teaching more effective coping strategies. CBT labels them ―dysfunctional‖ and those supporting a neurobiological-based approach to trauma label them ―maladaptive‖. Within the MTTF, Behrens (2014) states clients need to identify and unlearn the reactive responses that occur in the brain, responses that reflect the brain trying to cope with the neural changes due to trauma; and then relearn to use higher order processing to mediate the stress-related responses. With an eighthand final principle, CBT and MTTP both support a collaborative role of the client in the therapy process. As with CBT, the trauma-informed music therapist may take a more directive role in the beginning to evaluate strengths and needs, move from one music therapy experience to another, provide more external support for the development of clients’ self-esteem, and present decisions that become increasingly complex. Slow, successful steps where clients take on more and more responsibility are important to the development of the neural goals and treatment steps. These goals and treatment steps eventually lead to an internal ownership of the clients’ self-esteem and positive changes in clients’perceptual view of themselves, others, and the world.Music as therapy experiences that involve music making are inherentlyability-ordered in the hands of a music therapist, provide for success, and present a range of decision making opportunities. Although some specific CBT methods do not support recent neurobiology research, a review of the principles underlying CBT as a best practice approach also are found to highlight several important concepts in Behrens’ Music Therapy Trauma-Informed Framework (2014). Similarto trauma work, the tenets of CBTidentify the importance of clientstaking control of their lives while learning to manage stressors using new adaptive strategies.Although CBT focuses clients on learning to interpret their thoughts, feelings, and behaviors, the neurobiology of trauma research suggests caution in that these thoughts, feelings, and behaviors occur as a result of reactive neural responses that dysregulate ability to accurately interpret and mediate responses.Music-brain research on the reinforcing phenomena of using music as therapy adds a nonthreatening way to activate higher order processing and stimulate the emotional centers of the brain which are crucial to the accomplishment of the neural goals and treatment steps.While CBT did not become the predicted overwhelming approach for music therapists in 2016, (Cassity, 2007), cognitive behavioral principles still provide direction for music therapists approaching trauma work based on the neurobiology of trauma research. 41


References : Beck, J. S. (2011). Cognitive behavior therapy- Basics and beyond (2nd ed). New York, NY:Guildford Press. Behrens, G. A.(2011). How recent research and theory on traumatic stress relates to music therapy. Musiktherapeutische Umschau, 32(1), 372â&#x20AC;&#x201C;381. Behrens, G. A.(2014).Development of a music therapy framework for stress trauma treatment. Paper session presented at the meeting of American Music Therapy Association National Conference, Kansas City, MO. Bermudez, J., & Zatorre, R. (2005). Differences in gray matter between musicians and nonmusicans. Annals of the New York Academy of Sciences, 1060, 395-399. Bradshaw, D. H., Brown, C. J., Cepeda, M. S., & Pace, N. L. (2011). Music for pain relief. Cochrane

Pain,

Palliative

and

Supportive

Care

Group

Reviews,

2011,

DOI:

10.1002/14651858.CD009284 Cassity, M. D. (2007). Psychiatric music therapy in 2016: A Delphi poll of the future. Music Therapy Perspectives, 25, 86-93. Evers, S., & Suhr, B. (2000). Changes of the neurotransmitter serotonin but not of hormones during short time music perception. European Archives of Psychiatry and Clinical Neuroscience, 250(3), 144-147. Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (Eds.). (2009). Effective treatments for PTSD (2nd ed). New York, NY: Guilford. Hilliard, R. E.(2001). The use of cognitive-behavioral music therapyin the treatment of women with eating disorders. Music Therapy Perspectives, 19, 109-113. Hodges, D., Hairston, W., & Burdette, J. (2005). Aspects of multisensory perception: The integration of visual and auditory information in musical experiences. In G. Avanzini, L. Lopez, S. Koelsch, & M. Majno (eds.). The Neurosciences and Music II, (pp. 175-185). Annals of the New York Academy of Sciences, Vol. 1060. Hodges, D., & Sebald, D. (2011). Music in the human experience: An introduction to music psychology. NY: Routledge. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy Research, 36(5), 427-440. Isaacs, N. (2009). The cutting edge of trauma treatment: Healing through the body. Retrieved from http://www.kripalu.org/article/648 42


Kar, N (2011) Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: A review. Neuropsychiatric Disease and Treatment, 7, 167â&#x20AC;&#x201C;181. Lee, D., Chen, Y., & Schlaug, G. (2003). Corpus callosum: musician and gender effects. NeuroReport, 14(2), 205-209. Legge, A. W. (2015). On the neural mechanisms of music therapy in mental health care: Literature review and clinical implications. Music Therapy Perspectives, 33(2). 128-141. Luce, D. W. (2001). Cognitive therapy and music therapy. Music Therapy Perspectives, 19, 96-103. Markovich, R.,& Tatsumi, K. (2015). The effects of single-session music therapy interventions in comparison with a cognitive behavioral intervention on mood withadult psychiatric inpatients in an acute-care setting: A quasi-experimental trial. Music Therapy Perspectives, 33(2), 118-127. Menon, V., & Levitin, D. (2005). The rewards of music listening: Response and physiological connectivity of the mesolimbic system. Neuroimage, 28(1),175-184. Odgen, P., Pain, C.,& Fischer, J.(2006).A Sensorimotor approach to the treatment of trauma and dissociation. Psychiatric Clinics of North America, 29, 263-279. Perry, B. D. (2006), Applying principles of neurodevelopment to clinical work with maltreated and traumatized children: the neurosequential model of therapeutics. In N.B Webb (Ed.), Working with traumatized youth in child welfare (pp. 27-52). New York, NY: Guilford Press Perry, B., & Pollard, R. (1998). Homeostasis, stress, trauma, and adaptation: A neurodevelopmental view of childhood trauma. Childhood and Adolescent Psychiatric Clinics of North America, 7(1), 33-51 Perry, B., Pollard, R., Blakley, T., & Baker, W. (1995). Childhood trauma, the neurobiology of adaption and use-dependent development of the brain: How states become traits. Infant Mental Health Journal, 16(4), 271-91. Schlaug G. (2009). Listening to and making music facilitates brain recovery processes. Annals of New York Academy of Science, 1169, 372-373. Schlaug, G., Jancke, L., Huang, Y., & Steinmetz, H. (1994). In vivo morphometry of interhemispheric asymmetry and connectivity in musicians. In I Deliege (Ed.), Proceedings of the 3d international conference for music perception and cognition, (pp. 417â&#x20AC;&#x201C;418). Liege, Belgium. Sergent, J. (1993). Mapping the musician brain. Human Brain Mapping, 1(10), 20-38.

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Silverman, N, J. (2012). Effects of group songwriting on motivation and readiness for treatment on patients in detoxification: A randomized wait-list effectiveness study. Journal of Music Therapy, 49(4), 414-429. Silverman, N, J. (2014). Effects of a live educational music therapy intervention on acute psychiatric inpatientsâ&#x20AC;&#x2122; perceived social support and trust in the therapist: a four-group randomized effectiveness study. Journal of Music Therapy, 51(3), 228-249. Silverman, N, J. (2015). Effects of lyric analysis interventions on treatment motivation in patients on a detoxification unit: A randomized effectiveness study. Journal of Music Therapy, 52(1), 117-134. Solomon, E. P., & Heide, K. M. (2005). The biology of trauma: Implications for treatment. Journal of Interpersonal Violence, 20(1), 51-60. Standley, J. M. (1996). A meta-analysis on the effects of music as reinforcement for education/therapy objectives. Journal of Research in Music Education, 44(2), 105-133. van der Kolk, B. (2006). Clinical implications of neuroscience research in PTSD. Annals New York Academy Sciences.1071, 277-293. van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York:NY: Viking. van der Kolk, B., McFarlane, A., & Weisaeth, L. (Eds). (1996). Traumatic stress. New York: Guilford Press. Zayfert, C., Becker, C. B., & Gillock, K. L. (2002). Managing obstacles to the utilization ofexposure therapy with PTSD patients. In L. Vandecreek & T. L. Jackson (Eds.),Innovations in clinical practice: A sourcebook (Vol. 20, pp. 201-222). Sarasota, Fl:Professional Resource Press. Ziegler, D. (2011). Traumatic experience and the brain, (2nd ed.), Phoenix, AZ: Acacia.

44


Neurologic Music Therapy in Medical Rehabilitation Dr. Anna Bukowska is a physiotherapist, music therapist and scientific lecturer. She graduated from the ―Medical College of Jagiellonian University, Krakow‖ and the ―Musical Academy‖ in Wroclaw. In addition, she is a member of the ―Polish Music Therapists Association‖. Fr. Bukowska finished her PhD degree in June and is now assistant professor at University of Physical Education in Krakow, Poland. Her research concentrates on a group of patients with Parkinson’s disease. The goal of the study is to analyse music therapy treatments that set out to improve the daily life and the locomotion of the patients. Furthermore, she participated in the ―Therapy Advanced Fellowship Training‖ hosted by the ―International Training Institute in Neurologic Music Therapy and the Neurologic Music―. She is an expert in working with people with neurological diseases and is interested in neurosciences and the impact of music and rhythms on the human body and soul. Abstract : The goal of this paper is to introduce Neurologic Music Therapy (NMT) established 20 year ago in USA, as the model which can be easily incorporate in the medical rehabilitation programs for variety of patients. In the second part of the paper the current research titled ―The influence of Neurologic Music Therapy to improve locomotion in a group of patients with Idiopatic Parkinson’s disease‖ will be presented, based on NMT in Parkinson’s disease (PD) rehabilitation. The main hypothesis of research assumes the major role of sensorimotor techniques of Neurologic Music Therapy (NMT) in improving spatial and temporal gait parameters in a group of PD patients. The 55 PD-diagnosed subjects invited to the study were randomly assigned into two groups: experimental (n=30) and control (n=25). To evaluate the influence of NMT procedure on the locomotion, the 3D Movement Analysis System BTS Smart was utilized. Participants from the experimental group attended NMT sessions 4 times a week for 4 weeks. Participants from the control group got the recommendations for daily life activities. The measures were taken twice, both before and after 4 weeks of therapeutic program. The results demonstrated significant improvement in the spatial and temporal gait parameters in comparison between I and II trial in the experimental group. The confirmation of research hypothesis might be used to develop therapeutic strategy based on music and rhythm for improve and maintain locomotion and help this group of patients come back to social activity.

45


Introduction : Significant number of people experience a variety of movement disorders that cause difficulties completing daily life activities. In order to improve impaired motor skills and quality of life they seek help considering new treatment methods. It creates a space for cooperation between music therapy and medical rehabilitation. The goal of this paper is to introduce Neurologic Music Therapy (NMT) as the model which can be easily incorporate in the rehabilitation program. In the second part of the paper the current research will be presented, based on NMT in Parkinsonâ&#x20AC;&#x2122;s disease rehabilitation. History of Neurologic Music Therapy (NMT) NMT was established in the 90s of the twentieth century at the Center for Biomedical Research in Music at Colorado State University in the US, based on the research projects and neurophysiological theories. The group of researchers from Colorado is considered as a group of creators of NMT. That interdisciplinary group (music therapists, neurologists, physiotherapists and neurophysiologist and occupational therapists) led by dr. Michael Thaut, described theoretical background and practical application of NMT Definitions and theoretical background of NMT Definitions of NMT were described in the six major foundations: 1. NMT as therapeutic application in cognitive, sensory and motor dysfunctions in the course of disease and damage to the nervous system. 2. NMT as a neurophysiological model of perception and production of music and the music impact on the functional changes of the brain. 3. NMT techniques are based on research evidence and they are focused directly on achieving non musical therapeutic purposes. 4. NMT techniques were standardized in accordance with the terminology and clinical application, they are always focused on the patient's needs. 5. NMT requires additional training in the field of neurophysiology, pathology of the nervous system, medical terminology, rehabilitation, neuropsychology and speech pathology. 6. NMT as the interdisciplinary model, allowing professionals and researchers contribute to increase the effectiveness of therapeutic activities.

46


The effectiveness of NMT in medical rehabilitation are explained by neurophysiological theories, neuroplasticity and influence of music on cognitive processes. Moreover, it is based on the principles of motor learning, widely used in modern rehabilitation [1, 6, 7, 9, 11]. 3 NMT techniques The NMT techniques were developed based on research. They are directly aimed at functional therapeutic targets. Techniques were standardized and utilised in the therapy as a musical therapeutic intervention, adjusted according to the patient's needs. NMT distinguishes three groups of techniques: sensorimotor, cognitive and speech language (Table). Table. Names of NMT techniques. NMT TECHNIQUES Cognitive techniques

Music

Sensory

Sensorimotor

techniques

techniques

Orientation Melodic Intonation Therapy Rhythmic

Training (MSOT) Music

Speech/language

Neglect

(MIT)

Stimulation (RAS)

Training Musical Speech Stimulation Patterned

(MNT)

(MUSTIM)

Auditory Perception Training Rhythmic (APT)

Auditory

Sensory

Enhancement (PSE) Speech

Cueing Therapeutic

(RSC)

Instrumental

Music

Performance (TIMP) Musical

Attention

Control

Training Vocal Intonation Therapy (VIT)

(MACT) Musical Mnemonics Training (MMT)

Therapeutic Singing (TS)

Associative Mood and Memory Training Oral Motor and Respiratory Exercises (AAMT)

(OMREX)

Musical Executive Functions Training Developmental (MEFT)

Speech

and

Language

Training through Music (DSLM)

Symbolic Communication Training through Music (SYCOM)

The goals of cognitive techniques are stimulation of cognitive function, mostly attention, orientation, memory, auditory perception and executive function.

47


The goals of speech/language techniques are support for the development of verbal speech and communication, speech re-education after injury, enabling of nonverbal communication through music and breathing exercises. The goals of sensorimotor techniques are stimulation and facilitation of gait, enhancement of functional movement, improvement of balance, coordination, endurance, range of motion and muscles strength [2, 3, 11]. Transformational Design Model (TDM) In order to optimize rehabilitation process, NMT uses Transformational Design Model (TDM). TDM was based on the guidelines for research in music therapy. That allows to translate theoretical knowledge into clinical practice. It promotes proper assessment, individual design and implementation of therapeutic music interventions. TDM consists of five steps. The first includes elements of diagnostic and functional assessment of a patient. In the second step the treatment goals are set up and measurements are conducted. In the third step the appropriate functional exercises are selected, at this stage without musical elements. In the fourth step adequate musical stimulation is selected. The final, fifth step is to transfer functional activities to daily life, without music accompaniment [10, 11]. Research: The influence of neurologic music therapy to improve locomotion in a group of patients with Idiopatic Parkinsonâ&#x20AC;&#x2122;s disease. Background The main hypothesis of presented research assumes the major role of the combination of all three sensorimotor techniques of Neurologic Music Therapy (NMT) in improving spatial and temporal gait parameters and kinematics of gait in a group of patients with Idiopathic Parkinsonâ&#x20AC;&#x2122;s Disease (PD). Methods The 55 PD-diagnosed subjects invited to the study were randomly assigned into two groups: experimental (n=30) and control (n=25). To evaluate the influence of NMT procedure on the locomotion, the 3D Movement Analysis System BTS Smart was utilized. Participants from the experimental group attended NMT sessions 4 times a week for 4 weeks. Therapeutic Instrumental Music Performance (TIMP), Pattern Sensory Enhancement (PSE) and Rhythmic Auditory Stimulation (RAS) were used in every 45minute session as a training of pre-gait, gait and advanced gait pattern. Metronome, rhythmic music and percussion instruments were applied in every session. Participants

48


from the control group got the recommendations for daily life activities. The measures were taken twice, both before and after 4 weeks of therapeutic program. Results The results demonstrated significant improvement in the spatial and temporal gait parameters and in the kinematics of gait in comparison between I and II trial in the experimental group. Both groups were significantly differentiated in terms of changes in measured parameters. Conclusion The confirmation of research hypothesis might be used to develop therapeutic strategy based on music and rhythm for improve and maintain locomotion and help this group of patients come back to social activity [4]. The research was supported by the National Science Center, Poland under Grant no. 2012/05/N/NZ7/00651. 5

49


References : 1. Altenmüller, E., Kesselring, J., Wiesendanger, M. (Eds). (2006). Music, Motor Control and the Brain. Oxford University Press, USA. 2. Baker, F., Tamplin, J. (2006). Music Therapy Methods in Neurorehabilitation. A Clinician’s Manual. Jessica Kingsley Publishers. London. 3. Bukowska, A., Konieczna, L. (2010). Neuromuzykoterapia w pracy muzykoterapeutów, fizjoterapeutów, logopedów i terapeutów zajęciowych. W: Muzykoterapia. Tożsamość – Transgresja – Transdyscyplinarność. Pod redakcją P. Cylulko i J. GładyszewskiejCylulko. Wydawnictwo Akademii Muzycznej im. Karola Lipińskiego we Wrocławiu,. 4551. 4. Bukowska, AA,. Krężałek, P., Mirek, E., Bujas P., and Marchewka, A. (2016) Neurologic Music Therapy Training for Mobility and Stability Rehabilitation with Parkinson’s

Disease

APilot

Study.

Front.Hum.Neurosci.

9:710.

doi:10.3389/fnhum.2015.00710 5. Hoemberg, V. (2014). A Neurologist’s View of Neurologic Music Therapy. W: Handbook of Neurologic Music Therapy. Thaut M.H., Hoemberg V. (ed.): Oxford University Press. 7-11. 6. Kitago, T., Krakauer J.W. (2013). Motor learning principles for neurorehabilitation. In Barnes M.P., Good D.C. (Eds). Handbook of Clinical Neurology, Vol. 110 (3rd series) Neurological Rehabilitation. Elsevier B.V. 7. Leins, A.K., Spintge, R., Thaut, M.H. (2009). Music therapy in medical and neurological rehabilitation settings. In Hallan, S., Cross, I., Thaut, M.H. (Eds). The Oxford Handbook of Music Psychology. Oxford University Press. 8. McNevin, N.H., Wulf, G., Carlson, Ch. (2000). Effects of Attentional Focus, SelfControl, and Dyad Training on Motor Learning: Implications for Physical Rehabilitation. Phys Ther. 80:373-385. 9. Thaut M.H., McIntosh G.C., Hoemberg V. (2014). Neurologic Music Therapy: From Social Science to Neuroscience. W: Handbook of Neurologic Music Therapy. Thaut M.H., Hoemberg V. (red.): Oxford University Press. 1-6. 10. Thaut M.H.: Assessment and the Transformational Design Model (TDM). W: Handbook of Neurologic Music Therapy. Thaut M.H., Hoemberg V. (red.): Oxford University Press 2014. 60-68. 11. Thaut, M.H. (2005). Rhythm, Music and the Brain: Scientific Foundations and Clinical Applications. New York, New York: Taylor & Francis Group. 137-164. 50


Session - 4 Thoughts on Western Therapeutic Practices in Myanmar, Nagaland and Bethlehem Tsvia Horesh, MA, CMT is a Music therapist, graduate of Rubin Music Academy, David Yellin College and Hebrew University, Jerusalem, Israel. Ms. Horesh has worked in the field of drug and alcohol abuse, and researched, published and lectured extensively on this subject. She currently works individually with children with emotional disorders, ADHD, LD and developmental delays and counsels parents. Ms. Horesh has developed and taught a course in music therapy techniques for special education staff in Beit Jalla, Palestine. Since 2012, she has been conducting continuing training courses for special education teachers in Yangon, Myanmar, under the auspices of Eden Center for Disabled Children, Yangon; Montessori Childrenâ&#x20AC;&#x2122;s Home; the Israeli Embassy in Myanmar and Music as Therapy International, UK. Ms. Horesh has also conducted workshops for trauma aid facilitators from IDP camps in Kachin, Myanmar; for young women from the Pao ethnic minority, in Shan state, Myanmar, as part of an Early Child Care and Development course; and for teachers and church counselors in Kohima, Nagaland, India. Since 2010, I have been working as a music therapist and teacher in cultures different than my own. As a secular, Western-oriented music therapist, I have often encountered disparities between my own personal outlook and theoretical underpinnings and the personal, social and professional philosophies of my clients and students. My clinical and teaching practices have often been challenged by collectivist approaches, religious beliefs and the central roles family and society play in the communities I have worked in. The need for simultaneous translation (in Myanmar and Bethlehem) further complicated communication.

In this paper, I would like to share my thoughts on

teaching and providing therapy to people whose cultures differ from my own, illustrated by anecdotes from my experience. My Personal Cultural Identity I would like to introduce myself from a cultural perspective. I was born in the United States of America and immigrated to Israel with my family at the age of nine, in 1962. This was just fourteen years after Israel gained independence from the British mandate, and after the 1948 war between the new state of Israel and the surrounding Arab countries. Israel in those years was a fledgling society, struggling to define its culture. There was a strong socialist and militarist atmosphere, and as a young child I felt it necessary to renounce all aspects of my American identity, and to change my clothes, language, pastimes and (if I only could have) my parents â&#x20AC;&#x201C; in order to fit in with my peers. Over the years I have come to appreciate having English as my mother tongue, 51


and having the privilege to visit countries that Israelis are not allowed entry to with my American passport. I feel that the experiences I have had of being different and not fitting in have heightened my sensitivity to issues of ethnic and cultural differences. My daily work as a music therapist has taken me to the town of Bethlehem, where I have been working in a school for disabled children for the past six years. The staff members of the school are all Palestinian Christians, and the children are local Christians and Muslims. It is not common, due to the political situation, for Israeli Jews like myself to work in Palestinian schools in the occupied West Bank. The school is twenty minutes from my home, but culturally a world away. In the past I have also worked with religious Jewish children from ultra-Orthodox communities in Israel. They also lived not far from my home, but were also culturally a world away. In 2012 I gave the first training to special education teachers in Yangon, Myanmar, on the use of music as a therapeutic medium in their work. Since then I have gone back four more times to conduct trainings and follow-ups and have trained close to 80 teachers in total. Fifteen of my original students are still in touch with me and are implementing in their work the skills I taught them. My overseas work has also included the following: A five-day Art and Music Therapy workshop for relief workers from the Kachin ethnic minority in Myanmar, facilitated together with an art therapist friend. Many of the participants had personally experienced the war that the Myanmar government is waging against the Kachin minority, and had to flee their villages after being attacked by the Myanmar army. All the participants worked with internally displaced people (IDPs) in refugee camps. A two-day workshop for young women from the Pao minority in Shan state, Myanmar, as part of a course in Early Child Care and Development (ECCD)where they were training to become kindergarten teachers. A three-day Art and Music Therapy workshop in Kohima, Nagaland, Northeast India, for teachers and church counselors. In all these places where I have worked, I felt that I was perceived as different from the people I worked with. I am a secular Jew from Israel, with an American background. I feel that I do not represent anything apart from myself and my profession. But I assume that when I come to these places, I am seen as a representative of so much more:

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With my American English, I most probably represent to them American culture, the epitome of Western culture. I am white, working in countries that were formerly under British occupation. Do I, in some respects, unconsciously represent the former colonial occupier, onto whom complex emotions of fear, hate, admiration and reverence are projected? I am a professional music therapist, trained in a Western profession that cannot be studied in Bethlehem, Myanmar or Nagaland. I am most probably perceived as so much more than I actually am, with initial suspicion and reverence, and very high expectations. I want to share a few examples of how I am perceived in these places: In the first training I gave in Yangon, the students did not talk, ask questions or challenge what I said. They showed complete deference to my authority, while refraining from communicating any of their own wishes or thoughts, and from mentioning things they did not understand or even possibly did not agree with. My translators told me not to take this personally. It seems that in their society the teacher is held in such high regard that questioning her or stating oneâ&#x20AC;&#x2122;s own opinions would be seen as disrespect. This was a very strange experience for me. My teaching style is based upon dialogue and interactions. Israeli culture encourages dialogue and dispute, and it is an integral part of cultural norms for people to state their opinion freely.

I had never before been in a

situation where everything I said was accepted without question. Even when I asked if everything was clear (because I was sure it was not), no one replied. The experience actually affected me in the opposite way than their intention of treating me with respect, creating feelings of self- doubt and worthlessness in me. I felt as if what I had said had not made any impression on them at all, the very opposite of feeling respected and in high regard! When planning my most recent training in Yangon, I suggested to my local partner, who was organizing the training, that my former students join the new studentsâ&#x20AC;&#x2122; training and conduct some of the musical activities. I was hoping that by showing the new students what they know, these experienced students would be empowered and that this would enhance the sustainability of the project. My local partner, a highly educated school principal and former student of my first training herself, disagreed. She said: â&#x20AC;&#x2022;We are making such an effort to bring you here. You are the expert. The new students want to learn from you, not from us."In her opinion, I was the expert.

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My philosophy in teaching is not to present myself as the one who has all the answers, but to help my students develop their own creativity, their ability to analyze situations and to brainstorm with their colleagues. I strive, in all my trainings, to build upon the strengths, talents and skills of the students. I have seen, after working with some of these students over the course of four years, that many of them have developed their own unique methods of using music as a therapeutic medium with the children in their care. I feel that our learning process is a joint one and I am often in awe of their capabilities. I was sure that the new students could havebenefited from their guidance. Individualist versus Collectivist Cultures I believe that the characterization of individualist versus collectivist cultures is not necessarily

geographical,

Western

versus

Eastern,

but

rather

modern/secular/individualist versus traditional/ religion based/ collectivist.

We also

cannot define cultures as ―either/or‖. All cultures and societies can be gauged according to their place on a continuum. In Israel, one does not have to go far to find societies in different places along this continuum. The more religious the family, whether they are Jewish, Muslim or Christian, the more connected they will be to a like-minded community and the more paternalistic, family-oriented, traditional and community-based they will be. Essame writes about the characteristics of core ―Asian values‖ and traits, being family oriented, traditionally minded, respectful of authority, consensus seeking, tolerant and sharing (pg.92). I would add that modesty, issues of acceptable behavior for women, civil obedience, militarism and consumerism, are all aspects that are affected by the level of individualist or collectivist characteristics of the society. In the first training I gave to teachers in Yangon, I devoted the first sessions to a talk about the importance of play in child development. I had the feeling that many of the concepts I presented were either unknown to the participants, or difficult for them to understand and process. The whole first week of the two-week training was devoted to individual work with children, whereas the second week was devoted to group sessions. I felt that it was easier for the teachers to relate to the group work. At first I attributed this to the fact that they needed time to warm up to me and my teaching methods and also to the fact that they had more experience in working with groups in classrooms than individually with the children in their charge. I also asked myself why I chose to start with the individual and not the group setting. My individualistic personal outlook and professional training had led me to believe that it is more coherent to start from the individual needs of the child and from there move on to the collective ones.

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But could their difficulty in comprehending my teaching also have been related to their collectivist culture, where the individual is gauged according to his association to family and society? There is less emphasis on his goals and aspirations for self-expression and self-realization.

This seems to be especially true when discussing young, disabled

children, possibly because such children will always need to be cared for and therefore are seen as even less potentially independent than normally developed children. The teachers’ individual goals for the disabled children were mainly to help them achieve educational milestones and to help them become more manageable. The idea that these children had a need for self-expression and emotional outlet was new to them. An example of this educational stance came up when I asked the participants in the training to write an opening song for a music group of the children in their care. One of the songs went like this: ―Good morning dear teacher, we respect you and will obey your requests and do as you ask us. Let's make music together…‖ In comparison, my typical opening song asks each child in the group: "How are you today? Show us by using the instruments what you are feeling…‖ In Kohima, I visited a high school, and was asked to carry out a musical activity in one of the boys' classes. Many of the students, when asked, said that they liked music and some played a musical instrument.There were around fifty young boys sitting in the classroom, not knowing what to expect. I started a rhythm, clapping hands, and invited them to join in. I then asked for someone to beat out a solo rhythm with two pencils on the desk, on the base of the group beat. No one volunteered. After a while I asked specific boys to beat a solo. Many of the boys diverted their glance, so that I wouldn’t call on them. One boy that I called on blushed and froze. I then understood that this activity was completely wrong for them. I asked them if they would like to sing a song. They immediately asked me to teach them a song in my language, in Hebrew. Since they were devout Christians, I thought that they would enjoy learning a song with words from the Bible. I wrote out the words from Psalms 133, in transliteration to English, and they were soon singing the song as a round. The words are: ―Behold, how good and how pleasant it is for brethren to dwell together in unity.‖ Analyzing these two activities, one can see that the first activity called for individual, creative initiatives, which were possibly something that the boys had never been asked to do. But when we sang together it was clear to me that this was a familiar activity, and they were comfortable and happy doing it.

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We might hypothesize that participants from an individualistic society facing an activity similar to the first one, would behave differently.

Perhaps, members of a more

individualistic society, even if not familiar with this kind of activity, would be more independent and creative.

It is also possible that when people (from either kind of

society) are shy, lack confidence and are not sure how to behave in a situation, they stick to the familiar, preferring not to stand out nor to take initiative. More research and more time with the participants would be needed to determine the extent to which local cultural norms account for participants' responses to the various activities. In Bethlehem, I worked with a nine year old boy, who had genetic, progressive muscular dystrophy. He was aware of his condition and was very frustrated and angry and aggressive towards his peers, and so was referred to music therapy sessions. One day, after a few months of therapy, I felt that he could benefit from additional media for expression, and I offered him some colored play dough. He immediately took the brown play dough and made small balls, calling them ―kaka‖(the Arabic derogative word for feces). He then proceeded to throw them at his image in the nearby mirror. I felt that this was an important expression of his frustration and anger at his deteriorating physical condition, which until then he had never expressed in words. There was a translator working with me at the time, due to the fact that I was not fluent, at the time, in Arabic. She was a local mother of two small children. When she saw what we were doing, she became pale and said:‖ Tsvia, you cannot allow him to say that word. Only children from very bad families talk like that. You must tell him to stop‖. I could see that she was shocked and pained. I told her that I would explain later, so as not to stop the flow of the session. When the boy’s teacher came to take him back to class, I told her what had happened. I explained why I felt it was important for him to express what he truly felt. But we agreed, and explained to the boy, that he is only allowed to say that word in the therapy sessions with me and may never use it in the classroom or at home. This helped me set the boundaries and define the setting of the therapy. The boy understood, probably because he already had felt that our sessions were different than any situation he had been in before. In the first training in Yangon, I told this story in the context of a discussion about personal boundaries in our work with children. All my students were equally shocked, as the staff in Bethlehem had been. They all agreed that they could never let a child in their care talk or behave that way. I believe that in therapy, we should allow our clients to express themselves freely in the setting of the therapy, of course without harming others, even if what they say is culturally unacceptable. On the other hand, I accept the fact that those working with children or adults have the right to protect themselves from what they may perceive as abusive language.

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These two examples, of the high school students in Kohima and the boy from Bethlehem, are similar in showing how some forms of self-expression may not be culturally acceptable. In the classroom in Kohima, in a one-time session, it seemed clear that no one would behave differently than what is accepted in their society. But the boy from Bethlehem allowed himself to behave in a socially unacceptable way, possibly because of our therapeutic relationship and his unconscious perception that I, and the therapeutic setting, could contain this behavior. Music as a Cultural Attribute Rhythm is universal and it is physical, experienced in nature and in the body. What people who have had no experience making music do when confronted with instruments and a request to engage in a joint experience is universal. People whose musical culture has distinct rhythmic components will most probably implement these rhythms in their improvisation, but the basic bodily and emotional qualities of music- making tend to be more similar than different across cultures. How much is the music itself an issue in these cross cultural encounters? East and West are in a constant fluctuation of moving towards each other. Western music (popular and classical) is common and taught all over the world. Some of the worldâ&#x20AC;&#x2122;s most renowned classical pianists and string players are from Japan and China. In the Gitameit music school in Yangon, Myanmar, the sounds coming from most of the rooms are of Western music: piano, guitar and drum sets.

It is possible to study

traditional Burmese music there but there is no high demand for it. Facebook, Youtube and other social media have made the world smaller, with, it seems, a preference for Western culture. In the Asian Christian communities I have worked with in Kachin and Kohima, the Church influences musical preferences. The Christians in these areas were converted from animistic beliefs in the late 19th century, mostly by American and British missionaries who brought with them music from their own Western cultures. This is most prominent in Kohima, where English is the official language. Van Eck wrote about her experiences giving music workshops in Uganda, Africa, as a trainer with â&#x20AC;&#x2022;Musicians Without Bordersâ&#x20AC;&#x2013;. When she asked the group to sing a song, they sang something in English. When she asked them to sing in their language, they sang a Western tune with words in their language. It took them time to understand that she wanted to hear a local song, something she did not know. I have had the same experience in my work in Yangon, Kohima and Bethlehem. One explanation of this phenomena is that the people may feel that I, as a foreigner, would prefer to hear songs that I know and can then join in the singing. This sentiment may be due to the fact that participants do not realize that I am interested in their culture and want to hear their 57


music. They might believe that they will gain status in my eyes by demonstrating their knowledge of Western music and competence in Western culture. It is possible that they believe that Western culture and music are superior to their local musical culture or they may think that I believe this. Or it could simply be that they are trying to help me feel "at home". When I go to work in a culture unknown to me, I try to get a sense of the music, both modern and traditional, that is popular there. In many non-Western cultures, the people have an advantage over myself and other â&#x20AC;&#x2022;Westernersâ&#x20AC;&#x2013;. They have their own indigenous musical culture, and they also have an acquaintance with my culture, through the media. They straddle both cultures, even though many times their impressions of Western culture may be distorted. Possibly, by singing in English, they are doing what I do when meeting someone from a new culture, when I try to show off a few words I know in their language, or sing a song I learned. They want me to feel comfortable in their country and so try to accommodate me with something from my culture. It would be interesting to research this widespread phenomenon and the emotions and motivation that are behind it. Returning to the Middle East and to Arabic musical traditions, we find that usually when Palestinians, be they adults or children, are given traditional drums, many of them will happily beat out a traditional Arabic rhythm. A British music therapist friend, who was working in a childrenâ&#x20AC;&#x2122;s home in Bethlehem, felt frustrated hearing this rhythm again and again in the therapy sessions, interpreting it as resistance, as if the clients were hiding behind the culturally accepted music, not leaving their comfort zone, not willing to expand into the free, self-expressive improvisation that she was looking for. Behrens researched this issue while working with traumatized children in Bethlehem. She found that, on the whole, the children beat traditional rhythms when presented with the traditional tabla drum. But when offered non-traditional instruments, they played other organized rhythmic patterns and also creative, improvised styles, enabling a wider range of emotional expression. Her experience showed that the traditional instruments and rhythms were beneficial in structuring the sessions, and in developing trust, mastery and self-worth among the children. The use of non-traditional instruments, on the other hand, opened up areas of self-exploration, both musically and emotionally. From my experience working with disabled Palestinian children I have found that when a retarded child expresses himself by beating a traditional Arabic rhythm, it can be perceived as an unconscious claim of belonging to his family and society, and as an expression of his culturally acceptable competence. During a music therapy workshop I gave for special education teachers in Bethlehem, I found that they were reticent to participate in the free improvisation activities I guided, were self-conscious and quite slow in warming up to free flowing, unstructured music. 58


But, during the coffee break, I heard from the room amazing, joyful music. All the participants were there, singing, drumming and dancing. This happened without any guidance from myself, the workshop facilitator. This was their comfort zone, but it was also their expression of their communal cultural assets. This was, in a way, their own self-therapy, using their own music.

Through the music they were asserting their

identification as a group. In both of the above cases

the music makers (non-verbal developmentally disabled

children, and Palestinian adults living under occupation) are groups without a voice in their daily life. Playing their communal music is one way of being heard, of authentically asserting their cultural identity and sense of belonging. For my short term workshops in Kachin, Shan and Kohima, I developed the concept of ―non-instruments‖. The assumption was that, at least in Myanmar, there were very few instruments in the IDP camps or the remote kindergartens where the trainees would be working, hopefully implementing the skills they were to learn in the workshop. So instead of conventional instruments, I searched the kitchens, offices and gardens of each venue, collecting everyday tools to be used for music making. The lack of musical instruments forced me, and also the participants, to open our minds to new possibilities, to explore new and surprising sounds. Often non-musicians are apprehensive when starting a music therapy workshop, because they fear the encounter with musical instruments that, they assume, others know how to play better than themselves. But upon seeing the ―non-instruments‖ (large water jugs, kitchen utensils, plastic garden hose, PVC tubes) in the room and starting to explore their possibilities, the barriers fall and playfulness arises. When starting the workshop, I invite the participants to choose one non-instrument and explore its different, possible sounds. Since no one knows how to make music on these things, everyone is a novice. Simply trying to make a sound from an object which has other uses or connotations, forces one to do something for the first time, to be creative and innovative. The young women from the kindergarten teachers’ training came from small, remote, mostly Buddhist villages in Shan state, Myanmar. Music plays a large part in their culture, but the actual playing of the instruments is done mostly by men who are designated for this job. These young women have most probably never played any kind of music.

Improvising music

on

the

―non-instruments‖

was

an opportunity for

empowerment and self-discovery. In the Kachin workshop, however, one of the participants remarked that the pot lids and metal trays that we were playing on sounded like the traditional cymbals they use in their village festivals. On the other hand, another participant said that she knows families who still hold on to animistic beliefs, and said that they would not accept using 59


kitchen utensils for anything other than making food. It could annoy the spirits and be dangerous for the familyâ&#x20AC;&#x2122;s health. An Israeli music therapist friend told me that she spent a few months in India, taking singing lessons. During one of the lessons she suggested to her teacher that they do a vocal improvisation together, and demonstrated what she meant. Her teacher was shocked by the lack of musical structure in what my friend sang. In Indian classical music, one can improvise only in accordance with certain rules and forms; whereasin our therapeutic attitude to music, we bring a less structured, less hierarchical approach. Clinical improvisation, as my friend and I understand it, is based on inner, personal impulses, and is not restricted, or structured, by tradition or rules. In collectivist, traditional societies, creativity is defined and contained by cultural structures. These structures enable individuals, as members of society, to express themselves in socially accepted manners. What I, as a therapist and teacher, bring to therapeutic music making is the freedom of self- expression. It would be interesting to see if this approach can be integrated into a more highly structured society.

The very

nature of my work challenges the flexibility of social structures and calls some of their assumptions into question.

Through offering opportunities for self-expression, it is

possible that my work may be ultimately subversive of some social structures. I strive to maintain respect for the culture in which I am working, while still maintaining a professional stance that depends on offering greater opportunities for selfexpression than the culture usually permits. As a therapist from outside, I must learn to work within the cultural constraints of the society while maintaining the basis of freedom of expression that guides my work. When I think of therapy in general in all societies or, more specifically, freedom of expression within discipline and creativity within a culturally defined structure, I imagine a river, flowing between two clearly defined river banks. Sometimes the river flows calmly, the banks containing and directing its path. Sometimes it can overflow and cause havoc and destruction. One of the aims of therapy is to enable this havoc, contain it, and learn ways to control it or to disengage its destructive potential. Can the collectivist society keep its priorities in the face of such havoc, accepting the ebb and flow of the river as a metaphor to the human psyche? These and other questions will continue to accompany me in my work in cultures other than my own.

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References : Behrens, G. A. (2012) "Use of Traditional and Nontraditional Instruments with Traumatized Children in Bethlehem, West Bank" in Music Therapy Perspectives) Vol. 30 pgs. 196-202 Essame, C. (2012) "Collective versus Individualist Societies and the Impact of Asian Values on Art Therapy in Singapore," in Art Therapy in Asia, London and Philadelphia, PA, USA, Jessica Kingsley Pub. Van Eck, F. (2012)Exchange Between Cultures in Musical Pedagogical Issues,Increasing mutual learning, respect, and self-esteem through music workshops,Thesis for the degree of Master of Music Education (M.Mus.) in the Faculty of Music Education, the Jerusalem Academy of Music and Dance, Jerusalem

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Session 5: Paper Presentation 1 Abstract : TITLE: CAN MUSIC THERAPY BE AN EFFECTIVE COMPLEMENTARY THERAPY IN PULMONARY REHABILITATION TO ASTHMATICS? AUTHORS: *Dr.Sobana.R1, Dr.Sumathy Sundar2, Assistant Professor of Physiology, Mahatma Gandhi Medical College, Sri Balaji Vidyapeeth University, Pondicherry. 607402. Director,CMTER (Center for Music Therapy Education & Research), Sri Balaji Vidyapeeth University, Pondicherry. 607402 This is a cross sectional study on the impact of single music therapy session in the form of vocal exercise and monotone OM chanting for 20 minutes on the pulmonary functions, dyspnoeic level and perceived stress in (n=30)asthmatics. Parameters assessed were pulmonaryfunctions namely FEV1/FVC (Forced Expiratory Volume 1 second/Forced Vital Capacity), FVC (Forced Vital Capacity), dyspnoeic level (Visual Dyspnoea Assessment Scale _VDAS) and perceived stressscale (PSS). Patients chanted "OM" in the musical note "S" in their convenient pitch to the accompaniment of Tampura as a drone to activate the ―MOOLADHARA CHAKRA‖ and by induction of deep abdominal breathing.The above mentioned parameters were recorded before and aftermonotone OM chanting for 20 minutes. Analysis of the results by Chi square test show an increase in the mean FEVI/FVC from 61.03% to 72.11% (p≤0.001)and mean Forced Vital Capacity from 3.89 litres to 5.03 litres(p≤0.021), approximately 17% improvement in the lung functions. The dyspnoea level has fallen from 7.06 to 5.21 (p≤0.001) which is a shift from severe to mild breathless level according to AG.GIFT’s rating. The stress level (PSS) had come down from 36 to 23. The study had shown that Music therapy can act as a holistic approach in pulmonary rehabilitation as there is beneficial effect in the pulmonary functions, reduced breathlessness and stress level.

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Paper Presentation 2: EFFECT OF RELAXING MUSIC ON BLOOD PRESSURE AND HEART RATE IN HOSPITALIZED PRE-HYPERTENSIVE WOMEN IN 3RD TRIMESTER OF PREGNANCY: A RANDOMIZED CONTROL STUDY AUTHORS: Bhuvaneswari Ramesh1, Sumathy Sundar2 and Anandraj R3 Tutor, Center for Music Therapy Education and Research, SBV Director, Center for Music Therapy Education and Research, SBV Associate Professor, Department of OBGYN. Mahatma Gandhi Medical College and Research Institute, SBV

Abstract: Objective: To observe effect of relaxing music on systolic blood pressure, diastolic blood pressure and heart rates in hospitalized pre-hypertensive pregnant women in 3rd trimester of pregnancy Methods: 60 hospitalized pre-hypertensive pregnant women in 3rd trimester of pregnancy were included in the study. They were divided in to experiment (n=30) and control (n=30) groups by randomization. Experiment group received 3 15-minutesessions of receptive music therapy in form of non-rhythmic instrumental music. Control group did not receive music therapy intervention. Blood pressure and heart rates were measured before and after each session. Results: Experiment group showed significant reduction in systolic blood pressure, diastolic blood pressure and heart rate after each session of receptive music therapy. In comparison between two groups, systolic blood pressure showed significant reduction. No subject experienced any adverse effect. Conclusion: Listening to relaxing music can reduce blood pressure and heart rates in hospitalized pre-hypertensive pregnant women during 3rd trimester. The blood pressure lowering effect of relaxing music listening is more significant for systolic blood pressure. Receptive music therapy seems to be safe in pregnant women.

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Paper Presentation 3: THE EFFECTIVENESS OF MUSIC AND MOTHER'S VOICE ON PAIN REDUCTION DURING VENEPUNCTURE IN NEONATES - A RANDOMIZED CONTROL TRIAL AUTHOR: V. Haarika Post graduate Student, Department of Pediatrics Abstract : Background: Neonates in NICU undergo painful procedures as a part of therapeutic and diagnostic intervention. Previous literature showed that pain management during procedures is still below optimal level. Aims and objectives: We conducted a study to determine the effectiveness of music and mother’s voice on pain reduction in neonates during venepuncture using Neonatal Pain Agitation Sedation Score (NPASS) pre-validated scale. Methodology: A 3 arm open labeled randomized control study was conducted in NICU in a tertiary care hospital in Puducherry, South India. 300 term neonates undergoing venepuncture for routine investigations in the post natal ward were included and divided into music (n=98), mother’s voice (n=98) and control (n=96) groups. Eight neonates were excluded from this study as they were in sleep state and didn’t awake after venepuncture. 292 neonates were analyzed. Randomization was done by block method. Music group received pre recorded lullabies and mother’s voice group received pre recorded mother’s voice during venepuncture. The control group received no intervention during the venepuncture. NPASS was documented by the investigator; the physiological parameters were recorded by an independent observer. Physical and behavioral parameters before, during and after the venepuncture were recorded by investigator. Results: The NPASS was statistically significant (p=0.000) between the music (4·622·137) and control group (7·212·16). NPASS between the mother’s voice (infant directed speech) group (5·94 1·899)

and

control group (7·212·16) was significant (p=0.000). NPASS between the music (4·622·137) and mother’s voice group (5·941·899) was statistically significant (p=0.000). There were no adverse events during the study. Conclusion: Music and mother’s voice help in pain reduction in neonates. Music is better than mother’s voice in pain reduction during venepuncture.

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POSTER PRESENTATIONS Poster 1 EFFECT OF A SINGLE MUSICAL CHAKRA ACTIVATION MANOEUVRE ON BODY TEMPERATURE: A PILOT STUDY AUTHORS: Parin Parmar1, Sumathy Sundar2 Faculty, Center for Music Therapy Education and Research, SBV, Pondicherry Director, Center for Music Therapy Education and Research, SBV, Pondicherr Abstract : Context: Chakra activation or balancing and music therapy are part of the traditional Indian healing system. Little is known about effect of musical (vocal) technique of chakra activation on body temperature. Aim: To study effect of a single musical (vocal) chakra activation manoeuvre on body temperature in controlled settings. Settings & Design: A single-session exploratory study Methods & Material: Seven healthy adults performed a single musical (vocal) Chakra activation manoeuvre for approximately 12 minutes in controlled environmental conditions. Pre- and post-manoeuvre body temperatures were recorded with clinical mercury thermometer. Statistical analysis: Basic statistical formulas such as calculation of means were used. Results: After a single maneuver, increase in body temperature was recorded in all the seven subjects. The range of increase in body temperature was from 0.2 F to 1.4 F; with mean temperature rise being 0.5 F and median temperature rise being 0.4 F. Conclusions: A single session of musical (vocal) technique of chakra activation elevated body temperatures in all 7 subjects. Further research is required to study effects of various chakra activation techniques on body temperature and other physiological parameters. Key words: Chakra, Kundalini, healing, temperature, energy, music therapy, singing Key message: We describe a self-constructed musical (vocal) chakra activation technique which affects body temperature after a single session. Effects of ancient healing practices on body physiology need to be further explored scientifically.

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Poster 2 Music Therapy and Down Syndrome Dr. A.N. Uma Asst.Prof in Medical Genetics, Genetic Lab, Dept. of Anatomy, MGMCRI, Puducherry Down syndrome or trisomy 21 was linked to leukemia for the first time in a case report published in 1930. Since then, Down syndrome has been recognized as one of the most important leukemia-predisposing syndromes. Reports from researchers of profound Satellite associations seen in the chromosomes of Down syndrome clearly indicate increased DNA damage, signifying vulnerability to leukemia. Thus as an innovation, Music therapy was given to nine children between the age group of eight months to one year to find out if the DNA damaging profile most predominantly seen in these children decreased, rendering them a hope that they may not be susceptible to leukemia. The frequency of satellite association in the chromosome of the babies was 81% before the music therapy [Veena music] and after three months of 24 music therapy hearings, the satellite associations fell to a startling 60% indicating that music seem to play a role in reducing the DNA damage. The mechanism is still unknown yet we all know that soothing music stimulate calming alpha brain waves, helping to filter out stress, frustration, anxiety and agitation in Downâ&#x20AC;&#x2122;s syndrome patients in general, helping them to achieve a sense of calmness which could have played a role in reducing the frequency of satellite association. Music therapy treatment at an early age may provide such patients a success-oriented, normalized experience, giving them a more positive selfimage and a life free from any gross medical complications in future. More such studies are required before we arrive to a meaningful conclusion. Poster 3: IMPACT OF ADJUNCTIVE MUSIC LISTENING ON DEPRESSION AND ANXIETY - A QUASI-EXPERIMENTAL STUDY AUTHORS: Karthik Balakrishnan, Sivaprakash.B, Eswaran.S, Sumathy Sundar, Sukanto Sarkar, Ashwinth Jothy.P. Mahatma Gandhi Medical College-Puducherry Background: Music listening has previously been found to be effective in the treatment of depression & anxiety but the studies have been methodologically insufficient and lacking in clarity about the clinical model employed and there is a dearth of Indian studies on this matter. Aims:To study the impact of music listening on depression and anxiety in individuals diagnosed with depression attending a tertiary care hospital. 66


Objective: -1) To test the hypothesis that the adjunctive music listening to standard care helps in treating depression. 2) To study the impact of a clinician-supervised music listening followed by home-based musical listening with standard care alone on the outcome of depression and anxiety in depressed individuals. Method: This is a Quasi-experimental study patients(44 male & 16 female)

done on a total sample size of 60

who were diagnosed as having depression(F32

mild,moderate,severe), bipolar(F31.3, F31.4,ICD- 10), Recurrent depressive disorder(F 33) .Duration of the study- one year. Patients were divided into 2 groups (A & B).Group A(30

patients)(adjunctive

music

listening

+

standard

care),Group

B(30

patients)(standard care alone) . Patients were interviewed with semi structured questionnaire comprising of socio-demographic details, MADRS(Montgomery-Asberg Depression Rating Scale)., HARS(Hamilton Anxiety Rating Scale), on day 0,10,30. Patients in groups A

received daily scheduled sessions of

investigator supervised

adjunctive music listening for a duration of 10 sessions(30 min.each), followed by(20 sessions) self administered home based music listening with standard care .Patients in group B were given standard care alone without adjunctive music listening Appropriate / suitable music tracks from various musical genres were selected in collaboration with a qualified music therapist. Results: Participants receiving music listening plus standard care showed greater improvement than those receiving standard care only in both depressive symptoms and anxiety symptoms. There was significant difference in MADRS score between music listening plus standard care group and standard care group( mean difference 8.6, 95% CI 5.921 to 11.278, p value 0.00177 ) . There was significant difference in HARS score between

music

listening plus standard care group and standard care group ( mean difference 3.033, 95% CI 0.7453 to 5.3206 p value <0.001). Poster 4: EFFECT OF MUSIC THERAPY ON SPONTANEOUS VOCALIZATION OF NONVERBAL CHILDREN WITH AUTISM AUTHOR: Dr. Amrita Panda Language proficiency as one of the determinants of verbal communication has long been aimed to consider planning interventions for children with autism. Children with Autism Spectrum Disorder (ASD) show severe impairment particularly in the area of language and communication, which is thought to result from difficulties with the perception of human speech, parsing words from the speech stream, or mapping words to objects or 67


other environmental information. Any of these problems can affect the spontaneous vocalization in communication, stored representation of the word and potentially interfere with later retrieval of the word to speak. Hence, the facilitation of spontaneous vocalization could be one of the objectives to achieve language proficiency in children with ASD. Music therapy techniques can facilitate and support the desire to communicate (Thaut, 1984). The present study is an initial attempt in the form of a pilot study aimed to facilitate spontaneous vocalizations in children with autism through the therapeutic use of music in the course of individual sessions. Three non verbal children aged between 6 and 12 years with the diagnosis of ASD (according to DSM V) of moderate intelligence level (IQ 50 â&#x20AC;&#x201C; 69) were participated in the study from a special Autistic school of Kolkata. Children were assessed for spontaneous vocalization before and after the music therapy sessions using ABLLS-R (Partington, 2010). The obtained scores were compared and evaluated between the two occasions (pre and post) in each child and as a group. Ten music therapy sessions for each child was planned, each session for 40 minutes twice per week. Music therapy method applied was improvisation. The post evaluation measures were collected after 10 sessions of therapy. The pre and post measures were analyzed applying a non-parametric statistical technique called Wilcoxon Sign Rank Test using because of the small sample size and repeated measure design. Though results indicate no statistically significant effect of music therapy on the improvement of spontaneous vocalization scores from pre to post condition, the mean scores clearly reflect an improvement in the spontaneous vocalization of the participants. Overall, the study bears the promise to bring about a positive change still it requires further exploration and replications to ascertain the role of music therapy on verbal behavior of children with ASD. Poster 5: MUSIC

THERAPY

AS

GROUP

SINGING

IMPROVES

GERIATRIC

DEPRESSION SCALE SCORE AND LONELINESS IN INSTITUTIONALIZED GERIATRIC

ADULTS

WITH

MILD

DEPRESSION:

A

RANDOMIZED

CONTROLLED STUDY AUTHORS: Divya Mathew1, Dr. Sumathy Sundar2, Dr. S. Easwaran3, Dr. Parin Parmar4 1. Divya Mathew, PGDMT, Chennai School of Music Therapy 2. Director, Center for Music Therapy Education and Research 3. Professor and Head, Department of Psychiatry, MGMC & RI 4. Faculty, Center for Music Therapy Education and Research Abstract : Depression is a common geriatric problem. This study was conducted with an aim to evaluate effect of group music therapy in form of group singing, lead by a music 68


therapist, on depressive symptoms and loneliness in institutionalized geriatric individuals having mild depression. The study was conducted as a randomized control trial. The experiment group (n=40) received daily music therapy in form of group singing lead by a music therapist for three weeks. The control group (n=40) did not receive any specific intervention. Baseline and weekly Geriatric Depression Scale â&#x20AC;&#x201C; Short Form (GDS-SF) and UCLA Loneliness Scale scores were recorded in both groups. Statistically significant improvement (P<0.001) was seen in both the scores at end of three weeks in experiment group in both inter-group and intra-group comparison. No adverse event was reported. Keywords: Depression, Depressive Disorder, Geriatric Psychiatry, Complementary Therapies, Music Therapy Poster 6: EFFECT OF MUSIC ON HYPERTENSION AUTHORS: Narendiran.N , Shanmuga Priya, Dr.S.Sakthidevi, M.D.S., Dr.I .Karthikeyan M.D.S Indira Gandhi Institute of Dental Sciences, SBV, Pondicherry Abstract : Listening to music is a common leisure activity, made especially convenient with the variety of music players available to the consumers. There are several individual reactions to music that are dependent on individual preferences, mood emotions. Hypertension is one of the leading risk factors influencing morbidity and mortality.There is need for non-pharmacological management for the same. Music is known to reduce anxiety and holds promise for non pharmacological management of hypertension owing to low cost, ease of administration and safety. The efficacy of music to reduce blood pressure (BP) has not been established. So,

high blood pressure (hypertension) is a

common condition. Left untreated it is associated with serious conditions such as heart attack, stroke, heart failure and kidney disease. There are a variety of causes that are associated with hypertension and one of them is stress. At very high blood pressure, there is the risk of over-loading the heart compounded by possibility of bursting of minute blood vessels that supply the brain cells and other vital organs with possibility of endohemorrhegic complications and death, the human body system requires regulated blood pressure level to maintain its homeostasis. One relationship which has been studied is the effect that listening to music has on blood pressure; interestingly, different studies have come to different conclusions. In a study, after three month of music listening, researchers say systolic blood pressure significantly decreased, by nearly 6 69


mm/hg, among those who listened to music. Systolic B.P readings taken immediately after music sessions were lower by nearly 6 mmHg, sessions. People in the comparison group showed no change in blood pressure readings. The researchers say they do not know whether the apparent beneficial effects of music interventions will persist on a long-term basis and studies related are less, whereas short studies regarding music on hypertension is more and established .The researchers say more study is needed further evaluate their findings. However, besides being an enjoyable way to spend an afternoon, an evening, or a commute to work, listening to music may actually have some health related implications. Poster 7 LIVE MUSIC THERAPY IN WAITING AREA OF INTENSIVE CARE UNITS: A NOVEL CONCEPT FOR BETTERMENT OF CLOSE RELATIVES OF ICU PATIENTS AUTHORS: Bhuvaneswari Ramesh1, Sumathy Sundar1 Kala Varathan 1 Center for Music Therapy Education and Research Abstract : Family members of ICU patients experience high levels of stress and anxiety. We explored a novel concept of live music therapy for relatives of ICU patients. Weekly 1hour sessions of live music therapy consisting of devotional songs and prayers were performed in waiting area of ICU in a tertiary care hospital. Responses of 100 first degree relatives of ICU patients were documented using an 8-item questionnaire. 69% of the subjects rated live music therapy sessions as ―excellent‖; 50% of the subjects reported that they felt ―excellent‖ after a single session. Such sessions were reported as a felt need by 77% of the subjects; 92% of the subjects reported that there were high chances that they would recommend such sessions in the hospital in future. In our study, we found our concept to be feasible, acceptable and highly appreciated as well as encouraged by first degree relatives of ICU patients.

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